Chronic Kidney Disease Pathway Document Description Presented ...

Irbesartan*
Valsartan
Losartan*
*Specifically licensed for patients with type 2 diabetes and
nephropathy/microalbuminuria.
ARBs should be used as a second line treatment, only in patients who do not
tolerate ACE inhibitors (usually due to development of persistent dry cough which
does not disappear within two months of starting the ACE – check no other
caveats).
N.B Heart Failure
The commonest fear for not using an ACE/ARB in patients with Heart Failure
(HF) is the potential for worsening renal function. However, although the
CONSENSUS trial demonstrated a 30% rise in Creatinine; the subsequent
follow-up showed 19% returned to baseline and the ACE was generally well
tolerated.
Drug treatment with an ACE or ARB can contribute to hyperkalaemia, which can
also be exacerbated by treatment with spironolactone (indicated in the treatment
of heart failure).Severe hypovolaemia, may complicate the treatment of heart
failure with high dose diuretics, as it may also cause hyperkalaemia in the
presence of CKD, although in the presence of volume overload, diuretic
treatment may be a logical treatment for hyperkalaemia. For these reasons,
working out the cause and appropriate treatment of hyperkalaemia can be
difficult, and a good reason for referral to / advice from a nephrologist.
NSAIDs are associated with worsened outcomes in Heart Failure because they
oppose the benefits of ACE by inhibiting the production of prostacyclin.
Spironolactone should be avoided in patients with a GFR < 30 but can be used
with caution in patients where eGFR is between 30 – 60 ml/min. It should be
withheld in patients with diarrhoea and vomiting, who have heart failure and
CKD, due to dehydration and hyperkalaemia.
Spironolactone, ACE and ARB should be reduced or stopped if the serum
potassium is greater than 6.0 mmol/l. This includes potassium sparing diuretics.
http://www.renal.org/CKDguide/ckd.html
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