Original Article | Published:

Morning hypertension and night non-dipping in patients with diabetes and chronic kidney disease

Hypertension Research volume 38, pages 889894 (2015) | Download Citation

Abstract

Morning hypertension (HTN) and nocturnal non-dipping (ND) are closely associated with target organ damage and cardiovascular events. However, their importance in diabetics with advanced renal disease is unclear. We evaluated the relationships of morning HTN and ND with estimated glomerular filtration rate (eGFR) and proteinuria, and determined the risk of morning HTN and ND according to presence of diabetes mellitus (DM) and chronic kidney disease (CKD) stage. A total of 1312 patients, including 439 with diabetes, were prospectively recruited at 21 centers in Korea. All patients had HTN and an eGFR of 15–89 ml min−1 per 1.73 m2. Ambulatory 24-h blood pressure was assessed. The rates of morning HTN (25.2% vs. 13.6%, P<0.001) and ND (58.2% vs. 48.2%, P=0.002) were higher in diabetics than in non-diabetics. eGFR was correlated with ND in all patients (P<0.05) and with morning HTN only in non-diabetics (P=0.005). Proteinuria was related to ND in all patients (P<0.05) and to morning HTN only in diabetics (P=0.001). In a regression analysis, the risk of morning HTN was 2.093 (95% confidence interval (95% CI): 1.070–4.094) for the DMCKD2 group, 1.634 (95% CI: 1.044–2.557) for the CKD3–4-only group and 2.236 (95% CI: 1.401–3.570) for the DMCKD3–4 group compared with the CKD2-only group. The risk of ND was high for stage 3–4 CKD: 1.581 (95% CI: 1.180–2.120) for non-diabetics and 1.842 (95% CI: 1.348–2.601) for diabetics. Diabetics showed higher rates of morning HTN, ND and uncontrolled sustained HTN compared with non-diabetics with CKD of the same stages.

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References

  1. 1.

    , , , , , , , , , . Preserving renal function in adults with hypertension and diabetes: a consensus approach. National Kidney Foundation Hypertension and Diabetes Executive Committees Working Group. Am J Kidney Dis 2000; 36: 646–661.

  2. 2.

    Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO Clinical Practice Guideline for the Management of Blood Pressure in Chronic Kidney Disease. Kidney Int Suppl 2012; 2: 337–414.

  3. 3.

    , , , , , , , . Blood pressure and mortality in U.S. veterans with chronic kidney disease: a cohort study. Ann Intern Med 2013; 159: 233–242.

  4. 4.

    , , , . Diabetes, other risk factors, and 12- yr cardiovascular mortality for men screened in the Multiple Risk Factor Intervention Trial. Diabetes Care 1993; 16: 434–444.

  5. 5.

    , , , , , . Prognosis of "masked" hypertension and “white-coat” hypertension detected by 24- h ambulatory blood pressure monitoring 10-year follow-up from the Ohasama study. J Am Coll Cardiol 2005; 46: 508–515.

  6. 6.

    , , , , , , , , , . Non-dipping is a potent predictor of cardiovascular mortality and is associated with autonomic dysfunction in haemodialysis patients. Nephrol Dial Transplant 2003; 18: 563–569.

  7. 7.

    , , , , , , , , . Morning hypertension: the strongest independent risk factor for stroke in elderly hypertensive patients. Hypertens Res 2006; 29: 581–587.

  8. 8.

    , , . Ambulatory blood-pressure monitoring. N Engl J Med 2006; 354: 2368–2374.

  9. 9.

    , , , , , , . Association between the morning-evening difference in home blood pressure and cardiac damage in untreated hypertensive patients. J Hypertens 2009; 27: 712–720.

  10. 10.

    , , , , , , . Increase in nocturnal blood pressure and progression to microalbuminuria in type 1 diabetes. N Engl J Med 2002; 347: 797–805.

  11. 11.

    , , , . Diurnal variation of blood pressure; reproducibility and association with left ventricular hypertrophy in hemodialysis patients. Blood Press Monit 2005; 10: 25–32.

  12. 12.

    , , , , , , , , . Association between blood pressure and target organ damage in patients with chronic kidney disease and hypertension: results of the APrODiTe study. Hypertens Res 2014; 37: 172–178.

  13. 13.

    , , , , , , , , Chronic Kidney Disease Epidemiology Collaboration. Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med 2006; 145: 247–254.

  14. 14.

    . Morning surge in blood pressure and cardiovascular risk: evidence and perspectives. Hypertension 2010; 56: 765–773.

  15. 15.

    , , , . Prediction of the actual awake and asleep blood pressures by various methods of 24 h pressure analysis. J Hypertens 1996; 14: 557–563.

  16. 16.

    , . The relationship between central hemodynamics, morning blood pressure surge, glycemic control and sodium intake in patients with type 2 diabetes and essential hypertension. Diabetes Res Clin Pract 2014; 104: 420–426.

  17. 17.

    , , , , , , , . Diabetes and obesity are significant risk factors for morning hypertension: from Ibaraki Hypertension Assessment Trial (I-HAT). Life Sci 2014; 104: 32–37.

  18. 18.

    , , , , , , , , , Chronic Kidney Disease Japan Cohort Study Group. Clinical correlates of ambulatory BP monitoring among patients with CKD. Clin J Am Soc Nephrol 2013; 8: 721–730.

  19. 19.

    , . Early morning hypertension: a narrative review. Blood Press Monit 2013; 18: 291–296.

  20. 20.

    , . The role of ambulatory blood pressure monitoring in chronic and end-stage renal disease. Kidney Int 2006; 70: 1000–1007.

  21. 21.

    , , . Circadian blood pressure classification scheme and the health of patients with chronic kidney disease. Am J Nephrol 2009; 30: 536–546.

  22. 22.

    , , , , , , , , , , , , , , , . Morning hypertension in chronic kidney disease is sustained type, but not surge type. Blood Press Monit 2012; 17: 20–23.

  23. 23.

    , , . Clinical implication of morning blood pressure surge in hypertension. J Cardiovasc Pharmacol 2003; 42 (Suppl1): S87–S91.

  24. 24.

    , , , , , , , , , , . Diurnal variation of endothelial function and arterial stiffness in hypertension. J Hum Hypertens 2009; 23: 597–604.

  25. 25.

    , , , , , , , , , . Association between glycemic control and morning blood pressure surge with vascular endothelial dysfunction in type 2 diabetic patients. Diabetes Care 2014; 37: 644–650.

  26. 26.

    , . Nocturnal blood pressure, morning blood pressure surge, and cerebrovascular events. Curr Hypertens Rep 2012; 14: 219–227.

  27. 27.

    , , , , , , , , . Morning rise in blood pressure is a predictor of left ventricular hypertrophy in treated hypertensive patients. Hypertens Res 2004; 27: 939–946.

  28. 28.

    , , , , , , , , , , JMS-1 Study Group. Relationship between morning hypertension identified by home blood pressure monitoring and brain natriuretic peptide and estimated glomerular filtration rate: the Japan Morning Surge 1 (JMS-1) Study. J Clin Hypertens (Greenwich) 2008; 10: 34–42.

  29. 29.

    , , , , . 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.

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Acknowledgements

A special acknowledgment is extended to the APrODiTe study participants (Shin Wook Kang, Nam Ho Kim, Sung Gyun Kim, Ki Young Na, Hyunjin Nho, Cheol Whee Park, Hyung Chon Park, Sun Hee Park, Eun Young Sung, Sung Jun Shin, Chung Sik Lee, Eun Sil Jeon, Dong Chan Jin and Byoung Geun Han) for their time and commitment. This work was sponsored by Sanofi Korea.

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Affiliations

  1. Department of Internal Medicine, Inje University College of Medicine, Ilsan-Paik Hospital, Goyang, Korea

    • Se Won Oh
    • , Sang Youb Han
    •  & Kum Hyun Han
  2. Department of Internal Medicine, National Medical Center, Seoul, Korea

    • Ran-hui Cha
  3. Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea

    • Sejoong Kim
  4. Department of Internal Medicine, Catholic University College of Medicine, Uijeongbu, Korea

    • Sun Ae Yoon
  5. Department of Internal Medicine, School of Medicine, Ewha Womans University, Seoul, Korea

    • Dong-Ryeol Rhu
  6. Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea

    • Jieun Oh
  7. Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea

    • Eun Young Lee
  8. Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea

    • Dong Ki Kim
    •  & Yon Su Kim
  9. Department of Medical Science, Seoul National University College of Medicine, Seoul, Korea

    • Yon Su Kim

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The authors declare no conflict of interest.

Corresponding author

Correspondence to Sang Youb Han.

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DOI

https://doi.org/10.1038/hr.2015.89

Supplementary Information accompanies the paper on Hypertension Research website (http://www.nature.com/hr)

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