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Circadian rhythm of blood pressure (BP) is closely linked with sodium balance. With positive sodium balance the nocturnal BP is elevated, resulting in non-dipper pattern. Nocturnal BP elevation plays an important role in the cardio-renal association to cause the cardiovascular events. It is vey important, therefore, how to lower nocturnal hypertension especially in CKD.

When RAS inhibitors are prescribed as the first-line agent in hypertension, the combination of diuretics on them exerts several preferable effects in both blood pressure lowering and organ protection. As far as low-dose of diuretics, the unfavorable side effects such as hypokalemia and insulin resistance can be minimized by RAS inhibitors. Therefore, unless the compelling indication for Ca channel blockers exists, diuretics should be added on RAS inhibitors.

Among hypertensive cardiovascular complications only end-stage renal failure (ESRD) is progressively increasing, while the increases in the incidence of stroke and coronary heart disease have been suppressed. On the other hand, it is well established that CKD, especially due to diabetic nephropathy and IgA nephropathy, can be arrested into complete remission if treated in the early stages. Therefore, early detection program is highly and urgently required. To achieve this goal, we must consider what we can do now in nation-wide scale including patients, doctors and governments. There are remarkable regional differences in both the incidence of ESRD and the increasing rate within Japan. Japanese Society of Dialysis Therapy has the unique system to register the patients who reach ESRD, resulting in chronic dialysis therapy. Therefore, if we can build the patient identification system compatible to the above, then we immediately know who has reached ESRD. In this way, we can analyze the backgrounds of the ESRD patients to find out the risk factors of CKD in addition to the regional differences. I anticipate that the incidence of ESRD will be reduced in near future in Japan as seen in diabetic nephropathy in Denmark and USA. We must act now to accomplish this important issue: integrated care of CKD.

Pathogenesis of edema is in depth considered based on Starling's rule on capillary fluid dynamics. Edema can be divided into 4 types based on the mechanisms causing edema: increased capillary hydrostatic pressure, decreased plasma oncotic pressure, enhanced hydraulic permeability of capillary walls, and lymphatic obstruction. Each of the types can be further divided into generalized and local forms. Edema, defined as the expansion of interstitial fluid compartment, is initiated by imbalance of Starling forces across capillary walls between plasma and interstitium, but is maintained by enhanced sodium reabsorption from renal tubules.

Microalbuminuria is a sensitive marker of early renal damage in essential hypertension as well as diabetes mellitus. Elevated urinary albumin excretion has positive correlations with other cardiovascular risk factors. Microalbuminuria has an independent value to predict cardiovascular disease in the patients with not only diabetes mellitus but also with essential hypertension and even in general population. The seventh report of the joint national committee on prevention, detection, evaluation and treatment of high blood pressure (JNC 7) has adopted microalbuminuria or estimated glomerular filtration rate60 ml/min as one of the major cardiovascular risk factors. It is an important future task whether decrease in urinary albumin excretion with treatment improves prognosis of individual patients.