1. Dr ANAND YUVARAJ.,MD.,MRCP(UK)
PREVALENCE OF HYPERTENSION IN POST RENAL TRANSPLANT RECIPIENTS- A SOUTH INDIAN STUDY
Dr ANAND YUVARAJ.,MD.,MRCP(UK)
Madras Medical Mission
Chennai, India.

2. Conflict of interest
I have no personal or financial interests to declare
I have no financial support from any source for the current presentation

3. Background and objectives
Post transplant HTN is a strong predictor of patient and graft survival. HTN is BP>140/90mmHg or if a patient is treated with antihypertensive drugs
Zeier M, Mandelbaum A, Ritz E. Hypertension in the transplant patient.Nephron1998; 80: 257–268
As there is paucity of data, this retrospective analysis was done to look at the BP in 506 renal transplant recipients at the initial and 1 year post transplant and their determinants
Country
Awareness%
Treatment %
Control, %
USA 72 61 35
Canada 87 82 66
Cuba 78 60 40
China 45 28 8
India 24 20 6
Tanzania 31 11 7
Australia 62 51
Portugal 46 39
Barbados 75 38
SaileshMohan Norm R.C. Campbell . Hypertension Management. Hypertension.2009; 53: 

4. Renal transplant biopsy- HTN
Markedly thickened blood vessels with narrow slit like lumen. H&E , X100
Malignant hypertension. Hyperplastic arteriolosclerosis with concentric intimal thickening by mucoid ground substance and loosely arranged connective tissue fibres. PAS, X200
Benign nephrosclerosis. Note the thickening of the arteriolar wall by hyaline material accumulating under the endothelium. PAS, X200
Benign nephrosclerosis.Marked intimal fibrosis , luminal narrowing and duplication of the internal elastic lamina. H&E, X200

5. Hypertension and Graft survival Mortality after kidney transplant
Hypertension After Kidney Transplant
Hypertension and Graft survival
Mortality after kidney transplant
Association of hypertension at 1 year with transplant survival. Kidney transplant survival is inversely proportional to blood pressure. Abbreviation: SBP, systolic blood pressure.
Atherosclerotic disease is the most common cause of death after transplant (44%) and outweighs the contributions from infection and malignancy combined (33%)
Association of hypertension at 1 year with transplant survival. Kidney transplant survival is inversely proportional to blood pressure
Mahendra M, John PV. Hypertension After Kidney Transplant. American Journal of Kidney Diseases Feb; 57(2):

6. Anastomosis and HTN
Transplant renal artery stenosis and HTN is six times more common in end-to-end anastomosis than end to side anastomosis
Li JC, Ji ZG, Cai S, Jiang YX, Dai Q, Zhang JX.Evaluation of severe transplant renal artery stenosis with Doppler sonography. J Clin Ultrasound Jul-Aug;33(6):261-9

7. Kidney function and choice of antihypertensive agent
Kidney function and choice of antihypertensive agent. The achieved glomerular filtration rate (GFR) in patients treated with calcium channel blockers is greater than for those treated with angiotensin-converting enzyme inhibitors (measured at 3 weeks and 1 and 2 years after transplant).
The achieved GFR in patients treated with calcium channel blockers is greater than for those treated with angiotensin-converting enzyme inhibitors (measured at 3 weeks and 1 and 2 years after transplant).
Mahendra M, John PV. Hypertension After Kidney Transplant. American Journal of Kidney Diseases Feb; 57(2):

8. Immunosuppressive Agents and HTN
Steroids- Pharmacologic doses of steroids cause HTN - mineralocorticoid-induced sodium retention, increased responsiveness to vasoconstrictors, and decreased vasodilator production.
CNI- Both cyclosporine and tacrolimus have induced or exacerbated hypertension in transplant recipients. Cyclosporine activates the sympathetic nervous system, upregulates endothelin, and inhibits inducible nitric oxide, all of which cause potent vasoconstriction and systemic hypertension
Tacrolimus -has less of an effect on BP than cyclosporine
Margreiter R. Efficacy and safety of tacrolimus compared with ciclosporin microemulsion in renal transplantation: a randomised multicentre study. Lancet. 2002;359(9308):741–746

9. Materials and Methods
A retrospective analysis of 506 transplant recepients(M 240, F 266,mean age / years), looking at BP at the initial and after 1 year
Age, sex, height(cm), weight(kg), BMI(kg/m2),
DM, proteinuria, concentric LVH, antihypertensives, serum creatinine (mg/dl) at discharge post transplant with the estimated GFR in MDRD formula, native kidney disease,(Hb)(g/dl) and usage of erythropoietin were looked at

10. Results
Initial BP was normal in 24(4.74%), prehypertension in 145(28.65%), HTN stage I in 227(44.86%) and stage II in 110(21.73%) patients
1 year post transplant, out of 152 patients, BP was normal in 13(8.55%), Prehypertension in 46(30.26%), HTN stage I in 71(46.71%) and Stage II in 22(14.47%) patients

11. Results N Minimum Maximum Mean Std. Deviation Initial SBP 506 96 200
137.97
16.64
Initial DBP 42
118
85.65
10.95
SBP(1 yr later)
152 82
190
133.98
18.75
DBP(1yr later) 40
120
83.98
12.13
Creatinine(mg/dl)
0.5
7.3
1.44 1
Hb(g/dl) 3
15.1
9.15
1.79

12. GFR and HTN
Among 506 patients, 62(12.25%) -stage I 198(39.13%) - stage II 211(41.69%)-stage III 20(3.95%) -stage IV 15(2.96%) - stage V

13. LVH and HTN
LVH was noted in 304(60.07%) and no LVH in 202(39.92%) patients.

14. Diabetics and HTN

15. BMI and HTN
Among 506 patients,patients with BMI > 35kg/m2, had higher initial SBP(181+/- 14mmhg)(p=0.01), initial DBP(111+/- 14mmHg)(p=0.01) and also higher 1 year post transplant SBP (171+/- 12mmhg)(p=0.02) and DBP(110+/12mmHg)(p=0.01)

16. Conclusion
There is a high incidence of HTN in renal transplant recipients, 66.59% - HTN and 28.65% - prehypertension in the initial post transplant period and 61.18% - HTN and 30.26%- prehypertension in the one year post transplant period
Patients with BMI > 35kg/m2, have higher initial and 1 year post transplant BP
Diabetics have a higher initial SBP and should be closely monitored
LVH is a predictor of higher SBP later in the post transplant period

17. Post Transplant HTN Management
Dietary restriction and diuretics -Salt, fat, kcal restricted diet
Calcium Channel blockers – Preferred first line agents
ACEI/ARB – Reduction in :
Proteinuria
Hematocrit
GFR
Beta blockers