These include side effects that are also seen in the general population, side effects particular to kidney transplant patients (e.g., increased propensity to hyperkalemia or anemia with ACE-Is or ARBs), level of urine albumin, degree of hemodynamic stability and the associated potential to alter graft perfusion (especially in a period soon after transplanta- tion), co-morbid conditions that may indicate or preclude certain agents, interactions with immunosuppressive medica- tions or other medications unique to patients with kidney transplant patients, and long-term impact on graft function, CVD, and all-cause mortality.296 Because of these considera- tions and the absence of large trials with clinically important outcomes, there is marked variability in the prescription of cardioprotective medications after transplantation.294 Short-term RCTs (of duration r2 years) suggest a beneficial effect of calcium-channel blockers, as compared with either placebo or ACE-Is, with regard to level of kidney In addition, a recent meta-analysis of RCTs indicated that the use of calcium-channel blockers, versus placebo or no treatment (plus additional agents in either arm, as needed) was associated with a 25% lower rate of graft loss (relative risk [RR] 0.75; 95% CI 0.57 0.99) and higher These findings prompted the Canadian Society of Transplantation and Canadian Society of Nephrology to question the recommen- dation from the 2009 KDIGO Clinical Practice Guideline for the Care of Kidney Transplant Recipients to use any class of antihypertensive agent after kidney transplantation.292,302 Most transplantation centers prefer to use dihydropyridine calcium-channel blockers for initial therapy after transplan- tation, since these agents dilate afferent arterioles and counteract the vasoconstrictive effect of CNIs298,303 (Supple- mentary Tables 54 59 online). However, non-dihydropy- ridines might interfere with the metabolism and excretion of chapter 5 http://www.kidney-international.org & 2012 KDIGO the CNIs cyclosporine and tacrolimus, as well as the mTOR inhibitors sirolimus and everolimus. 