From the Guidelines
The most appropriate management for this patient is to discontinue lisinopril and add furosemide (option C). This 54-year-old woman with chronic kidney disease has developed significant adverse effects after starting lisinopril, an ACE inhibitor. Her creatinine has increased from 1.2 to 1.7 mg/dL, and her estimated GFR has decreased from 50 to 33 mL/min/1.73 m2, indicating worsening kidney function. Additionally, her potassium level has risen to 5.7 mEq/L, which is concerning for hyperkalemia. These changes, occurring within just two weeks of starting lisinopril, strongly suggest that the ACE inhibitor is causing acute kidney injury and hyperkalemia.
Key Considerations
- The patient's increase in creatinine and potassium levels exceeds the acceptable limits outlined in the guidelines 1.
- The European Society of Cardiology expert consensus document highlights the importance of managing hyperkalemia and worsening renal function in patients treated with renin-angiotensin-aldosterone system inhibitors 1.
- Discontinuing lisinopril is necessary to prevent further decline in kidney function and to manage the patient's hyperkalemia.
- Adding furosemide, a loop diuretic, will help manage the patient's edema and can help lower potassium levels by increasing urinary potassium excretion.
Management Options
- Continuing lisinopril would be dangerous given the significant adverse effects, and switching to losartan (an angiotensin receptor blocker) would likely cause similar problems as it affects the same renin-angiotensin-aldosterone system.
- The guidelines suggest that an increase in creatinine of up to 50% above baseline or an increase in potassium to ≤5.5 mmol/L is acceptable, but this patient's values exceed these limits 1.
- Specialist advice should be sought if the patient's condition does not improve after discontinuing lisinopril and adding furosemide.
Prioritizing Patient Outcomes
- The primary goal is to prioritize the patient's morbidity, mortality, and quality of life, and discontinuing lisinopril and adding furosemide is the most appropriate management strategy to achieve this goal.
- The patient's proteinuria, as evidenced by her elevated albumin-creatinine ratio, is a significant concern, but the current adverse effects take precedence and require immediate attention.
From the FDA Drug Label
Monitor renal function periodically in patients treated with lisinopril. Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, post-myocardial infarction or volume depletion) may be at particular risk of developing acute renal failure on lisinopril. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril [see Adverse Reactions (6. 1), Drug Interactions (7.4)]. Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on lisinopril
The patient has chronic kidney disease and has developed a clinically significant decrease in renal function (increase in creatinine from 1.2 mg/dL to 1.7 mg/dL and decrease in estimated glomerular filtration rate from 50 mL/min/1.73 m2 to 33 mL/min/1.73 m2) after starting lisinopril. The most appropriate management is to discontinue lisinopril. Adding furosemide may be considered to manage hyperkalemia and edema. Therefore, the correct answer is: C Discontinue lisinopril; add furosemide 2 2
From the Research
Patient Management
The patient is a 54-year-old woman with hypertension and chronic kidney disease, currently being treated with lisinopril and amlodipine. Her blood pressure has improved, but her creatinine and potassium levels have increased, and her estimated glomerular filtration rate (eGFR) has decreased.
Laboratory Results
- Creatinine: 1.7 mg/dL (increased from 1.2 mg/dL 2 weeks ago)
- Potassium: 5.7 mEq/L (increased from 4.4 mEq/L 2 weeks ago)
- eGFR: 33 mL/min/1.73 m2 (decreased from 50 mL/min/1.73 m2 2 weeks ago)
Management Options
- Continue lisinopril and add furosemide
- Continue lisinopril and recheck laboratory studies in 2 weeks
- Discontinue lisinopril and add furosemide
- Discontinue lisinopril and add losartan
Evidence-Based Decision
Based on the studies, lisinopril is generally well-tolerated and effective in patients with hypertension and chronic kidney disease 3, 4, 5. However, the patient's increased creatinine and potassium levels, and decreased eGFR, suggest that lisinopril may be contributing to her renal impairment. The study by 6 suggests that up-titration of ACE inhibitors/ARBs is not associated with adverse changes in renal function, but the patient's current renal function is already impaired. The study by 7 found that hyperkalemia and decreased eGFR are risk factors for ACE-I/ARB discontinuation.
Recommended Course of Action
Given the patient's laboratory results and the potential risks associated with continued lisinopril use, the most appropriate management option would be to continue lisinopril and recheck laboratory studies in 2 weeks, while also considering alternative treatments, such as adding furosemide or switching to a different antihypertensive medication, if necessary. This approach is supported by the studies, which suggest that ACE inhibitors can be effective in patients with chronic kidney disease, but require careful monitoring of renal function and electrolyte levels 3, 4, 5, 6, 7.
- The best answer is B.