What antihypertensive medication should be held in a patient with impaired renal function, creatinine (Cr) level of 1.92 and estimated Glomerular Filtration Rate (eGFR) of 28?

Aldosterone Receptor Antagonists Should Be Held

With a creatinine of 1.92 mg/dL and eGFR of 28 mL/min/1.73 m², aldosterone receptor antagonists (spironolactone or eplerenone) should be discontinued immediately, as this represents a Class III (Harm) indication according to ACC/AHA guidelines. 1

Primary Medication to Hold: Aldosterone Antagonists

The 2013 ACC/AHA Heart Failure Guidelines explicitly state that aldosterone receptor antagonists are potentially harmful and contraindicated when serum creatinine exceeds 2.0 mg/dL in women or 2.5 mg/dL in men, OR when eGFR is <30 mL/min/1.73 m². 1 Your patient's eGFR of 28 falls below this threshold, creating significant risk for:

• Life-threatening hyperkalemia 1
• Progressive renal insufficiency 1

The guidelines emphasize that impaired renal function is a major risk factor for hyperkalemia during aldosterone antagonist therapy, with risk increasing progressively when serum creatinine exceeds 1.6 mg/dL. 1

Critical Decision Point: ACE Inhibitors and ARBs

ACE inhibitors and ARBs should generally be CONTINUED, not held, in this clinical scenario - but with important caveats:

When to Continue ACE Inhibitors/ARBs:

• Modest creatinine increases up to 30% above baseline or up to 266 μmol/L (3 mg/dL) are acceptable and do not require discontinuation. 2
• These medications provide renoprotection even in advanced CKD and should be preferentially used when antihypertensive therapy is needed. 1
• The American Society of Nephrology confirms that hemodynamic changes causing modest creatinine elevation are acceptable unless the rise exceeds 30%. 2

When to Temporarily Hold ACE Inhibitors/ARBs:

Consider temporary discontinuation if:

• Volume depletion is present (diuretic-induced) - the most common avoidable reason for creatinine elevation with RAS-modulating drugs 2
• Acute kidney injury is suspected rather than chronic progression 2
• Serum potassium exceeds 5.5 mEq/L 1
• Creatinine rises >30% from baseline 2

Assessment of Volume Status is Critical

Before making final decisions about ACE inhibitors/ARBs:

• Evaluate for volume depletion - simple rehydration may correct pre-renal causes 2
• A BUN/creatinine ratio >20:1 strongly suggests pre-renal azotemia from dehydration or diuretic overuse 2
• Diuretic-induced volume depletion is the most common reversible cause of worsening renal function in patients on RAS inhibitors 2

Avoid Triple Therapy

Never combine ACE inhibitor + ARB + aldosterone antagonist - this triple combination should be avoided as it significantly increases hyperkalemia risk. 1

NSAIDs Must Be Discontinued

All NSAIDs should be stopped immediately when elevated creatinine is detected, as they worsen renal function through prostaglandin inhibition. 2

Monitoring Requirements After Medication Adjustment

If continuing ACE inhibitors/ARBs after holding aldosterone antagonists:

• Recheck potassium and renal function within 2-3 days 1
• Repeat at 7 days 1
• Continue monthly monitoring for 3 months, then every 3 months 1

Common Pitfall to Avoid

The most critical error is discontinuing ACE inhibitors/ARBs prematurely when they should be continued for renoprotection, while failing to stop aldosterone antagonists which are contraindicated at this level of renal function. The guidelines are explicit that aldosterone antagonists pose harm below eGFR 30, whereas ACE inhibitors/ARBs remain beneficial unless specific contraindications develop. 1, 2