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

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.

Pharmacist-based antihypertensive medication review and assignment of morning versus evening dosing of once-daily antihypertensive medications: A pilot study to assess feasibility and efficacy in chronic kidney disease patients

“…Nighttime systolic blood pressure may be the best predictor of cardiovascular disease and mortality (2); one prior study has shown that evening dosing of a single once daily antihypertensive medication may reduce adverse cardiovascular outcomes (2,3,8,9). Hermida et al studied 2156 randomized subjects to demonstrate significant effects of administration time, specifically a lower CVD event risk (i.e., death, myocardial infarction, stroke) (8).…”

“…Previous trials have demonstrated that treatment of hypertension reduces the risk for cardiovascular disease and all-cause mortality (1,2). Nearly all prior studies have investigated the effect of reduction in clinic blood pressure rather than in ambulatory blood pressure.…”

“…Clinic blood pressures are taken during daytime hours, while ambulatory blood pressure monitoring allows for the assessment of blood pressure throughout the day and night (3). Nighttime systolic blood pressure, which can be lowered through evening dosing of antihypertensive medications, has been shown to be predictive of cardiovascular disease and all-cause mortality (2–4), as well as the risk of renal events (5,6). Additionally, nighttime blood pressure is elevated in patients with CKD and proteinuria (7).…”

Different chronotherapeutic effects of valsartan and olmesartan in non-dipper hypertensive patients during valsartan treatment at morning

“…Recent advances in ambulatory blood pressure monitoring (ABPM) have demonstrated that a higher night-time BP and a nondipper BP pattern are good predictors of cardiovascular events (3,4) and progression of renal disease (5,6). Cardiovascular morbidity and mortality are also reported to elevate in hypertensive patients with a non-dipper BP pattern even under antihypertensive drugs (7).…”

Nocturnal Medications Dosing: Does It Really Make a Difference in Blood Pressure Control Among Patients with Chronic Kidney Disease?

“…In particular, nighttime blood may be a robust predictor of long term outcomes [5••]. This has raised increased interest in diurnal variation in BP and elevation in nocturnal BP as a prognostic and therapeutic target [4,6,7]. Chronic kidney disease (CKD) becomes particularly relevant, due to its high prevalence in populations with altered diurnal BP and its potential for target organ damage [8].…”