Importantly, the difference in UAER between 20 and 40 mg/day lisinopril remained significant after adjustment for changes in ambulatory blood pressure, suggesting that lisinopril 40 mg daily offers additional reductions in proteinuria in comparison with the currently recommended dose of 20 mg/day. Another two studies with a limited number of patients that uptitrated lisinopril from 10 to 40 mg daily came to different conclusions, as in one the uptitration Proteasome activity was associated with progressive

decrease in urinary albumin excretion while no such effect was seen in the other.14,15 In contrast, ARB have been tested over a wide range of doses, showing an increase of response with ultrahigh dose.16–18 In the DROP study,16 a multicentre, double-blind and randomized parallel trial, 391 hypertensive patients with type 2 diabetes and UAER of 20–700 µg were randomly treated with valsartan at 160, 320 and 640 mg/day. As shown in the results, the albuminuria reduction was comparable among the three groups at week 4. Subsequently, a highly significant albuminuria fall was observed with valsartan 320 mg and 640 mg versus 160 mg. At week 30, twice as many patients

returned to normal UAER with valsartan 640 mg versus 160 mg. In another double-blind, randomized, cross-over trial,17 52 hypertensive type 2 diabetes patients with microalbuminuria were treated randomly with irbesartan 300, 600 and 900 mg once daily with each dose for 2 months. The results showed that reductions in UAER from baseline click here were 52%, 49% and 59% with increasing doses of irbesartan, respectively. In comparison with the lower these doses, UAER was reduced significantly more by irbesartan 900 mg/day, a dose that was greatly beyond the currently recommended dose. A recent multicentre Canadian trial, the SMART study, further evaluated whether supramaximal doses of candesartan would reduce proteinuria to a greater extent than the maximum approved antihypertensive dose.18 In this randomized, double-blind, active-controlled study, 269 patients who had persistent proteinuria

despite 7 weeks of treatment with the highest approved dose of candesartan (16 mg/day), were randomly assigned to three groups receiving 16, 64 or 128 mg/day candesartan for 30 weeks. The results showed that the mean difference of the percentage change in proteinuria was −16% for patients receiving 64 mg/day candesartan and −33% for those receiving 128 mg/day candesartan as compared to those treated with 16 mg/day candesartan. Reductions in blood pressure were not different across the three treatment groups. Studies with hard end-points are currently lacking. Our recent study, the ROAD trial,19 demonstrated first that uptitration of an ACEI or an ARB against proteinuria conferred further benefit on renal outcome. In this randomized, blinded end-point trial, 360 non-diabetic patients with mean serum creatinine of 2.