Metabolic Alkalosis Vomiting Diuretics — ESENeph MCQ

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An adult with CKD starts an ACE inhibitor. Two weeks later creatinine has risen from 150 to 186 micromol/L, a 24% increase, and potassium is 4.8 mmol/L. The patient is clinically stable. What does NICE advise?

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Correct answer: D — Continue ACE inhibition and repeat blood tests soon

The best answer is “Continue ACE inhibition and repeat blood tests soon”. NICE advises repeating tests in 1-2 weeks and retaining the dose when the creatinine rise is below 30% or eGFR fall is below 25%. Larger changes prompt evaluation for volume depletion, NSAIDs and renovascular disease before dose reduction. “Stop the ACE inhibitor immediately because any creatinine rise is nephrotoxicity” is less appropriate because a rise below 30% is an expected haemodynamic change that does not by itself require dose reduction “Increase the dose now without repeating blood tests” is less appropriate because the change should be rechecked before further titration “Start dialysis because creatinine exceeds 180 micromol/L” is less appropriate because dialysis is not initiated from an isolated creatinine value in a stable person “Add an NSAID to restore glomerular filtration” is less appropriate because NSAIDs can worsen haemodynamic kidney injury and hyperkalaemia

Reference: NICE NG203: CKD assessment and management: https://www.nice.org.uk/guidance/ng203/chapter/Recommendations