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154]

Saudi J Kidney Dis Transpl 2016;27(2):241-249

2016 Saudi Center for Organ Transplantation Saudi Journal
of Kidney Diseases
and Transplantation

Original Article

Blood Pressure Measurement in Hemodialysis: The Importance of the

Measurement Technique
M. Kubrusly1,2, Claudia Maria Costa de Oliveira1,2, R. P. Silva2, M. A. Pinheiro1, M. B. C. Rocha1,
R. M. Magalhes1
1
Department of Nephrology, Unichristus Medical School, 2Department of Nephrology, Federal
University of Cear, Fortaleza, Cear, Brazil

ABSTRACT. Systemic arterial hypertension contributes to the high cardiovascular morbidity in

hemodialysis (HD) patients, but the accuracy of blood pressure (BP) measurement in this
population has not been well studied. To evaluate the agreement between BP measurement using
the routine measurement technique (usual method) and the technique recommended by the VII
Joint (standard method). This cross-sectional study enrolled 124 patients in a single center who
had undergone dialysis for more than three months and were 18 years of age or older. The BP was
verified at the start of dialysis by the nursing team (usual method) and by the researchers
(standard method). The agreement between the systolic and diastolic BP (SBP and DBP)
measurements was tested by the BlandAltman analysis. A difference in BP measurement higher
than 5 mm Hg was considered clinically significant. The studied group had a mean age of 53.2
years. The average difference between routine and standard BP measurement was 6 mm Hg for
SBP (limits of agreement: 40.128 mm Hg; P <0.001) and 5.6 mm Hg for DBP (limits of
agreement: 33.121.8 mm Hg; P <0.001). A clinically significant difference in BP measured by
both methods was observed in 69.4% of the patients for SBP and in 61.3% for DBP. The
disagreement between the results of different BP measurement methods in HD patients was
significant and the BP was underestimated using the usual BP method. BP measurement
standardization should be encouraged to avoid errors in diagnosis and therapy.

Introduction diagnose hypertension (HTN), to monitor

Blood pressure (BP) measurement is used to
Correspondence to:
Dr. Claudia Maria Costa de Oliveira,
Department of Nephrology,
Unichristus Medical School,
Fortaleza, Cear, Brazil, Federal University
of Cear, Fortaleza, Cear, Brazil.
E-mail: claudiadrl@gmail.com
hyperhypertensive patients, and to assess the-
rapeutic effectiveness. The professional who
performs the BP measurement plays a deter-
mining role in obtaining BP values.1-4 The
concern about developing and improving BP
measurement methods to improve HTN diag-
nosis and treatment is long-standing.5 Thus,
BP measurement is extremely important be-
cause high BP levels are considered one of the
main risk factors for cardiovascular morbidity
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242
and mortality, not only in the general popu-
lation, but also in patients undergoing hemo-
dialysis (HD).6,7
Systemic arterial HTN affects 6080% of HD
patients, but attempts to control this condition
remain largely ineffective.8-11 Although BP
measurement is widely disseminated through
several international societies and routinely
performed,3 it remains unstandardized, and prac-
titioners often do not follow the basic recom-
mendations to avoid measurement errors.8,9,12,13
These recommendations have not been well
documented and prioritized in most HD units,
despite their importance in clinical approaches
and epidemiological studies.14,15
The present study is aimed to determine the
practical applicability of the standardized BP
measurement technique and verify the diffe-
rences in BP values by comparing them with
measurements taken by nursing professionals
(using the usual measurement method).
Subjects and Methods
A cross-sectional study was conducted in a
single HD facility in the city of Fortaleza-
Brazil from October 2010 to February 2012.
All patients who are 18-year-old or older with
a minimum dialysis time of three months were
included in the study. Patients with vascular
access in both upper limbs, patients who could
not undergo direct height and weight measure-
ment, pregnant women, and those who did not
agree to participate in the study were excluded.
The study was approved by the Research
Ethics Committee of the UniChristus Medicine
College under protocol number 109/2010, and
the participants agreed to participate by signing
an informed consent form.
According to the guidelines from The Seventh
Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treat-
ment of High BP (JNCVII), the appropriate
cuff size for BP measurement is based on mid-
arm circumference (MAC). BP measurements
were obtained before the start of dialysis by
researchers who were trained to perform the
standardized measurement.16 The patients were
adequately prepared and positioned with the
Kubrusly M, de Oliveira CM, Silva RP, et al
arm extended along the body, and a flexible
measuring tape was placed around the arm at
the midpoint between the acromion and the
olecranon, avoiding the compression of soft
tissues to measure MAC.17 The arm chosen for
the measurement was the one contralateral to
the HD vascular access [i.e., the arteriovenous
fistula (AVF)]. The JNCVIII (2014) did not
change the orientations of BP measurement,
the diagnose of HTN, or the management of
those patients with CKD.18
The cuff types (child, small adult, adult, and
large adult) were determined according to the
American Heart Association recommenda-
tions.19,20
The researchers initially measured the BP of
each patient while the patient was seated. Two
measurements were taken with a 2 min inter-
val between them, and the measurement me-
thod followed the rules of JNCVII.16 To mea-
sure BP, a BIC sphygmomanometer was used,
and its cuffs were adjusted to the patients arm
circumference (covering at least 80% of the
arm), as recommended by Perloff et al.19 A
predialysis reading was taken in the arm,
contralateral to the AVF before the needle was
placed. The final BP value was the average
between the two measurements obtained. The
resulting value was called the standard mea-
surement for the purposes of this study.
To obtain an accurate BP measurement, the
researchers performed the following steps: (1)
obtain the arm circumference and adjust the
cuff; (2) place the cuff 23 cm above the
cubital fossa, leaving no gaps; (3) position the
cuff over the brachial artery; (4) estimate the
systolic pressure level by palpating the radial
pulse; (5) palpate the brachial artery in the
cubital fossa and place the stethoscopes bell
or diaphragm without applying too much
pressure; (6) quickly inflate the cuff until the
pressure is 2030 mm Hg higher than the
estimated systolic pressure, obtained by pal-
pation; (7) proceed to slowly deflate (at a
speed of 23 mm Hg/s); (8) determine the sys-
tolic pressure by auscultating the first sound
(Korotkoff Phase I) and then slightly increase
the deflation speed; (9) determine the diastolic
pressure when the sounds disappear (Korotkoff
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Blood pressure measurement technique in hemodialysis
Phase V); (10) auscultate for approximately
2030 mm Hg after the last sound to confirm
its disappearance and then proceed to fast and
complete deflation; (11) if the heartbeats
persist to Level 0, determine the diastolic pres-
sure when the sounds are muffling (Korotkoff
Phase IV) and write down the values for
systolic/diastolic/zero; (12) wait 2 min before
performing another measurement; (13) inform
the patient about the BP values obtained; (14)
write down the exact values, without rounding,
and the arm used for measuring the BP.
BP was also measured before the start of the
dialysis session by the staff (nursing assistants
and nurses) using the routine technique. The
staff performed only one measurement using a
BIC spheroid device and a standard cuff (22
28 cm). This measurement was recorded in the
patients medical record and, for the purposes
of the present study, it was called the usual
measurement.
Patients with a predialysis BP 140/90 mm
Hg were considered hypertensive.15 Clinical
agreement between the usual measurement and
the standard measurement was defined as a
maximum difference of 5 mm Hg between
the values obtained using the two methods.
Demographic and clinical data and data rela-
ted to the studied patients dialysis treatment
were obtained through a questionnaire and
medical records analysis. Antihypertensive
medications used by the patients were also
recorded. At the end of the HD session, the
patients weight and height were verified by
the researchers as long as the patients weight
was within the estimated dry weight. Weight
and height measurements were used to calcu-
late the body mass index (BMI), which was
calculated by dividing the weight in kilograms
(kg) by the squared height in meters (m),
resulting in a value expressed in kg/m2 accor-
ding to the World Health Organization report
(1995).21
Statistical analysis
The continuous variables were expressed as
means standard deviation, and the catego-
rical variables were expressed in percentages
243
or frequencies. The variables with normal
distribution were compared using Students t-
test, and those with other types of distribution
were compared using the MannWhitney test.
The linear correlation between the BP mea-
surements was tested with the Pearson corre-
lation coefficient.
The BP measurements obtained by both
methods (usual and standard) were compared
using the MacNemar test, and the agreement
between the methods was tested using the
BlandAltman method.22
The BP levels were assessed according to
both methods in groups divided according to
gender, age (<50 years or 50 years), BMI
(<25 kg/m2 and 25 kg/m2), and whether the
cuff used was of adequate size. This assess-
ment was performed to examine the interfe-
rence in BP measurement that may occur with
increasing age (older patients show a more
intense hardening of vessel walls, which may
result in higher diastolic pressure levels) and
high BMI (BP measurement may be more
difficult in obese patients).
The Statistical Package for the Social Sciences
[SPSS version 16.0 software program (SPSS
Inc., Chicago IL, USA)], was used for the
statistical analysis. P value 0.05 was consi-
dered significant.
Results
In total, 124 patients were included in the
study. The patients had an average age of 53.2
years, and 57.3% were males. Table 1 shows
the patients demographics, HD treatment
data, and anthropometric measurements, and
Table 2 shows the cuff distribution according
to the MAC.
Using the standardized BP measurement me-
thod, 58% of the patients (n = 72) were classi-
fied as hypertensive (predialysis BP 140/90
mm Hg). Fifty-three percent of these patients
(n = 38) had systolic and diastolic HTN, 25%
(n = 18) had only systolic HTN, and 22% (n =
16) had only diastolic HTN. Using the mea-
surement taken by the nursing staff (the usual
measurement), 47.5% of the patients (n = 59)
were considered hypertensive.
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244 Kubrusly M, de Oliveira CM, Silva RP, et al

Table 1. Demographic, anthropometric, and hemodialysis treatment data from the studied population.
Variable Mean Standard deviation Variation
Age (years) 53.23 15.57 1587
HD duration (hours) 3.96 0.19 34.5
HD frequency (per week) 2.88 0.67 26
Arm circumference (cm) 26.20 3.77 18.542
Predialysis weight (kg) 62.99 14.32 36134
Postdialysis weight (kg) 60.57 14.13 34.8130.5
Height (cm) 160 8 141187
BMI (kg/m2) 23.21 4.35 13.7633.99
Variable Percentage (n)
Male: 57.3% (n = 71)
Gender
Female: 42.7% (n = 53)
AVF: 94.4% (n = 117)
HD access
Catheter: 5.6% (n = 7)
Use of antihypertensive medication
0 50% (n = 62)
1 26.6% (n = 33)
2 20.2% (n = 25)
3 3.2% (n = 4)
HD: Hemodialysis, BMI: Body mass index, AVF: Arteriovenous fistula.

In 89 patients, there was an agreement on the
HTN diagnosis between the usual measure-
ment and the standardized measurement, and
in 35 patients (28.2%), there was no agreement.
If we consider the standardized measurement,
the most correct BP measurement, in the group
of patients for which there was no HTN
diagnosis agreement between the methods, 24
patients were false normotensive (19.3%) and
11 patients were false hypertensive (8.9%)
(Table 3).
Figure 1a and b show the linear correlation
between systolic BP (SBP) and diastolic BP
Table 2. Cuff distribution according to the arm circumference in the studied population.
Cuff type
Child (up to 22 cm)
Small adult (2226 cm)
Adult (2734 cm)
Large adult (>34 cm)
Total
(DBP) measurements by both methods. Accor-
ding to the studied parameters, there was a
significant correlation between the methods (r
= 0.695 for SBP and r = 0.579 for DBP; P
<0.001), although this finding does not mean
that there was an agreement between the
measurements.
The SBP and DBP agreement between the
two BP measurement methods was tested using
BlandAltman agreement analysis, which can
be found in Figure 2a and b.
The average difference between usual BP
measurement and standardized BP measurement
N %
21 17
34 27
66 53
3 2
124 100

Table 3. Association between systemic arterial hypertension diagnosis based on the usual method and
the standardized method.
HTN measurement technique HTN yes (standard) HTN no (standard) Total
HTN yes (usual) 48 11 59
HTN no (usual) 24 41 65
Total 72 52 124
MacNemar test. HTN: Hypertension.
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Blood pressure measurement technique in hemodialysis 245

A B
Figure 1a and b. Linear correlation between systolic blood pressure and diastolic blood pressure,
according to the usual method and the standardized method for blood pressure measurement.

was 6 mm Hg for SBP (limits of agreement:
40.128 mm Hg) and 5.6 mm Hg for DBP
(limits of agreement: 33.12188 mm Hg) (P
<0.001; Table 4). The measurements with
higher values were the ones with less agree-
ment.
The BlandAltman analysis was repeated in
groups divided according to male (n = 71) or
female (n = 53) gender and according to age
(<50 years: 55 patients and 50 years: 69
patients). The average differences in SBP and
DBP between the methods was significant in
both groups.
The SBP and DBP agreement between the
measurement groups was also tested in groups
divided according to BMI: BMI <25 (n = 81),
BMI within 25 and 29.9 kg/m2 (n = 34) and
BMI 30 kg/m 2 (n = 9). The average difference
between SBP and DBP was significant in pa-
tients with BMI <25 and in patients with BMI
within 25 and 29.9 kg/m2, but it was not
significant in the group with BMI 30 (3.3
mm Hg for SBP; P = 0.2024 and 4.4 mm Hg
for DBP; P = 0.1913).
Regarding the cuff, even among the patients
who were measured using an adequate-sized
cuff (n = 34), there was a significant average
difference for SBP (bias: 10 mm Hg, limits

A B
Figure 2a and b. Systolic blood pressure and diastolic blood pressure agreement analysis (BlandAltman)
according to the usual method and the standardized method of blood pressure measurement.
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246 Kubrusly M, de Oliveira CM, Silva RP, et al

Table 4. Average difference in systolic blood pressure and diastolic blood pressure, according to the
usual and the standardized blood pressure measurement techniques.
Usual BP mean Standard BP mean Average difference (bias)
Parameter
(mm Hg) (mm Hg) (mm Hg)
SBP 129.9 18.0 136.0 23.6* 6.0
DBP 79.1 9.3 84.7 15.8* 5.6
*P <0.001. SBP: Systolic blood pressure, DBP: Diastolic blood pressure, BP: Blood pressure.

of agreement: 38.4 18.4 mm Hg; P = 0.003) This finding is in opposition to those of

and DBP (bias: 4.5 mm Hg, limits of agree-
ment:
27.118.1 mm Hg; P = 0.0272). When the
usual technique was used, a small adult cuff
was used instead of an adult cuff in 66 patients
(53.2%) and a small adult cuff was used
instead of a large adult or a child cuff in 24
patients (19.3%).
The differences between the BP measure-
ments taken using the different measurement
techniques were divided in 5 mm Hg inter-
vals, as shown in Table 5. Clinical agreement
between the two measurements (defined as a
difference of up to 5 mm Hg) was observed
in 30.6% of the cases for SBP and in 38.7% of
the cases for DBP.
Discussion
HTN is a common problem among patients
undergoing chronic HD therapy,23 mostly
associated with fluid overload24 and also low
BP is linked with an increase of mortality.25
However, the (BP measurement techniques
recommended by international guidelines are
rarely used in HD patients.
In the present study, the SBP and DBP were
underestimated by the usual technique compared
with the standard technique (differences of 6
mm Hg for SBP and 5.6 mm Hg for DBP).
Rahman et al, which showed that the usual BP
measurement method overestimated the average
BP compared with the standardized method.26
This conflicting finding can be explained by
several errors that the nursing team in the
study unit made during BP measurement and
by the white coat HTN phenomenon, which has
been reported in 1540% of HD patients.27,28
The difference in the BP values obtained using
these two techniques resulted in a change in
the diagnosis of predialysis HTN in 28.2% of
the studied population. In total, 24 patients
(19.3%) were misdiagnosed as normotensive
and 11 patients (8.9%) were misdiagnosed as
hypertensive.
It is worth mentioning that 61.369.4% of the
measurements taken showed a clinically signi-
ficant BP difference, i.e., higher than 5 mm
Hg; in 50% of these patients, the difference
was higher than 10 mm Hg. In the study by
Rahman et al,26 clinical agreement between the
two measurements was observed in only 21%
and 39% of the patients. These differences
may result in inadequate therapeutic proce-
dures, such as increased or decreased intra-
dialytic ultrafiltration or use of antihyper-
tensive medication, which may cause arterial
hypotension episodes or HTN or may aggra-
vate the hypertensive condition, elevating the
cardiovascular morbidity and mortality.

Table 5. Difference between the usual and the standard blood pressure measurement, classified into 5
mm Hg intervals.
Difference between the usual and the standard measurement SBP (%) DBP (%)
More than 10 mm Hg higher 9.7 7.3
510 mm Hg higher 13.7 5.6
Difference of up to 5 mm Hg 30.6 38.7
510 mm Hg lower 19.4 24.2
More than 10 mm Hg lower 26.6 24.2
Total 100.0 100.0
SBP: Systolic blood pressure, DBP: Diastolic blood pressure.
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Blood pressure measurement technique in hemodialysis
Another determining factor for HTN mis-
diagnosis is the lack of knowledge and adhe-
rence to standardization of techniques recom-
mended by international HTN societies for BP
measurement. This concern with the standar-
dization of BP measurement is not new. Since
1939, the American Heart Association29 has
discussed a standardized procedure. Its recom-
mendations were edited in the years 1951,
1967, 1980, 1988, and most recently, 1993,18
and adjustments were made in 1997.30 Each
new recommendation prompts new discussions
of aspects related to observer, equipment,
patients, environment, and technique to reduce
the possibility of errors that compromise the
reliability of BP measurement. Corroborating
these recommendations, the present study
demonstrated through the use of a checklist
that 100% of the nursing assistants did not
follow all the steps of the standard measure-
ment technique (data not shown). This lack of
adherence to the standard techniques is not
exclusive to nursing professionals; Bobrie et al
reported that only 20% of general practi-
tioners, 25% of interns, and 35% of cardio-
logists know the recommendations.31 Further-
more, as physicians move away from their ini-
tial training, this knowledge decreases. Given
this finding, we may question whether the
solution lies in better training of nursing
assistants and supervising doctors and nurses
or in improving the ease of following the BP
measurement criteria, possibly by reducing the
number of essential steps and optimizing their
disclosure.
The use of inadequately sized cuffs is the
most discussed cause of imprecise measure-
ment. Although several recommendations have
been made for using cuffs with correct widths,
there is no consensus on the correct sizes for
use in children and in adults.32 Moreover,
different cuff sizes are usually not available in
HD units. The small adult cuff, which was
available at the dialysis clinic instead of the
adult cuff, corresponded to 53.2% of the
studied population. Thus, the most common
cuff error consisted of using a smaller size that
was ideal for the MAC.33
In the present study, even when the cuff size
247
was appropriate for the patients MAC (i.e., in
27.5% of the patients), there was a significant
difference between the results of the usual and
the standard method for SBP and DBP. This
difference, observed even when the appro-
priate cuff was used, most likely reflects the
percentage of errors that resulted from a
failure to follow the many recommended steps
for correct BP management, thus resulting in
multiple errors during the measurement of HD
patients BP.
It should also be noted that the use of
oscillometric devices, which are often part of
dialysis machines, was not analyzed in the
present study. The use of oscillometric devices
may decrease errors inherent to the device and
the observer. However, it is important to note
that not all validated studies on BP measure-
ment in HD patients demonstrated satisfactory
performance, even when an oscillometric de-
vice was used, compared to the results ob-
tained with a mercury sphygmomanometer,
which is the gold standard device.34 In addi-
tion, to avoid the influence of uncalibrated
devices on BP measurement, guidelines re-
commend calibrating nonmercury cuffs with a
mercury cuff every six months and performing
annual general maintenance for all sphygmo-
manometers.35 However, we should not forget
BP evaluation criteria that are not related to
the device used. Such criteria include posture,
cuff size, rest time, and the consumption of
vasoactive substances, which significantly con-
tribute to the reliability of BP measurement.16
Despite the importance of correct BP mea-
surement and its implication on the values
obtained, as demonstrated in the present study,
we recognize that many of the recommen-
dations are difficult to follow as part of the HD
unit routine. When we consider the differences
between the guidelines recommendations and
the reality of HD units, we encounter several
examples of the difficulty of putting guidelines
into practice: coffee consumption, cigarette
smoking, and exercising before BP measure-
ment are not recommended although these
practices are common among patients; the
patient must be relaxed, but not all patients
relax when facing the imminent needle punc-
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248
ture; BP measurement must be performed in
both arms for the first reading, but the
presence of an AVF in at least one of the arms
prevents that, and the measurement is often
performed on the lower limbs if both arms
have AVFs; it is difficult to rest in a quiet
environment for 5 min, as HD units are rarely
quiet; and it is uncommon to take two readings
and find their average because of the patients
discomfort during HD sessions.
Therefore, the use of a single predialysis BP
measurement for clinical decision-making is
often imprecise, and BP measurements are
difficult to perform according to the recom-
mended techniques. Thus, nephrologists should
evaluate the need to use more accurate BP
measurement methods, such as ambulatory BP
monitoring or intermittent home-measurement
in HD patients, and should make a great effort
to follow the standardized measurement tech-
niques as closely as possible in the dialysis
room to reduce the occurrence of related errors
as much as possible.
Conflict of interest: None declared.
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