Inhibition of the renin–angiotensin system

• In patients with established evidence-based indications for inhibition of the renin–angiotensin system, for example congestive cardiac failure or chronic kidney disease with proteinuria, this treatment should not generally be withheld on the basis of renovascular disease. • When an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) are used in patients with renovascular disease, renal function should be monitored regularly. This is especially important in patients with high-grade (>70%) bilateral renal artery stenosis or high-grade renal artery stenosis to a solitary functioning kidney. As a guide, following initiation of this treatment in patients with renovascular disease, serum creatinine and electrolytes should be checked after 1 and 4 weeks, and then at least every 3 months thereafter. • A significant increase in serum creatinine (>20%) following initiation of treatment with an ACE inhibitor or ARB correlates with the presence of renovascular disease and may be an indication for investigation for this condition. • Patients with atherosclerotic renovascular disease have a high risk of experiencing cardiovascular events and management should be optimized to reduce this risk. This includes the use of statins to lower lipids, antiplatelet therapy, smoking cessation and the control of blood pressure.