Current dilemmas in inhibiting the renin-angiotensin system: do not forget real life

Area of Science:

• Nephrology
• Cardiovascular Medicine
• Pharmacology

Background:

• The renin-angiotensin-aldosterone (RAA) axis inhibition was standard for progressive chronic kidney disease (CKD).
• The goal was to slow progression to end-stage renal disease (ESRD).
• Recent meta-analyses and studies in diabetic patients challenge the efficacy of angiotensin converting enzyme (ACE) inhibition in delaying dialysis.

Purpose of the Study:

• To critically review the ongoing debate on the role of RAA axis inhibition in CKD progression.
• To discuss the pros and cons of pharmacological interventions in managing CKD.
• To provide a cautious perspective for nephrologists regarding ACE inhibitor use in CKD.

Main Methods:

• Literature review and critical analysis of recent studies and meta-analyses.
• Discussion of conflicting data regarding ACE inhibition in CKD.
• Examination of potential overlooked factors in renal protection studies.

Main Results:

• Recent data raise questions about the established role of ACE inhibition in delaying dialysis in CKD patients.
• An intensive debate exists among nephrologists regarding the benefits and drawbacks of ACE inhibitors.
• Factors like central blood pressure, ambulatory blood pressure monitoring, and stroke risk may be crucial.

Conclusions:

• A cautious approach is recommended for practicing nephrologists.
• The distinction between clinical trial populations and real-world patients is important.
• Re-evaluation of ACE inhibitor therapy in CKD may be necessary, considering broader cardiovascular and hemodynamic parameters.