What alternative medications can be given to a patient with Acute Kidney Injury (AKI) or Chronic Kidney Disease (CKD) who cannot take lisinopril (Angiotensin-Converting Enzyme Inhibitor)?

Alternative Medications for AKI/CKD Patients Unable to Take Lisinopril

For patients with AKI or CKD who cannot take lisinopril, use calcium channel blockers (particularly dihydropyridines like amlodipine) as first-line alternatives, with thiazide-like diuretics or loop diuretics as additional options depending on kidney function severity. 1, 2

Primary Alternative: Calcium Channel Blockers

Dihydropyridine calcium channel blockers are the preferred alternative because they have minimal effects on renal hemodynamics and do not worsen kidney function like ACE inhibitors can in certain situations. 2, 3

Specific CCB Options:

• Amlodipine 2.5-10 mg once daily - Most commonly recommended, well-tolerated in CKD 1, 2
• Felodipine 2.5-10 mg once daily - Alternative dihydropyridine option 1
• Nifedipine LA 30-90 mg once daily - Long-acting formulation suitable for CKD 1

Important consideration: Dihydropyridines cause dose-related pedal edema, which is more common in women than men. 1

Secondary Alternatives Based on Kidney Function

For Mild-to-Moderate CKD (eGFR >30 mL/min):

Thiazide-like diuretics can be used:

• Chlorthalidone 12.5-25 mg once daily - Preferred over hydrochlorothiazide due to prolonged half-life and proven cardiovascular disease reduction 1
• Hydrochlorothiazide 25-50 mg once daily - Alternative option 1

Monitor for: Hyponatremia, hypokalemia, elevated uric acid and calcium levels. Use with caution in patients with history of acute gout unless on uric acid-lowering therapy. 1

For Moderate-to-Severe CKD (eGFR <30 mL/min) or AKI:

Loop diuretics are preferred over thiazides:

• Furosemide 20-80 mg twice daily 1, 2
• Torsemide 5-10 mg once daily 1
• Bumetanide 0.5-2 mg twice daily 1

Loop diuretics are particularly indicated in patients with volume overload and symptomatic heart failure. 1, 2

Additional Options for Specific Comorbidities

If Concomitant Ischemic Heart Disease or Heart Failure:

Beta-blockers can be added:

• Metoprolol succinate 50-200 mg once daily - Preferred in heart failure with reduced ejection fraction 1, 2
• Carvedilol 12.5-50 mg twice daily - Combined alpha/beta blocker, preferred in HFrEF 1
• Bisoprolol 2.5-10 mg once daily - Alternative for HFrEF 1

Caution: Avoid abrupt cessation of beta-blockers. Beta-blockers are not recommended as first-line agents for hypertension alone unless the patient has ischemic heart disease or heart failure. 1

Critical Considerations for ARB Use in AKI/CKD

If the patient was previously on an ARB (alternative to ACE inhibitor), it should be temporarily discontinued during active AKI. 2, 3

When ARBs Can Be Considered:

• After AKI resolution: Wait for GFR stabilization and volume optimization before reintroducing 2, 3
• In stable CKD: ARBs remain nephroprotective and should not be routinely discontinued even with eGFR <30 mL/min/1.73 m² 1, 2
• Acceptable creatinine rise: Up to 30% increase from baseline is expected hemodynamic effect, not actual kidney injury 3

ARB Options if Appropriate:

• Losartan 50-100 mg once daily 1, 4, 5
• Valsartan 80-320 mg once daily 1, 6
• Candesartan 8-32 mg once daily 1, 7

Critical contraindications for ARBs:

• Active AKI with volume depletion 2, 3
• Serum potassium >5.5 mEq/L 2
• Bilateral renal artery stenosis 1, 8
• Pregnancy 1, 6
• Combination with other RAS blockers (ACE inhibitors or direct renin inhibitors) 1, 2

Monitoring Requirements

For all alternatives in CKD/AKI patients:

• Check serum creatinine and potassium within 2-4 weeks after initiating therapy 9, 3
• Monitor eGFR annually at minimum for patients with eGFR <60 mL/min/1.73 m² 3
• More frequent monitoring after restarting any RAS blocker post-AKI (within 1 week) 2, 3

Common Pitfalls to Avoid

Do not combine multiple RAS blockers (ACE inhibitor + ARB + direct renin inhibitor) as this substantially increases risk of hyperkalemia, hypotension, and acute kidney injury without additional benefit. 1, 2, 9

Do not use thiazide diuretics as monotherapy in severe CKD (eGFR <30 mL/min) - they are minimally effective and loop diuretics are preferred. 1

Counsel patients to temporarily hold diuretics and any RAS blockers during intercurrent illness, dehydration, or "sick days" to prevent volume depletion-induced AKI. 1, 2

Avoid potassium supplements or potassium-sparing diuretics when using any RAS blocker due to increased hyperkalemia risk. 1, 2