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Dual RAS Blockade — ESENeph MCQ

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EasyHypertensionDual RAS BlockadeESENeph

A 60-year-old man with type 2 diabetes has eGFR 55 mL/min/1.73m2 and uACR 35 mg/mmol. He is on Losartan 100 mg. His BP is 125/72 mmHg. A colleague suggests adding Ramipril to the Losartan for additional renoprotection. Is this appropriate?

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Correct answer: A — Avoid combined ACE-inhibitor and ARB therapy

KDIGO 2024 specifically recommends avoiding any combination of ACEi, ARB, and direct renin inhibitor therapy in people with CKD (1B). The ONTARGET and VA NEPHRON-D trials showed dual RAS blockade increased adverse events (hyperkalaemia, AKI) without long-term kidney or cardiovascular benefit. Monotherapy with either ACEi or ARB at maximum tolerated dose is appropriate. SGLT2i and nsMRA provide additional benefit without the risks of dual RAS blockade.

Reference: https://guidelines.ukkidney.org