Advertisement

Is Nocturnal Blood Pressure Reduction the Secret to Reducing the Rate of Progression of Hypertensive Chronic Kidney Disease?

  • Rupal Mehta
  • Paul E. DrawzEmail author
Article

Abstract

Hypertension is a significant risk factor for cardiovascular and renal disease. Lowering blood pressure (BP) has been shown to reduce the incidence of cardiovascular disease, but randomized trials have not demonstrated a benefit of lowering BP for the progression of renal disease except in secondary analyses in patients with significant proteinuria. Recently, there has been increasing interest in measuring BP outside of the clinic, using both home and ambulatory blood pressure monitoring (ABPM). ABPM has the advantage of measuring BP throughout both the day and night. Elevated nighttime BP and a lack of decline in BP from day to night (nondipping) are more potent risk factors for cardiovascular and renal outcomes than elevated daytime or clinic BP. Studies have shown that it is possible to lower nighttime BP and restore normal dipping with the administration of antihypertensive medications in the evening, known as chronotherapy. Evening administration of antihypertensives not only lowers nighttime BP but also is associated with decreased urinary protein excretion, decreased cardiovascular events, and decreased all-cause mortality. Reducing nighttime BP may slow the progression of chronic kidney disease and may be the key to linking the treatment of hypertension with improved renal outcomes.

Keywords

Hypertension Chronic renal insufficiency Ambulatory blood pressure monitoring Drug chronotherapy Circadian rhythm Proteinuria Nighttime BP Risk factors 

Notes

Disclosure

No potential conflicts of interest relevant to this article were reported.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Jamerson KA, Townsend RR. The attributable burden of hypertension: Focus on CKD. Adv Chronic Kidney Dis. 2011;18:6–10.PubMedCrossRefGoogle Scholar
  2. 2.
    Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo Jr JL, et al. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: The JNC 7 Report. JAMA. 2003;289:2560–72.PubMedCrossRefGoogle Scholar
  3. 3.
    Effects of treatment on morbidity in hypertension. Results in patients with diastolic blood pressures averaging 115 through 129 mm hg. JAMA. 1967;202:1028–34.CrossRefGoogle Scholar
  4. 4.
    Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes: UKPDS 38. UK Prospective Diabetes Study Group. BMJ 1998;317:703–713.Google Scholar
  5. 5.
    Curb JD, Pressel SL, Cutler JA, Savage PJ, Applegate WB, Black H, et al. Effect of diuretic-based antihypertensive treatment on cardiovascular disease risk in older diabetic patients with isolated systolic hypertension. Systolic hypertension in the elderly program cooperative research group. JAMA. 1996;276:1886–92.PubMedCrossRefGoogle Scholar
  6. 6.
    Klag MJ, Whelton PK, Randall BL, Neaton JD, Brancati FL, Ford CE, et al. Blood pressure and end-stage renal disease in men. N Engl J Med. 1996;334:13–8.PubMedCrossRefGoogle Scholar
  7. 7.
    Ishani A, Grandits GA, Grimm RH, Svendsen KH, Collins AJ, Prineas RJ, et al. Association of single measurements of dipstick proteinuria, estimated glomerular filtration rate, and hematocrit with 25-year incidence of end-stage renal disease in the multiple risk factor intervention trial. J Am Soc Nephrol. 2006;17:1444–52.PubMedCrossRefGoogle Scholar
  8. 8.
    Haroun MK, Jaar BG, Hoffman SC, Comstock GW, Klag MJ, Coresh J. Risk factors for chronic kidney disease: a prospective study of 23,534 men and women in Washington County, Maryland. J Am Soc Nephrol. 2003;14:2934–41.PubMedCrossRefGoogle Scholar
  9. 9.
    Iseki K, Iseki C, Ikemiya Y, Fukiyama K. Risk of developing end-stage renal disease in a cohort of mass screening. Kidney Int. 1996;49:800–5.PubMedCrossRefGoogle Scholar
  10. 10.
    Klag MJ, Whelton PK, Randall BL, Neaton JD, Brancati FL, Stamler J. End-stage renal disease in African-American and white men. 16-year MRFIT findings. JAMA. 1997;277:1293–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Jafar TH, Schmid CH, Landa M, Giatras I, Toto R, Remuzzi G, et al. Angiotensin-converting enzyme inhibitors and progression of nondiabetic renal disease. A meta-analysis of patient-level data. Ann Intern Med. 2001;135:73–87.PubMedGoogle Scholar
  12. 12.
    Maschio G, Alberti D, Janin G, Locatelli F, Mann JF, Motolese M, et al. Effect of the angiotensin-converting-enzyme inhibitor benazepril on the progression of chronic renal insufficiency. The Angiotensin-Converting-Enzyme Inhibition in Progressive Renal Insufficiency Study Group. N Engl J Med. 1996;334:939–45.PubMedCrossRefGoogle Scholar
  13. 13.
    Brenner BM, Cooper ME, de Zeeuw D, Keane WF, Mitch WE, Parving HH, et al. Effects of losartan on renal and cardiovascular outcomes in patients with type 2 diabetes and nephropathy. N Engl J Med. 2001;345:861–9.PubMedCrossRefGoogle Scholar
  14. 14.
    Lewis EJ, Hunsicker LG, Clarke WR, Berl T, Pohl MA, Lewis JB, et al. Renoprotective effect of the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345:851–60.PubMedCrossRefGoogle Scholar
  15. 15.
    Toto RD, Mitchell HC, Smith RD, Lee HC, McIntire D, Pettinger WA. “Strict” blood pressure control and progression of renal disease in hypertensive nephrosclerosis. Kidney Int. 1995;48:851–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Lewis JB, Berl T, Bain RP, Rohde RD, Lewis EJ. Effect of intensive blood pressure control on the course of type 1 diabetic nephropathy. Collaborative Study Group. Am J Kidney Dis. 1999;34:809–17.PubMedCrossRefGoogle Scholar
  17. 17.
    Ruggenenti P, Perna A, Loriga G, Ganeva M, Ene-Iordache B, Turturro M, et al. Blood-pressure control for renoprotection in patients with non-diabetic chronic renal disease (REIN-2): Multicentre, randomised controlled trial. Lancet. 2005;365:939–46.PubMedCrossRefGoogle Scholar
  18. 18.
    Klahr S, Levey AS, Beck GJ, Caggiula AW, Hunsicker L, Kusek JW, et al. The effects of dietary protein restriction and blood-pressure control on the progression of chronic renal disease. Modification of diet in renal disease study group. N Engl J Med. 1994;330:877–84.PubMedCrossRefGoogle Scholar
  19. 19.
    Peterson JC, Adler S, Burkart JM, Greene T, Hebert LA, Hunsicker LG, et al. Blood pressure control, proteinuria, and the progression of renal disease. The modification of diet in renal disease study. Ann Intern Med. 1995;123:754–62.PubMedGoogle Scholar
  20. 20.
    Sarnak MJ, Greene T, Wang X, Beck G, Kusek JW, Collins AJ, et al. The effect of a lower target blood pressure on the progression of kidney disease: Long-term follow-up of the modification of diet in renal disease study. Ann Intern Med. 2005;142:342–51.PubMedGoogle Scholar
  21. 21.
    •• Cushman WC, Evans GW, Byington RP, Goff DC Jr, Grimm RH Jr, Cutler JA, Simons-Morton DG, Basile JN, Corson MA, Probstfield JL, Katz L, Peterson KA, Friedewald WT, Buse JB, Bigger JT, Gerstein HC, Ismail-Beigi F: Effects of intensive blood-pressure control in type 2 diabetes mellitus. N Engl J Med 2010;362:1575–1585. The ACCORD study found that, in diabetics, a low systolic BP target (<120 mm Hg) was not associated with reduced rates of cardiovascular disease or death compared with a systolic BP target of less than 140 mm Hg. The lower BP target was associated with an increased risk for stroke. PubMedCrossRefGoogle Scholar
  22. 22.
    Wright Jr JT, Bakris G, Greene T, Agodoa LY, Appel LJ, Charleston J, et al. Effect of blood pressure lowering and antihypertensive drug class on progression of hypertensive kidney disease: Results from the AASK trial. JAMA. 2002;288:2421–31.PubMedCrossRefGoogle Scholar
  23. 23.
    Appel LJ, Wright Jr JT, Greene T, Agodoa LY, Astor BC, Bakris GL, et al. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med. 2010;363:918–29.PubMedCrossRefGoogle Scholar
  24. 24.
    Bursztyn M, Ben-Dov IZ. Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med. 2010;363:2564. author reply 2565–2566.PubMedCrossRefGoogle Scholar
  25. 25.
    •• Pogue V, Rahman M, Lipkowitz M, Toto R, Miller E, Faulkner M, Rostand S, Hiremath L, Sika M, Kendrick C, Hu B, Greene T, Appel L, Phillips RA: Disparate estimates of hypertension control from ambulatory and clinic blood pressure measurements in hypertensive kidney disease. Hypertension 2009;53:20–27. This study demonstrated that clinic BP and ambulatory BP were discordant in 45% of subjects in the African American Study of Kidney Disease Cohort Study. PubMedCrossRefGoogle Scholar
  26. 26.
    Zaninelli A, Parati G, Cricelli C, Bignamini AA, Modesti PA, Pamparana F, et al. Office and 24-h ambulatory blood pressure control by treatment in general practice: The ‘Monitoraggio Della Pressione Arteriosa Nella Medicina Territoriale’ study. J Hypertens. 2010;28:910–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Perloff D, Sokolow M, Cowan R. The prognostic value of ambulatory blood pressures. JAMA. 1983;249:2792–8.PubMedCrossRefGoogle Scholar
  28. 28.
    White WB, Schulman P, McCabe EJ, Dey HM. Average daily blood pressure, not office blood pressure, determines cardiac function in patients with hypertension. JAMA. 1989;261:873–7.PubMedCrossRefGoogle Scholar
  29. 29.
    Ohkubo T, Imai Y, Tsuji I, Nagai K, Watanabe N, Minami N, et al. Prediction of mortality by ambulatory blood pressure monitoring versus screening blood pressure measurements: A pilot study in Ohasama. J Hypertens. 1997;15:357–64.PubMedCrossRefGoogle Scholar
  30. 30.
    Khattar RS, Swales JD, Banfield A, Dore C, Senior R, Lahiri A. Prediction of coronary and cerebrovascular morbidity and mortality by direct continuous ambulatory blood pressure monitoring in essential hypertension. Circulation. 1999;100:1071–6.PubMedGoogle Scholar
  31. 31.
    Pierdomenico SD, Cuccurullo F. Prognostic value of white-coat and masked hypertension diagnosed by ambulatory monitoring in initially untreated subjects: An updated meta analysis. Am J Hypertens. 2011;24:52–8.PubMedCrossRefGoogle Scholar
  32. 32.
    •• Hansen TW, Li Y, Boggia J, Thijs L, Richart T, Staessen JA: Predictive role of the nighttime blood pressure. Hypertension 2011;57:3–10. This article is a thorough review of a number of observational studies that evaluated the predictive ability of ambulatory BP. Across multiple studies, elevated nighttime BP and nondipping status are consistently significant risk factors for cardiovascular events and all-cause mortality independent of 24-hour BP levels. PubMedCrossRefGoogle Scholar
  33. 33.
    Lurbe E, Redon J, Kesani A, Pascual JM, Tacons J, Alvarez V, et al. Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med. 2002;347:797–805.PubMedCrossRefGoogle Scholar
  34. 34.
    • Syrseloudis D, Tsioufis C, Andrikou I, Mazaraki A, Thomopoulos C, Mihas C, Papaioannou T, Tatsis I, Tsiamis E, Stefanadis C: Association of nighttime hypertension with central arterial stiffness and urinary albumin excretion in dipper hypertensive subjects. Hypertens Res 2011;34:120–125. This study evaluated hypertensive patients and found that even among patients with a normal dipping pattern, elevated nighttime BP was associated with increased pulse wave velocity and increased urinary albumin excretion. PubMedCrossRefGoogle Scholar
  35. 35.
    Oliveras A, Armario P, Martell-Claros N, Ruilope LM, de la Sierra A. Urinary albumin excretion is associated with nocturnal systolic blood pressure in resistant hypertensives. Hypertension. 2011;57:556–60.PubMedCrossRefGoogle Scholar
  36. 36.
    Farmer CK, Goldsmith DJ, Cox J, Dallyn P, Kingswood JC, Sharpstone P. An investigation of the effect of advancing uraemia, renal replacement therapy and renal transplantation on blood pressure diurnal variability. Nephrol Dial Transplant. 1997;12:2301–7.PubMedCrossRefGoogle Scholar
  37. 37.
    Agarwal R, Light RP. GFR, proteinuria and circadian blood pressure. Nephrol Dial Transplant. 2009;24:2400–6.PubMedCrossRefGoogle Scholar
  38. 38.
    Davidson MB, Hix JK, Vidt DG, Brotman DJ. Association of impaired diurnal blood pressure variation with a subsequent decline in glomerular filtration rate. Arch Intern Med. 2006;166:846–52.PubMedCrossRefGoogle Scholar
  39. 39.
    • Redon J, Plancha E, Swift PA, Pons S, Munoz J, Martinez F: Nocturnal blood pressure and progression to end-stage renal disease or death in nondiabetic chronic kidney disease stages 3 and 4. J Hypertens 2010;28:602–607. In this small observational study, a nighttime systolic BP >130 mm Hg, compared with a nighttime systolic BP <120 mm Hg, was associated with an increased risk for ESRD. PubMedCrossRefGoogle Scholar
  40. 40.
    • Drawz PE, Rosenthal N, Babineau DC, Rahman M: Nighttime hospital blood pressure--a predictor of death, ESRD, and decline in GFR. Ren Fail 2010;32:1036–1043. Even when measured in hospitalized patients, nighttime systolic BP is a significant predictor of a composite of a 50% decline in GFR, ESRD, and all-cause mortality. PubMedCrossRefGoogle Scholar
  41. 41.
    Agarwal R, Andersen MJ. Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease. Kidney Int. 2006;69:1175–80.PubMedCrossRefGoogle Scholar
  42. 42.
    Agarwal R, Kariyanna SS, Light RP. Prognostic value of circadian blood pressure variation in chronic kidney disease. Am J Nephrol. 2009;30:547–53.PubMedCrossRefGoogle Scholar
  43. 43.
    Uzu T, Kimura G. Diuretics shift circadian rhythm of blood pressure from nondipper to dipper in essential hypertension. Circulation. 1999;100:1635–8.PubMedGoogle Scholar
  44. 44.
    Fujii T, Uzu T, Nishimura M, Takeji M, Kuroda S, Nakamura S, et al. Circadian rhythm of natriuresis is disturbed in nondipper type of essential hypertension. Am J Kidney Dis. 1999;33:29–35.PubMedCrossRefGoogle Scholar
  45. 45.
    Carter BL, Bergus GR, Dawson JD, Farris KB, Doucette WR, Chrischilles EA, et al. A cluster randomized trial to evaluate physician/pharmacist collaboration to improve blood pressure control. J Clin Hypertens (Greenwich). 2008;10:260–71.CrossRefGoogle Scholar
  46. 46.
    Weber CA, Ernst ME, Sezate GS, Zheng S, Carter BL. Pharmacist-physician comanagement of hypertension and reduction in 24-hour ambulatory blood pressures. Arch Intern Med. 2010;170:1634–9.PubMedCrossRefGoogle Scholar
  47. 47.
    Hermida RC, Ayala DE. Chronotherapy with the angiotensin-converting enzyme inhibitor ramipril in essential hypertension: Improved blood pressure control with bedtime dosing. Hypertension. 2009;54:40–6.PubMedCrossRefGoogle Scholar
  48. 48.
    Hermida RC, Ayala DE, Fontao MJ, Mojon A, Alonso I, Fernandez JR. Administration-time-dependent effects of spirapril on ambulatory blood pressure in uncomplicated essential hypertension. Chronobiol Int. 2010;27:560–74.PubMedCrossRefGoogle Scholar
  49. 49.
    Hermida RC, Ayala DE, Chayan L, Mojon A, Fernandez JR. Administration-time-dependent effects of olmesartan on the ambulatory blood pressure of essential hypertension patients. Chronobiol Int. 2009;26:61–79.PubMedCrossRefGoogle Scholar
  50. 50.
    Hermida RC, Ayala DE, Fernandez JR, Calvo C. Comparison of the efficacy of morning versus evening administration of telmisartan in essential hypertension. Hypertension. 2007;50:715–22.PubMedCrossRefGoogle Scholar
  51. 51.
    Hermida RC, Calvo C, Ayala DE, Fernandez JR, Covelo M, Mojon A, et al. Treatment of non-dipper hypertension with bedtime administration of valsartan. J Hypertens. 2005;23:1913–22.PubMedCrossRefGoogle Scholar
  52. 52.
    Hermida RC, Calvo C, Ayala DE, Lopez JE. Decrease in urinary albumin excretion associated with the normalization of nocturnal blood pressure in hypertensive subjects. Hypertension. 2005;46:960–8.PubMedCrossRefGoogle Scholar
  53. 53.
    Hermida RC, Ayala DE, Fernandez JR, Calvo C. Chronotherapy improves blood pressure control and reverts the nondipper pattern in patients with resistant hypertension. Hypertension. 2008;51:69–76.PubMedCrossRefGoogle Scholar
  54. 54.
    •• Hermida RC, Ayala DE, Mojon A, Fernandez JR: Influence of circadian time of hypertension treatment on cardiovascular risk: Results of the MAPEC study. Chronobiol Int 2010;27:1629–1651. The MAPEC study, a randomized controlled trial, is the first to demonstrate that nighttime dosing of antihypertensive medications reduces cardiovascular disease and all-cause mortality. PubMedCrossRefGoogle Scholar
  55. 55.
    Minutolo R, Gabbai FB, Borrelli S, Scigliano R, Trucillo P, Baldanza D, et al. Changing the timing of antihypertensive therapy to reduce nocturnal blood pressure in CKD: an 8-week uncontrolled trial. Am J Kidney Dis. 2007;50:908–17.PubMedCrossRefGoogle Scholar
  56. 56.
    Portaluppi F, Vergnani L, Manfredini R, degli Uberti EC, Fersini C. Time-dependent effect of isradipine on the nocturnal hypertension in chronic renal failure. Am J Hypertens. 1995;8:719–26.PubMedCrossRefGoogle Scholar
  57. 57.
    Levey AS, Cattran D, Friedman A, Miller WG, Sedor J, Tuttle K, et al. Proteinuria as a surrogate outcome in CKD: Report of a scientific workshop sponsored by the National Kidney Foundation and the US Food and Drug Administration. Am J Kidney Dis. 2009;54:205–26.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC (outside the USA)  2011

Authors and Affiliations

  1. 1.Louis Stokes Cleveland VA Medical CenterClevelandUSA
  2. 2.Department of MedicineUniversity Hospitals Case Medical Center, Case Western Reserve UniversityClevelandUSA

Personalised recommendations