Thiazides in advanced chronic kidney disease: time for a randomized controlled trial

Chronic kidney disease is common, associated with increased cardiovascular risk, and frequently complicated by hypertension, requiring multiple agents for control. Thiazides are naturally attractive for use in this population; unfortunately, they are classically thought to be ineffective in advanced chronic kidney disease based on both theoretical considerations and the earliest studies of these agents. This report reviews the studies of thiazide use in chronic kidney disease since the 1970s, including five randomized controlled trials, all of which report at least some degree of efficacy.

Two recent studies add further evidence for the utility and efficacy of thiazides in chronic kidney disease. Of these two, one used gold standard ambulatory blood pressure monitoring in patients with poorly controlled hypertension and advanced chronic kidney disease and found chlorthalidone reduces blood pressure. The second is the largest study to date of thiazides in chronic kidney disease; adding a fixed low-dose chlorthalidone as the first diuretic to the antihypertensive regimen improved blood pressure.

These numerous small but positive studies reinforce the need for a randomized trial to demonstrate safety and efficacy of thiazides in advanced chronic kidney disease.