What antihypertensives (Anti-Hypertensive medications) should be avoided in patients with Chronic Kidney Disease (CKD) or Acute Kidney Injury (AKI)?

Antihypertensives to Avoid in CKD/AKI

Potassium-sparing diuretics (amiloride, triamterene) and aldosterone antagonists (spironolactone, eplerenone) should be avoided in patients with significant CKD (GFR <45 mL/min) due to high risk of life-threatening hyperkalemia. 1

High-Risk Medications Requiring Caution or Avoidance

Potassium-Sparing Agents (AVOID in Advanced CKD)

• Potassium-sparing diuretics (amiloride, triamterene) should be avoided when GFR <45 mL/min 1
• Aldosterone antagonists (spironolactone, eplerenone) should be avoided with significant renal dysfunction and never combined with potassium supplements or other potassium-sparing drugs 1
• These agents carry substantial hyperkalemia risk, which increases cardiovascular mortality 1

Dual RAAS Blockade (CONTRAINDICATED)

• Never combine ACE inhibitors with ARBs - this combination increases hyperkalemia and acute kidney injury without cardiovascular or renal benefit 1
• Never combine ACE inhibitors or ARBs with direct renin inhibitors (aliskiren) - contraindicated due to increased adverse events including hyperkalemia, syncope, and AKI 1
• The combination of any two RAAS blockers should be avoided entirely 1

NSAIDs (HIGH RISK - Avoid if Possible)

• NSAIDs including ibuprofen should be avoided in patients with impaired renal function, especially those on diuretics, ACE inhibitors, or ARBs 2
• NSAIDs cause dose-dependent reduction in renal blood flow and can precipitate acute renal decompensation 2
• Patients with CKD taking diuretics and ACE inhibitors are at greatest risk for NSAID-induced acute renal failure 2
• If NSAIDs must be used, discontinue ACE inhibitors/ARBs 2-4 days prior when possible 3

Medications Requiring Dose Adjustment and Monitoring

ACE Inhibitors and ARBs (Use with Caution)

• ACE inhibitors and ARBs are NOT contraindicated in CKD but require careful monitoring 1
• These agents increase hyperkalemia risk, especially in CKD patients on potassium supplements or potassium-sparing drugs 1
• Risk of acute renal failure exists in severe bilateral renal artery stenosis 1
• Monitor serum creatinine and potassium after initiation and following dose increases 1
• A small, reversible decline in GFR at treatment onset is expected and actually correlates with better long-term renal protection 4, 5
• Consider withholding ACE inhibitors/ARBs 2-4 days prior to contrast exposure, acute illness, surgery, or bowel preparation for colonoscopy to prevent AKI 3

Thiazide Diuretics (Limited Efficacy in Advanced CKD)

• Standard thiazides become ineffective when GFR <30 mL/min 1, 6
• Loop diuretics (furosemide, bumetanide, torsemide) are preferred over thiazides in moderate-to-severe CKD (GFR <30 mL/min) 1, 6
• Chlorthalidone may retain some efficacy even in advanced CKD and can be considered at low doses (12.5 mg) 1, 6
• Monitor for hyponatremia, hypokalemia, and hyperuricemia 1

Critical Monitoring Parameters

Essential Laboratory Surveillance

• Check serum creatinine and potassium within 1-2 weeks of initiating or uptitrating ACE inhibitors, ARBs, diuretics, or aldosterone antagonists 1, 6
• Monitor electrolytes every 3-5 months for stage 4 CKD (GFR 15-29 mL/min) and every 1-3 months for stage 5 CKD (GFR <15 mL/min) 1
• Both hyperkalemia and hypokalemia increase cardiovascular risk and mortality 1

Clinical Scenarios Requiring Drug Withdrawal

• Temporarily discontinue ACE inhibitors/ARBs during:
  • Acute illness with volume depletion 1, 3
  • Perioperative period 3
  • Before iodinated contrast administration 3
  • During bowel preparation for colonoscopy 3
• This "renoprevention" strategy reduces AKI risk 3

Common Pitfalls to Avoid

• Do not assume ACE inhibitors/ARBs are contraindicated in CKD - they provide cardiovascular and renal protection when used appropriately 1, 4
• Do not combine multiple RAAS blockers thinking it provides additional benefit - it only increases harm 1
• Do not continue potassium-sparing agents as GFR declines below 45 mL/min without very close monitoring 1
• Do not overlook NSAID use (including over-the-counter ibuprofen) as a reversible cause of worsening renal function 2
• Do not fail to adjust medication doses based on declining renal function 1