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Ehrle H, Goebel J. A(nother) plea for better management of post-transplant cardiovascular morbidity. Pediatr Nephrol 2024; 39:1965-1966. [PMID: 38246943 DOI: 10.1007/s00467-024-06280-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 12/28/2023] [Accepted: 12/29/2023] [Indexed: 01/23/2024]
Affiliation(s)
- Haley Ehrle
- Departments of Pediatrics and Graduate Medical Education, Michigan State University, Helen DeVos Children's Hospital, Grand Rapids, MI, USA
| | - Jens Goebel
- Department of Pediatrics, Section of Pediatric Nephrology, Michigan State University, Helen DeVos Children's Hospital, 100 Michigna St. NE, Grand Rapids, MI, 49503, USA.
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2
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Kasap Demir B, Başaran C, Demircan T, Erfidan G, Özdemir Şimşek Ö, Arslansoyu Çamlar S, Alaygut D, Mutlubaş F, Karadeniz C. The Effect of "Unclassified" Blood Pressure Phenotypes on Left Ventricular Hypertrophy. Turk Arch Pediatr 2024; 59:43-48. [PMID: 38454259 PMCID: PMC10837538 DOI: 10.5152/turkarchpediatr.2024.23109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 10/17/2023] [Indexed: 03/09/2024]
Abstract
OBJECTIVE We aimed to evaluate the clinical significance of the "unclassified" blood pressure phenotypes on left ventricular hypertrophy in children. MATERIALS AND METHODS All children evaluated with ambulatory blood pressure monitoring in the pediatric nephrology department between October 2018 and January 2021 were included in the study. Prehypertension, normotensive, white coat hypertension, masked hypertension, ambulatory hypertension groups and 2 other groups including increased blood pressure load, normal ambulatory blood pressure measurements, but normal (unclassified group 1) or high (unclassified group 2) office blood pressure measurements were defined according to the American Heart Association 2014 statement. Left ventricular mass index, left ventricular mass index/95 percentile values, and left ventricular hypertrophy ratios were compared between the groups separately to establish the influence of the unclassified cases. RESULTS A total of 497 children were included. There were 52 cases in normotensive, 47 cases in unclassified group 1, 50 cases in masked hypertension, 79 cases in white coat hypertension, 104 cases in unclassified group 2, and 165 cases in the ambulatory hypertension group. Left ventricular mass index/95 percentile and left ventricular hypertrophy in masked hypertension were significantly higher than normotensive but similar between normotensive and unclassified group 1 groups. Left ventricular hypertrophy was significantly higher in the ambulatory hypertension group compared to white coat hypertension, and similar between white coat hypertension and unclassified group 2 groups. CONCLUSION Independent of age, we have found that interpretation of blood pressure load not only has a limited predictable effect on left ventricular hypertrophy but also causes a large group of patients to be unclassified. Cite this article as: Kasap-Demir B, Başaran C, Demircan T, et al. The effect of "unclassified" blood pressure phenotypes on left ventricular hypertrophy. Turk Arch Pediatr. 2024;59(1):43-48.
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Affiliation(s)
- Belde Kasap Demir
- Division of Pediatric Nephrology and Rheumatology, Department of Pediatrics, İzmir Katip Çelebi University Faculty of Medicine, İzmir, Turkey
| | - Cemaliye Başaran
- Division of Nephrology, Department of Pediatrics, University of Health Sciences, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Tülay Demircan
- Division of Cardiology, Department of Pediatrics, University of Health Sciences, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Gökçen Erfidan
- Department of Pediatric Nephrology, University of Health Sciences, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Özgür Özdemir Şimşek
- Department of Pediatric Nephrology, University of Health Sciences, İzmir Tepecik Training and Research Hospital, İzmir, Turkey
| | - Seçil Arslansoyu Çamlar
- Department of Pediatric Nephrology, University of Health Sciences School of Medicine, İzmir, Turkey
| | - Demet Alaygut
- Department of Pediatric Nephrology, University of Health Sciences School of Medicine, İzmir, Turkey
| | - Fatma Mutlubaş
- Department of Pediatric Nephrology, University of Health Sciences School of Medicine, İzmir, Turkey
| | - Cem Karadeniz
- Division of Cardiology, Department of Pediatrics, İzmir Katip Çelebi University Faculty of Medicine, İzmir, Turkey
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Chung J, Robinson C, Sheffield L, Paramanathan P, Yu A, Ewusie J, Sanger S, Mitsnefes M, Parekh RS, Sinha MD, Rodrigues M, Thabane L, Dionne J, Chanchlani R. Prevalence of Pediatric Masked Hypertension and Risk of Subclinical Cardiovascular Outcomes: A Systematic Review and Meta-Analysis. Hypertension 2023; 80:2280-2292. [PMID: 37737026 DOI: 10.1161/hypertensionaha.123.20967] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Masked hypertension (MH) occurs when office blood pressure is normal, but hypertension is confirmed using out-of-office blood pressure measures. Hypertension is a risk factor for subclinical cardiovascular outcomes, including left ventricular hypertrophy, increased left ventricular mass index, carotid intima media thickness, and pulse wave velocity. However, the risk factors for ambulatory blood pressure monitoring defined MH and its association with subclinical cardiovascular outcomes are unclear. A systematic literature search on 9 databases included English publications from 1974 to 2023. Pediatric MH prevalence was stratified by disease comorbidities and compared with the general pediatric population. We also compared the prevalence of left ventricular hypertrophy, and mean differences in left ventricular mass index, carotid intima media thickness, and pulse wave velocity between MH versus normotensive pediatric patients. Of 2199 screened studies, 136 studies (n=28 612; ages 4-25 years) were included. The prevalence of MH in the general pediatric population was 10.4% (95% CI, 8.00-12.80). Compared with the general pediatric population, the risk ratio (RR) of MH was significantly greater in children with coarctation of the aorta (RR, 1.91), solid-organ or stem-cell transplant (RR, 2.34), chronic kidney disease (RR, 2.44), and sickle cell disease (RR, 1.33). MH patients had increased risk of subclinical cardiovascular outcomes compared with normotensive patients, including higher left ventricular mass index (mean difference, 3.86 g/m2.7 [95% CI, 2.51-5.22]), left ventricular hypertrophy (odds ratio, 2.44 [95% CI, 1.50-3.96]), and higher pulse wave velocity (mean difference, 0.30 m/s [95% CI, 0.14-0.45]). The prevalence of MH is significantly elevated among children with various comorbidities. Children with MH have evidence of subclinical cardiovascular outcomes, which increases their risk of long-term cardiovascular disease.
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Affiliation(s)
- Jason Chung
- Temerty Faculty of Medicine, University of Toronto, Ontario, Canada (J.C.)
| | - Cal Robinson
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada (C.R.)
| | - Lauren Sheffield
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada (L.S.)
| | - Prathayini Paramanathan
- All Saints University College of Medicine, Kingstown, Saint Vincent and the Grenadines (P.P.)
| | - Andrew Yu
- Faculty of Science, University of Alberta, Edmonton, Canada (A.Y.)
| | - Joycelyne Ewusie
- Department of Health Research Methods, Evidence, and Impact, Research Institute - St Joseph's Healthcare Hamilton, McMaster University, Ontario, Canada (J.E., L.T.)
| | - Stephanie Sanger
- Department of Health Sciences: Health Science Library, McMaster University, Hamilton, Ontario, Canada (S.S.)
| | - Mark Mitsnefes
- Department of Pediatrics, Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.)
| | - Rulan S Parekh
- Department of Pediatrics and Medicine, Division of Nephrology, The Hospital for Sick Children, University Health Network and University of Toronto, Ontario, Canada (R.S.P.)
| | - Manish D Sinha
- Department of Paediatric Nephrology, King's College London, Evelina London Childrens Hospital, United Kingdom (M.D.S.)
| | - Myanca Rodrigues
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (M.R.)
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, Research Institute - St Joseph's Healthcare Hamilton, McMaster University, Ontario, Canada (J.E., L.T.)
- University of Johannesburg Faculty of Health Sciences, South Africa (L.T.)
| | - Janis Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, Vancouver, Canada (J.D.)
| | - Rahul Chanchlani
- Department of Pediatrics, Division of Pediatric Nephrology, McMaster Children's Hospital, McMaster University, Hamilton, Canada (R.C.)
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Seeman T, Šuláková T, Stabouli S. Masked Hypertension in Healthy Children and Adolescents: Who Should Be Screened? Curr Hypertens Rep 2023; 25:231-242. [PMID: 37639176 PMCID: PMC10491704 DOI: 10.1007/s11906-023-01260-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE OF REVIEW The goal is to review masked hypertension (MH) as a relatively new phenomenon when patients have normal office BP but elevated out-of-office BP. Firstly, it was described in children in 2004. It has received increased attention in the past decade. RECENT FINDINGS The prevalence of MH in different pediatric populations differs widely between 0 and 60% based on the population studied, definition of MH, or method of out-of-office BP measurement. The highest prevalence of MH has been demonstrated in children with chronic kidney disease (CKD), obesity, diabetes, and after heart transplantation. In healthy children but with risk factors for hypertension such as prematurity, overweight/obesity, diabetes, chronic kidney disease, or positive family history of hypertension, the prevalence of MH is 9%. In healthy children without risk factors for hypertension, the prevalence of MH is very low ranging 0-3%. In healthy children, only patients with the following clinical conditions should be screened for MH: high-normal/elevated office BP, positive family history of hypertension, and those referred for suspected hypertension who have normal office BP in the secondary/tertiary center.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics, Charles University Prague, 2nd Medical Faculty, V Úvalu 84, 15006, Prague, Czech Republic.
- Department of Pediatrics, University Hospital Ostrava, Ostrava, Czech Republic.
| | - Terezie Šuláková
- Department of Pediatrics, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Pediatrics, Medical Faculty, University of Ostrava, Ostrava, Czech Republic
| | - Stella Stabouli
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
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Goulas I, Evripidou K, Doundoulakis I, Kollios K, Nika T, Chainoglou A, Kotsis V, Stabouli S. Prevalence of masked hypertension and its association with left ventricular hypertrophy in children and young adults with chronic kidney disease: a systematic review and meta-analysis. J Hypertens 2023; 41:699-707. [PMID: 36883474 DOI: 10.1097/hjh.0000000000003402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
OBJECTIVES There are limited studies using ambulatory blood pressure monitoring (ABPM) to assess blood pressure (BP) status in young patients with chronic kidney disease (CKD) on dialysis or after kidney transplantation. The aim of this meta-analysis is to estimate the prevalence of both white-coat hypertension (WCH) and masked hypertension, along with the prevalence of left ventricular hypertrophy (LVH), in children and young adults with CKD on dialysis or after kidney transplantation. METHODS We performed a systematic review and meta-analysis of observational studies assessing the prevalence of BP phenotypes using ABPM, in children and young adults with CKD stages 2-5d. Records were identified by search in databases (Medline, Web of Science, CENTRAL) and sources of grey literature, until 31 December 2021. A random-effects meta-analysis of proportions (double arcsine transformation) was conducted. RESULTS Ten studies were included in the systematic review, reporting data from 1140 individuals (children and young adults with CKD with a mean age of 13.79 ± 4.35 years). Masked hypertension and WCH were diagnosed in 301 and 76 patients, respectively. It was estimated an overall pooled masked hypertension prevalence of 27% [95% confidence interval (95% CI) 18-36, I2 = 87%] and an overall pooled WCH prevalence of 6% (95% CI 3-9, I2 = 78%). Among kidney transplant recipients, masked hypertension had a prevalence of 29% (95% CI 14-47, I2 = 86%). The prevalence of LVH was found 28% (95% CI 0.19-0.39) in a total of 238 CKD patients with ambulatory hypertension. In 172 CKD patients with masked hypertension, LVH was present in 49, with the estimated prevalence being 23% (95% CI 0.15-0.32). CONCLUSION Masked hypertension has a significant prevalence in children and young adults with CKD. Masked hypertension carries an adverse prognosis, with an increased risk of LVH, warranting clinical attention when assessing cardiovascular risk in this population. Therefore, ABPM and echocardiography is of high importance when assessing BP status in children with CKD. PROTOCOL REGISTRATION NUMBER DOI 10.17605/OSF.IO/UKXAF.
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Affiliation(s)
- Ioannis Goulas
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki
| | - Kleo Evripidou
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki
| | - Ioannis Doundoulakis
- First Department of Cardiology, National and Kapodistrian University, 'Hippokration' Hospital, Athens
| | - Konstantinos Kollios
- 3 Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital
| | - Thomai Nika
- 3 Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital
| | - Athanasia Chainoglou
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki
| | - Vasilios Kotsis
- Hypertension-24 h ABPM ESH Center of Excellence, 3rd Department of Medicine, Aristotle School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Papageorgiou Hospital, Thessaloniki, Greece
| | - Stella Stabouli
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki
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van der Heijden LB, Groothoff JW, Feskens EJ, Janse AJ. Office blood pressure versus ambulatory blood pressure measurement in childhood obesity. BMC Pediatr 2023; 23:205. [PMID: 37120521 PMCID: PMC10148489 DOI: 10.1186/s12887-023-04010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 04/13/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND The prevalence of obesity-related co-morbidities is rising parallel to the childhood obesity epidemic. High blood pressure (BP), as one of these co-morbidities, is detected nowadays at increasingly younger ages. The diagnosis of elevated BP and hypertension, especially in the childhood population, presents a challenge to clinicians. The added value of ambulatory blood pressure measurement (ABPM) in relation to office blood pressure (OBP) measurements in obese children is unclear. Furthermore, it is unknown how many overweight and obese children have an abnormal ABPM pattern. In this study we evaluated ABPM patterns in a population of overweight and obese children and adolescents, and compared these patterns with regular OBP measurements. METHODS In this cross-sectional study in overweight or obese children and adolescents aged 4-17 years who were referred to secondary pediatric obesity care in a large general hospital in The Netherlands, OBP was measured during a regular outpatient clinic visit. Additionally, all participants underwent a 24-hour ABPM on a regular week-day. Outcome measures were OBP, mean ambulatory SBP and DBP, BP load (percentage of readings above the ambulatory 95th blood pressure percentiles), ambulatory BP pattern (normal BP, white-coat hypertension, elevated BP, masked hypertension, ambulatory hypertension), and BP dipping. RESULTS We included 82 children aged 4-17 years. They had a mean BMI Z-score of 3.3 (standard deviation 0.6). Using ABPM, 54.9% of the children were normotensive (95% confidence interval 44.1-65.2), 26.8% had elevated BP, 9.8% ambulatory hypertension, 3.7% masked hypertension, and 4.9% white-coat hypertension. An isolated night-time BP load > 25% was detected in almost a quarter of the children. 40% of the participants lacked physiologic nocturnal systolic BP dipping. In the group of children with normal OBP, 22.2% turned out to have either elevated BP or masked hypertension on ABPM. CONCLUSIONS In this study a high prevalence of abnormal ABPM patterns in overweight or obese children and adolescents was detected. Additionally, OBP poorly correlated with the child's actual ABPM pattern. Herewith, we emphasized the usefulness of ABPM as an important diagnostic tool in this population.
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Affiliation(s)
- Laila B van der Heijden
- Department of Pediatrics, Hospital Gelderse Vallei, P.O. Box 9025, Ede, 6710 HN, The Netherlands.
| | - Jaap W Groothoff
- Department of Pediatric Nephrology, Emma Children's Hospital Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
| | - Edith Jm Feskens
- Division of Human Nutrition and Health, Wageningen University, P.O. Box 17, Wageningen, 6700 AA, The Netherlands
| | - Arieke J Janse
- Department of Pediatrics, Hospital Gelderse Vallei, P.O. Box 9025, Ede, 6710 HN, The Netherlands
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Ladányi Z, Bárczi A, Fábián A, Ujvári A, Cseprekál O, Kis É, Reusz GS, Kovács A, Merkely B, Lakatos BK. Get to the heart of pediatric kidney transplant recipients: Evaluation of left- and right ventricular mechanics by three-dimensional echocardiography. Front Cardiovasc Med 2023; 10:1094765. [PMID: 37008334 PMCID: PMC10063872 DOI: 10.3389/fcvm.2023.1094765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 02/15/2023] [Indexed: 03/19/2023] Open
Abstract
BackgroundKidney transplantation (KTX) markedly improves prognosis in pediatric patients with end-stage kidney failure. Still, these patients have an increased risk of developing cardiovascular disease due to multiple risk factors. Three-dimensional (3D) echocardiography allows detailed assessment of the heart and may unveil distinct functional and morphological changes in this patient population that would be undetectable by conventional methods. Accordingly, our aim was to examine left- (LV) and right ventricular (RV) morphology and mechanics in pediatric KTX patients using 3D echocardiography.Materials and methodsPediatric KTX recipients (n = 74) with median age 20 (14–26) years at study enrollment (43% female), were compared to 74 age and gender-matched controls. Detailed patient history was obtained. After conventional echocardiographic protocol, 3D loops were acquired and measured using commercially available software and the ReVISION Method. We measured LV and RV end-diastolic volumes indexed to body surface area (EDVi), ejection fraction (EF), and 3D LV and RV global longitudinal (GLS) and circumferential strains (GCS).ResultsBoth LVEDVi (67 ± 17 vs. 61 ± 9 ml/m2; p < 0.01) and RVEDVi (68 ± 18 vs. 61 ± 11 ml/m2; p < 0.01) were significantly higher in KTX patients. LVEF was comparable between the two groups (60 ± 6 vs. 61 ± 4%; p = NS), however, LVGLS was significantly lower (−20.5 ± 3.0 vs. −22.0 ± 1.7%; p < 0.001), while LVGCS did not differ (−29.7 ± 4.3 vs. −28.6 ± 10.0%; p = NS). RVEF (59 ± 6 vs. 61 ± 4%; p < 0.05) and RVGLS (−22.8 ± 3.7 vs. −24.1 ± 3.3%; p < 0.05) were significantly lower, however, RVGCS was comparable between the two groups (−23.7 ± 4.5 vs. −24.8 ± 4.4%; p = NS). In patients requiring dialysis prior to KTX (n = 64, 86%) RVGCS showed correlation with the length of dialysis (r = 0.32, p < 0.05).ConclusionPediatric KTX patients demonstrate changes in both LV and RV morphology and mechanics. Moreover, the length of dialysis correlated with the contraction pattern of the right ventricle.
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Affiliation(s)
- Zsuzsanna Ladányi
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
- Correspondence: Zsuzsanna Ladányi
| | - Adrienn Bárczi
- 1st Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Alexandra Fábián
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Adrienn Ujvári
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Orsolya Cseprekál
- Department of Surgery, Transplantation and Gastroenterology, Semmelweis University, Budapest, Hungary
| | - Éva Kis
- Department of Pediatric Cardiology, Gottsegen György Hungarian Institute of Cardiology, Budapest, Hungary
| | | | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
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Hypertension in Pediatric Solid Organ Transplant Recipients. Curr Hypertens Rep 2023; 25:51-60. [PMID: 36862274 DOI: 10.1007/s11906-023-01237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE OF REVIEW To review the current literature regarding hypertension (HTN) following pediatric solid organ transplant (SOTx), including definition, prevalence, risk factors, outcomes, and treatment. RECENT FINDINGS In recent years several new guidelines for the definition, monitoring, and management of pediatric HTN have been published, but with no specific recommendations regarding SOTx recipients. HTN remains highly prevalent, yet underdiagnosed and undertreated in kidney transplant (KTx) recipients, especially when ambulatory blood pressure monitoring (ABPM) is utilized. There are little data regarding its prevalence in other SOTx recipients. HTN in this population is multifactorial and is associated with HTN status prior to Tx, demographic factors (age, sex, and race), weight status, and immunosuppression protocol. HTN is associated with subclinical cardiovascular (CV) end-organ damage, including left ventricular hypertrophy (LVH) and arterial stiffness, yet there are no recent data regarding its long-term outcomes. There are also no updated recommendations regarding the optimal management of HTN in this population. Given its high prevalence and the young age of this population facing years at increased CV risk, post-Tx HTN requires more clinical attention (routine monitoring, frequent application of ABPM, better BP control). Additional research is needed for a better understanding of its long-term outcomes as well as its treatment and treatment goals. Much more research is needed regarding HTN in other pediatric SOTx populations.
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9
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Hanevold CD. Racial-ethnic disparities in childhood hypertension. Pediatr Nephrol 2023; 38:619-623. [PMID: 35962260 DOI: 10.1007/s00467-022-05707-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 07/26/2022] [Accepted: 07/27/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Coral D Hanevold
- Professor Emeritus of Pediatrics, Division of Nephrology, University of Washington, Seattle, WA, USA.
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10
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The significance of central blood pressure for cardiovascular target organ damage in children and adolescents after kidney transplantation. Pediatr Nephrol 2023:10.1007/s00467-022-05857-y. [PMID: 36629915 PMCID: PMC10393860 DOI: 10.1007/s00467-022-05857-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 12/08/2022] [Accepted: 12/08/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cardiovascular (CV) complications are important causes of morbidity and mortality in children after kidney transplantation (KTx). In adults, central blood pressure (cBP) is an accepted predictor of CV sequelae. We aimed to assess the prognostic value of cBP over peripheral blood pressure (pBP) for existing CV damage. METHODS We measured cBP and pBP in 48 pediatric KTx recipients (mean age: 13.5 ± 4.2 years). Assessment of left ventricular mass index (LVMI) and aortic pulse wave velocity (PWV) allowed detection of CV target organ damage. LVMI and PWV were used as endpoints in multivariable linear regression models, in which cBP and pBP were compared for their predictive value. RESULTS Using cBP z-scores, we identified a larger number of patients with uncontrolled or untreated hypertension compared to pBP (36% vs. 7%). Central systolic blood pressure (cSBP) was a significant independent predictor of LVMI, while peripheral systolic blood pressure (pSBP) was not. Comparing central (cDBP) and peripheral (pDBP) diastolic blood pressure for their predictive value on PWV revealed a greater estimate for cDBP (0.035 vs. 0.026 for pDBP) along with a slightly better model fit for cDBP. CONCLUSIONS Our data in a small group of patients provide first evidence that cBP measurements in pediatric KTx recipients might be helpful in identifying patients at risk for the development of CV sequelae. Investigating a larger patient number, ideally repeatedly, is needed to create further evidence supporting our findings. In light of available devices measuring cBP noninvasively, the implementation of such clinical studies post-KTx care should be feasible. A higher resolution version of the Graphical abstract is available as Supplementary information.
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11
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Echocardiogram screening in pediatric dialysis and transplantation. Pediatr Nephrol 2023; 38:957-974. [PMID: 36114889 PMCID: PMC9925481 DOI: 10.1007/s00467-022-05721-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 10/14/2022]
Abstract
Transthoracic echocardiography is commonly used to identify structural and functional cardiac abnormalities that can be prevalent in childhood chronic kidney failure (KF). Left ventricular mass (LVM) increase is most frequently reported and may persist post-kidney transplant especially with hypertension and obesity. While systolic dysfunction is infrequently seen in childhood chronic KF, systolic strain identified by speckle tracking echocardiography has been frequently identified in dialysis and it can also persist post-transplant. Echocardiogram association with long-term outcomes has not been studied in childhood KF but there are many adult studies demonstrating associations between increased LVM, systolic dysfunction, strain, diastolic dysfunction, and cardiovascular events and mortality. There has been limited study of interventions to improve echocardiogram status. In childhood, improved blood pressure has been associated with better LVM, and conversion from hemodialysis to hemodiafiltration has been associated with better diastolic and systolic function. Whether long-term cardiac outcomes are also improved with these interventions is unclear. Echocardiography is a well-established technique, and regular use in childhood chronic KF seems justified. A case can be made to extend screening to include speckle tracking echocardiography and intradialytic studies in high-risk populations. Further longitudinal studies including these newer echocardiogram modalities, interventions, and long-term outcomes would help clarify recommendations for optimal use as a screening tool.
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12
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Changes in graft function after living donor kidney transplantation in children. Pediatr Nephrol 2023; 38:291-297. [PMID: 35482098 DOI: 10.1007/s00467-022-05540-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 03/11/2022] [Accepted: 03/11/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND This study aimed to evaluate the change in graft function in two groups stratified by the estimated glomerular filtration rate (eGFR) at 1 month after transplantation (eGFR-1 M) in pediatric living donor kidney transplant recipients. METHODS Forty-three pediatric recipients were classified as those with an eGFR-1 M ≥ 90 mL/min/1.73 m2 (n = 19; high eGFR group) or those with an eGFR-1 M of 60-89 mL/min/1.73 m2 (n = 24; middle eGFR group). In the two groups, changes in the eGFR were retrospectively evaluated for 5 years after kidney transplantation. RESULTS The mean recipient age at transplantation in the high/middle eGFR group was 6.1 ± 3.4/7.8 ± 4.0 years (P = 0.14). The mean eGFR-1, -12, and -60 M (mL/min/1.73 m2) in the high/middle eGFR group were 106.8 ± 2.99/78.5 ± 1.52 (P < 0.001), 79.3 ± 3.22/62.7 ± 2.38 (P < 0.001), and 73.1 ± 4.16/59.2 ± 2.79 (P = 0.006), respectively. The change in the mean eGFR remained mostly parallel in the two groups. In both groups, the eGFR significantly decreased only between 1 and 12 months after transplantation (P < 0.0001). Approximately 70% of the patients had an eGFR-60 M ≥ 60 mL/min/1.73 m2. CONCLUSIONS The high and middle eGFR groups showed a rapid decline in the eGFR by 1 year after transplantation, but the change thereafter was gradual. In pediatric living donor kidney transplant recipients, the eGFR was relatively well maintained up to 5 years after transplantation. A higher resolution version of the Graphical abstract is available as Supplementary information.
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13
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Alexandrou ME, Ferro CJ, Boletis I, Papagianni A, Sarafidis P. Hypertension in kidney transplant recipients. World J Transplant 2022; 12:211-222. [PMID: 36159073 PMCID: PMC9453294 DOI: 10.5500/wjt.v12.i8.211] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/07/2022] [Accepted: 08/05/2022] [Indexed: 02/05/2023] Open
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.
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Affiliation(s)
- Maria-Eleni Alexandrou
- 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
| | - Aikaterini Papagianni
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki 54642, Greece
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14
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de Verteuil I, Fitzpatrick J, Alvarez Elias AC, Banh T, Vasilevska-Ristovska J, Browne J, Bondi BC, Hui W, Slorach C, Wei Teoh C, Langlois V, Mertens L, Parekh RS. Longitudinal Changes in Cardiac Structure and Function in Pediatric Kidney Transplant Recipients. Hypertension 2022; 79:1680-1689. [PMID: 35652352 DOI: 10.1161/hypertensionaha.121.17483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Cardiovascular disease results in increased morbidity and mortality in pediatric kidney transplant recipients. Longitudinal changes in cardiac structure and function and the association with blood pressure control over time in pediatric kidney transplant recipients are unknown. METHODS To determine the influence of blood pressure control on cardiac changes following pediatric kidney transplant, we conducted a retrospective cohort study of children who received their first kidney transplant at the Hospital for Sick Children from 2004 to 2015. Children were followed until transfer to adult care or censoring in July 2018. Cardiac structure and function parameters were collected from clinical echocardiograms and assessed using standardized scores. Blood pressure control was determined by systolic blood pressure Z scores (above or below the 90th percentile) in combination with antihypertensive medications. A segmented mixed-effects model assessed Z scores of interventricular septum thickness, left ventricular end-diastolic dimension, and left ventricular posterior wall dimension. RESULTS Of 142 children included, 58% were men, mean age at transplant was 11 (±4.5) years, and average follow-up time was 4 (±3) years. All cardiac structural Z scores improved during follow-up. Interventricular septum thickness normalized at 4.0 years post-transplant. Left ventricular end-diastolic dimension normalized at 1.5 years post-transplant. Left ventricular posterior wall dimension normalized at 6.3 years post-transplant. Left ventricular mass index showed sustained improvement up to 12 years post-transplant. Individuals with uncontrolled blood pressure had increased left ventricular mass (β=2.97 [95% CI, 0.77-5.16]). CONCLUSIONS Cardiac structural abnormalities improve following kidney transplantation and normalize within 7 years, especially with controlled blood pressure. Strict blood pressure control is critical after pediatric kidney transplantation.
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Affiliation(s)
- Isabel de Verteuil
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jessica Fitzpatrick
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ana Catalina Alvarez Elias
- Division of Nephrology, (A.C.A.E., C.W.T., V.L., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation (A.C.A.E.), Toronto, Ontario, Canada
| | - Tonny Banh
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jovanka Vasilevska-Ristovska
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jordan Browne
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bianca C Bondi
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wei Hui
- Labatt Family Heart Center (W.H., C.S., L.M.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Cameron Slorach
- Labatt Family Heart Center (W.H., C.S., L.M.), The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chia Wei Teoh
- Division of Nephrology, (A.C.A.E., C.W.T., V.L., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty School of Medicine (C.W.T., V.L., L.M., R.S.P.), Toronto, Ontario, Canada
| | - Valerie Langlois
- Division of Nephrology, (A.C.A.E., C.W.T., V.L., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty School of Medicine (C.W.T., V.L., L.M., R.S.P.), Toronto, Ontario, Canada
| | - Luc Mertens
- Labatt Family Heart Center (W.H., C.S., L.M.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty School of Medicine (C.W.T., V.L., L.M., R.S.P.), Toronto, Ontario, Canada
| | - Rulan S Parekh
- Child Health Evaluative Sciences, Research Institute (I.d.V., J.F., T.B., J.V.-R., J.B., B.C.B., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Division of Nephrology, (A.C.A.E., C.W.T., V.L., R.S.P.), The Hospital for Sick Children, Toronto, Ontario, Canada.,Temerty School of Medicine (C.W.T., V.L., L.M., R.S.P.), Toronto, Ontario, Canada.,Toronto, Ontario, Canada and Dalla Lana School of Public Health (R.S.P.), Toronto, Ontario, Canada.,University of Toronto. University Health Network (R.S.P.) Toronto, Ontario, Canada
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15
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Variation in paediatric 24-h ambulatory blood pressure monitoring interpretation by Canadian and UK physicians. J Hum Hypertens 2022; 37:363-369. [PMID: 35513440 DOI: 10.1038/s41371-022-00702-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 04/01/2022] [Accepted: 04/22/2022] [Indexed: 12/18/2022]
Abstract
Twenty-four-hour ambulatory blood pressure monitoring (ABPM) is widely accepted as a more accurate method for measurement of blood pressure (BP) compared to a single office-based measurement of BP. However, it is unclear how physicians interpret ABPM and make management decisions. This study's goal is to investigate variation in ABPM interpretation among paediatric nephrologists (Canada and UK) and paediatric cardiologists (Canada only) via an online survey. The survey content included baseline demographics, questions on the use and indications for ABPM, interpretation of results, and subsequent management decisions in various clinical scenarios. The survey was sent to 196 Canadian physicians, with 69 (35.2%) total responses. Thirty-five UK clinicians also completed the survey. Most respondents were >44 years old, were in practice for at least 11 years, and were university-based. There were substantial differences among clinicians in ABPM interpretation for isolated systolic, diastolic, and night-time hypertension. For example, only 53.1% of physicians would initiate or modify treatment in those with diastolic HTN in CKD. Further, even for the same abnormal ABPM parameter, the decision to start or alter treatment was influenced by the underlying medical condition. There is significant variation in clinical practice among physicians for interpretation and management of hypertension when using ABPM. Differences in guidelines among various jurisdictions, as well as knowledge gaps in the research on which guidelines are based, create ambiguity regarding ABPM interpretation and management decisions. A more protocolized approach and further insight into the reasoning behind the variation in physicians' interpretation may help to standardise practice.
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16
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Plasma Netrin-1 & cardiovascular risk in children with end stage renal disease. Int J Health Sci (Qassim) 2022. [DOI: 10.53730/ijhs.v6ns4.6105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background: Cardiovascular disease (CVD) is the most common cause of mortality and morbidity in children with end stage kidney disease (ESKD) which arises from the interaction of several risk factors. The aim of the study is to assess CV risk of ESKD children and outline the impact of KTX on this CV risk. Also valuate the relation between plasma Netrin-1, chronic inflammatory markers and CV risk. Methods: Sixty ESKD (30 on regular hemodialysis (HD), 30 recipients of kidney transplant (KTX)) were assessed using 24 hour AMBP assessment, laboratory (including lipid profile and markers of chronic inflammation namely N/L and HsCRP) and echocardiographic data. Plasma netrin-1 was assessed by ELISA technique for all patients. Results: showed significant higher prevalence of hypertension, higher number of patients with 24hrs BP> 95th percentile by ABPM, more prevalence of nocturnal non-dipping BP, higher percentage of obese and overweight patients, worse biochemical analysis, higher chance of medical calcification by higher Po4 and Ca X Po4, higher triglyceride level and lower HDL level and higher N/L in HD than KTX group. Significant inverse relation was detected between plasma netrin 1 and Hs CRP and between netrin 1 and N/L (p<0.001).
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17
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Seeman T, Pfaff M, Sethna CB. Isolated nocturnal hypertension in pediatric kidney transplant recipients. Pediatr Transplant 2022; 26:e14192. [PMID: 34845793 DOI: 10.1111/petr.14192] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 10/29/2021] [Accepted: 10/31/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Isolated nocturnal hypertension (INH) is defined as nighttime hypertension in the setting of normal daytime blood pressure (BP), diagnosed by ambulatory BP monitoring (ABPM). METHODS AND RESULTS Hypertension affects 60%-80% of pediatric kidney transplant recipients, and INH is the most common type of ambulatory hypertension. INH is associated with an increased prevalence of hypertension-mediated target organ damage such as left ventricular hypertrophy in adults and in pediatric kidney transplant recipients. CONCLUSION Ambulatory BP monitoring should be performed annually in all pediatric kidney transplant recipients to diagnose hypertension phenotypes that are not detectable by office BP such as masked hypertension, white-coat hypertension, or INH. Isolated nocturnal hypertension in pediatric transplant patients requires study as a treatment target.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital, Munich, Germany.,Department of Pediatrics, 2nd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Mairead Pfaff
- Department of Pediatrics, Division of Pediatric Nephrology, Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York, USA
| | - Christine B Sethna
- Department of Pediatrics, Division of Pediatric Nephrology, Cohen Children's Medical Center, Northwell Health, New Hyde Park, New York, USA.,Zucker School of Medicine at Hofstra/Northwell, Uniondale, New York, USA
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18
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Végh A, Bárczi A, Cseprekál O, Kis É, Kelen K, Török S, Szabó AJ, Reusz GS. Follow-Up of Blood Pressure, Arterial Stiffness, and GFR in Pediatric Kidney Transplant Recipients. Front Med (Lausanne) 2021; 8:800580. [PMID: 34977101 PMCID: PMC8716619 DOI: 10.3389/fmed.2021.800580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/18/2021] [Indexed: 11/17/2022] Open
Abstract
Pediatric renal transplant recipients (RTx) were studied for longitudinal changes in blood pressure (BP), arterial stiffness by pulse wave velocity (PWV), and graft function. Patients and Methods: 52 RTx patients (22 males) were included; office BP (OBP) and 24 h BP monitoring (ABPM) as well as PWV were assessed together with glycemic and lipid parameters and glomerular filtration rate (GFR) at 2.4[1.0–4.7] (T1) and 9.3[6.3–11.8] years (T2) after transplantation (median [range]). Results: Hypertension was present in 67 and 75% of patients at T1 and T2, respectively. Controlled hypertension was documented in 37 and 44% by OBP and 40 and 43% by ABPM. Nocturnal hypertension was present in 35 and 30% at T1 and T2; 24 and 32% of the patients had masked hypertension, while white coat hypertension was present in 16 and 21% at T1 and T2, respectively. Blood pressure by ABPM correlated significantly with GFR and PWV at T2, while PWV also correlated significantly with T2 cholesterol levels. Patients with uncontrolled hypertension by ABPM had a significant decrease in GFR, although not significant with OBP. Anemia and increased HOMAi were present in ~20% of patients at T1 and T2. Conclusion: Pediatric RTx patients harbor risk factors that may affect their cardiovascular health. While we were unable to predict the evolution of renal function based on PWV and ABPM at T1, these risk factors correlated closely with GFR at follow-up suggesting that control of hypertension may have an impact on the evolution of GFR.
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Affiliation(s)
- Anna Végh
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - Adrienn Bárczi
- Medical Imaging Centre Semmelweis University, Budapest, Hungary
| | - Orsolya Cseprekál
- Department of Transplantation and Surgery Semmelweis University, Budapest, Hungary
| | - Éva Kis
- Gottsegen National Cardiovascular Center, Budapest, Hungary
| | - Kata Kelen
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - Szilárd Török
- Department of Transplantation and Surgery Semmelweis University, Budapest, Hungary
| | - Attila J. Szabó
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - György S. Reusz
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
- *Correspondence: György S. Reusz
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19
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Rizk JG, Lazo JG, Quan D, Gabardi S, Rizk Y, Streja E, Kovesdy CP, Kalantar-Zadeh K. Mechanisms and management of drug-induced hyperkalemia in kidney transplant patients. Rev Endocr Metab Disord 2021; 22:1157-1170. [PMID: 34292479 DOI: 10.1007/s11154-021-09677-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2021] [Indexed: 10/20/2022]
Abstract
Hyperkalemia is a common and potentially life-threatening complication following kidney transplantation that can be caused by a composite of factors such as medications, delayed graft function, and possibly potassium intake. Managing hyperkalemia after kidney transplantation is associated with increased morbidity and healthcare costs, and can be a cause of multiple hospital admissions and barriers to patient discharge. Medications used routinely after kidney transplantation are considered the most frequent culprit for post-transplant hyperkalemia in recipients with a well-functioning graft. These include calcineurin inhibitors (CNIs), pneumocystis pneumonia (PCP) prophylactic agents, and antihypertensives (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers). CNIs can cause hyperkalemic renal tubular acidosis. When hyperkalemia develops following transplantation, the potential offending medication may be discontinued, switched to another agent, or dose-reduced. Belatacept and mTOR inhibitors offer an alternative to calcineurin inhibitors in the event of hyperkalemia, however should be prescribed in the appropriate patient. While trimethoprim/sulfamethoxazole (TMP/SMX) remains the gold standard for prevention of PCP, alternative agents (e.g. dapsone, atovaquone) have been studied and can be recommend in place of TMP/SMX. Antihypertensives that act on the Renin-Angiotensin-Aldosterone System are generally avoided early after transplant but may be indicated later in the transplant course for patients with comorbidities. In cases of mild to moderate hyperkalemia, medical management can be used to normalize serum potassium levels and allow the transplant team additional time to evaluate the function of the graft. In the immediate post-operative setting following kidney transplantation, a rapidly rising potassium refractory to medical therapy can be an indication for dialysis. Patiromer and sodium zirconium cyclosilicate (ZS-9) may play an important role in the management of chronic hyperkalemia in kidney transplant patients, although additional long-term studies are necessary to confirm these effects.
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Affiliation(s)
- John G Rizk
- Arizona State University, Edson College, Phoenix, AZ, USA.
| | - Jose G Lazo
- UCSF Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - David Quan
- UCSF Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - Steven Gabardi
- Department of Transplant Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Youssef Rizk
- Department of Internal Medicine, Division of Family Medicine, Lebanese American University Medical Center - St. John's Hospital, Beirut, Lebanon
| | - Elani Streja
- Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation, School of Medicine, University of California, CA, Irvine, Orange, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kamyar Kalantar-Zadeh
- Department of Medicine, Division of Nephrology, Hypertension and Kidney Transplantation, School of Medicine, University of California, CA, Irvine, Orange, USA
- Department of Epidemiology, University of California, UCLA Fielding School of Public Health, Los Angeles, CA, USA
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20
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Mitsnefes M, Flynn JT, Brady T, Baker-Smith C, Daniels SR, Hayman LL, Tran A, Zachariah JP, Urbina EM. Pediatric Ambulatory Blood Pressure Classification: The Case for a Change. Hypertension 2021; 78:1206-1210. [PMID: 34601972 PMCID: PMC8516706 DOI: 10.1161/hypertensionaha.121.18138] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
In 1997, Soergel et al1 published the first set of normative values for ambulatory blood pressure monitoring (ABPM) in children. Since then, the clinical utility of ABPM has increased dramatically, and now, ABPM is accepted as the standard method to confirm the diagnosis of hypertension in children. Despite significant progress in the field of pediatric ABPM, many important questions remain unanswered. One of the most controversial issues is how to define ambulatory hypertension in children. The purpose of this review is to discuss the limitations of the current pediatric ABPM classification scheme and to provide the justification and rationale for a new classification.
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Affiliation(s)
- Mark Mitsnefes
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH (M.M., E.M.U.)
| | - Joseph T Flynn
- University of Washington and Seattle Children's Hospital (J.T.F.)
| | - Tammy Brady
- Johns Hopkins University, Baltimore, MD (T.B.)
| | | | | | | | - Andrew Tran
- Nationwide Children's Hospital, The Ohio State University, Columbus (A.T.)
| | | | - Elaine M Urbina
- Cincinnati Children's Hospital Medical Center, University of Cincinnati, OH (M.M., E.M.U.)
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21
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Hypertension in kidney transplantation: a consensus statement of the 'hypertension and the kidney' working group of the European Society of Hypertension. J Hypertens 2021; 39:1513-1521. [PMID: 34054055 DOI: 10.1097/hjh.0000000000002879] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Hypertension is common in kidney transplantation recipients and may be difficult to treat. Factors present before kidney transplantation, related to the transplantation procedure itself and factors developing after transplantation may contribute to blood pressure (BP) elevation in kidney transplant recipients. The present consensus is based on the results of three recent systematic reviews, the latest guidelines and the current literature. The current transplant guidelines, which recommend only office BP assessments for risk stratification in kidney transplant patients should be reconsidered, given the presence of white-coat hypertension and masked hypertension in this population and the better prediction of adverse outcomes by 24-h ambulatory BP monitoring as indicated in recent systematic reviews. Hypertension is associated with adverse kidney and cardiovascular outcomes and decreased survival in kidney transplant recipients. Current evidence suggests calcium channel blockers could be the preferred first-step antihypertensive agents in kidney transplant patients, as they improve graft function and reduce graft loss, whereas no clear benefit is documented for renin-angiotensin system inhibitor use over conventional treatment in the current literature. Randomized control trials demonstrating the clinical benefits of BP lowering on kidney and major cardiovascular events and recording patient-related outcomes are still needed. These trials should define optimal BP targets for kidney transplant recipients. In the absence of kidney transplant-specific evidence, BP targets in kidney transplant recipients should be similar to those in the wider chronic kidney disease population.
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22
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Should ACE inhibitors or calcium channel blockers be used for post-transplant hypertension? Pediatr Nephrol 2021; 36:539-549. [PMID: 32060819 DOI: 10.1007/s00467-020-04485-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/14/2020] [Accepted: 01/17/2020] [Indexed: 10/25/2022]
Abstract
Arterial hypertension in renal transplant recipients warrants antihypertensive treatment. The preferable choice of antihypertensives that should be used in patients after kidney transplantation remains a matter of debate; however, calcium channel blockers (CCB) and angiotensin-converting enzyme inhibitors (ACEI) are currently the most commonly used antihypertensives. This educational review summarizes the current evidence about the effects of these two classes of medications in transplant recipients. Several studies have demonstrated that both classes of drugs can reduce blood pressure (BP) to similar extents. Meta-analyses of adult randomized controlled trials have shown that graft survival is improved in patients treated with ACEIs and CCBs, and that CCBs increase, yet ACEIs decrease, graft function. Proteinuria is usually decreased by ACEIs but remains unchanged with CCBs. In children, no randomized controlled study has ever been performed to compare BP or graft survival between CCBs and ACEIs. Post-transplant proteinuria could be reduced in children along with BP by ACEIs. The results of the most current meta-analyses recommend that due to their positive effects on graft function and survival, along with their lack of negative effects on serum potassium, CCBs could be the preferred first-line antihypertensive agent in renal transplant recipients. However, antihypertensive therapy should be individually tailored based on other factors, such as time after transplantation, presence of proteinuria/albuminuria, or hyperkalemia. Furthermore, due to the difficulty in controlling hypertension, combination therapy containing both CCBs and ACEIs could be a reasonable first-step therapy in treating children with severe post-transplantation hypertension.
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23
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Van Loon E, Senev A, Lerut E, Coemans M, Callemeyn J, Van Keer JM, Daniëls L, Kuypers D, Sprangers B, Emonds MP, Naesens M. Assessing the Complex Causes of Kidney Allograft Loss. Transplantation 2021; 104:2557-2566. [PMID: 32091487 DOI: 10.1097/tp.0000000000003192] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Although graft loss is a primary endpoint in many studies in kidney transplantation and a broad spectrum of risk factors has been identified, the eventual causes of graft failure in individual cases remain ill studied. METHODS We performed a single-center cohort study in 1000 renal allograft recipients, transplanted between March 2004 and February 2013. RESULTS In total, 365 graft losses (36.5%) were identified, of which 211 (57.8%) were due to recipient death with a functioning graft and 154 (42.2%) to graft failure defined as return to dialysis or retransplantation. The main causes of recipient death were malignancy, infections, and cardiovascular disease. The main causes of graft failure were distinct for early failures, where structural issues and primary nonfunction prevailed, compared to later failures with a shift towards chronic injury. In contrast to the main focus of current research efforts, pure alloimmune causes accounted for only 17.5% of graft failures and only 7.4% of overall graft losses, although 72.7% of cases with chronic injury as presumed reason for graft failure had prior rejection episodes, potentially suggesting that alloimmune phenomena contributed to the chronic injury. CONCLUSIONS In conclusion, this study provides better insight in the eventual causes of graft failure, and their relative contribution, highlighting the weight of nonimmune causes. Future efforts aimed to improve outcome after kidney transplantation should align with the relative weight and expected impact of targeting these causes.
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Affiliation(s)
- Elisabet Van Loon
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Aleksandar Senev
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetic Laboratory, Red Cross-Flanders, Mechelen, Belgium
| | - Evelyne Lerut
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium.,Department of Pathology, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Coemans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Leuven Biostatistics and Statistical Bioinformatics Centre, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Jasper Callemeyn
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Jan M Van Keer
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
| | - Liesbeth Daniëls
- Histocompatibility and Immunogenetic Laboratory, Red Cross-Flanders, Mechelen, Belgium
| | - Dirk Kuypers
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
| | - Ben Sprangers
- Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium.,Department of Microbiology and Immunology, Laboratory of Molecular Immunology, Rega Institute, KU Leuven, Leuven, Belgium
| | - Marie-Paule Emonds
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Histocompatibility and Immunogenetic Laboratory, Red Cross-Flanders, Mechelen, Belgium
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of Nephrology and Renal Transplantation, University Hospitals Leuven, Leuven, Belgium
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24
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Charnaya O, Seifert M. Promoting cardiovascular health post-transplant through early diagnosis and adequate management of hypertension and dyslipidemia. Pediatr Transplant 2021; 25:e13811. [PMID: 32871051 DOI: 10.1111/petr.13811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/18/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
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.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Seifert
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, USA
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25
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Bock ME, Wall L, Dobrec C, Chandran M, Goebel J. Management of dyslipidemia in pediatric renal transplant recipients. Pediatr Nephrol 2021; 36:51-63. [PMID: 31897714 DOI: 10.1007/s00467-019-04428-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 11/11/2019] [Accepted: 11/19/2019] [Indexed: 01/07/2023]
Abstract
Dyslipidemia after kidney transplantation is a common complication that has historically been underappreciated, especially in pediatric recipients. It is also a major modifiable risk factor for cardiovascular disease, a top cause of morbidity and mortality of transplant patients. While most knowledge about post-transplant dyslipidemia has been generated in adults, recommendations and treatment strategies also exist for children and are presented in this review. Awareness of these applicable guidelines and approaches is required, but not sufficient, for the reliable management of dyslipidemia in our patients, and additional needs and opportunities for comprehensive care in this area (e.g., quality improvement) are outlined.
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Affiliation(s)
- Margret E Bock
- Section of Pediatric Nephrology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Leslie Wall
- Clinical Nutrition Department, Children's Hospital Colorado, Aurora, CO, USA
| | - Carly Dobrec
- Clinical Nutrition Department, Children's Hospital Colorado, Aurora, CO, USA
| | - Mary Chandran
- Pharmacy Department, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Jens Goebel
- Section of Pediatric Nephrology, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA.
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26
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Practical application of ABPM in the pediatric nephrology clinic. Pediatr Nephrol 2020; 35:2067-2076. [PMID: 31732802 DOI: 10.1007/s00467-019-04361-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/07/2019] [Accepted: 09/06/2019] [Indexed: 12/26/2022]
Abstract
The use of 24-h ABPM has become commonplace when diagnosing and managing hypertension in the pediatric population. Multiple clinical guidelines recommend ABPM as the preferred method for identifying white-coat hypertension, masked hypertension, and determining degree of blood pressure (BP) control. Accurate, timely diagnosis and optimal management are particularly important in certain populations, such as children with chronic kidney disease (CKD), diabetes, and other conditions with increased risk for cardiovascular disease. Understanding how best to utilize ABPM to achieve these goals is important for pediatric nephrologists and other hypertension specialists. This review will provide practical information on the equipment, application, interpretation, and documentation of ABPM in the specialty clinic.
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27
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Seifert ME, Dahale DS, Kamel M, Winterberg PD, Barletta GM, Belsha CW, Chaudhuri A, Flynn JT, Garro R, George RP, Goebel JW, Kershaw DB, Matossian D, Misurac J, Nailescu C, Nguyen CR, Pearl M, Pollack A, Pruette CS, Singer P, VanSickle JS, Verghese P, Warady BA, Warmin A, Weng PL, Wickman L, Wilson AC, Hooper DK. The Improving Renal Outcomes Collaborative: Blood Pressure Measurement in Transplant Recipients. Pediatrics 2020; 146:peds.2019-2833. [PMID: 32518170 PMCID: PMC7329257 DOI: 10.1542/peds.2019-2833] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/11/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Hypertension is highly prevalent in pediatric kidney transplant recipients and contributes to cardiovascular death and graft loss. Improper blood pressure (BP) measurement limits the ability to control hypertension in this population. Here, we report multicenter efforts from the Improving Renal Outcomes Collaborative (IROC) to standardize and improve appropriate BP measurement in transplant patients. METHODS Seventeen centers participated in structured quality improvement activities facilitated by IROC, including formal training in quality improvement methods. The primary outcome measure was the proportion of transplant clinic visits with appropriate BP measurement according to published guidelines. Prospective data were analyzed over a 12-week pre-intervention period and a 20-week active intervention period for each center and then aggregated as of the program-specific start date. We used control charts to quantify improvements across IROC centers. We applied thematic analysis to identify patterns and common themes of successful interventions. RESULTS We analyzed data from 5392 clinic visits. At baseline, BP was measured and documented appropriately at 11% of visits. Center-specific interventions for improving BP measurement included educating clinic staff, assigning specific team member roles, and creating BP tracking tools and alerts. Appropriate BP measurement improved throughout the 20-week active intervention period to 78% of visits. CONCLUSIONS We standardized appropriate BP measurement across 17 pediatric transplant centers using the infrastructure of the IROC learning health system and substantially improved the rate of appropriate measurement over 20 weeks. Accurate BP assessment will allow further interventions to reduce complications of hypertension in pediatric kidney transplant recipients.
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Affiliation(s)
- Michael E. Seifert
- Department of Pediatrics, University of Alabama and Children’s of Alabama, Birmingham, Alabama
| | - Devesh S. Dahale
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Margret Kamel
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Pamela D. Winterberg
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - Craig W. Belsha
- Department of Pediatrics, Saint Louis University, St Louis, Missouri
| | - Abanti Chaudhuri
- Department of Pediatrics, Stanford University, Stanford, California
| | | | - Rouba Garro
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Roshan P. George
- Department of Pediatrics, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | | | - David B. Kershaw
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Debora Matossian
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | - Jason Misurac
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - Corina Nailescu
- Riley Hospital for Children, Indiana University Health, Indianapolis, Indiana
| | - Christina R. Nguyen
- Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Meghan Pearl
- Mattel Children’s Hospital, University of California Los Angeles Health, Los Angeles, California
| | - Ari Pollack
- Seattle Children’s Hospital, Seattle, Washington
| | | | - Pamela Singer
- Cohen Children’s Medical Center, New Hyde Park, New York
| | | | - Priya Verghese
- Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | | | - Andrew Warmin
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Patricia L. Weng
- Mattel Children’s Hospital, University of California Los Angeles Health, Los Angeles, California
| | - Larysa Wickman
- Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Amy C. Wilson
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | - David K. Hooper
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
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Pais P, Dello Strologo L, Iyengar A, Velusamy V, Greenbaum LA. Nocturnal hypertension and left ventricular hypertrophy in pediatric renal transplant recipients in South India. Pediatr Transplant 2020; 24:e13710. [PMID: 32320120 DOI: 10.1111/petr.13710] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
HTN after renal transplantation is associated with cardiovascular morbidity. ABPM allows diagnosis of masked HTN and isolated nocturnal HTN. Longitudinal ABPM data in children post-transplant are limited. ABPM was performed in children post-transplant and repeated in 6-12 months. BP indices were used to determine the prevalence of masked HTN, masked uncontrolled HTN (masked HTN in patients on antihypertensive medications), and isolated nocturnal HTN. Linear regression determined the association between LVMI and ABPM indices. Thirty children underwent a baseline ABPM. Ambulatory HTN was present in 25 (83%). Masked HTN was present in 18 (60%) and isolated nocturnal HTN in 13 (43%). Nocturnal ambulatory BP was higher than corresponding daytime BPs (P < .001 for systolic and diastolic) and 25 (83%) had a blunted nocturnal dip. Prednisone dose predicted nocturnal DBP index and DBP load (r2 = .40, P = .024 and r2 = .178, P = .02). ABPM was repeated in 18 patients within 11 (±3) months. BP indices decreased with time, but nocturnal BPs remained higher than daytime (P < .001 for SBP and DBP). Blunted nocturnal dip did not improve. LVH was present in 12 (57%). LVMI was directly related to the nocturnal SBP index (r2 = .377, P = .003) and nocturnal DBP index (r2 = .493, P < .001). We found no association between LVMI and daytime BP indices. The prevalence of masked HTN, isolated nocturnal HTN, and blunted nocturnal dip was high in children with kidney transplants. Nocturnal BP predicted LVMI. Ambulatory BP improved on longitudinal follow-up, but the pattern of isolated nocturnal HTN persisted.
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Affiliation(s)
- Priya Pais
- Department of Pediatric Nephrology, St John's Medical College Hospital, St John's National Academy of Health Sciences, Bangalore, India
| | - Luca Dello Strologo
- Pediatric Nephrology and Renal Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Arpana Iyengar
- Department of Pediatric Nephrology, St John's Medical College Hospital, St John's National Academy of Health Sciences, Bangalore, India
| | - Vasanthakumar Velusamy
- Division of Clinical Research and Training, St John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
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29
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Amaral S. Secular Trends in Survival Outcomes of Kidney Transplantation for Children: Is the Future Bright Enough? Clin J Am Soc Nephrol 2020; 15:308-310. [PMID: 32096764 PMCID: PMC7057306 DOI: 10.2215/cjn.00370120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Sandra Amaral
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and .,Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
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30
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Weaver DJ, Mitsnefes M. Cardiovascular Disease in Children and Adolescents With Chronic Kidney Disease. Semin Nephrol 2019; 38:559-569. [PMID: 30413251 DOI: 10.1016/j.semnephrol.2018.08.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The lifespan of children with advanced chronic kidney disease (CKD), although improved over the past 2 decades, remains low compared with the general pediatric population. Similar to adults with CKD, cardiovascular disease accounts for a majority of deaths in children with CKD because these patients have a high prevalence of traditional and uremia-related risk factors for cardiovascular disease. The cardiovascular alterations that cause these terminal events begin early in pediatric CKD. Initially, these act to maintain hemodynamic homeostasis. However, as the disease progresses, these modifications are unable to sustain cardiovascular function in the long term, leading to left ventricular failure, depressed cardiorespiratory fitness, and sudden death. In this review, we discuss the prevalence of the risk factors associated with cardiovascular disease in pediatric patients with CKD, the pathophysiology that stimulates these changes, the cardiac and vascular adaptations that occur in these patients, and management of the cardiovascular risk in these patients.
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Affiliation(s)
- Donald J Weaver
- Division of Nephrology and Hypertension, Levine Children's Hospital, Charlotte, NC
| | - Mark Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
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31
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Severova-Andreevska G, Danilovska I, Sikole A, Popov Z, Ivanovski N. Hypertension after Kidney Transplantation: Clinical Significance and Therapeutical Aspects. Open Access Maced J Med Sci 2019; 7:1241-1245. [PMID: 31049114 PMCID: PMC6490475 DOI: 10.3889/oamjms.2019.264] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 12/14/2022] Open
Abstract
Most of the kidney transplanted patients develop arterial hypertension after renal transplantation. Together with very well-known and usual risk factors, post-transplant hypertension contributes to the whole cardiovascular morbidity and mortality in the kidney transplant population. The reasons of post-transplant hypertension are factors related to donors and recipients, immunosuppressive therapy like Calcineurin Inhibitors (CNI) and surgery procedures (stenosis and kinking of the renal artery and ureteral obstruction). According to Eighth National Committee (JNC 8) recommendations, blood pressure > 140/90 mmHg is considered as hypertension. The usual antihypertensive drugs used for the control of hypertension are Calcium channel blockers (CCB), Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin -II receptor blockers (ARB), B- blockers and diuretics. Follow the KDIGO guidelines the target blood pressure < 140/90 mmHg for patients without proteinuria and < 125/75 mmHg in patients with proteinuria is recommended. Better control of post-transplant hypertension improves the long-term graft and patient's survival.
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Affiliation(s)
- Galina Severova-Andreevska
- University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Ilina Danilovska
- University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Aleksandar Sikole
- University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Zivko Popov
- Macedonian Academy for Science and Arts, Skopje, Republic of Macedonia
- Zan Mitrev Clinic, Skopje, Republic of Macedonia
| | - Ninoslav Ivanovski
- Zan Mitrev Clinic, Skopje, Republic of Macedonia
- Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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32
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Ashoor IF, Dharnidharka VR. Non-immunologic allograft loss in pediatric kidney transplant recipients. Pediatr Nephrol 2019; 34:211-222. [PMID: 29480356 DOI: 10.1007/s00467-018-3908-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/26/2018] [Accepted: 01/26/2018] [Indexed: 01/13/2023]
Abstract
Non-immunologic risk factors are a major obstacle to realizing long-term improvements in kidney allograft survival. A standardized approach to assess donor quality has recently been introduced with the new kidney allocation system in the USA. Delayed graft function and surgical complications are important risk factors for both short- and long-term graft loss. Disease recurrence in the allograft remains a major cause of graft loss in those who fail to respond to therapy. Complications of over immunosuppression including opportunistic infections and malignancy continue to limit graft survival. Alternative immunosuppression strategies are under investigation to limit calcineurin inhibitor toxicity. Finally, recent studies have confirmed long-standing observations of the significant negative impact of a high-risk age window in late adolescence and young adulthood on long-term allograft survival.
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Affiliation(s)
- Isa F Ashoor
- Division of Nephrology, LSU Health New Orleans and Children's Hospital, 200 Henry Clay Avenue, New Orleans, LA, 70130, USA.
| | - Vikas R Dharnidharka
- Washington University and St. Louis Children's Hospital, 600 South Euclid Ave, St. Louis, MO, 63110, USA
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33
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Krmar RT, Ferraris JR. Clinical value of ambulatory blood pressure in pediatric patients after renal transplantation. Pediatr Nephrol 2018; 33:1327-1336. [PMID: 28842790 PMCID: PMC6019432 DOI: 10.1007/s00467-017-3781-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Rafael T. Krmar
- Department of Physiology and Pharmacology (FYFA), Karolinska Institute, C3, Nanna Svartz Väg 2, 171 77 Stockholm, Sweden
| | - Jorge R. Ferraris
- Departamento de Pediatría, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABB C.A.B.A, Código Argentina
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34
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Lancia P, Aurich B, Ha P, Maisin A, Baudouin V, Jacqz-Aigrain E. Adverse Events under Tacrolimus and Cyclosporine in the First 3 Years Post-Renal Transplantation in Children. Clin Drug Investig 2018; 38:157-171. [PMID: 29236209 DOI: 10.1007/s40261-017-0594-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Progress in immunosuppression has reduced acute rejection, graft loss and mortality after renal transplantation. Adverse drug reactions are well described in adults but few data are available in children. Our objectives were to analyse the adverse events reported in the first 3 years post-transplantation in children receiving tacrolimus or cyclosporine-based immunosuppression and compare them with the information of the Summary of Product Characteristics. METHODS This retrospective study included all children who underwent a renal transplant at Hospital Robert Debré between 2002 and 2015. Initial immunosuppression was based on induction, calcineurin inhibitor, mycophenolate mofetil and corticosteroids. Adverse events were collected from medical records and coded using the Medical Dictionary for Regulatory Activities and the implications of tacrolimus and cyclosporine analysed. Statistical analyses were performed using SAS 9.4. RESULTS One hundred and twenty-five children were included. During the observation period [2.7 years (0.6-4.3)], 105 patients received tacrolimus and 39 received cyclosporine. The incidence rate for gastrointestinal disorders was 0.128 and 0.056 by patient-years of exposure (p < 0.05), under tacrolimus and cyclosporine schedules. For neutropenia, it was 0.064 and 0.014 (p < 0.05). The frequencies of toxic nephropathy and gastrointestinal pain were higher than those in the Summary of Product Characteristics of tacrolimus (> 20%) and cyclosporine (> 10%). Cosmetic events for cyclosporine and neutropenia for tacrolimus were frequently observed (18 and 14.3%, respectively), although uncommon in the Summary of Product Characteristics. CONCLUSIONS The exposure-adjusted incidence rate of gastrointestinal disorders and neutropenia was higher in children under the tacrolimus schedule. Our findings contribute to the evaluation of the benefit-risk balance of immunosuppressive therapy following paediatric renal transplantation.
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Affiliation(s)
- Pauline Lancia
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Beate Aurich
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Phuong Ha
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Anne Maisin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Véronique Baudouin
- Department of Paediatric Nephrology, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France
| | - Evelyne Jacqz-Aigrain
- Department of Paediatric Pharmacology and Pharmacogenetics, Hospital Robert Debré, APHP, 48 Boulevard Sérurier, 75019, Paris, France. .,Clinical Investigation Center CIC1426, INSERM, Paris, France. .,Paris Diderot University, Sorbonne Paris Cité, Paris, France.
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35
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Pediatric Vascular Composite Allograft Transplantation: Medical Considerations. CURRENT TRANSPLANTATION REPORTS 2018. [DOI: 10.1007/s40472-018-0189-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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36
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37
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Barletta GM, Pierce C, Mitsnefes M, Samuels J, Warady BA, Furth S, Flynn J. Is Blood Pressure Improving in Children With Chronic Kidney Disease? A Period Analysis. Hypertension 2018; 71:444-450. [PMID: 29295853 PMCID: PMC5812788 DOI: 10.1161/hypertensionaha.117.09649] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 05/16/2017] [Accepted: 12/05/2017] [Indexed: 12/18/2022]
Abstract
Uncontrolled hypertension in children with chronic kidney disease (CKD) has been identified as one of the main factors contributing to progression of CKD and increased risk for cardiovascular disease. Recent efforts to achieve better blood pressure (BP) control have been recommended. The primary objective of this analysis was to compare BP control over 2 time periods among participants enrolled in the CKiD study (Chronic Kidney Disease in Children). Casual BP and 24-hour ambulatory BP monitor data were compared among 851 participants during 2 time periods: January 1, 2005, through July 1, 2008 (period 1, n=345), and July 1, 2010, through December 31, 2013 (period 2, n=506). Multivariable logistic regression to model the propensity of a visit record being in period 2 as a function of specific predictors was performed. After controlling for confounding variables (age, sex, race, socioeconomics, CKD duration, glomerular filtration rate, proteinuria, body mass index, growth failure, and antihypertensives), no significant differences were detected between time periods with respect to casual BP status (prehypertension: 15% versus 15%; uncontrolled hypertension: 18% versus 17%; P=0.87). Analysis of ambulatory BP monitor data demonstrated higher ambulatory BP indices, most notably masked hypertension in period 2 (36% versus 49%; P<0.001). Average sleep BP index (P<0.05) and sleep BP loads (P<0.05) were higher in period 2. Despite publication of hypertension recommendations and guidelines for BP control in patients with CKD, this study suggests that hypertension remains undertreated and under-recognized in children with CKD. This analysis also underscores the importance of routine ambulatory BP monitor assessment in children with CKD.
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Affiliation(s)
- Gina-Marie Barletta
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.).
| | - Christopher Pierce
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Mark Mitsnefes
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Joshua Samuels
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Bradley A Warady
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Susan Furth
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Joseph Flynn
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
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Hebert SA, Swinford RD, Hall DR, Au JK, Bynon JS. Special Considerations in Pediatric Kidney Transplantation. Adv Chronic Kidney Dis 2017; 24:398-404. [PMID: 29229171 DOI: 10.1053/j.ackd.2017.09.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Universally accepted as the treatment of choice for children needing renal replacement therapy, kidney transplantation affords children the opportunity for an improved quality of life over dialysis therapy. Immunologic and surgical advances over the last 15 years have improved the pediatric patient and kidney graft survival. Unique to pediatrics, congenital genitourinary anomalies are the most common primary diseases leading to kidney failure, many with urological issues. Early urological evaluation for post-transplant bladder dysfunction and emphasis on immunization adherence are the mainstays of pediatric pretransplant and post-transplant evaluations. A child's height can be challenging, sometimes requiring an intra-abdominally placed graft, particularly if the patient is <20 kg. Maintenance immunosuppression regimens are similar to adult kidney graft recipients, although distinctive pharmacokinetics may change dosing intervals in children from twice a day to thrice a day. Viral infections and secondary malignancies are problematic for children relative to adults. Current trends to reduce/remove corticosteroid therapy from post-transplant protocols have produced improved linear growth with less steroid toxicity; although these studies are still ongoing, graft function and survival are considered acceptable. Finally, all children with a kidney transplant need a smooth transition to adult clinics. Future research in pertinent psychosocial aspects and continued technological advances will only serve to optimize the transition process. Although some aspects of kidney transplantation are similar in children and adults, for instance immunosuppression and immunosuppressive regimens, and rejection mechanisms and their diagnosis using the Banff criteria, there are important differences this review will focus on and which continue to drive innovation.
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Ambulatory Blood Pressure Monitoring in Children and Adolescents: a Review of Recent Literature and New Guidelines. Curr Hypertens Rep 2017; 19:96. [DOI: 10.1007/s11906-017-0791-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Hamdani G, Nehus EJ, Hanevold CD, VanSickle JS, Hooper DK, Blowey D, Warady BA, Mitsnefes MM. Ambulatory Blood Pressure Control in Children and Young Adults After Kidney Transplantation. Am J Hypertens 2017; 30:1039-1046. [PMID: 28575139 DOI: 10.1093/ajh/hpx092] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ambulatory blood pressure (BP) monitoring (ABPM) is the preferred method to characterize BP status, and its use in kidney transplant recipients is increasing. Data on longitudinal ambulatory BP (ABP) trends in pediatric and young adult kidney transplant recipients are limited. METHODS Retrospective review of a large cohort of children and young adults following kidney transplantation and evaluation of their ABP status over time and its associations with any patient and clinical characteristics. RESULTS Two hundred and two patients had baseline ABPM available for analysis, and 123 of them had a follow up (median time 2.3 years) ABPM. At the time of follow up, more patients were treated for hypertension (80% vs. 72%, P = 0.02), and less patients had ambulatory hypertension (36% vs. 54%, P = 0.005), uncontrolled or untreated, compared with baseline, with 45% of all patients classified as having controlled hypertension (compared to 26% at baseline, P = 0.002). Prevalence of ambulatory hypertension decreased only in patients who were less than 18 years old at baseline. High baseline mean 24-hour systolic BP was independently associated with persistent hypertension. CONCLUSIONS In young kidney transplant recipients followed by ABPM, the prevalence of ambulatory hypertension decreases over time, mainly due to the increased number of patients with controlled hypertension.
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Affiliation(s)
- Gilad Hamdani
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Coral D Hanevold
- Division of Pediatric Nephrology, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Judith S VanSickle
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - David K Hooper
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Doug Blowey
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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Charnaya O, Moudgil A. Hypertension in the Pediatric Kidney Transplant Recipient. Front Pediatr 2017; 5:86. [PMID: 28507980 PMCID: PMC5410589 DOI: 10.3389/fped.2017.00086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 04/07/2017] [Indexed: 12/14/2022] Open
Abstract
Hypertension after kidney transplant is a frequent occurrence in pediatric patients. It is a risk factor for graft loss and contributes to the significant burden of cardiovascular disease (CVD) in this population. The etiology of posttransplant hypertension is multifactorial including donor factors, recipient factors, medications, and lifestyle factors similar to those prevalent in the general population. Ambulatory blood pressure monitoring has emerged as the most reliable method for measuring hypertension in pediatric transplant recipients, and many consider it to be essential in the care of these patients. Recent technological advances including measurement of carotid intima-media thickness, pulse wave velocity, and myocardial strain using specked echocardiography and cardiac magnetic resonance imaging have improved our ability to assess CVD burden. Since hypertension remains underrecognized and inadequately treated, an early diagnosis and an appropriate control should be the focus of therapy to help improve patient and graft survival.
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Affiliation(s)
- Olga Charnaya
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
| | - Asha Moudgil
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
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Hamdani G, Nehus EJ, Hooper DK, Mitsnefes MM. Masked hypertension and allograft function in pediatric and young adults kidney transplant recipients. Pediatr Transplant 2016; 20:1026-1031. [PMID: 27353352 DOI: 10.1111/petr.12752] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 11/27/2022]
Abstract
Masked hypertension is a common complication of pediatric kidney transplantation. While office hypertension is known to be associated with worse short- and long-term graft function, the role of masked hypertension in allograft dysfunction is not clear. We conducted a retrospective cross-sectional analysis of 77 consecutive pediatric kidney transplant recipients who had routine 24-h ambulatory blood pressure monitoring with the aims to estimate the prevalence of masked hypertension and examine its association with allograft function. Masked hypertension was defined as a 24-h systolic or diastolic blood pressure load ≥25%. Twenty-nine percent of patients had masked hypertension. Patients with masked hypertension had significantly lower allograft function estimated using the creatinine-based Schwartz-Lyon formula, a cystatin C-based formula, and combined cystatin C and creatinine-based formulas than patients with normal blood pressure (all p values <0.05). In a multivariable analysis, masked hypertension remained independently associated with worse allograft function after adjustment for age, sex, race, time post-transplant, rejection history, antihypertensive treatment, and hemoglobin level. We conclude that in young kidney transplant recipients, masked hypertension is common and is associated with worse allograft function. These results support the case for routine ambulatory blood pressure monitoring as the standard of care in these patients to detect and treat masked hypertension.
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Affiliation(s)
- Gilad Hamdani
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David K Hooper
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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