Significance of white-coat and masked hypertension in chronic kidney disease and end-stage renal disease

Hypertension is a frequent and modifiable cardiovascular risk factor with a cyclic relationship with chronic kidney disease (CKD). The diagnosis, treatment, monitoring and control of high blood pressure are all mandatory not only in CKD but also in end-stage renal disease (ESRD). As demonstrated by studies using population and hypertensive patients, white-coat hypertension (WCHT) and masked hypertension (MHT) carry a particular degree of risk. The advantages of ambulatory techniques in the management and prognostic stratification of patients with CKD and ESRD have also been recognized. However, most of the evidence underlines the importance of nocturnal hypertension and neglects WCHT and MHT. The absence of specific reports involving untreated and treated patients hinders the ability to significantly discriminate WCHT from the white-coat effect and MHT from masked uncontrolled hypertension. The heterogeneous definitions that are used add additional difficulty in translating experimental evidence into clinical practice. Reaching a consensus in definitions is mandatory for designing future research. Cross-sectional studies underscore the frequency of misdiagnosis, potentially leading to undertreatment (MHT) and overtreatment (WCHT) in renal disease. The divergent prevalence of WCHT and MHT reported in CKD could be related to the diverse definitions of hypertension and the heterogeneity of the pathologies pooled under the CKD definition. Even in the absence of randomized clinical trials specifically addressing this issue, the scarce longitudinal studies confirm that WCHT carries a risk close to that of sustained normotension, whereas MHT is associated with a risk close or identical to that of sustained hypertension.