PC1258: Utilizing Ambulatory Blood Pressure Monitoring for the Diagnosis of Masked Hypertension

Purpose/Objectives: The incidence of hypertension in patients with chronic kidney disease (CKD) is increasing. Patients with a history of CKD are more likely to have high-risk hypertension phenotypes such as masked HTN and as a result are at risk for cardiovascular disease. Masked HTN is defined as a normal blood pressure in the clinic but an elevated blood pressure outside of the clinic. Studies have shown that masked HTN is associated with increased risk for target organ damage including left ventricular hypertrophy, proteinuria, and decreased glomerular filtration rate resulting in end stage renal disease and mortality in the CKD population. A cross sectional analysis of CKD in children cohort with CKD stage 2 through 4, ages 9-15 found 38% of participants had masked HTN and 18% had HTN confirmed by ABPM. If masked HTN is identified early, it can serve as a modifiable risk factor. Ambulatory blood pressure monitoring (ABPM) is a 24 hour BP monitoring procedure used for a more accurate diagnosis of HTN. In comparison to blood pressures measured at clinic visits, ABPM serves as a more accurate representation to identify a patient with an underlying history of HTN and is more predictable of target organ damage.

ABPM is currently under utilized for accurate and timely diagnosis of hypertension, improving management of HTN, and screening for masked HTN . Our aim is to Increase the number of ABPM procedures performed by 10% over a 1 year time span in children ages 6-21 with a diagnosis of CKD to screen for masked HTN.

Design/Methods: A list of CKD patients age 6-21 were identified in the PSV nephrology clinic. Chart review was performed to confirm which patients had ABPM’s performed and what percentage of theses were diagnosed with masked HTN. Exclusion criteria included patient’s out of this age range and/or those with known diagnosis of HTN.

2 PSDA cycles were conducted. The first PSDA cycle included the corrective action of creating a sticky note reminder for providers in the chart for patients with CKD. The second PSDA cycle included the corrective action of placing posters in clinic rooms promoting screening with ABPM in CKD patients.

Results: Of the 92 patients with a known diagnosis of CKD, 18% underwent ABPM screening and out of this 53% had a diagnosis of masked HTN. The percentage of patients using ABPM increased from 0% to 18% by the end of December 2021 (figure 1).

Conclusion/Discussion: This quality improvement initiative was successful in achieving its aim to increase ABPM screening in pediatric patients with CKD. Doing so provides an opportunity to identify, treat masked HTN, and ultimately address a major contributing factor to progressive loss of kidney function in this vulnerable population.