Hypertension burden in CKD: is nocturnal hypertension the primary culprit?

Hypertension is a pervasive and progressive complication in chronic kidney disease (CKD) patients, affecting up to 90% of those in advanced stages or on dialysis. A particularly insidious aspect of this condition is nocturnal hypertension, characterized by high blood pressure (BP) during sleep and a blunted or absent nighttime BP dipping-phenomena associated with accelerated CKD progression and increased cardiovascular risk. Despite its strong prognostic significance, nocturnal hypertension remains underdiagnosed due to limited use of ambulatory BP monitoring. This narrative review explores the pathophysiological underpinnings of nocturnal hypertension in CKD, including impaired sodium handling, volume overload, autonomic dysfunction and dysregulation of the renin-angiotensin-aldosterone system. Emerging evidence highlights its associations with left ventricular hypertrophy, proteinuria, endothelial dysfunction and poor renal outcomes, emphasizing the need for comprehensive BP profiling and targeted management strategies. Current therapeutic approaches include lifestyle modifications, diuretics and antihypertensive pharmacotherapy, with growing interest in chronotherapy-the timing of medication administration to align with circadian BP rhythms. However, robust clinical data specifically guiding the treatment of nocturnal hypertension in CKD remain scarce. This review underscores the clinical importance of diagnosing and addressing nocturnal BP abnormalities and advocates for future trials focused on optimizing management strategies for this high-risk population.