This document discusses the use of ambulatory blood pressure monitoring (ABPM) and bioimpedance in monitoring and treating hypertension in patients with chronic kidney disease (CKD). It notes that hypertension becomes more prevalent at higher stages of CKD. ABPM is described as superior to office blood pressure measurements for diagnosing hypertension, assessing treatment response, and predicting outcomes. Non-dipping blood pressure patterns observed on ABPM are associated with worse renal function and cardiovascular damage in CKD patients. The document also discusses how bioimpedance analysis can provide accurate assessment of volume status, an important factor in hypertension, with advantages of being non-invasive, inexpensive, and predictive of outcomes. Bedtime dosing of antihy

1. ABPM and Bioimpedance in Monitoring and
Treatment of HTN in CKD
M,S Forghani MD, MUK

2. Hypertension is:
Based on data from the US Renal Data System
It is estimated that hypertension occurs in about
 23.3% of individuals without CKD
 35.8% of stage 1
 48.1% of stage 2
 59.9% of stage 3
 84.1% of stages 4 and 5 CKD patients
 most powerful risk factor of CVD
 independent risk factor of CKD progression
 The most common comorbidity

3. What is the best method for measuring blood
pressure in CKD patients?
 Manual Auscultatory Clinic Blood Pressure measurement (OBPM)
 Is essential yet
 Automated Office Blood Pressure measurement (AOBPM)
• Measurements compared to manual office measurements are more
compatible with ABPM, validated in CKD and essential hypertensive patients
 Home blood pressure monitoring (HBPM)
 compared to traditional OBPM, Reproducible, eliminate digit preference &
observer bias , prognostic indicator
 Ambulatory blood pressure monitoring (ABPM)
 In the general population and in patients with CKD, compared to office
measurements, there are vast documents regarding ABPM superiority in
hypertension diagnosis, treatment response, outcome prediction and
target organ damage prediction,
Andersen MJ, Khawandi W, Agarwal R. Home blood pressure monitoring in CKD. Am J Kidney Dis 2005; 45: 994–1001.
Journal of the American Society of Hypertension 4(2) (2010) 5-61

4. Ambulatory blood pressure
monitoring
Ambulatory blood pressure monitoring provides a vast amount of additional data
compared to office recordings, including:
 Blood pressure variability (Short term)
 Subtypes of hypertension identified
Morning hypertension
White Coat Hypertension
Masked Hypertension
Non dipping pattern
Reverse dipping
Extreme dipping

5. Different types of blood pressure variability (BPV), their
determinants, and prognostic relevance for cardiovascular and renal
outcomes
Role of Ambulatory and Home Blood Pressure Monitoring for Assessing Alterations in Blood Pressure
Variability and Blood Pressure Profiles, Hypertension. 2016 Jun;67(6):1102-10

6. Cross-
sectional
Mojón et al Higher prevalence of non-dipping in patients with CKD (eGFR <60)
versus pts with no CKD (eGFR >60); higher nocturnal SBP and lower DBP
in pts with CKD versus pts with no CKD
Cross-
sectional
Mulè et al Higher ABP variability in patients with reduced eGFR
Prospective Davidson et
al
Decline in eGFR in non-dippers; stable eGFR in dippers
Prospective Agarwal and
Andersen
Non-dipping associated with increased risk of ESRD and total
mortality
Prospective McMullan et
al
10% higher nocturnal dipping associated with decreased risk of CKD
and lower annual rate of eGFR decline
Prospective Gabbai et al ABP measurements predicted both renal and CV outcomes
Altered BP variability and ambulatory BP
pattern in CKD patients

7. Study
design
Patients
(n)
ABP profiles/outcomes Reference
s
Cross-sectional African
Americans with
CKD
(n=617)
Proteinuria and LVH more common in patients with
elevated nighttime BP and masked hypertension
Pogue et al.
Cross-sectional CKD
pts (n =1492)
Masked hypertension was independently
associated with low eGFR, higher proteinuria, and
higher LVMI
Drawz et al.
Cross-sectional CKD
pts (n = 540)
Reverse dipper BP pattern closely related to worse
renal function and severe CV damage
Wang et al.
Altered ambulatory BP profile and
cardiovascular events in patients with CKD

8. Altered ambulatory BP profile and cardiovascular events in
patients with end-stage renal disease
Study
design
Patients (n) ABP profiles/outcomes Refere
nces
Prospective Hypertensive HD
pts (n = 57)
Elevated nocturnal systolic BP were
independently associated with CV mortality
Amar et al.
Prospective HD patients (n =80) Nocturnal BP non-dipping positively associated with
CV events and CV mortality
Liu et al.
Prospective Nondiabetic HD
pts (n =168)
Night/day systolic BP ratio strongly
predicts total and CV mortality
Tripepi et
al.
Cross-
sectional
ESRD pts undergoing
APD (n = 20) versus
CAPD (n = 28)
LVMI higher in non-dippers compared to dippers; non-dipper
diastolic BP pattern associated with LVMI
Atas et al.

10. Significance of white-coat and masked hypertension in
chronic kidney disease and end-stage renal disease
Hypertension Research 37, 882-889 (October 2014) Clin J Am Soc Nephrol 2011; 6: 2003–2008.

11. The rate of morning HTN was significantly
different between diabetics and non-diabetics. In
stage 2 CKD, the rate of morning HTN was higher
in diabetics than in non-diabetics (22.7% vs. 9.5%,
P=0.001).
The rate of morning HTN differed
significantly according to eGFR in non-
diabetics, but not in diabetics.

12. Mechanisms of altered blood pressure variability and circadian
rhythm in chronic kidney disease.

13. Journal of the American Society of Hypertension 4(2) (2010) 5-61
When and how to use ambulatory blood pressure monitoring

14. ABPM and Effects of Antihypertensive Treatment
in CKD
 Hermida et al . The subjects randomized to bedtime dosing of ACEI
& ARB showed a better overall control of BP on ABPM, greater
reduction in mean asleep SBP, and a lower proportion of non-
dippers , greater reduction in albuminuria significant reduction in
CV death, myocardial infarction, or stroke compared to the control
group.
 Wang et al. showed that bedtime dosing of an ARB once daily was
significantly more effective than awakening dosing in reducing
nighttime BP, proteinuria, and left ventricular mass in CKD
patients with non-dipping pattern
 Minutolo et al. showed that changing the timing of antihypertensive
medication dosing from morning to evening decreased the night/day
ratio and restored normal circadian rhythm in 87.5%. Moreover,
proteinuria also was reduced with evening administration of
antihypertensive medications

15. ABPM and Effects of Antihypertensive Treatment
in CKD
 Generally, calcium channel blockers are more effective with bedtime
than morning dosing
 Other hypertension medications, including α-blocker doxazosin, β-
blockers carvedilol and nebivolol and loop-diuretic torasemide,
also show significantly enhanced nighttime BP reduction and
longer duration of BP-lowering effect with bedtime versus morning
(upon awakening) therapy
• diuretics and a low sodium diet selectively lower nocturnal BPs in
non-CKD patients with salt-sensitive hypertension, an effect that may
also occur in patients with CKD.
Bedtime, in comparison with upon awakening, ingestion of every one of
these combination therapies markedly reduces the asleep SBP/DBP
means and significantly increases the proportion of patients converted
from non-dipper to dipper patterning

16. Volume overload correlates with hypertension and cardiovascular risk
factors in patients with chronic kidney disease
 The clinical assessment of fluid status
 Ultrasonic evaluation of the diameter of the inferior vena cava
 Biomarkers such as brain natriuretic peptide (BNP) and N-
terminal pro-brain natriuretic peptide (NT-proBNP)
 Isotope dilution
What’s ideal method?
 Bioimpedance analysis
Volume status assessment
 Available
 Inexpensive
 Sensitive
 Specific
 Simple
 Outcome predictor

17. Bio impedance analysis is a promising method for volume status
assessment
the major advantages of this system are based on:
 It’s non-invasiveness
 Accuracy is Validated with gold standard method
 Safe
 Inexpensive
 Ease of use in clinic

21. Bioimpedance – Limitations and Errors
Although extensively used in the recent past, bioimpedance as the
bedside technique used in the assessment of body composition
has some potential limitations [23] :
• (1) it is contraindicated in pregnant women, children, and
subjects wearing a pacemaker;
• (2) measurements may be affected by eating, intense physical
activity, and alcohol and fluid intake before evaluation.
Moreover, extreme obesity and acute body mass changes
following protein malnutrition are also significant limitation of the
use of bioimpedance.
Patients should be prepared: avoidance of alcohol for at least 8 h
before the test and no water for 4 to 6 h; if the test is applied within
a 2–4 h interval after a meal.

24. A New Paradigm for Hypertension Management:
Bioimpedance and Office BP
• Am J Nephrol 2014;40:434–440
AmJNephrol2014;40:434–440,Publishedonline:
November22,2014