Blood pressure measurement in patients with chronic kidney disease: from clinical trial to clinical practice

disease burden, and it is a major modifiable risk factor for heart disease, stroke, and chronic kidney disease (CKD). Hypertension and CKD are closely associated, with an intermingled cause and effect relationship. Blood pressure (BP) typically rises in patients with CKD, and hypertension promotes progression of CKD [1]. The interaction between hypertension and CKD is complex and increases the risk of adverse cardiovascular event [2]. Thus, accurate measurement of BP is essential in the diagnosis and management of hypertension in CKD patients. BP can be measured using one of the following three acceptable strategies: ambulatory blood pressure monitoring (ABPM), home BP monitoring (HBPM), and officebased BP measurements (automated or manual). In the out-of-office setting, ABPM is the reference standard for diagnosis of hypertension, and it is a better predictor for hypertension-related target organ damage and clinical cardiovascular outcomes compared with office-based BP measurements [3,4]. Although the hypertension guidelines recommend ABPM to both confirm the diagnosis of hypertension and titrate the dosage of antihypertensive medications, its use has remained low because of availability and inconvenience, and most of the guidelines in recent years are associated with office-based BP measurement [3,4]. The superiority of ABPM over the other methods results from its ability to identify BP patterns (i.e., sustained, white-coat, masked, and nocturnal hypertension) that cannot be detected with office BP alone [3]. HBPM is another modality for assessing out-of-office BP. Although ABPM is preferred, HBPM with an appropriate protocol is an acceptable method for confirmation of hypertension diagnosis if ABPM is not available or not tolerated [3,4]. In contrast to ABPM, HBPM is better tolerated, more widely available, and associated with lower cost. HBPM is more strongly associated with target organ damage compared with routine office BP measurements [4]. HBPM reduces misclassification of hypertension due to the white coat and masked effects, which are seen with office-based BP measurement. HBPM is also useful in management of patients with an established diagnosis of hypertension. Self-monitoring enhances patient involvement, and it could improve compliance and BP control [4]. However, concerns have been raised about reporting bias and patient familiarity with the technology. The potential problems with HBPM can be minimized by providing adequate training and by having patients bring their devices to clinic visits for accuracy assessment. In addition, HBPM devices with built-in memory that automatically store readings or home BP telemonitoring with automated teletransmission of BP data to the treating Blood pressure measurement in patients with chronic kidney disease: from clinical trial to clinical practice Il Young Kim , Sang Heon Song Department of Internal Medicine, Pusan National University School of Medicine, Yangsan, Korea Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea Biomedical Research Institute, Pusan National University Hospital, Busan, Korea Editorial KIDNEY RESEARCH AND CLINICAL PRACTICE