Assessment and Management of Hypertension in Transplant Patients

Abstract

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 drugdrug 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.

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

“…The use of CCB is also associated with earlier allograft function recovery. Whether this results in long-term graft protection is however, unclear [1]. …”

“…The overall prevalence, defined as the use of antihypertensive agents with or without elevated blood pressure (BP), has been reported to be as high as 85% [1]. It is generally accepted that hypertension negatively influences kidney transplant outcomes.…”

Evaluation and Management of Proteinuria After Kidney Transplantation

“…This recommendation, however, was not graded due to the lack of evidence supporting this statement. 75 A recent review by Weir et al 76 They showed that use of these agents was associated with a significant reduction in proteinuria and GFR, but there was insufficient data to draw any conclusions regarding graft or patient survival.…”

“…76,95 A recent search of clinicaltrials. gov identified 2 proteinuria trials in renal transplantation.…”

Which Patients Does the SPRINT Study Not Apply To and What Are the Appropriate Blood Pressure Goals in These Populations?

“…BP threshold for treatment of kidney transplant recipients remains at 130/80 mm Hg, regardless of proteinuria. 9 The Secondary Prevention of Small Subcortical Strokes (SPS3) trial, which compared an SBP treatment target of <130 mm Hg with a target of 130 mm Hg to 149 mm Hg in participants with a recent lacunar stroke, showed a nonsignificant reduction in recurrent stroke in the group randomized to the lower target. 10 There are no specific studies that have evaluated BP targets in patients without other comorbidities who are younger than 50 years and who often have predominantly diastolic hypertension.…”