Sex-related short-term blood pressure variability differences in kidney transplant recipients

OBJECTIVE

Kidney transplant recipients (KTRs) display higher cardiovascular morbidity and mortality than the general population. Increased short-term blood pressure variability (BPV) is associated with a higher risk of adverse cardiovascular outcomes in chronic kidney disease (CKD). The aim of this study is to investigate sex differences in short-term BPV in KTRs.

METHODS

In total, 136 male and 69 female KTRs with valid 24 h ambulatory blood pressure monitoring were included in this analysis. Systolic and diastolic BPV indices [SD, weighted SD (wSD), coefficient of variation (CV), average real variability (ARV) and variability independent of the mean (VIM)] were calculated with validated formulas for the 24 h, daytime and nighttime periods.

RESULTS

Age, time from transplantation surgery and history of major comorbidities did not differ between men and women. During the 24-h period, systolic BPV indices did not differ between men and women (SBP-ARV: 9.4 ± 2.2 vs. 9.9 ± 2.5; P = 0.212). During the daytime period, SBP-CV and SBP-VIM were significantly higher in females compared with male participants (SBP-CV: 9.9 ± 2.4 vs. 11 ± 3.1%; P = 0.022 and SBP-VIM: 12.6 ± 3.0 vs 14.2 ± 3.9; P = 0.008); daytime SBP-SD and SBP-ARV, and all studied indexes during nighttime did not differ between groups. No significant between-group differences in 24 h and daytime diastolic BPV indices were detected. Nighttime DBP-CV was marginally higher in men (12.0 ± 3.6 vs. 11.4 ± 4.0; P = 0.053); the rest nighttime diastolic BPV indices measured were also nonsignificantly higher in men.

CONCLUSION

In conclusion, 24-h systolic and diastolic BPV parameters did not differ between male and female KTRs, but short-term BPV over the respective day- and nighttime periods showed different trends in men and women. Further studies are needed to examine possible differences in long-term BPV in KTRs.

Cardiopulmonary exercise testing in patients with end-stage kidney disease: principles, methodology and clinical applications of the optimal tool for exercise tolerance evaluation

Chronic kidney disease (CKD), especially end-stage kidney disease (ESKD), is associated with an increased risk for cardiovascular events and all-cause mortality. Exercise intolerance as well as reduced cardiovascular reserve is extremely common in patients with CKD. Cardiopulmonary exercise testing (CPET) is a non-invasive, dynamic technique that provides an integrative evaluation of cardiovascular, pulmonary, neuropsychological and metabolic function during maximal or submaximal exercise, allowing the evaluation of functional reserves of these systems. This assessment is based on the principle that system failure typically occurs when the system is under stress and thus CPET is currently considered to be the gold standard for identifying exercise limitation and differentiating its causes. It has been widely used in several medical fields for risk stratification, clinical evaluation and other applications, but its use in everyday practice for CKD patients is scarce. This article describes the basic principles and methodology of CPET and provides an overview of important studies that utilized CPET in patients with ESKD, in an effort to increase awareness of CPET capabilities among practicing nephrologists.

Management of intradialytic hypertension: current evidence and future perspectives

Intradialytic hypertension (IDH), that is, a paradoxical rise in blood pressure (BP) during or immediately after a hemodialysis session, affects approximately 10-15% of the hemodialysis population. It is currently recognized as a phenomenon of major clinical significance as recent studies have shown that BP elevation extends to the whole interdialytic interval and associates with increased cardiovascular and all-cause mortality. The pathophysiology of IDH is complex involving volume and sodium overload, endothelial dysfunction, excess renin-angiotensin-aldosterone system and sympathetic nervous system activation, and other mechanisms. For several years, there was a scarcity of studies regarding IDH treatment; recently, however, several attempts to examine the effect of nonpharmacological and pharmacological measures on BP levels in IDH are made. This review attempts to summarize this latest evidence in the field of management of IDH and discuss areas for future research.

Impact of public restrictive measures on hypertension during the COVID-19 pandemic: existing evidence and long-term implications

Coronavirus disease 2019 (COVID-19) is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that was first identified in December 2019 and emerged into an ongoing global pandemic. Both the pandemic itself and the associated public restrictive measures of social mobility established with different intensity over different periods in various countries have significantly affected everyday activities and life-style of people all over the world. The impact of lockdown and quarantine measures on hypertension incidence and blood pressure (BP) control is an important topic that requires further investigation. The aim of this review is: a) to present the current evidence regarding the actual effects of public restrictive measures on BP levels and control, originating primarily from studies investigating the impact of public restrictive measures on BP control with the use of various BP phenotypes; b) to summarize the possible pandemic-related effects of factors known to affect BP levels, including both traditional (e.g. dietary habits including alcohol and sodium intake, body weight, smoking, and physical activity) and non-traditional (e.g. sleep patterns, air pollution, environmental noise, delayed diagnosis and medication adherence) ones.

Blood Pressure and Cardiorenal Outcomes With Finerenone in Chronic Kidney Disease in Type 2 Diabetes

Chronic kidney disease is frequently associated with hypertension and poorly controlled blood pressure can lead to chronic kidney disease progression. Finerenone, a nonsteroidal mineralocorticoid receptor antagonist, significantly improves cardiorenal outcomes in patients with chronic kidney disease and type 2 diabetes. This analysis explored the relationship between office systolic blood pressure (SBP) and cardiorenal outcomes with finerenone in FIDELIO-DKD trial (Finerenone in Reducing Kidney Failure and Disease Progression in Diabetic Kidney Disease).

Chronic kidney disease as cardiovascular risk factor in routine clinical practice: a position statement by the Council of the European Renal Association

The European Society of Cardiology 2021 guideline on cardiovascular (CV) disease (CVD) prevention in clinical practice has major implications for both CV risk screening and kidney health of interest to primary care physicians, cardiologists, nephrol-ogists, and other professionals involved in CVD prevention. The proposed CVD prevention strategies require as first step the categorization of individuals into those with established atherosclerotic CVD, diabetes, familiar hypercholesterolaemia, or chronic kidney disease (CKD), i.e. conditions that are already associated with a moderate to very-high CVD risk. This places CKD, defined as decreased kidney function or increased albuminuria as a starting step for CVD risk assessment. Thus, for adequate CVD risk assessment, patients with diabetes, familiar hypercholesterolaemia, or CKD should be identified by an initial laboratory assessment that requires not only serum to assess glucose, cholesterol, and creatinine to estimate the glomerular filtration rate, but also urine to assess albuminuria. The addition of albuminuria as an entry-level step in CVD risk assessment should change clinical practice as it differs from the current healthcare situation in which albuminuria is only assessed in persons already considered to be at high risk of CVD. A diagnosis of moderate of severe CKD requires a specific set of interventions to prevent CVD. Further research should address the optimal method for CV risk assessment that includes CKD assessment in the general population, i.e. whether this should remain opportunistic screening or whether systematic screening.

Intradialytic hypertension: epidemiology and pathophysiology of a silent killer

The term intradialytic hypertension (IDH) describes a paradoxical rise in blood pressure (BP) during or immediately after the hemodialysis session. Although it was formerly considered a phenomenon without clinical implications, current evidence suggests that IDH may affect up to 15% of hemodialysis patients and exhibit independent associations with future cardiovascular events and all-cause mortality. Furthermore, during the last decade, several studies have tried to elucidate the complex pathophysiological mechanisms responsible for this phenomenon. Volume overload, intradialytic sodium gain, overactivity of the sympathetic-nervous-system and renin-angiotensin-aldosterone system, endothelial dysfunction and dialysis-related electrolyte disturbances have been proposed to be involved in the pathogenesis of the BP increase during hemodialysis. This review attempts to summarize existing evidence on the epidemiology, pathophysiology and clinical characteristics of the distinct phenomenon of IDH.

Hypertension in kidney transplant recipients

Kidney transplantation is considered the treatment of choice for end-stage kidney disease patients. However, the residual cardiovascular risk remains significantly higher in kidney transplant recipients (KTRs) than in the general population. Hypertension is highly prevalent in KTRs and represents a major modifiable risk factor associated with adverse cardiovascular outcomes and reduced patient and graft survival. Proper definition of hypertension and recognition of special phenotypes and abnormal diurnal blood pressure (BP) patterns is crucial for adequate BP control. Misclassification by office BP is commonly encountered in these patients, and a high proportion of masked and uncontrolled hypertension, as well as of white-coat hypertension, has been revealed in these patients with the use of ambulatory BP monitoring. The pathophysiology of hypertension in KTRs is multifactorial, involving traditional risk factors, factors related to chronic kidney disease and factors related to the transplantation procedure. In the absence of evidence from large-scale randomized controlled trials in this population, BP targets for hypertension management in KTR have been extrapolated from chronic kidney disease populations. The most recent Kidney Disease Improving Global Outcomes 2021 guidelines recommend lowering BP to less than 130/80 mmHg using standardized BP office measurements. Dihydropyridine calcium channel blockers and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers have been established as the preferred first-line agents, on the basis of emphasis placed on their favorable outcomes on graft survival. The aim of this review is to provide previous and recent evidence on prevalence, accurate diagnosis, pathophysiology and treatment of hypertension in KTRs.

Effect of patient gender on short-term blood pressure variability in hemodialysis patients

Increased blood pressure variability (BPV) is strongly associated with cardiovascular events in end-stage kidney disease patients. Male hemodialysis patients present higher cardiovascular risk compared with females. The aim of this study is to investigate sex differences in short-term BPV in hemodialysis patients. 129 male and 91 female hemodialysis patients that underwent 48-h ABPM were included in this analysis. Standard deviation (SD), weighted SD (wSD), coefficient of variation (CV), and average real variability (ARV) of SBP and DBP were calculated with validated formulas. Age, dialysis vintage and history of major comorbidities did not differ between men and women. 48-h SBP/DBP (137.2 ± 17.4/81.9 ± 12.1 mmHg vs 132.2 ± 19.2/75.9 ± 11.7 mmHg, p = 0.045/<0.001) was significantly higher in men than women. During the 48-h period, all systolic BPV indices were similar between men and women (48-h SBP-ARV: 12.0 ± 2.9 vs 12.1 ± 3.2 mmHg, p = 0.683); 48-h DBP-SD, DBP-wSD and DBP-ARV (9.1 ± 1.6 vs 8.4 ± 1.8 mmHg, p = 0.005) were higher in men. In conclusion, short-term diastolic BPV indices are higher in male than female hemodialysis patients. Increased BPV may impact on the higher incidence of cardiovascular events observed in male hemodialysis patients.

Intensive blood pressure control on dementia in patients with chronic kidney disease: Potential reduction in disease burden

Chronic kidney disease (CKD) and dementia are both common comorbidities creating considerable morbidity and mortality, especially in the elderly population with potential interactions. Even though various hypothetical mechanisms underlying the pathophysiology of increased risk of dementia and cognitive impairment in CKD patients have been implicated, no consensus has been reached so far. Recent clinical trials have investigated the therapeutic role of intensive blood pressure control on the risk of dementia in CKD patients with potentially improved outcomes. However, such trials have significant limitations that may influence the outcome and lack specific management guidelines. We reviewed the role of blood pressure and other factors on the risk of dementia in CKD patients which is an issue with high potential for clinical implications that may improve morbidity, mortality, and health expenditures along with its' potential pathophysiological mechanisms and future guidance.

Ambulatory blood pressure trajectories and blood pressure variability in kidney transplant recipients: a comparative study against chronic kidney disease patients

Background

Methods

Results

Conclusion

Peripheral endothelial and microvascular damage in liver cirrhosis: a systematic review and meta-analysis

OBJECTIVE

This is the first systematic review and meta-analysis of studies using any available functional method to examine differences in peripheral endothelial function between cirrhotic and non-cirrhotic individuals.

METHODS

Literature search involved PubMed, Web-of-Science and Scopus databases, as well as grey literature sources. We included studies in adult subjects evaluating endothelial function with any semi-invasive or non-invasive functional method in patients with and without liver cirrhosis.

RESULTS

From 3378 records initially retrieved, 15 studies with a total of 570 participants were included in the final quantitative meta-analysis. In 6 studies examining endothelial function with flow-mediated-dilatation no differences between patients with cirrhosis and controls were evident (WMD: 1.33, 95%CI [-2.87, 5.53], I² =97%, p<0.00001). Among studies assessing differences in endothelial-dependent or endothelial-independent vasodilation with venous-occlusion-plethysmography, there were no significant differences between the two groups. When pooling all studies together, regardless of the technique used, no significant difference in endothelial function between cirrhotic patients and controls was observed(SMD: 0.79, 95%CI[-0.04, 1.63], I2=94%, p<0.00001).

CONCLUSIONS

No differences in peripheral endothelial function assessed with semi-invasive or non-invasive functional methods exist between cirrhotic and non-cirrhotic subjects. The increasing co-existence of cardiovascular risk factors leading to impaired vascular reactivity in cirrhotic patients may partly explain these findings.

MO081: Ambulatory Blood Pressure Trajectories and Blood Pressure Variability in Kidney Transplant Recipients: A Comparative Study Against Chronic Kidney Disease Patients

BACKGROUND AND AIMS

Hypertension is a major cardiovascular risk factor in both kidney transplant recipients (KTRs) and patients with chronic kidney disease (CKD). Ambulatory blood pressure monitoring (ABPM) is considered the gold standard method for hypertension management in these subjects. This is the first study evaluating in comparison the full ambulatory BP profile and short-term BP variability (BPV) in KTRs versus CKD patients without kidney replacement therapy.

METHOD

93 KTRs were matched with 93 CKD patients for age, sex and eGFR. All participants underwent 24 h ABPM; mean ambulatory BP levels, BP trajectories and BPV indices [standard deviation (SD), weighted-SD and average real variability] were compared between the two groups.

RESULTS

There were no significant between-group differences in 24-h SBP/DBP (KTRs:126.9 ± 13.1/79.1 ± 7.9 versus CKD:128.1 ± 11.2/77.9 ± 8.1 mmHg,  P = 0.522/0.293), daytime SBP/DBP and nighttime SBP; nighttime DBP was slightly higher in KTRs (KTRs:76.5 ± 8.8 versus CKD:73.8 ± 8.8 mmHg, P = 0.040). For both ambulatory SBP/DBP, repeated-measurements-ANOVA showed a significant effect of time (SBP: F = [19, 3002]=11.735, P &lt; 0.001, partial η2 = 0.069) but not of KTR/CKD status (SBP: F = [1, 158] = 0.668, P = 0.415, partial η2 = 0.004). Ambulatory systolic/diastolic BPV indices were not different between KTRs and CKD patients, except for 24-h DBP-SD that was slightly higher in the latter (KTRs: 10.2 ± 2.2 versus CKD: 10.9 ± 2.6 mmHg, P = 0.041). No differences were noted in dipping pattern between the two groups.

CONCLUSION

Mean ambulatory BP levels, BP trajectories and short-term BPV indices are not significantly different between KTRs and CKD patients, suggesting that KTRs have a similar ambulatory BP profile compared with CKD patients without kidney replacement therapy.

MO743: The Influence of Ambulatory Blood Pressure on the Associations of Intradialytic Hypertension with Future Cardiovascular Events and Mortality in Haemodialysis Patients

BACKGROUND AND AIMS

Patients with intradialytic hypertension (IDH) have higher mean 44-h ambulatory blood pressure (BP) levels than patients without the phenomenon. IDH is associated with an increased risk of cardiovascular and all-cause mortality. Whether the excess risk for mortality in patients with IDH depends on the BP rise during dialysis per se or on elevated 44-h ambulatory BP is not known. This is the first study evaluating the association of IDH with cardiovascular events and all-cause mortality before and after adjustment for ambulatory BP and other cardiovascular risk factors.

METHOD

A total of 242 haemodialysis patients underwent 48-h ABPM with Mobil-O-Graph-NG and were followed for a median of 45.7 months. IDH was defined as: SBP rise ≥ 10 mmHg from pre- to post-dialysis and post-dialysis SBP ≥ 150 mmHg. The primary end-point was all-cause mortality; the secondary endpoint was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke, resuscitation after cardiac arrest, hospitalization for heart failure, coronary or peripheral revascularization procedures.

RESULTS

During follow-up, a total of 122 patients died; 69 due to cardiovascular causes. Cumulative freedom from both the primary and secondary endpoints was significantly lower for patients with IDH (log rank-P = 0.048/0.022, respectively). The risk for all-cause mortality was significantly higher for patients with IDH [HR = 1.566, 95% confidence interval (95% CI) (1.001, 2.450)]; similarly, the risk for the combined cardiovascular endpoint was higher for these individuals [HR = 1.675, 95% CI (1.071, 2.620)]. The observed associations attenuated after adjustment for 44-h SBP [all-cause mortality: HR = 1.529, 95% CI (0.952, 2.457)] and combined cardiovascular endpoint: HR = 1.388 95% CI (0.866, 2.225). After additional adjustment for age, interdialytic weight gain, dialysis vintage, 44-h pulse wave velocity, history of coronary artery disease, diabetes mellitus and heart failure the respective HRs were 1.409 [95% CI (0.851, 2.332)] and 1.435 [95% CI (0.879, 2.343)].

CONCLUSION

Patients with IDH presented higher risk for death and cardiovascular outcomes. Sustained high BP levels during the 44-h interdialytic period and not only intradialytic BP rise per se may be participating in the excess risk of this condition.

MO088: Peridialytic and Intradialytic Blood Pressure Measurements are Not Valid Estimates of 44-Hour Ambulatory Blood Pressure in Patients With Intradialytic Hypertension

BACKGROUND AND AIMS

In contrast with pre- and post-dialysis blood pressure (BP), intradialytic and home BP measurements are accurate metrics of ambulatory BP load in hemodialysis patients. This study assessed the agreement of peridialytic, intradialytic and scheduled interdialytic recordings with 44-h interdialytic BP in a distinct hemodialysis population, patients with intradialytic-hypertension (IDH).

METHOD

45 patients with IDH (defined as: SBP rise ≥ 10 mmHg from pre- to post-dialysis and post-dialysis SBP ≥ 150 mmHg) with valid 48-h ABPM and 197 without IDH were included in this analysis. With 44-h BP used as reference method, we tested the accuracy of the following BP metrics: Pre- and post-dialysis, intradialytic, intradialytic plus pre/post-dialysis readings and scheduled interdialytic BP (out-of-dialysis day: readings at 8:00 am, 8:00 pm or their average).

RESULTS

In patients with IDH, peri-dialytic and intradialytic BP metrics showed at best moderate correlations, while averaged-interdialytic-SBP/DBP exhibited strong correlation (r = 0.882/r = 0.855) with 44-h SBP/DBP. Bland-Altman plots showed large between-method difference for peri- and intradialytic BP, but only + 0.7 mmHg between-method difference and good 95% limits-of-agreement for averaged-interdialytic-SBP. The sensitivity/specificity and κ-statistic for diagnosing 44-h SBP ≥ 130 mmHg were low for pre-dialysis (72.5%/40.0%, κ-statistic = 0.074) and post-dialysis (90.0%/0.0%, κ-statistic = −0.110), intradialytic (85.0%/40.0%, κ-statistic = 0.198) and intradialytic plus pre/post-dialysis SBP (85.0%/20.0%, κ-statistic = 0.043). Averaged-interdialytic-SBP showed high values of sensitivity/specificity (97.5%/80.0%) and strong agreement (κ-statistic = 0.775). In ROC-analyses, the peri- and intradialytic BP metrics showed bad performance with low Area-Under-the-Curve values; scheduled interdialytic SBP/DBP had the largest AUC (0.967/0.951), along with the highest sensitivity(90.0%/88.0%) and specificity(100.0%/90.0%) for detecting elevated 44-h BP.

CONCLUSION

In patients with IDH, averaged-scheduled-interdialytic but not pre- and post-dialysis, nor intradialytic BP recordings show reasonable agreement with ambulatory BP. Interdialytic BP recordings only could be used for hypertension diagnosis and management in these subjects.

MO089: Comparison of Ambulatory Central Hemodynamics and Arterial Stiffness in Hemodialysis Patients With And Without Intradialytic Hypertension

BACKGROUND AND AIMS

Increased arterial stiffness is suggested to be involved in the pathogenesis of intradialytic hypertension (IDH). Ambulatory pulse wave velocity (PWV) is an independent predictor for all-cause-mortality in hemodialysis patients and its prognostic power is better than office PWV. This is the first study comparing ambulatory central blood pressure (BP) and arterial stiffness parameters between patients with and without IDH.

METHOD

This study examined 45 patients with IDH (defined as: SBP rise ≥ 10 mmHg from pre- to post-dialysis and post-dialysis SBP ≥ 150 mmHg) in comparison 197 without IDH. All participants underwent 48-h ABPM with the Mobil-O-Graph-NG device; parameters of central hemodynamics [central systolic (cSBP) and diastolic BP (cDBP), pulse pressure (PP)], wave reflection [augmentation index (AIx) and pressure (AP)] and PWV were estimated.

RESULTS

Age, dialysis vintage, interdialytic weight gain and prevalence of major comorbidities did not differ between the two study groups. Patients with IDH had higher 44-h cSBP (131.6 ± 16.7 versus 119.3 ± 15.6, P &lt; 0.001), 44-h cDBP (86.4 ± 12.8 versus 79.3 ± 11.7, P &lt; 0.001) and 44-h cPP (45.7 ± 10.7 versus 40.3 ± 10.3, P = 0.002) levels compared with patients without IDH. Similarly, during day- and nighttime periods, cSBP/cDBP and cPP levels were higher in IDH patients compared with non-IDH. 44-h augmentation pressure and index, but not AIx(75) were higher in patients with IDH than those without IDH. 44-h PWV (10.0 ± 2.0 vs. 9.2 ± 2.1 m/s, P = 0.020) was significantly higher in patients with IDH.

CONCLUSION

Patients with IDH have higher ambulatory central BP and increased arterial stiffness, as indicated by higher ambulatory cPP and PWV. Increased arterial stiffness could be a prominent factor associated with the high burden of cardiovascular disease in this population.

MO086: Sex Differences in Ambulatory Blood Pressure Trajectories and Blood Pressure Variability in Hemodialysis Patients

BACKGROUND AND AIMS

Ambulatory blood pressure (BP) control is worse in men than in women with chronic kidney disease (CKD), and this may partially explain the faster CKD progression in men. The aim of this study is to investigate possible sex-differences in ambulatory BP levels, BP trajectories and BP variability (BPV) in hemodialysis patients.

METHOD

129 male and 91 female hemodialysis patients that underwent 48-h ABPM with Mobil-O-Graph-NG were included in this analysis. Ambulatory BP levels over the 2-day interdialytic interval (including two daytime and two nighttime periods) were recorded. We calculated the standard deviation (SD), weighted SD (wSD), coefficient of variation (CV) and average real variability (ARV) of BP with validated formulas.

RESULTS

Age, dialysis vintage, antihypertensive treatment and history of major comorbidities did not differ between men and women. Pre-dialysis SBP levels did not differ between men and women (145.1 ± 22.7 versus 145.9 ± 25.7 mmHg, P = 0.808), but DBP was marginally higher in men (87.6 ± 14.0 versus 84.0 ± 13.7 mmHg, P =0.055). About 48-h SBP/DBP (137.2 ± 17.4/81.9 ± 12.1 mmHg versus 132.2 ± 19.2/75.9 ± 11.7 mmHg, P = 0.045/&lt;0.001) as well as DBP during the first and SBP/DBP during the second 24-h period were significantly higher in men than in women. Similarly, daytime SBP/DBP was significantly higher in men (138.3 ± 17.5/83.2 ± 12.3 mmHg versus 131.9 ± 19.4/76.4 ± 11.5 mmHg, P = 0.011/&lt;0.001). No significant between-group differences were detected for nighttime SBP. All SBP variability indices were similar between men and women; DBP-SD, DBP-wSD and DBP-ARV were higher in men (44-h DBP-ARV 9.4 ± 1.8 versus 8.6 ± 1.9, P = 0.002). No significant differences were revealed in the dipping pattern between men and women.

CONCLUSION

Ambulatory BP levels and trajectories, as well as DBP variability indices are higher in men than women hemodialysis patients. This worse ambulatory BP profile in male compared to female patients may impact on the incidence of cardiovascular events.

MO685: Brain Oxygenation Assessed by Near-Infrared Spectroscopy During a Mental Task and a Mild Physical Stress in Hemodialysis and Peritoneal Dialysis

BACKGROUND AND AIMS

Cognitive impairment is highly prevalent in end-stage kidney disease (ESKD) individuals. Brain oxygenation is a parameter that plays major role in cognitive function. This study aimed to examine for the first time changes in brain oxygenation during a mental and a mild physical task in hemodialysis (HD) and peritoneal dialysis (PD) patients.

METHOD

A total of 63 ESKD patients (≥18 years old) were enrolled in this cross-sectional study. Patients were allocated in two groups according to dialysis modality (n = 29 HD and n = 34 PD). All participants underwent a mental (countdown from 100 to 0 by 7, performed twice) and a mild physical task (a 3-min intermittent handgrip exercise at 35% of maximal handgrip strength). Changes in brain oxygenation [oxy—(O2Hb), deoxy—(HHb) and total—(tHb) hemoglobin] during the two tasks were continuously recorded via near-infrared spectroscopy (NIRS, Artinis).

RESULTS

Age, sex and dialysis vintage did not differ between the two groups. The average response in brain oxygenation during the mental task (O2Hb change from rest: 1.51 ± 1.68 versus 1.60 ± 1.82 μmol, in HD and PD, respectively, P = 0.841), as well as the duration needed for task completion (191.53 ± 124.27 versus 200.19 ± 118.84 s, P = 0.781) were similar between groups. Furthermore, the average response in brain oxygenation during the handgrip exercise also did not differ between the groups (O2Hb change 1.20 ± 1.03 versus 1.49 ± 0.95 μmol, respectively, P = 0.262). In the total cohort, the average response in brain oxygenation during handgrip exercise was inversely correlated with dialysis vintage (P &lt; 0.05).

CONCLUSION

Dialysis modality does not appear to have an impact on brain oxygenation, as HD and PD patients presented similar responses during a mental and a mild physical task. Dialysis vintage may negatively affect brain oxygenation in ESKD individuals.

MO087: Ambulatory Blood Pressure Trajectories and Blood Pressure Variability in Kidney Transplant Recipients: A Comparative Study Against Hemodialysis Patients

BACKGROUND AND AIMS

Hypertension is the most prevalent cardiovascular risk factor in kidney transplant recipients (KTRs). Preliminary data suggest similar ambulatory blood pressure (ΒP) levels in KTRs and hemodialysis (HD) patients. This is the first study evaluating in comparison the full ambulatory BP profile and short-term BP variability (BPV) in KTRs versus HD patients.

METHOD

Two hundred four KTRs were matched (2:1 ratio) with 102 HD patients for age and gender. BP levels, BP trajectories and BPV indices over a 24-h ambulatory BP monitoring (ABPM) in KTRs were compared against both the first and second 24-h period of a standard 48-h ABPM in HD. To evaluate the effect of renal replacement treatment and time on ambulatory BP levels, two-way-ANOVA for repeated-measurements was performed.

RESULTS

KTRs had significantly lower SBP and pulse-pressure (PP) levels compared with HD during all periods studied (24-h SBP: KTR: 126.5 ± 12.1 mmHg; HD first 24-h: 132.0 ± 18.1 mmHg, P = 0.006; second 24-h: 134.3 ± 17.7 mmHg, P &lt; 0.001); no significant differences were noted for DBP levels with the exception of second nighttime. Repeated-measurements-ANOVA showed a significant effect of RRT modality and time on ambulatory SBP levels during all periods studied, and a significant interaction between-them; the greatest between-group difference in BP (KTRs—HD in mmHg) was observed at the end of the second 24-h (−13.9 mmHg, 95%CI: −21.5 to −6.2, P &lt; 0.001). Ambulatory systolic and diastolic BPV indices were significantly lower in KTRs than in HD during all periods studied (24-h SBP-ARV: KTRs: 9.6 ± 2.3 mmHg; HD first 24-h: 10.3 ± 3.0 mmHg, P = 0.032; second 24-h: 11.5 ± 3.0 mmHg, P &lt; 0.001). No differences were noted in dipping pattern between the two groups.

CONCLUSION

SBP and PP levels and trajectories, and BPV were significantly lower in KTRs compared to age- and gender-matched HD patients during all periods studied. These findings suggest a more favorable ambulatory BP profile in KTRs, in contrast with previous observations.

MO858: Early Morning Haemodynamic Changes and Left Ventricular Hypertrophy and Mortality In Haemodialysis Patients

BACKGROUND AND AIMS

Amplified early morning increase in BP, a phenomenon accompanied by a parallel rise in heart rate (HR), is a marker of high cardiovascular risk in the general population. The early morning changes in these parameters have not been investigated in the haemodialysis population.

METHOD

In a pilot, single centre, study including a series of 58 haemodialysis patients we measured the pre-awakening BP and HR surges and the nocturnal dipping of the same parameters as well as other established indicators of autonomic function (weighted 24h systolic BP and HR variability) and tested their relationship with the left ventricular mass index (LVMI) and with the risk of death over a median follow up of 40 months.

RESULTS

The pre-awakening HR surge (r = –0.46; P = 0.001) was inversely associated with LVMI and the risk of death [HR (1 unit): 0.89, 95% confidence interval: 0.83–0.96; P = 0.001] while the corresponding BP surge largely failed to associate with these outcomes. The link between the pre-awakening HR surge with LVMI and death was robust and largely independent of established risk factors in the haemodialysis population, including the nocturnal dipping of BP. Weighted 24 h systolic BP and HR variability did not correlate with LVMI (all P &gt; 0.11) nor with the risk of death (P &gt; 0.11) and these parameters were also independent of the nocturnal dipping of systolic BP and HR.

CONCLUSION

This pilot study suggests that the low early morning changes in HR, likely reflecting enhanced sympathetic activity, entail a high risk for LVH and mortality in the haemodialysis population.

MO891: Poor Tolerability of the Standard, Extended, 48h Ambulatory Blood Pressure Monitoring in Haemodialysis Patients

BACKGROUND AND AIMS

Ambulatory blood pressure monitoring (ABPM), extended to 44h or 48h for the diagnosis of hypertension in end-stage kidney disease (ESKD) patients, is recommended by Consensus Documents of the American Society of Nephrology and the European Renal Association. About 10%–20% of individuals in the general population report sleeping problems and other symptoms during 24 h ABPM. Because the longer recording period (44 or 48 h versus 24 h), the notorious sleeping disturbances and the high symptom burden of the ESKD population, the feasibility of the technique may be limited in this population. However, the large-scale tolerability of ABPM in the haemodialysis population, has never been investigated.

METHOD

We performed an international survey of feasibility and tolerability of 48 h ABPM in six centres in three European countries. These centres are led by motivated clinical nephrologists, all members of the EURECA-m working group. 48 h ABPM recording was proposed to a large, representative sample of the whole dialysis population of these centres. Well validated instruments (AAMI/ESH/ISO) were applied in all centres. As recommended by the European Society of Hypertension guidelines, recordings were made at 15-min intervals during the day and 30 min during the night. Reasons for refusal to undergo the test were accurately registered. A tolerability (symptoms) questionnaire and a specific questionnaire for sleep evaluation were administered to all participants who underwent 48h ABPM. Reasons for not completing of the ABPM monitoring were systematically recorded.

RESULTS

In the whole haemodialysis population of participating centres including 735 patients, 440 (60%) were invited to participate in the study. Among these patients, 119 (27%) refused to undergo ABPM recording. Reasons for refusal were fear of discomfort (n = 30, 25%), measurement too long (n = 22, 18%), logistic problems (n = 17, 14%), previous negative experience (n = 13, 11%), clinical reasons (n = 12, 10%), other reasons (n = 25). Among the 321 patients who performed the 48h ABPM recording, 29 (9%) did not complete it and the main reason for interrupting the recording were discomfort [12 patients (41%)], followed by device failure [10 patients (34%)]. Among symptoms developed during the ABPM study, frequent interruption of sleeping because of noise or discomfort was reported by 32% of patients, followed by itching (24%) and pain during the measurements (20%). The detailed list of symptoms, is reported in the Table 1.

CONCLUSION

Overall, about 25% of haemodialysis patients consider 48h ABPM a laborious and discomforting test and prejudicially refuse to undergo it. Among patients who undergo 48h ABPM, itching and interruption of sleeping are complained by about 1/3 of patients. These figures are substantially higher than those reported in studies in the general population and in hypertensive patients and point to peculiar barriers at applying extended ABPM recordings in the haemodialysis population. Studies applying more tolerable instruments and a minimum set of measurements over a shorter time, with a reduced number of measurements overnight, are clinical research priority for extending the use of ABPM in the haemodialysis population.

MO198: Outcomes with Finerenone in Patients with Stage 4 Chronic Kidney Disease and Type 2 Diabetes: A Fidelity Subgroup Analysis

BACKGROUND AND AIMS

Patients with stage 4 chronic kidney disease (CKD) and type 2 diabetes (T2D) have a high residual risk of cardiovascular (CV) and kidney disease progression, and effective treatment options to reduce the risk are limited. The non-steroidal selective mineralocorticoid receptor antagonist finerenone has previously demonstrated significant cardiorenal benefits versus placebo in patients with stage 1–4 CKD [1–3]. This FIDELITY subgroup analysis investigated the effects of finerenone in patients with stage 4 CKD [estimated glomerular filtration rate (eGFR) &lt;30 mL/min/1.73 m2) versus those with stage 1–3 CKD (eGFR ≥ 30 mL/min/1.73 m2).

METHOD

FIDELIO-DKD and FIGARO-DKD were phase III trials of patients with CKD and T2D randomised 1:1 to finerenone or placebo. FIDELITY was an individual patient-level prespecified pooled efficacy and safety analysis of these studies. Efficacy outcomes included change in urine albumin-to-creatinine ratio (UACR) between baseline and month 4, change in eGFR over time, a kidney composite outcome (kidney failure, a sustained ≥57% decrease in eGFR from baseline over ≥ 4 weeks or renal death) and a CV composite outcome [CV death, non-fatal myocardial infarction, non-fatal stroke or hospitalization for heart failure (HHF)], as well as the individual components of these composite outcomes.

RESULTS

Of 13 023 patients included in the analysis, 890 patients (6.8%) had stage 4 CKD; key baseline characteristics are listed in Table 1. In patients with stage 4 CKD, finerenone reduced UACR by 31% vs placebo between baseline and month 4 [ratio of least-squares (LS) mean change 0.69; 95% confidence interval (CI) 0.63–0.77), an effect maintained for the duration of the study. Total eGFR slope (LS mean change in eGFR from randomisation to end of treatment) in patients with stage 4 CKD was –0.7 mL/min/1.73 m2/year with finerenone versus –1.6 mL/min/1.73 m2/year with placebo; the chronic eGFR slope (LS mean change in eGFR from month 4 to end of treatment) was –1.8 mL/min/1.73 m2/year with finerenone vs –3.2 mL/min/1.73 m2/year with placebo. The hazard ratio (HR) for risk of the kidney composite in stage 4 CKD was 1.01 (95% CI 0.75–1.37; Figure 1) for finerenone versus placebo. Reduction in risk of sustained ≥ 57% decrease in eGFR with finerenone (stage 4 CKD: HR 0.69, 95% CI 0.43–1.11) was similar between CKD subgroups (pinteraction = 0.71). Reduction in risk of the composite CV outcome (stage 4 CKD: HR 0.78, 95% CI 0.57–1.07) and HHF (stage 4 CKD: HR 0.99, 95% CI 0.62–1.58) was also consistent between CKD subgroups (pinteraction = 0.67 and 0.31, respectively). Overall, incidences of adverse events were balanced between treatment arms in patients with stage 4 CKD and stage 1–3 CKD. The incidence of hyperkalaemia leading to permanent discontinuation was low in patients with stage 4 CKD (3.2% versus 2.2% for finerenone versus placebo).

CONCLUSION

The cardiorenal benefits and safety profile of finerenone in FIDELITY were also observed in the subgroup of patients with stage 4 CKD.

MO090: Diagnostic Performance of Pre-Dialysis And Ambulatory Blood Pressure Levels in Men and Women Hemodialysis Patients

BACKGROUND AND AIMS

Ambulatory blood pressure (BP) control is worse in men than in women with chronic kidney disease or kidney transplantation. So far no study assessed in parallel possible effects of sex differences on the prevalence, control and BP phenotypes according to pre-dialysis and 48-h ABPM in hemodialysis patients. Further, no study has evaluated the diagnostic accuracy of pre-dialysis BP levels in men and women hemodialysis patients.

METHOD

129 male and 91 female hemodialysis patients that underwent 48-h ABPM with Mobil-O-Graph-NG were included in this analysis. Hypertension was defined as follows: (1) pre-dialysis BP ≥ 140/90 mmHg or use of antihypertensive agents, (2) 48-h BP ≥ 130/80 mmHg or use of antihypertensive agents.

RESULTS

The prevalence of hypertension was not different between men and women with the use of pre-dialysis BP (92.2% versus 92.3%, P = 0.987, respectively) or 48-h ABPM (92.2% versus 89%, P = 0.411). With the use of pre-dialysis BP men had significantly lower control rates than women (18.5% versus 32.1%, P = 0.025); a similar pattern of worse control in men was apparent with the use of ABPM, but the difference was not statistically significant (22.7% versus 28.4%, P = 0.360). The rate of patients with concordant lack of control by pre-dialysis and ABPM readings was significantly higher in men than women (65.3% versus 49.4%, P = 0.023); white-coat (14.9% versus 17.6%, P = 0.593) and masked hypertension (10.7% versus 18.8%, P = 0.101) did not differ between groups. However, the misclassifation rate with the use of pre-dialysis BP was lower in men than women. There was moderate or at best fair agreement between pre-dialysis and ambulatory BP with regards to the prevalence (men: κ-statistics = 0.39, P &lt; 0.001 and women: 0.27, P = 0.011) and control rates (κ-statistics = 0.25, P = 0.005 and 0.17, P = 0.124, respectively). Pre-dialysis BP ≥ 140/90 mmHg had sensitivity/specificity of 85.9%/51.4% in men and 72.4%/54.5% in women for the diagnosis of 48-h BP ≥ 130/80 mmHg. Receiver-operating-curve analyses confirmed this poor diagnostic performance.

CONCLUSION

The prevalence of hypertension is similar between men and women hemodialysis patients, but men have worse rates of office BP control. The diagnostic accuracy of pre-dialysis BP levels was equally poor in men and women hemodialysis patients.