Despite current practice, patients with
chronic kidney disease (CKD) are at increased risk of progression to
end-stage renal disease and cardiovascular events.
Neprilysin inhibition (NEPi) is a new therapeutic strategy with potential to improve outcomes for patients with CKD. NEPi enhances the activity of
natriuretic peptide systems leading to natriuresis, diuresis and inhibition of the renin-angiotensin system (RAS), which could act as a potentially beneficial counter-regulatory system in states of RAS activation such as chronic
heart failure (HF) and CKD. Early NEPi drugs were combined with
angiotensin-converting enzyme inhibitors but were associated with unacceptable rates of
angioedema and, therefore, withdrawn. However, one such agent (
omapatrilat) showed promise of NEP/RAS inhibition in treating CKD in animal models, producing greater reductions in
proteinuria, glomerulosclerosis and tubulointerstitial
fibrosis compared with isolated RAS inhibition. A new class of
drug called
angiotensin receptor neprilysin inhibitor (ARNi) has been developed. One such
drug,
LCZ696, has shown substantial benefits in trials in
hypertension and HF. In CKD, HF is common due to a range of mechanisms including
hypertension and structural
heart disease (including
left ventricular hypertrophy), suggesting that ARNi could benefit patients with CKD by both retarding the progression of CKD (hence delaying the need for
renal replacement therapy) and reducing the risk of
cardiovascular disease.
LCZ696 is now being studied in a CKD population.