ACE inhibitors and raised creatinine in chronic kidney disease (CKD)

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BHS guidelines advise that ACEIs and ARBs be used with caution and under specialist advice in the presence of "renal impairment"
NICE advises that ACEI (or ARBs) should be initiated under specialist supervision in patients with plasma creatinine concentration above 150 µmol/L
there is a risk that these drugs will precipitate acute renal failure as a result of unrecognised bilateral critical renal vascular disease, by interrupting the intrarenal production of angiotensin II that normally maintains GFR in the presence of reduced renal perfusion
even in the absence of atherosclerotic renal artery stenosis, antihypertensive drugs can cause reduction in GFR, by reducing renal perfusion; this is particularly likely in the presence of kidney disease, affecting autoregulation of renal blood flow
at what level of deterioration in GFR or creatinine concentration rise should specialist advice be sought:
- it has been recommended that discussion with a specialist if a patient's serum creatinine concentration rises by 30% or whose estimated GFR falls by 20% as an apparent consequence of ACEI/ARB use (1)
- 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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Last edited 10/2018

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ACE inhibitors and raised creatinine in chronic kidney disease (CKD)