Table 7 The main research recommendations

The following areas lack good-quality evidence for RAAS blockade and hypertension management in people with type 1 diabetes, and hence further research is necessary.

1. In light of the fact that the presence of microalbuminuria in people with type 1 diabetes may not be the best predictor of whether they will develop progressive renal disease, what is the role for other markers (such as kidney injury molecule-1 (KIM-1)) in predicting the risk of renal disease in those with type 1 diabetes?

2. What is the role of dual RAAS blockade in people with type 1 diabetes and nephropathy?

3. What is the role of aldosterone receptor blockers in people with type 1 diabetes and nephropathy?

4. Is there a role for home or ambulatory blood pressure monitoring in the diagnosis and management of hypertension in people with type 1 diabetes, particularly in those who have diabetic autonomic neuropathy?

5. Does measurement of plasma renin activity have a role in screening and managing hypertension in people with type 1 diabetes?

6. Does tight glycaemic control and blood pressure lowering reduce the incidence of people developing microvascular complications in type 1 diabetes?

7. What is the role of RAAS-blocking agents in people who have type 1 diabetes, progressive renal decline and normoalbuminuria?

8. What is the impact on renal function of lower blood pressure targets in younger people with type 1 diabetes and nephropathy?

The following areas lack good-quality evidence for RAAS blockade and hypertension management in people with type 2 diabetes, nephropathy and/or early CKD, and hence further research is necessary.

1. What is the best method for blood pressure measurement in people with type 2 diabetes who have CKD, particularly those with autonomic neuropathy?

2. What is the evidence-based lower limit for blood pressure reduction (< 130/80 mmHg) in people with type 2 diabetes who have CKD in terms of cardiovascular and renal endpoints?

3. Can novel potassium binders enable a higher dosage of RAAS inhibitors or dual blockade with better attainment of blood pressure control and improvement in cardiovascular and renal outcomes?

4. What are the best second- and third-line blood pressure lowering agents in people with type 2 diabetes who have CKD and proteinuria?

5. Is there a need for long-term outcome studies of non-dihydropyridine calcium channel blockers in diabetic nephropathy?

6. Does bedtime hypertension treatment improve cardiovascular and renal outcomes in patients with type 2 diabetes and CKD?

7. What is the role of lifestyle modifications (such as salt restriction, regular exercise, weight reduction) on blood pressure control, and cardiovascular and renal outcomes?

The following areas lack good quality evidence and further research may help in people with diabetes on dialysis

1. Which blood pressure measurement should be used to predict left ventricular hypertrophy (LVH) and mortality in people with diabetes who are on dialysis: pre-dialysis, post-dialysis, home or ambulatory blood pressure measurement?

2. What is the optimal upright blood pressure target for people with diabetes who are on dialysis?

3. Can bioimpedance spectroscopy devices be used to determine a target weight and predict the risk of cardiovascular morbidity for people with diabetes who are on dialysis?

4. Does treatment with ACEIs, ARBs, beta blockers or calcium channel blockers to lower blood pressure in people with diabetes who are on dialysis reduce cardiovascular morbidity and mortality?

5. Is there a role for diuretic therapy in people with diabetes who are on dialysis and have residual renal function?

6. Does salt restriction (< 5 g per day) in people with diabetes who are on dialysis influence blood pressure control or cardiovascular outcome?