Practicalities of treating with ACE inhibitors (or ARBs) in chronic kidney disease (CKD)

Practicalities of treatment with ACE inhibitors/ARBs

NICE suggest that (1,2):

• in people with CKD
  • measure serum potassium concentrations, estimate the GFR before starting ACE inhibitor/ARB therapy
  • repeat these measurements between 1 and 2 weeks after starting ACE inhibitor/ARB therapy and after each dose increase
• ACE inhibitor/ARB therapy should not normally be started if the pretreatment serum potassium concentration is significantly above the normal reference range (typically more than 5.0 mmol/litre)
• when hyperkalaemia precludes the use of ACE inhibitors/ARBs, assessment, investigation and treatment of other factors known to promote hyperkalaemia should be undertaken and the serum potassium concentration rechecked
• concurrent prescription of drugs known to promote hyperkalaemia is not a contraindication to the use of ACE inhibitors/ARBs
  • however clinicians must be aware that more frequent monitoring of serum potassium concentration may be required
• stop ACE inhibitor/ARB therapy if the serum potassium concentration rises to 6.0 mmol/litre or more and other drugs known to promote hyperkalaemia have been discontinued
• following the introduction or dose increase of ACE inhibitor/ARB, do not modify the dose if either the GFR decrease from pretreatment baseline is less than 25% or the plasma creatinine increase from baseline is less than 30%
• if there is a fall in eGFR or rise in plasma creatinine after starting or increasing the dose of ACE inhibitor/ARB, but it is less than 25% (eGFR) or 30% (serum creatinine) of baseline, the test should be repeated in a further 1-2 weeks. Do not modify the ACE inhibitor/ARB dose if the change in eGFR is less than 25% or the change in plasma creatinine is less than 30%
• if the change in eGFR is 25% or more or the change in plasma creatinine is 30% or more:
  • investigate other causes of a deterioration in renal function such as volume depletion or concurrent medication (for example, NSAIDs)
  • if no other cause for the deterioration in renal function is found, stop the ACE inhibitor/ARB therapy or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if required
• where indicated, the use of ACE inhibitors/ARBs should not be influenced by a person's age as there is no evidence that their appropriate use in older people is associated with a greater risk of adverse effects

Reference:

• (1) NICE (September 2008). Chronic Kidney Disease - Early identification and management of chronic kidney disease in adults in primary and secondary care
• (2) NICE (July 2014). Chronic Kidney Disease - Early identification and management of chronic kidney disease in adults in primary and secondary care