Discontinuation of Angiotensin Receptor Blockers in Chronic Kidney Disease

Indications for Discontinuation

The Kidney International guideline recommends discontinuing ARBs in CKD patients with symptomatic hypotension, uncontrolled hyperkalemia despite medical treatment, or advanced kidney failure (eGFR <15 ml/min per 1.73 m²) with uremic symptoms 1, 2
The Kidney International guideline suggests that ARBs should be discontinued in patients with uncontrolled hyperkalemia (serum potassium >6.5 mEq/L) that persists despite potassium-lowering interventions 4, 5
The Kidney International guideline recommends discontinuing ARBs in patients with serum creatinine rise >30% within 4 weeks of initiation or dose increase 5, 6
The Kidney International guideline advises against using ARBs in pregnancy or planning pregnancy due to fetal risks 5

For hyperkalemia (K+ 5.0-6.5 mEq/L), the Mayo Clinic Proceedings guideline recommends reviewing concurrent medications, implementing dietary potassium restriction, and considering adding or increasing diuretic therapy or potassium binders before reducing ARB dose 4, 6
For creatinine rise, the Kidney International guideline suggests evaluating for volume depletion, reviewing for potential causes of acute kidney injury, and reassessing concomitant medications before discontinuing ARBs 5, 6
For advanced CKD (eGFR <30 ml/min per 1.73 m²), the Kidney International guideline recommends continuing ARB therapy unless eGFR falls below 15 ml/min per 1.73 m² with uremic symptoms 1, 2

The Kidney International guideline states that ARBs provide significant renoprotection in CKD patients with albuminuria and should be continued unless contraindicated 1, 2
The Kidney International guideline recommends checking serum creatinine and potassium within 2-4 weeks after starting or changing ARB dose and monitoring every 3-6 months for stable patients on maintenance therapy 1, 5
The British Journal of Pharmacology guideline suggests that more frequent monitoring (every 1-2 weeks) may be needed in advanced CKD or after dose adjustments 8

The Kidney International guideline strongly recommends ARBs for diabetic patients with CKD and albuminuria and suggests considering adding SGLT2 inhibitor before discontinuing ARB in diabetic CKD patients with eGFR ≥20 ml/min per 1.73 m² 1, 5
The Mayo Clinic Proceedings guideline recommends greater tolerance for mild-moderate hyperkalemia (K+ 5.0-5.5 mEq/L) in heart failure patients with CKD due to cardiovascular benefits and considering potassium binders to maintain ARB therapy rather than discontinuation 4