What is the recommended dose of losartan (Angiotensin II Receptor Antagonist) for patients with Chronic Kidney Disease (CKD)?

Losartan Dosing for Chronic Kidney Disease

Start losartan at 50 mg once daily and titrate to 100 mg once daily to achieve maximum renoprotective benefits in patients with CKD, as this is the dose proven effective in landmark clinical trials. 1, 2

Initial Dosing Strategy

• Begin with 50 mg once daily for all CKD patients, regardless of stage, as this represents the standard starting dose that balances efficacy with tolerability 1, 2
• The 50 mg starting dose can be administered as a single daily dose or divided into twice-daily dosing if needed 2
• No dose adjustment is required for mild to moderate renal impairment (eGFR ≥30 mL/min/1.73 m²) 2, 3

Target Dose for Renoprotection

• Titrate to 100 mg once daily as the target dose for optimal kidney protection, as this was the dose used in major renoprotective trials 1, 2
• The landmark RENAAL trial demonstrating reduced risk of doubling serum creatinine (hazard ratio 0.84, p=0.02) and ESRD (hazard ratio 0.72, p=0.002) used losartan 100 mg daily 4
• A dose-finding study in nondiabetic patients with nephrotic-range proteinuria found 100 mg daily achieved optimal antiproteinuric response (-30%), while 50 mg was less effective (-13%) and 150 mg provided no additional benefit 5
• Achieving at least 50% of target dose (50 mg for losartan) is associated with improved outcomes, but full target dosing is preferred 3

Monitoring Requirements

Check serum creatinine and potassium within 2-4 weeks of initiation or any dose increase 1, 2, 3

Key monitoring parameters:

• Accept up to 30% increase in serum creatinine within 4 weeks—this is expected hemodynamic effect and not a reason to discontinue 1, 2
• Monitor for hyperkalemia, but manage with potassium-lowering measures rather than stopping losartan when possible 1
• Assess for symptomatic hypotension and adjust accordingly 1

Dose Adjustments Based on CKD Stage

CKD Stages 1-3a (eGFR ≥45 mL/min/1.73 m²):

• No dose adjustment needed 2, 3
• Standard dosing: 50-100 mg daily 2

CKD Stages 3b-4 (eGFR 15-44 mL/min/1.73 m²):

• No mandatory dose reduction required 1
• Continue targeting 100 mg daily unless adverse effects occur 1
• A study in patients with moderate to severe renal insufficiency (GFR 10-29 mL/min/1.73 m²) showed effective blood pressure reduction (-14.1/-10.6 mmHg) with 50-100 mg daily and good tolerability 6

CKD Stage 5 (eGFR <15 mL/min/1.73 m²) including hemodialysis:

• Continue losartan even when eGFR falls below 30 mL/min/1.73 m² unless symptomatic hypotension or uncontrolled hyperkalemia develops 1
• Hemodialysis patients achieved significant blood pressure reduction (-22.7/-18.0 mmHg) with 50-100 mg daily with good tolerability 6

Special Populations

Patients with diabetes and macroalbuminuria:

• Start at 50 mg and increase to 100 mg once daily 1
• This population showed the greatest benefit in clinical trials, with losartan 100 mg reducing proteinuria by 35% and slowing GFR decline by 0.8 mL/min/year 4

Patients with proteinuria ≥2 g/day:

• Losartan 25-100 mg daily reduced proteinuria by approximately 24% regardless of baseline proteinuria level 7
• The antiproteinuric effect appears independent of blood pressure reduction 7

Common Pitfalls to Avoid

Don't underdose: The most critical error is failing to titrate to 100 mg daily—renoprotective benefits proven in trials were achieved at this dose, not lower doses 1, 5

Don't stop for mild creatinine increases: Up to 30% increase in serum creatinine within 4 weeks is expected and represents appropriate hemodynamic response, not kidney injury 1, 2

Don't discontinue prematurely for hyperkalemia: Manage potassium medically (dietary restriction, potassium binders, diuretics) before reducing or stopping losartan 1

Don't combine with ACE inhibitors: Dual RAS blockade increases risk of hyperkalemia and hypotension without additional renoprotective benefit 2, 3

When to Reduce or Discontinue

Consider dose reduction or discontinuation only for:

• Symptomatic hypotension that persists despite management 1, 2
• Uncontrolled hyperkalemia (>6 mEq/L) despite medical management 1, 6
• Serum creatinine rise >30% within 4 weeks of initiation or dose increase 2

Additional Considerations

• Losartan can be combined with hydrochlorothiazide 12.5 mg for additional proteinuria reduction through blood pressure-independent mechanisms 8
• Even in advanced renal insufficiency (baseline creatinine 2.2-5.5 mg/dL), losartan 25-50 mg daily significantly slowed progression rate 9
• Contraindicated in pregnancy 2