ABPM and Bioimpedance in Monitoring and Treatment of HTN in CKD

M,S Forghani MD, MUK

Hypertension is:

Based on data from the US Renal Data SystemIt is estimated that hypertension occurs in about

23.3% of individuals without CKD 35.8% of stage 1 48.1% of stage 2 59.9% of stage 3 84.1% of stages 4 and 5 CKD patients

most powerful risk factor of CVD independent risk factor of CKD progression The most common comorbidity

What is the best method for measuring blood pressure in CKD patients?

Manual Auscultatory Clinic Blood Pressure measurement (OBPM) Is essential yet Automated Office Blood Pressure measurement (AOBPM)• Measurements compared to manual office measurements are more

compatible with ABPM, validated in CKD and essential hypertensive patients Home blood pressure monitoring (HBPM) compared to traditional OBPM, Reproducible, eliminate digit preference &

observer bias , prognostic indicator Ambulatory blood pressure monitoring (ABPM)

In the general population and in patients with CKD, compared to office measurements, there are vast documents regarding ABPM superiority in

hypertension diagnosis, treatment response, outcome prediction and target organ damage prediction,

Andersen MJ, Khawandi W, Agarwal R. Home blood pressure monitoring in CKD. Am J Kidney Dis 2005; 45: 994–1001.Journal of the American Society of Hypertension 4(2) (2010) 5-61

Ambulatory blood pressure monitoring

Ambulatory blood pressure monitoring provides a vast amount of additional data compared to office recordings, including:

Blood pressure variability (Short term)

Subtypes of hypertension identified

Morning hypertensionWhite Coat HypertensionMasked Hypertension

Non dipping patternReverse dippingExtreme dipping

Different types of blood pressure variability (BPV), their determinants, and prognostic relevance for cardiovascular and renal outcomes

Role of Ambulatory and Home Blood Pressure Monitoring for Assessing Alterations in Blood Pressure Variability and Blood Pressure Profiles, Hypertension. 2016 Jun;67(6):1102-10

Cross-sectional

Mojón et al Higher prevalence of non-dipping in patients with CKD (eGFR <60) versus pts with no CKD (eGFR >60); higher nocturnal SBP and lower DBP in pts with CKD versus pts with no CKD

Cross-sectional

Mulè et al Higher ABP variability in patients with reduced eGFR

Prospective Davidson et al

Decline in eGFR in non-dippers; stable eGFR in dippers

Prospective Agarwal and Andersen

Non-dipping associated with increased risk of ESRD and total mortality

Prospective McMullan et al

10% higher nocturnal dipping associated with decreased risk of CKD and lower annual rate of eGFR decline

Prospective Gabbai et al ABP measurements predicted both renal and CV outcomes

Altered BP variability and ambulatory BP pattern in CKD patients

Study design

Patients (n)

ABP profiles/outcomes References

Cross-sectional African Americans with

CKD(n=617)

Proteinuria and LVH more common in patients with elevated nighttime BP and masked hypertension

Pogue et al.

Cross-sectional CKD pts (n =1492) Masked hypertension was independently

associated with low eGFR, higher proteinuria, and higher LVMI

Drawz et al.

Cross-sectional CKD pts (n = 540)

Reverse dipper BP pattern closely related to worse renal function and severe CV damage

Wang et al.

Altered ambulatory BP profile and cardiovascular events in patients with CKD

Altered ambulatory BP profile and cardiovascular events in patients with end-stage renal disease

Study design

Patients (n) ABP profiles/outcomes References

Prospective Hypertensive HD pts (n = 57)

Elevated nocturnal systolic BP wereindependently associated with CV mortality

Amar et al.

Prospective HD patients (n =80) Nocturnal BP non-dipping positively associated with CV events and CV mortality

Liu et al.

Prospective Nondiabetic HD pts (n =168)

Night/day systolic BP ratio strongly predicts total and CV mortality

Tripepi et al.

Cross-sectional

ESRD pts undergoingAPD (n = 20) versus

CAPD (n = 28)

LVMI higher in non-dippers compared to dippers; non-dipperdiastolic BP pattern associated with LVMI

Atas et al.

Significance of white-coat and masked hypertension in chronic kidney disease and end-stage renal disease

Hypertension Research 37, 882-889 (October 2014) Clin J Am Soc Nephrol 2011; 6: 2003–2008.

The rate of morning HTN was significantly different between diabetics and non-diabetics. In stage 2 CKD, the rate of morning HTN was higher in diabetics than in non-diabetics (22.7% vs. 9.5%, P=0.001).

The rate of morning HTN differed significantly according to eGFR in non-diabetics, but not in diabetics.

Mechanisms of altered blood pressure variability and circadian rhythm in chronic kidney disease.

Journal of the American Society of Hypertension 4(2) (2010) 5-61

When and how to use ambulatory blood pressure monitoring

ABPM and Effects of Antihypertensive Treatmentin CKD

Hermida et al . The subjects randomized to bedtime dosing of ACEI & ARB showed a better overall control of BP on ABPM, greater reduction in mean asleep SBP, and a lower proportion of non-dippers , greater reduction in albuminuria significant reduction in CV death, myocardial infarction, or stroke compared to the control group.

Wang et al. showed that bedtime dosing of an ARB once daily was significantly more effective than awakening dosing in reducing nighttime BP, proteinuria, and left ventricular mass in CKD patients with non-dipping pattern

Minutolo et al. showed that changing the timing of antihypertensive medication dosing from morning to evening decreased the night/day ratio and restored normal circadian rhythm in 87.5%. Moreover, proteinuria also was reduced with evening administration of antihypertensive medications

ABPM and Effects of Antihypertensive Treatmentin CKD

Generally, calcium channel blockers are more effective with bedtime than morning dosing

Other hypertension medications, including α-blocker doxazosin, β-blockers carvedilol and nebivolol and loop-diuretic torasemide, also show significantly enhanced nighttime BP reduction and longer duration of BP-lowering effect with bedtime versus morning (upon awakening) therapy

• diuretics and a low sodium diet selectively lower nocturnal BPs in non-CKD patients with salt-sensitive hypertension, an effect that may also occur in patients with CKD.

Bedtime, in comparison with upon awakening, ingestion of every one of these combination therapies markedly reduces the asleep SBP/DBP

means and significantly increases the proportion of patients converted from non-dipper to dipper patterning

Volume overload correlates with hypertension and cardiovascular riskfactors in patients with chronic kidney disease

The clinical assessment of fluid status Ultrasonic evaluation of the diameter of the inferior vena cava Biomarkers such as brain natriuretic peptide (BNP) and N-

terminal pro-brain natriuretic peptide (NT-proBNP) Isotope dilution

What’s ideal method?

Bioimpedance analysis

Volume status assessment

Available Inexpensive Sensitive Specific Simple Outcome predictor

Bio impedance analysis is a promising method for volume status assessment

the major advantages of this system are based on: It’s non-invasiveness Accuracy is Validated with gold standard method Safe Inexpensive Ease of use in clinic

Bioimpedance – Limitations and Errors

Although extensively used in the recent past, bioimpedance as the bedside technique used in the assessment of body composition has some potential limitations [23] : • (1) it is contraindicated in pregnant women, children, and

subjects wearing a pacemaker; • (2) measurements may be affected by eating, intense physical

activity, and alcohol and fluid intake before evaluation. Moreover, extreme obesity and acute body mass changes following protein malnutrition are also significant limitation of the use of bioimpedance. Patients should be prepared: avoidance of alcohol for at least 8 h before the test and no water for 4 to 6 h; if the test is applied within a 2–4 h interval after a meal.

A New Paradigm for Hypertension Management:Bioimpedance and Office BP

• Am J Nephrol 2014;40:434–440A

m J N

ephrol 2014;40:434–440, Published online: N

ovember 22, 2014