Role of dual RAAS inhibition in Membranous Nephropathy
Is there a role for dual RAAS inhibition in MN?
Another approach to reducing proteinuria in MN is the use of dual RAAS inhibition with ACE inhibitors and ARBs (or addition of aliskiren [renin inhibitor]).
This approach will necessitate close monitoring secondary to the increased risk of hyperkalemia and AKI. Symptomatic hypotension on dual RAAS blockade can be an insuperable barrier in patients with normal or low baseline blood pressures, and therefore close monitoring of blood pressure is paramount.
The goal of dual blockade is to ameliorate glomerular sieving function, reduce proteinuria, and increase serum albumin levels with consequent improvement in hypercholesterolemia and other components of the nephrotic syndrome.
The risk of adverse events in patients on dual RAAS therapy with MN is primarily derived from patients with cardiovascular disease and proteinuria.
It should be noted that long-term outcome studies examining dual RAAS inhibition in MN have not been conducted, but only short-term studies looking at albuminuria reduction.
Therefore we recommend a cautious approach when considering dual RAAS blockade.