Feasibility of the extended, 48-h ambulatory blood pressure monitoring in hemodialysis patients: a multicenter study

Background: Ambulatory blood pressure monitoring (ABPM) is recommended as the gold standard for assessing blood pressure (BP) in patients with chronic kidney disease (CKD) on hemodialysis, as it enables detection of masked and nocturnal hypertension, phenomena linked to adverse outcomes. However, the real-world feasibility and tolerability of extended ABPM protocols in this frail population remain unclear. Methods: We conducted a multicenter, international survey inviting 440 consecutive adult in-center hemodialysis patients from eight nephrology units in Italy, Greece, and Slovenia. All patients were consecutively invited to undergo 48-h ABPM, with reasons for refusal or noncompletion systematically recorded. Tolerability and sleep disturbance were assessed using standardized questionnaires. ABPM was considered valid if at least 70% of measurements were obtained. Results: Of 440 invited patients, 119 (27%) refused ABPM or could not undergo recording. Among the 321 who initiated ABPM, 29 (9%) did not complete the protocol, and 35 (11%) had inadequate recordings, so that 257 patients (80% of those starting ABPM and 58% of all invited) successfully completed valid 48-h ABPM. The most common symptoms reported were sleep interruption (32%), itching (24%), and pain during BP measurements (20%). Continuous pain and inability to sleep were significantly associated with the “dipping” BP phenotype. Conclusion: Despite strong guideline recommendations, 48-h ABPM is feasible in only about half of hemodialysis patients, with discomfort and sleep disturbance being the most frequently cited reasons for refusal among those declining ABPM and important barriers to both acceptance and completion in a subset of patients. These findings highlight the need for patient-centered approaches, supportive measures, and careful selection when implementing ABPM in the hemodialysis population, as well as the importance of integrating patient perspectives into clinical practice guidelines.