The ability of the patient to adhere to complex poly-pharmacy should be taken into consi- deration. Some clinicians have expressed concerns about the use of drugs that block the renin angiotensin system in the elderly This concern is largely due to the perceived potential for these agents to cause more frequent adverse events in this population. A recent Cochrane review addressing pharmacotherapy of all types for treatment of hypertension in the elderly reported an increased risk of withdrawals due to adverse effects (RR 1.71; 95% CI 1.45 2.00).389 Since quality of life is particularly important in the elderly, it may be worth avoiding drugs that may have negative quality of life implications, but no clear advice can be given.388,399 Thus given the many differences between the elderly (particularly the very elderly) with CKD and younger patients with CKD, it is not possible to recommend any particular drug class for the reduction of BP in older CKD patients. However, it is advisable to consider the severity of CKD, presence of albuminuria, and co-morbidities and their treatment when prescribing. Therapeutic changes should be made gradually, with close monitoring for adverse effects due to low BP or side effects from prescribed agents. RESEARCH RECOMMENDATIONS An important NIH funded trial- SPRINT- is currently ongoing in the United States randomizing patients without diabetes or significant proteinuria to a systolic BP of o140 mmHg or o120 mm Hg. 