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

Written By : Medha Baranwal |Medically Reviewed By : Dr. Kamal Kant Kohli Published On 2022-01-29T09:00:45+05:30  |  Updated On 29 Jan 2022 9:01 AM IST
BP control and the use of RAAS-blocking agents in diabetic kidney disease: UK guidelines
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UK: A recent study, published in the journal BMC Nephrology, reports updated guidelines on the management of hypertension and renin-angiotensin-aldosterone system (RAAS) blockade in adults with diabetic kidney disease. The guidelines were developed jointly by the Association of British Clinical Diabetologists and the Renal Association UK.

Type 1 and type 2 diabetes patients are at risk of developing CKD and end-stage kidney failure. Hypertension is a major, reversible risk factor in diabetes patients for the development of impaired kidney function, albuminuria, end-stage kidney disease, and cardiovascular disease. Blood pressure control has shown to be beneficial in people with diabetes in slowing the progression of kidney disease and reducing cardiovascular events. However, the evidence of randomized controlled trials differs in type 1 and type 2 diabetes and different stages of CKD in terms of target blood pressure.

The guideline reviews the current evidence and makes recommendations about blood pressure control and the use of RAAS-blocking agents in different stages of chronic kidney disease (CKD) in people with both type 1 and type 2 diabetes.

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

"People with diabetes and CKD have an increased risk of morbidity and mortality. They experience excess cardiovascular events and progression of CKD," wrote the authors. "Hypertension is a common risk factor for both adverse outcomes. Tight control of blood pressure and the use RAAS inhibitors are associated with improved outcomes, particularly in the presence of proteinuria."

"RAAS inhibitors can cause side effects e.g. rising serum creatinine and hyperkalemia. However, guideline-based therapy such as mentioned here can prolong life, lower risk of cardiovascular events and hospital admissions, and prevent end-stage kidney failure requiring renal replacement therapy," they explained.

Reference:

Banerjee, D., Winocour, P., Chowdhury, T.A. et al. Management of hypertension and renin-angiotensin-aldosterone system blockade in adults with diabetic kidney disease: Association of British Clinical Diabetologists and the Renal Association UK guideline update 2021. BMC Nephrol 23, 9 (2022). https://doi.org/10.1186/s12882-021-02587-5

BMC Nephrologyhypertensionchronic kidney diseasediabetes
Source : BMC Nephrology
Medha Baranwal
Medha Baranwal

    MSc. Biotechnology

    Dr. Kamal Kant Kohli
    Dr. Kamal Kant Kohli

    Dr Kamal Kant Kohli-MBBS, DTCD- a chest specialist with more than 30 years of practice and a flair for writing clinical articles, Dr Kamal Kant Kohli joined Medical Dialogues as a Chief Editor of Medical News. Besides writing articles, as an editor, he proofreads and verifies all the medical content published on Medical Dialogues including those coming from journals, studies,medical conferences,guidelines etc. Email: drkohli@medicaldialogues.in. Contact no. 011-43720751

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