What adjustments should be made to the treatment plan for a patient with uncontrolled hypertension and stage IIIa chronic kidney disease, currently taking Losartan and Omeprazole?

Treatment Adjustment for Uncontrolled Hypertension with Stage IIIa CKD

Increasing losartan from 50mg to 100mg once daily is the correct first step for this patient with uncontrolled hypertension (180/90 mmHg) and stage IIIa CKD (eGFR 52 mL/min/1.73m²), as dose optimization of the current ARB should precede adding a third agent. 1

Rationale for Losartan Dose Escalation

• The 2024 ESC guidelines recommend optimizing doses of existing antihypertensive medications before adding additional drug classes in patients with CKD 1
• Losartan 100mg is the maximum recommended daily dose for hypertension and has demonstrated efficacy in patients with renal impairment without requiring dose adjustment 2
• In hypertensive patients with stage 3 CKD, losartan 100mg provides superior blood pressure reduction and renoprotection compared to lower doses 3, 4

Blood Pressure Targets in CKD

• For patients with non-diabetic CKD and eGFR >30 mL/min/1.73m², target systolic BP should be 120-129 mmHg if tolerated, though individualized treatment is recommended based on tolerability and impact on renal function 1
• The minimum acceptable target is <140/90 mmHg, with an optimal target of <130/80 mmHg for patients with CKD 1
• This patient's current BP of 180/90 mmHg represents stage 2 hypertension requiring immediate intensification 1

Renoprotective Benefits of ARBs in CKD

• RAS blockers like losartan are more effective at reducing albuminuria than other antihypertensive agents and are recommended as part of the treatment strategy in hypertensive patients with kidney disease 1
• Losartan has demonstrated renoprotective effects independent of blood pressure reduction in patients with proteinuric CKD, reducing urinary protein excretion by approximately 24% 5
• The antiproteinuric effect is maintained across different levels of baseline proteinuria 5

Safety Considerations in Stage IIIa CKD

• No dose adjustment of losartan is necessary in patients with renal impairment (including eGFR 52 mL/min/1.73m²) unless the patient is also volume depleted 2
• Monitor serum creatinine and potassium 2-4 weeks after dose escalation to detect potential hyperkalemia or acute changes in renal function 1
• Hyperkalemia (>6 mEq/L) requiring discontinuation is rare, occurring in only 1 patient out of 112 in studies of hypertensive patients with chronic renal disease 3

Next Steps if BP Remains Uncontrolled

• If blood pressure remains ≥140/90 mmHg after 2-4 weeks on losartan 100mg, add a calcium channel blocker (amlodipine 5-10mg daily) as the second agent 1, 6
• The combination of ARB + calcium channel blocker represents guideline-recommended dual therapy for patients with CKD 1, 6
• If triple therapy is needed, add a thiazide-like diuretic (chlorthalidone 12.5-25mg or hydrochlorothiazide 12.5-25mg) as the third agent 1, 6

Important Monitoring Parameters

• Recheck blood pressure within 2-4 weeks after increasing losartan to 100mg 1
• Monitor serum potassium and creatinine at 2-4 weeks to assess for hyperkalemia and changes in renal function 1
• The goal is to achieve target blood pressure within 3 months of treatment modification 6
• Continue strict BP monitoring as already prescribed 1

Common Pitfalls to Avoid

• Do not add a third drug class before maximizing the dose of losartan to 100mg—this violates guideline-recommended stepwise approaches 6
• Do not assume treatment failure without first confirming medication adherence, as non-adherence is the most common cause of apparent treatment resistance 7
• Avoid combining losartan with an ACE inhibitor due to increased adverse events without additional benefit 1
• Do not use potassium-sparing diuretics or potassium supplements without close monitoring given the risk of hyperkalemia with ARBs in CKD 1

Additional Considerations for This Patient

• The patient's low HDL (31 mg/dL) and borderline LDL (95 mg/dL) should be addressed with lifestyle modifications including dietary changes and exercise 1
• Sodium restriction to <2g/day can provide additive blood pressure reduction of 10-20 mmHg 6
• The omeprazole dose increase to 40mg twice daily is appropriate for GERD management and does not have clinically significant interactions with losartan 8