What is the recommended dose of Angiotensin Receptor Blocker (ARB) for kidney protection?

Recommended ARB Dosing for Kidney Protection

For kidney protection, start with losartan 50 mg daily (or equivalent ARB dose) and uptitrate to the maximum tolerated dose of 100 mg daily after 4-8 weeks if proteinuria remains elevated and the medication is well tolerated. 1, 2

Initial Dosing Strategy

• Start with losartan 50 mg once daily as the initial dose for patients with proteinuria and CKD, regardless of blood pressure status. 1
• For patients with CKD stage 4 (eGFR 15-29 mL/min/1.73 m²), consider starting at a lower dose of 2.5 mg lisinopril (if using an ACE inhibitor) or equivalent reduced ARB dose, then titrate upward. 2
• The goal is to reach maximum approved doses (losartan 100 mg daily, irbesartan 300 mg daily, or telmisartan 80 mg daily) because renoprotective benefits in clinical trials were achieved at these higher doses. 1, 2

Uptitration Protocol

• Uptitrate to losartan 100 mg daily after 4-8 weeks if proteinuria remains above target levels and the initial 50 mg dose is well tolerated. 1
• The 100 mg dose provides optimal antiproteinuric effect (30% reduction in proteinuria), while 50 mg is less effective (13% reduction) and 150 mg provides no additional benefit. 3, 4
• Check serum creatinine, eGFR, and potassium levels within 2-4 weeks of initiation or any dose increase. 1, 2

Critical Monitoring Parameters

• Accept up to 30% increase in serum creatinine within 4 weeks of starting or increasing the ARB dose—this reflects beneficial hemodynamic changes from reduced intraglomerular pressure and is not a reason to discontinue. 5, 1, 2
• Stop or reduce the ARB only if serum creatinine rises by more than 30%, continues to worsen beyond 4 weeks, or if refractory hyperkalemia develops. 5, 1
• Monitor blood pressure to ensure adequate control without symptomatic hypotension. 1

Blood Pressure Targets While on ARB Therapy

• Target systolic blood pressure <120 mm Hg using standardized office measurement in patients with proteinuria, as lower targets provide additional renoprotection. 5, 6
• If the patient cannot tolerate BP <120 mm Hg, aim for <130/80 mm Hg as an alternative target in proteinuric patients. 6, 2

Continuation at Low eGFR

• Continue the ARB even when eGFR falls below 30 mL/min/1.73 m² unless not tolerated, as discontinuation removes cardiovascular and renal protection. 1, 2
• Do not discontinue prematurely when creatinine rises modestly, as this is an expected hemodynamic effect. 2

Enhancing ARB Effectiveness

• Restrict dietary sodium to <2.0 g/day (<90 mmol/day) to enhance the antiproteinuric effect of ARBs. 5, 1, 6
• Instruct patients to temporarily hold the ARB during volume depletion (acute illness with vomiting/diarrhea, excessive diuresis). 5, 1

Common Pitfalls to Avoid

• Never combine an ACE inhibitor with an ARB—this increases risks of hyperkalemia and acute kidney injury without additional benefits. 5, 2
• Do not use suboptimal doses (e.g., staying at 25-50 mg losartan long-term)—the renoprotective benefit is dose-dependent up to 100 mg daily. 3, 4
• Do not stop the ARB for modest creatinine increases <30% or for declining eGFR alone, as this removes kidney protection. 1, 2

Equivalent Dosing for Other ARBs

While losartan is most studied, equivalent maximum renoprotective doses for other ARBs include:

• Irbesartan 300 mg daily 5
• Telmisartan 80 mg daily 5
• Valsartan 320 mg daily 5

Special Populations

• In normotensive patients with proteinuria, use the same dosing strategy (start 50 mg, uptitrate to 100 mg) as ARBs provide blood pressure-independent antiproteinuric effects. 7, 8
• In diabetic patients with albuminuria 30-299 mg/24h, either an ACE inhibitor or ARB at maximum tolerated dose is recommended. 5
• In diabetic or non-diabetic patients with albuminuria ≥300 mg/24h, an ACE inhibitor or ARB at maximum tolerated dose is strongly recommended. 5