Therefore, in those with diabetes and CKD G3 G4, A3, there is strong evidence supporting the treatment with RASi because of their renoprotective effects. Data for people with diabetes and CKD G1 G3, A2 comes from the Micro-HOPE study, in which people with diabetes, moderately increased albuminuria, and higher CV risks had improved CV outcomes when randomized to ACEi therapy compared to placebo.201 Speci cally, for the composite outcome of MI, stroke, and CV death, there was a relative risk reduction with diabetes from the Micro-HOPE study, with a mean follow- up of 4.5 years. Kidney bene t in this group was largely limited to reducing progression from moderately increased albumin- uria to severely increased albuminuria. Only 18 cases in total developed ESKD 10 on ramipril and 8 on placebo.163 In the Micro-HOPE study, baseline serum creatinine was 1.06 mg/dl (94 mmol/l), and 474 (14%) of 3238 people progressed to a serum creatinine level of $1.4 mg/dl (124 mmol/l) over the 4.5 years (231 on ramipril and 243 on placebo).202 In a meta-analysis performed by the ERT, we found that, for patients with diabetes (including patients with and without albuminuria [A1, A2, and A3]), ACEi compared to placebo or standard of care did not reduce the risk for all-cause mortality, up of 32 months (Supplementary Table S21163,203 223 ). The absolute difference was 26 fewer events per 1000 (95% CI: 57 fewer 20 more) and was not statistically signi cant. The risk of doubling of serum creatinine was reduced by 30% (RR: with a mean follow-up of 32 months and an absolute difference was not statistically signi cant.163,207,213,215,221,222 However, in patients with severely increased albuminuria, ACEi reduced doubling of serum creatinine by 42% (RR: 0.58; 95% CI: 0.37 ACEi also reduces albuminuria in the CKD population with diabetes. 