Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece.
Am J Kidney Dis. 2021 Nov;78(5):630-639.e1. doi: 10.1053/j.ajkd.2021.01.022. Epub 2021 Apr 20.
RATIONALE & OBJECTIVE: Current recommendations suggest the use of ambulatory blood pressure monitoring (ABPM) as the gold standard for hypertension diagnosis and management in hemodialysis patients. This study assesses the accuracy of peridialytic, intradialytic, and scheduled interdialytic recordings in detecting abnormally elevated 44-hour interdialytic blood pressure (BP).
Diagnostic test study.
SETTINGS & PARTICIPANTS: 242 Greek hemodialysis patients who successfully underwent ABPM.
Ambulatory BP was used as the reference method to evaluate the accuracy of the following BP metrics: predialysis and postdialysis BP, intradialytic BP, intradialytic plus pre/postdialysis BP, and scheduled interdialytic BP (on an off-dialysis day at 8:00 am, 8:00 pm, and their average).
44-hour ambulatory systolic BP/diastolic BP (SBP/DBP) ≥ 130/80 mm Hg.
The 44-hour SBP/DBP levels differed significantly from predialysis and postdialysis BP but showed no or minor differences compared with the other BP metrics. Bland-Altman plots showed an absence of systematic bias for all metrics but large between-method difference and wider 95% limits of agreement for predialysis and postdialysis BP compared with intradialytic, intradialytic plus pre/postdialysis, and averaged scheduled interdialytic BP. The sensitivity/specificity and κ-statistic for diagnosing 44-hour SBP ≥ 130 mm Hg were low for predialysis (86.5%/38.6%, κ-statistic = 0.27) and postdialysis BP (63.1%/73.3%, κ-statistic = 0.35), but better for intradialytic BP (77.3%/76.2%, κ-statistic = 0.53), intradialytic plus pre/postdialysis BP (76.6%/72.3%, κ-statistic = 0.49), and scheduled interdialytic BP (87.9%/77.2%, κ-statistic = 0.66). In receiver operating characteristic (ROC) analyses, the areas under the curve (AUC) of predialysis SBP (AUC = 0.723) and postdialysis SBP (AUC = 0.746) were significantly lower than that of intradialytic SBP (AUC = 0.850), intradialytic plus pre/postdialysis SBP (AUC = 0.850), and scheduled interdialytic SBP (AUC = 0.917) (z test, P < 0.001 for all pairwise comparisons). Similar observations were made for DBP.
Typical home BP data were not obtained, and no assessment was obtained of the reproducibility of the examined metrics over time.
Intradialytic, intradialytic plus pre/postdialysis, and scheduled interdialytic BP measurements were more accurate in detecting elevated 44-hour BP than predialysis and postdialysis BP. Averaged intradialytic BP recordings or scheduled readings at the off-dialysis day appear to be promising approaches to the diagnosis of elevated BP in hemodialysis.
目前的建议表明，在血液透析患者中，使用动态血压监测（ABPM）作为高血压诊断和管理的金标准。本研究评估了透析间期、透析内和计划透析间期记录在检测异常升高的 44 小时透析间期血压（BP）方面的准确性。
诊断测试研究。
242 名成功接受 ABPM 的希腊血液透析患者。
将 ABPM 作为参考方法，评估以下 BP 指标的准确性：透析前和透析后 BP、透析内 BP、透析内加预透析后 BP 和计划透析间期 BP（在透析日的 8:00 am、8:00 pm 和平均值）。
44 小时动态收缩压/舒张压（SBP/DBP）≥130/80mmHg。
44 小时 SBP/DBP 水平与透析前和透析后 BP 有显著差异，但与其他 BP 指标无差异或差异较小。Bland-Altman 图显示，所有指标均不存在系统偏差，但与透析内、透析内加预透析后和平均计划透析间期 BP 相比，透析前和透析后 BP 的方法间差异较大，95%一致性界限较宽。预测 44 小时 SBP≥130mmHg 的诊断准确性，透析前 BP（86.5%/38.6%，κ 统计量=0.27）和透析后 BP（63.1%/73.3%，κ 统计量=0.35）的敏感性/特异性较低，但透析内 BP（77.3%/76.2%，κ 统计量=0.53）、透析内加预透析后 BP（76.6%/72.3%，κ 统计量=0.49）和计划透析间期 BP（87.9%/77.2%，κ 统计量=0.66）较好。在接受者操作特征（ROC）分析中，透析前 SBP（AUC=0.723）和透析后 SBP（AUC=0.746）的曲线下面积（AUC）明显低于透析内 SBP（AUC=0.850）、透析内加预透析后 SBP（AUC=0.850）和计划透析间期 SBP（AUC=0.917）（z 检验，所有两两比较的 P<0.001）。类似的观察结果也适用于 DBP。
未获得典型的家庭 BP 数据，也未评估所检查指标随时间的重现性。
与透析前和透析后 BP 相比，透析内、透析内加预透析后和计划透析间期 BP 测量更能准确检测升高的 44 小时 BP。透析日内的平均透析内 BP 记录或计划读数似乎是诊断血液透析中升高 BP 的有前途的方法。
