Ace-Inhibitors Versus Angiotensin Receptor Blockers for Renoprotection : Conclusions From the Evidence and From the Evidence Behind the Evidence

The introduction of nephroprotective measures is of utmost importance, and this at all stages of renal failure (1). In view of the increasing prevalence of end stage renal disease, the slowing of progression of renal failure in patients with mild or moderate renal insufficiency, will have great impact on general health and health care budgets. In patients with already established pre-end stage and end stage renal disease, residual renal function is one of the most powerful predictors of outcome, so also in these patients preservation of renal function is of importance. Basic measures like convincing patients to stop smoking (2), advocating salt and moderate protein restriction (3) are already very effective, but often omitted for different reasons. Most physicians and patients will rather rely on pharmaceutical intervention, and in the last decades, a wide array of products has been developed, marketed and evaluated. Several largescale studies have provided evidence that blood pressure control is the first step to preservation of renal function (4). The concept that Angiotensin Converting Enzyme Inhibitors (ACE-I) have a nephroprotective effect above their blood pressure lowering effect was demonstrated in some large meta-analyses (5). The inhibition of the renine-angiotensine-aldosterone (RAA)-axis also proved to result in a decrease of proteinuria in itself an independent prognostic factor. In addition, also positive cardiovascular effects were demonstrated, like regression of left ventricular hypertrophy, improvement of left ventricular dysfunction and remodelling of the vascular wall. As many patients with renal disease also suffer from cardiovascular disease, administration of ACE-I to slow progression of renal insufficiency, and this at