I'm freaking confused. Some sources say ACE/ARB should not be used in renal disease, others say they SHOULD be used in renal disease to prevent further progression to ESRD.

who is right?

Let me give a few examples and I'll give my answers and you tell me if I'm right or wrong:

Case #1:

Joe has stage III CKD due to hypertension. He has 3+ urine protein. His creatinine is stable at 2.1. His BPs are in the 170s/110s. Can he be treated with ACE/ARBs?

Answer: YES, ACE and ARBs are proven to prevent further progression to stage 5 CKD. In addition both also slow progression of proteinuria.


Case #2:

John has stage III CKD due to hypertension. He has 3+ proteinuria. His creatinine on this clinic visit is elevated to 2.9 from his baseline of 2.1 after starting an ACE 2 weeks ago.

Answer: Yes, stop the ACE. ACE can cause dysautoregulation in some people with CKD. ACEs and ARBs should be stopped if they cause a rise in creatinine.


Case #3:

Jane has stage V CKD (ESRD) and is on dialysis. After completing dialysis her BPs are in the 180s/120s. Can she have ACE/ARB?

Answer: Not sure. On one hand her kidneys are already shot so you really dont give a damn if the ACE/ARB screws them up even further. On the other hand, do ACE/ARBs even work at all to reduce BPs in patients with severely damaged kidneys?


Case #4:

Jack has new onset HTN with BPs in the 160s/90s. Renal U/S shows right-sided renal artery stenosis. Use ACE/ARBs?

Answer: First thought is NO, you correct the RAS because

About the only reason you don't use an ARB or ACE in renal dz is for renal artery stenosis.

ACE-I have been shown to slow progression of Renal dz, especially in diabetic dz.


Case #1: - Yes, give ace, as above

Case #2: yes you stop the ACE. ACEs can cause an increase Cr after being started, a rough guideline on when to stop the ACE is if it causes 20% increase in Cr

Case #3: It depends on why you wan to the ACE. The Renin system has effects outside of the kidney, even if they aren't the main effects. For people with prior MIs and cardiomyopathys, absolutely, continue the ACE. for HTN? It is no longer one of my first choices,

Case #4: Nope, can cause ischemic renal failure in renal artery stenosis.

About the only reason you don't use an ARB or ACE in renal dz is for renal artery stenosis.

ACE-I have been shown to slow progression of Renal dz, especially in diabetic dz.

Case #1: - Yes, give ace, as above

Case #2: yes you stop the ACE. ACEs can cause an increase Cr after being started, a rough guideline on when to stop the ACE is if it causes 20% increase in Cr

Case #3: It depends on why you wan to the ACE. The Renin system has effects outside of the kidney, even if they aren't the main effects. For people with prior MIs and cardiomyopathys, absolutely, continue the ACE. for HTN? It is no longer one of my first choices,

Case #4: Nope, can cause ischemic renal failure in renal artery stenosis.


For Case #4, it is my understanding that ACE inhibition is only contraindicated in bilateral renal artery stenosis. However, it is the antihypertensive of choice for unilateral renal artery stenosis. Anyone heard differently?

For Case #4, it is my understanding that ACE inhibition is only contraindicated in bilateral renal artery stenosis. However, it is the antihypertensive of choice for unilateral renal artery stenosis. Anyone heard differently?

crap, I didn't see the unilateral. Yes you can use ACE-I in unilateral, but I do not know about it being the drug of choice, and a quick search on accessmedicine did not elucidate answers for that for me.