The dilemma of dual renin-angiotensin system blockade in chronic kidney disease: why beneficial in animal experiments but not in the clinic?

Physiol Res. 2017 May 4;66(2):181-192. doi: 10.33549/physiolres.933607.

Abstract

Drugs interfering with the renin-angiotensin-aldosterone system (RAAS) improved the prognosis in patients with hypertension, heart failure, diabetes and chronic kidney disease. However, combining different drugs brought no further benefit while increasing the risk of hyperkalemia, hypotension and acute renal failure. This was so with combining angiotensin converting enzyme inhibitors (ACEi) and angiotensin II receptors type 1 antagonists (ARB). Dissimilarly, in animal disease models this dual therapy proved clearly superior to single drug treatment and became the optimal standard regime for comparison with other treatments. This review analyzes the causes of the discrepancy of effects of the dual therapy between animal experiments versus clinical studies, and is focused on the outcomes in chronic kidney disease. Discussed is the role of species differences in RAAS, of the variability of the disease features in humans versus relative stability in animals, of the genetic uniformity in the animals but not in humans, and of the biased publication habits of experimental versus clinical studies. We attempt to understand the causes and reconcile the discordant findings and suggest to what extent dual RAAS inhibition should be continued in animal experiments and why its application in the clinics should be limited to strictly selected groups of patients.

Publication types

  • Review

MeSH terms

  • Acute Kidney Injury / chemically induced
  • Acute Kidney Injury / immunology
  • Acute Kidney Injury / prevention & control
  • Angiotensin II Type 1 Receptor Blockers / administration & dosage*
  • Angiotensin-Converting Enzyme Inhibitors / administration & dosage*
  • Angiotensin-Converting Enzyme Inhibitors / adverse effects
  • Animals
  • Disease Models, Animal*
  • Evidence-Based Medicine
  • Humans
  • Hyperkalemia / chemically induced
  • Hyperkalemia / immunology
  • Hyperkalemia / prevention & control
  • Hypertension / chemically induced
  • Hypertension / immunology
  • Hypertension / prevention & control
  • Renal Insufficiency, Chronic / drug therapy*
  • Renal Insufficiency, Chronic / immunology*
  • Renin-Angiotensin System / drug effects*
  • Renin-Angiotensin System / immunology*
  • Species Specificity
  • Treatment Outcome

Substances

  • Angiotensin II Type 1 Receptor Blockers
  • Angiotensin-Converting Enzyme Inhibitors