Effectiveness of thiazide and thiazide-like diuretics in advanced chronic kidney disease: a systematic review and meta-analysis

Ren Fail. 2023 Dec;45(1):2163903. doi: 10.1080/0886022X.2022.2163903.


Background and objective: Thiazide diuretics are first-line drugs for the treatment of hypertension, but hypertension treatment guidelines have systematically discouraged their use in patients with advanced chronic kidney disease (CKD). For the first time, a systematic review and random-effects meta-analysis were performed to assess the effectiveness of thiazides and thiazide-like diuretics to treat hypertension in patients with stages 3b, 4, and 5 CKD.

Design, setting, participants, & measurements: A systematic review and random-effects meta-analysis that included a literature search using the following databases were performed: MEDLINE through PubMed, Cochrane Database of Systematic Reviews (CDSR) and Cochrane Central Register of Controlled Trials (CENTRAL) through the Cochrane Library, Embase, and ISI - Web of Science (all databases). Prospective studies that evaluated the effectiveness of thiazide and thiazide-like diuretics in individuals with a GFR < 45 mL/min/1.73 m2 were included.

Results: Five clinical trials, totaling 214 participants, were included, and the mean GFR ranged from 13.0 ± 5.9 mL/min/1.73 m2 to 26.8 ± 8.8 mL/min/1.73 m2. There was evidence of a reduction in mean blood pressure and in GFR, as well as in fractional sodium excretion and fractional chloride excretion.

Conclusion: Thiazide and thiazide-like diuretics seem to maintain their effectiveness in lowering blood pressure in patients with advanced chronic kidney disease. These findings should spur new prospective randomized trials and spark discussions, particularly about upcoming hypertension guidelines.

Keywords: thiazides; Chronic kidney disease; diuretics; hypertension.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Antihypertensive Agents / therapeutic use
  • Blood Pressure
  • Diuretics / pharmacology
  • Diuretics / therapeutic use
  • Humans
  • Hypertension* / drug therapy
  • Prospective Studies
  • Renal Insufficiency, Chronic* / complications
  • Renal Insufficiency, Chronic* / drug therapy
  • Thiazides / pharmacology
  • Thiazides / therapeutic use


  • Diuretics
  • Thiazides
  • Antihypertensive Agents