Alpha-blockers do not require dose modification in cases of kidney failure, since they are excreted via the liver.4 Indications for alpha-blockers. Alpha-blockers reduce the symptoms of benign prostatic hyperplasia, which may be a co-morbidity to consider in older men with CKD. In general, alpha-blockers are not considered a first-line choice because of the common side effects of postural hypotension, tachycardia and headache. They should be commenced at a low dosage to avoid a first-dose hypotensive reaction. Drug combinations. There are few data available about alpha-blocker combinations with other BP lowering drugs. Vasodilatation can lead to peripheral edema, so diuretics are commonly combined with alpha-blockers, although the efficacy of this maneuver has not been studied. Alternatively, a non-selective beta-blocker can be used. Direct vasodilators Hydralazine and minoxidil both act by directly causing vascular smooth-muscle relaxation and hence vasodilatation. There have been no important changes to our understanding of these drugs since the publication of the KDOQI Clinical Practice Guidelines on Hypertension and Antihypertensives Agents in Chronic Kidney Disease in 2004.1 Dose considerations in CKD patients. Hydralazine and minoxidil do not require dose adjustment in patients with impaired kidney function.4 Indications for direct vasodilators. Hydralazine has little value in the management of chronically elevated BP in CKD, although it is sometimes used as a parenteral hypotensive agent. Minoxidil is generally used in patients with very resistant hypertension and thus may be helpful in patients with CKD. However, its side effects (e.g., severe fluid retention, headache, tachycardia, hirsutism, and pericardial effusion) limit its use to the most resistant cases. Drug combinations. Because of the side effects of fluid retention and tachycardia, direct vasodilators (especially minoxidil) are usually combined with a beta-blocker and loop diuretic. 