ACE Inhibitors and Renal Insufficiency

Renal insufficiency is a late complication of hypertension (354). This is why the choice of the antihypertensive drug selected as the firs (dine treatment of a condition that will persist for many years is so important. From this viewpoint, the fall in blood pressure induced by ACE inhibitors might have beneficial renal effects, in addition to those induced by any decrease in perfusion pressure of the kidneys, especially in diabetic patients (222, 355-358). It is unknown if, independendy of the hemodynamic effect, at an early stage of hypertension and before the initiation of a progressive decrease in renal function, a local decrease in angiotensin II (or increase in bradykinin) explains or direcdy participates in a so-called renoprotective effect (359). 

The Fallacy of the Concepts of Normotension and Hypertension and the Cardiovascular Protective Effects of ACE Inhibitors 

The normative approach to the practice of medicine, based on the definition of thresholds, is a different paradigm from the continuous distribution of most biological parameters and their associated risks, as described by physiologists and epidemiologists (360-362). Blood pressure, cholesterol, and renin have a logarithmic gaussian distribution in populations. Renin dependency, for instance, may be considered as a constant feature of all humans except when they have a positive sodium balance, which more or less mimics schematic animal models such as DOCA hypertension (349). In this extreme situation, cardiac, renal, and vascular damages may be direcdy induced by the excess of salt itself, in the absence of any functional RAS (363). 

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