Can lisinopril (Angiotensin-Converting Enzyme Inhibitor) be initiated with a Glomerular Filtration Rate (GFR) of 20 milliliters per minute, indicating Impaired Renal Function?

From the Guidelines

Lisinopril can be started cautiously in patients with a GFR of 20 ml/min, but dose adjustment is necessary, and it is recommended to start at a lower dose and monitor kidney function and potassium levels closely, as suggested by the most recent and highest quality study 1. When initiating lisinopril in patients with a GFR of 20 ml/min, it is essential to consider the potential risks and benefits. The study by 1 provides guidance on the use of RAAS antagonists, including ACE inhibitors like lisinopril, in patients with chronic kidney disease (CKD). According to this study, RAAS antagonists should not be routinely discontinued in people with GFR < 30 ml/min/1.73 m2, as they remain nephroprotective. However, it is crucial to start at a lower dose and assess GFR and measure serum potassium within 1 week of starting or following any dose escalation.

Some key points to consider when starting lisinopril in patients with a GFR of 20 ml/min include:

• Starting with a lower dose, such as 2.5-5 mg daily, compared to the typical 10 mg starting dose for those with normal kidney function
• Close monitoring of kidney function, blood pressure, and potassium levels, especially during the first few weeks of treatment
• Checking serum creatinine and potassium levels within 1-2 weeks of starting therapy
• Being aware of the potential risks of adverse effects, including hyperkalemia, worsening renal function, and hypotension
• Avoiding the use of other medications that affect potassium levels, such as potassium supplements, potassium-sparing diuretics, or NSAIDs, or using them with caution and close monitoring

It is also important to note that the study by 1 provides guidance on the use of ACE inhibitors in patients with heart failure, and recommends starting with a low dose, considering dose up-titration after 4-8 weeks, and monitoring blood chemistry closely. However, the study by 1 is more recent and provides more specific guidance on the use of RAAS antagonists in patients with CKD.

From the Research

Lisinopril Initiation with GFR 20ml/min

• The decision to start lisinopril when the glomerular filtration rate (GFR) is 20ml/min should be based on careful consideration of the patient's overall clinical condition and the potential risks and benefits of the medication.
• According to the study by 2, lisinopril was given to patients with hypertension associated with impaired renal function, including those with a GFR of less than 30 ml/min, with a starting dose of 2.5 mg.
• The study by 3 also suggests that the dose of lisinopril should be adjusted to the pretreatment GFR, and a decrease in dosage should be considered with prolonged treatment.
• However, the study by 4 notes that angiotensin-converting enzyme inhibitors, such as lisinopril, can pose a small risk for hyperkalemia in patients with reduced GFR, and this risk is incremental with declining GFR.
• The study by 5 emphasizes the importance of measuring GFR in certain clinical situations, including when estimated GFR is known to provide imprecise estimates of glomerular function.
• The study by 6 found that angiotensin receptor blockers, which are similar to lisinopril, had a favorable impact on blood pressure and renal parameters, but did not observe significant changes in eGFR during the short follow-up period.

Key Considerations

• The patient's GFR is an important factor in determining the starting dose and potential risks of lisinopril.
• Close monitoring of the patient's renal function, blood pressure, and serum potassium levels is necessary when initiating lisinopril, especially in patients with reduced GFR.
• The potential benefits of lisinopril in patients with hypertension and impaired renal function should be weighed against the potential risks, including hyperkalemia and changes in renal function.