Can Losartan Be Added to Lacidipine in End-Stage Renal Disease?
Yes, losartan should be added to lacidipine in this patient with type 2 diabetes, end-stage renal disease (eGFR ≈5 mL/min/1.73 m²), and uncontrolled hypertension (160/80 mmHg), because renin-angiotensin system inhibitors remain indicated even at very low eGFR levels for their cardiovascular and residual renal protective effects. 1
Primary Recommendation: Continue RAS Inhibition in ESRD
KDIGO 2024 guidelines explicitly state that ACE inhibitors or ARBs should be continued in people with CKD even when eGFR falls below 30 mL/min per 1.73 m², and only consider reducing the dose or discontinuing in the setting of symptomatic hypotension, uncontrolled hyperkalemia despite medical treatment, or to reduce uremic symptoms while treating kidney failure (eGFR <15 mL/min per 1.73 m²). 1
The FDA label for losartan specifically indicates its use for diabetic nephropathy with elevated serum creatinine and proteinuria in patients with type 2 diabetes and hypertension, with no absolute contraindication based on eGFR alone. 2
Losartan demonstrated significant renal benefits in the RENAAL trial, reducing the risk of doubling serum creatinine by 25% and end-stage renal disease by 28%, with a 32% reduction in first hospitalization for heart failure—benefits that extend beyond blood pressure reduction alone. 3
Specific Dosing and Monitoring for eGFR ≈5 mL/min/1.73 m²
Start losartan at 25 mg once daily (rather than the standard 50 mg) because patients with renal insufficiency have elevated plasma concentrations of losartan and its active metabolite compared to those with normal renal function. 2
Check serum creatinine and potassium within 2–4 weeks of initiation, then monitor potassium closely every 2–4 weeks initially, as hyperkalemia is the primary safety concern at this level of renal function. 1
Accept a rise in serum creatinine of up to 30% within 4 weeks following initiation without discontinuing therapy, as this reflects hemodynamic changes rather than true kidney injury. 1, 4
Blood Pressure Target and Combination Therapy
The current blood pressure of 160/80 mmHg is above the recommended target of <140/90 mmHg (or <130/80 mmHg if tolerated) for patients with diabetes and CKD. 1
Combining losartan (an ARB) with lacidipine (a dihydropyridine calcium channel blocker) is appropriate and commonly required, as CKD patients often need more than one medication to achieve blood pressure control. 1
Do not combine losartan with an ACE inhibitor, as dual RAAS blockade increases the risk of acute kidney injury and hyperkalemia without added renal or cardiovascular benefit. 1
Managing Hyperkalemia Without Stopping Losartan
Hyperkalemia associated with RAS inhibitors can often be managed by measures to reduce serum potassium levels (dietary potassium restriction, potassium binders such as patiromer or sodium zirconia cyclosilicate, optimizing diuretic therapy) rather than decreasing the dose or stopping the RAS inhibitor. 1
Only reduce the dose or discontinue losartan if hyperkalemia remains uncontrolled despite medical treatment, or if symptomatic hypotension develops. 1
Additional Considerations for This Patient
Add an SGLT2 inhibitor if eGFR is ≥20 mL/min/1.73 m² to reduce cardiovascular events and slow CKD progression; however, at eGFR ≈5 mL/min/1.73 m², SGLT2 inhibitors are not indicated for initiation but may be continued if already established. 1
Ensure tight glycemic control targeting HbA1c <7% (or <53 mmol/mol) to decrease microvascular complications, though recognize that HbA1c becomes less accurate in advanced CKD and may require alternative glucose monitoring. 1, 5
Refer to nephrology immediately for dialysis planning and management of CKD-related complications, as eGFR ≈5 mL/min/1.73 m² represents CKD stage 5 (kidney failure). 4
Common Pitfalls to Avoid
Do not withhold or discontinue losartan solely because of low eGFR; the cardiovascular and residual renal benefits persist even in ESRD, and premature discontinuation removes these protective effects. 1, 4
Do not use metformin at this eGFR level (contraindicated at eGFR <30 mL/min/1.73 m²) due to lactic acidosis risk. 5
Do not rely on HbA1c alone for glycemic assessment in ESRD, as it becomes inaccurate; use continuous glucose monitoring or frequent self-monitoring of blood glucose. 5
Avoid nephrotoxic agents (NSAIDs, high-dose iodinated contrast) and ensure adequate hydration during any procedures. 4