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Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 16  |  Issue : 2  |  Page : 189-194

A study comparing office blood pressure with ambulatory blood pressure in successful adult kidney-transplant recipients at a tertiary care center in North India


1 Department of Medicine, SKIMS Medical College, Bemina, Srinagar, Jammu and Kashmir, India
2 Department of Internal Medicine, SKIMS, Soura, Srinagar, Jammu and Kashmir, India
3 Department of Nephrology, SKIMS, Soura, Srinagar, Jammu and Kashmir, India
4 Department of Medicine, SKIMS Medical College, Bemina, India
5 Department of Urology, SKIMS, Soura, Srinagar, Jammu and Kashmir, India

Date of Submission11-May-2021
Date of Acceptance17-Oct-2021
Date of Web Publication30-Jun-2022

Correspondence Address:
Dr. Muzafar Naik
Department of General Medicine, SKIMS Medical College and Hospital, Bemina, Srinagar 190 015, Kashmir, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_46_21

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  Abstract 


Introduction: Hypertension is common following successful renal transplantation and has adverse effects on cardio-vascular and graft health. Blood pressure (BP) readings obtained during clinical visits can be misleading and ambulatory blood pressure monitoring (ABPM) is a more reliable and accurate non-invasive method of BP monitoring. Aims and Objectives: To compare office BP with ambulatory BP recordings in successful adult kidney transplant recipients (KTRs). Material and Methods: Office BP (OBP) was measured with mercury sphygmomanometer according to standardized procedure as the mean of two readings taken 1 minute apart; thereafter, 24 hour ABPM was done using automated oscillometric device (Meditech device) in 56 KTRs. Results: OBP missed hypertension in 68% of KTRs who had normal OBP (masked phenomenon) and OBP overestimated hypertension in 11% of KTRs with uncontrolled OBP (white coat phenomenon). Thirty-four percent of patients were normal dippers, 32% non-dippers, 25% reverse dippers and 9% were extreme dippers. Conclusions: ABPM is a valuable tool in detecting dipping status, white coat and masked phenomena which are frequent problems among KTRs and should be considered as part of routine management of hypertension in KTRs.

Keywords: Ambulatory blood pressure monitoring, masked hypertension, kidney-transplant recipients, white coat hypertension


How to cite this article:
Bhat T, Idrees M, Wani MM, Naik M, Wani IA, Wani AA, Wani MS, Bhat MA, Hamid A. A study comparing office blood pressure with ambulatory blood pressure in successful adult kidney-transplant recipients at a tertiary care center in North India. Indian J Transplant 2022;16:189-94

How to cite this URL:
Bhat T, Idrees M, Wani MM, Naik M, Wani IA, Wani AA, Wani MS, Bhat MA, Hamid A. A study comparing office blood pressure with ambulatory blood pressure in successful adult kidney-transplant recipients at a tertiary care center in North India. Indian J Transplant [serial online] 2022 [cited 2022 Aug 15];16:189-94. Available from: https://www.ijtonline.in/text.asp?2022/16/2/189/349353




  Introduction Top


Kidney transplantation (KT) is the renal replacement therapy of choice for most patients with end-stage renal disease (ESRD).[1],[2],[3] Hypertension (HTN) is common following successful KT affecting 75%–90% of recipients and has adverse effects on cardiovascular (CV) and graft health.[4],[5] CV disease remains the largest single cause of death in kidney-transplant recipients (KTRs) accounting for approximately 40% of all-cause mortality.[6],[7],[8],[9]

There are concerns regarding ideal blood pressure (BP) measurement and monitoring in KTRs. BP measurements taken in clinics may not always reflect BP outside the clinic.[10] BP variability is common and is superimposed on diurnal variation. Patients may exhibit white coat, nocturnal or masked HTN.[5] Hence, BP readings obtained during clinic visits can be misleading. Regardless of the method used to measure office BP (OBP), it must be recognized that BP is highly variable and is influenced by several factors not the least being the circumstances of the measurement itself such as respiration, emotional state, exercise, temperature, posture, pain, and eating.[11],[12] Hence, inadequate BP control may occur when OBP is used as the only method to monitor BP and guide treatment adjustment.[10]

Ambulatory blood pressure monitoring (ABPM) technique can record BP for 24 h or longer while patients do their normal daily activities. Adult studies indicate that 24-h ABPM provides a much better representation of the patient's BP pattern than office readings and is necessary to diagnose nocturnal, masked, and white-coat HTN.[13] ABPM is a much better predictor of adverse outcome than OBP.[14] Several studies conducted both in normotensive and hypertensive adult subjects have demonstrated that ABPM has a higher short- and long-term reproducibility than OBP measurement and is clinically superior to OBP in predicting target organ damage.[15],[16] By means of ABPM, it is also possible to explore the amplitude and frequency of BP fluctuations occurring during the entire 24-h period as increased BP variability is a well-established feature in hypertensive patients.[17] In addition, ABPM is not subject to digit preference and avoids the transient rise of patient's BP in response to the observer (white-coat effect).[18] The use of ABPM also provides additional insights (timing and frequency) into responses to antihypertensive therapy.[19],[20]

Given the dependence of graft health and survival on good BP control and the inadequacies of the periodic OBP checks, it is imperative to supplement the BP management of KTRs with ABPM.[21],[22],[23]

Aims and objectives

  • To determine the difference in detection of BP with conventional office BP with ambulatory BP and define hypertensive phenotypes in successful adult kidney-transplant recipients (KTRs)
  • To estimate the effect of discordance of detection of BP in changing the antihypertensives.



  Materials and Methods Top


This prospective study was conducted at Sher-i-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar, over a period of years and involved 56 patients. Due ethical clearance from the Institutional Ethical Committee was taken, and all the individuals gave informed consent to participate in the study. This study involved adult patients who had undergone successful KT at least 3 months earlier with stable renal function (serum creatinine <2 mg %).

Before doing ABPM, all the baseline parameters (name, age, sex, height, weight, BMI), date and time since KT, type of donor, primary renal disease, baseline serum creatinine, 24-h urinary protein, number of antihypertensive and immunosuppressive drugs, and their duration were recorded. OBP was measured according to standardized procedure with the use of calibrated mercury sphygmomanometer with cuff of adequate size after the patient had been resting in a seated position for 5 min. The appearance and disappearance of Kortokoff sounds were taken as systolic and diastolic BP, respectively; the mean of two clinic BP readings taken 1 min apart was used.

Thereafter, 24-h ABPM was performed with validated, automated, oscillometric device (Meditech device-USA) that was programmed to record BP at 15-min interval during the day (day-time interval was set between 6 am and 10 pm) and at 30-min interval at the night (night interval was set between 10 pm and 6 am). ABPM was recorded on the nondominant upper arm using the appropriate arm cuff. To improve the quality of BP recordings, recipients were given tailored instructions on the procedure and encouraged to maintain their usual activities. They were asked to complete a diary of events during the 24-h period, including their awake and asleep times. For analysis, mean of all valid readings was used. Valid measurements had to fulfil prespecified quality criteria, including the successful recording of at least 70% of systolic and diastolic BP readings during the 24-h recording period.

Following parameters in 24 h, ABP readings were taken into consideration in this study:

  1. 24-h mean BP, day-time mean BP, and night-time mean BP
  2. Maximum SBP, maximum DBP (during total 24-h period, daytime period, and night time period).
  3. Standard deviation of 24-h, daytime, and night-time BP.
  4. Percent time elevation (PTE) of 24-h, daytime, and night-time BP
  5. Hyperbaric impact (HBI) of 24-h, daytime, and nighttime BP
  6. Diurnal index and morning surge of 24-h BP.


The BP was considered as controlled or uncontrolled as per the definition given by the KDIGO guidelines for renal-transplant recipient patients [Table 1].[24]
Table 1: Criteria for defining blood pressure on office blood pressure and ambulatory blood pressure monitoring readings in patients of kidney transplant recipients

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The blood pressure phenotypes in renal transplant recipients were determined after assessing both office blood pressure and ambulatory blood pressure measurement readings [Table 2].
Table 2: Hypertensive phenotypes based on office blood pressure and ambulatory blood pressure monitoring readings in patients of kidney transplant recipients

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Statistical analysis

Statistical data analysis was done utilizing Statistical analysis was performed using IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. (Armonk, NY: IBM Corp.) . The normality of the test was done by the Shapiro-Wilk test. Median with interquartile range (IQR) was calculated for age, office systolic BP, and office diastolic BP. Median and standard deviation were calculated for height, weight, 24-h systolic BP, 24-h diastolic BP, active systolic BP, active diastolic BP, passive systolic BP, and passive diastolic BP. Nonparametric data were analyzed utilizing the Mann–Whitney U-test for two variables. Nominal categorical data between the groups were compared using the Fisher's exact test. Continuous categorical data between the groups were compared using a sample t-test. P < 0.05 was considered as statistically significant.

Declaration of patient consent

The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity.

Ethics statement

IEC/SKIMS MC Protocol No. 16/IEC/09/2016. The study was performed according to the guidelines in Declaration of Helsinki.


  Results Top


The current study was conducted in 56 adult (35 males and 21 females) kidney-transplant subjects aged 18–78 years (mean 37.85 ± 14.38) over a period of 2 years, to find out the prevalence and control of HTN as well as patterns of BP. Among them, 70% of the patients were between 18 and 59 years. All the patients had live kidney donor (44 related and 12 unrelated) [Table 3]. The cause of the primary renal disease was indeterminate in 27 (48%), IgA nephropathy in 11 (20%), diabetes mellitus in 9 (16%), HTN in 7 (12%), and FSGS and ADPKD in one each.
Table 3: Demographic and clinical parameters of study patients

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The time since transplantation varied between 3 months and 21 years and was over 1 year in about two–third (38) of the patients. Fifty-four patients were on combination of triple immunosuppressive drugs (prednisolone, calcineurin inhibitor, and antimetabolite) and two were on combination of prednisolone and antimetabolite. The comorbidities in our subjects included HTN in 47 and diabetes mellitus in 19; five patients had no comorbidity and 15 had two or more comorbidities.

Group 1: Kidney-transplant recipients with normal office blood pressure

In our study, out of 16 patients with normal OBP, six patients (37.5%) had controlled BP on ABPM, whereas rest 10 patients (62.5%) had uncontrolled BP on ABPM [Figure 1]. Out of the 6 patients with controlled BP on ABPM, 1 patient was not on any antihypertensive treatment (true normotensive), whereas 5 patients were on anti-hypertensive treatment (controlled HTN). Out of 10 patients with uncontrolled BP on ABPM, two patients were not on any antihypertensive treatment (masked HTN), whereas 8 patients were on antihypertensive treatment (masked uncontrolled HTN). In other words, out of 13 patients with normal BP on OBP measurement despite on anti-hypertensive treatment, only 5 (38.5%) had normal BP on ABPM and 16 (67.5%) had high BP on ABPM. The various descriptive parameters of renal transplant recipients based upon office blood pressure control are shown in [Table 4].
Figure 1: Flowchart showing ambulatory blood pressure measurement results in patients with normal office blood pressure. OBP: Office blood pressure, ABPM: Ambulatory blood pressure measurement

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Table 4: Descriptive variables of renal transplant recipients on office blood pressure control

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Group 2: Kidney transplant recipient's with high office blood pressure

Out of 40 patients with uncontrolled BP on OBP, 4 (10%) patients had controlled BP on ABPM whereas 36 (90%) patients had uncontrolled BP on ABPM [Figure 2]. All of the 4 patients with controlled BP on ABPM were on antihypertensive Rx (white-coat effect). Out of 36 patients with uncontrolled BP on ABPM, 6 patients were not on antihypertensive treatment (sustained HTN), whereas the rest 30 patients were on antihypertensive treatment (uncontrolled HTN). Out of these 30 patients with high BP on OBP and ABPM measurements, 14 were on 1 antihypertensive drug, 13 on two anti-hypertensive drugs, 2 on three anti-hypertensive drugs, and 1 on four anti-hypertensive drugs; the only patient with refractory HTN.
Figure 2: Flowchart showing ambulatory blood pressure measurement results in patients with high office blood pressure. OBP: Office blood pressure, ABPM: Ambulatory blood pressure measurement

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Out of 16 patients with normal OBP, 10 were having masked hypertension. All of these 10 patients with masked HTN had nocturnal hypertension (100%), whereas only 3 patients had daytime (active) HTN in addition to nocturnal HTN (passive). Seven out of 10 patients with masked HTN were either reverse or nondippers, 4 and 3, respectively, rest 3 patients were normal dippers. Of the 56 patients, 19 (34%) were normal dippers, 18 (32%) were nondippers, 14 (25%) were reverse dippers, and 5 (9%) were extreme dippers [Table 5]. In our study, 14 patients (25%) got benefited by ABPM because of discordance between OBP and ABPM, and the benefit was seen predominantly in patients with controlled OBP where 10 out of 16 patients (62.5%) had uncontrolled BP on ABPM, whereas in patients with uncontrolled OBP, only 4 out of 40 (10%) patients had controlled BP on ABPM.
Table 5: Dipping pattern of renal transplant recipients on ambulatory blood pressure monitoring

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  Discussion Top


HTN is the most prevalent CV risk factor reported in KTRs, affecting 75%–90% of recipients and is multifactorial in etiology.[4],[5] Posttransplant HTN is a powerful predictor of outcome and accurately diagnosing high BP remains a challenging task in KTRs.[3],[21],[22] Inadequate BP control may occur when OBP is used as the only method to monitor BP and adjust treatment.[15] Studies indicate that 24-h ABPM provides a much better representation of the patient's BP pattern than office readings and is a much better predictor of adverse outcomes than OBP.[18],[20] Moreover, ABPM is necessary to diagnose nocturnal HTN, masked HTN and white-coat HTN which have a bearing on outcome.[10],[25]

As reported in most series from India, there was a male preponderance in our series (35 males versus 21 females).[10],[20] Among the identifiable causes of renal failure, IgA nephropathy, DM and hypertension were the most common – a finding reported by Demirkol et al.[26] Our KTRs had a higher eGFR (78.08 ± 22.50 ml/min/m2) than reported by many Indian studies which may reflect younger age of our patients.[10],[20],[26]

The prevalence of HTN (84%) in our KTRs was comparable to the prevalence (80%–90%) reported in studies from India or overseas.[12],[18],[20],[27] Mean office SBP was 131.32 ± 13.49 mmHg and mean office DBP was 80.85 ± 8.53 mmHg. Mallamaci F et al. also reported mean office SBP of 132 mmHg and DBP of 78 mmHg.[27] In our study, 9, 20, 21, and 6 patients were on no, one, two, and three or more antihypertensive medications, respectively; similar figures were reported in studies by Ravichandran et al. and Mallamaci et al.[20],[27]

The percentage of normal dippers and nondippers (including reverse and extreme dippers) in our study were comparable with those reported by Demirkol et al.[26] However, in our study, the percentage of normal dippers was slightly higher and nondipper slightly lower as compared to studies by Paoletti et al., Fernandez Fresnedo et al., and Denise et al., which can be explained by the fact that most of our patients were taking long-acting antihypertensive medication and some patients were taking antihypertensives at bedtime.[22],[28],[29]

In 10 out of 16 (62.5%) of patients with controlled OBP, ABPM demonstrated hypertension. The rates of masked HTN on OBP compare well with those reported by Ahmad et al. (i.e., 58%) but are more than twice the rate (30%) reported by Paoletti et al.[10],[22] Our higher rates of masked HTN and fewer cases of WCP likely reflect more stringent criteria for BP and inclusion of nocturnal BP measurements.

Among patients with concordance, 1 patient (6.25%) was normotensive and 5 patients (31.25%) had controlled HTN on antihypertensive medication. Hence, our transplant clinic adequately controlled BP only in 6 (37.5%) out of 16 patients with controlled OBP. The percentage of KTRs achieving optimal BP control has been reported to vary very widely between 5 and 91%. The difference reflects, at least partly, the varying definitions of HTN (or optimal control) in the setting of ABPM; e.g., Paoletti et al. defined HTN as BP of >130/80 while David et al. used a cutoff of >135/85 to define HTN in the setting of ABPM.[22],[30]

Of 40 patients with uncontrolled OBP, 36 (90%) had uncontrolled BP on ABPM as well. These results compare well with those of David et al., who reported a concordance rate of 69% for the diagnosis of HTN at baseline which increased to 86% at 2nd month and stayed above 90% subsequently.[30] Haydar et al. also reported concordance rate between OBP and ABPM of 80% for diagnosing HTN. However, some studies have reported lower concordance rates for HTN and more cases of WCE than our study; the discrepancy is likely due to lower BP values for diagnosing HTN and inclusion of nocturnal HTN in our study group.[26],[31]

Clearly, ABPM provides information and clarity on a 24-h (including nocturnal) BP profile in a patient that a one-off clinic measurement just cannot.[32],[33],[34] Our study adds to the growing body of literature on the subject and shows major discrepancies between OBP and ABP. Our findings suggest that some antihypertensive medication should be prescribed at night and that ABPM would be a reliable tool for diagnosing HTN and monitoring treatment results.

Limitations

Our study revealed that OBP is much more misleading in KTRs who have normal OBP rather than in those KTRs who have uncontrolled OBP. Small sample size, OBP based on average of only 2 readings, and a single ABPM measurement are some of the limitations of our study. Further studies are needed to elucidate the effects of ABPM-guided antihypertensive therapy on BP control over longer follow-up period. We suggest ABPM should be considered as part of routine management of HTN in KTRs.


  Summary and Conclusions Top


OBP can underestimate HTN in 68% of KTRs who have normal OBP (masked phenomenon).

OBP can overestimate HTN in 11% of KTRs with uncontrolled OBP (White coat phenomenon).

Only 34% of KTRs had normal dipping pattern, while as 32% had nondipping and 25% had reverse-dipping pattern; 9% of KTRs had abnormally low nocturnal BP (extreme dippers).

We suggest that ABPM should be considered as part of routine management of HTN in KTRs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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[PUBMED]  [Full text]  
31.
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    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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