Strategies To Reduce Clinical Inertia In Hypertensive Kidney Transplant Recipients

James Kiberd; Romauld Panek; Bryce Kiberd

Disclosures

BMC Nephrology 

In This Article

Abstract and Background

Background: Many kidney transplant recipients have hypertension. Elevated systolic blood pressures are associated with lower patient and kidney allograft survival.
Methods: This retrospective analysis examined the prevalence of clinical inertia (failure to initiate or increase therapy) in the treatment of hypertension before and after the introduction of an automated device (BpTRU) in the kidney transplant clinic.
Results: Historically only 36% (49/134) of patients were prescribed a change in therapy despite a systolic blood pressure ≥ 130 mmHg. After the introduction of BpTRU, 56% (62/110) of the patients had a change in therapy. In a multivariate logistic regression analysis of the entire cohort (n = 244) therapeutic changes were associated with higher blood pressures (OR 1.08 per mmHg, 95% CI 1.04–1.12) and use of the BpTRU (OR 2.12, 95% CI 1.72–3.83). In addition patients on more medications were also more likely to have a change in therapy.
Conclusion: Blood pressure measurement with automated devices may help reduce clinical inertia in the kidney transplant clinic.

Several studies have shown that higher blood pressures are associated with reduced kidney allograft and patient survival.[1,2,3] For every 10 mmHg higher systolic pressure graft loss is increased by 12–15%.[2,3] The guidelines recommend blood pressure targets of <130/85 mmHg.[4] Despite these guidelines many patients have blood pressures above this level.[1,3]

Blood pressure is difficult to control in kidney transplant recipients in part because of the associated immunosuppressive medication, impaired graft function, older age, obesity and diabetes mellitus.[3] Many studies however report that clinicians under treat patients.[5,6,7] The literature describes the phenomena of clinical inertia when physicians fail to initiate or intensify therapy when warranted.[6,7] There is a growing literature on clinical inertia and hypertension in the general population but less is known in the kidney transplant population.

In a recent American Heart Association scientific statement, the authors point out the shortcomings of auscultatory office blood pressures in the clinical practice despite their long standing importance in clinical research.[8] Patients commonly report that their blood pressures are better at home and are aware of the white coat phenomena. Many clinics are not performing research quality blood pressure measurements. For these reasons clinicians may doubt the precision or certainty of the measurement and a therapeutic change will be deferred. Ambulatory blood pressure monitoring devices are one strategy to increase diagnostic accuracy and may better predict outcomes.[8] Unfortunately 24 hour ambulatory blood pressure monitoring is not convenient, especially for patients traveling great distances. One automated device that meets hypertension standards and that can be used in the office is the BpTRU automated device.[9,10] The mean difference between the reference standard systolic and BpTRU systolic measurement in one study was 0.47 ± 5.4 mmHg with 89.2 % of the measurements within 5 mmHg.[10] The BpTRU was also a better estimate of ambulatory blood pressures than routine office measurements.[11] We introduced the BpTRU device in our clinic on the recommendation of our hospital hypertension experts. In this report we describe our experience with the device and explore the impact on therapeutic changes in hypertensive kidney transplant recipients.

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