A recent study reported that patients on hemodialysis are prescribed an average of 11 different medications with a mean daily burden of 19 pills.1 Yet few randomized controlled trials support the efficacy of these medications in the dialysis population, in part because these patients are usually excluded from trials. Angiotensin converting enzyme inhibitors are commonly used in the dialysis population to control hypertension and heart failure; lisinopril was the seventh most commonly prescribed drug among hemodialysis patients in the United States in 2008, according to the 2011 Annual Data Report from the United States Renal Data System.2 Thus, the “real world” data reported by Bajaj et al,which suggest that ACEIs might not provide the benefits to dialysis patients that have been demonstrated among non–dialysis-dependent patients, are particularly relevant despite the limitations of observational data. Their results serve to highlight the need for more randomized trials to determine whether the burdens and the costs of the medications prescribed to these patients are warranted.