BP control and the use of RAAS-blocking agents in diabetic kidney disease: UK guidelines

Recommendations for people with type 1 diabetes include:

• In people with type 1 diabetes and urine albumin: creatinine ratio (UACR) < 3 mg/mmol [< 26.55 mg/g]), we recommend a threshold for blood pressure therapy of a persistent upright (sitting or standing) blood pressure that is ≥140/90 mmHg.
• In children and adolescents with type 1 diabetes, hypertension is defined as average systolic blood pressure and/or diastolic blood pressure that is greater than the 95th percentile for the person's gender, age, and height on more than three occasions.
• The authors recommend that angiotensin-converting-enzyme inhibitor (ACEI) therapy should be used as a first-line agent for blood pressure lowering and, if ACEI therapy is contraindicated or not tolerated, angiotensin receptor blockers (ARBs) should be considered.
• In most adults with type 1 diabetes and persistent UACR > 3 mg/mmol (> 26.55 mg/g), we recommend that ACEI therapy should be considered irrespective of blood pressure, and that the target upright blood pressure should be ≤130/80 mmHg (1B) if higher pre-treatment in younger adults but ≤140/90 mmHg for those aged over 65 (2D). We recommend that the dose of ACEI should be titrated to the maximum tolerated.
• There is no current evidence to support a role for ACEI therapy for blood pressure control or renal protection in people with type 1 diabetes who are normotensive and have UACR < 3 mg/mmol [< 26.55 mg/g]).
• There is some evidence to support the use of candesartan to prevent the development or progression of retinopathy in people with type 1 diabetes who are normotensive and have UACR < 3 mg/mmol [< 26.55 mg/g]).
• There is no firm evidence to support a role of dual blockade of the RAAS in people with type 1 diabetes.
• The authors recommend that people with type 1 diabetes should be advised to stop RAAS-blocking drugs during periods of acute illness and restart on recovery.
• The authors recommend that women of childbearing age should be encouraged to stop RAAS-blocking drugs prior to actively considering pregnancy.

Recommendations for type 2 diabetes, nephropathy, and/or early CKD include:

• In people with type 2 diabetes and hypertension, we recommend a salt intake of < 90 mmol per day (< 2 g per day of sodium – equivalent to 5 g of sodium chloride).
• In people with type 2 diabetes, CKD, and urine albumin: creatinine ratio (UACR) < 3 mg/mmol (< 26.55 mg/g), we recommend that their target upright blood pressure should be < 140/90 mmHg, using antihypertensive therapy in the maximum tolerated doses.
• In people with type 2 diabetes, CKD, and UACR of > 3 mg/mmol (> 26.55 mg/g), we suggest aiming for a target upright blood pressure that is consistently < 130/80 mmHg, using antihypertensive therapy in the maximum tolerated doses.
• There is no evidence to support either ACEI or ARB therapy as first-line blood pressure-lowering agents in comparison with other antihypertensive agents in people with type 2 diabetes, normal renal function, and normal UACR (< 3 mg/mmol [< 26.55 mg/g]).
• The authors suggest that ACEIs (or ARBs if ACEIs are not tolerated) should be preferentially used in people with type 2 diabetes and CKD who have UACR > 3 mg/mmol (> 26.55 mg/g). They recommend that the dose of ACEI (or ARB) should be titrated to the maximum tolerated.
• There is currently no evidence to support the role of home or ambulatory blood pressure monitoring in people with type 2 diabetes and CKD stages 2 and 3.
• There is currently no evidence to support the role of dual blockade of the RAAS in people with type 2 diabetes and CKD stages 1 to 3.
  8. Upright blood pressure targets should be set at no lower than 150/90 mmHg in those with type 2 diabetes who are aged 75 years or over.
• The authors recommend that people with type 2 diabetes should be advised to stop RAAS-blocking drugs during periods of acute illness and restart 24–48 h after recovery from the illness