Chronic Kidney Disease
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Safety Guidance for the use of ACEIs and ARBs in patients with CKD

o Introduction of ACEI or ARB treatment in CKD patients is associated with a small risk of hyperkalaemia or a progressive rise in serum creatinine. Both can be avoided or detected early by taking simple precautions:

    o Prevention of hyperkalaemia

        § Check serum potassium prior to initiating treatment. If elevated or borderline high give dietary counselling re low potassium diet

        § Stop potassium-sparing diuretics (amiloride, spironolactone)

        § Check serum potassium 5-7 days after first dose of ACEI or ARB

                    · If K+=5.5-6.0mmol/l: further dietary counselling; recheck potassium in 5-7 days

                    · If K+6.0-6.5mmol/l: stop ACEI or ARB; recheck potassium in 5-7 days

· If K+>6.5mmol/l: refer to hospital

    o Prevention of progressive creatinine rise: A small initial rise in serum creatinine (<20% over 3 months) predicts better long-term preservation of renal function and should not be regarded as an indication for stopping ACEI or ARB treatment.

§ Ensure adequate hydration

§ If appropriate omit diuretic / reduce dose for 2 days prior to first dose of ACEI or ARB

§ Stop NSAIDS

§ In patients with estimated GFR <60ml/min/1.73m2, start at lowest available dose

§ Check serum creatinine 5-7 days after first dose

· Creatinine stable: consider dose increase after 4-6 weeks

· Creatinine increased by <20%: repeat creatinine in 1 week; allow increase in serum creatinine of up to 20% in first 3 months

· Creatinine increased by >20%: stop treatment; recheck creatinine in 5 days. Refer to Renal Medicine for investigation.