Ambulatory blood pressure monitoring in pediatric renal transplantation

Restoration of nocturnal blood pressure dip and reduction of nocturnal blood pressure with evening anti-hypertensive medication administration in pediatric kidney transplant recipients: A pilot randomized clinical trial

Non-dipping and nocturnal hypertension are commonly found during ABPM in pediatric kidney transplant recipients. These entities are independently associated with increased cardiovascular disease risk in adults. Kidney transplant recipients aged 5-21 years with eGFR > 30 mL/min/1.73 m² and ABPM demonstrating non-dipping status and normal daytime BP were randomized to intervention (short acting BP medication added in the evening) or control (no medication change) in this pilot, randomized, open-label, blinded end-point clinical trial. ABPM, echocardiography, and PWV were performed at baseline, 3 months, and 6 months. The trial included 17 intervention and 16 control participants. Conversion to dipper status occurred in 53.3% vs 7.7% (P = .01) at 6 months for intervention and controls, respectively. Systolic dip was greater in the intervention group compared to controls (10.9 ± 4.5 vs 4.2 ± 4.6, P = .001), and average systolic nighttime BP was significantly lower in the intervention group (106 ± 8.3 vs 114.9 ± 9.5 mm Hg, P = .01) at 6 months. There were no significant differences in LVMI, PWV, or eGFR between groups. Within-group changes in the intervention group demonstrated improvements in non-dippers, dipping, systolic nighttime BP and nighttime BP load. Restoration of nocturnal dip and improvement in nocturnal BP were observed in the population following chronotherapy. Future studies are needed with larger sample sizes over a longer period of time to delineate the long-term effect of improved nocturnal dip on target organ damage.

Inadequate blood pressure control demonstrated by ambulatory blood pressure monitoring in pediatric renal transplant recipients

BACKGROUND

Adequate BP control in RT recipients should not rely only by normal office BP but also on normal 24-hour BP. This study aims to assess adequacy of BP control by ABPM and to assess ABPM parameters associated with LVMI in pediatric RT recipients.

MATERIALS AND METHODS

Patients aged 5-20 years who have been followed after RT were enrolled. Demographic data and BP assessed by office and ABPM were collected. Echocardiography was performed to detect LVMI.

RESULTS

Thirty RT recipients (18 males) with median age of 15 years (IQR 13-18.5) were included. Among 23 patients who were taking antihypertensive drugs, uncontrolled hypertension was detected in 34.8% and 78.3% by office BP measurement and ABPM, respectively. Thus, the difference in prevalence of uncontrolled hypertension observed by ABPM versus office BP was 43.5%. Those seven patients who were not taking antihypertensive drugs because of normal office BP, four patients (57.1%) had masked hypertension and one patient had elevated BP. Fifteen patients have progression of LVH after RT. Multivariate analysis revealed that age (OR 1.369, 95%CI 0.985-1.904, P-value = 0.062) had a trend to be associated with progression of LVH. Moreover, nighttime systolic BP z-score was significantly correlated with LVMI (r = 0.551, P-value = 0.002).

CONCLUSION

The difference in prevalence of uncontrolled hypertension uncovered by ABPM was 43.5%. Nighttime SBP z-score was significantly correlated with LVMI.

Steroid withdrawal improves blood pressure control and nocturnal dipping in pediatric renal transplant recipients: analysis of a prospective, randomized, controlled trial

BACKGROUND

Variable effects of steroid minimization strategies on blood pressure in pediatric renal transplant recipients have been reported, but data on the effect of steroid withdrawal on ambulatory blood pressure and circadian blood pressure rhythm have not been published so far.

METHODS

In a prospective, randomized, multicenter study on steroid withdrawal in pediatric renal transplant recipients (n = 42) on cyclosporine, mycophenolate mofetil, and methylprednisolone, we performed a substudy in 28 patients, aged 11.2 ± 3.8 years, for whom ambulatory blood pressure monitoring (ABPM) data were available.

RESULTS

In the steroid-withdrawal group, the percentage of patients with arterial hypertension, defined as systolic and/or diastolic blood pressure values recorded by ABPM > 1.64 SDS and/or antihypertensive medication, at month 15 was significantly lower (35.7%, p = 0.002) than in controls (92.9%). The need of antihypertensive medication dropped significantly by 61.2% (p < 0.000 vs. control), while in controls, it even rose by 69.3%. One year after steroid withdrawal, no patient exhibited hypertensive blood pressure values above the 95th percentile, compared to 35.7% at baseline (p = 0.014) and to 14.3% of control (p = 0.142). The beneficial impact of steroid withdrawal was especially pronounced for nocturnal blood pressure, leading to a recovered circadian rhythm in 71.4% of patients vs. 14.3% at baseline (p = 0.002), while the percentage of controls with an abnormal circadian rhythm (35.7%) did not change.

CONCLUSIONS

Steroid withdrawal in pediatric renal transplant recipients with well-preserved allograft function is associated with less arterial hypertension recorded by ABPM and recovery of circadian blood pressure rhythm by restoration of nocturnal blood pressure dipping.

Clinical value of ambulatory blood pressure in pediatric patients after renal transplantation

Hypertension is a highly prevalent co-morbidity in pediatric kidney transplant recipients. Undertreated hypertension is associated with cardiovascular complications and negatively impacts renal graft survival. Thus, the accurate measurement of blood pressure is of the utmost importance for the correct diagnosis and subsequent management of post-renal transplant hypertension. Data derived from the general population, and to a lesser extent from the pediatric population, indicates that ambulatory blood pressure monitoring (ABPM) is superior to blood pressure measurements taken in the clinical setting for the evaluation of true mean blood pressure, identification of patients requiring antihypertensive treatment, and in the prediction of cardiovascular outcome. This Educational Review will discuss the clinical value of ABPM in the identification of individual blood pressure phenotypes, i.e., normotension, new-onset hypertension, white-coat hypertension, masked hypertension, controlled blood pressure, and undertreated/uncontrolled hypertension in pediatric kidney transplant recipients. Finally, we examine the utility of performing repeated ABPM for treatment monitoring of post-renal transplant hypertension and on surrogate markers related to relevant clinical cardiovascular outcomes. Taken together, our review highlights the clinical value of the routine use of ABPM as a tool for identifying and monitoring hypertension in pediatric kidney transplant recipients.

Hypertension in children after renal transplantation

BACKGROUND

Hypertension (HT) is a common and serious complication following renal transplantation in children, and an important risk factor for cardiovascular morbidity and mortality. This study evaluated the clinical characteristics of HT in children after renal transplantation.

METHODS

Twenty-four children who were followed up at least 6 months after renal transplantation were enrolled in the study. From the clinical records, demographic and laboratory data, casual blood pressure (BP) measurement, ambulatory BP monitoring (ABPM), medication, and left ventricular mass index (LVMI) at echocardiogram were documented.

RESULTS

Mean age at time of transplantation was 12.6 ± 3.0 years and mean follow-up period was 19.6 ± 15.8 months. HT was detected in 21 children (87.5%) after renal transplantation. Twelve patients (50%) had HT both before and after transplantation and nine (38%) had HT only after transplantation. HT developed in 67% within the first week and in 95% within the first month. All hypertensive children had night-time HT and no child had isolated daytime HT. The efficacy of HT control was 42%. Median LVMI in patients with HT after renal transplantation was 42.3 g/m(2.7).

CONCLUSIONS

Severe HT, an important complication, was frequently seen in the early period after renal transplantation. Predominance of nocturnal HT and the lack of isolated daytime HT after transplantation underline the importance of ABPM. ABPM should be performed regularly in the first year after transplantation, not only for diagnosis but also for evaluation of HT control.

Post-transplant hypertension in pediatric kidney transplant recipients

BACKGROUND

The aim of the study was to investigate the prevalence of post-transplant hypertension (HT) and to assess the blood pressure (BP) of transplanted children with possible risk factors.

METHODS

Office and ambulatory blood pressure measurements were performed for each patient.

RESULTS

Twenty-nine patients were included in the study, including 13 patients with newly diagnosed untreated HT according to the results of ambulatory blood pressure monitoring (ABPM). Fourteen patients were on antihypertensive medication, but only in five of these patients was the HT under control; nine patients receiving antihypertensive drugs had uncontrolled HT. Of the 29 patients, two had normotension without any antihypertensive drug(s). Standard deviation scores (SDS) of the nocturnal diastolic BP of the ABPM were positively correlated with the prednisolone dosage per kilogram (p = 0.013, r = 0.45) and negatively correlated with the time period after transplantation (p = 0.024, r = -0.41). Similarly, the SDS of the 24-h diastolic BP was positively correlated with the prednisolone dosage per kilogram (p = 0.006, r = 0.50) and negatively correlated with the time period after transplantation (p = 0.016, r = -0.44). Patients with alternate-day steroid treatment had lower nocturnal systolic (p = 0.016), nocturnal diastolic (p = 0.001) and 24-h diastolic (p = 0.008) SDS when compared to those receiving daily steroid medication.

CONCLUSION

The prevalence of HT among children after renal transplantation was high among our patient cohort, and steroids had direct impact on nocturnal and diastolic BP.

An observational cohort study of the effect of hypertension on the loss of renal function in pediatric kidney recipients

BACKGROUND

Post-transplant hypertension impacts negatively on renal graft survival. Our primary objective was to analyze the effect of hypertension on the glomerular filtration rate (GFR) slope.

METHODS

All clinical charts of children who underwent renal transplantation since the introduction of the routine use of ambulatory blood pressure monitoring (ABPM) were reviewed. Eligibility criteria for inclusion were measurement of GFR at 3 months, at 1 year post-transplant, and thereafter at yearly intervals; ABPM performed annually after transplantation; and functioning graft for a minimum of 2 years.

RESULTS

Sixty-eight (39 males) of 79 patients, aged 9.1±5.3 years, met the inclusion criteria. The mean follow-up was 6.2±2.8 years. Twenty-four patients had normotension or controlled hypertension throughout their follow-up (normotensive group). Forty-four patients had hypertension or noncontrolled hypertension at some point(s) during the follow-up period (hypertensive group). GFR slope was -1.6ml/min/1.73 m(2) per year (95% confidence interval (CI = -3.7 to 0.4) in the normotensive group and -2ml/min/1.73 m(2) per year (95% CI = -3 to -1.1) in the hypertensive group (P = 0.42). There was no difference between groups with regard to the change in GFR values from 3 months to 1 year and to last control (P = 0.87). At most recent control, the overall prevalence of controlled hypertension was 78.2% (95% CI = 63.6-89.1).

CONCLUSIONS

Although the results of our study are encouraging, they need to be confirmed in a larger prospective study using the same post-transplant follow-up protocol.

Ambulatory blood pressure monitoring in pediatric renal transplantation

Hypertension is a common and serious complication after renal transplantation. It is an important risk factor for graft loss and adverse cardiovascular outcomes. Blood pressure (BP) in transplanted children should be measured not only by clinic BP (cBP) measurement, but also by ambulatory blood pressure monitoring (ABPM), because ABPM has distinct advantages over cBP, specifically the ability to reveal nocturnal, masked or white-coat hypertension. These types of hypertension are common in transplanted children (nocturnal hypertension 36-71 %, masked hypertension 24-45 %). It may also reveal uncontrolled hypertension in treated children, thereby improving control of hypertension. Regular use of ABPM and ABPM-guided therapy of hypertension may help to decrease cardiovascular and renal target organ damage in transplanted children. Therefore, ABPM should be routinely performed in all transplanted children at least once a year, regardless of the values of cBP.

Longitudinal relations between obesity and hypertension following pediatric renal transplantation

Obesity and hypertension frequently complicate renal transplantation (RTxp). The objective was to assess relations among obesity, hypertension, and glucocorticoids in pediatric RTxp recipients. A retrospective cohort study was carried out in 141 RTxp recipients, 2-21 years of age, with >or=12 months of follow-up. Body mass index Z-score (BMI-Z), systolic and diastolic blood pressure Z-scores (SBP-Z and DBP-Z), and medications at 1, 3, 6, and 12 months and annually thereafter were recorded. Quasi-least squares regression analysis was used. The prevalence of obesity (BMI>or=95th percentile) increased from 13% at baseline to >30% from 3 months onward. Greater glucocorticoid exposure (mg/kg/day) was associated with greater increases in BMI-Z (p<0.001). This association was greater in males, younger recipients, and those with lower baseline BMI-Z (all interactions p<0.02). The prevalence of systolic hypertension (SBP>or=95th percentile) was 73% at 1 month and >or=40% at all follow-up visits. Greater glucocorticoid exposure (p<0.001) and increases in BMI-Z (p=0.005) were independent determinants of SBP-Z over time. Cyclosporine (versus tacrolimus) was independently associated with greater SBP-Z and DBP-Z (p=0.001). Sustained obesity and hypertension frequently complicated pediatric RTxp. Obesity was an independent determinant of systolic hypertension. Strategies are needed to prevent obesity and its impact on hypertension, cardiovascular disease, and allograft survival.

Masked hypertension and hidden uncontrolled hypertension after renal transplantation

Arterial hypertension is a risk factor affecting graft function in pediatric kidney transplants. Recent pediatric studies reported a high prevalence of hypertension, especially nocturnal hypertension in this population. Data regarding the prevalence of masked hypertension in pediatric patients with kidney transplants are still scarce. The aim of this cross-sectional study was to assess the prevalence of masked and hidden uncontrolled hypertension after renal transplantation. A total of 41 patients (25 males) with stable functioning renal graft were included in the study. Their median age was 14.5 years with the median interval since transplantation of 2.5 years (range 0.3 to 20.6). Spacelabs 90207 was used to measure ambulatory blood pressure (BP) during a 24-h period. Ambulatory hypertension was defined as mean systolic and/or diastolic BP index at day-time or nighttime >or=1. Masked hypertension was defined as normal office BP but daytime ambulatory hypertension in patients without antihypertensive medications. Hidden uncontrolled hypertension was defined as daytime ambulatory hypertension undetected by office BP measurements in treated patients. Antihypertensive medications were prescribed to 58%. Prevalence of nocturnal hypertension was 68%. On the basis of combination of office and ABPM masked hypertension and hidden uncontrolled hypertension was detected in 24% and 21% of the study population, respectively. Regular use of ambulatory blood pressure monitoring in transplanted patients enables detection of masked and hidden uncontrolled hypertension.

Hypertension after renal transplantation

Hypertension is a common and serious complication after renal transplantation. It is an important risk factor for graft loss and morbidity and mortality of transplanted children. The etiology of posttransplant hypertension is multifactorial: native kidneys, immunosuppressive therapy, renal-graft artery stenosis, and chronic allograft nephropathy are the most common causes. Blood pressure (BP) in transplanted children should be measured not only by casual BP (CBP) measurement but also regularly by ambulatory BP monitoring (ABPM). The prevalence of posttransplant hypertension ranges between 60% and 90% depending on the method of BP measurement and definition. Left ventricular hypertrophy is a frequent type of end-organ damage in hypertensive children after transplantation (50-80%). All classes of antihypertensive drugs can be used in the treatment of posttransplant hypertension. Hypertension control in transplanted children is poor; only 20-50% of treated children reach normal BP. The reason for this poor control seems to be inadequate antihypertensive therapy, which can be improved by increasing the number of antihypertensive drugs. Improved hypertension control leads to improved long-term graft and patient survival in adults. In children, there is a great potential for antihypertensive treatment that could also result in improved graft and patient survival.

Blood pressure control in hypertensive pediatric renal transplants: role of repeated ABPM following transplantation

BACKGROUND

Hypertension in pediatric renal transplants is a widespread condition associated with high mortality risk in early adult life. Ambulatory blood pressure monitoring (ABPM) was found to be superior to office blood pressure (BP) in identifying true hypertensive and responders to treatment. The aim of this study was to investigate the role of repeated ABPM, performed at yearly intervals following transplantation, in the assessment and decision-making processes of post-transplant hypertension.

METHODS

Thirty-seven recipients (23 males; aged 10.5 +/- 4.3 years) who were followed for 4.3 +/- 2.2 years (range 2-9) after transplantation were eligible for analysis. The mean follow-up time between the baseline (1 year post-transplantation) and the most recent ABPM examination was 3.3 +/- 2.2 years (range 1-8).

RESULTS

Throughout the follow-up period, antihypertensive therapy was either started or intensified in 27 recipients. These interventions were decided based on ABPM results obtained on 40 of 44 occasions. At last follow-up, 24 of 29 treated hypertensive recipients displayed controlled BP. This figure was significantly higher compared to our historical hypertensive control recipients in whom ABPM was applied for the first time in treatment at 6 +/- 3.3 years (range 2-15) after transplantation, while therapeutic decisions were driven by office BP measurements (95 % confidence interval (95% CI) for the difference between proportions (80.6-32 %) 36-60 %, P = 0.001).

CONCLUSIONS

Our study shows that, in a population with high risk for hypertension, repeated ABPM may significantly help to improve BP control.

Oxidative stress and post-transplant hypertension in pediatric kidney-transplanted patients

OBJECTIVE

To test the hypothesis that oxidative stress signaling contributes to post-transplant endothelial dysfunction and hypertension in pediatric post-transplant hypertension.

STUDY DESIGN

This study evaluated in 16 pediatric renal transplant patients, divided in two groups based on the presence of post-transplant hypertension, the oxidative stress status measuring the gene expression (reverse transcription-polymerase chain reaction) of two major oxidative stress-related proteins, p22(phox) and heme oxygenase-1 (HO-1). Total plasma antioxidant power (ELISA) was also evaluated.

RESULTS

Mononuclear cell p22(phox) gene expression was higher in hypertensive patients compared with the normotensive group (0.91 +/- 0.06 vs 0.79 +/- 0.08 densitometric units, P < .02), whereas HO-1 RNA production and total plasma antioxidant power were higher in the normotensive group (0.38 +/- 0.04 vs 0.20 +/- 0.11 d.u., P < .006, and 1189.35 +/- 145.75 vs 772.71 +/- 196.03 micromol/L, P < .01, respectively).

CONCLUSIONS

Oxidative stress is associated with post-transplant hypertension in hypertensive pediatric kidney-transplant patients, who therefore are at risk of oxidative stress-induced organ damage. They might benefit from treatments addressing not only hypertension but also oxidant-related complications.

Control of hypertension in children after renal transplantation

The aim of this cross-sectional single-center study was to investigate the efficacy of hypertension control in children who underwent transplantation using ambulatory blood pressure (BP) monitoring, and to determine the risk factors associated with poor control of hypertension. Thirty-six children fulfilled the inclusion criteria. The mean age was 13.9+/-4.4 yr; the mean time after renal transplantation was 2.7+/-2.4 yr (0.5-10.1). Hypertension was defined as a mean ambulatory BP > or =95th centile for healthy children and/or requiring antihypertensive drugs. Hypertension was regarded as controlled if the mean ambulatory BP was <95th centile in children already on antihypertensive drugs, or uncontrolled if the mean ambulatory BP was > or =95th centile in treated children. Hypertension was present in 89% of children. Seventeen children (47%) had controlled hypertension, and 14 (39%) had uncontrolled hypertension. One child (3%) had untreated hypertension, and only four children (11%) showed normal BP without antihypertensive drugs. The efficacy of hypertensive control was 55% (17 of 31 children on antihypertensive drugs had a BP<95th centile), i.e. 45% of treated children still had hypertension. Children with uncontrolled hypertension had significantly higher cyclosporine doses (6.1 vs. 4.3 mg/kg/day, p=0.01) and tacrolimus levels (9.2 vs. 6.1 microg/L, p<0.05), and there was a tendency toward use of lower number of antihypertensive drugs (2.0 vs. 1.5 drugs/patient, p=0.06) and lower use of angiotensin-converting enzyme (ACE) inhibitors (7 vs. 35%, p=0.09) and diuretics (29 vs. 59%, p=0.14) than in children with controlled hypertension. In conclusion, nearly 90% of our children after renal transplantation are hypertensive and the control of hypertension is unsatisfactorily low. The control of hypertension could be improved by increasing the number of prescribed antihypertensive drugs, especially ACE inhibitors, and diuretics, or by using higher doses of currently used antihypertensives.

Neurocognitive outcomes in children with chronic kidney disease: Current findings and contemporary endeavors

Given the rise in chronic kidney disease (CKD) in both children and adults, CKD has recently been targeted as a public health priority. Childhood onset kidney disease is generally a noncurable and progressive condition that leads to kidney failure by early adulthood. Fortunately, improved identification of kidney problems allows for early intervention, which is thought to slow progression toward end-stage renal disease. In addition, medical interventions for pediatric end-stage renal disease have also improved, allowing children to take advantage of lifesaving renal replacement treatments such as dialysis and kidney transplantation. In spite of improvements in identification and treatment, CKD causes both direct and indirect insults to a variety of organ systems. This paper reviews recently published studies pertaining to the neurocognitive and psychosocial impact of CKD on children of various ages and at various stages of kidney failure. Specific attention is focused on summarizing peer reviewed research that describes associations between kidney functioning and cognitive functioning, language acquisition, visual spatial abilities, memory, and executive functioning. In addition, peer reviewed research describing psychosocial outcomes associated with CKD related to academic achievement, social-behavioral functioning, and quality of life are summarized. The authors also identified disease-specific factors that likely mediate neurocognitive outcomes (e.g., anemia, hypertension, cardiovascular) and endorse the importance of continued interdisciplinary research collaborations that will provide a better understanding of the mechanisms responsible for improved neurocognitive functioning after transplantation. The authors conclude this review by describing a multicenter, prospective, longitudinal, National Institutes of Health funded study that is currently examining the developmental outcomes of children with mild to moderate CKD. The authors speculate that the Chronic Kidney Disease in Children Prospective Cohort Study (CKiD) findings will provide additional evidence-based guidance for clinicians and researchers working with children and adolescents with deteriorating kidney function to improve medical and developmental outcomes.

Applications of 24-hour Noninvasive Ambulatory Blood Pressure Monitoring

Casual blood pressure (CBP) measurements using a standard sphygmomanometer have traditionally constituted the principal modality for the assessment and management of hypertension. However, CBP measurement has shortcomings. Ambulatory blood pressure monitoring (ABPM) provides abundant information on blood pressure (BP), including heart rate, all BP readings for test periods, BP average, BP variability, BP load, load index, distribution pattern of BP, reduction percentage of BP, trough/peak ratio, and summary statistics for overall 24-hour, daytime and nighttime periods. Over the last three decades, ABPM has evolved from a research device to an established and valuable clinical tool for assessment and management of hypertension. This technology has been proven to be useful in terms of the distribution pattern of BP, characterization of BP profiles in normotensive and hypertensive patients, evaluation of patients with mild or labile hypertension, physiologic and psychologic factors for fluctuation of BP, load index study, study of white coat hypertension, etiology of hypertension, prognosis of hypertension, and assessment of antihypertensive management. Nevertheless, the technology remains underused due to lack of insurance reimbursement in most countries. Accordingly, insurance reimbursement is crucial to promote increased utility of ABPM. Clinicians should be familiar with the role of this technology in the care of patients with abnormal BP. This review is an attempt to increase clinicians' understanding of ABPM and the appropriate use of this technology.

Ambulatory blood pressure monitoring in children after renal transplantation

Arterial hypertension is a common complication in children after renal transplantation and the control of hypertension is often difficult. This retrospective investigates the prevalence and rate of control of hypertension using ambulatory blood pressure monitoring (ABPM) in 45 children (mean age 14.1 +/- 4.3 years, mean time after renal transplantation 2.2 +/- 2.7 years), all on cyclosporine or tacrolimus, azathioprine or mycophenolate mofetil plus daily steroids. The overall prevalence of hypertension was 82%. None of the transplanted children had normal blood pressure without antihypertensive therapy (ie, spontaneous normotension). Twenty percent of children had untreated hypertension, 18% had controlled hypertension, and 62% had uncontrolled hypertension. Prevalence of the nondipping phenomenon was 53%. The mean number of antihypertensive drugs (without diuretic monotherapy) in treated patients was 1.9 drugs per patient. The prevalence of arterial hypertension in children after renal transplantation is high and the control of hypertension is often unsatisfactorily low.

Pathomechanisms and the diagnosis of arterial hypertension in pediatric renal allograft recipients

Arterial hypertension is common in pediatric renal allograft recipients. While the causes are multifactorial, including chronic graft rejection, immunosuppressive therapy, and renal vascular disorders, the effect of hypertension on renal allograft function is detrimental. As in adults, if not treated early and aggressively, hypertension may lead to cardiovascular damage and graft failure. Pathophysiological changes in the arteries and kidney af-ter renal transplantation and the impact of receptor regulation have not been studied extensively in children. For identifying children with hypertension following renal transplantation casual blood pressure measurements do not accurately reflect average arterial blood pressure and circadian blood pressure rhythm. Ambulatory 24-h blood pressure monitoring should regularly be applied in trans-plant patients. The purpose of this review is to analyze pathophysiological aspects of risk factors for arterial hypertension and underline the importance of regular blood pressure monitoring and early therapeutic intervention.

Is ABPM clinically useful after pediatric solid organ transplantation?

When ambulatory blood pressure monitoring (ABPM) is performed in populations with a high risk for secondary hypertension, such as solid organ transplant recipients, hypertension or abnormalities in circadian blood pressure variability are often discovered even in patients with normal office blood pressure (BP). To discuss whether ABPM should be routinely assessed in pediatric solid organ recipients, the available information on pathological findings, association of ABPM abnormalities with outcome parameters, and treatment options is reviewed. ABPM is a useful tool to optimize therapy in the large proportion of transplant recipients with confirmed hypertension. Whether the use of ABPM on a routine basis should be recommended for pediatric transplantation patients without office hypertension remains to be determined.

Predictors of progression in hypertensive renal disease in children

In hypertensive renal disease in children, several risk factors influence the development and the rate of progression of renal damage, including blood pressure levels, proteinuria, lipid disorders, and genetic differences. The impact of blood pressure on renal structures, the most important of the factors, depends not only on blood pressure levels, but also on the persistence of the blood pressure levels over time, mainly during the hours when the patient is resting or sleeping. Abnormal circadian variability is frequently observed in patients with renal damage, and nocturnal blood pressure reduction should be a major therapeutic objective to protect against a decline in renal function. Proteinuria is a guide for establishing targets and for monitoring treatment. It should be reduced as much as possible to obtain maximal renoprotective effect. The role of the other factors, such as lipid disorders and genetics, remains elusive.

The factors affecting blood pressure in pediatric renal transplant recipients

To investigate the parameters affecting systemic blood pressure in pediatric renal transplant recipients, we retrospectively examined the data from 19 adolescent renal transplant recipients including 6 girls overall, mean age of 15,47 +/- 3.56 years. Serum creatinine (Scr), fractional extraction of sodium (FENa), whole blood trough cyclosporine(C0), plasma total cholesterol (TC) and triglyceride levels, and systolic and diastolic blood pressure (SBP and DBP) were monitored during a total of 677 visits. SBP and DBP, classified as <95p (groups 1s and 1d) and >95p (groups 2s and 2d), were correlated with differences between groups 1 and 2. Group 2s Scr and FENa levels were higher than group 1s (P =.002 and P =.048, respectively), whereas C0 and FENa levels were higher in Group 2d than Group 1d (P = 0.028 and P = 0.036, respectively). Among the entire group, SBP and DBP positively correlated with C0; Scr and SBP, with FENa. While there was a positive correlation between SBP and C0 in groups 1s and 2s (r = 0.188, P <.000; and r = 0.145, P =.040), DBP was only associated with C0 in group 1d (P =.03, r = 0.156). In contrast, DBP showed a positive correlation with Scr in group 2d (P =.023, r = 0.132), and SBP with Scr in Group 1s. C0 and Scr levels were correlated in Groups 1s, 1d and 2d. At high BP levels (>95p), SBP is mostly affected by C0; DBP, with Scr. However, in both groups these two parameters positively correlate with each other. Thus, in adolescent renal transplant recipients the cause of high blood pressure does not appear to be solely related to cyclosporine related to induced allograft dysfunction.