Prognostic Significance of Ambulatory BP Monitoring in CKD: A Report from the Chronic Renal Insufficiency Cohort (CRIC) Study

Abstract

BackgroundWhether ambulatory BP monitoring is of value in evaluating risk for outcomes in patients with CKD is not clear.MethodsWe followed 1502 participants of the Chronic Renal Insufficiency Cohort (CRIC) Study for a mean of 6.72 years. We evaluated, as exposures, ambulatory BP monitoring profiles (masked uncontrolled hypertension, white-coat effect, sustained hypertension, and controlled BP), mean ambulatory BP monitoring and clinic BPs, and diurnal variation in BP—reverse dipper (higher at nighttime), nondipper, and dipper (lower at nighttime). Outcomes included cardiovascular disease (a composite of myocardial infarction, cerebrovascular accident, heart failure, and peripheral arterial disease), kidney disease (a composite of ESKD or halving of the eGFR), and mortality.ResultsCompared with having controlled BP, the presence of masked uncontrolled hypertension independently associated with higher risk of the cardiovascular outcome and the kidney outcome, but not with all-cause mortality. Higher mean 24-hour systolic BP associated with higher risk of cardiovascular outcome, kidney outcome, and mortality, independent of clinic BP. Participants with the reverse-dipper profile of diurnal BP variation were at higher risk of the kidney outcome.ConclusionsIn this cohort of participants with CKD, BP metrics derived from ambulatory BP monitoring are associated with cardiovascular outcomes, kidney outcomes, and mortality, independent of clinic BP. Masked uncontrolled hypertension and mean 24-hour BP associated with high risk of cardiovascular disease and progression of kidney disease. Alterations of diurnal variation in BP are associated with high risk of progression of kidney disease, stroke, and peripheral arterial disease. These data support the wider use of ambulatory BP monitoring in the evaluation of hypertension in patients with CKD.PodcastThis article contains a podcast at https://www.asn-online.org/media/podcast/JASN/2020_09_24_JASN2020030236.mp3

Prediction of Masked Hypertension and Masked Uncontrolled Hypertension Using Machine Learning

“…It is interesting to point out that eGFR and creatinine were included as predictor variables in three models. Several studies have shown that MH/MUCH is associated with the development of chronic kidney disease (CKD) and the progression of kidney disease (16,17). MUCH/MH is also common in patients with CKD and associated with lower eGFR (18), which is consistent with our finding that eGFR and creatinine were important variables for the prediction of MH/MUCH.…”

“…In total, 73 and 53 variables were recorded in cohort 1 and 2, respectively (Supplementary Table 1). Of these, 33 variables were selected or derived as the candidate variables for the model based on previous literature and taking into account the accessibility of data from outpatient clinics (4, 5, 7, [16][17][18][19][20][21][22][23][24][25][26][27]. These candidate variables were as follows: 1. demographic data [age, male sex, BMI, waist-to-hip ratio (WHR), current smoker]; 2. office BP parameters [office systolic BP (SBP), office diastolic BP (DBP), office mean arterial pressure (MAP), office pulse pressure (PP)]; 3. antihypertensive drug usage [angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB), beta-blocker, calcium channel blocker (CCB), thiazide, spironolactone, alpha-blocker, combination of ACEI/ARB and CCB, combination of ACEI/ARB and thiazide, combination of ACEI/ARB and CCB and thiazide, combination of CCB and thiazide, combination of ACEI/ARB and beta-blocker and CCB and thiazide, antihypertensive drug number]; and 4. biochemical profiles [total cholesterol (TC), triglyceride (TG), high-density lipoprotein-cholesterol (HDL-C), low-density lipoprotein-cholesterol (LDL-C), creatinine, sodium, potassium, alanine aminotransferase (ALT), uric acid (UA), glucose, aldosterone, estimated glomerular filtration rate (eGFR)] (Supplementary Material 1).…”

Clinical Effect of Mudan Granule on Peripheral Neuritis Caused by Chronic Renal Insufficiency

“…Under this high load, the nephron is constantly damaged, and renal function deteriorates and eventually enters end-stage renal disease [ 11 , 12 ]. The damage of renal tubule and its interstitium is also an important factor in the progression of CRI, which is related to the high metabolism of renal tubules and the increase of oxygen consumption, which leads to the increase of oxygen free radicals, which leads to the formation of membrane attack complex and the activation of complement bypass [ 13 ]. Other studies have indicated that intestinal flora can also affect the progression of CRI [ 14 ].…”

Hypertension Management in Patients with Chronic Kidney Disease

“…Masked hypertension was associated with more cardiovascular events and a more rapid decline in kidney function after a mean follow-up of 6.72 years. 4 Increasing use of ABPM or home blood pressure monitoring (HBPM) in clinical CKD practice will help confirm treatment responses and perhaps better characterize risk for future target organ damage.…”