Vol 21, No 4 (2017)
Original paper
Published online: 2017-08-30
Evaluation of the relationship between circadian blood pressure profile and natriuresis in patients with chronic kidney disease and renal transplant recipients
Arterial Hypertension 2017;21(4):171-179.
Abstract
Introduction. The disturbed circadian rhythm of blood pressure (BP) is more prevalent in patients with chronic kidney disease (CKD). Diminished renal capacity to excrete sodium may result in nocturnal BP elevation in order to enhance pressure natriuresis to compensate for impaired daytime natriuresis. We hypothesized that kidney transplantation (KTx) that restores glomerular filtration should normalize circadian BP profile.
The aim of the study was to assess and compare natriuresis and circadian BP profiles of patients at different stages of CKD and KTx recipients.
Material and methods. Blood pressure was monitored noninvasively for 24 hours and urinary samples were collected during the daytime and night-time to measure natriuresis among 55 patients with stable graft or kidney function: 41 with CKD and 14 patients after KTx.
Results. Mean awake systolic blood pressure (SBP) was lower in KTx recipients than in CKD at all stages. Night-time mean BP was lowest in CKD patients with eGFR > 45 ml/min (126/68 mmHg vs. KTx 130/75 mmHg; p = 0.005). The prevalence of dipper status was also highest in CKD patients with eGFR > 45 ml/min. 50% vs. 8.3% (CKD 3b), 0% (CKD 4–5) and 7.1% (KTx) (p < 0.01), whereas reverse status was the rarest. Nocturnal blood pressure fall correlated inversely with night to day natriuresis ratios in both groups (CKD r = –0.91 p < 0.01; KTx r = –0.63 p = 0.016). The dipping profile was present only in KTx patients with eGFR > 60 ml/min, whereas reverse dipping profile only in those with eGFR < 60 ml/min. More than half CKD patients were taking at least 4 antihypertensive medications. In contrast, 64% of KTx recipients were receiving no more than 3 antihypertensive drugs to control BP.
Conclusions. Kidney transplantation improves blood pressure control and reduces a number of antihypertensive drugs used. Normal circadian rhythm could be restored only in the transplant patients with well-functioning renal graft.
Keywords: circadian rhythm of blood pressurechronic kidney diseasekidney transplantationnatriuresis
References
- Wojtusik S, et al. Rola nerek w patogenezie nadciśnienia tętniczego. Przegląd Lekarski. 2012; 9: 680–686.
- Navar L. The Role of the Kidneys in Hypertension. J Clin Hypertens. 2005; 7(9): 542–549.
- Wong ND, Lopez VA, L'Italien G, et al. Inadequate control of hypertension in US adults with cardiovascular disease comorbidities in 2003-2004. Arch Intern Med. 2007; 167(22): 2431–2436.
- Fukuda M, Mizuno M, Kimura G. Nocturnal Hypertension and Chronic Kidney Disease. Current Hypertension Reviews. 2011; 7(1): 5–8.
- Kimura G. Kidney and Circadian Blood Pressure Rhythm. Hypertension. 2008; 51(4): 827–828.
- Sachdeva A, Weder AB. Nocturnal sodium excretion, blood pressure dipping, and sodium sensitivity. Hypertension. 2006; 48(4): 527–533.
- O'Brien E, Parati G, Stergiou G, et al. European Society of Hypertension Working Group on Blood Pressure Monitoring and Cardiovascular Variability, European Society of Hypertension Working Group on Blood Pressure Monitoring. European Society of Hypertension position paper on ambulatory blood pressure monitoring. J Hypertens. 2013; 31(9): 1731–1768.
- Mancia G, Fagard R, Narkiewicz K, et al. 2013 ESH/ESC Guidelines for the management of arterial hypertension. J Hypertens. 2013; 31(7): 1281–1357.
- Parving HH, Jacobsen P, Rossing K, et al. Benefits of long-term antihypertensive treatment on prognosis in diabetic nephropathy. Kidney Int. 1996; 49(6): 1778–1782.
- Wee Pt. Angiotensin-Converting Enzyme Inhibitors and Progression of Nondiabetic Chronic Renal Disease. Archives of Internal Medicine. 1993; 153(15): 1749–1759.
- Levey AS, Gassman JJ, Hall PM, et al. Assessing the progression of renal disease in clinical studies: effects of duration of follow-up and regression to the mean. Modification of Diet in Renal Disease (MDRD) Study Group. J Am Soc Nephrol. 1991; 1(9): 1087–1094.
- Sica D. The Kidney and Hypertension: Causes and Treatment. The Journal of Clinical Hypertension. 2008; 10(7): 541–548.
- Mojón A, Ayala DE, Piñeiro L, et al. Hygia Project Investigators. Comparison of ambulatory blood pressure parameters of hypertensive patients with and without chronic kidney disease. Chronobiol Int. 2013; 30(1-2): 145–158.
- Elung-Jensen T, Strandgaard S, Kamper AL. Longitudinal observations on circadian blood pressure variation in chronic kidney disease stages 3-5. Nephrol Dial Transplant. 2008; 23(9): 2873–2878.
- Aparci M, Kardesoglu E, Zafer I, et al. Blood pressure control and dipping status in hypertensive patients with mild renal dysfunction LOOD. Anatol J Clin Investig. 2009; 3: 123–126.
- Wolfe RA, Ashby VB, Milford EL, et al. Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med. 1999; 341(23): 1725–1730.
- Mangray M, Vella JP. Hypertension after kidney transplant. Am J Kidney Dis. 2011; 57(2): 331–341.
- Covic A, Gusbeth-Tatomir P, Mardare N, et al. Dynamics of the circadian blood pressure profiles after renal transplantation. Transplantation. 2005; 80(9): 1168–1173.
- Wadei HM, Amer H, Taler SJ, et al. Diurnal blood pressure changes one year after kidney transplantation: relationship to allograft function, histology, and resistive index. J Am Soc Nephrol. 2007; 18(5): 1607–1615.
- Beltrán S, Crespo J, Kanter J, et al. Ambulatory blood pressure monitoring in renal transplant patients: should it be routinely performed? Transplant Proc. 2010; 42(8): 2868–2870.
- Lee MH, Ko KM, Ahn SW, et al. The impact of kidney transplantation on 24-hour ambulatory blood pressure in end-stage renal disease patients. J Am Soc Hypertens. 2015; 9(6): 427–434.
- Fujii T, Uzu T, Nishimura M, et al. Circadian rhythm of natriuresis is disturbed in nondipper type of essential hypertension. Am J Kidney Dis. 1999; 33(1): 29–35.
- Fukuda M, Munemura M, Usami T, et al. Nocturnal blood pressure is elevated with natriuresis and proteinuria as renal function deteriorates in nephropathy. Kidney Int. 2004; 65(2): 621–625.
- Bankir L, Bochud M, Maillard M, et al. Nighttime blood pressure and nocturnal dipping are associated with daytime urinary sodium excretion in African subjects. Hypertension. 2008; 51(4): 891–898.
- Pickering TG. The clinical significance of diurnal blood pressure variations. Dippers and nondippers. Circulation. 1990; 81(2): 700–702.
- Kasiske BL, Anjum S, Shah R, et al. Hypertension after kidney transplantation. Am J Kidney Dis. 2004; 43(6): 1071–1081.
- Opelz G, Döhler B. Collaborative Transplant Study. Improved long-term outcomes after renal transplantation associated with blood pressure control. Am J Transplant. 2005; 5(11): 2725–2731.