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Twenty-Four-Hour Ambulatory Blood Pressure versus Clinic Blood Pressure Measurements and Risk of Adverse Outcomes in Children with CKD.

ABSTRACT: BACKGROUND:and objectives Our objective was to determine whether clinic BPs (taken at either a single visit or two sequential visits) are inferior to ambulatory BPs in their ability to discriminate risk of adverse outcomes in children with CKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS:We included 513 participants of the CKD in Children Study who had clinic BPs and 24-hour ambulatory BP monitoring performed during similar timeframes. Predictors of interest were systolic BPs taken at a single visit or two repeated visits within a 1-year period compared with mean wake and sleep systolic ambulatory BPs. Outcomes were left ventricular hypertrophy and ESKD. We determined the ability for each BP parameter to provide risk discrimination using c statistics. RESULTS:During mean follow-up of 3.5 years, 123 participants developed ESKD. In cross-sectional unadjusted analysis, every 0.1 increase in systolic BP index was associated with a 2.0 times higher odds of left ventricular hypertrophy (95% confidence interval, 1.5 to 2.8) by clinic BPs versus 1.8 times higher odds (95% confidence interval, 1.3 to 2.4) by ambulatory wake BP. The c statistic was highest for clinic BP (c=0.65; 95% confidence interval, 0.58 to 0.73) but similar to ambulatory wake BP (c=0.64; 95% confidence interval, 0.57 to 0.71) for the discrimination of left ventricular hypertrophy. In longitudinal unadjusted analysis, every 0.1 increase in systolic BP index was associated with a higher risk of ESKD using repeated clinic (hazard ratio, 1.5; 95% confidence interval, 1.3 to 1.8) versus ambulatory wake BP (hazard ratio, 1.6; 95% confidence interval, 1.3 to 2.0). Unadjusted c statistics were the same for wake (c=0.61; 95% confidence interval, 0.56 to 0.67) and clinic systolic BPs (c=0.61; 95% confidence interval, 0.55 to 0.66) for discriminating risk of ESKD. CONCLUSIONS:Clinic BPs taken in a protocol-driven setting are not consistently inferior to ambulatory BP in the discrimination of BP-related adverse outcomes in children with CKD.

SUBMITTER: Ku E

PROVIDER: S-EPMC5967676 | biostudies-literature | 2018 Mar

REPOSITORIES: biostudies-literature

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Twenty-Four-Hour Ambulatory Blood Pressure versus Clinic Blood Pressure Measurements and Risk of Adverse Outcomes in Children with CKD.

Ku Elaine E McCulloch Charles E CE Warady Bradley A BA Furth Susan L SL Grimes Barbara A BA Mitsnefes Mark M MM

Clinical journal of the American Society of Nephrology : CJASN 20180213 3

<h4>Background</h4><b>and objectives</b> Our objective was to determine whether clinic BPs (taken at either a single visit or two sequential visits) are inferior to ambulatory BPs in their ability to discriminate risk of adverse outcomes in children with CKD.<h4>Design, setting, participants, & measurements</h4>We included 513 participants of the CKD in Children Study who had clinic BPs and 24-hour ambulatory BP monitoring performed during similar timeframes. Predictors of interest were systolic ...[more]

PMID: 29440119

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Project description:Elevated blood pressure (BP) is frequently diagnosed in very elderly hospitalized patients. Accurate diagnosis of hypertension is challenging in the hospital environment, due to the "white coat effect," and both overtreatment and undertreatment can adversely affect clinical outcome. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has the potential to avoid the "white coat effect" and accurately guide the management of hypertension. However, effects of the hospital environment on ABPM are unknown in the very elderly. We set out to enroll 45 patients, age ≥70 years, with elevated conventional BP during hospitalization in this observational study. It was prespecified by protocol to assess initially the difference between 24-hour BP during hospital-admission and home follow-up. Subsequent analysis should investigate the change in anxiety (Hospital Anxiety and Depression Scale-A [HADS-A]) after discharge, the correlation with change in 24-hour BP after discharge, and the prevalence of orthostatic hypertension. Thirty-one patients were included in the final analysis (age 83.5 ± 4.4 years; 71% female). Twenty-four-hour BP decreased significantly after hospital discharge (systolic from 133.5 ± 15.6 to 126.2 ± 14.4 mm Hg [millimeter of mercury], P = .008; diastolic from 71.0 ± 9.0 to 68.3 ± 8.6 mm Hg, P = .046). Anxiety level (HADS-A) decreased significantly after discharge, from 7.5 (interquartile range [IQR]: 4.0-13.8) to 5.0 (IQR: 4.0-8.0, P = .012). The change in anxiety was a predictor of change in systolic BP after discharge (F[1,20] = 5.9, P = .025). Sixty-one percent of the patients had significant orthostatic hypotension during hospital stay. In conclusion, 24-hour BP in very elderly patients is lower in the home environment than during hospitalization. This phenomenon seems to be directly linked to a lower anxiety-level at home. Reassessing hypertension at home may decrease the need for (intensified) antihypertensive medical therapy in a substantial number of patients. This is particularly important in the very elderly, who have a high prevalence of symptomatic and asymptomatic orthostatic hypotension, making them prone to hazardous effects of antihypertensive therapy.

Project description:Background and objectivesHypertension is highly prevalent in patients with CKD as is cognitive impairment and frailty, but the link between them is understudied. Our objective was to determine the association between ambulatory BP patterns, cognitive function, physical function, and frailty among patients with nondialysis-dependent CKD.Design, setting, participants, & measurementsAmbulatory BP readings were obtained on 1502 participants of the Chronic Renal Insufficiency Cohort. We evaluated the following exposures: (1) BP patterns (white coat, masked, sustained versus controlled hypertension) and (2) dipping patterns (reverse, extreme, nondippers versus normal dippers). Outcomes included the following: (1) cognitive impairment scores from the Modified Mini Mental Status Examination of <85, <80, and <75 for participants <65, 65-79, and ≥80 years, respectively; (2) physical function, measured by the short physical performance battery (SPPB), with higher scores (0-12) indicating better functioning; and (3) frailty, measured by meeting three or more of the following criteria: slow gait speed, muscle weakness, low physical activity, exhaustion, and unintentional weight loss. Cognitive function and frailty were assessed at the time of ambulatory BP (baseline) and annually thereafter. SPPB was assessed at baseline logistic and linear regression and Cox discrete models assessed the cross-sectional and longitudinal relationship between dipping and BP patterns and outcomes.ResultsMean age of participants was 63±10 years, 56% were male, and 39% were black. At baseline, 129 participants had cognitive impairment, and 275 were frail. Median SPPB score was 9 (interquartile range, 7-10). At baseline, participants with masked hypertension had 0.41 (95% CI, -0.78 to -0.05) lower SPPB scores compared with those with controlled hypertension in the fully adjusted model. Over 4 years of follow-up, 529 participants had incident frailty, and 207 had incident cognitive impairment. After multivariable adjustment, there was no association between BP or dipping patterns and incident frailty or cognitive impairment.ConclusionsIn patients with CKD, dipping and BP patterns are not associated with incident or prevalent cognitive impairment or prevalent frailty.

Project description:BackgroundSodium-glucose co-transport 2 inhibitors (SGLT2i) lower blood pressure (BP) in normotensive subjects and in hypertensive and normotensive diabetic and non-diabetic patients. However, the mechanisms of these BP changes are not fully understood. Therefore, we examined the clinical and biochemical determinants of the BP response to empagliflozin based on 24-h ambulatory BP monitoring.MethodsIn this post-hoc analysis of a double-blind, randomized, placebo-controlled study examining the renal effects of empagliflozin 10 mg vs. placebo in untreated normotensive non-diabetic subjects, the 1-month changes in 24 h ambulatory BP were analyzed in 39 subjects (13 placebo/26 empagliflozin) in regard to changes in biochemical and hormonal parameters.ResultsAt 1 month, empagliflozin 10 mg decreased 24-h systolic (SBP) and diastolic (DBP) BP significantly by -5 ± 7 mmHg (p < 0.001) and -2 ± 6 mmHg (p = 0.03). The effect on SBP and DBP was more pronounced during nighttime (resp. -6 ± 11 mmHg, p = 0.004; -4 ± 7 mmHg, p = 0.007). The main determinants of daytime and nighttime SBP and DBP responses were baseline BP levels (for daytime SBP: coefficient -0.5; adj. R2: 0.36; p = 0.0007; for night-time SBP: coefficient -0.6; adj. R2: 0.33; p = 0.001). Although empaglifozin induced significant biochemical changes, none correlated with blood pressure changes including urinary sodium, lithium, glucose and urate excretion and free water clearance. Plasma renin activity and plasma aldosterone levels increased significantly at 1 month suggesting plasma volume contraction, while plasma metanephrine and copeptin levels remained the same. Renal resistive indexes did not change with empagliflozin.ConclusionSGLT2 inhibition lowers daytime and nighttime ambulatory systolic and diastolic BP in normotensive non-diabetic subjects. Twenty-four jour changes are pronounced and comparable to those described in diabetic or hypertensive subjects. Baseline ambulatory BP was the only identified determinant of systolic and diastolic BP response. This suggests that still other factors than sustained glycosuria or proximal sodium excretion may contribute to the resetting to lower blood pressure levels with SGLT2 inhibition.Clinical trial registration[https://www.clinicaltrials.gov], identifier [NCT03093103].

Dataset Information

Twenty-Four-Hour Ambulatory Blood Pressure versus Clinic Blood Pressure Measurements and Risk of Adverse Outcomes in Children with CKD.

Publications

Twenty-Four-Hour Ambulatory Blood Pressure versus Clinic Blood Pressure Measurements and Risk of Adverse Outcomes in Children with CKD.

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