From the Guidelines
The recommended plan for this 43-year-old male with hypertension who experienced a GFR decline from 53 to 43 while on lisinopril is to continue lisinopril with careful monitoring and consider additional blood pressure medications to achieve a target BP of <130/80 mmHg, as ACE inhibitors provide renoprotective benefits in chronic kidney disease, particularly in hypertensive patients 1.
Evaluation and Monitoring
The patient should undergo evaluation for potential causes of the GFR decline, including:
- Checking for dehydration, recent use of NSAIDs, or other nephrotoxic medications
- Urinalysis to assess for proteinuria and hematuria
- Renal ultrasound to rule out obstruction Electrolytes, particularly potassium and creatinine, should be checked within 1-2 weeks of any dose adjustment.
Lifestyle Modifications
Lifestyle modifications including:
- Sodium restriction (<2g/day)
- Regular exercise
- Weight management should be emphasized to help control blood pressure and slow the progression of kidney disease.
Nephrology Referral
Nephrology referral is appropriate given the significant GFR decline to stage 3b CKD, as patients with CKD are at higher risk for cardiovascular events and renal events, and require close monitoring and management to slow disease progression 1.
Additional Considerations
Additional blood pressure medications may be needed to achieve target BP, and the patient's medication regimen should be tailored to their individual needs, taking into account their kidney function and other comorbidities 1.
From the FDA Drug Label
- 4 Dose in Patients with Renal Impairation No dose adjustment of lisinopril tablets is required in patients with creatinine clearance > 30 mL/min. In patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, reduce the initial dose of lisinopril tablets to half of the usual recommended dose i.e., hypertension, 5 mg; systolic heart failure, 2.5 mg and acute MI, 2. 5 mg.
The patient's GFR is 43, which is above 30 mL/min.
- No dose adjustment of lisinopril is required for this patient. 2
From the Research
Patient Profile
- 43-year-old male with hypertension
- GFR decreased from 53 to 43
- Currently on lisinopril
Recommended Plan
- According to 3, patients with chronic kidney disease and proteinuria should be treated with an ACEI or ARB plus a thiazide diuretic or a calcium channel blocker
- Since the patient is already on lisinopril (an ACEI), adding a thiazide diuretic or a calcium channel blocker could be considered 3, 4
- However, 5 suggests that ARB monotherapy or combination therapy can have a favorable impact on blood pressure and renal parameters such as proteinuria
- Considering the patient's decreased GFR, it is essential to monitor renal function closely when adjusting medications 5
- Additionally, 6 found that twice-daily dosing of lisinopril was associated with greater systolic blood pressure reductions compared to once-daily dosing, which could be an alternative to adding a new medication
Potential Next Steps
- Monitor blood pressure and renal function closely
- Consider adding a thiazide diuretic or a calcium channel blocker to the patient's current regimen 3, 4
- Alternatively, consider adjusting the dosing frequency of lisinopril to twice daily 6
- Consult with a nephrologist or a cardiologist for further guidance on managing the patient's hypertension and chronic kidney disease 7