Can Novel Ambulatory Blood Pressure Monitoring (ABPM) Parameters Change the Way We Treat Hypertension in CKD?

Background: Blood pressure control rates in CKD continue to remain abysmal, in spite of advanced diagnostics and therapeutics. Novel ABPM entities such as BP variability, morning masked hypertension, “Double Risers” (rise of both nocturnal heart rate and BP) and Early Morning BP Surge (EMBS) by moving average sleep trough method can facilitate efficient management of hypertension in CKD. Our study aims to detect and compare these parameters between CKD and non-CKD patients. Methods: 100 hypertensive patients - CKD Group (Stage 1 to 4; n=50) and Non-CKD Group (n=50); underwent measurement of Single Office BP (SOBP), Automated averaged Office BP (AOBP) followed by 24 hours ABPM. Results: In CKD group, 48% had nocturnal non-dipping pattern, 12% had rising pattern of nocturnal BP and 10% were double risers. This was significantly higher than the non-CKD group. The CKD group had significantly higher EMBS (36% vs. 22%; p=0.04) by the newer “moving” average sleep trough method. In this method difference between Average Morning SBP (Average of morning SBPs taken during the first 2 hours after waking up) and Moving Lowest Nighttime SBP (Average of 3 SBP readings centered on the lowest night (nadir) SBP value) is calculated. Masked hypertension was seen in 76% of CKD and 40% of non-CKD patients. However, in CKD group masked hypertension in morning time (between 6 am to 10 am) was significantly higher (70%) than non CKD (12%). BP variability assessment by Standard Deviation method revealed no statistically significant difference between the CKD and the non-CKD groups (15.12+4.05 vs. 15.86+4.20 respectively). However, novel method such as Average Real Variability revealed statistically significant difference between the two groups (12.9+4.18 vs 11.6+3.63; p=0.03). Similarly, while considering Variability Independent of Mean as a parameter, CKD patients had higher BP variability (24.74+16.25) as compared to the non-CKD group (22.2+13.3; p=0.03). Conclusion: Hypertensive patients with CKD have a greater benefit from utilizing 24 hour ABPM as compared to those without CKD. Novel parameters such as morning masked hypertension, double risers, “moving” average sleep trough and average real variability can be assessed for better therapeutic interventions.