Is Nocturnal Blood Pressure Reduction the Secret to Reducing the Rate of Progression of Hypertensive Chronic Kidney Disease?
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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.
KeywordsHypertension Chronic renal insufficiency Ambulatory blood pressure monitoring Drug chronotherapy Circadian rhythm Proteinuria Nighttime BP Risk factors
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- 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.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
- 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
- 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
- 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
- 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.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
- 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
- 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
- 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.• 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
- 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