Browsing by Subject "Ambulatory blood pressure monitoring"

Now showing 1 - 5 of 5
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    Design and Baseline Characteristics of the Chlorthalidone in Chronic Kidney Disease (CLICK) Trial
    (Karger, 2020) Agarwal, Rajiv; Cramer, Andrew E.; Balmes-Fenwick, Mary; Sinha, Arjun D.; Ouyang, Fangqian; Tu, Wanzhu; Medicine, School of Medicine
    Background: Hypertension often accompanies chronic kidney disease (CKD), and diuretics are widely prescribed to reduce blood pressure (BP). Chlorthalidone (CTD) is a thiazide-like diuretic and an effective antihypertensive drug, yet little data exist to support its use in treating hypertension in individuals with advanced CKD. Methods: Chlorthalidone in Chronic Kidney Disease (CLICK) is a phase II, single-institution, multicenter, double-blind randomized control trial to test the hypothesis that CTD improves BP, through reduction of extracellular fluid volume, and results in target organ protection in patients with stage 4 CKD and poorly controlled hypertension. After a single-blind placebo run-in for 2 weeks and confirmation of hypertension by 24-h ambulatory blood pressure (ABP), patients are randomized to either placebo or CTD 12.5 mg once daily (QD) followed by dose escalation. Randomization is stratified by prior loop diuretic use, and the double-blind phase lasts 12 weeks. With a total of 160 patients, the study will have ≥80% power to detect a 6 mm Hg difference in systolic 24-h ABP between the 2 treatment groups. Results: Between June 2016 and October 2019, 131 patients have been randomized. The baseline characteristics are as follows: average age 65.8 years, 79% men, 36% Black, 79% with diabetes, mean eGFR 23.2 mL/min/1.73 m2, median urine albumin/creatinine ratio 923 mg/g, average number of BP medications 3.4, 60% on loop diuretics, and 24-h ABP averaged 141.7/73.8 mm Hg. Conclusion: Among patients with stage 4 CKD and uncontrolled hypertension, CLICK should answer the question whether CTD is safe and effective.
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    Effect of finerenone on ambulatory blood pressure in chronic kidney disease in type 2 diabetes
    (Wolters Kluwer, 2023) Agarwal, Rajiv; Ruilope, Luis M.; Ruiz-Hurtado, Gema; Haller, Hermann; Schmieder, Roland E.; Anker, Stefan D.; Filippatos, Gerasimos; Pitt, Bertram; Rossing, Peter; Lambelet, Marc; Nowack, Christina; Kolkhof, Peter; Joseph, Amer; Bakris, George L.; Medicine, School of Medicine
    Objective: Finerenone is a selective nonsteroidal mineralocorticoid receptor antagonist with a short half-life. Its effects on cardiorenal outcomes were thought to be mediated primarily via nonhemodynamic pathways, but office blood pressure (BP) measurements were insufficient to fully assess hemodynamic effects. This analysis assessed the effects of finerenone on 24-h ambulatory BP in patients with chronic kidney disease and type 2 diabetes. Methods: ARTS-DN (NCT01874431) was a phase 2b trial that randomized 823 patients with type 2 diabetes and chronic kidney disease, with urine albumin-to-creatinine ratio ≥30 mg/g and estimated glomerular filtration rate of 30-90 ml/min per 1.73 m2 to placebo or finerenone (1.25-20 mg once daily in the morning) administered over 90 days. Ambulatory BP monitoring (ABPM) over 24 h was performed in a subset of 240 patients at screening, Day 60, and Day 90. Results: Placebo-adjusted change in 24-h ABPM systolic BP (SBP) at Day 90 was -8.3 mmHg (95% confidence interval [CI], -16.6 to 0.1) for finerenone 10 mg (n = 27), -11.2 mmHg (95% CI, -18.8 to -3.6) for finerenone 15 mg (n = 34), and -9.9 mmHg (95% CI, -17.7 to -2.0) for finerenone 20 mg (n = 31). Mean daytime and night-time SBP recordings were similarly reduced and finerenone did not increase the incidence of SBP dipping. Finerenone produced a persistent reduction in SBP over the entire 24-h interval. Conclusions: Finerenone reduced 24-h, daytime, and night-time SBP. Despite a short half-life, changes in BP were persistent over 24 h with once-daily dosing in the morning.
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    Pro: Ambulatory blood pressure should be used in all patients on hemodialysis
    (Oxford University Press, 2015-09) Agarwal, Rajiv; Department of Medicine, IU School of Medicine
    In the adult population in general and among people with chronic kidney disease in particular, it is now well established that hypertension is a major driver of renal disease progression and cardiovascular morbidity and mortality. Although the contribution of hypertension to cardiovascular morbidity and mortality among patients on long-term dialysis continues to be debated, a major barrier to detect hypertension as a risk factor for cardiovascular events in these patients has been the inability to diagnose hypertension. Largely to blame has been the easy availability of pre-dialysis and post-dialysis blood pressure recordings in stark contrast to ambulatory blood pressure measurements in dialysis patients to accurately diagnose the presence or control of hypertension. It is increasingly becoming clear that out-of-office blood pressure recordings are superior to clinic recordings in making a diagnosis, assessing target organ damage, evaluating prognosis and managing patients with hypertension. In this debate, I have been asked to defend the position that ambulatory blood pressure recordings should be systematically applied to all patients on hemodialysis.
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    Setting the dry weight and its cardiovascular implications
    (Wiley, 2017-11) Sinha, Arjun D.; Agarwal, Rajiv; Medicine, School of Medicine
    Volume overload is common and associated with adverse outcomes in the hemodialysis population including systemic hypertension, pulmonary hypertension, left ventricular hypertrophy, and mortality. Since the beginning of the era of maintenance dialysis, prescribing and maintaining a dry weight remains the standard of care for managing volume overload on hemodialysis. Reducing dry weight even by relatively small amounts has been shown to improve blood pressure and has been associated with reductions in left ventricular hypertrophy. Maintaining an adequately low dry weight requires attention to sodium intake and adequate time on dialysis, as well as a high index of suspicion for volume overload. Reducing dry weight can provoke decreased cardiac chamber filling and is associated with risks including intradialytic hypotension. The ideal method to minimize intradialytic morbidity is unknown, but more frequent dialysis should be considered. Experimental methods of assessing volume status may allow identification of patients most likely both to tolerate and to benefit from dry weight reduction, but further study is needed.
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    Should we CLICK on chlorthalidone for treatment-resistant hypertension in chronic kidney disease?
    (Oxford University Press, 2022-12-20) Agarwal, Rajiv; Medicine, School of Medicine
    Treatment-resistant hypertension is common among patients with advanced chronic kidney disease (CKD). In people with preserved kidney function, spironolactone is an evidence-based treatment. However, the risk for hyperkalemia limits its use in people with more advanced CKD. In the Chlorthalidone in Chronic Kidney Disease (CLICK) trial, 160 patients with stage 4 CKD and poorly controlled hypertension as confirmed by 24-hour ambulatory blood pressure (ABP) monitoring were randomly assigned to either placebo or chlorthalidone 12.5 mg daily in a 1:1 ratio stratified by prior loop diuretic use. The primary endpoint was the change in 24-hour systolic ABP from baseline to 12 weeks. The trial showed a treatment-induced reduction of 24-hour systolic ABP by 10.5 mmHg. Of the 160 patients randomized, 113 (71%) had resistant hypertension, of which 90 (80%) were on loop diuretics and the mean number of antihypertensive medications prescribed was 4.1 (standard deviation 1.1). In this subgroup of patients with treatment-resistant hypertension, the adjusted change from baseline to 12 weeks in the between-group difference in 24-hour systolic ABP was -13.9 mmHg (95% CI -19.4 to -8.4; P < .0001). Furthermore, compared with placebo, the urine albumin:creatinine ratio in the chlorthalidone group at 12 weeks was 54% lower (95% CI -65 to -40). Following randomization, hypokalemia, reversible increases in serum creatinine, hyperglycemia, dizziness, orthostatic hypotension and hyperuricemia occurred more frequently in the chlorthalidone group. Chlorthalidone has the potential to improve BP control among patients with advanced CKD and treatment-resistant hypertension. However, caution is advised when treating patients, especially when they are on loop diuretics.