Hypertension Treatment Protocol in Patients with Diabetes and Kidney Disease
Blood Pressure Targets
For patients with diabetes and/or kidney disease, target blood pressure is <130/80 mmHg. 1, 2
Initial Assessment
Before initiating treatment, measure blood pressure at every visit and obtain the following:
- Urine albumin-to-creatinine ratio (UACR) to assess for albuminuria 1, 2
- Estimated glomerular filtration rate (eGFR) to evaluate kidney function 1, 2
- Serum potassium baseline level 1, 2
- Assessment for coronary artery disease presence 1, 2
Lifestyle Modifications (All Patients)
Implement comprehensive lifestyle therapy immediately, regardless of medication status: 1, 2
- Sodium restriction to <2,300 mg/day (ideally <1,500 mg/day) 1, 3
- Weight loss if overweight through caloric restriction 1, 2
- DASH diet with 8-10 servings of fruits/vegetables daily and 2-3 servings of low-fat dairy 1, 2
- Physical activity of at least 150 minutes of moderate-intensity aerobic exercise per week 1, 2
- Alcohol moderation to ≤2 drinks/day for men, ≤1 drink/day for women 1, 2
- Smoking cessation 1
Pharmacologic Treatment Algorithm
Step 1: Blood Pressure 130-149/80-89 mmHg
Start with single-drug therapy: 1, 2
- If albuminuria present (UACR ≥30 mg/g): ACE inhibitor (e.g., lisinopril 10 mg daily) OR ARB (e.g., losartan 50 mg daily) at maximum tolerated dose 1, 2
- If coronary artery disease present: ACE inhibitor or ARB as first-line 1, 2
- If no albuminuria or CAD: ACE inhibitor, ARB, thiazide-like diuretic (chlorthalidone preferred over hydrochlorothiazide), or dihydropyridine calcium channel blocker (e.g., amlodipine) 1, 2
Step 2: Blood Pressure ≥150/90 mmHg
Initiate dual-drug therapy immediately or use single-pill combination: 1, 3
- Preferred combination: ACE inhibitor or ARB + dihydropyridine calcium channel blocker 3, 2
- Alternative: ACE inhibitor or ARB + thiazide-like diuretic 1, 2
Step 3: Blood Pressure Not Controlled on Dual Therapy
Add third agent to create triple therapy: 2
- Standard triple combination: ACE inhibitor or ARB + calcium channel blocker + thiazide-like diuretic 2
- Example: Lisinopril 40 mg + amlodipine 10 mg + chlorthalidone 25 mg daily 2
Step 4: Resistant Hypertension (BP ≥140/90 on Triple Therapy)
Before adding a fourth agent, confirm: 2
- Medication adherence 2
- Rule out white coat hypertension with home/ambulatory monitoring 2
- Exclude secondary causes (primary aldosteronism, renal artery stenosis, sleep apnea) 2
Fourth-line agent: Add spironolactone 25-50 mg daily 2
Critical Medication Considerations
Never combine ACE inhibitor + ARB - this increases adverse events without cardiovascular benefit 1, 2
Avoid direct renin inhibitors with ACE inhibitors or ARBs - increased risk of hyperkalemia, syncope, and acute kidney injury 1
Continue ACE inhibitor or ARB even as eGFR declines to <30 mL/min/1.73 m² for cardiovascular benefit in patients already receiving these medications 1
Monitoring Requirements
Laboratory monitoring schedule: 1, 2
- Check serum creatinine/eGFR and potassium at baseline 1, 2
- Recheck 7-14 days after initiating or changing dose of ACE inhibitor, ARB, or diuretic 1, 2
- Monitor at least annually thereafter 1
Blood pressure monitoring: 3, 2
- Reassess 2-4 weeks after medication initiation or adjustment 2
- Achieve target BP within 3 months of treatment initiation or modification 3, 2
- Monthly follow-up for drug titration until controlled 3
Special Populations
Pregnancy considerations: 1
- ACE inhibitors, ARBs, mineralocorticoid receptor antagonists, direct renin inhibitors, and neprilysin inhibitors are contraindicated in pregnancy 1
- Avoid in sexually active individuals of childbearing potential not using reliable contraception 1
Patients with UACR ≥300 mg/g: 2
- ACE inhibitor or ARB is strongly recommended as first-line therapy to reduce progressive kidney disease 1, 2
Patients with UACR 30-299 mg/g: 2