Summary
The association between diurnal blood pressure variation and diabetic nephropathy was assessed in four groups of Type 1 (insulin-dependent) diabetic patients who underwent 24-h ambulatory blood pressure monitoring using an oscillometrie technique. Patients with nephropathy, who had never been treated for hypertension (group D3,n = 13), were individually matched for age, sex and diabetes duration to a group of microalbuminuric patients (D2,n = 26), to normoalbuminuric patients (D1,n = 26) and to healthy control subjects (C,n = 26). Group D3 was also compared to patients with advanced nephropathy receiving treatment for hypertension, mainly a combination of angiotensin converting enzyme inhibitors, metoprolol and diuretics (D4,n = 11). In group D3 24-h diastolic blood pressure (85 ± 8 mm Hg) was comparable to the results obtained in D4 (85 ± 8 mm Hg) but significantly higher than in D2 (78 ± 7 mm Hg), D1 (73 ± 7 mm Hg) and C (73 ± 7 mm Hg,p < 0.05, Tukey's test). The night/day ratio of diastolic blood pressure was higher in D3 (86 ± 5 %) and D2 (85 ± 7%) than in C (80 ± 7 %,p < 0.02). This ratio was also elevated in group D4 (94 ± 8%) compared to D3 (p < 0.05) corresponding to a marked smoothing of the diurnal blood pressure curve. The 24-h heart rate (beats per min) was significantly elevated in D3 (84 ± 8) and D2 (80 ± 10) compared with C (73 ± 11,p < 0.05 Tukey's test), suggesting the presence of parasympathetic neuropathy In conclusion the normal circadian variation of blood pressure was moderately disturbed in a group of microalbuminuric patients and patients with less advanced overt nephropathy. Patients with advanced diabetic nephropathy receiving antihypertensive therapy showed a marked reduction of nocturnal blood pressure fall, which can only be identified by the application of ambulatory blood pressure measurements to verify the 24-h effectiveness of blood pressure control.
Article PDF
Similar content being viewed by others
References
Andersen AR, Sandahl Christiansen J, Andersen JK, Kreiner S, Deckert T (1983) Diabetic nephropathy in type 1 (insulin-dependent) diabetes: an epidemiological study. Diabetologia 25: 496–501
Borch-Johnsen K, Kreiner S (1987) Proteinuria: value as predictor of cardiovascular mortality in insulin-dependent diabetes mellitus. Br Med J 294: 1651–1654
Mogensen CE (1982) Long-term antihypertensive treatment inhibiting progression of diabetic nephropathy. Br Med J 285: 685–688
Parving H-H, Smidt UM, Andersen AR, Svendsen PAa (1983) Early aggressive antihypertensive treatment reduces rate of decline in kidney function in diabetic nephropathy. Lancet 1: 1175–1179
Mathiesen ER, Borch-Johnsen K, Jensen DV, Deckert T (1989) Improved survival in patients with diabetic nephropathy. Diabetologia 32: 884–886
Walker JD, Dodds RA, Murrells TJ et al. (1989) Restriction of dietary protein and progression of renal failure in diabetic nephropathy. Lancet 11: 1411–1415
The National High Blood Pressure Education Program Coordinating Committee (1990) National high blood pressure education program working group report on ambulatory blood pressure monitoring. Arch Intern Med 150: 2270–2280
Liniger C, Favre L, Assal J-Ph (1991) Twenty-four hour blood pressure and heart rate profiles of diabetic patients with abnormal cardiovascular reflexes. Diabetic Med 8: 420–427
Liniger C, Favre L, Adamec R, Pernet A, Assal J-Ph (1987) Prodil nycthéméral de la pression artérielle et de la fréquence cardiaque dans la neuropathie diabétique autonome. Schweiz Med Wschr 117: 1949–1953
Chanudet X, Bauduceau B, Ritz P et al. (1989) Neuropathie végétative et régulation tensionnelle chez le diabétique. Arch Mal Cæur 82: 1147–1151
Zander E, Schulz B, Heinke P, Grimmberger E, Zander G, Gottschling HD (1989) Importance of cardiovascular autonomic dysfunction in IDDM subjects with diabetic nephropathy. Diabetes Care 12: 259–264
Mogensen CE (1987) Microalbuminuria as a predictor of clinical diabetic nephropathy. Kidney Int 31: 673–689
Hansen KW, Christensen CK, Andersen PH, Mau Pedersen M, Sandahl Christiansen J, Mogensen CE (1992) Ambulatory blood pressure in microalbuminuric type 1 diabetic patients. Kidney Int 41: 847–854
Parving H-H, Hommel E, Smidt UM (1988) Protection of kidney function and decrease in albuminuria by captopril in insulin dependent diabetics with nephropathy. Br Med J 297: 1086–1089
O'Brien E, Mee F, Atkins N, O'Malley K (1991) Evaluation of the Spacelabs 90202 according to the AAMI standard and BHS criteria. J Hum Hypertens 5: 223–226
Christensen CK, Ørskov C (1984) Rapid screening PEG radioimmunoassay for quantification of pathological microalbuminuria. Diabetic Nephropathy 3: 92–94
Engbaek F, Christensen SE, Jespersen B (1989) Enzyme immunoassay of hemoglobin AIc: analytical characteristics and clinical performance for patients with diabetes mellitus, with and without uremia. Clin Chem 35: 93–97
O'Brien PC (1983) The appropriateness of analysis of variance and multiple-comparison procedures. Biometrics 39: 787–794
Wiegmann TB, Herron KG, Chonko AM, Macdougall ML, Moore WV (1990) Recognition of hypertension and abnormal blood pressure burden with ambulatory blood pressure recordings in type 1 diabetes mellitus. Diabetes 39: 1556–1560
Mølgaard H, Christensen PD, Sørensen KE, Christensen CK, Mogensen CE (1992) Association of 24-h cardiac parasympathetic activity and degree of nephropathy in IDDM patients. Diabetes 41: 812–817
Ewing DJ, Borsey DO, Travis P, Bellavere F, Neilson JMM, Clarke BF (1983) Abnormalities of ambulatory 24-hour heart rate in diabetes mellitus. Diabetes 32: 101–105
Kleiger RE, Miller JP, Bigger JT, Moss AJ, the Multicenter Post-infarction research group (1987) Decreased heart rate variability and its association with increased mortality after acute myocardial infarction. Am J Cardiol 59: 256–262
Cripps TR, Malik M, Farrel TG, Camm AJ (1991) Prognostic value of reduced heart rate variability after myocardial infarction: clinical evaluation of a new analysis method. Br Heart J 65: 14–19
Malmberg K, Herlitz J, Hjalmarson Å, Ryden L (1989) Effects of metoprolol on mortality and late infarction in diabetics with suspected acute myocardial infarction. Retrospective data from two large studies. Eur Heart J 10: 423–428
Kjekshus J, Gilpin E, Cali G, Blackey AR, Henning H, Ross J Jr (1990) Diabetic patients and beta-blockers after acute myocardial infarction. Eur Heart J 11: 43–50
Jensen T, Borch-Johnsen K, Kofoed-Enevoldsen A, Deckert T (1987) Coronary heart disease in young type 1 (insulin-dependent) diabetic patients with and without diabetic nephropathy: incidence and risk factors. Diabetologia 30: 144–148
Hornung RS, Mahler RF, Raftery EB (1988) Ambulatory blood pressure and heart rate in diabetic patients: an assessment of autonomic function. Diabetic Med 6: 579–585
Nakano S, Uchida K, Kigoshi T et al. (1991) Circadian rhythm of blood pressure in normotensive NIDDM subjects. Its relationship to microvascular complications. Diabetes Care 14: 707–711
Meijer JL, Ardesch HG, van Rooijen JC, de Bruijn JHB (1986) Low dose captopril twice daily lowers blood pressure without disturbance of the normal circadian rhythm. Postgr Med J 62 [Suppl1]:101–105
Kieso HA, Gould BA, Mann S, Hornung RS, Altman DG, Raftery EB (1983) Effect on intra-arterial blood pressure of slow release metoprolol combined with placebo or chlorthalidone. Br Med J 287: 717–720
Mau Pedersen M, Hansen KW, Schmitz A, Sørensen K, Christensen CK, Mogensen CE (1992) Effects of ACE-inhibition supplementary to beta blockers and diuretics in early diabetic nephropathy. Kidney Int 41: 883–890
Dyrberg T, Benn J, Sandahl Christiansen J, Hilsted J, Nerup J (1981) Prevalence of diabetic autonomic neuropathy measured by simple bedside tests. Diabetologia 20: 190–194
Ewing DJ, Campbell IW, Clarke BF (1976) Mortality in diabetic autonomic neuropathy. Lancet 1: 601–603
Ewing DJ, Campbell IW, Clarke BF (1980) The natural history of diabetic autonomic neuropathy. Quart J Med 49: 95–108
O'Brien IA, McFadden JP, Corrall RJM (1991) The influence of autonomic neuropathy on mortality in insulin-dependent diabetes. Quart J Med 79: 495–502
Winocour PH, Dhar H, Anderson DC (1986) The relationship between autonomic neuropathy and urinary sodium and albumin excretion in insulin-treated diabetics. Diabetic Med 3: 436–440
Author information
Authors and Affiliations
Rights and permissions
About this article
Cite this article
Hansen, K.W., Pedersen, M.M., Marshall, S.M. et al. Circadian variation of blood pressure in patients with diabetic nephropathy. Diabetologia 35, 1074–1079 (1992). https://doi.org/10.1007/BF02221684
Received:
Revised:
Issue Date:
DOI: https://doi.org/10.1007/BF02221684