Ambulatory Blood Pressure Patterns in Children With Chronic Kidney Disease

Abstract

Ambulatory blood pressure monitoring (ABPM) is the best method of detecting abnormal blood pressure (BP) in patients with chronic kidney disease (CKD), whose hypertension may be missed with office BP measurements. We report ABPM findings in 332 children 1 year after entry in the Chronic Kidney Disease in Children (CKiD) cohort study. All subjects underwent casual and ambulatory BP measurement. BP was categorized based on casual and ABPM results into normal, white coat, masked, and ambulatory hypertension. Only half of the subjects had a normal ABPM. BP load was elevated (>25%) in 52% (n= 172) while mean BP was elevated in 32% (n= 105). In multivariate analysis, those using an ACE inhibitor (ACEi) were 89% more likely to have a normal ABPM than those who did not report using an ACEi (OR: 1.89, 95%CI: 1.17, 3.04). For every 20% faster decline in annualized GFR change, the odds of an abnormal ABPM increased 26% (OR: 1.26, 95%CI: 0.97, 1.64; p= 0.081). A 2.25 fold increase in urine protein:creatinine ratio annualized change was associated with a 39% higher odds of an abnormal ABPM (OR: 1.39, 95%CI: 1.06, 1.82; p= 0.019). Abnormalities on ABPM are common in children with CKD, and are strongly associated with known risk factors for end stage renal disease. Individuals on ACEi were less likely to have abnormal ABPM, suggesting a possible therapeutic intervention. ABPM should be used to monitor risk and guide therapy in children with CKD.

Evidence-based guidelines for the management of hypertension in children with chronic kidney disease

“…Early ABPM studies demonstrated blood pressure abnormalities and distorted circadian blood pressure rhythms in children with kidney disease [17]. Further studies have confirmed blood pressure abnormalities only identifiable with ABPM, including nocturnal hypertension, night-time nondipping, and masked hypertension [18][19][20][21]. ABPM shows improved consistency and reproducibility of blood pressure readings in children [22,23].…”

Hypertension in pediatric patients with chronic kidney disease: management challenges

“…24,25 Prevalence of HTN in children with CKD HTN in children is rare, with a prevalence of 3%-9%; however, in children with CKD, the prevalence rises to 50%. 4,8,26,27 The etiology of HTN in children varies depending on the age of diagnosis. Neonates and infants most commonly have HTN due to renovascular diseases such as renal venous thrombosis or renal artery stenosis, and other renal parenchymal diseases.…”

“…7,8 A more recent study of the CKiD cohort found that 52% of patients whose BP was measured by ambulatory blood pressure measurement (ABPM) met the criteria for HTN. 27 Furthermore, the North American Pediatric Renal Transplant and Collaborative Studies (NAPRTCS) registry determined that 48% of children met the criteria for HTN at baseline. 4,7 The prevalence of HTN is further increased in children on dialysis.…”

“…Creatinine ratio change was also associated with 39% higher odds of having an abnormal ABPM. 27 Even in children not previously diagnosed with HTN and not on antihypertensive medications, 57% were found to have ambulatory HTN. 99 Collectively, these studies illustrate that masked and undiagnosed HTN is still common in pediatric patients with CKD.…”

Between-person and within-person approaches to the prediction of ambulatory blood pressure: the role of affective valence and intensity

“…Moreover, ABP contributes to and has been hypothesized as a cause of target organ damage, including left ventricular hypertrophy (Bliziotis et al, 2012) and kidney damage (Palatini, 2008;Samuels et al, 2012). Based on the strong and broad range of associations between ABP and these sub-clinical and clinical outcomes, there have been calls for behavioral interventions targeted at reducing ABP (e.g., Hermida et al, 2013;Verdecchia, 2000).…”