The role of renin-angiotensin-aldosterone system in the progression of chronic kidney disease

Kidney Int Suppl. 2005 Dec;(99):S57-65. doi: 10.1111/j.1523-1755.2005.09911.x.

Abstract

The renin-angiotensin-aldosterone system (RAAS) is a well known regulator of blood pressure (BP) and determinant of target-organ damage. It controls fluid and electrolyte balance through coordinated effects on the heart, blood vessels, and Kidneys. Angiotensin II (AII) is the main effector of the RAAS and exerts its vasoconstrictor effect predominantly on the postglomerular arterioles, thereby increasing the glomerular hydraulic pressure and the ultrafiltration of plasma proteins, effects that may contribute to the onset and progression of chronic renal damage. AII may also directly contribute to accelerate renal damage by sustaining cell growth, inflammation, and fibrosis. Interventions that inhibit the activity of the RAAS are renoprotective and may slow or even halt the progression of chronic nephropathies. ACE inhibitors and angiotensin II receptor antagonists can be used in combination to maximize RAAS inhibition and more effectively reduce proteinuria and GFR decline in diabetic and nondiabetic renal disease. Recent evidence suggests that add-on therapy with an aldosterone antagonist may further increase renoprotection, but may also enhance the risk hyperkalemia. Maximized RAAS inhibition, combined with intensified blood pressure control (and metabolic control in diabetics) and amelioration of dyslipidemia in a multimodal approach including lifestyle modifications (Remission Clinic), may achieve remission of proteinuria and renal function stabilization in a substantial proportion of patients with proteinuric renal disease. Ongoing studies will tell whether novel drugs inhibiting the RAAS, such as the renin inhibitors or the vasopeptidase inhibitors, may offer additional benefits to those who do not respond, or only partially respond, to this multimodal regimen.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review

MeSH terms

  • Angiotensin II Type 1 Receptor Blockers / therapeutic use
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Animals
  • Blood Pressure / drug effects
  • Blood Pressure / physiology
  • Chronic Disease
  • Disease Progression
  • Drug Therapy, Combination
  • Glomerular Filtration Rate
  • Humans
  • Kidney Diseases / drug therapy
  • Kidney Diseases / economics
  • Kidney Diseases / physiopathology*
  • Kidney Failure, Chronic / drug therapy
  • Kidney Failure, Chronic / economics
  • Kidney Failure, Chronic / physiopathology*
  • Mineralocorticoid Receptor Antagonists
  • Nephritis / physiopathology
  • Polymorphism, Genetic
  • Receptors, Mineralocorticoid / physiology
  • Renin / antagonists & inhibitors
  • Renin / physiology
  • Renin-Angiotensin System / drug effects
  • Renin-Angiotensin System / genetics
  • Renin-Angiotensin System / physiology*
  • Transplantation Tolerance

Substances

  • Angiotensin II Type 1 Receptor Blockers
  • Angiotensin-Converting Enzyme Inhibitors
  • Mineralocorticoid Receptor Antagonists
  • Receptors, Mineralocorticoid
  • Renin