Epidemiology of Hypertension among Patients on Peritoneal Dialysis Using Standardized Office and Ambulatory Blood Pressure Recordings.

INTRODUCTION: Prior studies conducted in peritoneal dialysis (PD) patients in the late 1990s provided considerably variable estimates of the prevalence and control of hypertension. The present study aimed to investigate the current state of hypertension management in this high-risk population. METHODS: In 140 stable PD patients, we performed standardized automated office blood pressure (BP) measurements and 24-h ambulatory BP monitoring (ABPM) using the Mobil-O-Graph device (IEM, Germany). Office and ambulatory hypertension was diagnosed in patients with office BP ≥140/90 mm Hg and 24-h BP ≥130/80 mm Hg, respectively. Patients treated with ≥1 BP-lowering medications were also classified as hypertensives. RESULTS: The prevalence of office and ambulatory hypertension was 92.9% and 95%, respectively. In all, 92.1% of patients were being treated with an average of 2.4 BP-lowering medications daily. Adequate BP control was achieved in 52.3% and 38.3% of hypertensives by office BP and ABPM, respectively. The agreement between these 2 techniques in the identification of patients with BP levels above the diagnostic thresholds of hypertension was moderate (k-statistic: 0.524). In all, 5% of patients were normotensives with both techniques, 31.4% had controlled hypertension, 5% had white-coat hypertension, 19.3% had masked hypertension, and 39.3% had sustained hypertension. Isolated nocturnal hypertension was detected in 23.6% of patients, whereas no patient had isolated daytime hypertension. CONCLUSION: Among PD patients, hypertension is highly prevalent and remains often inadequately controlled. The use of ABPM enables the better classification of severity of hypertension and identification of isolated nocturnal hypertension, which is a common BP phenotype in the PD population.

Gender-Related Differences in the Levels of Ambulatory BP and Intensity of Antihypertensive Treatment in Patients Undergoing Peritoneal Dialysis.

Prior studies have shown that among patients with chronic kidney disease not yet on dialysis, the faster progression of kidney injury in men than in women is, at least partly, explained by sex differences in ambulatory blood pressure (BP) control. The present study aimed to investigate potential differences in the levels of ambulatory BP and intensity of antihypertensive treatment between men and women with end-stage kidney disease undergoing long-term peritoneal dialysis (PD). In a case-control design, 48 male PD patients were matched for age and heart failure status with 48 female patients in a 1:1 ratio. Ambulatory BP monitoring was performed with an oscillometric device, the Mobil-O-Graph (IEM, Stolberg, Germany). The BP-lowering medications actually taken by the patients were prospectively recorded. No gender-related differences were observed in 24 h systolic BP (129.0 ± 17.9 vs. 128.5 ± 17.6 mmHg, p = 0.890). In contrast, 24 h diastolic BP was higher in men than in women (81.5 ± 12.1 vs. 76.8 ± 10.3 mmHg, p = 0.042). As compared with women, men were being treated with a higher average number of antihypertensive medications daily (2.4 ± 1.1 vs. 1.9 ± 1.1, p = 0.019) and were more commonly receiving calcium-channel-blockers (70.8% vs. 43.8%, p = 0.007) and ß-blockers (85.4% vs. 66.7%, p = 0.031). In conclusion, the present study shows that among PD patients, the levels of ambulatory BP and intensity of antihypertensive treatment are higher in men than in women. Longitudinal studies are needed to explore whether these gender-related differences in the severity of hypertension are associated with worse cardiovascular outcomes for male patients undergoing PD.

Favorable effects of peritoneal dialysis in patients with refractory heart failure and overhydration.

BACKGROUND: Patients with refractory to optimal pharmacological treatment heart failure (HF) require frequent hospitalization. Peritoneal dialysis (PD) has been part of the management of such patients mainly for promoting ultrafiltration and management of overhydration independently of kidney function. The aim of this study was to evaluate the efficacy of PD, especially the use of icodextrin solutions and intermittent PD, in the hospitalization rate and cardiac functional status of patients with HF. METHODS: We conducted a retrospective study involving patients with New York Heart Association (NYHA) class IV HF and preserved renal function (estimated glomerular filtration rate (eGFR) > 25 ml/min), who were refractory to conservative treatment. Clinical data on weight loss, hospitalization rate before and after PD initiation, cardiac functional status, and technique complications during a 6-month observational period were analyzed. RESULTS: PD treatment was performed in 32 patients with a mean age of 63.8 ± 11.9 years and a follow-up of 20.78 ± 14.24 months. Hospitalizations were significantly reduced from 20.7 ± 13.7 to 7.7 ± 8.9 days/patients at 6 months. All patients showed improvement in NYHA class as well as in left ventricular ejection fraction. Overall, eGFR showed a significant decrease but only six patients reached end-stage renal disease. Complications included 18 cases of peritonitis. PD was well tolerated and no patient dropped out of the method. Survival rate reached 72% at 12 months but mortality rate was high with 23 patients dying at 16.65 ± 12.3 months after the initiation of treatment. Patients survival was not influenced by the type of PD modality or weight reduction achieved. CONCLUSIONS: PD showed to be a viable option for the treatment of patients with refractory HF leading to a better cardiac functional status and diminishing the number of hospital admissions.

Age dependence of brachial cuff-based ambulatory PWV in end-stage kidney disease patients undergoing long-term peritoneal dialysis.

BACKGROUND: The newly introduced device Mobil-O-Graph (IEM, Stolberg, Germany) combines brachial cuff oscillometry and pulse wave analysis, enabling the determination of pulse wave velocity (PWV) via complex mathematic algorithms during 24-h ambulatory blood pressure monitoring (ABPM). However, the determinants of oscillometric PWV in the end-stage kidney disease (ESKD) population remain poorly understood. METHODS: In this study, 81 ESKD patients undergoing long-term peritoneal dialysis underwent 24-h ABPM with the Mobil-O-Graph device. The association of 24-h oscillometric PWV with several demographic, clinical and haemodynamic parameters was explored using linear regression analysis. RESULTS: In univariate analysis, among 21 risk factors, 24-h PWV exhibited a positive relationship with age, body mass index, overhydration assessed via bioimpedance spectroscopy, diabetic status, history of dyslipidaemia and coronary heart disease, and it had a negative relationship with female sex and 24-h heart rate. In stepwise multivariate analysis, age (ß: 0.883), 24-h systolic blood pressure (BP) (ß: 0.217) and 24-h heart rate (ß: -0.083) were the only three factors that remained as independent determinants of 24-h PWV (adjusted R 2 = 0.929). These associations were not modified when all 21 risk factors were analysed conjointly or when the model included only variables shown to be significant in univariate comparisons. CONCLUSION: The present study shows that age together with simultaneously assessed oscillometric BP and heart rate are the major determinants of Mobil-O-Graph-derived PWV, explaining >90% of the total variation of this marker. This age dependence of oscillometric PWV limits the validity of this marker to detect the premature vascular ageing, a unique characteristic of vascular remodelling in ESKD.

A comparative analysis of ambulatory BP profile and arterial stiffness between CAPD and APD.

Prior studies have associated automated peritoneal dialysis (APD) with less effective volume and blood pressure (BP) control as compared with continuous ambulatory peritoneal dialysis (CAPD). Our study aimed to compare the volume status, ambulatory BP profile and severity of arterial stiffness between patients treated with CAPD versus APD. In a case-control design, 28 CAPD patients were matched in 1:1 ratio with 28 controls receiving APD for age, gender and diabetic status. Body composition was assessed with the method of bioimpendence spectroscopy. Twenty-four hours ambulatory BP monitoring with the Mobil-O-Graph device (IEM, Germany) was performed to determine peripheral and central hemodynamic parameters, heart rate-adjusted augmentation index (AIx75) and pulse wave velocity (PWV). Standardized office BP, antihypertensive medication use and extracellular-to-total body water ratio did not differ between CAPD and APD groups. Twenty-four hours brachial systolic BP (129.0 ± 17.3 vs. 128.1 ± 14.2 mmHg, P = 0.83) and 24-h aortic systolic BP (116.9 ± 16.4 vs. 116.4 ± 11.6 mmHg, P = 0.87) were similar in patients treated with CAPD versus APD. Similarly, there was no significant difference between PD modalities in severity of arterial stiffness, as assessed with 24-h AIx75 (24.8 ± 8.9 vs. 22.5 ± 9.1, P = 0.36) and 24-h PWV (9.1 ± 2.4 vs. 8.8 ± 2.1 m/s, P = 0.61). The present study suggests that there is no difference in peripheral and central hemodynamic parameters as well as in the severity of arterial stiffness between CAPD and APD. However, these observations should be interpreted within the context of clinical characteristics of patients included in this case-control study. The comparative effectiveness of these 2 PD modalities warrants further investigation in larger longitudinal studies.

Prevalence of Apparent Treatment-Resistant Hypertension in ESKD Patients Receiving Peritoneal Dialysis.

BACKGROUND: Apparent treatment-resistant hypertension (aTRH) is defined as failure to achieve adequate blood pressure (BP) control despite taking ≥3 antihypertensive medications from different categories or when taking ≥4 antihypertensives regardless of BP levels. METHODS: In this cross-sectional study, we estimated the prevalence of aTRH in 140 patients receiving long-term peritoneal dialysis (PD) in four centers of Northern Greece, using the "gold-standard" method of ambulatory BP monitoring for the assessment of BP control status. The presence of subclinical overhydration was evaluated with the method of bioimpedance spectroscopy (BIS). RESULTS: Incorporating the diagnostic threshold of 130/80 mmHg for 24-hour ambulatory BP, the prevalence of aTRH in the overall study population was 30%. Compared to patients without aTRH, those with aTRH tended to be older in age, had higher PD vintage, had higher dialysate-to-plasma creatinine ratio, had more commonly history of diabetes mellitus, and were more commonly current smokers. With respect to the volume status, the overhydration index in BIS was higher in those with versus without aTRH (2.0 ±â€…1.9 L vs. 1.1 ±â€…2.0 L, P < 0.05). The prevalence of volume overload, defined as an overhydration index in BIS > 2.5 L, was also higher in the subgroup of patients with aTRH (38.1% vs. 18.4, P = 0.01). CONCLUSION: The present study showed that among patients on PD, the prevalence of aTRH was 30%. However, 38% of PD patients with aTRH had subclinical overhydration in BIS, suggesting that the achievement of adequate volume control may be a therapeutic opportunity to improve the management of hypertension in this high-risk patient population.The present study showed that among patients on PD, the prevalence of aTRH was 30%. However, 38% of PD patients with aTRH had subclinical overhydration in BIS, suggesting that the achievement of adequate volume control may be a therapeutic opportunity to improve the management of hypertension in this high-risk patient population. CLINICAL TRIALS REGISTRATION: Trial Number NCT03607747.

Clinic and Home Blood Pressure Monitoring for the Detection of Ambulatory Hypertension Among Patients on Peritoneal Dialysis.

The International Society of Peritoneal Dialysis recommends that adequate blood pressure (BP) assessment among patients on peritoneal dialysis should at least include measurements performed once-weekly at home and at each visit at clinic. However, the quality of evidence to support this guidance is suboptimal. Using ambulatory daytime BP as reference standard, we explored the diagnostic performance of clinic and home BP recordings in a cohort of 81 stable patients receiving peritoneal dialysis. BP was recorded using 3 different methodologies: (1) triplicate automated clinic BP recordings after a 5-minute seated rest with the validated monitor HEM 705 CP (Omron Healthcare); (2) 1-week averaged home BP recorded with a validated automated monitor on awaking and at bedtime; and (3) ambulatory BP monitoring with the Mobil-O-Graph device (IEM, Germany). The area under the curve of receiver operating characteristic curves in detection of ambulatory daytime systolic BP (SBP) ≥135 mm Hg was similar for clinic [area under the curve, 0.859; 95% CI, 0.776-0.941] and home SBP (area under the curve, 0.895; 95% CI, 0.815-0.976). In Bland-Altman analysis, clinic SBP overestimated daytime ambulatory SBP by 5.02 mm Hg with 95% limits of agreement ranging from -17.92 to 27.96 mm Hg. Similarly, home SBP overestimated daytime ambulatory SBP by 4.23 mm Hg, again with wide 95% limits of agreement (-16.05 to 24.51 mm Hg). These results show that 1-week averaged home SBP is of at least similar accuracy with standardized clinic SBP in diagnosing hypertension confirmed by ambulatory BP monitoring among patients on peritoneal dialysis.

Hypertension screening during healthcare pediatric visits.

BACKGROUND: Guidelines in both Europe and the United States recommend screening for hypertension during child care pediatric visits in children above 3 years old. The aims of the study were to assess the frequency of blood pressure (BP) measurement during preventive or chronic care pediatric visits and determine the factors that may associate with screening. METHOD: We prospectively included in the study consecutive children hospitalized in our department. Anthropometric measurements were performed in all children. Office BP was measured in children above 5 years old and mothers and/or fathers. Personal and family history, and self-reported BP screening during pediatric visits were recorded. RESULTS: Hypertension screening had been performed at least once in 45.3% of the children during pediatric visits. Fifty per cent of the children with elevated BP levels had never been screened for hypertension. Low birth weight, history of prematurity, or chronic disease was not associated with increased frequency of screening, whereas screening was more likely in children above 3 years old with positive personal history (odds ratio 2.35, 95% confidence interval 1.07-5.15, P < 0.05). Obesity tended to increase the frequency of hypertension screening in all ages (odds ratio 2.60, 95% confidence interval 0.93-7.28, P = 0.06). Moreover, 37.5% of children without positive personal history exhibited BP levels above the 90th percentile, and 13.5% of mothers and 31.1% of fathers were not aware of their own elevated BP levels. CONCLUSION: These findings suggest that hypertension screening does not occur during pediatric visits for a considerable percentage of children, although a significant number of children and adolescents without positive history of hypertension or chronic disease may have elevated office BP levels.