Extremely low birth weight infants (birth weight ≤1000 g) have a significantly lower nephron number. The glomerular filtration rate (GFR) is usually sufficient under normal conditions but is unable to meet the needs during stress, which results in acute kidney injury (AKI). We describe the case of an extremely low birth weight infant (970 g) with a gestational age of 27 weeks (immature preterm) who was mechanically ventilated because of hyaline membrane disease. AKI with anuria and a rise in serum creatinine to 3.4 mg/dL developed in the second week. Diuresis was restored after diuretics and dopamine were administered intravenously and kidney function recovered in the next two weeks. However, he slowly became hypertensive, so intravenous enalapril was introduced in the 6th week. After the third dose, he suffered another AKI. After cessation of enalapril, kidney function recovered over the next few days. Although angiotensin-converting enzyme inhibitors (ACEi) may cause kidney injury, it can be used with great caution in the treatment of hypertension or heart failure in preterm infants. There remains a real dilemma of whether enalapril should be used in extremely low birth weight immature infants.

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