high sr. creatinine is ace inh indicated ? - fs3

[ArchivalUser]

if sr. creatinine is high is ace inh indicated or no ?
only if the baseline cr 0.5 , or if the baseline is >2 and the change is > 1 then its contraindicated. is this right ?
If so then in ADPKD if the creatinine is high can we give ace inh or should we go for other anti htn such as ca blockers as UW does in a ccs case ?

thanks for the replies.

[ArchivalUser]

sorry there are few words missing in the 2nd line in the starting.
i meant If the baseline Cr. < 2 and the change is < .5 or if the baseline > 2 and the change is > 1, after the starting ace inh only then its C.I.
and it should be actually given in high creatinine, like cases of ADPKD.
or is it like standard statement - cr > 2.5 -3 ace inh contraindicated

can someone clarify ?

thanks.

[ArchivalUser]

ACE inhibitors typically are well tolerated. However, a usually modest but sometimes severe acute decline in renal function can be observed in patients with already reduced intrarenal perfusion pressure (such as from bilateral renal artery stenosis or congestive heart failure). This is probably due to the ACE inhibitor's ability to relax the efferent arteriole leading to lower intraglomerular pressure with subsequent reduction of glomerular filtration rate (GFR). The rise of plasma creatinine typically begins three to five days after the start of an ACE inhibitor and thus it is suggested to check renal function at this time in patients thought to be at risk (Am J Kidney Dis. 2004;43[5 Supp1]:S1). A meta-analysis of randomized controlled trials evaluating this concern found a strong association between acute increases in serum creatinine of up to 30% that stabilize within the first two months of ACE-inhibitor therapy and long-term preservation of renal function “ even for those patients with a baseline creatinine >1.4 mg/dL. Given this, the authors suggested a dose reduction or withdrawal of ACE inhibitor therapy only with a rise in serum creatinine >30% from baseline in the first two months of medication use (Arch Intern Med. 2000;160:685-693). Formulas used to estimate creatinine clearance such as the MDRD equation and the Cockcroft-Gault equation are most accurate when creatinine is not rapidly changing, and the precision of these formulas depends upon the rapidity of the creatinine rise (Nephrol Dial Transplant. 2003;18:1446-1451).

[ArchivalUser]

fs3, you are correct.
ACEI must be used whenever there are definite indications even if creatinine is very high. There is no cut off on the creatinine for starting ACEI.
However, ACEI must be stopped if ACEI induced renal failure occurs i.e; ACEI induced renal failure is suspected when change from baseline creatinine more than 0.5mg% if baseline is less than 2.0 or if change is greater than 1mg% if baseline is more than 2.0

ACEI must be used in ADPKD irrespective of baseline creatinine level as they reduce the progression of the disease..........VERY IMPORTANT.

[ArchivalUser]

thanks for the replies thyrogen and nimish

In ccs case of adpkd in an afr-amer in uw ( read out case 35 )

Amlodipine was started rather than ace inh as we think and his sr. cr is 6.5 something

i know ca blockers work well in afr- americans but why not ace inh if we think it benefits adpkd ?

thanks.

[ArchivalUser]

nimish can u reply plz
thanks

[ArchivalUser]

ace dont work in blacks

[ArchivalUser]

wow thanks for the fact
i forgot it
thanks for the reply

[ArchivalUser]

-the cut-off for ACEI, ARB and/or mineralocorticoid receptor blocker is creatinine 5.6 (from Brenner-The Kidney)
-in African-Americans there is lower renin level, so they respond less to renin-inhibiting drugs.

[ArchivalUser]

thanks odin