Hyperkalemia Associated with Angiotensin Converting Enzyme Inhibitor or Angiotensin Receptor Blockers in Chronic Kidney Disease

Yudi Her Oktaviono, Novia Kusumawardhani


Inhibition of the renin-angiotensin-aldosterone system (RAAS) is a key strategy in treating hypertension in cardiovascular and renal diseases. However, RAAS inhibitors (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, aldosterone receptor antagonists, and direct renin inhibitors) increase the risk of hyperkalemia (serum potassium >5.5 mmol/L). This poses a therapeutic challenge because these patient groups comprise in whom the drugs are therapeutically indicated. Important considerations when initiating ACEI or ARB therapy include obtaining an estimate of glomerular filtration rate and a baseline serum potassium concentration, as well as assessing whether the patient has excessive potassium intake from diet, supplements, or drugs that can also increase serum potassium. Serum potassium monitoring shortly after initiation of therapy can assist in preventing hyperkalemia. If hyperkalemia does develop, prompt recognition of cardiac dysrhythmias and effective treatment to antagonize the cardiac effects of potassium, redistribute potassium into cells, and remove excess potassium from the body is important. Understanding the mechanism of action and monitoring of ACEI and ARB coupled with judicious drug use and clinical vigilance can minimize the risk to the patient of developing hyperkalemia.


hyperkalemia; angiotensin converting enzyme inhibitor; angiotensin receptor blocker; chronic kidney disesase


Raebel MA. Hyperkalemia associated with use of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers. Cardiovascular Ther. 2012;30:e156-66.

Sadjadi SA, McMillan JI, Jaipaul N, Blakely P, Hline SS. A comparative study of the prevalence of hyperkalemia with the use of angiotensin-converting enzyme inhibitors versus angiotensin receptor blockers. Ther Clin Risk Manag. 2009;5:547-52.

Maddirala S, Khan A, Vincent A, Lau K. Effect of angiotensin converting enzyme inhibitors and angiotensin receptor blockers on serum potassium levels and renal function in ambulatory outpatients: risk factors analysis. Am J Medical Sciences. 2008; 336:330-5.

Raebel MA, Ross C, Xu S, et al. Diabetes and drug-associated hyperkalemia: effect of potassium monitoring. J General Intern Med. 2010;25:326-33.

Ahuja TS, Freeman D, Jr., Mahnken JD, Agraharkar M, Siddiqui M, Memon A. Predictors of the development of hyperkalemia in patients using angiotensin-converting enzyme inhibitors. Am J Nephrol. 2000; 20:268-72.

Johnson ES, Weinstein JR, Thorp ML, et al. Predicting the risk of hyperkalemia in patients with chronic kidney disease starting lisinopril. Pharmacoepidemiol Drug Safety. 2010;19:266-72.

Palmer BF. Managing hyperkalemia caused by inhibitors of the renin-angiotensin-aldosterone system. New Engl J Med. 2004;351:585-92.

Bandak G, Sang Y, Gasparini A, et al. Hyperkalemia after initiating renin-angiotensin system blockade: The Stockholm creatinine measurements (SCREAM) project. J Am Heart Assoc. 2017;6.

Lehnhardt A, Kemper MJ. Pathogenesis, diagnosis and management of hyperkalemia. Pediatric Nephrol. 2011;26:377-84.

Levey AS, Eckardt KU, Tsukamoto Y, et al. Definition and classification of chronic kidney disease: a position statement from kidney disease: Improving Global Outcomes (KDIGO). Kidney Int. 2005;67:2089-100.

Remuzzi G, Perico N, Macia M, Ruggenenti P. The role of renin-angiotensin-aldosterone system in the progression of chronic kidney disease. Kidney Int Suppl. 2005:S57-65.

Zaman MA, Oparil S, Calhoun DA. Drugs targeting the renin-angiotensin-aldosterone system. Nature Rev Drug Discovery. 2002;1:621-36.

Schaefer TJ and Wolford RW. Disorders of potassium. Emergency medicine clinics of North America. 2005; 23:723-47.

Wilmer WA, Rovin BH, Hebert CJ, et al. Management of glomerular proteinuria: a commentary. J Am Soc Nephrol. 2003;14:3217-32.

Perazella MA. Drug-induced hyperkalemia: old culprits and new offenders. Am J Med. 2000;109:307-14.

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