The normal capacity of the kidney to auto-regulate GFR in the face of fluctuations in BP is impaired in CKD and further compromised by the use of ACE-Is or ARBs. Hypotension (e.g., as a result of hypovolemia or sepsis) may cause an acute decline in GFR in patients with CKD taking ACE-Is or ARBs.90 Several case series have reported a high risk of acute kidney injury in diabetic patients on an ACE-I or ARB during sepsis91 93 and when they are used in combination with NSAIDs94 Reducing the dose or holding off on using ACE-Is or ARBs until recovery is sensible in patients who develop inter-current illnesses that lead to dehydration as a result of diarrhea, vomiting, or high fever. Indications for ACE-Is and ARBs. In this guideline, ACE-Is and ARBs are recommended for specific groups of CKD patients with increased urinary albumin excretion in which context use of these agents may be associated with and cardiovascular outcomes.97 In non-CKD patients, these drugs are indicated for the treatment of heart failure and for use soon after myocardial infarction, stroke, and in patients with high cardiovascular risk.98 100 The Oregon Health Resources Commission reported in 2005 on the use of ACE-Is in essential hypertension. 