Chronic kidney disease is characterized by "double trouble" higher pulse pressure plus night-time systolic blood pressure and more severe cardiac damage

The association between circadian syndrome and chronic kidney disease in an aging population: a 4-year follow-up study

Introduction

Circadian syndrome (CircS) is proposed as a novel risk cluster based on reduced sleep duration, abdominal obesity, depression, hypertension, dyslipidemia and hyperglycemia. However, the association between CircS and chronic kidney disease (CKD) remains unclear. To investigate the cross-sectional and longitudinal association between CircS and CKD, this study was performed.

Methods

A national prospective cohort (China Health and Retirement Longitudinal Study, CHARLS) was used in this study. To define CKD, the estimated glomerular filtration rate (eGFR) was calculated based on the 2012 CKD-EPI creatinine-cystatin C equation. Participants with eGFR <60 mL.min-1/1.73/m2 were diagnosed with CKD. Multivariate binary logistic regression was used to assess the cross-sectional association between CircS and CKD. Subgroup and interactive analyses were performed to determine the interactive effects of covariates. In the sensitivity analysis, the obese population was excluded and another method for calculating the eGFR was used to verify the robustness of previous findings. In addition, participants without CKD at baseline were followed up for four years to investigate the longitudinal relationship between CircS and CKD.

Results

A total of 6355 participants were included in this study. In the full model, CircS was positively associated with CKD (OR = 1.28, 95% CI = 1.04-1.59, P < 0.05). As per one increase of CircS components, there was a 1.11-fold (95% CI = 1.04-1.18, P < 0.05) risk of prevalent CKD in the full model. A significant interactive effect of hyperuricemia in the CircS-CKD association (P for interaction < 0.01) was observed. Sensitivity analyses excluding the obese population and using the 2009 CKD-EPI creatinine equation to diagnose CKD supported the positive correlation between CircS and CKD. In the 2011-2015 follow-up cohort, the CircS group had a 2.18-fold risk of incident CKD (95% CI = 1.33-3.58, P < 0.01) in the full model. The OR was 1.29 (95% CI = 1.10-1.51, P < 0.001) with per one increase of CircS components.

Conclusion

CircS is a risk factor for CKD and may serve as a predictor of CKD for early identification and intervention.

Single-pill fixed-dose drug combinations to reduce blood pressure: the right pill for the right patient

Arterial hypertension is one of the major causes of cardiovascular morbidity and mortality worldwide. Effective and sustained reduction in blood pressure is essential to reduce individual cardiovascular risk. In daily clinical practice, single-pill fixed-dose combinations of different drug classes are important therapeutic resources that could improve both treatment adherence and cardiovascular risk management by targeting distinct pathophysiological mechanisms. The aim of this practical narrative review is to help physicians choosing the right single-pill fixed-dose combination for the right patient in the daily clinical practice, based on the individual clinical phenotype and cardiovascular risk profile.

Assessment of hypertension in kidney transplantation by ambulatory blood pressure monitoring: a systematic review and meta-analysis

Background

Hypertension (HTN) is common following renal transplantation and it is associated with adverse effects on cardiovascular (CV) and graft health. Ambulatory blood pressure monitoring (ABPM) is the preferred method to characterize blood pressure (BP) status, since HTN misclassification by office BP (OBP) is quite common in this population. We performed a systematic review and meta-analysis aimed at determining the clinical utility of 24-h ABPM and its potential implications for the management of HTN in this population.

Methods

Ovid-MEDLINE and PubMed databases were searched for interventional or observational studies enrolling adult kidney transplant recipients (KTRs) undergoing 24-h ABP readings compared with OBP or home BP. The main outcome was the proportion of KTRs diagnosed with HTN by ABPM, home or OBP recordings. Additionally, day-night BP variability and dipper/non-dipper status were assessed.

Results

Forty-two eligible studies (4115 participants) were reviewed. A cumulative analysis including 27 studies (3481 participants) revealed a prevalence of uncontrolled HTN detected by ABPM of 56% [95% confidence interval (CI) 46-65%]. The pooled prevalence of uncontrolled HTN according to OBP was 47% (95% CI 36-58%) in 25 studies (3261 participants). Very few studies reported on home BP recordings. The average concordance rate between OBP and ABPM measurements in classifying patients as controlled or uncontrolled hypertensive was 66% (95% CI 59-73%). ABPM revealed HTN phenotypes among KTRs. Two pooled analyses of 11 and 10 studies, respectively, revealed an average prevalence of 26% (95% CI 19-33%) for masked HTN (MHT) and 10% (95% CI 6-17%) for white-coat HTN (WCH). The proportion of non-dippers was variable across the 28 studies that analysed dipping status, with an average prevalence of 54% (95% CI 45-63%).

Conclusions

In our systematic review, comparison of OBP versus ABP measurements disclosed a high proportion of MHT, uncontrolled HTN and, to a lesser extent, WCH in KTRs. These results suggest that HTN is not adequately diagnosed and controlled by OBP recordings in this population. Furthermore, the high prevalence of non-dippers confirmed that circadian rhythm is commonly disturbed in KTRs.

Assessment of psychiatric comorbidities and serotonergic or noradrenergic medication use on blood pressure using 24-hour ambulatory blood pressure monitoring

In this study, the authors aimed to assess both nighttime and daytime blood pressure (BP) variability using 24-hour ambulatory BP monitoring (ABPM) in persons with and without psychiatric conditions and with or without selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) treatment. In this retrospective study, patients who underwent psychiatric evaluation and ABPM within 6 months of each other between January 1, 2012 and December 31, 2017 were identified using billing data. Participants were divided into three groups-participants with no psychiatric diagnosis and no psychiatric medicine (-Diagnosis/-Medication), those with psychiatric diagnosis and on SSRIs/SNRIs (+Diagnosis/+Medication), and psychiatric diagnosis but no psychiatric medications (+Diagnosis/-Medication). Day and nighttime systolic and diastolic BPs were compared between groups controlling for relevant variables using multivariable linear regression models. A total of 475 participants met inclusion criteria including 135 in the -Diagnosis/-Medication group, 232 in the +Diagnosis/+Medication group, and 108 in the +Diagnosis/-Medication group. In adjusted multivariable analysis, the +Diagnosis/+Medication group had higher nighttime systolic BP (median 120 vs 110 mm (Hg); p = .01) and nighttime diastolic BP (median 68 vs 63 mm (Hg); p = .006) as compared to -Diagnosis/-Medication. No statistically significant differences in BPs between the -Diagnosis/-Medication and +Diagnosis/-Medication groups were observed, after adjustment. Use of SSRIs/SNRIs was associated with significantly higher nocturnal systolic and diastolic BP among patients with psychiatric diagnosis using SSRIs/SNRIs but not associated with psychiatric diagnosis without SSRI/SNRI use. SSRIs/SNRIs use may be associated with higher BP levels and this merits future prospective studies using ABPM to assess day and nighttime BP changes with SSRIs/SNRIs use.

Inverted circadian variation of arterial pressure in a geriatric patient: an indicator of autonomic dysfunction

BACKGROUND

Orthostatic hypotension (OH) in geriatric patients frequently involves a component of autonomic failure (AF). The combination of OH with nocturnal hypertension (NHT) is indicative of AF, which is described as pure (PAF), when neurologic symptoms are absent, or as multisystem atrophy (MSA), when combined with motor disturbance (Parkinsonism or Parkinson disease).

CASE PRESENTATION

An 87-year-old man presented with long-lasting OH. He frequently fell, causing several fractures, and he developed heart failure. Blood pressure (BP) registration revealed a reversal of the day-night rhythm with NHT. An 18-FDG PET brain CT scan showed cerebellar hypometabolism, indicating MSA.

CONCLUSIONS

This case demonstrates the use of continuous BP registration in geriatric patients with OH for diagnosing NHT. It illustrates the usefulness of 18-FDG PET brain CT scan to specify the nature of the AF. The case also illustrates the difficulty of managing the combination of OH and NHT.

Nocturnal blood pressure dipping as a marker of endothelial function and subclinical atherosclerosis in pediatric-onset systemic lupus erythematosus

Background

Loss of the normal nocturnal decline in blood pressure (BP), known as non-dipping, is a potential measure of cardiovascular risk identified by ambulatory blood pressure monitoring (ABPM). We sought to determine whether non-dipping is a useful marker of abnormal vascular function and subclinical atherosclerosis in pediatric-onset systemic lupus erythematosus (pSLE).

Methods

Twenty subjects 9–19 years of age with pSLE underwent ABPM, peripheral endothelial function testing, carotid-femoral pulse wave velocity/analysis for aortic stiffness, and carotid intima-media thickness. We assessed the prevalence of non-dipping and other ABPM abnormalities. Pearson or Spearman rank correlation tests were used to evaluate relationships between nocturnal BP dipping, BP load (% of abnormally elevated BPs over 24-h), and vascular outcome measures.

Results

The majority (75%) of subjects had inactive disease, with mean disease duration of 3.2 years (± 2.1). The prevalence of non-dipping was 50%, which occurred even in the absence of nocturnal or daytime hypertension. Reduced diastolic BP dipping was associated with poorer endothelial function (r 0.5, p = 0.04). Intima-media thickness was significantly greater in subjects with non-dipping (mean standard deviation score of 3.0 vs 1.6, p = 0.02). In contrast, higher systolic and diastolic BP load were associated with increased aortic stiffness (ρ 0.6, p = 0.01 and ρ 0.7, p < 0.01, respectively), but not with endothelial function or intima-media thickness.

Conclusion

In a pSLE cohort with low disease activity, isolated nocturnal BP non-dipping is prevalent and associated with endothelial dysfunction and atherosclerotic changes. In addition to hypertension assessment, ABPM has a promising role in risk stratification and understanding heterogeneous mechanisms of cardiovascular disease in pSLE.

Chronodisruption: A Poorly Recognized Feature of CKD

Multiple physiological variables change over time in a predictable and repetitive manner, guided by molecular clocks that respond to external and internal clues and are coordinated by a central clock. The kidney is the site of one of the most active peripheral clocks. Biological rhythms, of which the best known are circadian rhythms, are required for normal physiology of the kidneys and other organs. Chronodisruption refers to the chronic disruption of circadian rhythms leading to disease. While there is evidence that circadian rhythms may be altered in kidney disease and that altered circadian rhythms may accelerate chronic kidney disease (CKD) progression, there is no comprehensive review on chronodisruption and chronodisruptors in CKD and its manifestations. Indeed, the term chronodisruption has been rarely applied to CKD despite chronodisruptors being potential therapeutic targets in CKD patients. We now discuss evidence for chronodisruption in CKD and the impact of chronodisruption on CKD manifestations, identify potential chronodisruptors, some of them uremic toxins, and their therapeutic implications, and discuss current unanswered questions on this topic.

Should We Consider the Cardiovascular System While Evaluating CKD-MBD?

Cardiovascular (CV) disease is highly prevalent in the population with chronic kidney disease (CKD), where the risk of CV death in early stages far exceeds the risk of progression to dialysis. The presence of chronic kidney disease-mineral and bone disorder (CKD-MBD) has shown a strong correlation with CV events and mortality. As a non-atheromatous process, it could be partially explained why standard CV disease-modifying drugs do not provide such an impact on CV mortality in CKD as observed in the general population. We summarize the potential association of CV comorbidities with the older (parathyroid hormone, phosphate) and newer (FGF23, Klotho, sclerostin) CKD-MBD biomarkers.

The Association Between Selected Molecular Biomarkers and Ambulatory Blood Pressure Patterns in African Chronic Kidney Disease and Hypertensive Patients Compared With Normotensive Controls: Protocol for a Longitudinal Study

Background

Chronic kidney disease (CKD) is a burgeoning epidemic in sub-Saharan Africa. Abnormal blood pressure variations are prevalent in CKD and potentiate the risk of cardiovascular morbidity and mortality. Certain genetic variants (angiotensin II receptor type 1 1166 A>C and angiotensin-converting enzyme insertion and deletion polymorphisms) and biomarkers such as interleukin–6, tumor necrosis factor, soluble (s) E-selectin, homocysteine, and highly sensitive C-reactive protein have been shown to affect blood pressure variability among non-African CKD, hypertensive. and nonhypertensive CKD population. However, the contributions of the pattern, genetic, and environmental determinants of ambulatory blood pressure in African CKD have not been characterized. Understanding these interactions may help to develop interventions to prevent major cardiovascular events among people with CKD.

Objective

The overarching objective of this study is to identify, document, and develop approaches to address related phenomic, genetic, and environmental determinants of ambulatory blood pressure patterns in African CKD and non-CKD hypertensive patients compared with normotensive controls.

Methods

This is a longitudinal short-term follow-up study of 200 adult subjects with CKD and 200 each of age-matched hypertensives without CKD and apparently healthy controls. Demographic information, detailed clinical profile, electrocardiography, echocardiography, and 24-hr ambulatory blood pressure measurements will be obtained. Blood samples will be collected to determine albumin-creatinine ratio, fasting plasma glucose, lipid profile, electrolytes, urea and creatinine, C-reactive protein, serum homocysteine, fibroblast growth factor–23, and complete blood count, while 2 mL blood aliquot will be collected in EDTA (ethylenediaminetetraacetic acid) tubes and mixed using an electronic rolling system to prevent blood clots and subsequently used for DNA extraction and genetic analysis.

Results

A total of 239 participants have been recruited so far, and it is expected that the recruitment phase will be complete in June 2020. The follow-up phase will continue with data analysis and publications of results.

Conclusions

This study will help stratify Nigerian CKD patients phenotypically and genotypically in terms of their blood pressure variations with implications for targeted interventions and timing of medications to improve prognosis.

International Registered Report Identifier (IRRID)

DERR1-10.2196/14820

Association between 24-hour diastolic blood pressure and renal function in patients receiving treatment for essential hypertension

Objectives

To evaluate the association between diastolic blood pressure (BP), measured by 24-hour ambulatory blood pressure monitoring (ABPM) and renal function in patients receiving treatment for essential hypertension.

Methods

In this cross-sectional study, ABPM, transthoracic echocardiography, estimated glomerular filtration rate (eGFR) on the basis of serum cystatin C (eGFRcyst) and the renal resistive index (RRI) were measured in patients with essential hypertension.

Results

The cohort consisted of 105 patients (39 men, 66 women), with a mean ± SD age of 58 ± 12 years who had been receiving treatment for 11 ± 8 years. 24-hour diastolic BP significantly positively correlated with eGFRcyst and negatively correlated with RRI. No correlation was observed with 24-hour systolic BP values. 24-hour diastolic BP values ≤70 mmHg were associated with eGFRcyst ≤60 ml/min/1.73 m2 (i.e., decreased GFR).

Conclusion

24-hour diastolic BP values were significantly associated with markers of kidney function in patients receiving treatment for essential hypertension and values ≤70 mmHg may be associated with subnormal eGFRcyst.

Nocturnal blood pressure decrease in patients with chronic kidney disease and in healthy controls - significance of obstructive sleep apnea and renal function

Background

Chronic kidney disease (CKD) is often associated with a blunted nocturnal BP decrease and OSA. However, it is not fully clear whether a relationship exists between reduction in renal function and obstructive sleep apnea (OSA) on the one hand and relative nocturnal BP decrease in CKD patients on the other. The aim of this study was to investigate the association between nocturnal BP decrease and renal function, the degree of OSA, vasoactive hormones, and renal sodium handling in CKD3-4 patients and healthy age-matched controls.

Methods

We performed brachial and central 24-hour ambulatory BP measurement and CRM in 70 CKD3-4 patients and 56 controls. In plasma, we measured renin, AngII, aldosterone, and vasopressin. In urine, 24-hour excretion of sodium, protein fractions from the epithelial sodium channel (u-ENaCγ), and the AQP2 water channels (u-AQP2) were measured.

Results

CKD patients had lower relative nocturnal BP decrease than controls: brachial (10% vs 17%, P=0.001) and central (6% vs 10%, P=0.001). Moderate-to-severe OSA was more frequent in patients (15 vs 1%, P<0.0001). Neither the presence of OSA nor eGFR were predictors of either brachial or central nocturnal BP decrease. CKD3-4 nondippers were more obese, had higher HbA1c level, and more often a history of acute myocardial infarction than CKD3-4 dippers (P<0.05).

Conclusion

CKD3-4 patients had lower brachial and central nocturnal BP decrease than healthy controls. OSA and eGFR were not associated with nondipping in CKD patients or healthy controls. Nondipping in CKD3-4 was associated with obesity, diabetes, and cardiovascular disease.

ClinicalTrials.gov ID

NCT01951196.

Chronotherapy for Hypertension

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.

Arterial stiffness but not endothelial dysfunction is associated with multidrug antihypertensive therapy and nondipper blood pressure pattern in kidney transplant recipients

Vascular injury related to chronic kidney disease results in increased arterial stiffness and endothelial dysfunction which may affect arterial blood pressure (BP) and influence patient and graft survival in kidney transplant recipients (KTRs).This cross-sectional study aims to elucidate the relationship between the above-mentioned measures of vascular damage and effectiveness of antihypertensive treatment in KTR.One hundred forty-five KTRs 7.6 ± 2.7 years after transplantation were enrolled in our study. Pulse wave velocity (PWV), flow-mediated dilation (FMD), and nitroglycerin-mediated dilation (NMD) were measured, and 24-hour ambulatory BP monitoring was performed.Overall, there were 62 patients with well-controlled or borderline BP and 83 subjects who did not achieve target BP despite antihypertensive treatment. Patients with suboptimal BP control were characterized by greater PWV (median 9.6/interquartile range: 3.9 vs 8.0/3.3 m/s, P = .002), but borderline lower FMD (8.4% ± 5.0% vs 9.9% ± 5.7%; P = .09) as compared with the group with better BP control. When patients were allocated to subgroups based on the number of current antihypertensive medications, no differences in FMD and NMD were found. However, a significant trend was observed for higher PWV values and decreased proportion of dippers along with the increasing number of drugs. PWV, diabetes, and total cholesterol level, but not FMD or NMD, were explanatory variables for systolic BP in multivariate analysis.Arterial stiffness but not endothelial dysfunction is associated with suboptimal BP control in stable KTRs. Less efficient antihypertensive treatment appears to be caused by inadequate control of nocturnal BP.

Plasma renin activity to plasma aldosterone concentration ratio correlates with night-time and pulse pressures in essential hypertensive patients treated with angiotensin-converting enzyme inhibitors/AT1 blockers

OBJECTIVES

Angiotensin-converting enzyme inhibitors (ACE-I) and AT1 blockers (ARB) are commonly used antihypertensive drugs, but several factors may affect their effectiveness. We evaluated the associations between ambulatory blood pressure (BP) monitoring (ABPM) parameters and plasma renin activity (PRA)-to-plasma aldosterone concentration (PAC) ratio (RAR) to test renin-angiotensin-aldosterone system inhibition in essential hypertensive patients treated with ACE-I or ARB for at least 12 months.

METHODS

We evaluated 194 consecutive patients referred to our Hypertension Centre. ABPM, PRA and PAC tests were performed without any changes in drug therapy. RAR, PRA and PAC tertiles were considered for the analyses.

RESULTS

Mean age: 57.4 ± 12.0 years; male prevalence: 63.9%. No differences between RAR tertiles regarding the use of ACE-I or ARB (P = 0.385), as well as the other antihypertensive drug classes, were found. A reduction of all ABPM values considered (24-h BP, daytime BP and night-time BP and 24-h pulse pressure (PP), daytime PP and night-time PP) and a better BP control were observed at increasing RAR tertiles, with an odds ratio = 0.12 to be not controlled during night-time period for patients in the third tertile compared with patients in the first tertile (P < 0.001). This association remained significant even after adjusting for 24-h BP control. All the associations were also confirmed for PRA tertiles, but not for PAC tertiles.

CONCLUSION

Higher RAR values indicate effective renin-angiotensin-aldosterone system inhibition and lower night-time and pulse pressures in real-life clinical practice. It could be a useful biomarker in the management of essential hypertensive patients treated with ACE-I or ARB.

Clinical Conditions and Predictive Markers of Non-Dipper Profile in Hypertensive Patients

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.

Discrepancies in Clinic and Ambulatory Blood Pressure in Korean Chronic Kidney Disease Patients

Blood pressure (BP) control is considered the most important treatment for preventing chronic kidney disease (CKD) progression and associated cardiovascular complications. However, clinic BP is insufficient to diagnose hypertension (HT) and to monitor overall BP control because it does not correlate well with ambulatory blood pressure monitoring (ABPM). We enrolled 387 hypertensive CKD patients (stages G1-G4, 58.4% male with median age 61 years) from 3 hospitals in Korea. HT of clinic BP and ABPM was classified as ≥ 140/90 and ≥ 130/80 mmHg, respectively. Clinic BP control rate was 60.2%. The median 24-hour systolic blood pressures (SBPs) of CKD G3b and CKD G4 were significantly higher than those of CKD G1-2 and CKD G3a. However, the median 24-hour SBPs were not different between CKD G1-2 and CKD G3a or between CKD G3b and CKD G4. Of all patients, 5.7%, 38.0%. 42.3%, and 14.0% were extreme-dippers, dippers, non-dippers, and reverse-dippers, respectively. Non-/reverse-dippers independently correlated with higher Ca × P product, higher intact parathyroid hormone (iPTH), and lower albumin. Normal BP was 33.3%, and sustained, masked, and white-coat HT were 29.7%, 26.9%, and 10.1%, respectively. White-coat HT independently correlated with age ≥ 61 years and masked HT independently correlated with CKD G3b/G4. In conclusion, ABPM revealed a high prevalence of non-/reverse-dippers and sustained/masked HT in Korean CKD patients. Clinicians should try to obtain a CKD patient's ABPM, especially among those who are older or who have advanced CKD as well as those with abnormal Ca × P product, iPTH, and albumin.

Blood Pressure and Metabolic Changes After 3-Month CPAP Therapy in a Very Elderly Obese with Severe Obstructive Sleep Apnea: A Case Report and Review of the Literature

Age is one of the main risk factor for the presence of obstructive sleep apnea (OSA). This syndrome is associated with hypertension, cardiovascular disease, cognitive impairment and metabolic abnormalities, such as type 2 diabetes. Continuous positive airway pressure (CPAP) represents the gold standard therapy, but its benefit is still to be determined in very elderly. We report the blood pressure and metabolic changes in a very elderly obese with severe OSA after 3-month CPAP therapy. We have evaluated a very elderly obese male affected by severe symptomatic OSA, poor controlled nocturnal hypertension and insulin resistance. After 3-month CPAP therapy, without any changes in drug therapy, we observed a normalization of circadian blood pressure (BP) pattern, an improved insulin sensitivity, together with a reduced resting energy expenditure, despite no significant change in weight. This case report shows the benefits of OSA treatment with CPAP, not only on BP profile, but also on metabolic parameters in a very elderly, a particular type of patient in which scientific evidence is still scant. Further studies are needed to better investigate the relationship between OSA, CPAP therapy and energy expenditure not only in adults but also in elderly patients.

Ambulatory and home blood pressure monitoring in people with chronic kidney disease. Time to abandon clinic blood pressure measurements?

PURPOSE OF REVIEW

There is currently much interest in the usefulness of out-of-office blood pressure (BP) for the diagnosis and the management of hypertension in patients with chronic kidney disease (CKD). This is not to suggest that office BP should be disregarded and we will take the opportunity to stress how it could be improved.

RECENT FINDINGS

Arterial hypertension constitutes a very relevant cardiovascular and renal risk factor in patients with CKD. To assess this risk, the best tool is ambulatory BP monitoring (ABPM), as it allows the detection of masked hypertension, masked untreated hypertension (MUCH) and nondipping pattern, conditions known to be associated with target organ damage that further contributes to increased risk to the patient. Home BP monitoring (HBPM) cannot fully substitute for ABPM because of the absence of BP data during the night. Despite this, there are good reasons to use HBPM systematically in patients with CKD during long-term follow-up.

SUMMARY

In the individual patient office, BP may significantly differ from out-of-office measurements. This shortcoming can be attenuated by repeated measurement at every visit, but even if office BP is considered normal, it is still highly desirable to obtain out-of-office data.

Cardiovascular Autonomic Dysfunction in Chronic Kidney Disease: a Comprehensive Review

Cardiovascular autonomic dysfunction is a major complication of chronic kidney disease (CKD), likely contributing to the high incidence of cardiovascular mortality in this patient population. In addition to adrenergic overdrive in affected individuals, clinical and experimental evidence now strongly indicates the presence of impaired reflex control of both sympathetic and parasympathetic outflow to the heart and vasculature. Although the principal underlying mechanisms are not completely understood, potential involvements of altered baroreceptor, cardiopulmonary, and chemoreceptor reflex function, along with factors including but not limited to increased renin-angiotensin-aldosterone system activity, activation of the renal afferents and cardiovascular structural remodeling have been suggested. This review therefore analyzes potential mechanisms underpinning autonomic imbalance in CKD, covers results accumulated thus far on cardiovascular autonomic function studies in clinical and experimental renal failure, discusses the role of current interventional and therapeutic strategies in ameliorating autonomic deficits associated with chronic renal dysfunction, and identifies gaps in our knowledge of neural mechanisms driving cardiovascular disease in CKD.

Influence of chronic kidney disease on cardiac structure and function

Chronic kidney disease (CKD), the presence of kidney dysfunction and/or damage, is a worldwide public health issue. Although CKD is independently associated with various subtypes of cardiovascular diseases, a recent international collaborative meta-analysis demonstrates that CKD is particularly strongly associated with heart failure, suggesting its critical impact on cardiac structure and function. Although numerous studies have investigated the association of CKD and cardiac structure and function, these studies substantially vary regarding source populations and methodology (e.g., measures of CKD and/or parameters of cardiac structure and function), making it difficult to reach universal conclusions. Nevertheless, in this review, we comprehensively examine relevant studies, discuss potential mechanisms linking CKD to alteration of cardiac structure and function, and demonstrate clinical implications as well as potential future research directions. We exclusively focus on studies investigating both CKD measures, kidney function (i.e., glomerular filtration rate [GFR], creatinine clearance, or levels of filtration markers), and kidney damage represented by albuminuria, since current international clinical guidelines of CKD recommend staging CKD and assessing its clinical risk based on both GFR and albuminuria.

Treatment of hypertension in children with chronic kidney disease

Hypertension (HTN) is increasingly recognized as a common feature of pediatric chronic kidney disease (CKD). A growing body of evidence demonstrates that HTN is both underdiagnosed and undertreated in this population. The consequences of untreated HTN include adverse effects on CKD progression, markers of cardiovascular morbidity, and neurocognitive functioning. Consensus guidelines issued over the past decade have incorporated recent research on the consequences of HTN in recommendations for the diagnosis and treatment of HTN in pediatric CKD and include lower BP targets. Agents which target the renin-angiotensin-aldosterone system (RAAS) should be considered first-line therapy in CKD-associated HTN in children, though multiple medications may be required to achieve sufficient BP control.

Left ventricular hypertrophy and chronic renal insufficiency in the elderly

BACKGROUND

The global population is aging. Cardiovascular disease is the leading cause of death in both men and women older than 65 years. In particular, elderly patients have an increased prevalence of left ventricular hypertrophy (LVH) and chronic kidney disease (CKD), both of which predict increased cardiovascular morbidity and mortality. LVH and CKD frequently coexist in the elderly, and LVH is a powerful predictor of mortality in patients with end-stage renal disease.

KEY MESSAGES

Several hemodynamic factors contribute to LVH and CKD in the elderly. Increased arterial stiffness in the elderly is associated with LVH and CKD. Studies using noninvasive measures of arterial stiffening have shown a correlation between these measures and LVH in patients with CKD. Hypertensive patients with an altered circadian blood pressure pattern such as nondippers have an increased incidence of LVH and CKD. Anemia is a risk factor for LVH in patients in all stages of CKD, and studies have shown correlations between age, anemia and LV mass. Nonhemodynamic factors include chronic inflammation, increased oxidative stress, and reduced autophagy, all of which are present in the elderly. Disordered mineral metabolism in the elderly with reduced levels of vitamin D and elevated levels of parathyroid hormone and phosphorus is associated with LVH and CKD.

CONCLUSIONS

Multiple pathophysiologic mechanisms contribute to the development of LVH and CKD in the elderly. Future research should be directed at interfering with this development and reducing the burden of cardiovascular and renal diseases in this growing population.