# Nocturnal Stage 1 Hypertension Defined by 2025 Guidelines in Adults With Chronic Kidney Disease

## TL;DR

The study found that nocturnal stage 1 hypertension, as defined by new 2025 guidelines, is linked to faster kidney disease progression in adults with chronic kidney disease.

## Contribution

This study is the first to evaluate the association between newly defined nocturnal stage 1 hypertension and kidney function decline in CKD patients not on dialysis.

## Key findings

- Nocturnal stage 1 hypertension was independently associated with increased risk of kidney failure and worsening kidney function.
- In older adults (aged ≥65), lower nocturnal BP (<110/65 mm Hg) was paradoxically linked to higher risk of kidney outcomes.
- The findings suggest a need for tailored management strategies for CKD patients with nocturnal stage 1 hypertension.

## Abstract

This cohort study evaluates whether nocturnal stage 1 hypertension as defined by 2025 American College of Cardiology/American Heart Association guidelines in patients with chronic kidney disease (CKD) is associated with worsening of kidney disease.

Is nocturnal stage 1 hypertension as defined by 2025 American College of Cardiology/American Heart Association (ACC/AHA) guidelines in patients with chronic kidney disease (CKD) associated with decline in kidney function?

In this cohort study of 2418 patients with CKD not receiving dialysis, nocturnal stage 1 hypertension, as defined by the 2025 ACC/AHA guidelines, was independently associated with kidney function deterioration.

These findings suggest that an optimal management strategy is needed for patients with CKD and stage 1 hypertension who are not receiving dialysis to benefit kidney outcomes.

The 2025 American College of Cardiology/American Heart Association (ACC/AHA) blood pressure (BP) guideline introduced new hypertension criteria. However, the association between newly defined nocturnal stage 1 hypertension (nocturnal BP 110-120/65-70 mm Hg) and kidney function progression in the population not receiving dialysis with chronic kidney disease (CKD) in China remains unclear.

To determine whether nocturnal stage 1 hypertension as defined by 2025 ACC/AHA guidelines in patients with CKD is associated with kidney function progression.

A retrospective cohort study involving patients with CKD not receiving dialysis was conducted in China at the Third Affiliated Hospital of Sun Yat-sen University from August 2010 to December 2017 and at the Fifth Affiliated Hospital of Sun Yat-sen University from November 2017 to December 2024.

Participants were categorized into 3 groups based on nocturnal BP measurements according to the 2025 ACC/AHA guidelines: nonhypertension (nocturnal BP <110/65 mm Hg), stage 1 hypertension (nocturnal BP 110-120/65-70 mm Hg), and stage 2 hypertension (nocturnal BP ≥120/70 mm Hg).

The primary outcome was a composite of kidney failure requiring replacement therapy (KFRT) and worsening kidney function (WKF). Secondary outcomes included the individual components of the primary outcome. Cox regression models were employed to assess the association between nocturnal stage 1 hypertension and outcomes.

Among 2418 participants with CKD stage 1 through 4 not receiving dialysis included in the study, 1412 (58.4%) were men, the mean (SD) age was 45.4 (14.4) years, 436 (18.0%) had nocturnal nonhypertension, 345 (14.3%) had nocturnal stage 1 hypertension, and 1637 (67.7%) had nocturnal stage 2 hypertension. Over a median (IQR) follow-up of 3.9 (1.5-4.7) years, 394 composite kidney outcomes, 203 cases of KFRT, and 235 instances of WKF were recorded. After adjusting for confounders, nocturnal stage 1 hypertension (compared with nocturnal nonhypertension) was independently associated with an increased risk of KFRT (hazard ratio [HR], 2.37; 95% CI, 1.17-4.82), WKF (HR, 3.79; 95% CI, 1.04-13.84), and the composite kidney outcome (HR, 2.49; 95% CI, 1.31-4.72). In the older population (aged ≥65 years), nocturnal BP less than 110/65 mm Hg was associated with a higher risk of WKF and the composite kidney outcome compared with nocturnal BP in the range of 110/65 to 120/70 mm Hg.

In this cohort study of adults with CKD not receiving dialysis, nocturnal stage 1 hypertension as defined by the 2025 ACC/AHA guidelines was independently associated with an increased risk of CKD progression.