Angiotensin converting enzyme (ACE) inhibitors have the broader effect of any drug in cardiovascular medicine, reducing the risk of death, myocardial infarction, stroke, diabetes, and renal impairment.A recent meta-analysis of 33,500 patients included in six randomized clinical trials and a pooled analysis of the Heart Outcomes Prevention Evaluation (HOPE), the European Trial on Reduction of Cardiac Events with Perindopril in Stable Coronary Artery Disease (EUROPA, and the Prevention of Events with Angiotensin-Converting-Enzyme Inhibition (PEACE) trials showed that ACE inhibitors reduce mortality and cardiovascular events also in subjects with coronary artery disease but preserved left ventricular function. However, all the above studies excluded patients with advanced renal insufficiency or end stage renal disease (ESRD). Thus, whether ACE inhibitors may have a specific cardioprotective effect also in this typology of patients is still matter of investigation. This is an issue of major clinical relevance since CV disease is the primary cause of morbidity and mortality in the ESRD population and affects as many as 50-60% of ESRD patients.The burden of CV disease in this population is predicted to dramatically increase over the next few years because of the rapidly increasing number of patients requiring renal replacement therapy and the increasing prevalence of ESRD patients at increased cardiovascular risk because of older age, diabetes and hypertension.