Is 24-hour ambulatory blood pressure monitoring appropriate in patients with Chronic Kidney Disease (CKD)?

From the Guidelines

24-hour ambulatory blood pressure monitoring (ABPM) is a recommended approach for patients with chronic kidney disease (CKD) as it provides a comprehensive assessment of blood pressure patterns. This approach is supported by the 2021 KDIGO clinical practice guideline for the management of blood pressure in CKD, which suggests that out-of-office BP measurements with ABPM or home BP monitoring be used to complement standardized office BP readings for the management of high BP 1. The guideline emphasizes the importance of accurate measurements and recommends using initial ABPM, where available, to supplement standardized office BP and home BP monitoring for ongoing management of BP.

Key Considerations for ABPM in CKD Patients

• ABPM should be performed using a validated device with an appropriate cuff size.
• Readings are typically taken every 15-30 minutes during daytime and every 30-60 minutes at night over a full 24-hour period.
• This monitoring is particularly valuable in CKD because these patients frequently have masked hypertension, white coat hypertension, or non-dipping patterns, which are associated with worse renal and cardiovascular outcomes.
• ABPM helps clinicians optimize antihypertensive therapy timing and dosing to achieve 24-hour blood pressure control, which is crucial for slowing CKD progression.

Target Blood Pressure for CKD Patients

• The target blood pressure for most CKD patients is typically below 130/80 mmHg for the 24-hour average, though individual targets may vary based on comorbidities and tolerance 1.
• The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline also supports a lower target of <130/80 mmHg for all patients with CKD, based on the SPRINT study results 1.

Clinical Implications

• The use of ABPM in CKD patients can help identify those with masked hypertension or non-dipping patterns, allowing for more targeted treatment and improved blood pressure control.
• Clinicians should consider the results of ABPM when making decisions about antihypertensive therapy, and adjust treatment as needed to achieve optimal blood pressure control.

From the Research

Appropriateness of 24-Hour Blood Pressure Monitoring in CKD Patients

• 24-hour blood pressure monitoring, also known as ambulatory blood pressure monitoring (ABPM), is considered a useful tool in the management of hypertension in patients with chronic kidney disease (CKD) 2, 3, 4, 5.
• ABPM provides more accurate blood pressure measurements than office-based blood pressure measurements, and is better at detecting hypertension and predicting cardiovascular risk in CKD patients 2, 3, 5.
• The use of ABPM can help identify patients with CKD who have masked hypertension, which is defined as elevated blood pressure outside of the clinical setting, but normal blood pressure in the clinic 3, 4.
• ABPM can also provide information on circadian blood pressure variation and short-term blood pressure variability, which are associated with cardiovascular and renal outcomes in CKD patients 2, 5.
• Studies have shown that ABPM is a superior prognostic marker compared to office blood pressure measurement, and can help identify CKD patients at increased risk of cardiovascular events and progression of kidney disease 2, 3, 5, 6.
• The analysis of rhythmic components in 24-hour ABPM profiles can also provide additional prognostic information, and can help identify subgroups of CKD patients at advanced risk of cardiovascular death 6.

Key Findings

• A study published in 2016 found that ABPM is better at detecting hypertension than office blood pressure measurement, and is a superior prognostic marker for cardiovascular risk in CKD patients 2.
• A study published in 2009 found that out-of-office blood pressure measurements, including ABPM, are better at predicting end-organ damage and mortality outcomes in CKD patients than office-based blood pressure measurements 3.
• A study published in 2018 found that 24-hour ABPM can detect abnormal blood pressure patterns in patients with CKD who have normal casual blood pressure measurements 4.
• A study published in 2013 found that ABPM is a useful tool for predicting cardiovascular risk and CKD progression in patients with CKD, and can provide additional prognostic information when used in combination with estimated glomerular filtration rate (eGFR) 5.
• A study published in 2023 found that the analysis of rhythmic components in 24-hour ABPM profiles can provide additional prognostic information, and can help identify subgroups of CKD patients at advanced risk of cardiovascular death 6.