Disparate Estimates of Hypertension Control From Ambulatory and Clinic Blood Pressure Measurements in Hypertensive Kidney Disease

Division of Nephrology, Department of Medicine, Columbia University Medical Center, Harlem Hospital Center, New York, NY 10037, USA.
Hypertension (Impact Factor: 7.63). 01/2009; 53(1):20-7. DOI: 10.1161/HYPERTENSIONAHA.108.115154
Source: PubMed

ABSTRACT Ambulatory blood pressure (ABP) monitoring provides unique information about day-night patterns of blood pressure (BP). The objectives of this article were to describe ABP patterns in African Americans with hypertensive kidney disease, to examine the joint distribution of clinic BP and ABP, and to determine associations of hypertensive target organ damage with clinic BP and ABP. This study is a cross-sectional analysis of baseline data from the African American Study of Kidney Disease Cohort Study. Masked hypertension was defined by elevated daytime (>or= 135/85 mm Hg) or elevated nighttime (>or= 120/70 mm Hg) ABP in those with controlled clinic BP (<140/90 mm Hg); nondipping was defined by a <or= 10% decrease in mean nighttime systolic BP; reverse dipping was defined by a higher nighttime than daytime systolic BP. Of the 617 participants (mean age: 60.2 years; 62% male; mean estimated glomerular filtration rate: 43.8 mL/min per 1.73 m(2)) with both clinic BP and ABP, 498 participants (80%) had a nondipping or reverse dipping profile. Of the 377 participants with controlled clinic BP (61%), 70% had masked hypertension. Compared with those with controlled clinic BP or white-coat hypertension, target organ damage (proteinuria and left ventricular hypertrophy) was more common in those with elevated nighttime BP, masked hypertension, or sustained hypertension. In conclusion, clinic BP provides an incomplete and potentially misleading assessment of the severity of hypertension in African Americans with hypertensive kidney disease, in large part because of increased nighttime BP. Whether lowering nighttime BP improves clinical outcomes is unknown but should be tested given the substantial burden of BP-related morbidity in this population.


Available from: Mohammed Sika, May 30, 2015
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Hypertension (HTN) and CKD are closely associated with an intermingled cause and effect relationship. Blood pressure (BP) typically rises with declines in kidney function, and sustained elevations in BP hasten progression of kidney disease. This review addresses current management issues in HTN in patients with CKD including altered circadian rhythm of BP, timing of antihypertensive medication dosing, BP targets, diagnostic challenges in evaluating secondary forms of HTN, and the role of salt restriction in CKD. HTN in patients with CKD is often accompanied by a decrease in the kidney's ability to remove salt. Addressing this salt sensitivity is critical for the management of HTN in CKD. In addition to the well-established use of an ACEI or angiotensin receptor blocker, dietary salt restriction and appropriate diuretic therapy make up the mainstay of HTN treatment in patients with CKD. Bedtime dosing of antihypertensive medications can restore nocturnal dips in BP, and future clinical practice guidelines may recommend bedtime dosing of 1 or more antihypertensive medications in patients with CKD. Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
    Advances in Chronic Kidney Disease 03/2015; 22(2). DOI:10.1053/j.ackd.2014.12.001 · 1.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Hypertension and CKD frequently coexist, and both are risk factors for cardiovascular events and mortality. Among people with hypertension, the loss of the normal fall in night-time BP, called nondipping, can only be diagnosed by ambulatory BP monitoring (ABPM) and is a risk factor for cardiovascular events. The pathophysiology of nondipping is complex, and CKD is an independent risk factor for nondipping. In fact, nondipping can be seen in as many as 80% of people with CKD. However, the evidence for nondipping as an independent risk factor or causal agent for adverse outcomes in CKD remains mixed. ABPM has been shown to be superior to clinical BP measurement for correlating with end-organ damage and prognosis in CKD. This review covers the evidence for the use of ABPM in CKD, the evidence linking ABPM patterns to outcome in CKD and the evidence for treatment of nondipping in CKD. Published by Elsevier Inc.
    Advances in Chronic Kidney Disease 03/2015; 22(2). DOI:10.1053/j.ackd.2015.01.003 · 1.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To review evidence for dosing antihypertensives at bedtime and possible cardiovascular risk reduction. A PubMed, EMBASE, and Cochrane Controlled Trials database literature search (1990-September 2014) limited to human subjects was performed using the search terms hypertension, chronotherapy, ambulatory blood pressure, morning administration, evening administration, and antihypertensives. Additional references were identified from literature citations. All prospective studies assessing cardiovascular outcomes or comparing morning to evening administration of antihypertensives were selected. Compared with morning administration, dosing one or more antihypertensive medications at bedtime helps induce a normal circadian blood pressure pattern and reduces the risk of cardiovascular disease morbidity and mortality in individuals with hypertension. Similar results have been reported in high-risk individuals with diabetes, chronic kidney disease, and resistant hypertension. A lack of diversity among studied populations and reliance on subgroup analyses are among the limitations of these data. All antihypertensive medications have not been studied in chronotherapy and do not uniformly achieve desired results. The most substantial evidence exists for medications affecting the renin-angiotensin-aldosterone system. Despite growing evidence and promise as a cost-effective strategy for reducing cardiovascular risk, chronotherapy is not uniformly recommended in the treatment of hypertension. Careful selection of patients and antihypertensives for chronotherapy is required. Further investigation is needed to evaluate the definitive impact of chronotherapy on cardiovascular outcomes. © The Author(s) 2014.
    Annals of Pharmacotherapy 12/2014; 49(3). DOI:10.1177/1060028014563535 · 2.92 Impact Factor