Current Hypertension Reports

, Volume 6, Issue 5, pp 393–399 | Cite as

Nocturnal hypertension: Will control of nighttime blood pressure prevent progression of diabetic renal disease?

  • K. M. Moorthi
  • Donn Hogan
  • Empar Lurbe
  • Josep Redon
  • Daniel Batlle


Patients with type 1 and 2 diabetes and nephropathy frequently have a blunted fall in nighttime arterial blood pressure. This abnormality is already seen in subjects with type 1 diabetes who are in the microalbuminuric phase of the disease, and we have also shown that an increase in nighttime systolic blood pressure precedes the development of microalbuminuria. These studies suggest that nocturnal hypertension may be an important early predictor of diabetic nephropathy. Various drugs have different effects on nocturnal blood pressure, and chronotherapy may be key in determining clinical outcomes. There is a compelling need for studies showing that treating nocturnal hypertension in diabetes can prevent renal disease progression.


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.

References and Recommended Reading

  1. 1.
    Drayer JI, Weber MA, DeYoung JL, et al.: Circadian blood pressure patterns in ambulatory hypertensive patients. Am J Med 1982, 73:493–499.PubMedCrossRefGoogle Scholar
  2. 2.
    Millar-Craig MW, Bishop CN, Raftery EB: Circadian variation of blood pressure. Lancet 1978, 15:795–797.CrossRefGoogle Scholar
  3. 3.
    Tofler GF, Brezinski D, Schafer AI, et al.: Concurrent morning increase in platelet aggregability and the risk of myocardial infarction and sudden cardiac death. N Engl J Med 1987, 316:1514–1518.PubMedCrossRefGoogle Scholar
  4. 4.
    Hansen KW, Schmitz A, Mau Pedersen M: Ambulatory blood pressure. Measurement in type 2 diabetic patients: methodological aspects. Diabetic Med 1991, 8:567–572.PubMedCrossRefGoogle Scholar
  5. 5.
    Pickering TG, Harshfield GA, Kleinert HD, et al.: Blood pressure during normal daily activities, sleep, and exercise. J Am Med Assoc 1982, 247:992–996.CrossRefGoogle Scholar
  6. 6.
    O’Brien E, Murphy J, Tyndall A, et al.: Twenty-four-hour ambulatory blood pressure in men and women aged 17 to 80 years: The Allied Irish Bank Study. J Hypertens 1991, 9:355–360.PubMedCrossRefGoogle Scholar
  7. 7.
    Hansen HP, Rossing P, Tarnow L, et al.: Circadian rhythm of arterial pressure and albuminuria in diabetic nephropathy. Kidney Int 1996, 50:579–85.PubMedCrossRefGoogle Scholar
  8. 8.
    Pickering TG: The clinical significance of diurnal blood pressure variations: Dippers and non-dippers. Circulation 1990, 81:700–702.PubMedGoogle Scholar
  9. 9.
    Hany S, Baumgart P, Frielingsdorf J, et al.: Circadian blood pressure variability in secondary and essential hypertension. J Hypertens 1987, 5(Suppl):487–489S.Google Scholar
  10. 10.
    Middeke M, Kluglich M, Holzgreve H: Circadian blood pressure rhythm in primary and secondary hypertension. Chronobiol Int 1991, 8:451–459.PubMedGoogle Scholar
  11. 11.
    Middeke M, Schrader J: Nocturnal blood pressure in normotensive subjects and those with white coat, primary, and secondary hypertension. Brit Med J 1994, 308:630–632.PubMedGoogle Scholar
  12. 12.
    Csiky B, Kovacs T, Wagner L, et al.: Ambulatory blood pressure monitoring and progression in patients with IgA nephropathy. Nephrol Dial Transpl 1999, 14:86–99.CrossRefGoogle Scholar
  13. 13.
    Hansen KW, Mau Pedersen M, Marshall SM, et al.: Circadian variation of blood pressure in patients with diabetic nephropathy. Diabetologia 1992, 35:1074–1079.PubMedCrossRefGoogle Scholar
  14. 14.
    Schmitz A, Mau Pedersen M, Hansen KW: Blood pressure by 24 hours ambulatory recordings in type 2 (non-insulin dependent) diabetics: relationship to urinary albumin excretion. Diab Metab 1991, 17:301–307.Google Scholar
  15. 15.
    Nielsen FS, Rossing P, Bang LE, et al.: On the mechanisms of blunted nocturnal decline in arterial blood pressure in NIDDM patients with diabetic nephropathy. Diabetes 1995, 44:783–789.PubMedCrossRefGoogle Scholar
  16. 16.
    Moore WV, Donaldson DL, Chonko AM, et al.: Ambulatory blood pressure in type I diabetes mellitus: comparison to presence of incipient nephropathy in adolescents and young adults. Diabetes 1992, 41:1035–1041.PubMedCrossRefGoogle Scholar
  17. 17.
    Lurbe A, Redon J, Pascual JM, et al.: Altered blood pressure during sleep in normotensive subjects with type I diabetes. Hypertension 1993, 21:227–235. One of the first cross-sectional studies finding that in type 1 diabetics with microalbuminuria, the physiologic nocturnal fall in blood pressure is blunted. It was postulated that it may prove to be a sensitive marker for renal disease and eventual progression to overt hypertension.PubMedGoogle Scholar
  18. 18.
    Poulsen PL, Ebbehøj E, Hansen KW, Mogensen CE: 24-h Blood pressure and autonomic function is related to albumin excretion within the normoalbuminuric range in IDDM patients. Diabetologia 1997, 40:718–725.PubMedCrossRefGoogle Scholar
  19. 19.
    Voros P, Lengyel Z, Nagy V, et al.: Diurnal blood pressure variation and albuminuria in normotensive patients with insulin-dependent diabetes mellitus. Nephrol Dial Transplant 1998, 13:2257–2260.PubMedCrossRefGoogle Scholar
  20. 20.
    Lafferty AR, Werther GA, Clarke CF: Ambulatory blood pressure, microalbuminuria, and autonomic neuropathy in adolescents with type 1 diabetes. Diabetes Care 2000, 23:533–538.PubMedCrossRefGoogle Scholar
  21. 21.
    Pecis M, Azevedo MJ, Moraes RS, et al.: Autonomic dysfunction and urinary albumin excretion rate are associated with an abnormal blood pressure pattern in normotensive normoalbuminuric type 1 diabetic patients. Diabetes Care 2000, 23:989–993.PubMedCrossRefGoogle Scholar
  22. 22.
    Poulsen PL, Hansen KW, Mogensen CE: Ambulatory blood pressure in the transition from normo- to microalbuminuria: a longitudinal study in IDDM patients. Diabetes 1994, 43:1248–1253. This study is a longitudinal follow-up of 44 initially normoalbuminuric type 1 diabetic patients that showed significant correlations between UAE and nocturnal hypertension.PubMedCrossRefGoogle Scholar
  23. 23.
    Lurbe E, Redon J, Kesani A, et al.: Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med 2002, 347:797–805. The two key findings of this prospective study are: 1) In type 1 diabetics, an increase in systolic blood pressure during sleep precedes the development of microalbuminuria. 2) In those subjects whose blood pressure during sleep decreases normally, the progression from normal albumin excretion to microalbuminuria appears to be less likely.PubMedCrossRefGoogle Scholar
  24. 24.
    Sturrock ND, George E, Pound N, et al.: Non-dipping circadian blood pressure and renal impairment are associated with increased mortality in diabetes mellitus. Diabetes Med 2000, 17:360–364.CrossRefGoogle Scholar
  25. 25.
    Nørgaard K, Feldt-Rasmussen B, Borch-Johnsen K, et al.: Prevalence of hypertension in type 1 (insulin-dependent) diabetes mellitus. Diabetologia 1990, 33:407–410.PubMedCrossRefGoogle Scholar
  26. 26.
    Ritz E, Orth SR: Nephropathy in patients with type 2 diabetes mellitus. N Engl J Med 1999, 341:1127–1133.PubMedCrossRefGoogle Scholar
  27. 27.
    Equiluz-Bruck S, Schnack C, Kopp HP, Schernthaner G: Non-dipping of nocturnal blood pressure is related to urinary albumin excretion rate in patients with type 2 diabetes mellitus. Am J Hypertens 1996, 9:1139–1143. This study showed that non-dipping is related to UAE rates in type 2 diabetics and also a correlation of nocturnal blood pressure to UAE rates.PubMedCrossRefGoogle Scholar
  28. 28.
    Hommel E, Mathiesen ER, Giese J, et al.: On the pathogenesis of arterial blood pressure elevation early in the course of diabetic nephropathy. Scand J Clin Lab Invest 1989, 49:537–544.PubMedGoogle Scholar
  29. 29.
    Mulec H, Blohme G, Kullenberg K, et al.: Latent overhydration and nocturnal hypertension in diabetic nephropathy. Diabetologia 1995, 38:216–220.PubMedGoogle Scholar
  30. 30.
    Nielsen FS, Hansen HP, Jacobson P, et al.: Increased sympathetic activity during sleep and nocturnal hypertension in type 2 diabetic patients with diabetic nephropathy. Diabetic Medicine 1999, 16:555–562.PubMedCrossRefGoogle Scholar
  31. 31.
    Gambardella S, Frontoni S, Spallone V, et al.: Increased left ventricular mass in normotensive diabetic patients with autonomic neuropathy. Am J Hypertens 1993, 6:97–102.PubMedGoogle Scholar
  32. 32.
    Poulsen PL, Ebbehoj E, Hansen KW, Mogensen CE: 24 h blood pressure and autonomic function is related to albumin excretion within the normoalbuminuric range in IDDM patients. Diabetologia 1997, 40:718–725.PubMedCrossRefGoogle Scholar
  33. 33.
    Farmer CK, Goldsmith DJ, Quin JD, et al.: Progression of diabetic nephropathy: Is diurnal blood pressure rhythm as important as absolute blood pressure level? Nephrol Dial Transplant 1998, 13:635–639. This is a retrospective study of 26 type 1 and type 2 patients, with nephropathy showing that non-dippers had a more rapid rate of decline of creatinine clearance than dippers.PubMedCrossRefGoogle Scholar
  34. 34.
    Timio M, Venanzi S, Lolli S, et al.: ‘Non-dipper’ hypertensive patients and progressive renal insufficiency: a 3-year longitudinal study. Clin Nephrol 1995, 43:382–387.PubMedGoogle Scholar
  35. 35.
    Nakano S, Fukuda M, Hotta F, et al.: Reversed circadian blood pressure rhythm is associated with occurrences of both fatal and nonfatal vascular events in NIDDM subjects. Diabetes 1998, 47:1501–1506.PubMedCrossRefGoogle Scholar
  36. 36.
    Spallone V, Maiello M, Cicconetti E, et al.: Factors determining the 24-h blood pressure profile in normotensive patients with type 1 and type 2 diabetes. J Hum Hypertens 2001, 15:239–246.PubMedCrossRefGoogle Scholar
  37. 37.
    Dzau VJ: Tissue renin-angiotensin system in myocardial hypertrophy and failure. Arch Intern Med 1993, 153:937–942.PubMedCrossRefGoogle Scholar
  38. 38.
    Myers MG: A dose-response study of perindopril in hypertension: effects on blood pressure 6 and 24 h after dosing. Can J Cardiol 1996, 12:1191–1196.PubMedGoogle Scholar
  39. 39.
    Svensson P, de Faire U, Sleight P, et al.: Comparative effects of ramipril on ambulatory and office blood pressures: a HOPE substudy. Hypertension 2001, 38:E28-E32.PubMedGoogle Scholar
  40. 40.
    Kohno I, Ijiri H, Takusagawa M, et al.: Effect of imidapril in dipper and nondipper hypertensive patients: comparison between morning and evening administration. Chronobiol Int 2000, 17:209–219.PubMedCrossRefGoogle Scholar
  41. 41.
    Conte G, Rigon N, Perrone A: Application of chronotherapy to cardiovascular diseases. Rec Prog Med 1998, 89:465–469.Google Scholar
  42. 42.
    Kohno I, Iwasaki H, Okutani M, et al.: Administrationtime-dependent effects of diltiazem on the 24-hour blood pressure profile of essential hypertension patients. Chronobiol Int 1997, 14:71–84.PubMedCrossRefGoogle Scholar
  43. 43.
    Kario K, Schwartz JE, Pickering TG: Changes in nocturnal blood pressure dipping status in hypertensives by nighttime dosing of the _-adrenergic blocker, doxazosin. Results from HALT study. Hypertension 2000, 35:787–794.PubMedGoogle Scholar
  44. 44.
    Hermida RC, Calvo C, Ayala DE, et al.: Administration timedependent effects of valsartan on ambulatory blood pressure in hypertensive subjects. Hypertension 2003, 42:283–290. A complete analysis of changes in blood pressure comparing nighttime versus daytime doses of valsartan, an angiotensin II blocker.PubMedCrossRefGoogle Scholar
  45. 45.
    Uzu T, Ishikawa K, Fujii T, et al.: Sodium restriction shifts circadian rhythm of blood pressure from nondipper to dipper in essential hypertension. Circulation 1997, 96:1859–1862.PubMedGoogle Scholar
  46. 46.
    Uzu T, Kimura G: Diuretics shift circadian rhythm of blood pressure from nondipper to dipper in essential hypertension. Circulation 1999, 100:1635–1638.PubMedGoogle Scholar
  47. 47.
    Czupryniak L, Wisniewska-Jaronsinska M, Drzewoski J: Trandolapril restores circadian blood pressure variation in normoalbuminuric normotensive type 1 diabetic patients. J Diabetes Complications 2001, 15:75–79.PubMedCrossRefGoogle Scholar
  48. 48.
    Scheer FA, Van Montfrans GA, van Someren EJ, et al.: Daily nighttime melatonin reduces blood pressure in male patients with essential hypertension. Hypertension 2004, 43:192–197.PubMedCrossRefGoogle Scholar
  49. 49.
    Cavallo A, Daniels SR, Dolan LM, et al.: Blood pressurelowering effect of melatonin in type 1 diabetes. J Pineal Res 2004, 36:262–266.PubMedCrossRefGoogle Scholar

Copyright information

© Current Science Inc. 2004

Authors and Affiliations

  • K. M. Moorthi
    • 1
  • Donn Hogan
    • 1
  • Empar Lurbe
    • 1
  • Josep Redon
    • 1
  • Daniel Batlle
    • 1
  1. 1.Division of Nephrology and HypertensionNorthwestern University Feinberg School of MedicineChicagoUSA

Personalised recommendations