Prevalence and control of hypertension by 48-h ambulatory blood pressure monitoring in haemodialysis patients: a study by the European Cardiovascular and Renal Medicine (EURECA-m) working group of the ERA-EDTA

Abstract

<jats:title>Abstract</jats:title> <jats:sec> <jats:title>Background</jats:title> <jats:p>Population-specific consensus documents recommend that the diagnosis of hypertension in haemodialysis patients be based on 48-h ambulatory blood pressure (ABP) monitoring. However, until now there is just one study in the USA on the prevalence of hypertension in haemodialysis patients by 44-h recordings. Since there is a knowledge gap on the problem in European countries, we reassessed the problem in the European Cardiovascular and Renal Medicine working group Registry of the European Renal Association-European Dialysis and Transplant Association.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>A total of 396 haemodialysis patients underwent 48-h ABP monitoring during a regular haemodialysis session and the subsequent interdialytic interval. Hypertension was defined as (i) pre-haemodialysis blood pressure (BP) ≥140/90 mmHg or use of antihypertensive agents and (ii) ABP ≥130/80 mmHg or use of antihypertensive agents.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>The prevalence of hypertension by 48-h ABP monitoring was very high (84.3%) and close to that by pre-haemodialysis BP (89.4%) but the agreement of the two techniques was not of the same magnitude (κ statistics = 0.648; P &amp;lt;0.001). In all, 290 participants were receiving antihypertensive treatment. In all, 9.1% of haemodialysis patients were categorized as normotensives, 12.6% had controlled hypertension confirmed by the two BP techniques, while 46.0% had uncontrolled hypertension with both techniques. The prevalence of white coat hypertension was 18.2% and that of masked hypertension 14.1%. Of note, hypertension was confined only to night-time in 22.2% of patients while just 1% of patients had only daytime hypertension. Pre-dialysis BP ≥140/90 mmHg had 76% sensitivity and 54% specificity for the diagnosis of BP ≥130/80 mmHg by 48-h ABP monitoring.</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The prevalence of hypertension in haemodialysis patients assessed by 48-h ABP monitoring is very high. Pre-haemodialysis BP poorly reflects the 48 h-ABP burden. About a third of the haemodialysis population has white coat or masked hypertension. These findings add weight to consensus documents supporting the use of ABP monitoring for proper hypertension diagnosis and treatment in this population.</jats:p> </jats:sec>

A Comparative Study of Short-Term Blood Pressure Variability in Hemodialysis Patients with and without Intradialytic Hypertension

“…In patients with end-stage-renal-disease (ESRD) undergoing hemodialysis, the prevalence of hypertension is estimated at 70-90% [1,2]. During hemodialysis blood pressure (BP) levels vary.…”

Fluid overload is associated with use of a higher number of antihypertensive drugs in hemodialysis patients

“…A recent survey that included 160 U.S. practicing nephrologists found that the highest percentage of respondents prescribe CCAs (68%) because they consider it to be more effective in treating hypertension in dialysis patients, followed by BB (35%), ACE (32%), BRA (29%), and diuretics (25%) . Studies suggest that lower systolic and diastolic blood pressure with the use of antihypertensive drugs results in a 30% lower risk of cardiovascular events and mortality, but adequately controlled hypertension is observed in only 65% of hypertensive patients …”

“…Elevated blood pressure (BP) is highly prevalent in the dialysis population affecting more than 80% of patients and is a risk factor for cardiovascular outcomes, including ventricular hypertrophy, cardiac insufficiency, and cardiovascular events …”

“…Sodium intake retained in the body due to the lack of renal function, consequent thirst‐driven fluid intake and volume overload are the main pathogenic mechanisms of blood pressure elevation in this population. However, other factors such as increased arterial stiffness, activation of the renin‐angiotensin‐aldosterone system, sleep apnea, activation of the sympathetic nervous system and use of recombinant erythropoietin are also be involved further accentuating the complexity …”

Volume overload in hemodialysis: diagnosis, cardiovascular consequences, and management

“…Thus volume overload is currently considered the main pathogenic mechanism of hypertension in the ESRD population [ 5 ]. As a matter of fact, the worldwide prevalence of hypertension in this population is as high as 85% [ 40 ]. The increase in volume during the interdialytic intervals likely contributes to short-term BP variability from Day 1 to Day 2 of the regular interdialytic interval [ 41 ], which has been implicated in the risk for cardiovascular events independent of BP levels [ 42 ].…”