An ACE inhibitor (or an ARB, in case of ACE inhibitor intolerance) is a preferred drug for treatment of hyperten- sion if albuminuria ( 300 mg/day or 300 mg/g creatinine by first morning void) is present, although the evidence is (Figure 6). In the course of reducing intra- glomerular pressure and thereby reducing albuminuria, serum creatinine may increase up to 30% because of concur- rent reduction in GFR.S9.3-32 Further GFR decline should be investigated and may be related to other factors, including volume contraction, use of nephrotoxic agents, or renovas- The combination of an ACE inhibitor and an ARB should be avoided because of reported harms dem- onstrated in several large cardiology trialsS9.3-34,S9.3-35 and in 1 diabetic nephropathy trial.S9.3-36 Because of the greater risk of hyperkalemia and hypotension and lack of demonstrated benefit, the combination of an ARB (or ACE inhibitor) and a direct renin inhibitor is also contraindicated during manage- ment of patients with CKD.S9.3-37 Figure 6 is an algorithm on management of hypertension in patients with CKD. Recommendation-Specific Supportive Text 1. We recommend ASCVD risk assessment in all adults with hypertension, including those with CKD. As a matter of convenience, however, it can be assumed that the vast majority of patients with CKD have a 10-year ASCVD risk 10%, placing them in the high risk cat- egory that requires initiation of antihypertensive drug therapy at BP 130/80 mm Hg (see Section 8.1.2, Figure 4 and Table 23 for BP thresholds for initiating antihypertensive drug treatment). In SPRINT, the par- ticipants with CKD who were randomized to intensive antihypertensive therapy (SBP target <120 mm Hg) ap- peared to derive the same beneficial reduction in CVD events and all-cause mortality that was seen in their counterparts without CKD at baseline. 