Optimal dose of angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker for renoprotection

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin II type 1 receptor blockers (ARB) have become the cornerstone in the treatment of chronic kidney disease (CKD), as numerous lines of evidence have shown that these agents have a blood pressure lowing independent anti-proteinuric effect. However, despite the benefits of ACEI or ARB therapy, a substantial proportion of patients still experience renal morbidity and mortality. Considering the prognostic impact of proteinuria reduction, it is currently assumed that titration of ACEI or ARB for optimal anti-proteinuric effect would be a logical step towards improvement of renoprotection. Recent published studies, performed with higher than recommended doses of either ACEI or particularly ARB, suggest that the approach is associated with a further decrement in urinary protein excretion and probably improved renal outcome. Although most patients achieve their maximum benefit at standard doses, there is a residual group of patients who may do so at higher doses of renin-angiotensin system inhibitors. Because patients who would benefit from higher doses are not identifiable a priori, a titration process might be cogent in order to provide more robust anti-proteinuric benefit to such patients.