Losartan Use in Dialysis Patients
Yes, losartan can be safely prescribed to patients on dialysis without dose adjustment, as it is not removed by hemodialysis and has demonstrated efficacy and tolerability in this population. 1, 2
Pharmacokinetic Rationale
The FDA label explicitly states that "neither losartan nor its active metabolite can be removed by hemodialysis," which is the fundamental basis for its use in dialysis patients 1. This finding was confirmed in clinical pharmacokinetic studies showing that losartan and its active metabolite E-3174 have negligible dialysability during standard 4-hour hemodialysis sessions 2.
No dose adjustment is required for dialysis patients, and no post-dialysis supplementation is needed. 1, 2
Clinical Evidence Supporting Use
Blood Pressure Control
- Losartan 50-100 mg once daily effectively reduced blood pressure in hemodialysis patients, with mean reductions of -22.7/-18.0 mm Hg (systolic/diastolic) at 12 weeks 3
- A large multicenter study of 406 hemodialysis patients demonstrated significant reductions in both pre- and post-dialysis blood pressure at 3 and 6 months 4
Renoprotective Effects in Pre-Dialysis CKD
While dialysis patients have minimal residual renal function, the European Heart Journal guidelines recommend losartan for hypertension or renal failure in type 2 diabetes with microalbuminuria at 50-100 mg/day, with regular monitoring of electrolyte balance and serum creatinine 5. The landmark RENAAL trial demonstrated that losartan reduced progression to ESRD in diabetic nephropathy patients 6.
Dosing Recommendations
Standard dosing: Start with 50 mg once daily, which can be increased to 100 mg once daily if blood pressure control is inadequate 3, 4
- Timing relative to dialysis sessions is not clinically relevant since the drug is not dialyzed 1, 2
- The same doses used in patients with normal renal function apply to dialysis patients 1, 2
Safety Profile in Dialysis Patients
Tolerability
Losartan demonstrated excellent tolerability in hemodialysis populations 3, 4:
- Only 6 of 112 patients (5.4%) discontinued due to adverse events in one controlled trial 3
- In the larger ELHE study, only 15 of 406 patients (3.7%) discontinued due to losartan-related adverse reactions 4
Critical Safety Advantage Over ACE Inhibitors
Losartan has a significantly lower risk of anaphylactoid reactions compared to ACE inhibitors when used with AN69 dialysis membranes 4. In the ELHE study, only 2 of 406 patients experienced possible anaphylactoid reactions with losartan and AN69 membranes, and notably, 9 patients with prior anaphylactoid reactions to ACE inhibitors plus AN69 had no complications when switched to losartan 4.
Hyperkalemia Risk
Hyperkalemia requiring discontinuation occurred in only 1 of 112 patients in a controlled trial 3. However, the European guidelines emphasize that regular monitoring of electrolyte balance and serum creatinine is recommended when using losartan in patients with renal failure 5.
Additional Benefits in Dialysis Patients
Beyond blood pressure control, losartan demonstrated beneficial effects on:
- Oxidative stress reduction: A 3-month trial showed losartan decreased oxidative stress index from 7.1 to 5.0 and increased antioxidant capacity in hemodialysis patients 7
- Uric acid lowering: Plasma uric acid levels declined during losartan administration, even in patients with no residual renal function 2
- Neurohumoral effects: Plasma aldosterone levels decreased and plasma renin activity increased appropriately 2
Key Clinical Pitfalls to Avoid
- Do not reduce the dose based solely on dialysis status—the pharmacokinetics are minimally altered in ESRD 1, 2
- Do not give supplemental doses after dialysis—the drug is not removed by hemodialysis 1, 2
- Monitor potassium levels regularly, particularly when initiating therapy, as hyperkalemia remains a theoretical concern despite low incidence 5, 3
- Avoid combining with other potassium-sparing agents without close monitoring 5