Problem considered: Compare The Efficacy Of Triple Blockade With That Of Double And Single Blockade Of RAAS In Non-Diabetic Chronic Kidney Disease Patients

Objectives: To study the effect of triple blockade of RAAS using ACE Inhibitors, ARBs and EPLERENONE in Non diabetic CKD patients, To compare it with that of single and double blockade using ACEI and ARBs and To evaluate whether the combination therapy is detrimental to renal status.

Materials and Methods: Patients between age of 18 to 60 years of age were taken in the study. only stable non diabetic chronic kidney disease patients were included in the study. After the washout period of two weeks 45 patients were selected, all were thoroughly interrogated, investigated and put on a planned treatment. All the patients were divided into three groups of 15 patients. All patients of Stage 1, Stage 2, Stage 3, Stage 4 whose last 3 months GFR is stable, Stage 5 whose last 6 month GFR is stable will be selected. All diabetic patients, Patient developed acute on CKD, Serum potassium value more than 5.0,Stage 4 patients whose last 3 month eGFR is unstable, Stage 5 patients whose last 6 months eGFR is unstable were excluded.

Results: eGFR was stable in all patients in the three groups at 0 month of study (21.33±3.95 vs 20.10±2.43 vs 20.06±2.53). It did not change significantly in all three groups during the entire duration of study. At the end of 10th month of study it was 21.14±3.81 ml/min in group 1 and 20.44±2.42 ml/min in group 2 and 20.05±2.19 in group 3 (p>0.05). When we compared mean eGFR of group I and group III, we got P value >0.05 at the end of 10th month of study which is non-significant. Similar finding we got in comparing group II and group III. The baseline urine protein level was not much different in all the three groups at the start of study at 0 months it was (1032.26±187.75 vs 1042.40±156.4 vs 1055.1±137.77).It was also seen that rate of decrease in proteinuria was more in group-3 in comparison to group-2 and it was more in group-2 in comparison to group-1 (779.23±193.18 vs 756.34±195.07 vs 618.04±77.97).The decrement in proteinuria (3> 2> 1) remained sustained throughout the duration of study (P<0.05) that is significant. When we compared mean BP of group I and group III at the end of 10 months, we got P value >0.05, which is non-significant. Similar finding we got in comparing group II and group III.Patients in group containing RAMIPRIL + TELMISARTAN + EPLERENONE were always at higher risk of developing hyperkalemia as compared to patients on RAMIPRIL+TELMISARTAN and patients on RAMIPRIL alone(group 3 > group 2 > group 1),though the differences were non-significant.

Conclusions: Triple blockade is effective in decreasing proteinuria in non-diabetic kidney disease patients but it does not halt the progression of disease. There is also risk of hyperkalemia, especially with triple blockade. There is no added advantage of using Triple blockade compared to a Double or a Single blockade of RAAS with regard to improvement in eGFR or decrease in Mean Arterial Pressure of the subjects during the study period of 10 months.

Keywords: CKD, tripleblockade, proteinuria.