Masked hypertension and elevated nighttime blood pressure in CKD: Prevalence and association with target organ damage

Paul E. Drawz, Arnold B. Alper, Amanda H. Anderson, Carolyn S. Brecklin, Jeanne Charleston, Jing Chen, Rajat Deo, Michael J. Fischer, Jiang He, Chi Yuan Hsu, Yonghong Huan, Martin G. Keane, John W. Kusek, Gail K. Makos, Edgar R. Miller, Elsayed Z. Soliman, Susan P. Steigerwalt, Jonathan J. Taliercio, Raymond R. Townsend, Matthew R. WeirJackson T. Wright, Dawei Xie, Mahboob Rahman, Chronic Renal Insufficiency Cohort Study Investigators

Research output: Contribution to journalArticlepeer-review

90 Scopus citations


Background and objectives Masked hypertension and elevated nighttime BP are associated with increased risk of hypertensive target organ damage and adverse cardiovascular and renal outcomes in patients with normal kidney function. The significance of masked hypertension for these risks in patients with CKD is less well defined. The objective of this study was to evaluate the association between masked hypertension and kidney function and markers of cardiovascular target organ damage, and to determine whether this relationship was consistent among those with and without elevated nighttime BP. Design, setting, participants, & measurements This was a cross-sectional study. We performed 24-hour ambulatory BP in 1492 men and women with CKD enrolled in the Chronic Renal Insufficiency Cohort Study. We categorized participants into controlled BP, white-coat, masked, and sustained hypertension on the basis of clinic and 24-hour ambulatory BP. We obtained echocardiograms and measured pulse wave velocity in 1278 and 1394 participants, respectively. Results The percentages of participants with controlled BP, white-coat, masked, and sustained hypertension were 49.3%, 4.1%, 27.8%, and 18.8%, respectively. Compared with controlled BP, masked hypertension independently associated with low eGFR (-3.2 ml/min per 1.73 m 2; 95% confidence interval, -5.5 to -0.9), higher proteinuria (+0.9 unit higher in log 2 urine protein; 95% confidence interval, 0.7 to 1.1), and higher left ventricular mass index (+2.52 g/m 2.7; 95% confidence interval, 0.9 to 4.1), and pulse wave velocity (+0.92 m/s; 95% confidence interval, 0.5 to 1.3). Participants with masked hypertension had lower eGFR only in the presence of elevated nighttime BP (-3.6 ml/min per 1.73 m 2; 95% confidence interval, -6.1 to -1.1; versus -1.4 ml/min per 1.73 m 2; 95% confidence interval, -6.9 to 4.0, among those with nighttime BP <120/70 mmHg; P value for interaction with nighttime systolic BP 0.002). Conclusions Masked hypertension is common in patients with CKD and associated with lower eGFR, proteinuria, and cardiovascular target organ damage. In patients with CKD, ambulatory BP characterizes the relationship between BP and target organ damage better than BP measured in the clinic alone.

Original languageEnglish (US)
Pages (from-to)642-652
Number of pages11
JournalClinical Journal of the American Society of Nephrology
Issue number4
StatePublished - Apr 7 2016

Bibliographical note

Funding Information:
The study was supported in part through a Career Development Award K23DK087919 (P.E.D.) from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Funding for the CRIC Study was obtained under a cooperative agreement from the NIDDK (U01DK060990, U01DK060984, U01DK061022, U01DK061021, U01DK061028, U01DK060980, U01DK060963, and U01DK060902). In addition, this work was supported in part by: the Perelman School of Medicine at the University of Pennsylvania Clinical and Translational Science Award National Institutes of Health (NIH)/National Center for Advancing Translational Sciences (NCATS) UL1TR000003, Johns Hopkins University UL1 TR-000424, University of Maryland General Clinical Research Center M01 RR-16500, Clinical and Translational Science Collaborative of Cleveland, UL1TR000439 from the NCATS component of the NIH and NIH roadmap for Medical Research, Michigan Institute for Clinical and Health ResearchUL1TR000433, University of Illinois at Chicago Clinical and Translational Science Award UL1RR029879, Tulane University Translational Research in Hypertension and Renal Biology P30GM103337, Kaiser Permanente NIH/National Center for Research Resources University of California San Francisco-Clinical and Translational Science Institute UL1 RR-024131, and K01DK092353. PWV measurements were funded through NIH/NIDDK DK-067390. This work was presented at the American Society of Nephrology Kidney Week Annual Meeting, November 7-10, 2013, in Atlanta, Georgia. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIDDK or the NIH.

Publisher Copyright:
© 2016 by the American Society of Nephrology.


  • Ambulatory blood pressure monitoring
  • Blood pressure
  • Cardiovascular disease
  • Chronic kidney disease
  • Humans
  • Hypertension
  • Left ventricular hypertrophy
  • Masked hypertension
  • Nighttime
  • Pulse wave analysis

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