ACUTE-RENAL-FAILURE AFTER THE USE OF ANGIOTENSIN-CONVERTING-ENZYME INHIBITORS IN PATIENTS WITHOUT RENAL-ARTERY STENOSIS

During a 4-year period, acute renal failure was observed in 27 patient s (mean age 65 years) treated by various angiotensin-converting-enzyme (ACE) inhibitors for hypertension, heart failure, or a combination of both. None had significant renal artery stenosis on angiography. Over t volume depletion was present in 21 and hypotension in 12 cases. All patients received diuretic therapy and/or a low-salt diet. Other facil itating factors included cardiac failure, pre-existing chronic renal i nsufficiency, combined therapy with non-steroidal anti-inflammatory dr ugs, and diabetes mellitus. Twenty-two patients had two or more of the se factors at presentation. A renal biopsy performed in 10 cases showe d severe arteriosclerosis of small renal arteries in eight and acute t ubular necrosis in five instances. Therapy comprise volume expansion, and withdrawal of diuretics and, except in two patients, of ACE inhibi tors. Twenty-one patients recovered normal renal function, two died, a nd permanent renal damage remained in four. These results suggest that sodium depletion has a critical role in inducing acut renal failure, whose outcome is not always benign. A combination of diuretics and ACE inhibitors should be prescribed with caution, especially in older pat ients with small as well as with large renal vessel disease.