Management of Diabetic Kidney Disease With Persistent Hypotension: A Case of Lifestyle-Driven Renal Recovery

Diabetic kidney disease (DKD) is typically accompanied by hypertension, which enables guideline-directed renoprotective therapy. We describe a 61-year-old woman with type 2 diabetes mellitus (T2DM) and persistent hypotension (≈92/55-98/65 mmHg) without albuminuria, in whom angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and sodium-glucose cotransporter-2 (SGLT2) inhibitors were deemed unsafe due to baseline low blood pressure. Management, therefore, emphasized non-pharmacologic measures, tight glycemic control, weight reduction (~10 lb), hydration, and avoidance of nephrotoxins in a resource-limited setting. Renal function improved from an eGFR of 55 mL/min/1.73 m² (2023) to 69 (2024) and stabilized at 67.2 (2025) with HbA1c 6.3-6.6% and continued lack of albuminuria; neurologic and ophthalmic diabetic manifestations remained stable. This case illustrates a guideline gap: when persistent hypotension and absent albuminuria preclude standard agents, individualized metabolic and lifestyle strategies may achieve renal stabilization. Although causality cannot be inferred, the temporal association between improved weight/glycemia and estimated glomerular filtration rate (eGFR) recovery suggests a pragmatic pathway for hypotensive T2DM patients outside conventional algorithms.