Diabetic nephropathy and ACEIs/ARBs

Patients with diabetic nephropathy do not benefit and may be harmed by dual angiotensin converting-enzyme inhibitor (ACEI)/angiotensin-receptor blocker (ARB) therapy, according to new research. In a Veterans Affairs’ study, 1448 patients with type 2 diabetes and albuminuria were randomized to losartan 100 mg per day or losartan plus lisinopril (10 to 40 mg per day). The primary endpoints were decline in glomerular filtration rate, end-stage renal disease, or death. The study was stopped early after a median follow-up of 2.2 years when it was found that the dual therapy group had a rate of acute kidney injury that was 1.7 times higher than the monotherapy group (12.2 vs 6.7 events per 100 person years, P < 0.001). Combination therapy also significantly increased the risk of hyperkalemia. The authors conclude that “the use of combination therapy with an ACE inhibitor and an ARB in patients with proteinuric diabetic kidney disease does not provide an overall clinical benefit” (N Engl J Med 2013;369:1892-1903). In an editorial titled, “The End of Dual Therapy with Renin-Angiotensin-Aldosterone System Blockage?” Dr. de Zeeuw states that “dual RAAS blockade for the treatment of patients with diabetes cannot currently be recommended” (N Engl J Med 2013;369:1960-1962).