Some support for lower BP targets is provided by the ACCORD and ABCD trials population. However in ACCORD, these benefits must be balanced against the increased risk of adverse events. As a result, it was felt that the risk-to-benefit ratio is likely to be unfavorable for at least some groups of individuals with diabetes and CKD. These include patients with diabetes and non-albuminuric CKD, who may be likely to have additional co-morbidities; the elderly, who are prone to falls; patients with marked systolic hypertension; and those with severe autonomic neuropathy. Such patients may have been under- represented in the RCTs and observational studies. A target BP of r140 systolic and r90 mm Hg diastolic may appear to require less aggressive therapy than the targets recommended in some other guidelines for patients with diabetes. However, whether this is true depends on how targets are interpreted by clinicians. There is extensive evidence from routine clinical practice that many patients do not achieve the targets set in guidelines; instead, achieved values often have a normal distribution around the target.22 This distribution of values is the reason for the wording we have chosen for the recommendation statements: that BP be consistently below a given level. For instance, to account for random fluctuations in resting office BP over time, the intervention threshold needs to be significantly o130 mm Hg to achieve a systolic BP consistently o130 mm Hg. The Work Group, therefore, is confident that most individuals with diabetes and CKD should have their usual BP lowered to be consistently r140/90 mm Hg (hence the grade of 1B for recommendation 4.1), and that targets lower than r140/90 mm Hg could be considered on an individual basis for patients believed to be more likely to benefit than to be harmed by the treatment (e.g.