What is the ideal blood pressure goal for a diabetic and hypertensive (high blood pressure) patient with Impaired renal function (kidney disease)?

Blood Pressure Goal for a Diabetic and Hypertensive 72-Year-Old with Impaired Renal Function

The blood pressure goal for a 72-year-old patient with diabetes, hypertension, and chronic kidney disease should be less than 130/80 mmHg. 1

Target Blood Pressure Recommendations

For Patients with Diabetes and CKD

• Adults with hypertension and chronic kidney disease (CKD) should be treated to a blood pressure goal of less than 130/80 mmHg 1
• Patients with diabetes and hypertension are automatically assigned to the high-risk category for atherosclerotic cardiovascular disease (ASCVD), with the BP threshold for pharmacologic treatment at 130/80 mmHg or higher 1
• Most patients with CKD die of cardiovascular disease complications, and evidence supports a BP target of less than 130/80 mmHg for these patients 1

Age Considerations

• For noninstitutionalized, ambulatory, community-dwelling adults aged 65 years or older with an average SBP of 130 mmHg or higher, treatment with an SBP goal of less than 130 mmHg is recommended 1
• Careful titration of BP-lowering medications and close monitoring are especially important in older adults with a high burden of comorbidity 1
• For elderly patients, initiation of BP-lowering therapy, especially with 2 drugs, should be done with caution, with careful monitoring for adverse effects, including orthostatic hypotension 1

Contrasting Recommendations

It's important to note that there are some differences in recommendations among guidelines:

• The 2021 KDIGO guidelines recommend a more aggressive systolic BP target of <120 mmHg for CKD patients, but this is considered an outlier among major international guidelines 1
• The 2024 European Society of Cardiology guidelines recommend a systolic BP range of 130-139 mmHg for patients with CKD, and 120-129 mmHg for those with moderate-to-severe CKD with eGFR >30 mL/min/1.73 m² 1
• Some older guidelines (pre-2017) recommended less stringent targets of <140/90 mmHg for elderly patients with CKD 1

Treatment Approach

First-line Medications

• For patients with CKD (stage 3 or higher or stage 1 or 2 with albuminuria ≥300 mg/d), treatment with an ACE inhibitor is reasonable to slow kidney disease progression 1
• If an ACE inhibitor is not tolerated, an angiotensin receptor blocker (ARB) may be used 1
• Losartan (an ARB) has been shown to reduce proteinuria by an average of 34% and slow the rate of decline in glomerular filtration rate in patients with type 2 diabetes and nephropathy 2

Monitoring and Follow-up

• After initiation of drug therapy, management should include monthly evaluation of adherence and therapeutic response until control is achieved 1
• Laboratory monitoring and clinic follow-up should occur every 3 to 6 months once target BP is achieved, depending on medications utilized and patient stability 1
• Blood pressure should be monitored in both sitting and standing positions in elderly patients to detect orthostatic hypotension 3

Special Considerations

Avoiding Excessive BP Lowering

• In elderly patients with isolated systolic hypertension, maintain diastolic BP above 60 mmHg to prevent coronary perfusion issues 3
• For frail elderly patients, excessive BP lowering should be avoided due to increased risk of falls, fractures, acute kidney injury, and stroke 1
• Multiple antihypertensive agents are usually required to reach target blood pressure in patients with diabetes and CKD 1

Treatment Intensification

• For stage 2 hypertension (BP ≥160/100 mmHg), initiation of 2 antihypertensive agents from different classes is recommended 1
• Interventions to promote BP control, such as home BP monitoring, team-based care, and telehealth, are useful in improving BP control 1

By following these evidence-based recommendations, the risk of cardiovascular events, kidney disease progression, and mortality can be significantly reduced in elderly patients with diabetes, hypertension, and chronic kidney disease.