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Lee EKP, Wang S, Ng WL, Ramdzan SN, Tse ETY, Chan L, Rashid AA, Chin WY, Yu CP, Sit R, Poon P. Evening dosing versus morning dosing of antihypertensive medications for nocturnal hypertension: a systematic review and meta-analysis of 107 randomized controlled trials. J Hypertens 2024; 42:1653-1664. [PMID: 39196688 PMCID: PMC11356681 DOI: 10.1097/hjh.0000000000003783] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 05/20/2024] [Indexed: 08/30/2024]
Abstract
Since the effects of once-daily antihypertensive (HT) medications are more pronounced within the first few hours of ingestion, evening administration of anti-HT medications can be a feasible treatment for nocturnal HT. However, no relevant meta-analysis has been conducted in patients with nocturnal HT. This meta-analysis included randomized controlled trials involving patients with elevated mean nocturnal blood pressure (BP) and compared evening anti-HT administration with morning administration. Multiple databases, including grey literature (e.g. clincialtrial.gov), were searched. Study selection and data extraction were conducted by two independent authors. Risk of bias assessment and overall quality of evidence were conducted using Cochrane risk-of-bias tool and GRADE by two independent authors. A total of 107 studies were included, 76 of which were investigated in China and had not been identified in previous reviews. Only one trial was ranked low risk-of-bias. Evening administration of anti-HT medications was effective in reducing nocturnal systolic BP (4.12-9.10 mmHg; I2 = 80.5-95.2%) and diastolic BP (3.38-5.87 mmHg; I2 = 87.4-95.6%). Subgroup analyses found that the effectiveness of evening administration was contributed by data from the Hermida group and China. Evening administration did not provide additional nocturnal/daytime/24-h BP reduction in non-Hermida/non-China studies (I2 = 0) and in meta-analyses that included studies with unclear or low risk of bias. The effectiveness of nocturnal BP reduction was similar across different types, doses, and half-lives of medications. Evening administration of anti-HT medications may reduce proteinuria, left ventricular hypertrophy (LVH), nondipping and morning surge. The overall quality of evidence was ranked as very low to low. Our results highlight the scarcity of low risk-of-bias studies and emphasize the need for such trials to evaluate the efficacy of evening dosing of anti-HT medications as a standard treatment for patients with nocturnal HT across diverse populations.
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Affiliation(s)
- Eric Kam-Pui Lee
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, HKSAR, China
| | - S Wang
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, HKSAR, China
| | - WL Ng
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur
| | - SN Ramdzan
- Department of Primary Care Medicine, Faculty of Medicine, Universiti Malaya, Kuala Lumpur
| | - ETY Tse
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, HKSAR, China
- Department of Family Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen
| | - L Chan
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, HKSAR, China
- The Bau Institute of Medical and Health Sciences Education, Li Ka Shing Faculty of Medicine, The University of Hong Kong, HKSAR
- Department of Family Medicine, University of Hong Kong-Shenzhen Hospital, Shenzhen
| | - AA Rashid
- Department of Family Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, UPM, Serdang, Malaysia
| | - WY Chin
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, HKSAR, China
| | - CP Yu
- Li Ping Medical Library, The Chinese University of Hong Kong, HKSAR, China
| | - R Sit
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, HKSAR, China
| | - P Poon
- JC School of Public Health and Primary Care, The Chinese University of Hong Kong, HKSAR, China
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Cooper TE, Teng C, Tunnicliffe DJ, Cashmore BA, Strippoli GF. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for adults with early (stage 1 to 3) non-diabetic chronic kidney disease. Cochrane Database Syst Rev 2023; 7:CD007751. [PMID: 37466151 PMCID: PMC10355090 DOI: 10.1002/14651858.cd007751.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Chronic kidney disease (CKD) is a long-term condition that occurs as a result of damage to the kidneys. Early recognition of CKD is becoming increasingly common due to widespread laboratory estimated glomerular filtration rate (eGFR) reporting, raised clinical awareness, and international adoption of the Kidney Disease Improving Global Outcomes (KDIGO) classifications. Early recognition and management of CKD affords the opportunity to prepare for progressive kidney impairment and impending kidney replacement therapy and for intervention to reduce the risk of progression and cardiovascular disease. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system. Beneficial effects of ACEi and ARB on kidney outcomes and survival in people with a wide range of severity of kidney impairment have been reported; however, their effectiveness in the subgroup of people with early CKD (stage 1 to 3) is less certain. This is an update of a review that was last published in 2011. OBJECTIVES To evaluate the benefits and harms of ACEi and ARB or both in the management of people with early (stage 1 to 3) CKD who do not have diabetes mellitus (DM). SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies up to 6 July 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and Embase, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting the effect of ACEi or ARB in people with early (stage 1 to 3) CKD who did not have DM were selected for inclusion. Only studies of at least four weeks duration were selected. Authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria. DATA COLLECTION AND ANALYSIS Data extraction was carried out by two authors independently, using a standard data extraction form. The methodological quality of included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another. When more than one study reported similar outcomes, data were pooled using the random-effects model. Heterogeneity was analysed using a Chi² test and the I² test. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach MAIN RESULTS: Six studies randomising 9379 participants with CKD stages 1 to 3 (without DM) met our inclusion criteria. Participants were adults with hypertension; 79% were male from China, Europe, Japan, and the USA. Treatment periods ranged from 12 weeks to three years. Overall, studies were judged to be at unclear or high risk of bias across all domains, and the quality of the evidence was poor, with GRADE rated as low or very low certainty. In low certainty evidence, ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo may make little or no difference to death (any cause) (2 studies, 8873 participants): RR 2.00, 95% CI 0.26 to 15.37; I² = 76%), total cardiovascular events (2 studies, 8873 participants): RR 0.97, 95% CI 0.90 to 1.05; I² = 0%), cardiovascular-related death (2 studies, 8873 participants): RR 1.73, 95% CI 0.26 to 11.66; I² = 54%), stroke (2 studies, 8873 participants): RR 0.76, 95% CI 0.56 to 1.03; I² = 0%), myocardial infarction (2 studies, 8873 participants): RR 1.00, 95% CI 0.84 to 1.20; I² = 0%), and adverse events (2 studies, 8873 participants): RR 1.33, 95% CI 1.26 to 1.41; I² = 0%). It is uncertain whether ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo reduces congestive heart failure (1 study, 8290 participants): RR 0.75, 95% CI 0.59 to 0.95) or transient ischaemic attack (1 study, 583 participants): RR 0.94, 95% CI 0.06 to 15.01; I² = 0%) because the certainty of the evidence is very low. It is uncertain whether ARB (losartan 50 mg) compared to placebo (1 study, 226 participants) reduces: death (any-cause) (no events), adverse events (RR 19.34, 95% CI 1.14 to 328.30), eGFR rate of decline (MD 5.00 mL/min/1.73 m2, 95% CI 3.03 to 6.97), presence of proteinuria (MD -0.65 g/24 hours, 95% CI -0.78 to -0.52), systolic blood pressure (MD -0.80 mm Hg, 95% CI -3.89 to 2.29), or diastolic blood pressure (MD -1.10 mm Hg, 95% CI -3.29 to 1.09) because the certainty of the evidence is very low. It is uncertain whether ACEi (enalapril 20 mg, perindopril 2 mg or trandolapril 1 mg) compared to ARB (olmesartan 20 mg, losartan 25 mg or candesartan 4 mg) (1 study, 26 participants) reduces: proteinuria (MD -0.40, 95% CI -0.60 to -0.20), systolic blood pressure (MD -3.00 mm Hg, 95% CI -6.08 to 0.08) or diastolic blood pressure (MD -1.00 mm Hg, 95% CI -3.31 to 1.31) because the certainty of the evidence is very low. AUTHORS' CONCLUSIONS There is currently insufficient evidence to determine the effectiveness of ACEi or ARB in patients with stage 1 to 3 CKD who do not have DM. The available evidence is overall of very low certainty and high risk of bias. We have identified an area of large uncertainty for a group of patients who account for most of those diagnosed as having CKD.
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Affiliation(s)
- Tess E Cooper
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
| | - Claris Teng
- Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
| | | | - Brydee A Cashmore
- Centre for Kidney Research, The University of Sydney and The Children's Hospital at Westmead, Sydney, Australia
| | - Giovanni Fm Strippoli
- Sydney School of Public Health, The University of Sydney, Sydney, Australia
- Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, Australia
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Borrelli S, Garofalo C, Gabbai FB, Chiodini P, Signoriello S, Paoletti E, Ravera M, Bussalino E, Bellizzi V, Liberti ME, De Nicola L, Minutolo R. Dipping Status, Ambulatory Blood Pressure Control, Cardiovascular Disease, and Kidney Disease Progression: A Multicenter Cohort Study of CKD. Am J Kidney Dis 2023; 81:15-24.e1. [PMID: 35709922 DOI: 10.1053/j.ajkd.2022.04.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 04/19/2022] [Indexed: 12/24/2022]
Abstract
RATIONALE & OBJECTIVE Ambulatory blood pressure (BP) monitoring allows concurrent evaluation of BP control and nocturnal BP dipping status, both related to adverse outcomes. However, few studies have assessed the prognostic role of combining information on dipping status and achieved ambulatory BP in patients with chronic kidney disease (CKD). STUDY DESIGN Prospective observational cohort study. SETTING & PARTICIPANTS 906 patients with hypertension and CKD attending 1 of 3 Italian nephrology clinics. EXPOSURE Four groups were defined by simultaneously classifying systolic ambulatory BP levels as being at goal (daytime SBP <135 and nighttime SBP <120 mm Hg) or above goal, and the presence or absence of nocturnal dipping (nighttime to daytime SBP ratio of <0.9 versus ≥0.9). OUTCOME The composite of time to initiation of maintenance dialysis or estimated glomerular filtration rate (eGFR) decline ≥50%, and the composite of fatal and nonfatal cardiovascular events. ANALYTICAL APPROACH Multivariable Cox proportional hazards models were used to estimate risks of kidney disease progression and cardiovascular disease in the 4 exposure groups where nocturnal dipping with systolic ambulatory BP at goal was the reference group. RESULTS The mean patient age was 63.8 years, 61% were male, and 26.4% had diabetes; eGFR was 41.1 ± 20.8 mL/min/1.73 m2. The dipping prevalence in each of the 4 groups was as follows: nocturnal dipping with ambulatory BP at goal, 18.6%; no nocturnal dipping with ambulatory BP at goal, 20.5%; nocturnal dipping with ambulatory BP above goal, 11.8%; and no nocturnal dipping with ambulatory BP above goal, 49.1%. Among patients with ambulatory BP above goal, the risk of cardiovascular events was greater in the absence (HR, 2.79 [95% CI, 1.64-4.75]) and presence (HR, 2.05 [95% CI, 1.10-3.84]) of nocturnal dipping. The same held true for risk of kidney disease progression (HRs of 2.40 [95% CI, 1.58-3.65] and 2.11 [95% CI, 1.28-3.48] in the absence and presence of nocturnal dipping, respectively). Patients at the ambulatory BP goal but who did not experience nocturnal dipping had an increased risk of the cardiovascular end point (HR, 2.06 [95% CI, 1.15-3.68]) and the kidney disease progression outcome (HR, 1.82 [95% CI, 1.17-2.82]). LIMITATIONS Lack of a diverse cohort (all those enrolled were White). Residual uncontrolled confounding. CONCLUSIONS Systolic ambulatory BP above goal or the absence of nocturnal dipping, regardless of ambulatory BP, is associated with higher risks of cardiovascular disease and kidney disease progression among patients with CKD. PLAIN-LANGUAGE SUMMARY Among patients with chronic kidney disease (CKD), ambulatory blood pressure (BP) monitoring improves the identification of individuals at high risk of clinical disease outcomes. Those with uncontrolled ambulatory BP are known to have a higher risk of developing cardiovascular disease and kidney disease progression, particularly when their ambulatory BP does not decline by at least 10% at night. Whether this is also true for patients with presence of optimal ambulatory BP levels but a BP pattern of no nighttime decline is largely unknown. We measured ambulatory BP in 900 Italian patients with CKD and followed them for several years. We found that, independent of ambulatory BP level, the absence of nighttime reductions in BP was associated with worsening of CKD and more frequent cardiovascular events. The absence of nighttime declines in BP is an independent risk factor for adverse events among patients with CKD. Future studies are needed to examine whether treating the absence of nighttime declines in BP improves clinical outcomes.
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Affiliation(s)
- Silvio Borrelli
- Division of Nephrology, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - Carlo Garofalo
- Division of Nephrology, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - Francis B Gabbai
- Department of Medicine, VA San Diego Healthcare System and University of California at San Diego Medical School, San Diego, California
| | - Paolo Chiodini
- Division of Nephrology and Medical Statistics Unit, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - Simona Signoriello
- Division of Nephrology and Medical Statistics Unit, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - Ernesto Paoletti
- Nephrology, Dialysis and Transplantation Unit, Policlinico San Martino, Genoa, Italy
| | - Maura Ravera
- Nephrology, Dialysis and Transplantation Unit, Policlinico San Martino, Genoa, Italy
| | - Elisabetta Bussalino
- Nephrology, Dialysis and Transplantation Unit, Policlinico San Martino, Genoa, Italy
| | - Vincenzo Bellizzi
- Nephrology Unit, University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Salerno, Italy
| | - Maria Elena Liberti
- Division of Nephrology, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - Luca De Nicola
- Division of Nephrology, University of Campania, Luigi Vanvitelli, Naples, Italy
| | - Roberto Minutolo
- Division of Nephrology, University of Campania, Luigi Vanvitelli, Naples, Italy.
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Kenig A, Kolben Y, Asleh R, Amir O, Ilan Y. Improving Diuretic Response in Heart Failure by Implementing a Patient-Tailored Variability and Chronotherapy-Guided Algorithm. Front Cardiovasc Med 2021; 8:695547. [PMID: 34458334 PMCID: PMC8385752 DOI: 10.3389/fcvm.2021.695547] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 07/21/2021] [Indexed: 01/12/2023] Open
Abstract
Heart failure is a major public health problem, which is associated with significant mortality, morbidity, and healthcare expenditures. A substantial amount of the morbidity is attributed to volume overload, for which loop diuretics are a mandatory treatment. However, the variability in response to diuretics and development of diuretic resistance adversely affect the clinical outcomes. Morevoer, there exists a marked intra- and inter-patient variability in response to diuretics that affects the clinical course and related adverse outcomes. In the present article, we review the mechanisms underlying the development of diuretic resistance. The role of the autonomic nervous system and chronobiology in the pathogenesis of congestive heart failure and response to therapy are also discussed. Establishing a novel model for overcoming diuretic resistance is presented based on a patient-tailored variability and chronotherapy-guided machine learning algorithm that comprises clinical, laboratory, and sensor-derived inputs, including inputs from pulmonary artery measurements. Inter- and intra-patient signatures of variabilities, alterations of biological clock, and autonomic nervous system responses are embedded into the algorithm; thus, it may enable a tailored dose regimen in a continuous manner that accommodates the highly dynamic complex system.
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Affiliation(s)
- Ariel Kenig
- Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Yotam Kolben
- Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Rabea Asleh
- Department of Cardiology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
| | - Offer Amir
- Department of Cardiology, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
- The Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel
| | - Yaron Ilan
- Department of Medicine, Hebrew University-Hadassah Medical Center, Jerusalem, Israel
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Tiwari V, Chaudhary AR, Dasgupta S, Divyaveer S, Sahu RK, Pal A, Mondal R, Chakravarty K, Mandal AK, Sircar D, Pandey R. Effect of Chronotherapy of Antihypertensives in Chronic Kidney Disease: A Randomized Control Trial. Indian J Nephrol 2021; 31:9-15. [PMID: 33994681 PMCID: PMC8101668 DOI: 10.4103/ijn.ijn_322_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/13/2019] [Accepted: 04/03/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction: There is a higher prevalence of non-dipping pattern in hypertensive chronic kidney disease (CKD) patients. Nocturnal hypertension has been shown to predict cardiovascular mortality and morbidity and is often superior to daytime blood pressure. We studied the effect of shifting or adding antihypertensive to night time on blood pressure profile of CKD III-IV patients. Methods: In this single-center, prospective, randomized controlled trial, eligible participants were adults from eastern India aged 18–65 years with CKD stages 3 and 4, with a non-dipping pattern on ambulatory blood pressure monitor (ABPM). The intervention group received all the antihypertensives in the night time whereas the standard care group continued to take the medication in the morning. Both groups were followed up for 1 year. The primary outcome was the number of patients changed from non-dippers to dippers in the standard care group and intervention group. Secondary outcomes included a change in estimated glomerular filtration rate (eGFR) and change in the cardiac structure. Results: 39 patients in the intervention group and 36 patients in the standard care group were analyzed. 10 patients (26%) reverted to dipping pattern in the intervention group as compared to none in the standard care group. Mean changes in eGFR were −2.55 and −0.18 mL/min/1.73 m2 in the standard care and intervention group at the end of the study, respectively. Between-group difference in eGFR was significant at 1 year (5.22 [95% CI, 4.3–6.1] ml/min/1.73 m2); (P = 0.03). The cardiac structure showed no significant changes in either group. Conclusions: Bedtime administration of antihypertensives reverted non-dippers to dippers and slowed the decline in eGFR in CKD stages 3 and 4 compared to morning administration of antihypertensives.
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Affiliation(s)
- Vaibhav Tiwari
- Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India
| | - Arpita Ray Chaudhary
- Department of Nephrology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Sanjay Dasgupta
- Department of Nephrology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | | | - Raju Kumar Sahu
- Department of Nephrology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Atanu Pal
- Department of Nephrology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Rajib Mondal
- Department of Nephrology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Kapiljit Chakravarty
- Department of Nephrology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Asit Kumar Mandal
- Department of Nephrology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Dipankar Sircar
- Department of Nephrology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
| | - Rajendra Pandey
- Department of Nephrology, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India
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Hermida RC, Mojón A, Hermida-Ayala RG, Smolensky MH, Fernández JR. Extent of asleep blood pressure reduction by hypertension medications is ingestion-time dependent: Systematic review and meta-analysis of published human trials. Sleep Med Rev 2021; 59:101454. [PMID: 33571840 DOI: 10.1016/j.smrv.2021.101454] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 12/23/2020] [Indexed: 12/20/2022]
Abstract
Combined evidence of published prospective outcome trials and meta-analyses substantiate elevated asleep blood pressure (BP) and blunted sleep-time relative BP decline (non-dipping), regardless of wake-time office BP and awake or 24 h BP means, are jointly the most highly significant independent prognostic markers of cardiovascular disease (CVD) risk and worthy therapeutic targets for prevention. Nonetheless, current guidelines continue to recommend the diagnosis of hypertension, when based on ambulatory BP monitoring (ABPM), rely, solely, on either the 24 h or "daytime" BP means. They also fail to recommend the time to treat patients. We conducted a systematic review of published human trials regarding ingestion-time differences in the effects of hypertension medications on asleep BP and sleep-time relative BP decline. Some 62 such trials published between 1992 and 2020, totaling 6120 hypertensive persons, evaluated 21 different single and 8 dual-fixed combination therapies. The vast (82.3%) majority of the trials substantiate the bedtime/evening vs. upon-waking/morning treatment schedule produces statistically significant better clinical benefits, including enhanced reduction of asleep systolic BP by an average 5.17 mmHg (95%CI [4.04, 6.31], P < 0.001 between treatment-time groups) without inducing sleep-time hypotension, reduced prevalence of the high CVD risk non-dipper 24 h BP pattern, improved kidney function, and reduced cardiac pathology. Furthermore, systematic and comprehensive review of the ABPM-based literature published the past 29 years reveals no single study that reported significantly better benefits of the most recommended, yet unjustified by medical evidence, morning hypertension treatment-time scheme.
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Affiliation(s)
- Ramón C Hermida
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (atlanTTic), University of Vigo, Vigo, 36310, Spain; Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, 78712-0238, USA.
| | - Artemio Mojón
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (atlanTTic), University of Vigo, Vigo, 36310, Spain
| | - Ramón G Hermida-Ayala
- Chief Pharmacology Officer, Circadian Ambulatory Technology & Diagnostics (CAT&D), Santiago de Compostela, 15703, Spain
| | - Michael H Smolensky
- Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, 78712-0238, USA
| | - José R Fernández
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (atlanTTic), University of Vigo, Vigo, 36310, Spain
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Jeong JH, Fonkoue IT, Quyyumi AA, DaCosta D, Park J. Nocturnal blood pressure is associated with sympathetic nerve activity in patients with chronic kidney disease. Physiol Rep 2020; 8:e14602. [PMID: 33112490 PMCID: PMC7592496 DOI: 10.14814/phy2.14602] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 09/11/2020] [Indexed: 01/04/2023] Open
Abstract
Elevated nocturnal blood pressure (BP) and nocturnal non-dipping are frequently observed in patients with chronic kidney disease (CKD) and are stronger predictors of cardiovascular complications and CKD progression than standard office BP. The sympathetic nervous system (SNS) is thought to modulate diurnal hemodynamic changes and the vascular endothelium plays a fundamental role in BP regulation. We hypothesized that SNS overactivity and endothelial dysfunction in CKD are linked to elevated nocturnal BP and non-dipping. In 32 CKD patients with hypertension (56 ± 7 years), office BP, 24-hr ambulatory BP, muscle sympathetic nerve activity (MSNA) and endothelial function via flow-mediated dilation (FMD) were measured. Participants were subsequently divided into dippers (nighttime average BP > 10% lower than the daytime average BP, n = 8) and non-dippers (n = 24). Non-dippers had higher nighttime BP (p < .05), but not office and daytime BP, compared to dippers. MSNA burst incidence (81 ± 13 versus 67 ± 13 bursts/100 HR, p = .019) was higher and brachial artery FMD (1.7 ± 1.5 versus 4.7 ± 1.9%, p < .001) was lower in non-dippers compared to dippers. MSNA and FMD each predicted nighttime systolic (β = 0.48,-0.46, p = .02, 0.07, respectively) and diastolic BP (β = 0.38,-0.47, p = .04, 0.03, respectively) in multivariate-adjusted analyses. Our novel findings demonstrate that unfavorable nocturnal BP profiles are associated with elevated SNS activity and endothelial dysfunction in CKD. Specifically, CKD patients with higher nighttime BP and the non-dipping pattern have higher MSNA and lower FMD. These support our hypothesis that SNS overactivation and endothelial dysfunction are linked to the dysregulation of nighttime BP as well as the magnitude of BP lowering at nighttime in CKD.
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Affiliation(s)
- Jin H. Jeong
- Division of Renal MedicineDepartment of MedicineEmory University School of MedicineAtlantaGAUSA
- Department of Veterans Affairs Health Care SystemResearch Service LineDecaturGAUSA
| | - Ida T. Fonkoue
- Division of Renal MedicineDepartment of MedicineEmory University School of MedicineAtlantaGAUSA
- Department of Veterans Affairs Health Care SystemResearch Service LineDecaturGAUSA
| | - Arshed A. Quyyumi
- Division of CardiologyDepartment of MedicineEmory University School of medicineAtlantaGAUSA
| | - Dana DaCosta
- Division of Renal MedicineDepartment of MedicineEmory University School of MedicineAtlantaGAUSA
- Department of Veterans Affairs Health Care SystemResearch Service LineDecaturGAUSA
| | - Jeanie Park
- Division of Renal MedicineDepartment of MedicineEmory University School of MedicineAtlantaGAUSA
- Department of Veterans Affairs Health Care SystemResearch Service LineDecaturGAUSA
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8
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Aoki T, Ohashi N, Isobe S, Ishigaki S, Matsuyama T, Sato T, Fujikura T, Kato A, Miyajima H, Yasuda H. Chronotherapy with a Renin-angiotensin System Inhibitor Ameliorates Renal Damage by Suppressing Intrarenal Renin-angiotensin System Activation. Intern Med 2020; 59:2237-2244. [PMID: 32938851 PMCID: PMC7578605 DOI: 10.2169/internalmedicine.4243-19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 02/24/2020] [Indexed: 01/10/2023] Open
Abstract
Objective The intrarenal renin-angiotensin system (RAS) is activated in chronic kidney disease (CKD) patients and is not suppressed at night in CKD patients showing nocturnal hypertension, contributing to renal damage. Furthermore, changes in RAS inhibitor administration from morning to evening, namely chronotherapy, ameliorates renal damage at night. We attempted to clarify whether or not chronotherapy ameliorates renal damage by suppressing the intrarenal RAS activity. Methods We recruited 34 CKD patients with RAS inhibitors in the morning. We conducted ambulatory blood pressure (BP) monitoring and urine collection and evaluated urinary albumin (Alb) and angiotensinogen (AGT), which are surrogate markers for intrarenal RAS activity during the day and at night, respectively. The same experiments were conducted after changing the administration time. The ratio of values associated with morning versus evening dosing was defined as the morning to evening (M/E) ratio. Results The M/E ratio of urinary Alb had a significant and positive relationship with that of urinary AGT during the day and at night in all CKD patients. However, no significant relationships were found between the M/E ratios of urinary Alb and AGT using multiple linear regression analyses. Conversely, there was a significant and positive relationship between the M/E ratios of urinary Alb and AGT at night but not during the day in CKD patients whose estimated glomerular filtration rate was <45 mL/min/1.73 m2 and whose night-to-day ratio of systolic BP was >0.90, even after adjustment. Conclusion This study indicated that chronotherapy with RAS inhibitors improved the renal damage via intrarenal RAS suppression, especially in CKD patients with an impaired renal function and nocturnal hypertension.
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Affiliation(s)
- Taro Aoki
- Internal Medicine 1, Hamamatsu University School of Medicine, Japan
| | - Naro Ohashi
- Internal Medicine 1, Hamamatsu University School of Medicine, Japan
| | - Shinsuke Isobe
- Internal Medicine 1, Hamamatsu University School of Medicine, Japan
| | - Sayaka Ishigaki
- Blood Purification Unit, Hamamatsu University School of Medicine, Japan
| | | | - Taichi Sato
- Internal Medicine 1, Hamamatsu University School of Medicine, Japan
| | | | - Akihiko Kato
- Blood Purification Unit, Hamamatsu University School of Medicine, Japan
| | - Hiroaki Miyajima
- Internal Medicine 1, Hamamatsu University School of Medicine, Japan
| | - Hideo Yasuda
- Internal Medicine 1, Hamamatsu University School of Medicine, Japan
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9
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Chronotherapy for reduction of cardiovascular risk. Med Clin (Barc) 2020; 154:505-511. [PMID: 32336474 DOI: 10.1016/j.medcli.2020.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 01/25/2023]
Abstract
Numerous prospective studies establish that elevated asleep blood pressure (BP) constitutes a significant cardiovascular disease (CVD) risk factor, irrespective of daytime office BP measurements or awake and 24h BP measurements. Moreover, except for a small number of studies with flawed methodology, multiple clinical trials of high consistency document significantly better BP-lowering efficacy of hypertension medication and their combinations when ingested at bedtime compared to upon awakening as is customary. Additionally, recent trials conclude bedtime hypertension chronotherapy markedly reduces CVD risk not only in the general population, but also in more vulnerable patients of advanced age, with kidney disease, diabetes, or resistant hypertension. Collectively, these results call for a new definition of true arterial hypertension and its proper diagnosis and management.
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10
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Hermida RC, Smolensky MH, Mojón A, Crespo JJ, Ríos MT, Domínguez-Sardiña M, Otero A, Fernández JR. New perspectives on the definition, diagnosis, and treatment of true arterial hypertension. Expert Opin Pharmacother 2020; 21:1167-1178. [PMID: 32543325 DOI: 10.1080/14656566.2020.1746274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Office blood pressure measurements (OBPM), still used today for diagnosis and management of hypertension, fail to reveal clinically important features of the mostly predictable blood pressure (BP) 24 h pattern, and lead to >45% of individuals being misclassified. Current hypertension guidelines do not provide recommendation on when-to-treat, despite multiple prospective clinical trials documenting improved normalization of 24 h BP pattern and significant reduction in cardiovascular disease (CVD) events when hypertension medications are ingested at bedtime rather than upon waking. AREAS COVERED In this review, the authors discuss current evidence on the: (i) most relevant attributes of the 24 h BP pattern deterministic of CVD risk; (ii) asleep systolic BP (SBP) mean as the most significant therapeutic target for CVD risk reduction; (iii) ingestion-time differences in pharmacodynamics of BP-lowering medications as reported with high consistency in multiple clinical trials; and (iv) enhanced prevention of CVD events achieved by bedtime hypertension chronotherapy. EXPERT OPINION Several prospective trials consistently document asleep SBP mean and sleep-time relative SBP decline (dipping) constitute highly significant CVD risk factors, independent of OBPM. Bedtime, compared to customary upon-waking, hypertension chronotherapy reduces risk of major CVD events. Collectively, these findings call for new definition of true hypertension and, accordingly, its proper diagnosis and management.
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Affiliation(s)
- Ramón C Hermida
- Bioengineering & Chronobiology Laboratories, University of Vigo , Vigo, Spain.,Atlantic Research Center for Information and Communication Technologies (Atlanttic), University of Vigo , Vigo, Spain
| | - Michael H Smolensky
- Department of Biomedical Engineering, Cockrell School of Engineering, the University of Texas at Austin , Austin, TX, USA
| | - Artemio Mojón
- Bioengineering & Chronobiology Laboratories, University of Vigo , Vigo, Spain.,Atlantic Research Center for Information and Communication Technologies (Atlanttic), University of Vigo , Vigo, Spain
| | - Juan J Crespo
- Bioengineering & Chronobiology Laboratories, University of Vigo , Vigo, Spain.,Atlantic Research Center for Information and Communication Technologies (Atlanttic), University of Vigo , Vigo, Spain.,Estructura de Xestión Integrada de Vigo, Servicio Galego de Saúde (SERGAS) , Vigo, Spain
| | - María T Ríos
- Bioengineering & Chronobiology Laboratories, University of Vigo , Vigo, Spain.,Atlantic Research Center for Information and Communication Technologies (Atlanttic), University of Vigo , Vigo, Spain.,Estructura de Xestión Integrada de Vigo, Servicio Galego de Saúde (SERGAS) , Vigo, Spain
| | | | - Alfonso Otero
- Servicio de Nefrología, Complejo Hospitalario Universitario de Ourense, Estructura de Xestión Integrada de Ourense, Verín e O Barco de Valdeorras, Servicio Galego de Saúde (SERGAS) , Ourense, Spain
| | - José R Fernández
- Bioengineering & Chronobiology Laboratories, University of Vigo , Vigo, Spain.,Atlantic Research Center for Information and Communication Technologies (Atlanttic), University of Vigo , Vigo, Spain
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11
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Abstract
Numerous physiological functions exhibit substantial circadian oscillations. In the kidneys, renal plasma flow, the glomerular filtration rate and tubular reabsorption and/or secretion processes have been shown to peak during the active phase and decline during the inactive phase. These functional rhythms are driven, at least in part, by a self-sustaining cellular mechanism termed the circadian clock. The circadian clock controls different cellular functions, including transcription, translation and protein post-translational modifications (such as phosphorylation, acetylation and ubiquitylation) and degradation. Disruption of the circadian clock in animal models results in the loss of blood pressure control and substantial changes in the circadian pattern of water and electrolyte excretion in the urine. Kidney-specific suppression of the circadian clock in animals implicates both the intrinsic renal and the extrarenal circadian clocks in these pathologies. Alterations in the circadian rhythm of renal functions are associated with the development of hypertension, chronic kidney disease, renal fibrosis and kidney stones. Furthermore, renal circadian clocks might interfere with the pharmacokinetics and/or pharmacodynamics of various drugs and are therefore an important consideration in the treatment of some renal diseases or disorders.
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Affiliation(s)
- Dmitri Firsov
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland.
| | - Olivier Bonny
- Department of Pharmacology and Toxicology, University of Lausanne, Lausanne, Switzerland. .,Service of Nephrology, Department of Medicine, Lausanne University Hospital, Lausanne, Switzerland.
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12
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Yang K, Wang Y, Ding Y, Cui H, Zhou D, Chen L, Ma Z, Wang W, Zhang W, Luan J. Valsartan chronotherapy reverts the non-dipper pattern and improves blood pressure control through mediation of circadian rhythms of the renin-angiotensin system in spontaneous hypertension rats. Chronobiol Int 2019; 36:1058-1071. [PMID: 31096810 DOI: 10.1080/07420528.2019.1610419] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Kui Yang
- School of Pharmacy, Wannan Medical College, Wuhu, Anhui, P.R. China
- Department of Pharmacy, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, P.R. China
| | - Yaqin Wang
- School of Pharmacy, Wannan Medical College, Wuhu, Anhui, P.R. China
- Department of Pharmacy, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, P.R. China
| | - Yanyun Ding
- School of Pharmacy, Wannan Medical College, Wuhu, Anhui, P.R. China
- Department of Pharmacy, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, P.R. China
| | - Haiju Cui
- Department of Pharmacy, XuanCheng Vocational & Technical college, XuanCheng, Anhui, P.R. China
| | - Deixi Zhou
- Department of Pharmacy, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, P.R. China
| | - Lu Chen
- School of Pharmacy, Wannan Medical College, Wuhu, Anhui, P.R. China
| | - Zhangqing Ma
- School of Pharmacy, Wannan Medical College, Wuhu, Anhui, P.R. China
| | - Wusan Wang
- School of Pharmacy, Wannan Medical College, Wuhu, Anhui, P.R. China
| | - Wen Zhang
- School of Pharmacy, Wannan Medical College, Wuhu, Anhui, P.R. China
- Department of Pharmacy, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, P.R. China
| | - Jiajie Luan
- School of Pharmacy, Wannan Medical College, Wuhu, Anhui, P.R. China
- Department of Pharmacy, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, P.R. China
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Abstract
PURPOSE OF REVIEW Given the emerging knowledge that circadian rhythmicity exists in every cell and all organ systems, there is increasing interest in the possible benefits of chronotherapy for many diseases. There is a well-documented 24-h pattern of blood pressure with a morning surge that may contribute to the observed morning increase in adverse cardiovascular events. Historically, antihypertensive therapy involves morning doses, usually aimed at reducing daytime blood pressure surges, but an absence of nocturnal dipping blood pressure is also associated with increased cardiovascular risk. RECENT FINDINGS To more effectively reduce nocturnal blood pressure and still counteract the morning surge in blood pressure, a number of studies have examined moving one or more antihypertensives from morning to bedtime dosing. More recently, such studies of chronotherapy have studied comorbid populations including obstructive sleep apnea, chronic kidney disease, or diabetes. Here, we summarize major findings from recent research in this area (2013-2017). In general, nighttime administration of antihypertensives improved overall 24-h blood pressure profiles regardless of disease comorbidity. However, inconsistencies between studies suggest a need for more prospective randomized controlled trials with sufficient statistical power. In addition, experimental studies to ascertain mechanisms by which chronotherapy is beneficial could aid drug design and guidelines for timed administration.
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Affiliation(s)
- N P Bowles
- Oregon Institute of Occupational Health Sciences, Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Rd. L606, Portland, OR, 97239, USA.
| | - S S Thosar
- Oregon Institute of Occupational Health Sciences, Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Rd. L606, Portland, OR, 97239, USA
| | - M X Herzig
- Oregon Institute of Occupational Health Sciences, Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Rd. L606, Portland, OR, 97239, USA
| | - S A Shea
- Oregon Institute of Occupational Health Sciences, Oregon Health and Sciences University, 3181 S.W. Sam Jackson Park Rd. L606, Portland, OR, 97239, USA
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14
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Wang C, Ye Y, Liu C, Zhou Y, Lv L, Cheng C, Li S, Lou T, Liu X. Evening versus morning dosing regimen drug therapy for chronic kidney disease patients with hypertension in blood pressure patterns: a systematic review and meta-analysis. Intern Med J 2018; 47:900-906. [PMID: 28544243 DOI: 10.1111/imj.13490] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 04/25/2017] [Accepted: 05/06/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evening dosing regimen drug therapy on blood pressure (BP) control is used widely, but its clinical benefits and preservation or re-establishment of the normal 24-h BP dipping pattern in chronic kidney disease (CKD) patients is not known. AIMS To investigate the effect of an evening dosing regimen of antihypertensive drugs on BP patterns of CKD patients with hypertension. METHODS A systematic review was conducted by searching PUBMED, EMBASE, ASN-ONLINE, the Cochrane Library and the reference lists of relevant articles of published papers. All trials designed to evaluate the effects of evening versus morning dosing regimen drug therapy for CKD patients with hypertension were included. Meta-analysis was performed using random or fixed effects models. RESULTS Five randomised controlled trials and one comparative study, including 3732 patients, met the inclusion criteria. Compared with morning dosing regimen drug therapy, evening administration of antihypertensive medication was associated with a significant reduction of 40% in non-dipper BP patterns (risk ratio (RR), 95% CI, (0.43, 0.84)). We noted a significant decrease in nocturnal systolic blood pressure (SBP) (MD -3.17 mmHg, 95% CI (-5.41, -0.94)), a significant reduction in nocturnal diastolic blood pressure (DBP) (MD -1.37 mmHg, 95% CI (-2.05, -0.69)) and a significant increase in awake SBP (MD 1.15 mmHg, 95% CI (0.10, 2.19)) in patients assigned to the evening dosing regimen drug therapy group. Patients showed no significant differences for all-cause mortality and cardiovascular mortality. CONCLUSION This review shows that evening dosing regimen drug therapy could reverse non-dipper BP patterns in hypertensive CKD patients.
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Affiliation(s)
- Caixia Wang
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China.,Department of Nephrology, The Second People's Hospital of Shanxi Province, Shanxi, China
| | - Yuqiu Ye
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Chunyong Liu
- Department of Laboratory Medicine, The Second Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine, Guangzhou, China
| | - Yongming Zhou
- Department of Endocrinology, The Affiliated Tianyou Hospital, Wuhan University of Science and Technology, Wuhan, China
| | - Linsheng Lv
- Operation Room, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Cailian Cheng
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Shaomin Li
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Tanqi Lou
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xun Liu
- Department of Nephrology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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15
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Clinical Conditions and Predictive Markers of Non-Dipper Profile in Hypertensive Patients. ACTA MEDICA MARISIENSIS 2018. [DOI: 10.2478/amma-2018-0006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
Hypertension remains one of the primary causes of premature cardiovascular mortality representing a major independent risk factor.
The importance of ambulatory blood pressure monitoring in clinical evaluation of hypertensive patients, beyond diagnosis, is the identification of circadian dipping/non-dipping profile. The non-dipper pattern in hypertensive and normotensive patients is associated with significant target organ damage and worse outcomes, as an increased cardiovascular risk condition. Non-dipping pattern has been found to be associated with specific clinical conditions. Obesity, diabetes mellitus, metabolic syndrome, obstructive sleep apnea syndrome, chronic kidney disease, autonomic and baroreflex dysfunctions, salt sensitivity, hormonal changes, gender and age were extensively studied. Research efforts are focused on recognizing and exploring predictive markers of abnormal blood pressure circadian pattern. Previous studies acknowledge that red cell distribution width, mean platelet volume, fibrinogen level, C-reactive protein, serum uric acid and gamma-glutamyltransferase, are independently significant and positive associated to non-dipping pattern. Moreover, research on new biomarkers are conducted: Chitinase 3-Like-Protein 1, atrial and B-type natriuretic peptide, brain-derived neurotrophic factor, chemerin, sphingomyelin and the G972R polymorphism of the insulin receptor substrate-1 gene. This review summarizes the current knowledge of different clinical conditions and biomarkers associated with the non-dipper profile in hypertensive patients.
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16
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Hypertension in patients with CKD in China: clinical characteristics and management. Front Med 2017; 11:307-309. [DOI: 10.1007/s11684-017-0578-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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17
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Li X, Jiang Q, Wu W, Xu X, Miao L, Jin L, Xue L, Huang T, Di J, Liu J, He X. Night-time blood pressure and pulse wave velocity in dialysis patients. Clin Exp Nephrol 2017; 22:173-178. [PMID: 28791560 DOI: 10.1007/s10157-017-1464-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 06/20/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Ambulatory blood pressure (ABP) monitoring and carotid-femoral pulse wave velocity (cfPWV) provide important cardiovascular risk information for dialysis patients. This study aims to evaluate the risk factors of cfPWV and the associations between ambulatory blood pressure, especially night-time blood pressure and cfPWV. METHODS We conducted a cross-sectional study in patients on maintenance hemodialysis. ABP and cfPWV were measured on a midweek interdialytic day. Associations were determined using Pearson's correlation analysis and multiple stepwise regression model. RESULTS Systolic BPs and pulse pressures, but not diastolic BPs, were significantly and positively associated with cfPWV. In a stepwise regression model, age, diabetes mellitus and all-period systolic BP were independently associated with cfPWV. When day-time and night-time BPs were included in the analysis, respectively, only night-time systolic BP and age remained as independently associated with cfPWV. CONCLUSION Ambulatory BPs are potent associates of cfPWV and night-time systolic BP, rather than day-time BPs, is an independently predictor of cfPWV. Our results support the view that controlling of nocturnal hypertension provides a unique cardiovascular protection effect.
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Affiliation(s)
- Xiurong Li
- Department of Hemodialysis, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Qingbo Jiang
- Department of Laboratory, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Wenhui Wu
- Department of Hemodialysis, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xianlin Xu
- Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Liying Miao
- Department of Hemodialysis, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Lina Jin
- Department of Hemodialysis, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Lina Xue
- Department of Hemodialysis, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Tian Huang
- Department of Hemodialysis, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Jia Di
- Department of Hemodialysis, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Jinfeng Liu
- Department of Hemodialysis, The Third Affiliated Hospital of Soochow University, Changzhou, China.,Department of Laboratory, The Third Affiliated Hospital of Soochow University, Changzhou, China.,Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xiaozhou He
- Department of Hemodialysis, The Third Affiliated Hospital of Soochow University, Changzhou, China. .,Department of Urology, The Third Affiliated Hospital of Soochow University, Changzhou, China.
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18
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Hermida RC, Ayala DE, Fernández JR, Mojón A, Crespo JJ, Ríos MT, Smolensky MH. Bedtime Blood Pressure Chronotherapy Significantly Improves Hypertension Management. Heart Fail Clin 2017; 13:759-773. [PMID: 28865783 DOI: 10.1016/j.hfc.2017.05.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Consistent evidence of numerous studies substantiates the asleep blood pressure (BP) mean derived from ambulatory BP monitoring (ABPM) is both an independent and a stronger predictor of cardiovascular disease (CVD) risk than are daytime clinic BP measurements or the ABPM-determined awake or 24-hour BP means. Hence, cost-effective adequate control of sleep-time BP is of marked clinical relevance. Ingestion time, according to circadian rhythms, of hypertension medications of 6 different classes and their combinations significantly improves BP control, particularly sleep-time BP, and reduces adverse effects.
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Affiliation(s)
- Ramón C Hermida
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (AtlantTIC), E.I. Telecomunicación, University of Vigo, Campus Universitario, Pontevedra, Vigo 36310, Spain.
| | - Diana E Ayala
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (AtlantTIC), E.I. Telecomunicación, University of Vigo, Campus Universitario, Pontevedra, Vigo 36310, Spain
| | - José R Fernández
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (AtlantTIC), E.I. Telecomunicación, University of Vigo, Campus Universitario, Pontevedra, Vigo 36310, Spain
| | - Artemio Mojón
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (AtlantTIC), E.I. Telecomunicación, University of Vigo, Campus Universitario, Pontevedra, Vigo 36310, Spain
| | - Juan J Crespo
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (AtlantTIC), E.I. Telecomunicación, University of Vigo, Campus Universitario, Pontevedra, Vigo 36310, Spain; Centro de Salud de Bembrive, Estructura de Gestión Integrada de Vigo, Servicio Galego de Saúde (SERGAS), Vigo, Spain
| | - María T Ríos
- Bioengineering & Chronobiology Laboratories, Atlantic Research Center for Information and Communication Technologies (AtlantTIC), E.I. Telecomunicación, University of Vigo, Campus Universitario, Pontevedra, Vigo 36310, Spain; Centro de Salud de A Doblada, Estructura de Gestión Integrada de Vigo, Servicio Galego de Saúde (SERGAS), Vigo, Spain
| | - Michael H Smolensky
- Department of Biomedical Engineering, Cockrell School of Engineering, The University of Texas at Austin, Austin, TX, USA
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19
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Chronotherapy for hypertension in patients with chronic kidney disease: a systematic review and meta-analysis in non-black patients. Int Urol Nephrol 2016; 49:651-659. [PMID: 27844408 DOI: 10.1007/s11255-016-1437-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/11/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE To investigate the effects of chronotherapy on blood pressure in patients with chronic kidney disease (CKD). METHODS We searched PUBMED, EMBASE, ASN-ONLINE, the Cochrane Library and the reference articles of published papers without language restriction, for randomized and non-randomized trials that assessed the effect of chronotherapy versus morning dosing regimen drug therapy for CKD patients with hypertension. Meta-analysis was done with random-effect models. RESULTS After application of inclusion/exclusion criteria, three randomized controlled trials including 3380 patients were analyzed. Compared with morning dosing regimen drug therapy, chronotherapy was associated with a significant decrease of 3.55% in sleep-time relative decline of systolic blood pressure (SBP) (mean difference [MD], 95% CI, [0.22, 6.88]). In the chronotherapy group, we noted a significant decrease in nocturnal SBP (MD -3.79 mmHg, 95% CI, [-7.18, -0.41]) and nocturnal diastolic blood pressure (MD -1.55 mmHg, 95% CI. [- 2.28, -0.82]), but there was a small increase in awake SBP by 1.19 mmHg (MD, 95% CI, [0.06, 2.31]). No significant difference was noted in all-cause mortality and cardiovascular mortality. CONCLUSION This meta-analysis suggests that chronotherapy could reduce nocturnal BP in hypertensive CKD patients.
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20
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Wang C, Li Y, Zhang J, Ye Z, Zhang Q, Ma X, Peng H, Lou T. Prognostic Effect of Isolated Nocturnal Hypertension in Chinese Patients With Nondialysis Chronic Kidney Disease. J Am Heart Assoc 2016; 5:JAHA.116.004198. [PMID: 27792646 PMCID: PMC5121515 DOI: 10.1161/jaha.116.004198] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Isolated nocturnal hypertension (INH) has been studied among the general population and hypertensive patients. However, little insight is available on the prognostic effect of INH in patients with chronic kidney disease (CKD). This study investigated the prognostic effect of INH in a cohort of Chinese patients with nondialysis CKD. METHODS AND RESULTS A total of 588 Chinese CKD patients who were admitted to the Third Affiliated Hospital of Sun Yat-Sen University were enrolled in this study. We monitored blood pressure (BP) throughout the day and followed health outcomes in the 588 CKD patients admitted to our hospital division. We recorded time to total mortality, cardiovascular mortality, renal events, and cardiovascular events. A total of 370 (62.92%) individuals had nocturnal hypertension, which included 136 (23.13%) patients with INH. Multivariable Cox regression analyses showed that nocturnal BP was a significant risk factor for renal events and cardiovascular events in CKD patients, even when adjusted for clinic BP, 24-hour BP, or daytime BP. Patients with nocturnal hypertension showed a worse prognosis compared with patients with nocturnal normotension (P<0.05), and nocturnal hypertension (versus nocturnal normotension) was associated with an increased risk for renal events (hazard ratio [HR], 3.81; 95% CI, 1.74-8.36) and cardiovascular events (HR, 8.34; 95% CI, 1.98-35.07). In addition, patients with INH had a worse prognosis than patients with normotension (P<0.017), whereas INH (versus normotension) was associated with a higher risk of renal events (HR, 2.78; 95% CI, 1.16-6.65) and cardiovascular events (HR, 6.82; 95% CI, 1.52-30.63). CONCLUSIONS INH was associated with a poor prognosis in Chinese nondialysis CKD patients.
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Affiliation(s)
- Cheng Wang
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yan Li
- Department of Pathology, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Jun Zhang
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Zengchun Ye
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Qunzi Zhang
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xinxin Ma
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Hui Peng
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Tanqi Lou
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
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Prognostic Value of Reverse Dipper Blood Pressure Pattern in Chronic Kidney Disease Patients not Undergoing Dialysis: Prospective Cohort Study. Sci Rep 2016; 6:34932. [PMID: 27713498 PMCID: PMC5054683 DOI: 10.1038/srep34932] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 09/20/2016] [Indexed: 12/30/2022] Open
Abstract
The "reverse dipping" blood pressure (BP) pattern has been studied among the general population and in individuals suffering from hypertension. However, the prognosis of this pattern in chronic kidney disease (CKD) patients is not known. We monitored BP throughout the day and followed health outcomes in 588 CKD patients admitted to our hospital. Time to all-cause mortality, cardiovascular mortality, renal events and cardiovascular events was recorded. Multivariate-adjusted Cox regression analyses were carried out to detect the prognostic value of a reverse dipping BP pattern. Prevalence of a "dipper", "non-dipper" and "reverse dippers" was 34.69%, 43.54% and 18.03%, respectively. Patients with a reverse dipping pattern had a higher prevalence of total mortality, cardiovascular mortality, renal events and cardiovascular events than patients with a dipping pattern (P < 0.025). Multivariate-adjusted Cox regression analyses showed that reverse dippers (versus dippers) were associated with a higher risk of total mortality (hazard ratio [HR], 5.08; 95% confidence interval [CI], 1.79~14.47), cardiovascular mortality (4.17; 1.25~13.88), renal events (3.00; 1.59~5.65) and cardiovascular events (4.12; 1.78~9.51) even after adjustment by 24-h systolic BP. These data suggest that a reverse dipping BP pattern, independent of 24-h levels of systolic BP, has prognostic value in CKD patients not undergoing dialysis.
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Velasquez MT, Beddhu S, Nobakht E, Rahman M, Raj DS. Ambulatory Blood Pressure in Chronic Kidney Disease: Ready for Prime Time? Kidney Int Rep 2016; 1:94-104. [PMID: 28164170 PMCID: PMC5283800 DOI: 10.1016/j.ekir.2016.05.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/15/2016] [Accepted: 05/18/2016] [Indexed: 12/15/2022] Open
Abstract
Hypertension is common in patients with chronic kidney disease (CKD) and is the most important modifiable risk factor for CKD progression and adverse cardiovascular events in these patients. Diagnosis and successful management of hypertension are critically dependent on accurate blood pressure (BP) measurement. This is most relevant to CKD patients, in whom BP control is difficult to achieve and in whom early antihypertensive treatment is imperative to prevent kidney and cardiovascular complications. Accumulated data indicate that ambulatory blood pressure monitoring (ABPM) is better in detecting hypertension than office BP measurement. ABPM is also a superior prognostic marker compared with office BP and has successfully identified hypertensive CKD patients at increased risk. Additionally, ABPM provides information on circadian BP variation and short-term BP variability, which is associated with cardiovascular and renal outcomes. This paper reviews the evidence for the usefulness of ABPM in detection and management of hypertension in CKD patients and discusses our current understanding of the pathophysiology of altered circadian BP rhythm and variability in CKD and the role of abnormal BP patterns detected by ABPM in relation to outcomes in CKD. In addition, this Review examines the emerging role of antihypertensive chronotherapy to tailor BP management to the circadian BP pattern abnormality detected by 24-hour ABPM.
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Affiliation(s)
- Manuel T. Velasquez
- Division of Renal Diseases and Hypertension, The George Washington University, Washington, DC, USA
| | - Srinivasan Beddhu
- University of Utah School of Medicine, Kidney and Liver Clinic, Salt Lake City, Utah, USA
| | - Ehsan Nobakht
- Division of Renal Diseases and Hypertension, The George Washington University, Washington, DC, USA
| | - Mahboob Rahman
- University Hospitals Case Medical Center, Department of Medicine–Hypertension, Cleveland, Ohio, USA
| | - Dominic S. Raj
- Division of Renal Diseases and Hypertension, The George Washington University, Washington, DC, USA
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Dallmann R, Okyar A, Lévi F. Dosing-Time Makes the Poison: Circadian Regulation and Pharmacotherapy. Trends Mol Med 2016; 22:430-445. [PMID: 27066876 DOI: 10.1016/j.molmed.2016.03.004] [Citation(s) in RCA: 178] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 03/17/2016] [Indexed: 12/14/2022]
Abstract
Daily rhythms in physiology significantly modulate drug pharmacokinetics and pharmacodynamics according to the time-of-day, a finding that has led to the concept of chronopharmacology. The importance of biological clocks for xenobiotic metabolism has gained increased attention with the discovery of the molecular circadian clockwork. Mechanistic understanding of the cell-autonomous molecular circadian oscillator and the circadian timing system as a whole has opened new conceptual and methodological lines of investigation to understand first, the clock's impact on a specific drug's daily variations or the effects/side effects of environmental substances, and second, how clock-controlled pathways are coordinated within a given tissue or organism. Today, there is an increased understanding of the circadian modulation of drug effects. Moreover, several molecular strategies are being developed to treat disease-dependent and drug-induced clock disruptions in humans.
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Affiliation(s)
- Robert Dallmann
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK; Warwick Systems Biology Centre, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK.
| | - Alper Okyar
- Department of Pharmacology, Faculty of Pharmacy, Istanbul University, Beyazit-Istanbul, Turkey
| | - Francis Lévi
- Warwick Medical School, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK; Warwick Systems Biology Centre, University of Warwick, Gibbet Hill Road, Coventry, CV4 7AL, UK
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Chronotherapy with conventional blood pressure medications improves management of hypertension and reduces cardiovascular and stroke risks. Hypertens Res 2015; 39:277-92. [PMID: 26657008 DOI: 10.1038/hr.2015.142] [Citation(s) in RCA: 82] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Revised: 11/16/2015] [Accepted: 11/17/2015] [Indexed: 12/22/2022]
Abstract
Correlation between blood pressure (BP) and target organ damage, vascular risk and long-term patient prognosis is greater for measurements derived from around-the-clock ambulatory BP monitoring than in-clinic daytime ones. Numerous studies consistently substantiate the asleep BP mean is both an independent and a much better predictor of cardiovascular disease (CVD) risk than either the awake or 24 h means. Sleep-time hypertension is much more prevalent than suspected, not only in patients with sleep disorders, but also among those who are elderly or have type 2 diabetes, chronic kidney disease or resistant hypertension. Hence, cost-effective adequate control of sleep-time BP is of marked clinical relevance. Ingestion time, according to circadian rhythms, of hypertension medications of six different classes and their combinations significantly affects BP control, particularly sleep-time BP, and adverse effects. For example, because the high-amplitude circadian rhythm of the renin-angiotensin-aldosterone system activates during nighttime sleep, bedtime vs. morning ingestion of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers better reduces the asleep BP mean, with additional benefit, independent of medication terminal half-life, of converting the 24 h BP profile into more normal dipper patterning. The MAPEC (Monitorización Ambulatoria para Predicción de Eventos Cardiovasculares) study, first prospective randomized treatment-time investigation designed to test the worthiness of bedtime chronotherapy with ⩾1 conventional hypertension medications so as to specifically target attenuation of asleep BP, demonstrated, relative to conventional morning therapy, 61% reduction of total CVD events and 67% decrease of major CVD events, that is, CVD death, myocardial infarction, and ischemic and hemorrhagic stroke. The MAPEC study, along with other earlier conducted less refined trials, documents the asleep BP mean is the most significant prognostic marker of CVD morbidity and mortality; moreover, it substantiates attenuation of the asleep BP mean by a bedtime hypertension treatment strategy entailing the entire daily dose of ⩾1 hypertension medications significantly reduces CVD risk in both general and more vulnerable hypertensive patients, that is, those diagnosed with chronic kidney disease, diabetes and resistant hypertension.
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Wang C, Deng W, Gong W, Zhang J, Zhang Q, Ye ZC, Lou T. Nocturnal Hypertension Correlates Better With Target Organ Damage in Patients With Chronic Kidney Disease than a Nondipping Pattern. J Clin Hypertens (Greenwich) 2015; 17:792-801. [PMID: 26041362 PMCID: PMC8031545 DOI: 10.1111/jch.12589] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Revised: 04/08/2015] [Accepted: 04/09/2015] [Indexed: 11/26/2022]
Abstract
Both nocturnal hypertension and nondipping pattern are associated with target organ damages (TODs); however, no data exist with respect to Chinese patients with chronic kidney disease (CKD). The authors recruited 1322 patients with CKD admitted to our hospital division and referred with data in this cross-sectional study. Patients with nocturnal systolic hypertension had a lower estimated glomerular filtration rate (eGFR) and higher left ventricular mass index (LVMI) and carotid intima-media thickness (cIMT) compared with patients with normal nocturnal systolic blood pressure (SPB; all, P<.001), while patients in the dipper and nondipper groups had similar levels of eGFR, LVMI, and cIMT when the patients had a similar nocturnal SBP. Factorial-designed analysis of variance indicated that the main effect of nocturnal SBP was significant for all TOD differences (all, P<.001), but no significance existed with respect to the main effect of the dipper pattern and an interaction between the two factors (all, P>.05). Nocturnal systolic hypertension, rather than nondipping pattern, was an independent risk factor for TOD in CKD patients. Nocturnal hypertension, rather than a nondipping pattern, was better associated with TOD in CKD patients.
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Affiliation(s)
- Cheng Wang
- Division of NephrologyDepartment of MedicineThird Affiliated Hosptial of Sun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Wen‐Jie Deng
- Division of NephrologyDepartment of MedicineThird Affiliated Hosptial of Sun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Wen‐Yu Gong
- Division of NephrologyDepartment of MedicineThird Affiliated Hosptial of Sun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Jun Zhang
- Division of NephrologyDepartment of MedicineThird Affiliated Hosptial of Sun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Qun‐Zi Zhang
- Division of NephrologyDepartment of MedicineThird Affiliated Hosptial of Sun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Zeng Chun Ye
- Division of NephrologyDepartment of MedicineThird Affiliated Hosptial of Sun Yat‐Sen UniversityGuangzhouGuangdongChina
| | - Tanqi Lou
- Division of NephrologyDepartment of MedicineThird Affiliated Hosptial of Sun Yat‐Sen UniversityGuangzhouGuangdongChina
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Wang C, Deng WJ, Gong WY, Zhang J, Tang H, Peng H, Zhang QZ, Ye ZC, Lou T. High prevalence of isolated nocturnal hypertension in Chinese patients with chronic kidney disease. J Am Heart Assoc 2015; 4:e002025. [PMID: 26089178 PMCID: PMC4599541 DOI: 10.1161/jaha.115.002025] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background Isolated nocturnal hypertension (INH) has been studied among the general population and hypertensive patients. However, little insight is available on the prevalence of INH and its role in target-organ damage among patients with chronic kidney disease (CKD). Methods and Results We recruited 1282 CKD patients admitted to our hospital division. Patients were divided into 4 groups: INH; isolated daytime hypertension; day–night sustained; and ambulatory normotension. Multiple linear regression analyses were used to evaluate the correlation between INH and renal/cardiovascular parameters. A total of 262 (20.44%) CKD patients had isolated nocturnal hypertension and 651 (50.78%) had day–night sustained hypertension, whereas only 350 (27.30%) patients showed normotension and 19 (1.48%) had isolated daytime hypertension. Multivariate logistic regression analysis showed that INH was associated mainly with age, estimated glomerular filtration rate, clinic diastolic blood pressure, and that INH was determined only by age, estimated glomerular filtration rate, and clinic diastolic blood pressure. The prevalence of impaired renal function, left ventricular hypertrophy, and carotid intima-media thickness in patients with INH were higher than in normotensive patients (P<0.05), whereas impaired renal function and left ventricular hypertrophy in these patients were lower than patients in the day–night sustained hypertension group (P<0.05). INH was correlated with estimated glomerular filtration rate, left ventricular mass index, and carotid intima-media thickness according to multiple linear regression analyses. Conclusions The prevalence of INH in CKD patients was high, and INH was correlated with target-organ damage in CKD patients.
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Affiliation(s)
- Cheng Wang
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (C.W., W.J.D., W.Y.G., J.Z., H.T., H.P., Q.Z.Z., Z.C.Y., T.L.)
| | - Wen-Jie Deng
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (C.W., W.J.D., W.Y.G., J.Z., H.T., H.P., Q.Z.Z., Z.C.Y., T.L.)
| | - Wen-Yu Gong
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (C.W., W.J.D., W.Y.G., J.Z., H.T., H.P., Q.Z.Z., Z.C.Y., T.L.)
| | - Jun Zhang
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (C.W., W.J.D., W.Y.G., J.Z., H.T., H.P., Q.Z.Z., Z.C.Y., T.L.)
| | - Hua Tang
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (C.W., W.J.D., W.Y.G., J.Z., H.T., H.P., Q.Z.Z., Z.C.Y., T.L.)
| | - Hui Peng
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (C.W., W.J.D., W.Y.G., J.Z., H.T., H.P., Q.Z.Z., Z.C.Y., T.L.)
| | - Qun-Zi Zhang
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (C.W., W.J.D., W.Y.G., J.Z., H.T., H.P., Q.Z.Z., Z.C.Y., T.L.)
| | - Zeng-Chun Ye
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (C.W., W.J.D., W.Y.G., J.Z., H.T., H.P., Q.Z.Z., Z.C.Y., T.L.)
| | - Tanqi Lou
- Division of Nephrology, Department of Medicine, Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China (C.W., W.J.D., W.Y.G., J.Z., H.T., H.P., Q.Z.Z., Z.C.Y., T.L.)
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Disparate assessment of clinic blood pressure and ambulatory blood pressure in differently aged patients with chronic kidney disease. Int J Cardiol 2015; 183:54-62. [PMID: 25662054 DOI: 10.1016/j.ijcard.2015.01.051] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 10/23/2014] [Accepted: 01/25/2015] [Indexed: 01/11/2023]
Abstract
BACKGROUND Ambulatory blood pressure monitoring (ABPM) is recommended to assess hypertensive status in patients with chronic kidney disease (CKD). However, the difference in blood pressure (BP) based on clinic and ambulatory monitoring in CKD patients of different ages is not known. METHODS We recruited 1116 CKD patients admitted to our hospital division and referred with data in this cross-sectional study. Patients were divided into three groups: young, middle age and old. Inter-method agreement between clinic BP and ABPM in different age groups was assessed using the Kappa (κ) coefficient. Linear and logistic regression analyses were used to evaluate renal and cardiovascular parameters. RESULTS κ coefficient for inter-method agreement between clinic BP and ABP in patients from young, middle-age and old groups was 0.472 (p<0.001), 0.335 (p<0.001) and 0.102 (p=0.086), respectively. Age was the main factor determining the difference in clinic BP and ABP by multiple linear regression analyses. Prevalence of masked hypertension in older patients was higher than that in young and middle-age patients (p<0.001), and age was associated with the onset of masked hypertension. Age and ABP were independently correlated with estimated glomerular filtration rate (eGFR) and left ventricular mass index (LVMI), whereas age and clinic BP were associated with carotid intima media thickness (cIMT) by linear and logistic regression analyses. CONCLUSIONS We have provided evidence of disparate assessment of the diagnosis and correlation with TOD from clinic BP and ABP in untreated, different-aged, CKD patients. Good-quality, long-term, large longitudinal trials are needed to validate the role of ABPM for Chinese CKD patients.
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Stranges PM, Drew AM, Rafferty P, Shuster JE, Brooks AD. Treatment of hypertension with chronotherapy: is it time of drug administration? Ann Pharmacother 2014; 49:323-34. [PMID: 25515866 DOI: 10.1177/1060028014563535] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To review evidence for dosing antihypertensives at bedtime and possible cardiovascular risk reduction. DATA SOURCES 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. STUDY SELECTION All prospective studies assessing cardiovascular outcomes or comparing morning to evening administration of antihypertensives were selected. DATA SYNTHESIS 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. CONCLUSIONS 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.
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Affiliation(s)
- Paul M Stranges
- St Louis College of Pharmacy, MO, USA Barnes-Jewish Hospital Department of Pharmacy, St Louis, MO, USA
| | - Amy M Drew
- St Louis College of Pharmacy, MO, USA Mercy Clinic Family Medicine, St Louis, MO, USA
| | - Patricia Rafferty
- St Louis College of Pharmacy, MO, USA St Louis County Department of Health, MO, USA
| | - Jerrica E Shuster
- St Louis College of Pharmacy, MO, USA Barnes-Jewish Hospital Department of Pharmacy, St Louis, MO, USA
| | - Amie D Brooks
- St Louis College of Pharmacy, MO, USA St Louis County Department of Health, MO, USA
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29
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Liu X, Liu X, Huang W, Leo S, Li Y, Liu M, Yuan H. Evening -versus morning- dosing drug therapy for chronic kidney disease patients with hypertension: a systematic review. Kidney Blood Press Res 2014; 39:427-40. [PMID: 25471279 DOI: 10.1159/000368456] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS There is a strong correlation between non-dipping status and cardiovascular events in chronic kidney disease (CKD) patients. Our study is designed to identify the effect of evening administration of antihypertensive drugs to hypertensive CKD patients. METHODS A comprehensive search of Medline, Embase, the Chinese Biomedical Literature Database, Wanfang Data, Chinese National Knowledge Infrastructure, and the Cochrane Central Register of Controlled Trials was performed in July 2014. Concurrent controlled or crossover trials (including randomized and non-randomized experimental trials) designed to evaluate the effects of evening- versus morning-dosing hypertensive drug regimens on clinical outcomes in CKD patients with hypertension were included. All statistical analyses were performed using the RevMan software, which is available free from the Cochrane Collaboration. RESULTS Seven trials involving 1277 patients were identified, and the randomized controlled trials (RCTs) and non-randomized controlled trials (non-RCTs) were classified into two groups. Taking at least one blood pressure-lowering medication at bedtime was not shown to reduce total death (P=0.056) or cardiovascular death (P=0.059) but was shown to reduce total events (P<0.001) and major cardiovascular events (P<0.001) in both RCTs and non-RCTs. Compared with a morning dosing regimen, taking antihypertensive drug in the evening significantly lowered nighttime systolic blood pressure (SBP) (P<0.0001) and diastolic blood pressure (P<0.05) in patients in the RCTs but did not affect blood pressure in patients in the non-RCTs (P<0.05). There is limited evidence from one non-RCT that taking an antihypertensive drug (benazepril 10 mg) in the evening did not increase adverse events (P=0.72) or withdrawals due to adverse events (P=0.64). CONCLUSIONS A regimen of antihypertensive drugs in the evening should be considered for CKD patients with hypertension to lower nighttime blood pressure and help prevent total events and cardiovascular mortality. More studies are needed to verify the results of this study.
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Affiliation(s)
- Xing Liu
- Department of Cardiology, the Third Xiang-Ya Hospital, Central South University, Changsha, Hunan, China
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Hermida RC, Smolensky MH, Ayala DE, Fernández JR, Moyá A, Crespo JJ, Mojón A, Ríos MT, Fabbian F, Portaluppi F. Abnormalities in chronic kidney disease of ambulatory blood pressure 24 h patterning and normalization by bedtime hypertension chronotherapy. Nephrol Dial Transplant 2014; 29:1160-1167. [PMID: 24009285 DOI: 10.1093/ndt/gft285] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
In chronic kidney disease (CKD), the prevalence of hypertension is very high, escalating with diminishing renal function. Typically, the diagnosis of hypertension and the clinical decisions regarding its treatment are based on daytime clinic blood pressure (BP) measurements. However, the correlation between BP level and target organ damage, cardiovascular risk and long-term prognosis is greater for ambulatory than clinic measurements. Moreover, evidence is consistent among numerous studies that the elevated risk and incidence of end-organ injury and fatal and non-fatal cardiovascular events are significantly associated with blunted night-time BP decline, and that the asleep BP better predicts cardiovascular events than either the awake or 24-h BP mean. The prevalence of abnormally high asleep BP is extensive in CKD, significantly increasing with its severity. In CKD, the diagnoses of hypertension and its therapeutic control are often inaccurate in the absence of complete and careful assessment of the entire 24 h, i.e. daytime and night-time, BP pattern. Accordingly, ambulatory BP monitoring should be the preferred method to comprehensively assess and decide the optimal clinical management of patients with CKD. Recent findings indicate therapeutic restoration of normal physiologic BP reduction during night-time sleep is the most significant independent predictor of decreased cardiovascular and cerebrovascular risk, both in patients with and without CKD, and is best achieved when antihypertensive medications, mainly those blocking the renin-angiotensin-aldosterone system, are routinely taken at bedtime.
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Affiliation(s)
- Ramón C Hermida
- Bioengineering & Chronobiology Laboratories, University of Vigo, Campus Universitario, Vigo, Spain
| | - Michael H Smolensky
- Cockrell School of Engineering, Department of Biomedical Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Diana E Ayala
- Bioengineering & Chronobiology Laboratories, University of Vigo, Campus Universitario, Vigo, Spain
| | - José R Fernández
- Bioengineering & Chronobiology Laboratories, University of Vigo, Campus Universitario, Vigo, Spain
| | - Ana Moyá
- Bioengineering & Chronobiology Laboratories, University of Vigo, Campus Universitario, Vigo, Spain Centro de Salud de Lérez, Gerencia Única Integrada Pontevedra-Salnés, Servicio Galego de Saúde (SERGAS), Pontevedra, Spain
| | - Juan J Crespo
- Bioengineering & Chronobiology Laboratories, University of Vigo, Campus Universitario, Vigo, Spain Centro de Salud de Bembrive, Estructura de Gestión Integrada de Vigo, Servicio Galego de Saúde (SERGAS), Vigo, Spain
| | - Artemio Mojón
- Bioengineering & Chronobiology Laboratories, University of Vigo, Campus Universitario, Vigo, Spain
| | - María T Ríos
- Bioengineering & Chronobiology Laboratories, University of Vigo, Campus Universitario, Vigo, Spain Centro de Salud de A Doblada, Estructura de Gestión Integrada de Vigo, Servicio Galego de Saúde (SERGAS), Vigo, Spain
| | - Fabio Fabbian
- Hypertension Center, University Hospital S. Anna and Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Francesco Portaluppi
- Hypertension Center, University Hospital S. Anna and Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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Chronotherapeutics of Conventional Blood Pressure-Lowering Medications: Simple, Low-Cost Means of Improving Management and Treatment Outcomes of Hypertensive-Related Disorders. Curr Hypertens Rep 2014; 16:412. [DOI: 10.1007/s11906-013-0412-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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32
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Reversed dipper blood-pressure pattern is closely related to severe renal and cardiovascular damage in patients with chronic kidney disease. PLoS One 2013; 8:e55419. [PMID: 23393577 PMCID: PMC3564807 DOI: 10.1371/journal.pone.0055419] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 12/22/2012] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND A non-dipper blood pressure (BP) pattern is very common in chronic kidney disease (CKD) patients and affects the progression and development of cardiovascular disease. However, data on the reversed dipper BP pattern on target-organ damage in Chinese CKD patients are lacking. METHODS A total of 540 CKD patients were enrolled. Ambulatory blood pressure monitoring (ABPM), clinical BP, ultrasonographic assessment and other clinical data were collected. Univariate and multivariate analyses were used to ascertain the relationship between ABPM results and clinical parameters. RESULTS A total of 21.9% CKD patients had a reversed dipper BP pattern, 42% of patients had a non-dipper BP pattern and 36.1% of patients had a dipper BP pattern. Patients with reversed dipper BP pattern had the worst renal function and most severe cardiovascular damages among these CKD patients (p<0.05). The estimated glomerular filtration rate (eGFR) and left ventricular mass index (LVMI) correlated significantly with the rate of decline of nocturnal BP. A reversed dipper BP pattern was an independent factor affecting kidney damage and left ventricular hypertrophy. Age, lower hemoglobin level, higher 24-h systolic BP from ABPM, and higher serum phosphate levels were independent associated with a reversed dipper BP pattern after multivariate logistic regression analyses. CONCLUSION The reversed dipper BP pattern is closely related to severe renal damage and cardiovascular injuries in CKD patients, and special attention should be given to these CKD patients.
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