From the Guidelines
For a 75-year-old Black male with stage three chronic kidney disease, I recommend starting with losartan 25 mg once daily, as this low initial dose is appropriate given the patient's advanced age and kidney impairment, allowing for assessment of tolerability before considering dose adjustments. The dose can be titrated up to 50-100 mg daily as needed for blood pressure control, with careful monitoring of kidney function and potassium levels, as suggested by the KDIGO 2024 clinical practice guideline for the evaluation and management of chronic kidney disease 1. Losartan is preferred because it has hepatic elimination, making it safer in kidney disease compared to ARBs with primarily renal clearance. When initiating therapy, baseline measurements of blood pressure, serum creatinine, and potassium should be obtained, with follow-up testing within 1-2 weeks of starting treatment, as recommended by the guideline 1. ARBs are beneficial in this patient as they provide renoprotection by reducing intraglomerular pressure and proteinuria while controlling hypertension, potentially slowing CKD progression. If this patient has diabetes or significant proteinuria, these benefits become even more important.
Some key points to consider when using RASi (ACEi or ARB) in patients with CKD include:
- Administering the highest approved dose that is tolerated to achieve the benefits described, as the proven benefits were achieved in trials using these doses 1
- Monitoring changes in BP, serum creatinine, and serum potassium within 2-4 weeks of initiation or increase in the dose of a RASi, depending on the current GFR and serum potassium 1
- Managing hyperkalemia associated with use of RASi by measures to reduce the serum potassium levels rather than decreasing the dose or stopping RASi, unless symptomatic hypotension or uncontrolled hyperkalemia despite medical treatment occur 1
- Continuing ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation of treatment or an increase in dose, or to reduce uremic symptoms while treating kidney failure (estimated glomerular filtration rate [eGFR] <15 ml/min per 1.73 m2) 1
From the FDA Drug Label
The usual starting dose of losartan is 50 mg once daily. A starting dose of 25 mg is recommended for patients with possible intravascular depletion (e.g., on diuretic therapy). The dose should be increased to 100 mg once daily based on blood pressure response.
The medication and dose of an ARB that a 75-year-old black male with stage three chronic kidney disease should be started on is losartan at a dose of 50 mg once daily. However, if the patient has possible intravascular depletion, the starting dose should be 25 mg once daily. The dose can be increased to 100 mg once daily as needed to control blood pressure 2.
From the Research
Medication and Dose for a 75-year-old Black Male with Stage Three Chronic Kidney Disease
- The patient should be started on an Angiotensin II Receptor Blocker (ARB) as it has been shown to have renoprotective effects in patients with chronic kidney disease (CKD) and hypertension 3.
- Losartan is a suitable ARB for this patient, with a daily dose of 25-100 mg/day 3, 4.
- The dose of losartan can be adjusted based on the patient's blood pressure response, with a target dose of 50 mg/day 4.
- It is essential to monitor the patient's renal function, blood pressure, and urinary protein excretion regularly to adjust the treatment plan as needed 3, 5.
- Combination therapy with a calcium channel blocker or diuretic may be considered if the patient's blood pressure is not adequately controlled with losartan alone 5.
Considerations for Older Adults with CKD
- Older adults with CKD stage 3 have a higher risk profile for CKD progression and cardiovascular events compared to younger patients 6.
- Serum creatinine levels may underestimate the presence of CKD in older adults, and estimated glomerular filtration rate (eGFR) should be used to diagnose and monitor CKD 7.
- The patient's age, medical history, and demographic data should be taken into account when developing a treatment plan 6.