What is the recommendation about dual therapy for patients with CKD with or without diabetes?
Dual therapy should be discouraged for patients with CKD with or without diabetes, with or without albuminuria. The belief that dual therapies of RASi are beneficial, compared to monotherapies, stemmed only from the improvement in albuminuria with dual therapy. Limited data have shown that the addition of an MRA, such as spironolactone, eplerenone, or nerenone, to an ACEi or ARB for renoprotection in patients with diabetes and kidney disease resulted in a reduction of albuminuria but a higher risk of hyperkalemia. Resource utilization and costs increase, instead of decrease, by instituting dual RASi therapy compared to monotherapy. Patients and providers would want to avoid hyperkalemia and AKI because of the associated downstream risks as well as the need for more frequent laboratory tests, office and emergency department visits, additional short-term therapies, and adjustment in diet.