Assessment of hypertension in kidney transplantation by ambulatory blood pressure monitoring: a systematic review and meta-analysis

Abstract

Background Hypertension (HTN) is common following renal transplantation and it is associated with adverse effects on cardiovascular (CV) and graft health. Ambulatory blood pressure monitoring (ABPM) is the preferred method to characterize blood pressure (BP) status, since HTN misclassification by office BP (OBP) is quite common in this population. We performed a systematic review and meta-analysis aimed at determining the clinical utility of 24h ABPM and its potential implications for the management of HTN in this population. Methods Ovid-MEDLINE and PubMed databases were searched for interventional or observational studies enrolling adult kidney transplant recipients (KTRs) undergoing 24-hour ABP readings compared with office or home BP. Main outcome was: proportion of KTRs diagnosed with HTN by ABPM, home or office recordings. Additionally, day-night BP variability and dipper/non-dipper status were assessed. Results Forty-two eligible studies (4115 participants) were reviewed. A cumulative analysis including 27 studies (3481 participants) revealed a prevalence of uncontrolled HTN detected by ABPM of 56% (95% CI, 46%-65%). The pooled prevalence of uncontrolled HTN according to office BP was 47% (95% CI, 36%-58%) in 25 studies (3261 participants). Very few studies reported on home BP recordings. The average concordance rate between office and ABPM measurements in classifying patients as controlled or uncontrolled hypertensive was 66% (95% CI, 59%-73%). ABPM revealed HTN phenotypes among KTRs. Two pooled analyses of eleven and ten studies, respectively, revealed an average prevalence of 26% (95% CI, 19%-33%) for masked HTN and 10% (95% CI, 6%-17%) for white-coat HTN. The proportion of non-dippers was variable across the 28 studies that analyzed dipping status, with an average prevalence of 54% (95% CI, 45%-63%). Conclusions In our systematic review, comparison of office vs. ambulatory BP measurements disclosed a high proportion of masked, uncontrolled HTN and, to a lesser extent, white-coat HTN in KTRs. These results suggest that HTN is not adequately diagnosed and controlled by office recordings in this population. Furthermore, the high prevalence of non-dippers confirmed that circadian rhythm is commonly disturbed in KTRs.

A parallel evaluation of short- and mid-term changes of ambulatory blood pressure in kidney transplant recipients and kidney donors

“…In addition, we observed an overall beneficial effect of KTx on BP control; the proportion of KTRs with concordant lack of control by both office and ABPM was reduced, whereas the percentage of patients with concordant control of BP was almost quadrupled. Despite these beneficial effects, the rates of uncontrolled hypertension in our cohort are considered high and are similar to those reported in recent meta-analyses [ 30 ]. In addition, no significant changes were noted in dipping patterns, with the proportion of non-dippers and reverse dippers remaining considerably high (53.1% and 31.3%, respectively), similar to previously reported rates (42% and 34%) 12 months after KTx [ 33 ].…”

“…However, office BP has several limitations in the diagnosis and management of hypertension compared with the gold standard of BP measurement, which is 24-h ABPM [ 12 , 13 ]. The latter enables identification of white coat and masked hypertension phenotypes, which are particularly common in KTRs [ 30 ], and displays stronger associations than office BP with target-organ damage [ 11 ]. Ιn view of the above, recent guidelines and consensus documents highlight the need of more extended ABPM use in the diagnosis and management of hypertension in KTRs [ 5 , 14 ].…”

Denervation Aggravates Renal Ischemia Reperfusion Injury via BMAL1-mediated Nrf2/ARE pathway

“…Clinical observations have shown that the rhythm disorder after renal transplant remained, such as sleep disturbance, fatigue, hypertension and metabolic impairment in ERSF patients, which indicates that circadian clock system involved in the graft's function of renal transplant patient (Mendoza-Romo-Ramírez, et al, 2021) (Pisano, et al, 2021). The literature has demonstrated that nocturnal surgery might increase the morbidity and mortality with a higher risk of postoperative complications compared to daytime surgery in lung transplant and cardiac surgery and myocardial tolerance to IRI imposed daytime variation (Qiu, et al, 2018) (Montaigne, et al, 2018) (Cunningham, et al, 2019).…”

“…Clinically, patients with ERSF show a variety of rhythm disorders of physiological functions, such as low sleep quality, recurrence of hypertension, restless legs syndrome and so on, which can be aggravated by hemodialysis treatment (So, et al, 2020) (Firsov, et al, 2018). Unfortunately, renal transplantation can only temporarily improve a series of symptoms caused by circadian rhythm disorder, but the long-term syndromes still exist (Mendoza-Romo-Ramírez, et al, 2021) (Pisano, et al, 2021). Meanwhile, the latest cohort study with 10291 patients observed that compared to nocturnal de-clamping, day-time de-clamping was associated with a better prognosis of kidney transplantation despite a longer duration of cold ischemia (Montaigne, et al, 2021).…”

Hypertension in kidney transplantation: a consensus statement of the ‘hypertension and the kidney’ working group of the European Society of Hypertension

“…The most recent systematic review confirmed that altered circadian BP profile and nocturnal hypertension are frequent in the transplant population [15]. Moreover, the use of ABPM in kidney transplant recipients indicated a great proportion of both masked hypertension and white-coat hypertension [15].…”