Another nail in the coffin for combination ACE/ARB in diabetic nephropathy!
http://www.nejm.org/doi/full/10.1056/NEJMoa1303154?query=TOC
Also see Kiran/Pradeep's posts on this article on Nov 10th.
Regarding Pradeep's question: might there still be a role for combined ACE/ARB in non-diabetics with CKD and proteinuria? Obviously this study was in diabetics and will not directly inform ACE+ARB use in non-diabetics. But its impressive that their findings generally confirm those in ONTARGET, suggesting adverse outcomes (renal failure, hyperkalemia) with combination therapy. ONTARGET included both diabetics and non-diabetics, and subgroup analysis suggested the adverse outcomes were not affected by the presence/absence of diabetes.
So I will continue to consider combined ACE/ARB only in very exceptional circumstances (perhaps multi-drug resistant hypertension and/or severe refractory proteinuria), and only with diligent laboratory monitoring.