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Dual RAS Blockade — RACP Adult Medicine MCQ

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ModerateNephrologyDual RAS BlockadeRACP Adult Medicine

A 62-year-old man with CKD stage 3b has persistent proteinuria (ACR 85 mg/mmol) on ramipril 10 mg daily. Adding an ARB for dual RAS blockade is being considered. What does the evidence show?

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Correct answer: A — Dual RAS blockade reduces proteinuria but increases adverse events (hyperkalaemia, AKI)

The ONTARGET and VA NEPHRON-D trials demonstrated that dual RAS blockade (ACEi + ARB) reduced proteinuria but significantly increased adverse events including hyperkalaemia, hypotension, and AKI, without cardiovascular or renal benefit. Dual blockade is NOT recommended. For residual proteinuria on maximised ACEi or ARB, adding an SGLT2 inhibitor or finerenone is the evidence-based approach.

Reference: KHA-CARI – 2024 – CKD Guidelines; KDIGO – 2024 – CKD Management