What is the most appropriate additional treatment for a patient with chronic kidney disease (CKD) already on losartan (Angiotensin Receptor Blocker (ARB))?

From the Guidelines

For a patient with chronic kidney disease already on losartan (an ARB), the most appropriate additional treatment would be a diuretic, specifically a loop diuretic such as furosemide, to further lower blood pressure and reduce albuminuria, as recommended by the 2018 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1.

The patient's current blood pressure is 148/94 mmHg, which is above the target blood pressure for patients with chronic kidney disease. The use of a diuretic, such as furosemide, can help to further lower blood pressure and reduce albuminuria, which is a key component of chronic kidney disease management.

• The patient's laboratory results show an elevated urine albumin-creatinine ratio (1500 mg/g) and a reduced estimated glomerular filtration rate (24 mL/min/1.73 m2), indicating significant kidney disease.
• The patient is already on losartan, an ARB, which is recommended for patients with chronic kidney disease and albuminuria, but additional treatment is needed to further lower blood pressure and reduce albuminuria.
• The use of a diuretic, such as furosemide, is recommended as additional therapy to further lower blood pressure in patients already treated with maximum doses of ACE inhibitors or ARBs, as stated in the 2015 study on microvascular complications and foot care 1.
• The 2021 study on diabetes management in chronic kidney disease also recommends the use of diuretics, such as furosemide, as additional therapy to further lower blood pressure in patients with chronic kidney disease 1.

Overall, the use of a diuretic, such as furosemide, is a reasonable additional treatment for this patient with chronic kidney disease already on losartan, to further lower blood pressure and reduce albuminuria.

From the FDA Drug Label

7.4 Dual Blockade of the Renin-Angiotensin System (RAS) Dual blockade of the RAS with angiotensin receptor blockers, ACE inhibitors, or aliskiren is associated with increased risks of hypotension, syncope, hyperkalemia, and changes in renal function (including acute renal failure) compared to monotherapy In most patients no benefit has been associated with using two RAS inhibitors concomitantly. In general, avoid combined use of RAS inhibitors.

The most appropriate additional treatment for this patient with chronic kidney disease (CKD) already on losartan (Angiotensin Receptor Blocker (ARB)) is not an ACE inhibitor like Lisinopril, due to the risks associated with dual blockade of the renin-angiotensin system. Considering the patient's symptoms, such as jugular venous distension and pitting edema, the most appropriate additional treatment would be a diuretic like Furosemide to help manage fluid overload and reduce blood pressure. Carvedilol and Hydralazine may also be considered, but Furosemide is the most direct treatment for the patient's current condition. 2

From the Research

Patient Profile

• The patient is a 62-year-old woman with hypertension and chronic kidney disease.
• She is currently on losartan and amlodipine, and is adherent to her medication regimen and low sodium diet.
• Her blood pressure is 148/94 mm Hg, and she has a BMI of 30.
• Laboratory studies show a creatinine level of 2.6 mg/dL, potassium level of 4.9 mEq/L, and an estimated glomerular filtration rate of 24 mL/min/1.73 m2.

Treatment Options

• The patient's current treatment regimen includes an angiotensin receptor blocker (ARB), losartan.
• The addition of an angiotensin-converting enzyme (ACE) inhibitor, such as lisinopril, may be considered to further reduce proteinuria and slow disease progression 3, 4.
• However, the use of dual therapy with an ACE inhibitor and an ARB requires close surveillance of renal function and blood pressure, as it may increase the risk of acute renal failure 5.
• The risk of hyperkalemia should also be considered when adding an ACE inhibitor to the patient's regimen, particularly in patients with chronic kidney disease 6.

Recommended Treatment

• Based on the patient's profile and laboratory results, the most appropriate additional treatment would be to add an ACE inhibitor, such as lisinopril, to her current regimen.
• This decision is supported by studies showing the renoprotective effects of ACE inhibitors in patients with chronic kidney disease 3, 7.
• However, close monitoring of the patient's renal function, blood pressure, and potassium levels is necessary to minimize the risk of adverse effects.
• The choice of lisinopril is based on its established efficacy in reducing proteinuria and slowing disease progression in patients with chronic kidney disease 3, 4.