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Ambulatory Blood Pressure Measurement in Patients with Renal Disease
masked hypertension is present in 10% of patients whose blood hypertensive patients at risk of cardiovascular events, and thus indicate
pressure is measured in similar circumstances, it follows that those in need of aggressive blood pressure lowering.
10
Therefore, the
hypertension is being misdiagnosed in as many as one-third of all case for ABPM in general clinical practice is overwhelming.
11
patients attending for routine blood pressure measurement.
There is also considerable evidence supporting the use of ABPM in
It is estimated that pre-hypertension occurs in about 28% of American patients with renal disease. The prevalence of chronic kidney disease
adults (or 59 million people),
8
but we must question the accuracy of (CKD), currently estimated to be 11% in the US, is increasing because
these figures as they are derived from conventional blood pressure of increased longevity and the accompanying rise in diabetes and
measurements. If as many as 20% of these patients have white coat hypertension, the main causes of CKD.
12
Almost invariably, patients
hypertension, it follows that the diagnosis of pre-hypertension will be with CKD have a non-dipping nocturnal blood pressure that puts them
erroneous in nearly one-quarter of the patients diagnosed with this
condition. The financial implications for society are obvious and ABPM
provides a cost-effective means of accurately determining the true
Ambulatory blood pressure
prevalence of pre-hypertension.
measurement should be an integral
The evidence for ABPM as a methodology for guiding drug treatment in
part of good clinical practice. The
clinical practice is growing. The technique provides evidence for efficacy
case is particularly compelling in
of blood pressure control over 24 hours, allows resistant hypertension to
nephrological practice.
be differentiated from a white coat reaction that misleadingly suggests
resistance to therapy and provides evidence of overtreatment, particularly
in the elderly, who are prone to hypotension.
9
ABPM is the only accurate at high risk, and this pattern can be detected only with ABPM.
13,14
means of monitoring nocturnal blood pressure, which has been largely Patients with CKD, who, like diabetic patients, are at high risk from the
ignored in clinical practice. This is despite many studies showing that cardiovascular complications of hypertension, need optimal control of
nocturnal phenomena such as non-dipping, reverse dipping, extreme blood pressure, which is best assessed over a 24-hour period with
dipping, nocturnal hypertension and a morning surge are associated with ABPM. Finally, there are aspects of CKD that lend themselves to
a poor prognosis.
5
ABPM is also valuable in special populations such as assessment using ABPM. These include the evaluation of the
the elderly and patients with diabetes (in whom optimal 24-hour control interdialytic blood pressure in haemodialysis patients and assessing
of blood pressure is mandatory) and in pregnancy.
9
the adequacy of therapy throughout the interdialytic period.
15
Conclusion
Ambulatory blood pressure
First, ABPM should be an integral part of good clinical practice. The case
measurement is the only accurate
is particularly compelling in nephrological practice. It is the responsibility
of healthcare providers to reimburse doctors adequately for the
means of monitoring nocturnal blood
procedure given the assurance of considerable cost savings. Second,
pressure, which has been largely practising physicians must agitate for a technique that will provide them
ignored in clinical practice.
with the means of diagnosing hypertensive patients more accurately,
guiding drug prescription more efficiently and predicting risk and
outcome in individual patients. Third, manufacturers of ABPM devices
Recently, ABPM has been used to achieve more subtle insights into must improve monitors in keeping with the innovative possibilities that
circadian hypertension. The Ambulatory Arterial Stiffness Index (AASI), contemporary technology provides, and also ensure that software
which has been shown to predict cardiovascular mortality in a large options allow for standardised presentation of data, statistics and plots,
cohort of hypertensive individuals, particularly stroke even in interpretation of recordings and an electronic means of sharing data in
normotensive subjects, may prove to be a readily applicable index that order to further patient management and hypertension research. Finally,
can be derived from a routine ABPM to predict outcome. The practical patients must be aware of the possibilities of ABPM and ask why it is
importance of such an index is that it may permit early identification of being denied to them so often. ■
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Times Gaz, 1895;23:29–30. 2005;45:481–2. chronic kidney disease and decreased renal function in the
2. O’Brien E, Fitzgerald D, The history of indirect blood pressure 8. Thom T, Haase N, Rosamond W, et al., Heart Disease and adult US population: Third National Health and Nutrition
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of Hypertension, 1991;1–54. Heart Association Statistics Committee and Stroke Statistics 13. Redon J, Oliver V, Zaragoza MD, Galindo MJ, Ambulatory
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the ‘literature’, Br Med J, 1979;2:1201–2. Hypertension recommendations for conventional, ambulatory 14. Bianchi S, Bigazzi R, Baldari G, et al., Diurnal variations of
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5. O’Brien E, Ambulatory Blood Pressure Measurement: A Trove 10. Dolan E, Thijs L, Li Y, et al., Ambulatory Arterial Stiffness 15. Santos SFF, Peixoto AJ, Ambulatory Blood Pressure in
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EUROPEAN RENAL DISEASE 2007 53
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