In the latest AJKD, this trial by Bianchi et al. makes for provocative reading, although I feel the results must be interpreted with caution. They randomized 128 patients with a clinical diagnosis of idiopathic chronic GN to either intensive therapy (ACE + ARB + spironolactone + high dose statin) or conventional therapy (ACE + low dose statin). The endpoints were change in GFR, proteinuria and adverse events at 3 years. The intensive arm experienced a far greater reduction in proteinuria and stable GFR over time compared to the conventional arm (who lost ~ 7ml/min over the study period) at the expense of more hyperkalemia and discontinued therapy.
I was surprised at how little hyperkalemia developed in the intensive arm (9 vs 3 events). I would have to admit to being pretty nervous of triple RAAS blockade for fear of this complication. That said, if patients can tolerate the combination, the outcomes based on this small study look promising.
Thanks to Dr. Rafael Santamaria for bringing this trial to my attention.