How to manage a 71-year-old male with hypertension on olmisartan, presenting with impaired renal function, hypertension, and elevated conjugated bilirubin?

Management of Decreased GFR in a 71-Year-Old Male with Hypertension on Olmisartan

Discontinue olmisartan immediately and switch to an alternative antihypertensive medication due to the significant decline in renal function, which is likely related to ARB use in this elderly patient with uncontrolled hypertension. 1, 2

Assessment of Current Situation

• The patient has experienced a significant drop in GFR from 89 to 61 ml/min/1.73m², which is consistent with acute kidney injury likely related to olmisartan therapy 1
• Blood pressure remains uncontrolled at 160/108 mmHg despite olmisartan treatment 2
• Elevated conjugated bilirubin (5) with normal indirect bilirubin suggests potential hepatobiliary issues that should be investigated separately 3
• The combination of hypertension, anxiety disorder, and declining renal function requires prompt intervention 2

Immediate Management Steps

• Stop olmisartan immediately as ARBs can cause acute kidney injury, especially in patients with possible renal artery stenosis or volume depletion 1, 4
• Check for volume status and hydrate the patient if signs of volume depletion are present 1
• Monitor serum electrolytes, particularly potassium, as ARBs can cause hyperkalemia 1
• Measure urine albumin-to-creatinine ratio to assess for proteinuria, which would indicate kidney damage 2
• Consider renal ultrasound with Doppler to evaluate for renal artery stenosis, which is common in elderly patients with resistant hypertension 2

Alternative Antihypertensive Therapy

• For immediate blood pressure control, consider a calcium channel blocker (CCB) such as amlodipine, which is less likely to affect renal function 2
• Add a thiazide-like diuretic (e.g., chlorthalidone) if no contraindications exist, as this combination is recommended for elderly patients with hypertension 2
• Target blood pressure should be <130/80 mmHg, but not <120/70 mmHg to avoid hypoperfusion 2
• If the patient has proteinuria, consider reintroducing a RAS blocker at a lower dose once renal function stabilizes 3

Monitoring Plan

• Recheck renal function (creatinine and GFR) within 48-72 hours after stopping olmisartan 1
• Monitor blood pressure daily until stabilized 2
• Reassess liver function tests to evaluate the elevated conjugated bilirubin 3
• Follow up GFR and electrolytes weekly until stabilized, then monthly 2

Special Considerations

• In elderly patients (>65 years), ARBs like olmisartan have increased bioavailability and longer half-life, requiring lower dosing 5
• A transient decrease in GFR (up to 30%) can occur with ARBs but a drop from 89 to 61 is concerning and warrants medication change 3
• The combination of elevated blood pressure and declining renal function increases cardiovascular risk significantly 2
• Consider nephrology referral if renal function does not improve after stopping olmisartan 3

Potential Complications to Watch For

• Hyperkalemia is a common complication of ARB therapy, especially with declining renal function 1
• Renal artery stenosis should be suspected in elderly patients with acute kidney injury after starting ARBs 4, 2
• The patient may experience rebound hypertension after stopping olmisartan, requiring close monitoring 2
• Anxiety disorder may worsen with changes in medication and should be addressed concurrently 2

Long-term Management

• Once renal function stabilizes, consider a comprehensive cardiovascular risk assessment 2
• If renal function improves significantly, a lower dose of ARB may be reconsidered with careful monitoring 6
• Consider SGLT2 inhibitors if the patient has diabetes, as they provide renoprotection and cardiovascular benefits 2
• Regular monitoring of renal function at least every 3-6 months is recommended for patients with history of ARB-induced kidney injury 3