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To the Editor:Angiotensin-converting enzyme (ACE) inhibitors are frequently used in the treatment of hypertension, heart failure, and renal disease but may cause acute renal failure in patients with renal artery stenosis (RAS).1 We describe a novel adverse effect of ACE inhibitors in patients with advanced chronic kidney disease (CKD) and RAS.We observed 4 episodes of severe paradoxical hypertension in 3 patients with CKD (Table) and bilateral RAS, during initiation or titration of the ACE inhibitor ramipril (Tritace, Sanofi-Aventis). The etiology of CKD was atherosclerotic renovascular disease in each case. Bilateral, hemodynamically significant RAS had been demonstrated previously with both Doppler ultrasound and renal angiography in all 3 of the patients and magnetic resonance angiography in 2 patients. Blood pressure (BP) measurement using …

Severe Paradoxical Hypertension With Angiotensin-Converting Enzyme Inhibitors: An Unusual Feature of Renal Artery Stenosis