How low should we go? Optimal blood pressure targets for people with type 2 diabetes to reduce kidney and cardiovascular outcomes

The World Health Organization (WHO) has recognised that kidney disease will be one the top five preventable causes of death by the year 2050, placing a focus on early identification and prevention. Recently, the European Renal Association initiated the Protect Your Kidneys, Protect Your Future campaign, emphasising the need to assess and treat ABCDE (albuminuria, blood pressure, cholesterol, diabetes, estimated glomerular filtration rate) to improve cardiovascular–kidney–metabolic health.¹ The NHS also has a strong focus on preventing chronic disease in its 10-year plan, aligning with the WHO resolution. There are currently over 7 million people in the UK living with chronic kidney disease (CKD). Early diagnosis and intervention aim to slow kidney disease progression and avoid the need for renal replacement therapy, which carries significant patient and economic burdens.

Diabetes and hypertension are the leading causes of CKD and both are increasing in prevalence. Wang et al undertook a meta-analysis of studies that included over 5.8 million people with type 2 diabetes to examine the relationship of blood pressure (BP) to clinical outcomes, including the impact of lower BP targets, which are poorly understood.² Outcomes included cardiovascular (CV), renal and all-cause mortality. CV outcomes included two of coronary artery disease, heart failure, stroke, peripheral artery disease or CV mortality. Renal outcomes included at least two of development or progression of albuminuria, doubling of serum creatinine, decline in estimated glomerular filtration rate (eGFR), end-stage renal disease or death due to renal diseases. Over 1 million participants had systolic BP <120 mmHg, and a large number with diastolic blood pressure <70 mmHg were included. The study found J-shaped associations between BP and both mortality and CV events, alongside a linear relationship to renal events. These findings highlight the importance of aggressive BP management in reducing adverse CV and renal outcomes. 

The current NICE BP target for adults with diabetes and CKD is <130/80 mmHg, a recommendation supported by Wang et al. However, their findings also suggest that aiming for even lower BP targets may further reduce the risk of long-term adverse kidney outcomes. There are limitations to Wang’s data, as it was observational and showed significant heterogeneity between the included studies. At present, therefore, their findings should be used as hypothesis-generating for future studies. Nevertheless, this review serves as a reminder of how important good BP control is and that it should be reviewed at every patient contact, including in primary care.

In addition to good BP management for people with CKD, we now have the sodium–glucose cotransporter-2 inhibitors (SGLT2i) and glucagon-like peptide-1 receptor agonists (GLP-1 RA), both of which have been shown to slow kidney decline and reduce CV events in people with and without type 2 diabetes. Two articles published recently compared SGLT2i versus GLP-1 RA in people with type 2 diabetes to assess long-term kidney outcomes.^3,4 Further data would be required to provide the evidence needed to recommend the order of their initiation, but both medication classes offer options to further slow kidney disease progression.

A digest of the study by Wang and colleagues can be read here.

References

1. European Renal Association (ERA) Council; ERA Senior Staff (2026) ERA’s ABCDE framework for kidney disease prevention: turning the WHO kidney health resolution into action. Nephrol Dial Transplant 8 Jan [Epub ahead of print] 
2. Wang S, Wang K, Gu H et al (2025) Blood pressure levels and outcomes in type 2 diabetes: dose–response meta-analysis of 5.87 million cohort participants. J Am Coll Cardiol. 14 Jan [Epub ahead of print] 
3. Hartsell SE, Wei G, Singh R et al (2026) Comparative effectiveness of SGLT2i and GLP-1 RA on kidney and cardiovascular outcomes by kidney failure risk. J Am Soc Nephrol 13 Jan [Epub ahead of print] 
4. Jensen SK, Heide-Jørgensen U, Andersen IT et al (2026) SGLT2 inhibitors vs GLP-1 receptor agonists for kidney outcomes in individuals with type 2 diabetes. JAMA Intern Med 20 Jan [Epub ahead of print]