Ambulatory blood pressure (BP) monitoring (ABPM) is the preferred method to characterize BP status, and its use in kidney transplant recipients is increasing. Data on longitudinal ambulatory BP (ABP) trends in pediatric and young adult kidney transplant recipients are limited. Retrospective review of a large cohort of children and young adults following kidney transplantation and evaluation of their ABP status over time and its associations with any patient and clinical characteristics. Two hundred and two patients had baseline ABPM available for analysis, and 123 of them had a follow up (median time 2.3 years) ABPM. At the time of follow up, more patients were treated for hypertension (80% vs. 72%, P = 0.02), and less patients had ambulatory hypertension (36% vs. 54%, P = 0.005), uncontrolled or untreated, compared with baseline, with 45% of all patients classified as having controlled hypertension (compared to 26% at baseline, P = 0.002). Prevalence of ambulatory hypertension decreased only in patients who were less than 18 years old at baseline. High baseline mean 24-hour systolic BP was independently associated with persistent hypertension. In young kidney transplant recipients followed by ABPM, the prevalence of ambulatory hypertension decreases over time, mainly due to the increased number of patients with controlled hypertension.
Accuracy of blood pressure (BP) measurement is important for the evaluation of hypertension in children and adolescents, and it is critically dependent upon the accuracy of the BP measuring device. A device that could pass validated protocols with reliable accuracy would be desirable in clinical and research settings. Several scientific organizations have published recommendations on the validation of different BP measuring devices. Most of them focus on adults but separate recommendations and validation criteria for BP devices intended for use in children and adolescents are included in some validation protocols. In this review, we compare the validation criteria for BP measuring devices among consensus documents from different scientific organizations focusing on the pediatric population and we discuss the evidence gaps targeting the needs for validated BP measuring devices in children and adolescents. We also highlight common pitfalls in the validation studies of BP measuring devices in children and adolescents using the example of office BP devices.
Hypertensive target organ damage (TOD) is associated with increased risk for cardiovascular (CV) events. Ambulatory blood pressure (ABP) allows better prediction of TOD than clinic BP in adults, but data in youth are lacking. We aimed to determine if BP phenotype, based on a combination of clinic BP and ABP, predicts underlying CV TOD in otherwise healthy adolescents. We evaluated clinic BP (mean of 6 auscultatory BP’s), ABP (Spacelabs OnTrak), left ventricular mass index (LVMI), pulse wave velocity (PWV), diastolic function (E/e’), and systolic function (longitudinal strain) in 244 adolescents (median age 15.7 yrs, 63% white, 54% male). Clinic HTN was defined according to pediatric guidelines, and ambulatory HTN was defined as wake systolic BP > 95 th percentile for sex and height. General linear models were used to evaluate associations between BP phenotype and TOD. Normal BP phenotype was found in 162 participants (66%), while 44 (18%), 16 (7%), and 22 (9%) had white coat (WCH), masked (MH), and ambulatory (AH) HTN, respectively. Participants with an abnormal BP phenotype had higher LVMI and PWV compared to those with normal BP (table). Participants with AH also had significantly higher PWV than those with WCH or MH. Adolescents with MH or AH had worse diastolic function (higher E/e’) compared to those with normal BP or WCH. Only participants with AH had significantly worse systolic function (less negative strain) compared to those with normal BP; there was no significant difference in strain among subjects with normal BP, WCH and MH. In conclusion, ABPM improves TOD risk stratification in adolescents evaluated for HTN.
Ambulatory blood pressure (BP) monitoring provides a more precise measure of BP status than clinic BP and is currently recommended in the evaluation of high BP in children and adolescents. However, ambulatory BP monitoring may not always be available. Our aim was to determine the clinic BP percentile most likely to predict ambulatory hypertension. We evaluated clinic and ambulatory BP in 247 adolescents (median age, 15.7 years; 63% white; 54% male). Clinic BP percentile (based on the fourth report and the 2017 American Academy of Pediatrics clinical practice guidelines) and ambulatory BP status (normal versus hypertension) were determined by age-, sex-, and height-specific cut points. Sensitivity and specificity of different clinic BP percentiles and cutoffs to predict ambulatory hypertension were calculated. Forty (16%) and 67 (27%) patients had systolic hypertension based on the fourth report and the 2017 guidelines, respectively, whereas 38 (15%) had wake ambulatory systolic hypertension. The prevalence of ambulatory wake systolic hypertension increased across clinic systolic BP percentiles, from 3% when clinic systolic BP was <50th percentile to 41% when ≥95th percentile. The 2017 guidelines' 85th systolic percentile had similar sensitivity (86.8%) and better specificity (57.4% versus 48.1%) than elevated BP (≥90th percentile or ≥120 mm Hg) to diagnose ambulatory hypertension. When evaluating adolescents for hypertension, 2017 guidelines' clinic systolic 85th percentile may be the optimal threshold at which to perform ambulatory BP monitoring.
Transition from pediatric to adult care services is a complex process, carrying medical, psychosocial and emotional issues. It is known that, during this period, patients may drop-out from follow-up, lose their adherence and suffer from psychosocial complications. This period is prone to rejection of the transplanted kidney. Managing this process correctly, can empower the young adult and make him a better and more compliant patient. The study aimed to create a new model for the Transition Clinic and analyze its impact on the transition process of young transplanted patients.
Hypertensive target organ damage (TOD) is associated with increased risk for CV events. Ambulatory BP (ABP) measures are more strongly related to TOD than casual BP in adults but data in youth are lacking. Our objective was to determine which ABP parameters associated with TOD in adolescents. We evaluated casual BP (mean of 6 measures by auscultation), ABP (Spacelabs OnTrak), anthropometrics, labs, LVM, pulse wave velocity (PWV), diastolic function (E/E’ ratio), and systolic function (global longitudinal strain, GLS) in 132 adolescents (mean 15.8 + 1.4 yrs, 66% white, 57% male). Day, night and 24H SBP and DBP index (mean/95 th %ile for sex and height) and loads (%readings above the 95 th %ile) were defined according to sex and height-specific pediatric cut-points. General linear models were used to determine independent associations between ABP and TOD. Only systolic ABP means and loads were associated with LVMI and diastolic function, while both systolic and diastolic ABP means and loads were associated with PWV. There was a weak association between systolic and diastolic loads and GLS. In multiple regression analysis (full model: demographics, age, BMI, HR, ABP, metabolic profile, CRP) day SBP index was the strongest predictor of LVMI (β=15.2, R 2 0.4, p=0.006) and E/E’ (β=5.2, R 2 0.23, all p=0.007), while day DBP index was the strongest predictor of PWV (β=3.0, R 2 0.37, p<0.0001). Day DBP load was the sole independent ABP predictor of GLS (β=0.05, R 2 0.25, p=0.02). We conclude that during adolescence, systolic and diastolic ABP parameters are differentially associated with TOD: SBP predicted LVMI, while DBP predicted PWV. ABP parameters may be used to evaluate risk for BP-related TOD.
Background C3 Glomerulopathy (C3G) is a complement-mediated disease, with predominant C3 deposits, where pathogenic genetic variants in complement system components and circulating autoantibodies result in loss of control of the alternative pathway, have been described. A high incidence of disease recurrence including graft failure has been reported after kidney transplantation (KTx). Currently treatment modalities for preventing and treating post KTx C3G recurrence (plasma exchange, rituximab and eculizumab) in adults have yielded inconsistent results. Data on post KTx C3G recurrence in childhood-onset C3G is still unknown . Methods A comprehensive case study of patients diagnosed with C3G as children or adolescents, who underwent KTx between the years 2015–2023. Data collected included complement workup, treatment modalities, and outcomes. Results 19 patients with C3G were identified during the study period. Five patients developed ESRD and received a kidney transplant. C3G recurrence was diagnosed post KTx in 100% of patients. Graft function improved in 3 of these patients (two with anti-factor H antibodies) after eculizumab treatment, one patient reached graft failure 9 months after transplantation despite eculizumab, recieved a second successful transplantation with pre-emptive eculizumab treatment and one patient showed histologic signs of disease recurrence without clinical signs. Conclusions C3G recurrence after KTx in patients diagnosed as children or adolescents may be higher than previously described. Treatment with eculizumab is beneficial in some patients. New treatments are needed for improving post-transplant outcome in patients with C3G.
INTRODUCTION The prevalence of pediatric primary hypertension (HTN) has increased in the past few decades, most probably related to the increased prevalence of overweight/obesity in this population. According to various estimates 3.5-5% of children and adolescents have HTN. Children and especially adolescents with HTN are at an increased risk for HTN in early adulthood, and for early subclinical cardiovascular morbidity. Therefore, screening for and treatment of pediatric HTN is highly recommended, especially in high risk populations, such as overweight children. In the past few years, new guidelines for the diagnosis, evaluation and treatment of pediatric HTN were published by both the European Society of Hypertension and the American Academy of Pediatrics. The following review will discuss central aspects of the epidemiology, risk factors, definitions, and initial clinical approach of primary HTN in children and adolescents.
Hypertension is associated with left ventricular hypertrophy (LVH), a risk factor for cardiovascular events. Since cardiovascular events in youth are rare, hypertension has historically been defined by the 95th percentile of the normal blood pressure (BP) distribution in healthy children. The optimal BP percentile associated with LVH in youth is unknown. We aimed to determine the association of systolic BP (SBP) percentile, independent of obesity, on left ventricular mass index (LVMI), and to estimate which SBP percentile best predicts LVH in youth. We evaluated SBP, anthropometrics, and echocardiogram in 303 adolescents (mean age 15.6 years, 63% white, 55% male) classified by SBP as low-risk (L=141, <80th percentile), mid-risk (M=71, 80–<90th percentile), or high-risk (H=91, ≥90th percentile) using the mean of 6 measurements at 2 visits according to the 2017 guidelines. Logistic regression was used to determine the sensitivity and specificity of various SBP percentiles associated with LVH. Results: BP groups did not differ by age or demographics but differed slightly by body mass index. Mean BP, LVMI, and prevalence of LVH increased across groups (BP: L=111/75, M=125/82, and H=133/92 mm Hg; LVMI: L=31.2, M=34.2, and H=34.9 g/m 2.7 ; LVH: L=13%, M=21%, H=27%, all P <0.03). SBP percentile remained a significant determinant of LVMI after adjusting for covariates. The 90th percentile for SBP resulted in the best balance between sensitivity and specificity for predicting LVH (LVMI≥38.6 g/m 2.7 ). Abnormalities in cardiac structure in youth can be found at BP levels below those used to define hypertension.
Children who receive a non-renal solid organ transplant may develop secondary renal failure requiring kidney transplantation. We investigated outcomes of 165 pediatric kidney transplant recipients who previously received a heart, lung, or liver transplant using data from 1988 to 2012 reported to the United Network for Organ Sharing. Patient and allograft survival were compared with 330 matched primary kidney transplant (PKT) recipients. Kidney transplantation after solid organ transplant (KASOT) recipients experienced similar allograft survival: 5- and 10-year graft survival was 78% and 60% in KASOT recipients, compared to 80% and 61% in PKT recipients (p = 0.69). However, KASOT recipients demonstrated worse 10-year patient survival (75% KASOT vs. 97% PKT, p < 0.001). Competing risks analysis indicated that KASOT recipients more often experienced graft loss due to patient death (p < 0.001), whereas allograft failure per se was more common in PKT recipients (p = 0.01). To study more recent outcomes, kidney transplants performed from 2006 to 2012 were separately investigated. Since 2006, KASOT and PKT recipients had similar 5-year graft survival (82% KASOT vs. 83% PKT, p = 0.48), although 5-year patient survival of KASOT recipients remained inferior (90% KASOT vs. 98% PKT, p < 0.001). We conclude that despite decreased patient survival, kidney allograft outcomes in pediatric KASOT recipients are comparable to those of PKT recipients.
