From the Guidelines
Losartan can be used in patients with renal artery stenosis, but with caution and close monitoring, as most patients with significant RAS tolerate ACEIs or ARBs without difficulty, according to the 2017 ESC guidelines 1.
Key Considerations
- The use of losartan in patients with renal artery stenosis requires careful consideration of the potential risks and benefits, as it can reduce glomerular capillary hydrostatic pressure and cause a transient decrease in glomerular filtration rate 1.
- Most antihypertensive drugs, including ACEIs, ARBs, calcium channel blockers, beta-blockers, and diuretics, are effective for treating hypertension and may lead to slowing of the progression of renal disease 1.
- However, ACEIs and ARBs may be introduced in the case of bilateral RAS and when the lesion affects a single functioning kidney, provided that the patients are very carefully monitored 1.
Monitoring and Precautions
- Patients with suspected renal artery stenosis should undergo appropriate imaging studies before starting losartan or other ARBs, and alternative antihypertensive agents such as calcium channel blockers or beta-blockers should be considered instead if necessary 1.
- Close monitoring of renal function and blood pressure is essential when using losartan in patients with renal artery stenosis, as the optimal blood pressure in this setting is unknown 1.
Benefits and Risks
- The benefits of using losartan in patients with renal artery stenosis include reducing mortality and morbidity, as shown in large observational studies 1.
- However, the risks of using losartan in this population include worsening kidney function and potentially causing acute kidney injury, particularly if the patient has bilateral severe RAS or RAS in a single functional kidney 1.
From the FDA Drug Label
- 3 Renal Function Deterioration Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system and by diuretics. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, or volume depletion) may be at particular risk of developing acute renal failure on losartan. Monitor renal function periodically in these patients Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on losartan
Losartan can be used in patients with renal artery stenosis, but with caution.
- Patients with renal artery stenosis may be at particular risk of developing acute renal failure on losartan.
- It is recommended to monitor renal function periodically in these patients.
- Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on losartan 2
From the Research
Losartan Use in Patients with Renal Artery Stenosis
- Losartan, an Angiotensin II Receptor Antagonist, may not be suitable for patients with bilateral renal artery stenosis or unilateral renal artery stenosis in a solitary kidney, as it can cause renal dysfunction 3, 4.
- The use of losartan in patients with renal artery stenosis can lead to acute renal failure, especially in those with reduced renal plasma flow 3.
- Renal function should be monitored closely when using losartan in patients with underlying renal dysfunction, and the medication should be discontinued if signs of renal dysfunction appear 3.
- In patients with unilateral renal artery stenosis and two kidneys, losartan may be used with caution, but it is recommended to avoid its use in patients with bilateral renal artery stenosis or unilateral stenosis in a solitary kidney 4.
- Revascularization of renal arterial stenosis, such as percutaneous transluminal angioplasty with stent placement, may be considered in acute settings, such as uncontrolled arterial hypertension or acute renal failure, and can lead to rapid normalization of renal function 5.
Renal Artery Stenosis Management
- The management of renal artery stenosis is a subject of controversy, and optimal treatment approaches are still being debated 6.
- Restoration of blood flow alone may not improve renal or cardiovascular outcomes in patients with renal artery stenosis, and new approaches to treatment depend on a better understanding of the underlying mechanisms of chronic renal disease 6.
- Inflammation, oxidative stress, and interactions between the renin-angiotensin system play a critical role in the development and progression of renal damage in renal artery stenosis 6.