OBJECTIVES: Neither national nor international clinical guidelines do consistently recommend treating non-diabetic proteinuric patients with advanced renal disease with an angiotensin-converting enzyme (ACE) inhibitor. The aim of our study was to determine the cost-effectiveness of ACE inhibitor therapy in non-diabetic proteinuric patients with advanced renal disease in the Netherlands. METHODS: Two strategies were compared: treating patients with advanced renal disease with an ACE inhibitor and no ACE inhibitor treatment. A lifetime Markov decision model was developed using published data on costs and health outcomes and simulating the progression of renal disease. A health care perspective was adopted.  RESULTS: In the base-case analysis, ACE inhibitor treatment is associated with lower costs and higher benefit and therefore dominates the no-treatment strategy. A probabilistic sensitivity analysis shows that the probability of savings is 83%. CONCLUSIONS: ACE inhibitor treatment for non-diabetic patients with advanced renal disease in the Netherlands is highly cost-effective. Savings would be even larger if prevention of cardiovascular events were considered.