OBJECTIVES The objective of this study was to determine the likelihood of receiving renin system agents as the first HTN treatment among patients with prior renal disease. METHODS This retrospective study utilized data from the Henry Ford Health System to identify HTN patients with renal disease who received a renin system agent at any time. Patients were >18 years old with a minimum of one year enrollment in the health plan of one year following the first HTN visit in the study period. The first HTN treatment was characterized as monotherapy or combination therapy with renin system agents. Logistic regression modeling determined the likelihood of receiving a renin system agent first line among patients diagnosed with renal disease before initiating HTN therapy compared to patients diagnosed with renal disease after initiating HTN therapy while adjusting for covariates. RESULTS A total of 4,523 patients had a diagnosis of HTN and renal disease (mean age 64 years, 50% white and 54% male). Approximately 58% of patients were treated with two HTN agents and 42% with three or more. Only 338 (7.5%) patients were diagnosed with renal disease before their HTN treatment. Slightly higher proportions of patients diagnosed with renal disease before, compared to after initiating HTN therapy (59% vs. 51% respectively), were prescribed renin system agents first line. After adjusting for covariates, patients diagnosed with renal disease before initiating HTN therapy were not more likely to receive a renin system agent first-line compared to patients diagnosed with renal disease after initiating HTN therapy (OR: 0.863, 95% CI: 0.664 - 1.123). CONCLUSIONS While all patients received renin system agents, those with prior renal disease were not more likely to receive this treatment first line suggesting an opportunity to optimize treatment for renal patients with medications that block the Renin-Angiotensin-Aldosterone System.