RENAL DATA FROM THE ARAB WORLD
|Year : 2019 | Volume
| Issue : 4 | Page : 913-918
|Usefulness of ambulatory blood pressure monitoring in chronic kidney disease: The moroccan experience
Mohammed Asserraji1, Abdelmajed Bouzerda2, Safia Soukrate3, Omar Maoujoud1, Merouane Belarbi1, Nadir Zemraoui1, Leila Bendriss3, Ali Khatouri3
1 Department of Nephrology, Avicenne Military Hospital and Marrakech School of Medicine, Cadi Ayyad University, Marrakech, Morocco
2 Department of Cardiology, Mohammed V Armed Forces Hospital, Rabat, Morocco
3 Department of Cardiology, Avicenne Armed Forces Hospital, Marrakesh, Morocco
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|Date of Submission||04-Nov-2018|
|Date of Acceptance||09-Dec-2018|
|Date of Web Publication||27-Aug-2019|
| Abstract|| |
Among patients with chronic kidney disease (CKD), hypertension (HTN) is very common and widely recognized to accelerate the progression of CKD and increase the risk for cardiovascular events. Accumulated data indicate that ambulatory blood pressure monitoring (ABPM) is better in detecting HTN than office blood pressure (BP) measurement. The goal of this study is to describe the ABPM characteristics in a group of CKD and hypertensive patients. A transversal study was conducted over a period of six months, to evaluate the ABPM patterns among a group of hypertensive patients with CKD (Group 1) and compared the data with a control group (Group 2). ABPM was performed with measurement rate every 15 min during daytime and 30 min at night. Nondipping BP patterns were defined as the absence of fall in nocturnal systolic and diastolic BP >10% of daytime values. Masked HTN was defined as controlled office BP (<140/90 mm Hg) with an elevated overall average BP by 24-h ABPM (>125/75 mm Hg), and white-coat HTN was defined as association of elevated BP readings (>140/90 mm Hg) in a clinical setting and normal 24-h average BP levels (<130/80 mm Hg). Fifty patients were included in each group. HTN was much longer in duration among hypertensive patients with CKD and frequently associated with obesity, dyslipidemia, and diabetes (64% vs. 39.60%). Positive proteinuria was present in 82% of CKD patients with HTN. CKD patients with HTN received more antihypertensive drugs than Group 2 patients. HTN was much more uncontrolled among CKD patients (60% vs. 24%), more serious with higher daytime and nighttime SBP, and loss of physiologic dipping during nighttime BP measurement (80%). Out-of-office BP monitoring by ABPM may improve the assessment and the successful management of HTN in patients with CKD. Standardized definitions for the diagnosis of masked and white-coat HTN would facilitate research.
|How to cite this article:|
Asserraji M, Bouzerda A, Soukrate S, Maoujoud O, Belarbi M, Zemraoui N, Bendriss L, Khatouri A. Usefulness of ambulatory blood pressure monitoring in chronic kidney disease: The moroccan experience. Saudi J Kidney Dis Transpl 2019;30:913-8
|How to cite this URL:|
Asserraji M, Bouzerda A, Soukrate S, Maoujoud O, Belarbi M, Zemraoui N, Bendriss L, Khatouri A. Usefulness of ambulatory blood pressure monitoring in chronic kidney disease: The moroccan experience. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Sep 21];30:913-8. Available from: http://www.sjkdt.org/text.asp?2019/30/4/913/265468
| Introduction|| |
Hypertension (HTN) is well recognized as a major and modifiable risk factor for cardiovascular events, chronic kidney diseases (CKDs), and mortality. In the setting of CKD, HTN is a very frequent comorbidity and blood pressure (BP) increases with decline of glomerular filtration.,, According to the US Renal Data System data, HTN was seen in 35.8% of CKD Stage 1 and in up to 84.1% of CKD Stages 4 and 5. Differences between clinic BP measurement and ambulatory BP measurement (ABPM) lead to three abnormal BP patterns that are well identified in CKD. The first one is the nocturnal nondipping feature that occurs frequently in CKD patients and has been identified as potential contributor to cardiovascular events and deterioration of kidney function in such patients.,,,, Many reports identified CKD as a powerful condition that alters circadian BP patterns. Nocturnal BP tends even to increase in CKD. The second and important ambulatory BP dysfunction in CKD is what has been described as “masked HTN.”, It refers to CKD patients with normal clinic BP levels but elevated ABPM levels. The last one is white-coat HTN and is related to elevated office BP with normal overall average BP by ABPM., White-coat HTN is present in approximately 5%–20% of patients with CKD and is associated with both traditional risk factors and surrogate markers of cardiovascular disease (CVD) such as albuminuria, increased carotid intima-media, or increased left ventricular mass.,, All these abnormal BP patterns in CKD have made some authors to consider ABPM as superior to clinic BP measurement in CKD patients. In this study, we aim to describe ABPM characteristics in a group of CKD and hypertensive patients.
| Materials and Methods|| |
Study design and population
During a six-month period (March–September 2016), a transversal study has been conducted to evaluate the ABPM patterns among a group of hypertensive patients with CKD (Group 1) in comparison with a control group (Group 2 = hypertensive patients without CKD). HTN was defined according to the Eighth Joint National Committee as systolic pressure ≥140 mm Hg and/or diastolic pressure ≥90 mm Hg during manual BP measurement in the office setting. Grades of HTN and antihypertensive therapy were recorded. The glomerular filtration rate (GFR) was estimated according to the MDRD equation. CKD was defined according to the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 classification. Among Group 1 subjects, only hypertensive patients with GFR equal to 60 mL/min/1.73 m2 or lower were included for assessment of BP by ABPM.
ABPM was performed by Spacelab device 90207 with measurement rate every 15 min during daytime and 30 min at night. The cutoff for ABPM was set, according to the American College of Cardiology/American Heart Association (ACC/AHA) guidelines [systolic blood pressure (SBP)/diastolic blood pressure (DBP): 125/75 mm Hg for 24-h BP, 130/80 mm Hg for daytime BP, and 110/65 mm Hg for nighttime BP]. Nondipping BP patterns were defined as the absence of fall in nocturnal SBP and DBP >10% of daytime values. Masked HTN was defined as controlled office BP (<140/90 mm Hg) with an elevated overall average BP by 24-h ABPM (>125/75 mm Hg), and white-coat HTN was defined as association of elevated BP readings (>140/90 mm Hg) in a clinical setting and normal 24-h average BP levels (<130/80 mm Hg).
Patients were also enrolled for cardiovascular assessment including electrocardiography (ECG) and echocardiography.
| Statistical Analysis|| |
The data were analyzed using the Statistical Package for the Social Sciences version 19.0 software for Windows (IBM Corp., Armonk, NY, USA). Quantitative data were presented as mean and standard deviation, and qualitative data were presented as number and per centages. Quantitative data were compared using t-test and qualitative data were compared using Chi-square test. Multivariable analysis by logistic regression was performed to evaluate risk factors of ABPM pattern. P ≤0.05 was considered statistically significant.
| Results|| |
Fifty patients were included in each group. According to the KDIGO classification, 10% of Group 1 patients were in Category 3A (GFR 59–45 mL/min/1.73 m2), 2% were in Category 3B (GFR 44–30 mL/min/1.73 m2), 48% were in Category 4 (GFR 29–15 mL/min/1.73 m2), and 40% were in Category 5 (GFR ≤15 mL/min/1.73 m2). HTN was of much longer duration among hypertensive patients with CKD and frequently associated with obesity, dyslipidemia, and diabetes (64% vs. 39.60). Positive proteinuria was present in 82% of CKD patients with HTN. CKD patients with HTN received more antihyper-tensive drugs than Group 2 patients. Patients’ demographic and HTN characteristics are shown in [Table 1].
|Table 1: Demographic and hypertension characteristics among the study subjects.|
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The assessment of HTN by ABPM highlights some special patterns in hypertensive patients with CKD. Among CKD patients, HTN was much more uncontrolled (60% vs. 24%), more serious with higher daytime and nighttime SBP and loss of physiologic dipping during nighttime BP measurement (80%). CKD was recognized as a risk factor of nondipping HTN in Group 1. The ABPM results in the two groups are summarized in [Table 2]. [Figure 1] shows different types of HTN in the two groups (one and two) according to the ABPM measurement. Eight percent of CKD patients with HTN showed masked HTN and 30% had white-coat HTN.
|Table 2: Results of ambulatory blood pressure measurement in the two groups.|
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| Discussion|| |
Diagnosis and efficient management of HTN are dependent on appropriate BP measurement. This is most relevant to CKD patients in whom HTN is common. CKD patients are at higher risk of HTN-related adverse out-comes.,, The management of HTN is therefore particularly important in patients with CKD.
Ambulatory BP monitoring has been used since the 1980s. The ABPM protocol involves application of an appropriate-sized cuff to the nondominant arm and measurement of BP every 30 min during the day and night for a 24-h period.
BP should be appreciated as a continuous variable that variates throughout the day and night following a circadian rhythm with levels rising during daytime and falling during sleep.,,,,,,,
The special case of alteration in BP variability and circadian BP patterns in CKD patients has been documented in multiple cross-sectional and prospective studies using 24-h ABPM.
Several reports, especially the Spanish studies by Mojon et al and Gorostidi et al, showed that in comparison to hypertensive patients with eGFR ≥60 mL/min/1.73 m2, CKD patients with HTN showed higher prevalence of non-dipping, higher nocturnal SBP and lower DBP, and higher daytime and nighttime SBP and DBP variability.
Furthermore, the prevalence of both non- dipping and rising nocturnal SBP patterns were predictive of renal and cardiovascular outcomes and total mortality.,
In our study, 80% of the CKD patients with HTN showed nondipping and even rising nocturnal BP patterns, and the prevalence of uncontrolled HTN was higher among those patients with organ damage.
Location-dependent HTN (masked HTN and white-coat HTN) impacts the prognosis of patients with HTN.,, Among 980 patients with CKD identified in six studies that were included in a meta-analysis published by Bangash and Agarwal, the overall prevalence of masked HTN was 8.3% and of white-coat HTN was 18.3%. The authors consider that clinic BP measurements alone lead to substantial misclassification of BP among CKD patients and estimate that out-of-office BP monitoring may improve the management of HTN in patients with CKD.
White-coat HTN is linked to lower risk for progression to ESRD in CKD patients than sustained HTN. Masked HTN is, however, associated with rapid progression to ESRD and death., Thus, estimating the prevalence of masked and white-coat HTN is of epide-miologic as well as of clinical importance. In our study, 8% of the CKD patients with HTN showed masked HTN and 30% had white coat HTN.
Proteinuria is also associated with abnormal ambulatory BP profiles, including sustained HTN, nighttime HTN, and masked HTN.,.
Recently, the SBP Intervention Trial (SPRINT) showed that, among hypertensive patients with and without CKD, intensive lowering of SBP to a target ≤120 mm Hg reduced risk for CVD and all-cause mortality compared with a standard BP target of <140 mm Hg. However, some authors highlighted the difficulty to translate the results of SPRINT into clinical practice arguing that the BP measurement protocol during the trial is not observed routinely in many clinical practices.
In conclusion, the usefulness of ABPM to assess HTN in CKD patients is supported by some evidence. ABPM seems to be superior to clinic BP measurement in establishing an appropriate diagnosis and classification of HTN, identifying target organ damage, predicting outcomes, and evaluating response to therapy in patients with CKD, in whom optimal BP control is often difficult to achieve.,,,
Conflict of interest: None declared.
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Department of Nephrology, Avicenne Military Hospital, Marrakech
[Table 1], [Table 2]
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