Arterial hypertension (HTN) in children after kidney transplantation is an important risk factor not only for graft loss but also for cardiovascular morbidity and mortality. The prevalence of posttransplant HTN ranges between 60% and 90%. The etiology of posttransplant HTN is multifactorial and includes residual chronic native kidney disease, immunosuppressive therapy, and chronic allograft dysfunction among other causes. Clinic blood pressure (BP) should be measured at each outpatient visit. However, ambulatory blood pressure monitoring (ABPM) is the gold standard method for BP evaluation in children after kidney transplantation, as it often reveals masked and nocturnal HTN; given this, it should be regularly performed in each transplanted child. All classes of antihypertensive drugs are used in the treatment of posttransplant HTN because it has never been proven that one class is better than another. However, in several retrospective studies, the use of calcium channel blockers is associated with better graft function. The optimal target BP for transplanted children is still a matter of debate; it is recommended to target the same BP as for healthy children, that is, <95th percentile. Control of HTN in transplanted children remains poor - only 20%-50% of treated children have normal BP. There is a great potential for improvement of antihypertensive treatment that could potentially result in improvement of both graft and patient survival in children after kidney transplantation.

Children's Hospital of Eastern Ontario University of Ottawa Ottawa Ontario Canada

Department of Pediatrics 2nd Faculty of Medicine Charles University Prague Prague Czech Republic

Department of Pediatrics Dr von Hauner Children's Hospital University Hospital Ludwig Maximilian University Munich Munich Germany

Department of Pediatrics University Hospital Ostrava Ostrava Czech Republic

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Kramer AM, van Stralen KJ, Jager KJ, et al. Demographics of blood pressure and hypertension in children on renal replacement therapy in Europe. Kidney Int. 2011;80:1092-1098.

Tutone VK, Mark PB, Stewart GA, et al. Hypertension, antihypertensive agents and outcomes following renal transplantation. Clin Transplant. 2005;19:181-192.

Opelz G, Wujciak T, Ritz E, Collaborative Transplant Study. Association of chronic kidney graft failure with recipient blood pressure. Kidney Int. 1998;53:217-222.

Mitsnefes MM, Omoloja A, McEnery PT. Short-term pediatric renal transplant survival: blood pressure and allograft function. Pediatr Transplant. 2001;5:160-165.

Lurbe E, Agabiti-Rosei E, Cruickshank JK, et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016;34:1887-1920.

Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics. 2017;140:e20171904.

Seifert ME, Dahale DS, Kamel M, et al. The improving renal outcomes collaborative: blood pressure measurement in transplant recipients. Improving renal outcomes collaborative (IROC). Pediatrics. 2020;146:e20192833.

Pisano A, Mallamaci F, D'Arrigo G, et al. Blood pressure monitoring in kidney transplantation: a systematic review on hypertension and target organ damage. Nephrol Dial Transplant. 2021;36:1326-1346. doi:10.1093/ndt/gfab076

Flynn JT. Ambulatory blood pressure monitoring should be routinely performed after pediatric renal transplantation. Pediatr Transplant. 2012;16:533-536.

Seeman T. Ambulatory blood pressure monitoring in pediatric renal transplantation. Curr Hypertens Rep. 2012;14:608-618.

Hamdani G, Nehus EJ, Hanevold CD, et al. Ambulatory blood pressure, left ventricular hypertrophy, and allograft function in children and young adults after kidney transplantation. Transplantation. 2017;30:1039-1046.

Jacobi J, Rockstroh J, John S, et al. Prospective analysis of the value of 24-hour ambulatory blood pressure on renal function after kidney transplantation. Transplantation. 2000;70:819-827.

Flynn JT, Urbina EM, Brady TM, et al. Ambulatory blood pressure monitoring in children and adolescents: 2022 update: a scientific statement from the American Heart Association. Hypertension. 2022;79:e114-e124.

Wühl E, Hadtstein C, Mehls O, Schaefer F, Escape Trial Group. Home, clinic, and ambulatory blood pressure monitoring in children with chronic renal failure. Pediatr Res. 2004;55:492-497.

Morgan H, Khan I, Hashmi A, Hebert D, Balfe JW. Ambulatory blood pressure monitoring after renal transplantation in children. Pediatr Nephrol. 2001;16:843-847.

Seeman T, Šimková E, Kreisinger J, et al. Control of hypertension in children after renal transplantation. Pediatr Transplant. 2006;10:316-322.

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.

Seeman T, Pfaff M, Sethna CB. Isolated nocturnal hypertension in pediatric kidney transplant recipients. Pediatr Transplant. 2022;26(2):e14192.

Krmar RT, Berg UB. Long-term reproducibility of routine ambulatory blood pressure monitoring in stable pediatric renal transplant recipients. Am J Hypertens. 2005;18:1408-1414.

Flynn JT, Daniels SR, Hayman LL, et al. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63:1116-1135.

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.

Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group. KDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int. 2021;99:S1-S87.

Bald M, Böhm W, Feldhoff C, Bonzel KE. Home blood pressure self-measurement in children and adolescents with renal replacement therapy. Klin Padiatr. 2001;213:21-25.

Hooper DK, Mitsnefes M. A systems-based approach to managing blood pressure in children following kidney transplantation. Pediatr Nephrol. 2016;31:1593-1604.

Stergiou GS, Yiannes NG, Rarra VC, Panagiotakos DB. Home blood pressure normalcy in children and adolescents: the Arsakeion school study. J Hypertens. 2007;25:1375-1379.

Marouane A, Cornelissen EAM, Nusmeier A, Bootsma-Robroeks CMHHT. Oscillometric and intra-arterial blood pressure in children post-kidney transplantation: is invasive blood pressure measurement always needed? Pediatr Transplant. 2019;23:e13309.

Sinha MD, Kerecuk L, Gilg J, Reid CJ, British Association for Paediatric Nephrology. Systemic arterial hypertension in children following renal transplantation: prevalence and risk factors. Nephrol Dial Transplant. 2012;27:3359-3368.

Dobrowolski LC, van Huis M, van der Lee JH, et al. Epidemiology and management of hypertension in paediatric and young adult kidney transplant recipients in The Netherlands. Nephrol Dial Transplant. 2016;31:1947-1956.

Kim HC, Kwon JK, Park SB, Cho WH, Park CH. Hypertension in kidney transplantation recipients: effect on long-term renal allograft survival. Transplant Proc. 1998;30:3906-3907.

Sinha MD, Gilg JA, Kerecuk L, Reid CJ. Progression to hypertension in non-hypertensive children following renal transplantation. British Association for Paediatric Nephrology. Nephrol Dial Transplant. 2012;27:2990-2996.

Giussani A, Ardissino G, Belingheri M, et al. Posterior reversible encephalopathy syndrome after kidney transplantation in pediatric recipients: two cases. Pediatr Transplant. 2016;20:68-71.

Gordjani A, Offner G, Hoyer PF, Brodehl J. Hypertension after renal transplantation in patients treated with cyclosporine and azathioprine. Arch Dis Child. 1990;65:275-279.

Seeman T. Hypertension after renal transplantation. Pediatr Nephrol. 2009;24:959-972.

Halimi JM, Ortiz A, Sarafidis PA, et al. 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.

Tantisattamo E, Molnar MZ, Ho BT, et al. Approach and management of hypertension after kidney transplantation. Front Med (Lausanne). 2020;7:229.

Sorof JM, Sullivan EK, Tejani A, Portman RJ. Antihypertensive medication and renal allograft failure: a North American pediatric renal transplant cooperative study report. J Am Soc Nephrol. 1999;10:1324-1330.

El-Husseini AA, Foda MA, Shokeir AA, Shebab El-Din AB, Sobh MA, Ghoneim MA. Determinants of graft survival in pediatric and adolescent live donor kidney transplant recipients: a single center experience. Pediatr Transplant. 2005;9:763-769.

Höcker B, Weber LT, Feneberg R, et al. Improved growth and cardiovascular risk after late steroid withdrawal: 2-year results of a prospective, randomised trial in paediatric renal transplantation. Nephrol Dial Transplant. 2010;25:617-624.

Höcker B, Weber LT, John U, et al. Steroid withdrawal improves blood pressure control and nocturnal dipping in pediatric renal transplant recipients: analysis of a prospective, randomized, controlled trial. Pediatr Nephrol. 2019;34:341-348.

Sarwal MM, Ettenger R, Dharnidharka V, et al. Complete steroid avoidance is effective and safe in children with renal transplants: a multicenter randomized trial with three-year follow-up. Am J Transplant. 2012;12:2719-2729.

Weaver DJ Jr, Selewski D, Janjua H, Iorember F. Improved cardiovascular risk factors in pediatric renal transplant recipients on steroid avoidance immunosuppression: a study of the Midwest Pediatric Nephrology Consortium. Pediatr Transplant. 2016;20:59-67.

Trompeter R, Filler G, Webb NJ, et al. Randomized trial of tacrolimus versus cyclosporin microemulsion in renal transplantation. Pediatr Nephrol. 2002;17:141-149.

Büscher R, Vester U, Wingen AM, Hoyer PF. Pathomechanisms and the diagnosis of arterial hypertension in pediatric renal allograft recipients. Pediatr Nephrol. 2004;19:1202-1211.

Mitsnefes MM, Khoury PR, McEnery PT. Early posttransplant hypertension and poor long-term allograft survival in pediatric patients. J Pediatr. 2003;143:98-103.

Hanevold CD, Ho PL, Talley L, Mitsnefes MM. Obesity and renal transplant outcome: a report of the North American pediatric renal transplant cooperative study. Pediatrics. 2005;115:352-356.

Wilson AC, Greenbaum LA, Barletta GM, et al. High prevalence of the metabolic syndrome and associated left ventricular hypertrophy in pediatric renal transplant recipients. Pediatr Transplant. 2010;14:52-60.

Lendvai Z, Pásti K, Szeifert L, et al. Cardiometabolic correlates of sleep-disordered breathing in renal transplant children. Pediatr Transplant. 2019;23:e13529.

Santos LB, Borges LM, Souza LV, Felipe CR, Medina-Pestana JO. Franco MDC is low birth weight an additional risk factor for hypertension in paediatric patients after kidney transplantation? J Dev Orig Health Dis. 2020;11:3-6.

Balzano R, Lindblad YT, Vavilis G, Jogestrand T, Berg UB, Krmar RT. Use of annual ABPM, and repeated carotid scan and echocardiography to monitor cardiovascular health over nine yr in pediatric and young adult renal transplant recipients. Pediatr Transplant. 2011;15:635-641.

Matteucci MC, Giordano U, Calzolari A, Turchetta A, Santilli A, Rizzoni G. Left ventricular hypertrophy, treadmill tests, and 24-hour blood pressure in pediatric transplant patients. Kidney Int. 1999;56:1566-1570.

Borchert-Mörlins B, Thurn D, Schmidt BMW, et al. Factors associated with cardiovascular target organ damage in children after renal transplantation. Pediatr Nephrol. 2017;32:2143-2154.

Schmidt BMW, Sugianto RI, Thurn D, et al. Early effects of renal replacement therapy on cardiovascular comorbidity in children with end-stage kidney disease: findings from the 4C-T study. Transplantation. 2018;102:484-492.

Ramoğlu MG, Uçar T, Yılmaz S, et al. Hypertension and improved left ventricular mass index in children after renal transplantation. Pediatr Transplant. 2017;21(8):e13066. doi:10.1111/petr.13066

Kitzmueller E, Vécsei A, Pichler J, et al. Changes of blood pressure and left ventricular mass in pediatric renal transplantation. Pediatr Nephrol. 2004;19:1385-1389.

de Verteuil I, Fitzpatrick J, Alvarez Elias AC, et al. Longitudinal changes in cardiac structure and function in pediatric kidney transplant recipients. Hypertension. 2022;79:1680-1689.

Kis E, Cseprekál O, Horváth Z, et al. Pulse wave velocity in end-stage renal disease: influence of age and body dimensions. Pediatr Res. 2008;63:95-98.

Litwin M, Wuhl E, Jourdan C, et al. Altered morphologic properties of large arteries in children with chronic renal failure and after renal transplantation. J Am Soc Nephrol. 2005;16:1494-1500.

Sugianto RI, Memaran N, Schmidt BMW, et al. Findings from 4C-T study demonstrate an increased cardiovascular burden in girls with end stage kidney disease and kidney transplantation. Kidney Int. 2022;101:585-596.

Groothoff JW, Gruppen MP, Offringa M, et al. Mortality and causes of death of end-stage renal disease in children: a Dutch cohort study. Kidney Int. 2002;61:621-629.

Lurbe E, Cifkova R, Cruickshank JK, et al. Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens. 2009;27:1719-1742.

Wilson AC, Mitsnefes MM. Cardiovascular disease in CKD in children: update on risk factors, risk assessment, and management. Am J Kidney Dis. 2009;54:345-360.

Brubaker AL, Stoltz DJ, Chaudhuri A, et al. Superior hypertension management in pediatric kidney transplant patients after native nephrectomy. Transplantation. 2018;102:1172-1178.

Pickles C, Kaur A, Wallace D, et al. Bilateral native nephrectomies for severe hypertension in children with stage 5 chronic kidney disease leads to improved BP control following transplantation. Pediatr Nephrol. 2020;35:2373-2376.

Silverstein DM, Palmer J, Baluarte HJ, Brass C, Conley SB, Polinsky MS. Use of calcium-channel blockers in pediatric renal transplant recipients. Pediatr Transplant. 1999;3:288-292.

Stigant CE, Cohen J, Vivera M, Zaltzman JS. ACE inhibitors and angiotensin II antagonists in renal transplantation: an analysis of safety and efficacy. Am J Kidney Dis. 2000;35:58-63.

Arbeiter K, Pichler A, Stemberger R, et al. ACE inhibition in the treatment of children after renal transplantation. Pediatr Nephrol. 2004;19:222-226.

Seeman T, Dusek J, Vondrak K, Janda J. Ramipril in the treatment of proteinuria in children after renal transplantation. Pediatr Transplant. 2010;14:283-287.

Rosík T, Chadimová M, Dušek J, et al. Proteinuria 1 year after renal transplantation is associated with impaired graft survival in children. Pediatr Nephrol. 2015;30:1853-1860.

Simões E, Silva AC, Teixeira MM. ACE inhibition, ACE2 and angiotensin-(1-7) axis in kidney and cardiac inflammation and fibrosis. Pharmacol Res. 2016;107:154-162.

Heinze G, Mitterbauer C, Regele H, et al. Angiotensin-converting enzyme inhibitor or angiotensin II type 1 receptor antagonist therapy is associated with prolonged patient and graft survival after renal transplantation. J Am Soc Nephrol. 2006;17:889-899.

Suszynski TM, Rizzari MD, Gillingham KJ, et al. Antihypertensive pharmacotherapy and long-term outcomes in pediatric kidney transplantation. Clin Transplant. 2013;27:472-480.

Opelz G, Zeier M, Laux G, Morath C, Dohler B. No improvement of patient or graft survival in transplant recipients treated with angiotensin-converting enzyme inhibitors or angiotensin II type 1 receptor blockers: a collaborative transplant study report. J Am Soc Nephrol. 2006;17:3257-3262.

Calvino J, Lens XM, Romero R, Sánchez-Guisande D. Long-term anti-proteinuric effect of losartan in renal transplant recipients treated for hypertension. Nephrol Dial Transplant. 2000;15:82-86.

Hausberg M, Barenbrock M, Hohage H, Müller S, Heidenreich S, Rahn KH. ACE inhibitor versus beta-blocker for the treatment of hypertension in renal allograft recipients. Hypertension. 1999;33:862-868.

Agarwal R, Sinha AD. Thiazide diuretics in advanced chronic kidney disease. J Am Soc Hypertens. 2012;6:299-308.

Shao SC, Lai CC, Chen YH, Lai EC, Hung MJ, Chi CC. Associations of thiazide use with skin cancers: a systematic review and meta-analysis. BMC Med. 2022;20:228.

Seeman T, Feber J. Should ACE inhibitors or calcium channel blockers be used for post-transplant hypertension? Pediatr Nephrol. 2021;36:539-549.

McGlothan KR, Wyatt RJ, Ault BH, et al. Predominance of nocturnal hypertension in pediatric renal allograft recipients. Pediatr Transplant. 2006;10:558-564.

Pisano A, Bolignano D, Mallamaci F, et al. Comparative effectiveness of different antihypertensive agents in kidney transplantation: a systematic review and meta-analysis. Nephrol Dial Transplant. 2020;35:878-887.

Sethna CB, Grossman LG, Dhanantwari P, et al. Restoration of nocturnal blood pressure dip and reduction of nocturnal blood pressure with evening anti-hypertensive medication administration in pediatric kidney transplant recipients: a pilot randomized clinical trial. Pediatr Transplant. 2020;24:e13854.

Neale J, Smith AC, Bishop NC. The effects of exercise and sport in solid organ transplant recipients: a review. Am J Phys Med Rehabil. 2017;96:273-288.

Stabouli S, Polderman N, Nelms CL, et al. Assessment and management of obesity and metabolic syndrome in children with CKD stages 2-5 on dialysis and after kidney transplantation-clinical practice recommendations from the Pediatric Renal Nutrition Taskforce. Pediatr Nephrol. 2022;37:1-20.

Salvatierra O Jr, Singh T, Shifrin R, et al. Successful transplantation of adult-sized kidneys into infants requires maintenance of high aortic blood flow. Transplantation. 1998;66:819-823.

Porn-Feldman H, Davidovits M, Nahum E, Weissbach A, Kaplan E. Kadmon G fluid overload and renal function in children after living-donor renal transplantation: a single-center retrospective analysis. Pediatr Res. 2021;90:625-631.

Chatzikyrkou C, Schmieder RE, Schiffer M. Update on treatment of hypertension after renal transplantation. Curr Hypertens Rep. 2021;23:25.

Ari E, Fici F, Robles NR. Hypertension in kidney transplant recipients: where are we today? Curr Hypertens Rep. 2021;23:21.

Wuhl E, Trivelli A, Picca S, et al. Strict blood-pressure control and progression of renal failure in children. N Engl J Med. 2009;361:1639-1650.

Seeman T, Vondrák K, Dušek J. Effects of the strict control of blood pressure in pediatric renal transplant recipients-ESCORT trial. Pediatr Transplant. 2019;23:e13329.

Flynn JT. Hypertension and future cardiovascular disease in pediatric renal transplant recipients. Pediatr Transplant. 2006;10:276-278.

Seeman T, Šimková E, Kreisinger J, et al. Improved control of hypertension in children after renal transplantation: results of a two-yr interventional trial. Pediatr Transplant. 2007;11:491-497.

Stabouli S, Printza N, Dotis J, et al. Long-term changes in blood pressure after pediatric kidney transplantation. Am J Hypertens. 2016;29:860-865.

Sugianto RI, Schmidt BMW, Memaran N, et al. Sex and age as determinants for high blood pressure in pediatric renal transplant recipients: a longitudinal analysis of the CERTAIN registry. Pediatr Nephrol. 2020;35:415-426.

Opelz G, Dohler B, Collaborative Transplant Study. Improved long-term outcomes after renal transplantation associated with blood pressure control. Am J Transplant. 2005;5:2725-2731.

Becker-Cohen R, Nir A, Ben-Shalom E, et al. Improved left ventricular mass index in children after renal transplantation. Pediatr Nephrol. 2008;23:1545-1550.