Nephrol Dial Transplant (2003) 18: 563-569
© 2003 European Renal Association-European Dialysis and Transplant Association
Non-dipping is a potent predictor of cardiovascular mortality and is associated with autonomic dysfunction in haemodialysis patients
1 Division of Clinical Immunology, Department of Medicine, Nagoya University Graduate School of Medicine, Nagoya and 2 Department of Medicine, Nagoya Kyoritsu Hospital, Nagoya, Japan
Background. Lack of nocturnal blood pressure (BP) fall (non-dipping) is common among haemodialysis (HD) patients, but much less is known regarding its association with cardiovascular (CV) disease morbidity and mortality.
Methods. Eighty HD patients initially underwent 24 h ambulatory BP monitoring (ABPM), and then they were defined as either ‘dippers' (n=24, nocturnal BP fall 
10%) or ‘non-dippers' (n=56, fall <10%). Coronary angiography was performed in the patients who had signs and/or symptoms of coronary artery disease (CAD). Twenty-four hour ambulatory ECG was recorded in 20 dippers and 20 non-dipper HD patients, and in 20 normal subjects. All patients were followed for up to 5.8 years (33.0±19.1 months). The outcome events studied were the hospitalisations due to CV diseases and CV death.
Results. Compared with dippers, non-dippers initially had a higher incidence of coronary artery stenosis (P<0.05) along with left ventricular asynergy (both Ps<0.01). The circadian rhythm of autonomic function was impaired in non-dippers. The incidences of CV events and CV deaths were 3.5 and 9 times higher in non-dippers than in dippers. The cumulative CV event-free survival and CV survival rates were lower in non-dippers than in dippers (P=0.02 and P=0.005, respectively). Based on Cox analysis, non-dipping was associated positively with CV events and CV mortality [hazard ratio (HR) 2.46, 95% CI 1.02–5.92, P=0.038 and HR 9.62, 95% CI 1.23–75.42, P=0.031, respectively]. Meanwhile, nocturnal systolic BP fall, diurnal systolic BP and diurnal pulse pressure were negatively associated with CV event/death. The clinic BP was not associated with CV event/death.
Conclusions. The non-dipping phenomenon is closely related to a high incidence of CV diseases, a poor long-term survival and profound autonomic dysfunction. ABPM is useful in predicting long-term CV prognosis in HD patients.
Keywords: ambulatory blood pressure monitoring; cardiovascular diseases; cumulative survival; haemodialysis; heart rate variability; non-dipping
Correspondence and offprint requests to: Seiichi Matsuo, MD, Division of Clinical Immunology, Department of Medicine, Nagoya University Graduate School of Medicine, 65 Tsurumai-Cho, Showa-Ku, Nagoya 466-8550, Japan. Email: smatsuo{at}med.nagoya-u.ac.jp
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