The steroidal MRAs spironolactone and eplerenone have, in small and short-term studies, been found to reduce BP in resistant hypertension (de ned as uncontrolled hypertension on 3 antihypertensive agents including a diuretic) in a popu- lation that included CKD and non-CKD171,273 and to lower albuminuria in patients with diabetes and elevated urinary Side effects, particularly hyperkalemia and decline in kidney function,274 are however a concern when added to background therapy with an ACEi, ARB, or diuretic, particularly among patients with eGFR <45 ml/min per 1.73 Thus, MRAs should not be used in patients with high risk of hyperkalemia (e.g., hypoaldosteronism or type 4 renal tubular acidosis). Results from the AMBER trial showed that in patients with resistant hypertension and advanced CKD (25 ), concomitant use of the oral po- tassium binder patiromer compared with placebo allowed a larger proportion of patients using spironolactone at 12 A recent trial, FIDELIO, examining the impact of the nonsteroidal MRA nerenone showed kidney protection; however, the effect on BP was modest and the risk of hyperkalemia-related events was increased.258 Research recommendations  RASi in patients with CKD G3 G4, A1 and A2 with or without diabetes have not been adequately studied. Future studies should examine if RASi, in the presence or absence of other renoprotective agents such as SGLT2 inhibitors and glucagon-like peptide-1 (GLP-1) receptor agonists, provide kidney, CV, and survival bene ts to this important subgroup.  There are insuf cient data on the role of diuretics as rst- line therapy for the treatment of high BP in patients with CKD. It would be helpful to clarify the role of diuretics as initial therapy in this population. 