ACE inhibitors, angiotensin receptor blockers, SGLT2 inhibitors, mineralocorticoid receptor antagonists and aldosterone pathway drugs all reduce intraglomerular pressure, which commonly lowers eGFR in the first weeks. A fall of up to about 30% that then stabilises is expected and reflects a haemodynamic effect rather than kidney injury.
Stopping the drug because of this early dip forfeits the long-term kidney protection that the same mechanism provides. A larger fall, a continuing decline or rising potassium warrants review for volume depletion, renal artery stenosis or interacting drugs.
- Check creatinine and potassium one to four weeks after starting or increasing a RAAS-acting drug.
- Continue treatment if eGFR falls by less than about 30% and then stabilises.
- Look for volume depletion, NSAIDs or renal artery stenosis when the fall is larger.
- Manage mild hyperkalaemia with diet review and binders before stopping protective drugs.
Why it matters
Premature withdrawal for an expected dip is a common reason CKD patients lose kidney-protective therapy.
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