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Introduction Hypertension is a major reversible risk factor for proteinuria, worsening renal function, end-stage renal disease (ESRD), and cardiovascular disease in patients with diabetic nephropathy (DKD)
.
Controlling blood pressure has been shown to benefit patients with DKD
.
However, differences in diabetes type and chronic kidney disease (CKD) stage can lead to differences in blood pressure targets
.
Moreover, there are many kinds of antihypertensive drugs.
How can we manage the blood pressure of DKD patients? On January 3, 2022, the British Association of Clinical Diabetes (ABCD) and the British Society of Nephrology updated the guidelines for the management of hypertension and renin-angiotensin-aldosterone system blockade in adults with DKD
.
This article is compiled from the guideline, which includes four parts, namely blood pressure goals, medication recommendations for patients with type 1 diabetes, medication recommendations for patients with type 2 diabetes, and life>
.
1.
Antihypertensive goals Individualized antihypertensive goals are summarized in the table below according to the type of diabetes, renal function, and patient age (Table 1)
.
Table 1 Table of blood pressure targets for diabetic patients Notes: 1.
The unit of all blood pressure values is mmHg; 2.
The specific classification and recommendation degree are recommended in parentheses
.
Medication recommendations for patients with type 1 diabetes 1.
If the urine protein-to-creatinine ratio (UACR) of patients with type 1 diabetes is less than 3 mg/mmol (26.
55 mg/g), the treatment threshold for orthostatic blood pressure is 140/90 mmHg (1B); 2.
For For children and adolescents with type 1 diabetes, hypertension is defined as mean systolic and/or diastolic blood pressure exceeding the 95th percentile for sex, age, and height more than three times (1B); 3.
Vascular tension is recommended Acetin-converting enzyme inhibitors (ACEI) should be used as first-line antihypertensive drugs.
If patients have contraindications or intolerance to ACEIs, angiotensin receptor blockers (ARBs) should be considered (1B); 4.
Most patients with Adults and young adults with type 1 diabetes and persistent UACR >3 mg/mmol should have a blood pressure lowering target of 130/80 mmHg (1B), while those over 65 years old should have a blood pressure lowering target of 140/90 mmHg (2D).
In addition, ACEI The dose is independent of blood pressure and should be titrated to the maximum tolerated dose (1B)
.
5.
At present, there is no evidence that ACEI treatment is beneficial to patients with type 1 diabetes with UACR < 3mg/mmol and normal blood pressure, especially in controlling blood pressure or protecting the kidneys (1C); 6.
For normal blood pressure and UACR < 3mg/ mmol of type 1 diabetic patients, there is evidence that candesartan medoxomil can prevent the progression of retinopathy (1C); 7.
There is currently no conclusive evidence to support the role of RAAS double blockade in patients with type 1 diabetes (1C); 8 .
For patients with acute exacerbation of type 1 diabetes, the use of RAAS blockers should be discontinued and resumed after recovery from the acute phase (1C); 9.
For patients who need pregnancy, RAAS blockers should be discontinued when trying to conceive (1B)
.
Suggested medication for patients with type 2 diabetes 1 Patients with CKD stage 1-3 ① For patients with type 2 diabetes, the salt intake should be < 5g/d (1C); ② For patients with type 2 diabetes with UACR < 3mg/mmol, The antihypertensive target is <140/90mmHg, and the maximum tolerated dose of antihypertensive drugs should be used (1D).
③ For patients with type 2 diabetes mellitus with UACR>3mg/mmol and CKD, the blood pressure target is <130/80mmHg and should be used The maximum tolerated dose of antihypertensive drugs (2D); ④For patients with type 2 diabetes with normal renal function and UACR<3mg/mmol, there is no evidence to support ACEI or ARB as first-line antihypertensive drugs (1A); ⑤For UACR>3mg For type 2 diabetic patients with CKD and CKD, ACEI (or ARB if ACEI is not tolerated) should be used preferentially and titrated to the maximum tolerated dose (2D); ⑥ For type 2 diabetic patients with CKD, there is no Evidence proves the role of home blood pressure or ambulatory blood pressure monitoring (1D); ⑦ For patients with type 2 diabetes in CKD stages 1-3, there is currently no conclusive evidence to support the role of dual RAAS blockers (1B); ⑧ For patients over 75 years old For patients with type 2 diabetes, the blood pressure target should not be lower than 150/90 mmHg (2B); 9.
For patients with acute type 2 diabetes, the use of RAAS blockers should be stopped and resumed after 24-48 hours of recovery in the acute phase (1C)
.
2CKD stage 4-5 (non-dialysis) ① Patients with type 2 diabetes in CKD stage 4-5 should regularly monitor blood pressure, proteinuria level, plasma electrolyte level and renal function (1B); ② If blood pressure is poorly controlled, electrolyte abnormalities or kidney disease If there is progression, monitoring should be performed 2-4 times a year according to the CKD stage and individual needs (1B); ③ For T2DM patients with UACR<3mg/mmol and CKD stage 4-5, if the blood pressure is ≥140/90mmHg, the The blood pressure target is <140/90mmHg (1B); ④ For patients with type 2 diabetes mellitus with UACR>3mg/mmol and CKD stage 4-5, if the blood pressure is ≥130/80mmHg, the blood pressure target is <130/80mmHg (2C) 5) For type 2 diabetic patients with CKD stage 4-5 combined with proteinuria, ACEI (or ARB if ACEI is not tolerated) is the first choice of antihypertensive drug (1B); ⑥ For CKD stage 4-5 type 2 diabetes mellitus For patients with type 2 diabetes in CKD stage 4-5, acidosis should be corrected and diuretics should be used to lower serum potassium (not rated); 8.
CKD 3b-5 is recommended Patients with stage 2 diabetes mellitus should use new potassium binders.
If the patient's serum potassium is ≥6mmol/L, ACEI or ARB should not be used or the dose should be reduced (not rated); ⑨ It is recommended for all patients with type 2 diabetes, advanced CKD and hypertension All patients should follow a low-sodium diet (1B)
.
3 Dialysis patients ① It is recommended to use ambulatory blood pressure or home blood pressure monitoring to monitor blood pressure in dialysis diabetic patients (1C); ② For dialysis diabetic patients, if ambulatory blood pressure or home blood pressure monitoring is not available, it should be used before, during and after hemodialysis.
Standardized blood pressure measurement should be performed, and if the patient is on peritoneal dialysis, standardized clinical blood pressure monitoring should be used (2D); ③ Incorporate volume management into the first-line management plan to optimize blood pressure control in dialysis diabetic patients (1B); ④ Salt in dialysis diabetic patients Intake should be less than 5g/d (2C); ⑤ For type 2 diabetic patients on hemodialysis, blood pressure during dialysis should be less than 140/90 mmHg.
If there are multiple comorbidities, the blood pressure target should be adjusted individually (2D); ⑥ For type 2 diabetic patients on peritoneal dialysis, blood pressure during dialysis should be less than 140/90 mmHg (2D); ⑦ Intradialysis hypotension should be avoided in hemodialysis patients (1B); ⑧ ACEI or ARB (not in combination), β receptors are recommended Individualized combined use of blockers and calcium antagonists can reduce the risk of cardiovascular disease in dialysis diabetic patients (2B); 9.
For dialysis diabetic patients with residual renal function, diuretics should be used (2C)
.
Four Life>
.
Some short-term studies have found that salt restriction reduces blood pressure, and long-term trials have shown that higher sodium intake is associated with an increased risk of all-cause mortality and ESRD development
.
For diabetic patients with CKD, due to decreased renal function and decreased sodium excretion capacity, the impact of salt intake on the body is increased
.
In addition, salt restriction is an inexpensive intervention
.
More importantly, salt restriction reduced blood pressure and urinary protein in patients receiving ARB therapy
.
In summary, despite the lack of large-scale, long-term randomized controlled trials of salt restriction in patients with CKD, the guidelines still believe that salt restriction is needed in patients with DKD or diabetes and CKD
.
2 Weight Management Obesity may be associated with the progression of CKD, but the results of related trials are conflicting and reliable data are scarce
.
Overall, improving body weight to within the normative range will improve blood pressure and prognosis in patients with CKD, especially in patients with early (stage 1-2) CKD
.
However, patients with advanced CKD need to be careful to avoid malnutrition, not to lose weight
.
3 Physical Exercise The KDIGO guidelines recommend individualized physical exercise for CKD patients, with the goal of exercising at least 5 times a week for 30 minutes each time
.
To be sure, increased physical activity is beneficial for the general population, but there are no randomized controlled trials in CKD patients
.
For patients with CKD, the benefits of physical activity on blood pressure and health may be similar to those in the general population
.
4 Drinking Alcohol consumption can affect blood pressure
.
Although most of the current studies have focused on the general population and no specific data on CKD patients are available, CKD patients still need to limit alcohol intake
.
The KDIGO guidelines recommend that men drink no more than 2 standard drinking units per day and women no more than 1 standard drinking unit (one standard drinking unit is 14g of alcohol)
.
Typesetting: Don Reviewing: Amy, Sam References: 1.
BanerjeeD, Winocour P, Chowdhury TA, et al.
Management of hypertension andrenin-angiotensin-aldosterone system blockade in adults with diabetic kidneydisease: Association of British Clinical Diabetologists and the RenalAssociation UK guideline update 2021.
BMC Nephrol.
2022 Jan 3;23(1):9.
.
Controlling blood pressure has been shown to benefit patients with DKD
.
However, differences in diabetes type and chronic kidney disease (CKD) stage can lead to differences in blood pressure targets
.
Moreover, there are many kinds of antihypertensive drugs.
How can we manage the blood pressure of DKD patients? On January 3, 2022, the British Association of Clinical Diabetes (ABCD) and the British Society of Nephrology updated the guidelines for the management of hypertension and renin-angiotensin-aldosterone system blockade in adults with DKD
.
This article is compiled from the guideline, which includes four parts, namely blood pressure goals, medication recommendations for patients with type 1 diabetes, medication recommendations for patients with type 2 diabetes, and life>
.
1.
Antihypertensive goals Individualized antihypertensive goals are summarized in the table below according to the type of diabetes, renal function, and patient age (Table 1)
.
Table 1 Table of blood pressure targets for diabetic patients Notes: 1.
The unit of all blood pressure values is mmHg; 2.
The specific classification and recommendation degree are recommended in parentheses
.
Medication recommendations for patients with type 1 diabetes 1.
If the urine protein-to-creatinine ratio (UACR) of patients with type 1 diabetes is less than 3 mg/mmol (26.
55 mg/g), the treatment threshold for orthostatic blood pressure is 140/90 mmHg (1B); 2.
For For children and adolescents with type 1 diabetes, hypertension is defined as mean systolic and/or diastolic blood pressure exceeding the 95th percentile for sex, age, and height more than three times (1B); 3.
Vascular tension is recommended Acetin-converting enzyme inhibitors (ACEI) should be used as first-line antihypertensive drugs.
If patients have contraindications or intolerance to ACEIs, angiotensin receptor blockers (ARBs) should be considered (1B); 4.
Most patients with Adults and young adults with type 1 diabetes and persistent UACR >3 mg/mmol should have a blood pressure lowering target of 130/80 mmHg (1B), while those over 65 years old should have a blood pressure lowering target of 140/90 mmHg (2D).
In addition, ACEI The dose is independent of blood pressure and should be titrated to the maximum tolerated dose (1B)
.
5.
At present, there is no evidence that ACEI treatment is beneficial to patients with type 1 diabetes with UACR < 3mg/mmol and normal blood pressure, especially in controlling blood pressure or protecting the kidneys (1C); 6.
For normal blood pressure and UACR < 3mg/ mmol of type 1 diabetic patients, there is evidence that candesartan medoxomil can prevent the progression of retinopathy (1C); 7.
There is currently no conclusive evidence to support the role of RAAS double blockade in patients with type 1 diabetes (1C); 8 .
For patients with acute exacerbation of type 1 diabetes, the use of RAAS blockers should be discontinued and resumed after recovery from the acute phase (1C); 9.
For patients who need pregnancy, RAAS blockers should be discontinued when trying to conceive (1B)
.
Suggested medication for patients with type 2 diabetes 1 Patients with CKD stage 1-3 ① For patients with type 2 diabetes, the salt intake should be < 5g/d (1C); ② For patients with type 2 diabetes with UACR < 3mg/mmol, The antihypertensive target is <140/90mmHg, and the maximum tolerated dose of antihypertensive drugs should be used (1D).
③ For patients with type 2 diabetes mellitus with UACR>3mg/mmol and CKD, the blood pressure target is <130/80mmHg and should be used The maximum tolerated dose of antihypertensive drugs (2D); ④For patients with type 2 diabetes with normal renal function and UACR<3mg/mmol, there is no evidence to support ACEI or ARB as first-line antihypertensive drugs (1A); ⑤For UACR>3mg For type 2 diabetic patients with CKD and CKD, ACEI (or ARB if ACEI is not tolerated) should be used preferentially and titrated to the maximum tolerated dose (2D); ⑥ For type 2 diabetic patients with CKD, there is no Evidence proves the role of home blood pressure or ambulatory blood pressure monitoring (1D); ⑦ For patients with type 2 diabetes in CKD stages 1-3, there is currently no conclusive evidence to support the role of dual RAAS blockers (1B); ⑧ For patients over 75 years old For patients with type 2 diabetes, the blood pressure target should not be lower than 150/90 mmHg (2B); 9.
For patients with acute type 2 diabetes, the use of RAAS blockers should be stopped and resumed after 24-48 hours of recovery in the acute phase (1C)
.
2CKD stage 4-5 (non-dialysis) ① Patients with type 2 diabetes in CKD stage 4-5 should regularly monitor blood pressure, proteinuria level, plasma electrolyte level and renal function (1B); ② If blood pressure is poorly controlled, electrolyte abnormalities or kidney disease If there is progression, monitoring should be performed 2-4 times a year according to the CKD stage and individual needs (1B); ③ For T2DM patients with UACR<3mg/mmol and CKD stage 4-5, if the blood pressure is ≥140/90mmHg, the The blood pressure target is <140/90mmHg (1B); ④ For patients with type 2 diabetes mellitus with UACR>3mg/mmol and CKD stage 4-5, if the blood pressure is ≥130/80mmHg, the blood pressure target is <130/80mmHg (2C) 5) For type 2 diabetic patients with CKD stage 4-5 combined with proteinuria, ACEI (or ARB if ACEI is not tolerated) is the first choice of antihypertensive drug (1B); ⑥ For CKD stage 4-5 type 2 diabetes mellitus For patients with type 2 diabetes in CKD stage 4-5, acidosis should be corrected and diuretics should be used to lower serum potassium (not rated); 8.
CKD 3b-5 is recommended Patients with stage 2 diabetes mellitus should use new potassium binders.
If the patient's serum potassium is ≥6mmol/L, ACEI or ARB should not be used or the dose should be reduced (not rated); ⑨ It is recommended for all patients with type 2 diabetes, advanced CKD and hypertension All patients should follow a low-sodium diet (1B)
.
3 Dialysis patients ① It is recommended to use ambulatory blood pressure or home blood pressure monitoring to monitor blood pressure in dialysis diabetic patients (1C); ② For dialysis diabetic patients, if ambulatory blood pressure or home blood pressure monitoring is not available, it should be used before, during and after hemodialysis.
Standardized blood pressure measurement should be performed, and if the patient is on peritoneal dialysis, standardized clinical blood pressure monitoring should be used (2D); ③ Incorporate volume management into the first-line management plan to optimize blood pressure control in dialysis diabetic patients (1B); ④ Salt in dialysis diabetic patients Intake should be less than 5g/d (2C); ⑤ For type 2 diabetic patients on hemodialysis, blood pressure during dialysis should be less than 140/90 mmHg.
If there are multiple comorbidities, the blood pressure target should be adjusted individually (2D); ⑥ For type 2 diabetic patients on peritoneal dialysis, blood pressure during dialysis should be less than 140/90 mmHg (2D); ⑦ Intradialysis hypotension should be avoided in hemodialysis patients (1B); ⑧ ACEI or ARB (not in combination), β receptors are recommended Individualized combined use of blockers and calcium antagonists can reduce the risk of cardiovascular disease in dialysis diabetic patients (2B); 9.
For dialysis diabetic patients with residual renal function, diuretics should be used (2C)
.
Four Life>
.
Some short-term studies have found that salt restriction reduces blood pressure, and long-term trials have shown that higher sodium intake is associated with an increased risk of all-cause mortality and ESRD development
.
For diabetic patients with CKD, due to decreased renal function and decreased sodium excretion capacity, the impact of salt intake on the body is increased
.
In addition, salt restriction is an inexpensive intervention
.
More importantly, salt restriction reduced blood pressure and urinary protein in patients receiving ARB therapy
.
In summary, despite the lack of large-scale, long-term randomized controlled trials of salt restriction in patients with CKD, the guidelines still believe that salt restriction is needed in patients with DKD or diabetes and CKD
.
2 Weight Management Obesity may be associated with the progression of CKD, but the results of related trials are conflicting and reliable data are scarce
.
Overall, improving body weight to within the normative range will improve blood pressure and prognosis in patients with CKD, especially in patients with early (stage 1-2) CKD
.
However, patients with advanced CKD need to be careful to avoid malnutrition, not to lose weight
.
3 Physical Exercise The KDIGO guidelines recommend individualized physical exercise for CKD patients, with the goal of exercising at least 5 times a week for 30 minutes each time
.
To be sure, increased physical activity is beneficial for the general population, but there are no randomized controlled trials in CKD patients
.
For patients with CKD, the benefits of physical activity on blood pressure and health may be similar to those in the general population
.
4 Drinking Alcohol consumption can affect blood pressure
.
Although most of the current studies have focused on the general population and no specific data on CKD patients are available, CKD patients still need to limit alcohol intake
.
The KDIGO guidelines recommend that men drink no more than 2 standard drinking units per day and women no more than 1 standard drinking unit (one standard drinking unit is 14g of alcohol)
.
Typesetting: Don Reviewing: Amy, Sam References: 1.
BanerjeeD, Winocour P, Chowdhury TA, et al.
Management of hypertension andrenin-angiotensin-aldosterone system blockade in adults with diabetic kidneydisease: Association of British Clinical Diabetologists and the RenalAssociation UK guideline update 2021.
BMC Nephrol.
2022 Jan 3;23(1):9.
