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Dual RAS Blockade Harm — ESENeph MCQ

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EasyChronic Kidney DiseaseDual RAS Blockade HarmESENeph

A 45-year-old man with CKD G3a on Ramipril 10 mg has persistent proteinuria of 1.5 g/day. His BP is 122/74 mmHg. He is already on Dapagliflozin 10 mg. His clinician considers adding Losartan to the Ramipril for additional proteinuria reduction (dual RAS blockade). Why is this inappropriate?

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Correct answer: D — KDIGO 2024 recommends avoiding dual RAS blockade (ACEi + ARB) due to increased risk of hyperkalaemia and AKI without long-term kidney or cardiovascular benefit

KDIGO 2024 specifically recommends (1B) avoiding any combination of ACEi, ARB, and direct renin inhibitor therapy in CKD. The ONTARGET and VA NEPHRON-D trials showed that while dual blockade reduced proteinuria more than monotherapy, it increased serious adverse events (hyperkalaemia, AKI, hypotension) without improving hard kidney or cardiovascular endpoints. Alternative add-on agents with proven benefit include SGLT2i (already prescribed) and Finerenone (if diabetic with albuminuria).

Reference: KDIGO 2024 – CKD Guideline; ONTARGET Trial; VA NEPHRON-D