Angiotensin converting enzyme inhibitors and chronic kidney diseases

Angiotensin converting enzyme inhibitors (ACE-I), besides blockers of angiotensin II type 1 receptor (sartans) are currently the drug of choice in the renoprotective treatment of patients with chronic glomerulopathies with concomitant proteinuria or arterial hypertension. The renoprotective effect of ACE-I exceeds consequences of blood pressure reduction and is the result of intraglomerular pressure decline related to inhibition of angiotensin II dependent vasoconstriction of efferent vessels. In addition ACE-I selectively decreases mesangial cells proliferation, matrix accumulation and podocytes injury. As the consequence ACE-I reduces proteinuria, which is not only a marker of glomerular injury but also the agent leading to interstitial fibrosis. This paper summarizes the up to date knowledge concerning the effectiveness of ACE-I in prophylaxis of microalbuminuria, progression of microalbuminuria to overt proteinuria and worsening of glomerular filtration in patients with diabetes mellitus. Moreover ACE-I medication may reduce the risk of de novo diabetes mellitus. This review quotes results of studies and meta-analyses concerning the role of those drugs in patients with nondiabetic nephropathies and optimal blood pressure values for renoprotection. Indications for initiation of ACE-I treatment and contradictions are presented in details. Adverse reactions (hyperkalaemia, acute renal failure, cough, angioedema) and their predictors and incidence rate is discussed.