Promoting cardiovascular health post‐transplant through early diagnosis and adequate management of hypertension and dyslipidemia

Abstract

Despite correction of underlying solid organ failure by transplantation, pediatric transplant recipients still have increased mortality rates compared to the general pediatric population, in part due to increased cardiovascular risk. In particular, pediatric kidney and non‐kidney transplant recipients with chronic kidney disease have significant cardiovascular risk that worsens with declining kidney function. Biomarkers associated with future cardiovascular risk such as casual and ambulatory hypertension, dyslipidemia, vascular stiffness and calcification, and left ventricular hypertrophy can be detected throughout the post‐transplant period and in patients with stable kidney function. Among these, hypertension and dyslipidemia are two potentially modifiable cardiovascular risk factors that are highly prevalent in kidney and non‐kidney pediatric transplant recipients. Standardized approaches to appropriate BP measurement and lipid monitoring are needed to detect and address these risk factors in a timely fashion. To achieve sustained improvement in cardiovascular health, clinicians should partner with patients and their caregivers to address these and other risk factors with a combined approach that integrates pharmacologic with non‐pharmacologic approaches. This review outlines the scope and impact of hypertension and dyslipidemia in pediatric transplant recipients, with a particular focus on pediatric kidney transplantation given the high burden of chronic kidney disease‐associated cardiovascular risk. We also review the current published guidelines for monitoring and managing abnormalities in blood pressure and lipids, highlighting the important role of therapeutic lifestyle changes in concert with antihypertensive and lipid‐lowering medications.

Etiology, risk factors and management of hypertension post liver transplantation

“…58,59 Besides that, the accuracy of oscillometric F I G U R E 4 Potential algorithm for monitoring, management and treatment of hypertension in pediatric liver transplant recipients in clinical practice. 6,9,11,22,[24][25][26][27][28][29]31,47,48,51 ambulatory blood pressure measurements is lower for diastolic than for systolic blood pressure. 58,60…”

“…Since the procedure has favorable outcomes in both the short and long term, the focus has shifted towards the prevention and treatment of long‐term complications which are often related to the chronic use of immunosuppressive drugs 1–4,6 . Hypertension is a frequently occurring adverse effect of immunosuppression, in the first instance of calcineurin inhibitor tacrolimus, the cornerstone of most immunosuppressive protocols after liver transplantation 6–29 . It is a recognized risk factor for post‐transplant morbidity and mortality 11,22,24–27,29,30 .…”

Isolated nocturnal hypertension in pediatric kidney transplant recipients

“…In young kidney transplant children with a greater misalignment of cardiac output and nephron mass, these low BP targets might not be as safe. 78 However, in the ESCORT trial, no serious adverse effects were seen in the group with target BP <50th percentile during the 3-year study. There is still more research to be conducted to determine whether decreasing BP to these levels will decrease blood flow to the kidney and cause secondary negative long-term effects beyond 3 years.…”

“…This strict target BP could be used for transplanted children, but there is still some debate regarding how low becomes dangerous to target for pediatric BP. In young kidney transplant children with a greater misalignment of cardiac output and nephron mass, these low BP targets might not be as safe 78 . However, in the ESCORT trial, no serious adverse effects were seen in the group with target BP <50th percentile during the 3‐year study.…”

Healthy living in pediatric transplant recipients: What does it take?

“…Graft and patient survival are important metrics to measure the safety and success of a transplant, but they do not capture the totality of transplant‐related chronic health issues that can profoundly impact a patient's life. Charnaya et al discuss the promotion of cardiovascular health and describe the need for meticulous attention, monitoring, and intervention—areas that need ongoing investigation in order to improve the overall health of pediatric transplant recipients 5 . Additionally, Kusumi and colleagues address bone health, another important facet to improving the quality of life in organ transplant recipients 6…”