Diurnal Variation in Blood Pressure and Arterial Stiffness in Chronic Kidney Disease The Role of Endothelin-1

Hypertension and arterial stiffness are important independent cardiovascular risk factors in chronic kidney disease (CKD) to which endothelin-1 (ET-1) contributes. Loss of nocturnal blood pressure (BP) dipping is associated with CKD progression, but there are no data on 24-hour arterial stiffness variation. We examined the 24-hour variation of BP, arterial stiffness, and the ET system in healthy volunteers and patients with CKD and the effects on these of ET receptor type A receptor antagonism (sitaxentan). There were nocturnal dips in systolic BP and diastolic BP and pulse wave velocity, our measure of arterial stiffness, in 15 controls (systolic BP, -3.2 +/- 4.8%, P<0.05; diastolic BP, -6.4 +/- 6.2%, P=0.001; pulse wave velocity, -5.8 +/- 5.2%, P<0.01) but not in 15 patients with CKD. In CKD, plasma ET-1 increased by 1.2 +/- 1.4 pg/mL from midday to midnight compared with healthy volunteers (P<0.05). Urinary ET-1 did not change. In a randomized, double-blind, 3-way crossover study in 27 patients with CKD, 6-week treatment with placebo and nifedipine did not affect nocturnal dips in systolic BP or diastolic BP between baseline and week 6, whereas dipping was increased after 6-week sitaxentan treatment (baseline versus week 6, systolic BP: -7.0 +/- 6.2 versus -11.0 +/- 7.8 mm Hg, P<0.05; diastolic BP: -6.0 +/- 3.6 versus -8.3 +/- 5.1 mm Hg, P<0.05). There was no nocturnal dip in pulse pressure at baseline in the 3 phases of the study, whereas sitaxentan was linked to the development of a nocturnal dip in pulse pressure. In CKD, activation of the ET system seems to contribute not only to raised BP but also the loss of BP dipping. The clinical significance of these findings should be explored in future clinical trials.