What is the best Angiotensin Receptor Blocker (ARB) to order for a patient with End-Stage Renal Disease (ESRD)?

Best ARB for End-Stage Renal Disease (ESRD)

For patients with ESRD, losartan is the preferred ARB based on pharmacokinetic data showing no dosage adjustment is required in dialysis-dependent renal failure, and it is not removed by dialysis. 1

Key Considerations for ARB Selection in ESRD

Pharmacokinetic Profile

• Losartan demonstrates optimal pharmacokinetics in ESRD patients, with minimal alteration in drug levels and no need for dose adjustment even in dialysis-dependent patients 1
• Both losartan and its active metabolite E-3174 are not dialyzable, eliminating the need for post-dialysis supplementation 1
• The standard dose of losartan 100 mg daily can be safely administered without modification in ESRD 1

Evidence-Based Renoprotection

While the primary question addresses ESRD (where kidney protection is no longer the goal), understanding the evidence base is important:

• Losartan has FDA approval specifically for nephropathy in type 2 diabetic patients, reducing progression to ESRD as measured by doubling of serum creatinine or need for dialysis/transplantation 2
• Irbesartan also has strong evidence from the IDNT trial, showing a 20% risk reduction in the composite endpoint of doubling serum creatinine, ESRD, or death in type 2 diabetic nephropathy patients 3
• Irbesartan reduced the occurrence of sustained doubling of serum creatinine by 33% versus placebo 3

Practical Considerations for ESRD

Important caveats for ARB use in ESRD:

• Monitor serum potassium closely - ARBs can increase potassium levels (mean increase 0.11 mEq/L), which is particularly concerning in ESRD patients already at risk for hyperkalemia 4
• Check for postural hypotension regularly when treating with ARBs, as ESRD patients may be volume-sensitive 5
• Avoid combining ACE inhibitors with ARBs - dual therapy increases adverse events (hyperkalemia, acute kidney injury) without additional benefit 5

Dosing Recommendations

For losartan in ESRD:

• Start with standard dosing (50-100 mg daily) without adjustment 1
• No supplemental dosing needed after hemodialysis 1
• Monitor blood pressure response and potassium levels within 1-2 weeks of initiation 1

For irbesartan (if chosen):

• Titrate to maintenance dose of 300 mg daily as tolerated 3
• 83% of patients in IDNT received target dose more than 50% of the time 3

When ARBs May Not Be Appropriate in ESRD

• Significant hyperkalemia risk (K+ >5.5 mEq/L) - consider alternative antihypertensives 5
• Severe hypotension or volume depletion - address volume status first 5
• Bilateral renal artery stenosis (though rare in ESRD patients already on dialysis)

Alternative Considerations

If blood pressure control is the primary goal in ESRD (rather than renoprotection, which is no longer relevant):

• Other antihypertensive classes may be equally appropriate 5
• Loop diuretics (if residual urine output exists) may help with volume management 6
• Calcium channel blockers or beta-blockers can be used as alternatives or in combination 5