Non-dihydropyridines have direct effects on the myocar- dium, including the sinoatrial and atrioventricular nodes and reduce the heart rate and cardiac-muscle contraction. Calcium-channel blockers also vary in their effects on glomerular arterioles, reflecting differential blockage of T- channel receptors (on the afferent and efferent arteriole) versus L-channel receptors (predominantly on the afferent arteriole). T-channel blockade leads to a reduction in intra- glomerular pressure, and accordingly a fall in urine albumin levels, while an increase in the urine albumin level can occur with blockade of L-channel receptors. In general, dihydro- pyridine calcium-channel blockers act on L-channel recep- tors, hence have the effect of increasing urine albumin excretion, whereas non-dihydropyridines tend not be asso- ciated with this side effect.130 Later generation dihydropyr- idines (e.g., manipine, cilnidipine) are less prone to increasing albumin excretion and may even reduce it. Dose considerations in CKD patients. Most calcium- channel blockers do not accumulate in patients with impaired kidney function, with the exception of nicardipine and nimodipine. Accumulation of these agents may also be due to reduced blood flow to the liver in the elderly.129 Caution is thus advised when using these two agents in elderly patients with CKD. Indications for calcium-channel blockers. Calcium-chan- nel blockers are widely used in the treatment of hypertension, angina, and supra-ventricular tachycardia. The Oregon Health Resources Commission report on calcium-channel blockers in 2005 concluded that there was no clear evidence to differentiate the antihypertensive effects of one calcium- channel blocker from another (inadequate evidence for Whether these observations can be translated to the CKD population is uncertain. It is wise to avoid dihydropyridine calcium channel blockers in CKD patients with already increased urinary albumin excretion, particularly if there is not concomitant use of an ACE-I or ARB.132 Drug combinations. 