Management of Angiotensin Receptor Blockers in Chronic Kidney Disease with eGFR of 4

Introduction to ARB Management

The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends considering reducing the dose or discontinuing the Angiotensin Receptor Blocker (ARB) in patients with an estimated glomerular filtration rate (eGFR) of 4 mL/min/1.73 m², particularly if there are uremic symptoms, uncontrolled hyperkalemia, or symptomatic hypotension 1, 2, 3

The American College of Cardiology recommends continuing ARB therapy if the patient is tolerating it well, with no symptomatic hypotension, manageable potassium levels, and no severe uremic symptoms, as the cardiovascular and renal protective benefits may still outweigh risks 1, 2, 3
The National Kidney Foundation suggests discontinuing or reducing the ARB dose in specific situations, such as uremic symptoms, uncontrolled hyperkalemia, or symptomatic hypotension 1, 2, 3

The Kidney Disease: Improving Global Outcomes (KDIGO) guideline recommends checking serum potassium immediately and assessing blood pressure to document whether the patient has symptomatic hypotension or asymptomatic low readings 1, 2
The American Journal of Kidney Diseases suggests evaluating for uremic symptoms, such as nausea, vomiting, altered mental status, and pruritus, and reviewing recent creatinine trends to assess for hemodynamic intolerance 1, 2, 3

The Kidney International journal recommends avoiding all potassium supplements and potassium-based salt substitutes, and counseling on limiting high-potassium foods 6
The Circulation journal suggests never combining ARB with ACE inhibitors or direct renin inhibitors, as dual RAS blockade is contraindicated and increases risks of hyperkalemia, hypotension, and acute kidney injury 1, 2, 3

The American Journal of Kidney Diseases recommends that SGLT2 inhibitors are generally not initiated at eGFR <20 mL/min/1.73 m², but if already on one, it can be continued until dialysis initiation 1, 2, 3
The Kidney International journal suggests that nonsteroidal MRAs (finerenone) are contraindicated at eGFR <25 mL/min/1.73 m² and should not be used at this level of kidney function 1, 3
The Praxis Medical Insights guideline recommends that statin therapy should be continued or initiated for cardiovascular protection in patients ≥50 years with eGFR <60 mL/min/1.73 m² 5