Blood Pressure Elevation in Diabetes: Results From 24-H Ambulatory Blood Pressure Recordings in Diabetes

Hansen, Klavs Würgler; Poulsen, Per Løgstrup

doi:10.1007/978-1-4757-6746-9_24

The Kidney and Hypertension in Diabetes Mellitus 1994

DOI: 10.1007/978-1-4757-6746-9_24

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Blood Pressure Elevation in Diabetes: Results From 24-H Ambulatory Blood Pressure Recordings in Diabetes

Klavs Würgler Hansen¹,

Per Løgstrup Poulsen²

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1997

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Cited by 3 publications

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“…It is well documented that the normal night-time drop in BP is reduced in patients with increased urinary albumin excretion (UAE) and in patients with autonomic neuropathy (1). It is well documented that the normal night-time drop in BP is reduced in patients with increased urinary albumin excretion (UAE) and in patients with autonomic neuropathy (1).…”

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“…If true, ambulatory BP monitoring could identify normoalbuminuric patients at risk of progressing to microalbuminuria as those with a disturbed diurnal BP variation. Diabetes duration is an important confounder, since the night/ day ratio of BP is elevated in very long-term normo¬ albuminuric patients, who a priori are expected to have a favourable prognosis (1,7). However, we do not know how many of these patients ultimately develop microalbuminuria.…”

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Diurnal blood pressure profile, autonomic neuropathy and nephropathy in diabetes

Hansen

1997

European Journal of Endocrinology

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Given the crucial role of elevated blood pressure (BP) in the progression of diabetic nephropathy, the study of the diurnal variation in BP in diabetes is a surprisingly late phenomenon. It is well documented that the normal night-time drop in BP is reduced in patients with increased urinary albumin excretion (UAE) and in patients with autonomic neuropathy (1). Several recent studies have demonstrated an association between autonomic neuropathy, reduced night-time fall in BP and elevated UAE (2, 3).The question of a possible causative role of autonomic neuropathy in the development of diabetic nephropathy has naturally arisen (2, 3) and was actually coined 10 years ago (4, 5). The proposed pathogenic link is a higher BP burden at night which is more readily transmitted to glomeruli because of renal vasodilation. If true, ambulatory BP monitoring could identify normoalbuminuric patients at risk of progressing to microalbuminuria as those with a disturbed diurnal BP variation. In support of the theory it has been reported that even in normoalbuminuric patients a proportion present abnormal regulation of BP (6). However, we do not know how many of these patients ultimately develop microalbuminuria. The night/day ratio of BP in patients who progress during a 3-year follow-up study overlaps with the values for the non-progressors (7). Diabetes duration is an important confounder, since the night/ day ratio of BP is elevated in very long-term normo¬ albuminuric patients, who a priori are expected to have a favourable prognosis (1, 7). Against the theory is the fact that a substantial number of patients with micro¬ albuminuria show a night/day ratio which is considered normal. Thus a disturbed diurnal BP regulation cannot be decisive for progression to microalbuminuria (8).Furthermore, it should be recognized that the night/day ratio of BP is not a very reproducible parameter and this problem cannot be overcome by remeasurement as easily as for UAE. Therefore it is not plausible that ambulatory BP monitoring will become a sensitive instrument for detecting normoalbuminuric patients at risk of progressing.Alternatively, autonomie neuropathy and blunted diurnal variation of BP could merely be cofactors. According to this view autonomie neuropathy has no independent role in the development of diabetic renal disease (but may promote progression of nephropathy when established). The coexistence of autonomie neuro¬ pathy and nephropathy might be explained by the effects of poor metabolic control on a background of unknown genetic factors. Obviously there is a need for longitudinal studies in normoalbuminuric patients; this should combine information about the evolution of UAE, ambulatory BP and autonomie neuropathy.The discussion of the role of very early autonomie neuropathy in insulin-dependent diabetes mellitus (IDDM) patients closely mimics the classical controversy about the temporal relationship between UAE and BP in incipient diabetic nephropathy (i.e. which is the first to rise?). Our understanding of this relationshi...

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Diurnal blood pressure profile, autonomic neuropathy and nephropathy in diabetes

Hansen

1997

European Journal of Endocrinology

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Diabetic Renal Disease: The Quest for Normotension—and Beyond

Mogensen

1995

Diabetic Medicine

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Over the past two decades there has been an increasing interest in hypertension as a risk factor for diabetic renal disease and in particular for the possibility of early antihypertensive intervention. Therefore, it would seem timely to review the history of hypertension in diabetes, with special reference to renal disease and the need for normotension, in a manner resembling glycaemic control. Elevated blood pressure (BP) associated with diabetes mellitus has been recognized since the beginning of the century and was initially particularly documented in association with the demonstration of the striking histological lesion in glomeruli, starting with the observation of Kimmelstiel and Wilson in 1936. These patients in many cases also showed hypertension, as confirmed in several subsequent reports, very similar to the studies of Kimmelstiel and Wilson. However, the development was hampered by the lack of effective antihypertensive agents and also by some who believed that elevated BP could be of importance to preserve renal function in these individuals. Indeed, it was suggested that reduction of BP could mean permanent deterioration in renal function. BP remained very high in the standard care of diabetic patients up to the middle 1970s. At this time it was documented that elevated BP was very closely related to development of diabetic renal disease in Type 1 (insulin-dependent) diabetic (IDDM) patients, and studies also showed a correlation between blood pressure and rate of progression. This correlation stimulated research in intervention, and indeed in the 1980s and 1990s several long-term studies reported that antihypertensive treatment can reduce the rate of decline in glomerular filtration rate (GFR) from about 12 ml min-1 yr-1 down to about 2 ml min-1 yr-1 in the most optimistic reports; usually a mean level of 2-5 ml min-1 yr-1 is achievable by antihypertensive treatment, in clinical situations where glycaemic control often is far from perfect. Many studies have also documented that BP starts to rise in the early phase of incipient diabetic nephropathy characterized by microalbuminuria. This is a stage with well-preserved GFR and therefore probably an ideal stage for intervention in these at risk patients. Many studies, in particular those employing angiotensin converting enzyme (ACE) inhibitors based on important pathophysiological concepts proposed by Brenner, have shown that microalbuminuria can be reduced or stabilized by early antihypertensive treatment, just as we see with optimized glycaemic control. ACE inhibitors have also been widely used in patients with overt nephropathy and the rate of decline in GFR has been reduced considerably.(ABSTRACT TRUNCATED AT 400 WORDS)

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Diabetes and Hypertension: Prognostic and Therapeutic Considerations

1995

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Hypertension and diabetes are common disorders which frequently co-exist. Both are risk factors for atherosclerotic vascular disease and their combination is associated with an increased incidence of nephropathy, ischaemic heart disease, peripheral vascular disease, and stroke. Several trials such as the HDFP and SHEP studies that included diabetic patients have demonstrated the beneficial effects of antihypertensive therapy in reducing mortality. In diabetes, studies have focussed predominantly on the efficacy of antihypertensive therapy in reducing the progression of diabetic kidney disease. Such therapy has been shown to decrease albuminuria in the setting of "normal" and elevated blood pressure in both type I and type II diabetic patients. This reduction in albuminuria has been observed in microalbuminuric diabetic patients and also in those with overt renal disease. Recent studies in type I diabetic patients with overt nephropathy indicate that these effects on urinary albumin excretion are associated with reduction in the rate of decline in renal function and development of end-stage renal failure. Indeed, several groups have shown that the initiation of antihypertensive therapy improves the prognosis of type I diabetic patients with nephropathy. While certain classes of drugs may reduce the rate of progression of complications such as nephropathy, others have side effect profiles that are disadvantageous in patients with diabetes.

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Blood Pressure Elevation in Diabetes: Results From 24-H Ambulatory Blood Pressure Recordings in Diabetes

Cited by 3 publications

References 40 publications

Diurnal blood pressure profile, autonomic neuropathy and nephropathy in diabetes

Diurnal blood pressure profile, autonomic neuropathy and nephropathy in diabetes

Diabetic Renal Disease: The Quest for Normotension—and Beyond

Diabetes and Hypertension: Prognostic and Therapeutic Considerations

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