Use of ultrahigh RAAS blockade: Implications for exacerbation of renal failure
Authors: M.A.C. Onuigbo, N.T.C. Onuigbo
Journal: Kidney International (2005)

To the Editor: Rossing et al.,1.Rossing K. Schjoedt K.J. Jensen B.R. et al.Enhanced renoprotective effects of ultrahigh doses of irbesartan in patients with type 2 diabetes and microalbuminuria.Kidney Int. 2005; 68: 1190-1198Google Scholar lately, reported using irbesartan, up to 900 mg/day, in 52 type II diabetic microalbuminurics, compared to 300 mg/day, and showed additional renoprotection. Recently, concern has been raised of an increasing end-stage renal disease epidemic in the USA, which was observed to coincide with the increasing use of renin-angiotensin-aldosterone system (RAAS) blockade.2.Jones C.A. Krolewski A.S. Rogus J. et al.Epidemic of end-stage renal disease in people with diabetes in the United States population: do we know the cause?.Kidney Int. 2005; 67: 1684-1691Google Scholar This raises a troubling suspicion for iatrogenic end-stage renal disease.2.Jones C.A. Krolewski A.S. Rogus J. et al.Epidemic of end-stage renal disease in people with diabetes in the United States population: do we know the cause?.Kidney Int. 2005; 67: 1684-1691Google Scholar We recently reported a previously unrecognized syndrome of late-onset renal failure from angiotensin blockade in patients on stable doses of RAAS blockade.3.Onuigbo M.A.C. Onuigbo N.T.C. Late onset renal failure from angiotensin blockade (LORFFAB): a prospective thirty-month Mayo Health System clinic experience.Med Sci Monit. 2005; 11: CR462-CR469Google Scholar Mean serum creatinine improved from 2.9±0.9 to 1.8±0.4 mg/dl (P=0.04) following discontinuation of RAAS blockade.3.Onuigbo M.A.C. Onuigbo N.T.C. Late onset renal failure from angiotensin blockade (LORFFAB): a prospective thirty-month Mayo Health System clinic experience.Med Sci Monit. 2005; 11: CR462-CR469Google Scholar We are very concerned about the potential implications of the escalating and possibly uncontrolled use of ultrahigh doses of RAAS blockade. The subjects were relatively young, mean age 58 years, with normal baseline glomerular filtration rate, mean 103 ml/min/1.73 m2.1.Rossing K. Schjoedt K.J. Jensen B.R. et al.Enhanced renoprotective effects of ultrahigh doses of irbesartan in patients with type 2 diabetes and microalbuminuria.Kidney Int. 2005; 68: 1190-1198Google Scholar By contrast, the Antihypertensive and Lipid-Lowering Treatment to prevent Heart Attack Trial cohort of 33 357 patients was older, mean age 67 years, with lower mean baseline glomerular filtration rate, 78 ml/min/1.73 m2.4.ALLHAT Officers and Coordinators for the ALLHAT Collaborative research Group The Antihypertensive and Lipid-Lowering Treatment to prevent Heart Attack Trial. Major outcomes in moderately hypercholesterolemic, hypertensive patients randomized to pravastatin vs usual care: The Antihypertensive and Lipid-Lowering Treatment to prevent Heart Attack trial (ALLHAT-LLT).JAMA. 2004; 292: 2622-2631Google Scholar Furthermore, treatment with irbesartan, 900 mg/day, was only for 2 months.1.Rossing K. Schjoedt K.J. Jensen B.R. et al.Enhanced renoprotective effects of ultrahigh doses of irbesartan in patients with type 2 diabetes and microalbuminuria.Kidney Int. 2005; 68: 1190-1198Google Scholar The general applicability of such intense and overriding total RAAS blocking strategies, particularly long term, and more so in susceptible elderly diabetic hypertensives, with lower glomerular filtration rates, is at the least very troubling. Until we understand the long-term consequences of such therapeutic maneuvers, strong caution must be advised. Finally, we recommend more long-term monitoring of kidney function in all patients on RAAS blockade, more so in the susceptible elderly population.3.Onuigbo M.A.C. Onuigbo N.T.C. Late onset renal failure from angiotensin blockade (LORFFAB): a prospective thirty-month Mayo Health System clinic experience.Med Sci Monit. 2005; 11: CR462-CR469Google Scholar