Dual blockade of the renin-angiotensin system: the ultimate treatment for renal protection?

The prevalence of chronic renal diseases is increasing worldwide. There is a great need to identify therapies that arrest disease progression to end-stage renal failure. Inhibition of the renin-angiotensin system both by angiotensin-converting enzyme inhibitors and angiotensin II receptor antagonists is probably the best therapeutic option available. Several large, multicenter studies have indeed shown a significant reduction in the risk for doubling baseline serum creatinine or progression toward end-stage renal failure in patients who do and do not have diabetes and have chronic nephropathies that are treated with angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists. However, the number of patients who reach end-stage renal failure is still considerably high. Significant reduction of the incidence of ESRD is likely to be achieved in the near future for chronic nephropathies, provided that the degree of renoprotection can be improved. This goal may be attainable with a more complex strategy than with a single or dual pharmacologic intervention on the renin-angiotensin system. Strict control of BP and protein excretion rate, lowering of blood lipids, tight glucose control for individuals with diabetes, and lifestyle changes form part of the future multimodal protocol for treatment of patients with chronic nephropathies.