Initial Treatment Approach for CKD and Diabetes with Uncontrolled Hypertension

First-Line Pharmacologic Therapy

The American College of Cardiology recommends initiating an ACE inhibitor or ARB as the cornerstone of therapy for all CKD patients with diabetes and hypertension, particularly when albuminuria is present, with a target systolic blood pressure of 120-129 mmHg 1, 2, 3
The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines suggest titrating to the maximum approved dose of ACE inhibitor or ARB that is tolerated, as the proven renoprotective and cardiovascular benefits were achieved in trials using these doses 1, 2, 3
If ACE inhibitor causes intolerable cough, the European Society of Cardiology recommends switching to an ARB, as both classes provide equivalent renoprotection 2, 3

The American Diabetes Association recommends starting an SGLT2 inhibitor for all patients with type 2 diabetes, CKD, and eGFR ≥20 mL/min/1.73 m², regardless of albuminuria level, to provide kidney protection, cardiovascular benefit, and modest blood pressure lowering 1, 4
The European Heart Journal suggests continuing SGLT2 inhibitor even if eGFR falls below 20 mL/min/1.73 m² once initiated, unless not tolerated or kidney replacement therapy begins 1

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines recommend targeting a systolic blood pressure of 120-129 mmHg using standardized office measurement if tolerated, as this provides superior cardiovascular and renal protection compared to less intensive targets 1, 3, 4

The American Journal of Kidney Diseases recommends checking blood pressure, serum creatinine, and serum potassium within 2-4 weeks of starting or increasing the dose of ACE inhibitor or ARB, and continuing the RAS inhibitor unless creatinine rises >30% within 4 weeks 1, 2, 3
The American Heart Association suggests restricting dietary sodium to <2.3 g/day, recommending 150 minutes per week of moderate-intensity physical activity, advising smoking cessation, and encouraging a plant-based diet with reduced ultra-processed foods 3, 8