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

Guideline-aligned answer with reasoning, red flags and references. Clinically reviewed by Dr Kola Tytler MBBS CertHE MBA MRCGP.

Posted: 16 August 2025Updated: 16 August 2025 Guideline-Aligned (High Confidence) Clinically Reviewed
Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX

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 ,,.
    • 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 ,,.
    • 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 ,,. Clinical judgement should be used for adults with frailty, target organ damage, or multimorbidity ,.
  • 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 ,. Offer an angiotensin-converting enzyme (ACE) inhibitor, provided there are no contraindications ,. If an ACE inhibitor is not tolerated, offer an angiotensin-II receptor antagonist (AIIRA) if appropriate ,.
    • 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 ,.
    • Start with a low dose and titrate up to the maximum tolerated therapeutic dose by doubling the dose every 1–2 weeks ,. After each upward titration, monitor the person's renal function, serum potassium level, and blood pressure ,.
    • Consider adding a sodium-glucose co-transporter 2 (SGLT-2) inhibitor for diabetic kidney disease in people with type 2 diabetes ,.
  • 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 ,. Advise adults with type 1 diabetes and nephropathy about the advantages of avoiding a high-protein diet .
  • Additional Considerations:
    • Be aware that it may be necessary to prescribe other antihypertensive drugs to improve blood pressure control ,,.
    • Check for postural hypotension in people with type 2 diabetes or those aged 80 and over, or if symptoms are present . 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 .
    • If hypertension is detected, early treatment can reduce the risk of complications ,. Improving blood glucose control can also reduce the risk of disease progression if microalbuminuria is detected ,.
    • 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 ,. Liaise with a specialist team if there is uncertainty about managing results ,. Referral criteria for tertiary care should be agreed between local diabetes specialists and nephrologists .

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Educational content only. Always verify information and use clinical judgement.