2. Ambulatory Blood Pressure Monitoring and Lung
Ultrasound as New Predictors of Cardiovascular
Morbidity in End Stage Renal Disease Patients
Thesis
Submitted for partial fulfillment of MSc. Degree in
Internal Medicine
By
Amr Refay Albitar
Faculty of Medicine
Cairo University
2014

3. 3
Prof. Dr. Amin Mohamed Roshdy
Professor of Internal Medicine
Faculty of Medicine - Cairo University
Prof.Dr. Hatem Mohamed AL- Azizi
Lecturer of Diagnostic Radiology
Faculty of Medicine - Cairo University
Dr. Sahier Omar EL- Khashab
Assist. Professor of Internal medicine
Faculty of Medicine - Cairo University
Supervisors

4. 1) Introduction.
2) Aim of the work.
3) Material and Methods.
4) Results.
5) Discussion.
6) Conclusion.
7) Recommendations.
Agenda
4

6.  Pulmonary congestion is highly prevalent and often asymptomatic
among patients with ESRD treated with hemodialysis ( HD ) , but
whether its presence predicts clinical outcomes is unknown
(zoccali C ; et al., 2013)
 Volume expansion is perhaps the most insidious and common
modifiable risk factor for the exceedingly high death risk of patients
with kidney failure on dialysis (CKD stage 5D)
(zoccali C; et al ., 2013)
6

7.  Lung ultrasound (US) is a novel, validated technique that
has been increasingly applied to estimate lung water in
patients with heart disease and patients with acute
respiratory failure treated in intensive care units
(picano E; et al .,2010)
 Lung ultrasound can detect asymptomatic pulmonary
congestion in hemodialysis patients, and the resulting BL-
US score ( Number of B lines as evident by lung ultrasound
) is a strong, independent predictor of death and cardiac
events in this population
(zoccali C; et al . , 2013)
7

8.  Visit-to-visit BP variability was extremely high in hemodialysis patients
compared with other populations and a major determinant of
cardiovascular events (Rossignol P; et al., 2012)
 Out-of-dialysis unit blood pressure among hemodialysis patients is
prognostically more informative than that recorded just before and
after dialysis. Therefore, the management of hypertension among these
patients should focus on blood pressure recordings outside the dialysis
unit (Agarwal R. 2010)
8

9.  NICE hypertension guidlines, states that ambulatory blood
pressure monitoring (ABPM) reduces misdiagnosis and
allows better targeted treatment. (lovibond k; et al .,2011)
 KDOQI practice guidelines recommend predialysis blood
pressure <140/90 mm Hg; however, most prior studies had
found elevated mortality with low, not high, systolic blood
pressure (Robinson BM ;et al., 2012)
9

10. Lung Ultrasound
 “The ultrasound imaging is not useful for evaluation of
the pulmonary parenchyma” (Harrison , 1992)
It was the old concept regarding lung ultrasound , that
air is the enemy of ultrasound waves
10

11. 11

12. 12

13. 13

14. Terminology
A- Lines B- Lines
14

15. 15

16. Ambulatory blood pressure
monitoring
16

17. Indications
In accordance with published practice guidelines and expert panel
recommendations, ambulatory monitoring should be considered in the
following circumstances “
(Mancia G,et al.2013)
 Suspected white coat hypertension
 Suspected episodic hypertension (eg, pheochromocytoma)
 Hypertension resistant to increasing medications
 Hypotensive symptoms while taking antihypertensive medications
 Autonomic dysfunction
 To establish nondipper status or nocturnal hypertension
 Large variations in self-measured blood pressure values
 To evaluate whether antihypertensive therapy is moderating the early morning
blood pressure surge
 Elevated office blood pressure in pregnant women, with preeclampsia suspected
17

18. 18

19. 19

20. 20

21. 21

22.  Identify blood pressure pattern in ESRD patients on
regular hemodialysis to detect non –dippers as one of
the best predictors of cardiovascular complications .
 Test the prognostic value of extravascular lung water
measured by a simple, well validated ultrasound B-
lines score (BL-US)
 Correlate between interadialytic weight gain , blood
pressure variability and lung congestion in ESRD
patient
22

24. 24
Our study included 50 persons:
Group I : included 25 patients with IDWG
more than 4 kg
Group II : included 25 patients with IDWG
less than 4 kg

25.  Inclusion criteria
 Stable ESRD (Ambulated, complaint to 3 dialysis sessions / week)
 Hypertensive.( Systolic > 140, diastolic > 90)
 Age (20 – 60)
 Exclusion criteria:
 Diabetic patients.
 RHD (rheumatic heart disease)
 COPD (chronic obstructive pulmonary disease)
 Congestive heart failure
 Renal transplants
25

26. Patients were subjected to the following:
1. Detailed medical history taking.
2. Complete physical examination.
3. Laboratory investigations: total cholesterol and
triglycerides
4. ECG
5. Ambulatory blood pressure monitoring
6. Lung ultrasound
26

27. 27

28. Descriptive data
Variables Mean+SD Median Range
Age 44.9+10 48 23-60
HD 3.8+2.3 3 0.3-10
28
pt
>4kg
n=25
< 4kg
n=25
Variables
>0.05
NS1.446.6+842.5+9Age(mean+SD)
>0.05
NS
0,8#
14(56%)
11(44%)
10(40%)
15(60%)
Gender
Male
Female

29. Comparison between blood Pressure( pre and post ) among
both groups
>4kg
n=25
<4kg
n=25
Variables
140+20149.6+25SBP pre
134.4+22134.9+20SBP post
1.4
>0.05NS
3
<0.001HS
t
p
88+8.791.6+10DBP pre
81+1284.3+11DBP post
3
<0.001HS
4
<0.001HS
t
p
29

30. 30
0
20
40
60
80
100
120
140
160
<4 kg >4kg
SBP pre
SBP post
DBP pre
DBP post

31. Comparison between the studied groups regard max and min
blood pressure detected by ABPM
Pt
>4kg
n=25
<4kg
n=25
Variables
>0.05
NS
1.7178+20187+25Max SBP
>0.05
NS1.8104+22113+20Max DBP
>0.05
NS
1.1124+21131+22Min SBP
>0.05
NS
0.671+2079+12Min DBP
<0.05
S
2.410.5+35.9+2Sleep dip sys
>0.05
NS
1.712.7+48.9+3Sleep dib dias
31

32. Comparison between max and min blood pressure detected by ABPM and
the usual pre dialytic BP measurements
>4kg
n=25
<4kg
n=25
Variables
140+20149.6+25SBP pre
178+20187+25Max SBP
5.4
<0.001HS
6.5
<0.001HS
t
p
88+8.791.6+10DBP pre
104+22113+20Max DBP
5
<0.001HS
3.3
<0.001HS
t
p
32

33. Comparison between the studied groups regard lung U/S
Pt
>4kg
n=25
<4kg
n=25
Variables
>0.05
NS0.73.3+1.13.8+1.3Mean+SD
33

34. Correlation between lung U/S versus ABPM parameters among
group with less than 4kg
Lung U/S
r PVariables
<0.05S0.34Max SBP
<0.05S0.40Max DBP
<0.05S0.37Min SBP
<0.05S0.32Min DBP
>0.050.12Sleep dip systolic
>0.050.17Sleep dib diastolic
34

35. ): correlation between lung U/S versus ABPM parameters among
group with more than 4kg
Lung U/S
r PVariables
>0.050.16Max SBP
>0.050.09Max DBP
>0.050.17Min SBP
<0.05 S0.38Min DBP
>0.050.10Sleep dip systolic
>0.050.11Sleep dib diastolic
35

36. Relation between ECG versus lung U/S among both groups
PZ
ECG
No Yes
Variables
<0.05
S
2.84.8+2.52.4+2Mean+SD (lung U/S)
36
•More than 4 kg
PZ
ECG
No YesVariables
<0.001
HS3.54.6+2.91.5+1Mean+SD (lung U/S)
•Less than 4 kg

37. Relation between ECG versus lung U/S among both groups
B-lines
37
Ischemic changesIschemic changes
B-lines
Less than 4kgMore than 4kg

38. Relation between ECG versus dipper and non dipper among
total group
PECG
No Yes
Variables
<0.001
HS
24(80%)8(40%)Non dipper
5(20%)12(60%)Dipper
38
0
10
20
30
40
50
60
70
80
normal ECG IHD
non-dipper
dipper

39. Relation between ECG versus general data among total group
Pt
ECG
No Yes
Variables
<0.001
HS
2.848+840+10Age
>0.05
NS
0.43.9+1.93.6+1.2Duration of HD
<0.05
S
Fisher10(33.3%)
20(66.7%)
14(70%)
6(30%)
Gender
Male
Female
39

40. 40

41.  Our study was conducted on 50 patients, divided in two groups
regarding IDWG with normally distributed data, and there was no
difference regarding duration of hemodialysis, hypertension and
number of antihypertensive drugs and that gave strength to the
comparison of other variables present in the two groups.
 Also, there was no statistically significance between the 2 groups
regarding ECG findings, a number of B-lines, lipid profile and dyspnea
grade by using NYHA classification
41

42. Interdialytic weight gain and blood pressure
(pre & post )
 Our study confirmed that increased ultrafiltration dose of
heomdialysis patient may be accepted modality of control diastolic BP
(significant decline in both groups , but not sufficient alone to control
or lowering systolic blood pressure.
 that was evident by comparison of systolic BP (alone)pre and post
hemodialysis session on each group , that showed significant decline
of systolic blood pressure in group 2 (IDWG less than 4 kg) while not
in the group 1 (IDWG more than 4 kg) .
42

43.  That was partially against (Katzarski KS et al,2003 ) that state in his
thesis “Extracellular volume changes and blood pressure levels in
hemodialysis patients.” that The removal of excess fluid is necessary
for adequate BP control ( systolic and diastolic )and especially for the
reduction in elevated BP during the night .
 But the limitations of his study was the low number of patients 16
patients ,10 of them showed a reduction in extracellular volume after
gradual increasing of the ultrafiltration dose in 3-4 , also dealing with
blood pressure without taking in consideration systol & diastol
separate items .
43

44. Ambulatory blood pressure monitoring versus the usual
visit –to visit BP reading in hemodialysis patients
 Sleep systolic dipping was higher among group 1 (IDWG higher than
4 kg) with statistically significant difference between both studied
groups as regard ambulatory blood pressure with positive correlation,
so the more IDWG and UF the more systolic dipping !!
44

45.  Non dippers represented 80% of the ischemic heart disease peoples
in all our studied groups, while dippers represented only 20% of them
 That was agreedwith Satoshi et al that showed in their study that
nondipping of nocturnal BP seems to be a determinant of cardiac
hypertrophy and remodeling, and may result in a cardiovascular risk
independent of ambulatory BP levels in normotensives
 The advantages of Satoshi et al are the large number of patients ( 74
normotensive patients ) and the more investigations implied in the
study as mbulatory blood pressure (BP) monitoring, echocardiography
, carotid ultrasonography, measured natriuretic peptides and urinary
albumin
45

46.  We cannot depend on the pre-dialytic BP (systolic and diastolic) as the
representative of highest BP because there was high statistically
significance between the pre-dialytic readings and the maximum BP
detected by ABPM, so the ABPM is the preferred method of assessment
of blood pressure in hemodilysis patient rather than depending on the
pre diastolic BP
46

47.  so results agreed with (Roberto et al, 2011) that confirmed in his work
“Prognostic Role of Ambulatory Blood Pressure Measurement in
Patients With Nondialysis Chronic Kidney Disease” that In chronic
kidney disease, ambulatory BP measurement and, in particular,
nighttime BP measurement, allows more accurate prediction of renal
and cardiovascular risk; office measurement of BP does not predict any
outcome
47

48. Coronary artery disease and strong correlation with
systolic blood pressure and B-lines .
 In both groups there was a strong positive correlation with
statistically significant difference between ischaemic heart disease as
evident by ECG and number of B-lines by lung ultrasound
 In group 2 (IDWG less than 4 kg) there was strong positive
correlation between ischemic heart disease as evident by ECG , and
systolic blood pressure with statistically significant difference
 while in group 1 (IDWG more than 4 kg) no correlation between the
ECG and the blood pressure at all .
48

49. Female CRF on regular hemodialysis more vulnerable
to CAD than males !!!
 In both groups most of the ischemic heart disease were females 66.7
% while males 33.3 % with mean of age 48+8 , and that was against
what is expected and may be explained by menopause and dialysis
which in turn render the females more vulnerable to develop ischemic
heart disease , while the duration of dialysis did not show any
statistically significant difference
49

50. 50

51.  Ultra filtration was not the suitable method for reduction of
hypertension (only can decline diastolic blood pressure ) .
 The more decline of diastolic blood pressure , the high risk of
pulmonary congestion in the overloaded patients
 Systolic dipping was obvious with the increased IDWG.
 The Ambulatory blood pressure monitoring was more accurate for
catching the highest (max) blood pressure, not the usual pre dialytic
BP readings.
51
Conclusion

52.  There was a strong correlation between the systolic blood pressure and
ischaemic heart disease.
 There was Strong correlation between number of B- Lines and
ischaemic heart disease.
 Non dippers were more susceptible to ischemic heart disease (80 % of
the ischemic heart disease were non-dipper).
 Females on regular hemodialysis were more risky to develop ischemic
heart disease than males.
52

53. 53

54.  Early installation of anti hypertensive medications and meticulous
ultrafiltration are essential for proper control of hypertension in
hemodialysis patients.
 Over decline of diastolic blood pressure, increase the risk of pulmonary
congestion and increase cardiovascular morbidity .
 Ambulatory blood pressure monitoring is preferred investigation of
choice every 3 months in hemodialysis patient to unmask the extremes
of blood pressure and select the non-dippers for more meticulous
cardiac assessment and follow up .
 Lung ultrasound as bed side test for assessment of lung congestion
and prediction of ischemic heart disease became accessible
54
Recommendations

55. 55