Taking precautions with angiotensin converting enzyme inhibitors
Authors: J. D Louden, J. Main, D. R Murdoch, T. A Chowdhury, M. Ferris, A Kumar, M Asim, A M Davison
Journal: BMJ (1999)

# Angiotensin converting enzyme inhibitors are not proved to cause loss of renal mass {#article-title-2} EDITOR—We agree with Kumar et al that an awareness of the high risk of atherosclerotic renal artery stenosis is important in patients with vascular disease elsewhere, particularly if treatment with angiotensin converting enzyme inhibitors is being considered.1 We strongly disagree with the suggestion, however, that high risk patients starting treatment with angiotensin converting enzyme inhibitors should first be screened for unilateral renal artery stenosis, for two reasons. Firstly, the assertion that angiotensin convert ing enzyme inhibitors cause loss of renal mass is unproved. Irreversible structural damage to kidneys with renal artery stenosis may result from hypertensive nephrosclerosis, cholesterol embolisation, ischaemia as a result of tight renal artery stenosis, and, ultimately, total occlusion.2 Angiotensin converting enzyme inhibitors cause an acute decrease in glomerular filtration rate, but in cases where this proves irreversible, the likeliest explanation is progression of the underlying disease. Renal blood flow is not specifically reduced by angiotensin converting enzyme inhibitors,3 although any drug that lowers blood pressure might reduce renal blood flow in the presence of clinically important renal artery stenosis.4 If screening for unilateral atherosclerotic renal artery stenosis were important, it would therefore be important for all high risk patients, not only those prescribed angiotensin converting enzyme inhibitors. Secondly, however, we do not believe that screening for unilateral atherosclerotic renal artery stenosis is worth while. The rationale for screening would presumably be to prevent end stage renal failure secondary to bilateral renal artery occlusion. Evidence is lacking that percutaneous angioplasty, with or without stenting, prevents end stage renal failure in unilateral atherosclerotic renal artery stenosis.5 Although unilateral atherosclerotic renal artery stenosis is common and easy to find in high risk patients, current evidence does not tell us how to manage it once it is found. 1. ↵1. Kumar A, 2. Asim M, 3. Davison AM .Taking precautions with ACE inhibitors.BMJ1998;316: 1921[Free Full Text]. (27 June.) [OpenUrl][1][FREE Full Text][2] 2. ↵1. Scoble JE, 2. Cook JR .Individual kidney function in atherosclerotic nephropathy.Nephrol Dial Transplant1998;13: 842–844 [OpenUrl][3][FREE Full Text][4] 3. ↵1. Navar LG, 2. Inscho EW, 3. Majid DSA, 4. Imig JD, 5. Harrison-Bernard LM, 6. Mitchell KD .Paracrine regulation of the renal micro circulation.Physiol Rev1996;76: 425–536 [OpenUrl][5][Abstract/FREE Full Text][6] 4. ↵1. Jacobson HR .Ischemic renal disease: an overlooked clinical entity?Kidney Int1988;34: 729–743 [OpenUrl][7][CrossRef][8][PubMed][9][Web of Science][10] 5. ↵1. Preston RA, 2. Epstein M .Ischemic renal disease: an emerging cause of chronic renal failure and end-stage renal disease.J Hypertens1997;15: 1365–1377 [OpenUrl][11][CrossRef][12][PubMed][13][Web of Science][14] # Screening for unilateral renal artery stenosis cannot be justified {#article-title-8} EDITOR—The editorial by Kumar et al reminds … [1]: {openurl}?query=rft.jtitle%253DBMJ%26rft.stitle%253DBMJ%26rft.issn%253D0007-1447%26rft.aulast%253DKumar%26rft.auinit1%253DA%26rft.volume%253D316%26rft.issue%253D7149%26rft.spage%253D1921%26rft.epage%253D1930%26rft.atitle%253DTaking%2Bprecautions%2Bwith%2BACE%2Binhibitors%26rft_id%253Dinfo%253Apmid%252F9641925%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/ijlink?linkType=FULL&journalCode=bmj&resid=316/7149/1921&atom=%2Fbmj%2F318%2F7178%2F257.atom [3]: {openurl}?query=rft.jtitle%253DNephrology%2BDialysis%2BTransplantation%26rft.stitle%253DNephrol%2BDial%2BTransplant%26rft.issn%253D0931-0509%26rft.aulast%253DScoble%26rft.auinit1%253DJ.%26rft.volume%253D13%26rft.issue%253D4%26rft.spage%253D842%26rft.epage%253D844%26rft.atitle%253DIndividual%2Bkidney%2Bfunction%2Bin%2Batherosclerotic%2Bnephropathy%26rft_id%253Dinfo%253Adoi%252F10.1093%252Fndt%252F13.4.842%26rft_id%253Dinfo%253Apmid%252F9568835%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [4]: /lookup/ijlink?linkType=PDF&journalCode=ndt&resid=13/4/842&atom=%2Fbmj%2F318%2F7178%2F257.atom [5]: {openurl}?query=rft.jtitle%253DPhysiological%2BReviews%26rft.stitle%253DPhysiol.%2BRev.%26rft.issn%253D0031-9333%26rft.aulast%253DNavar%26rft.auinit1%253DL.%2BG.%26rft.volume%253D76%26rft.issue%253D2%26rft.spage%253D425%26rft.epage%253D536%26rft.atitle%253DParacrine%2Bregulation%2Bof%2Bthe%2Brenal%2Bmicrocirculation%26rft_id%253Dinfo%253Apmid%252F8618962%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [6]: /lookup/ijlink?linkType=ABST&journalCode=physrev&resid=76/2/425&atom=%2Fbmj%2F318%2F7178%2F257.atom [7]: {openurl}?query=rft.jtitle%253DKidney%2Binternational%26rft.stitle%253DKidney%2BInt%26rft.aulast%253DJacobson%26rft.auinit1%253DH.%2BR.%26rft.volume%253D34%26rft.issue%253D5%26rft.spage%253D729%26rft.epage%253D743%26rft.atitle%253DIschemic%2Brenal%2Bdisease%253A%2Ban%2Boverlooked%2Bclinical%2Bentity%253F%26rft_id%253Dinfo%253Adoi%252F10.1038%252Fki.1988.240%26rft_id%253Dinfo%253Apmid%252F3059028%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [8]: /lookup/external-ref?access_num=10.1038/ki.1988.240&link_type=DOI [9]: /lookup/external-ref?access_num=3059028&link_type=MED&atom=%2Fbmj%2F318%2F7178%2F257.atom [10]: /lookup/external-ref?access_num=A1988Q582500018&link_type=ISI [11]: {openurl}?query=rft.jtitle%253DJournal%2Bof%2Bhypertension%26rft.stitle%253DJ%2BHypertens%26rft.aulast%253DPreston%26rft.auinit1%253DR.%2BA.%26rft.volume%253D15%26rft.issue%253D12%2BPt%2B1%26rft.spage%253D1365%26rft.epage%253D1377%26rft.atitle%253DIschemic%2Brenal%2Bdisease%253A%2Ban%2Bemerging%2Bcause%2Bof%2Bchronic%2Brenal%2Bfailure%2Band%2Bend-stage%2Brenal%2Bdisease.%26rft_id%253Dinfo%253Adoi%252F10.1097%252F00004872-199715120-00001%26rft_id%253Dinfo%253Apmid%252F9431840%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [12]: /lookup/external-ref?access_num=10.1097/00004872-199715120-00001&link_type=DOI [13]: /lookup/external-ref?access_num=9431840&link_type=MED&atom=%2Fbmj%2F318%2F7178%2F257.atom [14]: /lookup/external-ref?access_num=A1997YH35600001&link_type=ISI