Role of Ambulatory Blood Pressure Monitoring (ABPM) in chronic kidney patients: a review

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Antonella Netti

Antonella Netti1, Silvio Borrelli1, Nicola Peruzzu1, Lucio Polese1, Carlo Vita1, Toni De Stefano1, Giuseppe Conte1, Luca De Nicola1, Roberto Minutolo1, Michele Provenzano2, Carlo Garofalo1

1 U.O. Nefrologia, Università degli Studi della Campania, “Luigi Vanvitelli”, Napoli, Italia
2 U.O. Nefrologia, Università “Magna Graecia”, Catanzaro, Italia

Corrispondenza a:
Antonella Netti
U.O. Nefrologia e Dialisi, Ospedale Santa Maria del Popolo degli Incurabili di Napoli,
Via Maria Longo 50,
08138 Napoli, Italia
Tel 081 2549405
E-mail: nettiantonella@gmail.com

 

Abstract

About 90%of patients with chronic kidney disease (CKD) have arterial hypertension; the main international guidelines recommend maintaining blood pressure (BP) values below 130/80 mmHg to reduce the cardio-renal risk in this population. Twenty-four-hour Ambulatory Blood Pressure Monitoring (ABPM) is the golden standard for the identification of the BP profiles and patterns, as well as for the assessment of the circadian rhythm and BP variability. The correct interpretation of ABPM allows to optimize anti-hypertensive treatment and to reduce cardio-renal risk in CKD patient.

In fact, in patients with CKD, the ABPM has a greater role in terms of renal and cardio-vascular prognosis when compared to clinical BP measurements. Patients with ABPM in target present a low cardio-renal risk, regardless of clinical BP values; on the contrary, if the clinical PA is normal and the ABPM not in target, this risk increases significantly. Moreover, in the CKD population, non-dipping is associated with a higher risk of cardiovascular events and end stage renal disease (ESRD), making identifying nocturnal hypertension greatly important.

Therefore, ABPM is an instrument of primary importance in the diagnostic and therapeutic work-out of renal patients.

 

KEYWORDS: ABPM, CKD, blood pressure

Sorry, this entry is only available in Italian.

Introduzione        

La malattia renale cronica (Chronic Kidney Disease, CKD) coinvolge in Italia circa 2 milioni di persone, con una prevalenza del 7% all’interno della popolazione generale, come osservato nello studio CARHES condotto in Italia nel 2010 [1–3]. 

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Between old and new targets: blood pressure control in hypertensive outpatients

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Antonio Del Giudice

Antonio Del Giudice1, Andrea Fontana2, Antonio Cicchella1, Claudio Carmine Guida1, Antonio Gesuete1, Rachele Grifa1, Antonio Mangiacotti1, Filomena Miscio1, Matteo Piemontese1, Michele Prencipe1, Michele Vergura1, Massimiliano Copetti2, Filippo Aucella1

1Dipartimento di Scienze Mediche, Struttura Complessa di Nefrologia e Dialisi e Centro per l’Ipertensione Arteriosa, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italia
2Unità di Biostatistica, IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italia

Autore corrispondente:
Antonio Del Giudice
S.C. di Nefrologia e Dialisi e Centro per l’Ipertensione Arteriosa
IRCCS Casa Sollievo della Sofferenza
Viale Cappuccini
71013 San Giovanni Rotondo, Italia
Tel. 0882410397 / Fax. 0882410944
E-mail: a.delgiudice@operapadrepio.it

 

Abstract

Objective. In developed countries, blood pressure (BP) control has increased over the past few decades and is now approaching 70% of patients. Herewith we report the results of a cross-sectional study carried out on hypertensive outpatients.

Design and methods. In a cohort of 1,412 consecutive hypertensive outpatients (790 females, 622 males; mean age: 60.3±12.2 years) evaluated from January 2015 to December 2016, the following parameters were assessed: age, gender, body mass index (BMI), waist circumference (WC), smoking habits, BP in the sitting position, estimated glomerular filtration rate (eGFR), serum glucose, lipid profile, antihypertensive drugs prescribed. In agreement with the European guidelines, hypertension was defined as sitting BP ≥140/90 mmHg or use of antihypertensive drugs. Patients whose BP was <140/90 mmHg were considered as having achieved BP control. Furthermore, in compliance with the redefinition of hypertension suggested by the American College of Cardiology/American Heart Association (ACC/AHA), a second level of BP control (BP <130/80 mmHg) was evaluated.

Results. Overall, 75.7% of hypertensive patients achieved BP levels <140/90 mmHg, while 50.5% achieved BP levels <130/80 mmHg. In both contexts, compared with patients whose BP was not controlled, those achieving the BP targets were mainly younger and females with a lower prevalence of obesity, diabetes and chronic kidney disease. Furthermore, they also had a lower WC and a higher eGFR.

Conclusions. Nearly 76% of patients achieved the BP target of <140/90 mmHg, a result which is higher than the 70% achieved in Europe, and 50.6% achieved that of <130/80 mmHg, a result which is slightly higher than the 47% recently reported in USA.

Keywords: Blood pressure, blood pressure control, hypertension.

Sorry, this entry is only available in Italian.

Introduzione

L’ipertensione arteriosa è uno dei maggiori fattori di rischio indipendenti e modificabili per cardiopatia ischemica, scompenso cardiaco, accidenti cerebrovascolari, insufficienza renale e mortalità cardiovascolare in tutti i gruppi di età (1).

 

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Renal manifestation of Autosomal Dominant Polycystic Kidney Disease

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Marco Galliani1, Silvana Chicca1, Elio Vitaliano1, Luca Di Lullo2, Konstantinos Giannakakis3, Antonio Paone1

1UOC Nefrologia, Dialisi e Litotrissia, Ospedale Sandro Pertini, ASL RM2, Roma, Italia
2UOC Nefrologia e Dialisi, Ospedale L. Parodi Delfino, Colleferro (RM), Italia
3 Dipartimento Scienze Radiologiche, Oncologiche e Anatomo Patologiche, Università di Roma “La Sapienza”, Italia

Autore Corrispondente:
Marco Galliani
UOC Nefrologia, Dialisi e Litotrissia, Ospedale Sandro Pertini, ASL RM2
Via dei Monti Tiburtini, 385
00157 Roma, Italia
Tel. 0641433575
E-mail: marco.galliani@aslroma2.it

 

Abstract

Autosomal dominant polycystic kidney disease affects over 12 million people in the world and is the fourth cause of ESRD. It is the main monogenic kidney disease and causes the progressive formation of cysts leading to renal failure after a few decades. The main manifestations of the disease are observed even at a young age.
The early sign of ADPKD is impaired urinary concentrating capacity, due to medullary alteration by cysts, and resistance to vasopressin.
These anatomical alterations determine hyperfiltration, altered ammonium transport, nephrolithiasis, and, above all, hypertension even in pediatric age. Activation of the renin-angiotensin-aldosterone system has been shown responsible for the maintenance of high pressure values as well as the growth of cysts and renal fibrosis. Arterial hypertension would be responsible for ventricular hypertrophy.
Many recent studies have confirmed the role of pressure control, especially if rigorous, in decreasing the progression of renal disease, and the use of ACE inhibitors seems to have higher efficacy than other antihypertensive drugs.
The progression of renal disease is evidenced by the reduction of glomerular filtration which may be minimal in the early years, due to hyperfiltration, but, then, may even exceed 5 ml / min per year, especially when the total kidney volume (TKV) exceeds 1500 ml.
In more rapid progression forms, ESRD may appear at about 55 years of age. The main risk factors are age, genetic mutation, familiarity with ESRD, macrohematuria episodes, and early onset hypertension. Some authors have proposed both genetic and clinical scores that can provide guidance on the probability of rapid progression.
Other renal manifestations include kidney pain, nephrolithiasis, urinary tract infections and cyst hemorrhage. Renal cell carcinoma is a very rare event.

 

Keywords: Autosomal dominant polycystic kidney disease, hypertension, renin-angiotensin-aldosterone system, compensatory hyperfiltration, renal volume, ESRD.

Sorry, this entry is only available in Italian.

Introduzione

Il rene policistico rappresenta la malattia ereditaria monogenica più frequente in ambito nefrologico. Ne sono affetti circa 12,5 milioni di individui nel mondo ed è la quarta causa di insufficienza renale terminale dopo il diabete, l’ipertensione e le glomerulonefriti (1). 

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PRES (Posterior Reversible Encephalopathy Syndrome): Potential complication of hypertensive crisis. Case report and literature review

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Michele Vergura

Vergura Michele1, Prencipe Michele1, Del Giudice Antonio Maria1, Grifa Rachele1, Miscio Filomena1, Pennelli Anna Maria2, Popolizio Teresa2, Simeone Anna2, Ferrare Mariangela3, Leone Maurizio3, Aucella Filippo1

1 Struttura Complessa di Nefrologia e Dialisi IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo (FG)
2 Dipartimento di Diagnostica per Immagini IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo (FG)
3 Struttura Complessa di Neurologia IRCCS “Casa Sollievo della Sofferenza”, San Giovanni Rotondo (FG)

Autore Corrispondente:
Vergura Michele
Struttura Complessa Nefrologia e Dialisi  IRCCS “ Casa Sollievo della Sofferenza “,
V.le Cappuccini, 1, 71013 San Giovanni Rotondo
Tel: 0882 410293
Fax: 0882 410208
Email: m.vergura@operapadrepio.it

 

Abstract

Posterior reversible encephalopathy syndrome (PRES) is a clinical-radiological syndrome, usually reversible, characterized by vasogenic oedema in cerebral posterior regions in patients with autoimmune diseases, nephropathies, hypertensive crisis, eclampsia and exposure to cytotoxic drugs. The main symptoms are: headache, nausea, vomiting, seizures, visual disturbance and altered consciousness. Complications as cerebral hemorrhage and recurrences are rare.

We describe a case of a 65 years old woman, affected by chronic kidney disease, recently exacerbated, diabetes and hypertension in treatment, who showed an heterogeneous clinical presentation with vomiting, headache, blurred vision and impaired consciousness during an episode of acute hypertension. After an adjustement of the antihypertensive treatment we observed a regression of symptoms in one week. FLAIR sequences on MRI showed cerebral bilateral vasogenic oedema in posterior regions, typical for PRES. This case was suggestive for PRES and a prompt adjustement of the antihypertensive treatment was critical for clinical recovery. Brain MRI was crucial for diagnosis. It is important for clinicians to recognize PRES as a possible complication of renal disease and hypertensive crisis.

Key words: Chronic kidney disease, Hypertension, Magnetic Resonance Imaging, Posterior reversible encephalopathy syndrome

Sorry, this entry is only available in Italian.

INTRODUZIONE

La PRES è una entità clinico-radiologica descritta per la prima volta nel 1996 da Hinchey e coll. (1) sulla base di 15 casi clinici. Nel corso degli anni è stata contrassegnata da diversi acronimi e sigle tra cui leucoencefalopatia posteriore reversibile, sindrome dell’edema cerebrale posteriore reversibile, encefalopatia parieto-occipitale reversibile, ma PRES è l’acronimo generalmente accettato. Tuttavia, ancora recentemente, tale definizione è stata rimessa in discussione poiché si è documentato un tasso di mortalità fino al 15% (2–3). Descritta in corso di crisi ipertensive, disordini immunitari, terapie antirigetto e malattia renale cronica, essa è caratterizzata dall’associazione variabile di crisi epilettichecefalea  disturbi del visus, nausea, vomito e segni neurologici focali in un contesto quasi costante di scarso controllo della pressione arteriosa. Il segno distintivo di questa condizione è la presenza di edema cerebrale vasogenico, a patogenesi non completamente chiarita ma, verosimilmente associata ad una alterazione dei meccanismi di autoregolazione del flusso ematico cerebrale da parte dell’unità neuro vascolare, che predomina nel circolo cerebrale posteriore. Pertanto il gold standard per la diagnosi è la risonanza magnetico nucleare (RMN) specie nelle sequenze “ fluid-attenuated inversion recovery (FLAIR)”  la cui diffusione ha contribuito all’aumento della frequenza della diagnosi.Tipicamente è una malattia reversibile, una volta che la causa è rimossa o sotto controllo, risolvendosi clinicamente e radiologicamente in un lasso di tempo estremamente variabile e difficilmente prevedibile. Tuttavia, l’esito non è sempre favorevole, possono reliquare esiti importanti e a volte, in presenza di coma o stato epilettico, è necessario il trattamento in un reparto di terapia intensiva. Si descrive il caso clinico di una paziente con evoluzione clinica paradigmatica della PRES.
 

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