Renin-Angiotensin-Aldosterone system blockade in diabetic kidney disease: A critical and contrarian point of view

Diabetes mellitus is the most common cause of end-stage renal disease (ESRD) worldwide. Diabetic kidney disease (DKD) is associated with high morbidity and cardiovascular mortality. A number of guidelines and recommendations have been issued over the years recommending the use of renin-angiotensin-aldosterone system (RAAS) blockade in the management of DKD. This critical analysis takes a contrarian view, based on a selection of key clinical trials in the field, to argue that albuminuria should not be considered a target for treatment but instead a surrogate marker of DKD progression. The review also challenges, through a careful and critical analysis of a number of key clinical trials, the dogma that RAAS blockade's benefits in DKD is beyond mere good blood pressure control. While selective and somewhat biased the authors make compelling arguments to shed serious doubt over the strength of the evidence upon which the current guidelines favoring the use of RAAS blockade in DKD are based.