Renoprotective therapy: is it blood pressure or albuminuria that matters?

Abstract

In today's Lancet, Piero Ruggenenti and colleagues, for the REIN-2 Study Group, address whether reduction of blood pressure below 140/90 mm Hg offers additional renoprotection. They added the dihydropyridine calcium-channel-blocker felodipine to ramipril, an inhibitor of angiotensin-converting enzyme (ACE) in 335 patients with a baseline glomerular filtration rate of 35 mL/min and overt proteinuria (urinary protein loss 2·9 g a day). Felodipine was not renoprotective. This finding is remarkable given that felodipine lowered systolic and diastolic blood pressures by 4 and 3 mm Hg, respectively. On the basis of their findings, the authors inadvertently challenge the widely accepted view of nephrologists that further reduction of blood pressure should be aimed at to achieve optimum renoprotection. 1 Peterson JC Adler S Burkart JM et al. Blood pressure control, proteinuria, and the progression of renal disease. Ann Intern Med. 1995; 123: 754-762 Crossref PubMed Scopus (1223) Google Scholar , 2 Jafar TH Stark PC Schmid CH et al. Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med. 2003; 139: 244-252 Crossref PubMed Scopus (951) Google Scholar Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): multicentre, randomised controlled trialIn patients with non-diabetic proteinuric nephropathies receiving background ACE-inhibitor therapy, no additional benefit from further blood-pressure reduction by felodipine could be shown. Full-Text PDF