ACE inhibitors, angiotensin receptor blockers and SGLT2 inhibitors lower glomerular pressure, and an early fall in eGFR is expected in the first weeks. This haemodynamic dip is not kidney injury, and in trials it has not predicted worse long-term outcomes.
Recheck creatinine and potassium within a few weeks of starting. A fall of up to about 30% is generally accepted; a larger fall should prompt a search for volume depletion, renal artery stenosis or interacting drugs such as NSAIDs and diuretics, rather than automatic withdrawal.
- Recheck creatinine and potassium within a few weeks of starting an ACE inhibitor, ARB or SGLT2 inhibitor.
- Accept an early eGFR fall of up to about 30% without stopping the drug.
- Investigate a larger fall for volume depletion, NSAIDs, diuretics or renal artery stenosis.
- Explain the expected dip to patients so a routine result does not cause alarm.
Why it matters
Stopping kidney-protective drugs for an expected dip is one of the commonest avoidable errors in CKD care.
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