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Michael B. Davidson, DO; John K. Hix, MD; Donald G. Vidt, MD; Daniel J. Brotman, MD

Arch Intern Med. 2006;166:846-852.

Background  Most healthy people exhibit a decrease in systolic blood pressure (SBP) at night. A drop of less than 10% from mean daytime values (nondipping) is associated with chronic kidney disease, insulin resistance, and cardiovascular events. Whether nondipping precedes a decline in renal function remains unclear. We hypothesized that nondipping would predict a decline in the glomerular filtration rate (GFR) over time.

Methods  Consecutive patients referred for ambulatory blood pressure monitoring were included in our retrospective cohort if they had a serum creatinine level noted at the time of their ambulatory blood pressure recording and a follow-up creatinine level recorded at least 1 year later. Mean day and night SBPs were compared (daytime SBP–nighttime SBP ratio). We defined nondipping as a daytime SBP–nighttime SBP ratio higher than 0.90. The GFR was calculated using the Modification of Diet in Renal Disease 4-variable equation.

Results  Of 322 patients included, 137 were dippers and 185 were nondippers; their mean baseline GFRs were 80.5 mL/min per 1.73 m² and 76.4 mL/min per 1.73 m², respectively. During a median follow-up of 3.2 years, the GFRs remained stable among dippers (mean change, 1.3%) but declined among nondippers (mean change, –15.9%) (P<.001). The creatinine levels increased by more than 50% in 2 dippers (1.5%) and in 32 nondippers (17.3%) (P<.001). These findings persisted after adjustment for other predictors of GFR decline.

Conclusion  Blunted diurnal blood pressure variation is associated with a subsequent deterioration in renal function that is independent of SBP load and other risk factors for renal impairment.

Author Affiliations: Departments of General Internal Medicine (Drs Davidson and Brotman) and Hypertension and Nephrology (Drs Hix and Vidt), Cleveland Clinic Foundation, Cleveland, Ohio; and Department of Medicine, The Johns Hopkins Hospital, Baltimore, Md (Dr Brotman).

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