Aims: Renin-angiotensin system blockers reduce the incidence and progression of microalbuminuria and the subsequent development of end-stage renal disease (ESRD) in patients with type 2 diabetes. We aimed to examine the effect of valsartan on kidney outcomes in patients with impaired glucose tolerance (IGT). Methods: In a double-blind randomized trial, 9306 patients with IGT were assigned to valsartan (160 mg daily) or placebo. The co-primary endpoints were the development of diabetes and two composite cardiovascular outcomes. Prespecified renal endpoints included the composite of renal death, ESRD, or doubling of serum creatinine; estimated glomerular filtration rate (eGFR) ≤30 mL/min/1.73 m2; hospitalization for renal failure; and progression from normoalbuminuria to microalbuminuria, microalbuminuria to macroalbuminuria, and normoalbuminuria to macroalbuminuria. The median follow-up was 6.2 years. Results: Valsartan reduced the incidence of diabetes but not cardiovascular events. In the valsartan group, 25/4631 patients (0.5%), versus 26/4675 (0.6%) patients in the placebo group, developed ESRD or experienced doubling of serum creatinine (HR 0.96, 95% CI 0.55–1.66, P = 0.87). Few patients in either group developed an eGFR of ≤30 mL/min/1.73 m2 or had a renal hospitalization. Fewer patients on valsartan (237/4084 [5.8%]) than on placebo (342/4092 [8.4%]) developed microalbuminuria (HR 0.68, 95% CI 0.57–0.80; P lt; 0.0001), and fewer valsartan-treated patients developed macroalbuminuria. Overall, UACR was 11% lower with valsartan (95% CI 8–13%, P