Nighttime blood pressure fall in renal disease patients

OBJECTIVE: There are controversial reports in the prevalence of abnormal nighttime blood pressure fall in renal patients. It has been evaluated nocturnal BP in renal patients using 24 h blood pressure monitoring (ABPM) in comparison with nontreated control subjects either normotensives or hypertensives. DESIGN: AND METHODS: It has been reviewed 137 ABPM studies performed in renal patients (47.8 +/- 15.4 years, 76 men and 61 women). The control group includes 119 subjects without kidney disease, 65 were normotensives, and 49 were hypertensives, aged 46.8 +/- 12.1 years, 59 men and 60 women. The ambulatory BP was measured noninvasively for 24h by the SpaceLabs 90207 device programmed to measure BP every 15 min during daytime and every 20 min during nighttime. The definition of daytime and nighttime was made on the basis of wakefulness and sleep or bed rest periods, obtained from a diary kept by each subject. RESULTS: SBP, but not DBP, was higher (133.9/81.7) in renal disease patients when compared to nonrenal subjects (127.9/80.8, p < 0.01). When the control group was split into normotensive and hypertensive patients there were still significant differences, but hypertensives had higher BP than renal disease patients (139.0/89.7, p < 0.05). Nocturnal SBP fall in renal disease patients was reduced (5.8%, p < 0.001) and so was DBP fall (11.1%, p < 0.001) compared with the overall nonrenal patients sample (SBP 10.8; DBP 15.3%). The frequency of nondipper status in renal disease patients (39.6%) was higher than in control patients (18.4%, p < 0.001). Nontreated normotensive renal disease patients did not show any difference in either SBP or DBP nighttime fall with respect to control normotensives. Neither do nontreated hypertensive renal patients as compared with control hypertensives. There were not differences between proteinuric and nonproteinuric patients in nocturnal BP fall. The same result was obtained when hypertensive and normotensive nontreated renal patients were compared. The presence of renal failure did not induce a reduction of nocturnal BP fall. Most of treated renal patients were mainly receiving drug therapy during the morning and frequently this was the single daily dose. CONCLUSIONS: Altered diurnal rhythm should not be considered as a usual complication of renal disease. Inadequate antihypertensive pharmacotherapy could be related to the abnormalities of nighttime BP fall when it is detected.     

Relationship between arterial hypertension and renal damage in chronic kidney disease: insights from ABPM

BACKGROUND: To date, few studies have used ambulatory pressure monitoring (ABPM) in patients with chronic kidney disease (CKD) before the start of dialysis treatment. The aim of this study was therefore to ascertain the correlates of arterial hypertension assessed by ABPM in CKD patients at their first referral to a nephrologist. METHODS: We studied 244 (164 men; mean age 63 years) nondiabetic patients with CKD. Each patient had blood pres-sure (BP) measured by 24-hour ABPM, creatinine clearance (CrCl) estimated according to the Cockcroft-Gault formula, and Hgb concentration, serum lipids, iPTH, daily urinary protein (Uprot) and sodium (UNa) excretion assessed using routine methods. RESULTS: According to ABPM data analysis, 81 patients were normotensives, 78 were stable hypertensives, 26 had day-time hypertension and 59 had nocturnal hypertension. ANOVA showed both lower CrCl (p=0.0033), and higher Uprot (p<0.0001) in stable and nighttime hypertensives as compared with normotensives and daytime hypertensives. In the whole group each set of both systolic (SBP) and pulse pressure (PP) readings was directly associated with both age and Uprot (p<0.05), and inversely with both CrCl and Hgb (p<0.05). In multivariate analysis, however, Uprot emerged among modifiable risk factors, as the most significant predictor of both SBP and PP; the strength of this association was in the order nighttime PP > nighttime SBP > 24-hour PP > daytime PP > daytime SBP > 24-hour SBP. CONCLUSION: In CKD patients, proteinuria is the strongest correlate of arterial hypertension and particularly of increased nocturnal PP, possibly as an expression of vascular damage. On the basis of these results, ABPM appears to be the most reliable tool for detecting the associations between raised BP (particularly nighttime hypertension) and renal damage in CKD patients not yet on renal replacement therapy (RRT).     

慢性肾脏病患者血压昼夜节律异常的研究

目的 观察慢性肾脏病(CKD)患者24 h血压动态变化，探讨昼夜节律异常与肾功能损害的关系。方法 随机选择本院肾脏科CKD患者236例，高血压科原发性高血压住院患者43例。病例分组:正常对照组(NC)14例；原发性高血压组(EHC)43例；CKD血压正常组(NCKD)130例；CKD伴血压升高组(HCKD)106例。动态血压监测(ABPM)采用携带式的动态血压检测仪，ABP Report Mangement System Version 1.03.03进行数据分析。夜间血压下降率:(白昼平均值-夜间平均值)/白昼平均值，下降率≥10%，称勺型血压；<10%，称非勺型血压。结果 在血压正常的患者中，NCKD组的平均夜间收缩压和舒张压数值均高于NC组[(111.2±10.8)比 (91.6±7.5)，(68.7±9.5) 比 (56.2±4.6)mm Hg，P < 0.05]；而日间收缩压和舒张压无明显差异。在高血压患者中，HCKD组患者夜间收缩压和舒张压数值均高于EHC组[(141.9±16.5) 比(118.6±16.4)， (84.5±10.6)比(73.0±11.1)mm Hg， P < 0.05]。CKD患者无论血压正常或升高，其心率均较其对照组明显加快，尤其是夜间心率无明显下降。NCKD组、HCKD组与NC组、EHC组相比，夜间收缩压和舒张压下降数值较小，尤其是CKD伴血压升高组，呈典型的非勺型血压模式。NC组血压节律消失者占7.14%，EHC组为37.2%，NCKD组为70.0%，HCKD组为81.6%。结论 CKD患者无论血压正常或升高，夜间收缩压和舒张压下降减少或消失，呈典型的非勺型血压；血压昼夜节律异常率明显高于原发性高血压患者。在积极降低血压值的同时，还需降低血压负荷和调整血压昼夜节律，以延缓肾功能恶化。     

Treatment of primary and secondary hypertension in children

The incidence of pediatric hypertension (HTN) is increasing, mainly due to an increase in primary (essential) HTN, or PH. There are only a limited number of studies assessing the characteristics and treatment efficacy of PH versus secondary HTN (SH). We conducted a retrospective analysis of 158 pediatric patients (mean age: 10.8 years; sex ratio: 51.1% female, 48.9% male) with HTN of whom 34.4% had PH and 65.6% had SH. The vast majority were either African-American or Caucasian. Among all patients, therapy induced a significant decrease in systolic blood pressure (SBP) and diastolic BP (DBP) (both p<0.0001). SBP (p<0.0001) and DBP (p=0.002) declined significantly in PH patients. PH and SH patients with a body mass index (BMI) >95th percentile (%) had a significantly higher post-therapy SBP (both p<0.05) than those with a BMI <95th%. SBP declined similarly in PH patients treated with calcium-channel blockers (CCB) and angiotensin-converting enzyme inhibitors (ACEI). DBP declined only in PH patients treated with ACEI. SBP and DBP (both p<0.0001) declined significantly in SH patients. Post-therapy BP was similar in SH patients treated with either CCB or ACEI. Post-therapy SBP and DBP were significantly lower in SH patients than in PH patients; moreover, therapy induced a greater decline in SBP and DBP in the SH patients. Compared to PH patients, SH patients were twofold more likely to achieve a SBP less than the 95th% after therapy. We conclude that (1) significant lowering of BP with either CCB or ACEI is achievable in most children with HTN, and (2) SH patients respond better to therapy than those with PH.     

Improved 24-Hour Blood Pressure Control With Sirolimus Versus Calcineurin Inhibitor Based Immunosuppression in Renal Transplant Recipients

Introduction

Calcineurin inhibitors (CNI) have brought dramatic improvements in early renal allograft survival. However, CNI are associated with posttransplant hypertension (PTHTN), a risk factor for mortality from cardiovascular disease and graft failure. Sirolimus (SRL) is emerging as an alternative to CNI. SRL effects on blood pressure (BP) in humans are unclear. We compared the prevalence of PTHTN among patients receiving SRL as maintenance immunosuppression with a group receiving CNI by using 24-hour ambulatory BP (AMBP). AMBP has been shown to predict cardiovascular events and progression of kidney disease better than casual office BP measurements in chronic kidney disease (CKD) patients.

Methods

Renal transplant recipients with office hypertension (defined as BP > 130/80 or on antihypertensive medications), receiving stable immunosuppression and displaying consistent serum creatinine values for ≥6 months were eligible. We enrolled the first 40 patients to consent. Office BP was measured twice using a BP-Tru machine. AMBP was then analyzed for systolic BP (SBP), diastolic BP (DBP), and nocturnal blood pressure fall (NF; “dipping”). Patients were placed in the SRL group (n = 18) and the CNI group (n = 20) based on their maintenance immunosuppressive protocol. Two patients were excluded because of incomplete data. All patients received mycophenolate mofetil, and 14/38, maintenance steroids. We collected, demographics as well as type and date of renal allograft, medications, comorbidities, CKD stage, proteinuria, and plasma creatinine at the time of study enrollment.

Results

Patients in the SRL group displayed lower 24-hour SBP than the CNI group (128.0 ± 10.8 vs 137.7 ± 14; P = .029). Nightime MAP, nightime SBP, and nighttime DBP were all lower in the SRL group. NF did not reach significance between the SRL and CNI groups (44% vs 15%; P = .074). Patient demographics and number of antihypertensive medications did not differ.

Conclusion

The lower 24-hour SBP seen in the SRL group by AMBP may lead to improved cardiovascular and renal outcomes over time. Long-term patient follow-up will be needed to clarify the effect of the lower 24-hour SBP.     

The Impact of Posttraumatic Stress Disorder on Blood Pressure and Heart Rate in a Veteran Population

Hyperarousal is a hallmark of posttraumatic stress disorder (PTSD). PTSD has been associated with increased blood pressure (BP) and heart rate (HR) in veteran populations. We retrospectively identified male patients consulted to outpatient psychiatry at the Iowa City Veterans Affairs Healthcare System. Patients were divided into PTSD (n = 88) and non‐PTSD (n = 98) groups. All PTSD patients and a subset of non‐PTSD patients had documented blast exposure during service. The study investigated whether patients with PTSD had higher systolic blood pressure (SBP), diastolic blood pressure (DBP), and heart rate (HR) than patients without PTSD. The effect of trauma exposure on BP was also examined. Mean SBP (133.8 vs. 122.3 mm Hg; p < .001), DBP (87.6 vs. 78.6 mm Hg; p < .001), and HR (78.9 vs. 73.1 bpm; p < .001) were all significantly higher in the PTSD group. Trauma‐exposed patients without PTSD had significantly higher BP than nonexposed patients. The prevalence of hypertension (HTN) was 34.1% (diagnosed and undiagnosed) among PTSD patients. Patients with PTSD had higher BP and HR compared to patients without PTSD. Trauma exposure may increase BP in this population. These findings will increase awareness about the cardiovascular implications of PTSD.     

Blood pressure after cardiac transplantation in childhood.

BACKGROUND: There has been little formal study of blood pressure in children after cardiac transplantation. METHODS: Twenty-four-hour and clinical blood pressure (BP) were measured in 28 children (>6 months after transplantation) and compared with a large amount of normal data. RESULTS: Conventional (clinical) systolic BP (SBP) was elevated in 9 (32.1%) of 28 (95% confidence interval [CI] 15.8 to 52.3), and conventional diastolic BP (DBP) was elevated in 5 (17.8%) of 28 (95% CI 6.0 to 36.8). Mean 24-hour BP was >97.5 percentile in 2 (7.7%) of 26 (95% CI 0.9 to 25.1) for SBP and in 7 (28.0%) of 25 (95% CI 12.1 to 49.4) for DBP. In comparison with the control population, mean nighttime SBP was 8.9 mm Hg higher in the transplanted group (95% CI 4.8 to 13.1), but daytime and mean 24-hour SBP were similar. Mean day, night, and 24-hour DBP was significantly higher in the transplanted patients. The nighttime decrease in BP was significantly less than controls for SBP, but not for DBP. Conventional BP measurement was poorly predictive of 24-hour BP. There was a significant association between mean 24-hour SBP and interventricular septal thickness (r(2)=0.35; p=0.01). DBP was not associated with interventricular septal thickness (r(2)=0.07; p=0.20) but was significantly correlated with the time since transplantation (r=0.42; p=0.03 for conventional DBP and r=0.43; p=0.04 for 24-hour DBP). CONCLUSIONS: The elevation of DBP in children after cardiac transplantation is unexplained. The elevation in nighttime SBP has possible important therapeutic implications and is not predicted by conventional (clinical) BP measurement.     

Effects of Manidipine and Nifedipine on Blood Pressure and Renal Function in Patients with Chronic Renal Failure: A Multicenter Randomized Controlled Trial

Several studies suggest the distinctive advantages of ACE-inhibitors and calcium-channel blockers in protecting the residual renal function in hypertensive patients. Pre-clinical and clinical studies have shown rare adverse events in the treatment with manidipine, which is commonly used as antihypertensive drug. We therefore decided to compare the effects of manidipine and nifedipine, on blood pressure, and renal function. One hundred and one hypertensive patients with chronic renal failure were randomly assigned to receive either manidipine 20 mg daily or nifedipine 60 mg daily, respectively. Patients were assessed every two weeks during the active treatment period with the final follow-up after three months. The primary endpoint was the achievement of DBP ≤90 mmHg or a 10 mmHg DBP reduction from the baseline values, whilst the secondary endpoints was the improvement of the renal function assessed through the creatinine clearance, creatinine blood levels, protein and sodium urine excretion. Significant reduction in SBP (p<0.001) and DBP (p<0.001), compared to the baseline values, was reached in both treatments. Creatinine blood levels (p<0.05) and creatinine clearance (p<0.01) significantly increased in the manidipine group. Protenuria did not significantly change in the manidipine group but increased in the nifedipine group (p<0.05). The number of patients with severe adverse reactions differed significantly (p<0.01) between the groups with the highest frequency for nifedipine (14.5%) compared to manidipine (8.5%). The withdrawal rate was not significantly different between the groups. Manidipine is equally safe and effective as nifedipine and it may have more activity on renal function and less severe side effects compared to nifedipine.     

Lipid Profile Before and After Renal Transplantation—A Longitudinal Study

Background. The data on lipid profile in renal transplant recipients from the Indian subcontinent is scant. Methods.?Lipid profile was studied in 30 consecutive patients of end stage renal disease before renal transplantation (0 month) and prospectively posttransplantation at 1, 3, and 6 months. The results were compared with 30, age and sex matched, healthy controls. All the patients received triple immunosuppression (prednisolone, azathioprine and cyclosporine). Results.?Pretransplantation, the hypertriglyceridemia and hypercholesterolemia was present in 20% and 7% of the patients and the difference (elevation) in the mean values of various lipid fractions was not significant compared to healthy controls except a fall in HDL (p<.01). After renal transplantation, there was a significant elevation in the mean values of total cholesterol, triglycerides, VLDL, and LDL cholesterol at 1, 3, and 6 months. HDL cholesterol levels remained significantly lower as compared to healthy controls. Although, the mean values of serum triglycerides and cholesterol were significantly higher in diabetic end stage renal disease compared to nondiabetic ESRD, however there was insignificant difference in the lipid profile amongst diabetic and nondiabetic renal allograft recipients. Conclusion.?Our data shows distinct elevation in the lipids and lipoproteins after renal transplantation and immunosuppressive drugs seem to be the culprit.     

Effect of Spironolactone on Urinary Protein Excretion in Patients with Chronic Kidney Disease

Aim.?To investigate antiproteinuric effect of spironolactone in patients with chronic kidney disease (CKD) treated with angiotensin-converting enzyme (ACE) inhibitors and/or angiotensin II type 1 receptor blockers (ARBs).?Methods.?This study was performed in 33 CKD patients with proteinuria. 24 h urinary protein excretion and biochemical parameters were obtained before the therapy. Then, spironolactone (25 mg/d) was added to the therapy. The antiproteinuric effect of spironolactone was examined for eight weeks.?Results.?At eight weeks, there was a significant decrease in proteinuria (p < 0.001, 47.9% decrease). Systolic and diastolic blood pressures were significantly decreased (p < 0.004, p < 0.001, respectively). However, no correlation was detected between the reductions in systolic and diastolic BP and the reduction in proteinuria (p = 0.464, p = 0.239, respectively). Serum potassium level increased significantly (p < 0.001).?Conclusions.?Our study suggests that spironolactone significantly reduces urinary protein excretion. This strategy may be useful to slow the progression of CKD. However, hyperkalemia is the most important side effect of treatment, and it is necessary to monitor potassium level. Further studies are needed to determine the efficacy of spironolactone on proteinuria.     

Prolonged elevated postprandial sugar augments severity in kidney disease: a North Indian hospital-based study

Aim: Diabetes plays a major role in progression of renal failure. The risk-factor profile changes during the progression of chronic kidney disease (CKD) from mild/moderate to end-stage renal disease. The relationship between glycemic indices, blood pressure, body mass index (BMI) and age at diagnosis in Indians has been less investigated. We assessed association of these risk factors with CKD stages in Indian population. Methods: This study was carried out on patients (n?=?162) who were diagnosed with CKD and normal control group (n?=?155). For BMI, National Institutes for Health criteria were used to categorize the patients. Result: The mean age of CKD patients were significantly increased with the advancement of stage. BMI, systolic blood pressure (SBP), postprandial sugar level (PP), urea and creatinine were also significantly higher with elevated stages, whereas no differences were observed in diastolic blood pressure (DBP) and fasting blood sugar (FBS). The logistic regression study gave a significant result (p?=?0.000) when we compared the group of CKD patients with established/prolonged postprandial blood sugar. It was independently associated with mild CKD [odds ratio (OR)?=?5.213, 95% confidence interval (CI)?=?2.06–13.21, p?=?0.000], moderate CKD (OR?=?7.724, 95% CI?=?4.05–14.74, p?=?0.000) and severe CKD (OR?=?7.610, 95% CI?=?4.03–14.36, p?=?0.000). Conclusion: SBP and PP were the best predictors of prevalent nephropathy in this population, while DBP and FBS were found to be less effective. This may have implication for kidney disease risk stratification and protection.     

Salt sensitivity of blood pressure in non-dialysis patients with chronic kidney disease

Background: Chronic kidney disease (CKD) is a world-wide public health problem. Hypertension is both a cause and a complication of CKD, and a risk factor for progression of kidney disease. The effect of salt intake on blood pressure (BP) and the salt sensitivity in non-dialysis patients with CKD were studied. Methods: One hundred and thirty non-dialysis patients with CKD were enrolled in the present study. Daily urinary excretion of sodium (representative of daily sodium intake) and BP was monitored in conditions of original eating habits. Estimated glomerular filtration rate (eGFR) was measured by the creatinine clearance (Ccr). Results: There was a linear positive relationship between the salt intake and systolic blood pressure (SBP) (β?=?0.250, p?=?0.004). It had been found that the log of BP/24-h urinary sodium (salt sensitivity index) had linear relationship with the log of eGFR (β_syst?=??0.364, p?=?0.000, β_diast?=??0.345, p?=?0.000, respectively). Multi-stepwise regression analysis showed SBP was mainly influenced by salt intake and eGFR. There was a negative correlation between diastolic blood pressure (DBP) and age. Conclusion: These results demonstrated a linear relationship between the salt intake and SBP in non-dialysis patients with CKD. The salt sensitivity of BP rose with the decline of renal function.     

Repeated ambulatory blood pressure monitoring in adolescents with mild hypertension

The reproducibility of serial measurements of ambulatory blood pressure monitoring (ABPM) has not been well explored in children. We performed 24-h ABPM in 59 subjects (38 boys) aged 8-19 years with repeatedly elevated casual blood pressure (BP). According to the results of ABPM, the individuals were divided into a hypertensive group (mean 24-h systolic or diastolic BP >95th percentile for height, n=28) and a normotensive group (n=31). No antihypertensive agents were given. Both groups were reexamined after 1 year. In the hypertensive group, systolic and diastolic BP dropped significantly by an average of 2.1-4.5 mmHg when measured either during the daytime or over 24 h, but not at nighttime. In the normotensive group, only small BP changes were observed except for a significant increase in systolic BP at night. At the repeat examination after 1 year, 54% of the originally hypertensive subjects were defined as normotensive and 23% of the originally normotensive subjects as hypertensive. The study indicates that a single ABPM measurement is not sufficient for definitive classification of young individuals into hypertensives or normotensives.     

Predictors of poor renal outcome in patients with biopsy‐proven lupus nephritis

Aim: The development of lupus nephritis (LN) is associated with increased morbidity and mortality. In view of scarce data from South Africa on factors affecting renal outcome in LN, the authors' experience was reviewed to identify predictors of poor renal outcome. Methods: This is a retrospective review of 105 patients with biopsy‐proven LN under our care from January 1995 to December 2007. Results: Forty‐three (41.0%) patients reached the composite end‐point of persistent doubling of the serum creatinine over the baseline value, development of end‐stage renal disease (ESRD) or death during a mean follow‐up period of 51.1 months (range 1–137 months). Baseline factors associated with the composite end‐point included presence of systemic hypertension (P = 0.016), mean systolic blood pressure (SBP) (P = 0.004), mean diastolic blood pressure (DBP) (P = 0.001), mean serum creatinine (P = 0.001), estimated glomerular filtration rate (eGFR) (P = 0.003) and diffuse proliferative glomerulonephritis (World Health Organization class IV) (P = 0.024). Interstitial inflammation (P = 0.049), failure of remission in the first year following therapy (P < 0.001), the mean SBP on follow up (P < 0.001) and mean DBP on follow up (P < 0.001) were also associated with composite end‐point. On multivariate analysis, baseline serum creatinine, non‐remission following therapy (P = 0.038) and mean SBP on follow up (P = 0.016) were predictors of poor renal outcome. Conclusion: Baseline serum creatinine, failure of remission in the first year and mean SBP were predictors of poor renal outcome.     

Arterial stiffness and enlargement in mild-to-moderate chronic kidney disease

Chronic kidney disease (CKD) is associated with an increased risk of cardiovascular morbidity and mortality. Arterial stiffness and remodeling have been well documented in patients with end-stage renal disease, but little is known about arterial phenotype in CKD patients with moderate reduction in glomerular filtration rate (GFR). In total, 95 patients (58+/-15 years, mean+/-s.d.) with CKD and GFR measured by renal clearance of (51)Cr-ethylenediaminetetraacetate were compared to 121 hypertensive patients without CKD (59+/-11 years), and 57 normotensive subjects (56+/-6 years). Common carotid artery diameter, intima-media thickness (IMT), distensibility, and Young's elastic modulus were noninvasively determined with a high-definition echotracking system. Patients with CKD had a significantly larger carotid internal diameter than in hypertensives and normotensives (6.32+/-1.05, 5.84+/-0.74, and 5.50+/-0.64 m x 10(-3), respectively; P<0.001), resulting in 25% and 11% increases in circumferential wall stress, respectively, since no significant difference in IMT was observed. Carotid distensibility and elastic modulus did not significantly differ between CKD and hypertensives; normotensives had significantly higher distensibility and lower elastic modulus than CKD and hypertensive patients. Carotid-femoral pulse wave velocity was significantly higher in CKD patients than in hypertensives and normotensives. In multivariate analyses either involving the entire population or restricted to CKD patients, GFR was independently and strongly related to carotid diameter and elastic modulus. Arterial enlargement and increased arterial stiffness occur in parallel with the decline in renal function in patients with mild-to-moderate CKD.     

Blood pressure profile in renal transplant recipients and its relation to diastolic function: tissue Doppler echocardiographic study

Hypertension is a common complication after renal transplantation and is associated with increased risk of cardiovascular disease. The aim of the current study was to investigate the diurnal blood pressure pattern and its relation to structural and functional cardiac changes in renal transplant recipients. Sixty-six stable renal transplant patients (34 female, 32 male), aged 7 to 25 years (mean 17.4 ± 4.3 years) were enrolled in this study. Cardiac function assessed by tissue Doppler echocardiography and blood pressure measurement performed using both the ambulatory and the casual method. Hypertension was demonstrated in 57% of recipients by the casual method and in 75.7% by ambulatory blood pressure monitoring (ABPM). The efficacy of BP control among patients on antihypertensive drugs was 60%. The prevalence of non-dipping was 73%. There was significant inverse correlation between systolic or diastolic day-time or night-time BP index and post-transplant duration (p < 0.001, r =−0.386), but no correlation between ABP parameters and BMI, gender, and eGFR. There was a significant relationship between all ABP parameters and left ventricular mass index (LVMI) (p = 0.025–0.007, r = 0.28–0.38). LVMI was significantly higher in hypertensive than in normotensive cases (p = 0.034). There was no difference in diastolic function between hypertensive and normotensive patients or between patients with and without left ventricular hypertrophy (LVH). In conclusion, our study showed the advantage of ABPM over the casual method of diagnosis of hypertension. LVH is common in transplant patients and is likely associated with arterial hypertension. Hypertension and LVH cannot differentiate transplant patients with diastolic malfunction.     

Association of Atherosclerotic Coronary Artery Disease and Pulse Pressure with Renal Disease Progression

Background.?This study was performed to identify the association of atherosclerotic coronary artery disease (CAD) and pulse pressure with renal disease progression in patients with mild chronic renal disease. Methods.?Eligibility criteria for enrollment in this study included age 18 to 70 years, mild chronic renal disease (CRD), undergoing thallium SPECT and echocardiography and followed longer than three years. Mild CRD was defined as serum creatinine level of 1.5 to 3.0 mg/dL in men and 1.4 to 3.0 mg/dL in women. Patients with serious illness, history of kidney transplantation, ejection fraction less than 40% on echocardiography and development of acute renal failure during follow-up were excluded. Results.?A total of 87 patients were included in this study. The underlying renal disease included diabetic nephropathy in 51 patients. Forty-five patients showed positive findings on thallium SPECT and they were classified as having CAD. Coronary angiography showed significant stenosis in 41 of 42 patients studied. Median duration of follow-up was 56 months. During the follow-up period, 40 patients required chronic dialysis therapy and 16 patients showed a doubling of baseline serum creatinine in three years. These 56 patients were classified as progressors. Comparison of clinical and laboratory parameters between progressors and nonprogressors showed a difference in the presence of diabetic nephropathy, mean arterial pressure, 24-h urine protein (p<0.001), pulse pressure (p<0.01), total cholesterol and presence of CAD (p<0.05). There was no association between the progression of CRD and the results of CAD or treatment of CAD. Multivariate logistic regression analysis showed that the presence of diabetic nephropathy and mean arterial pressure ≥100 mm Hg were independent predictors of CRD progression. Conclusion.?Atherosclerotic coronary artery disease and pulse pressure were associated with renal disease progression.     

Clinical and pathological significance of circadian blood pressure rhythm change in IgA nephropathy patients with hypertension

Objective To investigate whether the clinical and pathological injury of kidney in IgA nephropathy (IgAN) patients with hypertension is associated with circadian blood pressure rhythm change, particularly with elevated nocturnal blood pressure (BP). Methods This study was a retrospective cross-sectional study. Clinic and renal histopathological injury data were obtained from 83 IgAN patients with hypertension. First, 24 h ambulatory BP monitoring (ABPM) data were analyzed. Second, all these IgAN patients were divided into two groups, elevated nocturnal BP group and nocturnal normotensive BP group, and the clinical and pathological differences between this two groups were analyzed. Third, logistic regression analysis was used to analyze the influencing factors of renal tubulointerstitial injury in IgAN patients with hypertension. At last, all these IgAN patients were divided into two groups according to the level of estimated glomerular filtration rate (eGFR), group of patients with eGFR≥60 ml?min-1?(1.73 m2)-1 and the other group with eGFR＜60 ml?min-1?(1.73 m2)-1, and the 24 h ABPM data were compared. Results (1) The proportion of non-dipper circadian rhythm of BP in IgAN patients with hypertension was 79.5%. (2) Compared with nocturnal normotensive BP group, patients in elevated nocturnal BP group had significantly higher levels of 24-hour urinary protein quantity and blood uric acid (both P＜0.05), and lower eGFR and urine osmotic pressure clinically (both P＜0.05). Index of interstitial fibrosis and tubular atrophy was significantly higher in nocturnal normotensive BP group (P＜0.05), while the proportion of glomerular ischemia lesion was not significantly different between two groups. (3) Multivariate logistic regression analysis showed that elevated nocturnal BP was an independent risk factor for severe tubulointerstitial injury of IgAN (OR=1.113, 95%CI 1.038-1.192, P=0.002). (4) Compared with the group of eGFR≥60 ml?min-1?(1.73 m2)-1, 24-hour systolic blood pressure (SBP) and diastolic blood pressure (DBP), daytime SBP and DBP, nocturnal SBP and DBP were significantly higher in group of eGFR＜60 ml?min-1?(1.73 m2)-1 (all P＜0.05). Conclusion The proportion of non-dipper circadian rhythm of BP in IgAN patients with hypertension is as high as 79.5%. Elevated nocturnal BP is associated with the severity of renal damage, and elevated nocturnal BP is an independent risk factor for severe tubulointerstitial injury in IgAN patients with hypertension. Therefore, 24 h ABPM should be emphasized, and elevated nocturnal BP should be well controlled to slow the progression of IgAN.     

Ambulatory blood pressure monitoring and progression in patients with IgA nephropathy.

BACKGROUND: Hypertension is a recognized marker of poor prognosis in IgA nephropathy. METHODS: The present study investigated the prevalence of white-coat hypertension, the diurnal rhythm of blood pressure (BP), the effectiveness of antihypertensive drug therapy, and the effect of the above on the progression of the kidney disease in IgA nephropathy. One hundred twenty-six IgA nephropathy patients were selected consecutively for 24-h ambulatory blood pressure monitoring (ABPM). Fifty-five patients were normotensive and 71 were treated hypertensives. Their antihypertensive drugs were angiotensin-converting enzyme inhibitors (ACEI) alone or in combination with calcium-channel blockers (CCB). RESULTS: The mean night-time BP of normotensives (108+/-9/67+/-6 mmHg) was significantly lower than their day-time BP (125+/-8/82+/-7 mmHg, P<0.05). There was no significant difference between the mean day-time and night-time BP in hypertensive patients (125+/-9/82+/-7 mmHg vs 128+/-10/85+/-9 mmHg). The circadian variation of BP was preserved ('dippers') in 82% of the normotensive and 7% of the hypertensive patients (P<0.001). There were 10 'white-coat hypertensives' among the patients classified as normotensives with ABPM (mean office blood pressure 149+/-7/96+/-8 mmHg, 24-h blood pressure 127+/-6/83+/-5 mmHg, P<0.05) and 14 among treated hypertensives (mean office BP 152+/-8/98+/-6 mmHg, 24-h BP 130+/-4/85+/-8 mmHg, P<0.05). There was no difference in mean day-time BP among normotensive and treated hypertensive patients (125+/-8/81+/-5 mmHg vs 128+/-10/85+/-9 mmHg). Hypertensives had significantly higher night-time BP (125+/-9/85+/-9 mmHg) than normotensives (108+/-9/67+/-6 mmHg, P<0.001). There was no difference in serum creatinine levels among the different groups at the time of the ABPM. However, thirty-six+/-4.1 months after the ABPM, hypertensive patients (n=52) had higher serum creatinine levels (124+/-32 micromol/l) than at the time of the ABPM (101+/-28 micromol/l). The serum creatinine of normotensive patients (n=43) did not change during the follow-up period. 'Non-dipper' normotensives (n=10) had significantly higher serum creatinine levels at the end of the follow-up period than at its beginning (106+/-17 micromol/l vs 89+/-18 micromol/l, P<0.05). There was no increase in serum creatinine of 'dipper' normotensives. The mean serum creatinine of 'white-coat hypertensives' was significantly higher at the end of the study period than at its beginning. CONCLUSIONS: There is no diurnal blood pressure variation in most of the hypertensive IgA nephropathy patients. ACEI and CCB treatment have better effect on day-time than night-time hypertension. The lack of the circadian rhythm and 'white-coat hypertension' seems to accelerate the progression of IgA nephropathy.     

Combination of Pentoxifylline with Angiotensin Converting Enzyme Inhibitors Produces an Additional Reduction in Microalbuminuria in Hypertensive Type 2 Diabetic Patients

Objective.?To investigate the anti proteinuric effect of pentoxifylline in diabetic patients, we prospectively studied in 25 hypertensive type 2 diabetic patients with persistent microalbuminuria and normal renal function the impact of combining pentoxifylline with an angiotensin converting enzyme inhibitor, lisinopril, on urinary albumin excretion and compared the results with those obtained in a control group of 25 type 2 diabetic patients treated with lisinopril only. Material and Methods.?Fifty hypertensive type 2 diabetic patients with persistent microalbuminuria (31 males and 19 females, aged between 47–73 years) were randomly assigned to two groups. Group A received lisinopril 10 mg/day, while group B was given lisinopril 10 mg/day and pentoxifylline 600 mg/day for nine months. There were no significant differences between serum creatinine, HbA1c, blood pressure and urinary albumin excretion in both groups (p>0.05). Results.?Serum creatinine, creatinine clearance, blood pressure, HbA1c levels did not change significantly during the study. Urinary albumin excretion decreased from 228 ± 28 to 148 ± 15 mg/day in group A (p<0.05). In group B urinary albumin excretion decreased from 219 ± 26 to 128 ± 12 mg/day (p<0.05). Pentoxifylline and lisinopril combination caused a significant additional reduction in urinary albumin excretion when compared to lisinopril regimen (p<0.05).

Conclusions.?Our findings suggest that the combination of pentoxifylline with an angiotensin converting enzyme inhibitor in hypertensive type 2 diabetic patients with persistent microalbuminuria causes a significant reduction in urinary albumin excretion and this effect seems independent from blood pressure and glycemic control.