ACEI and ARBs in CKD: Should Anyone Not Receive Them?
In an evidence-based medicine approach, the bottom line is:
• ACEIs/ARBs extend the lives of patients with CKD;
• ACEIs/ARBs slow the progression of kidney disease (taking into account this early "rise" in creatinine);
• ACEIs/ARBs delay the progression to dialysis regardless of when they are begun; and
• The rise in creatinine associated with ACEIs/ARBs is not necessarily a bad thing. It needs to be interpreted. Large rises may indicate such clinical scenarios as right-heart failure. Smaller rises may indicate a kidney that is relieved to have its internal pressures lowered.
These data support the widespread use of ACEIs/ARBs in patients with CKD. I am reminded of the words of the program director when I was a resident, oh so many decades ago: "No decision is ever wrong, as long as you make it at the bedside." Translation: If you think it is indicated, try it, and follow up. If it doesn't work, as long as you are there to correct it, you have done the right thing.
ACEIs/ARBs may be more complicated to prescribe and monitor than calcium-channel blockers. But to a kidney in distress, they are worth the extra effort. Think of GFR as the gas gauge in your car. If the level goes down a little after initiation of an ACEI/ARB, the kidneys perceive the tank as a little less full. The data, however, demonstrate that running around on a seven-eighths full tank may be better for the engine.
The Bottom Line
In an evidence-based medicine approach, the bottom line is:
• ACEIs/ARBs extend the lives of patients with CKD;
• ACEIs/ARBs slow the progression of kidney disease (taking into account this early "rise" in creatinine);
• ACEIs/ARBs delay the progression to dialysis regardless of when they are begun; and
• The rise in creatinine associated with ACEIs/ARBs is not necessarily a bad thing. It needs to be interpreted. Large rises may indicate such clinical scenarios as right-heart failure. Smaller rises may indicate a kidney that is relieved to have its internal pressures lowered.
These data support the widespread use of ACEIs/ARBs in patients with CKD. I am reminded of the words of the program director when I was a resident, oh so many decades ago: "No decision is ever wrong, as long as you make it at the bedside." Translation: If you think it is indicated, try it, and follow up. If it doesn't work, as long as you are there to correct it, you have done the right thing.
ACEIs/ARBs may be more complicated to prescribe and monitor than calcium-channel blockers. But to a kidney in distress, they are worth the extra effort. Think of GFR as the gas gauge in your car. If the level goes down a little after initiation of an ACEI/ARB, the kidneys perceive the tank as a little less full. The data, however, demonstrate that running around on a seven-eighths full tank may be better for the engine.
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