|Year : 2016 | Volume
| Issue : 2 | Page : 241-249
|Blood pressure measurement in hemodialysis: The importance of the measurement technique
M Kubrusly1, Claudia Maria Costa de Oliveira1, RP Silva2, MA Pinheiro3, M. B. C. Rocha3, RM Magalhães3
1 Department of Nephrology, Unichristus Medical School; Department of Nephrology, Federal University of Ceará, Fortaleza, Ceará, Brazil
2 Department of Nephrology, Federal University of Ceará, Fortaleza, Ceará, Brazil
3 Department of Nephrology, Unichristus Medical School, Fortaleza, Ceará, Brazil
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|Date of Web Publication||11-Mar-2016|
| Abstract|| |
Systemic arterial hypertension contributes to the high cardiovascular morbidity in hemodialysis (HD) patients, but the accuracy of blood pressure (BP) measurement in this population has not been well studied. To evaluate the agreement between BP measurement using the routine measurement technique (usual method) and the technique recommended by the VII Joint (standard method). This cross-sectional study enrolled 124 patients in a single center who had undergone dialysis for more than three months and were 18 years of age or older. The BP was verified at the start of dialysis by the nursing team (usual method) and by the researchers (standard method). The agreement between the systolic and diastolic BP (SBP and DBP) measurements was tested by the Bland-Altman analysis. A difference in BP measurement higher than ±5 mm Hg was considered clinically significant. The studied group had a mean age of 53.2 years. The average difference between routine and standard BP measurement was −6 mm Hg for SBP (limits of agreement: −40.1-28 mm Hg; P <0.001) and −5.6 mm Hg for DBP (limits of agreement: −33.1-21.8 mm Hg; P <0.001). A clinically significant difference in BP measured by both methods was observed in 69.4% of the patients for SBP and in 61.3% for DBP. The disagreement between the results of different BP measurement methods in HD patients was significant and the BP was underestimated using the usual BP method. BP measurement standardization should be encouraged to avoid errors in diagnosis and therapy.
|How to cite this article:|
Kubrusly M, de Oliveira CM, Silva R P, Pinheiro M A, Rocha M, Magalhães R M. Blood pressure measurement in hemodialysis: The importance of the measurement technique. Saudi J Kidney Dis Transpl 2016;27:241-9
|How to cite this URL:|
Kubrusly M, de Oliveira CM, Silva R P, Pinheiro M A, Rocha M, Magalhães R M. Blood pressure measurement in hemodialysis: The importance of the measurement technique. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Dec 6];27:241-9. Available from: http://www.sjkdt.org/text.asp?2016/27/2/241/178251
| Introduction|| |
Blood pressure (BP) measurement is used to diagnose hypertension (HTN), to monitor hyperhypertensive patients, and to assess therapeutic effectiveness. The professional who performs the BP measurement plays a determining role in obtaining BP values. ,,, The concern about developing and improving BP measurement methods to improve HTN diagnosis and treatment is long-standing.  Thus, BP measurement is extremely important because high BP levels are considered one of the main risk factors for cardiovascular morbidity and mortality, not only in the general population, but also in patients undergoing hemodialysis (HD). ,
Systemic arterial HTN affects 60-80% of HD patients, but attempts to control this condition remain largely ineffective. ,,, Although BP measurement is widely disseminated through several international societies and routinely performed,  it remains unstandardized, and practitioners often do not follow the basic recommendations to avoid measurement errors. ,,, These recommendations have not been well documented and prioritized in most HD units, despite their importance in clinical approaches and epidemiological studies. ,
The present study is aimed to determine the practical applicability of the standardized BP measurement technique and verify the differences in BP values by comparing them with measurements taken by nursing professionals (using the usual measurement method).
| Subjects and Methods|| |
A cross-sectional study was conducted in a single HD facility in the city of Fortaleza-Brazil from October 2010 to February 2012. All patients who are 18-year-old or older with a minimum dialysis time of three months were included in the study. Patients with vascular access in both upper limbs, patients who could not undergo direct height and weight measurement, pregnant women, and those who did not agree to participate in the study were excluded.
The study was approved by the Research Ethics Committee of the UniChristus Medicine College under protocol number 109/2010, and the participants agreed to participate by signing an informed consent form.
According to the guidelines from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP (JNCVII), the appropriate cuff size for BP measurement is based on mid-arm circumference (MAC). BP measurements were obtained before the start of dialysis by researchers who were trained to perform the standardized measurement.  The patients were adequately prepared and positioned with the arm extended along the body, and a flexible measuring tape was placed around the arm at the midpoint between the acromion and the olecranon, avoiding the compression of soft tissues to measure MAC.  The arm chosen for the measurement was the one contralateral to the HD vascular access [i.e., the arteriovenous fistula (AVF)]. The JNCVIII (2014) did not change the orientations of BP measurement, the diagnose of HTN, or the management of those patients with CKD. 
The cuff types (child, small adult, adult, and large adult) were determined according to the American Heart Association recommendations. ,
The researchers initially measured the BP of each patient while the patient was seated. Two measurements were taken with a 2 min interval between them, and the measurement method followed the rules of JNCVII.  To measure BP, a BIC sphygmomanometer was used, and its cuffs were adjusted to the patient's arm circumference (covering at least 80% of the arm), as recommended by Perloff et al.  A predialysis reading was taken in the arm, contralateral to the AVF before the needle was placed. The final BP value was the average between the two measurements obtained. The resulting value was called the standard measurement for the purposes of this study.
To obtain an accurate BP measurement, the researchers performed the following steps: (1) obtain the arm circumference and adjust the cuff; (2) place the cuff 2-3 cm above the cubital fossa, leaving no gaps; (3) position the cuff over the brachial artery; (4) estimate the systolic pressure level by palpating the radial pulse; (5) palpate the brachial artery in the cubital fossa and place the stethoscope's bell or diaphragm without applying too much pressure; (6) quickly inflate the cuff until the pressure is 20-30 mm Hg higher than the estimated systolic pressure, obtained by palpation; (7) proceed to slowly deflate (at a speed of 2-3 mm Hg/s); (8) determine the systolic pressure by auscultating the first sound (Korotkoff Phase I) and then slightly increase the deflation speed; (9) determine the diastolic pressure when the sounds disappear (Korotkoff Phase V); (10) auscultate for approximately 20-30 mm Hg after the last sound to confirm its disappearance and then proceed to fast and complete deflation; (11) if the heartbeats persist to Level 0, determine the diastolic pressure when the sounds are muffling (Korotkoff Phase IV) and write down the values for systolic/diastolic/zero; (12) wait 2 min before performing another measurement; (13) inform the patient about the BP values obtained; (14) write down the exact values, without rounding, and the arm used for measuring the BP.
BP was also measured before the start of the dialysis session by the staff (nursing assistants and nurses) using the routine technique. The staff performed only one measurement using a BIC spheroid device and a standard cuff (22- 28 cm). This measurement was recorded in the patient's medical record and, for the purposes of the present study, it was called the usual measurement.
Patients with a predialysis BP ≥140/90 mm Hg were considered hypertensive.  Clinical agreement between the usual measurement and the standard measurement was defined as a maximum difference of ±5 mm Hg between the values obtained using the two methods.
Demographic and clinical data and data related to the studied patients' dialysis treatment were obtained through a questionnaire and medical records' analysis. Antihypertensive medications used by the patients were also recorded. At the end of the HD session, the patients' weight and height were verified by the researchers as long as the patients' weight was within the estimated dry weight. Weight and height measurements were used to calculate the body mass index (BMI), which was calculated by dividing the weight in kilograms (kg) by the squared height in meters (m), resulting in a value expressed in kg/m 2 according to the World Health Organization report (1995). 
| Statistical analysis|| |
continuous variables were expressed as means ± standard deviation, and the catego rical variables were expressed in percentages or frequencies. The variables with normal distribution were compared using Student's ttest, and those with other types of distribution were compared using the Mann-Whitney test. The linear correlation between the BP measurements was tested with the Pearson correlation coefficient.
The BP measurements obtained by both methods (usual and standard) were compared using the MacNemar test, and the agreement between the methods was tested using the Bland-Altman method. 
The BP levels were assessed according to both methods in groups divided according to gender, age (<50 years or ≥50 years), BMI (<25 kg/m 2 and ≥25 kg/m 2 , and whether the cuff used was of adequate size. This assessment was performed to examine the interference in BP measurement that may occur with increasing age (older patients show a more intense hardening of vessel walls, which may result in higher diastolic pressure levels) and high BMI (BP measurement may be more difficult in obese patients).
The Statistical Package for the Social Sciences [SPSS version 16.0 software program (SPSS Inc., Chicago IL, USA)], was used for the statistical analysis. P value ˂0.05 was considered significant.
| Results|| |
total, 124 patients were included in the study. The patients had an average age of 53.2 years, and 57.3% were males. [Table 1] shows the patients' demographics, HD treatment data, and anthropometric measurements, and [Table 2] shows the cuff distribution according to the MAC.
|Table 1: Demographic, anthropometric, and hemodialysis treatment data from the studied population.|
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|Table 2: Cuff distribution according to the arm circumference in the studied population.|
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Using the standardized BP measurement method, 58% of the patients (n = 72) were classified as hypertensive (predialysis BP ≥140/90 mm Hg). Fifty-three percent of these patients (n = 38) had systolic and diastolic HTN, 25% (n = 18) had only systolic HTN, and 22% (n = 16) had only diastolic HTN. Using the measurement taken by the nursing staff (the usual measurement), 47.5% of the patients (n = 59) were considered hypertensive.
In 89 patients, there was an agreement on the HTN diagnosis between the usual measurement and the standardized measurement, and in 35 patients (28.2%), there was no agreement. If we consider the standardized measurement, the most correct BP measurement, in the group of patients for which there was no HTN diagnosis agreement between the methods, 24 patients were false normotensive (19.3%) and 11 patients were false hypertensive (8.9%) [Table 3].
|Table 3: Association between systemic arterial hypertension diagnosis based on the usual method and the standardized method.|
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[Figure 1]a and b show the linear correlation between systolic BP (SBP) and diastolic BP (DBP) measurements by both methods. According to the studied parameters, there was a significant correlation between the methods (r = 0.695 for SBP and r = 0.579 for DBP; P <0.001), although this finding does not mean that there was an agreement between the measurements.
|Figure 1a and b: Linear correlation between systolic blood pressure and diastolic blood pressure, according to the usual method and the standardized method for blood pressure measurement.|
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The SBP and DBP agreement between the two BP measurement methods was tested using Bland-Altman agreement analysis, which can be found in [Figure 2]a and b.
|Figure 2a and b: Systolic blood pressure and diastolic blood pressure agreement analysis (Bland–Altman) according to the usual method and the standardized method of blood pressure measurement.|
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The average difference between usual BP measurement and standardized BP measurement was −6 mm Hg for SBP (limits of agreement: −40.1-28 mm Hg) and −5.6 mm Hg for DBP (limits of agreement: −33.1-2188 mm Hg) (P <0.001; [Table 4]. The measurements with higher values were the ones with less agreement.
|Table 4: Average difference in systolic blood pressure and diastolic blood pressure, according to the usual and the standardized blood pressure measurement techniques.|
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The Bland-Altman analysis was repeated in groups divided according to male (n = 71) or female (n = 53) gender and according to age (<50 years: 55 patients and ≥50 years: 69 patients). The average differences in SBP and DBP between the methods was significant in both groups.
The SBP and DBP agreement between the measurement groups was also tested in groups divided according to BMI: BMI <25 (n = 81), BMI within 25 and 29.9 kg/m 2 (n = 34) and BMI ≥30 kg/m 2 (n = 9). The average difference between SBP and DBP was significant in patients with BMI <25 and in patients with BMI within 25 and 29.9 kg/m 2 , but it was not significant in the group with BMI ≥30 (−3.3 mm Hg for SBP; P = 0.2024 and −4.4 mm Hg for DBP; P = 0.1913).
Regarding the cuff, even among the patients who were measured using an adequate-sized cuff (n = 34), there was a significant average difference for SBP (bias: −10 mm Hg, limits of agreement: −38.4 −18.4 mm Hg; P = 0.003) and DBP (bias: −4.5 mm Hg, limits of agreement:
−27.1-18.1 mm Hg; P = 0.0272). When the usual technique was used, a small adult cuff was used instead of an adult cuff in 66 patients (53.2%) and a small adult cuff was used instead of a large adult or a child cuff in 24 patients (19.3%).
The differences between the BP measurements taken using the different measurement techniques were divided in ±5 mm Hg intervals, as shown in [Table 5]. Clinical agreement between the two measurements (defined as a difference of up to ±5 mm Hg) was observed in 30.6% of the cases for SBP and in 38.7% of the cases for DBP.
|Table 5: Difference between the usual and the standard blood pressure measurement, classified into ±5 mm Hg intervals.|
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| Discussion|| |
HTN is a common problem among patients undergoing chronic HD therapy,  mostly associated with fluid overload  and also low BP is linked with an increase of mortality.  However, the (BP measurement techniques recommended by international guidelines are rarely used in HD patients.
In the present study, the SBP and DBP were underestimated by the usual technique compared with the standard technique (differences of −6 mm Hg for SBP and −5.6 mm Hg for DBP).
This finding is in opposition to those of Rahman et al, which showed that the usual BP measurement method overestimated the average BP compared with the standardized method.  This conflicting finding can be explained by several errors that the nursing team in the study unit made during BP measurement and by the white coat HTN phenomenon, which has been reported in 15-40% of HD patients. , The difference in the BP values obtained using these two techniques resulted in a change in the diagnosis of predialysis HTN in 28.2% of the studied population. In total, 24 patients (19.3%) were misdiagnosed as normotensive and 11 patients (8.9%) were misdiagnosed as hypertensive.
It is worth mentioning that 61.3-69.4% of the measurements taken showed a clinically significant BP difference, i.e., higher than ±5 mm Hg; in 50% of these patients, the difference was higher than ±10 mm Hg. In the study by Rahman et al,  clinical agreement between the two measurements was observed in only 21% and 39% of the patients. These differences may result in inadequate therapeutic procedures, such as increased or decreased intradialytic ultrafiltration or use of antihypertensive medication, which may cause arterial hypotension episodes or HTN or may aggravate the hypertensive condition, elevating the cardiovascular morbidity and mortality.
Another determining factor for HTN misdiagnosis is the lack of knowledge and adherence to standardization of techniques recommended by international HTN societies for BP measurement. This concern with the standardization of BP measurement is not new. Since 1939, the American Heart Association  has discussed a standardized procedure. Its recommendations were edited in the years 1951, 1967, 1980, 1988, and most recently, 1993,  and adjustments were made in 1997.  Each new recommendation prompts new discussions of aspects related to observer, equipment, patients, environment, and technique to reduce the possibility of errors that compromise the reliability of BP measurement. Corroborating these recommendations, the present study demonstrated through the use of a checklist that 100% of the nursing assistants did not follow all the steps of the standard measurement technique (data not shown). This lack of adherence to the standard techniques is not exclusive to nursing professionals; Bobrie et al reported that only 20% of general practitioners, 25% of interns, and 35% of cardiologists know the recommendations.  Furthermore, as physicians move away from their initial training, this knowledge decreases. Given this finding, we may question whether the solution lies in better training of nursing assistants and supervising doctors and nurses or in improving the ease of following the BP measurement criteria, possibly by reducing the number of essential steps and optimizing their disclosure.
The use of inadequately sized cuffs is the most discussed cause of imprecise measurement. Although several recommendations have been made for using cuffs with correct widths, there is no consensus on the correct sizes for use in children and in adults.  Moreover, different cuff sizes are usually not available in HD units. The small adult cuff, which was available at the dialysis clinic instead of the adult cuff, corresponded to 53.2% of the studied population. Thus, the most common cuff error consisted of using a smaller size that was ideal for the MAC. 
In the present study, even when the cuff size was appropriate for the patient's MAC (i.e., in 27.5% of the patients), there was a significant difference between the results of the usual and the standard method for SBP and DBP. This difference, observed even when the appropriate cuff was used, most likely reflects the percentage of errors that resulted from a failure to follow the many recommended steps for correct BP management, thus resulting in multiple errors during the measurement of HD patients' BP.
It should also be noted that the use of oscillometric devices, which are often part of dialysis machines, was not analyzed in the present study. The use of oscillometric devices may decrease errors inherent to the device and the observer. However, it is important to note that not all validated studies on BP measurement in HD patients demonstrated satisfactory performance, even when an oscillometric device was used, compared to the results obtained with a mercury sphygmomanometer, which is the gold standard device.  In addition, to avoid the influence of uncalibrated devices on BP measurement, guidelines recommend calibrating nonmercury cuffs with a mercury cuff every six months and performing annual general maintenance for all sphygmomanometers.  However, we should not forget BP evaluation criteria that are not related to the device used. Such criteria include posture, cuff size, rest time, and the consumption of vasoactive substances, which significantly contribute to the reliability of BP measurement. 
Despite the importance of correct BP measurement and its implication on the values obtained, as demonstrated in the present study, we recognize that many of the recommendations are difficult to follow as part of the HD unit routine. When we consider the differences between the guidelines' recommendations and the reality of HD units, we encounter several examples of the difficulty of putting guidelines into practice: coffee consumption, cigarette smoking, and exercising before BP measurement are not recommended although these practices are common among patients; the patient must be relaxed, but not all patients relax when facing the imminent needle puncture; BP measurement must be performed in both arms for the first reading, but the presence of an AVF in at least one of the arms prevents that, and the measurement is often performed on the lower limbs if both arms have AVFs; it is difficult to rest in a quiet environment for 5 min, as HD units are rarely quiet; and it is uncommon to take two readings and find their average because of the patient's discomfort during HD sessions.
Therefore, the use of a single predialysis BP measurement for clinical decision-making is often imprecise, and BP measurements are difficult to perform according to the recommended techniques. Thus, nephrologists should evaluate the need to use more accurate BP measurement methods, such as ambulatory BP monitoring or intermittent home-measurement in HD patients, and should make a great effort to follow the standardized measurement techniques as closely as possible in the dialysis room to reduce the occurrence of related errors as much as possible.
Conflict of interest: None declared.
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Claudia Maria Costa de Oliveira
Department of Nephrology, Unichristus Medical School, Fortaleza, Ceará; Federal University of Ceará, Fortaleza, Ceará
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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