How to titrate ACE inhibitors and angiotensin receptor blockers in renal patients: according to blood pressure or proteinuria?

The inhibition of the effects of angiotensin II is necessary to ensure the best degree of renal protection by the simultaneous control of blood pressure (BP) and the achievement of the maximal antiproteinuric capacity. The inhibition can be attained through the administration of either an angiotensin-converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB). Uptitration of antihypertensive therapy is frequently required to achieve the desired BP goal in patients presenting with renal disease, with or without proteinuria. Control of BP is good for both cardiovascular and renal protection. Sometimes, in particular when BP levels are high in the absence of therapy, the simple control of BP without inhibiting the renin- angiotensin system can be accompanied by a significant drop in proteinuria. On the other hand, the possibility that an ACE inhibitor or an ARB diminishes protein excretion in urine in the absence of changes in BP has been considered after the known evidence that these classes of drugs are renoprotective independently of their effect on BP control. The aim of this paper is to briefly review the evidence in favor of uptitration of either class of inhibitors of the renin-angiotensin system as compared with the combination of the two for the control of either BP or proteinuria.