Starting Dose of Losartan for ESRD
For patients with end-stage renal disease (ESRD), losartan can be initiated at the standard starting dose of 25-50 mg once daily without dose adjustment, as the drug and its active metabolite are not removed by hemodialysis and no dosage modification is required for renal impairment. 1, 2
Dosing Recommendations
- No dose adjustment is necessary for losartan in patients with ESRD or any degree of renal insufficiency, including those on hemodialysis 1, 2
- The standard starting dose is 25-50 mg once daily, which can be titrated up to a maximum of 100 mg daily based on blood pressure response and tolerability 1, 3
- Losartan and its active metabolite E 3174 are not removed during hemodialysis, eliminating the need for supplemental dosing after dialysis sessions 2
Titration Strategy
- Target at least 50 mg daily (50% of the maximum target dose of 100 mg) to achieve optimal cardiovascular and renal protective benefits 4, 1
- Titration should occur gradually, with the American College of Cardiology recommending dose increases no more frequently than every 2 weeks 4
- The therapeutic range of 50-100 mg daily has been extensively studied in patients with diabetic nephropathy and demonstrated significant renal protection 3, 5
Critical Monitoring Parameters
- Monitor serum creatinine and potassium within 2-4 weeks after initiating therapy or increasing the dose 1
- Hyperkalemia risk is elevated in ESRD patients taking ARBs; potassium levels require particularly close attention 1
- Blood pressure should be monitored to assess therapeutic response and guide titration 3
Important Precautions
- Avoid combining losartan with ACE inhibitors or direct renin inhibitors due to substantially increased risk of hyperkalemia and hypotension in ESRD patients 1
- While losartan is generally well tolerated, the risk of hyperkalemia necessitates vigilant electrolyte monitoring in the ESRD population 1, 5
- Despite ESRD, the pharmacokinetics remain linear and dose-proportional, supporting standard dosing practices 2
Evidence Base
The landmark RENAAL trial demonstrated that losartan 50-100 mg daily significantly reduced progression to ESRD, doubling of serum creatinine, and death in patients with type 2 diabetes and nephropathy, with a 16% risk reduction for the composite primary endpoint (p=0.02) 5. This benefit was independent of blood pressure reduction, supporting the renoprotective mechanism of ARBs 5, 6. The drug was well tolerated with discontinuation rates similar to placebo 3.