From the Guidelines
Lisinopril is recommended for patients with chronic kidney disease (CKD) as it provides renoprotective benefits beyond blood pressure control. The typical starting dose is 5-10 mg once daily, which can be titrated up to 40 mg daily based on blood pressure response and kidney function 1. For patients with CKD, especially those with proteinuria, ACE inhibitors like lisinopril can slow disease progression by reducing intraglomerular pressure and proteinuria.
When starting lisinopril, monitor kidney function and potassium levels within 1-2 weeks, as some patients may experience an initial decrease in GFR or develop hyperkalemia 1. Patients should be advised to maintain adequate hydration but avoid NSAIDs which can worsen kidney function when combined with lisinopril. Common side effects include dry cough, dizziness, and rarely angioedema. Lisinopril is contraindicated during pregnancy and should be used cautiously in patients with bilateral renal artery stenosis.
Some key points to consider when using lisinopril in CKD patients include:
- The strength of evidence for benefit varies according to the presence or absence of diabetes and of proteinuria 1
- Many patients with CKD will require combination therapy to achieve the SBP target of less than 120 mm Hg; no RCTs have compared different combination therapies in CKD 1
- The recommendation of target SBP <120 mm Hg is based not on renoprotective effects but on cardioprotective and survival benefits 1
- A recent network meta-analysis by Xie et al. examined the benefits of treating with RASi compared to other active therapies or placebo for kidney and cardiovascular outcomes, and found that both ACEi and ARB reduced the risk of kidney failure and major cardiovascular events 1
For maximum renoprotection, the dose should be optimized to achieve both blood pressure targets and maximum tolerable reduction in proteinuria. It is essential to weigh the benefits and risks of intensive blood pressure lowering in individual patients, considering factors such as the presence of diabetes, proteinuria, and cardiovascular risk factors.
From the Research
Lisinopril for Chronic Kidney Disease (CKD)
- Lisinopril, an angiotensin-converting enzyme inhibitor (ACEI), has been shown to slow the progression of CKD and reduce proteinuria in patients with CKD 2, 3.
- A study published in 2019 found that treatment with ACEI or angiotensin receptor blockers (ARBs) had a superior effect on slowing kidney disease progression and reducing proteinuria compared to no ACEI or ARB treatment 2.
- Another study published in 2001 found that lisinopril was more effective than other antihypertensive agents in slowing the progression of non-diabetic chronic renal diseases in patients with baseline proteinuria ≤1.0 g/day 3.
- The use of lisinopril in patients with CKD has also been associated with a reduced risk of hyperkalemia, a potentially fatal adverse effect, although the risk increases with declining estimated glomerular filtration rate (eGFR) 4.
Comparison with Other Treatments
- A study published in 2010 compared the effects of lisinopril and losartan, an angiotensin II receptor antagonist, in patients with idiopathic membranous nephropathy and nephrotic syndrome, and found that both treatments had similar effects on renal function, hypoalbuminemia, proteinuria, and blood pressure 5.
- Another study published in 2019 found that discontinuation of ACEIs and ARBs was common in patients with CKD, particularly in those with lower eGFR, and was associated with hyperkalemia, hypotension, low bicarbonate level, and hospitalization 6.
Key Findings
- Lisinopril is effective in slowing the progression of CKD and reducing proteinuria in patients with CKD.
- The use of lisinopril is associated with a reduced risk of hyperkalemia, although the risk increases with declining eGFR.
- Lisinopril has similar effects to losartan on renal function, hypoalbuminemia, proteinuria, and blood pressure in patients with idiopathic membranous nephropathy and nephrotic syndrome.
- Discontinuation of ACEIs and ARBs is common in patients with CKD, particularly in those with lower eGFR, and is associated with hyperkalemia, hypotension, low bicarbonate level, and hospitalization.