renal damage and ACE inhibitor use in renal artery stenosis

Last edited 07/2021 and last reviewed 07/2021

The glomerular filtration pressure is determined by three main variables:

  • systemic blood pressure
  • vasomotor tone in the afferent arteriole
  • vasomotor tone in the efferent arteriole

In cases of bilateral renal artery stenosis (or unilateral stenosis if there is only one functional kidney):

  • the glomerular filtration pressure is dependent on the vasoconstriction of the efferent arteriole because the resistance of the afferent blood vessels has been pathologically increased
    • vasoconstriction of the efferent arteriole is mediated by angiotensin II
    • administration of an ACE inhibitor abolishes the vasoconstriction of the efferent arteriole resulting in an abrupt fall in the glomerular filtration rate
    • the deterioration in renal function due to ACE inhibitors is usually reversible on stopping the drug

The EMC states that a contraindication to use of an ACE inhibitor is

  • significant bilateral renal artery stenosis or renal artery stenosis in a single functioning kidney (1)