How should I adjust the management plan for a patient with diabetic nephropathy who is also presenting with hypertension?

To adjust the management plan for a patient with diabetic nephropathy who is also presenting with hypertension, focus on achieving specific blood pressure targets and initiating appropriate pharmacological treatment, alongside lifestyle modifications and careful monitoring.

• Blood Pressure Targets:
• For adults with a urine albumin:creatinine ratio (ACR) less than 70 mg/mmol, aim for a clinic systolic blood pressure less than 140 mmHg (target range 120 to 139 mmHg) and a clinic diastolic blood pressure less than 90 mmHg ¹,²,⁵.
• For adults with an ACR of 70 mg/mmol or more, aim for a clinic systolic blood pressure less than 130 mmHg (target range 120 to 129 mmHg) and a clinic diastolic blood pressure less than 80 mmHg ¹,²,⁵.
• In adults aged 80 or more, regardless of ACR, aim for a clinic systolic blood pressure less than 150 mmHg (target range 140 to 149 mmHg) and a clinic diastolic blood pressure less than 90 mmHg ¹,²,⁵. Clinical judgement should be used for adults with frailty, target organ damage, or multimorbidity ¹,².
• First-line Pharmacological Treatment:
• Start a trial of a renin-angiotensin system (RAS) blocking drug as first-line treatment for hypertension in adults with type 1 diabetes ¹,². Offer an angiotensin-converting enzyme (ACE) inhibitor, provided there are no contraindications ¹,². If an ACE inhibitor is not tolerated, offer an angiotensin-II receptor antagonist (AIIRA) if appropriate ¹,².
• For people with type 2 diabetes and a urine ACR greater than 3 mg/mmol with elevated blood pressure, ACE inhibitor therapy may be needed ³,⁴.
• Start with a low dose and titrate up to the maximum tolerated therapeutic dose by doubling the dose every 1–2 weeks ¹,². After each upward titration, monitor the person's renal function, serum potassium level, and blood pressure ¹,².
• Consider adding a sodium-glucose co-transporter 2 (SGLT-2) inhibitor for diabetic kidney disease in people with type 2 diabetes ³,⁴.
• Lifestyle Modifications:
• Provide information on the potential for lifestyle changes, such as smoking cessation, diet, and exercise, to improve blood pressure control and associated outcomes ¹,². Advise adults with type 1 diabetes and nephropathy about the advantages of avoiding a high-protein diet ⁶.
• Additional Considerations:
• Be aware that it may be necessary to prescribe other antihypertensive drugs to improve blood pressure control ¹,²,⁶.
• Check for postural hypotension in people with type 2 diabetes or those aged 80 and over, or if symptoms are present ⁵. When prescribing antihypertensive medicines, take care not to increase the risk of orthostatic hypotension from the combined effects of sympathetic autonomic neuropathy and blood pressure lowering medicines ⁶.
• If hypertension is detected, early treatment can reduce the risk of complications ³,⁴. Improving blood glucose control can also reduce the risk of disease progression if microalbuminuria is detected ³,⁴.
• Consider non-diabetic causes of renal disease, and a specialist nephrology opinion is needed if there is a urine ACR greater than 30 mg/mmol ³,⁴. Liaise with a specialist team if there is uncertainty about managing results ³,⁴. Referral criteria for tertiary care should be agreed between local diabetes specialists and nephrologists ⁶.