ACE Inhibitors in Chronic Kidney Disease

Recommendations Based on Albuminuria and Diabetes Status

The American College of Cardiology recommends starting ACE inhibitors in patients with CKD and severely increased albuminuria (≥300 mg/24h or A3 category) even without hypertension, with a strong recommendation (1B) 1
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest a weaker recommendation (2C) to start ACE inhibitors or ARBs in patients with CKD and moderately increased albuminuria (30-300 mg/24h or A2 category) 1, 2
The American Diabetes Association recommends starting ACE inhibitors or ARBs in patients with diabetes, CKD, and moderately to severely increased albuminuria (A2 and A3 categories), with a strong recommendation (1B) 1, 3

The National Kidney Foundation recommends checking serum creatinine and potassium within 2-4 weeks after initiation or dose increase of ACE inhibitors 1, 3
The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) suggests continuing ACE inhibitor therapy unless serum creatinine rises by more than 30% within 4 weeks of starting treatment 1, 3

The American Heart Association recommends avoiding any combination of ACE inhibitor, ARB, and direct renin inhibitor therapy as this increases adverse effects without additional benefit 1
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest considering adding SGLT2 inhibitors in appropriate patients, which have complementary renoprotective effects 1

The Annals of Internal Medicine reports that the benefits of ACE inhibitors in reducing cardiovascular events and kidney disease progression generally outweigh the risks of hyperkalemia and acute kidney injury for most patients 2

The American College of Physicians recommends ACE inhibitors as first-line therapy in non-diabetic CKD patients with severely increased albuminuria (≥300 mg/24h or ≥300 mg/g albumin-to-creatinine ratio), even in the absence of hypertension, based on strong evidence showing reduced risk of kidney failure and cardiovascular events 4, 5
ACE inhibitors are recommended for non-diabetic CKD patients with severely increased albuminuria to slow kidney disease progression in this high-risk group 6
For non-diabetic CKD patients with moderately increased albuminuria (30-300 mg/24h), ACE inhibitors may be considered even without hypertension, though the evidence is less robust (Grade 2C recommendation) 4

When initiating ACE inhibitors in non-hypertensive CKD patients, check basic metabolic profile within 2-4 weeks after starting therapy to monitor for hyperkalemia and changes in kidney function 6
Patients should be educated to temporarily reduce or hold ACE inhibitor doses during periods of decreased oral intake, vomiting, or diarrhea to prevent acute kidney injury 6
Monitor for hypotension, especially in volume-depleted patients 7

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend ACE inhibitor use in non-hypertensive CKD patients with albuminuria, with the strength of recommendation increasing with the degree of albuminuria 4
For elderly CKD patients without albuminuria, carefully consider the risk-benefit ratio before starting ACE inhibitors in the absence of hypertension 8
Combining ACE inhibitors with ARBs increases risk of adverse events without additional benefit 9