In addition, type 2 diabetes is a leading cause of CKD, accounting for 30 to 50% of new cases of kidney failure in the industrialized world.202 Microalbuminuria is one of the earliest detectable manifesta- tions of kidney disease in patients with diabetes, with a prevalence of 25% after 10 years of diabetes and an annual rate of progression to overt nephropathy of approximately The risk of incident and progressive microalbumin- uria is highly associated with BP levels.204 Progression of retinopathy is also closely associated with high BP.205 208 It is therefore important that the clinician is provided with clear, evidence-based recommendations on the use of BP-lowering drugs in the management of patients with diabetes and CKD. This management should also include interventions for multiple risk factors, which have been shown to improve outcomes in patients with diabetes.209 211 The Work Group recognizes that the benefits of BP reduction in patients with diabetes and CKD may include reductions of the risks of progressive loss of kidney function, CVD and progression of diabetic retinopathy. We also took into account the fact that the effects of BP reduction may differ among outcomes; for instance, a lower achieved BP may be associated with an increased risk of one outcome but a reduced risk of another. These recommendations are not stratified by CKD stage as there are remarkably few studies in which the effect of BP- lowering therapy has been reported according to CKD stage. The Work Group could find no evidence that the balance of benefits and harms of BP-lowering therapy, or specific types of therapy, varied with the GFR other than the known risks of hyperkalemia, particularly with agents that directly interfere with renin angiotensin aldosterone system (see Chapter 2). 