Can losartan be used in patients with End-Stage Renal Disease (ESRD)?

Use of Losartan in End-Stage Renal Disease (ESRD)

Losartan can be used in patients with ESRD, but it is not the preferred angiotensin receptor blocker (ARB) for this population due to safety concerns regarding mortality and morbidity outcomes.

Pharmacokinetics and Dosing in ESRD

Losartan's pharmacokinetics are minimally altered in ESRD patients, and dosage adjustment is generally not required in dialysis-dependent renal failure 1. Key points about losartan in ESRD:

• Losartan and its active metabolite E-3174 are not significantly removed by hemodialysis
• Post-dialysis supplementation is not required due to negligible dialysability 1

Evidence-Based Recommendations for ARBs in ESRD

The 2020 KDIGO guidelines for diabetes management in CKD provide important context for ARB use in advanced kidney disease:

• In severe non-dialysis CKD (Stage IV, CrCl 15-30 mL/min), selected ARBs including losartan can be used with caution 2
• For end-stage renal disease (CrCl <15 mL/min or dialysis-dependent), individualized decision-making is appropriate 2
• In ESRD patients, well-managed vitamin K antagonists with TTR >65-70% are generally preferred over ARBs 2

Preferred ARBs in Advanced Kidney Disease

When considering ARBs in severe kidney disease:

• For CrCl 15-30 mL/min: Rivaroxaban 15 mg daily, apixaban 2.5 mg twice daily, or edoxaban 30 mg daily are preferred over losartan based on pharmacokinetic data 2
• For ESRD patients on hemodialysis: In the US, apixaban 5 mg twice daily is FDA-approved for use in AF patients receiving hemodialysis 2

Opioid Considerations in ESRD

While not directly related to losartan, it's worth noting that when managing pain in ESRD patients:

• Avoid meperidine, codeine, and morphine in ESRD due to active metabolites and accumulation 2
• Tramadol and tapentadol are not recommended in ESRD 2
• Opioids with no active metabolites (fentanyl, sufentanil, methadone) are preferred for ESRD patients 2

Monitoring Recommendations

If losartan is used in ESRD patients, careful monitoring is essential:

• Monitor blood pressure, renal function, and electrolytes (particularly potassium) closely
• Assess for signs of hypotension, especially in patients with heart failure or on diuretic therapy
• Be vigilant for potential complications in patients with renovascular disease 3

Potential Benefits of Losartan in Diabetic Nephropathy

The RENAAL study demonstrated that losartan reduced the risk of doubling serum creatinine and progression to ESRD in patients with type 2 diabetes and proteinuria 4, 5. However, these benefits were primarily shown in patients with earlier stages of kidney disease, not specifically in ESRD.

Cautions and Contraindications

• Losartan should be used with extreme caution in patients with renovascular disease, as it can cause serious complications including anuria 3
• Avoid losartan in pregnancy and in patients with a history of angioedema with ARBs 6
• Use caution in patients with elevated potassium levels (>5.0 mEq/L) 6

Conclusion

While losartan can be used in ESRD patients without dosage adjustment, other medications may be preferred for optimal outcomes in this population. The decision to use losartan in ESRD should consider the individual patient's comorbidities, particularly cardiovascular disease, diabetes, and the risk of hyperkalemia.