New onset hypertension after transplantation

Table 3 Studies regarding the management of posttransplant hypertension

	Study type	Title	Ref.	Intervention	Outcome	Conclusion
1	Four cross-sectional Retrospective analysis	Treatment of Hypertension in Renal Transplant Recipients in Four Independent Cross-Sectional Analysis	Kuxmiuk-Glembin et al[64], 2018	-Beta-blockers 80%); -Calcium channel blockers (53%); -Diuretics (37%); -Alpha-blockers (35%); -Angiotensin-converting enzyme inhibitors (ACEi) (32%); -ARB (7%)	Blood pressure controlled using BB (43.9 controlled, 56.1 not controlled P = 0.007); -Number of antihypertensive agents: 2.43 +/- 1.3 (controlled BP); 1.88 +/- 1.5 (Uncontrolled BP) P < 0.001. -ACEI &/ARB: Yes: 57.1 (controlled, 42.9 (Uncontrolled); No ACEI/ARB: 48 (Controlled), 52 (uncontrolled) P = 0.08	The commonly used monotherapy agents:-BB followed by CCB. -Use of ACEI, diuretics, and alpha-blockers was about the same. -ARB therapy was least utilized. -Significant increase was observed in the mean number of antihypertensive drugs per patient in subsequent years
2	Randomized controlled trials systemic review	Antihypertensive treatment for kidney transplant recipients	Cross et al[71], 2009	60 studies involving 3802 recipients. -29 studies (2262 participants) compared calcium channel blocker to placebo/no treatment. -10 studies (445 participants) compared ACEi to placebo/no treatment. -7 studies (405 participants) compared CCB to ACEi	-CCB compared to placebo/no treatment reduced graft loss (RR 0.75, 95%CI: 0.57-0.99) and improved glomerular filtration rate (GFR), (MD, 4.45 mL/min, 95%CI: 2.22-6.68). -ACEi versus placebo/no treatment were inconclusive for GFR (MD -8.07 mL/min, 95%CI: -18.57-2.43) and variable for graft loss, precluding meta-analysis. -Direct comparison with CCB, ACEi decreased GFR (MD -11.48 mL/min, 95%CI: -5.75 to -7.21), proteinuria (MD -0.28 g/24 h, 95%CI: -0.47 to -0.10), hyperkalaemia (RR 3.74, 95%CI: 1.89-7.43)	CCB may be used as first-line agents for hypertensive kidney transplant recipients. ACEi have few detrimental effects in kidney transplant recipients
3	Double-blind, randomized, placebo-controlled trial.	Angiotensin II blockade in kidney transplant recipients.	Ibrahim et al[72], 2013	-The effect of losartan compared to placebo and initiated within three months of transplantation	Doubling of renal cortical volume – Measure of interstitial fibrosis/tubular atrophy	-Use of losartan tended to be protective, with an odds ratio (OR) of 0.39 (95%CI: 0.13–1.15, P = 0.08). -Losartan had no significant effect on time to a composite of ESRD, death, or doubling of creatinine level. The mean time to doubling of serum creatinine was longer in the losartan group, compared with placebo (1065 versus 450 d [hazard ratio (HR) 7.28, 95%CI: 2.22–32.78])
4	Prospective Controlled Trial	Converting-enzyme inhibitor versus calcium antagonist in cyclosporine-treated renal transplants	Mourad et al[73], 1993	-6 mo after transplantation, patients were randomly allocated to treatment by the angiotensin-converting enzyme inhibitor lisinopril (ACEI, alone or associated with frusemide; n = 14), or the calcium antagonist, nifedipine (CA, alone or associated with atenolol; n = 11)	-Before initiation of antihypertensive therapy, the two groups had similar mean arterial pressures and GFRs. -Both ACEI and CA treatments were associated with no change in renal function, a similar change in mean arterial pressure (ACEI -18 +/- 3; CA -13 +/- 5 mm Hg), and identical trough blood levels cyclosporine	In cyclosporine-treated transplant recipients, satisfactory control of hypertension was obtained by ACEIs based on their potential to minimize arterial pressures
5	Prospective Randomized Trial	Randomized trial of steroid withdrawal in kidney recipients treated with mycophenolate mofetil and cyclosporine	Pellitier et al[74], 2006	-121 patients were randomized either to discontinue or remain on steroids (60 patients per group)	There were no significant differences in patient and graft survival rates at 1 year or at last follow-up (approximate 3.7y). -Incidence of acute and chronic rejection as well as graft function were the same within 1 yr	Steroid withdrawal in low-risk kidney transplant recipients is safe and ameliorates many of the unwanted side effects of steroid use
6	Retrospective study	Lack of long-term benefits of steroid withdrawal in renal transplant recipients	Sivaram et al[75], 2001	-Retrospective review identified 58 patients administered cyclosporine, azathioprine, and prednisone who underwent complete steroid withdrawal	-Post-steroid withdrawal follow up: 7.6 +/- 1.9 years; -9 patients restarted therapy; 3 patients lost their graft (2 of which are those who restarted prednisone therapy). -2 died with functioning grafts	When prednisone dosage was tapered from 10 mg/d to 10 mg every other day, clinically significant improvements were seen in weight, systolic and diastolic blood pressures, glycosylated hemoglobin levels, and diabetes-related outcomes