when implementing blockade of the renin-angiotensin system start treatment with an ACE inhibitor first then move to an ARB if the ACE inhibitor is not tolerated
offer a low-cost renin-angiotensin system antagonist (ACE inhibitor or ARB) to people with CKD and:
diabetes and an ACR of 3 mg/mmol or more (ACR category A2 or A3)
hypertension and an ACR of 30 mg/mmol or more (ACR category A3)
an ACR of 70 mg/mmol or more (irrespective of hypertension or cardiovascular disease)
do not offer a combination of renin-angiotensin system antagonists to people with CKD
measure serum potassium concentrations and estimate the GFR before starting renin-angiotensin system antagonists. Repeat these measurements between 1 and 2 weeks after starting renin-angiotensin system antagonists and after each dose increase
do not routinely offer a renin-angiotensin system antagonist to people with CKD if their pretreatment serum potassium concentration is greater than 5.0 mmol/litre
when hyperkalaemia precludes use of renin-angiotensin system antagonists, 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 renin-angiotensin system antagonists, but be aware that more frequent monitoring of serum potassium concentration may be required
stop renin-angiotensin system antagonists if the serum potassium concentration increases to 6.0 mmol/litre or more and other drugs known to promote hyperkalaemia have been discontinued
following the introduction or dose increase of renin-angiotensin system antagonists, do not modify the dose if either the GFR decrease from pretreatment baseline is less than 25% or the serum creatinine increase from baseline is less than 30%
if there is a decrease in eGFR or increase in serum creatinine after starting or increasing the dose of renin-angiotensin system antagonists, but it is less than 25% (eGFR) or 30% (serum creatinine) of baseline, repeat the test in 1-2 weeks. Do not modify the renin-angiotensin system antagonist dose if the change in eGFR is less than 25% or the change in serum creatinine is less than 30%
if the eGFR change is 25% or more, or the change in serum 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 renin-angiotensin system antagonist or reduce the dose to a previously tolerated lower dose, and add an alternative antihypertensive medication if required
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