ACEi Continuation Low eGFR — ESENeph MCQ

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ModerateChronic Kidney DiseaseACEi Continuation Low eGFRESENeph

A 65-year-old man with CKD G4 (eGFR 22 mL/min/1.73m2) and hypertension on Ramipril 10 mg has a potassium of 5.1 mmol/L. His eGFR has declined from 30 over 12 months despite BP control. Should the ACEi be continued?

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Correct answer: B — Continue ramipril with potassium and renal monitoring

KDIGO 2024 practice point 3.6.7 specifically states: continue ACEi or ARB in people with CKD even when eGFR falls below 30 mL/min/1.73m2. Stopping RASi at low eGFR denies patients the ongoing proteinuria-reducing and cardiovascular benefits. The reversible haemodynamic effect on eGFR does not represent true nephron loss. Potassium of 5.1 mmol/L is manageable and does not warrant RASi cessation. Monitoring should be enhanced but the drug should be continued. The competing options do not fit the renal phenotype, temporal relationship, treatment threshold or safety constraint described. Management still requires confirmation of current medicines, renal trajectory and relevant contraindications, followed by timely biochemical and clinical reassessment. Escalate urgently if life-threatening electrolyte disturbance, respiratory compromise, shock, neurological deterioration or a dialysis indication develops.

Reference: KDIGO 2024 – CKD Guideline: https://www.nice.org.uk/guidance/ng136/chapter/recommendations