title: Has RAAS Blockade Reached Its Limits in the Treatment of Diabetic Nephropathy?
abstract: Medications that block the renin-angiotensin-aldosterone system (RAAS) are a cornerstone of diabetic nephropathy treatment. These agents play an important role in slowing the nephropathy progression in patients with diabetes. Clinical outcome trials that investigated use of these drug classes in patients with diabetic nephropathy have demonstrated clinical significant benefit in slowing nephropathy progression only in people with >300 mg/day of proteinuria. Thus, guidelines mandate their use in such patients. Conversely, combinations of RAAS blocking agents in these patients can worsen renal outcomes. Moreover, use of RAAS blockers in patients with a glomerular filtration rate below 45 mL/min/1.73 m(2) is limited by hyperkalemia. New agents that predictably bind excess potassium in the colon offer the possibility of extending RAAS inhibitor use in advanced chronic kidney disease (CKD) to allow evaluation of RAAS blockade for nephropathy and cardiovascular outcomes. These new potassium-binding agents may provide an opportunity to continue full-dose RAAS inhibition and assess if the benefits of RAAS blockade seen in stage 3 CKD can be extrapolated to persons with stages 4 and 5 CKD, not previously tested due to hyperkalemia.
authors.affiliation: Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, ASH Comprehensive Hypertension Center, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 1027, Chicago, IL, 60637, USA.
authors.forename: Collen
authors.initials: C
authors.lastname: Majewski
authors.affiliation: Department of Medicine, Section of Endocrinology, Diabetes and Metabolism, ASH Comprehensive Hypertension Center, The University of Chicago Medicine, 5841 S. Maryland Ave. MC 1027, Chicago, IL, 60637, USA. gbakris@gmail.com.
authors.forename: George L
authors.initials: GL
authors.lastname: Bakris
mesh_terms: D000806:Angiotensin-Converting Enzyme Inhibitors / Q000627:therapeutic use; D003928:Diabetic Nephropathies / Q000188:drug therapy*; D018450:Disease Progression; D004359:Drug Therapy, Combination; D006801:Humans; D012084:Renin-Angiotensin System / Q000187:drug effects*
chemical_list: D000806:Angiotensin-Converting Enzyme Inhibitors
keywords: Angiotensin; Angiotensin receptor blocker; Angiotensin-converting enzyme inhibitor; Diabetes; Hypertension; Nephropathy