Abstract-Blood pressures (BPs) obtained in the dialysis unit correlate poorly with ambulatory BP and left-ventricular hypertrophy (LVH). We compared the performance of BP obtained within and outside the dialysis unit as a correlate of LVH. BP was obtained in the dialysis unit using routine and standardized methods and outside the dialysis unit using home and ambulatory BP monitoring in 140 patients (mean age, 56 years; 89 men; 129 blacks; and 59 with diabetes mellitus) on chronic hemodialysis for Ն3 months. Dialysis unit BP recordings were averaged over 2 weeks, and home BP averaged over 1 week.

Ambulatory systolic blood pressure (BP) correlates better with risk factors for progression of chronic kidney disease (CKD) compared to clinic measured BP, but its role in predicting end-stage renal disease (ESRD) and death in patients with CKD is unknown. In a cohort study of 217 Veterans with CKD BP was measured by ambulatory monitoring and in the clinic. Twenty-four hour ambulatory BP was 133.5 +/- 16.6/73.1 +/- 11.1 mm Hg and clinic BP was 155.2 +/- 25.6/84.7 +/- 14.2 mm Hg. The composite renal end point of ESRD or death over a median follow-up of 3.5 years occurred in 75 patients (34.5%), death occurred in 52 patients (24.0%), and ESRD in 36/178 patients (20.2%). Thirty-nine patients died before reaching ESRD. One standard deviation (s.d.) increase in systolic BP increased the risk of composite outcome to 1.69 (95% confidence interval (CI) 1.32-2.17) for standard clinic measurement and to 1.88 (95% CI 1.48-2.39) for 24 h ambulatory BP recording. One s.d. increase in 24 h ambulatory systolic BP increased the risk of ESRD to 3.04 (95% CI 2.13-4.35) and to 2.20 (95% CI 1.43-3.39) when adjusted for standard clinic systolic BP. Non-dipping was associated with increased risk of total mortality and composite end point. In patients with CKD, BPs obtained by ambulatory monitoring are a stronger predictor of ESRD or death compared to BPs obtained in the clinic. Systolic ambulatory BP and nondipping are independent predictors for ESRD after adjusting for clinic BP. However, adjustment for other risk factors for CKD progression removes the independent prognostic value of ambulatory BP.

Using interdialytic ambulatory blood pressure (BP) recordings as the reference standard, we compared the performance of routine, standardized and home BP monitoring in 104 predominantly black patients on chronic hemodialysis for at least 3 months. Dialysis unit BP recordings were averaged over 2 weeks and home BP over 1 week. Awake ambulatory BP of > or =135 mmHg systolic or > or =85 mmHg diastolic was taken as evidence of hypertension. Average awake ambulatory BP was 128.1+/-21.6/73.5+/-13.5 mmHg, home BP 141.3+/-21.9/78.7+/-11.9 mmHg, standardized pre-dialysis BP 141.7+/-22.6/74.2+/-13.5 mmHg and post-dialysis 119.9+/-20.5/69.1+/-13.1 mmHg, routine pre-dialysis 145.4+/-21.8/79.0+/-13.1 mmHg and post-dialysis 131.5+/-19.2/72.5+/-11.4 mmHg. Sixty-three percent of the patients had well-controlled BP by ambulatory BP monitoring and isolated diastolic hypertension was rare (3%). The standard deviation of the differences between ambulatory and routine pre-dialysis BP was 17.6 mmHg, routine post-dialysis was 16.1 mmHg, standardized pre-dialysis was 16.4 mmHg, standardized post-dialysis was 14.1 mmHg, and home BP was 14.2 mmHg. The area under receiver operating characteristic curves was similar for home and standardized BP but lower for routine BP. Home systolic BP of > or =150 mmHg averaged over 1 week had the best combination of sensitivity (80%) and specificity (84.1%) in diagnosing systolic hypertension--present in 94% of the hypertensive dialysis patients. Home BP monitoring is similar to standardized recording of BP in hemodialysis patients. A systolic BP threshold of 150 mmHg at home averaged over 1 week serves as a useful predictor of hypertension diagnosed by ambulatory BP monitoring.