Masked Hypertension in CKD: Increased Prevalence and Risk for Cardiovascular and Renal Events.

PURPOSE OF REVIEW: Hypertension and chronic kidney disease (CKD) are inextricably linked. The causal nature of the relationship is bidirectional. This relationship holds when blood pressure is assessed in the clinic and outside the clinic with home and ambulatory blood pressure monitoring. Patients with CKD are more likely to have high-risk hypertension phenotypes, such as masked and sustained hypertension, and are at increased risk for cardiovascular disease. The purpose of this review is to describe the increased prevalence of masked hypertension in patients with CKD and then describe the increased risk for target organ damage and adverse clinical events associated with masked hypertension in patients with CKD. RECENT FINDINGS: The prevalence of masked hypertension is greater in patients with CKD than that of the general population. Recent studies have demonstrated that masked hypertension is associated with increased risk for target organ damage including left ventricular hypertrophy, elevated pulse wave velocity, proteinuria, and decreased estimated glomerular filtration rate in patients with CKD. Additionally, in patients with CKD, masked hypertension is associated with increased risk for cardiovascular disease, end-stage renal disease, and all-cause mortality. Patients with CKD are at increased risk for masked hypertension. Masked hypertension is associated with increased risk for target organ damage and adverse cardiovascular and renal outcomes in patients with CKD. Further research is necessary to better understand the pathophysiology of masked hypertension, the optimal method for diagnosing masked hypertension, and to determine whether masked hypertension is a modifiable risk factor.

Ultrafiltration rate in conventional hemodialysis: Where are the limits and what are the consequences?

BACKGROUND: Ultrafiltration rate (UFR) has attracted attention as a modifiable aspect of volume management. OBJECTIVE: The objective of this review is to summarize the evidence that links UFR to patient outcomes and discuss UFR cut-offs proposed, and discuss possible consequences of adapting UFR as a quality metric. RESULTS: Higher UFRs has been associated with younger age, longer dialysis vintage, greater prevalence of comorbidities, higher Kt/V, lower weight, greater interdialytic weight gain, lower residual renal function, and shorter treatment times. Many of the characteristics associated with high UFRs have also been independently associated with poor patient outcomes. Four observational studies have assessed the association between UFR and patient mortality. All of them reported an association between higher UFR and greater patient mortality, though the studies differed in their definition of UFR, follow-up, and adjustment for confounding. Evidence for the association between higher UFR and potential mediations of the mortality association, such as interdialytic hypotension, cardiac remodeling, and cardiovascular events was less consistent. There was a graded association between higher UFRs and all-cause mortality; no definitive cut-off for acceptable UFR can be established based on the current evidence. Targeting UFR in isolation might result in volume expansion and worsening patient outcomes. Residual confounding likely contributed to the findings of the observational studies. No randomized controlled trials addressed the questions. CONCLUSION: Evidence supporting UFR limits is weak and confounded. Randomized controlled trials are needed before UFR can be used as a quality of care indicator.