It is estimated that in the United States there are approximately 8 million individuals who
have moderate to severe chronic kidney disease (CKD). Among them hypertension is common and
is often poorly controlled due to an expanded volume state; diuretics are frequently
prescribed. Loop diuretics are potent and effective in lowering blood pressure (BP) but their
use is associated with acute kidney injury. Thiazide diuretics, on the other hand, are less
potent, their use may be associated with less acute kidney injury, but as yet there are no
firm data to support that thiazide diuretic therapy can improve BP among subjects with
advanced CKD. The investigators found 13 studies on the use of thiazide diuretics in advanced
CKD either alone or in combination with loop diuretics and concluded that thiazides may be
useful. Thiazides cause a negative Na balance, increase Na excretion by 10-15% and weight
loss by 1-2 kg in observational studies. Observational data show that thiazides lead to an
improvement in seated clinic BP of about 10-15 mmHg systolic and 5-10 mmHg diastolic whereas
randomized trials show about a 15 mmHg reduction in mean BP. Randomized trials had only
between 7 and 23 subjects each; accordingly, larger studies are needed to evaluate their
safety and efficacy in moderate to advanced CKD.