Blood Pressure Target for Patients with CKD and Diabetes
For patients with chronic kidney disease and diabetes mellitus, target a blood pressure of <130/80 mmHg, using a RAAS blocker (ACE inhibitor or ARB) as first-line therapy, particularly when proteinuria or microalbuminuria is present. 1
Guideline-Based Blood Pressure Targets
The European Society of Cardiology (ESC) explicitly recommends a systolic BP <130 mmHg and diastolic BP <80 mmHg for patients with both diabetes and CKD, with the goal of reducing microvascular and macrovascular complications. 1 This target is more aggressive than the general CKD population and reflects the higher cardiovascular risk in this dual-diagnosis group.
The American College of Cardiology/American Heart Association (ACC/AHA) similarly recommends <130/80 mmHg for CKD patients, which aligns with the diabetic CKD population. 2, 3
Critical Lower Limits to Avoid
Do not lower systolic BP below 120 mmHg in patients with diabetes and CKD, as this may increase the risk of hypoperfusion and has not demonstrated additional cardiovascular benefit in this population. 1
Do not lower diastolic BP below 70 mmHg, as this may paradoxically increase cardiovascular risk. 1
The ACCORD trial specifically demonstrated no overall cardiovascular benefit at the <120 mmHg target in diabetic patients, though stroke reduction was observed. 1, 2
Evidence Quality and Nuances
The <130/80 mmHg target for diabetic CKD patients is supported by the 2019 ESC/EASD guidelines, which recommend more intensive control in high-risk patients like those with diabetes and CKD. 1 Importantly, the SPRINT trial—which forms the basis for the more aggressive <120 mmHg target in some CKD populations—explicitly excluded patients with diabetes, making its findings less applicable to this specific population. 1
The RENAAL study in type 2 diabetic patients with nephropathy used a BP goal of 140/90 mmHg as the treatment target, and achieved mean BP of 143/76 mmHg in the losartan group, demonstrating significant reductions in doubling of serum creatinine (25%) and progression to ESRD (29%). 4 This provides real-world evidence that BP control in the 140s systolic range with RAAS blockade provides meaningful renal protection in diabetic CKD.
Pharmacologic Treatment Algorithm
First-line therapy:
- Start with a RAAS blocker (ACE inhibitor or ARB), particularly if proteinuria (>300 mg/day) or microalbuminuria (≥30 mg/g) is present. 1, 2, 5
- Losartan reduced proteinuria by 34% and slowed GFR decline by 13% in diabetic nephropathy patients beyond its BP-lowering effects. 4
Second-line therapy:
- Add a long-acting dihydropyridine calcium channel blocker (CCB) if BP target is not achieved. 1, 3
- Non-dihydropyridine CCBs can reduce albuminuria and slow kidney function decline. 5
Third-line therapy:
Special Considerations for Proteinuria
For patients with significant proteinuria (>300 mg/day or ACR >300 mg/g), the <130/80 mmHg target is particularly important and may provide additional renoprotective benefit. 2, 6
For patients without significant proteinuria (ACR <300 mg/g), a target of <140/90 mmHg may be reasonable, though the <130/80 mmHg target remains preferred given the concurrent diabetes diagnosis. 2
Blood Pressure Measurement Technique
- Use standardized office BP measurement with automated oscillometric devices when possible, not routine casual BP readings. 2, 3
- The aggressive <120 mmHg targets from KDIGO apply only to standardized automated measurements and should never be applied to routine office BP measurements in diabetic CKD patients. 2, 3
Common Pitfalls to Avoid
- Do not stop RAAS inhibitors for creatinine increases <30%, as this is expected and acceptable. 3
- Avoid aggressive BP lowering that drives diastolic BP too low (<70 mmHg), as this increases cardiovascular risk. 1, 3
- Do not use dihydropyridine CCBs as monotherapy in proteinuric patients; always combine with a RAAS blocker. 5