***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: OBJECTIVE --To assess the effectiveness of angiotensin converting enzyme inhibition in preventing the development of diabetic nephropathy ( albuminuria greater than 300 mg/24h ) . DESIGN --Open r and omised controlled study of four years ' duration . SETTING --Outpatient diabetic clinic in tertiary referral centre . PATIENTS --44 normotensive ( mean blood pressure 127/78 ( SD 12/10 ) mm Hg ) insulin dependent diabetic patients with persistent microalbuminuria ( 30 - 300 mg/24h ) . INTERVENTIONS --The treatment group ( n = 21 ) was initially given captopril ( 25 mg/24 h ) . The dose was increased to 100 mg/24 h during the first 16 months and thiazide was added after 30 months . The remaining 23 patients were left untreated . MAIN OUTCOME MEASURES --Albuminuria , kidney function , development of diabetic nephropathy ( albuminuria greater than 300 mg/24 h ) , and arterial blood pressure . RESULTS -- Clinical and laboratory variables were comparable at baseline . Urinary excretion of albumin was gradually reduced from 82 ( 66 - 106 ) to 57 ( 39 - 85 ) mg/24 h ( geometric mean ( 95 % confidence interval ) ) in the captopril treated group , whereas an increase from 105(77 - 153 ) to 166 ( 83 - 323 ) mg/24 h occurred in the control group ( p less than 0.05 ) . Seven of the untreated patients progressed to diabetic nephropathy , whereas none of the captopril treated patients developed clinical overt diabetic nephropathy ( p less than 0.05 ) . Systemic blood pressure , glomerular filtration rate , haemoglobin A1c concentration , and urinary excretion of sodium and urea remained practically unchanged in the two groups . CONCLUSIONS --The findings suggest that angiotensin converting enzyme inhibition postpones the development of clinical overt diabetic nephropathy in normotensive insulin dependent diabetic patients with persistent microalbuminuria Abstract This study tested the hypothesis that passive exposure to posters containing essential information on cardiopulmonary resuscitation ( CPR ) displayed on lavatory walls improves theoretical knowledge and the performance of CPR . There was a significant increase in both knowledge and performance of CPR after exposure to the posters . This technique is inexpensive and simple , and it warrants more widespread use as a means of maintaining knowledge and proficiency in CPR Recent studies utilizing converting enzyme inhibitors ( CEI ) in diabetic rats document reductions in both renal hypertrophy and albuminuria . Four separate clinical studies in normotensive patients with diabetes demonstrate reduction of microalbuminuria with CEIs independent of blood pressure reduction . The present pilot study examines the results of reducing an elevated glomerular filtration rate on changes in renal size and microalbuminuria in normotensive , hyperfiltering insulin-dependent diabetic ( IDDM ) patients . Fifteen IDDM patients were r and omized to either placebo or the CEI , lisinopril . Dosage of lisinopril was titrated over 3 months to reduce glomerular filtration rate ( GFR ) to < or = 2.33 mL/sec . Evaluation at 18 months demonstrated the lisinopril group had a marked reduction in renal size ( 16.9 + /- 1.1 , baseline versus 12.8 + /- 0.9 cm , 18 months ; p < 0.05 ) and microalbuminuria ( 92 + /- 11 micrograms/min , baseline versus 23 + /- 26 micrograms/min , 18 months ; p < 0.05 ) . No change in renal size was noted in the placebo group ( 15.4 + /- 0.8 , baseline versus 14.9 + /- 0.7 cm , 18 months ; NS ) and albuminuria increased ( 118 + /- 15 micrograms/min , baseline versus 293 + /- 32 micrograms/min , 18 months ; p < 0.05 ) . Mean arterial pressure at 18 months was significantly lower in the lisinopril group compared to placebo ( 102 + /- 4 , placebo versus 87 + /- 6 mm Hg , CEI , p < 0.05 ) . This study supports previous animal studies that document reductions in both microalbuminuria and renal size by a CEI . The overall impact of these findings on preservation of renal function can not be assessed , however , in this short-term study PURPOSE To determine whether angiotensin-converting enzyme ( ACE ) inhibition with captopril reduces the progression of microalbuminuria to overt proteinuria in normotensive patients with insulin-dependent diabetes mellitus ( IDDM ) . PATIENTS AND METHODS This study was a prospect i ve r and omized , double-blind , placebo-controlled trial involving 26 centers in the United States and Canada . One hundred forty-three subjects , 14 to 57 years of age , with IDDM for 4 to 33 years , blood pressure < 140/90 mm Hg in the absence of antihypertensive therapy , and persistent albumin excretion 20 to 200 micrograms/min were r and omized to double-blind treatment with captopril 50 mg or placebo BID . Albumin excretion rate ( AER ) , blood pressure , and glycohemoglobin were determined every 3 months , and creatinine clearance ( CrCl ) and urea excretion were measured every 6 months . RESULTS Within 24 months , 6.0 % ( 4/67 ) of captopril-treated subjects and 18.6 % ( 13/70 ) of placebo-treated subjects progressed to clinical proteinuria , defined as AER > 200 micrograms/min and at least 30 % above baseline ( risk reduction = 67.8 % , P = 0.037 ) . AER increased at an annual rate of 11.8 % ( 95 % confidence interval [ CI ] -3.3 % to 29.1 % ) in the placebo group , while it declined by 17.9 % ( CI -29.6 % to -4.3 % ) in the captopril group ( P = 0.004 ) . CrCl decreased by 4.9 mL/min per 1.73 m2 per year in the placebo group , while it remained stable in the captopril group ( 0.9 mL/min per 1.73 m2 per year , P = 0.039 between groups ) . Ten subjects required treatment for hypertension ; 8 in the placebo group and 2 in the captopril group . There was little correlation between the 24-month changes in mean arterial blood pressure and AER in either group . Glycohemoglobin and urinary urea excretion did not differ between groups . CONCLUSIONS After 24 months of therapy with captopril , compared with placebo , normotensive subjects with IDDM experienced significantly less progression of microalbuminuria to clinical proteinuria , reduced albumin excretion , and preserved CrCl rate . The ACE inhibitor , captopril , was well tolerated The effect of long term , aggressive antihypertensive treatment on kidney function in diabetic nephropathy was studied prospect ively in 11 insulin dependent diabetics ( mean age 30 ) . During the mean pretreatment period of 32 ( range 23 - 66 ) months the glomerular filtration rate decreased significantly and albuminuria and the arterial blood pressure increased significantly . During the 72 ( range 32 - 91 ) month period of antihypertensive treatment the average arterial blood pressure fell from 143/96 mm Hg to 129/84 mm Hg and albuminuria decreased from 1038 micrograms/min to 504 micrograms/min . The rate of decline in the glomerular filtration rate decreased from 0.89 ( range 0.44 - 1.46 ) ml/min/month before treatment to 0.22 ( range 0.01 - 0.40 ) ml/min/month during treatment . The rate of decline in the glomerular filtration rate was significantly smaller during the second three years compared with the first three years in patients who received long term antihypertensive treatment ( greater than or equal to 6 years ) . One patient died from acute myocardial infa rct ion ( glomerular filtration rate 46 ml/min/1.74 m2 ) . Effective antihypertensive treatment postpones renal insufficiency in diabetic nephropathy The effects of a long term reduction in blood pressure on the kidney function of normotensive diabetic patients who had persistent microalbuminuria ( 30 - 300 mg albumin/24 hours ) were studied in two groups of 10 such patients before and during six months of treatment with either 20 mg  enalapril or placebo daily . Treatments were assigned r and omly in a double blind fashion . Before treatment both groups had similar clinical characteristics , weight , diet , total glycosylated haemoglobin , median albumin excretion rate ( enalapril group 124 mg/24 h , placebo group 81 mg/24 h ) , and mean arterial pressure ( enalapril group 100 ( SD 8) mm Hg , placebo group 99 ( 6 ) mm Hg ) . During treatment weight , urinary urea excretion , and total glycosylated haemoglobin remained unchanged . The mean arterial pressure decreased in the enalapril group but not in the placebo group ( enalapril group 90 ( 10 ) mm Hg , placebo group 98 ( 8) mm Hg ) . The median albumin excretion rate also fell in the enalapril group but not in the placebo group ( enalapril group 37 mg/24 h , placebo group 183 mg/24 h. ) The glomerular filtration rate rose in the enalapril group from 130 ( 23 ) ml/min/1.73 m2 to 141 ( 24 ) ml/min/1.73 m2 , and total renal resistances and fractional albumin clearance decreased while fractional albumin clearance increased in the placebo group . These results show that in patients who have diabetes but not hypertension a reduction in blood pressure by inhibition of converting enzyme for six months can reduce persistent microalbuminuria , perhaps by decreasing the intraglomerular pressure OBJECTIVE To study the effect of Captopril on ambulatory blood pressure , renal and cardiac function and extracellular volume in microalbuminuric Type 1 diabetic patients . DESIGN R and omized , double blind placebo controlled study of two years duration . SETTING University clinic . PATIENTS Twenty-two patients without hypertension . INTERVENTION Patients received 50 mg Captopril or placebo twice a day . MEASUREMENTS Ambulatory blood pressure , renal function , extracellular volume , and echocardiographic indices of cardiac function and dimensions were assessed annually . Clinic blood pressure and urinary albumin excretion were measured every 3 months . RESULTS Twenty-four hour mean arterial blood pressure was unchanged in the Captopril group ( mean + /- SD ) ( baseline 93 + /- 4 and follow up 91 + /- 8 mmHg ) and in the placebo group ( 96 + /- 7 and 97 + /- 10 mmHg , NS ) . Night/day ratio of blood pressure was unaffected . Glomerular filtration rate was unchanged and renal plasma flow increased in the Captopril ( 557 + /- 97 and 600 + /- 112 ml min-1 ) versus the placebo group ( 574 + /- 85 and 535 ml min-1 , p = 0.05 ) . Filtration fraction was reduced in the Captopril versus the placebo group ( p < 0.05 ) . Extracellular volume and echocardiographically derived parameters were unaffected . The relative change in day time mean arterial blood pressure in the Captopril group correlated with changes in urinary albumin excretion ( Spearmans r = 0.85 , p < 0.05 ) unlike clinic mean arterial blood pressure ( r = 0.33 , p = 0.35 ) . CONCLUSION Diurnal rhythm of blood pressure was unaffected by long term administration of Captopril .  Renal plasma flow was increased and filtration fraction reduced . A significant association between changes in urinary albumin excretion and blood pressure after Captopril was revealed only by the implementation of ambulatory blood pressure measurements Based on animal experiments it has been proposed that antihypertensive agents may differentially influence albuminuria through their divergent effects on glomerular haemodynamics or glomerular sieving properties and may beneficially influence the progression of diabetic nephropathy even without an effect on blood pressure . However , to date this hypothesis has not been tested in normotensive patients with diabetic nephropathy . The main aim of this study was therefore to investigate the effects of the administration of two antihypertensive agents on albuminuria during rest and exercise . The study consisted of 3 x 3 r and omised , cross-over periods with five days double blind administration of enalapril ( E : 2.5 mg bid ) , nitrendipine ( N : 5 mg bid ) and placebo ( P ) on 18 Type 1 normotensive ( blood pressure < 140/90 mmHg ) di 
    Output:
    
Treatment provided a significant reduction in albumin excretion rate in both insulin dependent diabetes mellitus and non insulin dependent diabetes mellitus .
Treatment with either captopril , enalapril or lisinopril reduced albumin excretion rate in comparison with control patients .
A greater lowering of blood pressure was experienced by initially normotensive patients in the angiotensin converting enzyme inhibitor than in the placebo group .
Pooled end-of- study mean blood pressures for the treated group were significantly lower than for the untreated group , although this was not so for all individual studies .
The apparent ( treatment - placebo ) ' effect ' on systolic and diastolic pressures had a larger st and ard error for longer lasting studies .
Average haemoglobin fell a little in the treated patients and rose in the controls but neither this nor the difference in changes in glomerular filtration rate reached statistical significance .
REVIEW ER 'S CONCLUSIONS Inhibition of angiotensin converting enzyme can arrest or reduce the albumin excretion rate in microalbuminuric normotensive diabetics , as well as reduce or prevent an increase in blood pressure .
But , given the drop in blood pressure in patients on angiotensin converting enzyme inhibitors , it is not possible to be certain that the reduction of albumin excretion rate is due to a separate renal effect .
A direct link with postponement of end-stage renal failure has not been demonstrated .
There appear to be no substantial side effects