Loss of nighttime blood pressure dipping as a risk factor for coronary artery calcification in nondialysis chronic kidney disease

Abstract

Diurnal variations in blood pressure (BP) loss are closely associated with target organ damage and cardiovascular events. The quantity of coronary artery calcification (CAC) correlates with the atherosclerotic plaque burden, and an increased quantity indicates a substantially increased risk of cardiovascular events. This study investigated the nighttime diurnal variation in BP loss associated with CAC in patients with chronic kidney disease (CKD).Of the 1958 participants, we enrolled 722 participants with CKD without a history of acute coronary syndrome or symptomatic coronary artery disease. CAC was measured with computed tomography. BP was measured using 24-hour ambulatory BP monitoring. Central BP was measured using a SphygmoCor waveform analysis system.Participants with CAC had significantly higher 24-hour systolic, daytime systolic, and nighttime systolic ambulatory BP and central systolic BP. The percentage of participants with dipping loss was significantly higher among those with CAC. Multivariate logistic regression analysis indicated that dipping loss and dipping ratio were independently associated with CAC after adjusting for traditional and nontraditional cardiovascular risk factors and other BP parameters, including measurements of office-measured BP and central BP. The dipping status improved risk prediction for CAC after considering traditional risk factors and office-measured BP, using the net reclassification improvement and integrated discrimination improvement.Nighttime loss of diurnal variation in BP is an independent risk factor for CAC in CKD patients.

Different Relevance of Peripheral, Central or Nighttime Blood Pressure Measurements in the Prediction of Chronic Kidney Disease Progression in Patients with Mild or No-Proteinuria

“…This difference may arise from the fact that none of our patients had diabetes and diabetic patients were quite common in a cited study - 46.3%, and diabetes is known to cause disturbances in the autonomic nervous system. Nonetheless, the lack of dipping was a risk factor for coronary artery calcifications in the study by Choi et al what seems to be in general concordance with our study where we have found that the difference in dipping is related to kidney function loss in patients with mild or no proteinuria [29]. The loss of dipping of the diastolic blood pressure seems to be a crucial factor which leads to the increase load of diastolic blood pressure during the night-time in these patients [20].…”

“…The prevalence of dippers in our study was quite high for patients with CKD. In a study by Choi et al [29] the loss of dipping was reported in 56% of patients with coronary artery calcifications and in 44% of patients without coronary artery calcifications. In our populations the non-dipping pattern occurred in 27% of patients at the beginning of the study and 35% after the one-year observation period.…”

Nocturnal blood pressure is associated with sympathetic nerve activity in patients with chronic kidney disease

“…A non‐dipping pattern characterized by the loss of the normal BP drop of 10%–20% during nighttime from daytime, as well as reverse dipping or nocturnal hypertension, are frequently observed and associated with worse prognosis in CKD (Iimuro et al., (2013); Pogue et al., 2009). Furthermore, non‐dipping is shown to be an independent risk factor for subclinical target organ damage including coronary artery calcification (Choi et al., 2017) and cardiac hypertrophy (Jaques et al., 2018), and is a significant predictor of CVD and mortality in patients with CKD (Wang et al., 2016). Despite the clinical significance of non‐dipping BP, the underlying mechanisms responsible for aberrant ABPM patterns in CKD are poorly understood.…”

In response to nocturnal dipping profile in chronic kidney disease: Searching for underlying mechanisms in order to prevent adverse events

“…The sample size is on the higher side for typical microneurographic studies, and we were able to detect significant group differences. Indeed, the majority of studies linking nocturnal non-dipping with adverse cardiovascular outcomes in patients with CKD and hypertension have used the dichotomous grouping strategy (Choi et al, 2017;Jaques et al, 2018). We do agree that we were not powered to investigate multiple categories of diurnal BP profiles, and we think it would be very interesting to investigate the mechanisms underlying the morning BP surge as well as the role of salt sensitivity.…”

“…As noted in the commentary, our study was the first to demonstrate the link between nocturnal blood pressure (BP) profiles, elevated sympathetic nervous system (SNS) activation, and impaired vascular endothelial function in patients with chronic kidney disease (CKD; Jeong et al, 2020). Despite the high prevalence of non-dipping BP patterns (Iimuro et al, 2013;Pogue et al, 2009) and its strong prognostic value for target organ damage and worse cardiovascular outcomes in patients with CKD (Choi et al, 2017;Jaques et al, 2018), there is a lack of knowledge in the pathophysiological mechanisms underlying non-dipping in this population. Our study attempted to provide a groundwork for potential mechanisms to explain the abnormally elevated nighttime BP with multiple analytic approaches.…”