Can an Angiotensin Receptor Blocker (ARB) blood pressure medication be given to a patient with acute kidney injury?

ARBs Should Be Avoided in Patients with Acute Kidney Injury

ARBs should be avoided in patients with acute kidney injury (AKI) as they can exacerbate kidney dysfunction and increase the risk of acute kidney disease (AKD). 1

Mechanism and Risks

• ARBs directly affect renal hemodynamics by blocking angiotensin II receptors, which can decrease glomerular filtration pressure and further compromise already impaired kidney function in AKI patients 1
• ARBs are recognized as potential nephrotoxins that should be avoided when a patient has AKI, especially when alternative antihypertensive medications with less nephrotoxic potential are available 1
• The FDA label for losartan (an ARB) specifically warns about renal function deterioration, stating: "Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system" 2

When to Avoid ARBs in AKI

ARBs should be avoided in AKI patients when:

• The patient has known risk factors for kidney injury (advanced age, previous AKI episodes, CKD, diabetes, proteinuria, hypertension) 1
• A suitable and less nephrotoxic alternative is available 1
• The ARB is considered non-essential for the patient's condition 1
• The patient is already receiving another nephrotoxic drug 1
• There is concern about lack of appropriate follow-up of serum creatinine and/or drug concentration monitoring 1

Alternative Antihypertensive Options for AKI Patients

For patients with AKI requiring blood pressure management, consider these alternatives:

• Calcium channel blockers (CCBs), particularly dihydropyridines like amlodipine, which have minimal effects on renal hemodynamics 1
• Thiazide-like diuretics (e.g., chlorthalidone) in mild-moderate AKI, though they should be used with caution 1
• Loop diuretics (e.g., furosemide) for patients with volume overload, which are preferred in patients with moderate-to-severe kidney dysfunction 1
• Beta-blockers if the patient has concomitant ischemic heart disease or heart failure 1

Special Considerations

• If the patient was previously on an ARB, it should be discontinued during the AKI episode and potentially reintroduced only after GFR has stabilized and volume status is optimized 1
• Patients on ARBs who develop AKI have a higher risk of hyperkalemia, which requires close monitoring 3
• Some recent research suggests potential benefits of ARB continuation after AKI resolution in specific populations, but this remains controversial and should not override the recommendation to avoid ARBs during active AKI 3, 4

Monitoring if ARB Cannot Be Avoided

If an ARB must be used in a patient with AKI (e.g., in cases of severe heart failure where benefits may outweigh risks):

• Monitor renal function (serum creatinine, eGFR) frequently 2
• Check serum potassium levels regularly 2
• Consider withholding or discontinuing therapy if there is a clinically significant decrease in renal function 2
• Ensure the patient is not volume depleted; correct volume depletion before ARB administration 2

Resuming ARBs After AKI Resolution

• Consider reintroducing ARBs only after GFR has stabilized and volume status is optimized 1
• Start with lower doses and titrate slowly while monitoring renal function and potassium levels 1
• The risk-benefit ratio must be carefully considered and therapy personalized according to individual patient risks 1

Remember that while ARBs have established benefits in chronic conditions like hypertension, heart failure, and CKD with proteinuria, these benefits may not apply during acute kidney injury, and the risks likely outweigh potential benefits during active AKI 1.