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  • Special Issue: Current evidence and perspectives for hypertension management in Asia
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Prognostic value of nighttime blood pressure in patients with chronic kidney disease

Hypertension Research volume 48, pages 1351–1362 (2025)Cite this article

A Comment to this article was published on 19 February 2025

Abstract

The optimal blood pressure (BP) in patients with chronic kidney disease (CKD) remains uncertain. Therefore, this cohort study aimed to investigate the prognostic value of ambulatory blood pressure (ABP) in patients with CKD and to determine the optimal range for ABP. In total, 1051 hospitalized patients with CKD were enrolled. The prognosis of patients with CKD was evaluated in terms of all-cause death, cardiovascular death, cardiovascular events, and renal events. Our results showed that systolic blood pressure (SBP) had a higher predictive value than diastolic blood pressure in the multivariate-adjusted models. Additionally, nighttime SBP was found to be the best predictor of prognosis in patients with CKD. Furthermore, when dividing the nighttime SBP into quartiles (quartile 1: <110 mmHg, quartile 2: 110–124 mmHg, quartile 3:124–139 mmHg, and quartile 4: ≥139 mmHg). Nighttime SBP ≥ 124 mmHg had an impact on prognosis in patients with CKD, nighttime SBP 124–139 mmHg: total mortality (hazard ratio [HR], 3.017 [95% confidence interval (CI): 1.367–6.660]), cardiovascular death (HR, 2.570 [95% CI, 1.744–6.151]), all cardiovascular events (HR, 2.401 [95% CI, 1.288–4.475]), and 110–124 mmHg had an impact on the renal prognosis (HR, 1.975 [95% CI, 1.311–2.976]). Therefore, nighttime SBP is an independent risk factor for CKD and a significant predictor of prognosis in patients with CKD. Furthermore, the prognosis of patients with CKD improved when the nighttime SBP was maintained below 124 mmHg; however, maintaining it below 110 mmHg can further lower the incidence of renal disease.

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References

  1. Jager KJ, Kovesdy C, Langham R, Rosenbergl M, Jha V, Zoccali C. A single number for advocacy and communication-worldwide more than 850 million individuals have kidney diseases. Kidney Int. 2019;96:1048–50.

    Article  PubMed  Google Scholar 

  2. Webster AC, Nagler EV, Morton RL, Masson P. Chronic kidney disease. Lancet 2017;389:1238–52.

    Article  PubMed  Google Scholar 

  3. Muntner P, Anderson A, Charleston J, Chen Z, Ford V, Makos G, et al. Hypertension awareness, treatment, and control in adults with ckd: results from the chronic renal insufficiency cohort (CRIC) study. Am J Kidney Dis. 2010;55:441–51.

    Article  CAS  PubMed  Google Scholar 

  4. Danaei G, Lu Y, Singh GM, Carnahan E, Stevens GA, Cowan MJ, et al. Cardiovascular disease, chronic kidney disease, and diabetes mortality burden of cardiometabolic risk factors from 1980 to 2010: a comparative risk assessment. Lancet Diabetes Endocrinol. 2014;2:634–47.

    Article  Google Scholar 

  5. Drawz PE, Alper AB, Anderson AH, Brecklin CS, Charleston J, Chen J, et al. Masked hypertension and elevated nighttime blood pressure in CKD: prevalence and association with target organ damage. Clin J Am Soc Nephrol. 2016;11:642–52.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  6. Brook RD, Rajagopalan S. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. a report of the American College of Cardiology/American Heart Association Task Force on clinical practice guidelines. J Am Soc Hypertens. 2018;12:238.

    Article  PubMed  Google Scholar 

  7. Williams B, Mancia G, Spiering W, Rosei EA, Azizi M, Burnier M, et al. 2018 ESC/ESH Guidelines for the management of arterial hypertension. Rev Esp Cardiol (Engl Ed). 2019;72:160.

    Google Scholar 

  8. Leung AA, Nerenberg K, Daskalopoulou SS, McBrien K, Zarnke KB, Dasgupta K, et al. Hypertension Canada’s 2016 Canadian Hypertension education program guidelines for blood pressure measurement, diagnosis, assessment of risk, prevention, and treatment of hypertension. Can J Cardiol. 2016;32:569–88.

    Article  PubMed  Google Scholar 

  9. Yang W-Y, Melgarejo JD, Thijs L, Zhang Z-Y, Boggia J, Wei F-F, et al. Association of office and ambulatory blood pressure with mortality and cardiovascular outcomes. JAMA 2019;322:409–20.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Cho M-C. Clinical significance and therapeutic implication of nocturnal hypertension: relationship between nighttime blood pressure and quality of sleep. Korean Circ J. 2019;49:818–28.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Staplin N, de la Sierra A, Ruilope LM, Emberson JR, Vinyoles E, Gorostidi M, et al. Relationship between clinic and ambulatory blood pressure and mortality: an observational cohort study in 59124 patients. Lancet 2023;401:2041–50.

    Article  PubMed  Google Scholar 

  12. Kanno A, Kikuya M, Asayama K, Satoh M, Inoue R, Hosaka M, et al. Night-time blood pressure is associated with the development of chronic kidney disease in a general population: the Ohasama Study. J Hypertens. 2013;31:2410–7.

    Article  CAS  PubMed  Google Scholar 

  13. Kollias A, Ntineri A, Stergiou GS. Association of night-time home blood pressure with night-time ambulatory blood pressure and target-organ damage: a systematic review and meta-analysis. J Hypertens. 2017;35:442–52.

    Article  CAS  PubMed  Google Scholar 

  14. Hansen TW, Li Y, Boggia J, Thijs L, Richart T, Staessen JA. Predictive role of the nighttime blood pressure. Hypertension 2011;57:3–U46.

    Article  CAS  PubMed  Google Scholar 

  15. Boggia J, Li Y, Thijs L, Hansen TW, Kikuya M, Bjorklund-Bodegard K, et al. Prognostic accuracy of day versus night ambulatory blood pressure: a cohort study. Lancet 2007;370:1219–29.

    Article  PubMed  Google Scholar 

  16. Sega R, Facchetti R, Bombelli M, Cesana G, Corrao G, Grassi G, et al. Prognostic value of ambulatory and home blood pressures compared with office blood pressure in the general population—follow-up results from the Pressioni Arteriose Monitorate e Loro Associazioni (PAMELA) study. Circulation 2005;111:1777–83.

    Article  PubMed  Google Scholar 

  17. Zhang J, Song J, Zhou L, Zhou W, Rao J, Li Y, et al. Lower ambulatory nocturnal SBP is associated with less cardiovascular and renal damage in normotensive hospitalized patients with chronic kidney disease. J Hypertens. 2021;39:2241–9.

    Article  CAS  PubMed  Google Scholar 

  18. Fu X, Ren H, Xie J, Wang W, Li Y, Gao P, et al. Association of nighttime masked uncontrolled hypertension with left ventricular hypertrophy and kidney function among patients with chronic kidney disease not receiving dialysis. Jama Netw Open. 2022;5:e2214460.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Wang Q, Wang Y, Wang J, Zhang L, Zhao M-H, Chinese Cohort Study Chronic K. Nocturnal systolic hypertension and adverse prognosis in patients with CKD. Clin J Am Soc Nephrol. 2021;16:356–64.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Hamrahian SM, Falkner B. Hypertension in chronic kidney disease. I. Adv Exp Med Biol. 2017;956:307–25

  21. Poulter NR, Savopoulos C, Anjum A, Apostolopoulou M, Chapman N, Cross M, et al. Randomized crossover trial of the impact of morning or evening dosing of antihypertensive agents on 24-hour ambulatory blood pressure: the HARMONY trial. Hypertension 2018;72:870–3.

    Article  CAS  PubMed  Google Scholar 

  22. White WB, Wakefield DB, Moscufo N, Guttmann CRG, Kaplan RF, Bohannon RW, et al. Effects of intensive versus standard ambulatory blood pressure control on cerebrovascular outcomes in older people (INFINITY). Circulation 2019;140:1626–35.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Wang C, Zhang J, Li Y, Ma X, Ye Z, Peng H, et al. Masked hypertension, rather than white-coat hypertension, has a prognostic role in patients with non-dialysis chronic kidney disease. Int J Cardiol. 2017;230:33–9.

    Article  PubMed  Google Scholar 

  24. Wang C, Deng W-J, Gong W-Y, Zhang J, Tang H, Peng H, et al. High Prevalence of Isolated Nocturnal Hypertension in Chinese Patients With Chronic Kidney Disease. J Am Heart Assoc. 2015;4:e002025.

  25. Wang C, Deng W-J, Gong W-Y, Zhang J, Zhang Q-Z, Ye ZC, et al. 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.

    Article  PubMed  Google Scholar 

  26. Wang C, Zhang J, Liu X, Li C, Ye Z, Peng H, et al. 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.

  27. Luepker RV, Apple FS, Christenson RH, Crow RS, Fortmann SP, Goff D, et al. 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;108:2543–9.

    Article  PubMed  Google Scholar 

  28. Alpert JS, Antman E, Apple F, Armstrong PW, Bassand JP, de Luna AB, et al. Myocardial infarction redefined -: a consensus Document of the Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. J Am Coll Cardiol. 2000;36:959–69.

    Article  CAS  PubMed  Google Scholar 

  29. Pogue V, Rahman M, Lipkowitz M, Toto R, Miller E, Faulkner M, et al. Disparate estimates of hypertension control from ambulatory and clinic blood pressure measurements in hypertensive kidney disease. Hypertension 2009;53:20–7.

    Article  CAS  PubMed  Google Scholar 

  30. Stevens PE, Levin A, Kidney Dis Improving G. Evaluation and management of chronic kidney disease: synopsis of the kidney disease: improving global outcomes 2012 clinical practice guideline. Ann Intern Med. 2013;158:825–30.

    Article  PubMed  Google Scholar 

  31. Levey AS, Stevens LA, Schmid CH, Zhang Y, Castro AF III, Feldman HI, et al. A new equation to estimate glomerular filtration rate. Ann Intern Med. 2009;150:604–12.

    Article  PubMed  PubMed Central  Google Scholar 

  32. American Diabetes A. Standards of medical care in diabetes-2011. Diabetes Care. 2011;34:S11–61.

    Article  Google Scholar 

  33. Pocock SJ, Clayton TC, Altman DG. Survival plots of time-to-event outcomes in clinical trials: good practice and pitfalls. Lancet 2002;359:1686–9.

    Article  PubMed  Google Scholar 

  34. Rahman M, Wang X, Bundy JD, Charleston J, Cohen D, Cohen J, et al. Prognostic significance of ambulatory BP monitoring in CKD: a report from the chronic renal insufficiency cohort (CRIC) study. J Am Soc Nephrol. 2020;31:2609–21.

    Article  PubMed  PubMed Central  Google Scholar 

  35. El Jamal N, Brooks TG, Cohen J, Townsend RR, Sosa GRD, Shah V, et al. Prognostic utility of rhythmic components in 24-h ambulatory blood pressure monitoring for the risk stratification of chronic kidney disease patients with cardiovascular co-morbidity. J Hum Hypertens. 2024;38:420–9.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Ayodele OE, Alebiosu CO. Burden of chronic kidney disease: an international perspective. Adv Chronic Kidney Dis. 2010;17:215–24.

    Article  PubMed  Google Scholar 

  37. Jha V, Garcia-Garcia G, Iseki K, Li Z, Naicker S, Plattner B, et al. Chronic kidney disease: global dimension and perspectives. Lancet 2013;382:260–72.

    Article  PubMed  Google Scholar 

  38. Jha V. End-stage renal care in developing countries: the India experience. Ren Fail. 2004;26:201–8.

    Article  PubMed  Google Scholar 

  39. Jiang X, Li X, Peng H, Li M, Wang C. Prognostic value of nighttime double product in nondialysis chronic kidney disease with hypertension. J Am Heart Assoc. 2023;12:e031627.

  40. Flint AC, Conell C, Ren X, Banki NM, Chan SL, Rao VA, et al. Effect of systolic and diastolic blood pressure on cardiovascular outcomes. N Engl J Med. 2019;381:243–51.

    Article  PubMed  Google Scholar 

  41. Kario K, Shin J, Chen C-H, Buranakitjaroen P, Chia Y-C, Divinagracia R, et al. Expert panel consensus recommendations for ambulatory blood pressure monitoring in Asia: the HOPE Asia network. J Clin Hypertens. 2019;21:1250–83.

    Article  Google Scholar 

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Acknowledgements

The authors would like to acknowledge all patients and their families for participating in this study. The study was supported by China Chronic Kidney Disease Management Innovation Program (202206080010), Guangdong Basic and Applied Basic Research Fund Enterprise Joint Fund (Provincial enterprise joint Fund) (2021B1515230005), and Special Project of National Natural Science Foundation of China of the Third Affiliated Hospital of Sun Yat-sen University in 2022(No.2022GZRPYMS09).

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  1. These authors contributed equally: Jiawen Li, Qin Wei.

Authors and Affiliations

  1. Department of Nephrology, The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China

    Jiawen Li, Qin Wei, Shaomin Li, Jun Zhang & Hui Peng

  2. Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China

    Jun Song

  3. Division of Nephrology, Department of Medicine, The Fifth Affiliated Hospital, Sun Yat-sen University, Zhuhai, Guangdong, China

    Cheng Wang

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  1. Jiawen Li
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Contributions

Jiawen Li: Conceptualization, formal analysis, investigation, writing–original draft. Qin Wei: Methodology, investigation, visualization. Shaomin Li: Biochemical index examination. Jun Song: Data curation. Cheng Wang: Data curation. Jun Zhang: Project administration, writing—review and editing. Hui Peng: Project administration.

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Correspondence to Jun Zhang or Hui Peng.

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Li, J., Wei, Q., Li, S. et al. Prognostic value of nighttime blood pressure in patients with chronic kidney disease. Hypertens Res 48, 1351–1362 (2025). https://doi.org/10.1038/s41440-024-02080-0

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