Review
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Aug 18, 2022; 12(8): 211-222
Published online Aug 18, 2022. doi: 10.5500/wjt.v12.i8.211
Hypertension in kidney transplant recipients
Maria-Eleni Alexandrou, Charles J Ferro, Ioannis Boletis, Aikaterini Papagianni, Pantelis Sarafidis
Maria-Eleni Alexandrou, Aikaterini Papagianni, Pantelis Sarafidis, Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
Charles J Ferro, Department of Renal Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2WB, United Kingdom
Ioannis Boletis, Department of Nephrology, Laiko General Hospital, National and Kapodistrian University, Athens 11527, Greece
Author contributions: Sarafidis P and Ferro CJ conceived and designed the work; Alexandrou ME and Ferro CJ performed the bibliography search; Alexandrou ME, Ferro CJ and Sarafidis P prepared the original draft; Boletis I and Papagianni A critically revised the manuscript; Sarafidis P supervised the project; and all authors have read and approved the final manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Pantelis Sarafidis, MD, MSc, PhD, Associate Professor, Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Konstantinoupoleos 49, Thessaloniki 54642, Greece. psarafidis11@yahoo.gr
Received: April 30, 2022
Peer-review started: April 30, 2022
First decision: May 31, 2022
Revised: June 7, 2022
Accepted: August 6, 2022
Article in press: August 6, 2022
Published online: August 18, 2022
Processing time: 109 Days and 12.2 Hours
Abstract

Kidney transplantation is considered the treatment of choice for end-stage kidney disease patients. However, the residual cardiovascular risk remains significantly higher in kidney transplant recipients (KTRs) than in the general population. Hypertension is highly prevalent in KTRs and represents a major modifiable risk factor associated with adverse cardiovascular outcomes and reduced patient and graft survival. Proper definition of hypertension and recognition of special phenotypes and abnormal diurnal blood pressure (BP) patterns is crucial for adequate BP control. Misclassification by office BP is commonly encountered in these patients, and a high proportion of masked and uncontrolled hypertension, as well as of white-coat hypertension, has been revealed in these patients with the use of ambulatory BP monitoring. The pathophysiology of hypertension in KTRs is multifactorial, involving traditional risk factors, factors related to chronic kidney disease and factors related to the transplantation procedure. In the absence of evidence from large-scale randomized controlled trials in this population, BP targets for hypertension management in KTR have been extrapolated from chronic kidney disease populations. The most recent Kidney Disease Improving Global Outcomes 2021 guidelines recommend lowering BP to less than 130/80 mmHg using standardized BP office measurements. Dihydropyridine calcium channel blockers and angiotensin-converting enzyme inhibitors/angiotensin-II receptor blockers have been established as the preferred first-line agents, on the basis of emphasis placed on their favorable outcomes on graft survival. The aim of this review is to provide previous and recent evidence on prevalence, accurate diagnosis, pathophysiology and treatment of hypertension in KTRs.

Keywords: Hypertension; Kidney transplantation; Epidemiology; Diagnosis; Physiopathology; Therapy

Core Tip: Kidney transplantation is considered the treatment of choice for end-stage kidney disease patients. However, the residual cardiovascular risk remains significantly higher in kidney transplant recipients than in the general population. This article summarizes available evidence on prevalence, abnormal blood pressure phenotypes and diurnal patterns as well as on the association of hypertension with target organ damage and clinical outcomes in kidney transplantation. The complex pathophysiology, treatment goals and recent data on therapeutic options for management of hypertension in kidney transplant recipients are also discussed.