Date of download: 7/7/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Angiotensin-Converting Enzyme Inhibitor–Associated Elevations in Serum Creatinine: Is This a Cause for Concern? Arch Intern Med. 2000;160(5): doi: /archinte Possible changes in serum creatinine levels in individuals with normal renal function with volume depletion, heart failure, or bilateral renal artery stenosis started on therapy with an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) (A); individuals with abnormal renal function started on therapy with an ACEI or ARB, without conditions noted in case A (B); and individuals with normal renal function started on therapy with an ACEI or ARB (C). Figure Legend:

Date of download: 7/7/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Angiotensin-Converting Enzyme Inhibitor–Associated Elevations in Serum Creatinine: Is This a Cause for Concern? Arch Intern Med. 2000;160(5): doi: /archinte Effects of an angiotensin-converting enzyme inhibitor (ACEI) on creatinine clearance in 23 patients with type 2 diabetes mellitus who received therapy for an average of 5.6 years. Glomerular filtration rate (GFR) returns toward baseline with good blood pressure (BP) control maintained by treatment with clonidine. Asterisk indicates P<.05 compared with baseline. Bars indicate SD. Figure Legend:

Date of download: 7/7/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Angiotensin-Converting Enzyme Inhibitor–Associated Elevations in Serum Creatinine: Is This a Cause for Concern? Arch Intern Med. 2000;160(5): doi: /archinte Changes in glomerular filtration rate (GFR) among patients with GFR between 13 and 24 mL/min from the Modification of Dietary Protein in Renal Disease trial as a function of the different levels of proteinuria. Asterisk indicates P<.05 compared with initial fall in GFR; dagger, P<.05 compared with initial GFR from less proteinuric groups. MAP indicates mean arterial pressure. Bars indicate SD. Figure Legend:

Date of download: 7/7/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Angiotensin-Converting Enzyme Inhibitor–Associated Elevations in Serum Creatinine: Is This a Cause for Concern? Arch Intern Med. 2000;160(5): doi: /archinte Relationship of glomerular filtration rate (GFR) decline to change and serum creatinine level. Persons older than 65 years and adults weighing less than 49.5 kg have much lower GFRs for a given level of serum creatinine compared with the usual reference population. Laboratory (lab) manifestations of renal failure start to occur when the GFR is about 30 mL/min. This may occur at serum creatinine values as low as 177 µmol/L (2 mg/dL). These changes include mild anemia and elevations in serum phosphorus levels. As GFR falls below 20 mL/min, additional problems occur, such as acidosis and a tendency toward hyperkalemia. The lighter shaded area indicates the area of shown protection from clinical trials and the darker shaded area indicates the range of where dialysis is usually required. ACEI indicates agiotensin-converting enzyme inhibitor. Figure Legend:

Date of download: 7/7/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Angiotensin-Converting Enzyme Inhibitor–Associated Elevations in Serum Creatinine: Is This a Cause for Concern? Arch Intern Med. 2000;160(5): doi: /archinte Risk factors with relative risk (and 95% confidence interval) for developing hyperkalemia from use of angiotensin-converting enzyme inhibitors (ACEI). Adapted from Reardon and Macpherson. Figure Legend:

Date of download: 7/7/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Angiotensin-Converting Enzyme Inhibitor–Associated Elevations in Serum Creatinine: Is This a Cause for Concern? Arch Intern Med. 2000;160(5): doi: /archinte Representative changes in heart rate (HR) or glomerular filtration rate (GFR) in response to exercise or protein loading in the presence and absence of a given angiotensin-converting enzyme inhibitor (ACEI). Figure Legend:

Date of download: 7/7/2016 Copyright © 2016 American Medical Association. All rights reserved. From: Angiotensin-Converting Enzyme Inhibitor–Associated Elevations in Serum Creatinine: Is This a Cause for Concern? Arch Intern Med. 2000;160(5): doi: /archinte A schematic approach to a patient with renal insufficiency started on therapy with an angiotensin-converting enzyme inhibitor (ACEI). Asterisk indicates blood pressure (BP) less than 130/85 mm Hg for those with renal insufficiency or diabetes; double asterisks, if serum creatinine level increases more than 30%, reduce ACEI dose by 50% and add other BP-lowering agents; plus sign, if serum creatinine rise is greater than 30% and less than 50% within the first month of therapy, causes for hypoperfusion are eliminated, and nonsteroidal anti-inflammatory drugs (NSAIDs) are not given, treat as if bilateral renal arterial disease is present. Figure Legend: