Hypertension in Renal Tx Transplants 100% Hypertension most common - - PowerPoint PPT Presentation

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Megan Schoettler, MSN, CPNP-AC Pediatric Nephrology Nurse Practitioner Pediatric Hypertension Program Nurse Practitioner

Post Transplant Hypertension: Why does this transplanted child have a BP of a 60 year old?

Nothing to disclose

Hypertension in Pediatric Solid Organ Transplants

0% 20% 40% 60% 80% 100% Renal Tx Liver Tx Heart Tx Lung Tx

Hypertension in Renal Tx

Hypertension most common modifiable CV risk factor in

children post Renal Tx

NAPRTCS registry indicates that immediately post-

transplant >80% of children require antihypertensive medications

70% of DDRT and 60% of LRRT require antihypertensive

medications 5 yrs after transplantation

One study found for each 10% increase in SBP at 1 yr post-

transplant there was a two-fold risk for subsequent graft failure

Weir, et al, JASN 2015

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Hypertension in Liver Tx

~40% of pediatric liver

transplant recipients develop CKD post- transplant

~25% are left with

clinical hypertension

ABPM studies echo this

at a 30% prevalence of masked hypertension

McLin et al, AJT, 2012 Matloff, CGR, 2015

Hypertension in Heart Tx

Common, severe and occurs frequently at night Associated with the number and type of immunosuppressive

agents used, specifically with the combo of Sirolimus and Prednisone

Difficult to control, therefore advocating for alternative

interventions like decreased sodium intake

Filler, PT, 2016 Roche, JHLT, 2008

Hypertension in Lung Tx

Outcome Within 1 Year Total N with known response Within 5 Years Total N with known response Within 7 Years Total N with known response Hypertension 41.4% (N = 765) 67.7% (N = 229) – Renal Dysfunction 9.4% (N = 795) 29.6% (N = 247) 42.8% (N = 138) Abnormal Creatinine ≤ 2.5 mg/dl 6.5% 23.1% 32.6% Creatinine > 2.5 mg/dl 1.9% 4.0% 6.5% Chronic Dialysis 0.8% 1.6% 0.7% Renal Transplant 0.3% 0.8% 2.9%

Pediatric Hypertension Definitions

BP Classification SBP and/or DBP Percentile

Normal BP <90th percentile Pre-Hypertension 90th percentile to <95th percentile; adolescents BP >120/80 up to <95th percentile Stage 1 hypertension 95th percentile up to the 99th percentile plus 5 mm Hg Stage 2 hypertension >5 mm Hg above 99th percentile

BP Classification SBP and/or DBP Percentile

Normal BP <90th percentile Pre-Hypertension 90th percentile to <95th percentile; adolescents BP >120/80 up to <95th percentile Stage 1 hypertension 95th percentile up to the 99th percentile plus 5 mm Hg Stage 2 hypertension >5 mm Hg above 99th percentile

4thTask Force Data, Pediatrics, 2004

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BP measurement standards

Measure BP in all children ≥3 years old or

<3 years old with chronic illness

Auscultation is preferred method Use appropriate BP cuff size

length should cover 80%-100% of the upper arm circumference bladder width ≥ 40% of arm circumference

High BP must be confirmed on repeated measurement BP >90th percentile obtained by oscillometric device should

be repeated by auscultation

Ambulatory Blood Pressure Monitoring

Oscillometric measurement of BP

• ver a 24 hour period

Daytime: every 20-30 min Nighttime: every 30-60 min Standards are established for normals based on European

pediatric patients ages 6-17

Results are expressed as Systolic and Diastolic Load

Ambulatory Blood Pressure Monitoring ABPM classification

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Masked Hypertension

BP <95% in office setting but >95% by ABPM Prevalence ~8% in unselected pediatric population Prevalence in pediatric solid organ tx patients is ~26-46% Associated with higher LV mass in children Risk of LVH as high as in those with ambulatory HTN

Hypertension in pediatric solid organ transplants

Tainio, JCH, 2015

Nocturnal Hypertension

BP should decrease 10-20% at night BP which does not decrease at night is considered non-

dipping with diagnosis of nocturnal hypertension

Risk of LVH is equal to those with ambulatory HTN Hypertensive BP values can occur at night even in patients

taking anti-hypertensive medications

Hypertension across all transplants

Multifactorial:

Impaired renal function Medication induced hypertension (Calcinurin-inhibition and

corticosteroids)

Fluid overload Obesity

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Impaired Renal Function

Renal perfusion compromised by hemodynamic instability,

hypotension and prolonged cross-clamp time can lead to ischemia and AKI

Repeated episodes of AKI, regardless of interim return to

baseline function, are associated with impaired renal function and progression to CKD

hypertension is a hallmark of CKD and is independently

associated with CKD progression

Strict BP control can substantially slow CKD progression

Matloff, CGR, 2015

Medication-induced hypertension

Calcinurin inhibitors causes vasoconstriction of the afferent

and efferent glomerular arterioles, reduction in renal blood flow and thereby decreased GFR

Impairment of endothelial cell function leads to reduced

production of vasodilators and enhanced release of vasoconstrictors

Sodium retention and sensitivity is related to afferent

glomerular arteriole vasoconstriction and activation of sodium chloride co-transporter

Classes of Antihypertensive Drugs

Diuretics Direct acting vasodilators

Hydralazine, minoxidil, nitroprusside

Sympathetic blockers

Central: clonidine β receptor: propranolol, metoprolol α and β receptor: labetalol

Angiotensin blockade

ACE I: enalapril, benazapril ARB: candesartan

Calcium channel blockers

Nifedipine, amlodipine, nicardipine

Choice of Antihypertensive Drug Based on Likely Etiology

Fluid overload, steroid therapy

Diuretics

Renal injury/scarring

ACE I, ARB

Renal artery stenosis

ACE I, ARB

CSA, Prograf

Calcium channel blockers

CNS disease

Clonidine

Adolescents

Once daily therapy

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So why does your patient have a BP of a 60 yr old?

Look at the prevelance of the specific solid organ transplant Multifactorial but could be due to medication, decreased

renal function, fluid overload or obesity

You diagnosed with a 24 hrABPM You can treat based on the underlying pathology Monitor with yearly with ABPM and ECHO

Resources

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Resources Continued

• Garcia-Bello, J.A., Romo-Del Rio, E.G., Mendoza-Gomez, E., Camarena-Arias,P

.A. (2016). Effect of Immunosuppressive Therapy on Cardiovascular Risk Factor Prevalence in Kidney-transplanted Children: Comparative Study. Journal of Transplantation proceedings, 48, 639-642.

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pediatric and young adults kidney transplant recipients. Pediatric Transplant , 00: 1– 6.

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hypertrophy, and allograft function in children and young adults after kidney transplantation.Transplantation

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Resources Continued

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., Rosenthal, P . (2012). Impact of the Donor Body Mass Index on the Survival of Pediatric LiverTransplant Recipients and Post-transplant Obesity. LiverTransplatation, 18, 930- 939.

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.F., (2008). Hypertension After Pediatric Heart Transplantation is Primarily Associated with Immunosuppressive Regimen. Journal of Heart and Lung Transplantation, 27, 501-507.

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Resources Continued

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., Papachristou, F. (2016). Long-term changes in Blood Pressure After Pediatric Kidney

• Transplantation. American Journal of Hypertension,

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T., Jalanko, H. (2015). Blood Pressure Profiles 5 to 10 Years After Transplant in Pediatric Solid Organ Recipients. The Journal of Clinical Hypertension, 17(2), 154-161

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M.M., Sica, D.A. (2015). Assessment and Management of Hypertension in Transplant Patients. Journal of American Society of Nephrology, 26, 1248-1260.

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Papadimitriou, J., Brisco, M.A., Blahut, S., Fink, J. C., Fisher, M.L., Bartlett, S.T., Weir, M.R. (2005). Effect of Kidney transplantation on Left ventricular Systolic Dysfunction ad Congestive Heart Failure in Patients with End-Stage Renal Disease. Journal of the American College of Cardiology, 45 (7), 1051- 1060.