Can a person with Chronic Kidney Disease (CKD) take an Angiotensin-Converting Enzyme (ACE) inhibitor like Lisinopril (Zestril)?

From the Guidelines

Yes, a person with Chronic Kidney Disease (CKD) can often take an ACE inhibitor like lisinopril, as recommended by the most recent guidelines 1.

Benefits of ACE Inhibitors in CKD

ACE inhibitors like lisinopril are beneficial in CKD because they reduce protein leakage in the urine and help slow kidney disease progression by decreasing pressure within the kidney's filtering units, as supported by studies 1. They also provide blood pressure control and heart protection.

Monitoring and Precautions

However, this medication requires close supervision by a healthcare provider with regular blood tests to monitor kidney function and potassium levels, as emphasized in the guidelines 1. When starting lisinopril, patients should expect blood tests within 1-2 weeks to check kidney function and electrolytes. Some patients may experience side effects like dry cough, dizziness, or elevated potassium levels. Certain situations require caution, including severe kidney impairment, pregnancy, or history of angioedema. Patients should stay well-hydrated but temporarily stop taking lisinopril during severe illness with vomiting, diarrhea, or high fever to prevent acute kidney problems, as advised in the guidelines 1.

Key Considerations

• Lisinopril is typically started at a low dose (2.5-5 mg daily) for CKD patients and gradually increased as needed and tolerated, with careful monitoring.
• The dose should be reduced or withdrawn in those who develop symptomatic hypotension, uncontrolled hyperkalemia, and acute kidney injury, as recommended in the guidelines 1.
• For patients who develop hyperkalemia during drug initiation or dose titration, various measures to control potassium levels should be considered, such as moderating potassium intake, diuretic initiation, and concomitant use of gastrointestinal cation exchangers, as suggested in the studies 1.

Conclusion is not allowed, so the answer will be ended here.

From the FDA Drug Label

1. 3 Impaired Renal Function Monitor renal function periodically in patients treated with lisinopril. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure on lisinopril. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril [see Adverse Reactions (6. 1), Drug Interactions (7.4)].

Lisinopril can be used in patients with CKD, but with caution.

• Patients with chronic kidney disease (CKD) may be at particular risk of developing acute renal failure on lisinopril.
• It is recommended to monitor renal function periodically in patients treated with lisinopril.
• Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril 2.

From the Research

ACE Inhibitors and CKD

• ACE inhibitors, such as Lisinopril, are commonly used to treat patients with chronic kidney disease (CKD) 3, 4, 5.
• The use of ACE inhibitors in CKD patients has been shown to have both beneficial and adverse effects, including reducing the risk of kidney events, cardiovascular events, and all-cause death, but also increasing the risk of hyperkalemia, cough, and hypotension 3, 5.
• The safety and efficacy of ACE inhibitors in patients with advanced CKD (stages 3-5) are still a topic of debate, with some studies suggesting that they may be beneficial in reducing the risk of kidney events and cardiovascular outcomes, while others have raised concerns about their potential to worsen renal function, particularly in older patients 4, 6.

Benefits and Risks of ACE Inhibitors in CKD

• Benefits:
  • Reduced risk of kidney events, cardiovascular events, and all-cause death 5.
  • Improved renoprotection, particularly when combined with moderate reduction in dietary sodium intake 3.
• Risks:
  • Increased risk of hyperkalemia, cough, and hypotension 5.
  • Potential to worsen renal function, particularly in older patients with ischemic hypertensive nephropathy 6.

Clinical Considerations

• Patients with CKD should be closely monitored for adverse effects when taking ACE inhibitors, including regular checks of renal function, potassium levels, and blood pressure 3, 5.
• The use of ACE inhibitors in patients with advanced CKD should be individualized, taking into account the patient's overall health status, comorbidities, and potential risks and benefits 4, 6.
• Alternative treatment options, such as angiotensin receptor blockers (ARBs) or other antihypertensive agents, may be considered in patients who are unable to tolerate ACE inhibitors or have contraindications to their use 5.