A Reversible Syndrome of Acute R enal 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. vol- ume 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 accom- paniment. 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. dis- continuance 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.