Notes

Hypertension in the Transplant Patient
Prevalent in 75–90 % of kidney transplant recipients
Evolution in KTx

1. Hypertension Immediately Post-KTx:
* Postoperative pain, hypervolemia, hypoxemia, anxiety, and discontinuation of oral antihypertensive medications (pre-transplant ACEi, ARB, or clonidine) or withdrawal (for example, clonidine).
* Initiation of common immunosuppressants such as CNIs (tacrolimus or cyclosporine) and steroids.

2. Chronic Hypertension Post-KTx
* Modifiable factors: Obesity, non-steroidal anti-inflammatory drug (NSAID) use, alcohol consumption, excess sodium, sleep apnea, renal artery stenosis, primary hyperaldosteronism, pheochromocytoma, and hypothyroidism.
* CNIs: Kidney transplant who were on belatacept based (non-CNI) immunosuppression needed fewer antihypertensive medications (median 2 drugs)compared with those on CNI based regimens. Impair vascular tone by causing vasoconstriction and/or impairing vasodilatation. Chronic administration of CNIs has been associated with obliterative arteriolopathy, ischemic glomeruli, and striped fibrosis of the renal interstitium. Sirolimus and belatacept (@EdoardoMelilli et al. 2015) are both associated with reduced vascular stiffness and hypertension as compared to CNIs.
* Corticosteroids: Usually more important during early post-transplant period; however, kidney transplant recipients maintained on corticosteroids long term tend have higher blood pressure than those in steroid avoidance or withdrawal programs.

3. Unique conditions in KTx
* Donor related factors: Increased donor age, presence of donor hypertension, expanded criteria donors.
* Renal artery stenosis of the transplant renal artery (TRAS): Prevalence is 1–23 % of renal transplant recipients, presentation
between 3 months and 2 years is typical.

4. Measurement: Home and ambulatory blood pressure monitoring are useful adjuncts to in-office blood pressure readings; in fact, home blood pressure readings correlate better with ambulatory blood pressure readings than office reading. Warning: The lack of
nocturnal fall in SBP is related to poor allograft function, high chronic vascular score on biopsy, and high resistive index irrespective of allograft fibrosis.

5. Management goals: SPRINT trial suggests that certain patients (including some high risk patients with CKD) may do better with even lower blood pressures (a lot to debate on this issue).KDOQI commentary on the 2012 KDIGO guidelines stipulate that a target blood pressure of <130/80 in kidney transplant recipients is not guided by evidence, and in the absence of data to support the benefits of a BP goal <140/90 mmHg in transplant recipients, it is better to individualize BP goal decisions, taking into account risk and benefit profiles.

Use medications the patient used prior to transplantation unless there are particular drug-drug interactions or adverse effects.