CKD G5, suggesting the possibility of some degree of systemic adaptation to hyperkalemia with kidney impairment.75 However, the absolute risks of death associated with hyperkalemia over an 18-month period were higher among those with CKD, heart failure, and diabetes.76 In a cohort of patients managed by nephrologists, however, hypokalemia was associated with even higher risks of death than hyperkalemia.77 Novel potassium-binding drugs, such as patiromer and sodium zirconium cyclosilicate, could potentially change the pharmacotherapy for hypertension, but conference participants felt it was too early to evaluate the role of these drugs in routine clinical practice. Further research is needed to examine whether potassium binders allow better treatment of hypertension, for example, using RAAS blockers, and thus reduce cardiovascular and renal complications (Table 2). Dual inhibition of the renin-angiotensin system Post hoc analyses from the ONgoing Telmisartan Alone and in Combination with Ramipril Global Endpoint Trial (ONTARGET) and data from the Aliskiren Trial in Type 2 Diabetes Using Cardiorenal Endpoints (ALTITUDE) and the Veterans Affairs Nephropathy in Diabetes (VA NEPHRON-D) trials suggested that dual therapy with an ACEi, an ARB, and/or a direct renin inhibitor did not provide cardiovascular or kidney benefit compared with monotherapy in patients with low eGFR and elevated albuminuria, although BP was somewhat lower.81 Additionally, the risks of hyperkalemia, acute kidney injury, and hypotension were greater with dual regimens.82 In 2014, the European Medicines Agency endorsed restrictions on combining different classes of RAAS inhibitors in patients with diabetic nephropathy. A more recent meta-analysis suggested that dual ACEi and ARB treatments have efficacy in preventing ESKD in adults with diabetic kidney disease, if the treatments can be implemented safely.83 Conference participants discussed the possibility that dual RAAS regimens have long-term benefits in specific subgroups of patients, particularly those with a substantially lower degree of albuminuria while they are on dual versus monotherapy of RAAS inhibitors or when dual blockers are used in combination with potassium binders. Combining an ACEi or ARB with mineralocorticoid receptor antagonist may also confer additional protection, but the absence of informative RCTs means that we cannot currently assess the relative risks (including acute kidney injury and hyperkalemia) and benefits. KDIGO executive conclusions AK Cheung et al.: Blood pressure in kidney disease: A KDIGO conference report 1030 Kidney International (2019) 95, 1027–1036 This controversial area calls for RCTs to be studied in specific patient groups. Resistant hypertension Resistant hypertension is common in CKD. The conference participants discussed the possible role of mineralocorticoid receptor antagonists (e.g., spironolactone, epleronone) in the treatment of resistant hypertension (by extension from studies in the general population) and as add-on anti-proteinuric treatment, with or without the concomitant use of novel potassium-binding drugs. However, participants concluded that evidence is insufficient to define the role of these agents in practice for those with CKD. MANAGING BLOOD PRESSURE IN OLDER PATIENTS WITH CKD The 2012 KDIGO BP guideline assigned a chapter to older patients and noted that very little evidence is available to guide management in nondiabetic older patients with CKD. Conference participants agreed that, although the term “older patients” has no universal definition, treatment decisions should carefully take into account age, comorbidities, and other concomitant therapies, and that dose escalation of antihypertensive agents should be gradual, with close attention to adverse events.1 The BP treatment target for older patients with advanced CKD is particularly controversial. Given the increasing incidence of ESKD in the older hypertensive population, study of the effects of antihypertensive therapy on cardiovascular and renal outcomes in older patients with advanced CKD remains an unmet need. Initiating antihypertensive therapy and treatment targets in older patients with CKD Conference participants recognized that for nonambulatory or nursing-home patient populations with CKD, no clinical trial data are available to inform decisions about antihypertensive therapy. Given that the aggregate benefits of antihypertensive therapy do not appear until 1–2 years after initiation of treatment, decisions regarding initiation of BP therapy and goals of treatment in persons with otherwise limited life expectancy should be based on shared decisionmaking with patients, family members, and caregivers, taking other medical and social conditions into consideration. Based on available data,2,68,69,84 conference participants discussed whether the target for SBP should vary by age in adult CKD patients. First, participants noted that most trials in the older population have targeted SBP instead of DBP, since SBP better predicts cardiovascular disease, and isolated diastolic hypertension is rare in older adults. The SPRINT trial did not capture the whole spectrum of CKD patients, as patients with diabetes mellitus, eGFR 1 g/d were excluded.2 Nonetheless, results from the SPRINT study