What are the next steps for a 56-year-old male with Chronic Kidney Failure (CKF), noncompliant with treatment, presenting with lower extremity edema and hypertension, currently on Carvedilol (Beta Blocker) 6.25 MG, Losartan Potassium (Angiotensin II Receptor Antagonist) 50 MG, and recently started on Lasix (Furosemide) 20mg twice daily?

Management of CKD Patient with Edema, Hypertension, and Hyperkalemia at 2-Week Follow-Up

Your immediate priority is to optimize the furosemide dosing to scheduled twice-daily administration (rather than PRN), increase the losartan dose toward target, monitor electrolytes closely within 1-2 weeks, and strongly consider adding an SGLT2 inhibitor given the patient's CKD and cardiovascular risk profile. 1, 2

Optimize Diuretic Regimen

Convert furosemide from PRN to scheduled dosing at 20-40mg twice daily to achieve more consistent diuresis and better edema control. 2, 3 The current 20mg twice daily is appropriate as a starting point, but you should:

• Increase furosemide by 20mg increments every 6-8 hours until desired diuresis is achieved if edema persists, with doses up to 600mg/day possible in severe cases. 1, 3
• Twice-daily dosing is superior to once-daily for maintaining consistent fluid balance in CKD patients. 2
• Monitor daily weights and instruct the patient to adjust diuretic dose within a specified range based on weight changes to improve adherence. 1

Address Noncompliance and Sodium Restriction

Implement strict sodium restriction to <2g/day as this is critical for diuretic efficacy and blood pressure control. 1, 2 Noncompliance is likely contributing to both edema and hyperkalemia:

• Patient education is essential: Explain the direct relationship between sodium intake, fluid retention, and medication effectiveness. 1
• Daily self-weighing with written instructions on when to contact you can detect early decompensation. 1
• Avoid potassium-containing salt substitutes given the hyperkalemia risk with losartan. 4

Optimize RAS Inhibition

Increase losartan toward the maximum tolerated dose (typically 100mg daily) as current 50mg dosing is suboptimal for renoprotection in CKD. 1, 5

• KDIGO 2024 guidelines recommend using the highest approved dose of RAS inhibitors to achieve proven benefits in CKD with albuminuria. 1
• Check serum creatinine and potassium 2-4 weeks after dose increase, accepting up to 30% creatinine rise unless symptomatic. 1
• Continue losartan even if eGFR falls below 30 ml/min/1.73m² unless uncontrolled hyperkalemia or symptomatic hypotension develops. 1

Manage Hyperkalemia

Do NOT discontinue losartan for hyperkalemia unless potassium >6.0 mEq/L or refractory to treatment. 1, 6 Instead:

• Optimize furosemide dosing first as loop diuretics promote potassium excretion and may resolve mild hyperkalemia. 2, 3
• Ensure sodium restriction compliance as volume overload can worsen hyperkalemia. 2
• If potassium remains 5.5-6.0 mEq/L despite optimization, consider adding a potassium binder (patiromer or sodium zirconium cyclosilicate) rather than reducing losartan. 6
• Avoid potassium supplements given the patient is on losartan. 6, 4

Add SGLT2 Inhibitor

Strongly consider initiating an SGLT2 inhibitor if eGFR ≥20 ml/min/1.73m², as this is a 1A recommendation from KDIGO 2024 for adults with CKD. 1

• SGLT2 inhibitors provide mortality and renal protection benefits independent of diabetes status when ACR ≥200 mg/g or heart failure is present. 1
• Continue SGLT2i even if eGFR falls below 20 once initiated, unless not tolerated. 1
• The reversible eGFR decrease on initiation is not an indication to stop therapy. 1

Monitoring Protocol

Check electrolytes (especially potassium), creatinine, and BUN within 1-2 weeks given the medication adjustments and hyperkalemia. 1, 2, 3

• Recheck at 3 months, then every 6 months once stable. 1, 6
• More frequent monitoring is needed given noncompliance history and CKD. 2, 3
• Monitor for signs of volume depletion (hypotension, dizziness, worsening renal function) but don't let excessive concern about azotemia prevent adequate diuresis. 1

Optimize Beta-Blocker Dosing

Consider increasing carvedilol from 6.25mg as this is a very low dose and may not provide adequate cardiovascular protection. 1

• Target doses shown effective in trials should be the goal unless limited by side effects. 1
• Beta-blockers reduce mortality in CKD patients with cardiovascular disease. 1

Critical Pitfalls to Avoid

• Do not use thiazide diuretics with eGFR <30 ml/min except synergistically with loop diuretics in refractory cases. 1
• Avoid NSAIDs completely as they worsen renal function, reduce diuretic efficacy, and increase hyperkalemia risk. 1, 3, 4
• Do not add potassium-sparing diuretics (spironolactone, amiloride) given hyperkalemia and losartan use. 1, 6
• Persistent volume overload limits efficacy and safety of other HF medications - adequate diuresis is the cornerstone of successful treatment. 1
• Underutilization of diuretics due to excessive concern about hypotension/azotemia leads to refractory edema. 1

Address Noncompliance Directly

Close follow-up is essential given the noncompliance history. 1

• Schedule 2-week follow-up to assess response and reinforce adherence. 2
• Consider involving family members or social work if adherence barriers persist. 1
• Simplify regimen where possible but don't compromise necessary therapy. 1