Background: Renin inhibition with aliskiren induced the largest increases in renal plasma flow (RPF) in salt-depleted healthy volunteers of all renin-angiotensin system (RAS) blockers. However, given its side-effects at doses higher than 300 mg, no maximum effect of renin inhibition could be established. We hypothesized that VTP-27999, a novel renin inhibitor without major side-effects at high doses, would allow us to establish this. Methods and results: The effects of escalating VTP-27999 doses (75-600mg) on RPF, glomerular filtration rate (GFR), and plasma RAS components were compared with those of 300mg aliskiren in 22 normal volunteers on a low-sodium diet. VTP-27999 dose-dependently increased RPF and GFR; its effects on both parameters at 600mg (increases of 18 ± 4 and 20 ± 4%, respectively) were equivalent to those at 300 mg, indicating that a maximum had been reached. The effects of 300 mg aliskiren (increases of 13 ± 5 and 8 ± 6%, respectively; P < 0.01 vs. 300 and 600 mg VTP- 27999) resembled those of 150mg VTP-27999. VTP-27999 dose-dependently increased renin, and lowered plasma renin activity and angiotensin II to detection limit levels. The effects of aliskiren on RAS components were best comparable to those of 150mg VTP-27999. Conclusion: Maximum renal renin blockade in healthy, salt-depleted volunteers, requires aliskiren doses higher than 300 mg, but can be established with 300 mg VTP- 27999. To what degree such maximal effects (exceeding those of angiotensin-converting enzyme inhibitors and AT1 -receptor blockers) are required in patients with renal disease, given the potential detrimental effects of excessive RAS blockade, remains to be determined.

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Journal of Hypertension
Erasmus MC: University Medical Center Rotterdam

Barkoudah, E, van Thiel, B.S, Fisher, N.D.L, Gregg, R.A, Danser, A.H.J, Moukarbel, G.V, & Hollenberg, N.K. (2016). Maximum renal responses to renin inhibition in healthy study participants: VTP-27999 versus alisk iren. Journal of Hypertension, 34(5), 935–941. doi:10.1097/HJH.0000000000000860