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Shankar Prasad Nagaraju, Srinivas Vinayak Shenoy, Indu Ramachandra Rao, Mohan V Bhojaraja, Dharshan Rangaswamy, Ravindra Attur Prabhu Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Udupi, Karnataka, 576104, IndiaCorrespondence: Mohan V Bhojaraja, Email mohan.vb@manipal.eduAbstract: Chronic kidney disease (CKD) is extremely common all over the world and is strongly linked to cardiovascular disease (CVD). The great majority of CKD patients have hypertension, which raises the risk of cardiovascular disease (CVD), end-stage kidney disease, and mortality. Controlling hypertension in patients with CKD is critical in our clinical practice since it slows the course of the disease and lowers the risk of CVD. As a result, accurate blood pressure (BP) monitoring is crucial for CKD diagnosis and therapy. Three important guidelines on BP thresholds and targets for antihypertensive medication therapy have been published in the recent decade emphasizing the way we measure BP. For both office BP and out-of-office BP measuring techniques, their clinical importance in the management of hypertension has been well defined. Although BP measurement is widely disseminated and routinely performed in most clinical settings, it remains unstandardized, and practitioners frequently fail to follow the basic recommendations to avoid measurement errors. This may lead to misdiagnosis and wrong management of hypertension, especially in CKD patients. Here, we review presently available all BP measuring techniques and their use in clinical practice and the recommendations from various guidelines and research gaps emphasizing CKD patients.Keywords: ambulatory BP, office BP, chronic kidney disease, out-of-office BP, standardized BP

Shankar Prasad Nagaraju,1 Mohan V Bhojaraja,1 Ganesh Paramasivam,2 Ravindra Attur Prabhu,1 Dharshan Rangaswamy,1 Indu Ramachandra Rao,1 Srinivas Vinayak Shenoy1 1Department of Nephrology, Kasturba Medical College, Manipal, Manipal Academy Higher Education, Manipal, Karnataka, 576104, India; 2Department of Cardiology, Kasturba Medical College, Manipal, Manipal Academy Higher Education, Manipal, Karnataka, 576104, IndiaCorrespondence: Mohan V Bhojaraja Email mohan.vb@manipal.eduIntroduction: Pulmonary hypertension (PH) is an underestimated cardiovascular consequence and a mortality predictor in patients on hemodialysis (HD). Thus, we studied its prevalence, risk factors, association with inflammation/oxidative stress, and cardiac changes in HD patients.Methods: This was a single-center cross-sectional observational study conducted at a tertiary care hospital. Patients aged > 18 years on hemodialysis for at least three months were included and divided into those with and without PH; patients with secondary causes for PH were excluded. Clinical characteristics, HD-related factors, lab parameters (C-reactive protein and malondialdehyde with thiol assay were used as markers of inflammation and oxidative stress, respectively), and echocardiography details were compared. PH was defined as a mean pulmonary artery pressure of > 25 mmHg at rest, and it was further divided as mild (25– 40 mmHg), moderate (40– 60 mmHg), and severe (> 60 mmHg).Results: Of 52 patients, 28 patients had PH (mild 24, moderate 4, and none had severe PH) with prevalence of 54%. No difference was found in clinical characteristics, dialysis-related factors, biochemical parameters including inflammation (C-reactive protein; p=0.76), or oxidative stress (thiol; p=0.36 and MDA; p=0.46) between the groups. When compared to individuals without PH, HD patients with PH exhibited significantly more mitral regurgitation (p=0.002).Conclusion: Hemodialysis patients have a high prevalence of PH. PH was significantly associated with the presence of mitral regurgitation on echocardiography. Our study did not find differences in traditional risk factors, HD-related factors, and inflammation/oxidative markers between the groups with and without PH.Keywords: chronic kidney disease, hemodialysis, inflammation, oxidative stress, pulmonary hypertension

Ravindra Attur Prabhu,1 Srinivas V Shenoy,1 Shankar Prasad Nagaraju,1 Dharshan Rangaswamy,1 Indu Ramachandra Rao,1 Mohan V Bhojaraja,1 Deepak Nayak M,2 Sindhura Lakshmi Koulmane Laxminarayana,2 Karan Saraf,1,3 Ashok Ramaswamy1,4 1Department of Nephrology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India; 2Department of Pathology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India; 3Department of Nephrology, Excelcare Hospitals, Guwahati, Assam, India; 4Department of Nephrology, Saveetha Medical College, Chennai, Tamil Nadu, IndiaCorrespondence: Srinivas V ShenoyDepartment of Nephrology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, IndiaTel +91 9844374705Email shenoy.srinivas@manipal.eduPurpose: Diabetic kidney disease (DKD) represents a unique subset of patients with chronic kidney disease (CKD). Acute kidney injury (AKI) is implicated in DKD progression; however, their interplay is not studied well. We studied risk factors for AKI and the effect of AKI on disease progression in a homogeneous group of patients with DKD.Patients and Methods: We conducted a retrospective open cohort study of patients with DKD at a single tertiary care centre between August 2016 – August 2019. Patients with a minimum follow-up of 2 years were included in the study. The incidence, etiology and risk factors for AKI were studied. The primary outcome studied was the effect of AKI on reduction in estimated glomerular filtration rate (eGFR) in DKD. Loss in eGFR by 50% and need for renal replacement therapy or reaching CKD stage V were studied as secondary outcomes.Results: Two hundred and ninety-two DKD patients meeting the study criteria with a follow-up of 29.57 (± 4.3) months were included. The incidence of AKI was 31.1%. Sepsis was the most common etiology (61%). Proteinuria was an independent risk factor for AKI after adjusting for covariates (adjusted OR - 1.158; 95% CI (1.018– 1.316); p=0.025). In patients with AKI, median decline in eGFR was 10.29 mL/min/1.73m2/year (IQR-5.58– 13.84) which was significantly higher compared to patients with no AKI [eGFR 7.25 (IQR 5.06– 11.38); p-0.014]. On subgroup analysis, sepsis-induced AKI (versus non-sepsis AKI; p< 0.001) and higher AKI stage (stage 2/3 versus stage 1; p=0.019) were associated with a faster decline in eGFR.Conclusion: AKI is common in patients with DKD with sepsis being the most common etiology. AKI in diabetic kidney disease is associated with a faster decline in eGFR. Baseline proteinuria is an independent risk factor for AKI.Keywords: diabetic kidney disease, acute kidney injury, GFR decline, proteinuria, sepsis