Nighttime Hypertension Research Articles

Lactoferrin in Pediatric Chronic Kidney Disease and Its Relationship with Cardiovascular Risk.

Pediatric CKD is associated with a high risk of cardiovascular disease (CVD). Early detection of subclinical CVD in childhood CKD can be achieved through various cardiovascular (CV) assessments, including carotid intima-media thickness (cIMT), ambulatory blood pressure monitoring (ABPM), and arterial stiffness indices. Lactoferrin (LF), a key functional glycoprotein found in breast milk, has been linked to several diseases and has potential as a biomarker. In our study of 102 children with CKD stages G1-G4, we explored the relationship between LF and CV risk markers. We found that LF concentration was not related to the severity or underlying causes of childhood CKD, but was positively correlated with overweight/obesity. Lower LF levels were correlated with increased cIMT and elevated arterial stiffness indices. Notably, abnormalities in ABPM profiles were observed in up to 60% of the children with CKD, with low LF levels linked to nighttime hypertension, nocturnal non-dipping, and ABPM abnormalities. In conclusion, LF shows promise as a biomarker for detecting subclinical CVD in children with CKD. Its potential utility in early detection could be instrumental in guiding timely interventions and improving long-term CV outcomes, although further research is needed to clarify the underlying mechanisms.

Reproducibility of daytime hypertension, night-time hypertension, and nocturnal blood pressure dipping patterns in young to middle age patients with stage 1 hypertension.

To investigate the reproducibility of ambulatory BP sub-periods and nocturnal dipping phenotypes assessed twice 3 months apart in young-to-middle-age untreated individuals screened for stage 1 hypertension. We investigated 1096, 18-to-45-year old participants from the HARVEST. Their office BP was 145.8 ± 10.4/93.7 ± 5.7 mmHg. Office BP and 24 h BP were measured at baseline and after 3 months. Office, 24-h, daytime and night-time hypertensions, and nocturnal dipping patterns were defined according to the 2023 ESH guidelines. Between-recording agreement was evaluated with kappa statistics. Reproducibility evaluated with weighted kappa was moderate for both 24 h hypertension (K = 0.48) and daytime hypertension (K = 0.50) and was only fair for night-time hypertension (K = 0.36). Between-measurement agreement was even worse for isolated night-time hypertension (K = 0.24), and was poor for office hypertension (K = 0.14). The better reproducibility of daytime than night-time period was confirmed by the analysis of BP as continuous variable (all between-period differences, P < 0.001). Nondipping was present in 31.8%, and showed a fair agreement (K = 0.28,). Poorer agreement was shown by extreme dipping (K = 0.18) and reverse dipping (K = 0.07). These data show that within the ambulatory sub-periods, daytime hypertension has a better reproducibility than night-time hypertension. This suggests that the better association with adverse outcomes shown by sleep BP compared to wake BP in observational studies is not due to a better reproducibility of the former. The between-measurement agreement is even worse for isolated nocturnal hypertension and dipping patterns, especially for extreme and reverse dipping. Thus, these BP phenotypes should be confirmed with repeat ambulatory BP monitoring.

O57 NOCTURNAL BLOOD PRESSURE FLUCTUATION AND DIPPING PATTERNS IN PATIENTS WITH SEVERE OBSTRUCTIVE SLEEP APNOEA

Background and Objective: Nighttime blood pressure (BP) is important for diagnosis of hypertension and for cardiovascular risk stratification. Remarkably, a reverse dipping pattern is a strong and independent predictor of overall mortality and major adverse cardiovascular events. Therefore, the further clarification of the underlying mechanisms of non- and reverse dipping is crucial to improve the treatment of patients with nighttime hypertension. Methods: We investigated 97 patients with suspected obstructive sleep apnoea (OSA, AHI &gt;30) using standard polysomnography and continuous BP measurement based on the pulse-transit-time method (SOMNOscreen Plus®, SOMNOmedics). Frequency and amplitude of fluctuations in systolic BP following sleep disturbances (OSA) were investigated. Results: Apnoeic events went along with transient increases of BP. In some cases, systolic BP did not reach the value before the apnoea but increased over time. We defined elevations of the systolic BP baseline by &gt;10 mmHg with a duration of &gt;10 min as BP superpositions. The superposition periods were also characterized by increased BP amplitudes with peak values of BP up to 220 mmHg. Superposition occurred in 48 patients. Further, 65% of the OSA patients were identified as non-dippers. However, nearly all the patients with superposition (98%) were identified to have non-dipper or reverse dipper patterns. Conclusions: Our study strongly suggests that non-dipping and reverse dipping in patients with severe OSA are causally linked to OSA related BP fluctuations. Further, continuous elevations in SBP baseline (superpositions) result in extreme BP values. This behaviour with high BP peaks may be contributing to the increased mortality in patients with reverse dipping. Therefore, identification and adequate treatment of patients with reverse dipping reduces the cardiovascular risk and may prolong their life.

Efficacy of antihypertensive treatment for target organ protection in patients with masked hypertension (ANTI-MASK): a multicentre, double-blind, placebo-controlled trial

Masked hypertension is associated with target organ damage (TOD) and adverse health outcomes, but whether antihypertensive treatment improves TOD in patients with masked hypertension is unproven. In this multicentre, randomised, double-blind, placebo-controlled trial at 15 Chinese hospitals, untreated outpatients aged 30-70 years with an office blood pressure (BP) of <140/<90mm Hg and 24-h, daytime or nighttime ambulatory BP of ≥130/≥80, ≥135/≥85, or ≥120/≥70mm Hg were enrolled. Patients had ≥1 sign of TOD: electrocardiographic left ventricular hypertrophy (LVH), brachial-ankle pulse wave velocity (baPWV) ≥1400cm/s, or urinary albumin-to-creatinine ratio (ACR) ≥3.5mg/mmol in women and ≥2.5mg/mmol in men. Exclusion criteria included secondary hypertension, diabetic nephropathy, serum creatinine ≥176.8μmol/L, and cardiovascular disease within 6 months of screening. After stratification for centre, sex and the presence of nighttime hypertension, eligible patients were randomly assigned (1:1) to receive antihypertensive treatment or placebo. Patients and investigators were masked to group assignment. Active treatment consisted of allisartan starting at 80mg/day, to be increased to 160mg/day at month 2, and to be combined with amlodipine 2.5mg/day at month 4, if the ambulatory BP remained uncontrolled. Matching placebos were used likewise in the control group. The primary endpoint was the improvement of TOD, defined as normalisation of baPWV, ACR or LVH or a ≥20% reduction in baPWV or ACR over the 48-week follow-up. The intention-to-treat analysis included all randomised patients, the per-protocol analysis patients who fully adhered to the protocol, and the safety analysis all patients who received at least one dose of the study medication. This study is registered with ClinicalTrials.gov, NCT02893358. Between February 14, 2017, and October 31, 2020, 320 patients (43.1% women; mean age±SD 53.7±9.7 years) were enrolled. Baseline office and 24-h BP averaged 130±6.0/81±5.9mm Hg and 136±8.6/84±6.1mm Hg, and the prevalence of elevated baPWV, ACR and LVH were 97.5%, 12.5%, and 7.8%, respectively. The 24-h BP decreased on average (±SE) by 10.1±0.9/6.4±0.5mm Hg in 153 patients on active treatment and by 1.3±0.9/1.0±0.5mm Hg in 167 patients on placebo. Improvement of TOD occurred in 79 patients randomised to active treatment and in 49 patients on placebo: 51.6% (95% CI 43.7%, 59.5%) versus 29.3% (22.1, 36.5%; p<0.0001). Per-protocol and subgroup analyses were confirmatory. Adverse events were generally mild and occurred in 38 (25.3%) and 43 (26.4%) patients randomised to active treatment and placebo, respectively (p=0.83). Our results suggest that antihypertensive treatment improves TOD in patients with masked hypertension, highlighting the need of treatment. However, the long-term benefit in preventing cardiovascular complications still needs to be established. Salubris China.

Nighttime Blood Pressure Abnormalities in Iranian CKD Patients: Necessity to Perform Ambulatory Blood Pressure Monitoring.

Ambulatory blood pressure monitoring (ABPM) is a valuable tool for detecting abnormalities in nighttime blood pressure (BP), including non-dipping and nighttime hypertension. These abnormalities are independent predictors of a poor prognosis in patients with chronic kidney disease (CKD). The aim of our study was to analyze ABPM data and evaluate nighttime BP abnormalities in an Iranian CKD population. This cross-sectional study was conducted on sixty two patients at stages III and IV of CKD who were referred to a nephrology clinic in Tehran, Iran. The patients were classified as either dippers (19.4%) or non-dippers (80.6%), as well as nighttime normotensives (38.7%) or hypertensives (61.3%), based on ABPM data and in accordance with 2023 ESC/ESH guidelines. We compared demographic data, estimated glomerular filtration rate (eGFR), and daytime BP levels among these groups. The mean age of patients was 56.34 years, with 61.1% of them being male. Daytime pulse pressure was significantly greater in non-dippers compared to dippers (52.67 vs. 44 mmHg, P = .02). We found a significant correlation between the extent of BP dipping and eGFR (R = 0.281, P = .02). Systolic and diastolic daytime BP levels were significantly higher in individuals with nighttime hypertension. Diabetic patients were more likely to be non-dippers and have nighttime hypertension. After adjusting for age, diabetes mellitus, and daytime pulse pressure in a multivariable model, we determined that eGFR independently predicted the extent of BP dipping. Our results showed that both non-dipping and nighttime hypertension are highly prevalent in CKD patients, but they have distinct contributing factors. The eGFR was identified as an independent predictor of BP dipping, whereas nighttime BP levels were primarily determined by daytime BP levels. DOI: 10.52547/ijkd.7559.

NIGHTTIME BLOOD PRESSURE ASSESSED USING HOME MONITORING IN HYPERTENSIVE PATIENTS WITH TYPE 2 DIABETES/PREDIABETES: ASSOCIATION AND AGREEMENT WITH AMBULATORY MONITORING

Objective: To investigate the agreement between nighttime blood pressure (BP) measurements using home (HBPM) or ambulatory BP monitors (ABPM) in individuals with hypertension and type 2 diabetes mellitus (DM2) or prediabetes. Design and method: Adults with hypertension (treated or untreated) and DM2 or prediabetes underwent ABPM (measurements at 20 minutes intervals, Microlife WatchBP03) and HBPM (duplicate morning/evening measurements for 7 days, 3 nights with 3 measurements/night, Microlife WatchBP Home-N). Nighttime hypertension was defined as BP &gt;= 120/70 mmHg (systolic/diastolic). Nighttime BP dipping was calculated as the ratio of nighttime BP decline to the daytime levels. Individuals with nighttime BP dip (systolic and/or diastolic) &lt;10% were classified as non-dippers. Results: Data from 113 participants were analyzed (mean age [SD] 65±9.1 years, 67% men, body mass index 30.7±4.8 kg/m2, 84% with DM2, 22% cardiovascular disease, 94% treated hypertension). Average daytime HBPM was 129.2±13.2/73.3±7.8 mmHg and ABPM 126.7±12.1/72.5±7.4 mmHg (systolic/diastolic, p&lt;0.01/p=NS), whilst nighttime HBPM was 115.3±13.1/63.6±7.6 mmHg and ABPM 113.9±13.4/63±7.1 mmHg (systolic/diastolic, p&lt;0.05/p=NS). Strong correlation was observed between HBPM and ABPM levels: daytime r=0.71/0.74 and nighttime 0.86/0.78, systolic/diastolic, p&lt;0.01)]. Good agreement was also found between ABPM and HBPM in diagnosing nighttime hypertension (81%/90%; kappa=0.55/0.70 systolic/diastolic). Among the participants, 32%/31% were classified as non-dippers (HBPM/ABPM, p=NS), with a 74% agreement (kappa=0.41) in detecting non-dippers. Conclusions: These preliminary findings indicate that in individuals with hypertension and DM2 or prediabetes, nighttime BP assessed by a novel home monitor is feasible and shows strong correlation and satisfactory agreement with reference ABPM in detecting nighttime hypertension and non-dipping.

ANALYSIS OF DETECTION RATE OF EARLY EVENING ELEVATED BLOOD PRESSURE IN HYPERTENSIVE PATIENTS BY AMBULATORY BLOOD PRESSURE MONITORING

Objective: The aim of the study is to investigate the detection rate of early evening elevated blood pressure (EEE) in treated and untreated hypertensive patients by ambulatory blood pressure monitoring. Design and method: From February 1, 2020 to February 28, 2023, the total of 1413 hypertensive patients underwent ambulatory blood pressure monitoring in 13 medical institutions through the National 13th Five Year Plan Major Cooperation Group for Chronic Disease Prevention and Control (Research on the Application of Lifestyle and Nutritional Intervention Techniques and Strategies for Obesity and Hypertension, No. 2016YFC1300100). Among them, 1026 patients had taken antihypertensive drugs and 387 patients had not taken antihypertensive drugs. EEE is defined as average systolic blood pressure is higher or equal to 135mmHg or average diastolic blood pressure is higher or equal to 85mmHg from 6PM to 10PM. Results: 1. The detection rate of EEE in treated hypertensive patients was 60.4% (620 patients), while the detection rate of EEE in untreated hypertensive patients was 70.5% (273 patients); 2. The detection rate of daytime hypertension in treated hypertensive patients was 55.8% (573 patients), while the detection rate of daytime hypertension in untreated hypertensive patients was 71.6% (277 patients); 3. The detection rate of nighttime hypertension in treated hypertensive patients was 81.2% (833 patients), while the detection rate of nighttime hypertension in untreated hypertensive patients was 87.6% (339 patients); 4. The detection rate of whole-day hypertension in treated hypertensive patients was 69.3% (711 patients), while the detection rate of whole-day hypertension in untreated hypertensive patients was 80.9% (313 patients); 5. The detection rate of morning hypertension in treated hypertensive patients was 61.1% (627 patients), while the detection rate of morning hypertension in untreated hypertensive patients was 72.9% (282 patients). Conclusions: In this study, the detection rate of EEE in treated hypertensive patients did not significantly decrease compared to those untreated patients, while the detection rate of EEE was similar to that of morning hypertension. It is necessary to conduct further research to reveal the correlation between EEE and cardiovascular diseases.

Office or home versus 24-h blood pressure measurement in stable kidney transplant recipients.

The aim of this study was to quantify hypertension control and evaluate concordance between all commonly available blood pressure (BP) modalities in kidney transplant recipients (KTRs). For this prospective cross-sectional study, 89 stable KTRs were recruited at the Charité Transplant Outpatient Clinic. For each study participant office [manual office BP (MOBP) and automated office BP (AOBP)], 7-day home (HBPM) and 24-hour ambulatory BP (24h-ABPM) measurements were performed. 80 of the 89 patients recruited had sufficient BP recordings. The mean BP for MOBP, AOBP, HBPM and 24h-ABPM was 129/73, 126/71, 131/85 and 130/81mmHg, respectively. Uncontrolled hypertension, as defined by 24h-ABPM (mean ≥130/80mmHg), was present in 53 (66%) patients. MOBP, AOBP and HBPM classified 19 (24%), 22 (28%) and 41 (51%) patients, respectively, as 'uncontrolled hypertensive'. The Bland-Altman plot showed good agreement between systolic MOBP, AOBP, HBPM and daytime-ABPM (mean bias: -1±13mmHg, -4±13mmHg, 1±10mmHg, respectively). Uncontrolled night-time hypertension was present in 74 (93%) KTRs, with 71 (89%) patients showing a non-physiological dipping pattern. Moderate positive correlation between daytime-ABPM/HBPM and night-time-ABPM (Pearson correlation coefficients: 0.62-0.73), followed by MOBP/AOBP (Pearson correlation coefficients: 0.49-0.59) was noted. Estimated eGFR and proteinuria displayed weak correlation with 24h-, daytime- and night-time-ABPM (absolute values of Pearson correlation coefficients: 0.04-0.41). No robust association with either 24h-, daytime- or night-time-ABPM was observed for volume status exams. Masked hypertension is highly prevalent in KTRs, especially due to high rates of uncontrolled night-time hypertension. HBPM shows the narrowest limits of agreement with daytime-ABPM. Daytime-ABPM and HBPM show the highest, albeit clinically insufficient, correlation with night-time-ABPM. Systematic integration of 24h-ABPM into clinical practice, as proposed by the 2023 ESH guidelines for the management of arterial hypertension, should not be withheld for the KTR population. Clinical trials evaluating the treatment of hypertension in KTRs are urgently needed.

Abstract 15801: Nighttime Hypertension is a Risk Factor for Cardiovascular Events in Stage B Heart Failure Patients

Background: Nighttime blood pressure (BP) was reported to have a stronger association with cardiovascular outcome and hypertensive organ damage than clinic BP, 24-hour BP, and daytime BP in hypertensives. However, the significance of nighttime BP was not established in stage B heart failure (HF) patients. We hypothesized that nighttime BP measured by home BP monitoring device was associated with cardiovascular outcome in stage B HF patients. Method: We used the dataset of Japan Morning Surge-Home Blood Pressure study (J-HOP study), and selected 417 of stage B HF patients. The definition of stage B HF was based on Universal definition of HF. The patients with history of HF hospitalization were excluded. BP was measured on waking, before bedtime and during the night. The cardiovascular event was followed. Result: Mean follow-up period was 6.6±3.8 years, and 59 cardiovascular events were occurred. When nighttime hypertension was defined as nighttime BP &gt;120mmHg, nighttime HT group showed higher BMI, serum creatinine, HbA1c, and higher prevalence of diabetes, atrial fibrillation, and chronic kidney disease, and lower HDL-cholesterol than nighttime normotension (NT) group. With regard to BP, nighttime HT group, clinic BP, home morning BP, home evening BP, and home nighttime BP were higher in nighttime HT group than in nighttime NT group. In Kaplan-Meier analysis, nighttime HT group had a higher incident of cardiovascular event than nighttime NT group (P&lt;0.01). In Cox multivariate analysis, nighttime HT was significant predictor for cardiovascular event adjusting by significant variables (Hazard ratio 1.84, 95% Confidence interval: 1.01-3.36, P=0.046). Conclusions: Nighttime HT was a prognostic factor in stage B HT patients. Nighttime BP was a therapeutic target to improve the outcome in stage B HT patients.

Updating approaches to patient management in the light of new European guidelines on arterial hypertension: analytical review

Data from epidemiological studies show a high prevalence of cardiovascular diseases, including arterial hypertension (AH) and the risk of complications, with changes in AH control and treatment techniques. The review article summarizes the main directions of the new European guidelines on hypertension, which help implement different patient groups in outpatient practice. Secondary risk factors for cardiovascular disease are revised in the new clinical guidelines. The recommendation outlines a diagnostic and therapeutic approach for resistant arterial hypertension, its associated phenotypes, and night-time hypertension. The use and position of renal denervation for antihypertensive treatment have been updated compared with previous recommendations. The new European clinical guidelines reflect a differentiated approach to target indicators of ambulatory blood pressure in different age groups, with functional levels of aging, comorbidity, and AH phenotypes, which is of great clinical importance for a primary care physician and can significantly reduce the risk of heart disease vascular complications.

Age-related patterns of ambulatory blood pressure in a large cohort of individuals referred to Italian community pharmacies: results from the templar project.

Ambulatory blood pressure monitoring (ABPM) provides extensive information on several BP parameters other than the average BP during daily life. Through this analysis of the TEMPLAR study, we sought to understand better the features of age-related changes in ABP patterns and phenotypes. ABPMs were obtained in 53 350 individuals visiting 866 Italian community pharmacies (age 3-101 years, 54.3% female individuals). ABPM patterns were assessed across 10-year age categories. SBP steadily increased with age. DBP increased from the youth to the middle adulthood and then declined. Daytime BP was higher than night-time BP, but the difference narrowed with aging, reducing the prevalence of dippers. An enhanced SBP morning surge and increased prevalence of abnormal morning rise were observed with aging. SBP and DBP variabilities increased with age with a typical U or J shape, more evident in the case of DBP. The proportion of participants with ambulatory hypertension increased with age. However, an elevated daytime BP was more common in younger individuals and elevated night-time hypertension in older individuals. The prevalence of white-coat hypertension remained stable or slightly declined through the age groups, whereas that of masked hypertension steadily increased. Our results confirm that ABP patterns interplay and change in a complex way with age. Such changes, particularly the age-related increase in BP variability and prevalence of nocturnal hypertension, nondipping, enhanced morning rise, and masked hypertension, may increase the risk of cardiovascular events and must be carefully considered by the physician when managing BP in the elderly.

Bedtime dosing of antihypertensive medications: systematic review and consensus statement: International Society of Hypertension position paper endorsed by World Hypertension League and European Society of Hypertension.

Antihypertensive drug therapy is one of the most efficient medical interventions for preventing disability and death globally. Most of the evidence supporting its benefits has been derived from outcome trials with morning dosing of medications. Accumulating evidence suggests an adverse prognosis associated with night-time hypertension, nondipping blood pressure (BP) profile and morning BP surge, with increased incidence of cardiovascular events during the first few morning hours. These observations provide justification for complete 24-h BP control as being the primary goal of antihypertensive treatment. Bedtime administration of antihypertensive drugs has also been proposed as a potentially more effective treatment strategy than morning administration. This Position Paper by the International Society of Hypertension reviewed the published evidence on the clinical relevance of the diurnal variation in BP and the timing of antihypertensive drug treatment, aiming to provide consensus recommendations for clinical practice. Eight published outcome hypertension studies involved bedtime dosing of antihypertensive drugs, and all had major methodological and/or other flaws and a high risk of bias in testing the impact of bedtime compared to morning treatment. Three ongoing, well designed, prospective, randomized controlled outcome trials are expected to provide high-quality data on the efficacy and safety of evening or bedtime versus morning drug dosing. Until that information is available, preferred use of bedtime drug dosing of antihypertensive drugs should not be routinely recommended in clinical practice. Complete 24-h control of BP should be targeted using readily available, long-acting antihypertensive medications as monotherapy or combinations administered in a single morning dose.

Association of Nighttime Masked Uncontrolled Hypertension With Left Ventricular Hypertrophy and Kidney Function Among Patients with Chronic Kidney Disease Not Receiving Dialysis

Nighttime hypertension is prevalent and associated with adverse outcomes in patients with chronic kidney disease (CKD), but nighttime hypertension, a subtype of masked uncontrolled hypertension (MUCH), is often undetected among patients with controlled office blood pressure. Little attention has been paid to patients with CKD and nighttime MUCH. To investigate the prevalence of nighttime MUCH and its associations with cardiovascular and kidney outcomes in patients with CKD who were not receiving dialysis. This retrospective cohort study included patients with nondialysis CKD and hypertension, enrolled in Shanghai, China, from July 2012 through November 2020 and followed up for a median of 39 months. Participants were classified as having controlled hypertension, sustained hypertension, and MUCH, which was further divided into isolated nighttime MUCH and day-night MUCH, assessed by office and ambulatory blood pressure monitoring. Left ventricular hypertrophy (LVH) was determined by echocardiography. The composite kidney outcome consisted of end-stage kidney diseases (ESKD) and a reduction of estimated glomerular filtration rate (eGFR) by 50% or more. Logistic and Cox regression assessed the associations of hypertension subtypes with LVH and kidney outcomes. The 675 patients (425 [63.0%] men; mean [SD] age, 50.8 [15.9] years; mean [SD] eGFR, 61.6 [29.4] mL/min/1.73 m2) included 125 (19.3%) with controlled hypertension, 244 (37.6%) with MUCH, and 280 (43.1%) sustained hypertension. Among patients with MUCH, 2 (0.8%) had isolated daytime MUCH, 154 (63.1%) had isolated nighttime MUCH, and 88 (36.1%) had day-night MUCH. During a median (IQR) follow-up of 39 (19-64) months, 130 composite kidney events, including 97 ESKD events, occurred. Compared with controlled hypertension, MUCH and sustained hypertension were associated with LVH (eg, MUCH: odds ratio [OR], 2.94; 95% CI, 1.18-7.34; P = .02) and the composite kidney outcome (eg, MUCH: hazard ratio [HR], 4.12; 95% CI, 1.75-9.73; P = .001) after adjustment for age, sex, proteinuria, eGFR, and other baseline risk factors. Multivariate-adjusted associations were also significant between day-night MUCH and LVH (OR, 3.26; 95% CI, 1.15-9.25) and between isolated nighttime MUCH and the composite kidney outcome (HR, 4.27; 95% CI, 1.69-10.77). In this cohort study, nighttime MUCH was common and associated with LVH and poor kidney outcomes among patients with hypertension and nondialysis CKD. These findings suggest that ambulatory blood pressure monitoring was inadequately used in patients with CKD and hypertension, calling for more widespread use, even in patients with controlled office hypertension.

Nighttime Hypertension in Chronic Kidney Disease—Are We in the Dark Without Ambulatory Blood Pressure Monitoring?

Nighttime Hypertension in Chronic Kidney Disease—Are We in the Dark Without Ambulatory Blood Pressure Monitoring?

Variation in paediatric 24-h ambulatory blood pressure monitoring interpretation by Canadian and UK physicians.

Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is widely accepted as a more accurate method for measurement of blood pressure (BP) compared to a single office-based measurement of BP. However, it is unclear how physicians interpret ABPM and make management decisions. This study's goal is to investigate variation in ABPM interpretation among paediatric nephrologists (Canada and UK) and paediatric cardiologists (Canada only) via an online survey. The survey content included baseline demographics, questions on the use and indications for ABPM, interpretation of results, and subsequent management decisions in various clinical scenarios. The survey was sent to 196 Canadian physicians, with 69 (35.2%) total responses. Thirty-five UK clinicians also completed the survey. Most respondents were >44 years old, were in practice for at least 11 years, and were university-based. There were substantial differences among clinicians in ABPM interpretation for isolated systolic, diastolic, and night-time hypertension. For example, only 53.1% of physicians would initiate or modify treatment in those with diastolic HTN in CKD. Further, even for the same abnormal ABPM parameter, the decision to start or alter treatment was influenced by the underlying medical condition. There is significant variation in clinical practice among physicians for interpretation and management of hypertension when using ABPM. Differences in guidelines among various jurisdictions, as well as knowledge gaps in the research on which guidelines are based, create ambiguity regarding ABPM interpretation and management decisions. A more protocolized approach and further insight into the reasoning behind the variation in physicians' interpretation may help to standardise practice.

Effects of circadian blood pressure patterns on development of microvascular complications in pediatric patients with type 1 diabetes mellitus.

Purpose The effects of circadian blood pressure (BP) alterations on the development and progression of microvascular complications in type 1 diabetes mellitus (T1DM) patients are unknown. We evaluated the effects of circadian BP alterations with development of microvascular complications during follow-up with patients with childhood-onset T1DM.Methods We investigated the medical records of 81 pediatric patients with T1DM who underwent 24-hour ambulatory BP monitoring (ABPM) between January 2009 and February 2010.Results Mean age at diagnosis and ABPM evaluation was 8.0±3.9 and 15.6±2.4 years, respectively. Hypertension (daytime, nighttime, and 24-hour mean hypertension) data were available in 42 patients. During the 8 years of follow-up after ABPM, microvascular complications occurred in 8 patients (diabetic retinopathy [DR] alone in 5, microalbuminuria alone in 2, and both in 1), of whom 7 had nondipper BP. Nighttime diastolic BP, nighttime mean arterial pressure, and glycated hemoglobin A (HbA1c) level were higher in patients with DR than in those without DR (P<0.05 for all). Daytime or nighttime BP and presence of dipper BP were not related to microvascular complications, but diabetic microvascular complications were more likely to occur in patients with an older age at diagnosis and higher HbA1c level. The proportion of patients with DR was higher in those with nondipper hypertension (83.3%) compared with dipper and nondipper normotension (0% and 16.7%, respectively; P=0.021).Conclusions As a predictor of microvascular complications, nondipper hypertension was not significant. Glycemic control rather than nondipper hypertension is the predominant factor determining DR in T1DM patients.

Isolated nocturnal hypertension in pediatric kidney transplant recipients.

Isolated nocturnal hypertension (INH) is defined as nighttime hypertension in the setting of normal daytime blood pressure (BP), diagnosed by ambulatory BP monitoring (ABPM). Hypertension affects 60%-80% of pediatric kidney transplant recipients, and INH is the most common type of ambulatory hypertension. INH is associated with an increased prevalence of hypertension-mediated target organ damage such as left ventricular hypertrophy in adults and in pediatric kidney transplant recipients. Ambulatory BP monitoring should be performed annually in all pediatric kidney transplant recipients to diagnose hypertension phenotypes that are not detectable by office BP such as masked hypertension, white-coat hypertension, or INH. Isolated nocturnal hypertension in pediatric transplant patients requires study as a treatment target.

Single-Nephron Salt Excretion and Nighttime Hypertension: A Cross-Sectional Study in Patients with IgA Nephropathy

Single-Nephron Salt Excretion and Nighttime Hypertension: A Cross-Sectional Study in Patients with IgA Nephropathy

Nighttime Home Blood Pressure in Children: Association with Ambulatory Blood Pressure and Preclinical Organ Damage.

[Figure: see text].

SEASONAL VARIATION OF MASKED UNCONTROLLED NOCTURNAL HYPERTENSION MEASURED BY NIGHTIME HOME BLOOD PRESSURE: THE J-HOP NOCTURNAL BLOOD PRESSURE STUDY

Objective: Usual daytime (morning and evening) home blood pressure (BP) monitoring can not detect nighttime hypertension. Masked uncontrolled nocturnal hypertension is defined as uncontrolled nighttime BP nonetheless controlled usual daytime home BP (HBP). Although previous studies have reported seasonal variation of nighttime BP evaluated by ambulatory BP monitoring is higher in summer than winter, seasonal variation in prevalence of masked uncontrolled nocturnal hypertension evaluated by nighttime HBP measurements remains unclear. Hence, we assessed the seasonal variation in nighttime HBP and the prevalence of masked uncontrolled nocturnal hypertension using a dataset of the Japan Morning Home-Surge BP (J-HOP) Nocturnal BP study. Design and method: This is a cross-sectional, post-hoc analysis using the dataset of the J-HOP Nocturnal BP study, which recruited patients with a history of or risk factors of cardiovascular disease. Participants underwent consecutive 14-day HBP measurements (morning and evening) and nighttime HBP measurements (a.m. 2, 3, and 4). We divided participants into four groups in each season. Masked uncontrolled nocturnal hypertension was defined as controlled daytime HBP (mean of morning and evening home systolic BP [SBP] &lt; 135 mmHg and diastolic BP [DBP] &lt; 85 mmHg) and uncontrolled nocturnal HBP (mean nighttime home SBP &gt;= 120 or DBP &gt;= 70 mmHg). Results: Among 2545 participants (age, 63.3 ± 10.3 yrs; 49% of male; antihypertensive medication use, 82.6%), 629, 596, 719, and 601 participants were enrolled in spring, summer, autumn, and winter, respectively. Nighttime home SBP/DBP were higher in summer than winter (SBP/DBP in summer, 123.3 ± 14.6/70.4 ± 8.9 mmHg; vs. in winter, 119.3 ± 14.0/69.1 ± 8.4 mmHg, p &lt; 0.05). In 1490 participants with controlled daytime HBP, moreover, the prevalence of masked uncontrolled nocturnal hypertension was higher in summer than other seasons (summer, 55.7% vs. spring, 41.8%; vs. autumn, 42.9%; vs. winter, 39.7%, all p &lt; 0.01). These relationships were also observed in multivariate logistic regression analysis (Table). Conclusions: In the present study, we revealed the prevalence of masked uncontrolled nocturnal hypertension was higher in summer than other seasons.