Hypertension, renovascular disease and ACEI (17)

This 65 year old lady has a history of resistant hypertension and renal artery stenosis.  She previously had angioplasty to the left renal artery in 1994 and 1997 and had a right renal artery stent inserted in 2002 for an ostial stenosis.  She has been maintained on antihypertensive treatment since, though good control has never been obtained.

 She was kept on lisinopril until she was admitted with a haematemesis 2 years ago.  Her lisinopril was stopped but reintroduced and titrated up to 10mg. Her potassium rose to 5.6 on repeated measurement and lisinopril was stopped.

 Blood pressure control remains poor with levels typically around 170-180 systolic.  Do you think it would be a good idea to give her a small dose of lisinopril again?

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Her eGFR has slowly declined and is 43 at present and PCR is 117.

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She was well on her previous ACEI & her baseline state hasn’t changed.  It was, and always is, approriate to stop her ACEI when she was critically unwell, but she is now well, hypertensive & proteinuric, so yes – give her the lisinopril back & watch and see what happens to her U&Es.  I would accept up to a 20% increase in creatinine and potassium up to 6.


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