慢性肾脏病患者血压变异性与肾功能损伤关系的研究

目的研究不同肾功能水平的慢性肾脏病(chronic kidney disease,CKD)患者24 h动态血压特点,探讨血压变异性与肾功能损伤之间的关系。方法选择上海交通大学附属瑞金医院肾脏科的CKD住院患者509例,收集并记录患者的基本信息、实验室检查数据,采用携带式动态血压检测仪监测患者24 h动态血压参数,采用GEVivid7彩色超声心动图检查仪记录患者左心室质量指数(left ventricular mass index,LVMI)参数。采用SPSS 15.0统计软件进行数据统计分析。结果本研究共纳入CKD患者509例,其中CKD 1期102例(占20.0%),CKD2期107例(占21.0%),CKD3期114例(占22.4%),CKD4期97例(占19.1%),CKD 5期89例(占17.5%)。随着CKD患者肾功能水平的下降,患者的24 h平均收缩压逐渐升高(P0.05),而24 h平均舒张压的改变无统计学差异(P0.05)。CKD 4期和5期患者的白昼平均收缩压、夜间平均收缩压、夜间平均舒张压明显高于CKD 1~3期患者(P0.05),而白昼平均舒张压的差异则无统计学意义。CKD 4期和5期患者的24 h收缩压标准差(24 h systolic standard deviation,24hSSD)、白天收缩压标准差(day systolic standard deviation,dSSD)、夜间收缩压标准差(night systolic standard deviation,nSSD)明显高于CKD 1~3期患者(P0.05),而24 h舒张压标准差(24 h diastolic standard deviation,24hDSD)、白天舒张压标准差(day diastolic standard deviation,dDSD)、夜间舒张压标准差(night diastolic standard deviation,nDSD)则无统计学差异(P0.05)。CKD患者非杓型血压的比例随肾功能下降逐渐升高,CKD 1期患者的非杓型血压比例为54.1%,而CKD 5期患者的非杓型血压比例甚至高达85.6%。LVMI异常的CKD患者的24hSSD及dSSD高于LVMI正常的CKD患者(P0.05),而nDSD,nSSD,dDSD,24hDSD的差异无统计学意义。结论随着CKD患者肾功能下降及平均血压水平升高,血压变异性增加,血压昼夜节律减退,非杓型血压比例增加。控制血压水平及调整血压昼夜节律对CKD患者的治疗具有重要意义。     

IgA肾病患者血压节律及其与临床病理指标的关系

目的 探讨IgA肾病患者血压昼夜节律与临床病理指标的关系.方法 采用横断面调查研究.选择2009年3月至8月在IgA肾病数据库登记的原发性IgA肾病患者,收集临床病理资料,并通过动态血压监测IgA肾病患者血压昼夜节律情况.用(日间血压平均值-夜间血压平均值)/日间血压平均值判断血压昼夜节律状况.比较血压节律正常组及异常组的临床病理指标.结果 共93例患者完成动态血压监测并纳入分析.其中68例(73％)血压节律消失,在慢性肾脏病(CKD)1期、2期及3期以上组血压节律消失的比例分别70％、70％及81％,3组间差异无统计学意义(P=0.587).非勺型血压在血压正常组与高血压组比例分别为69％和77％(P=0.373).血压节律消失与年龄、性别、血压、蛋白尿、肾功能以及肾脏病理损伤程度无相关.在随访时间超过12个月的54例中,非勺型血压组eGFR下降速率虽快于勺型血压组,但差异无统计学意义(P=0.329)；在其中29例并发高血压患者中,非勺型血压组eGFR下降速率快于勺型血压组,且差异有统计学意义[(-6.79±11.58)比(-0.34±1.74)ml·min-1·(1.73 m2)-1·年-1,P=0.019].结论 IgA肾病早期即可出现明显的血压节律消失.IgA肾病伴高血压患者的血压节律消失可能是影响肾功能进展的危险因素.     

原发性高血压合并脑梗死患者24小时动态血压变化特点的研究

目的分析原发性高血压合并脑梗死患者24h动态血压变化特点，探讨血压异常与脑梗死的关系。方法对38例原发性高血压患者（单纯高血压组）和94例原发性高血压合并脑梗死患者（高血压合并脑梗死组）进行24h动态血压监测，并对两组患者的24h、日间、夜间血压平均值，血压负荷值，血压变异性和血压昼夜节律性进行统计分析。结果高血压合并脑梗死组患者24h、日间、夜间收缩压（SBP）和舒张压（DBP）及SBP和DBP负荷值均明显高于单纯高血压组患者，差异有统计学意义（P〈0．01或〈0．05）。高血压合并脑梗死组日间SBP变异性高于单纯高血压组[（15．84±4．56）mmHg（1mmHg=0．133kPa）比（14．21±4．29）mmHg]，SBP和DBP夜间下降率低于单纯高血压组[（5±8）％比（9±11）％，（7±6）％比（11±10）％]，差异有统计学意义（P〈0．05或〈0．01）。结论血压平均值和血压负荷值增高及血压昼夜节律性消失与脑梗死相关。     

慢性肾脏病患者动态血压参数及血压变异的特点分析

目的 分析慢性肾脏病（chronic kidney disease,CKD）患者动态血压参数与肾小球滤过率（GFR）及尿蛋白定量的相关性,并探讨血压变异性参数特点.方法 收集首次治疗的伴有高血压及蛋白尿的CKD患者70例.测量肾功能、24 h尿蛋白定量等生化检测结果,采用动态血压监测仪监测24 h血压并记录参数.根据GFR将患者分为CKD1~2期组和CKD3~5期组.根据24 h尿蛋白定量分为以下3组：Ⅰ组＜1.0 g,Ⅱ组1.0～3.5 g,Ⅲ组＞3.5 g.比较各组动态血压参数,并探讨监测结果与肾功能及蛋白尿的关系.结果 随着患者肾功能恶化,24 h收缩压、舒张压、脉压差、白昼收缩压、夜间收缩压等指标明显升高（P＜0.05）,且与GFR成负相关,白昼收缩压是GFR下降的独立危险因素.Ⅲ组的白昼舒张压（92.94±15.32）mm Hg明显高于Ⅰ组的（85.25±8.64）mm Hg（P＜0.05）.白昼舒张压与蛋白尿水平呈正相关（r=0.257,P=0.032）.所有患者舒张压变异性均明显高于收缩压变异性（P＜0.05）.结论 本研究样本中收缩压与肾功能恶化明显相关,白昼收缩压和舒张压分别与GFR下降及蛋白尿有关,舒张压变异性应受到更多重视.     

慢性肾脏疾病患者血压昼夜节律及临床意义研究进展

血压昼夜节律是生物体内普遍存在的一种生理现象，是人类进化过程中自然形成的。正常人的血压从清晨6时左右开始上升，约上午8时～9时达白昼高峰，以后渐趋下降至平稳状态，中午12时～下午2时降至白昼最低点，至下午5时～下午6时出现白昼第2个高峰，夜间0时～凌晨2时左右为最低点，出现一个夜间低谷，以后血压渐趋平稳。正常生理状态下，人体血压24h内呈“双峰一谷”长柄勺形周期性节律变化，目前多采用夜间血压下降率来判断血压昼夜节律状况，即（白昼平均值一夜间平均值）／白昼平均值。     

慢性肾脏病患者血压非勺型节律与左心室肥厚之间的关系

目的 探讨24 h动态血压（ABPM）非勺型节律与慢性肾脏病（CKD）患者左心室肥厚（LVH）之间的关系。 方法 共有257例CKD 1~5期患者入选,根据肾功能分为两组：CKD1~3期组和CKD4~5期组。采用GE Marquette Tonoport V Eng动态血压计测定各组患者动态血压参数和昼夜节律;心脏彩色多普勒超声了解心脏结构的改变,并探讨血压非勺型节律与LVH之间的关系。 结果 CKD患者血压正常的生理节律丧失的现象普遍,总体血压非勺型昼夜节律发生率达75.4％,即使在血压正常者中也达到71.3%,随着肾功能下降血压非勺型昼夜节律的发生率也在上升。CKD患者血压非勺型节律组的心脏结构改变较勺型组明显,LVH的发生率也较高。相关性分析显示左室心肌质量指数（LVMI）与血压水平、非勺型的昼夜节律等相关。多元逐步回归分析显示24 h-收缩压（SBP）（β = 0.417,P < 0.01）、三酰甘油 （β = -0.132,P = 0.007）、血红蛋白（Hb）（β = -0.394,P = 0.016）及性别（β = 0.158,P = 0.039）是影响LVMI的独立危险因素。 结论 CKD患者的血压非勺型昼夜节律现象普遍,并随着肾功能的下降其发生率逐渐升高。血压非勺型节律患者心脏结构改变更明显,LVH的发生率高。非勺型节律与LVMI密切相关。     

慢性肾脏病不同阶段的动态血压分析

目的：研究慢性肾脏病不同阶段的动态血压形态特征。方法：慢性肾脏病住院患者129例,患者入院后1h记录安静状态卧位诊室血压,并进行24h动态血压监测,血压〉140/90mmHg（1mmHg=0.133kPa）为诊室血压升高。24h动态血压平均值〉130/80mmHg,日间平均值〉135/85mmHg,夜间平均值〉125/75mmHg为血压升高。结果：本组资料显示,在CKD各期动态血压监测提示24h平均收缩压均超过130mmHg,各组间P〈0.01,提示各组平均收缩压间差异有统计学意义。而日间收缩压及夜间收缩压在CKD各期也有明显差异。但比较24h平均舒张压、日间平均舒张压、夜间平均舒张压在各阶段差异不大,P值均〉0.05。在CKD各期的病例中,正常的杓形血压只占少数,而在各期中比较（P〈0.05）,提示CKD早期病例中动态血压就可能已经发生了变化。结论：慢性肾脏病各期动态血压的形态均以非杓形,反杓形为主,随着肾小球滤过率下降,收缩压有逐渐升高趋势。     

应用子午流注理论解释慢性肾脏病1～2期患者的“非杓型”血压节律改变

目的:通过对CKD1~2期非高血压患者血压昼夜节律特点与子午流注理论对应关系的研究,探讨非杓型血压产生的原因,将子午流注这一古老的中医学概念更广泛地应用于中医内科疾病的诊疗。方法:收集47例CKD1~2期非高血压患者及30例健康人的24 h动态血压数据,比较两组血压昼夜异常节律的发生情况。将时间段按照十二时辰进行分组,分析十二时辰与血压非杓型改变的对应关系及疾病的脏腑归经。结果:CKD组亥时、子时及寅时收缩压高于正常对照组,差异有统计学意义(P0.05)。而两组丑时及卯时收缩压间的差异无统计学意义(P0.05)。除卯时外,CKD组的舒张压在夜间各时段均高于正常对照组,差异具有统计学意义(P0.05)。结论:亥时及子时分属于手少阳三焦经及足少阳胆经,因此非杓型血压模式的产生可能与少阳枢机不利,气机运行不畅,从而导致气化失司,水液不化而停聚体内有关。     

慢性肾脏病患者病理类型与血压水平及昼夜节律变化的关系

目的分析慢性肾脏病(CKD)患者不同病理类型与血压水平和昼夜节律异常的相关性,及后者与肾小动脉病变程度的关系。方法收集济南军区总医院、解放军117医院、北京大学第三医院2008年至2013年行肾活检且行24 h动态血压监测的CKD患者1 746例,根据2013年欧洲高血压实践指南对患者血压进行分析判断。24 h平均血压≥130/80 mmHg为高血压;夜间血压下降幅度=[(白天血压-夜间血压)/白天血压]×100%;夜间血压下降20%为深勺型节律,10%~20%为勺型节律,10%为非勺型节律,0%为反勺型节律;将深勺型和勺型定义为正常血压节律,非勺型和反勺型定义为异常血压节律。病理诊断与分型参照1995年WHO肾小球疾病组织学分型修订方案和国内2001年肾活检病理诊断标准指导意见。肾脏小动脉损伤评分参照IgA肾病牛津分型的评分标准进行评分。结果 (1)1 746例患者年龄(47.4±24.9)岁,男性929例(占53.2%);24 h平均血压≥130/80 mmHg 560例(32.1%)、白天平均血压≥135/85 mmHg 474例(27.1%)、夜间平均血压≥120/70 mmHg 762例(43.6%);深勺型血压38例(2.2%)、勺型血压647例(37.1%)、非勺型血压908例(52.0%)、反勺型血压155例(8.9%)。(2)不同病理类型CKD患者高血压发生率为,糖尿病肾病75.5%(74例)、局灶节段肾小球硬化症41.8%(62例)、IgA肾病39.2%(246例)、狼疮性肾炎25.2%(41例)、膜性肾病22.3%(37例)、肾小球轻微病变与系膜增生性肾小球肾炎18.4%(100例),各组之间差异有统计学意义(χ2=163.309,P0.001)。不同病理类型CKD患者血压昼夜节律异常发生率为,糖尿病肾病81.6%(80例)、局灶节段肾小球硬化症64.2%(95例)、IgA肾病66.7%(419例)、狼疮肾炎58.9%(96例)、膜性肾病51.8%(86例)、肾小球轻微病变与系膜增生性肾小球肾炎52.9%(287例),各组之间差异有统计学意义(χ2=48.087,P0.001)。(3)根据IgA肾病牛津评分对肾组织小动脉进行评分,0~1分(未见小动脉明显病变)789例,其中高血压发生率10.6%(84例)、血压节律异常发生率57.9%(457例);2~4分(肾小动脉轻度病变)632例,其中高血压发生率35.4%(224例)、血压节律异常发生率56.0%(354例);5~7分(肾小动脉重度病变)326例,其中高血压发生率77.3%(252例)、血压节律异常发生率74.2%(242例),分别比较差异有统计学意义(χ2=475.8,χ2=219.647;P0.001)。秩相关性分析显示,血压水平越高以及夜间血压水平下降越少,肾脏小动脉损伤越重。结论 CKD患者高血压和血压节律异常发生率高,尤其是糖尿病肾病和IgA肾病患者;CKD患者肾脏小动脉病变程度与高血压及血压节律异常相关。     

慢性肾脏病1～2期血压昼夜节律变化的中医病因病机探讨

目的:观察慢性肾脏病(CKD)1~2期非高血压患者24 h血压变异情况,应用中医辨证方法分析CKD1~2期血压昼夜节律异常的中医病因病机。方法:收集47例CKD1~2期非高血压患者及30例健康人的24 h动态血压数据,比较两组血压昼夜异常节律的发生情况。对CKD组进行中医证候评分,根据中医基础理论,分析不同中医证素与非杓型血压的对应关系。结果:CKD组非杓型血压的发生率较正常对照组高(P0.05)。CKD组昼夜平均舒张压差、昼夜平均舒张压变化率低于正常对照组(P0.05)。CKD1~2期患者的主要病位为在肾、在脾,气虚、阴虚为其主要病因病机。在CKD组中反杓型血压患者脏腑辨证病位在肾及阳虚的发生率较非反杓型患者高(P0.05)。结论:CKD1~2期患者的主要病因病机为脾肾气阴两虚;肾阳亏虚,阴阳失调可能是CKD1~2期非高血压患者血压昼夜节律改变的中医病因病机。     

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.     

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 24 h 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.     

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.     

Ambulatory blood pressure and left ventricular mass in normotensive patients with autosomal dominant polycystic kidney disease

Higher left ventricular mass (LVM) has been found in early stages of autosomal dominant polycystic kidney disease (ADPKD). The mechanisms involved in the increase of LVM are unknown. To investigate whether LVM in ADPKD may be influenced by abnormal diurnal BP variations, the 24-h ambulatory BP profile was analyzed in a group of young normotensive ADPKD patients. Ambulatory BP monitoring and two-dimensional echocardiography were performed in 26 young normotensive ADPKD with normal renal function and in 26 healthy control subjects. LVM index was higher in ADPKD patients than in controls (90.8+/-19.6 g/m2 versus 73.9+/-16.1 g/m2, P = 0.001). Average 24-h and daytime systolic, diastolic, and mean BP were similar in both groups. Nighttime diastolic and mean BP, but not systolic BP, were greater in ADPKD patients. The average and percent nocturnal decrease of systolic BP was lower in ADPKD patients than in control subjects (10.0 mm Hg [-3 to 24] versus 15.5 mm Hg [-4 to 31], P = 0.009, and 9.0% [-2 to 22] versus 14.2% [-2 to 25], P = 0.016, respectively). On the basis of their profile BP patterns, 54% of ADPKD subjects and 31% of controls were classified as nondippers (P = 0.092). There were no differences between dippers and nondippers in left ventricular wall thickness, chamber dimensions, and mass indexes. In ADPKD patients, simple regression analysis showed that LVM index was correlated with 24-h, daytime, and nighttime systolic BP. On multiple regression analysis, the 24-h systolic BP was the only variable linked to LVM index. It is concluded that young normotensive ADPKD patients have higher LVM that is closely related to the ambulatory systolic BP. The nocturnal fall in BP is attenuated in these patients, although it is not associated with the higher LVH that they present.     

Nighttime blood pressure control in hypertensive chinese chronic kidney disease patients

Objective To evaluate the nighttime blood pressure(BP) control status of hypertensive Chinese chronic kidney disease (CKD) patients and related risk factors. Methods This cross - sectional study enrolled 337 hypertensive CKD in - patients. The clinical and ambulatory BP monitoring (ABPM) data were retrieved from the electronic database of the hospital. High ambulatory BP were defined as >130/80 mmHg (average 24 - hour BP) and >135/85 mmHg (daytime) />120/70 mmHg (nighttime), respectively. Multivariable analysis was used to evaluate the risk factors for lack of nighttime BP control and circadian rhythm. Results There were 38.6% of the whole population had average 24-hour BP controlled. But only 22.8% of them achieved nighttime BP control, which was far less than the 50.7% of daytime BP control (P＜0.01). Even among those patients who achieved average 24 - hour BP control shown by ABPM, there were still 44.6% of them with uncontrolled nighttime BP. Multiple analyses showed urinary protein excretion (OR: 1.151, 95%CI: 1.035-1.279) was independent risk factor for lack of nighttime BP control. About 80% of patients presented with non- dipping BP pattern, among whom 37.3% were presented with reverse-dipper pattern. Lack of nighttime BP control was independent risk factor for lack of normal circadian rhythm (both P＜0.001). Conclusions Lack of nighttime BP control was common in hypertensive CKD patients and contributed to the abnormal circadian rhythm. ABPM should be performed more commonly in clinical practice to help nighttime BP control in the future.     

Impact of cardiac transplantation in 24 hours circadian blood pressure and heart rate profile

OBJECTIVE: The aim of the present study was to evaluate 24 hours blood pressure (BP) and heart rate changes as well as 24-hour circadian BP rhythm of cardiac transplant recipients. METHODS: Twenty-five transplant recipients and twenty-five healthy volunteers underwent 24-hour ambulatory BP monitoring. Parameters of 24-hour ambulatory BP monitoring (24-h/daytime/nightime systolic, diastolic BP, pulse pressure, and heart rate) were determined in all patients. RESULTS: Clinic systolic/diastolic BP, mean 24-h systolic/diastolic BP, mean daytime systolic/diastolic BP, mean nighttime systolic/diastolic BP, and mean 24-h/daytime/nighttime heart rate were significantly higher in transplant recipients than in control group subjects. Standard deviations of 24-h/daytime/nighttime heart rates were significantly lower in transplant recipients. Dippers were 48% of the control and only 12% of the transplantation group. CONCLUSIONS: Cardiac transplant recipients had increased ambulatory BP. They also had increased 24-h/daytime/nighttime heart rate and decreased heart rate variability. Also, diminished nocturnal decrease of BP was found in transplant recipients.     

Blunted nocturnal blood pressure decrease and left-ventricular mass in hypertensive hemodialysis patients

Left-ventricular hypertrophy (LVH) represents a frequent complication in hemodialysis (HD) patients. Hypertension is a well-known risk factor of cardiac morbidity which is present in 2 of 3 patients: among them about 60% have a blunted nocturnal decrease of blood pressure (BP). Although some large studies on essential hypertensives have documented that non-dipper patients have a higher number of cardiac events and a higher left ventricle (LV) mass than dipper ones, conflicting results have been reported for dialysis patients. Therefore, the aim of our study was to assess differences in LV mass between dipper and non-dipper hypertensive HD patients. We studied 66 patients with 24-hour ambulatory BP monitoring performed on HD and on inter-HD day. They were classified as dipper when a decrease of at least 10% of nocturnal systolic blood pressure on the inter-HD day was present. Echocardiography and bioimpedance were performed. 29% of the patients were classified as dippers and 71% as non-dippers. The 48-hour systolic and diastolic BP were not significantly different between the two groups (SBP: dipper = 144 +/- 12.9 mm Hg, non-dipper = 149 +/- 17.8 mm Hg; DBP: dipper = 80 +/- 9.9 mm Hg, non-dipper = 81 +/- 10.6 mm Hg). LV mass index (LVMi) did not differ between the two groups (dipper = 143.1 +/- 40.7 g/m(2); non-dipper = 159.4 +/- 46.3 g/m(2)). No differences were reported between dipper and non-dipper patients regarding extracellular water distribution (ECW: 48.1 +/- 7.7 vs. 49.8 +/- 10.8%). SBP night/day ratio and 48-hour SBP were not correlated to LVMi. A strong correlation was reported between ECW% and LVMi (r = 0.53, p < 0.001). In conclusion, 2 of 3 hypertensive HD patients are non-dipper, and this condition does not seem to be associated with significant differences in 48-hour blood pressure and LV mass. Volume overload appears to be the main independent determinant of LVH in these patients.     

The reproducibility of the circadian BP rhythm in treated hypertensive patients with polycystic kidney disease and mild chronic renal impairment--a prospective ABPM study

BACKGROUND: Diurnal BP rhythm is known to be abnormal (reduced BP fall with sleep) in chronic renal failure, dialysis and renal transplantation patients. In subjects with primary hypertension and with reduced diurnal BP fall with sleep there is consistent evidence of increased target-organ damage. However, the few studies that have addressed the reproducibility of diurnal rhythm in normal or hypertensive subjects have concluded that the BP fall with sleep is poorly reproducible. It is not known whether the same is true for patients with renal disease. METHODS: In 30 subjects with autosomal polycystic kidney disease (ADPKD), mild chronic renal failure and normal office BP levels on standardised anti-hypertensive treatment, ambulatory blood pressure monitoring (ABPM) was done three times over a twelve month period to assess the reproducibility of blood pressure fall with sleep. RESULTS: When comparing ABPM 2 with the ABPM 1 recording (3 months difference between measurements) only 43.3% of the patients maintained the initial dipping category (defined by quartiles of the ABPM 1 diurnal BP distribution). The same proportion of subjects had a similar dipping category, when ABPM 3 was compared to ABPM 1 (9 months difference between measurements), but a large (24%) subset of patients had dramatic shifts in their amplitude in nocturnal BP fall, significantly greater than those recorded after a shorter inter-measurement interval. Equally important, our study reveals the fact that, with time, there is no tendency to decrease circadian variation: a similar proportion (a quarter to one third) of patients increased or decreased their amplitude in nocturnal BP fall, at 3 and 9 months. When several ABPM measurements are repeated for the same patients, the repeatability is even worse, since only 36.6% of our study population maintained the initial dipping category across all three ABPM determinations (ABPM 1 and ABPM 2 and ABPM 3). CONCLUSIONS: There is a widespread abnormality in diurnal BP rhythm in ADPKD patients with renal impairment, but the extent of this abnormality varies considerably over time. It is too simplistic to assume that, having arbitrarily categorised subjects into "dippers" or "non-dippers", these labels will always be valid. Thus, it would be unwise to extrapolate the impact of a single baseline circadian BP profile on organ target end points.     

Role of renal prostaglandin E2 in chronic renal disease hypertension

The role played by renal prostaglandin E2 in the maintenance of hypertension in chronic renal disease has been investigated through studying the response of body weight, blood pressure, glomerular filtration rate (GFR), 24-hour natriuresis, plasma renin activity (PRA), plasma aldosterone and urinary PGE2 excretion to the administration of indomethacin (2mg/kg daily, during 3 days). A group of 37 patients diagnosed as having chronic renal parenchymatous disease with creatinine clearance above 25 ml/min was included in the study. 21 of them were hypertensive (BP greater than 160/95). 27 normotensive volunteers were also studied and considered as the control group. The initial study disclosed similar levels of PGE2, PRA and plasma aldosterone in volunteers, normotensive patients and hypertensive patients, although the sodium intake was lower in the last two groups. A positive correlation between PRA and urinary PGE2 was found both in normotensive (r = 0.507, p less than 0.01) and in hypertensive patients (r = 0.609, p less than 0.01). The administration of indomethacin induced a diminution of PRA, plasma aldosterone and urinary PGE2 levels together with an increase in diastolic blood pressure (p less than 0.05-0.01) in both volunteers and patients. The remaining parameters measured did not change in volunteers or in normotensive patients. On the contrary, in hypertensive patients, during indomethacin administration, lower values of creatinine clearance (p less than 0.005) and 24-hour natriuresis (p less than 0.05) together with an increase in body weight (p less than 0.01) were observed. These results point to the existence of a protective role of renal prostaglandin E2 upon renal function when hypertension appears in the course of chronic renal parenchymatous disease.