A Reversible Syndrome of Acute Renal Failure Associated with Renin-Angiotensin Inhibitor Drugs

Background and Aims: Previous studies indicate that angiotensin converting enzyme inhibitors (ACEI) cause acute renal failure (ARF) in patients with diabetes, hypertension, and congestive heart failure. Volume depletion is a determining factor for ACEI-induced ARF. This study presents a syndrome of reversible ARF accompanied by hyperkalemia, metabolic acidosis, and anemia associated with ACEI and angiotensin receptor blocker (ARB). Methods: Data were collected from a total of 12 patients; 11 were admitted to the hospitals and 1 as an outpatient. Six patients had uncontrolled diabetes. Four of these patients also had hypertension. Eight patients (67 percent) received lisinopril; 4 (33 percent) received ARB. Diuretics were the commonest accompaniment. They showed moderate to severe azotemia. Estimated glomerular filtration rate (eGFR) ranged from 9.3 to 32.2 ml/min with an average eGFR of 14.1 ml/min. Six patients (50 percent) had moderate to severe hyperkalemia. All but 2 patients had metabolic acidosis, and 6 patients (50 percent) were anemic. ACEI or ARB and diuretics were discontinued in all patients, and all hospitalized patients were treated with normal saline or bicarbonate infusion, erythropoietin, and 9-alpha fluodrohydrocortisone, as required. Results: Azotemia reversed and renal function improved to normal or near normal in 8 patients (67 percent). One of these patients required one-time hemodialysis. Renal function returned to baseline or better in 3 patients with preexisting renal insufficiency. Renal function improved in 1. All hyperkalemic patients became normokalemic, and all but 1 recovered from metabolic acidosis. Anemia also improved. Conclusions: This novel observation substantiates our previous observation and further reiterates that ACEI/ARB causes a syndrome of reversible azotemia, hyperkalemia, metabolic acidosis, and anemia. Discontinuance of ACEI/ARB and diuretics—and treatment with a combination of bicarbonate infusion, 9-alpha fluodrohydrocortisone (Florinef®), and exogenous erythropoietin—hasten recovery from this syndrome. Continuation of a diuretic but without ACEI/ARB doesn’t hinder renal function recovery.