Re: Efficacy and safety of dual blockade of the renin-angiotensin system: meta-analysis of randomised trials
Mekani et al have presented an excellent review reinforcing two well-known principles in medicine: firstly, do no harm and secondly, more is not always better. The deleterious effects of dual blockade of the renin-angiotensin system (RAS) on all cause mortality, hypotension and renal failure may in part be mediated by episodes of intravascular volume depletion. Patients complying with sodium restriction and those on diuretics (e.g. heart failure patients and those with nephrotic syndrome) will be at increased risk of volume depletion. While hospitalised patients at risk of volume depletion can be identified and euvolaemia preserved, volume loss frequently arises in the community due to intercurrent illness such as gastroenteritis. There is no consensus on how to ensure early identification of such patients in order to prevent harm. A better understanding of this common clinical phenomenon will help us deliver more balanced treatment regimens in the future, aiming to preserve potential benefits from RAS blockade while minimising harm.
Competing interests:
No competing interests
11 March 2013
Catherine Maclean
Specialty Trainee Renal Medicine/ General (Internal) Medicine
Rapid Response:
Re: Efficacy and safety of dual blockade of the renin-angiotensin system: meta-analysis of randomised trials
Mekani et al have presented an excellent review reinforcing two well-known principles in medicine: firstly, do no harm and secondly, more is not always better. The deleterious effects of dual blockade of the renin-angiotensin system (RAS) on all cause mortality, hypotension and renal failure may in part be mediated by episodes of intravascular volume depletion. Patients complying with sodium restriction and those on diuretics (e.g. heart failure patients and those with nephrotic syndrome) will be at increased risk of volume depletion. While hospitalised patients at risk of volume depletion can be identified and euvolaemia preserved, volume loss frequently arises in the community due to intercurrent illness such as gastroenteritis. There is no consensus on how to ensure early identification of such patients in order to prevent harm. A better understanding of this common clinical phenomenon will help us deliver more balanced treatment regimens in the future, aiming to preserve potential benefits from RAS blockade while minimising harm.
Competing interests: No competing interests