ARB Starting Dose in ESRD
For patients with End-Stage Renal Disease (ESRD) on hemodialysis, start losartan at 50 mg once daily without dose adjustment, as ARBs are not removed by dialysis and this dose has been proven safe and effective in this population. 1
Evidence-Based Dosing in ESRD
The standard starting dose for losartan in ESRD patients, including those on hemodialysis, is 50 mg once daily 2. This recommendation is supported by:
Clinical trial data demonstrating safety and efficacy: In a study of 112 hypertensive patients with renal impairment, including 28 on hemodialysis, losartan 50 mg once daily effectively reduced blood pressure (systolic/diastolic reductions of -17.0/-12.7 mm Hg at week 4, progressing to -22.7/-18.0 mm Hg at week 12) with excellent tolerability 1
No dose adjustment required: Losartan and its active metabolite E-3174 are not removed during hemodialysis, eliminating the need for post-dialysis supplementation 3
Pharmacokinetic stability: The pharmacokinetics of losartan remain linear and dose-proportional across various degrees of renal insufficiency, with no clinically significant changes requiring dose modification 3
Titration Strategy
After initiating at 50 mg daily, the dose can be increased to 100 mg once daily after 4 weeks if blood pressure remains elevated (sitting diastolic BP ≥90 mm Hg or reduction <5 mm Hg) 1. This titration approach was well-tolerated even in patients with severe renal impairment and those on hemodialysis 1.
For patients requiring maximum renoprotective benefits (though less relevant in ESRD), target doses of 100 mg daily have been used in clinical trials 2, 4.
Critical Monitoring Parameters
Within 2-4 weeks of initiation, monitor 4:
- Serum potassium (discontinue if >6 mEq/L)
- Serum creatinine
- Blood pressure for symptomatic hypotension
Key safety finding: In the renal impairment study, hyperkalemia requiring discontinuation occurred in only 1 of 112 patients, demonstrating excellent tolerability 1.
Common Pitfalls to Avoid
Do not reduce the starting dose below 50 mg based solely on ESRD status—this population tolerates standard dosing well 1
Do not withhold ARBs in hemodialysis patients due to concerns about drug removal—losartan is not dialyzed and maintains therapeutic levels 3
Do not assume all ARBs require adjustment: While some medications need dose reduction in ESRD, losartan specifically does not require initial dose modification 3, 1
Alternative ARB Options
If using other ARBs in ESRD 2:
- Candesartan: Start at 4-8 mg once daily
- Valsartan: Start at 40 mg twice daily
These doses represent the evidence-based starting points from heart failure trials, though specific ESRD dosing data is most robust for losartan 2.