Theoretically, beta-blockers may reduce cardiac output and, subsequently, renal perfusion pressure, thereby exacerbating renal dysfunction. The sympathetic nervous system (SNS) is activated in CKD, which is a known factor in the progression of renal disease. Therefore, it is possible that blocking the effects of beta-adrenergic receptors will further destabilize the diseased kidney. In fact, studies have shown that long-term use of beta-blockers is associated with decreased creatinine clearance (CCr) and increased risk of developing end-stage renal disease (ESRD). These studies include patients taking beta-blockers for conditions such as hypertension, heart failure, and angina. However, not all beta-blockers are created equal. For example, studies have shown that non-selective beta-blockers are more likely to cause renal dysfunction than selective beta-1 blockers. Beta-blockers can also cause or exacerbate diabetes mellitus by reducing insulin secretion and increasing insulin resistance. Therefore, this group of medications should be used with caution in patients with impaired glucose tolerance or diabetes mellitus. Finally, because beta-blockers can lead to paradoxical reactions during times of stress, they should be discontinued before elective surgeries/procedures/tests/episodes/etc.