Potential adverse effects generic to treatment used to lower BP include decreases in cerebral perfusion (contributing to dizziness, confusion and falls) and acute deterioration in kidney function. It is widely acknowledged that achievement of a reduction in BP can be difficult in CKD patients, particularly in the elderly, those with co-morbidities, and those with diabetes Increased conduit-artery stiffness, resulting in high pulse pressure (with high systolic and low diastolic pressures) is common in CKD patients, the elderly and patients with diabetes.31 36 Arterial stiffening is associated with an increased risk of CVD independent of other recognized risk factors.37 39 With a high pulse pressure, efforts to reduce systolic BP in older patients and those with coronary artery disease (CAD) can result in lowering diastolic BP to levels well below diastolic targets, which may be associated with greater morbidity or mortality.40,41 A J-shaped relationship between achieved BP and outcome has been observed in the elderly and in patients with vascular disease, possibly suggesting that BP can be reduced too far in Discussion of this issue is further elaborated in Chapters 7 and 8. Unfortunately, in CKD patients, the available evidence proved to be insufficient to allow the Work Group to define the lowest BP targets (see Chapter 8). Similarly, when considering the choice of BP-lowering agents, decision making should be tailored to the individual patient. For instance, ACE-Is and ARBs are potentially harmful in the presence of significant renovascular disease or volume depletion, or when used in combination with nonsteroidal anti-inflammatory drugs (NSAIDs) or cycloox- ygenase-2 (COX-2) inhibitors (as outlined later in this chapter). The presence of diabetic retinopathy in a CKD patient may also influence BP target and choice of agent as outlined in Chapter 4. 