Brief Review

Hypertension in Chronic Kidney Disease Part 1

Out-of-Office Blood Pressure Monitoring: Methods, Thresholds,
and Patterns
Gianfranco Parati, Juan Eugenio Ochoa, Grzegorz Bilo, Rajiv Agarwal, Adrian Covic,
Friedo W. Dekker, Danilo Fliser, Gunnar H. Heine, Kitty J. Jager, Luna Gargani,
Mehmet Kanbay, Francesca Mallamaci, Ziad Massy, Alberto Ortiz, Eugenio Picano,
Patrick Rossignol, Pantelis Sarafidis, Rosa Sicari, Raymond Vanholder, Andrzej Wiecek,
Gerard London, Carmine Zoccali; on behalf of the European Renal and Cardiovascular Medicine
(EURECA-m) working group of the European Renal Association–European Dialysis Transplantation
Association (ERA-EDTA)

H ypertension is highly prevalent in chronic kidney dis-

ease (CKD), particularly in patients with end-stage renal
disease (ESRD) receiving hemodialysis.1,2 The identification
and treatment of hypertension in CKD has to face peculiar
problems because of the marked alterations in 24-hour blood
pressure (BP) profile, in particular of a reduced BP dipping at
night, and the high prevalence of specific hypertension phe-
notypes, such as white coat (WCH) and masked hypertension
(MH). Moreover, the ebb and flow of fluid volume in hemo-
dialysis patients makes a proper assessment and achievement
of BP control even more difficult. Although conventional BP
measurements (CBP), performed in the office or in the dialysis
unit by healthcare personnel, are currently recommended and
applied for the diagnosis and management of hypertension in
and home BP monitoring (HBPM), as acknowledged by a con-
sensus document by the American Society of Hypertension
and the American Society of Nephrology.5 In this article, we
highlight the advantages and disadvantages of out-of-office
BP monitoring for the management of arterial hypertension in
these conditions, based on a thorough literature search through
classical engines, such as Pubmed and Web of Science, supple-
mented by the authors' own expertise.
BP Thresholds for the Diagnosis and Treatment
of Hypertension in CKD and in ESRD Patients
The thresholds to define hypertension and BP targets for
antihypertensive treatment in CKD patients are debated.6,7
The recommendation to lower office BP to <130/80 mm Hg

patients with CKD, including those on dialysis, these metrics
are intrinsically inaccurate.3,4 CBP measurements are known to
fail providing reliable estimates of the actual BP burden in sev-
eral clinical conditions, and this is even more so in CKD and
in hemodialysis patients. Thus, in addition to CBP measure-
in CKD provided by former guidelines for management of
arterial hypertension8–10 has been challenged by randomized
controlled trials showing that the risk of death and progres-
sion to ESRD is not significantly reduced in patients who
achieve an office systolic BP (SBP) of 125 to 130 mm Hg.11–

 
ments, proper assessment and management of hypertension in 13
Besides, meta-analyses of trials exploring different BP
these patients should be ideally based also on out-of-office BP targets in subjects with CKD did not show consistent car-
measurements, including ambulatory BP monitoring (ABPM) diovascular and renal benefits in patients randomized to an

From the Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy (G.P., J.E.O.); Department of Cardiovascular, Neural and
Metabolic Sciences, San Luca Hospital, IRCCS Istituto Auxologico Italiano, Milan, Italy (G.P., J.E.O., G.B.); Indiana University and VAMC, Indianapolis
(R.A.); Clinic of Nephrology, C. I. Parhon University Hospital, Gr. T. Popa University of Medicine and Pharmacy, Iasi, Romania (A.C.); Department of
Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands (F.W.D.); Department of Internal Medicine IV, Saarland University
Medical Centre, Homburg, Saarland, Germany (D.F., G.H.H.); European Renal Association-European Dialysis and Transplant Association (ERA-EDTA)
Registry, Department of Medical Informatics, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands (K.J.J.); CNR, Institute
of Clinical Physiology, Pisa, Italy (L.G., E.P., R.S.); Division of Nephrology, Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
(M.K.); Nephrology, Dialysis and Transplantation Unit and CNR-IFC Clinical Epidemiology and Pathophysiology of Renal Diseases and Hypertension,
Reggio Calabria, Italy (F.M., C.Z.); Division of Nephrology, Ambroise Paré Hospital, Assistance Publique Hôpitaux de Paris, Boulogne-Billancourt, Paris,
France; University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), and Inserm U-1018, Centre de recherche en épidémiologie et santé
des populations (CESP), Equipe 5, Villejuif; Paris-Sud University (PSU) and University of Paris Ouest–Versailles-Saint-Quentin-en-Yvelines (UVSQ),
F-CRIN-INI-CRCT, Paris, France (Z.M.); IIS-Fundación Jiménez Díaz, Universidad Autónoma de Madrid, Fundación Renal Iñigo Alvarez de Toledo,
Madrid, Spain (A.O.); Inserm, Centre d’Investigations Cliniques-Plurithématique 1433, Inserm U1116, Nancy, France (P.R.); CHU Nancy, Département
de Cardiologie, Institut Lorrain du Cœur et des Vaisseaux, Vandoeuvre lès Nancy, France (P.R.); Université de Lorraine, Nancy, France (P.R.); INI-
CRCT (Cardiovascular and Renal Clinical Trialists), French-Clinical Research Infrastructure Network (F-CRIN), Paris, France (P.R., G.L.); Department
of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece (P.S.); Department of Internal Medicine, Nephrology
Section, University Hospital Ghent, Belgium (R.V.); Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia,
Katowice, Poland (A.W.); and INSERM U970, Hopital Européen Georges Pompidou, Paris, France (G.L.).
Correspondence to Gianfranco Parati, Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano &
University of Milan-Bicocca; Piazza Brescia 20, Milan 20149, Italy. E-mail gianfranco.parati@unimib.it
(Hypertension. 2016;67:1093-1101. DOI: 10.1161/HYPERTENSIONAHA.115.06895.)
© 2016 American Heart Association, Inc.
Hypertension is available at http://hyper.ahajournals.org DOI: 10.1161/HYPERTENSIONAHA.115.06895

1093
1094 Hypertension June 2016
office BP target lower than the conventional one (<140/90
mm Hg).14,15 In contrast, preliminary data of a large inter-
vention trial including CKD patients16—the systolic BP
intervention trial (SPRINT)—have recently suggested a
substantial benefit of lowering SBP below 120 mm Hg. In
the predefined subgroup of patients with CKD, the benefit
from intensive BP lowering in terms of the primary study
outcome did not reach statistical significance, whereas there
was a significant benefit in overall mortality, superimposable
with what observed in subjects without CKD. The recent
2013 European Society of Hypertension/European Society
of Cardiology guidelines issued more prudent recommenda-
tions, indicating an office BP <140/90 mm Hg as a treatment
target also in CKD patients.9 However, the same guidelines
suggest lowering office SBP to <130 mm Hg when overt
proteinuria is present, provided that changes in estimated
glomerular filtration rate are monitored. Similar recommen-
dations were made by the Eighth Joint National Committee
(JNC-8). The Kidney Disease: Improving Global Outcomes
(KDIGO) Guidelines recommendations indicate a target of
<130/80 mm Hg in CKD patients with albuminuria. Although
the African American Study of Kidney Disease (AASK),
the Ramipril in Non-Diabetic Renal Failure (REIN), and
Modification of Diet in Renal Disease (MDRD) trials do not
generally support target values of ≤130/80 mm Hg for CKD,
subgroup analyses show a benefit of tighter BP control in
CKD patients with albuminuria. Also recent long-term anal-
yses of the MDRD trial have supported a legacy effect of
lower BP targets.17
A U-shaped or an inverse relationship between BP lev-
els and risk of mortality was noted in hemodialysis patients
almost 2 decades ago18 and confirmed in several studies.19
Notably, pre- and postdialysis SBP levels between 120 and
180 mm Hg were practically not associated with different car-
diovascular risk, in contrast with the associations found in the
general population or in other high-risk groups. Furthermore,
a decline rather than an increase in predialysis SBP over time
associates with adverse cardiovascular outcomes.20 However,
observational studies like those discussed earlier are inher-
ently inadequate to solve the problem of defining BP thresh-
olds and BP targets in the hemodialysis population. As it will
be discussed later, predialysis BP mainly reflects a volume-
expanded state, and therefore, the relationship of predialysis
BP parameters with death or cardiovascular events may not
coincide with the relationship between the actual daily life
BP burden characterizing these patients and the same out-
comes. Recent analyses in patients from the Chronic Renal
Insufficiency Cohort (CRIC) who progressed to kidney failure
and started hemodialysis again confirmed a U-shaped rela-
tionship between predialysis BP and the risk of death but also
showed that in the same patients’ office SBP measured outside
the dialysis unit during a standard visit was almost linearly
related with the risk of death, as in the general population.21
In sharp contrast with observational data showing a nonlin-
ear association between BP and clinical outcomes, a meta-
analysis of clinical trials testing antihypertensive medications
applied to treat hypertension, left ventricular systolic dysfunc-
tion, or heart failure in hemodialysis patients showed better
outcomes with lower achieved BP values.22
Are CBP Measurements Adequate for the
Assessment and Management of Hypertension
in CKD?
The prevalence of hypertension gradually increases as renal
function deteriorates, and a high BP condition is almost
universal in patients who progress to ESRD.23,24 Population
studies with CBP measurements have shown hypertension
prevalence around 70% to 80% in patients with stage 1 CKD,
whereas in stages 4 and 5 before initiation of dialysis, this rate
increases to >95%.25,26 CBP measurements are less than ideal
to guide hypertension treatment in CKD. They are misleading
in a large proportion of patients because as much as 40% of
those who are apparently normotensive by CBP turn out to
be hypertensive by HBP.27 On the other hand, an analysis by
investigators of the Spanish ABPM Registry including over
5000 hypertensive patients with CKD stage G1-5 showed that
hypertension as assessed by office BP measurements (≥140/90
mm Hg: 78%) was much more frequent than when assessed by
24-hour ABPM (≥130/80 mm Hg: 56.5%). They also found a
high prevalence of WCH and a significant prevalence of MH
(estimated around 30% and 7%, respectively), supporting a
wider use of ABPM to diagnose and reliably evaluate the effi-
cacy of hypertension treatment in this population.28
Assessment of BP control in ESRD patients is even more
complex. The increase in intravascular volume during the
interval between dialysis sessions, fluid removal during dialy-
sis, left ventricular dysfunction, arterial rigidity, erythropoi-
esis-stimulating agents, abolished renal excretion, modified
intestinal uptake, and dialysis clearance of antihypertensive
drugs all contribute to the marked BP variability and incon-
sistent BP control in these high-risk patients. The application
of ABPM in hemodialysis patients, however, faces particular
problems, including the frequent technical inability to perform
BP monitoring because of multiple arterio-venous fistula or
arterial graft interventions and limited tolerance of the ABPM
apparatus by dialysis patients who already have serious sleep-
ing problems because of pain and itching.29 Hemodialysis
patients who initially accept ABPM, after the first experience,
often refuse repeating a 24-hour BP recording. In a recent sur-
vey by the European Renal Association–European Dialysis
Transplantation Association (ERA-EDTA), less than half of
dialysis centers declared to apply ABPM.29 Thus, the large-
scale applicability of ABPM in hemodialysis patients clearly
deserves further investigation.
Hypertension remains a major problem even after renal
transplantation, and at least 50% of these patients are frankly
hypertensive.30 Calcineurin inhibitors like cyclosporine and
tacrolimus induce hypertension and contribute to a paradoxi-
cal nocturnal BP rise in the transplant population.31 In contrast
to early CKD, hypertension in transplanted patients tends to
be more severe when evaluated by ABPM than by CBP and
is frequently associated with nocturnal hypertension and BP
nondipping (the latter issue will be further developed in a
twin manuscript separately published).32 Only 16% of kidney
recipients off antihypertensive drugs are truly normotensive
(normal CBP and ABP levels), and ≈44% of those receiving
antihypertensive treatment fail to achieve BP control when
assessed by ABPM (ie, they are characterized by masked
uncontrolled hypertension).33 These findings, along with the
 Parati et al Out-of-Office BP in CKD 1095

  
  
frequent occurrence of MH, further point to the relevance of ABPM to titrate antihypertensive treatment with the aim of
implementing ABPM also in the transplant population. reducing ABP below these levels, given the high cardiovascu-
lar risk of this population, BP goals in hemodialysis patients
ABPM in CKD and ESRD: ABPM Thresholds should be established individually, taking into account age,
As repeatedly emphasized, CBP measurements cannot track comorbid conditions, cardiac function, and neurological sta-
the BP changes occurring in daily life, and pre- and post- tus. Clinical trials based on ABPM measurements and well-
dialysis BP correlate poorly with 24-hour ABP in ESRD designed ABPM registries thus remain a priority if we are to
patients.34,35 Thus, adequate diagnosis and management of apply evidence-based treatment of hypertension in CKD and
hypertension in these patients should include out-of-office in ESRD patients.
BP measurements. Noninvasive ABPM techniques, based on
automated oscillometric, arm-cuff BP readings, are widely HBPM in CKD and ESRD
available and allow collection of a large number of BP read- Because of the wide availability of accurate automated BP
ings over the 24 hours during the daily life behaviors char- measuring devices, their relatively low cost, and their easy
acterizing daytime and nighttime subperiod conditions.35 The acceptability by both patients and physicians, recent guide-
technical aspects to consider when performing ABPM in clini- lines have recommended routine clinical use of HBPM.37,38
cal practice (ie, device selection and validation, measurement For diagnostic evaluation, guidelines suggest collecting
intervals, editing and interpretation of BP recordings) and HBP measures daily on at least 3 to 4 days and preferably
the description of the advantages and disadvantages of this over 7 consecutive days in the morning as well as in the eve-
technique for guiding and assessing antihypertensive treat- ning. Measures should be performed in a quiet room, with
ment and for predicting cardiovascular prognosis have been the patient in seated position, back and arm supported, after
addressed in a recent position paper of the European Society 5 minutes of rest, and with two measurements per occasion
of Hypertension.35,36 However, although there is consistent taken 1 to 2 minutes apart.37,38 By enhancing patients’ involve-
evidence to define normalcy levels for ABP values in non- ment and compliance with treatment, this technique has the
CKD populations (ie, <135/85 mm Hg for daytime, <120/70 potential to increase the rates of BP control. BP measure-
 
mm Hg for nighttime, and <130/80 mm Hg for 24 hours),35 no ments obtained by patients at home over several days, weeks,
 
 
solid, specific information exists for CKD patients, and thus, or months provide a representative measure of patient’s day-
no specific ABPM targets are given in current guidelines on time BP load, also allowing assessment of BP changes in the
ABPM for this population.35,36 In line with the prudent attitude long term. Compared with CBP, HBP measurements are more
adopted by the European Society of Hypertension guidelines strongly associated with target organ damage, progression of
for office BP targets,9 the ABPM targets suggested by the CKD, functional decline in the elderly, cardiovascular events,
position paper of the same society35 can be provisionally rec- and all-cause mortality.38–45 To which extent the standardiza-
ommended also for CKD patients before starting hemodialy- tion of HBP measurements, which is still a problem in routine
sis (Table). According to a document of the American Society practice, may influence these relationships is still unknown,
of Hypertension and the American Society of Nephrology,5 in however.46 Although HBP targets to be attained with antihy-
ESRD patients on dialysis, the diagnosis of hypertension is pertensive treatment in essential hypertensive patients with-
made when 44-hour ABP over the dialysis interval is ≥135/85 out CKD are still to be defined, the European Society of
mm Hg. Although awaiting for specific studies adopting Hypertension position paper on HBPM suggested to use a
 
Table. Definition of Hypertension and Indications for Drug Therapy of Hypertension in CKD and in ESRD Patients
 
Definition
Hypertension in CKD and in dialysis patients should be defined on the basis of home (HBPM) or 24-h ambulatory BP monitoring (ABPM) during a mid-week
 
dialysis interval. Thresholds proposed by the ESH and the ESC can be adopted for CKD patients,9 and those by the ASH and the ASN,5 for hemodialysis patients,
as below
Home BP measurements: ≥135/85 mm Hg both for CKD patients and for hemodialysis patients.
 
 
Twenty-four-hour ambulatory BP ≥130/80 mm Hg for CKD patients and ≥135/85 mm Hg for hemodialysis patients. In hemodialysis patients, ABPM should be
 
 
 
performed during a mid-week dialysis interval and, whenever feasible, extended to 44 h.
For hemodialysis patients, no recommendation can be made on the basis of predialysis or postdialysis BP. When neither ABPM nor home BP measurements
 
are applicable in dialysis patients, the diagnosis and the management of hypertension can be made on the basis of conventional BP (CBP) measurements taken
during the dialysis interval. At variance with predialysis BP which has an U-shaped relationship with risk of death, in the same patients, the average of 3 office
measurements (obtained in the sitting position after at least 5 min of quiet rest by trained personnel) is almost linearly related to the risk of the same outcome.21
The threshold of office BP (≥140/90 mm Hg) recommended by current guidelines for the definition of hypertension in CKD patients9 can be extended also to
 
hemodialysis patients.
Drug therapy goals
Particularly for hemodialysis patients, arterial pressure goals should be established individually, taking into account age, comorbid conditions, cardiac function,
 
and neurological status
ASH indicates Americal Society of Hypertension; ASN, American Society of Nephrology; BP, blood pressure; CKD, chronic kidney disease; ESC, European Society of
Cardiology; ESH, European Society of Hypertension; ESRD, end-stage renal disease.
1096 Hypertension June 2016

  
  
threshold value ≥135/85 mm Hg (corresponding to an office (MUCH), whereas the finding of elevated CBP with normal

 
BP ≥140/90 mm Hg) for diagnosing hypertension38 (Table), ABP/HBP is defined as white coat–resistant hypertension.

based on several observational studies and meta-analyses.47–52
In the absence of specific studies for CKD patients, the same
threshold has been suggested also for this population. For
hemodialysis patients, 2 daily HBP measurements, one in the
morning and the other before the night sleep, taken the day
after a midweek dialysis session and averaged over 4 weeks
are considered adequate for the diagnosis of hypertension.53
While waiting for ad hoc studies, the same hypertension
threshold as adopted in the general population and provision-
This categorization (Figure 1) provides useful information for
the assessment of hypertension and its response to treatment.
In a cross-sectional analysis of the Spanish ABPM Registry
examining the concordance/discordance between office BP–
based and ABP based control in treated hypertensive patients
with CKD, MUCH, and white coat–resistant hypertension had
a 7.0% and 28.8% prevalence, respectively.28 In a report of
the AASK, ≈70% of subjects with controlled CBP (<140⁄90
mm Hg) were shown to have elevated systolic/diastolic ABP

 
ally suggested for CKD patients (≥135/85 mm Hg; Table) levels (MUCH, ie, ≥135⁄85 mm Hg during daytime or ≥120⁄70

 
 
is also proposed to be applied in hemodialysis patients. The mm Hg during nighttime),55 and cardiac and renal organ dam-

frequency of measurements should be higher when excessive
BP lability is noted. In the sole cohort study published to
date in this condition, all-cause and cardiovascular mortality
were lowest in patients with home SBP ranging from 120 to
145 mm Hg.44
Masked and White Coat Hypertension in CKD
The combination of office and out-of-office BP allows iden-
tification of specific hypertension phenotypes in untreated
patients,54 that is, sustained hypertension (elevated CBP and
ABP/HBP), sustained normotension (normal CBP and ABP/
HBP), WCH (elevated CBP and normal ABP/HBP), and MH
(normal CBP and elevated ABP/HBP). When considering
treated patients, the occurrence of normal CBP with elevated
ABP/HBP is defined masked uncontrolled hypertension
age was significantly higher in patients with elevated night-
time BP, MH (or MUCH, if treated), or sustained hypertension
as compared with those with truly controlled BP or WCH
(white coat–resistant hypertension if treated).55 The high prev-
alence and adverse cardiovascular prognosis associated with
MH and MUCH emphasize the importance of detecting these
phenotypes in CKD patients to better prevent cardiovascular
and renal complications associated with these conditions.
Current guidelines recommend implementation of ABPM/
HBPM in most treated hypertensives, even if they have con-
trolled BP based on CBP measurements, in particular in
patients likely to have MUCH (ie, >60 years with high-normal
systolic CBP, smokers, or male patients >70 years), as well
as in patients with high-normal CBP at a high cardiovascular
risk or with established cardiovascular disease.37 On the other

Figure 1. Classification of patients based on the comparison of conventional office blood pressure (CBP) and home (HBP) or ambulatory
blood pressure (ABP) levels separately in untreated individuals (left) and in treated hypertensive patients (right). Reference threshold
values for ambulatory BP levels during daytime (ie, 135/85 mm Hg), 24 hours (ie, 130/80 mm Hg), and nighttime (ie, 120/70 mm Hg) and for
 
 
 
average HOME BP levels (ie, 135/85 mm Hg) are provided according to recent guidelines.35,36 Modified from Parati et al37 with permission
 
of the publisher. Copyright © 2008, Wolters Kluwer Health, Inc.

hand, identification of WCH, which may be present in ≈50%
of patients with CKD56 may avoid unnecessary BP-lowering
treatment, which in particular conditions, such as the elderly
or in presence of severe atherosclerotic disease, may compro-
mise renal and cardiac perfusion leading to episodes of acute
kidney injury or coronary ischemia.53,57,58 Recent studies inves-
tigating the potential long-term implications of WCH, how-
ever, have indicated that subjects with this BP pattern have a
higher risk for developing sustained hypertension, metabolic
abnormalities, cardiovascular organ damage, and cardiovascu-
lar events and mortality than those with sustained normoten-
sion, although this risk is lower than in individuals with MH
and sustained hypertension. It has therefore been suggested
that patients with WCH could benefit from active follow-up
and lifestyle counseling and even from drug treatment in spe-
cific high-risk cases.59–64
A recent report of a large study in CKD has provided
estimates on the prevalence and reproducibility of MUCH in
this specific population. Overall, the prevalence of MUCH
was 26.7% by daytime ABP, 32.8% by 24-hour ABP,
56.1% by daytime or nighttime ABP, and 50.8% by HBP.
Reproducibility of the diagnosis of MUCH was assessed by
repeating these measurements after 4 weeks. Agreement in
MUCH diagnosis by repeated ABP was 75% to 78% (k coef-
ficient for agreement, 0.44–0.51), depending on the definition
used. In contrast, HBP showed an agreement of only 63%
and a k coefficient of 0.25. Because reproducibility of HBP
was not different from that of CBP in diagnosing MUCH,
the study concluded that confirmation of MUCH diagnosis
should rely on ABPM.65
Evidence that ABPM may have a value in ESRD patients
to detect WCH and MH has also been provided by recent stud-
ies in hemodialysis patients in whom the prognostic value of
BP obtained in the dialysis unit was refined with ambulatory
BP levels.24
Improving BP Control With ABPM and HBPM
in CKD and in ESRD
BP control rates in CKD are unsatisfactorily low. Only
27% of treated hypertensives with CKD have CBP <140/90
mm Hg and only 11% reach a CBP target <130/85 mm Hg.1,66
Population studies with CBP measurements suggest that
hypertension control rates are low in individuals with CKD;
only 20% to 38% of individuals achieve CBP <140/90
mm Hg, whereas this rate falls to 6% to 18% when the thresh-
old <130/80 mm Hg is used.25 Notably, control rates slightly
increase with advancing stages of CKD because of increased
awareness and treatment of hypertension.25 In CKD patients,
the prevalence of systolic and diastolic hypertension (defined
as daytime ambulatory SBP ≥130 mm Hg and DBP ≥80
mm Hg) is 62% and 30%, respectively,66 indicating that in
these patients, attention should focus more on SBP control. In
a meta-analysis of studies comparing ABP and pre- and postdi-
alysis BP measurements in hemodialysis patients, predialysis
BP overestimated ABP levels during the 48-hour interdialysis
period, whereas postdialysis values underestimated ABP lev-
els, and the agreement between ABP and pre- and postdialysis
BP was poor.3 On this basis, an expert’s consensus proposed
performance of ABPM during the interdialytic period as the
Parati et al Out-of-Office BP in CKD 1097
standard approach for the assessment of BP levels in ESRD,67
and this recommendation was reiterated by the joint statement
of the American Society of Hypertension and the American
Society of Nephrology. Because hypertension in hemodialysis
patients largely reflects volume overload and BP normaliza-
tion may be an index of extracellular euvolemia, ABPM might
represent also a tool to assess BP-lowering strategies aimed
at normalizing sodium and fluid balance in ESRD (ie, dry
weight probing).68 However, only few studies have explored
the benefits of implementing ABPM for guiding antihyper-
tensive treatment in hemodialysis. As previously discussed,
although there are no doubts on the theoretical superiority of
ABPM over other BP measuring techniques, the large-scale
applicability of ABPM is an open issue and, because of par-
ticular patient-related barriers and of reimbursement issues,
the majority of dialysis centers still do not apply ABPM in
hemodialysis patients.29
With regards to HBPM, current guidelines for manage-
ment of arterial hypertension recommend its use as part of the
routine diagnostic and therapeutic approach to hypertension8,9
and give precise indications for BP measurement at home.37
As alluded to before, the use of HBPM for the diagnosis of
hypertension and the achievement of BP goals in CKD is sup-
ported by the fact that it reduces the misclassification resulting
from the white coat effect,66 but there is still no solid study on
the value of using this technique toward achieving BP goals.
In patients with ESRD, a proper implementation of HBPM
allows sampling BP levels at different time points throughout
the interdialytic period, thus providing a better assessment of
BP control. In line with observations in patients with essen-
tial hypertension, in an open trial comparing the effective-
ness of antihypertensive treatment in 2 groups, one applying
HBPM and the other using predialysis CBP measurements,
in the HBP-based management group, a 12 mm Hg decrease
in 24-hour systolic ABP was observed, whereas 24-hour ABP
levels remained unmodified in the group managed based on
predialysis CBP.69 Another advantage of HBP is that it reflects
ABP changes brought about by ultrafiltration intensification
to improve hypertension control in hemodialysis patients.53
Telemonitoring of HBP values increases compliance to treat-
ment and BP control in treated essential hypertensives70,71 and
might prove useful also in ESRD patients, but limited evi-
dence is available in this regard.
Superior Prognostic Value of Average ABP and
HBP Values in CKD and in ESRD Patients
There is solid evidence supporting the superior prognostic
value of ABP (either over 24 hours or daytime or nighttime)
and of HBP levels over CBP values. However, although most
of this evidence comes from studies conducted in the general
population or hypertensive subjects, there are few hard out-
come trials comparing HBP, ABP, and CBP levels in CKD
populations.
In CKD patients, the superior prognostic power of ABP
over CBP was demonstrated in a cohort of 436 consecutive
patients with CKD by Minutolo et al.56 In this study, ABP lev-
els (particularly nighttime SBP) nicely predicted the primary
end points of renal death and fatal and nonfatal CV events
after 4.2 years of follow-up, whereas CBP largely failed to
1098 Hypertension June 2016
Figure 2. Risk of fatal and nonfatal cardiovascular (CV) events
(A) and renal death (B) in patients stratified according to
achievement of daytime blood pressure (BP) target (<135/85
mm Hg) and nighttime BP target (<120/70 mm Hg). CI indicates
confidence interval; and HR, hazard ratio. Data refer to a cohort
of 436 chronic kidney disease (CKD) patients. Reproduced from
Minutolo et al56 with permission of the publisher. Copyright ©
2011, American Medical Association. All rights reserved.
predict the same outcomes (Figure 2). The superior prognostic
value of ABP over CBP in CKD was also shown in several
other studies.43,72,73 In a study by Gabbai et al, in treated hyper-
tensives with CKD with apparently adequate SBP control (ie,
systolic CBP <130 mm Hg), the risk of death, cardiovascular
disease, and progression to kidney failure was higher in the
subgroup with relatively higher average 24-hour, daytime, and
nighttime systolic ABP levels.72
In a study by Agarwal et al in hemodialysis patients,43
ABP showed a better association with left ventricular hyper-
trophy (LVH) than CBP, whereas ABP and CBP had a similar
degree of association with LVH in another study in the same
population.73 On the contrary, evidence has been produced
that ABP outperforms CBP as a predictor of cardiovascular
events42,74 and all-cause mortality75,76 in ESRD. ABPM dur-
ing the interdialytic period is a direct predictor of mortality
and is clearly superior to pre- and postdialysis measurements
for prognostic evaluation in these patients.77 In another cohort
study in the same population, ABP measures performed dur-
ing the interdialytic period predicted mortality, whereas nei-
ther pre- nor postdialysis BP was associated with the same
outcome.45 As to HBPM, the superior value of this technique
over CBP in predicting progression of renal dysfunction39,40
and development of cardiovascular events and mortality41,42 is
well supported. In a cohort of veterans with CKD, home SBP
emerged as an independent and better predictor of ESRD and
mortality as compared with CBP.41 Also in patients with ESRD,
HBP values seem superior to pre- or postdialysis CBP read-
ings. Indeed HBP measurements were associated with LVH
more strongly than pre- and postdialysis CBP, and the strength
of the HBP-LVH association was of the same order as the one
between ABP and the same outcome measure.43 Finally, 2
cohort studies comparing pre- and postdialysis BP versus HBP
measurements during the interdialytic period documented the
superiority of HBP in predicting all-cause and cardiovascular
mortality in the hemodialysis population44,45 (Figure 3).
Conclusions
CBP measurements performed in the office or in the hemo-
dialysis unit fail to provide a representative estimation of the
actual BP load in renal patients. A proper identification and
management of elevated BP levels in CKD as well as in ESRD
patients should thus include out-of-office BP measurements
in addition to CBP. This might reduce misclassification of
hypertension by identifying WCH and MH or MUCH, may
allow initiation of treatment in MH and prevent unnecessary
therapy for WCH. Such information might be useful to the
practicing physician to optimize antihypertensive treatment
and to achieve stable BP control in the long term. Reliance
on CBP alone for the diagnostic and therapeutic approach to
Figure 3. Hazard ratios for all-cause
mortality for quartiles of systolic blood
pressure (BP). Both home BP and
ambulatory BP had prognostic information.
Conversely, dialysis unit BP recordings
did not achieve statistical significance in
terms of prognostic value. P values are
those reported for linear trend. HD indicates
hemodialysis; and Q, quartile. Reproduced
from Alborzi et al44 with permission of the
publisher. Copyright © 2007, American
Society of Nephrology.

hypertension in CKD needs thus to be reconsidered. Current
international guidelines strongly support the use of ABPM
and HBPM in clinical practice as a fundamental complement
to conventional office or pre- and postdialytic BP measure-
ments.8,9 Data from ABPM registries in CKD will help to clar-
ify still pending important issues, such as defining the ABP
targets that maximize CV protection in CKD and to what
extent guiding BP-lowering strategies and assessing BP con-
trol with ABPM/HBPM might help to reduce CV morbidity
and mortality in CKD. Finally, to more consistently support
the clinical usefulness of ABPM and HBPM in CKD patients,
we would need randomized intervention outcome trials com-
paring these BP measuring methods with CBP by using treat-
ment algorithms designed to aim at appropriately defined
targets for each specific randomization group and focusing
on their impact on clinical outcomes. Special studies are also
needed to assess the applicability of ABPM on a large scale in
hemodialysis patients.
Disclosures
None.
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 Hypertension in Chronic Kidney Disease Part 1: Out-of-Office Blood Pressure
Monitoring: Methods, Thresholds, and Patterns
Gianfranco Parati, Juan Eugenio Ochoa, Grzegorz Bilo, Rajiv Agarwal, Adrian Covic, Friedo
W. Dekker, Danilo Fliser, Gunnar H. Heine, Kitty J. Jager, Luna Gargani, Mehmet Kanbay,
Francesca Mallamaci, Ziad Massy, Alberto Ortiz, Eugenio Picano, Patrick Rossignol, Pantelis
Sarafidis, Rosa Sicari, Raymond Vanholder, Andrzej Wiecek, Gerard London and Carmine
Zoccali
on behalf of the European Renal and Cardiovascular Medicine (EURECA-m) working group of
the European Renal AssociationEuropean Dialysis Transplantation Association (ERA-EDTA)

Hypertension. 2016;67:1093-1101; originally published online May 2, 2016;

doi: 10.1161/HYPERTENSIONAHA.115.06895
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