Lowering BP and reducing proteinuria may be as easy as having patients take one antihypertensive agent in the evening instead of the morning. An eight-week trial in Italy involving 32 outpatients attending a renal clinic put this theory to the test, with impressive results.

The patients had chronic kidney disease (CKD) due to hypertensive nephrosclerosis, diabetes, or interstitial disease, but none was undergoing dialysis or had received a kidney transplant. The subjects had a normal daytime ambulatory BP of <135/85 mm Hg but were “nondippers,” that is, their BP did not follow the normal pattern of falling by at least 10% at night.

This “nondipping phenomenon,” common among CKD patients because of their high sodium sensitivity, can increase cardiovascular morbidity and mortality. Patients who took only one antihypertensive medication a day were instructed to take it in the evening. Those taking two or more drugs were instructed to change the one scheduled for closest to evening into an evening dose. The only drug not to be shifted to evening was a diuretic. This was done to prevent nighttime awakening.

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Eight weeks after shifting a drug, 28 of the 32 patients achieved dipping status—a pattern that persisted when systolic and diastolic BPs were considered separately. Office measurements also decreased significantly following the shift (from 136 to 131). In addition, urinary protein excretion declined significantly, particularly among those patients who had greater proteinuria (protein >300 mg/day) (Am J Kidney Dis. 2007;50:908-917).