Lisinopril Use in End-Stage Renal Disease
Lisinopril is not contraindicated in ESRD and can be safely used in dialysis patients, but requires specific dosing adjustments and critical monitoring for hyperkalemia and hypotension. 1
Key Safety Considerations
ACE inhibitors including lisinopril are frequently used in dialysis patients and may provide cardiovascular mortality benefits. 1, 2 However, several critical precautions must be observed:
Absolute Contraindication
- Never administer lisinopril to patients dialyzed with polyacrylonitrile (AN69) membranes due to risk of life-threatening anaphylactoid reactions. 1, 2 Switch to a different membrane type or alternative antihypertensive class. 1
Dosing Strategy in ESRD
Lisinopril has predominant renal excretion with prolonged half-life in ESRD, making it ideal for supervised thrice-weekly administration immediately after dialysis sessions. 3 This approach enhances blood pressure control and simplifies adherence. 3
- Start with 2.5 mg orally every 24 hours initially. 4
- Lisinopril is significantly dialyzed (mean post-/pre-dialysis ratio 0.47), requiring dose timing consideration. 5, 4 Administer after dialysis to maintain stable therapeutic levels. 1, 2
- Many patients require dose reduction to alternate-day or once-weekly schedules due to intradialytic hypotension. 4 In one study, 6 of 10 patients needed such adjustments. 4
Critical Monitoring Requirements
Check serum potassium and creatinine within 1-2 weeks of initiation and regularly thereafter. 1, 6
- Hyperkalemia is relatively common in ESRD patients on ACE inhibitors, though typically modest (≈1 mEq/L increase). 1 Risk factors include diabetes and concurrent potassium-sparing agents. 7
- Avoid potassium supplements, potassium-containing salt substitutes, and potassium-sparing diuretics. 1, 6, 7
- Monitor for intradialytic hypotension, particularly during the first 2 weeks and after dose increases. 7, 4
Cardiovascular Benefits in ESRD
ACE inhibitors may reduce mortality in hemodialysis patients independent of blood pressure lowering effects. 8 One study demonstrated 52% mortality risk reduction overall (RR 0.482, p<0.0019), with 79% risk reduction in patients ≤65 years (RR 0.211, p<0.0006). 8
Additional benefits include:
- Reduction in left ventricular hypertrophy 3
- Decreased aortic pulse wave velocity and systolic pressure augmentation 3
- Possible reduction in C-reactive protein and oxidative stress 3
Common Pitfalls to Avoid
Do not discontinue ACE inhibitors solely because GFR is <30 mL/min/1.73 m² or patient is on dialysis—they remain nephroprotective and cardioprotective. 1, 6
Do not combine lisinopril with ARBs in ESRD patients. 6, 2 Combination therapy increases adverse events (particularly hyperkalemia) without additional benefit in this population. 6, 2
Do not select ACE inhibitors that are not dialyzed if stable therapy is desired. 1, 2 Since lisinopril is significantly dialyzed, timing administration post-dialysis is essential. 5, 4
Perioperative Management
Consider withholding lisinopril 24-48 hours before major surgery to reduce risk of profound intraoperative hypotension, though evidence is conflicting. 1, 6 Hypotension during surgery is an independent risk factor for postoperative acute renal failure. 1, 6
Alternative Considerations
If lisinopril causes intolerable hypotension or requires overly complex dosing, consider ARBs as alternatives. 5 ARBs are not dialyzable, have more predictable pharmacokinetics in ESRD, and lack the anaphylactoid dialyzer reaction risk. 5 However, they share the hyperkalemia risk. 5
Beta-blockers (particularly atenolol, also with renal excretion) can be administered thrice-weekly post-dialysis and provide mortality benefits in ESRD. 3