Should losartan (Angiotensin II Receptor Antagonist) be held in a patient with Acute Kidney Injury (AKI)?

From the Guidelines

Losartan should not be held in patients with acute kidney injury (AKI) if the increase in serum creatinine is less than 30% from baseline and there is no associated volume depletion. When a patient develops AKI, it is crucial to distinguish between a minor increase in serum creatinine and actual kidney injury. According to the most recent guidelines from the Diabetes Care journal 1, elevations in serum creatinine up to 30% from baseline with renin-angiotensin system (RAS) blockers, such as losartan, should not be confused with AKI. The key considerations in managing patients with AKI and losartan include:

• Monitoring serum creatinine and potassium levels regularly
• Avoiding discontinuation of losartan for minor increases in serum creatinine (<30%) in the absence of volume depletion
• Continuing RAS blockade, such as losartan, when increases in serum creatinine are up to 30% and do not have associated hyperkalemia, as supported by the analysis of the Action to Control Cardiovascular Risk in Diabetes Blood Pressure (ACCORD BP) trial 1. However, if the patient's condition worsens or if there are significant increases in serum creatinine or hyperkalemia, losartan may need to be held or adjusted to prevent further kidney damage. It is essential to weigh the benefits of continuing losartan against the potential risks in the context of AKI, considering the patient's overall clinical picture and the latest evidence from studies such as those published in Diabetes Care 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

Yes, consider holding losartan with Acute Kidney Injury (AKI), as it may cause a decrease in renal function.

• Monitor renal function periodically in patients at risk.
• Withhold or discontinue losartan if a clinically significant decrease in renal function occurs 2.

From the Research

Losartan and Acute Kidney Injury (AKI)

• The management of AKI involves determining volume status, fluid resuscitation, treatment of volume overload, discontinuation of nephrotoxic medications, and adjustment of prescribed drugs according to renal function 3.
• Losartan, an angiotensin II receptor blocker (ARB), has been studied in the context of AKI, with some evidence suggesting that it may have renoprotective effects 4.
• A systematic review and meta-analysis found that exposure to ACEi/ARB after AKI onset was associated with lower risks of all-cause mortality, recurrent AKI, and progression to incident CKD 5.
• However, the use of ACEi/ARB was also associated with a higher risk of hyperkalemia, highlighting the need for close clinical monitoring 5.

Considerations for Holding Losartan with AKI

• The decision to hold losartan in patients with AKI should be based on individual patient factors, including the severity of AKI, the presence of other comorbidities, and the potential benefits and risks of continuing or discontinuing the medication.
• In patients with chronic heart failure, high-dose losartan was associated with an increased risk of acute rise in serum creatinine, but also with reduced risk of death or hospitalization for heart failure 6.
• There is no clear consensus on whether losartan should be held in patients with AKI, and further studies are needed to determine the optimal management strategy 7, 3, 4, 5, 6.

Key Points to Consider

• The pathophysiology of AKI is complex and involves multiple mechanisms, including inflammation, oxidative stress, and endothelial dysfunction 7, 4.
• The management of AKI requires a multifaceted approach, including fluid and electrolyte management, discontinuation of nephrotoxic medications, and adjustment of prescribed drugs according to renal function 3.
• Losartan may have renoprotective effects in certain contexts, but its use in patients with AKI requires careful consideration of the potential benefits and risks 4, 5, 6.