AANP Family Nurse Practitioner (FNP) Certification ExamEvaluationHard
A 62-year-old male with chronic kidney disease (CKD) Stage 3 is prescribed lisinopril for hypertension. His baseline creatinine was 1.5 mg/dL with an eGFR of 45 mL/min/1.73m². One week after starting lisinopril, his creatinine is 1.8 mg/dL and eGFR is 38 mL/min/1.73m². He reports no new symptoms. What is the most appropriate action?
- AContinue lisinopril and recheck renal function in 2-4 weeks.
- BAdd a loop diuretic to counteract the renal effect.
- CDiscontinue lisinopril immediately.
- DDecrease the dose of lisinopril by 50%.
Show answer & explanationAnswer & explanation
Correct answer: A. Continue lisinopril and recheck renal function in 2-4 weeks.
A small, stable increase in creatinine (up to 30% above baseline) is expected and acceptable when initiating an ACE inhibitor or ARB in patients with CKD, as it reflects the drug's beneficial hemodynamic effects on the kidney. Discontinuation is usually reserved for larger or progressive increases.
Why the other options are wrong
- B. Adding a loop diuretic would not address the underlying mechanism of the creatinine increase and could potentially worsen dehydration or electrolyte imbalances.
- C. Discontinuation is usually warranted for larger increases in creatinine (>30% from baseline) or symptomatic acute kidney injury.
- D. Dose reduction might be considered if the increase was >30% or if there were other concerning signs; this increase is within the acceptable range.
ACEI/ARB & CKD Monitoring
A mild, stable increase in serum creatinine (up to 30% from baseline) is an expected and acceptable response when initiating an ACE inhibitor or ARB in patients with chronic kidney disease.
- ACEIs/ARBs are renoprotective in CKD despite initial GFR drop.
- Monitor creatinine and potassium 1-2 weeks after initiation or dose change.
- Increase >30% or hyperkalemia warrant dose adjustment or discontinuation.
Memory trick: ACEIs are kidney friends, but check their balance, not too much, not too little.