Lisinopril Use in End-Stage Renal Disease

Key Safety Considerations

The American Heart Association recommends that ACE inhibitors, including lisinopril, can be safely used in dialysis patients, but requires specific dosing adjustments and critical monitoring for hyperkalemia and hypotension 1, 2, 3
The American College of Cardiology suggests that ACE inhibitors, including lisinopril, are frequently used in dialysis patients and may provide cardiovascular mortality benefits 1, 2
Never administer lisinopril to patients dialyzed with polyacrylonitrile (AN69) membranes due to risk of life-threatening anaphylactoid reactions, as recommended by the American Heart Association 1, 2, 3

The American College of Cardiology recommends checking serum potassium and creatinine within 1-2 weeks of initiation and regularly thereafter 4
Hyperkalemia is relatively common in ESRD patients on ACE inhibitors, though typically modest, according to the American Heart Association 1, 2
The National Kidney Foundation advises avoiding potassium supplements, potassium-containing salt substitutes, and potassium-sparing diuretics in patients taking lisinopril 5

The American Journal of Kidney Diseases recommends not discontinuing ACE inhibitors solely because GFR is <30 mL/min/1.73 m² or patient is on dialysis—they remain nephroprotective and cardioprotective 5
The American Heart Association suggests not combining lisinopril with ARBs in ESRD patients, as combination therapy increases adverse events without additional benefit in this population 5
The Circulation journal recommends not selecting ACE inhibitors that are not dialyzed if stable therapy is desired, since lisinopril is significantly dialyzed 3

The American College of Cardiology considers withholding lisinopril 24-48 hours before major surgery to reduce risk of profound intraoperative hypotension, though evidence is conflicting 1, 2

ACE inhibitors and ARBs can be safely used in patients with end-stage renal disease (ESRD) undergoing hemodialysis, and may provide significant cardiovascular benefits despite the absence of kidney function, according to the American Heart Association 6
ACE inhibitors and ARBs are frequently used in dialysis patients and are not contraindicated in ESRD, as stated by the American College of Cardiology 6

When selecting an ACE inhibitor for hemodialysis patients, consider drugs that are not significantly dialyzed to maintain stable therapy, as recommended by the National Kidney Foundation 6

ACE inhibitors should not be administered to patients treated with polyacrylonitrile dialysis membranes due to the risk of anaphylactoid dialyzer reactions, as warned by the American Heart Association 6
Combined use of ACE inhibitors and ARBs should be avoided due to increased risk of adverse events without additional benefits, according to the American Diabetes Association 7

For patients with variable dialysis schedules, prefer ARB or non-dialyzable ACE inhibitor, as suggested by the National Kidney Foundation 6