Etiology and Management of Hypertension in Chronic Kidney Disease

Andersen, Martin J.; Agarwal, Rajiv

doi:10.1016/j.mcna.2004.12.001

Cited by 17 publications

(12 citation statements)

References 151 publications

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“…The causes of nondipping in these patients are not clear, but many factors have been proposed, eg, sodium sensitivity, autonomic activation, and endocrine dysfunction. 13,14 Mansoor et al 15 found that, in patients with untreated hypertension, Nondihydropyridines, n (%)…”

Section: Discussionmentioning

confidence: 99%

Nocturia, Nocturnal Activity, and Nondipping

et al. 2009

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Abstract-Patients with chronic kidney disease have less than expected decline in blood pressure during sleep (nondipping) and commonly experience the vexing symptom of nocturia. To better understand the relationship among nocturia, nighttime physical activity, and nondipping, we studied 98 patients with chronic kidney disease on 2 occasions, 1 month apart, with 24-hour ambulatory blood pressure monitoring and simultaneous activity monitoring with wrist actigraphy. Patients with nocturia had greater actigraphically recorded nighttime physical activity compared to those with no nocturia. The drop in activity from wake to sleep was reduced to a similar extent whether the patients had nocturia once or twice, but patients who had nocturia Ն3 times had the least reduction from wake to sleep activity (PϽ0.001 versus those with less degrees of nocturia). Those with nocturia had a lesser drop in systolic ambulatory blood pressure during sleep compared with those without nocturia. The average fall in sleep systolic blood pressure was 9.8 mm Hg (95% CI: 8.0 to 11.6 mm Hg) in those without nocturia compared with 3.4 mm Hg (95% CI: 2.7 to 4.1 mm Hg) in those with any severity of nocturia (PϽ0.001 for difference). Nondipping in patients with nocturia was mediated by nighttime physical activity. These differences were independent of estimated glomerular filtration rate, albuminuria, or use of diuretics. Thus, nocturia, which may reflect impaired renal tubular function, is associated with nondipping in patients with chronic kidney disease and appears to be mediated by increased nocturnal activity. Whether nocturia itself or the resulting nondipping associated with nocturia is of prognostic importance for cardiorenal events in patients with chronic kidney disease should be tested in future studies. Key Words: hypertension Ⅲ ambulatory blood pressure monitoring Ⅲ actigraphy Ⅲ CKD Ⅲ physical activity Ⅲ nocturia H ypertension, which is a widely prevalent and treatable cardiovascular risk factor in patients with chronic kidney disease (CKD), 1 is often difficult to assess accurately, because many patients with CKD have white-coat hypertension or masked hypertension. 2,3 Out-of-clinic measured blood pressure (BP) recordings are the preferred method of BP assessment, 4 and some studies have demonstrated that outof-clinic measured BP may be of greater prognostic importance for predicting cardiovascular and end-stage renal disease outcomes compared with clinic-measured BP recordings. 5,6 Home BP measurement and ambulatory BP monitoring are currently available tools to measure out-ofclinic BP, of which the latter has the advantage of measuring the fall in BP during sleep, a phenomenon termed "dipping." Although the exact cause for nondipping is unclear, nondipping is associated with CKD, sleep apnea, volume overload, sympathetic activation, and other factors. 4 Nocturia is defined as any waking at night to void and occurs when the rate of production of urine exceeds that of bladder volume. Many factors, eg, age, benign prostatic hyperp...

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Section: Discussionmentioning

confidence: 99%

Nocturia, Nocturnal Activity, and Nondipping

et al. 2009

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“…However, many other factors such as activation of sympathoadrenal system, renin-angiotensin system, and circulating inhibitors of NO are also responsible for the high prevalence of hypertension. 3 Although blood pressure (BP) control is paramount in preventing the progression of renal disease, factors related to BP control in the CKD population have scarcely been examined. In the Modification of Diet in Renal Disease (MDRD) study, 5 risk factors were found to be independent predictors of the presence of hypertension.…”

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confidence: 99%

Correlates of Systolic Hypertension in Patients With Chronic Kidney Disease

2005

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Abstract-Hypertension in patients with chronic kidney disease (CKD) is predominantly systolic. The contribution of risk factors for hypertension to the overall systolic blood pressure (BP) is unknown. To study the relationship between risk factors for hypertension and systolic BP in patients with CKD, 232 veterans (mean age 67 years; 96% men; 20% black; 39% with diabetes mellitus; estimated glomerular filtration rate [GFR] 48 mL/min per 1.73 m 2 ) had clinic (routine and standardized measurements) and out-of-clinic (home and 24-hour ambulatory) BPs recorded. In multivariate analysis, using 17 risk factors, the log of the urine protein/creatinine ratio was the strongest predictor of systolic BP regardless of the BP measurement technique. The strength of the relationship between proteinuria and systolic BP was in the order ambulatory Ͼ home Ͼ standardized clinic Ͼ routine clinic BP measurement. Other independent predictors were age, race, and number of antihypertensive drugs used, and the model fit was better for out-of-clinic than clinic BP recordings. Estimated GFR was not an independent predictor of systolic BP by any technique. Nocturnal dipping was associated with higher estimated GFR, higher serum albumin, younger age, and less proteinuria. Proteinuria is the most important correlate of systolic BP in older men, the strongest relationship of which was with ambulatory and home systolic BP. Out-of-clinic BP recordings correlate better with target organ damage, as measured by proteinuria, and may be of greater clinical value than clinic BP recordings in predicting hypertension-related outcomes such as end-stage renal disease and death. (Hypertension. 2005;46:514-520.) Key Words: proteinuria Ⅲ kidney H ypertension is very common in patients with chronic kidney disease (CKD); its prevalence increases with falling glomerular filtration rate (GFR) and reaches an estimated 86% in patients with end-stage renal disease (ESRD). 1 In the third National Health and Nutrition Examination Survey, 70% of those with an elevated serum creatinine had hypertension. 2 Sodium and water retention with progressive decrease in GFR is thought to be etiologically related to the high prevalence of hypertension. However, many other factors such as activation of sympathoadrenal system, renin-angiotensin system, and circulating inhibitors of NO are also responsible for the high prevalence of hypertension. 3 Although blood pressure (BP) control is paramount in preventing the progression of renal disease, factors related to BP control in the CKD population have scarcely been examined. In the Modification of Diet in Renal Disease (MDRD) study, 5 risk factors were found to be independent predictors of the presence of hypertension. 4 In decreasing order of significance, these factors were GFR, body mass index (BMI), black race, increasing age, and male gender. In a survey of 1921 patients with CKD in Europe, the odds of presence of hypertension were increased independently by the following risk factors listed in the order of significance: creat...

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“…The causes of nondipping in these patients are not clear, but many factors have been proposed, such as sodium sensitivity, autonomic activation, and endocrine dysfunction (31,32). We found that sleep activity was increased in patients with nondipping, which raises the hypothesis that patients with nondipping have poor sleep quality.…”

Section: Discussionmentioning

confidence: 62%

Physical Activity and Hemodynamic Reactivity in Chronic Kidney Disease

Agarwal

Light

2008

Clinical Journal of the American Society of Nephrology

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Background and objectives: Patients with chronic kidney disease (CKD) have an elevated cardiovascular risk. This study was designed to understand better the presence and strength of the relationship between physical activity and BP and to explore determinants of hemodynamic reactivity.Design, setting, participants, & measurements: Twenty-four patients with CKD (mean age 69.5 yr; 3.1 antihypertensive drugs; estimated GFR 47 ml/min per 1.73 m 2 , albumin/creatinine ratio 403 mg/g) were studied on three occasions during a 6-wk period with 24-h ambulatory BP monitoring and simultaneous activity monitoring with wrist actigraphy.Results: Nondippers were found have a greater level of sleep activity compared with dippers, although the awake activity level was similar (7.06 versus 6.73) between groups (P ‫؍‬ 0.042 for interaction). In 3587 BP activity pairs, hemodynamic reactivity was variable between individuals (systolic BP reactivity 1.06 [SD 10.50]; diastolic BP reactivity 0.89 [SD 7.80] heart rate reactivity 1.18 [SD 11.00]); those who were more sedentary had a greater increment in systolic BP compared with those who were less sedentary. Antihypertensive drugs blunted hemodynamic reactivity. Hemodynamic reactivity was greatest between 12 a.m. and 8 a.m., making this a vulnerable period for cardiovascular events.Conclusions: Greater hemodynamic reactivity in sedentary people with CKD offers a possible and thus far unrecognized mechanism of cardiovascular damage. Besides reducing BP, antihypertensive drugs reduce hemodynamic reactivity, which offers another plausible mechanism of cardiovascular protection with their use.

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Etiology and Management of Hypertension in Chronic Kidney Disease

Cited by 17 publications

References 151 publications

Nocturia, Nocturnal Activity, and Nondipping

Nocturia, Nocturnal Activity, and Nondipping

Correlates of Systolic Hypertension in Patients With Chronic Kidney Disease

Physical Activity and Hemodynamic Reactivity in Chronic Kidney Disease

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