Using lisinopril and losartan for High Blood pressure in Patients with CKD

Patients with chronic kidney disease (CKD) commonly have hypertension. A common therapy to help lower the blood pressure and prevent or decrease the progression of CKD over time is to use a class of blood pressure medications called ACEs and ARBs (pronounced “Ace-is” and “A” “R” “Bees”).

The name of the most commonly used ACE inhibitor is lisinopril. The name of the most commonly used ARB is losartan. They have been around for a long time and are generic.

We use these medications throughout the stages of chronic kidney disease. If a patient has albumin or protein in the urine and stage 1 or 2, we might also offer you this therapy. Your kidney doctor may ask for a urine sample the day of the appointment or a few weeks after to see if you qualify for lisinopril or losartan.

These therapies have a mechanism of action: they block the renin-angiotensin-aldosterone system, which can raise the potassium level in the blood. So, we commonly ask you to repeat blood work a few weeks after starting the lisinopril or losartan.

If the creatinine increases too much, or the GFR worsens, or the potassium goes too high, we still have options:

• We can lower the dose of the ACE or the ARB (the lisinopril or the losartan).
• We can adjust the current blood pressure therapy, stopping the lisinopril or losartan and choosing an alternative. There are many ways to do this. We have multiple effective blood pressure medications with different mechanisms of action that can lower the blood pressure while we wait for the effects of the lisinopril or the losartan to wear off.
• If the plan is to continue the lisinopril or losartan, given the importance of the therapy, such as the treatment of heart failure, but the potassium is elevated, we can add a diuretic (that is a water pill) such as Lasix (which is also known as furosemide). Furosemide causes potassium to spill into the urine. But caution is required here: furosemide lowers blood pressure further. So we must be careful.
• Other options to consider if we want to continue the ACE or ARB: we can add a potassium binder if the benefit of the therapy makes it worth it.
• Sometimes we stop the lisinopril or losartan and rechallenge at a lower dose in the future after altering other medications. Do not be surprised if that occurs.

Patients with CKD can have acute kidney injury or AKI, or sudden worsening of kidney function for a variety of reasons. Here, we hold the “nephrotoxins” or medications that are helpful in chronic kidney disease but can harmful when the kidneys suddenly get worse. When the patient has stabilized, we consider restarting some or all of the medications that were on hold.