Background: In some patients with renal disease, use of angiotensin-converting enzyme (ACE) inhibitors is thought to improve renal function, whereas in others their use leads to worsening. Many questions remain about the categories of patients that benefit from ACE inhibitor use.
Objective: To clarify the use of ACE inhibitors in patients with renal disease.
Study design: A literature review focusing on various renal diseases, ACE inhibitors, and criteria of cost effectiveness was performed.
Results: Almost 100 clinical studies were reviewed. Treatment with ACE inhibitors seems to have beneficial effects in type 1 and type 2 diabetes mellitus with nephropathy, AIDS nephropathy, and other nondiabetic renal diseases. Use of these agents in these diseases decreases the progression of renal disease and the need for dialysis, resulting in potential cost savings and improved quality of life. Data supporting goal blood pressures indicate the need to aggressively decrease this risk factor. Use of ACE inhibitors is hazardous in bilateral renal artery stenosis, particularly with volume depletion, but may be valuable in patients with unilateral stenosis. In African Americans, ACE inhibitor treatment is likely to be of benefit, although required doses may be higher than for whites, and caution must be exercised in certain situations. The potential efficacy of angiotensin receptor blockers and other new drugs that affect the renin-angiotensin system is assessed.
Conclusions: Use of ACE inhibitors has benefit in renal disease states characterized by increased glomerular perfusion pressure, their use in other renal disease states, particularly those characterized by reduced glomerular perfusion pressure, may be risky. The benefits conferred by ACE inhibitor therapy are so dramatic in terms of cost savings and improved quality of life that their use in certain clinical situations should be strongly encouraged in managed care and other practice settings.