Can telmisartan (angiotensin II receptor blocker) be given in patients with Acute Kidney Injury (AKI)?

Telmisartan Should Not Be Given in Acute Kidney Injury

Telmisartan (an angiotensin II receptor blocker) should not be given to patients with acute kidney injury (AKI) as it can worsen kidney function and increase the risk of complications. 1

Mechanism of ARB-Related Kidney Injury in AKI

• ARBs like telmisartan directly affect renal hemodynamics by blocking angiotensin II receptors, which decreases glomerular filtration pressure and can further compromise already impaired kidney function in AKI patients 1
• As a consequence of inhibiting the renin-angiotensin-aldosterone system, telmisartan can cause changes in renal function in susceptible individuals, particularly those with severe heart failure or existing renal dysfunction 2
• In patients whose renal function depends on the activity of the renin-angiotensin-aldosterone system, ARBs have been associated with oliguria, progressive azotemia, and rarely acute renal failure 2

Evidence Supporting Discontinuation in AKI

• The FDA drug label for telmisartan specifically warns about impaired renal function as a potential adverse effect, noting that changes in renal function should be anticipated in susceptible individuals 2
• Patients with AKI who continue taking RAS blockers (including ARBs) during hospitalization have been shown to have longer hospital stays and higher mortality rates compared to those who discontinue these medications 3
• Case reports document AKI and dangerous hyperkalemia with ECG changes in patients taking telmisartan, particularly when combined with other medications that affect kidney function 4

Risk Factors for ARB-Related Kidney Injury

• Patients with pre-existing chronic kidney disease are at higher risk for developing worsening kidney function when taking ARBs during acute illness 3
• Hypotension during hospitalization significantly increases the risk of AKI in patients continuing RAS blockers 3
• Concurrent use of other nephrotoxic medications (particularly NSAIDs like diclofenac) with telmisartan can precipitate AKI and dangerous hyperkalemia 4
• Surgical procedures increase the risk of AKI in patients maintained on ARBs 3

Alternative Antihypertensive Options During AKI

• Calcium channel blockers (particularly dihydropyridines like amlodipine) have minimal effects on renal hemodynamics and can be used as alternatives during AKI episodes 1
• Beta-blockers can be considered if the patient has concomitant ischemic heart disease or heart failure 1
• If diuretics are needed, loop diuretics (e.g., furosemide) are preferred in patients with moderate-to-severe kidney dysfunction 1

Considerations for Restarting ARBs After AKI Resolution

• ARBs should only be reintroduced after GFR has stabilized and volume status is optimized 1
• When restarting, begin with lower doses and titrate slowly while monitoring renal function and potassium levels 1
• The decision to reintroduce ARBs after AKI resolution should be individualized based on the patient's underlying conditions 1
• In patients with proteinuria and stable kidney function, telmisartan has demonstrated benefits in reducing proteinuria and blood pressure, but should only be used after complete resolution of AKI 5

Monitoring Recommendations When Using ARBs

• Monitor serum creatinine and potassium levels closely when initiating or adjusting ARB therapy, especially in patients with risk factors for AKI 2
• Consider periodic determinations of serum electrolytes to detect possible electrolyte imbalances, particularly hyperkalemia 2
• If signs of worsening renal function develop, the ARB should be promptly discontinued as several case reports suggest that ARB-induced renal dysfunction is typically reversible upon discontinuation 6