Masked Hypertension in CKD: Increased Prevalence and Risk for Cardiovascular and Renal Events

  • Megha Babu
  • Paul DrawzEmail author
Hypertension (DS Geller and DL Cohen, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Hypertension


Purpose of Review

Hypertension and chronic kidney disease (CKD) are inextricably linked. The causal nature of the relationship is bidirectional. This relationship holds when blood pressure is assessed in the clinic and outside the clinic with home and ambulatory blood pressure monitoring. Patients with CKD are more likely to have high-risk hypertension phenotypes, such as masked and sustained hypertension, and are at increased risk for cardiovascular disease. The purpose of this review is to describe the increased prevalence of masked hypertension in patients with CKD and then describe the increased risk for target organ damage and adverse clinical events associated with masked hypertension in patients with CKD.

Recent Findings

The prevalence of masked hypertension is greater in patients with CKD than that of the general population. Recent studies have demonstrated that masked hypertension is associated with increased risk for target organ damage including left ventricular hypertrophy, elevated pulse wave velocity, proteinuria, and decreased estimated glomerular filtration rate in patients with CKD. Additionally, in patients with CKD, masked hypertension is associated with increased risk for cardiovascular disease, end-stage renal disease, and all-cause mortality.


Patients with CKD are at increased risk for masked hypertension. Masked hypertension is associated with increased risk for target organ damage and adverse cardiovascular and renal outcomes in patients with CKD. Further research is necessary to better understand the pathophysiology of masked hypertension, the optimal method for diagnosing masked hypertension, and to determine whether masked hypertension is a modifiable risk factor.


Hypertension Chronic kidney disease Cardiovascular disease Masked hypertension Ambulatory blood pressure monitoring 



The authors would like to acknowledge Craig Solid of Solid Research Group for his assistance with manuscript preparation.

Compliance with Ethical Standards

Conflict of Interest

Megha Babu and Paul Drawz declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Muntner P, Anderson A, Charleston J, Chen Z, Ford V, Makos G, et al. Hypertension awareness, treatment, and control in adults with CKD: results from the Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Kidney Dis. 2010;55(3):441–51.PubMedCrossRefGoogle Scholar
  2. 2.
    Sarafidis PA, Li S, Chen SC, Collins AJ, Brown WW, Klag MJ, et al. Hypertension awareness, treatment, and control in chronic kidney disease. Am J Med. 2008;121(4):332–40.PubMedCrossRefGoogle Scholar
  3. 3.
    Mennuni S, Rubattu S, Pierelli G, Tocci G, Fofi C, Volpe M. Hypertension and kidneys: unraveling complex molecular mechanisms underlying hypertensive renal damage. J Hum Hypertens. 2014;28(2):74–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Pirkle JL, Freedman BI. Hypertension and chronic kidney disease: controversies in pathogenesis and treatment. Minerva Urol Nefrol. 2013;65(1):37–50.PubMedPubMedCentralGoogle Scholar
  5. 5.
    Agarwal R, Andersen MJ. Prognostic importance of clinic and home blood pressure recordings in patients with chronic kidney disease. Kidney Int. 2006;69(2):406–11.PubMedCrossRefGoogle Scholar
  6. 6.
    Gansevoort RT, Correa-Rotter R, Hemmelgarn BR, Jafar TH, Heerspink HJL, Mann JF, et al. Chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention. Lancet. 2013;382(9889):339–52.PubMedCrossRefGoogle Scholar
  7. 7.
    United States Renal Data System, 2014 Annual Data Report: Epidemiology of Kidney Disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, 2014., accessed on September 13, 2017. In.
  8. 8.
    Kokubo Y, Kamide K. High-normal blood pressure and the risk of cardiovascular disease. Circ J. 2009;73(8):1381–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Sarnak MJ, Greene T, Wang X, Beck G, Kusek JW, Collins AJ, et al. The effect of a lower target blood pressure on the progression of kidney disease: long-term follow-up of the modification of diet in renal disease study. Ann Intern Med. 2005;142(5):342–51.PubMedCrossRefGoogle Scholar
  10. 10.
    Ku E, Gassman J, Appel LJ, Smogorzewski M, Sarnak MJ, Glidden DV, et al. BP control and long-term risk of ESRD and mortality. J Am Soc Nephrol. 2017;28(2):671–7.PubMedCrossRefGoogle Scholar
  11. 11.
    Wright JT, Williamson JD, Whelton PK, et al. A randomized trial of intensive versus standard blood-pressure control. N Engl J Med. 2015;373(22):2103–16.PubMedCrossRefGoogle Scholar
  12. 12.
    Drawz PE, Pajewski NM, Bates JT, Bello NA, Cushman WC, Dwyer JP, et al. Effect of intensive versus standard clinic-based hypertension management on ambulatory blood pressure: results from the SPRINT (Systolic Blood Pressure Intervention Trial) Ambulatory Blood Pressure Study. Hypertension. 2017;69(1):42–50.PubMedCrossRefGoogle Scholar
  13. 13.
    Franklin SS, O’Brien E, Staessen JA. Masked hypertension: understanding its complexity. Eur Heart J. 2017;38(15):1112–8.PubMedGoogle Scholar
  14. 14.
    Anstey DE, Pugliese D, Abdalla M, Bello NA, Givens R, Shimbo D. An update on masked hypertension. Curr Hypertens Rep. 2017;19(12):94.PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Anstey DE, Shimbo D. Masked hypertension-what lies ahead? J Hum Hypertens. 2017;31(9):545–6.PubMedCrossRefGoogle Scholar
  16. 16.
    Drawz PE, Abdalla M, Rahman M. Blood pressure measurement: clinic, home, ambulatory, and beyond. Am J Kidney Dis. 2012;60(3):449–62.PubMedPubMedCentralCrossRefGoogle Scholar
  17. 17.
    Siu AL. Force USPST. Screening for high blood pressure in adults: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163(10):778–86.PubMedCrossRefGoogle Scholar
  18. 18.
    •• Whelton PK, Carey RM, Aronow WS, et al. ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol 2018. 2017;71(19):e127–248 This guideline recommends out-of-office BP measurements to detect white-coat and masked hypertension in both the diagnosis and treatment of hypertension. CrossRefGoogle Scholar
  19. 19.
    Hänninen MR, Niiranen TJ, Puukka PJ, Kesäniemi YA, Kähönen M, Jula AM. Target organ damage and masked hypertension in the general population: the Finn-Home study. J Hypertens. 2013;31(6):1136–43.PubMedCrossRefGoogle Scholar
  20. 20.
    Asayama K, Thijs L, Li Y, Gu YM, Hara A, Liu YP, et al. Setting thresholds to varying blood pressure monitoring intervals differentially affects risk estimates associated with white-coat and masked hypertension in the population. Hypertension. 2014;64(5):935–42.PubMedPubMedCentralCrossRefGoogle Scholar
  21. 21.
    Bobrie G, Chatellier G, Genes N, et al. Cardiovascular prognosis of “masked hypertension” detected by blood pressure self-measurement in elderly treated hypertensive patients. JAMA. 2004;291(11):1342–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Liu JE, Roman MJ, Pini R, Schwartz JE, Pickering TG, Devereux RB. Cardiac and arterial target organ damage in adults with elevated ambulatory and normal office blood pressure. Ann Intern Med. 1999;131(8):564–72.PubMedCrossRefGoogle Scholar
  23. 23.
    Verberk WJ, Kessels AG, de Leeuw PW. Prevalence, causes, and consequences of masked hypertension: a meta-analysis. Am J Hypertens. 2008;21(9):969–75.PubMedCrossRefGoogle Scholar
  24. 24.
    Drawz PE, Alper AB, Anderson AH, Brecklin CS, Charleston J, Chen J, et al. Masked hypertension and elevated nighttime blood pressure in CKD: prevalence and association with target organ damage. Clin J Am Soc Nephrol. 2016;11(4):642–52.PubMedPubMedCentralCrossRefGoogle Scholar
  25. 25.
    Iimuro S, Imai E, Watanabe T, Nitta K, Akizawa T, Matsuo S, et al. Clinical correlates of ambulatory BP monitoring among patients with CKD. Clin J Am Soc Nephrol. 2013;8(5):721–30.PubMedPubMedCentralCrossRefGoogle Scholar
  26. 26.
    Pogue V, Rahman M, Lipkowitz M, Toto R, Miller E, Faulkner M, et al. Disparate estimates of hypertension control from ambulatory and clinic blood pressure measurements in hypertensive kidney disease. Hypertension. 2009;53(1):20–7.PubMedCrossRefGoogle Scholar
  27. 27.
    Bangash F, Agarwal R. Masked hypertension and white-coat hypertension in chronic kidney disease: a meta-analysis. Clin J Am Soc Nephrol. 2009;4(3):656–64.PubMedPubMedCentralCrossRefGoogle Scholar
  28. 28.
    Drawz PE, Brown R, De Nicola L, et al. Variations in 24-hour BP profiles in cohorts of patients with kidney disease around the world: the I-DARE Study. Clin J Am Soc Nephrol. 2018;13(9):1348–57.PubMedCrossRefPubMedCentralGoogle Scholar
  29. 29.
    Matsui Y, Eguchi K, Ishikawa J, Hoshide S, Shimada K, Kario K. Subclinical arterial damage in untreated masked hypertensive subjects detected by home blood pressure measurement. Am J Hypertens. 2007;20(4):385–91.PubMedCrossRefGoogle Scholar
  30. 30.
    Fagard RH, Cornelissen VA. Incidence of cardiovascular events in white-coat, masked and sustained hypertension versus true normotension: a meta-analysis. J Hypertens. 2007;25(11):2193–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Tang H, Gong WY, Zhang QZ, Zhang J, Ye ZC, Peng H, et al. Prevalence, determinants, and clinical significance of masked hypertension and white-coat hypertension in patients with chronic kidney disease. Nephrology (Carlton). 2016;21(10):841–50.CrossRefGoogle Scholar
  32. 32.
    Kanno A, Metoki H, Kikuya M, et al. Usefulness of assessing masked and white-coat hypertension by ambulatory blood pressure monitoring for determining prevalent risk of chronic kidney disease: the Ohasama study. Hypertens Res. 2010;33(11):1192–8.PubMedCrossRefGoogle Scholar
  33. 33.
    Agarwal R, Light RP. GFR, proteinuria and circadian blood pressure. Nephrol Dial Transplant. 2009;24:2400–6.PubMedCrossRefGoogle Scholar
  34. 34.
    Agarwal R, Pappas MK. Delayed systolic blood pressure recovery following exercise as a mechanism of masked uncontrolled hypertension in chronic kidney disease. Nephrol Dial Transplant. 2017;32(10):1710–7.PubMedGoogle Scholar
  35. 35.
    •• Banegas JR, Ruilope LM, de la Sierra A, et al. Relationship between Clinic and Ambulatory Blood-Pressure Measurements and Mortality. N Engl J Med. 2018;378(16):1509–20 This large study from Spain demonstrated increased risk for both all-cause and cardiovascular mortality in patients with masked and masked uncontrolled hypertension. PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Mwasongwe S, Min YI, Booth JN, et al. Masked hypertension and kidney function decline: the Jackson Heart Study. J Hypertens. 2018;36(7):1524–32.PubMedPubMedCentralCrossRefGoogle Scholar
  37. 37.
    Kushiro T, Kario K, Saito I, et al. Increased cardiovascular risk of treated white coat and masked hypertension in patients with diabetes and chronic kidney disease: the HONEST Study. Hypertens Res. 2017;40(1):87–95.PubMedCrossRefGoogle Scholar
  38. 38.
    Minutolo R, Gabbai FB, Agarwal R, Chiodini P, Borrelli S, Bellizzi V, et al. Assessment of achieved clinic and ambulatory blood pressure recordings and outcomes during treatment in hypertensive patients with CKD: a multicenter prospective cohort study. Am J Kidney Dis. 2014;64(5):744–52.PubMedCrossRefGoogle Scholar
  39. 39.
    Wang C, Zhang J, Li Y, Ma X, Ye Z, Peng H, et al. Masked hypertension, rather than white-coat hypertension, has a prognostic role in patients with non-dialysis chronic kidney disease. Int J Cardiol. 2017;230:33–9.PubMedCrossRefGoogle Scholar
  40. 40.
    Agarwal R, Andersen MJ. Prognostic importance of ambulatory blood pressure recordings in patients with chronic kidney disease. Kidney Int. 2006;69(7):1175–80.PubMedCrossRefGoogle Scholar
  41. 41.
    Agarwal R, Andersen MJ. Blood pressure recordings within and outside the clinic and cardiovascular events in chronic kidney disease. Am J Nephrol. 2006;26(5):503–10.PubMedCrossRefGoogle Scholar
  42. 42.
    Gabbai FB, Rahman M, Hu B, Appel LJ, Charleston J, Contreras G, et al. Relationship between ambulatory BP and clinical outcomes in patients with hypertensive CKD. Clin J Am Soc Nephrol. 2012;7(11):1770–6.PubMedPubMedCentralCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Essentia HealthFargoUSA
  2. 2.Division of Renal Diseases & HypertensionUniversity of MinnesotaMinneapolisUSA

Personalised recommendations