Orthostatic Hypotension in Asymptomatic Patients with Chronic Kidney Disease

Abstract

Background and objective: Orthostatic hypotension (OH) is a decrease in systolic blood pressure (BP) of 20 mm Hg and in diastolic BP of 10 mm Hg when changing the position from lying to standing. Arterial hypertension (AH), comorbidities and polypharmacy contribute to its development. The aim was to assess the presence of OH and its predictors in asymptomatic chronic kidney disease (CKD) patients. Material and methods: 45 CKD patients with estimated glomerular filtration rate (eGFR) ≤ 60 mL/min/1.73 m2 (CKD+) were examined for signs of OH and its predictors. The results were compared with the control group of 22 patients with eGFR > 60 mL/min/1.73 m2 (CKD–). Asymptomatic patients without ischemic heart disease and previous stroke were qualified. Total blood count, serum creatinine, eGFR, urea, phosphates, calcium, albumins, parathyroid hormone, uric acid, C reactive protein, N-terminal pro b-type natriuretic peptide, lipid profile, and urine protein to creatinine ratio were assessed. Simultaneously, patients underwent echocardiography. To detect OH, a modified Schellong test was performed. Results: OH was diagnosed in 17 out of 45 CKD+ patients (average age 69.12 ± 13.2) and in 8 out of 22 CKD– patients (average age 60.50 ± 14.99). The CKD+ group demonstrated significant differences on average values of systolic and diastolic BP between OH+ and OH– patients, lower when standing. In the eGFR range of 30–60 mL/min/1.73 m2 correlation was revealed between OH and β-blockers (p = 0.04), in the entire CKD+ group between β-blockers combined with diuretics (p = 0.007) and ACE-I (p = 0.033). Logistic regression test revealed that chronic heart failure (CHF, OR = 15.31), treatment with β-blockers (OR = 13.86) were significant factors influencing the presence of OH. Conclusions: Predictors of OH in CKD may include: CHF, treatment with β-blockers, combined with ACE-I and diuretics.

Orthostatic hypotension in kidney transplant recipients

“…There was no difference in the history of falls or fainting between the OH+ and OH-groups. It is in line with earlier studies showing that OH was asymptomatic in the majority of patients [6,13]. If patients are screened for OH based only on clinical symptoms connected with blood pressure fall after standing, the detected prevalence would underestimate the real prevalence [6,8].…”

“…Chronic kidney disease (CKD) is associated with a high prevalence of OH. In a group of asymptomatic CKD patients (mean age 69 years, eGFR 36 mL/min/1.73m 2 ), the prevalence of OH was 38% [13]. In the present study, KTRs with OH were older and more often diabetic than patients without OH.…”

“…In several studies in non-transplant populations association between treatment with beta-blockers and OH was documented [6,13,15]. In AASK Trial the risk of OH was higher among patients treated with metoprolol than in patients receiving ramipril or amlodipine [15].…”

Aortic stiffness and central systolic pressure are associated with ambulatory orthostatic BP fall in chronic kidney disease

“…However, as antihypertensive use was in accordance with British Hypertension Society guidelines, it is likely that regimens were similar between patients with similar eGFR. There is no clear evidence suggesting certain antihypertensives are more likely to cause OH in this patient group, with some weak evidence linking beta blockers to OH in some combinations and at some eGFR levels [46]. Chan et al found no significant difference in OH risk between patients on ACE I or ARB medications in a variety of combinations [47], while Sasaki et al found no significant difference in the presence or absence of OH in patients taking calcium antagonists, beta blockers, ACE I or diuretics either before or after initiation of haemodialysis [21].…”