Preventing Progression of Chronic Kidney Disease: Renin–Angiotensin–Aldosterone System Blockade Beyond Blood Pressure

There is clear evidence for the pathogenic role of the renin–angiotensin–aldosterone system (RAAS) in the development and progression of CKD. Treatment with either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker has been shown to reduce proteinuria and preserve kidney function in patients with established chronic kidney disease, beyond blood pressure lowering. Such findings have led to widespread recommendations for early and sustained blockade of the RAAS to be considered as the first-line treatment for the management of established CKD. Some of these benefits may reflect the better tolerability, efficacy, and side-effect profile of RAAS blockers, compared to other antihypertensive agents. Specific actions on kidney hemodynamics, oxidative stress, inflammation, and other pathogenic elements may also contribute to “BP-independent effect” of RAAS blockade in the setting of CKD. This chapter specifically explores the utility of RAAS blockade to prevent the development and slow the progression of chronic kidney disease, beyond their actions to lower blood pressure.