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Has RAAS Blockade Reached Its Limits in the Treatment of Diabetic Nephropathy?

  • Microvascular Complications—Nephropathy (AP Maxwell, Section Editor)
  • Published:
Current Diabetes Reports Aims and scope Submit manuscript

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 m2 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.

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Authors and Affiliations

  1. 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

    Collen Majewski & George L. Bakris

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  1. Collen Majewski
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  2. George L. Bakris
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Correspondence to George L. Bakris.

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Conflict of Interest

Collen Majewski declares that she has no conflict of interest.

George L. Bakris reports other from Bayer AG, personal fees from Boehringer Ingelheim GmbH, personal fees from Janssen Pharmaceuticals, Inc., other from Medtronic, other from Relypsa, Inc., other from Takeda Pharmaceutical Company, other from AbbVie, and personal fees from NxStage. Fees from these result from my efforts as either a PI or co-PI of a clinical trial or member of a Steering committee or advisory board for a particular study or concept development.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Microvascular Complications—Nephropathy

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Majewski, C., Bakris, G.L. Has RAAS Blockade Reached Its Limits in the Treatment of Diabetic Nephropathy?. Curr Diab Rep 16, 24 (2016). https://doi.org/10.1007/s11892-016-0713-y

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  • DOI: https://doi.org/10.1007/s11892-016-0713-y

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