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Previous Volume 347:797-805 September 12, 2002 Number 11 Next

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ABSTRACT

Background Patients with type 1 diabetes mellitus and microalbuminuria often have elevated blood pressure while they are asleep, but it is not known whether the elevation develops concomitantly with microalbuminuria or precedes it.

Methods We monitored 75 adolescents and young adults who had had type 1 diabetes with normal urinary albumin excretion and blood pressure for more than five years. Ambulatory blood-pressure monitoring was used to assess blood pressure at the initial evaluation and about two years later, at which time all subjects had normal urinary albumin excretion. Subsequently, subjects were monitored for the development of microalbuminuria.

Results Microalbuminuria developed in 14 subjects, whereas the other 61 continued to have normal urinary albumin excretion. The mean (±SD) systolic pressure during sleep increased significantly in the subjects who ultimately had microalbuminuria (from 109.9±11.3 to 114.9±11.7 mm Hg, P=0.01) but not in the subjects with normal albumin excretion (from 106.0±8.8 to 106.4±14.8 mm Hg). The risk of progression to microalbuminuria was examined in relation to the ratio of systolic pressure during sleep to systolic pressure in the daytime. A ratio of 0.9 or lower, used to define a normal fall in nocturnal pressure, had a negative predictive value of 91 percent for the development of microalbuminuria. Moreover, the risk of microalbuminuria was 70 percent lower (95 percent confidence interval, 44 to 110 percent) in subjects with a ratio of 0.9 or less than in those with a ratio higher than 0.9 (P=0.01).

Conclusions In persons with type 1 diabetes, an increase in systolic blood pressure during sleep precedes the development of microalbuminuria. In those whose blood pressure during sleep decreases normally, the progression from normal albumin excretion to microalbuminuria appears to be less likely.

Source Information

From the Pediatric Nephrology Unit, Department of Pediatrics, Hospital General and University of Valencia, Valencia, Spain (E.L., J.T., V.A.); the Hypertension Clinic, Department of Medicine, Hospital Clinico and University of Valencia, Valencia, Spain (J.R.); the Division of Nephrology and Hypertension, Feinberg School of Medicine, Northwestern University, Chicago (A.K., D.B.); and the Department of Medicine, Hospital de Sagunto, Sagunto, Spain (J.M.P.).

Address reprint requests to Dr. Batlle at the Division of Nephrology and Hypertension, Feinberg School of Medicine, Northwestern University, 320 E. Superior St., 10-475 Searle Bldg., Chicago, IL 60611.

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Related Letters:

Increase in Nocturnal Blood Pressure and Progression to Microalbuminuria in Diabetes
Brotman D. J., Girod J. P., Thomas S., Poulsen P. L., Hansen K. W., Mogensen C. E., Caramori M. L., Pecis M., Azevedo M. J., Marfella R., Esposito K., Giugliano D., Lurbe E., Redon J., Batlle D.
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N Engl J Med 2003; 348:260-264, Jan 16, 2003. Correspondence

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