Hypertension In Renal Transplant Recipients Research Articles

Hypertensive renal transplant recipients adhering to mediterranean diet present better periodontal status

Rationale: Previous studies showed negative effects of more advanced stages of periodontitis (chronic inflammation of gingival tissue and supporting bone structures) on renal transplant recipients (RTRs). Arterial hypertension (AH) and periodontitis share common comorbidities and are highly prevalent amongst RTRs which puts them at higher risk of developing cardiovascular diseases. Mediterranean Diet (MeDi) is useful to prevent the early onset of chronic non-transmittable diseases and plays an important factor in periodontal health status.

Post-Kidney Transplant Visit-to-Visit Body Mass Index Variability as a Risk of Post-Transplant Systolic Hypertension

Abstract Objectives Overweight and obesity are associated with hypertension (HTN) in renal transplant recipients (RTR). Body weight variability is known to be associated with HTN and poor cardiovascular (CV) outcomes in diabetic patients. After successful kidney transplantation (KT), weight change is very common due partly to perioperative and immunological factors. Association between body weight variability and HTN in RTR is unknown. We hypothesize that high body weight variability is associated with post-transplant HTN. Methods Body weight variability of RTR from a single transplant center was assessed as visit-to-visit body mass index variability (VVBMIV) by using average successive variability (ASV = the average absolute difference between successive values of BMI measured at 4, 12, 24, 36, and 48 weeks after KT). Multi-variable Cox proportional hazard regression analysis was used to examine association between post-transplant VVBMIV and systolic and diastolic HTN (SHTN and DHTN), which are defined as SBP and DBP ≥130 and 80 mmHg, respectively. Results Of 104 RTR, mean ± SD age was 54.29 ± 11.65 years and 62% were female. The majority (36%) were obese followed by normal weight (33%), and overweight (31%). Incidence of SBP was 0.041 person-weeks and median time to event was 12.86 weeks; while the incidence of DBP was 0.036 person-weeks with a slightly longer median time-to-event of 13 weeks. Mean ASV of BMI was 1.26 ± 0.82 kg/m2 (0.47 to 2.18). Risk of SHTN is increased 32% for every 1 kg/m2 increase in VVBMIV (HR 1.32, 95%CI 1.04 to 1.68, P 0.022). After adjusted for age, gender, and their interaction terms, very 1 kg/m2 increase in VVBMIV is associated with a 29% greater risk of developing SHTN (HR 1.29, 95% CI 1.01 to 1.65, P 0.043). However, increase in VVBMIV is not associated with an increased risk of DHTN for both univariable (HR 1.15, 95%CI 0.88 to 1.49, P 0.308) and multi-variable Cox regressions models (HR 1.13, 95%CI 0.86 to 1.49, P 0.391). Conclusions Post-kidney transplant VVBMIV is independently associated post-transplant SHTN, but not DHTN. Further studies is needed to examine mechanism of body weight variability and blood pressure outcomes in RTR. Funding Sources None.

SAT-326 ARTERIAL HYPERTENSION IN KIDNEY TRANSPLANT RECIPIENTS

Cardio vascular disease are known to be the first mortality cause in kidney transplantation (KT). Arterial hypertension (HT) is common in renal transplant recipients (RTRs) and it is reported to occur from 50% to 80 % of cases. We report here the prevalence of HT in RTRs in our kidney transplantation center and it’s predictive factors. Our study is about 78 RTRs from a living kidney donor in 97.5 % of cases in our kidney transplantation department from 2011 to 2018. Our report is about 78 KTR in one KT department (La Rabta Hospital Tunis Tunisia) from 2011 to 2018. We study here the prevalence of HT in KTR in our KT department. We performed a comparative study of 2 groups (HT recipients and normotensive recipients) in order to determine predictive factors for HT in KTR. This study is about 78 KTR from a living kidney donor in 97.5 % of cases and deceased donor in 2,5 % of cases and it is about 51 males and 27 females with a mean age of 34±7 years old. After KT, HT was noted in 46 patients (59.7 %) and 32 patients were normotensive (41%). Among normotensive patients, we noted that 6 patients (18%) had HT before KT which disappeared after KT. Among HT patients, HT was not controlled in 22% of cases (based on target blood pressure levels ≤ 130/80 mm Hg). All these patients had at least 2 or 3 anti-hypertensive medications. In our report of 78 KTR, some factors were noted: dyslipidaemia in 2% of cases, obesity and overweight in 24% of cases and donor HT in 4 % of cases. Delayed graft function was noted in 6 cases (8%) and immunosuppressive therapy was based on steroids in all cases (Prednisone 10 mg/day reached at the first month and maintained for all patients), ciclosporin in 14 patients (18%), sirolimus in 10 patients (12%) and tacrolimus in 70 % of cases. Our comparative study showed that many factors can be predictive of HT after KT such as HT before KT, diabetes, tabaco, delayed graft function, creatinine at 1 year after KT > 1.5 mg/dl, immunosuppressive medicament such ciclosporin use and donor factors (age donor > 50 years old). All these correlations are statistically significant. Our data show that HT had a high prevalence in kidney recipient (59.7%). Our comparative study showed that many factors can be significantly predictive of HT after KT such as HT before KT, diabetes, tabaco, delayed graft function, creatinine at 1 year after KT > 1.5 mg/dl, immunosuppressive medicament such ciclosporin use and donor factors (age donor > 50 years old). Most of these factors are reported by authors to be HT predictive factors in KTR. Some of these factors can be prevented in KTR in order to control HT prevalence after KT to reduce cardio-vascular mortality and to improve graft survival.

Should ACE inhibitors or calcium channel blockers be used for post-transplant hypertension?

Arterial hypertension in renal transplant recipients warrants antihypertensive treatment. The preferable choice of antihypertensives that should be used in patients after kidney transplantation remains a matter of debate; however, calcium channel blockers (CCB) and angiotensin-converting enzyme inhibitors (ACEI) are currently the most commonly used antihypertensives. This educational review summarizes the current evidence about the effects of these two classes of medications in transplant recipients. Several studies have demonstrated that both classes of drugs can reduce blood pressure (BP) to similar extents. Meta-analyses of adult randomized controlled trials have shown that graft survival is improved in patients treated with ACEIs and CCBs, and that CCBs increase, yet ACEIs decrease, graft function. Proteinuria is usually decreased by ACEIs but remains unchanged with CCBs. In children, no randomized controlled study has ever been performed to compare BP or graft survival between CCBs and ACEIs. Post-transplant proteinuria could be reduced in children along with BP by ACEIs. The results of the most current meta-analyses recommend that due to their positive effects on graft function and survival, along with their lack of negative effects on serum potassium, CCBs could be the preferred first-line antihypertensive agent in renal transplant recipients. However, antihypertensive therapy should be individually tailored based on other factors, such as time after transplantation, presence of proteinuria/albuminuria, or hyperkalemia. Furthermore, due to the difficulty in controlling hypertension, combination therapy containing both CCBs and ACEIs could be a reasonable first-step therapy in treating children with severe post-transplantation hypertension.

Patterns of hypertension in renal transplant patients evaluated with 24 h ambulatory blood pressure monitoring

Prevalence of the different patterns of hypertension in renal transplant recipients (RTR) using 24 h ambulatory blood pressure monitoring (ABPM) along with their determining factor are lacking. The aim of our study was to describe the epidemiology of hypertension in RTR, based on ambulatory blood pressure monitoring (ABPM). In this cross-sectional study, prevalent RTR were proposed systematic blood pressure work-up consisting of ABPM, office blood pressure (3 consecutive blood pressure measurements performed by a nurse after 5 minutes of quiet rest) and detection of orthostatic hypotension. Optimal target was defined as BP < 130/80 mmHg for office BP. ABPM goals was defined using the ESH guidelines but we also defined another targets using only the 24 h average ABPM as seen in the literature. Two hundred and fifty-eight RTR underwent ABPM. Mean ABPM was 132/76 mmHg not different from the mean office BP (132/73 mmHg). Prevalence of patients with resistant hypertension and uncontrolled BP when we considered day-time and night-time values were respectively 23% and 48% versus 20% and 41% when we take into consideration only the 24 h average ABPM. Twenty % of RTR had orthostatic hypotension. When we identified the patterns of BP, 31% of patients had masked hypertension with circadian ABPM versus 20% with only 24 h average ABPM. All the patients identified as having uncontrolled BP or masked hypertension with circadian ABPM and not with 24 h average ABPM presented only nocturnal hypertension. Our results show a suboptimal control of BP in a cohort of RTR with 20% of patients with resistant hypertension and more than 50% of patients with uncontrolled BP. ABPM is a valuable tool to detect nocturnal hypertension. Prevalence of hypertension is underestimated in RTR because of the lack of established definition of blood pressure using ABPM in this population. ABPM goals need to be better defined to assess correctly hypertension and improve the management of BP in RTR.

A14395 Hypertension in renal transplant recipients- A cross-sectional study

A14395 Hypertension in renal transplant recipients- A cross-sectional study

Influence of Renin-Angiotensin System Blockers on Graft Function in Retrospective Analysis of Pairs of Renal Transplant Recipients From the Same Donor

BackgroundRenin-angiotensin system (RAS) blocking agents efficiently control hypertension in renal transplant recipients (RTRs), and reduce proteinuria and post-transplant erythrocytosis. A beneficial effect on the retardation of the long-term decline in renal function has not yet been demonstrated. The aim of the study was to evaluate the effects of RAS blockade on allograft function. MethodsIn order to minimize donor variability and bias, 33 pairs of RTRs receiving grafts from the same donor were included into the retrospective analysis. A total of 66 RTRs were enrolled in which 1 patient from the pair used an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for a minimum period of 60 months (RAS[+]) and the second one did not use it at all (RAS[-]). ResultsThere were no differences between RAS(+) and RAS(-) subjects in terms of age, body mass index, mismatches number, duration of total ischemia, episodes of cytomegalovirus infections, acute rejections, or immunosuppressive treatment. Significantly, more RAS(+) patients presented with diabetes and cardiovascular complications. Among RAS(+) patients, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers were used in 28 (84.84%) and 5 (15.15%) patients in a mean dose of 23.03 ± 16.83% and 30 ± 11.18% of their maximum doses, respectively. There were no significant differences in estimated glomerular filtration rate changes (−0.37 ± 12.68 vs 2.54 ± 20.76 mL/min) and serum creatinine changes (0.05 ± 0.39 vs 0.14 ± 0.79 mg/dL) between RAS(+) and RAS(-) patients during the 60 months follow-up. ConclusionAgents inhibiting the RAS did not significantly affect graft function in RTRs during 60 months of observation.

Prevalence, clinical profiles, and outcome of hypertension in renal transplant recipients

Background: Hypertension is more prevalent risk factor for cardiovascular morbidity and mortality among renal transplant recipients. Materials and Methods: It is a retrospective study conducted to assess the prevalence, clinical profiles, and outcome of hypertension in renal transplant recipients. Posttransplant hypertension was defined as systolic blood pressure (BP) ≥140 mmHg, diastolic BP ≥80 mmHg, or the need of antihypertensive medication. Donor and recipient demographical details were obtained from medical records. Patients who underwent second renal transplant or graft nephrectomy were excluded from the study. Results: Among 375 patients, 88% were male. The mean age of our study population was 35.82 ± 9.37 years. Almost 82.67% of patients had posttransplant hypertension, of which 80.97% had pretransplant hypertension. Nearly 19.03% patients developed hypertension posttransplant. Following transplantation, hypertension resolved in 12.85%. The prevalence of well controlled, poorly controlled, and resistant posttransplant hypertension was 49.68%, 50.32%, and 7.42%, respectively. Majority of them (90.97%) received calcium channel blockers. In univariate analyses, recipient sex, pretransplant hypertension, etiology of kidney disease, female donors, female donors of male recipient's subgroup, use of cyclosporine, left ventricular mass, weight gain, and presence of metabolic syndrome were statistically significant. In multiple logistic regression analyses, recipient sex, presence of metabolic syndrome, and use of cyclosporine were associated with posttransplant hypertension. Kaplan–Meier analyses showed low graft survival in posttransplant hypertensive patients when compared to normotensives. Conclusion: The prevalence of hypertension in our renal transplant recipients was 82.67%. Early identification of risk factors, treatment, and adequate BP control will improve the long-term patient, graft survival.

Treatment of Hypertension in Renal Transplant Recipients in Four Independent Cross-Sectional Analyses

Background/Aims: This retrospective study analysed hypertension management and adherence to blood pressure (BP) targets among renal transplant recipients (RTRs) under specialized care in the Outpatient Transplantation Unit in the Department of Nephrology, Transplantology and Internal Medicine at Gdansk University Hospital. Methods: Medical records of 101, 316, 639 and 818 RTRs diagnosed with hypertension, who received outpatient care in 2001, 2006, 2011 and 2014, respectively were analysed in four independent cross-sectional surveys. All RTRs received antihypertensive regimens. Results: The overall most commonly used antihypertensive agents were beta-blockers (BB) (range 66.3-82.5%) followed by calcium channel blockers (CCB) (range 52.8-64.2%). Whilst a significant, upward tendency of BB usage (p<0.01) was observed, CCB usage (p<0.001) displayed a downward tendency as a first line therapy in the subsequent years. The average number of antihypertensive agents used per patient increased significantly from 2.24±1.03 in 2001 to 2.55±1.25 in 2014 (p<0.05). The most frequently used combination of hypotensive therapy consisted of two or three antihypertensive drugs depending on the survey. The most common two drug combination consisted of BB and CCB followed by BB accompanied by angiotensin converting enzyme inhibitors. A significant, upward tendency in the use of four (p<0.001) and five (p<0.05) antihypertensive drugs simultaneously, was observed in subsequent years. The target values of BP i.e. <140/90 mmHg were accomplished in 47, 58, 60 and 46% of RTRs in subsequent years. In a secondary - stratified analysis of data from 2014, younger patients (p<0.05), patients with better graft function (p<0.001), patients treated with a higher number of antihypertensive agents (p<0.001) and those not treated with BB (p<0.01) were shown to reach the BP target of below 140/90 mmHg more often. Conclusion: The study showed intensification of hypertension treatment in RTRs in subsequent years with BB assuming a dominant role.

Association Between GLCCI1 Promoter Polymorphism (Rs37972) and Post-Transplant Hypertension in Renal Transplant Recipients

Background/Aims: Post-transplant hypertension is highly prevalent in renal transplant recipients and is a risk factor for graft loss, cardiovascular disease and death. Glucocorticoid is used to prevent rejection, but simultaneously increases the risk of post-transplant hypertension. The glucocorticoid-induced transcript 1 (GLCCI1) promoter polymorphism (rs37972) has been reported to be associated with response to glucocorticoid therapy in asthma. We therefore examined the association between GLCCI1 promoter polymorphism and post-transplant hypertension in renal transplant recipients. Methods: We conducted a retrospective cohort study of renal transplantation at a single university hospital from October 2003 to January 2014. Fifty consecutive adult recipients were analyzed, with clinical data retrieved from a prospectively collected database. Genotyping was carried out using genomic DNA derived from recipient’s blood. GLCCI1 immunoreactivity in vascular endothelial cells was quantitatively analyzed by immunohistochemical staining of recipients’ native kidney biopsy-specimens. The primary outcome measure was post-transplant hypertension. Results: Post-transplant hypertension was observed in 14/17 (82%) of recipients with CC, 18/20 (90%) with CT, and 2/13 (15%) with TT genotype. CC/CT genotype was significantly associated with post-transplant hypertension, even after adjustment for covariates (odds ratio, 10.6; 95% confidence intervals, 1.32 to 85.8; P = 0.026). In addition, we observed that GLCCI1 immunoreactivity in arteriolar endothelial cells was higher in kidney specimens obtained from recipients with a CC/CT genotype than a TT genotype (P = 0.021). Conclusion: GLCCI1 promoter polymorphism rs37972 may be associated with post-transplant hypertension.

Prevalence of hypertension in postrenal transplant recipients: A retrospective tertiary care study

Aim: Posttransplant hypertension (HTN) is a strong predictor of patient and graft survival. As there is a paucity of data in India, this retrospective analysis was done to look at the blood pressure (BP) in 506 renal transplant recipients, with 240 males, 266 females, mean age 42.90 ± 13.31 years, looking at their BP, at the initial and after 1 year later. Methods: This is a retrospective tertiary care study looking at serial BP measurements in 506 renal transplant recipients, correlating with their body mass index (BMI), graft function, proteinuria, antihypertensive used, erythropoietin usage, echocardiography native kidney disease, and new-onset diabetes mellitus till 1 year after transplantation. Results: According to the Joint National Committee 7 classification, initial BP was normal in 24 (4.74%), pre-HTN in 145 (28.65%), HTN Stage I in 227 (44.86%), and Stage II in 110 (21.73%) patients. One year later, BP was normal in 43 (8.55%), pre-HTN in 153 (30.26%), HTN Stage I in 236 (46.71%), and Stage II in 74 (14.47%) patients. Diabetics had a higher initial systolic BP (SBP) (P = 0.005). Patients with left ventricular hypertrophy had a higher SBP 1 year later (P = 0.001). Patients with BMI > 35 kg/m2, had higher initial SBP (P = 0.01), initial diastolic BP (DBP) (P = 0.01) and also higher 1 year posttransplant SBP (P = 0.02) and DBP (P = 0.01). Conclusion: There was a high incidence of HTN in renal transplant recipients, 66.59% patients with HTN and 28.65% with pre-HTN in the initial posttransplant period, and 61.18% with HTN and 30.26% with pre-HTN in the 1-year posttransplant period.

Prevalence and Risk Factors of Noncontrolled and Resistant Arterial Hypertension in Renal Transplant Recipients

Prevalence and Risk Factors of Noncontrolled and Resistant Arterial Hypertension in Renal Transplant Recipients

Prevalence and risk factors of noncontrolled and resistant arterial hypertension in renal transplant recipients.

Arterial hypertension (HT) is common in renal transplant recipients (RTRs). Control of HT is not optimal in this high-risk population despite recommendations for target blood pressure levels under 130/80 mm Hg. We performed a cross-sectional analysis of the prevalence of uncontrolled HT, and using a Cox regression model, we identified the risk factors associated with resistant HT. Eight hundred eleven RTRs (>1 year after transplantation) were included. A total of 10.5% were normotensive (<130/80 mm Hg without treatment), 41% had controlled HT, 32.5% uncontrolled HT, and 16% resistant HT. In univariate analysis, compared to controlled HT, the RH group had significantly higher body mass index and older donors, delayed graft function, prevalence of metabolic syndrome (69.2 vs. 51.9%), fast glycemia and glycated hemoglobin, albuminuria, triglycerides and uric acid levels, and worse measured glomerular filtration rate (mGFR). In multivariate analysis, recipient age (P < 0,001), mGFR (P = 0.037), albuminuria (P < 0.001), and metabolic syndrome (P = 0.007) were significantly associated with RH. Association of metabolic syndrome with RH was much stronger than each of its components. Our data show that despite the recommendations issued by scientific societies, blood pressure control in RTRs is far from the recommended targets. At least a third of our patients (uncontrolled HT) did not receive optimal treatment and suffered therapeutic inertia. Decreased mGFR, metabolic syndrome, and urinary albumin excretion emerged as strong predictors of poor HT control. Whether prevention and management of the metabolic syndrome and reduction of albuminuria could help to more consistently reach the blood pressure recommended targets deserves further investigation.

Graft Function and Arterial Stiffness: Can Bioimpedance Analysis Be Useful in Renal Transplant Recipients?

ObjectiveWe aimed to determine the total body water (TBW) by means of bioimpedance analysis (BIA) and to analyze the association of TBW, graft function, and arterial stiffness by means of pulse-wave velocity (PWV) and echocardiographic measurements in renal transplant (RT) recipients. MethodsEighty-two RT recipients (mean age, 38.7 ± 11.5 y; 58 male) who were using ≥1 antihypertensive treatment were enrolled in the study. Biochemical parameters, 24-hour urinary protein loss, estimated glomerular filtration rate (eGFR), transthoracic echocardiography, bioimpedance analysis according to systolic blood pressure, TBW, lean tissue index (LTI), extracellular water (ECW), intracellular water (ICW), lean tissue mass (LTM), phase angle (Phi50) levels, and renal resistive index (RRI) were evaluated. ResultsTBW and ECW were significantly correlated with systolic blood pressure. Urinary protein loss, pulmonary artery pressure, frequency of overhydration, systolic blood pressure, TBW, LTI, ECW, ICW, LTM, and Phi50 values were significantly higher in patients with estimated glomerular filtration rate (eGFR) 15–49 mL/min but similar in patients with eGFR 50–70 mL/min. ConclusionsHypertensive RT recipients have increased TBW, LTI, ICW, FTI, LTM, and Phi50 values. Graft function is positively correlated with systolic blood pressure and BIA parameters. Therefore, hypertensive RT recipients should be closely followed with the use of BIA for an early diagnosis of loss of graft function.

Assessment and management of hypertension in transplant patients.

Hypertension in renal transplant recipients is common and ranges from 50% to 80% in adult recipients and from 47% to 82% in pediatric recipients. Cardiovascular morbidity and mortality and shortened allograft survival are important consequences of inadequate control of hypertension. In this review, we examine the epidemiology, pathophysiology, and management considerations of post-transplant hypertension. Donor and recipient factors, acute and chronic allograft injury, and immunosuppressive medications may each explain some of the pathophysiology of post-transplant hypertension. As observed in other patient cohorts, renal artery stenosis and adrenal causes of hypertension may be important contributing factors. Notably, BP treatment goals for renal transplant recipients remain an enigma because there are no adequate randomized controlled trials to support a benefit from targeting lower BP levels on graft and patient survival. The potential for drug-drug interactions and altered pharmacokinetics and pharmacodynamics of the different antihypertensive medications need to be carefully considered. To date, no specific antihypertensive medications have been shown to be more effective than others at improving either patient or graft survival. Identifying the underlying pathophysiology and subsequent individualization of treatment goals are important for improving long-term patient and graft outcomes in these patients.

Non-Dipping Hypertension in Renal Transplant Recipients.

Purpose: Posttransplantation hypertension has been asociated with the incidence of both cardiovascular disorders and renal allograft failure.Additionally, the loss of circadian blood pressure (BP) may be an additional risk factor for comorbid conditions. The aim of this study is to evaluate the association between impact of post transplant hypertension determined by office and ambulatory blood pressure monitoring (ABPM), presence of nondipper status on cardiovascular indices and graft dysfunction in kidney recipients. Methods: One hundred recipients with normal graft functions (38.74±11.03 years, 67 male, 45.9±9.8 months post-transplantation period) were enrolled into the study. Office and ambulatory blood pressure monitoring (ABPM), pulse wave velocity and body composition analysis were cross-sectionally performed and patient's post-transplant clinical and laboratory data were retrieved from the records. Renal graft function is evaluated with the yearly decline in eGFR. Patients body composition were analyzed by the Body Composition Analyzer (Tanita BC- 420MA) and PWv was determined from pressure tracing over carotid and femoral arteries using the SphygmoCor system. Results: Thirty-five patients (%35) were hypertensive with office BP>140/80 mmHg and ABPM mean levels>130/85 mmHg. Sistolic hypertension was positively correlated with PWv (r:0.697, p:0.04) and serum uric acid levels (r:0.588, p:0.013). Majority (n:75, 75%) of patients had non-dipping BP pattern. Patients with non-dipping BP pattern had significantly lower HDL levels before (38.1 vs. 46.4 mg/dL, p: 0.044) and after transplantation (47.2 vs. 54.6 mg/dL, p:0.046) than patients with dipper HT. Non-dipper patients had significantly higher PWv levels than dipper patients (7.25 vs. 5.59 m/s respectivelyi p:0.0001). Transplantation from a deceased donor was more frequent in patients with non-dipping BP pattern than dipper patients (25% vs. 9.5%, p:0.039). Yearly decline in eGFR levels were significantly higher in hypertensive patients (7.6% vs. 9.4%, p:.0001) than normotensive ones. Conclusions: The non-dipper pattern was associated with arterial stiffness, dyslipidemia, graft dysfunction and transplantation from deceased donor. Posttransplantation HT should be aggressively treated to prevent the development of end-organ damage.

Prospective blood pressure measurement in renal transplant recipients.

Blood pressure (BP) control at home is difficult when managed only with office blood pressure monitoring (OBPM). In this prospective study, the reliability of BP measurements in renal transplant patients with OBPM and home blood pressure monitoring (HBPM) was compared with ambulatory blood pressure monitoring (ABPM) as the gold standard. Adult patients who had living-related renal transplantation from March 2007 to February 2008 had BP measured by two methods; OBPM and ABPM at pretransplantation, 2nd, 4th, 6th, and 9th months and all the three methods: OBPM, ABPM, and HBPM at 6 months after transplantation. A total of 49 patients, age 35 ± 11 years, on prednisolone, tacrolimus, and mycophenolate were evaluated. A total of 39 were males (79.6%). Systolic BP (SBP) and diastolic BP (DBP) measured by OBPM were higher than HBPM when compared with ABPM. When assessed using OBPM and awake ABPM, both SBP and DBP were significantly overestimated by OBPM with mean difference of 3-12 mm Hg by office SBP and 6-8 mm Hg for office DBP. When HBPM was compared with mean ABPM at 6 months both the SBP and DBP were overestimated by and 7 mm Hg respectively. At 6 months post transplantation, when compared with ABPM, OBPM was more specific than HBPM in diagnosing hypertension (98% specificity, Kappa: 0.88 vs. 89% specificity, Kappa: 0.71). HBPM was superior to OBPM in identifying patients achieving goal BP (89% specificity, Kappa: 0.71 vs. 50% specificity Kappa: 0.54). In the absence of a gold standard for comparison the latent class model analysis still showed that ABPM was the best tool for diagnosing hypertension and monitoring patients reaching targeted control. OBPM remains an important tool for the diagnosis and management of hypertension in renal transplant recipients. HBPM and ABPM could be used to achieve BP control.

Specific Management of Anemia and Hypertension in Renal Transplant Recipients: Influence of Renin-Angiotensin System Blockade

Background: Renin-angiotensin system (RAS) inhibition has proven to be helpful in reducing cardiovascular and kidney disease progression in the general population; whether kidney transplant patients would derive similar benefits is unknown. RAS inhibition also reduces posttransplantation erythrocytosis in kidney transplant recipients, but its effect on hemoglobin (Hb) levels in patients without posttransplantation erythrocytosis is unclear. Methods: The Specific Management of Anemia and Hypertension in Renal Transplant (SMAhRT) recipients study was designed to examine the cardiovascular benefits of RAS blockade with telmisartan 80 mg versus placebo, and Hb management with darbepoetin α in a randomized, double-blind, single-center controlled trial in 2,000 patients over 3 years. The primary efficacy variable was a composite of all-cause mortality, myocardial infarction or stroke. Results: The SMAhRT study was stopped prematurely due to a lower than expected event rate. At that point, 136 patients were enrolled and were followed for a mean duration of 15 months. The use of RAS blockade was not associated with an increased risk of adverse events such as worsening anemia or hyperkalemia. Likewise, the correction of Hb with darbepoetin was not associated with any increase in thrombotic events. Conclusions: This study provides insight into the safety of RAS inhibition and Hb correction with an erythrocyte-stimulating agent in kidney transplant recipients.

Blood pressure measurements, blood pressure variability and endothelial function in renal transplant recipients

Background/Aims: Hypertension is an important cardiovascular risk factor in renal transplant recipients. Elevated blood pressure variability (BPV) during 24-h ambulatory blood pressure monitoring (ABPM) is associated with increased risk of target organ damage and cardiovascular events, independent of mean blood pressure levels. We aimed to evaluate the relationship between endothelial function, blood pressure levels obtained by various measurement methods, and BPV in renal transplant recipients.Methods: In total, 73 hypertensive renal transplant recipients were included in the study. Office blood pressure measurements, central blood pressure measurements, home blood pressure measurements and 24-h ABPM were obtained from the subjects. BPV was calculated using the average real variability index. All patients underwent brachial flow-mediated vasodilatation tests. Predictive values of blood pressures obtained by different measurement techniques and BPV on endothelial functions were investigated.Results: Endothelial dysfunction was present in 68.5% of the patients. No difference was found between the group with and without endothelial dysfunction with regard to office systolic or diastolic blood pressure, central blood pressure or home systolic blood pressure. In the group with endothelial dysfunction, 24-h ambulatory systolic blood pressure and night-time ambulatory systolic blood pressure were higher. In patients with endothelial dysfunction, the 24-h systolic, diastolic and mean BPV were all higher. There was also a negative correlation between the percentage of flow-mediated vasodilatation with 24-h mean and systolic BPV.Conclusion: Patients with endothelial dysfunction had significantly higher ambulatory blood pressure values and higher BPV. There was a significant negative correlation between endothelial function and BPV.

Hypertension after Kidney Transplantation: A Pathophysiologic Approach

Post-transplant hypertension is associated with decreased graft and patient survival and cardiovascular morbidity. Unfortunately, post-transplant hypertension is often poorly controlled. Important risk factors include immunosuppressive medications, complications of the transplant surgery, delayed graft function, rejection, and donor and recipient risk factors. The effects of immunosuppressive medications are multifactorial including increased vascular and sympathetic tone and salt and fluid retention. The immunosuppressive agents most commonly associated with hypertension are glucocorticoids and calcineurin inhibitors. Drug therapy for hypertension should be based on the comorbidities and pathophysiology. Evidence-based approaches to defining and treating hypertension in renal transplant recipients are predominantly extrapolated from large-scale studies performed in the general population. Thus, there continues to be a need for larger studies examining the pathophysiology, diagnosis and treatment of hypertension in renal transplant recipients.