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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE  
Year : 2019  |  Volume : 30  |  Issue : 5  |  Page : 1038-1043
Evaluation of blood pressure profile in chronic hemodialysis patients using two measurement methods: Home blood pressure measurement and conventional measurement


1 Department of Nephrology, Cheikh Anta Diop University; Department of Nephrology, Aristide Le Dantec University Hospital, Dakar, Senegal
2 Department of Nephrology, Aristide Le Dantec University Hospital, Dakar, Senegal

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Date of Submission24-Apr-2018
Date of Acceptance25-Jul-2018
Date of Web Publication4-Nov-2019
 

   Abstract 


The monitoring of hypertension (HTN) in dialysis is often delicate with potentially false measurements due to the white coat effect on the one hand and masked HTN (M-HTN) on the other hand. In this population, there is much controversy over the ideal moment for taking blood pressure (BP) and the target values. An answer to these questions is given by home BP measurement that can detect white coat HTN (WC-HTN) and M-HTN. The aim of this study was to determine the respective prevalence of permanent HTN (P-HTN), WC-HTN, M-HTN, and permanently normotensive (P-NTN) in this population and to analyze the risk factors of M-HTN and WC-HTN in hemodialysis (HD) centers in sub-Saharan Africa. This was a multicenter, descriptive, and analytical cross-sectional study conducted over a period of one month and 23 days. Data collection was performed using a home BP measurement form, conventional BP measurement form, and clinical and laboratory data collection form. The study included all patients who could take their BP at home using an electronic BP machine and record results on the BP forms. All analyses were performed using the Sphinx plus software version 5. The significance level for all statistical tests was set at 5%. The mean age of patients was 45.57 years ± 14.11, with a sex ratio of 1.42. The mean duration in dialysis was 57.96 months ± 34.86. Adherence to the home BP measurement was 100% in 71.7%. P-NTN patients were 15.2% (7 patients), WC-HTN patients were 13% (6 patients), M-HTN patients were 17.5% (8 patients), and P-HTN patients were 54.3% (25 patients). A statistically significant association was observed between WC-HTN and age (P = 0.01). In this work, we noted an important proportion of M-HTN and WC-HTN. This result confirms the need for home BP measurement in the follow-up of BP in HD patients.

How to cite this article:
Faye M, Faye M, Lemrabott AT, Cisse MM, Fall K, Ismael Keita AR, Mbengue M, Ba B, Keita N, Diagne S, Niang A, Diouf B, Ka EF. Evaluation of blood pressure profile in chronic hemodialysis patients using two measurement methods: Home blood pressure measurement and conventional measurement. Saudi J Kidney Dis Transpl 2019;30:1038-43

How to cite this URL:
Faye M, Faye M, Lemrabott AT, Cisse MM, Fall K, Ismael Keita AR, Mbengue M, Ba B, Keita N, Diagne S, Niang A, Diouf B, Ka EF. Evaluation of blood pressure profile in chronic hemodialysis patients using two measurement methods: Home blood pressure measurement and conventional measurement. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2019 Nov 23];30:1038-43. Available from: http://www.sjkdt.org/text.asp?2019/30/5/1038/270258



   Introduction Top


High blood pressure (BP) is defined as a BP higher than 140 mm Hg for the systolic value and 90 mm Hg for the diastolic value.[1] the monitoring of hypertension (HTN) in dialysis is often delicate due to high likelihood of false measurements. These are mainly due to the white coat effect on the one hand and masked HTN (M-HTN) on the other hand. Nowadays, the BP measurement methods in health care units or private clinics are questioned, and this is especially the case for chronic dialysis patients. In this population, there is controversy regarding the ideal moment to take measurements and the target values. An answer to these questions is given by the ambulatory BP measurement and home BP measurement, which allow the detection of white coat HTN (WC-HTN) and M-HTN. WC-HTN is characterized by increased values at the hospital and normal ones at home, whereas in M-HTN, there are normal values at the hospital and elevated ones at home. Home BP measurement allows more regular BP monitoring than the ambulatory method, and it provides better therapeutic education and is cheaper. The main study conducted on home BP measurement in dialysis patients is that of Agarwal in the USA.[2] Results obtained in those patients are similar to those of the general population.[3] M-HTN is associated with important cardiovascular mortality and morbidity.

The objective of this study was to determine the respective prevalence of permanent HTN (P-HTN), WC-HTN, M-HTN, and permanent normotensive (P-NTN) patients in this population and to analyze the respective risk factors of these categories in hemodialysis (HD) centers of sub-Saharan Africa.


   Patients and Method Top


This is a multicenter, descriptive, and the analytical cross-sectional study conducted over one month and 23 days (25 April 2016 to 18 June 2016). It included a total of 136 patients followed in two HD centers of Aristide Le Dantec (HALD) Hospital and Hôpital Général du Grand Yoff. We included all patients with the ability to take their BP at home using an electronic BP machine and record it on provided forms after having signed a written consent form. Patients with known chronic hypotension were not included, and those with <50% of BP measurement records were excluded.

Data collection was performed using provided home BP measurement forms and conventional BP measurement forms together with clinical and paraclinical data collection forms. BP machines of type OMRON and SPENGLER were used for measurement. Patients autonomously took their BP at home twice a day, respecting the existing criteria of validity for this measurement and noted results on the BP record forms.[4] They took three consecutive measurements at 1 min of interval, in the morning before breakfast and evening before going to sleep. With regard to the classical method of home BP measurement, which is done for three days, we asked our patients to take records over six days to analyze different interdialytic periods.[5] First-day measurements were excluded from interpretation. The mean of the other values was calculated and represents the mean BP obtained by BP home measurement.

Using conventional BP measurement forms, we collected BP values obtained by dialysis nurses at the start of the dialysis session after 5 min of rest just before connecting the lines, and the BP record at the end of the session after fluid restitution for the same 6-day period. The same BP machine was used by the patient at home BP measurement and by a nurse in conventional BP measurement. We took into account mean values of this dialysis BP measurements for a week (three sessions of HD) to measure the mean dialysis BP. Retained definitions for the diagnosis of HTN were as follows: for conventional measurement, the weekly mean value of dialysis BP ≥140 mm Hg for the systolic value and/or 90 mm Hg for the diastolic value. In the home BP measurement group, the weekly mean BP value for HTN was ≥135 mm Hg for systolic and 85 mm Hg for diastolic.[6] With regard to the above definitions, patients were classified into four groups: P-HTN, P-NTN, WC-HTN, and M-HTN.


   Statistical Analyses Top


Results are presented in the form of means and standard deviations for quantitative parameters, and in the form of percentages for qualitative ones. Quantitative parameters were compared by ANOVA test and qualitative parameters by the Chi-square test of Pearson. The significance threshold for all statistical tests was fixed at 5%. All analyses were carried out using Sphinx plus version five software (Chavanod, France).


   Results Top


We included 49 patients or 33.8% of 136 patients. Out of these patients, three were excluded, two for having recorded <50% of measurements and one for losing his home BP measurement form. In total, 46 patients were retained [Figure 1].
Figure 1: Patients inclusion diagram.

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The mean age of patients was 45.57 years ± 14.11, with a sex ratio of 1.42. The average duration in dialysis was 57.96 months ± 34.86. The proportion of hypertensive nephropathy was the highest (43.5%). The underlying kidney disease was unknown in 15.2% of cases. Forty-five patients had a 4-h session three times a week. Residual diuresis was present in 14 patients (30.4%). Out of 46 patients, 17 (37%) were on erythropoietin stimulating agents, only four patients (8.7%) were on iron alone, and 17 patients (67.4%) were on the antihypertensive treatment of a combination of at least two molecules ±1.06. The mean hemoglobin level was 9.65 g/dL ± 2.20 and was within KDIGO targets in eight patients. The mean PTH level was 666.63 ng/mL ± 529.90, and hyperparathyroidism was noted in 13 patients (50%). Left ventricular hypertrophy (LVH) was found in 15 patients (36.6%). The compliance to home BP measorement was 100% in 71.7% [Table 1].
Table 1: Comparison between masked hypertension and other patients.

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P-NTN patients were 15.2% (7 patients), WC-HTN patients were 13% (6 patients), M-HTN patients were 17.5% (8 patients), and P-HTN patients were 54.3% (25 patients) [Table 2]. The statistical analysis noted a significant association between WC-HTN and age (P = 0.01) [Table 3]. A significant association was also noted between P-NTN and intradialytic hypotension (P= 0.01).
Table 2: Patients distribution according to their blood pressure in H-BP and C-BP measurement.

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Table 3: Comparison between white coat hypertension and other patients.

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   Discussion Top


In our study, principal results are an important proportion of WC-HTN and M-HTN together with the statistical significance between WC-HTN and age. This proportion of M-HTN confirms the high prevalence reported in the general population (8%–48%).[7] It also confirms the figures of 5%–70% in advanced chronic kidney disease patients observed by Agarwal. Though it is lower than that reported by Ariane in France (22%).[2],[8] This finding should raise awareness, as we all know the unfavorable prognosis of M-HTN in terms of cardiovascular mortality and morbidity in HD patients: The mean BP value in home BP measurement over a week was correlated to LVH and mortality.[9],[10],[11] In our series, we noted the usually associated factors to M-HTN, which are high body mass index, active smoking, and male gender.[7] The high prevalence of WC-HTN in our study also confirms data described by Agarwal.[2] We should highlight the troubling nature of this WC-HTN in HD patients, as it can mislead doctors to inappropriate therapeutic interventions like decreasing the dry weight and/or prescribing anti-hypertensive medication.

These measures constitute factors of deleterious intradialytic hypotension.[12] They are also likely to increase personal and collective spending, especially in developing countries where resources are limited. In our study, there was a statistical significance between WC-HTN and age (P = 0.01). To our knowledge, this association has not been reported in the HD population. We should mention the high frequency of WC-HTN in populations where HTN is predominantly systolic.[13] This systolic HTN affects at least a quarter of the population of those at least in their sixties, due to aorta rigidity and large artery walls.[14] This fact can in part explain that association.

We noted a small proportion of P-NTN (15.2%) and a large proportion of P-HTN (54.3%). This poor control of high BP in our patients can be explained by the problem of compliance and availability of antihypertensive treatment. It also can be explained by the lack of awareness of the cardiovascular risk associated with nonobservance of lifestyle measures and interdialytic weight gain of up to 8% and the slow therapeutic response by doctors.

In another study conducted in our department, only 34% of patients were properly compliant to their treatment.[15] In our series, we noted a statistically significant association between permanently controlled HTN and intradialytic hypotension. To our knowledge, this association has not been reported before in the HD population. However, our cohort is too small to confirm this association. Interdialytic weight gain was slightly lower (3% vs. 3.6%) in the group without permanently controlled HTN. This finding can partly explain the risk of intradialytic hypotension. Although home BP measurement is recommended in the follow-up of HD patients, it remains difficult to implement in daily practice due to the high cost of electronic BP machines and insufficient patient training.


   Conclusion Top


In this work, we noted an important proportion of M-HTN and WC-HTN. This result confirms the need for home BP measurement in the follow-up of BP in HD patients. Conventional BP measurement still has its place, as it allows the monitoring of hemodynamic parameters during an HD session, whereas home BP measurement better assesses interdialytic BP levels and is extremely useful to adapt dry weight and anti-hypertensive drug doses and to evaluate the global cardiovascular risk of patients.

Conflict of interest: None declared.



 
   References Top

1.
Astagneau P, Lang T, Delarocque E, Jeannee E, Salem G. Arterial hypertension in urban Africa: An epidemiological study on a representative sample of Dakar inhabitants in Senegal. J Hypertens 1992;10:1095-101.  Back to cited text no. 1
    
2.
Agarwal R, Andersen MJ, Bishu K, Saha C. Home blood pressure monitoring improves the diagnosis of hypertension in hemodialysis patients. Kidney Int 2006;69:900-6.  Back to cited text no. 2
    
3.
Bobrie G, Chatellier G, Genes N, et al. Cardiovascular prognosis of “masked hypertension” detected by blood pressure self-measurement in elderly treated hypertensive patients. JAMA 2004;291:1342-9.  Back to cited text no. 3
    
4.
Bauduceau B, Hamon E, Bordier L. Self-monitoring of blood pressure in practice. Méd Mal Métabol 2011;5:169-72.  Back to cited text no. 4
    
5.
Parati G, Stergiou GS, Asmar R, et al. European Society of Hypertension guidelines for blood pressure monitoring at home: A summary report of the Second International Consensus Conference on Home Blood Pressure Monitoring. J Hypertens 2008;26:1505-26.  Back to cited text no. 5
    
6.
K/DOQI Workgroup. K/DOQI clinical practice guidelines for cardiovascular disease in dialysis patients. Am J Kidney Dis 2005;45: Sl-153.  Back to cited text no. 6
    
7.
Bobrie G, Clerson P, Ménard J, et al. Masked hypertension: A systematic review. J Hypertens 2008;26:1715-25.  Back to cited text no. 7
    
8.
Duval-Sabatier A, Brunet P, Seck SM, et al. Experiment of self blood pressure measurement at home in haemodialysis patients in a hospital unit. Nephrol Ther 2011;7:544-8.  Back to cited text no. 8
    
9.
Agarwal R, Brim NJ, Mahenthiran J, Andersen MJ, Saha C. Out-of-hemodialysis-unit blood pressure is a superior determinant of left ventricular hypertrophy. Hypertension 2006;47:62-8.  Back to cited text no. 9
    
10.
Moriya H, Ohtake T, Kobayashi S. Aortic stiffness, left ventricular hypertrophy and weekly averaged blood pressure (WAB) in patients on haemodialysis. Nephrol Dial Transplant 2007;22:1198-204.  Back to cited text no. 10
    
11.
Agarwal R. Blood pressure and mortality among hemodialysis patients. Hypertension 2010;55:762-8.  Back to cited text no. 11
    
12.
Shoji T, Tsubakihara Y, Fujii M, Imai E. Hemodialysis-associated hypotension as an independent risk factor for two-year mortality in hemodialysis patients. Kidney Int 2004;66:1212-20.  Back to cited text no. 12
    
13.
Bombelli M, Sega R, Facchetti R, et al. Prevalence and clinical significance of a greater ambulatory versus office blood pressure (‘reversed white coat’ condition) in a general population. J Hypertens 2005;23:513-20.  Back to cited text no. 13
    
14.
Thomas F, Bean K, London G, Danchin N, Pannier B. Ncidence of arterial hypertension in French population after 60 years. Ann Cardiol Angeiol (Paris) 2012;61:140-4.  Back to cited text no. 14
    
15.
Rchouk M. Evaluation of therapeutic adherence in hemodialysis patients. Aristide Le Dantec Hospital in Dakar. These Med: Nephrology: UCAD: Dakar: 2015; 1048  Back to cited text no. 15
    

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Correspondence Address:
Maria Faye
Department of Nephrology, Aristide Le Dantec University Hospital, Dakar
Senegal
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DOI: 10.4103/1319-2442.270258

PMID: 31696841

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    Abstract
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