Losartan Therapy in Chronic Kidney Disease

Initial Dosing and Titration

The American College of Cardiology recommends starting losartan at 50 mg once daily and titrating to 100 mg once daily to achieve maximum renoprotective benefits, as clinical trials demonstrating kidney protection used these higher doses 1, 2
For patients with moderately to severely increased albuminuria (A2-A3) with diabetes, start at 50 mg and increase to 100 mg once daily 1, 2
The European Society of Cardiology recommends a target dose of 100 mg once daily for maximum renoprotection 1, 2

Monitor serum creatinine, serum potassium, and blood pressure within 2-4 weeks of initiation or dose increase, and accept up to 30% increase in serum creatinine within 4 weeks 2
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend monitoring for hyperkalemia and managing with potassium-lowering measures rather than stopping losartan when possible 2
Assess for symptomatic hypotension and adjust the dose accordingly 2

Continue losartan even when eGFR falls below 30 mL/min/1.73 m², unless symptomatic hypotension or uncontrolled hyperkalemia develops 2
The European Heart Journal recommends targeting office BP 130-139/80-90 mmHg for most CKD patients, and considering targeting systolic BP 120-129 mmHg if tolerated for eGFR >30 mL/min/1.73 m² 2, 3
RAS blockers like losartan are recommended as part of the treatment strategy for hypertensive CKD patients with albuminuria 3

Don't stop losartan for mild creatinine increases (<30%): this is expected and does not indicate harm 2
Don't underdose: the proven renoprotective benefits in trials were achieved with 100 mg daily, not lower doses 1, 2
Don't discontinue prematurely for hyperkalemia: manage potassium medically before reducing or stopping losartan 2