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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Hyperkalaemia in Polycystic Kidney Disease (3)

I was looking for a little advice regarding this 68 year old lady with polycystic kidney disease – either with regard to her medication or whether or not you felt she should be reviewed in clinic.

She had routine bloods and BP performed several weeks ago, her BP was 119/89 mmHg and her bloods came back with a raised ALP of 138 mmol/L, a potassium of 5.3 mmoml/L, an eGFR of 26 (previously 27) and her FBC was ok. These were repeated and her potassium remains elevated at 5.4 mmol/L, with a now normal ALP, calcium and phosphate. Her eGFR is now 23.

In view of her persistent hyperkalaemia and reduced eGFR I was wondering if she should reduce her lisinopril, this would obviously potentially increase her BP and reduce the nephroprotective effect. I have made no alterations at present and look forward to hearing your opinion. If you feel she requires a clinic review please let me know.

What further information would you seek before giving your opinion?

See more of the history or available results?

The only other information available was her list of current medication; Lisinopril 10mg, Atenolol 50mg, Atorvastatin 20mg (not very compliant), Bendroflumathiazide 2.5mg OD, Quinine 300mg

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BP seems well controlled on current medications and I would be inclined to leave them unaltered; the potassium is ok.

Renal function is declining slowly – not out of keeping for ADPKD. I would recommend that she be referred back to clinic if the eGFR fell to less than 20.

Two things worth checking;

  1. Bicarbonate level – if she is becoming more acidotic it might explain the small rise in potassium
  2. PTH – rising PTH, in the context of secondary hyperparathyroidism, is a possibility to explain the rise in ALP. If PTH >180 then worth starting her on a small dose of oral alfacalcidol (0.25 mcg/day).


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Things to read:

  • Edinburgh Renal Unit – GP Referral criteria
  • Clinical Review of Hyperkalaemia in BMJ – Moffat J Nyirenda, Justin I Tang, Paul L Padfield, Jonathan R Seckl. Hyperkalaemia. BMJ 2009;339.
  • Edinburgh Renal Unit – Inherited Conditions