In a patient with acute kidney injury, which antihypertensive medications should be held?

Management of Blood Pressure Medications in Acute Kidney Injury

When a patient develops AKI, immediately hold diuretics, ACE inhibitors, and ARBs, while discontinuing NSAIDs entirely. 1

Medications to Hold During AKI

ACE Inhibitors and ARBs (Renin-Angiotensin System Blockers)

• Temporarily suspend all ACE inhibitors and ARBs when AKI is diagnosed 1
• These agents reduce glomerular filtration pressure by blocking compensatory renal hemodynamics, which can worsen kidney function during acute injury 2
• Hold these medications until GFR stabilizes and volume status is optimized 1, 2
• Despite concerns, do NOT permanently discontinue these agents—they remain nephroprotective and should be restarted after recovery 1, 3

Diuretics

• Hold all diuretics (both loop and thiazide) immediately when AKI is diagnosed 1
• Diuretics can exacerbate volume depletion and reduce renal perfusion during AKI 1
• Exception: Diuretics may be cautiously used if there is significant volume overload, but only after adequate volume repletion has been achieved 1

NSAIDs

• Discontinue NSAIDs completely—do not simply hold them 1
• NSAIDs are particularly dangerous when combined with diuretics and ACE inhibitors/ARBs (the "triple whammy"), with each additional nephrotoxin increasing AKI risk by 53% 4
• These agents should remain avoided throughout the AKI episode and recovery period 1

Non-Selective Beta-Blockers

• Hold non-selective beta-blockers in patients with cirrhosis and AKI 1
• Selective beta-blockers may be continued if needed for cardiac indications, though dose reduction by 50% is recommended when GFR <30 mL/min/1.73 m² 1

Medications That Can Generally Be Continued

Calcium Channel Blockers

• Dihydropyridine calcium channel blockers (amlodipine, nifedipine) have minimal effects on renal hemodynamics and can be safely continued 1, 2
• These are preferred alternatives for blood pressure control during AKI 2

Critical Management Steps

Immediate Actions

1. Discontinue all nephrotoxins identified as causally related to AKI 1, 4
2. Assess and correct volume status—administer albumin 1 g/kg/day for 2 days if creatinine doubles from baseline 1
3. Monitor urine output, vital signs, and consider echocardiography or CVP monitoring 1
4. Perform comprehensive medication reconciliation 4

When to Restart ACE Inhibitors/ARBs

The evidence on restarting these medications is nuanced and somewhat contradictory:

• Restart criteria: GFR has stabilized, volume status is optimized, mean arterial pressure >65 mmHg, and serum potassium <5.5 mEq/L 2
• Start at lower doses and assess GFR and potassium within 1 week of restarting 1, 2
• Recent high-quality evidence shows that continuing ACE inhibitors/ARBs after AKI recovery is associated with reduced mortality and cardiovascular events without increased recurrent AKI risk 3
• Conversely, permanent discontinuation after AKI may increase 30-day mortality, possibly from hypertensive rebound 1

Important Caveats

The "sick day rules" controversy: While guidelines recommend holding ACE inhibitors/ARBs during intercurrent illness 1, recent research suggests this practice may not be evidence-based and could potentially cause harm through treatment interruption 1, 5. However, during established AKI with rising creatinine, the consensus remains to temporarily hold these agents 1, 4.

Avoid combining multiple nephrotoxins: Each additional nephrotoxic medication increases AKI odds by 53%, and combining 3+ nephrotoxins more than doubles AKI risk 4

Monitor closely: Check serum creatinine, eGFR, and potassium within 1 week of any medication restart 1, 2

Patient education: Counsel patients to hold ACE inhibitors/ARBs and diuretics during future episodes of volume depletion (vomiting, diarrhea, excessive sweating, inadequate fluid intake) 1