Can Angiotensin-Converting Enzyme Inhibitors (ACEI) and Angiotensin Receptor Blockers (ARB) be used after revascularization of renal artery stenosis?

From the Guidelines

Yes, ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) can generally be used after revascularization of renal artery stenosis, as they confer a long-term mortality benefit and can be tolerated after successful revascularization, even in patients who experienced a rise in creatinine during initial treatment 1.

Key Considerations

• The use of ACEIs or ARBs in patients with renal artery stenosis was previously limited due to concerns about reducing efferent arteriolar tone and compromising glomerular filtration pressure in a kidney with reduced perfusion.
• However, after revascularization, the benefits of renin-angiotensin system blockade on blood pressure control and renal protection often outweigh the risks, as noted in the 2018 scientific statement from the American Heart Association 1.
• Patients who experience a rise in creatinine during ACE inhibitor or ARB treatment usually tolerate restarting the medication after successful revascularization, suggesting that the initial adverse effect is often transient and related to changes in renal autoregulation and intravascular volume.

Clinical Approach

• When initiating ACEIs or ARBs after revascularization, it is recommended to start with low doses and titrate upward as needed based on blood pressure response and kidney function.
• Close monitoring of serum creatinine and potassium levels is essential, particularly within the first 1-2 weeks after starting these medications.
• The choice between ACEIs and ARBs should be based on individual patient factors, including comorbidities, potential side effects, and specific renal protective benefits.
• Overall, the use of ACEIs and ARBs after revascularization of renal artery stenosis can be a valuable component of a comprehensive treatment plan aimed at controlling hypertension and protecting renal function, as supported by recent guidelines and evidence 1.

From the FDA Drug Label

7.4 Dual Blockade of the Renin-Angiotensin System (RAS) Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, syncope, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy In most patients no benefit has been associated with using two RAS inhibitors concomitantly. In general, avoid combined use of RAS inhibitors.

The use of ACEI and ARB after revascularization of renal artery stenosis is not directly addressed in the provided drug labels. However, the labels do warn against the dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren due to increased risks of hypotension, hyperkalemia, and changes in renal function.

• The labels recommend avoiding combined use of RAS inhibitors in most patients, as no benefit has been associated with using two RAS inhibitors concomitantly [2] [3]. It is recommended to closely monitor blood pressure, renal function, and electrolytes in patients on losartan and other agents that affect the RAS or lisinopril and other agents that affect the RAS. No conclusion can be drawn regarding the use of ACEI and ARB after revascularization of renal artery stenosis.

From the Research

Use of ACEI and ARB after Revascularization of Renal Artery Stenosis

• The use of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in patients with renal artery stenosis is generally contraindicated due to the risk of azotemia 4.
• However, a study published in 2006 found that patients with bilateral renal artery stenosis who underwent successful revascularization using renal artery stenting could be safely treated with long-term ACEI therapy 4.
• In this study, 72% of patients were maintained on a target dose of ACEIs, while 2 patients were treated with ARBs due to cough, and 5 patients were treated with a hydralazine/nitrate combination due to cough or baseline renal insufficiency 4.
• There is no direct evidence in the provided studies regarding the use of ACEIs and ARBs after revascularization of renal artery stenosis in terms of their efficacy or safety compared to medical therapy alone 5, 6, 7, 8.
• The decision to use ACEIs and ARBs after revascularization of renal artery stenosis should be made on a case-by-case basis, taking into account the individual patient's clinical characteristics and medical history 4.