Can I continue lisinopril 40 mg daily with an estimated glomerular filtration rate of 25 mL/min/1.73 m²?

Can You Continue Lisinopril 40 mg Once Daily with eGFR 25?

Yes, you can continue lisinopril 40 mg daily with an eGFR of 25 mL/min/1.73 m², but you must reduce the initial dose to half (20 mg) and carefully uptitrate while monitoring renal function and potassium closely. 1

FDA-Approved Dosing for Renal Impairment

The FDA label for lisinopril provides explicit guidance for patients with reduced kidney function 1:

• eGFR > 30 mL/min: No dose adjustment required 1
• eGFR 10-30 mL/min (which includes your patient at eGFR 25): Reduce the initial dose to half of the usual recommended dose 1
  • For hypertension: Start at 5 mg (instead of 10 mg) 1
  • For heart failure: Start at 2.5 mg (instead of 5 mg) 1
  • Maximum dose after uptitration: 40 mg daily 1

This means if your patient is already on 40 mg and tolerating it well, continuation is appropriate, but if restarting or initiating therapy, you must begin at the reduced dose. 1

Guideline Support for Continuation in Advanced CKD

The KDOQI guidelines explicitly state that RAAS antagonists (including ACE inhibitors like lisinopril) should NOT be routinely discontinued when eGFR falls below 30 mL/min/1.73 m² because they remain nephroprotective 2. This is a critical point that contradicts older, overly cautious practices.

Key recommendations from KDOQI 2:

• Start at a lower dose when eGFR < 45 mL/min/1.73 m² 2
• Assess eGFR and potassium within 1 week of starting or dose escalation 2
• Temporarily suspend during acute illness, IV contrast administration, bowel prep, or major surgery 2
• Do not routinely discontinue at eGFR < 30 mL/min/1.73 m² 2

Critical Monitoring Requirements

When continuing lisinopril at eGFR 25, you must implement rigorous monitoring 2:

1. Check potassium and eGFR within 1 week of any dose change 2
2. Hold therapy if:
   • Potassium rises above 5.5 mEq/L 2
   • eGFR drops by more than 30% from baseline 2
   • Signs of acute kidney injury develop 2
3. Avoid concomitant nephrotoxins: NSAIDs, aminoglycosides 2
4. Discontinue potassium supplements or reduce them significantly 2

Evidence from Clinical Trials

Multiple studies demonstrate that lisinopril is both effective and safe in patients with significantly reduced renal function:

• A 12-week trial in 26 hypertensive patients with eGFR ≤ 60 mL/min (mean GFR 36 mL/min) showed excellent blood pressure control with lisinopril (median dose 10 mg daily), and mean GFR remained stable throughout the study 3
• A similar study in 24 patients with impaired renal function (GFR ≤ 60 mL/min, mean 37 mL/min) demonstrated effective BP reduction with no overall change in GFR after 12 weeks 4
• Long-term follow-up (1 year) in 16 patients showed sustained blood pressure control and stable GFR 3
• A systematic review confirmed that lisinopril causes only a slight reduction in GFR, especially in patients with baseline GFR < 90 mL/min, but this is not clinically significant and does not outweigh the nephroprotective benefits 5

Common Pitfalls to Avoid

1. Do not automatically discontinue ACE inhibitors when eGFR drops below 30 – this is outdated practice and removes nephroprotection 2
2. Do not ignore hyperkalemia risk – one-third of patients with impaired renal function develop hyperkalemia on ACE inhibitors 6
3. Do not continue potassium supplements without careful monitoring 2
4. Do not forget to hold during acute illness – dehydration, sepsis, or contrast exposure requires temporary suspension 2
5. Do not use aldosterone antagonists concurrently unless eGFR > 30 mL/min/1.73 m² and potassium < 5.0 mEq/L 2

Practical Algorithm for Your Patient

If the patient is already on lisinopril 40 mg and stable:

• Continue current dose 1
• Check potassium and eGFR within 1 week 2
• Monitor monthly for 3 months, then every 3 months 2
• Hold during acute illness 2

If restarting or initiating lisinopril:

• Start at 5 mg daily (for hypertension) or 2.5 mg daily (for heart failure) 1
• Check potassium and eGFR in 1 week 2
• Uptitrate by 5 mg increments every 2-4 weeks as tolerated 1
• Maximum target dose: 40 mg daily 1

Discontinue or hold if:

• Potassium > 5.5 mEq/L 2
• eGFR drops > 30% from baseline 2
• Acute illness, dehydration, or planned procedures 2