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Carey NP, Curtis F, Eisenbeisz ML, Akbari S, Sambharia M, Jalal DI, Wilkinson TJ. Does home blood pressure monitoring improve blood pressure-related outcomes in people living with chronic kidney disease? A systematic review. J Clin Hypertens (Greenwich) 2024; 26:314-329. [PMID: 38523586 PMCID: PMC11007799 DOI: 10.1111/jch.14795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/29/2024] [Accepted: 02/26/2024] [Indexed: 03/26/2024]
Abstract
High blood pressure is an important risk factor for cardiovascular disease and disease progression in chronic kidney disease (CKD). Evidence on the effects of home blood pressure monitoring (HBPM) is limited. This review aimed to determine the effect of HBPM on systolic (SBP) and diastolic blood pressure (DBP) in patients with CKD. We searched medical literature databases for eligible studies presenting pre- and post-data for interventions utilizing HBPM. Study quality was assessed using the NHLBI tools for quality assessment. Heterogeneity prohibited a meta-analysis so estimates of effects were calculated along a sign test to examine the probability of observing the given pattern of positive effect direction. Eighteen studies were included (n = 1187 participants, mean age 56.7 [± 7.7] years). In 15 studies, HBPM was conducted within the context of additional high-level tailored support. Overall, the quality of n = 7/18 studies was rated as "good"; n = 6/18 were "fair," and n = 5/18 were rated as "poor." Interventions utilizing HBPM had a significant effect on SBP, with 14/16 studies favoring the intervention (88% [95% CI: 62%-98%], P = .002). Favorable effects were also seen on DBP (73% [95% CI: 45%-92%], P = .059). HBPM had a favorable effect on blood pressure goal attainment (86% [95% CI: 42%-100%], P = .062). HBPM in patients with CKD as part of a multicomponent intervention may lead to clinically significant reductions in blood pressure; however, research is needed to support the validity of this claim due to the high heterogeneity across the studies included.
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Affiliation(s)
- Nathan P. Carey
- Leicester Diabetes CentreUniversity of LeicesterLeicesterUK
- NIHR Applied Research Collaboration East MidlandsLeicesterUK
| | - Ffion Curtis
- Leicester Diabetes CentreUniversity of LeicesterLeicesterUK
- Liverpool Reviews and Implementation Group (LRiG), Institute of Population HealthUniversity of LiverpoolLiverpoolUK
| | - McKenna L. Eisenbeisz
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
- Center for Access & Delivery Research and Evaluation (CADRE)Iowa City VA HCSIowa CityIowaUSA
| | - Sadaf Akbari
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
- Center for Access & Delivery Research and Evaluation (CADRE)Iowa City VA HCSIowa CityIowaUSA
| | - Meenakshi Sambharia
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
- Center for Access & Delivery Research and Evaluation (CADRE)Iowa City VA HCSIowa CityIowaUSA
| | - Diana I. Jalal
- Department of Internal MedicineUniversity of Iowa Carver College of MedicineIowa CityIowaUSA
- Center for Access & Delivery Research and Evaluation (CADRE)Iowa City VA HCSIowa CityIowaUSA
| | - Thomas J. Wilkinson
- Leicester Diabetes CentreUniversity of LeicesterLeicesterUK
- NIHR Applied Research Collaboration East MidlandsLeicesterUK
- NIHR Leicester Biomedical Research CentreLeicesterUK
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Georgianos PI, Agarwal R. Resistant Hypertension in Dialysis: Epidemiology, Diagnosis, and Management. J Am Soc Nephrol 2024; 35:505-514. [PMID: 38227447 PMCID: PMC11000742 DOI: 10.1681/asn.0000000000000315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 01/08/2024] [Indexed: 01/17/2024] Open
Abstract
Apparent treatment-resistant hypertension is defined as an elevated BP despite the use of ≥3 antihypertensive medications from different classes or the use of ≥4 antihypertensives regardless of BP levels. Among patients receiving maintenance hemodialysis or peritoneal dialysis, using this definition, the prevalence of apparent treatment-resistant hypertension is estimated to be between 18% and 42%. Owing to the lack of a rigorous assessment of some common causes of pseudoresistance, the burden of true resistant hypertension in the dialysis population remains unknown. What distinguishes apparent treatment-resistance from true resistance is white-coat hypertension and adherence to medications. Accordingly, the diagnostic workup of a dialysis patient with apparent treatment-resistant hypertension on dialysis includes the accurate determination of BP control status with the use of home or ambulatory BP monitoring and exclusion of nonadherence to the prescribed antihypertensive regimen. In a patient on dialysis with inadequately controlled BP, despite adherence to therapy with maximally tolerated doses of a β -blocker, a long-acting dihydropyridine calcium channel blocker, and a renin-angiotensin system inhibitor, volume-mediated hypertension is the most important treatable cause of resistance. In daily clinical practice, such patients are often managed with intensification of antihypertensive therapy. However, this therapeutic strategy is likely to fail if volume overload is not adequately recognized or treated. Instead of increasing the number of prescribed BP-lowering medications, we recommend diet and dialysate restricted in sodium to facilitate achievement of dry weight. The achievement of dry weight is facilitated by an adequate time on dialysis of at least 4 hours for delivering an adequate dialysis dose. In this article, we review the epidemiology, diagnosis, and management of resistant hypertension among patients on dialysis.
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Affiliation(s)
- Panagiotis I. Georgianos
- 2nd Department of Nephrology, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indiana
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Symonides B, Lewandowski J, Małyszko J. Resistant hypertension in dialysis. Nephrol Dial Transplant 2023; 38:1952-1959. [PMID: 36898677 DOI: 10.1093/ndt/gfad047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Indexed: 03/12/2023] Open
Abstract
Hypertension is the most common finding in chronic kidney disease patients, with prevalence ranging from 60% to 90% depending on the stage and etiology of the disease. It is also a significant independent risk factor for cardiovascular disease, progression to end-stage kidney disease and mortality. According to the current guidelines, resistant hypertension is defined in the general population as uncontrolled blood pressure on three or more antihypertensive drugs in adequate doses or when patients are on four or more antihypertensive drug categories irrespective of the blood pressure control, providing that antihypertensive treatment included diuretics. The currently established definitions of resistant hypertension are not directly applicable to the end-stage kidney disease setting. The diagnosis of true resistant hypertension requires confirmation of adherence to therapy and confirmation of uncontrolled blood pressure values by ambulatory blood pressure measurement or home blood pressure measurement. In addition, the term "apparent treatment-resistant hypertension," defined as an uncontrolled blood pressure on three or more antihypertensive medication classes, or use of four or more medications regardless of blood pressure level was introduced. In this comprehensive review we focused on the definitions of hypertension, and therapeutic targets in patients on renal replacement therapy, including the limitations and biases. We discussed the issue of pathophysiology and assessment of blood pressure in the dialyzed population, management of resistant hypertension as well as available data on prevalence of apparent treatment-resistant hypertension in end-stage kidney disease. To conclude, larger sample-size and even higher quality studies about drug adherence should be conducted in the population of patients with the end-stage kidney disease who are on dialysis. It also should be determined how and when blood pressure should be measured in the group of dialysis patients. Additionally, it should be stated what the target blood pressure values in this group of patients really are. The definition of resistant hypertension in this group should be revisited, and its relationship to both subclinical and clinical endpoints should be established.
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Affiliation(s)
- Bartosz Symonides
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jacek Lewandowski
- Department of Internal Medicine, Hypertension and Vascular Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jolanta Małyszko
- Department of Nephrology, Dialysis and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Georgianos PI, Vaios V, Sgouropoulou V, Eleftheriadis T, Tsalikakis DG, Liakopoulos V. Hypertension in Dialysis Patients: Diagnostic Approaches and Evaluation of Epidemiology. Diagnostics (Basel) 2022; 12:diagnostics12122961. [PMID: 36552968 PMCID: PMC9777179 DOI: 10.3390/diagnostics12122961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 11/14/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Whereas hypertension is an established cardiovascular risk factor in the general population, the contribution of increased blood pressure (BP) to the huge burden of cardiovascular morbidity and mortality in patients receiving dialysis continues to be debated. In a large part, this controversy is attributable to particular difficulties in the accurate diagnosis of hypertension. The reverse epidemiology of hypertension in dialysis patients is based on evidence from large cohort studies showing that routine predialysis or postdialysis BP measurements exhibit a U-shaped or J-shaped association with cardiovascular or all-cause mortality. However, substantial evidence supports the notion that home or ambulatory BP measurements are superior to dialysis-unit BP recordings in diagnosing hypertension, in detecting evidence of target-organ damage and in prognosticating the all-cause death risk. In the first part of this article, we explore the accuracy of different methods of BP measurement in diagnosing hypertension among patients on dialysis. In the second part, we describe how the epidemiology of hypertension is modified when the assessment of BP is based on dialysis-unit versus home or ambulatory recordings.
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Affiliation(s)
- Panagiotis I. Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Vasilios Vaios
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | - Vasiliki Sgouropoulou
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
| | | | - Dimitrios G. Tsalikakis
- Department of Electrical and Computer Engineering, University of Western Macedonia, 50100 Kozani, Greece
| | - Vassilios Liakopoulos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece
- Correspondence: ; Tel./Fax: +30-2310-994-694
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Cohen JB, Hsu CY, Glidden D, Linke L, Palad F, Larson HL, Mehrotra R, Townsend RR, Bansal N. Ambulatory and Home Blood Pressure Monitoring in Hemodialysis Patients: A Mixed-Methods Study Evaluating Comparability and Tolerability of Blood Pressure Monitoring. Kidney Med 2021; 3:457-460. [PMID: 34136793 PMCID: PMC8178468 DOI: 10.1016/j.xkme.2020.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Affiliation(s)
- Jordana B Cohen
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California-San Francisco, San Francisco, CA
| | - David Glidden
- Department of Biostatistics, University of California-San Francisco, San Francisco, CA
| | - Lori Linke
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Farshad Palad
- Division of Nephrology, University of California-San Francisco, San Francisco, CA
| | - Hanna L Larson
- Kidney Research Institute, Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | | | - Raymond R Townsend
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nisha Bansal
- Division of Nephrology, University of Washington, Seattle, WA
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Tsikliras NC, Georgianos PI, Vaios V, Kousoula V, Kirgialanis A, Chatzidimitriou C, Mavromatidis K, Liakopoulos V, Zebekakis PE, Balaskas EV. Physical examination for the detection of hypervolemia among patients on chronic dialysis: A diagnostic-test study. Hemodial Int 2021; 25:391-398. [PMID: 33694314 DOI: 10.1111/hdi.12920] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/18/2021] [Accepted: 02/19/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Assessment of dry-weight among patients on dialysis is challenging in the absence of reliable markers to define fluid overload (FO). This study aimed to explore the value of two simple clinical signs, pedal edema, and crackles at pulmonary auscultation, in diagnosing hypervolemia, using bioimpendence spectroscopy (BIS) as reference standard. METHODS In a cohort of 107 asymptomatic dialysis patients, FO was assessed with physical examination and BIS shortly before the mid-week dialysis session. Patients were also asked to perform home blood pressure (BP) monitoring with a validated, automatic device (HEM-705, Omron, Healthcare) for 1 week in order to determine their BP outside of dialysis. FINDINGS Patients within the high tertile of predialysis FO had longer dialysis vintage, lower serum albumin and higher home systolic BP, despite the more aggressive treatment with a higher average number of antihypertensives daily. In receiver-operating-characteristic (ROC) curve analysis, pedal edema (area under curve [AUC]: 0.534; 95% confidence interval [CI]: 0.416-0.651) and pulmonary crackles (AUC: 0.551; 95% CI: 0.432-0.671) had limited accuracy in detecting excess predialysis FO > 2.2 L. The agreement of pedal edema (k-coefficient: 0.065) and pulmonary crackles (k-coefficient: 0.122) with BIS-derived FO was poor. In multivariate linear regression analysis, longer dialysis vintage (β: 0.306, p < 0.001) and higher home systolic BP (β: 0.287, p < 0.01) were the two factors that were associated with predialysis FO. CONCLUSIONS This study showed that among asymptomatic dialysis patients, pedal edema and pulmonary crackles in physical examination had limited discriminatory power in detection of FO, as assessed with the method of BIS.
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Affiliation(s)
- Nikolaos C Tsikliras
- Hemodialysis Unit, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Hemodialysis Unit, General Hospital of Xanthi, Xanthi, Greece
| | - Panagiotis I Georgianos
- Hemodialysis Unit, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Therapeutiki Dialysis Center, Thessaloniki, Greece
| | - Vasilios Vaios
- Hemodialysis Unit, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- Therapeutiki Dialysis Center, Thessaloniki, Greece
| | | | | | | | | | - Vassilios Liakopoulos
- Hemodialysis Unit, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Pantelis E Zebekakis
- Hemodialysis Unit, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Elias V Balaskas
- Hemodialysis Unit, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Bansal N, Glidden DV, Mehrotra R, Townsend RR, Cohen J, Linke L, Palad F, Larson H, Hsu CY. Treating Home Versus Predialysis Blood Pressure Among In-Center Hemodialysis Patients: A Pilot Randomized Trial. Am J Kidney Dis 2021; 77:12-22. [PMID: 32800842 PMCID: PMC7752836 DOI: 10.1053/j.ajkd.2020.06.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/11/2020] [Indexed: 01/13/2023]
Abstract
RATIONALE & OBJECTIVE Observational studies have reported a U-shaped association between blood pressure (BP) before a hemodialysis session and death. In contrast, because a linear association between out-of-dialysis-unit BP and death has been reported, home BP may be a better target for treatment. To test the feasibility of this approach, we conducted a pilot trial of treating home versus predialysis BP in hemodialysis patients. STUDY DESIGN A 4-month, parallel, randomized, controlled trial. SETTINGS & PARTICIPANTS 50 prevalent hemodialysis patients in San Francisco and Seattle. Participants were randomly assigned using 1:1 block randomization, stratified by site. INTERVENTIONS To target home systolic BP (SBP) of 100-<140 mm Hg versus predialysis SBP of 100-<140mm Hg. Home and predialysis SBPs were ascertained every 2 weeks. Dry weight and BP medications were adjusted to reach the target SBP. OUTCOMES Primary outcomes were feasibility, adherence, safety. and tolerability. RESULTS 50 of 70 (71%) patients who were approached agreed to participate. All enrollees completed the study except for 1 who received a kidney transplant. In the home BP treatment group, adherence to obtaining/reporting home BP was 97.4% (and consistent over the 4 months). There was no increased frequency of high (defined as SBP>200mm Hg; 0.2% vs 0%) or low (defined as<90mm Hg; 1.8% vs 1.2%) predialysis BP readings in the home versus predialysis treatment arms, respectively. However, participants in the home BP arm had higher frequency of fatigue (32% vs 16%). LIMITATIONS Small sample size. CONCLUSIONS This pilot trial demonstrates feasibility and high adherence to home BP measurement and treatment in hemodialysis patients. Larger trials to test the long-term feasibility, efficacy, and safety of home BP treatment in hemodialysis patients should be conducted. FUNDERS National Institutes of Health, Satellite Healthcare, and Northwest Kidney Centers. TRIAL REGISTRATION Registered at ClinicalTrials.gov with study number NCT03459807.
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Affiliation(s)
- Nisha Bansal
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA.
| | - David V Glidden
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | - Rajnish Mehrotra
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, CA
| | | | - Jordana Cohen
- Division of Nephrology, University of Pennsylvania, Philadelphia, PA
| | - Lori Linke
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Farshad Palad
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
| | - Hannah Larson
- Division of Nephrology, Kidney Research Institute, University of Washington, Seattle, WA
| | - Chi-Yuan Hsu
- Division of Nephrology, University of California, San Francisco, San Francisco, CA
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Georgianos PI, Agarwal R. Can We Study Hypertension in Patients on Dialysis? Yes We Can. Am J Kidney Dis 2020; 77:4-6. [PMID: 33342462 DOI: 10.1053/j.ajkd.2020.08.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 08/26/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Panagiotis I Georgianos
- Section of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN; Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN.
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Ng SYA, Haynes R, Herrington WG. Haemodialysis, blood pressure and risk: at the limit of non-randomized evidence. Nephrol Dial Transplant 2020; 35:1465-1468. [PMID: 32170952 DOI: 10.1093/ndt/gfaa043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 02/11/2020] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sarah Y A Ng
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), Oxford, UK
| | - Richard Haynes
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), Oxford, UK.,Oxford Kidney Unit, Churchill Hospital, Headington, Oxford, UK
| | - William G Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health (NDPH), Oxford, UK.,Oxford Kidney Unit, Churchill Hospital, Headington, Oxford, UK
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Maruyama T, Takashima H, Abe M. Blood pressure targets and pharmacotherapy for hypertensive patients on hemodialysis. Expert Opin Pharmacother 2020; 21:1219-1240. [PMID: 32281890 DOI: 10.1080/14656566.2020.1746272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Hypertension is highly prevalent in patients with end-stage kidney disease on hemodialysis and is often not well controlled. Blood pressure (BP) levels before and after hemodialysis have a U-shaped relationship with cardiovascular and all-cause mortality. Although antihypertensive drugs are recommended for patients in whom BP cannot be controlled appropriately by non-pharmacological interventions, large-scale randomized controlled clinical trials are lacking. AREAS COVERED The authors review the pharmacotherapy used in hypertensive patients on dialysis, primarily focusing on reports published since 2000. An electronic search of MEDLINE was conducted using relevant key search terms, including 'hypertension', 'pharmacotherapy', 'dialysis', 'kidney disease', and 'antihypertensive drug'. Systematic and narrative reviews and original investigations were retrieved in our research. EXPERT OPINION When a drug is administered to patients on dialysis, the comorbidities and characteristics of each drug, including its dialyzability, should be considered. Pharmacological lowering of BP in hypertensive patients on hemodialysis is associated with improvements in mortality. β-blockers should be considered first-line agents and calcium channel blockers as second-line therapy. Renin-angiotensin-aldosterone system inhibitors have not shown superiority to other antihypertensive drugs for patients on hemodialysis.
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Affiliation(s)
- Takashi Maruyama
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
| | - Hiroyuki Takashima
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
| | - Masanori Abe
- Division of Nephrology, Hypertension and Endocrinology, Department of Internal Medicine, Nihon University School of Medicine , Tokyo, Japan
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Villar R, Sánchez RA, Boggia J, Peñaherrera E, Lopez J, Barroso WS, Barbosa E, Cobos L, Hernández Hernández R, Octavio JA, Parra Carrillo JZ, Ramírez AJ, Parati G. Recommendations for home blood pressure monitoring in Latin American countries: A Latin American Society of Hypertension position paper. J Clin Hypertens (Greenwich) 2020; 22:544-554. [DOI: 10.1111/jch.13815] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 12/30/2019] [Indexed: 12/24/2022]
Affiliation(s)
| | - Ramiro A. Sánchez
- Arterial Hypertension and Metabolic Unit University Hospital Favaloro Foundation Buenos Aires Argentina
| | - José Boggia
- Unidad de Hipertensión Centro de Nefrología Hospital Dr. Manuel Quintela Universidad de la República Montevideo Uruguay
| | | | - Jesús Lopez
- Unidad de Hipertension Arterial Hospital Universitario Dr. Jose M. Vargas San Cristobal Venezuela
| | | | - Eduardo Barbosa
- Hypertension League Hospital San Francisco Complexo Ermandade Santa Casa de Porto Alegre Porto Alegre Brazil
| | | | - Rafael Hernández Hernández
- Hypertension and Cardiovascular Risk Factors Clinic School of Medicine Universidad Centro Occidental Lisandro Alvarado Barquisimeto Venezuela
| | - José Andrés Octavio
- Department of Experimental Cardiology Tropical Medicine Institute Universidad Central de Venezuela Caracas Venezuela
| | | | - Agustín J. Ramírez
- Arterial Hypertension and Metabolic Unit University Hospital Favaloro Foundation Buenos Aires Argentina
| | - Gianfranco Parati
- Department of Medicine and Surgery University of Milano‐Bicocca Milan Italy
- Cardiology Unit San Luca Hospital IRCCSIstituto Auxologico Italiano Milan Italy
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12
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Trukhanova MA, Orlov AV, Tolkacheva VV, Troitskaya EA, Villevalde SV, Kobalava ZD. [Office and 44-hour ambulatory blood pressure and central haemodynamic parameters in the patients with end-stage renal diseases undergoing haemodialysis]. ACTA ACUST UNITED AC 2019; 59:63-72. [PMID: 31526363 DOI: 10.18087/cardio.2681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 09/16/2019] [Indexed: 11/18/2022]
Abstract
AIM To assess the incidence of blood pressure (BP) control and various phenotypes of BP by comparing the results of office and 44-hour ambulatory brachial and central BP measurement in patients with end-stage renal disease (ESRD) on program hemodialysis (HD). MATERIALS AND METHODS In 68 patients ESRD receiving renal replacement therapy we evaluated office peridialysis BP and performed 44-hour ambu latory monitoring (ABPM) of brachial and central BP during peridialysis period using a validated oscillometric device BPLabVasotens (OOO "Petr Telegin"). Results were considered statistically significant with p<0.05. RESULTS The frequency of control of peripheral office BP before the HD session was 25%, after - 23.5%; control of central BP - 48.6% and 49%, respectively. According to office measurement the frequency of systolic-diastolic hypertension was 44.1%, isolated systolic hypertension - 25%, isolated diastolic hypertension - 5.9%. The values of peripheral and central office systolic BP (SBP) before and after HD were not consistent with the corresponding mean and daily SBP levels for 44 hours and for the first and second days of the interdialysis period. The frequency of true uncontrolled arterial hypertension (AH) according to peripheral ABPM was 66.5%, masked uncontrolled AH - 9%. Circadian rhythm abnormalities for 44-h peripheral BP were detected in 77%, for central - in 76%. In 97% of patients agreement between phenotypes of the daily profile of peripheral and central BP was observed. 73% of patients had a significant increase in peripheral and central SBP and pulse pressure (PP) and an increase in the proportion of non-dippers from the 1st to the 2nd day. CONCLUSION Patients with ESRD on HD were characterized by poor control of BP control and predominance of unfavourable peripheral and central ambulatory BP phenotypes. A single measurement of clinical peripheral and central BP in the peridialysis period was not sufficient to assess the control of hypertension in this population. The 24-h BP profiles in the 1st and 2nd days of interdialysis period had significant differences.
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Affiliation(s)
| | - A V Orlov
- National Research Nuclear University MEPhI (Moscow Engineering Physics Institute)
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Vaios V, Georgianos PI, Vareta G, Dounousi E, Dimitriadis C, Eleftheriadis T, Papagianni A, Zebekakis PE, Liakopoulos V. Clinic and Home Blood Pressure Monitoring for the Detection of Ambulatory Hypertension Among Patients on Peritoneal Dialysis. Hypertension 2019; 74:998-1004. [PMID: 31401878 DOI: 10.1161/hypertensionaha.119.13443] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The International Society of Peritoneal Dialysis recommends that adequate blood pressure (BP) assessment among patients on peritoneal dialysis should at least include measurements performed once-weekly at home and at each visit at clinic. However, the quality of evidence to support this guidance is suboptimal. Using ambulatory daytime BP as reference standard, we explored the diagnostic performance of clinic and home BP recordings in a cohort of 81 stable patients receiving peritoneal dialysis. BP was recorded using 3 different methodologies: (1) triplicate automated clinic BP recordings after a 5-minute seated rest with the validated monitor HEM 705 CP (Omron Healthcare); (2) 1-week averaged home BP recorded with a validated automated monitor on awaking and at bedtime; and (3) ambulatory BP monitoring with the Mobil-O-Graph device (IEM, Germany). The area under the curve of receiver operating characteristic curves in detection of ambulatory daytime systolic BP (SBP) ≥135 mm Hg was similar for clinic [area under the curve, 0.859; 95% CI, 0.776-0.941] and home SBP (area under the curve, 0.895; 95% CI, 0.815-0.976). In Bland-Altman analysis, clinic SBP overestimated daytime ambulatory SBP by 5.02 mm Hg with 95% limits of agreement ranging from -17.92 to 27.96 mm Hg. Similarly, home SBP overestimated daytime ambulatory SBP by 4.23 mm Hg, again with wide 95% limits of agreement (-16.05 to 24.51 mm Hg). These results show that 1-week averaged home SBP is of at least similar accuracy with standardized clinic SBP in diagnosing hypertension confirmed by ambulatory BP monitoring among patients on peritoneal dialysis.
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Affiliation(s)
- Vasilios Vaios
- From the Peritoneal Dialysis Unit, 1st Department of Medicine, AHEPA Hospital (V.V., P.I.G., G.V., P.E.Z., V.L.), Aristotle University of Thessaloniki, Greece
| | - Panagiotis I Georgianos
- From the Peritoneal Dialysis Unit, 1st Department of Medicine, AHEPA Hospital (V.V., P.I.G., G.V., P.E.Z., V.L.), Aristotle University of Thessaloniki, Greece
| | - Georgia Vareta
- From the Peritoneal Dialysis Unit, 1st Department of Medicine, AHEPA Hospital (V.V., P.I.G., G.V., P.E.Z., V.L.), Aristotle University of Thessaloniki, Greece
| | - Evangelia Dounousi
- Department of Nephrology, University Hospital of Ioannina, Greece (E.D.)
| | - Chrysostomos Dimitriadis
- Department of Nephrology, Hippokration Hospital (C.D., A.P.), Aristotle University of Thessaloniki, Greece
| | | | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital (C.D., A.P.), Aristotle University of Thessaloniki, Greece
| | - Pantelis E Zebekakis
- From the Peritoneal Dialysis Unit, 1st Department of Medicine, AHEPA Hospital (V.V., P.I.G., G.V., P.E.Z., V.L.), Aristotle University of Thessaloniki, Greece
| | - Vassilios Liakopoulos
- From the Peritoneal Dialysis Unit, 1st Department of Medicine, AHEPA Hospital (V.V., P.I.G., G.V., P.E.Z., V.L.), Aristotle University of Thessaloniki, Greece
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Huang B, Li Z, Wang Y, Xia J, Shi T, Jiang J, Nolan MT, Li X, Nigwekar SU, Chen L. Effectiveness of self-management support in maintenance haemodialysis patients with hypertension: A pilot cluster randomized controlled trial. Nephrology (Carlton) 2019; 23:755-763. [PMID: 28666310 DOI: 10.1111/nep.13098] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/20/2017] [Accepted: 06/22/2017] [Indexed: 01/23/2023]
Abstract
AIM Uncontrolled hypertension is an independent risk factor for cardiovascular disease and is the leading cause of mortality in haemodialysis patients. The aim of this study was to examine the effectiveness of self-management support (SMS) for blood pressure (BP) control and health behaviours. METHODS We conducted a cluster randomized controlled trial (RCT) in which 90 adult haemodialysis patients were assigned to either an SMS or common intervention (CI) group. The SMS group received an intervention consisting of self-management education and motivational interviewing. The CI group received standard care and routine health education. The primary outcome was the BP monitored before each haemodialysis. Secondary outcomes included salt intake (measured using a balance formula), home BP monitoring (HBPM) (assessed using two self-administered questions), and medication adherence (measured using the Medication-taking Behavior Scale). Data were collected at baseline and at 1, 3 and 6 months post-intervention. RESULTS The SMS group showed continuous reductions in systolic BP from baseline: -9.2, -8.7, and -8.4 mmHg at 1, 3 and 6 months after the intervention, respectively (P < 0.01). Compared with the CI group, the SMS group had a greater decrease in systolic BP at 1 month: -5.9 mmHg (P = 0.0388), but no significant difference was found at 3 or 6 months (P > 0.05). SMS patients showed an improvement in health behaviours relative to baseline (less salt intake, more consistent HBPM, and greater medication adherence) (P < 0.05). CONCLUSIONS Self-management support obtained short-term success in improving salt restriction, regular performance of HBPM and medication adherence, which led to better BP control.
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Affiliation(s)
- Baoyan Huang
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.,School of Nursing, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zheng Li
- School of Nursing, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ying Wang
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jinghua Xia
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Tao Shi
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jingmei Jiang
- Department of Epidemiology & Biostatistics, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Marie T Nolan
- School of Nursing, Johns Hopkins University, Baltimore, USA
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Sagar U Nigwekar
- Division of Nephrology, Massachusetts General Hospital, Boston, MA, USA
| | - Limeng Chen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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15
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Abstract
The association between blood pressure (BP) and mortality is unique in hemodialysis patients compared with that in the general population. This is because of an altered benefit-risk balance associated with BP reduction in these patients. An adequately designed study comparing BP targets in hemodialysis patients remains to be conducted. The current evidence available to guide dialysis providers regarding treatment strategies for managing hypertension in this population is limited to large observational studies and small randomized controlled trials. In this opinion article, we review these data and discuss the key points regarding BP management for hemodialysis patients. Our aim is to provide a practical opinion regarding BP targets that nephrologists can incorporate into clinical practice, with a focus on moving away from dialysis unit BPs and focusing on out-of-dialysis unit BPs.
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Affiliation(s)
- Jeffrey M Turner
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Aldo J Peixoto
- Section of Nephrology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
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16
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Georgianos PI, Champidou E, Liakopoulos V, Balaskas EV, Zebekakis PE. Home blood pressure–guided antihypertensive therapy in chronic kidney disease: more data are needed. ACTA ACUST UNITED AC 2018; 12:242-247. [DOI: 10.1016/j.jash.2018.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 10/18/2022]
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17
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Nerenberg KA, Zarnke KB, Leung AA, Dasgupta K, Butalia S, McBrien K, Harris KC, Nakhla M, Cloutier L, Gelfer M, Lamarre-Cliche M, Milot A, Bolli P, Tremblay G, McLean D, Padwal RS, Tran KC, Grover S, Rabkin SW, Moe GW, Howlett JG, Lindsay P, Hill MD, Sharma M, Field T, Wein TH, Shoamanesh A, Dresser GK, Hamet P, Herman RJ, Burgess E, Gryn SE, Grégoire JC, Lewanczuk R, Poirier L, Campbell TS, Feldman RD, Lavoie KL, Tsuyuki RT, Honos G, Prebtani APH, Kline G, Schiffrin EL, Don-Wauchope A, Tobe SW, Gilbert RE, Leiter LA, Jones C, Woo V, Hegele RA, Selby P, Pipe A, McFarlane PA, Oh P, Gupta M, Bacon SL, Kaczorowski J, Trudeau L, Campbell NRC, Hiremath S, Roerecke M, Arcand J, Ruzicka M, Prasad GVR, Vallée M, Edwards C, Sivapalan P, Penner SB, Fournier A, Benoit G, Feber J, Dionne J, Magee LA, Logan AG, Côté AM, Rey E, Firoz T, Kuyper LM, Gabor JY, Townsend RR, Rabi DM, Daskalopoulou SS. Hypertension Canada's 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children. Can J Cardiol 2018; 34:506-525. [PMID: 29731013 DOI: 10.1016/j.cjca.2018.02.022] [Citation(s) in RCA: 416] [Impact Index Per Article: 69.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 02/20/2018] [Accepted: 02/20/2018] [Indexed: 12/13/2022] Open
Abstract
Hypertension Canada provides annually updated, evidence-based guidelines for the diagnosis, assessment, prevention, and treatment of hypertension in adults and children. This year, the adult and pediatric guidelines are combined in one document. The new 2018 pregnancy-specific hypertension guidelines are published separately. For 2018, 5 new guidelines are introduced, and 1 existing guideline on the blood pressure thresholds and targets in the setting of thrombolysis for acute ischemic stroke is revised. The use of validated wrist devices for the estimation of blood pressure in individuals with large arm circumference is now included. Guidance is provided for the follow-up measurements of blood pressure, with the use of standardized methods and electronic (oscillometric) upper arm devices in individuals with hypertension, and either ambulatory blood pressure monitoring or home blood pressure monitoring in individuals with white coat effect. We specify that all individuals with hypertension should have an assessment of global cardiovascular risk to promote health behaviours that lower blood pressure. Finally, an angiotensin receptor-neprilysin inhibitor combination should be used in place of either an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in individuals with heart failure (with ejection fraction < 40%) who are symptomatic despite appropriate doses of guideline-directed heart failure therapies. The specific evidence and rationale underlying each of these guidelines are discussed.
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Affiliation(s)
- Kara A Nerenberg
- Division of General Internal Medicine, Departments of Medicine, Obstetrics and Gynecology, Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
| | - Kelly B Zarnke
- O'Brien Institute for Public Health and Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexander A Leung
- Division of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kaberi Dasgupta
- Department of Medicine and Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Sonia Butalia
- Departments of Medicine and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Kerry McBrien
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kevin C Harris
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Meranda Nakhla
- Department of Medicine and Centre for Outcomes Research and Evaluation, McGill University and Research Institute of the McGill University Health Centre, Montreal, Quebec, Canada
| | - Lyne Cloutier
- Department of Nursing, Université du Québec à Trois-Rivières, Trois-Rivières, Quebec, Canada
| | - Mark Gelfer
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Alain Milot
- Department of Medicine, Université Laval, Québec, Quebec, Canada
| | - Peter Bolli
- McMaster University, Hamilton, Ontario, Canada
| | - Guy Tremblay
- CHU-Québec-Hopital St. Sacrement, Québec, Quebec, Canada
| | - Donna McLean
- Alberta Health Services and Covenant Health, Edmonton, Alberta, Canada
| | - Raj S Padwal
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Karen C Tran
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Steven Grover
- McGill Comprehensive Health Improvement Program (CHIP), Montreal, Quebec, Canada
| | - Simon W Rabkin
- Vancouver Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Gordon W Moe
- St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan G Howlett
- Departments of Medicine and Cardiac Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Patrice Lindsay
- Director of Stroke, Heart and Stroke Foundation of Canada, Adjunct Faculty, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mike Sharma
- McMaster University, Hamilton Health Sciences, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Thalia Field
- University of British Columbia, Vancouver Stroke Program, Vancouver, British Columbia, Canada
| | - Theodore H Wein
- McGill University, Stroke Prevention Clinic, Montreal General Hospital, Montreal, Quebec, Canada
| | - Ashkan Shoamanesh
- McMaster University, Hamilton Health Sciences, Population Health Research Institute, Hamilton, Ontario, Canada
| | - George K Dresser
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Pavel Hamet
- Faculté de Médicine, Université de Montréal, Montréal, Quebec, Canada
| | - Robert J Herman
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Ellen Burgess
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Steven E Gryn
- Department of Medicine, Western University, London, Ontario, Canada
| | - Jean C Grégoire
- Université de Montréal, Institut de cardiologie de Montréal, Montréal, Quebec, Canada
| | - Richard Lewanczuk
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Luc Poirier
- Institut National d'Excellence en Sante et Services Sociaux, Québec, Quebec, Canada
| | - Tavis S Campbell
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Ross D Feldman
- Winnipeg Regional Health Authority and the University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kim L Lavoie
- University of Quebec at Montreal (UQAM), Montreal Behavioural Medicine Centre, CIUSSS-NIM, Hôpital du Sacré-Coeur de Montréal, Montréal, Quebec, Canada
| | - Ross T Tsuyuki
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - George Honos
- CHUM, University of Montreal, Montreal, Quebec, Canada
| | - Ally P H Prebtani
- Internal Medicine, Endocrinology and Metabolism, McMaster University, Hamilton, Ontario, Canada
| | - Gregory Kline
- Division of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Sheldon W Tobe
- University of Toronto, Toronto, Ontario, and Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Richard E Gilbert
- University of Toronto, Division of Endocrinology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Lawrence A Leiter
- University of Toronto, Division of Endocrinology, St Michael's Hospital, Toronto, Ontario, Canada
| | - Charlotte Jones
- Department of Medicine, UBC Southern Medical Program, Kelowna, British Columbia, Canada
| | - Vincent Woo
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Robert A Hegele
- Departments of Medicine (Division of Endocrinology) and Biochemistry, Western University, London, Ontario, Canada
| | - Peter Selby
- Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Pipe
- University of Ottawa Heart Institute, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Philip A McFarlane
- Division of Nephrology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Paul Oh
- University Health Network, Toronto Rehab and Peter Munk Cardiac Centre, Toronto, Ontario, Canada
| | - Milan Gupta
- Department of Medicine, McMaster University, Hamilton, Ontario, and Canadian Collaborative Research Network, Brampton, Ontario, Canada
| | - Simon L Bacon
- Department of Exercise Science, Concordia University, and Montreal Behavioural Medicine Centre, CIUSSS-NIM, Hôpital du Sacré-Coeur de Montréal, Montréal, Quebec, Canada
| | - Janusz Kaczorowski
- Department of Family and Emergency Medicine, Université de Montréal and CRCHUM, Montréal, Quebec, Canada
| | - Luc Trudeau
- Division of Internal Medicine, Department of Medicine, McGill University, Montréal, Quebec, Canada
| | - Norman R C Campbell
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Swapnil Hiremath
- University of Ottawa and the Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Michael Roerecke
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Joanne Arcand
- Faculty of Health Sciences, University of Ontario Institute of Technology, Oshawa, Ontario, Canada
| | - Marcel Ruzicka
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Michel Vallée
- Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Quebec, Canada
| | - Cedric Edwards
- Division of Nephrology, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Praveena Sivapalan
- Division of General Internal Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - Anne Fournier
- Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Geneviève Benoit
- Service de néphrologie, Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Janusz Feber
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Janis Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Laura A Magee
- Department of Women and Children's Health, St Thomas' Hospital, London, and Department of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | | | | | - Evelyne Rey
- CHU Sainte-Justine, University of Montreal, Montreal, Quebec, Canada
| | - Tabassum Firoz
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Laura M Kuyper
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Jonathan Y Gabor
- Interlake-Eastern Regional Healthy Authority, Concordia Hospital, Winnipeg, Manitoba, Canada
| | - Raymond R Townsend
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Doreen M Rabi
- Division of Endocrinology and Metabolism, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Departments of Medicine and Community Health Sciences, O'Brien Institute for Public Health and Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Stella S Daskalopoulou
- Division of Internal Medicine, Department of Medicine, McGill University, Montréal, Quebec, Canada
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18
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Sarafidis PA, Persu A, Agarwal R, Burnier M, de Leeuw P, Ferro C, Halimi JM, Heine G, Jadoul M, Jarraya F, Kanbay M, Mallamaci F, Mark PB, Ortiz A, Parati G, Pontremoli R, Rossignol P, Ruilope L, Van der Niepen P, Vanholder R, Verharr MC, Wiecek A, Wuerzner G, London GM, Zoccali C. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). J Hypertens 2017; 35:657-76. [PMID: 28157814 DOI: 10.1097/HJH.0000000000001283] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
In patients with end-stage renal disease treated with hemodialysis or peritoneal dialysis, hypertension is very common and often poorly controlled. Blood pressure (BP) recordings obtained before or after hemodialysis display a J-shaped or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar hemodynamic setting related with dialysis treatment. Elevated BP by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnea and the use of erythropoietin-stimulating agents may also be involved. Nonpharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium-volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
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19
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Abstract
PURPOSE OF REVIEW In the absence of 'hard' clinical-trial evidence to define optimal blood pressure (BP) targets and validate different BP measurement techniques, management of hypertension in hemodialysis is based on expert opinions. In this review, we provide a comparative evaluation of out-of-dialysis BP monitoring versus dialysis-unit BP recordings in diagnosing hypertension, guiding its management and prognosticating mortality risk. RECENT FINDINGS Owing to their high variability and poor reproducibility, predialysis and postdialysis BP recordings provide inaccurate reflection of the actual BP load outside of dialysis. Contrary to the reverse association of peridialytic BP with mortality, elevated home and ambulatory BP provides a direct mortality signal. Out-of-dialysis BP monitoring, even when done in the clinic, is a reliable approach to manage hypertension in the dialysis unit. Whenever none of these measures are available, median intradialytic SBP can provide a better estimate of interdialytic BP levels compared with peridialytic BP measurements. SUMMARY Although out-of-dialysis BP monitoring have better diagnostic accuracy and prognostic validity, randomized trials are needed to ascertain BP targets for managing hypertension in hemodialysis patients.
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20
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Sarafidis PA, Persu A, Agarwal R, Burnier M, de Leeuw P, Ferro CJ, Halimi JM, Heine GH, Jadoul M, Jarraya F, Kanbay M, Mallamaci F, Mark PB, Ortiz A, Parati G, Pontremoli R, Rossignol P, Ruilope L, Van der Niepen P, Vanholder R, Verhaar MC, Wiecek A, Wuerzner G, London GM, Zoccali C. Hypertension in dialysis patients: a consensus document by the European Renal and Cardiovascular Medicine (EURECA-m) working group of the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) and the Hypertension and the Kidney working group of the European Society of Hypertension (ESH). Nephrol Dial Transplant 2017; 32:620-640. [PMID: 28340239 DOI: 10.1093/ndt/gfw433] [Citation(s) in RCA: 106] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 11/14/2016] [Indexed: 01/07/2023] Open
Abstract
In patients with end-stage renal disease (ESRD) treated with haemodialysis or peritoneal dialysis, hypertension is common and often poorly controlled. Blood pressure (BP) recordings obtained before or after haemodialysis display a J- or U-shaped association with cardiovascular events and survival, but this most likely reflects the low accuracy of these measurements and the peculiar haemodynamic setting related to dialysis treatment. Elevated BP detected by home or ambulatory BP monitoring is clearly associated with shorter survival. Sodium and volume excess is the prominent mechanism of hypertension in dialysis patients, but other pathways, such as arterial stiffness, activation of the renin-angiotensin-aldosterone and sympathetic nervous systems, endothelial dysfunction, sleep apnoea and the use of erythropoietin-stimulating agents may also be involved. Non-pharmacologic interventions targeting sodium and volume excess are fundamental for hypertension control in this population. If BP remains elevated after appropriate treatment of sodium and volume excess, the use of antihypertensive agents is necessary. Drug treatment in the dialysis population should take into consideration the patient's comorbidities and specific characteristics of each agent, such as dialysability. This document is an overview of the diagnosis, epidemiology, pathogenesis and treatment of hypertension in patients on dialysis, aiming to offer the renal physician practical recommendations based on current knowledge and expert opinion and to highlight areas for future research.
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Affiliation(s)
- Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alexandre Persu
- Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, and Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
| | - Michel Burnier
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | - Peter de Leeuw
- Department of Medicine, Maastricht University Medical Center, Maastricht and Zuyderland Medical Center, Geleen/Heerlen, The Netherlands
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jean-Michel Halimi
- Service de Néphrologie-Immunologie Clinique, Hôpital Bretonneau, François-Rabelais University, Tours, France
| | - Gunnar H Heine
- Saarland University Medical Center, Internal Medicine IV-Nephrology and Hypertension, Homburg, Germany
| | - Michel Jadoul
- Division of Nephrology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Faical Jarraya
- Department of Nephrology, Sfax University Hospital and Research Unit, Faculty of Medicine, Sfax University, Sfax, Tunisia
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
| | - Patrick B Mark
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Alberto Ortiz
- IIS-Fundacion Jimenez Diaz, School of Medicine, University Autonoma of Madrid, FRIAT and REDINREN, Madrid, Spain
| | - Gianfranco Parati
- Department of Cardiovascular, Neural, and Metabolic Sciences, San Luca Hospital, Istituto Auxologico Italiano and Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Roberto Pontremoli
- Università degli Studi and IRCCS Azienda Ospedaliera Universitaria San Martino-IST, Genova, Italy
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, and Association Lorraine de Traitement de l'Insuffisance Rénale, Nancy, France
| | - Luis Ruilope
- Hypertension Unit & Institute of Research i?+?12, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Patricia Van der Niepen
- Department of Nephrology and Hypertension, Universitair Ziekenhuis Brussel - VUB, Brussels, Belgium
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine, Ghent University Hospital, Gent, Belgium
| | - Marianne C Verhaar
- Department of Nephrology and Hypertension, University Medical Center Utrecht, The Netherlands
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Katowice, Poland
| | - Gregoire Wuerzner
- Service of Nephrology and Hypertension, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases Unit, Ospedali Riuniti, Reggio Calabria, Italy
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Affiliation(s)
- Dana C. Miskulin
- Department of Medicine; Tufts University School of Medicine; Boston Massachusetts
| | - Daniel E. Weiner
- Department of Medicine; Tufts University School of Medicine; Boston Massachusetts
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Abstract
Among patients on dialysis, hypertension is highly prevalent and contributes to the high burden of cardiovascular morbidity and mortality. Strict volume control via sodium restriction and probing of dry weight are first-line approaches for the treatment of hypertension in this population; however, antihypertensive drug therapy is often needed to control BP. Few trials compare head-to-head the superiority of one antihypertensive drug class over another with respect to improving BP control or altering cardiovascular outcomes; accordingly, selection of the appropriate antihypertensive regimen should be individualized. To individualize therapy, consideration should be given to intra- and interdialytic pharmacokinetics, effect on cardiovascular reflexes, ability to treat comorbid illnesses, and adverse effect profile. β-Blockers followed by dihydropyridine calcium-channel blockers are our first- and second-line choices for antihypertensive drug use. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers seem to be reasonable third-line choices, because the evidence base to support their use in patients on dialysis is sparse. Add-on therapy with mineralocorticoid receptor antagonists in specific subgroups of patients on dialysis (i.e., those with severe congestive heart failure) seems to be another promising option in anticipation of the ongoing trials evaluating their efficacy and safety. Adequately powered, multicenter, randomized trials evaluating hard cardiovascular end points are urgently warranted to elucidate the comparative effectiveness of antihypertensive drug classes in patients on dialysis. In this review, we provide an overview of the randomized evidence on pharmacotherapy of hypertension in patients on dialysis, and we conclude with suggestions for future research to address critical gaps in this important area.
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Affiliation(s)
- Panagiotis I. Georgianos
- Division of Nephrology and Hypertension, First Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine, Indianapolis, Indianapolis; and
- Division of Nephrology, Department of Medicine, Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Indianapolis
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Malachias MVB, Amodeo C, Paula RB, Cordeiro AC, Magalhães LBNC, Bodanese LC. 7th Brazilian Guideline of Arterial Hypertension: Chapter 8 - Hypertension and Associated Clinical Conditions. Arq Bras Cardiol 2016; 107:44-48. [PMID: 27819387 PMCID: PMC5319465 DOI: 10.5935/abc.20160158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Abstract
The diagnosis and management of hypertension among patients on chronic dialysis is challenging. Routine peridialytic blood pressure recordings are unable to accurately diagnose hypertension and stratify cardiovascular risk. By contrast, blood pressure recordings taken outside the dialysis setting exhibit clear prognostic associations with survival and might facilitate the diagnosis and long-term management of hypertension. Once accurately diagnosed, management of hypertension in individuals on chronic dialysis should initially involve non-pharmacological strategies to control volume overload. Accordingly, first-line strategies should focus on achieving dry weight, individualizing dialysate sodium concentrations and ensuring dialysis sessions are at least 4 h in duration. If blood pressure remains unresponsive to volume management strategies, pharmacological treatment is required. The choice of appropriate antihypertensive regimen should be individualized taking into account the efficacy, safety, and pharmacokinetic properties of the antihypertensive medications as well as any comorbid conditions and the overall risk profile of the patient. In contrast to their effects in the general hypertensive population, emerging evidence suggests that β-blockers might offer the greatest cardioprotection in hypertensive patients on dialysis. In this Review, we discuss estimates of the epidemiology of hypertension in the dialysis population as well as the challenges in diagnosing and managing hypertension among these patients.
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Affiliation(s)
- Panagiotis I Georgianos
- Division of Nephrology and Hypertension, 1st Department of Medicine, AHEPA Hospital, Aristotle University of Thessaloniki, St. Kyriakidi 1, Thessaloniki GR54006, Greece
| | - Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Mail Code: 111N, 1481 West 10th Street, Indianapolis 46202-2884 USA
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Valika A, Peixoto AJ. Hypertension Management in Transition: From CKD to ESRD. Adv Chronic Kidney Dis 2016; 23:255-61. [PMID: 27324679 DOI: 10.1053/j.ackd.2016.02.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2015] [Revised: 12/25/2015] [Accepted: 02/07/2016] [Indexed: 12/24/2022]
Abstract
Hypertension is present in ∼90% of patients in late-stage CKD. There are scarce data focusing on the transition period between CKD Stages 4 and 5 (end-stage kidney disease) as it relates to hypertension evaluation and management. Here, we propose that a combination of the principles used in the management of patients with CKD Stages 4 and 5 be applied to patients in this transition. These include the use of out-of-office blood pressure (BP) monitoring (eg, home BP), avoidance of excessively tight BP goals, emphasis of sodium restriction, preferential use of blockers of the renin-angiotensin system and diuretics, and consideration of the use of beta blockers.
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Parati G, Ochoa JE, Bilo G, Agarwal R, Covic A, Dekker FW, Fliser D, Heine GH, Jager KJ, Gargani L, Kanbay M, Mallamaci F, Massy Z, Ortiz A, Picano E, Rossignol P, Sarafidis P, Sicari R, Vanholder R, Wiecek A, London G, Zoccali C. Hypertension in Chronic Kidney Disease Part 1. Hypertension 2016; 67:1093-101. [DOI: 10.1161/hypertensionaha.115.06895] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Gianfranco Parati
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Juan Eugenio Ochoa
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Grzegorz Bilo
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Rajiv Agarwal
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Adrian Covic
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Friedo W. Dekker
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Danilo Fliser
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Gunnar H. Heine
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Kitty J. Jager
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Luna Gargani
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Mehmet Kanbay
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Francesca Mallamaci
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Ziad Massy
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Alberto Ortiz
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Eugenio Picano
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Patrick Rossignol
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Pantelis Sarafidis
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Rosa Sicari
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Raymond Vanholder
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Andrzej Wiecek
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Gerard London
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
| | - Carmine Zoccali
- From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis (R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of Clinical Epidemiology, Leiden University Medical Center,
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Qudah B, Albsoul-Younes A, Alawa E, Mehyar N. Role of clinical pharmacist in the management of blood pressure in dialysis patients. Int J Clin Pharm 2016; 38:931-40. [DOI: 10.1007/s11096-016-0317-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Accepted: 05/05/2016] [Indexed: 10/21/2022]
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Breaux-Shropshire TL, Judd E, Vucovich LA, Shropshire TS, Singh S. Does home blood pressure monitoring improve patient outcomes? A systematic review comparing home and ambulatory blood pressure monitoring on blood pressure control and patient outcomes. Integr Blood Press Control 2015; 8:43-9. [PMID: 26170715 PMCID: PMC4498728 DOI: 10.2147/ibpc.s49205] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Our objective was to compare the clinical effectiveness of home blood pressure monitoring (HBPM) and 24-hour ambulatory blood pressure monitoring (ABPM) on blood pressure (BP) control and patient outcomes. DESIGN A systematic review was conducted. We also appraised the methodological quality of studies. DATA SOURCES PubMed, Scopus, CINAHL, and the Cochrane Central Register of Control Trials (CENTRAL). INCLUSION CRITERIA Randomized control trials, prospective and retrospective cohort studies, observational studies, and case-control studies published in English from any year to present that describe HBPM and 24-hour ABPM and report on systolic and/or diastolic BP and/or heart attack, stroke, kidney failure and/or all-cause mortality for adult patients. Due to the nature of the question, studies with only untreated patients were not considered. RESULTS Of 1,742 titles and abstractions independently reviewed by two reviewers, 137 studies met predetermined criteria for evaluation. Nineteen studies were identified as relevant and included in the paper. The common themes were that HBPM and ABPM correlated with cardiovascular events and mortality, and targeting HBPM or ABPM resulted in similar outcomes. Associations between BP measurement type and mortality differed by study population. Both the low sensitivity of office blood pressure monitoring (OBPM) to detect optimal BP control by ABPM and the added association of HBPM with cardiovascular mortality supported the routine use of HBPM in clinical practice. There was insufficient data to determine the benefit of using HBPM as a measurement standard for BP control. CONCLUSION HBPM encourages patient-centered care and improves BP control and patient outcomes. Given the limited number of studies with both HBPM and ABPM, these measurement types should be incorporated into the design of randomized clinical trials within hypertensive populations.
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Affiliation(s)
- Tonya L Breaux-Shropshire
- Vascular Biology and Hypertension Program, Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA ; Veterans Administration, Birmingham, AL, USA
| | - Eric Judd
- Vascular Biology and Hypertension Program, Cardiovascular Disease, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Lee A Vucovich
- Lister Hill Library, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Toneyell S Shropshire
- Department of Physical Therapy, Louisiana State University Health Sciences Center, New Orleans, LA, USA
| | - Sonal Singh
- Department of Medicine, John Hopkins School of Medicine, Baltimore, MD, USA
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Agarwal R. Pro: Ambulatory blood pressure should be used in all patients on hemodialysis. Nephrol Dial Transplant 2015; 30:1432-7. [PMID: 26022728 DOI: 10.1093/ndt/gfv243] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 03/13/2015] [Indexed: 11/14/2022] Open
Abstract
In the adult population in general and among people with chronic kidney disease in particular, it is now well established that hypertension is a major driver of renal disease progression and cardiovascular morbidity and mortality. Although the contribution of hypertension to cardiovascular morbidity and mortality among patients on long-term dialysis continues to be debated, a major barrier to detect hypertension as a risk factor for cardiovascular events in these patients has been the inability to diagnose hypertension. Largely to blame has been the easy availability of pre-dialysis and post-dialysis blood pressure recordings in stark contrast to ambulatory blood pressure measurements in dialysis patients to accurately diagnose the presence or control of hypertension. It is increasingly becoming clear that out-of-office blood pressure recordings are superior to clinic recordings in making a diagnosis, assessing target organ damage, evaluating prognosis and managing patients with hypertension. In this debate, I have been asked to defend the position that ambulatory blood pressure recordings should be systematically applied to all patients on hemodialysis.
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Affiliation(s)
- Rajiv Agarwal
- Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA
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Zoccali C, Tripepi R, Torino C, Tripepi G, Mallamaci F. Moderator's view: Ambulatory blood pressure monitoring and home blood pressure for the prognosis, diagnosis and treatment of hypertension in dialysis patients. Nephrol Dial Transplant 2015; 30:1443-8. [PMID: 26022727 DOI: 10.1093/ndt/gfv241] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Major health agencies now recommend the systematic application of ambulatory blood pressure monitoring (ABPM) for the diagnosis of hypertension. Given the exceedingly high prevalence of nocturnal hypertension, masked and white coat hypertension and the overt inadequacy of peridialysis (pre-, intra- and post-dialysis) BP measurements, more extensive application of ABPM for the diagnosis of hypertension in dialysis patients would appear logical. In a recent survey performed in NDT Educational, organizational problems and/or cognitive resistance emerged as important factors hindering more extensive application of ABPM and home BP by nephrologists. External validation of observations made in landmark studies in a single institution about hypertension subcategorization by ABPM is urgently needed. Furthermore, apparent cognitive resistance by nephrologists may be justified by the fact that these techniques have been insufficiently tested in the dialysis population for applicability in everyday clinical practice, tolerability, organizational impact and cost-effectiveness. We should be more resolute in abandoning peridialysis measurements for diagnosing and treating hypertension in haemodialysis patients. Home BP is a formidable educational instrument for patient empowerment and self-care, and evidence exists that this technique is superior to peridialysis values to better hypertension control as defined on the basis of ABPM. We should strive to promote more extensive application of home BP monitoring to diagnose and manage hypertension in haemodialysis patients. ABPM with novel, user friendly and better tolerated techniques is to be awaited in the near future.
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Affiliation(s)
- Carmine Zoccali
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, Reggio Calabria, Italy
| | - Rocco Tripepi
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, Reggio Calabria, Italy
| | - Claudia Torino
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, Reggio Calabria, Italy
| | - Giovanni Tripepi
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, Reggio Calabria, Italy
| | - Francesca Mallamaci
- CNR-IFC, Clinical Epidemiology and Pathophysiology of Hypertension and Renal Diseases, Ospedali Riuniti, Reggio Calabria, Italy Nephrology, Hypertension and Renal Transplantation Unit, Ospedali Riuniti, Reggio Calabria, Italy
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology; Indiana University School of Medicine and VA Medical Center; Indianapolis Indiana
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Abstract
Hypertension is common, difficult to diagnose, and poorly controlled among patients with ESRD. However, controversy surrounds the diagnosis and treatment of hypertension. Here, we describe the diagnosis, epidemiology, and management of hypertension in dialysis patients, and examine the data sparking debate over appropriate methods for diagnosing and treating hypertension. Furthermore, we consider the issues uniquely related to hypertension in pediatric dialysis patients. Future clinical trials designed to clarify the controversial results discussed here should lead to the implementation of diagnostic and therapeutic techniques that improve long-term cardiovascular outcomes in patients with ESRD.
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Affiliation(s)
- Rajiv Agarwal
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine and Richard L. Roudebush Veterans Affairs Medical Center, Indianapolis, Indiana;
| | - Joseph Flynn
- Division of Nephrology, Seattle Children's Hospital, University of Washington, Seattle, Washington
| | - Velvie Pogue
- formerly Division of Nephrology, Harlem Hospital, Columbia University College of Physicians & Surgeons, New York, New York
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Case Medical Center, Louis Stokes Cleveland Veterans Affairs Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Efrain Reisin
- Division of Nephrology and Hypertension, Louisiana State University Health Science Center, New Orleans, Louisiana; and
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
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Abstract
Hypertension is highly prevalent in hemodialysis patients but its management remains a matter of debate. In this review, we discuss the observational studies on the association of blood pressure with outcomes, measurement of blood pressure in hemodialysis patients and present an opinion-based approach to treating hypertension.
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Affiliation(s)
- Tariq Shafi
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Welch Center for Prevention, Epidemiology, and Clinical Research, Baltimore, Maryland
| | - Sana Waheed
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Philip G. Zager
- Division of Nephrology, University of New Mexico, Albuquerque, New Mexico
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Abbasi MR, Lessan-Pezeshki M, Najafi MT, Gatmiri SM, Karbakhsh M, Mohebi-Nejad A. Comparing the frequency of hypertension determined by peri-dialysis measurement and ABPM in hemodialysis patients. Ren Fail 2014; 36:682-6. [PMID: 24502240 DOI: 10.3109/0886022x.2014.883933] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Controlling blood pressure in hemodialysis patients is crucial but not always easy. The most common blood pressure measurement method is peri-dialysis measurement, but due to interdialytic blood pressure fluctuations, we are unsure if it is the proper way for evaluating blood pressure. Some studies have shown the superiority of 24-h ambulatory blood pressure monitoring over peri-dialysis blood pressure measurement. We aimed to compare the consistency of these methods in determining hypertension among hemodialysis patients. We studied 50 patients (mean age: 55.8 years) on regular hemodialysis in Imam Khomeini University Hospital, Tehran, Iran. Peri-dialysis blood pressure and interdialytic 24-h ambulatory blood pressure monitoring were recorded for each patient. Patients' demographic data and peri-dialysis weight were recorded too. All data were analyzed using the PASW Statistics 18.0, SPSS Inc. (Chicago, IL). There was a significant difference between pre-dialysis mean systolic blood pressure (146.1 ± 23.3 mmHg) and mean systolic blood pressure recorded by ambulatory blood pressure monitoring (135.3 ± 19.3 mmHg) (p = 0.001). There was also a significant difference between pre-dialysis mean diastolic blood pressure (83 ± 14 mmHg) and mean diastolic blood pressure recorded by ambulatory blood pressure monitoring (77.3 ± 10 mmHg) (p = 0.003). But the frequencies of hypertension measured with both methods were significantly consistent and the Kappa agreement coefficient was 0.525 (p = 0.001). Considering ambulatory blood pressure monitoring as the gold standard for blood pressure measurement, our recommendation for the best cutoff point to diagnose hypertension, with the highest sensitivity and specificity would be 135/80 mmHg for pre-dialysis blood pressure and 115/70 mmHg for post-dialysis blood pressure.
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Affiliation(s)
- Mohammad-Reza Abbasi
- Nephrology Research Center, Tehran University of Medical Sciences , Tehran , Iran and
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Abstract
Chronic kidney disease (CKD) affects approximately 20 million adults in the United States. Patients with CKD have an increased risk of cardiovascular (CV) disease. Ambulatory blood pressure monitoring (ABPM) provides superior BP measurements when compared to office BP measurements in normotensive, hypertensive and CKD patients. ABPM measurements are often abnormal in CKD, with CKD patients frequently showing an altered circadian rhythm with an increased rate of non-dipping and reverse dipping. The prevalence of non-dippers and reverse-dippers increases progressively as stage of CKD progresses. ABPM has been shown to be a better tool for predicting CV risk, CKD progression, end stage renal disease (ESRD) or death than office-based pressures. ABPM is also additive and adds prognostic value for predicting CKD and CV outcomes when added to estimated glomerular filtration rate (eGFR). Although ABPM is time consuming, it is worth considering, as the data demonstrates that information from ABPM can potentially impact future CV and renal outcomes in patients with CKD.
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Affiliation(s)
- Debbie L Cohen
- Perelman School of Medicine at the University of Pennsylvania, Renal, Electrolyte and Hypertension Division, 1 Founders Building 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Imai Y. Clinical significance of home blood pressure and its possible practical application. Clin Exp Nephrol 2013; 18:24-40. [DOI: 10.1007/s10157-013-0831-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2012] [Accepted: 06/14/2013] [Indexed: 10/26/2022]
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Imai Y, Kario K, Shimada K, Kawano Y, Hasebe N, Matsuura H, Tsuchihashi T, Ohkubo T, Kuwajima I, Miyakawa M. The Japanese Society of Hypertension Guidelines for Self-monitoring of Blood Pressure at Home (Second Edition). Hypertens Res 2012; 35:777-95. [PMID: 22863910 DOI: 10.1038/hr.2012.56] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yutaka Imai
- Department of Planning for Drug Development and Clinical Evaluation, Tohoku University Graduate School of Pharmacological Sciences, Sendai, Japan
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Agarwal RL. Debate from the 2012 ASH Annual Scientific Sessions: should blood pressure be reduced in hemodialysis patients? Pro position. ACTA ACUST UNITED AC 2012; 6:439-42. [PMID: 23079076 DOI: 10.1016/j.jash.2012.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2012] [Accepted: 08/26/2012] [Indexed: 10/27/2022]
Abstract
Among chronic hemodialysis patients with hypertension, blood pressure should be lowered. Blood pressure reduction with antihypertensive drugs does not increase mortality; in contrast, meta-analysis of randomized trials suggests that treatment of hypertension in this high-risk population may, in fact, improve cardiovascular outcomes. The association of low blood pressure with increased mortality in longitudinal studies should not be considered as evidence against lowering blood pressure. Lowering blood pressure among hypertensive patients should primarily be done by sodium restriction and dry-weight reduction. Treatment is perhaps better directed to home blood pressure than pre- or post-dialysis blood pressure recordings. Although no firm data are available, it appears that treating home blood pressure to <140/90 mm Hg appears reasonable. Nonetheless, all blood pressure recordings during dialysis are important to ensure patient safety. Adequately designed and powered randomized trials are needed to examine the notion that blood pressure lowering and, if so, to what level of blood pressure will improve clinically meaningful outcomes among chronic dialysis patients.
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Affiliation(s)
- Rajiv L Agarwal
- Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, IN, USA.
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Roberts MA, Pilmore HL, Tonkin AM, Garg AX, Pascoe EM, Badve SV, Cass A, Ierino FL, Hawley CM. Challenges in blood pressure measurement in patients treated with maintenance hemodialysis. Am J Kidney Dis 2012; 60:463-72. [PMID: 22704141 DOI: 10.1053/j.ajkd.2012.04.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2011] [Accepted: 04/10/2012] [Indexed: 11/11/2022]
Abstract
The association between blood pressure and cardiovascular outcomes in patients undergoing hemodialysis remains controversial. This may relate in part to the technique and device used and the timing of the blood pressure measurement in relation to the hemodialysis procedure. Emerging evidence indicates that standardized hemodialysis unit blood pressure measurements or measurements obtained at home, either by the patient or using an ambulatory blood pressure monitor, may offer advantages over routine hemodialysis unit blood pressure measurements for determining cardiovascular risk and treatment. This review discusses the available evidence and implications for clinicians and clinical trials.
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Abstract
This review discusses 10 current controversies regarding the dialysis patient with hypertension. The clinician is faced with a dilemma at the bedside on how to evaluate blood pressure and treat this condition in a patient on long-term hemodialysis. The evidence base to give firm recommendations is thin, but the epidemiological evidence tells us to do nothing. This appears to be an incorrect strategy, at least based on what we know today. Evaluating home BP in every dialysis patient, evaluating volume status on a regular basis, and treating hypertension predominantly with nonpharmacological strategies are worthwhile.
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Affiliation(s)
- Rajiv Agarwal
- Indiana University School of Medicine and Roudebush VA Medical Center, Indianapolis, Indiana 46202, USA.
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Duval-sabatier A, Brunet P, Seck SM, Haddad F, Giaime P, Ramananarivo P, Bouchouareb D, Berland Y. Expérience de l’automesure tensionnelle à domicile chez des patients hémodialysés dans une unité hospitalière. Nephrol Ther 2011; 7:544-8. [PMID: 21596638 DOI: 10.1016/j.nephro.2011.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Revised: 03/16/2011] [Accepted: 03/27/2011] [Indexed: 11/23/2022]
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Abstract
PURPOSE OF REVIEW Most guidelines recommend that seated clinic blood pressure (BP) be targeted to less than 130/80 mmHg in patients with chronic kidney disease (CKD). The evidence underlying these recommendations is the subject of this review. RECENT FINDINGS The best evidence to target a certain level of BP in patients with CKD comes from randomized trials. Only three trials have prospectively examined the level to which BP should be lowered. These trials conducted exclusively among patients with CKD have demonstrated that compared to a less aggressive BP goal, a BP goal of less than 130/80 mmHg neither saves lives nor protects the kidney or the cardiovascular system. SUMMARY It is reasonable to achieve a goal of less than 140/90 mmHg in most patients with CKD. More aggressive lowering is not firmly supported by current data. Since BP control is important, hypertension therapy should be individualized. Individualization through home BP measurements to diagnose, monitor and treat hypertension appears to be an attractive option.
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Agarwal R, Martinez-Castelao A, Wiecek A, Massy Z, Suleymanlar G, Ortiz A, Blankestijn PJ, Covic A, Dekker FW, Jager KJ, Lindholm B, Goldsmith D, Fliser D, London G, Zoccali C. The lingering dilemma of arterial pressure in CKD: what do we know, where do we go? Kidney Int Suppl (2011) 2011; 1:17-20. [PMID: 25018898 PMCID: PMC4089679 DOI: 10.1038/kisup.2011.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Despite many advances in the management of hypertensive chronic kidney disease (CKD) patients, both on and off dialysis, there exist several gaps in our knowledge. Although the modern techniques to measure blood pressure (BP) indirectly have been available for a long time, among those with CKD, how to best assess hypertension and the level to which it should be lowered are mired in controversy. Other controversial areas relate to a lack of a consensus definition of hypertension among hemodialysis patients, uncertainty in the definition and assessment of volume excess, and the lack of adequately powered randomized trials to evaluate the level to which BP can be lowered in those on dialysis. This review discusses the limitations of the available evidence base and suggests areas for future research. Suggestions include evaluation of techniques to assess volume, randomized trials to target different levels of BP among hypertensive hemodialysis patients, evaluation of ambulatory BP monitoring, and non-pharmacological means to lower BP in CKD. It is hoped that among patients with CKD these data will improve the dismal cardiovascular outcomes.
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Affiliation(s)
- Rajiv Agarwal
- Indiana University and VAMC , Indianapolis, Indiana, USA
| | | | - Andrzej Wiecek
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia , Katowice, Poland
| | - Ziad Massy
- INSERM ERI-12 (EA 4292) , Amiens, France ; Amiens University Hospital and the Jules Verne University of Picardie , Amiens, France
| | - Gultekin Suleymanlar
- Nephrology Division, Department of Medicine, Akdeniz University Medical School , Antalya, Turkey
| | - Alberto Ortiz
- IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo , Madrid, Spain
| | - Peter J Blankestijn
- Department of Nephrology, University Medical Center , Utrecht, The Netherlands
| | - Adrian Covic
- Clinic of Nephrology, C.I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy , Iasi, Romania
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center , Leiden, The Netherlands
| | - Kitty J Jager
- ERA-EDTA Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam , Amsterdam, The Netherlands
| | - Bengt Lindholm
- Department of Clinical Science, Intervention and Technology, Karolinska Institutet , Stockholm, Sweden
| | - David Goldsmith
- Renal Unit, Guy's and St Thomas' NHS Foundation Hospital, King's Health Partners , London, UK
| | - Danilo Fliser
- Department of Internal Medicine IV, Saarland University Medical Centre , Homburg/Saar, Germany
| | - Gerard London
- INSERM U970, Hôpital Européen Georges Pompidou , Paris, France
| | - Carmine Zoccali
- Nephrology, Dialysis and Transplantation Unit and CNR-IBIM Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension , Reggio Calabria, Italy
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Abstract
PURPOSE OF REVIEW To review recent developments in the field of hypertension in hemodialysis patients. RECENT FINDINGS Despite the fact that hypertension is the most common complication of end-stage kidney disease, no evidence-based blood pressure (BP) targets exist for hemodialysis patients. There is growing evidence that outcomes are better predicted by out-of-office BP values, such as home or ambulatory BP monitoring. Intradialytic hypertension is associated with increased risk of death or hospitalization, and is probably mediated by volume overload. BP management should focus on volume control: dry weight 'probing' is well tolerated and effective in lowering BP, as are other strategies that minimize expansion of the extracellular fluid volume, such as avoidance of hypernatric dialysate. We discuss each of these issues in our review. SUMMARY Modest advances in the understanding of hypertension have occurred in the past 2 years. Clinical trials that focus on BP targets and treatment choices are essential to guide future practice.
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Affiliation(s)
- Aldo J Peixoto
- Medical Service, VA Connecticut Healthcare System, West Haven, CT, USA.
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Stergiou GS, Bliziotis IA. Home blood pressure monitoring in the diagnosis and treatment of hypertension: a systematic review. Am J Hypertens 2011; 24:123-34. [PMID: 20940712 DOI: 10.1038/ajh.2010.194] [Citation(s) in RCA: 122] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND It is recognized that for the reliable assessment of blood pressure (BP) and the accurate diagnosis of hypertension, out-of-office BP measurement with ambulatory (ABPM) or home BP monitoring (HBPM) is often required. The clinical usefulness of ABPM is well established. However, despite the wide use of HBPM, only in the last decade convincing evidence on its usefulness has accumulated. METHODS Systematic review of the evidence on applying HBPM in the diagnosis and treatment of hypertension (PubMed, Cochrane Library, 1970-2010). RESULTS Sixteen studies in untreated and treated subjects assessed the diagnostic ability of HBPM by taking ABPM as reference. Seven randomized studies compared HBPM vs. office measurements or ABPM for treatment adjustment, whereas many studies compared HBPM with office measurements in assessing the antihypertensive drug effects. Several studies with different design investigated the role of HBPM vs. office measurements in improving patients' compliance with treatment and hypertension control rates. The evidence on the cost-effectiveness of HBPM is limited. The studies reviewed consistently showed moderate diagnostic agreement between HBPM and ABPM, and superiority of HBPM compared to office measurements in diagnosing uncontrolled hypertension, assessing antihypertensive drug effects and improving patients' compliance and hypertension control. Preliminary evidence suggests that HBPM has the potential for cost savings. CONCLUSIONS There is conclusive evidence that HBPM is useful for the initial diagnosis and the long-term follow-up of treated hypertension. These data are useful for the optimal application of HBPM, which is widely used in clinical practice. More studies on the cost-effectiveness of HBPM are needed.
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Agarwal R, Bills JE, Hecht TJW, Light RP. Role of home blood pressure monitoring in overcoming therapeutic inertia and improving hypertension control: a systematic review and meta-analysis. Hypertension 2010; 57:29-38. [PMID: 21115879 DOI: 10.1161/hypertensionaha.110.160911] [Citation(s) in RCA: 267] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hypertension remains the most common modifiable cardiovascular risk factor, yet hypertension control rates remain dismal. Home blood pressure (BP) monitoring has the potential to improve hypertension control. The purpose of this review was to quantify both the magnitude and mechanisms of benefit of home BP monitoring on BP reduction. Using a structured review, studies were selected if they reported either changes in BP or percentage of participants achieving a pre-established BP goal between randomized groups using home-based and office-based BP measurements. A random-effects model was used to estimate the magnitude of benefit and relative risk. The search yielded 37 randomized controlled trials with 9446 participants that contributed data for this meta-analysis. Compared with clinic-based measurements (control group), systolic BP improved with home-based BP monitoring (-2.63 mm Hg; 95% CI, -4.24, -1.02); diastolic BP also showed improvement (-1.68 mm Hg; 95% CI, -2.58, -0.79). Reductions in home BP monitoring-based therapy were greater when telemonitoring was used. Home BP monitoring led to more frequent antihypertensive medication reductions (relative risk, 2.02 [95% CI, 1.32 to 3.11]) and was associated with less therapeutic inertia defined as unchanged medication despite elevated BP (relative risk for unchanged medication, 0.82 [95% CI, 0.68 to 0.99]). Compared with clinic BP monitoring alone, home BP monitoring has the potential to overcome therapeutic inertia and lead to a small but significant reduction in systolic and diastolic BP. Hypertension control with home BP monitoring can be enhanced further when accompanied by plans to monitor and treat elevated BP such as through telemonitoring.
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Affiliation(s)
- Rajiv Agarwal
- Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, Indianapolis, Ind 46202, USA.
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Agarwal R. Managing hypertension using home blood pressure monitoring among haemodialysis patients--a call to action. Nephrol Dial Transplant 2010; 25:1766-71. [PMID: 20350928 DOI: 10.1093/ndt/gfq171] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Rajiv Agarwal
- Indiana University School of Medicine and Richard L. Roudebush Veterans Administration Medical Center, 1481 West 10th St., Indianapolis, IN 46202, USA.
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