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The activation of the renin angiotensin aldosteron (RAA) system plays a major role in the progression of chronic kidney disease (CKD). Inhibition of the RAA system ameliorates renal injury and improves the prognosis of CKD patients (1-3). On the basis of solid evidence from numerous animal model experiments and clinical trials of RAA inhibitors, beyond their action of lowering blood pressure, they have beneficial effects on local tissue remodeling and inhibition of tissue damage, which occurs by locally generated angiotensin II in the kidney. According to the guidelines, both ACEI and ARB have been used as the first-line drugs for the treatment of CKD, however, the superiority between ACEI and ARB has not been well studied. In this issue of Internal Medicine, Shoda et al (4) reported that ACEI significantly attenuated the progression of CKD to end-stage renal failure than ARB in non-diabetic CKD patients during a 5-year observation. Proteinuria was significantly lowered by treatment with ACEI compared to those with ARB. More importantly, ACEI showed a better risk reduction of progression to ESRD than ARB. This is the first report to demonstrate the superiority of the ACEI in the treatment of stage 3 CKD patients when the mean blood pressure was equally controlled to around 130/80 mmHg. The study, however, contains some limitations: the number of enrolled patients is small. The study was not conducted in a double-blind manner. The baseline renal function and proteinuria tended to be worse in the patients assigned to ARB, although there was no significant difference in statistics.

Is ACEI Superior to ARB for CKD?