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Original Investigation |

Prognostic Role of Ambulatory Blood Pressure Measurement in Patients With Nondialysis Chronic Kidney Disease FREE

Roberto Minutolo, MD, PhD; Rajiv Agarwal, MD; Silvio Borrelli, MD; Paolo Chiodini, MSc; Vincenzo Bellizzi, MD, PhD; Felice Nappi, MD; Bruno Cianciaruso, MD; Pasquale Zamboli, MD; Giuseppe Conte, MD; Francis B. Gabbai, MD; Luca De Nicola, MD, PhD
[+] Author Affiliations

Author Affiliations: Division of Nephrology, Second University of Naples and Santa Maria del Popolo degli Incurabili Hospital-Azienda Sanitaria Locale NA1, Naples, Italy (Drs Minutolo, Borrelli, Zamboli, Conte, and De Nicola); Division of Nephrology, Department of Medicine, School of Medicine, Indiana University, and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana (Dr Agarwal); Department of Medicine and Public Health, Second University of Naples (Mr Chiodini); Nephrology Division, University Hospital, Salerno, Italy (Dr Bellizzi); Nephrology Division, County Hospital, Nola, Italy (Dr Nappi); Division of Nephrology, University Federico II, Naples (Dr Cianciaruso); and Department of Medicine, Veterans Affairs San Diego Healthcare System and School of Medicine, University of California, San Diego (Dr Gabbai).


Arch Intern Med. 2011;171(12):1090-1098. doi:10.1001/archinternmed.2011.230.
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Published online

Background  Ambulatory blood pressure (BP) measurement allows a better risk stratification in essential hypertension compared with office blood pressure measurement, but its prognostic role in nondialysis chronic kidney disease has been poorly investigated.

Methods  The prognostic role of daytime and nighttime systolic BP (SBP) and diastolic BP (DBP) in comparison with office measurements was evaluated in 436 consecutive patients with chronic kidney disease. Primary end points were time to renal death (end-stage renal disease or death) and time to fatal and nonfatal cardiovascular events. Quintiles of BP were used to classify patients.

Results  The mean (SD) age of the patients was 65.1 (13.6) years, and the glomerular filtration rate was 42.9 (19.7) mL/min/1.73 m2; 41.7% of the participants were women, 36.5% had diabetes, and 30.5% had cardiovascular disease. Office-measured SBP/DBP values were 146 (19)/82 (12) mm Hg; daytime SBP/DBP was 131 (17)/75 (11) mm Hg, and nighttime SBP/DBP was 122 (20)/66 (10) mm Hg. During follow-up (median, 4.2 years), 155 and 103 patients reached the renal and cardiovascular end points, respectively. Compared with a daytime SBP of 126 to 135 mm Hg, patients with an SBP of 136 to 146 mm Hg and those with an SBP higher than 146 mm Hg had an increased adjusted risk of the cardiovascular end point (hazard ratio [HR], 2.23; 95% confidence interval [CI], 1.13-4.41 and 3.07; 1.54-6.09) and renal death (1.72; 1.02-2.89 and 1.85; 1.11-3.08). Nighttime SBPs of 125 to 137 mm Hg and higher than 137 mm Hg also increased the risk of the cardiovascular end point (HR, 2.52; 95% CI, 1.11-5.71 and 4.00; 1.77-9.02) and renal end point (1.87; 1.03-3.43 and 2.54; 1.41-4.57) with respect to the reference SBP value of 106-114 mm Hg. Office measurement of BP did not predict the risk of the renal or cardiovascular end point. Patients who were nondippers and those who were reverse dippers had a greater risk of both end points.

Conclusion  In chronic kidney disease, ambulatory BP measurement and, in particular, nighttime BP measurement, allows more accurate prediction of renal and cardiovascular risk; office measurement of BP does not predict any outcome.

Figures in this Article

Guidelines13 have repeatedly highlighted the importance of lowering blood pressure (BP) to less than 130/80 mm Hg in all patients with chronic kidney disease (CKD) not requiring dialysis. However, this recommendation is mainly derived from observational data or post hoc analysis47 of large trials showing that achieving such a BP goal improves renal and cardiovascular outcomes, with a greater benefit in patients with proteinuria. However, recent studies have challenged the guidelines' recommendation,8,9 contributing to the debate on the BP goal in CKD.1012

The controversial results of studies on the prognostic role of office BP measurement in patients with CKD might relate, to some extent, to the limited ability of office BP readings to stratify the global risk of this population. This can be ascribed to the high prevalence of white coat hypertension in CKD1316 and to the fact that a patient's nocturnal BP profile, without the pressor effect of physical activity, emotional stress, and environmental factors that are usually present during the day, is more representative of the true BP status17 and a stronger predictor of cardiovascular outcomes.18,19 Furthermore, an altered circadian pattern of BP has been associated with higher levels of proteinuria.20,21 Ambulatory blood pressure monitoring (ABPM) constitutes the only tool to identify simultaneously white coat hypertension and nighttime hypertension.

Solid evidence has accumulated over the past decade of the substantial benefits of ABPM measures to use for risk stratification of the general population,2224 hypertensive patients,25,26 and elderly individuals.27 Conversely, very few data are available in patients with CKD.28,29 In fact, in this high-risk population, Agarwal and Andersen demonstrated that ABPM is superior to clinic BP measurement in predicting end-stage renal disease (ESRD) and/or all-cause mortality28 and cardiovascular events.29 However, the predictive value diminished after adjustment for the main recognized factors of cardiorenal risk; whether this was because of the major role of other risk factors or the inadequate power of those studies remains to be elucidated. In addition, the finding that the predictive role of ABPM was greater than that of office BP measurement was limited to a single cohort of 217 US veterans, mostly men, with CKD.

Therefore, whether the relationship between ABPM and outcome holds true in a heterogeneous cohort that is more representative of the general CKD population needs to be addressed. Indeed, women have a slower progression of CKD and a lower incidence of mortality compared with men.3033 In addition, age-adjusted cardiovascular mortality rates associated with hypertension, diabetes mellitus, and hypercholesterolemia are significantly higher in the United States than in Japan and Mediterranean countries.34

This multicenter, prospective cohort study was designed to compare the prognostic role of ABPM and office BP measurement in fatal and nonfatal cardiovascular events and renal death in a heterogeneous cohort of 436 patients with CKD regularly monitored in 4 Italian nephrology clinics.

In this multicenter, prospective cohort study, consecutive patients were recruited in the nephrology clinics of 4 nephrology units from January 1, 2003, to December 31, 2005. In the 4 participating institutions, ABPM is performed in all patients with hypertension (systolic BP [SBP] ≥130 mm Hg and/or diastolic BP [DBP] ≥80 mm Hg or patients are receiving antihypertensive treatment). Hypertensive patients were included in this study if they had been monitored for at least 6 months in the nephrology clinics and if they had CKD stages 2 to 5, that is, either with an estimated glomerular filtration rate (GFR) by the 4-variable Modified Diet in Renal Disease equation GFR < 60 mL/min/1.73 m2 or a GFR of 60 to 90 mL/min/1.73 m2 plus proteinuria of more than 0.3 g/24 h, in 2 consecutive visits with an interval 3 months or more. Exclusion criteria were true normotension (BP <130/80 mm Hg without antihypertensive therapy), changes in GFR of more than 30% in the previous 3 months, changes in antihypertensive therapy 2 weeks before ABPM, atrial fibrillation, dialysis treatment or renal transplantation, and inadequate ABPM (No. of SBP/DBP recordings, <14 and <7 during the day and the night, respectively35). Data on medical history, laboratory test results, and current therapy were collected at the initial visit. Institutional review boards of the participating centers approved the protocol, and informed consent was obtained from patients before study enrollment.

During the physician's visit (8 to 11 AM), office BP was measured according to the recommendations of the European Society of Hypertension.35 Systolic and diastolic BP (Korotkoff phase 1 and phase 5) were measured with the patient seated 3 times at 5-minute intervals. The office BP measurement values reported herein are the mean of the 6 values recorded in the 2 consecutive days in which the ABPM device was installed and removed. Measurements were obtained by the same physician, who was not aware of the results of the ABPM recordings.

Similar ABPM protocols and monitors (Spacelabs 90207; Spacelabs Healthcare, Issaquah, Washington) were used in all centers. Specifically, cuff size was chosen according to the patient's arm circumference and fixed to the nondominant arm. Three BP readings were taken in the morning (8-11 AM) concomitantly with sphygmomanometric measurements to ensure a difference of less than 5 mm Hg between the 2 sets of values. The monitor recorded BP every 15 minutes between 7 AM and 11 PM and every 30 minutes between 11 PM and 7 AM. Daytime and nighttime periods were derived from the diaries recorded by the patients during monitoring. The ABPM was always obtained on a workday and while the patient was receiving regular antihypertensive therapy. Patients had no access to the ABPM values. The BP was considered at target when daytime and nighttime values were less than 135/85 mm Hg and less than 120/70 mm Hg, respectively.35 Dipping status was based on the night to day ratio of mean ambulatory BP. We stratified patients as extreme dippers, dippers, nondippers, and reverse dippers when the night to day ratio was less than 0.80, 0.80 to less than 0.90, 0.90 to 1.00, and greater than 1.00, respectively.19

In each center, patients were always seen by the same nephrologist. All patients were instructed, with use of a personalized written regimen, to restrict dietary salt (<6 g/d of sodium chloride) and protein (≤0.8 g/kg of body weight per day). Antihypertensive medications were administered to achieve office BP values less than 130/80 mm Hg, according to current Kidney Disease Outcomes Quality Initiative guidelines.2 Drugs were distributed from 8 AM to 10 PM; doses of furosemide of 50 mg/d or more were divided in 2 administrations (8 AM and 8 PM).

OUTCOMES

Renal outcomes were defined a priori and included a composite end point of ESRD or death, whichever occurred first. The end point of ESRD was reached on the day of the first dialysis session. Death certificates and autopsy reports were used to establish the underlying cause of death and to adjudicate cardiovascular deaths based on the ninth revision of the International Classification of Diseases. Cardiovascular outcomes included a composite end point of fatal and nonfatal cardiovascular events that required hospitalization (myocardial infarction, congestive heart failure, stroke, revascularization, peripheral vascular disease, and nontraumatic amputation), whichever occurred first. We collected hospital records to identify the diagnosis according to the American College of Cardiology and the European Society of Cardiology criteria.36,37 Patients were followed up until September 30, 2010, or death or ESRD and censored on the date of the last nephrology clinic visit.

STATISTICAL ANALYSIS

Continuous variables are expressed as mean (SD) or as median (interquartile range), according to their distribution. A multivariable Cox proportional hazards regression model, stratified by center, was used to estimate hazard ratio (HR) and corresponding 95% confidence interval (CI). All Cox models were adjusted for baseline covariates known to be determinants of renal and cardiovascular outcome (age; sex; body mass index, calculated as weight in kilograms divided by height in meters squared; diabetes mellitus; cardiovascular disease; hemoglobin level; proteinuria; and GFR). Office BP measurement and ABPM were analyzed, categorizing patients by means of quintile values. We tested the association of ABPM with risk of renal and cardiovascular end points by stratifying patients according to whether the daytime and nighttime BP targets were achieved. This analysis was performed with each BP target included in the Cox regression model separately or simultaneously (daytime and nighttime). Nested models were compared using the likelihood ratio test. The nonlinear relationship of time and BP was evaluated using restricted cubic splines. Specifically, we placed 5 knots at 0.050, 0.275, 0.500, 0.725, and 0.950 quantiles of the x variable (SBP or DBP).38 The role of nighttime hypertension was further assessed using the defined categories of dipping status; in this Cox model, we further adjusted for 24-hour mean BP, according to the suggestion from the IDACO (International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes) investigators.19

Data were analyzed using commercially available software (SPSS version 12.0; SPSS Inc, Chicago, Illinois; and R version 2.9.2; R Foundation for Statistical Computing, Vienna, Austria). All statistical tests were 2-tailed, and P < .05 was considered significant.

We included 459 of 530 eligible patients, all of whom were white. Reasons for exclusion were inadequate ABPM recordings (n = 35), change of antihypertensive therapy 2 weeks before the study (n = 24), atrial fibrillation (n = 8), and a GFR change of more than 30% (n = 4). Twenty-three patients were subsequently excluded because they were lost to follow-up after their initial visit. Demographic, clinical, and treatment information on the 436 patients included in the cohort are presented in Table 1 and Table 2.

Table Graphic Jump LocationTable 1. Demographic and Clinical Characteristics of 436 Patients
Table Graphic Jump LocationTable 2. Office and Ambulatory Blood Pressure Measurement and Antihypertensive Therapy

The median duration of follow-up was 4.2 years (interquartile range, 3.0-5.1 years). During this period, CKD in 86 patients progressed to ESRD and 69 patients died. We recorded 63 nonfatal cardiovascular events and 52 cardiovascular deaths (12 occurring after a first nonfatal cardiovascular event); in particular, we registered 62 acute myocardial infarctions (34 fatal), 22 strokes (12 fatal), 16 peripheral vascular accidents (2 fatal), and 15 acute heart failures (4 fatal). Crude event rates for the composite renal end point (ESRD or death) was 9.01 per 100 patient-years and 6.56 per 100 patient-years for the composite cardiovascular end point (occurrence of fatal/nonfatal cardiovascular episodes).

Table 3 and Table 4 present the results of the predictive role of BP for cardiovascular and renal end points. Patients with daytime SBP in the range of 136 to 146 mm Hg and higher than 146 mm Hg had a 2.23- and 3.07-fold greater risk, respectively, of the cardiovascular end point; these 2 quintiles were also associated with a greater risk of renal death. Similarly, patients in the highest quintile of daytime DBP (Table 4) had a significantly greater risk for both end points. A daytime DBP in the range of 78 to 84 mm Hg was predictive of renal events but not of cardiovascular events. Nighttime readings of SBP higher than 124 mm Hg predicted both end points (Table 3), and DBP values higher than 70 and higher than 75 mm Hg predicted the cardiovascular end point and renal death, respectively (Table 4). Hazard ratios for renal events and cardiovascular events of quintiles of ambulatory SBP/DBP remained unchanged after adjustment for office measurement of SBP/DBP (data not shown). In contrast, office BP measurement (either SBP or DBP) did not predict cardiovascular or renal events.

Table Graphic Jump LocationTable 3. Risk of Fatal and Nonfatal CV Events and Renal Death According to Quintiles of Office, Daytime, and Nighttime SBP Measurementa
Table Graphic Jump LocationTable 4. Risk of Fatal and Nonfatal CV Events and Renal Death According to Quintiles of Office, Daytime, and Nighttime DBP Measurementa

The adjusted risk associated with ABPM levels is shown in Figure 1 and Figure 2. The risk of renal death increased in a linear fashion with the increment in daytime and nighttime SBP/DBP (Figure 1). A similar pattern was observed for the cardiovascular end point, with the exception of a relationship with the daytime SBP that appeared J-shaped (Figure 2).

Place holder to copy figure label and caption
Figure 1.

Relationship between risk for renal death and either daytime (A and B) or nighttime (C and D) systolic and diastolic blood pressure (BP). The solid line indicates the hazard ratio; dashed lines, 95% confidence interval.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Relationship between risk for fatal and nonfatal cardiovascular (CV) events and either daytime (A and B) or nighttime (C and D) systolic (SBP) and diastolic (DBP) blood pressure. The solid line indicates the hazard ratio; dashed lines, 95% confidence interval.

Graphic Jump Location

Two hundred thirty-nine patients (54.8%) achieved only the daytime BP target (<135/85 mm Hg) and 189 patients (43.3%) achieved only the nighttime target (<120/70 mm Hg); 166 patients (38.1%) achieved both targets and 174 patients (39.9%) achieved neither target. Patients who did not achieve either target had the greatest risk of cardiovascular (HR, 1.99) and renal (HR, 2.65) end points (Figure 3). Within the group of patients reaching only 1 of the target levels, those achieving only the nighttime target value did not have a greater risk of the renal and cardiovascular end points; conversely, patients achieving exclusively the daytime target had a greater risk of the renal end point. The greater predictive role of the nighttime target BP was confirmed by the likelihood ratio test; indeed, adding the nighttime to the daytime target increased the model fit for renal death (P = .003) but not for the cardiovascular end point (P = .11); the model fit for both end points did not improve when the daytime target was added to the nighttime target (P = .07 for both).

Place holder to copy figure label and caption
Figure 3.

Risk of fatal and nonfatal cardiovascular (CV) events (A) and renal death (B) in patients stratified according to achievement of daytime blood pressure (BP) target (<135/85 mm Hg) and nighttime BP target (<120/70 mm Hg). CI indicates confidence interval; HR, hazard ratio.

Graphic Jump Location

An office BP measurement target lower than 130/80 mm Hg did not influence the outcomes (for renal death, HR 0.91; 95% CI, 0.57-1.44; P = .68 and for fatal/nonfatal cardiovascular events, 1.06; 0.60-1.88; P = .85). This finding persisted after removing 189 patients with white coat hypertension from the analysis (for renal death, HR, 0.71; 95% CI, 0.43-1.16; P = .17 and for fatal/nonfatal cardiovascular events, 0.79; 0.43-1.45; P = .44).

When patient outcomes were stratified according to dipping status, we found that office BP measurement did not change significantly across categories, from extreme dippers to reverse dippers: 146 (17)/86 (12), 146 (18)/83 (11), 146 (20)/81 (11), and 147 (20)/81 (13) mm Hg. Crude event rates for renal death in extreme dippers, dippers, nondippers, and reverse dippers were 3.8, 6.5, 11.0, and 14.6 per 100 patient-years, respectively, and event rates for the cardiovascular end point were 3.9, 3.6, 8.9, and 10.6 per 100 patient-years. Patients who were nondippers and those who were reverse dippers had an increased risk of renal death and cardiovascular events (Table 5).

Table Graphic Jump LocationTable 5. Risk of Fatal and Nonfatal CV Events and Renal Death According to Dipping Status Based on Nighttime to Daytime Ratio of Mean BPa

This study demonstrates that ABPM is a better predictor of renal and cardiovascular end points compared with office BP measurement in patients with CKD. Only 2 studies28,29 have previously compared the prognostic role of ABPM and office BP measurement in this population. The current study confirms the greater predictive value of ABPM and extends this observation to a more heterogeneous population including women and non-US patients. In contrast to previous studies, our results demonstrate that the predictive role of ABPM is independent of other risk factors, such as diabetes mellitus, cardiovascular disease, proteinuria, hemoglobin level, and GFR. Of interest, the lack of predictive value of office BP measurement, as well as office BP target level, raises concerns regarding the adequacy of recommendations of hypertension guidelines that are derived mainly from expert opinion and post hoc analyses rather than randomized trials.1012 We speculate that cardiorenal risk may actually increase in some subgroups of patients (eg, elderly individuals, those with severe atherosclerotic disease, or those with white coat hypertension)39 in which stricter BP control based on office measurements may compromise renal and/or cardiac perfusion.12,40 However, office measurements alone obviate the possibility of diagnosing and treating masked hypertension, which, when present in patients with CKD, is associated with worse outcomes.29 The ongoing randomized Systolic Blood Pressure Intervention Trial (SPRINT) (http://clinicaltrials.gov/ct2/show/NCT01206062), which is comparing the effect on cardiorenal prognosis of 2 office BP target levels (systolic <120 mm Hg vs <140 mm Hg), will probably provide helpful information for management decisions in this population.

Systolic ABPM was a better predictor of adverse outcomes than was ambulatory DBP values. Among the components of ABPM, nighttime systolic BP was a stronger predictor than daytime systolic BP for both end points, with an increased risk for the renal end point occurring for daytime SBP higher than 135 mm Hg and an increased risk for the cardiovascular end point occurring for nighttime SBP higher than 124 mm Hg. In contrast, DBP had a different association with renal and cardiovascular end points, whereas daytime values allowed a better definition of renal prognosis, nighttime DBP better predicted the risk of fatal/nonfatal cardiovascular events. The analysis with continuous variables confirmed the data obtained with the categorization of BP in quintiles. Interestingly, our data suggest that caution should be exercised with excessively low daytime SBP values because of the potential increase in cardiovascular risk (Figure 2).

The analysis of daytime and nighttime BP target levels provides another important finding of our study. International guidelines13,35 do not provide specific thresholds for daytime and nighttime BP for patients with CKD. We found that achieving daytime and nighttime BP goals lower than 135/85 mm Hg and lower than 120/70 mm Hg, respectively, was associated with better outcomes. To determine whether achieving these goals implies a favorable risk factor profile or is causally associated with good outcomes will require randomized controlled trials. Our results therefore suggest that the ABPM target levels recommended for patients with essential hypertension can be reasonably used in patients with CKD.

This study also provides evidence that the lack of physiological BP decline during nighttime predicts important clinical outcomes in CKD, as described in a non-CKD population.18,19 Our results demonstrate a 2-fold greater risk of cardiovascular events in nondipper and reverse dipper subgroups; in these patients, the risk of renal death increased by 62% and 72% in comparison with dippers. Interestingly, this analysis also confirmed the poor predictive role of office BP measurement, as it was ineffective in discriminating risk profile across dipping categories. Previous small, retrospective studies reported4144 the relationship between altered circadian pattern of BP and more rapid decline in renal function in specific subgroups of patients with CKD; however, none of these studies used important clinical end points such as ESRD, death, or cardiovascular events. More recently, Redon et al45 evaluated the risk of renal death in a small number of patients with CKD stages 3 and 4. They found a greater risk of progression to ESRD in patients with nighttime SBP higher than 130 mm Hg, independent of their dipping status. However, the population studied was scarcely representative of a typical CKD population because diabetic patients, those with previous cardiovascular disease, and those with more advanced CKD were excluded. This selection bias led to an event rate in these patients much lower than that in the current study and in the cohort evaluated by Agarwal and Andersen,28 therefore making the study by Redon et al somewhat underpowered.

Only 1 study has investigated the effect of nondipping on cardiovascular outcome. Analyzing a cohort of US veterans, Agarwal and Andersen29 found that nondipping was associated with increased cardiovascular risk, but its predictive role disappeared after adjusting for other risk factors with the use of propensity scores. In contrast, our study found that an abnormal dipping pattern was a strong predictor of renal and cardiovascular outcomes, even after adjusting for the main demographic and clinical factors influencing dipping status.17 Our larger sample size may account for this difference.

The current study has some limitations. First, our study included few diabetic patients and was racially homogenous. A larger study with a more diverse population would allow generalization of our findings to patients with diabetes and nonwhite individuals. Second, ABPM data are based on a single set of measurements, which can lead to some imprecision, in particular, for dipping status. Some studies46,47 have reported a low reproducibility of this phenomenon in the CKD population, with a change in dipping status involving 24% to 38% of patients. The third limitation relates to treatment of hypertension. The IDACO investigators demonstrated that use of antihypertensive drugs removed the significant association between cardiovascular events and daytime BP.19 However, at variance with the IDACO results, a larger number of patients in our study received antihypertensive therapy (90% vs 22%). Finally, patients with true normotension were excluded, which may explain the difference with the IDACO study.19

In conclusion, our results show that ABPM is prognostically superior to office BP measurement, even among patients with CKD. The prediction of renal and cardiovascular risk among patients with CKD treated according to BP measured in physicians' offices was better with ABPM, in particular, nighttime BP and an abnormal dipping pattern. In contrast, office BP measurement was prognostically less informative. Interventional studies based on ABPM rather than office BP measurement are urgently required in this high-risk population.

Correspondence: Roberto Minutolo, MD, PhD, Department of Nephrology, Second University of Naples, Via Tiberio 90 I-80125, Naples, Italy (roberto.minutolo@unina2.it).

Accepted for Publication: March 10, 2011.

Author Contributions: Dr Minutolo had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Minutolo, Chiodini, Nappi, Zamboli, Conte, and De Nicola. Acquisition of data: Borrelli, Bellizzi, Nappi, Cianciaruso, and Zamboli. Analysis and interpretation of data: Minutolo, Agarwal, Borrelli, Chiodini, Bellizzi, Gabbai, and De Nicola. Drafting of the manuscript: Minutolo, Chiodini, Bellizzi, Cianciaruso, Conte, Gabbai, and De Nicola. Critical revision of the manuscript for important intellectual content: Minutolo, Agarwal, Borrelli, Chiodini, Bellizzi, Nappi, Cianciaruso, Zamboli, Conte, Gabbai, and De Nicola. Statistical analysis: Agarwal, Borrelli, and Chiodini. Administrative, technical, and material support: Zamboli and De Nicola. Study supervision: Minutolo, Agarwal, Conte, and De Nicola.

Financial Disclosure: None reported.

Chobanian  AVBakris  GLBlack  HR  et al. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee, Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42 (6) 1206- 1252
PubMed Link to Article
Kidney Disease Outcomes Quality Initiative (K/DOQI), K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis 2004;43 (5) ((suppl 1)) S1- S290
PubMed Link to Article
Mancia  GDe Backer  GDominiczak  A  et al. Task Force for the Management of Arterial Hypertension of the European Society of Hypertension; Task Force for the Management of Arterial Hypertension of the European Society of Cardiology, 2007 Guidelines for the management of arterial hypertension. Eur Heart J 2007;28 (12) 1462- 1536
PubMed
Sarnak  MJGreene  TWang  X  et al.  The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the Modification of Diet in Renal Disease Study. Ann Intern Med 2005;142 (5) 342- 351
PubMed Link to Article
Bakris  GLWeir  MRShanifar  S  et al. RENAAL Study Group, Effects of blood pressure level on progression of diabetic nephropathy: results from the RENAAL study. Arch Intern Med 2003;163 (13) 1555- 1565
PubMed Link to Article
Pohl  MABlumenthal  SCordonnier  DJ  et al.  Independent and additive impact of blood pressure control and angiotensin II receptor blockade on renal outcomes in the Irbesartan Diabetic Nephropathy Trial: clinical implications and limitations. J Am Soc Nephrol 2005;16 (10) 3027- 3037
PubMed Link to Article
Jafar  THStark  PCSchmid  CH  et al. AIPRD Study Group, Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med 2003;139 (4) 244- 252
PubMed Link to Article
Appel  LJWright  JT  JrGreene  T  et al. AASK Collaborative Research Group, Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med 2010;363 (10) 918- 929
PubMed Link to Article
Landray  MJEmberson  JRBlackwell  L  et al.  Prediction of ESRD and death among people with CKD: the Chronic Renal Impairment in Birmingham (CRIB) prospective cohort study. Am J Kidney Dis 2010;56 (6) 1082- 1094
PubMed Link to Article
Toto  RD Debate: PRO position: people with chronic kidney disease should have a blood pressure lower than 130/80 mm Hg. Am J Nephrol 2010;32 (4) 370- 373, 379-380
PubMed Link to Article
Agarwal  R Debate: CON position: people with chronic kidney disease should have a blood pressure lower than 130/80 mm Hg. Am J Nephrol 2010;32 (4) 374- 378
PubMed Link to Article
Lewis  JB Blood pressure control in chronic kidney disease: is less really more? J Am Soc Nephrol 2010;21 (7) 1086- 1092
PubMed Link to Article
Minutolo  RBorrelli  SScigliano  R  et al.  Prevalence and clinical correlates of white coat hypertension in chronic kidney disease. Nephrol Dial Transplant 2007;22 (8) 2217- 2223
PubMed Link to Article
Bangash  FAgarwal  R Masked hypertension and white-coat hypertension in chronic kidney disease: a meta-analysis. Clin J Am Soc Nephrol 2009;4 (3) 656- 664
PubMed Link to Article
Andersen  MJKhawandi  WAgarwal  R Home blood pressure monitoring in CKD. Am J Kidney Dis 2005;45 (6) 994- 1001
PubMed Link to Article
Pogue  VRahman  MLipkowitz  M  et al. African American Study of Kidney Disease and Hypertension Collaborative Research Group, Disparate estimates of hypertension control from ambulatory and clinic blood pressure measurements in hypertensive kidney disease. Hypertension 2009;53 (1) 20- 27
PubMed Link to Article
Minutolo  RBorrelli  SChiodini  P  et al.  Effects of age on hypertensive status in patients with chronic kidney disease. J Hypertens 2007;25 (11) 2325- 2333
PubMed Link to Article
Fagard  RHCelis  HThijs  L  et al.  Daytime and nighttime blood pressure as predictors of death and cause-specific cardiovascular events in hypertension. Hypertension 2008;51 (1) 55- 61
PubMed Link to Article
Boggia  JLi  YThijs  L  et al. International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes (IDACO) Investigators, Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study. Lancet 2007;370 (9594) 1219- 1229
PubMed Link to Article
Minutolo  RGabbai  FBBorrelli  S  et al.  Changing the timing of antihypertensive therapy to reduce nocturnal blood pressure in CKD: an 8-week uncontrolled trial. Am J Kidney Dis 2007;50 (6) 908- 917
PubMed Link to Article
Hermida  RCCalvo  CAyala  DELópez  JE Decrease in urinary albumin excretion associated with the normalization of nocturnal blood pressure in hypertensive subjects. Hypertension 2005;46 (4) 960- 968
PubMed Link to Article
Ohkubo  TImai  YTsuji  I  et al.  Prediction of mortality by ambulatory blood pressure monitoring versus screening blood pressure measurements: a pilot study in Ohasama. J Hypertens 1997;15 (4) 357- 364
PubMed Link to Article
Sega  RFacchetti  RBombelli  M  et al.  Prognostic value of ambulatory and home blood pressure compared with office blood pressure in the general population: follow-up results from the PAMELA study. Circulation 2005;1111777- 1783
PubMed Link to Article
Kikuya  MOhkubo  TAsayama  K  et al.  Ambulatory blood pressure and 10-year risk of cardiovascular and noncardiovascular mortality: the Ohasama study. Hypertension 2005;45 (2) 240- 245
PubMed Link to Article
Clement  DLDe Buyzere  MLDe Bacquer  DA  et al. Office Versus Ambulatory Pressure Study Investigators, Prognostic value of ambulatory blood-pressure recordings in patients with treated hypertension. N Engl J Med 2003;348 (24) 2407- 2415
PubMed Link to Article
Dolan  EStanton  AThijs  L  et al.  Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin Outcome Study. Hypertension 2005;46 (1) 156- 161
PubMed Link to Article
Staessen  JAThijs  LFagard  R  et al. Systolic Hypertension in Europe Trial Investigators, Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. JAMA 1999;282 (6) 539- 546
PubMed Link to Article
Agarwal  RAndersen  MJ Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease. Kidney Int 2006;69 (7) 1175- 1180
PubMed Link to Article
Agarwal  RAndersen  MJ Blood pressure recordings within and outside the clinic and cardiovascular events in chronic kidney disease. Am J Nephrol 2006;26 (5) 503- 510
PubMed Link to Article
Neugarten  JAcharya  ASilbiger  SR Effect of gender on the progression of nondiabetic renal disease: a meta-analysis. J Am Soc Nephrol 2000;11 (2) 319- 329
PubMed
Halbesma  NBrantsma  AHBakker  SJ  et al. PREVEND Study Group, Gender differences in predictors of the decline of renal function in the general population. Kidney Int 2008;74 (4) 505- 512
PubMed Link to Article
Hyvärinen  MQiao  QTuomilehto  JSöderberg  SEliasson  MStehouwer  CDA The difference between acute coronary heart disease and ischaemic stroke risk with regard to gender and age in Finnish and Swedish populations. Int J Stroke 2010;5 (3) 152- 156
PubMed Link to Article
Carrero  JJde Mutsert  RAxelsson  J  et al. NECOSAD Study Group, Sex differences in the impact of diabetes on mortality in chronic dialysis patients. Nephrol Dial Transplant 2011;26 (1) 270- 276
PubMed Link to Article
van den Hoogen  PCWFeskens  EJMNagelkerke  NJDMenotti  ANissinen  AKromhout  DSeven Countries Study Research Group, The relation between blood pressure and mortality due to coronary heart disease among men in different parts of the world. N Engl J Med 2000;342 (1) 1- 8
PubMed Link to Article
O’Brien  EAsmar  RBeilin  L  et al. European Society of Hypertension Working Group on Blood Pressure Monitoring, European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens 2003;21 (5) 821- 848
PubMed Link to Article
Alpert  JSThygesen  KAntman  EBassand  JPAmerican College of Cardiology Committee, Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction [published correction appears in J Am Coll Cardiol. 2001;37(3):973.]. J Am Coll Cardiol 2000;36 (3) 959- 969
PubMed Link to Article
Luepker  RVApple  FSChristenson  RH  et al. AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; National Heart, Lung, and Blood Institute, Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; the European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; and the National Heart, Lung, and Blood Institute. Circulation 2003;108 (20) 2543- 2549
PubMed Link to Article
Harrell  FE  JrLee  KLPollock  BG Regression models in clinical studies: determining relationships between predictors and response. J Natl Cancer Inst 1988;80 (15) 1198- 1202
PubMed Link to Article
Agarwal  R Blood pressure components and the risk for end-stage renal disease and death in chronic kidney disease. Clin J Am Soc Nephrol 2009;4 (4) 830- 837
PubMed Link to Article
Messerli  FHMancia  GConti  CR  et al.  Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006;144 (12) 884- 893
PubMed Link to Article
Timio  MVenanzi  SLolli  S  et al.  “Non-dipper” hypertensive patients and progressive renal insufficiency: a 3-year longitudinal study. Clin Nephrol 1995;43 (6) 382- 387
PubMed
Farmer  CKGoldsmith  DJQuin  JD  et al.  Progression of diabetic nephropathy—is diurnal blood pressure rhythm as important as absolute blood pressure level? Nephrol Dial Transplant 1998;13 (3) 635- 639
PubMed Link to Article
Csiky  BKovács  TWágner  LVass  TNagy  J Ambulatory blood pressure monitoring and progression in patients with IgA nephropathy. Nephrol Dial Transplant 1999;14 (1) 86- 90
PubMed Link to Article
Knudsen  STLaugesen  EHansen  KWBek  TMogensen  CEPoulsen  PL Ambulatory pulse pressure, decreased nocturnal blood pressure reduction and progression of nephropathy in type 2 diabetic patients. Diabetologia 2009;52 (4) 698- 704
PubMed Link to Article
Redon  JPlancha  ESwift  PAPons  SMuñoz  JMartinez  F Nocturnal blood pressure and progression to end-stage renal disease or death in nondiabetic chronic kidney disease stages 3 and 4. J Hypertens 2010;28 (3) 602- 607
PubMed Link to Article
Covic  AMititiuc  IGusbeth-Tatomir  PGoldsmith  DJ The reproducibility of the circadian BP rhythm in treated hypertensive patients with polycystic kidney disease and mild chronic renal impairment—a prospective ABPM study. J Nephrol 2002;15 (5) 497- 506
PubMed
Elung-Jensen  TStrandgaard  SKamper  AL Longitudinal observations on circadian blood pressure variation in chronic kidney disease stages 3-5. Nephrol Dial Transplant 2008;23 (9) 2873- 2878
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Relationship between risk for renal death and either daytime (A and B) or nighttime (C and D) systolic and diastolic blood pressure (BP). The solid line indicates the hazard ratio; dashed lines, 95% confidence interval.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Relationship between risk for fatal and nonfatal cardiovascular (CV) events and either daytime (A and B) or nighttime (C and D) systolic (SBP) and diastolic (DBP) blood pressure. The solid line indicates the hazard ratio; dashed lines, 95% confidence interval.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Risk of fatal and nonfatal cardiovascular (CV) events (A) and renal death (B) in patients stratified according to achievement of daytime blood pressure (BP) target (<135/85 mm Hg) and nighttime BP target (<120/70 mm Hg). CI indicates confidence interval; HR, hazard ratio.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Demographic and Clinical Characteristics of 436 Patients
Table Graphic Jump LocationTable 2. Office and Ambulatory Blood Pressure Measurement and Antihypertensive Therapy
Table Graphic Jump LocationTable 3. Risk of Fatal and Nonfatal CV Events and Renal Death According to Quintiles of Office, Daytime, and Nighttime SBP Measurementa
Table Graphic Jump LocationTable 4. Risk of Fatal and Nonfatal CV Events and Renal Death According to Quintiles of Office, Daytime, and Nighttime DBP Measurementa
Table Graphic Jump LocationTable 5. Risk of Fatal and Nonfatal CV Events and Renal Death According to Dipping Status Based on Nighttime to Daytime Ratio of Mean BPa

References

Chobanian  AVBakris  GLBlack  HR  et al. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee, Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42 (6) 1206- 1252
PubMed Link to Article
Kidney Disease Outcomes Quality Initiative (K/DOQI), K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis 2004;43 (5) ((suppl 1)) S1- S290
PubMed Link to Article
Mancia  GDe Backer  GDominiczak  A  et al. Task Force for the Management of Arterial Hypertension of the European Society of Hypertension; Task Force for the Management of Arterial Hypertension of the European Society of Cardiology, 2007 Guidelines for the management of arterial hypertension. Eur Heart J 2007;28 (12) 1462- 1536
PubMed
Sarnak  MJGreene  TWang  X  et al.  The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the Modification of Diet in Renal Disease Study. Ann Intern Med 2005;142 (5) 342- 351
PubMed Link to Article
Bakris  GLWeir  MRShanifar  S  et al. RENAAL Study Group, Effects of blood pressure level on progression of diabetic nephropathy: results from the RENAAL study. Arch Intern Med 2003;163 (13) 1555- 1565
PubMed Link to Article
Pohl  MABlumenthal  SCordonnier  DJ  et al.  Independent and additive impact of blood pressure control and angiotensin II receptor blockade on renal outcomes in the Irbesartan Diabetic Nephropathy Trial: clinical implications and limitations. J Am Soc Nephrol 2005;16 (10) 3027- 3037
PubMed Link to Article
Jafar  THStark  PCSchmid  CH  et al. AIPRD Study Group, Progression of chronic kidney disease: the role of blood pressure control, proteinuria, and angiotensin-converting enzyme inhibition: a patient-level meta-analysis. Ann Intern Med 2003;139 (4) 244- 252
PubMed Link to Article
Appel  LJWright  JT  JrGreene  T  et al. AASK Collaborative Research Group, Intensive blood-pressure control in hypertensive chronic kidney disease. N Engl J Med 2010;363 (10) 918- 929
PubMed Link to Article
Landray  MJEmberson  JRBlackwell  L  et al.  Prediction of ESRD and death among people with CKD: the Chronic Renal Impairment in Birmingham (CRIB) prospective cohort study. Am J Kidney Dis 2010;56 (6) 1082- 1094
PubMed Link to Article
Toto  RD Debate: PRO position: people with chronic kidney disease should have a blood pressure lower than 130/80 mm Hg. Am J Nephrol 2010;32 (4) 370- 373, 379-380
PubMed Link to Article
Agarwal  R Debate: CON position: people with chronic kidney disease should have a blood pressure lower than 130/80 mm Hg. Am J Nephrol 2010;32 (4) 374- 378
PubMed Link to Article
Lewis  JB Blood pressure control in chronic kidney disease: is less really more? J Am Soc Nephrol 2010;21 (7) 1086- 1092
PubMed Link to Article
Minutolo  RBorrelli  SScigliano  R  et al.  Prevalence and clinical correlates of white coat hypertension in chronic kidney disease. Nephrol Dial Transplant 2007;22 (8) 2217- 2223
PubMed Link to Article
Bangash  FAgarwal  R Masked hypertension and white-coat hypertension in chronic kidney disease: a meta-analysis. Clin J Am Soc Nephrol 2009;4 (3) 656- 664
PubMed Link to Article
Andersen  MJKhawandi  WAgarwal  R Home blood pressure monitoring in CKD. Am J Kidney Dis 2005;45 (6) 994- 1001
PubMed Link to Article
Pogue  VRahman  MLipkowitz  M  et al. African American Study of Kidney Disease and Hypertension Collaborative Research Group, Disparate estimates of hypertension control from ambulatory and clinic blood pressure measurements in hypertensive kidney disease. Hypertension 2009;53 (1) 20- 27
PubMed Link to Article
Minutolo  RBorrelli  SChiodini  P  et al.  Effects of age on hypertensive status in patients with chronic kidney disease. J Hypertens 2007;25 (11) 2325- 2333
PubMed Link to Article
Fagard  RHCelis  HThijs  L  et al.  Daytime and nighttime blood pressure as predictors of death and cause-specific cardiovascular events in hypertension. Hypertension 2008;51 (1) 55- 61
PubMed Link to Article
Boggia  JLi  YThijs  L  et al. International Database on Ambulatory Blood Pressure Monitoring in Relation to Cardiovascular Outcomes (IDACO) Investigators, Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study. Lancet 2007;370 (9594) 1219- 1229
PubMed Link to Article
Minutolo  RGabbai  FBBorrelli  S  et al.  Changing the timing of antihypertensive therapy to reduce nocturnal blood pressure in CKD: an 8-week uncontrolled trial. Am J Kidney Dis 2007;50 (6) 908- 917
PubMed Link to Article
Hermida  RCCalvo  CAyala  DELópez  JE Decrease in urinary albumin excretion associated with the normalization of nocturnal blood pressure in hypertensive subjects. Hypertension 2005;46 (4) 960- 968
PubMed Link to Article
Ohkubo  TImai  YTsuji  I  et al.  Prediction of mortality by ambulatory blood pressure monitoring versus screening blood pressure measurements: a pilot study in Ohasama. J Hypertens 1997;15 (4) 357- 364
PubMed Link to Article
Sega  RFacchetti  RBombelli  M  et al.  Prognostic value of ambulatory and home blood pressure compared with office blood pressure in the general population: follow-up results from the PAMELA study. Circulation 2005;1111777- 1783
PubMed Link to Article
Kikuya  MOhkubo  TAsayama  K  et al.  Ambulatory blood pressure and 10-year risk of cardiovascular and noncardiovascular mortality: the Ohasama study. Hypertension 2005;45 (2) 240- 245
PubMed Link to Article
Clement  DLDe Buyzere  MLDe Bacquer  DA  et al. Office Versus Ambulatory Pressure Study Investigators, Prognostic value of ambulatory blood-pressure recordings in patients with treated hypertension. N Engl J Med 2003;348 (24) 2407- 2415
PubMed Link to Article
Dolan  EStanton  AThijs  L  et al.  Superiority of ambulatory over clinic blood pressure measurement in predicting mortality: the Dublin Outcome Study. Hypertension 2005;46 (1) 156- 161
PubMed Link to Article
Staessen  JAThijs  LFagard  R  et al. Systolic Hypertension in Europe Trial Investigators, Predicting cardiovascular risk using conventional vs ambulatory blood pressure in older patients with systolic hypertension. JAMA 1999;282 (6) 539- 546
PubMed Link to Article
Agarwal  RAndersen  MJ Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease. Kidney Int 2006;69 (7) 1175- 1180
PubMed Link to Article
Agarwal  RAndersen  MJ Blood pressure recordings within and outside the clinic and cardiovascular events in chronic kidney disease. Am J Nephrol 2006;26 (5) 503- 510
PubMed Link to Article
Neugarten  JAcharya  ASilbiger  SR Effect of gender on the progression of nondiabetic renal disease: a meta-analysis. J Am Soc Nephrol 2000;11 (2) 319- 329
PubMed
Halbesma  NBrantsma  AHBakker  SJ  et al. PREVEND Study Group, Gender differences in predictors of the decline of renal function in the general population. Kidney Int 2008;74 (4) 505- 512
PubMed Link to Article
Hyvärinen  MQiao  QTuomilehto  JSöderberg  SEliasson  MStehouwer  CDA The difference between acute coronary heart disease and ischaemic stroke risk with regard to gender and age in Finnish and Swedish populations. Int J Stroke 2010;5 (3) 152- 156
PubMed Link to Article
Carrero  JJde Mutsert  RAxelsson  J  et al. NECOSAD Study Group, Sex differences in the impact of diabetes on mortality in chronic dialysis patients. Nephrol Dial Transplant 2011;26 (1) 270- 276
PubMed Link to Article
van den Hoogen  PCWFeskens  EJMNagelkerke  NJDMenotti  ANissinen  AKromhout  DSeven Countries Study Research Group, The relation between blood pressure and mortality due to coronary heart disease among men in different parts of the world. N Engl J Med 2000;342 (1) 1- 8
PubMed Link to Article
O’Brien  EAsmar  RBeilin  L  et al. European Society of Hypertension Working Group on Blood Pressure Monitoring, European Society of Hypertension recommendations for conventional, ambulatory and home blood pressure measurement. J Hypertens 2003;21 (5) 821- 848
PubMed Link to Article
Alpert  JSThygesen  KAntman  EBassand  JPAmerican College of Cardiology Committee, Myocardial infarction redefined—a consensus document of The Joint European Society of Cardiology/American College of Cardiology Committee for the redefinition of myocardial infarction [published correction appears in J Am Coll Cardiol. 2001;37(3):973.]. J Am Coll Cardiol 2000;36 (3) 959- 969
PubMed Link to Article
Luepker  RVApple  FSChristenson  RH  et al. AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; National Heart, Lung, and Blood Institute, Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA Council on Epidemiology and Prevention; AHA Statistics Committee; World Heart Federation Council on Epidemiology and Prevention; the European Society of Cardiology Working Group on Epidemiology and Prevention; Centers for Disease Control and Prevention; and the National Heart, Lung, and Blood Institute. Circulation 2003;108 (20) 2543- 2549
PubMed Link to Article
Harrell  FE  JrLee  KLPollock  BG Regression models in clinical studies: determining relationships between predictors and response. J Natl Cancer Inst 1988;80 (15) 1198- 1202
PubMed Link to Article
Agarwal  R Blood pressure components and the risk for end-stage renal disease and death in chronic kidney disease. Clin J Am Soc Nephrol 2009;4 (4) 830- 837
PubMed Link to Article
Messerli  FHMancia  GConti  CR  et al.  Dogma disputed: can aggressively lowering blood pressure in hypertensive patients with coronary artery disease be dangerous? Ann Intern Med 2006;144 (12) 884- 893
PubMed Link to Article
Timio  MVenanzi  SLolli  S  et al.  “Non-dipper” hypertensive patients and progressive renal insufficiency: a 3-year longitudinal study. Clin Nephrol 1995;43 (6) 382- 387
PubMed
Farmer  CKGoldsmith  DJQuin  JD  et al.  Progression of diabetic nephropathy—is diurnal blood pressure rhythm as important as absolute blood pressure level? Nephrol Dial Transplant 1998;13 (3) 635- 639
PubMed Link to Article
Csiky  BKovács  TWágner  LVass  TNagy  J Ambulatory blood pressure monitoring and progression in patients with IgA nephropathy. Nephrol Dial Transplant 1999;14 (1) 86- 90
PubMed Link to Article
Knudsen  STLaugesen  EHansen  KWBek  TMogensen  CEPoulsen  PL Ambulatory pulse pressure, decreased nocturnal blood pressure reduction and progression of nephropathy in type 2 diabetic patients. Diabetologia 2009;52 (4) 698- 704
PubMed Link to Article
Redon  JPlancha  ESwift  PAPons  SMuñoz  JMartinez  F Nocturnal blood pressure and progression to end-stage renal disease or death in nondiabetic chronic kidney disease stages 3 and 4. J Hypertens 2010;28 (3) 602- 607
PubMed Link to Article
Covic  AMititiuc  IGusbeth-Tatomir  PGoldsmith  DJ The reproducibility of the circadian BP rhythm in treated hypertensive patients with polycystic kidney disease and mild chronic renal impairment—a prospective ABPM study. J Nephrol 2002;15 (5) 497- 506
PubMed
Elung-Jensen  TStrandgaard  SKamper  AL Longitudinal observations on circadian blood pressure variation in chronic kidney disease stages 3-5. Nephrol Dial Transplant 2008;23 (9) 2873- 2878
PubMed Link to Article

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