We have read the review article entitled ‘Renin angiotensin aldosterone inhibitors in the treatment of proteinuria in children with congenital anomalies of the kidney and urinary tract: more evidence needed’ by Rivetti et al., published in Expert Review of Clinical Pharmacology [Citation1]. We would like to thank the authors for this insightful review and make some contributions.
In the Special Report article, it has been indicated that the evidence about the efficacy of renin angiotensin aldosterone inhibitors (RAAS-i) in congenital anomalies of the kidney and urinary tract (CAKUT) is still unclear. We think that this uncertainty may be in part due to the type of proteinuria in these children. In fact, current literature [Citation2,Citation3] highlighted the significant impact of these drugs in chronic kidney disease (CKD) progression thanks to reduction in albuminuria [Citation4]. In CAKUT, conversely, it is possible to find, in a good proportion of patients, tubular proteinuria that may not be reduced by Angiotensin Converting Enzyme inhibitors (ACE-i) or Angiotensin II receptor blockers (ARBs). Thus, it might be wise to classify the type of proteinuria in these children, given the affordability of the technique [Citation5] and treat with these medications only the ones with glomerular proteinuria. On the other hand, a recent review [Citation6] showed that the RAAS system activation might be implicated in kidney damage in CAKUT in an early stage, making us wonder about the need for treatment at diagnosis, before proteinuria or hypertension is even present. Moreover, RAAS-i may have a key role in managing hypertension, that is highly associated with CAKUT [Citation7–9] and may significantly contribute to CKD progression. In particular, as previously showed by our group [Citation10], the association of ACE-i and ARBs, instead of single high-dose treatment, might have a better effect either on proteinuria, hypertension and left ventricular mass, enhancing the protection from non-immunological progression [Citation11] and cardio-vascular complications, especially in children with glomerular proteinuria; in children with tubular proteinuria the benefit of renin angiotensin aldosterone inhibitors (RAAS-i) treatment is still unclear.
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The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
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References
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