From the Guidelines
An eGFR of 33 indicates moderate to severe chronic kidney disease (CKD stage 3b), and prompt referral to a nephrologist for specialized care and monitoring is essential. According to the most recent guidelines, patients with CKD stage 3b should have their eGFR reassessed at clinically relevant intervals, more often the lower the eGFR, and the higher the albuminuria at baseline 1.
Key Interventions
- Controlling blood pressure is crucial, with a target of less than 130/80 mmHg, using ACE inhibitors or ARBs if appropriate 1.
- Managing diabetes is also critical, aiming for an HbA1c around 7% 1.
- Dietary modifications are important, including limiting sodium to less than 2 grams daily, moderating protein intake to 0.8 g/kg/day, and avoiding nephrotoxic medications like NSAIDs.
- Regular lab monitoring every 3-6 months is necessary to track kidney function, electrolytes, and anemia 1.
Medication Considerations
- For patients with type 2 diabetes and CKD, metformin should be considered the first-line treatment, but its use should be guided by eGFR, with contraindication at eGFR < 30 mL/min/1.73 m2 1.
- SGLT2 inhibitors and GLP-1 RAs should be considered for patients with type 2 diabetes and CKD who require another drug added to metformin or cannot use or tolerate metformin, as they reduce risks of CKD progression, CVD events, and hypoglycemia 1.
Complications and Monitoring
- Patients with CKD stage 3b are at higher risk for complications like anemia, bone disease, and cardiovascular problems, and regular monitoring is essential to detect these complications early 1.
- Evaluation of elevated blood pressure and volume overload should occur at every clinical contact, with laboratory evaluations generally indicated every 3-5 months for stage 4 CKD, and every 1-3 months for stage 5 CKD, or as indicated to evaluate symptoms or changes in therapy 1.
From the FDA Drug Label
5.3 Renal Function Deterioration Changes in renal function including acute renal failure can be caused by drugs that inhibit the renin-angiotensin system and by diuretics. Patients whose renal function may depend in part on the activity of the renin-angiotensin system (e.g., patients with renal artery stenosis, chronic kidney disease, severe congestive heart failure, or volume depletion) may be at particular risk of developing acute renal failure on losartan. Monitor renal function periodically in these patients Consider withholding or discontinuing therapy in patients who develop a clinically significant decrease in renal function on losartan
7.3 Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) Including Selective Cyclooxygenase-2 Inhibitors (COX-2 Inhibitors) In patients who are elderly, volume-depleted (including those on diuretic therapy), or with compromised renal function, coadministration of NSAIDs, including selective COX-2 inhibitors, with angiotensin II receptor antagonists (including losartan) may result in deterioration of renal function, including possible acute renal failure. These effects are usually reversible. Monitor renal function periodically in patients receiving losartan and NSAID therapy.
The patient has an eGFR of 33, which indicates compromised renal function.
- Losartan may cause a decrease in renal function, and patients with compromised renal function are at a higher risk of developing acute renal failure.
- Monitoring of renal function is recommended for patients taking losartan, especially those with compromised renal function.
- NSAIDs should be used with caution in patients taking losartan, as they may increase the risk of renal function deterioration.
- Consider withholding or discontinuing losartan therapy if the patient develops a clinically significant decrease in renal function 2.
From the Research
eGFR 33 Overview
- eGFR (estimated Glomerular Filtration Rate) is a measure of kidney function, with a value of 33 indicating moderate to severe kidney disease.
- Several studies have investigated the effects of various medications on kidney function, including losartan, an angiotensin II receptor blocker (ARB) 3, 4, 5, 6, 7.
Medications and Kidney Function
- Losartan has been shown to have similar effects to enalapril on systemic blood pressure, renal function, and serum uric acid in patients with chronic kidney disease (CKD), but carries a higher risk of dry cough 3.
- The long-term effect of losartan on kidney disease in patients with type 2 diabetes has been investigated, with results suggesting that early administration of losartan does not significantly slow the progression of diabetic kidney disease over an extended period 4.
- Dual renin-angiotensin system blockade, which includes losartan, has been associated with an increased risk of acute kidney injury (AKI) compared to monotherapy, but AKI in the setting of monotherapy was associated with lower rates of recovery of kidney function, higher mortality, and higher risk of progression of kidney disease 5.
- High-dose losartan has been shown to be associated with an increased risk of acute rise in serum creatinine and greater long-term reductions in eGFR, but retains its net clinical benefit and is associated with reduced risk of death or hospitalization for heart failure 6.
- Individual responses to losartan and empagliflozin, a sodium glucose cotransporter inhibitor (SGLT2i), have been investigated, with results showing large individual variability in response to treatment with these medications 7.
Implications for Patients with eGFR 33
- Patients with an eGFR of 33 should be closely monitored for changes in kidney function and should discuss their treatment options with their healthcare provider.
- Losartan and other medications may be effective in slowing the progression of kidney disease, but individual responses to treatment can vary greatly 7.
- Clinicians should consider switching from one kidney protective drug to another in non-responders, and patients should be aware of the potential risks and benefits of different medications 7.