Before starting

Required

• Baseline
  • Blood pressure
  • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
  • Serum potassium
  • Serum sodium
  • Urea

Caution in patients with CKD and raised potassium

Initiation not normally appropriate if pre-treatment potassium greater than 5.0mmol/L

Seek specialist advice for some patients

Seek specialist advice prior to initiation for patients where there is:

• severe or unstable heart failure
• renovascular disease
• eGFR less than 30ml/min/1.73m²
• hyponatraemia (sodium less than 130mmol/L)
• hypovolaemia
• hypotension (SBP less than 90mmHg)
• concomitant multiple or high-dose diuretics
• concomitant high-dose vasodilator

After started or dose changed

Heart failure

• Within 2 weeks, then monthly for 3 months
  • Blood pressure
  • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
  • Serum sodium
  • Serum potassium

Recommendations for heart failure are comprehensive

The most comprehensive monitoring is recommended for patients with heart failure. It may be appropriate to adopt these locally as the standard for all patients and indications.

Continuation period

Continue for 3 months once target or maximum daily dose reached; repeat monitoring if patient acutely unwell.

Heart failure with other risk factors

• Within 7 days
  • Blood pressure
  • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
  • Serum sodium
  • Serum potassium

Other risk factors

Other risk factors includes people:

• with existing CKD stage 3 or higher
• aged 60 years or over
• with relevant co-morbidities such as diabetes mellitus or peripheral arterial disease
• taking a combination of an ACE-inhibitor plus a diuretic or an aldosterone antagonist

Hypertension

• Within 2 weeks
  • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)
  • Serum sodium
  • Serum potassium
• Within 1 month
  • Blood pressure

Hypertension with other risk factors

• Within 7 days
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate
  • Serum sodium
  • Serum potassium
• Within 1 month
  • Blood pressure

Other risk factors

Other risk factors includes people:

• with hyperkalaemia
• with deteriorating renal function (e.g. with peripheral vascular disease, diabetes mellitus, or pre-existing renal impairment or older people)

Chronic Kidney Disease

• Within 2 weeks
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate
  • Serum potassium
  • Blood pressure

Post myocardial infarction

• Within 2 weeks
  • Blood pressure
  • Serum creatinine
  • Electrolytes

Increasing monitoring frequency for some patients

Myocardial infarction patients at increased risk of deterioration of renal function may need more frequent monitoring than normal.

Ongoing once stable

Heart failure

• 6 monthly
  • Serum creatinine (for creatinine clearance) or Estimated glomerular filtration rate
  • Serum sodium
  • Serum potassium

Increasing frequency for some patients

Consider more frequent monitoring (for example every 3 months) when there are concerns regarding the person’s clinical condition, concomitant drugs, or co-morbidities.

Hypertension

• Annually
  • Electrolytes
  • Estimated glomerular filtration rate or Serum creatinine (for creatinine clearance)

Post myocardial infarction

• Annually
  • Blood pressure
  • Electrolytes
  • Serum creatinine

Increasing monitoring frequency for some patients

Myocardial infarction patients at increased risk of deterioration of renal function may need more frequent monitoring than normal.

Abnormal results

Potassium

Value between 5.5-6.0mmol/L

• Stop ACEI/ARB and seek specialist advice.
• Review concurrent medication.

Value between 5.0-5.9mmol/L in hypertensive patient

• Review other potassium sparing treatments; if level persists reduce ACEI/ARB dose and review in 5-7 days.

Value above 6mmol/L

• Stop ACEI/ARB and other drugs known to promote hyperkalaemia and seek urgent clinical advice.

Sodium

Value is below 132mmol/L

• Obtain specialist advice

Renal Function

Creatinine increase between 20-30%; eGFR decrease more than 15%

• Remeasure renal function within 2 weeks

Creatinine increase between 30-50%; level greater than 200micromol/L; eGFR less than 30ml/min/1.73m²

• Review volume status
• Reduce dose temporarily
• Stop diuretic (if applicable)
• Stop ACEI/ARB

Creatinine increase between 50-100%; level greater than 256micromol/L; eGFR between 20-25ml/min/1.73m²

• Reduce dose
• Stop diuretic (if applicable)
• Stop ACE/ARB
• Consider specialist referral

Creatinine increase greater than 100%; level greater than 310micromol/L; eGFR less than 20ml/min/1.73m²

• Stop ACEI/ARB and referral to specialist

Bibliography

• National Institute for Health and Care Excellence (NICE). Chronic heart failure in adults: management [CG108]. Aug 2010 [cited 31/07/2020]
• National Institute for Health and Care Excellence (NICE). Chronic kidney disease in adults: assessment and management [CG182]. Jul 2014 [updated Jan 2015; cited 31/07/2020]
• National Institute for Health and Care Excellence (NICE). Myocardial infarction: cardiac rehabilitation and prevention of further cardiovascular disease [CG172]. Nov 2013 [cited 31/07/2020]
• Joint Formulary Committee. British National Formulary (online) London: BMJ Group and Pharmaceutical Press [cited 31/07/2020]
• Smellie WSA, Forth J, ColemanJJ, et al. Best practice in primary care pathology: review 6. J Clin Pathol. 2007;60(3):225-34 [cited June 2020]
• NICE Clinical Knowledge Summaries (CKS). Hypertension (not diabetic). Updated October 2019 [cited 31/07/2020]
• NICE Clinical Knowledge Summaries (CKS). Chronic kidney disease. Updated March 2019 [cited 31/07/2020]
• National Institute for Health and Care Excellence (NICE). Hypertension in adults: diagnosis and management [NG136]. Aug 2019 [cited 01/09/2020]
• NICE Clinical Knowledge Summaries (CKS). Heart-failure – chronic. Updated Jan 2017 [cited 31/07/2020]
• Think Kidneys Board. “Sick day” guidance in patients at risk of Acute Kidney Injury: Position Statement from the Think Kidneys Board. Jan 2020 [cited 31/07/2020]
• NICE Clinical Knowledge Summaries (CKS). MI – secondary prevention. Updated May 2020 [cited 31/07/2020]

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