Latent overhydration and nocturnal hypertension in diabetic nephropathy

Mulec, H.; Blohm�, G.; Kullenberg, K.; Nyberg, G.; Bj�rck, S.

doi:10.1007/s001250050273

Cited by 11 publications

(13 citation statements)

References 21 publications

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“…Among diabetic patients, this phenomenon has been described to occur more often in individuals with autonomic neuropathy (2) and with different degrees of diabetic nephropathy (3)(4)(5). The reasons why this abnormal pattern of blood pressure is present more frequently in these groups of diabetic patients have not been completely elucidated.…”

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confidence: 99%

“…The reasons why this abnormal pattern of blood pressure is present more frequently in these groups of diabetic patients have not been completely elucidated. An increased extracellular volume (ECV) and nocturnal sympathetic predominance have been proposed as the mechanisms related to such blood pressure abnormalities in patients with diabetic nephropathy and autonomic dysfunction (2,3,6).…”

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Autonomic dysfunction and urinary albumin excretion rate are associated with an abnormal blood pressure pattern in normotensive normoalbuminuric type 1 diabetic patients.

et al. 2000

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Abbreviations: CV, coefficient of variation; dBP, diastolic blood pressure; ECG, electrocardiogram; ECV, extracellular volume; GFR, glomerular filtration rate; HF, high frequency; HRV, heart rate variability; LF, low frequency; LF/HF ratio, ratio of power in low-frequency and high-frequency bands; n.u., normalized units; PNN50, the percentage of differences between adjacent R-R intervals Ͼ50 ms; PSA, power spectral analysis; RMSSD, the root mean square of successive differences of adjacent R-R intervals; RRMED, the mean of all R-R intervals; sBP, systolic blood pressure; SDANNi, the SD of the averages of the R-R intervals calculated in 5-min segments; SDNN, the SD of the R-R intervals; SDNNi, the mean of the SD of R-R intervals calculated in 5-min segments; UAER, urinary albumin excretion rate.A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances. RESEARCH DESIGN AND METHODS -A total of 39 normotensive normoalbuminuric type 1 diabetic patients were studied. Glomerular filtration rate ( 51 Cr-EDTA technique), extracellular volume ( 51 Cr-EDTA distribution volume), and urinary albumin excretion rate (UAER) (by radioimmunoassay) were measured. The subjects' 24-h ambulatory blood pressure and a 24-h electrocardiogram were recorded simultaneously. Heart rate variability was calculated in the time domain for 24 h, in the frequency domain at night, at rest in the supine position, and during tilt. Patients were classified according to diastolic blood pressure (dBP) night/day ratio as dipper patients (Յ0.9) and nondipper patients (Ͼ0.9). Autonomic Dysfunction and UrinaryRESULTS -Nondipper patients presented a higher low-frequency (LF) component (a sympathetic index) and higher LF/high-frequency (HF) ratio during sleep than dipper patients (0.29 ± 0.12 vs. 0.19 ± 0.10 normalized units [n.u.], P = 0.008; and 0.98 ± 0.53 vs. 0.55 ± 0.45 n.u., P = 0.007, respectively). At rest, the LF component in nondipper patients (0.38 ± 0.13 n.u.) was higher than in dipper patients (0.27 ± 0.12 n.u., P = 0.04). After the tilt, nondipper patients did not show an increase in the LF component (P = 0.32), but in dipper patients, the increase was significant (P = 0.001). In both groups, tilting promoted a decrease in the HF component (a parasympathetic index). In a stepwise multiple linear regression analysis, the LF component during sleep and the UAER accounted for 24% of the variability in the dBP night/day ratio.CONCLUSIONS -The predominance of sympathetic activity and increased levels of UAER, although within the normal range, are associated with a blunted fall in nocturnal dBP

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Autonomic dysfunction and urinary albumin excretion rate are associated with an abnormal blood pressure pattern in normotensive normoalbuminuric type 1 diabetic patients.

et al. 2000

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“…Evidence suggests that the lack of dipping increases car diac strain and thus may contribute to the enhanced car diovascular morbidity and mortality found in diabetic patients with incipient and overt diabetic nephropathy. The pathophysiological factors leading to blunted noctur nal arterial blood pressure reduction are likely to be multi factorial as suggested by the recent finding that latent fluid retention may contribute to nocturnal hypertension in diabetic nephropathy [23], Other studies in IDDM and NIDDM patients with diabetic nephropathy have been unable to confirm this suggestion [22,24], However, reduction in parasympathetic activity and a relative lack of sympathetic withdrawal during sleep seem to be impor tant features of nocturnal hypertension in diabetic ne phropathy. Furthermore, it should be recalled that patients with long-standing diabetes have an abnormal rise in systemic blood pressure during exercise as compared to short-term diabetics and subjects without diabetes.…”

Section: Arterial Blood Pressure In Diabetic Kidney Diseasementioning

confidence: 78%

Renal Protection in Diabetes-An Emerging Role for Calcium Antagonists

1997

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The combination of diabetes and hypertension increases the chances of progressive renal disorder and ultimately renal failure. Roughly 40% of all diabetics, whether insulin dependent or not, develop diabetic nephropathy. Diabetic nephropathy is the single most important cause of end-stage renal disease in the western world and accounts for more than a quarter of all end-stage renal diseases. It is also a major cause of increased morbidity and mortality in diabetic patients. Increased arterial blood pressure is an early and common phenomenon in incipient and overt diabetic nephropathy. The relationship between arterial blood pressure and diabetic nephropathy is a complex one, diabetic nephropathy increasing blood pressure and blood pressure accelerating the course of nephropathy. Calcium antagonists antagonize preglomerular vasoconstriction. Furthermore, additional putative mechanisms include the ability to retard renal growth and possibly to attenuate mesangial entrapment of macromolecules and to attenuate the mitogenic effects of diverse growth factors. Calcium antagonists (except the old short-acting dihydropyridine drugs) reduce microalbuminuria and preserve kidney function in diabetic patients with incipient diabetic nephropathy. Long-term trials using the new long-acting dihydropyridine calcium antagonists for the treatment of patients with incipient nephropathy are still lacking. A recent 1-year randomized double-blind study in hypertensive insulin-dependent diabetic patients with diabetic nephropathy showed a more beneficial effect on the decline rate in the glomerular filtration rate of nisoldipine (long-acting dihydropyridine) than angiotensin-converting-enzyme (ACE) inhibition. The mean arterial blood pressure during the study based on 24-hour recordings was nearly identical, 103 (SD 9) and 101 (SD 11) mm Hg in the two groups. Furthermore, a recent 5-year randomized open study in hypertensive noninsulin-dependent patients with diabetic nephropathy has revealed the same beneficial effect of a calcium antagonist and ACE inhibition on the progression of nephropathy. In a third group treated with sympatholytic drugs, more than 50% of the subjects had a doubling of their creatinine as compared to less than 10% in the two other groups mentioned above. However, long-term studies are needed to consolidate these findings and expand them to insulin-dependent diabetic patients with diabetic kidney disease.

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“…7 In patients with diabetic nephropathy, fluid retention was reported to contribute to nocturnal hypertension. 8 These findings strongly suggest that the kidneys and/or fluid status play a major role in the genesis of circadian BP rhythm.…”

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confidence: 91%