Can losartan (Angiotensin II Receptor Antagonist) be used in patients with Chronic Kidney Disease (CKD) stage V, also known as End-Stage Renal Disease (ESRD)?

From the Guidelines

Losartan can be used in patients with Chronic Kidney Disease (CKD) stage V, but with careful monitoring and dose adjustment, as recommended in the guidelines 1. The use of losartan in CKD stage V requires careful consideration of the potential benefits and risks, including the risk of hyperkalemia and further kidney function decline.

• The recommended dose of losartan in patients with severe kidney disease (eGFR <30 ml/min/1.73m²) is often lower than standard, typically 25-50 mg once daily, with potential titration based on blood pressure response and tolerability 1.
• Regular monitoring of kidney function, potassium levels, and blood pressure is essential when using losartan in advanced CKD, with serum creatinine and potassium checks within 1-2 weeks of initiation or dose changes.
• Despite kidney disease, losartan may provide benefits by reducing proteinuria and potentially slowing CKD progression through its angiotensin II receptor blocking effects, as supported by recent guidelines 1. However, the risk of hyperkalemia and further kidney function decline increases in stage V CKD, and losartan should be discontinued if significant hyperkalemia (potassium >5.5 mEq/L) develops or if there's acute kidney injury.
• Nephrologist consultation is advisable before starting losartan in stage V CKD, especially in patients approaching or on dialysis, as management differs in these situations, and careful evaluation of the risk-benefit ratio is necessary 1.

From the FDA Drug Label

5.3 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

The use of losartan in patients with Chronic Kidney Disease (CKD) stage V, also known as End-Stage Renal Disease (ESRD), is not directly addressed in the provided drug labels. However, the labels do mention that patients with chronic kidney disease may be at particular risk of developing acute renal failure on losartan, and that renal function should be monitored periodically in these patients.

• Key considerations:
  • Monitor renal function
  • Risk of acute renal failure
  • Potential need to withhold or discontinue therapy if renal function decreases Based on the available information, it is not possible to draw a conclusion about the use of losartan in patients with CKD stage V or ESRD. 2 2

From the Research

Use of Losartan in Patients with CKD Stage V

• Losartan, an angiotensin II receptor antagonist, has been studied in patients with chronic kidney disease (CKD) for its efficacy and safety 3, 4, 5, 6.
• While there is evidence to suggest that losartan can be used in patients with CKD, its use in patients with CKD stage V, also known as end-stage renal disease (ESRD), is not well established 4.
• A study published in 1998 found that losartan may cause renal dysfunction in patients with underlying renal pathology, and its use should be avoided in patients with bilateral renal artery stenosis or unilateral renal artery stenosis in a solitary kidney 4.
• However, another study published in 2000 found that losartan can be used in patients with mild to moderate renal dysfunction without requiring dosage adjustment, and its renal tolerability is similar to that of captopril 7.
• A more recent study published in 2012 found that losartan 50 mg can provide renoprotective effects in normotensive Chinese patients with nondiabetic stage 3 CKD, without changing blood pressure 6.
• The use of losartan in patients with CKD stage V should be approached with caution, and renal function should be closely monitored 4, 5.

Key Considerations

• Losartan can cause renal dysfunction in patients with underlying renal pathology 4.
• The use of losartan in patients with CKD stage V should be individualized, and renal function should be closely monitored 4, 5.
• Losartan may be a viable alternative to ACE inhibitors in patients with CKD, but its use should be approached with caution 4, 5.