How to achieve renal protection in the light of ONTARGET?

Inhibition of the renin-angiotensin system (RAS) either with an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) has been shown to be beneficial for cardiorenal protection. The combination of both is an exciting prospect and pathophysiologically plausible. The ONgoing Telmisartan Alone and in combination with Ramipril Global Endpoint Trial (ONTARGET) study provides evidence that dual blockade does not further reduce cardiovascular events or worsen renal outcomes. However, in patients with existing diabetic nephropathy, a trend towards a better outcome was observed. Therefore, combination of ARBs and ACEIs could be an alternative for selected patients, but not a standard approach in the management of chronic kidney disease. The benefits of dual blockade on hard renal endpoints remain to be shown.