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Heavy reversible proteinuria induced by antihypertensive treatment with low doses of captopril has recently been reported by our group in psoriatic patients. To ascertain whether an increased permeability of the glomerular basal membrane of psoriatics can lead to an enhanced urinary excretion of albumin independently from the presence or absence of coexisting diabetes or hypertension, the latter parameter was measured in 39 patients affected by diffuse psoriasis. A high prevalence of microalbuminuria was observed in diabetic and hypertensive psoriatics. Moreover, a direct correlation was found between the diastolic blood pressure (BP) values and the urinary excretion of albumin in the entire group of psoriatics, thus suggesting systemic hypertension as one of the factors responsible for proteinuria in these patients. However, more than 50% of normotensive psoriatics showed an enhanced excretion of albumin. Since microalbuminuria has been indicated as a reliable index to predict the development of renal impairment, the finding of an enhanced albumin loss in psoriatics represents a further risk factor in these patients, who are particularly susceptible to experience cardiovascular complications.

A retrospective analysis of renal vein renin results has been done in 96 patients with renal artery stenosis and hypertension studied in two Italian centers (Sassari and Pisa) with respect to the outcome of either surgery or percutaneous transluminal angioplasty (PTA). In all patients the renal vein renin ratio and the V-A/A ratios for the affected and unaffected kidney were calculated. Each patient underwent surgery (75) of PTA (21): 71 subjects were cured, 17 improved whereas the arterial pressure did not vary after revascularisation procedure in 8 patients. In the Pisa series all 54 patients showed a lateralisation with contralateral renin suppression and 95% of them benefitted from surgery. In the Sassari series 42 patients were submitted to PTA or surgery, not only on the basis of a positive renal vein renin study but taking into account a complete clinical evaluation: 8 of them were cured or improved in spite of negative renal vein renin criteria. In the two series, the better predictive index appeared to be the suppression of the renin secretion from the contralateral kidney while the high/low renin ratio showed a consistent amount of false-positive and false-negative results. Our retrospective study demonstrates that the renal vein test in hypertensive patients with renal artery stenosis is highly predictive of the curability of the disease, particularly when contralateral suppression of renin secretion is present. On the other hand, since patients with negative renin indexes can also take benefit from surgery of PTA, the renin parameters cannot be adopted as the sole criterion in making the decision to operate.

We have previously reported on a high prevalence of high renin essential hypertension in psoriasis. Since angiotensin-converting enzyme (ACE) was also reported to be increased in some psoriatics, we found it rational to treat 10 patients with hypertension and diffuse psoriasis with captopril at a dose of 25 mg t.i.d. Five patients had high PRA levels and in 1 of them serum ACE was also increased. Serum creatinine, BUN and urinalysis were normal in all of them. SPB fell from 163 +/- 3 to 138 +/- 3 and DBP from 107 +/- 3 to 86 +/- 2 mm Hg after 1 month of captopril treatment. A surprising clinical improvement of the cutaneous lesions occurred in 3 patients previously resistant to every local or systemic treatment. Unfortunately, however, 3 patients developed heavy proteinuria (greater than 2 g/day) which disappeared after captopril discontinuation. The unexpected incidence of reversible proteinuria induced by low doses of captopril in our patients recommends a careful monitoring of the renal function every time this drug is employed in the treatment of hypertension in a psoriatic.

To test the hypothesis that acute angiotensin-converting enzyme (ACE) inhibition might predict the postoperative blood pressure outcome, a single oral dose of captopril ranging from 12.5 to 100 mg, was given to 26 patients with renovascular disease and its hypotensive effect was compared with that of surgery (21 patients) or of percutaneous transluminal angioplasty (PTA) (5 patients). Both systolic and diastolic blood pressure fell significantly (p less than 0.001) from 179.9 +/- 5.4/114.1 +/- 2.1 to 148.4 +/- 3.8/94.1 +/- 1.9 after captopril and to 141.1 +/- 3.7/88.9 +/- 2.0 at least 3 months after operation. Postoperative pressure values were directly related to those after captopril (SBP: r = 0.65, p less than 0.001; DBP: r = 0.45, p less than 0.05) as were their absolute decrements (SBP: r = 0.70, p less than 0.001; DBP: r = 0.64, p less than 0.001). However, after captopril, individual pressure tended to be higher (and their decrements to be lower) than after operation. 12 out of 19 patients cured by surgery were considered cured by captopril, while 5 out of the remaining 7 were improved and 2 not cured. The 6 patients improved by surgery or PTA were also improved by captopril and the only patient not cured by surgery was not cured by captopril. Therefore, if we consider both cure and improvement as a positive result, the captopril test gave 23 true-positive, 1 true-negative and 2 false-negative responses. Taken together, these data suggest that acute ACE inhibition may be an useful tool in predicting postoperative blood pressure of patients with renovascular disease.