Disputes in the Treatment of Diabetic Nephropathy: The Dual Blockade of Renin-Angiotensin System

被引:6
作者
Grolla, E. [1 ]
Bonanni, L. [2 ]
Cutolo, A. [1 ]
Presotto, F. [2 ]
Dalla Vestra, M. [2 ]
机构
[1] Dell Angelo Hosp, Dept Cardiol, Venice, Italy
[2] Dell Angelo Hosp, Dept Internal Med, Venice, Italy
关键词
diabetic nephropathy; hypertension; RAAS blockade; albuminuria; RANDOMIZED CONTROLLED-TRIAL; II RECEPTOR BLOCKER; ACE-INHIBITION; COMBINATION THERAPY; KIDNEY-DISEASE; BLOOD-PRESSURE; DOUBLE-BLIND; RENAL OUTCOMES; END-POINTS; LOSARTAN;
D O I
10.1055/s-0042-101242
中图分类号
R5 [内科学];
学科分类号
1002 ; 100201 ;
摘要
The prevention and the treatment with drugs interacting with the renin-angiotensin system (RAAS) are one of the greatest successes of the pharmacological research in the last years. Many trials demonstrated the efficacy of ARBs and ACEi in preventing or reducing the progression of albuminuria, the loss of kidney function and the mortality in diabetic population. The rationale for applying a dual RAAS blockade is based on data showing that ACEi monotherapy produces an incomplete RAAS blockade with angiotensin I and renin accumulation and the subsequent angiotensin II 'escape' production by non-ACE pathways. The use of ARBs and ACEi in combination could lead to a stronger RAAS block and consequently to a more effective nephroprotection. Years ago, some studies per-formed in small groups of patients with diabetic nephropathy confirmed the effectiveness of this pharmacological approach. In contrast recent important trials, like ONTARGET, ALTITUDE and VA NEPHRON-D failed to demonstrate the effectiveness of this therapeutic strategy, suggesting that probably not all the diabetic patients with nephropathy should be considered equal as regard the response to this therapy. These 3 long-term studies showed that the dual blockade of RAAS may bring cardiovascular and renal adverse events, even in presence of a reduction of albuminuria. Dual blockade of RAAS is not currently feasible in patients with diabetic nephropathy, but we consider that the effort to try to apply a complete RAAS blockade should be pursued and that probably through an accurate selection of patients in the future we could reconsider this kind of therapy.
引用
收藏
页码:361 / 366
页数:6
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