Preventing End-Stage Kidney Disease in Older Adults with Type 2 Diabetes Mellitus: Optimal Blood Pressure Targets

Jae-Seung Yun; Seung-Hyun Ko

doi:10.4093/dmj.2025.1017

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Editorial Preventing End-Stage Kidney Disease in Older Adults with Type 2 Diabetes Mellitus: Optimal Blood Pressure Targets: Jae-Seung Yun, Seung-Hyun Ko; Diabetes & Metabolism Journal 2025;49(6):1198-1200.
DOI: https://doi.org/10.4093/dmj.2025.1017
Published online: November 1, 2025

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Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea

Corresponding author: Seung-Hyun Ko

Division of Endocrinology and Metabolism, Department of Internal Medicine, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Korea E-mail: kosh@catholic.ac.kr

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Chronic kidney disease (CKD) is a major contributor to morbidity and mortality associated with noncommunicable diseases [1]. CKD is an independent predictor of premature mortality, increased hospitalization, and economic burden on patients, payers, and healthcare infrastructure, as well as reduced quality of life [1]. There is substantial variation in the prevalence of CKD between countries in the Asia region that ranges between 7.0% and 34.3%, with a global prevalence of 13.4% [1,2]. In Korea, CKD prevalence is 5.5 million, and the incidence of kidney failure is 355 per million population [3]. The number of patients with end-stage kidney disease (ESKD) increased from 58,860 in 2010 to 134,826 in 2022—a 2.3-fold rise over 12 years. According to the annual report of the Korean Renal Data System (KORDS), adults aged 65 years or older accounted for 56.6% of all patients with ESKD in 2022 [4,5].

Diabetes mellitus (DM) and hypertension are common risk factors of CKD in developed countries and the prevalence of CKD in patients with DM ranged from 25% to 53% [3]. Over the past two decades, DM has remained the leading cause of ESKD in South Korea. The proportion of diabetic CKD has remained between 46.4% and 51.0% of all ESKD patients in the KORDS registry. According to a recent study based on the Korean National Health Insurance Service (NHIS), even in patients with normal renal function, those with long-standing DM had a 14-fold higher risk of ESKD compared to nondiabetic individuals. A strong association was observed between DM duration and the incidence of ESKD across all CKD stage categories [6].

Beyond glycemic control, optimal blood pressure (BP) control is essential to prevent the progression of CKD to ESKD in patients with type 2 diabetes mellitus (T2DM) [7]. In patients with T2DM, BP control—alongside glycemic control—seeks to prevent cardiovascular disease (CVD), reduce mortality, and avert DM-related complications, as well as to prevent CKD and progression of CKD to ESKD. The target BP for these aims does not differ materially across guidelines. For both primary and secondary prevention of CVD, a target of <130/80 mm Hg is recommended, a position consistently endorsed by the Korean Diabetes Association (KDA), American Diabetes Association (ADA), American Heart Association (AHA), and American College of Cardiology (ACC) guidelines [7,8]. The same <130/80 mm Hg target is also recommended to prevent the need for kidney replacement therapy and delay CKD progression, conferring benefits for both CVD mortality and renal outcomes [7,8]. Moreover, the Kidney Disease: Improving Global Outcomes (KDIGO) 2024 clinical practice guideline for the evaluation and management of CKD recommended that adults with high BP and CKD (including patients with T2DM) be treated with a target systolic blood pressure (SBP) of <120 mm Hg when tolerated, using standardized office BP measurement [9]. The European Society of Hypertension (ESH) guidelines also recommend a higher BP target (<140/90 mm Hg) for patients with hypertension and CKD than the ACC/AHA guideline (<130/80 mm Hg), but recommend the same BP target (<130/80 mm Hg) for patients with hypertension and coexisting CVD and DM [10].

However, there is little information regarding target BP levels in older adults with T2DM and hypertension to prevent the occurrence of ESKD. Recently, Hong et al. [11] evaluated the potential relationships between BP levels and ESKD development using the Korean NHIS Database (2009 to 2018) in older adults (≥65 years) with T2DM (n=249,903). When they used SBP of 121 to 130 mm Hg and diastolic blood pressure (DBP) <70 mm Hg as the reference level, they found that ESKD was the lowest in groups with an SBP of 100 to 119 mm Hg and DBP of <80 mm Hg. In patients with an SBP of 111 to 120 mm Hg, the incidence of the primary outcome was 27% lower compared to the SBP 131 to 140 mm Hg group (relative risk, 0.85 [95% confidence interval, CI, 0.75 to 0.96] vs. 1.12 [95% CI, 1.02 to 1.24]) and lower than that observed in all other SBP groups. When the DBP <70 mm Hg group was used as the reference group, the risk of the primary outcome increased significantly with higher DBP (>90 mm Hg). The risk of ESKD was the lowest in patients with an SBP of 110 to 129 mm Hg taking hypertension medication and the highest in the group with an SBP of ≥160 mm Hg. Based on their analysis, they suggested a BP target of <120/80 mm Hg for the prevention of ESKD in older subjects with Korean T2DM without CVD [11].

Older adults with DM represent a highly heterogeneous population in both clinical and physiological aspects [12]. The optimal BP target likely varies according to multiple individual factors, including frailty status, functional capacity, comorbidities (particularly CVD and CKD stage), polypharmacy, susceptibility to orthostatic hypotension, presence of albuminuria, and baseline estimated glomerular filtration rate. Regarding prevention of CVD, CKD, or ESKD, there remains some discrepancy in target BP levels among different guidelines for older people with T2DM. Treatment to a target BP of <130/80 mm Hg is generally recommended by KDA, ADA, AHA/ACC guidelines; however, individualization is highly emphasized for older adults [7,13,14]. Specifically, excessive BP lowering should be avoided when risks such as falls, orthostatic hypotension, polypharmacy, and comorbidities are present, and the intensity of therapy should be tailored to functional status, overall clinical condition, life expectancy, and frailty, with targets up to <140/80–90 mm Hg. The ESH guidelines recommend BP treatment targets that differ on the basis of age. Although the ESH guidelines recommend the same BP treatment target as the ACC/AHA guideline for many adults, they recommend higher BP treatment thresholds for adults >65 years of age, and a target BP of <140/80 mm Hg for patients 65 to 79 years of age. For patients in this age group with isolated systolic hypertension and for adults ≥80 years of age, the threshold is even more lenient, with a target SBP between 140 and 150 mm Hg. The ESH also recommend less intensive BP-lowering therapy in people with frailty, high risk of falls and fractures, very limited life expectancy, or symptomatic postural hypotension [10]. In general, BP treatment goals for the prevention of ESKD in older adults with T2DM tend to be less strict than general population except for KDIGO guidelines (standardized office SBP <120 mm Hg, if tolerable).

Moreover, in older adults with DM, an increased pulse pressure (PP) primarily reflects irreversible structural changes from arterial stiffening, which are difficult to normalize through pharmacologic interventions [15]. Intensive lowering of SBP below 120 mm Hg may further reduce DBP, particularly in individuals with widened PP, potentially leading to diastolic hypotension (<60 mm Hg). Such reductions in DBP could compromise coronary and renal perfusion, suggesting that a universal goal of <120/80 mm Hg may not be optimal for older adults with high PP. Future studies should specifically evaluate the clinical consequences and safety thresholds of diastolic hypotension accompanying SBP reduction in this subgroup, to refine the safe and effective BP targets for elderly individuals with T2DM.

Previous reports on BP targets to prevent ESKD in older adults with T2DM in Korea have primarily been based on large-scale observational studies of the NHIS database. Although clinically meaningful, further clinical research is also needed on the duration and stability of BP control, individual characteristics, antihypertensive adherence, and long-term glycemic control, as well as the correlation of BP thresholds with future ESKD development.

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CONFLICTS OF INTEREST

Seung-Hyun Ko has been the executive editor of the Diabetes & Metabolism Journal since 2022. He was not involved in the review process of this article. Otherwise, there was no conflict of interest.

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Preventing End-Stage Kidney Disease in Older Adults with Type 2 Diabetes Mellitus: Optimal Blood Pressure Targets

Diabetes Metab J. 2025;49(6):1198-1200. Published online November 1, 2025

DOI: https://doi.org/10.4093/dmj.2025.1017

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Preventing End-Stage Kidney Disease in Older Adults with Type 2 Diabetes Mellitus: Optimal Blood Pressure Targets

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Yun JS, Ko SH. Preventing End-Stage Kidney Disease in Older Adults with Type 2 Diabetes Mellitus: Optimal Blood Pressure Targets. Diabetes Metab J. 2025;49(6):1198-1200.

DOI: https://doi.org/10.4093/dmj.2025.1017.

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