Our guideline includes a statement of caution in aggressively pursuing low BP targets in children with CKD. We recognize that children are particularly susceptible to intercurrent illnesses, gastroenteritis and dehydration, and aggressive use of BP lowering medications in polyuric and dehydrated patients can lead to hypotension and alterations in renal perfusion. Clinicians who prescribe anti-hypertensive medications, particularly ACE-Is and ARBs in children need to be aware of the risk of drug toxicity in children susceptible to intravascular dehydration. Clinicians should consider discontinuing the drugs in the presence of acute diarrhea.338 Additionally we recognize that reaching a target of less than percentile BP may be quite difficult in some children with CKD. The risks of polypharmacy have to be weighed against the potential benefits of achieving lowered BP. In the ESCAPE trial,14 468 hypertensive children with a 24-hour MAP above the 95th percentile for age, sex, and height, and a GFR (based on the Schwartz formula) of , received ramipril at a fixed dose of /day and were randomized to target a 24-hour MAP, measured by means of ABPM, of either between the 50th and percentile or below the 50th percentile. Additional anti- hypertensive agents, except for other antagonists of the RAAS, were added at the discretion of the local provider to achieve the target BP. In this study the largest prospective RCT of BP therapy in children with CKD to date fixed-dose ramipril and a lower therapeutic BP target (MAP below the 50th percentile for age, sex, and height by ABPM delayed the progression to kidney failure. There were no differences in the frequency or types of adverse events between the intensified and conven- tional BP target arms in the trial. In subsequent stratified analyses, the effects were more pronounced in children with glomerulopathy and kidney hypodysplasia or dysplasia. 