Combination ACEI and ARB therapy: additional benefit in renoprotection?

The fact that angiotensin-converting enzyme inhibitors and angiotensin receptor blockers antagonize the renin-angiotensin system at different levels suggests that these agents, already each of confirmed clinical benefit in retarding the progression of chronic renal disease, may have additive effects that result in even greater renoprotection when used in combination. In the light of the persisting need for treatments that afford more effective renoprotection, this Special Commentary examines available experimental and clinical evidence in support of this hypothesis.

Experimental studies to date have failed to distinguish clearly between the additive antihypertensive effects of combination therapy and additive intrinsic renoprotective effects. Clinical studies, albeit with relatively small patient numbers and short follow-up periods, have shown that combination therapy results in greater antihypertensive and antiproteinuric effects than monotherapy in diabetic nephropathy and non-diabetic forms of chronic renal disease.

At present we recommend the addition of angiotensin receptor blocker therapy in patients with continued hypertension or proteinuria despite angiotensin-converting enzyme inhibition. Further long-term studies are required to evaluate more fully the renoprotective potential of this combination.