Dual therapy difficulties in angiotensin blockade for proteinuria: a teachable moment.

Story From the Front Lines The patient was initially referred to renal clinic in 2010 for elevated serum creatinine level and was found to have nephrotic range proteinuria at 3.7 g/d. He was prescribed losartan to control his proteinuria and blood pressure and observed subsequently by multiple nephrologists. His proteinuria gradually improved, but creatinine levels remained elevated while he was receiving losartan, and 3 years later lisinopril was added to his regimen in an effort to reduce proteinuria to less than 1 g/d. One month later, he developed acute kidney injury (AKI) and his losartan dose was decreased. At his next appointment (the one prior to his visit with us), proteinuria remained above goal despite combination therapy, so the lisinopril dose was increased. The patient subsequently developed progressive fatigue. At his first visit to us, he was hypotensive, with a blood pressure of 90/56 mm Hg, and we discontinued his lisinopril use. The patient reported feeling better, and his blood pressure returned to normal at his next primary care visit.