Achieving a systolic blood pressure target is a key management goal in diabetic nephropathy. When a renin-angiotensin system (RAS) inhibitor — an ACE inhibitor or angiotensin II receptor blocker titrated to the highest approved tolerated dose — has not brought systolic blood pressure to the required target, a defined next-line approach applies.
The first-line regimen in this setting combines lifestyle interventions (low sodium intake, physical exercise, smoking cessation, and weight control), protein intake adjusted for patients not on dialysis, a statin for most patients, and — when hypertension or albuminuria is present — an ACEi or ARB titrated to the highest approved tolerated dose.
Escalation to this protocol is triggered when systolic blood pressure has not been controlled to a target of <130 mm Hg (or <140 mm Hg when the lower target is not tolerated).
The structured protocol for this situation involves adding an additional antihypertensive agent to the existing RAS inhibitor. A specific class of agent — chosen based on clinical criteria set out in the protocol — is introduced to help achieve the blood pressure goal. The complete decision logic, agent selection, and clinical criteria are in the full protocol.
DOI: 10.1016/j.nefro.2024.11.002
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