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Braekman E, De Bruyne R, Vandekerckhove K, Prytula A. Etiology, risk factors and management of hypertension post liver transplantation. Pediatr Transplant 2024; 28:e14630. [PMID: 37915282 DOI: 10.1111/petr.14630] [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] [Received: 04/24/2023] [Revised: 09/09/2023] [Accepted: 10/11/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Cardiovascular events are one of the most important causes of morbidity and mortality in the long-term follow-up of liver transplant recipients. Hypertension is a significant cardiovascular risk factor that occurs frequently after pediatric liver transplantation. Chronic use of immunosuppressants - mainly calcineurin inhibitors - plays a major role in the development of post-transplant hypertension and circadian disturbances such as flattening of the nocturnal blood pressure dip. This requires special attention in children given the long timeframe during which immunosuppressive therapy is necessary. Careful and structured blood pressure monitoring and adequate treatment of hypertension are essential to optimize the quality of life and life expectancy of pediatric liver transplant patients. However, evidence-based guidelines for monitoring and management of post-transplant hypertension and its complications are lacking. METHODS We conducted a comprehensive review of the current knowledge and practices concerning post-transplant hypertension. The databases Pubmed, Embase, Web of Science and Google Scholar were scanned with the following keywords: pediatric liver transplantation, immunosuppression, tacrolimus, cardiovascular effects, hypertension, heart function, kidney function, circadian rhythm, mechanism, monitoring, and management. RESULTS In this review, we describe the incidence and etiology of hypertension in pediatric liver transplant recipients, the underlying mechanisms and characteristics of calcineurin inhibitor-induced hypertension, and the consequences of and risk factors for post-transplant hypertension. We hereby present an overview of the current practices in blood pressure monitoring and antihypertensive treatment as well as an algorithm for the evaluation and management of hypertension post liver transplantation. Finally, we discuss knowledge gaps and suggestions for future research.
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Affiliation(s)
- Eline Braekman
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
| | - Ruth De Bruyne
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, Ghent University Hospital, Ghent, Belgium
| | - Kristof Vandekerckhove
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
- Department of Pediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - Agnieszka Prytula
- Department of Internal Medicine and Pediatrics, Ghent University, Ghent, Belgium
- Department of Pediatric Nephrology and Rheumatology, Ghent University Hospital, Ghent, Belgium
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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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Lipid Complications after Hematopoietic Stem Cell Transplantation (HSCT) in Pediatric Patients. Nutrients 2020; 12:nu12092500. [PMID: 32825002 PMCID: PMC7551147 DOI: 10.3390/nu12092500] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Revised: 08/16/2020] [Accepted: 08/17/2020] [Indexed: 01/05/2023] Open
Abstract
HSCT (hematopoietic stem cell transplantation) is a widely applied method of treatment of pediatric patients with leukemia and other bone marrow-associated disorders. Metabolic disturbances can appear as procedure side effects. This study aimed to report incidence of lipid and thyroid disorders and time of their onset in pediatric patients after HSCT. There were 198 pediatric patients (123 males) aged 0.5–20 years who were subjected to HSCT. Patients were mostly diagnosed with Acute Leukemia (n = 190). The analysis of lipids, thyroid hormones, and thyroid antibodies levels comprised one month before the HSCT to last follow up visit between 2016 and 2019 (median 3.8 ± 1.8 years after HSCT). In males, the triglycerides levels increased over two times in the course of HSCT in both patients with initially low and elevated HDL (high-density lipoprotein) levels. Most of the lipid disorders occurred in six months after HSCT. Patients treated with L-thyroxine exhibited decreased LDL (low-density lipoprotein) levels. HDL remained at a lower level in males. Thyroid hormone abnormalities were evenly distributed in time until 4 years after HSCT. Patients require long term follow up including lipid metabolism and thyroid function analysis. HSCT survivors demand introduction of polyunsaturated fatty acids into the diet to reduce risk of developing the lipid complications.
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Memaran N, Borchert-Mörlins B, Schmidt BMW, Sugianto RI, Wilke H, Blöte R, Baumann U, Bauer E, von Wick A, Junge N, Leiskau C, Pfister ED, Thurn-Valsassina D, Richter N, Goldschmidt I, Melk A. High Burden of Subclinical Cardiovascular Target Organ Damage After Pediatric Liver Transplantation. Liver Transpl 2019; 25:752-762. [PMID: 30742355 DOI: 10.1002/lt.25431] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/24/2019] [Indexed: 02/07/2023]
Abstract
Cardiovascular (CV) events account for 8%-13% of deaths after liver transplantation (LT) in adulthood. Although CV risk factors (RFs) are present, little is known about the prevalence of subclinical CV target organ damage (TOD) in children after LT. The aim of this prospective observational study was to assess the prevalence of subclinical CV TOD in children after LT and to identify RFs contributing to CV damage as potential targets for clinical intervention. In this study, 104 children after LT (54% female, 46% male; aged 11.5 ± 3.8 years) underwent cross-sectional assessment of subclinical TOD by carotid-femoral pulse wave velocity (PWV), carotid intima-media thickness (IMT), and left ventricular mass index (LVMI). Results were correlated with the presence of CV RFs (obesity, hypertension, dyslipidemia, renal impairment, anemia, and microinflammation). Of the patients, 22% were exposed to 2 CV RFs, and 36% displayed 3 or more CV RFs. Pathological results for PWV, IMT, and LVMI were found in 21.9%, 57.0%, and 11.1% of patients, respectively. In the multivariate analysis, diastolic blood pressure (P = 0.01) and estimated glomerular filtration rate (eGFR; P = 0.03) were independently associated with PWV, eGFR (P = 0.005), and age at LT (P = 0.048) with IMT and body mass index with LVMI (P = 0.004). In conclusion, patients after pediatric LT carry a substantial burden of subclinical CV TOD. Identification of modifiable CV RFs opens opportunities for targeted intervention in order to reduce CV morbidity and mortality in the future.
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Affiliation(s)
- Nima Memaran
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Bianca Borchert-Mörlins
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Bernhard M W Schmidt
- Department of Nephrology and Hypertension, Hannover Medical School, Hannover, Germany
| | - Rizky I Sugianto
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Hannes Wilke
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Ricarda Blöte
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Ulrich Baumann
- Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Elena Bauer
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Anika von Wick
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Norman Junge
- Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Christoph Leiskau
- Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Eva D Pfister
- Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Daniela Thurn-Valsassina
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Nicolas Richter
- Department of General, Visceral, and Transplantation Surgery, Hannover Medical School, Hannover, Germany
| | - Imeke Goldschmidt
- Pediatric Gastroenterology and Hepatology, Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
| | - Anette Melk
- Department of Pediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School, Hannover, Germany
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Healthy Body Weights With Corticosteroid-free Immunosuppression Is the Best Predictor of Cardiovascular Health in Children After Liver Transplantation. J Pediatr Gastroenterol Nutr 2019; 68:713-719. [PMID: 30676521 DOI: 10.1097/mpg.0000000000002271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Cardiometabolic dysregulation (CMD) influences morbidity and mortality risk in adults post-liver transplantation (LTx). CMD is reported in 10% to 25% of pediatric LTx recipients, but no information regarding the longitudinal expression of CMD is available. The study objective was to examine the longitudinal expression of CMD and associations with body composition and growth in children post-LTx. METHODS A retrospective review was conducted in youth (34 F/30 M) who underwent LTx between 1994 and 2015 at the Stollery Children's Hospital. Primary outcomes included serum markers of CMD (insulin, glucose, hemoglobin A1C [A1C], homeostasis model assessment for insulin resistance [abnormal >3], lipid panel triglycerides, total cholesterol, high-density lipoprotein-cholesterol, low-density lipoprotein-cholesterol) and systolic/diastolic blood pressure (BP: absolute/z scores). RESULTS Mean (±SD) age, weight z, height z, body mass index z was 9.7 ± 3.4 years (3.5-17.9), 0.26 ± 1.03, 0.017 ± 1.2, and 0.41 ± 1.05, respectively. The majority of children had percentage fat mass, percentage fat-free mass within normal reference ranges. Systolic/diastolic BP was within healthy references ranges in 83.1% and 93.5% of children, respectively. Serum insulin (83.4%) and high-density lipoprotein-cholesterol (43.9%) concentrations were low, with abnormal findings of other laboratory markers found in <5% of participants. Abnormal findings for metabolic parameters were independent of weight z, body mass index z, fat mass, and corticosteroids but were positively related to child's age (>9.7 years) and fat-free mass (total, arms). Insulin levels decreased significantly in the first 4 years post-LTx, but no changes in lipid panel, A1C and glucose were noted over 10 years. CONCLUSIONS Pediatric LTx recipients with healthy body weights and corticosteroid-free immunosuppression have a low expression of CMD over 10 years.
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Johnson JN, Filler G. The importance of cardiovascular disease in pediatric transplantation and its link to the kidneys. Pediatr Transplant 2018; 22:e13146. [PMID: 29441655 DOI: 10.1111/petr.13146] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2017] [Indexed: 02/07/2023]
Abstract
Cardiovascular disease is a frequent cause of morbidity and mortality in pediatric patients following solid organ transplant. CKD is also common in pediatric patients after a solid organ transplant, and the link between CKD and cardiovascular morbidity is strong. In this review, we examine potential etiologies to explain the risk of cardiovascular morbidity and mortality in pediatric solid organ recipients and identify targets for improving outcomes.
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Affiliation(s)
- Jonathan N Johnson
- Department of Pediatrics/Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota.,Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Guido Filler
- Department of Paediatrics, Schulich School of Medicine & Dentistry, London, ON, Canada.,Department of Medicine, Schulich School of Medicine & Dentistry, London, ON, Canada.,Department of Pathology and Laboratory Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, London, ON, Canada
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Perito ER, Phelps A, Vase T, Feldstein VA, Lustig RH, Rosenthal P. Subclinical Atherosclerosis in Pediatric Liver Transplant Recipients: Carotid and Aorta Intima-Media Thickness and Their Predictors. J Pediatr 2018; 193:119-127.e1. [PMID: 29224938 PMCID: PMC5794603 DOI: 10.1016/j.jpeds.2017.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 08/21/2017] [Accepted: 10/10/2017] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To investigate prevalence and predictors of cardiovascular risk in pediatric liver transplant recipients using noninvasive markers of subclinical atherosclerosis: carotid intima-media thickness (cIMT) and aorta intima-media thickness (aIMT). STUDY DESIGN Cross-sectional study of 88 pediatric liver transplant recipients. The cIMT and aIMT were measured by ultrasound imaging using standardized protocol. RESULTS Participants were 15.4 ± 4.8 years of age, and 11.2 ± 5.6 years post-transplantation. The cIMT and aIMT were both higher in males than females. In analyses adjusted for sex, age, and height, the cIMT was higher in subjects transplanted for chronic/cirrhotic liver disease and lower in subjects on cyclosporine (n = 9) than tacrolimus (n = 71). The cIMT was not associated with rejection history or current corticosteroid use. The cIMT increased with increasing diastolic blood pressure and triglycerides. The aIMT (n = 83) also increased with age, and its rate of increase post-transplant varied by age at transplantation. In adjusted analyses, aIMT was higher in subjects with glucose intolerance. In analysis of patients ≤20 years of age for whom blood pressure percentiles could be calculated (n = 66), aIMT increased with increasing diastolic blood pressure percentile (0.010 mm per 5-percentile; 95% CI, 0.000-0.021; P = 0.05). Neither the cIMT nor the aIMT was associated with obesity, systolic hypertension, or other dyslipidemia at study visit. CONCLUSION Measures of long-term cardiovascular risk were associated with conditions that are more common in pediatric liver transplant recipients than nontransplanted peers, namely, diastolic hypertension and glucose intolerance. Larger, longitudinal studies are warranted to investigate whether cIMT could be useful for stratifying these patients' cardiovascular risk-and potential need for proactive intervention-during long-term follow-up.
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Affiliation(s)
- Emily R. Perito
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA,Department of Epidemiology and Biostatistics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Andrew Phelps
- Department of Radiology and Biomedical Imaging, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Tabitha Vase
- School of Medicine, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Vickie A. Feldstein
- Department of Radiology and Biomedical Imaging, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Robert H. Lustig
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
| | - Philip Rosenthal
- Department of Pediatrics, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA,Department of Surgery, UCSF Benioff Children’s Hospital, University of California, San Francisco, San Francisco, CA
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