Letters

Taking precautions with angiotensin converting enzyme inhibitors

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7178.257 (Published 23 January 1999) Cite this as: BMJ 1999;318:257

Angiotensin converting enzyme inhibitors are not proved to cause loss of renal mass

  1. Jonathan D Louden, Research fellow,
  2. John Main, Consultant nephrologist
  1. South Cleveland Hospital, Middlesbrough, TS4 3BW
  2. Department of Cardiology, Hairmyres Hospital, East Kilbride G75 8RG
  3. Heartlands Diabetes Centre, Birmingham Heartlands Hospital, Birmingham B9 5SS
  4. Lakenham Surgery, Norwich NR1 3JJ
  5. Renal Unit, St James's University Hospital, Leeds LS9 7TF

    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.

    References

    Screening for unilateral renal artery stenosis cannot be justified

    1. David R Murdoch, Specialist registrar in cardiology
    1. South Cleveland Hospital, Middlesbrough, TS4 3BW
    2. Department of Cardiology, Hairmyres Hospital, East Kilbride G75 8RG
    3. Heartlands Diabetes Centre, Birmingham Heartlands Hospital, Birmingham B9 5SS
    4. Lakenham Surgery, Norwich NR1 3JJ
    5. Renal Unit, St James's University Hospital, Leeds LS9 7TF

      EDITOR—The editorial by Kumar et al reminds …

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