From the Guidelines
Lisinopril can be initiated in patients with chronic kidney disease (CKD) with a glomerular filtration rate (GFR) of 45 ml/min/1.73 m2 or higher, and should be started at a lower dose in those with GFR less than 45 ml/min/1.73 m2. When initiating lisinopril in CKD patients, it's essential to monitor serum creatinine, potassium levels, and blood pressure closely, particularly within 1 week of starting therapy or after dose adjustments, as recommended by the 2014 KDOQI guidelines 1. The guidelines also suggest assessing GFR and measuring serum potassium within 1 week of starting or following any dose escalation, and temporarily suspending the medication during intercurrent illness, planned IV radiocontrast administration, bowel preparation prior to colonoscopy, or prior to major surgery.
Key Considerations
- Lisinopril is beneficial in CKD as it reduces intraglomerular pressure, decreases proteinuria, and slows CKD progression, especially in patients with diabetes or proteinuria.
- However, caution is needed as ACE inhibitors like lisinopril can cause hyperkalemia and acute kidney injury, particularly in patients with bilateral renal artery stenosis or volume depletion.
- The 2024 ESC guidelines for the management of elevated blood pressure and hypertension recommend targeting systolic BP to 120–129 mmHg in adults with moderate-to-severe CKD who are receiving BP-lowering drugs and who have eGFR >30 mL/min/1.73 m², if tolerated 1.
- In patients with CKD, it is crucial to individualize BP targets and consider the use of SGLT2 inhibitors to improve outcomes, as recommended by the 2024 ESC guidelines 1.
Monitoring and Dose Adjustment
- Monitor serum creatinine, potassium levels, and blood pressure closely, particularly within 1 week of starting therapy or after dose adjustments.
- Temporary increases in serum creatinine up to 30% may occur and are generally acceptable, but larger increases warrant dose reduction or discontinuation.
- Adjust the dose of lisinopril based on kidney function, with lower doses recommended for patients with severe CKD (stages 4-5).
From the FDA Drug Label
In patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, reduce the initial dose of lisinopril tablets to half of the usual recommended dose No dose adjustment of lisinopril tablets is required in patients with creatinine clearance > 30 mL/min. For patients on hemodialysis or creatinine clearance < 10 mL/min, the recommended initial dose is 2.5 mg once daily Lisinopril can be initiated in patients with CKD at the following levels:
- No dose adjustment is needed for patients with creatinine clearance > 30 mL/min.
- For patients with creatinine clearance ≥ 10 mL/min and ≤ 30 mL/min, the initial dose should be reduced to half of the usual recommended dose.
- For patients on hemodialysis or creatinine clearance < 10 mL/min, the recommended initial dose is 2.5 mg once daily 2
From the Research
Initiation of Lisinopril in CKD
- Lisinopril can be initiated in patients with chronic kidney disease (CKD) as it has been shown to be effective in reducing blood pressure and slowing disease progression 3, 4.
- The starting dose of lisinopril may vary depending on the patient's glomerular filtration rate (GFR), with a starting dose of 2.5 mg recommended for patients with GFR < 30 ml/min and 5 mg for all other patients 3.
- Studies have demonstrated that lisinopril is well-tolerated in patients with CKD, with no significant changes in GFR or other renal function parameters 3, 4.
CKD Severity and Lisinopril Initiation
- Lisinopril can be initiated in patients with mild to moderate CKD, with an estimated GFR (eGFR) of 30-60 ml/min/1.73 m^2 5, 6.
- The risk of hyperkalemia, a potential side effect of lisinopril, increases with declining eGFR, but there is no apparent threshold for contraindicating ACE-inhibitors like lisinopril 5.
- Patients with more severe CKD (eGFR < 30 ml/min) may require closer monitoring of renal function and electrolyte levels when initiating lisinopril 5.
Predicting Outcomes with Lisinopril in CKD
- A risk score has been developed to predict the risk of hyperkalemia in patients with CKD starting lisinopril, which includes factors such as age, eGFR, diabetes, and potassium supplements 5.
- Studies have shown that lisinopril use is associated with lower all-cause mortality in patients with CKD and heart failure, particularly in those with mild to moderate CKD 6.
- The effectiveness of lisinopril in slowing disease progression and reducing cardiovascular events in patients with CKD is supported by several studies 3, 4.