Starting Losartan in Patients with Chronic Kidney Disease
For patients with CKD, start losartan at 50 mg once daily and titrate to 100 mg once daily based on blood pressure response and tolerability, with careful monitoring of serum creatinine and potassium within 2-4 weeks of initiation. 1
Initial Dosing Strategy
- Standard starting dose: 50 mg once daily for most CKD patients with hypertension 1
- Target dose: 100 mg once daily to achieve maximum renoprotective benefits, as clinical trials demonstrating kidney protection used these higher doses 2
- Consider starting at 25 mg once daily only if the patient has possible intravascular volume depletion (e.g., concurrent diuretic therapy) or hepatic impairment 1
Specific CKD Indications and Dosing
For CKD with Albuminuria
- Moderately to severely increased albuminuria (A2-A3) with diabetes: Start at 50 mg, increase to 100 mg once daily 2
- Severely increased albuminuria (A3) without diabetes: Start at 50 mg, increase to 100 mg once daily 2
- The RENAAL trial demonstrated that losartan 100 mg daily reduced doubling of serum creatinine, ESKD, and death by 16% each in patients with type 2 diabetes and proteinuria >1 g/day 2
For Advanced CKD (eGFR <30 mL/min/1.73 m²)
- No dose adjustment required based on renal function alone 1, 3
- Continue losartan even when eGFR falls below 30 mL/min/1.73 m², unless symptomatic hypotension or uncontrolled hyperkalemia develops 2
- Studies confirm efficacy and safety in patients with moderate to severe renal insufficiency (eGFR 10-29 mL/min/1.73 m²) at doses of 50-100 mg daily 3
Monitoring Requirements
Critical monitoring timeframe: 2-4 weeks after initiation or dose increase 2
Check the following parameters:
- Serum creatinine: Accept up to 30% increase within 4 weeks; if exceeds 30%, consider dose reduction or discontinuation 2
- Serum potassium: Monitor for hyperkalemia; manage with potassium-lowering measures rather than stopping losartan when possible 2
- Blood pressure: Assess for symptomatic hypotension 2
Dose Titration Algorithm
- Week 0: Start losartan 50 mg once daily 1
- Week 2-4: Check creatinine, potassium, and blood pressure 2
- Week 4-8: If blood pressure not at goal (<130/80 mmHg for CKD) and tolerating well, increase to 100 mg once daily 2, 1
- Week 6-8: Recheck creatinine and potassium after dose increase 2
- Ongoing: Continue 100 mg daily as the maintenance dose for maximum renoprotection 2
Combination Therapy Considerations
- Adding hydrochlorothiazide 12.5 mg daily to losartan 50-100 mg can provide additional blood pressure reduction and antiproteinuric effects in CKD patients 4, 5
- This combination reduced proteinuria more effectively than losartan alone in stage 3 CKD patients, even when blood pressure was similarly controlled 4, 5
- The low-dose thiazide (12.5 mg) minimizes metabolic adverse effects while enhancing renoprotection 4
Common Pitfalls to Avoid
- Don't stop losartan for mild creatinine increases (<30%): This is expected and does not indicate harm 2
- Don't underdose: The proven renoprotective benefits in trials were achieved with 100 mg daily, not lower doses 2
- Don't discontinue prematurely for hyperkalemia: Manage potassium medically (dietary restriction, potassium binders) before reducing or stopping losartan 2
- Don't avoid in advanced CKD: Losartan remains beneficial even with eGFR <30 mL/min/1.73 m² and can be continued until dialysis initiation 2, 3
Special Populations
Hepatic Impairment
- Start at 25 mg once daily in mild-to-moderate hepatic impairment 1
- Losartan has not been studied in severe hepatic impairment 1
Pediatric CKD
- Not recommended in children <6 years or with eGFR <30 mL/min/1.73 m² 1
- For eligible children: start at 0.7 mg/kg once daily (maximum 50 mg), titrate to maximum 1.4 mg/kg (not exceeding 100 mg) 1