Hypertension was traditionally considered a risk factor for organ donation….But, there were many studies conducted later which proved that hypertension if well controlled could donate kidneys…
This review article providing a level of evidence of V…
Various guidelines have described contraindications to organ donation based on blood pressure readings
Amsterdam forum, American Society of Transplantation – >140/90mm of Hg not to donate
British Transplantation society/Australian Transplant network/Canadian society >140/90 mm of Hg not to donate
OPTN network – BP.130/85 in donors less than 50 years old – contraindication for organ donation
KDIGO – Individualized BP approach
Assessment and Evaluation of Pre donation BP:
It is important to always check the BP on 2 separate occasions and never rely on one BP reading.. Many different phenotypes of hypertension are present including white coat hypertension and masked hypertension which may predispose to long term damage of end organs many decades later…In fact there are studies of donors with normal blood pressure, after the usage of ABPM they have been found to have 16% hypertension due to masked hypertension…
in general
BP<130/80 mm on office readings, non obese, non africans – Allowed for donation
BP >130/80 < 160/100 or BP > 130/80 with obesity, Africans heritage, OSA with 1 or 2 Antihypertensive drugs – Ambulatory Blood pressure recordings – if ABPM readings after 15-30min intervals in day and 60 min interval at night recordings of BP <125/85 – Allow for organ donation. If any of the above factors are present – Lifestyle and pharmacological interventions
BP >160/100mm with end organ damage with use of 3 or more antihypertensives – Pharmacotherapy and Life style interventions. Re evaluate for organ donation only if the ABPM recordings are normal
KDIGO in 2017 have told about giving an individualized approach for organ donation considering the risk profile for all donors to increase the organ donation pool
In summary – Donors with hypertension and no end organ damage with 1 or 2 anti hypertensives, who are not very young, non obese, non African lineage will be able to donate organs..
Development of Hypertension post organ donation: Post surgery there is always hyperfiltration, upregulation of RAS and changes in vascular tone which may all elevate the BP but in the long term they are not the factors considered in elevating the blood pressure. It is said that a little elevated BP in the immediate post operative period is needed to maintain the glomerular perfusion pressure. Many studies prospective and retrospective studies have been conducted in the past and the high risk groups like obese, young age, African lineage (due to increased expression of MYH9 and APOL1 gene), pre existing hypertension all have been shown to have impact on long term hypertension development. These are the groups of individual who will need yearly follow up with blood tests, urine tests
Naglaa Abdalla
2 years ago
This review, handle
The current living kidney donation guidelines with respect to “hypertension,”
The impact of living kidney donation on “hypertensive” donors,
The risk of and factors contributing to the development of “hypertension”
post donation in normotensive donors, and
Medical and lifestyle management of BP in living kidney donors
Wee Leng Gan
2 years ago
The most current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation. In healthy, well-selected donors with no known risk factors, living kidney donation does not significantly predispose them to developing hypertension postdonation;However, certain risk factors, such as being African American or Hispanic, obese, or older, are associated with higher likelihoods of developing hypertension postdonation. The choice of BP targets and medications needs to be carefully individualized. In general, a BP <130/80 mm Hg is needed, along with lifestyle modifications.
Dalia Ali
2 years ago
Despite all the benefits and promise of living kidney donation, there has been an overall decline in number of living kidney donations since 2004, while the waiting list for kidney donors increases every year.This decline can largely be attributed to the medical unsuitability of potential donors, who often present with a multitude of health concerns, such as hypertension, obesity, diabetes, and impaired kidney function.
Current Living Kidney Donation Guidelines Elevated BP has long been considered as one of the main contraindications to live kidney donation, but the risks of donation in mild, well-controlled “hypertension” are not well understood. This has led to the creation of several different guidelines that try to delineate the exact benchmark of “hypertension” .In addition, despite the release of such consensus guidelines, most transplant centers adhere to their own standards when evaluating for hypertension in potential live kidney donors
Evaluation and Assessment of BP Predonation In general, screening for hypertension in potential donors should include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated. If BP is determined to be high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements
Preexisting Hypertension in Kidney Donor Candidates Despite hypertension being a known risk factor for renal and cardiovascular disease, more and more transplant centers are relaxing their selection criteria to include donors with well-regulated hypertension in response to decreasing supply of donor organs and increasing demand for kidney transplants. Observational studies of hypertensive donors have produced conflicting results.Some studies have found that donors with predonation hypertension have a decline in kidney function (evidenced by increasing serum creatinine and decreased estimated GFR),while others have maintained that there is no significant difference in kidney function between normotensive and hypertensive donors.
Development of Hypertension in Kidney Donors Postdonation
Even though kidney donation often leads to physiological alterations (kidney hyperfiltration, upregulation of renin-angiotensin-aldosterone system, and changes in vascular tone) that may elevate BP, it is not considered to be a risk factor in developing hypertension postdonation. An important prospective study by Kasiske et al followed living kidney donors over a 3-year period.
They observed systolic and diastolic BP increased slightly and significantly over time in both donors and controls, but there were no significant differences between the 2 groups; in addition, after 3 years, the 24-hour ABPM of both groups was not statistically significant either.
Management of BP and Hypertension Postdonation in Living Kidney Donors Early after donation, it is suggested to allow BP (<160/90
mm Hg) to be elevated to allow for optimal kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).Long-term control of BP in kidney donors depends
on the individual patient, and thus it is difficult to recommend a general medication regimen.Specific pharmacotherapy
must be individualized according to comorbidities, drug-drug interactions, drug side effects, and kidney function. Townsend et al recommend that angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
Based on the current literature, we suggest the following protocol in evaluating potential living kidney donors on the basis of their BPs .Office readings should be carried out as recommended in most guidelines: patient will rest 5 minutes before readings are conducted. BP should be measured with a properly sized BP cuff. The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading. If there are additional concerns about a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered and measurements take place every 15– 30 minutes during the daytime and 30–60 minutes at night for 24 hours with measurements.
CONCLUSIONS
“Hypertension” criteria have changed substantially in the last few years. The goal of being more inclusive for kidney donors with elevated BP may be considered given the opportunity to control BP in an effective manner. No longer should they be considered “marginal” donors. Currently, some of the guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, when hypertensive donors are allowed to donate, they do not seem to be at a significantly increased risk of developing renal or cardiovascular health issues. Another concern for living kidney donors is the possibility of developing hypertension after kidney donation, especially if they are younger, overweight, or of African heritage.
Asmaa Khudhur
2 years ago
Blood Pressure and Living Kidney Donors: A Clinical Perspective
Despite all the advantages and potential of living kidney donation, there has been a general fall in the frequency of donations since 2004, and the waiting list for kidney transplants has increased. annual growth in donors. The medical unsuitability of potential donors, who frequently come with a variety of health issues such hypertension, obesity, diabetes, and poor kidney function, can be partly blamed for this reduction. One of the most important exclusion criteria for living kidney donation is elevated blood pressure (BP), as it raises the likelihood of unfavorable outcomes for both kidney transplant patients and living kidney donors. Despite the fact that hypertension affects both kidney recipients and donors, its effects on the latter have not been as thoroughly researched or understood.
Current Living Kidney Donation Guidelines
The criteria of hypertension have been updated in light of the recent publication of the 2017 High Blood Pressure Clinical Practice Guidelines by the ACC/AHA. Systolic blood pressure that is elevated is 120–129 mm Hg, and stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg.
In a population with a mean age of 68 years, no signs of diabetes, and an estimated glomerular filtration rate (GFR) of about 72mL/min/1.73 m2, SPRINT (Systolic Blood Pressure Intervention Trial) amply demonstrated that a lower BP goal (120/80 mm Hg) was associated with a reduction in cardiovascular events. in particular if they are younger, heavier, or of African descent, there may be cause to think that kidney donors need lower BP targets.
Evaluation and Assessment of BP Predonation
In general, BP measurement on 2 distinct occasions by clinical staff that is trained to measure BP reliably, with equipment that has been calibrated, should be part of the screening process for hypertension in potential donors. If BP is found to be high or high normal, especially if there is variability, the patient is younger, overweight, or of African ancestry, BP should be checked again using standardized blood pressure measurements.It should be emphasized that BP is frequently misclassified, particularly when there is fluctuation.
Office, home, and ABPM readings can differ significantly from one another, and phenotypes like white coat hypertension and masked hypertension may be indicative of future prognosis. There hasn’t been any prospective research on the variability and phenotypic variations in kidney donors.
In the past, antihypertensive drug use or a blood pressure level more than 140/90 mm Hg were regarded as contraindications to donation. On the other hand, low-risk kidney donors may be accepted in some cases for patients whose hypertension can be effectively managed with one or two medications and who show no signs of target organ damage. In order to determine a person’s eligibility to give blood, additional tests and imaging procedures may be taken into account in cases with borderline hypertension or anomalies. The KDIGO working group report of 2017suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
Preexisting Hypertension in Kidney Donor Candidates
In response to a shortage of organ donors and rising demand for kidney transplants, more and more transplant centers are loosening their selection criteria to allow donors with well-controlled hypertension, despite the fact that it is a known risk factor for renal and cardiovascular disease.
In conclusion, donors with well-controlled blood pressure (BP 140/90 controlled with 1-2 antihypertensive drugs and no evidence of target organ damage) appear to be at low risk of developing hypertension or worsening kidney function, strengthening the case for their inclusion in, and consequent expansion of, the living kidney donor pool.
Development of Hypertension in Kidney Donors Postdonation
Despite the fact that kidney donation frequently results in physiological changes (kidney hyperfiltration, upregulation of the renin-angiotensin-aldosterone system, and changes in vascular tone)that may raise blood pressure, it is not thought to be a risk factor for developing hypertension after donation.
Management of BP and Hypertension Postdonation in Living Kidney Donors
Early on after donation, it is advised to enable BP to rise to an ideal level (160/90 mm Hg), which can be maintained with certain, short-acting hypertensive medications (such as calcium channel blocker or clonidine).
Individualized pharmacotherapy must take into account kidney function, drug side effects, drug interactions, and comorbidities.
Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided after surgery because of adaptive hyperfiltration and anticipated volume changes, according to Townsend et al.
Living kidney donors must adopt a healthy lifestyle that includes weight management, moderate dietary sodium reduction, regular exercise, quitting smoking, and moderate alcohol consumption in addition to a customized pharmaceutical regimen. Additionally, they need to be properly educated on how to monitor and manage their own blood pressure at home.
The KDIGO Clinical Practice Guidelines advise that accurate blood pressure readings be taken once a year as part of postdonation care. Living kidney donors who have hypertension should be monitored more frequently than the usual, normotensive donor and should undergo routine blood pressure, laboratory, and albumin-to-creatinine ratio tests. They should also have good control over their other cardiovascular risk factors.
higher risk patients may also require lower BP targets for treatment.
Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
The majority of guidelines state that patients should rest for five minutes before readings are taken in the office. A BP cuff of the appropriate size should be used to measure BP. The final blood pressure will be calculated as the average of 3 readings taken with a minimum 1-minute break in between. The use of ABPM should be taken into consideration if there are additional concerns regarding a potential donor’s blood pressure, younger age, obesity, or African ancestry. Measurements are taken every 15 to 30 minutes during the day and every 30 to 60 minutes at night for a period of 24 hours.
According to the most recent ACC/AHA guidelines, a patient should be considered for donation with the proper individualization and counseling if their average office blood pressure reading is less than 130/80 mm Hg over three measurements. Patients should not be considered for kidney donation if they have an average office blood pressure level of less than 160/100 mm Hg, show signs of end-organ damage (such as left ventricular hypertrophy or albuminuria), or are on more than two antihypertensive medications.
Since obesity has been shown to be a risk factor for end-stage renal disease (ESRD), we raise concern about patients with an average office blood pressure reading of less than 130/80 mm Hg but greater than 160/100 mm Hg, who are taking two or fewer anti-hypertensive medications, who have obstructive sleep apnea or are of African descent, or who have a waist circumference of less than 94 cm for men and less than 80 cm for women They ought to have an ABPM and, if possible, make an effort to decrease weight. The patient should be considered for donation if their 24-hour ABPM blood pressure reading is less than 125/75 mm Hg. The patient should get pharmacological and lifestyle therapies to reduce their blood pressure and weight if their 24-hour ABPM value is less than 125/75 mm Hg.
Regarding the assessment of blood pressure after donation, we advocate maintaining a clinic blood pressure of less than 130/80 mm Hg, which is in accordance with current recommendations for both live kidney donors and the general public. It’s interesting to wonder whether patients who are fat or who may have high risk APOL1 mutations need lower blood pressure targets.
CONCLUSIONS
Given the opportunity to effectively control blood pressure, the objective of being more inclusive for kidney donors with elevated blood pressure may be taken into consideration. They should no longer be viewed as “marginal” donors. A 24-hour ABPM BP value of >140/90 mm Hg or usage of AHMs is currently advised as a contraindication to donation, according to certain standards. When hypertension donors are permitted to donate, however, they don’t appear to have a noticeably higher risk of having kidney or cardiovascular problems. The potential for developing hypertension following kidney donation is another worry for living kidney donors, particularly if they are younger, heavier, or of African descent.
Studies have demonstrated that living kidney donation does not significantly increase the chance of developing hypertension after donation in healthy, well chosen donors without any known risk factors; However, several risk factors, such being Hispanic or African American, fat, or older, are linked to an increased likelihood of having postdonation hypertension. After kidney donation, BP and hypertension should be managed with personalized medication, healthy lifestyle adjustments, and more follow-up sessions.
level of evidence 5
Fatima AlTaher
2 years ago
Presence of HPN is potential donor usually leads to exclusion from donation specially if was controlled by two or more antihypertensive drugs or if the donor has evidence of end organ damage, as HPN is a well known risk factor for CV morbidity and mortality in general population. Beside its poor impact on the donated graft.
The risk of developing HPN after kidney donation is increased theoritically due to post nephrectomy single nephrone hyperfilteration that could end in glomerular hypertension and glomerular sclerosis.
In this review, the authors revised the current living donor guild lines regarding HPN in potential donors.In 2017,ACC/AHA revised the definitions of hypertension to consider BP > 130–139 mm Hg or diastolic 80–89 mm Hg as grade 1 HPN instead of previous levels of > 140/90 mmHg. The SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated that lower BP goal (<120/80 mm Hg) was associated with decrease in CV events in elderly population with a mean age of 68 years with no diabetes, and e GFR around 72mL/min/1.73 m2.
These new changes in guild lines have their impact on kidney dobation practice as more donors will be considered HPN and could be excluded from donation , beside the need for more strict control of BP to lower the risk of CV complications. BP diagnosic approach to potential donor :
1- BP < 130/80 , not obese or African American, allow kidney donation.
2- BP < 130/80 , obese or African American or BP> 130/80 consider confirmation of BP with ABPM if controlled proceed to donation while if not controlled treat as hypertension .
3- BP>160/90 mmHg or end organ damage , exclude from donation. Development of hypertension in kidney donors Postdonation:
Several studied revelead increased risk for HPN post kidney donation due to altered vascular tone , stimulation of RAS and glomerular hyperfilteration , but it’s usually of mild degree and can be controlled easily. Thus many of the current guidelines prevent donation from obese donors (BMI >30-35 )as they have higher risk for developing post donation HPN. Management of post donation BP
During early post donation period, it’s advisable to allow elevated BP to around 160/90 to maintain adequate kidney perfusion and consider short acting VD drugs as CaCB for higher BP levels. Long term management of BP is the same as non donor population but avoid diuretics and ACEI.
level of evidence :5
Hinda Hassan
2 years ago
The cut off value for rejecting a donor with hypertension varies between guidelines. Caring for Australasians with Renal Impairment (CASI), British Transplantation Society (BTS) and Canadian Council for Donation and Transplantation (CCDT) recommend avoiding donors with >140/90 mm Hg on 3 occasion. Amsterdam Forum, American Society of Transplantation (AST) avoid >140/90 mm Hg. European Association of Urology (EAU) and European Best Practice Guidelines (EBPG) avoid Uncontrolled hypertension. Organ Procurement and Transplantation Network (OPTN) avoid >130/85 mm Hg (in donors <50 y old). Kidney Disease Improving Global Outcomes (KDIGO) avoid >140/90 mm Hg on <2 AHMs, end-organ damage or predicted lifetime ESRD risk exceeding transplant center’s acceptable risk threshold
the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA define hypertension as: Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg.
SPRINT (Systolic Blood Pressure Intervention Trial) evidently established that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events.
Evaluation of donors includes BP measurement on 2 separate occasions by a trained staff and calibrated device.
There are differences between office, home, and ABPM readings which were not studied in a sufficient way. This is important as in the past donors were discarded if they have a BP reading >140/90 mm Hg and/or use of antihypertensive medications. Recently, easily controlled hypertension with 1 or 2 agents and no evidence of target organ damage may be accepted as low-risk kidney donors. The KDIGO suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy. The authors added a concern in younger donors, especially if they are overweight or have African ancestry, or both.
predonation hypertension was not associated with an increased risk of any perioperative complications, such as gastrointestinal, bleeding, respiratory, and surgical injuries. Some studies have found that donors with predonation hypertension have a decline in kidney function while others have not.
These discrepancies are due to variance in follow-up length, study population, hypertension definitions, sample size, short follow-up times, unrepresentative patient populations, and low rates of followup. a 5-mm Hg increase in systolic BP had a very small effect on ESRD risk compared with other factors, although there was marked glomerulopenia in hypertensive donors, there was a nonsignificant difference in GFR, hyperfiltration capacity, or compensatory renocortical hypertrophy. older donors with hypertension had a higher risk of ESRD but not mortality for 15 years postdonation.
systolic and diastolic BP increased slightly and significantly over time in both donors and controls, but there were no significant differences between the 2 groups; in addition, after 3 years, the 24-hour ABPM of both groups was not statistically significant either. There are also reports that suggest that there is an increased risk of developing hypertension postdonation but there was no comparison of these statistics with that of the normal population.
African American donors had a 37% higher relative likelihood of any antihypertensive medication use after donation compared with Caucasian living donors and they were less likely to have their BP controlled despite equal access to care. MYH9 and APOL1 loci on Chromosome 22 have been linked with nondiabetic kidney disease in several recent studies. After controlling for multiple risk factors, including age, gender, and ethnicity, on average, obese donors (BMI >30) had higher mean systolic and diastolic BPs than nonobese donors, leading to a significant increase in ESRD risk.
Specific antihypertensive therapy in living kidney donors must be individualized according to comorbidities, drug-drug interactions, drug side effects, and kidney function. Management should include positive lifestyle changes, including weight control, modest dietary sodium reduction and regular exercise, smoking avoidance, and modest alcohol intake and avoid angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics perioperatively due to adaptive hyperfiltration and expected shifts in volume. The KDIGO Clinical Practice Guidelines suggest that annual BP measurements and hypertensive living kidney donors should be followed more frequently.
The authors suggested evaluating potential living kidney donors on the basis of their BPs The average of 3 office readings 1 minutes apart after 5 minutes rest before readings are conducted with a properly sized BP cuff. ABPM should be considered for any concerns or younger age, overweight, or African heritage. if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling. If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation. reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive medication, who has obstructive sleep apnea orAfrican heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women , should have an ABPM and preferably try to lose some weight. If the patient’s 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation. If the patient’s 24 hour ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight; when their BP becomes <125/75 mm Hg on a subsequent 24 hour ABPM reading or over multiple office measurements, they could then be reevaluated for living kidney donation. they adopted target post donation BP ≤130/80 mm Hg.
Level of evidence is 5
Mohammed Sobair
2 years ago
Introduction:
Elevated blood pressure (BP) is one of the leading exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both kidney transplant recipients and living kidney donors alike.
Despite hypertension affecting both kidney recipients and donors, the impact of hypertension on the latter has not been as well studied and understood. The definitions of “hypertension” are variable depending on the guidelines. Guidelines and their contraindications to donation for hypertension: Contraindication
Caring for Australasians with Renal Impairment (CASI), British Transplantation Society (BTS),
Canadian Council for Donation and Transplantation (CCDT) >140/90 mm Hg on 3 occasions
Amsterdam Forum, American Society of Transplantation >140
European Association of Urology, European Best Practice Guidelines Uncontrolled hypertension.
Organ Procurement and Transplantation Network (OPTN) >130/85 mm Hg (donors less 50).
KDIGO >140/90 mm Hg on 2AHM, end- organ damage
Or predicted lifetime ESRD risk exceeding
Transplant center’s acceptable risk threshold.
Evaluation and Assessment of BP:
Screening for hypertension in potential donors should include BP measurement on two separate occasions If BP is determined to be high, or high normal, especially if there is
Variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements.
Controlled hypertension with one or two agents and no evidence of target organ damage may be accepted as low-risk kidney donors on a case-by-case basis.
Additional examinations and imaging studies may be considered in those with borderline hypertension or abnormalities to assess their qualification to donate.
The KDIGO working group report of 2017, suggested that potential donors with hypertension should be individualized in relation to the transplant program’, should be counseled that donation might accelerate the rise in BP and increase the need for more antihypertensive therapy.
This is also a concern in younger donors, especially if they are overweight or have African ancestry, or both. Preexisting Hypertension in Kidney Donor Candidates:
Donors with well-controlled BP with one or two medication and evidence of TOD have low risk of ESRD or hypertension post donation. Development of Hypertension in Kidney Donors Post donation:
There is conflicting result, but those with marginal factors like obese, African American have more risk than Caucasian is. Management of BP and Hypertension Post donation:
Early after donation, it is suggested to allow BP keep Blood pressure. Below 169/90.
Late individualized treatment with indication.
Avoid diuretic, ACE and ARB.
KDIGO Guidelines suggest that proper BP measurements should be performed annually.
Hypertensive living kidney donors (whether the hypertension developed pre or post donation) should be followed more frequently than the average,
Normotensive donor and to have regular BP, laboratory, and urinary albumin: creatinine ratio tests conducted.
Based on the most recent ACC/AHA guidelines,
If the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling. If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking > less than 130/80 , two antihypertensive medication, then they should be considered kidney donation.
If blood pressure more than 160/90, evidence of TOD or take more than two medication should be excluded from donation.
Level of evidence V
CARLOS TADEU LEONIDIO
2 years ago
Please summarise this article in your own words
The queue of transplant recipients is only increasing and a possible solution that also brings better survival results for the graft and the recipient is the donation from living donors. However, over the years, the number of donors has been decreasing, mainly because the number of proposed qualified donors has also been decreasing. The main factors involved are: hypertension, diabetes, obesity and impaired renal function.
Of those already mentioned, high blood pressure is one of the main criteria for exclusion. It is perhaps the least studied, in addition to being the most confusing, as new definitions are constantly emerging. The 2017 ACC/AHA Hypertension Clinical Practice Guidelines defined high blood pressure as systolic pressure between 120-129 mmHg and Stage 1 Hypertension – systolic pressure between 130-139 mmHg or diastolic pressure between 80-80 mmHg , while the guidelines on hypertension in living kidney donors use systolic pressure greater than 140 mmHg.
This review aims to examine the latest guidelines with respect to the following points;
A – HYPERTENSION
The first point that should be noted is that misclassification of blood pressure (BP) is common, especially if there is perceived variability between office, home and Ambulatory Blood Pressure Monitoring (ABPM) measurements.
The SPRINT (Systolic Blood Pressure Intervention Trial) clearly demonstrated that a lower BP goal (< 120 mmHg) was associated with a reduction in cardiovascular events in a population with a mean age of 68 years, no evidence of diabetes, and a low filtration rate estimated glomerular (GFR) of approximately 72 mL/min/1.73 m2. This same study demonstrated that the consistency of the benefit in reducing cardiovascular events was substantial, regardless of the participants’ GFR.
B – IMPACT OF LIVING DONATION IN HYPERTENSIVE DONORS
From a short-term perspective, Lentine et al concluded that pre-donation hypertension was not associated with an increased risk of any perioperative complications, such as gastrointestinal, hemorrhage, respiratory and surgical injuries. Therefore, donors with well-controlled BP (BP < 140/90 mmHg with 1 to 2 antihypertensive drugs or NO evidence of end-organ damage) appear to have minimal risk of developing worsening renal function or hypertension.
C- RISK FACTORS FOR DEVELOPING HYPERTENSION AFTER DONATION (NORMOTENSIVE DONORS)
Although kidney donation often leads to physiological changes (renal hyperfiltration, upregulation of the renin-angiotensin-aldosterone system and changes in vascular tone) that can increase BP, it is not considered a risk factor for the development of post-donation hypertension.
An important prospective study by Kasiske et al followed living kidney donors over a 3-year period. They observed that systolic and diastolic BP increased slightly and significantly over time in donors and controls, but there were no significant differences between the 2 groups. Furthermore, after 3 years, the 24-hour ABPM of both groups was also not statistically significant.
However, it is important to keep donors with risk factors: African-American and Hispanic ancestry, BMI, and age under surveillance, as they appear to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation.
D – MEDICAL AND LIFESTYLE MANAGEMENT OF BLOOD PRESSURE IN LIVING DONORS
Long-term BP control in kidney donors is patient-specific and therefore it is difficult to recommend a general medication regimen. Specific pharmacotherapy should be individualized according to comorbid conditions, drug interactions, drug side effects, and renal function. Townsend et al recommend that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided in the perioperative period due to adaptive hyperfiltration and expected changes in urinary volume.
Along with a personalized medication regimen, living kidney donors also need to make positive lifestyle changes, including weight management, modest reduction in dietary sodium and regular exercise, avoidance of smoking, and modest alcohol intake. They should also receive proper education on how to take BP at home for self-BP monitoring and management.
What is the level of evidence provided by this article?
This is level 05 – narrative review
Mahmud Islam
2 years ago
Living donation increased with an increase in demand for kidney donation. This was affected By the change in the definition of HT over time. The balance between risk and benefit is needed. In this review, HT and its effect on living kidney donation was reviewed. Most guidelines, including KDIGO, stated BP>140/90 as a contraindication to living donation. OPT set donors less than 50 years old with BP>135/85 as a contraindication. Many differences are present, with a lack of studies differentiating between home and hospital-based measurements. Although HT is a known risk for cardiovascular disease, some studies included well-controlled HT patients without end-organ damage and extended the pool of donors. It seems that patients with BP<140/90 on one medication and no end organ damage have low risk after donation. The results of studies are variable. Some retrospective studies showed 2.4 fold increase in the risk of HT post-donation. Early post-donation, there is a permissive HT to allow sufficient perfusion of kidney. In general, more guidelines suggest BP>140/90 in ABPM contraindication to living donation.
Mohamed Fouad
2 years ago
Blood Pressure and Living Kidney Donors:
Elevated blood pressure has been one of the main exclusion criteria for living kidney donation, as it is a risk factor for renal and cardiovascular disease. living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation.
In general, screening for hypertension in potential donors should include BP measurement on 2 separate occasions with equipment that has been calibrated. If BP is determined to be high, or high normal, or the patient is younger, overweight, or has African origin, then BP should be evaluated with ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements.
In the past, a BP reading >140/90 mm Hg and/or use of antihypertensive medications (AHMs) was considered as contraindications to donation. However, patients with easily controlled hypertension with 1 or 2 agents and no evidence of target organ damage may be accepted as low-risk kidney donors on a case-by-case basis.
The KDIGO working group report of 2017 suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counselled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
Development of Hypertension in Kidney Donors Post donation kidney donation often leads to physiological alterations (kidney hyperfiltration, upregulation of renin-angiotensin-aldosterone system, and changes in vascular tone) that may elevate BP, it is not considered to be a risk factor in developing hypertension postdonation.it is important to keep these risk factors (African American and Hispanic descent, BMI, and age) in mind when evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation.
Management of BP and Hypertension Post donation in Living Kidney Donors
The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of post donation follow-up care. Hypertensive living kidney donors (whether the hypertension developed pre or post donation) should be followed more frequently than the average with laboratory, and urinary albumin: creatinine ratio tests assessment.
Nasrin Esfandiar
2 years ago
Donor’s hypertension (HTN) is a contraindication for live donation. The definition of hypertension was revised by AHA 2017 guideline. So, elevated HTN is 120-129 mmHg for systolic and stage 1 HTN is 130-139 for systolic or 80-89 mmHg for diastolic. While in the past BP more than140 mmHg was considered high and contraindication for donation donors BP should be measured on 2 separate visits. If BP is high and the patient is young, overweight or black American, the ABPM should be performed, BP more than 140/90 on less than2 anti-hypertensive drug or end-organ damage are considered contraindication of donation according the KD1GO guideline. However, in the case of donation, they are not at significant risk of CVD or renal diseases. Risk factors of past donation HTN are obesity African American or Hispanic and older donors which need to fallow-up after donation. They suggested four items: 1- BP more than 160/100 mmHg, with end organ damage and using more than 2 antihypertensive medication (AHM)are excluded from donation. 2- Candidates with BP less than 130/80 but abuse or African or those with BP more than 130/80 but less than 160/90 with use of 1-2 AHM or obstructive sleep apnea should have ABPM and if their ABPM shows 24 h BP less than 125/75 will be considered for donation. 3- Candidates with BP less 130/80 mmHg without obesity or being African are considered for donation. 4- If ABPM shows more than 125/75 mmHg, life style modification and drugs should have started with weight control. If BP become less than 125/75 they could be revised for donation. This article is a review with expert opinion and level of evidence is 5.
Ahmed Fouad Omar
2 years ago
Hypertension (HTN) is one of the most common obstacles that can disqualify a person from live kidney donation because it is associated with increased risks for kidney transplant recipients as well as living kidney donors.
Risk factors of HTN after kidney donation
Higher BP before donation
Old age
Obesity: the incidence of HTN post donation increase around 10% for each unit increase in BMI
African American and Hispanic (have 50 % risk of developing hypertension post donation
Genetic predisposition APOL1 which is more common in African American
Evaluation of BP before kidney donation 1- Clinic BP
Blood pressure is measured in 2 separate occasions by trained staff & well calibrated equipment
2. Home BP
Clinic BP readings should be confirmed with sequential home BP readings
3. ABPM:
ABPM correlated well with cardiovascular and all-cause mortality and is recommended if the clinic BP ≥ 130/85, African American, overweight, suspicion of masked or white coat hypertension.
Contraindications to donation for hypertension >140/90 mm Hg on 3 occasions:
Uncontrolled hypertension
>130/85 mm Hg in young ≺ 50 years
ABPM >15% of systolic BP readings >140/90 mm Hg
>140/90 mm Hg on one or 2 antihypertensive medication
>140/90 mm Hg and end organ damage (LVH, albuminuria)
Preexisting Hypertension in Kidney Donor Candidates Donors with well-controlled BP on 1–2 antihypertensive drugs with no evidence of target organ damage are considered at lower risk of renal complications.
BP assessment post-donation:
· Maintain a clinic BP ≤130/80 mm Hg. · All donors should monitor their BP with home BP readings. · Donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension. living kidney donors who were hypertensive or developed post-donation should have more frequent BP checks, laboratory assessment of renal functions and urinary albumin:creatinine ratio.
Treatment of hypertension post donation – Non pharmacological measures: include life style measures like exercise, salt restriction, DASH diet and stress reduction.
– Pharmacological treatment : Early after donation: Initiate drug treatment only if BP is ≥ 160/90 to allow for optimal kidney perfusion (calcium channel blockers are preferred) Avoid ACE/ARBS and diuretics to allow for kidney compensation and hyper filtration. Long term: Blood pressure control is selected on individual basis, taking into consideration comorbidities, renal function and volume status.
Conclusion Criteria for diagnosis HTN changed in the last few years. Some of guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of antihypertensive medications be a contraindication to donation. Hypertensive donors are allowed to donate if they have no increased risk of developing renal or cardiovascular health problems. Level of evidence of this article review article, level V
Hamdy Hegazy
2 years ago
This is a review study that looked at the impact of hypertension on kidney donors.
Donors with BP below 120/80 were associated with lower risk of cardiovascular events as evidenced by SPRINT study. Pre-donation BP measurement should be done at 2 separate occasions by well trained staff using a proper cuff in proper environment. Ambulatory BP monitoring is recommended in case of high BP or high normal or younger donors with high BMI, or African origin.
Donors with well controlled hypertension with one or two anti-hypertensive medications without target organ damage are accepted as kidney donors. Some observational studies revealed that donors with pre-donation hypertension had declining GFR. Other studies revealed that there was no difference in GFR in normotensive and hypertensive donors.
Kidney donation is not a risk factor for development of hypertension after donation. Donors of African American or Hispanic ethnicity, or with high BMI or with older age are more prone to post-donation hypertension. The evidence of this study is V.
Jamila Elamouri
2 years ago
Blood Pressure and Living Kidney Donors: A Clinical Perspective
Living kidney donation has many benefits, as possibility of preemptive transplantation, but the number of living kidney donations has been decline since 2004. That can be because of presence of health concerns, such as obesity, hypertension, diabetes, and impaired kidney function. This causing the waiting list for kidney donors increases every year. Elevated blood pressure (BP) is one of the exclusion criteria for living kidney donation.
The definition of BP evolved over time. For the kidney donors, it is better to define the hypertension as that level of BP in which the benefits of treatment out-weight the risks of inaction, if this is possible. As this allows appropriately individualize the care plan. Current Living Kidney Donation Guidelines
High BP has been one of the main contraindications to living kidney donation, but the donation risks in mild, well-controlled hypertension are not well understood. This leads to the development of several different guidelines that try to define hypertension. Despite these guidelines, most transplant centers adhere to their own standards while evaluating donors with hypertension.
2017 high blood pressure clinical practice guidelines by ACC/AHA, defines an elevated BP is 120—129 mm Hg systole and stage 1 is 130—139 mmHg systole or 80—89 mmHg diastole. The effects of these guidelines remain to be seen. Old guidelines have raised concerns about donors with systolic BP > 140 mmHg, and some even for systolic BP > 130 mmHg, especially in younger donors. Also, treatment goals of these donors remains a question in light of these newer guidelines.
The SPRINT clearly found that a BP goal < 120/80 mmHg is associated with a decrease in cardiovascular events in individuals with mean age of 68 years, not diabetic, and an e GFT of about 72ml/min/1.73m2. But, it does not provide evidence that lower systolic BP goals are important in delaying the progression of kidney disease, and because the mean GFR in SPRINT study participants is not different from that observed in kidney donors there may be reason to believe that kidney donors might need lower BP targets, especially in young age, obesity, and African. Evaluation and Assessment of BP Predonation
Screening for hypertension in potential donors should include 2 measurements on 2 separate occasions by trained clinical staff with calibrated equipment. If high or high normal especially in young age, overweight, or African then BP should be measured with ambulatory BP monitoring (ABPM) or repeated standard BP measurements. Patients with easily controlled hypertension with 1 or 2 drugs and no evidence of end organ damage may be accepted as low risk kidney donors on a case-by-case basis. Donors with borderline hypertension may require imaging studies. KDIGO working group advice to counsel donors that BP may accelerate post-donation, and there may be need to more antihypertensive drugs.
Preexisting Hypertension in Kidney Donor
As response to decreasing supply of donor organs and increase demand, many centers are relaxing their criteria to include donors with well-controlled hypertension.
In summary, donors with well-controlled BP (BP <140/90) controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension, strengthening the support for their inclusion into, and consequent expansion of, the living kidney donor pool. Yet, the available studies are of short duration, and there are phenotypes, such as obese, or people with African heritage who may be at more risk, and genotypes such as APOL1 which may confer more risk over time. Development of Hypertension in Kidney Donors Postdonation
It is important to consider risk factors (African American and Hispanic descent, BMI, and age) when
evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation. Donors with risk factors for hypertension may require earlier and more intensive strategies to control BP. Management of BP and Hypertension Postdonation in Living Kidney Donors
in the early post-donation period, it is allowed to maintain high BP < 160/90 mm Hg for optimal kidney perfusion. This can be maintained by short acting agents like calcium channel blocker or clonidine. Treatment of BP elevation on the long-term should be individualized according to comorbidities, drug-drug interaction, drug side effect, and kidney function.
In addition to pharmacological therapy, donors should have positive life style modifications. Such as regular exercise, decrease salt intake, ideal body weight, avoid smoking, and moderate alcohol intake.
KDIGO guidelines suggest that postdonation BP should be measured annually. Hypertensive donors should have more frequently than normotensive donors, also should have laboratory, and urinary albumin:creatinine ratio test and cardiovascular risks modifications. Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
Office BP measurement should be carried out as recommended. If there is another concerns about a donor’s BP or young age, over-weight, or African origin then ABPM should be considered.
According to ACC/AHA guidelines, patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (LVH, albuminuria), or is taking 2 antihypertensive medications, then they should be excluded from kidney donation.
This study raises a concernabout patients with an average office BP reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive medication, who has obstructive sleep apnea or African origin, or has obesity (waist circumference of ≥94cm for men and ≥80cm for women) which are risk for ESRD. These donors should have an ABPM and lose weight. If ABPM BP <125/75 mm Hg can be considered for donation. If donor’s 24 hrs ABPM reading is ≥125/75 mm Hgm they should receive drug and lifestyle interventions to control their BP and weight; when their BP becomes < 125/75 mmHg on a subsequent 24 hrs ABPM reading or office measurements, they could then be reevaluated for living kidney donation.
Postdonation BP is suggested to maintained ≤130/80 mmHg clinic measurement, which is in line with current guidelines for general populations. ABPM is best than office BP in predicting the prognosis of high BP, but no data to support its use for all potential donors, because of cost, and availability. Conclusion
Currently, some of the guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, when hypertensive donors are allowed to donate, they do not seem to be at a significantly increased risk of developing renal or cardiovascular health issues.
Amna Khalifa
2 years ago
the demand for kidney donations much more than the supply of deceased donor allografts
outcome of Live kidney Transplant is much better than deceased donors.
live kidney donations can be used as preemptive or early interventional treatment
overall decline in number of living kidney donations since 2004, while the waiting list for kidney donors increases every year. This decline could be due to the medical unsuitability of potential donors
Elevated blood pressure (BP) is one of the most important cause of rejection of the donor due to the dual adverse effect and outcome on the recipient and the donor
The review will discuss the following: Current Living Kidney Donation Guidelines
· most guidelines have raised concerns about donors with systolic BP >140 mm Hg, or systolic blood pressure >130 mm Hg, especially in younger donors.
· SPRINT (Systolic Blood Pressure Intervention Trial) clearly demonstrated that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events in a population with a mean age of 68 years, no evidence of diabetes, and an estimated glomerular filtration rate (GFR) of approximately 72mL/min/1.73 m2 ><120/80 mm Hg) was associated with a reduction in cardiovascular events in a population
· Of note, the mean GFR in the SPRINT study participants of ~70mL per minute which is equivalent to those who donated a kidney.
· kidney donors might need lower BP targets, especially if they are younger, overweight, or have African ancestry. Evaluation and Assessment of BP Pre-donation
· screening for hypertension in potential donors should include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated
· if high then do ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements
· earlier hypertensives were not accepted as donor however as the demand of the donors increased , patients with mild controlled hypertensives were accepted as kidney donors.
· The KDIGO working group report of 2017 suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy. This is especially true in younger donors, overweight or have African ancestry Preexisting Hypertension in Kidney Donor Candidates
· The Observational studies or retrospective studies showed controversies in their results , some reported decline in kidney function while others have maintained their kidney function .
· This could be due to difference in the duration of follow up , and sample size in addition to the definition of hypertension in each study.
· pre-donation BP has a small effect on ESRD risk compared with other factors, such as increased proteinuria or reduced GFR.
· Studies showed older donors with hypertension had a higher risk of ESRD but not mortality for 15 years post-donation.
· In summary, donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension.
· However there are certain individual who carries higher risk such as
· Obese
· people with African heritage
· genotypes such as APOL1
they are not ideal candidate despite a BP of 115/70 mm Hg.
However, proper counseling on the risks (increased BP and potential end organ damage), should be conducted. Development of Hypertension in Kidney Donors Post-donation
· Even though kidney donation often leads to physiological alterations (kidney hyperfiltration, upregulation of renin-angiotensin-aldosterone system, and changes in vascular tone) that may elevate BP, it is not considered to be a risk factor in developing hypertension postdonation.
· Studies comparing donor and non donor did not show a significant difference in developing hypertension in both groups.
· studies often fail to compare their study population with age matched controls.
· The long-term risk of hypertension were studied in living kidney donors showed statistically significant increase in BP postdonation, with 21% of the donors developed hypertension that required AHM use. However, the increase in BP was from 113/75 to 116/77 mm Hg, values that are well below the normal benchmarks for hypertension. But there was no comparison of these statistics with that of the normal population,
· Another study showed that the risk of developing hypertension, defined as >140/90 mm Hg, increased 3.64-fold 1-year post-donation. However, the mean predonation systolic and diastolic BP values of the normotensive donors who were hypertensive after 1 year postdonation were significantly higher than those donors who were normotensive after 1 year postdonation.
· This suggests that these patients may have been prehypertensive or more susceptible to developing hypertension.
· While those who remained normotensive after 1 year and 5 years, there was only a modest and nonsignificant increase in risk of developing hypertension.
· Thus, this study suggests that kidney donation itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP, and if your predonation systolic BP is 135 mm Hg, you are more likely to reach 140mm Hg than if your BP was 125 mm Hg over the course of several years.
· African American donors had a 37% higher relative likelihood of any antihypertensive medication use after donation compared with Caucasian living donors. This is due to the fact that African American patients with hypertension have resistant hypertension and higher rates of incident ESRD than European Americans.
· MYH9 and APOL1 loci on Chromosome 22 have been linked with nondiabetic kidney disease in several recent studies.
· Two alleles of the APOL1 gene, G1, and G2, are associated with higher risk of focal glomerulosclerosis and hypertension-attributed kidney disease.
· the risk allele frequency in African Americans for G1 or G2 is ~30%, it is much lower in Hispanics with African admixture and extremely low in European Americans.
· These variants may explain 70% of the excess focal segmental glomerulosclerosis, HIV-associated nephropathy, and hypertensive kidney disease in African Americans.
· Screening for APOL1 susceptibility variants in kidney donors before surgery may have an important impact on outcomes for kidney transplant recipients.
· Donors with 2 APOL1 variants convey higher risk of allograft failure to recipients.
· Current consensus guidelines have contraindicated donors with a BMI >30–35. And these group is more likely to have predonation hypertension and each increase in year of donor age was associated with a 5%–7% higher likelihood of hypertension.
· frequency of hypertension increased by 10% for each 1-unit increase in BMI, with higher BMI being associated with higher rates of hypertension 5 years postnephrectomy.
· BMI status at time of evaluation determines one’s postdonation prognosis.
· In summary, it is important to keep these risk factors (African American and Hispanic descent, BMI, and age) in mind when evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation. As discussed below, donors with risk factors for hypertension may require earlier and more intensive strategies to control BP. Management of BP and Hypertension Postdonation in Living Kidney Donors
· Early after donation, it is suggested to allow BP(<160/90 mm Hg) to be elevated to allow for optimal kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
· Long-term control of BP in kidney must be individualized according to comorbidities, drug-drug interactions, drug side effects, and kidney function. It is recommend that angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
· living kidney donors also need to make positive lifestyle changes, including weight control, modest dietary sodium reduction and regular exercise, smoking avoidance, and modest alcohol intake.
· They should also receive proper education on taking home BP for self-BP monitoring and management.
· The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of postdonation follow-up care.
· Hypertensive living kidney donors (whether the hypertension developed pre or postdonation) should be followed more frequently than the average, normotensive donor and to have regular BP, laboratory, and urinary albumin:creatinine ratio tests conducted.
· They should also have their other cardiovascular risk factors well controlled.
· However, these recommendations are somewhat unrealistic, given frequent lack of follow-up of living kidney donors. Ideally, there should be a systematic approach. Moreover, higher risk patients may also require lower BP targets for treatment. Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
Based on the current literature, we suggest the following protocol in evaluating potential living kidney donors on the basis of their BPs
· Office readings should be carried out as recommended in most guidelines:
· patient will rest 5 minutes before readings are conducted.
· BP should be measured with a properly sized BP cuff.
· The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading.
· If there are additional concerns about a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered and measurements take place every 15– 30 minutes during the daytime and 30–60 minutes at night for 24 hours with measurements.
· Based on the most recent ACC/AHA guidelines, if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling.
· If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.
· In the absence of any available clinical data, we raise concern about patients with an average office BP reading ≥130/80 mm Hg but <160/100 mm Hg, and is taking 2 or fewer antihypertensive medication.
· Patients who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94cm for men and ≥80cm for women as obesity has been shown to be a risk factor for ESRD.
· They should have an ABPM and preferably try to lose some weight. If the patient’s 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation.
· Other wise they should be counseled then reevaluated for living kidney donation.
· With respect to BP assessment post-donation, we suggest maintaining a clinic BP ≤130/80 mm Hg, which is in line with current guidelines, not only for living kidney donors but for the general population.
· Whether patients who are obese or possibly carry high risk APOL1 variants require lower BP targets is an intriguing question.
· However this proposal does not take into account “masked hypertension,” defined as normal BP in the office with elevated BP in nonoffice settings, as the prevalence of masked hypertension in the healthy population has not been clearly elucidated.
· In addition, there is currently not enough data to support the use of ABPM for all potential donors, as we have to be mindful of the cost, availability, and expertise needed to perform ABPM correctly.
· We recommend that ideally all potential donors should monitor their BP with home BP readings. CONCLUSIONS
living kidney donors is the possibility of developing hypertension after kidney donation, especially if they are younger, overweight, or of African heritage. Studies have shown that in healthy, well-selected donors with no known risk factors, living kidney donation does not significantly predispose them to developing hypertension postdonation.
Personalized pharmacotherapy along with beneficial lifestyle changes and more follow-up appointments should be utilized to manage BP and hypertension after kidney donation.
level of evidence , it is a review article -level 5
Ahmed Abd El Razek
2 years ago
Introduction
No doubt renal transplantation is considered the best successful solution for ESRD patients ,even living donation has the best outcome rather than the deceased donation outcomes regarding both patient and graft survival ,however a list of considerable obstacles face living donation especially donor clinical dilemmas. Living donation also can widen the option of timing for donation whether pre emptive or interventional after the establishment of dialytic support.
Among the discussed exclusion criteria for renal donation hypertension, obesity, diabetes, and impaired kidney function. The definition of hypertension has been evolving over the years. For living renal donors, hypertension represents a clinical conflict and our role as transplant nephrologists is how best to assess this balance between BP and long-term outcomes.
Current Living Kidney Donation Guidelines
Most guidelines have concerns regarding donors with systolic BP >140 mm Hg. the SPRINT (Systolic blood Pressure Intervention Trial) stated that the lower BP goal (<120/80 mm Hg), the more associated reduction in cardiovascular events. Kidney donors might need lower BP targets, particularly if they are young in age, overweight, or of African background.
Evaluation and Assessment of BP Predonation
Screening for hypertension must include BP measurement on 2 separate occasions by experienced clinical personnel. Cases with suspected elevated blood pressures ought to perform ambulatory BP monitoring (ABPM) for further evaluation.
A study conducted by Armanyous et al referring to daytime ABPM as a gold standard revealed a 16% prevalence of hypertension in candidate renal donors. They also detected a substantial percentage of patients having masked hypertension, determined with ABPM.
Historically, HTN per se was considered as a contraindication for donation, however in this era patients with easily controlled hypertension with 1 or 2 agents and without evidence of target organ damage can be accepted as low-risk candidate donors.
According to Lentine et al study a conclusion of predonation hypertension was not associated with any increased risk of any perioperative complications, like gastrointestinal, bleeding, respiratory, and surgical injuries was established.
However, the KDIGO recommended that donors ought to be counseled that donation might accelerate the rise in their BP and increase the need for more antihypertensive therapy.
Preexisting Hypertension in Kidney Donor Candidates
Some studies stated that donors with predonation hypertension have a decline in renal function (evidenced by increasing serum creatinine and decreased estimated GFR), whereas other studies concluded that there were no difference in renal function between normotensive and hypertensive donors. These studies had many limitations varying between follow-up duration, study population, hypertension definitions as well as sample size.
According to Lenihan et al there was marked glomerulopenia in hypertensive donors, but not associated with significant difference in GFR, hyperfiltration capacity, or compensatory renocortical hypertrophy later on.
In fact older donors with hypertension had a higher potential risk of ESRD but not mortality for 15 years post donation. Furthermore, donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and with no evidence of target organ damage) are considered of minimal risk of occurrence of worsening kidney function or hypertension.
Thus, these previously discussed data augments the expansion of living donor pool.
Development of Hypertension in Kidney Donors Post donation
Kasiske et al conducted a study of 3 year donation concerned with systolic and diastolic BP in renal donors which increased slightly and significantly over time in both donors and controls, with conclusion that no significant differences between both groups.
This study highlights that kidney donation itself is not associated with significant increase in the risk of occurrence of hypertension, rather than other factors that might cause progressive rise in BP, as if the predonation systolic BP is 135 mm Hg, this is more likely to reach 140 mm Hg than if the BP was 125 mm Hg over the course of several years.
Hypertension was estimated by 41% of African American donors in a study compared with 30% of Caucasians on follow up of 7 years duration. African American donors present a 37% higher relative tendency for the use of antihypertensive medication post donation compared to those Caucasian living donors.
The fact that African Americans have higher rates of development of ESRD than European Americans due to their genetic background as MYH9 and APOL1 loci on Chromosome 22 have been clearly linked to occurrence of nondiabetic kidney disease in several recent studies. The presence of the APOL1 gene, G1, and G2 explains the potential higher risk of focal glomerulosclerosis and hypertension renal diseases.
This genetic background explains 70% of the progression to focal segmental glomerulosclerosis, HIV-associated nephropathy, and hypertensive renal disease in African Americans. So it is preferred to apply screening for APOL1 susceptibility variants in donors prior to donation. Even donors with 2 APOL1 variants confront higher risk of allograft failure in renal transplant recipients afterwards.
Lentine et al recommended refusing obese donors as they are more prone to hypertension as well as each increase in year of donor age was accompanied by a 5%–7% higher likelihood of hypertension. The frequency of hypertension increases by 10% for each 1-unit increase in BMI; the higher the BMI, the higher rates of hypertension 5 years post nephrectomy, the more associated ESRD risk probability. Hip-to-waist ratio is a promising tool which may be more sensitive prognostic tool for determining health outcomes than BMI.
Management of BP and Hypertension Post donation in Living Kidney Donors
Townsend et al suggest the avoidance of both angiotensin converting enzyme inhibitors, angiotensin receptor blockers as well as diuretics perioperatively for proper adaptive hyperfiltration and expected shifts in volume.
Living donors need to adopt healthy lifestyle with special emphasis on weight control, modest dietary sodium reduction, regular exercise and smoking cessation. They must also perform frequent BP monitoring and management if needed.
The KDIGO Clinical Practice Guidelines recommend for donors follow up to be carried on annual basis including regular BP, laboratory, and urinary albumin: creatinine ratio tests.
CONCLUSIONS
Hypertensive donors are allowed to donate based on the absence of significant risk for developing renal or cardiovascular health issues. More strict strategies to evaluate BP in candidate living donors and maintain proper BP control post donation ought to be adopted finally.
Level of evidence 5.
Abhijit Patil
2 years ago
Current Living Kidney Donation Guidelines
2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA definition
Elevated BP is 120–129 mm Hg systolic Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg
Most guidelines for donor evaluation contraindicate kidney donation with blood pressure more than 140/90mmHg
The authors of the study have the following guidelines:
Office readings as following-
patient will rest 5 minutes before readings
BP should be measured with a properly sized BP cuff.
The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading.
If there are additional concerns about a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered and measurements take place every 15– 30 minutes during the daytime and 30–60 minutes at night for 24 hours with measurements.
Based on the most recent ACC/AHA guidelines,
if the patient has an average office BP reading <130/80 mm Hg over 3 measurements –> considered for donation with appropriate individualization and counseling.
If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication–> excluded from kidney donation.
average office BP reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive medication, who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women as obesity has been shown to be a risk factor for ESRD.
They should have an ABPM and preferably try to lose some weight.
If the patient’s 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation.
If the patient’s 24 hour ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight; when their BP becomes <125/75 mm Hg on a subsequent 24 hour ABPM reading or over multiple office measurements, they could then be reevaluated for living kidney donation
Maintain a post-donation clinic BP =130/80 mm Hg
Level of evidence Level V
Tahani Ashmaig
2 years ago
Blood Pressure and Living Kidney Donors:A Clinical Perspective
Elevated blood pressure (BP) is one of the leading exclusion criteria for living kidney donation, as it is a risk factor for renal and cardiovascular disease.
The most current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation.
This review, have examined the current living kidney donation guidelines with respect to HTN, the impact of living kidney donation on “hypertensive” donors, the risk of and factors contributing to the development of “hypertension” postdonation in normotensive donors, and medical and lifestyle management of BP in living kidney donors. Current Living Kidney Donation Guidelines The defnitions of HTN have been revised with the recent release of the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA. Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or
diastolic 80–89 mm Hg. Evaluation and Assessment of BP Predonation Screening for HTN in potential donors should include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated.
If BP is determined to be high, or high normal, then BP should be evaluated with ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements.
Preexisting Hypertension in Kidney Donor Candidates
Some transplant centers are relaxing their selection criteria to include donors
with well-regulated hypertension
Donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension. Yet, the available studies are of short duration, and there are phenotypes, such as obese,
or people with African heritage who may be at more risk, and genotypes such as APOL1 which may confer more risk over time. Development of Hypertension in Kidney Donors Postdonation
It is important to keep these risk factors (African American and Hispanic descent, BMI, and age) in mind when evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation. Management of BP and Hypertension Postdonation in Living Kidney Donors
Early after donation, it is suggested to allow BP (<160/90 mm Hg) to be elevated to allow for optimal kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
Long-term control of BP in kidney donors depends on the individual patient and lifestyle changes (weight control, modest dietary sodium reduction and regular exercise, smoking avoidance, and modest alcohol intake). They should also receive proper education on taking home BP for self-BP monitoring and management.
The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of postdonation follow-up care. Hypertensive living kidney donors should:
i. Be followed more frequently
ii. Have regular BP, laboratory, and urinary albumin: creatinine ratio tests conducted.
iii. Have their other cardiovascular risk factors well controlled. CONCLUSIONS
Currently, some of the guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, hypertensive donors do not seem to be at a significantly increased risk of developing renal or CVD.
Another concern for living kidney donors is the possibility of developing HTN after kidney donation, especially if they are younger, overweight, or of African heritage.
Studies have shown that in healthy, well-selected donors with no known
risk factors, living kidney donation does not signifcantly predispose them to developing HTN postdonation; however, certain risk factors, such as being African American or Hispanic, obese, or older, are associated with higher likelihoods of developing hypertension postdonation.
Personalized pharmacotherapy along with beneficial lifestyle changes and more follow-up appointments should be utilized to manage BP and HTN after kidney donation.
Abdullah Raoof
2 years ago
Q1- Please summarise this article in your own words.
Abstract
The guidelines state that a BP >140/90 mm Hg with 1–2 AHM or evidence of end-organ damage to be excluded from living kidney donation.
But , the definitions of “hypertension” have changed according to American guidelines suggesting that 120–129 mm Hg is elevated BP and Stage 1 hypertension is 130 mm Hg.
There is a fact that the kidney function (eGFR) of “hypertensive” donors does not significantly worse postdonation compared to that of “normotensive” donors and the kidney donation itself is not considered to be a risk factor for developing hypertension, but other risk factors play a role (African American or Hispanic descent, obesity, age).
The choice of BP targets and medications should be individualized. In general, a BP target of <130/80 mm Hg is needed, with lifestyle modifications.
In general there is an increase in the numbers of ESRD patients but with adecrease in donor pool , this usually because of the high prevelance of disease in donors like HT,DM , renal impairment . Current Living Kidney Donation Guidelines
Previously high BP considered as a contraindications to kidney donation.
Although the new BP guideline has changed according to ACC/AHA,
the definitions also are changed
Elevated BP is 120–129 mm Hg systolic and
Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg.
Even though the most guidelines concerns about donors with systolic BP >140 mm Hg, although some raised questions about systolic blood pressure >130 mm Hg, especially in younger donors.
SPRINT demonstrated that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events but SPRINT study does not provide evidence that lower systolic pressure goals are important in delaying the progression of kidney disease.
Evaluation and Assessment of BP Predonation
screening should include BP measurement on 2 separate occasions ( by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated ).
If BP is high, or high normal, if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with (ABPM) .
In the past , a BP >140/90 mm Hg and/or use of (AHMs) was considered as contraindications to donation. However, patients with easily controlled hypertension with 1 or 2 agents and no evidence of target organ damage may be accepted as low-risk kidney donors.
The KDIGO working group report of 201711 suggested that potential donors with hypertension should be individualized should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy. , especially if they are overweight or have African ancestry. Preexisting Hypertension in Kidney Donor Candidates
more transplant centers are relaxing their selection criteria to include donorswith well-regulated hypertension in response to decreasingsupply of donor organs .
Kiberd noted that a 5-mm Hg increase in systolic BP had a very small effect on ESRD risk compared with other factors, such as increased proteinuria or reduced GFR.
In summary, donors with well-controlled BP (BP <140/90 controlled with 1–2 AHM and no evidence of target organ damage) seem to be at minimal risk of develop ing worsening kidney function or hypertension, Development of Hypertension in Kidney Donors Postdonation
although kidney donation leads to physiological alterations (kidney hyperfiltration, upregulation ofrenin-angiotensin-aldosterone system, and changes in vascular tone) that may elevate BP, it is not considered to be a risk factor in developing hypertension postdonation.
Study by Kim et al study the long-term risk of hypertension in living kidney donors and found that there was a statistically significant increase in BP postdonation, with 21% of the donors developing hypertension that required AHM use. However, the increase in BP was from 113/75 to 116/77 mm Hg .
A study Thiel et al by suggests that kidney donation itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP .
In One study Hypertension was identified in 41% of African American donors compared with 30% of Caucasians. African American and Hispanic donors are at about a 50% increased relative risk of developing hypertension post donation.
Current consensus guidelines have contraindicated donors with a BMI >30–35.
obese donors (BMI >30) had higher mean systolic and diastolic BPs than non obese donors. studies have also shown that hip-to-waist ratio may be a more sensitive prognostic for determining health outcomes than BMI.
In summary, it is important to keep these risk factors (African American and Hispanic descent, BMI, and age) in mind when evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation. Management of BP and Hypertension Postdonation in Living Kidney Donors
Early after donation, to allow BP (<160/90 mm Hg) to allow kidney perfusion, which can be controlled by calcium channel blocker or clonidine .
Long-term control of BP in kidney donors should be individualized . Townsend et al recommend that ACEI , ARBS , and diuretics should be avoided perioperatively .
The KDIGO Guidelines suggest that proper BP measurements should be performed annually , or more frequently in Hypertensive living kidney. Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
Office readings needs
· patient will rest 5 minutes before readings are conducted.
· BP should be measured with a properly sized BP cuff.
· The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading.
If there are additional concerns , then ABPM will be considered.
Based on the ACC/AHA guidelines,
· if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation.
· If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage or is taking >2 antihypertensive medication,
then they should be excluded from kidney donation.
In the absence of any available clinical data, we raise concern about patients with an average office BP reading ≥130/80mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive
medication, who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women as obesity has been shown to be a risk factor for ESRD.
They should have an ABPM and preferably try to lose some weight.
· If the patient’s 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation.
· If the patient’s 24 hour ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight.
The author suggest maintaining post donation clinic BP ≤130/80 mm Hg .
Q2- What is the level of evidence provided by this article?
Level of evidence – 5
amiri elaf
2 years ago
# Please summarise this article in your own words
# The objective:
*This study, estimate the recent living kidney donation guidelines with respect to “HTN,” the impact of living kidney donation on HTN donors, the risk of and factors contributing to the development of “HTN” postdonation in normotensive donors, and medical and lifestyle management of BP in living kidney donors.
#Current Living Kidney Donation Guidelines
High BP has long been considered as contraindications to live kidney donation, but the risks of donation in mild, well-controlled HTN are not well clarified.
*With the curent release of the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA, the definitions of HTN have been revised. Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg.
*The implications of these new guidelines on other published guidelines regarding kidney donation and HTN remain to be seen.
*The SPRINT clearly conducted that a lower BP goal (<120/80 mm Hg) was associated with a low cardiovascular events in a population with a mean age of 68 years, no evidence of DM, and e -GFR 72 mL/min/1.73 m2.
* Thus, kidney donors might need lower BP targets, especially if they are younger, obese, or have African ancestry.
# Evaluation and Assessment of BP Predonation
*The BP measurement accurately on 2 separate occasions by clinical staff, with equipment that has been calibrated.
* If BP is high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with (ABPM) or repeated with standardized BP measurements.
*The KDIGO working group report of 201711 suggested that potential donors with hypertension should be individualized in relation to the transplant programs, the donors should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
*So we can add that this is also a concern in younger donors, especially if they are overweight or have African ancestry, or both.
# Preexisting Hypertension in Kidney Donor Candidates
*Some studies have found that donors with predonation HTN have a decline in kidney function, while others have maintained that there is no significant difference in kidney function between normotensive and hypertensive donors.
*The discrepancy between these studies could be explained by the variance in follow-up length, study population, hypertension definitions, and sample size.
*In summary, donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension.
# Development of Hypertension in Kidney Donors Postdonation
*The risk factors (African American and Hispanic descent, BMI, and age) should be consider when evaluating potential living kidney donors, as they seem to pose a higher risk of developing HTN and other long-term medical complications as a result of donation.
*Donors with risk factors for hypertension may require earlier and more intensive strategies to control BP.
# Management of BP and Hypertension Postdonation in Living Kidney Donors
*Early after donation, to allow BP (<160/90 mm Hg) and to allow for optimal kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
*Townsend et al recommend that ACEI,ARBs, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
*Lifestyle changes are important (wt control, modest dietary sodium reduction and regular exercise, avoidance smoking and alcohol intake).
*The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of postdonation follow-up care laboratory, and urinary albumin:creatinine ratio tests conducted.
# Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
*Based on the current literature, the suggestion are:
Office readings should be carried out at rest 5 minutes before readings are conducted. The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading.
*If the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation.
* If the average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.
*If the average office BP reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive medication, who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women as obesity has been shown to be a risk factor for ESRD they should have an ABPM and preferably try to lose some weight.
* If the 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation. If the ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight; when their BP becomes <125/75 mm Hg on a subsequent 24 hour ABPM reading or over multiple office measurements, they could then be reevaluated for living kidney donation.
# What is the level of evidence provided by this article?
*The level of evidence is 5
Alaa eddin salamah
2 years ago
Despite all the advantages and potential of living kidney donation, since 2004 there has been a general fall in the number of such donations.
Increased likelihood of negative outcomes for both kidney transplant recipients and living kidney donors makes elevated blood pressure (BP) one of the most common exclusion criteria for living kidney donation.
Potential donors should have their blood pressure checked twice to check for hypertension by clinical staff that has been trained to measure blood pressure reliably and with calibrated equipment.
In the past, antihypertensive drug use or a blood pressure level more than 140/90 mm Hg were regarded as contraindications to donation. On the other hand, low-risk kidney donors may be accepted in some cases for patients whose hypertension can be effectively managed with one or two medications and who show no signs of target organ damage.
Although some studies have found a decline in kidney function in predonation hypertensive donors (as shown by rising serum creatinine and falling estimated GFR), other studies have maintained that there is no appreciable difference in kidney function between normotensive and hypertensive donors.
Donors with well-controlled blood pressure (BP 140/90 controlled with 1-2 antihypertensive drugs and no signs of target organ damage) appear to be at low risk of developing worsening kidney function or hypertension, supporting their inclusion in, and consequent expansion of, the living kidney donor pool. However, the studies that are now available are of limited duration, and there are phenotypes, such as obesity or people with African ancestry, as well as genotypes, such as APOL1, that may increase risk over time.
When assessing potential living kidney donors, it’s crucial to keep these risk variables in mind because they seem to pose a higher chance of developing hypertension and other long-term medical issues. These risk factors include age, BMI, and people of African American and Hispanic heritage.
This is a narrative review (level 5 evidence)
rindhabibgmail-com
2 years ago
It was discussed with evidenced from different guideline(AHA/ACC, SPRINT) that the pre donation hypertension, American African donors, obesity, BMI >30, and APOL1 gens are at higher risk developing hypertension post donation.
The new definition of hypertension has changed now >129/79 systolic is stage 1 hypertension, and hypertension is one of the main exclusion criteria for living donation.
Those with higher waist (male >94, female >80) BP at three different occasion higher then 140 systolic are at higher risk of developing hypertension post donation. so its strongly advised to reduce wait, BP control with lifestyle modification, and single medication can be individualized for donation.
level of evidence 5
Eusha Ansary
2 years ago
Summary:
Hypertension is one of the main exclusion criteria for living kidney donation, as it is a risk factor for renal and cardiovascular disease.
The effect of elevated BP in living kidney donors is not well studied or understood.
The most current living kidney donation guidelines advocate donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation.
Though, the definitions of “hypertension” have changed with the release of the American Heart Association (AHA)/American College of Cardiology (ACC) clinical practice guidelines suggesting that 120–129 mm Hg is elevated BP and Stage 1 hypertension is 130 mm Hg.
However, the kidney function of hypertensive living kidney donors does not fare significantly worse post donation compared with that of normotensive donors.
In addition, even though living kidney donation itself is not considered to be a risk factor for developing hypertension, there exist certain risk factors African American or Hispanic descent, obesity, age.
The choice of BP targets and medications needs to be carefully individualized.
Level of evidence: 5
Giulio Podda
2 years ago
Please summarise this article in your own words
Hypertension,” is one of the main exclusion criteria for living kidney dona- tion. The effect of hypertension in living donors is not known. Hypertension is a risk factor for renal and cardiovascular disease. Donors with a BP >140/90 mm Hg with 1–2 antihypertensive drugs or evidence of end-organ damage should be excluded from living donation (as per guidelines). According to the American Heart Association (AHA)/American College of Cardiology (ACC) a BP 120–129 mm Hg is an elevated and a BP of 130 mmHg is considered stage 1 hypertension.
Some studies have shown that donors with pre-donation hypertension have a decline in kidney function while others have demonstrated no significant difference in kidney function between living donors with normal BP and donors with hypertension. However, the majority of the studies have shown that after the donation the kidney function of the living donors with hypertension does not progress significantly compared to the living donors with a normal BP. Moreover, there are factors which increase the risk of developing hypertension in living kidney donors with normal BP after donation, such as obesity, age and ethnicity (African American or Hispanic descent). Obese donors were more likely to have pre-donation hypertension and each increase in the year of donor age was associated with a 5%–7% higher likelihood of hypertension. BP less than 130/80 mmHg is considered acceptable together with lifestyle adjusted to the individual.
What is the level of evidence provided by this article
This is a review article (Level 5)
Theepa Mariamutu
2 years ago
This review article { Evidence level V} explores the hypertension and intervention prior to transplant.
Hypertension is one of exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both recipients and donors.
Current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded.
The impact of hypertension on donor has not been as well studied. The definitions of “hypertension” are variable depending on the guidelines.
Current LKD Guidelines
Risks of donation in mild, well-controlled “hypertension” are not well understood and most transplant centres adhere to their own standards when evaluating for hypertension in living donors
2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA, elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg
SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events in a population with a mean age of 68 years, no evidence of diabetes, and an estimated glomerular filtration rate (GFR) of approximately 72mL/min/1.73 m2 . mean GFR in the SPRINT study participants of ~70mL per minute is not different than observes in donors.so, kidney donors might need lower BP targets, especially if they are younger, overweight, or have African ancestry.
Evaluation and Assessment of BP pre-donation
Blood pressure in donors include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated.
If BP is determined to be high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ABPM or repeated with standardized BP measurements
Armanyous et al using daytime ABPM as a gold standard found a 16% prevalence of hypertension in kidney donors.
KDIGO WG report suggested that donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counselled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
Pre-existing Hypertension in Kidney Donor Candidates
Transplant centres are relaxing their selection criteria to include donors with well controlled hypertension.
Observational studies of hypertensive donors have shown heterogeneous results, Some studies found that donors with predonation hypertension have a decline in kidney function ,while some ither studies showed no significant difference .
The discrepancy between these studies could be explained by the variance in follow-up length, study population, hypertension definitions, and sample size.
Observational study of 24 533 older donors (≥50 y of age), including 2265 with predonation hypertension, demonstrated that older donors with hypertension had a higher risk of ESRD but not mortality for 15 years after donation.
It is suggested that donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at negligible risk of developing worsening kidney function or hypertension.
Kidney donation leads to physiological alterations (kidney hyperfiltration, upregulation of RAAS, and changes in vascular tone)
Studies done with follow-up for short period didn’t find significant increase in bp post donation
it was suggested that LKD itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP includes obesity, African American, smoking, older age.
Current consensus guidelines have contraindicated donors with a BMI >30–35. Lentine et al confirmed that obese donors were more likely to have predonation hypertension and each increase in year of donor age was associated with a 5%–7% higher likelihood of hypertension.
Study also demonstrated that the frequency of hypertension increased by 10% for each 1-unit increase in BMI, with higher BMI being associated with higher rates of hypertension 5 years post nephrectomy.
obese donors (BMI >30) had higher mean systolic and diastolic BPs than nonobese donors, leading to a significant increase in ESRD risk.
Management of BP and Hypertension Postdonation in Living Kidney Donors
Early after donation, it is suggested to allow BP (<160/90 mm Hg) to be elevated to keep kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
Townsend et al recommend that ACEi, ARB, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
KDIGO suggest that proper BP measurements annually as part of postdonation follow-up care.
Hypertensive living kidney donors should be followed more frequently than the average, normotensive donor and to have regular BP, laboratory, and urinary albumin: creatinine ratio tests examined.
When There is concerns about donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered, and measurements take place every 15– 30 minutes during the daytime and 30–60 minutes at night for 24 hours with measurements.
ACC/AHA guidelines stated that if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation
If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as LVH, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.
Huda Al-Taee
2 years ago
Please summarise this article in your own words
Current Living Kidney Donation Guidelines:
With the recent release of the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA, the definitions of hypertension have been revised. The implications of these new guidelines on other published guidelines regarding kidney donation and hypertension remain to be seen.
SPRINT study does not provide evidence that lower systolic pressure goals are important in delaying the progression of kidney disease.
Evaluation and Assessment of BP Pre-donation:
Screening for hypertension in potential donors should include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated.
If BP is determined to be high or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ambulatory BP monitoring.
Pre-existing Hypertension in Kidney Donor Candidates:
Observational studies of hypertensive donors have produced conflicting results. Some studies have found that donors with pre-donation hypertension have a decline in kidney function (evidenced by increasing serum creatinine and decreased eGFR while others have maintained that there is no significant difference in kidney function between normotensive and hypertensive donors.
Development of Hypertension in Kidney Donors Post-donation:
Physiological changes that happened post-donation are not considered a risk factor for HTN post-donation.
There may be an inherent factor that may contribute to the development of elevated BP aside from living kidney donation.
Pre-hypertension is a risk factor for post-donation HTN.
African American and Hispanic donors are also at about a 50% increased relative risk of developing HTN post-donation.
Obese donors were more likely to have pre-donation hypertension and each increase in the year of donor age was associated with a 5%–7% higher likelihood of hypertension.
Management of BP and Hypertension Post-donation in Living Kidney Donors:
personalized medication regimen.
positive lifestyle changes
proper education on taking home BP for self-BP monitoring and management.
What is the level of evidence provided by this article
Level 5 ( review article ).
Rahul Yadav rahulyadavdr@gmail.com
2 years ago
Please summarize this article in your own words
This review explores current guidelines of Live related kidney transplant with respect to Hypertension in Donors, impact of kidney donation on Hypertensive donors, contributory factors of post donation Hypertension in Normotensive donors and lifestyle management to control BP in living kidney donors
Suggestions/Considerations made by Authors:
BP recording:
a. Office BP recording: Rest for 5 mins and average of 3 readings at 1 min gap each.
b. Ambulatory 24-hour BP measurement: Day recording every 15-30 mins and night recording 30-60 mins in 24 hours.
Consider ABPM in following subsets of patients
i. if BP≥130/80 on averaged office readings
ii. Obese patient
iii. African or Hispanic descent
iv. Use of 1 or 2 Anti-hypertensive drugs
v. Obstructive Sleep Apnea
Consideration for Donor selection with respect to BP:
· If office readings/24 hours ABPM <130/80, consider for donation.
· If office/24hour ABPM ≥ 130/80 but <160/100, taking ≤ 2 Antihypertensives(AHT), OSA, African/Hispanic Descent and Obese, advise lifestyle and Pharmacological interventions and should be revaluated for live kidney donation if 24 hour ABPM becomes < 125/75.
· If office reading>160/100, End-organ Damage (LVH, Albuminuria, Hypertensive retinopathy), use of 3+ AHT, exclude from Donor’s list.
Management of BP and Hypertension Post donation:
· Early after donation, elevated BP (<160/90) allowed for optimal kidney perfusion and filtration
· Preferred AHTs are short acting and selective (CCB or clonidine)
· Avoid ACEI, ARB, Diuretics perioperatively due to adaptive hyperfiltration and expected shifts in volume.
· BP measurement and Urine Albumin: Creatinine ratio annually
· Educate for Positive Lifestyle changes:
o Weight management
o Exercise Regularly
o Modest sodium reduction in diet
o Avoid smoking
o Modest Alcohol Intake
o Proper education on measuring home BP for self-Monitoring
What is the level of evidence provided by this article?
It’s a Review article and level of evidence in 5.
Ahmed Omran
2 years ago
Review article level 5 Summary:
Hypertension is a contraindication for donation as it is associated with poor outcome for donor and recipient. SPRINT show that low blood pressure <120/80 was associated with less CV events in elderly without DM and eGFR ~70ml/min/m. The mean of eGFR in SPRINT was approximate to kidney donor so the donor may need to have lower blood pressure level especially if they are young aged , over weight or African .BP should be estimated properly in different 2 occasions.
KDOGO guideline suggest that acceptance of donor with hypertension should be individualized following transplant program acceptable risk profile threshold and donor information regarding risk of acceleration of hypertension and need for more anti-hypertensive medications.
Studies showed conflicting results of outcomes of LKD with pre-existing hypertension. Some showed deterioration of renal function after donation while others showed maintained normal renal function with non significant differences between normotensive and hypertensive donors. This could be explained by variability in follow up duration , population, hypertension definition and sample size.
LKD can cause hyperfiltration, up-regulation of RAS system in addition to change in vascular tone, which can lead to development of hypertension. Several studies showed that SBP & DBP can be increased slightly post donation but insignificantly when compared to control. The risk of HT development post LKD increased with risk factors as African American descend( APOL1 diversity), obesity and elderly.
Early post donation, it is better to maintain blood pressure <160/90 for adequate kidney perfusion with selective short acting drugs as CCB or clonidine.
Long term BP control relies on individual factors and co-morbidities.
BP evaluation:
_Office reading of average BP<130/80 on 3 occasions is considered suitable for donation. BP equal or more than160/100, signs of end organ damage or use >2 antihypertensive drugs not to proceed for donation. Post donation target is equal or less than 130/80. AMBP: if BP >130/80 but <160/100, on more than 2 antihypertensive medications, OSA, African American descent, waist >96cm(male) or >80cm(female) not to donate. If AMBP <125/80 precede with donation but if >125/80 control BP with drugs and ABPM repeated.
Marius Badal
2 years ago
III. Blood Pressure and Living Kidney Donors: A Clinical Perspective
Please summaries this article in your own words
Hypertension has been a challenge and an issue for many pathologies and continues to be. It causes cardiovascular diseases and other complications. It is no difference when it comes to kidney transplantation. It is still a current issue and can be contraindication for kidney transplant. There are guidelines that is being created to help to control BP and allow kidney transplantation. The definition of hypertension is BP reading of greater than 140/90 mmHg. So due to the number of patients with kidney failure, the donor pool needs to be increased, and as such, donor with mild HTN and on mono therapy or two AHM with no end organ failure then the patient can be a donor. Individuals must follow the guidelines especially if the pressure is elevated or high, overweight, based on ethnic group, etc. Most guidelines concerned about BP greater than 140/90 and others especially in young donor a BP greater than 130 mmHg. Based on the AHA/ACC, BP in this range 120-129 systolic and stage 1 HTN 130-139 are considered elevated. Based on SPRINT a BP lower than 120/80 should be the goal. Once the donor is decided to donate, he or she must be evaluated to ensure that: 1) The blood pressure of the potential donor must be measured on 2 separate occasions. 2) To ensure BP is determined to be high or high normal, ABPM should be considered especially in patients who are overweight, younger age and ethnic group especially the black race, 3) Blood pressures that is controlled on one or two medications with no end organ damage, is considered low risk kidney donors. There have been studies, that has shown discrepancy and contradiction as it regards to HTN and in LKD. Some studies have proven that pre donation blood pressure has related to decrease in kidney function while others do not prove the same. Once the patient has been transplanted, there can be appearance of HTN post transplantation. The blood pressure post-transplant depends on: 1) Alteration of kidney physiology that is related to hyper filtration, upregulation or renin angiotensin aldosterone system. 2) There has been studies that shows increase of blood pressures post donation but fails to compare their study population with age matched control and an increase in BP was from 113/75 to 116/77 mmHg. 3) There was a poor donor size. 4) The follow up percentage was small. There are certain risk factors for elevated BP post-donation and they are: 1) African and Hispanic 2) Obesity 3) Older donors or elderly 4) Genetic Once the patient has BP and HTN post donation, it must be monitored and treated. In situation like: 1) Post donation the BP must try to maintain a BP less than 160/90 to allow proper kidney perfusion. 2) Individuals with high risk of BP their pressure needs to maintain low 3) Treatment for BP must be individualized 4) Proper patient education must be considered 5) Guidelines like KDIGO ensures that BP be monitored annually. The suggested BP for living donors are as follows: 1) Resting period before BP is taken 2) A reading of more than 3 times and a BP of less than 130/80 is considered adequate for transplantation 3) Patients with elevated pressure greater than 160/90, organ damage and is taking more than 2 antihypertensive medications is not to be considered. 4) A blood pressure of 125/75 is accepted if ABPM is used.
What is the level of evidence provided by this article?
The article reviewed is a level 5.
Nandita Sugumar
2 years ago
Summary : a clinical perspective of blood pressure and living kidney donor
This article is about a crucial and recurrent theme among live donors, i.e., prevalence of hypertension. Hypertension in certain conditions becomes an exclusion criteria for donors.
Living kidney donation guidelines indicate that donors with well controlled BP under 140/90 mm Hg with 1-2 anti-hypertensive medications with no evidence of end organ damage. If not, the donor should be excluded from live donation.
Certain characters can become risk factors for hypertension in the donor. These include :
African American descent
Hispanic descent
Obesity
Age
Lifestyle modifications form an important part of management in these donors. These modifications include :
control of weight
reduction in dietary sodium consumption
smoking abstinence lifelong
reduced or modest alcohol consumption
regular exercise 3-5 days every week
self monitoring of BP and recording it
Regular follow up
Level of evidence
This is a narrative review, and thus level of evidence is 5.
abosaeed mohamed
2 years ago
– Studies have shown that recipients who received allografts from living donors survive longer and perform significantly better than those who received grafts from deceased donors.
– Elevated blood pressure (BP) is one of the leading exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both kidney transplant recipients and living kidney donors alike
– Despite hypertension affecting both kidney recipients and donors, the impact of hypertension on the latter has not been as well studied and understood. The definitions of “hypertension” are variable depending on the guidelines. The definitions have also evolved over time. If one were to define “hypertension” as that level of BP in which the benefits of treatment outweigh the risks of inaction, then one could more appropriately individualize the care plan. For kidney donors, this is the clinical conundrum: how best to assess this balance between BP and long-term outcome
– In this review, we will examine the current living kidney donation guidelines with respect to “hypertension,” the impact of living kidney donation on “hypertensive” donors, the risk of and factors contributing to the development of “hypertension” postdonation in normotensive donors, and medical and lifestyle management of BP in living kidney donors. Understanding “hypertension” in living kidney donors will improve not only patient education during the donor recruitment process but also patient care postdonation. With this knowledge, it may be possible to delineate more specific and standardized guidelines for living kidney donation, which may very well be what we need to narrow the gap between the supply and demand for living kidney transplants
Current Living Kidney Donation Guidelines
– Elevated bl.p. is one of the exclusion criteria for kidney donation .
– Many guidelines like KDIGO , excluding donors with bl.p.>140/90 with 1-2 anti hypertensive medications or evidence of end organ damage, however , Each centre is adhering to his limit of bl.p.
– The new ACC/AHA guidelines defines elevated bl.p. : 120-129 systolic &
stage 1 Hypertension : 130-139 / 80-89 .
– The SPRINT trial clearly demonstrated that lower bl.p. goal < 120/80 is associated with low cardiovascular events in population with no evidence of diabetes , aged 86 ys & eGFR approximately 72 ml/m
– Based on this data , may be a reason to believe that lower bl.p. target in kidney donors is needed especially if young , obese or African ethnicity
Evaluation and Assessment of BP Predonation
– Bl.p. measurements in 2 separate occasions with trained persons with calibrated equipments , if bl.p. < 130/80 , none obese & no African heritage >>can proceed for transplantation
– Otherwise , if bl.p.>130/80 especially in younger or obese or African heritage >>then 24 hrs ambulatory bl.p. monitoring should be considered .
– Patient with easily controlled hypertension with 1-2 medications with no end organ damage like LVH or albuminuria , can be considered for donation .
– Kdigo 2017 suggested that hypertensive donors should be individualized as case by case & as per centre acceptable risk profile & tat they should be counselled that donation may accelerate theier hypertension or increase need for anti hypertensive medications & here we can add special concern regarding younger , obese & African heritage donors .
Preexisting Hypertension in Kidney Donor Candidates
– Data may be conflicting if pre hypertensive doors is at increased risk of rapid GFR decline , reaching ESRD or worsening of HTN .
– In summary of many results , easily controlled hypertension with bl.p. < 130/80 on 1-2 AHM with no EOD carry low risk but special concern should be given in younger , obese & African heritage .
development of Hypertension in Kidney Donors Postdonation
– Again the studies are giving avconflicting data regarding increased risk of developing post donation HTN between that showing no difference between donors & the control groups & others showing increased risk of developing HTN post donation .
– But there are risk factors should be kept in mind for increasing the risk which are ypunger , obese ( BMI >30 ) , African heritage ( donors with 2 APOLI 1 variants carry high risk ) .
Management of BP and Hypertension Postdonation in Living Kidney Donors
– Early post donation : highr target is better < 160/90 , to allow optimal kidney perfusion , can achieved using short acting drugs like CCB or clonidine .
– ACE I , ARBS , diuretics should to be avoided perioperatively due to hyperfiltration & expected shift in volume .
– Life style modifications , low salt diet , regular exercise , avoid smoking & alcohol & regular monitoring of BL.P at home & at regular visits post donation with follow up of alb./cr. Ratio & control of other CV risk factors should be obtained .
Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
This literature suggest that :
1- Office bl.p. measurement for all donors ( after 5 minutes rest with calibrated equibment , 3 readings with 1 minute rest in between each & average of these readings ) >>if bl.p. < 130/80 can be considered for donation .
2- If office bl.p. > 160/100 , EOD ( LVH or albuminuria) or use of 3 or more AHM >>>should be excluded from donation .
3- If bl.p. > 130/80 or obese ( BMI >30 , waist circumference > 94 cm in males or > 80 cm in females ) or African heritage or obstructive sleep apnea , then ABPM should be obtained
4- If ABPM < 130/ 80 ( even after weight loss or 1-2 AHM ) so can be considered for donation .
5- Special concern for younger , obese & African heritage should be given
level of evidence >> level 5
Ramy Elshahat
2 years ago
This is a review study (level of evidence V) discussing the risk of hypertension post-donation. Hypertension is one of the common contraindications of kidney donation, but the definition of Hypertension and the best method for measuring BP is still there is no standardization and it differs from one center to another.
· Caring for Australasians with Renal Impairment (CASI), British Transplantation Society (BTS), Canadian Council for Donation and Transplantation (CCDT): exclude donors with blood pressure >140/90 mm Hg on 3 occasions.
· European Association of Urology (EAU), European Best Practice Guidelines (EBPG): exclude donors with uncontrolled hypertension. · Organ Procurement and Transplantation Network (OPTN): exclude donors with blood pressure >130/85 mm Hg (in donors>50 y old). Measurement of BP There are 3 main methods for evaluation of BP 1. Office blood pressure (OBP): 1st patient will rest 5 minutes before readings then BP should be measured with a properly sized BP cuff by well-trained staff. The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading. 2. Home blood pressure monitoring (HBPM): recording at least twice the daily average of two home blood pressure readings over a minimum of 4 days.HBPM is better correlated to 24-h ABPM, and superior to OBP when predicting hard outcomes 3. Ambulatory 24h blood pressure monitoring (ABPM): considered the best way the evaluation of BP and showed a better correlation with clinical outcomes. Best it’s not the standard practice in donor evaluation as its expensive butABPM should be considered If there are concerns about a potential donor’s BP or younger age, overweight, or African heritage, and measurements take place every 15–30 minutes during the daytime and 30–60 minutes at night for 24 hours Suggestions for Living Kidney Donor by the author: · Evaluation with Respectto OBPreadings should be carried out as recommended
If the average office BP reading is <130/80 mm Hg: donation is accepted
If the average office BP reading is ≥160/100 mm Hg or evidence of end-organ damage or is taking >2 antihypertensive medications: donation is not allowed.
· Evaluation with Respectto ABPM is indicated for patients (in the gray zone) with
patient with an office BP ≥130/80 mm Hg but <<160/100 mm Hg
Patients on 2 or fewer medications
Patients with African heritage
patients were high BMI or has a waist circumference of ≥94cm for men and ≥80cm for women
If the patient’s 24-hour ABPM reading is ≥125/75 mm Hg, they should afford pharmacological and non-pharmacological lifestyle management and when their BP becomes <125/75 mm Hg in 24-hour ABPM follow-up: donation can be allowed otherwise donation is not allowed. Management of BP and Hypertension Post-donation -all living kidney donors should make lifestyle changes like weight control, dietary sodium reduction, regular exercise, smoking cessation, and decreased alcohol intake to decrease the risk of development of post-donation hypertension. -They should also receive proper education regarding self- BP monitoring and proper BP measurements should be performed annually as part of post-donation follow-up care. -if pharmacological intervention is needed: ACEi, ARBs, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume. risk factors for developing post-donation hypertension such as
African American or Hispanic: 2.4 folds higher risk for development of hypertension post donation than Caucasian.
Obesity: the incidence of HTN post donation increase around 10% for each unit increase in BMI.( hip-to-waist ratio may be a more sensitive prognostic for determining health outcomes than BMI)
Higher BP before donation.
Older.
Wael Jebur
2 years ago
This review study was conducted to assess the potential influence of donor hypertension severity on suitability for donation and the consequent effect of donation on the donor hypertension.
It’s a telling truth that expanding the living donor pool effort was facing an ever-increasing difficulty, leading to massive limitation of Kidney transplantation rate and enlarging the waiting list. In order to overcome this hurdle and increases the living donor pool, one of the possible options, was to loosen the criteria for selecting the suitable donors. Hypertensive patients were always an accessible pool for kidney donation, and the criteria for selecting the hypertensive donors was expressing number of changes over the recent years with conflicting data on the suitability for donation and the potential consequences on hypertension progress thereafter.
definition of hypertension was changed recently, and the ACA noticed a blood pressure limit of 130/80 as stage 1 hypertension. Prior guideline defined hypertension as 140/90.
The hypertensive donors were categorized as acceptable living donors if they meet certain features including:
Blood pressure less than 140/80
No end organ damage.
On 2 anti-hypertensive medications maximum.
Hypertensive patients are at an escalating risk of renal and cardiovascular disease, therefore donating kidneys are theoretically linked to this hazard and proper selection is crucial. The landmark SPRINT study revealed improved cardiovascular outcome with blood pressure limit below 120/80. However, there was no renal assessment and outcome with this level of blood pressure control. Nevertheless, some transplant centers advocated the cut off 130/80 as a baseline blood pressure for kidney donation.
Several studies investigated the long-term effect of kidney donation on hyper with conflicting results. Special patients’ categories, such as African American, Hispanic, obese, old age and those with APOL 1 genotype are prone to have progressed hypertension post donation, even when its within normal range before transplantation.
Early blood pressure reaction post donation is usually elevated due to activation of RAAS system and vascular changes, which will be normalized thereafter.
Of note, as highlighted by more than one study is to avoid RAASi post transplantation, to improve the renal perfusion and support renal function. My conclusion for this review article, is that each patient has to be taken as per his own merits, looking at him holistically in a way that in addition for having well controlled blood pressure without end organ damage, obesity, ethnicity and age have to take a very important part in deciding upon proceed with a hypertensive kidney donation.
Filipe prohaska Batista
2 years ago
This is a Narrative Review – Level 5
It is a study to evaluate blood pressure intervention in living kidney donor patients. The objective is to evaluate the impact of hypertension on the organ donor and its evolution over time. Despite several different protocols around the world, some similarities can be discussed, especially in young, overweight patients with African ancestry.
In these higher risk patients, the need for continuous outpatient measurement is more indicated.
Higher blood pressure, use of antihypertensive drugs prior to transplantation and target organ damage decrease the chance of organ donation, increasing the need for monitored outpatient evaluation and pre-transplant care.
However, blood pressures controlled with one or two antihypertensive drugs can be included as donors by expansion criteria.
Expected relative risk for those of African ancestry is 50% for hypertension after donation, likely due to a higher frequency of MYH9 and APOL1 at the Chromosome 22 loci, increasing focal segmental glomerusclerosis, nephropathy, and kidney disease. Even those with two APOL 1 variants have a high risk of rejection in recipients.
Another important risk factor is obesity, especially with a BMI greater than 30 or 35.
The appropriate choice of antihypertensive drug and the best time (avoiding diuretics in the perioperative period, for example) are important to minimize the risk of kidney damage, and consequently, organ rejection for the recipient and induction of hypertension for the donor.
For these reasons, donor counseling is essential, emphasizing the need for metabolic control (glycemia, weight, dyslipidemia, albuminuria), blood pressure control (values below 130 x 80), pre and post transplant care. Blood pressure monitoring and drug intervention when necessary should be performed.
Amit Sharma
2 years ago
Please summarise this article in your own words
Kidney transplant with a living donor is the best form of treatment for patients with ESRD. The article deals with living kidney donation guidelines with respect to hypertension, the impact of donation on hypertensive donors, the risk of hypertension development post-donation, and the management of hypertension in renal donors.
Living kidney donation guidelines with respect to blood pressure:
According to most guidelines, high blood pressure or hypertension is a contraindication for donation if the BP is more than 140/90 mm Hg on 1-2 antihypertensives or is associated with target-organ damage.
SPRINT trial concluded that BP<120/80 in patients with eGFR~70 ml/min reduced cardiovascular events. The GFR post-donation is similar to the SPRINT study participants, hence extrapolating those results, a renal donor should have target BP of <120/80.
BP assessment prior to donation:
BP should be measured by well trained staff using well calibrated instruments on 2 separate occasions (average of 3 readings, 1 minute apart and after 5-minute rest). If BP is found high (>130/80), and the donor is young, overweight or African-American, or if the donor has obstructive sleep apnea, increased waist circumference (>94 cm in males and > 80 cm in females) or uses 1-2 antihypertensives, then Ambulatory BP monitoring (ABPM) should be performed. The donor can be allowed to donate only if ABPM is within normal limits (BP<125/75). If 24 hour ABPM is high, pharmacological and non-pharmacological interventions including losing weight should be undertaken and once BPis <125/75, the donor should be reassessed.
KDIGO guidelines suggest individualization of donor evaluation with respect to hypertension and counselling regarding rise of BP and increased requirement of anti-hypertensives post-donation should be done.
Pre-existing hypertension in living kidney donor:
The study of impact of hypertension on kidney donation has shown conflicting results with some studies showing deterioration in renal function post-donation while others did not show any such decline, mainly on account of short-term follow-up and unrepresentative patient population. Overall, donors with well controlled BP (<140/90) on 1-2 antihypertensives and no target organ damage have been shown to have minimal risk of developing renal function worsening or hypertension, but there is increased risk in obese, African-Americans and those with genotype APOL1.
Hypertension development post-donation:
Hyperfiltration, upregulation of RAAS and changes in vascular tone may increase BP post-donation. Studies have shown slight increase in systolic and diastolic BP in donors as well as controls oner time, with no difference in ABPM 3 years post-donation form control group. Obese patients are more likely to have pre-donation hypertension. Increase in BMI by 1 increase the risk of hypertension by 10%. Increase in age by 1 year increases risk of hypertension by 507%. So risk factors for hypertension like African-American ancestry, Hispanics, BMI and age should be kept in mind.
Management of BP in donor post-donation:
Avoid ACE inhibitors/ ARBs or diuretics in peri-operative period.
Keep BP<160/90 using calcium channel blockers or clonidine in early post-operative period to allow optimal renal perfusion. Emphasize on lifestyle modifications including diet, weight control, avoiding smoking, regular exercise etc. More frequent follow-up and management of other cardiovascular risk factors is important.
Donor evaluation with respect to BP:
All potential donors should monitor their BP at home. The BP evaluation should be done as per the protocol mentioned above. Those with BP > 160/100 or target organ damage like LVH or albuminuria, or using 3 or more antihypertensives should undergo 24 hour ABPM.
What is the level of evidence provided by this article?
Level of evidence: Level 5: Narrative review
Huda Saadeddin
2 years ago
Elevated blood pressure (BP), or “hypertension,” has been one of the main exclusion criteria for living kidney donation, as it is a risk factor for renal and cardiovascular disease. The most current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation
The choice of BP targets and medications needs to be carefully individualized. In general, a BP <130/80 mm Hg is needed, along with lifestyle modifications.
Elevated blood pressure (BP) is one of the leading exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both kidney transplant recipients and living kidney donors alike. Despite hypertension affecting both kidney recipients and donors, the impact of hypertension on the latter has not been as well studied and understood
Understanding “hypertension” in living kidney donors will improve not only patient education during the donor recruitment process but also patient care postdonation.
donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension, strengthening the support for their inclusion into, and consequent expansion of, the living kidney donor pool. Yet, the available studies are of short duration, and there are phenotypes, such as obese, or people with African heritage who may be at more risk, and genotypes such as APOL1 which may confer more risk over time. For example, as 25-year-old overweight male homozygous for APOL1 risk variants may not be an ideal candidate despite a BP of 115/70 mm Hg. However, proper counseling on the aforementioned risks (increased BP and potential endorgan damage), albeit small, should be conducted
Hypertension criteria have changed substantially in the last few years. The goal of being more inclusive for kidney donors with elevated BP may be considered given the opportunity to control BP in an effective manner. No longer should they be considered “marginal” donors. Currently, some of the guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, when hypertensive donors are allowed to donate, they do not seem to be at a significantly increased risk of developing renal or cardiovascular health issues. Another concern for living kidney donors is the possibility of developing hypertension after kidney donation, especially if they are younger, overweight, or of African heritage. Studies have shown that in healthy, well-selected donors with no known risk factors, living kidney donation does not significantly predispose them to developing hypertension postdonation;
however, certain risk factors, such as being African American or Hispanic, obese, or older, are associated with higher likelihoods of developing hypertension postdonation. Personalized pharmacotherapy along with beneficial lifestyle changes and more follow-up appointments should be utilized to manage BP and hypertension after kidney donation. Lastly, we have put forth suggestions for evaluating BP in potential living kidney donors and maintaining BP control postdonation.
Evidence level V
Wadia Elhardallo
2 years ago
This review explores and examine hypertension and the living kidney donation in different aspects: starting with the guidelines with respect to hypertension the impact of living kidney donation on hypertensive donors, the risk of and factors contributing to the development of hypertension post donation in normotensive donors, and medical and lifestyle management of BP in living kidney donors.
Guidelines and their contraindications to donation for hypertension:
According to Kidney Disease Improving Global Outcomes (KDIGO) BP >140/90 mm Hg on <2 anti-hypertensive medications, end-organ damage or predicted lifetime ESRD risk exceeding transplant centre’s acceptable risk threshold is contraindication for donation
British Transplantation Society (BTS), Blood pressure must be assessed on at least two separate occasions, Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation
Pre-existing Hypertension in Kidney Donor Candidates:
Observational studies of hypertensive donors have produced conflicting results Some studies have found that donors with predonation hypertension have a
decline in kidney function while others have maintained that there is no significant difference in kidney function between normotensive and hypertensive donors. The discrepancy between these studies could be explained by the variance in follow-up length, study population, hypertension definitions, and sample size. Other existing retrospective studies have also been limited by short follow-up times, unrepresentative patient populations, and low rates of follow up.
· Tsinalis et al: 1 y,No change in BP or UACR, eGFR4mL/min lower in H donors
· Gracida et al: Mean 80.7 ± 32-month Creatinine 1.37 H vs 1.1 mg/dL N, (P < 0.001)
· Textor et al, 6–12 month No effect on BP, eGFR, or UACR
· Tent et al,1 and 5 y, systolic blood pressure higher in H, eGFR without difference
· Lenihan et al: 6 months No difference in eGFR or BP more glomerular in H
· Srivastava et:21 ± 1 months, increase in creatinine of 0.5 ± 0.2 mg/dL in H Vs N, no proteinuria
· Sofue et al: 2 y No change in BP. No significant change in eGFR although higher UACR associated with lower eGFR
Development of Hypertension in Kidney Donors Post donation:
An important prospective study: Kasiske et al followed living kidney donors over a 3-year period. systolic and diastolic BP increased slightly and significantly over time in both donors and controls, but there were no significant differences between the 2 groups; in addition, after 3 years, the 24-hour ABPM of both groups was not statistically significant either. Kim et al studied the long-term risk of hypertension in living kidney donors and found that
there was a statistically significant increase in BP postdonation, with 21% of the donors developing hypertension that required AHM use. However, the increase in BP was from 113/75 to 116/77 mm Hg; in addition, the total sample size of donors whose hypertension histories could be obtained was 43, with only 11% of the total sample size having a follow-up of >1 year.
Thiel et al found that the risk of developing hypertension, defined as >140/90 mm Hg, increased 3.64-fold 1-year postdonation. However, the mean predonation systolic and diastolic BP values of the normotensive donors who were hypertensiveafter 1 year postdonation were significantly higher than those donors who were normotensive after 1 year postdonation. This suggests that these patients may have been prehypertensive or more susceptible to developing hypertension.
There have been a few studies that have looked at these at risk groups to see how they fare postdonation. Hypertension was identified in 41% of African American donors in a study with an average follow up length of 7 years, compared with 30% of Caucasians.
African American and Hispanic donors are also at about a 50% increased relative risk of developing hypertension postdonation
Lentine et al confirmed that obese donors were more likely to have predonation
hypertension and each increase in year of donor age was associated with a 5%–7% higher likelihood of hypertension. Another study demonstrated that the frequency of hypertension increased by 10% for each 1-unit increase in BMI, with higher BMI being associated with higher rates of hypertension 5 years postnephrectomy.
Management of BP and Hypertension Post donation in Living Kidney Donors:
· Early after donation: allow BP (<160/90 mm Hg) to be elevated to allow for optimal kidney perfusion, which can be maintained with selective, short-acting
hypertensive agents (such as calcium channel blocker or clonidine).
· Long-term control of BP in kidney donors depends on the individual patient.
· The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of postdonation follow-up care.
What is the level of evidence provided by this article?
Level 5, narrative review article.
Shereen Yousef
2 years ago
Summary of the article
-Studies have shown that recipients who received allografts from living donors survive longer than deceased donors.
-Elevated blood pressure (BP) is one of exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both recipients and donors most current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihy-pertensive medications or evidence of end-organ damage should be excluded from living kidney donation.
– the impact of hypertension on donor has not been as well studied.
-definitions of “hypertension” are variable depending on the guidelines.
▪︎Current Living Kidney Donation Guidelines
-the risks of donation in mild, well-controlled “hypertension” are not well understood and most transplant centers adhere to their own standards when evaluating for hypertension in liviing donors
-the recent release of the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA, the definitions of hypertension have been revised.
Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg
– SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events in a population with a mean age of 68 years, no evidence of diabetes, and an estimated glomerular filtration rate (GFR) of approximately 72mL/min/1.73 m2
the mean GFR in the SPRINT study participants of ~70mL per minute is not different than observes in donors.
so it is believed that kidney donors might need lower BP targets, especially if they are younger, overweight, or have African ancestry.
▪︎ Evaluation and Assessment of BP Predonation
– screening for hypertension in donors include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated.
– If BP is determined to be high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ABPM or repeated with standardized BP measurements
-Armanyous et al using daytime ABPM as a gold standard found a 16% prevalence of hypertension in kidney donors.
-The KDIGO working group report suggested that donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
▪︎Preexisting Hypertension in Kidney Donor Candidates
-more transplant centers are relaxing their selection criteria to include donors with well-regulated hypertension.
Observational studies of hypertensive donors have produced conflicting results ,Some studies found that donors with predonation hypertension have a decline in kidney function ,while other studies showed no significant difference .
– The discrepancy between these studies could be explained by the variance in follow-up length, study population, hypertension definitions, and sample size.
-A recent observational study of 24 533 older donors (≥50 y of age), including 2265 with predonation hypertension, demonstrated that older donors with hypertension had a higher risk of ESRD but not mortality for 15 years postdonation.
-it was suggested that donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension.
– kidney donation often leads to physiological alterations (kidney hyperfiltration, upregulation of
renin-angiotensin-aldosterone system, and changes in vascular tone)
– most studies done with follow-up for short period didn’t found significant increase in bp post donation
-And it was suggested that kidney donation itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP.
-risk factors includes obesity, African American, smoking, older age .
-Current consensus guidelines have contraindicated donors with a BMI >30–35.2 Lentine et al confirmed that obese donors were more likely to have predonation hypertension and each increase in year of donor age was associated with a 5%–7% higher likelihood of hypertension.
– Another study demonstrated that the frequency of hypertension increased by 10% for each 1-unit increase in BMI, with higher BMI being associated with higher rates of hypertension 5 years postnephrectomy.
obese donors (BMI >30) had higher mean systolic and diastolic BPs than nonobese donors, leading to a significant increase in ESRD risk.
▪︎Management of BP and Hypertension Postdonation in Living Kidney Donors
-Early after donation, it is suggested to allow BP (<160/90 mm Hg) to be elevated to keep kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
Townsend et al recommend that angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
-KDIGO Guidelines suggest that proper BP measurements annually as part of postdonation follow-up care.
-Hypertensive living kidney donors should be followed more frequently than the average, normotensive donor and to have regular BP, laboratory, and urinary albumin:creatinine ratio tests conducted.
additional concerns about donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered and measurements take place every 15– 30 minutes during the daytime and 30–60 minutes at night for 24 hours with measurements.
-Based on the most recent ACC/AHA guidelines, if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation
If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.
Evidence level V
Manal Malik
2 years ago
1-Summary of Blood Pressure and Living Kidney Donors: A Clinical PerspectiveHTN is the one of exclusion criteria for living kidney donation as increase the risk for both kidney transplant recipients and living kidney donor alike.
In this review, highlight living donation guide line with respect to HTN, include develop of post donation HTN and management of HTN in living kidney donors.
Current living kidney donation guide lines for donor with HTN:
CAST, BTS, CCDT and American society of transplantation CAST is contra indication to donation of BP > 140/90 mm Hg on 3 occasions.
European Associations of urology and European Best practice Guide lines uncontrolled HTN is contra indicated.
Organ procurement and transplantations network donations is contraindication of BP > 130/85 mm Hg ( in donors < 50y old).
Kidigo guide lines donations is contraindicated if BP > 140/90 mm Hg or < 2 AHMs ,end organ damage as predicted lifetime ESRD risk.
The kidney working group report of 2017 suggest that potential donors with HTN should be individualized in relation the transplant programs acceptable risk profile threshold and that they should recounseled that donation may accelerate the risk in BP and increase the need for more anti hypertension therapy.
Observation study of older donor > 50y of age including 2265 with pre donation hypertension had a higher risk of ESRD but not mortality far 15 years post donation but no significant effect an BP or change in AHM use in hypotensive donor post donation
development of HTN in Kidney donors post donation:
Kidney donations lead to Kidney hyper filtration, upregulation of Renin- angiotensin aldosterone and change in vascular tone.
Kasiske etal prospective study felling living donors are a – 3yers period. Theirs observed systolic and diastolic BP increased slightly and significantly one time in both donors and control, but there is no significant different between two group management if BP and HTN post donation in living Kidney donors.
Early after donation HIS suggested to allow BP < 160/90 mmHg to be elevated to allow far optional kidney perfusion using calcium channel blacker or clonidine.
Avoid ACE and diuretics should be avoid perioperative due to adaptive hyper filtration and expected shifts in volume.
2- level 5
Abdul Rahim Khan
2 years ago
Please summarise this article in your own words
The LKD is best option in renal transplantation. The transplant waiting list in increasing but the donor pool on decreasing trend. The main reason for this is the medical co morbidities. Elevated blood pressure is one of the leading exclusion criteria. Donation with hypertension in associated with poor outcomes for donor and recipient.
In this review they examined current living donation guidelines as regards hypertension, impact of living kidney donation on hypertensive donors the risks and factors contributing t o the development of hypertension , post donation in normotensive donors and lifestyle management of hypertension in living donors.
SPRINT study ( systolic blood pressure intervention trial) concluded than blood pressure less than 120/80 was associated with less cardiovascular events. So it was concluded that kidney donors may need lower blood pressure targets if they are younger, overweight or have African ancestry.
Blood pressure measurements.
Measure blood pressure by trained staff at 2 occasions in a week
Ambulatory blood pressure monitoring in young hypertensives, overweight, or Africans.
Kidney donation with hypertension can be dealt with case to case by individual transplant programme . The donor can be warned to acceleration in hypertension post donation and need for medical therapy.
Pre existing hypertension in kidney donor candidates
Observational studies have produced conflicting results. Some studies have shown that pre donation hypertension does not affect post donation decline in renal function while others have shown decline in GFR.
This variability can be due to different sample size, methodology and population.
Post Donation Development of Hypertension
Despite risks associated with donation many transplant centres are relaxing criteria for donation by well controlled suitable hypertensives. Post donation there is hyperfilteration , alteration in vascular tone and activation of renin and angiotensin system which can lead to development of hypertension. This development of hypertension post donation can be precipitated by high risk factors like high BMI, old age and african race.
Management of hypertension Post donation
Post donation a blood pressure of 160/90 mm Hg is permitted to allow graft perfusion. It can be maintained by calcium channel blockers and clonidine. Long term management is individualized according to patients condition. KDIGO practice guidelines recommends assessment of blood pressure annually post donation.
LKD evaluation with regards to blood pressure
On three measurements if the blood pressure is <130/80- proceed with donation
Exclude from donation-
BP>160/90
Use of two antihypertensive drugs
End organ damage
24 hour ABPM BP reading is <125/80 – Proceed
ABPM >130/80 , on 2 medications, African or American descent- Donor proceed with donation
What is the level of evidence provided by this article?
ABPM >130/80 , on 2 medications, African or American descent- Donot proceed with donation ( Sorry there was typo above)
Mu'taz Saleh
2 years ago
Introduction
HTN in living kidney donation is one of the most important topics as its the leading cause of exclusive criteria
as the living donation is the management of choice in ESRD and number of potential donors needed in increasing year after year so the impact of living kidney donation on “hypertensive” donors, the risk of and factors contributing to the development of hypertension” post donation in normotensive donors, and medical and lifestyle management of BP in living kidney donors should be studied well .
there is to fixed definition of HTN and it is variable according to differant studies or guild lines and the threshold to accept the donor with HTN its also differentiate from one center to other
Office readings should be carried out as recommended in most guidelines , If there are additional concerns about a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered .
according to ACC/AHA
office BP reading <130/80 mm Hg , then they should be considered for donation
with appropriate individualization and counseling.
If the
office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication,then they should be excluded from kidney donation.
office BP reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive medication, who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women They should have an ABPM and preferably try to lose some weight. If the patient’s 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation. If the patient’s 24 hour ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight; when their BP becomes <125/75 mm Hg on a subsequent 24 hour ABPM reading or over multiple office measurements, they could then be reevaluated for living kidney donation.
Preexisting Hypertension in Kidney Donor Candidates
Donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing
worsening kidney function or hypertension, strengthening the support for their inclusion into, and consequent expansion of, the living kidney donor pool. Yet, the available studies are of short duration, and there are phenotypes, such as obese, or people with African heritage who may be at more risk, and genotypes such as APOL1 which may confer more risk over time.
Development of Hypertension in Kidney Donors Postdonation
.Post donation HTN could be due to glomerular hyperfiltration, upregulated renin-angiotensin-aldosterone system and cahnges in vascular tone, African have higher incidence of HTN and ESRD than other population, supposed to be related to MYH9 and APOL1 loci in chromosome 22.
Management of BP and Hypertension Postdonation in Living Kidney Donors
With respect to BP assessment postdonation, we suggest maintaining a clinic BP ≤130/80 mm Hg, which is in line with current guidelines, not only for living kidney donors but for the general population. Whether patients who are obese or possibly carry high risk APOL1 variants require lower BP targets is an intriguing question.
What is the level of evidence provided by this article?
What is the level of evidence provided by this article? 5
Dr. Tufayel Chowdhury
2 years ago
High blood pressure is one of the leading exclusion criteria for living kidney donation. Current KDIGO guideline suggests BP > 140/90 mmhg on <2 antihypertesive medicine, end organ damage are contraindicated for donation.
BP <130/80 mmhg on office, non obese, no African heritage allowed for donation.
BP < 130/80 mmhg and either obese or African heritage, > or equal 130/80 mmhg on office, use of 1 or 2 AHMs, obstructive sleep apnoea – ask for 24 hour ambulatory BP measurement- if normal allow for donations.
BP > or equal 160/100mmhg , end organ damage( left ventricular hypertrophy, albuminuria) and use of 3 anti hypertensive medicines- 24 hour ABPM- lifestyle and pharmacologic interventions- re evaluate for donations after attaining normal BP.
The KDIGO 2017 suggests, potential donors with hypertension should be indivisualized and they should be counseled that donation may accelerate the rise of BP.
Study suggests that kidney donation itself does not significantly increase the risk developing hypertension, but there are factors that lead to progressive rise in BP. Risk factors are: African American and Hispanic descent, BMI and age.
KDIGO suggests, proper BP measurement should be performed annually as part of post donation follow up care.
KAMAL YOUSIF ELGORASHI ADAM
2 years ago
While the BP has been one of the exclusion criteria of live kidney donation, as the risk of future CKD and CVD, most common current living kidney donation guidelines, stated that; donors of BP > 140/90 and those taking 1-2 AHM, or there is any evidence end organ damage, should be excluded.
Kidney function (eGFR) of hypertensive living kidney donors does not significantly worse post donation compared to that of normotensive donors, in addition, live kidney donation it self not considered to be a risk factor of developing HTN, with a risk factor that increase the risk of HTN; African American, Hispanic descent, obesity, and age . Current living kidney donation guidelines;
HTN is considered one of the main CI to live kidney donation, different guidelines BP level of which donors can be excluded. Excluding BP level from donation according to ;
caring of Australian with renal impairment CASI, British transplant society BTS, Canadian council for donation and transplantation CCDT, is >140/90 on 3 occasions.
Amesterdam forum, and american society of transplantation, AST, > 140/90.
European assossiation pf urology EAU , and European best practice guidelines, EBPG, = uncontrolled HTN.
Organ procurement and transplantation network, OPTN; > 130/85.
KDIGO; >140/90, on < 2AHM, end organ damage or predicted lifetime risk of ESKD, exceeding transplant centers acceptable risk threshold.
SPRINT trial:
SPRINT; systolic BP intervention trial; clearly demonstrated that; lower BP level < 120/80 is associated with decrease of CV event in mean age of 68 , with no evidence of DM, and eGFR of approximately 72 ml/min/1.73m2
So SPRINT does not, provide evidence that law systolic BP is important in delaying the progression of kidney disease . Evaluation and assessment of BP pre donation;- Armanyous et al.; using day time ABPM is the gold standard way of assessing BP , found that 16% prevelance of HTN in live kidney donors, using Joint National Commission definition, while found that 34% in live kidney donors having HTN pre donation. using ACC/AHA, concluded that; easily controlled HTN on 1-2 drugs, with no evidence of end organ damage , may be acceptef as law risk live kidney donor, and may need additional examination and imaging study. Lentile et al.; concluded that predonation HTN, is not associated with increase risk of any perioperative complications. KDIGO 2017; stated that potential donors with HTN should be individualized , provide counselling to donors that BP may rise and may need post donation medication.
Pre existing HTN in live kidney donors, although HTN may increase risk of renal and CVD, more centers include donors with well regulated HTN. Observational studies produce conflict results;
Tsinalis et al.; define HTN as >150/90 mmHg, or medication use, with median follow-up of 1yr. found that no change in BP oe uACR, and eGFR is lower in HTN donors.
Gracida et al.; not defined HTN, medication use, MAP of 107.8, median follow up 80.7+- 32 month, found that cr rise to 1.37 in HTN donor compare to 1.1 mg/dl in normotensive donora (p<0.001).
Textor et al.; clinic BP >140/90, or ABPM>135/85, with median follw up 6-12 month found that, no effect on BP, eGFR, or uACR.
Tent et al.; medicaton use hypertensive donors, with median follow up 1-5 yrs., found that early (2 mo) systolic BP higher in HTN donors, 1 and 5 yrs eGFR without difference.
Lenihan et al,; ABPM > 140/90, or medication use, for 6 month, found that, no difference in eGFR or BP more glomerular in HTNsive donors.
Srivastava et al.; BP < 140/90 with medication use, for 21+- 1 mon. found that mean increase in cr 0.5 +-0.2 mg/dl in H vs N, and no protienurea.
Sofue et al.; not define BP , for 2 yrs. found that; no change in BP, no sign. change in eGFR although higher uACR associated wiyh lower eGFR.
Development of HTN in kidney donors post donation;-
Kidney donation lead to physiological alteration ;
Kidney hyperfilteration .
Upregulation of RAAS, and change in vascular tone
The 2 changes increase BP but it’s not considered to be a risk for inducing HTN post donation. Important prospective studies , post donation follow up for BP;-
Kasiske et al.; following live kidney donors for 3 yrs, found that systolic and diastolic BP increase significantly and significantly overtime in both kidney donors and controll group, but no significantly difference between 2 group neven after 3 yrs.
Kim et al.; Long term risk of HTn in live donors statistically significant rise in BP post donation, with 21% donors develop HTN requiring AHM use.
Thied et al.; risk of HTn > 140/90, increased 4.64 fold in 1 yr. and pre donation mean S/D BP in normotensive who develop HTn post donation was higher than those was normotensive post 1 yrs follow up, so suggest that donors has prehypertensive , or susceptible to develop HTN, so result of the study suuggest that kidney donation is not itself increase risk of developing HTn.
Lentire et al.; confirmed obese donors, more likely to have pre donation HTN increase ESKD risk, post donation.
Management of BP and HTN post donation in live kidney donors;
Early post donation allow BP < 160/90 to be increase to allow optimium kidney perfusion , maintained with Ca channel blocker, . Townsend et al.; recommend ACE-i ,ARB, diuretics, should be avoided perioperatively due to adaptive hyperfiltration and expected shift in volume, plus treatment , advice to change life style, diet, weight control, smoking cessation.
KDIGO suggest proper BP measurement performed annually, and more frequently in hypertensive donors, and more microalbuminurea testing plus controll of CV risk factor. Suggestion of live kidney donor evaluation for HTN;
potential donors, BP < 130/80 , office reading nonobese , nonAfrican = proceed for donation.
BP < 130/80, either obese or african-american or > 130/80, or use of 1 or 2 AHM, do 24 ABPM, if normal proceed for donation, if high ; life style , medication, and re evaluate for future donation.
If BP >/ 160/60 , EOD, OR use of 3 AHM; do 24 hours ABPM, life style, exclude from donation.
Level of doanation ((5)).
Mohammad Alshaikh
2 years ago
Please summarise this article in your own words:
Hypertension is one of concern in evaluation and exclusion criteria for kidney dononrs, because is associated with increased cardiovascular risk and mortality, and graft loss in recipients.
The definition of hypertension is variable and changing according to guidelines.
Current ACC/AHA guidelines: elevated blood pressure 120-129 mmHg, stage1 HTN 130-139 mmHg systolic/80-89 mmHg diastolic. the B/p should be measured twice if high then ABPM is mandatory, in obese, young and Africans ABPM is better, the prevalence of HTN among kidney donor is 16% according to JNC7, and 34% using ACC/AHA guidelines. Thus the KDIGO working group report of 201711 suggested that potential donors with hypertension should be individualized.
Preexisting Hypertension in kidney donor candidates: in the face of increased need for kidney transplantation to meet the increase in ESRD, make some centers to be flexible in inclusion criteria for donation, as there is conflicting results from the studies regarding the decline in kidney function post donation, so the donors with B/P <140/90 mmHg controlled with one or two antihypertensives and no end organ damage, are at minimal risk for developing HTN and worsening kidney function.
Post donation HTN could be due to glomerular hyperfiltration, upregulated renin-angiotensin-aldosterone system and cahnges in vascular tone, African have higher incidence of HTN and ESRD than other population, supposed to be related to MYH9 and APOL1 loci in chromosome 22.
They suggest Office readings should be carried out as recommended in most guidelines: BP should be measured with a properly sized BP cuff. The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading. If there are additional concerns about a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered for 24 hours.
patient with BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling. in patients with an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation, other comorbidities should be evaluated and treated(ie obesity,OSA,,,etc).
Conclusion:
pre and post donation evaluation of HTN and management is a must, as there is increased cardiovascular disease risk and risk for worsening kidney function after donation.
special concern to African, obese and older population, because of increased of the above mentioned risks.
Personalized pharmacotherapy along with beneficial lifestyle changes and more follow-up appointments should be utilized to manage BP and hypertension after kidney donation.
What is the level of evidence provided by this article? Level V erratic review.
Assafi Mohammed
2 years ago
Blood Pressure and Living Kidney Donors: A Clinical Perspective summary
HTN was considered as a contraindication to living kidney donor transplantation for long time, currently there are different guidelines being created with respect to mild and controlled HTN in the field of kidney donation. Current Living Kidney Donation Guidelines 1) Most guidelines have raised concerns about donor with SBP > 140 mmHg and some guidelines have concern about SBP >130 especially in younger donors. 2) ACC/AHA 2017 guidelines: Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg (implications of these revision remain to be seen). 3) A lower BP goal(<120/80) is clearly demonstrated by the SPRINT: i) SPRINT study does not provide evidence that lower systolic pressure goals are important in delaying the progression of kidney disease. ii) the mean GFR in the SPRINT study participants of ~70 mL per minute is not substantially different than what one observes in people who have donated a kidney. 4) There may be reason to believe that kidney donors might need lower BP targets, especially if they are younger, overweight, or have African ancestry. Evaluation and Assessment of BP Pre-donation 1) BP measurement in potential donor on 2 separate occasions. 2) ABPM should be considered when BP is determined to be high or high normal, especially in the presence of variability, younger age, overweight or African heritage. 3) The variability and phenotype differences(white coat HTN and masked HTN) have not been prospectively studied in kidney donors. 4) Easily controlled hypertension with 1 or 2 agents and no evidence of target organ damage may be accepted as low-risk kidney donors. 5) The KDIGO working group report of 201711 suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy. Preexisting Hypertension in Kidney Donor Candidates
1) There were discrepancy and contradiction between previous studies on HTN in the LKD. Some studies stated that pre-donation HTN is associated with a decline in kidney function, while other studies showed that there is no significant difference in kidney function between normotensive and hypertensive donors. . The discrepancy between these studies could be explained by:
i) the variance in follow-up length.
ii) Study population.
iii) hypertension definitions.
iv) sample size.
2) Compounding that may confer more risk over time:
i. Obese.
ii. People with African heritage.
iii. genotypes such as APOL1.
3) Lenihan et al discovered that although there was marked glomerulopenia in hypertensive donors, there was a nonsignificant difference in GFR, hyper- filtration capacity, or compensatory renocortical hypertrophy.
4) A recent observational study of 24 533 older donors (≥50 y of age), including 2265 with predonation hypertension, demonstrated that older donors with hypertension had a higher risk of ESRD but not mortality for 15 years postdonation. Development of Hypertension in Kidney Donors Postdonation
1. Physiological alterations after kidney donation:
i. Kidney hyperfiltration.
ii. Upregulation of renin-angiotensin-aldosterone system.
iii. Changes in vascular tone.
2. There were reports suggested an increased risk of developing hypertension post-donation:
i. These studies failed to compare their study population with age-matched controls.
ii. The increase in BP was from 113/75 to 116/77 mm Hg, values that are well below the normal benchmarks for hypertension.
iii. The sample size of the donors was small.
iv. Small percentage (11%) had follow-up > 1y.
3. Thiel et al found that the risk of developing hypertension(>140/90), increased 3.64-fold 1-year post-donation.
i. the mean pre-donation systolic and diastolic BP values of the normotensive donors who were hypertensive after 1year post-donation were significantly higher than those donors who were normotensive after 1year post-donation. This suggest pre-donation HTN or more susceptibility to developing HTN.
ii. In 5years follow-up, there was only a modest and nonsignificant increase in risk of developing hypertension.
iii. This study suggests that kidney donation itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP.
4. Risks for HTN post-donation:
i. African American and Hispanic descent.
ii. Obese donors.
iii. Elderly donors.
iv. MYH9 and APOL1 loci on Chromosome 22 have been linked with nondiabetic kidney disease in several recent studies.
v. Two alleles of the APOL1 gene, G1, and G2, are associated with higher risk of focal glomerulosclerosis and hypertension-attributed kidney disease. Management of BP and Hypertension Postdonation in Living Kidney Donors
1. Early after donation, it is suggested to allow BP (<160/90 mm Hg) to be elevated to allow for optimal kidney perfusion.
2. Higher risk patients may require lower BP targets for treatment.
3. Long-term control of BP in kidney donors depends on the individual patient Specific pharmacotherapy must be individualized according to comorbidities, drug-drug interactions, drug side effects, and kidney function.
4. Living kidney donors also need to make positive lifestyle changes, including weight control, modest dietary sodium reduction and regular exercise, smoking avoidance, and modest alcohol intake.
5. Proper education on taking home BP for self-BP monitoring and management.
6. The KDIGO suggest that proper BP measurements should be performed annually as part of post-donation follow-up care.
Suggestions for Living Kidney Donor Evaluation With Respect to BP
1. Office readings as recommended in most guidelines after rest of 5minutes.
2. BP reading <130/80 mm Hg over 3 measurements, should be considered for donation with appropriate individualization and counseling.
3. To exclude from kidney donation list if:
i. The patient has an average office BP reading ≥160/100 mm Hg.
ii. Evidence of end-organ damage.
iii. On more than 2 antihypertensive medications.
4. ABPM BP <125/75 mm Hg, should be considered for donation. What is the level of evidence provided by this article?
Review article
level of evidence; 5
Abdulrahman Ishag
2 years ago
1-Office readings should be carried out as recommended in most guidelines:
The final BP will be averaged over 3 readings conducted.
2-a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered.
3-Based on the most recent ACC/AHA guidelines recommend ;
1- if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling.
2-If the patient has an average office BP reading ≥160/100 mm Hg,evidence of end-organ damage (such as left ventricular hyper trophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.-
3- patients with an average office BP reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer anti- hypertensive medication, who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women as obesity has been shown to be a risk factor for ESRD. They should have an ABPM and preferably try to lose some weight.
4-If the patient’s 24 hour ABPM BP reading is ;
1- <125/75 mm Hg, they should be considered for donation.
2-If the patient’s 24 hour ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight; when their BP becomes <125/75 mm Hg on a subsequent 24 hour ABPM reading or over multiple office measurements, they could then be reevaluated for living kidney donation.
The KDIGO working group report of 2017;
suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy. We agree with these statements and would add that this is also a concern in younger donors, especially if they are overweight or have African ancestry, or both.
Guidelines and their contraindications to donation for hypertension
1-Caring for Australasians with Renal Impairment (CASI), British Transplantation Society (BTS), Canadian Council for Donation and Transplantation (CCDT).
If the BP is >140/90 mm Hg on 3 occasions ,the donation is contra indicated
2-Amsterdam Forum, American Society of Transplantation (AST)
If the BP is >140/90 mm Hg, the donation is contra indicated
3-European Association of Urology (EAU), European Best Practice Guidelines (EBPG) Uncontrolled hypertension Organ Procurement and Transplantation Network (OPTN).
If the BP is >130/85 mm Hg (in donors <50 y old) ,the donation is contra indicated
4-Kidney Disease Improving Global Outcomes (KDIGO) >140/90 mm Hg on <2 AHMs, end-organ damage or predicted lifetime ESRD risk exceeding transplant center’s acceptable risk threshold.
Development of Hypertension in Kidney Donors Post donation;
The risk factors include ;
1- African American and Hispanic descent.
2- Increased BMI
3- Age ( old age has increased risk )
1- The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of post donation follow-up care.
2- Hypertensive living kidney donors (whether the hypertension developed pre or post donation) should be followed more frequently than the average, normotensive donor and to have regular BP, laboratory, and urinary albumin:creatinine ratio tests conducted.They should also have their other cardiovascular risk factors well controlled.
What is the level of evidence provided by this article?
Level V
Rihab Elidrisi
2 years ago
Global standard definition of hypertension is BP reading of >140/90 . Generally as part of increase the donor pools ,and donor with mild HTN and on mono therapy or two AHM with no end organ faluier can donate his kidney ,and he has to know the risk of developing high bp and kidney injury. The donor should be of life long follow up program .
if BP is determined to be high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ambulatory BP monitoring or repeated with standardized BP measurements Despite hypertension being a known risk factor for renal and cardiovascular disease,15-17 more and more transplant centers are relaxing their selection criteria to include donors with well-regulated hypertension in response to decreasing supply of donor organs and increasing demand for kidney transplants
post donation HTN:
An important prospective study by Kasike et al followed up living kidney donors for a period of threes years. he found no statistically significant difference between the donors and controls in both SBPs and DBPs Other studies have shown that the risk is higher in developing elevated BPs post-donation. The major risk factor was a higher BP pre-donation. Most of these studies excluded marginal donors, donors with an African-American heritage, the obese donors and the elderly donors. Donor who have an African American heritage have a higher risk of developing post-donation HTN than caucasians. The risk is thought to be high due to the higher presence of the APOL 1 gene. Presence of the APOL1 gene in the donor can also have an impact on graft outcome in the recipient
Donor after donation will be treated and monitored regularly and his bp specially in young donor not >130/90 and in early post operative period preferable to be 160/90 not to affect kidney perfusion .
Generally,CCB,Beta blocker and central acting medications can be used in patient after donation better to avoid ARB,ACEI.
the level of evidence of this article is systemic view ,level V.
Heba Wagdy
2 years ago
Living kidney donation has several advantages as it increase the donor pool, associated with better graft and patient outcome than deceased donor transplant and can be used preemptive, but the medical unfitness of donors remains as a barrier against living donation.
HTN is the commonest cause of exclusion of kidney donors. Current living kidney donation guidelines:
Different guidelines are available.
The recent guidelines by ACC/AHA define stage1 HTN as systolic BP 130-139 or diastolic BP 80-89, so concerns were raised about donors with systolic BP>130 and their target BP after donation.
The SPRINT showed that keeping BP<120/80 is associated with less cardiovascular events in patients with mean age 68 years, nondiabetic and with eGFR approximately 72, so kidney donors may benefit from lower BP targets after donation. Evaluation of BP pre-donation:
Screening should include standardized BP measurement on 2 separate occasions.
ABPM should be considered in donors with high or high normal BP, overweight, young age or Africans.
Phenotypes as masked HTN and white coat HTN should be considered during assessment.
KDIGO guidelines suggest that accepting donor with HTN should be individualized according to the risk of having accelerated HTN after donation. Preexisting HTN in kidney donor candidates:
Most centers include donors with controlled HTN to increase donor pool.
Results of studies on hypertensive donors and associated risk of having renal impairment were controversial.
Most retrospective studies showed that hypertensive donors had no significant increase in BP or antihypertensive agents after donation. Patients with controlled HTN on 1 or 2 medications with no evidence of target organ damage are accepted for donation after proper counseling about risk of elevated BP and potential end organ damage. Young, obese or Africans could be at increased risk and should be included on individual basis. Development of HTN in kidney donors post-donation:
Physiologic alterations after donation are not considered a risk factor for developing HTN after donation.
A prospective study showed that both donors and controls have the same increase in BP after 3 years of follow up.
A trial showed that patients with untreated HTN developed stage 1 HTN over 4 years while those treated with candesartan had lower incidence of HTN suggesting the possibility of modifying BP after donation.
Few studies included marginal donors who are at higher risk of developing HTN before donation.
African Americans have higher relative risk for developing HTN and higher incidence of having ESRD post-donation than Caucasians, several small studies suggest association between presence of donor variants and adverse outcomes of recipients of kidneys with APOL1 susceptibility.
Potential donors with BMI >30-35 are excluded as they have increased risk for having HTN and for developing ESRD after donation, BMI during evaluation can predict prognosis post donation.
African Americans, obese and young age donors require earlier and more intensive treatment to control BP after donation. Management of BP and HTN post-donation in living kidney donors: Early after donation: BP is kept elevated <160/90 to keep optimal kidney perfusion. Long term control: should be individualized according to comorbidities, drug interaction, side effects and kidney function, control should include lifestyle changes, medications and education about self BP monitoring
ACEI, ARB and diuretics are not recommended in perioperative period.
KDIGO guidelines suggest annual follow up after donation and more frequent follow up in hypertensive donors.
Other cardiovascular risk factors should be well controlled. Suggestions for living kidney donor evaluation with respect to BP:
Standardized BP measurement during evaluation.
High risk potential donors as African Americans, obese and young age should have ABPM
Patients with BP<130/80 can be included with proper individualization and counseling counseling.
Patients with BP >160/100, evidence of end organ damage or taking >2 antihypertensive agents should be excluded.
Those with BP between 130/80 and 160/100, taking 1 or 2 antihypertensive medications, have obstructive sleep apnea, African American or have waist circumference >94cm in men and >80cm in women should have ABPM and if BP<125/75 they can be considered for donation
If BP >125/75, BP should be controlled with lifestyle changes and pharmacologic agents, then to be reevaluated for donation.
Post donation BP should be kept <130/80
Those suggestions are limited as they didn’t consider masked HTN, ABPM is expensive and not widely available and need several studies to determine its role.
Level of evidence: 5 (Review article)
Mohamed Mohamed
2 years ago
Please summarise this article in your own words
Guidelines & their contraindications to donation for hypertension: 1. CASI, BTS, CCDT: >140/90 mm Hg on 3 occasions. 2. Amsterdam Forum, AST: >140/90 mm Hg 3. EAU, EBPG: Uncontrolled hypertension
4. OPTN: >130/85 mm Hg (in donors <50 years old) 5. KDIGO: >140/90 mm Hg on <2 AHMs, end-organ damage or predicted lifetime ESRD risk exceeding transplant center’s acceptable risk threshold
Contraindications to donation for hypertension in different studies:
1. 24 h ABPM with >15% of SBP>140/90 mm Hg (Moore et al)
2. >130/90 mm Hg in someone <50 year old, end-organ damage, non-Caucasian, or 3+ AHMs (Lapasia et al)
3. >140/90 mm Hg (Haghighi et al; Nagib et al; Sofue et al; Perlis et al)
4. >140/90 mm Hg or AHMs use (Clayton et al; Lagou et al; Lentine et al; Thiel et al; Mjoen et al)
Summary:
Donors with BP <140/90 controlled with 1–2 drugs & no end-organ damage are at minimal risk of worsening kidney function or HTN following donation; however, the available studies are of short duration, & some pheno-or geno-types (obese, African heritage, or APOL1) may be at more risk.
Data comparing influence of BP on renal outcomes in LKDs: Prospective studies: 1. Tsinalis et al: 46 HTN, 75 Normotensive (BP >150/99 mm Hg ormedication use) followed for 1 year.
Outcome: No change in BP or UACR, eGFR 4 mL/min lower in HTN donors. 2. Gracida et al: 16 HTN, 422 Normotensive
(MAP of H 107.8 mm Hg) followed for a mean 80.7 ± 32 months.
Outcome: Creatinine 1.37 in HTN versus 1.1 mg/dL in Normotensives (P < 0.001). 3. Textor et al: 24 HTN, 124 Normotensive (Clinic BP >140/90 mm Hg or ABPM >135/ 85 mm Hg) followed for 6–12 month.
Outcome: No effect on BP, eGFR, or UACR. 4.Tent et al: 47 HTN, 94 Normotensive (Medication use) followed for 1 & 5 years. Outcome:
Early (2 mo) SBP higher in HTN
1 & 5 y eGFR without difference 5. Lenihan et al: 10 HTN, 10 Normotensive (ABPM >140/90 mm Hg or medication use)
Followed for 6 months
Outcome: No difference in eGFR or BP more glomerular in HTN. Retrospective studies: 1.Srivastava et al: 18 HTN, 64 Normo-tensive ( BP <140/90 mm Hg with medication use)followed for 21 ± 1 months. Outcome: Mean increase in creatinine 0.5 ± 0.2 mg/dL in HTN versus Normotensive, no proteinuria. 2.Sofue et al: 14 HTN, 38 Normotensive(BP level not defined) followed for 2 years. Outcome: No change in BP. No significant change in eGFR although higher UACR associated with lower eGFR. Suggestions based on the current literature:
1. Office readings as recommended in most guidelines:
– Rest 5 min before readings.
– A properly sized BPcuff.
– Final BP averaged from >3 readings with a minimum of a 1-min rest in between each reading.
– ABPM –in certain situations (e.g, younger age, overweight, or African heritage)
2. Based on ACC/AHA guidelines:
– If an average office BP <130/80 mm Hg over 3 measurements, donation is considered.
– If average office BP≥160/100 mm Hg, end-organ damage (LVH, albuminuria), or on >2 antihypertensive medication, then exclude from donation.
-Office BP ≥130/80mm Hg but <<160/100 mm Hg, & on 2 or fewer medication: no available clinical data.
– Postdonation: suggested clinic BP ≤130/80 mm Hg (in line with current guidelines, not only for LKDs but for the general population).
Caveats to the above suggestions:
– “masked hypertension” (BP normal in office, elevated BP in non-office) is not considered.
– Currently no enough data to support the use of ABPM for all potential donors (cost, availability, & expertise needed to perform ABPM correctly).
– No evidence-based guidelines currently available for identifying levels of BP which would pose risk from kidney donation, especially if they are obese, African heritage, or have an APOL1 high risk variant.
– Nor any data on an optimal BP target or treatment plan. Conclusions
Some guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, when allowed to donate, there is no significantly increased risk of developing renal or CV disease.
There is a concern for LKDs of developing HTN after donation, especially if younger, overweight, or of African heritage. ====================== What is the level of evidence provided by this article? Level V
Hypertension was traditionally considered a risk factor for organ donation….But, there were many studies conducted later which proved that hypertension if well controlled could donate kidneys…
This review article providing a level of evidence of V…
Various guidelines have described contraindications to organ donation based on blood pressure readings
Amsterdam forum, American Society of Transplantation – >140/90mm of Hg not to donate
British Transplantation society/Australian Transplant network/Canadian society >140/90 mm of Hg not to donate
OPTN network – BP.130/85 in donors less than 50 years old – contraindication for organ donation
KDIGO – Individualized BP approach
Assessment and Evaluation of Pre donation BP:
It is important to always check the BP on 2 separate occasions and never rely on one BP reading.. Many different phenotypes of hypertension are present including white coat hypertension and masked hypertension which may predispose to long term damage of end organs many decades later…In fact there are studies of donors with normal blood pressure, after the usage of ABPM they have been found to have 16% hypertension due to masked hypertension…
in general
BP<130/80 mm on office readings, non obese, non africans – Allowed for donation
BP >130/80 < 160/100 or BP > 130/80 with obesity, Africans heritage, OSA with 1 or 2 Antihypertensive drugs – Ambulatory Blood pressure recordings – if ABPM readings after 15-30min intervals in day and 60 min interval at night recordings of BP <125/85 – Allow for organ donation. If any of the above factors are present – Lifestyle and pharmacological interventions
BP >160/100mm with end organ damage with use of 3 or more antihypertensives – Pharmacotherapy and Life style interventions. Re evaluate for organ donation only if the ABPM recordings are normal
KDIGO in 2017 have told about giving an individualized approach for organ donation considering the risk profile for all donors to increase the organ donation pool
In summary – Donors with hypertension and no end organ damage with 1 or 2 anti hypertensives, who are not very young, non obese, non African lineage will be able to donate organs..
Development of Hypertension post organ donation: Post surgery there is always hyperfiltration, upregulation of RAS and changes in vascular tone which may all elevate the BP but in the long term they are not the factors considered in elevating the blood pressure. It is said that a little elevated BP in the immediate post operative period is needed to maintain the glomerular perfusion pressure. Many studies prospective and retrospective studies have been conducted in the past and the high risk groups like obese, young age, African lineage (due to increased expression of MYH9 and APOL1 gene), pre existing hypertension all have been shown to have impact on long term hypertension development. These are the groups of individual who will need yearly follow up with blood tests, urine tests
This review, handle
The current living kidney donation guidelines with respect to “hypertension,”
The impact of living kidney donation on “hypertensive” donors,
The risk of and factors contributing to the development of “hypertension”
post donation in normotensive donors, and
Medical and lifestyle management of BP in living kidney donors
The most current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation. In healthy, well-selected donors with no known risk factors, living kidney donation does not significantly predispose them to developing hypertension postdonation;However, certain risk factors, such as being African American or Hispanic, obese, or older, are associated with higher likelihoods of developing hypertension postdonation. The choice of BP targets and medications needs to be carefully individualized. In general, a BP <130/80 mm Hg is needed, along with lifestyle modifications.
Despite all the benefits and promise of living kidney donation, there has been an overall decline in number of living kidney donations since 2004, while the waiting list for kidney donors increases every year.This decline can largely be attributed to the medical unsuitability of potential donors, who often present with a multitude of health concerns, such as hypertension, obesity, diabetes, and impaired kidney function.
Current Living Kidney Donation Guidelines Elevated BP has long been considered as one of the main contraindications to live kidney donation, but the risks of donation in mild, well-controlled “hypertension” are not well understood. This has led to the creation of several different guidelines that try to delineate the exact benchmark of “hypertension” .In addition, despite the release of such consensus guidelines, most transplant centers adhere to their own standards when evaluating for hypertension in potential live kidney donors
Evaluation and Assessment of BP Predonation In general, screening for hypertension in potential donors should include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated. If BP is determined to be high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements
Preexisting Hypertension in Kidney Donor Candidates Despite hypertension being a known risk factor for renal and cardiovascular disease, more and more transplant centers are relaxing their selection criteria to include donors with well-regulated hypertension in response to decreasing supply of donor organs and increasing demand for kidney transplants. Observational studies of hypertensive donors have produced conflicting results.Some studies have found that donors with predonation hypertension have a decline in kidney function (evidenced by increasing serum creatinine and decreased estimated GFR),while others have maintained that there is no significant difference in kidney function between normotensive and hypertensive donors.
Development of Hypertension in Kidney Donors Postdonation
Even though kidney donation often leads to physiological alterations (kidney hyperfiltration, upregulation of renin-angiotensin-aldosterone system, and changes in vascular tone) that may elevate BP, it is not considered to be a risk factor in developing hypertension postdonation. An important prospective study by Kasiske et al followed living kidney donors over a 3-year period.
They observed systolic and diastolic BP increased slightly and significantly over time in both donors and controls, but there were no significant differences between the 2 groups; in addition, after 3 years, the 24-hour ABPM of both groups was not statistically significant either.
Management of BP and Hypertension Postdonation in Living Kidney Donors Early after donation, it is suggested to allow BP (<160/90
mm Hg) to be elevated to allow for optimal kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).Long-term control of BP in kidney donors depends
on the individual patient, and thus it is difficult to recommend a general medication regimen.Specific pharmacotherapy
must be individualized according to comorbidities, drug-drug interactions, drug side effects, and kidney function. Townsend et al recommend that angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
Based on the current literature, we suggest the following protocol in evaluating potential living kidney donors on the basis of their BPs .Office readings should be carried out as recommended in most guidelines: patient will rest 5 minutes before readings are conducted. BP should be measured with a properly sized BP cuff. The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading. If there are additional concerns about a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered and measurements take place every 15– 30 minutes during the daytime and 30–60 minutes at night for 24 hours with measurements.
CONCLUSIONS
“Hypertension” criteria have changed substantially in the last few years. The goal of being more inclusive for kidney donors with elevated BP may be considered given the opportunity to control BP in an effective manner. No longer should they be considered “marginal” donors. Currently, some of the guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, when hypertensive donors are allowed to donate, they do not seem to be at a significantly increased risk of developing renal or cardiovascular health issues. Another concern for living kidney donors is the possibility of developing hypertension after kidney donation, especially if they are younger, overweight, or of African heritage.
Blood Pressure and Living Kidney Donors: A Clinical Perspective
Despite all the advantages and potential of living kidney donation, there has been a general fall in the frequency of donations since 2004, and the waiting list for kidney transplants has increased. annual growth in donors. The medical unsuitability of potential donors, who frequently come with a variety of health issues such hypertension, obesity, diabetes, and poor kidney function, can be partly blamed for this reduction. One of the most important exclusion criteria for living kidney donation is elevated blood pressure (BP), as it raises the likelihood of unfavorable outcomes for both kidney transplant patients and living kidney donors. Despite the fact that hypertension affects both kidney recipients and donors, its effects on the latter have not been as thoroughly researched or understood.
Current Living Kidney Donation Guidelines
The criteria of hypertension have been updated in light of the recent publication of the 2017 High Blood Pressure Clinical Practice Guidelines by the ACC/AHA. Systolic blood pressure that is elevated is 120–129 mm Hg, and stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg.
In a population with a mean age of 68 years, no signs of diabetes, and an estimated glomerular filtration rate (GFR) of about 72mL/min/1.73 m2, SPRINT (Systolic Blood Pressure Intervention Trial) amply demonstrated that a lower BP goal (120/80 mm Hg) was associated with a reduction in cardiovascular events. in particular if they are younger, heavier, or of African descent, there may be cause to think that kidney donors need lower BP targets.
Evaluation and Assessment of BP Predonation
In general, BP measurement on 2 distinct occasions by clinical staff that is trained to measure BP reliably, with equipment that has been calibrated, should be part of the screening process for hypertension in potential donors. If BP is found to be high or high normal, especially if there is variability, the patient is younger, overweight, or of African ancestry, BP should be checked again using standardized blood pressure measurements.It should be emphasized that BP is frequently misclassified, particularly when there is fluctuation.
Office, home, and ABPM readings can differ significantly from one another, and phenotypes like white coat hypertension and masked hypertension may be indicative of future prognosis. There hasn’t been any prospective research on the variability and phenotypic variations in kidney donors.
In the past, antihypertensive drug use or a blood pressure level more than 140/90 mm Hg were regarded as contraindications to donation. On the other hand, low-risk kidney donors may be accepted in some cases for patients whose hypertension can be effectively managed with one or two medications and who show no signs of target organ damage. In order to determine a person’s eligibility to give blood, additional tests and imaging procedures may be taken into account in cases with borderline hypertension or anomalies. The KDIGO working group report of 2017suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
Preexisting Hypertension in Kidney Donor Candidates
In response to a shortage of organ donors and rising demand for kidney transplants, more and more transplant centers are loosening their selection criteria to allow donors with well-controlled hypertension, despite the fact that it is a known risk factor for renal and cardiovascular disease.
In conclusion, donors with well-controlled blood pressure (BP 140/90 controlled with 1-2 antihypertensive drugs and no evidence of target organ damage) appear to be at low risk of developing hypertension or worsening kidney function, strengthening the case for their inclusion in, and consequent expansion of, the living kidney donor pool.
Development of Hypertension in Kidney Donors Postdonation
Despite the fact that kidney donation frequently results in physiological changes (kidney hyperfiltration, upregulation of the renin-angiotensin-aldosterone system, and changes in vascular tone)that may raise blood pressure, it is not thought to be a risk factor for developing hypertension after donation.
Management of BP and Hypertension Postdonation in Living Kidney Donors
Early on after donation, it is advised to enable BP to rise to an ideal level (160/90 mm Hg), which can be maintained with certain, short-acting hypertensive medications (such as calcium channel blocker or clonidine).
Individualized pharmacotherapy must take into account kidney function, drug side effects, drug interactions, and comorbidities.
Angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided after surgery because of adaptive hyperfiltration and anticipated volume changes, according to Townsend et al.
Living kidney donors must adopt a healthy lifestyle that includes weight management, moderate dietary sodium reduction, regular exercise, quitting smoking, and moderate alcohol consumption in addition to a customized pharmaceutical regimen. Additionally, they need to be properly educated on how to monitor and manage their own blood pressure at home.
The KDIGO Clinical Practice Guidelines advise that accurate blood pressure readings be taken once a year as part of postdonation care. Living kidney donors who have hypertension should be monitored more frequently than the usual, normotensive donor and should undergo routine blood pressure, laboratory, and albumin-to-creatinine ratio tests. They should also have good control over their other cardiovascular risk factors.
higher risk patients may also require lower BP targets for treatment.
Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
The majority of guidelines state that patients should rest for five minutes before readings are taken in the office. A BP cuff of the appropriate size should be used to measure BP. The final blood pressure will be calculated as the average of 3 readings taken with a minimum 1-minute break in between. The use of ABPM should be taken into consideration if there are additional concerns regarding a potential donor’s blood pressure, younger age, obesity, or African ancestry. Measurements are taken every 15 to 30 minutes during the day and every 30 to 60 minutes at night for a period of 24 hours.
According to the most recent ACC/AHA guidelines, a patient should be considered for donation with the proper individualization and counseling if their average office blood pressure reading is less than 130/80 mm Hg over three measurements. Patients should not be considered for kidney donation if they have an average office blood pressure level of less than 160/100 mm Hg, show signs of end-organ damage (such as left ventricular hypertrophy or albuminuria), or are on more than two antihypertensive medications.
Since obesity has been shown to be a risk factor for end-stage renal disease (ESRD), we raise concern about patients with an average office blood pressure reading of less than 130/80 mm Hg but greater than 160/100 mm Hg, who are taking two or fewer anti-hypertensive medications, who have obstructive sleep apnea or are of African descent, or who have a waist circumference of less than 94 cm for men and less than 80 cm for women They ought to have an ABPM and, if possible, make an effort to decrease weight. The patient should be considered for donation if their 24-hour ABPM blood pressure reading is less than 125/75 mm Hg. The patient should get pharmacological and lifestyle therapies to reduce their blood pressure and weight if their 24-hour ABPM value is less than 125/75 mm Hg.
Regarding the assessment of blood pressure after donation, we advocate maintaining a clinic blood pressure of less than 130/80 mm Hg, which is in accordance with current recommendations for both live kidney donors and the general public. It’s interesting to wonder whether patients who are fat or who may have high risk APOL1 mutations need lower blood pressure targets.
CONCLUSIONS
Given the opportunity to effectively control blood pressure, the objective of being more inclusive for kidney donors with elevated blood pressure may be taken into consideration. They should no longer be viewed as “marginal” donors. A 24-hour ABPM BP value of >140/90 mm Hg or usage of AHMs is currently advised as a contraindication to donation, according to certain standards. When hypertension donors are permitted to donate, however, they don’t appear to have a noticeably higher risk of having kidney or cardiovascular problems. The potential for developing hypertension following kidney donation is another worry for living kidney donors, particularly if they are younger, heavier, or of African descent.
Studies have demonstrated that living kidney donation does not significantly increase the chance of developing hypertension after donation in healthy, well chosen donors without any known risk factors; However, several risk factors, such being Hispanic or African American, fat, or older, are linked to an increased likelihood of having postdonation hypertension. After kidney donation, BP and hypertension should be managed with personalized medication, healthy lifestyle adjustments, and more follow-up sessions.
level of evidence 5
Presence of HPN is potential donor usually leads to exclusion from donation specially if was controlled by two or more antihypertensive drugs or if the donor has evidence of end organ damage, as HPN is a well known risk factor for CV morbidity and mortality in general population. Beside its poor impact on the donated graft.
The risk of developing HPN after kidney donation is increased theoritically due to post nephrectomy single nephrone hyperfilteration that could end in glomerular hypertension and glomerular sclerosis.
In this review, the authors revised the current living donor guild lines regarding HPN in potential donors.In 2017,ACC/AHA revised the definitions of hypertension to consider BP > 130–139 mm Hg or diastolic 80–89 mm Hg as grade 1 HPN instead of previous levels of > 140/90 mmHg. The SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated that lower BP goal (<120/80 mm Hg) was associated with decrease in CV events in elderly population with a mean age of 68 years with no diabetes, and e GFR around 72mL/min/1.73 m2.
These new changes in guild lines have their impact on kidney dobation practice as more donors will be considered HPN and could be excluded from donation , beside the need for more strict control of BP to lower the risk of CV complications.
BP diagnosic approach to potential donor :
1- BP < 130/80 , not obese or African American, allow kidney donation.
2- BP < 130/80 , obese or African American or BP> 130/80 consider confirmation of BP with ABPM if controlled proceed to donation while if not controlled treat as hypertension .
3- BP>160/90 mmHg or end organ damage , exclude from donation.
Development of hypertension in kidney donors Postdonation:
Several studied revelead increased risk for HPN post kidney donation due to altered vascular tone , stimulation of RAS and glomerular hyperfilteration , but it’s usually of mild degree and can be controlled easily. Thus many of the current guidelines prevent donation from obese donors (BMI >30-35 )as they have higher risk for developing post donation HPN.
Management of post donation BP
During early post donation period, it’s advisable to allow elevated BP to around 160/90 to maintain adequate kidney perfusion and consider short acting VD drugs as CaCB for higher BP levels. Long term management of BP is the same as non donor population but avoid diuretics and ACEI.
level of evidence :5
The cut off value for rejecting a donor with hypertension varies between guidelines. Caring for Australasians with Renal Impairment (CASI), British Transplantation Society (BTS) and Canadian Council for Donation and Transplantation (CCDT) recommend avoiding donors with >140/90 mm Hg on 3 occasion. Amsterdam Forum, American Society of Transplantation (AST) avoid >140/90 mm Hg. European Association of Urology (EAU) and European Best Practice Guidelines (EBPG) avoid Uncontrolled hypertension. Organ Procurement and Transplantation Network (OPTN) avoid >130/85 mm Hg (in donors <50 y old). Kidney Disease Improving Global Outcomes (KDIGO) avoid >140/90 mm Hg on <2 AHMs, end-organ damage or predicted lifetime ESRD risk exceeding transplant center’s acceptable risk threshold
the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA define hypertension as: Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg.
SPRINT (Systolic Blood Pressure Intervention Trial) evidently established that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events.
Evaluation of donors includes BP measurement on 2 separate occasions by a trained staff and calibrated device.
There are differences between office, home, and ABPM readings which were not studied in a sufficient way. This is important as in the past donors were discarded if they have a BP reading >140/90 mm Hg and/or use of antihypertensive medications. Recently, easily controlled hypertension with 1 or 2 agents and no evidence of target organ damage may be accepted as low-risk kidney donors. The KDIGO suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy. The authors added a concern in younger donors, especially if they are overweight or have African ancestry, or both.
predonation hypertension was not associated with an increased risk of any perioperative complications, such as gastrointestinal, bleeding, respiratory, and surgical injuries. Some studies have found that donors with predonation hypertension have a decline in kidney function while others have not.
These discrepancies are due to variance in follow-up length, study population, hypertension definitions, sample size, short follow-up times, unrepresentative patient populations, and low rates of followup. a 5-mm Hg increase in systolic BP had a very small effect on ESRD risk compared with other factors, although there was marked glomerulopenia in hypertensive donors, there was a nonsignificant difference in GFR, hyperfiltration capacity, or compensatory renocortical hypertrophy. older donors with hypertension had a higher risk of ESRD but not mortality for 15 years postdonation.
systolic and diastolic BP increased slightly and significantly over time in both donors and controls, but there were no significant differences between the 2 groups; in addition, after 3 years, the 24-hour ABPM of both groups was not statistically significant either. There are also reports that suggest that there is an increased risk of developing hypertension postdonation but there was no comparison of these statistics with that of the normal population.
African American donors had a 37% higher relative likelihood of any antihypertensive medication use after donation compared with Caucasian living donors and they were less likely to have their BP controlled despite equal access to care. MYH9 and APOL1 loci on Chromosome 22 have been linked with nondiabetic kidney disease in several recent studies. After controlling for multiple risk factors, including age, gender, and ethnicity, on average, obese donors (BMI >30) had higher mean systolic and diastolic BPs than nonobese donors, leading to a significant increase in ESRD risk.
Specific antihypertensive therapy in living kidney donors must be individualized according to comorbidities, drug-drug interactions, drug side effects, and kidney function. Management should include positive lifestyle changes, including weight control, modest dietary sodium reduction and regular exercise, smoking avoidance, and modest alcohol intake and avoid angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics perioperatively due to adaptive hyperfiltration and expected shifts in volume. The KDIGO Clinical Practice Guidelines suggest that annual BP measurements and hypertensive living kidney donors should be followed more frequently.
The authors suggested evaluating potential living kidney donors on the basis of their BPs The average of 3 office readings 1 minutes apart after 5 minutes rest before readings are conducted with a properly sized BP cuff. ABPM should be considered for any concerns or younger age, overweight, or African heritage. if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling. If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation. reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive medication, who has obstructive sleep apnea orAfrican heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women , should have an ABPM and preferably try to lose some weight. If the patient’s 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation. If the patient’s 24 hour ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight; when their BP becomes <125/75 mm Hg on a subsequent 24 hour ABPM reading or over multiple office measurements, they could then be reevaluated for living kidney donation. they adopted target post donation BP ≤130/80 mm Hg.
Level of evidence is 5
Introduction:
Elevated blood pressure (BP) is one of the leading exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both kidney transplant recipients and living kidney donors alike.
Despite hypertension affecting both kidney recipients and donors, the impact of hypertension on the latter has not been as well studied and understood. The definitions of “hypertension” are variable depending on the guidelines.
Guidelines and their contraindications to donation for hypertension:
Contraindication
Caring for Australasians with Renal Impairment (CASI), British Transplantation Society (BTS),
Canadian Council for Donation and Transplantation (CCDT) >140/90 mm Hg on 3 occasions
Amsterdam Forum, American Society of Transplantation >140
European Association of Urology, European Best Practice Guidelines Uncontrolled hypertension.
Organ Procurement and Transplantation Network (OPTN) >130/85 mm Hg (donors less 50).
KDIGO >140/90 mm Hg on 2AHM, end- organ damage
Or predicted lifetime ESRD risk exceeding
Transplant center’s acceptable risk threshold.
Evaluation and Assessment of BP:
Screening for hypertension in potential donors should include BP measurement on two separate occasions If BP is determined to be high, or high normal, especially if there is
Variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements.
Controlled hypertension with one or two agents and no evidence of target organ damage may be accepted as low-risk kidney donors on a case-by-case basis.
Additional examinations and imaging studies may be considered in those with borderline hypertension or abnormalities to assess their qualification to donate.
The KDIGO working group report of 2017, suggested that potential donors with hypertension should be individualized in relation to the transplant program’, should be counseled that donation might accelerate the rise in BP and increase the need for more antihypertensive therapy.
This is also a concern in younger donors, especially if they are overweight or have African ancestry, or both.
Preexisting Hypertension in Kidney Donor Candidates:
Donors with well-controlled BP with one or two medication and evidence of TOD have low risk of ESRD or hypertension post donation.
Development of Hypertension in Kidney Donors Post donation:
There is conflicting result, but those with marginal factors like obese, African American have more risk than Caucasian is.
Management of BP and Hypertension Post donation:
Early after donation, it is suggested to allow BP keep Blood pressure. Below 169/90.
Late individualized treatment with indication.
Avoid diuretic, ACE and ARB.
KDIGO Guidelines suggest that proper BP measurements should be performed annually.
Hypertensive living kidney donors (whether the hypertension developed pre or post donation) should be followed more frequently than the average,
Normotensive donor and to have regular BP, laboratory, and urinary albumin: creatinine ratio tests conducted.
Based on the most recent ACC/AHA guidelines,
If the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling. If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking > less than 130/80 , two antihypertensive medication, then they should be considered kidney donation.
If blood pressure more than 160/90, evidence of TOD or take more than two medication should be excluded from donation.
Level of evidence V
The queue of transplant recipients is only increasing and a possible solution that also brings better survival results for the graft and the recipient is the donation from living donors. However, over the years, the number of donors has been decreasing, mainly because the number of proposed qualified donors has also been decreasing. The main factors involved are: hypertension, diabetes, obesity and impaired renal function.
Of those already mentioned, high blood pressure is one of the main criteria for exclusion. It is perhaps the least studied, in addition to being the most confusing, as new definitions are constantly emerging. The 2017 ACC/AHA Hypertension Clinical Practice Guidelines defined high blood pressure as systolic pressure between 120-129 mmHg and Stage 1 Hypertension – systolic pressure between 130-139 mmHg or diastolic pressure between 80-80 mmHg , while the guidelines on hypertension in living kidney donors use systolic pressure greater than 140 mmHg.
This review aims to examine the latest guidelines with respect to the following points;
A – HYPERTENSION
The first point that should be noted is that misclassification of blood pressure (BP) is common, especially if there is perceived variability between office, home and Ambulatory Blood Pressure Monitoring (ABPM) measurements.
The SPRINT (Systolic Blood Pressure Intervention Trial) clearly demonstrated that a lower BP goal (< 120 mmHg) was associated with a reduction in cardiovascular events in a population with a mean age of 68 years, no evidence of diabetes, and a low filtration rate estimated glomerular (GFR) of approximately 72 mL/min/1.73 m2. This same study demonstrated that the consistency of the benefit in reducing cardiovascular events was substantial, regardless of the participants’ GFR.
B – IMPACT OF LIVING DONATION IN HYPERTENSIVE DONORS
From a short-term perspective, Lentine et al concluded that pre-donation hypertension was not associated with an increased risk of any perioperative complications, such as gastrointestinal, hemorrhage, respiratory and surgical injuries. Therefore, donors with well-controlled BP (BP < 140/90 mmHg with 1 to 2 antihypertensive drugs or NO evidence of end-organ damage) appear to have minimal risk of developing worsening renal function or hypertension.
C- RISK FACTORS FOR DEVELOPING HYPERTENSION AFTER DONATION (NORMOTENSIVE DONORS)
Although kidney donation often leads to physiological changes (renal hyperfiltration, upregulation of the renin-angiotensin-aldosterone system and changes in vascular tone) that can increase BP, it is not considered a risk factor for the development of post-donation hypertension.
An important prospective study by Kasiske et al followed living kidney donors over a 3-year period. They observed that systolic and diastolic BP increased slightly and significantly over time in donors and controls, but there were no significant differences between the 2 groups. Furthermore, after 3 years, the 24-hour ABPM of both groups was also not statistically significant.
However, it is important to keep donors with risk factors: African-American and Hispanic ancestry, BMI, and age under surveillance, as they appear to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation.
D – MEDICAL AND LIFESTYLE MANAGEMENT OF BLOOD PRESSURE IN LIVING DONORS
Long-term BP control in kidney donors is patient-specific and therefore it is difficult to recommend a general medication regimen. Specific pharmacotherapy should be individualized according to comorbid conditions, drug interactions, drug side effects, and renal function. Townsend et al recommend that angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided in the perioperative period due to adaptive hyperfiltration and expected changes in urinary volume.
Along with a personalized medication regimen, living kidney donors also need to make positive lifestyle changes, including weight management, modest reduction in dietary sodium and regular exercise, avoidance of smoking, and modest alcohol intake. They should also receive proper education on how to take BP at home for self-BP monitoring and management.
This is level 05 – narrative review
Living donation increased with an increase in demand for kidney donation. This was affected By the change in the definition of HT over time. The balance between risk and benefit is needed. In this review, HT and its effect on living kidney donation was reviewed. Most guidelines, including KDIGO, stated BP>140/90 as a contraindication to living donation. OPT set donors less than 50 years old with BP>135/85 as a contraindication. Many differences are present, with a lack of studies differentiating between home and hospital-based measurements. Although HT is a known risk for cardiovascular disease, some studies included well-controlled HT patients without end-organ damage and extended the pool of donors. It seems that patients with BP<140/90 on one medication and no end organ damage have low risk after donation. The results of studies are variable. Some retrospective studies showed 2.4 fold increase in the risk of HT post-donation. Early post-donation, there is a permissive HT to allow sufficient perfusion of kidney. In general, more guidelines suggest BP>140/90 in ABPM contraindication to living donation.
Blood Pressure and Living Kidney Donors:
Elevated blood pressure has been one of the main exclusion criteria for living kidney donation, as it is a risk factor for renal and cardiovascular disease. living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation.
In general, screening for hypertension in potential donors should include BP measurement on 2 separate occasions with equipment that has been calibrated. If BP is determined to be high, or high normal, or the patient is younger, overweight, or has African origin, then BP should be evaluated with ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements.
In the past, a BP reading >140/90 mm Hg and/or use of antihypertensive medications (AHMs) was considered as contraindications to donation. However, patients with easily controlled hypertension with 1 or 2 agents and no evidence of target organ damage may be accepted as low-risk kidney donors on a case-by-case basis.
The KDIGO working group report of 2017 suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counselled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
Development of Hypertension in Kidney Donors Post donation kidney donation often leads to physiological alterations (kidney hyperfiltration, upregulation of renin-angiotensin-aldosterone system, and changes in vascular tone) that may elevate BP, it is not considered to be a risk factor in developing hypertension postdonation.it is important to keep these risk factors (African American and Hispanic descent, BMI, and age) in mind when evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation.
Management of BP and Hypertension Post donation in Living Kidney Donors
The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of post donation follow-up care. Hypertensive living kidney donors (whether the hypertension developed pre or post donation) should be followed more frequently than the average with laboratory, and urinary albumin: creatinine ratio tests assessment.
Donor’s hypertension (HTN) is a contraindication for live donation. The definition of hypertension was revised by AHA 2017 guideline. So, elevated HTN is 120-129 mmHg for systolic and stage 1 HTN is 130-139 for systolic or 80-89 mmHg for diastolic. While in the past BP more than140 mmHg was considered high and contraindication for donation donors BP should be measured on 2 separate visits.
If BP is high and the patient is young, overweight or black American, the ABPM should be performed, BP more than 140/90 on less than2 anti-hypertensive drug or end-organ damage are considered contraindication of donation according the KD1GO guideline.
However, in the case of donation, they are not at significant risk of CVD or renal diseases. Risk factors of past donation HTN are obesity African American or Hispanic and older donors which need to fallow-up after donation. They suggested four items:
1- BP more than 160/100 mmHg, with end organ damage and using more than 2 antihypertensive medication (AHM)are excluded from donation.
2- Candidates with BP less than 130/80 but abuse or African or those with BP more than 130/80 but less than 160/90 with use of 1-2 AHM or obstructive sleep apnea should have ABPM and if their ABPM shows 24 h BP less than 125/75 will be considered for donation.
3- Candidates with BP less 130/80 mmHg without obesity or being African are considered for donation.
4- If ABPM shows more than 125/75 mmHg, life style modification and drugs should have started with weight control. If BP become less than 125/75 they could be revised for donation.
This article is a review with expert opinion and level of evidence is 5.
Hypertension (HTN) is one of the most common obstacles that can disqualify a person from live kidney donation because it is associated with increased risks for kidney transplant recipients as well as living kidney donors.
Risk factors of HTN after kidney donation
Evaluation of BP before kidney donation
1- Clinic BP
2. Home BP
3. ABPM:
Contraindications to donation for hypertension >140/90 mm Hg on 3 occasions:
Preexisting Hypertension in Kidney Donor Candidates
Donors with well-controlled BP on 1–2 antihypertensive drugs with no evidence of target organ damage are considered at lower risk of renal complications.
BP assessment post-donation:
· Maintain a clinic BP ≤130/80 mm Hg.
· All donors should monitor their BP with home BP readings.
· Donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension.
living kidney donors who were hypertensive or developed post-donation should have more frequent BP checks, laboratory assessment of renal functions and urinary albumin:creatinine ratio.
Treatment of hypertension post donation
– Non pharmacological measures: include life style measures like exercise, salt restriction, DASH diet and stress reduction.
– Pharmacological treatment :
Early after donation: Initiate drug treatment only if BP is ≥ 160/90 to allow for optimal kidney perfusion (calcium channel blockers are preferred)
Avoid ACE/ARBS and diuretics to allow for kidney compensation and hyper filtration.
Long term: Blood pressure control is selected on individual basis, taking into consideration comorbidities, renal function and volume status.
Conclusion
Criteria for diagnosis HTN changed in the last few years. Some of guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of antihypertensive medications be a contraindication to donation. Hypertensive donors are allowed to donate if they have no increased risk of developing renal or cardiovascular health problems.
Level of evidence of this article
review article, level V
This is a review study that looked at the impact of hypertension on kidney donors.
Donors with BP below 120/80 were associated with lower risk of cardiovascular events as evidenced by SPRINT study.
Pre-donation BP measurement should be done at 2 separate occasions by well trained staff using a proper cuff in proper environment. Ambulatory BP monitoring is recommended in case of high BP or high normal or younger donors with high BMI, or African origin.
Donors with well controlled hypertension with one or two anti-hypertensive medications without target organ damage are accepted as kidney donors.
Some observational studies revealed that donors with pre-donation hypertension had declining GFR. Other studies revealed that there was no difference in GFR in normotensive and hypertensive donors.
Kidney donation is not a risk factor for development of hypertension after donation.
Donors of African American or Hispanic ethnicity, or with high BMI or with older age are more prone to post-donation hypertension.
The evidence of this study is V.
Blood Pressure and Living Kidney Donors: A Clinical Perspective
Living kidney donation has many benefits, as possibility of preemptive transplantation, but the number of living kidney donations has been decline since 2004. That can be because of presence of health concerns, such as obesity, hypertension, diabetes, and impaired kidney function. This causing the waiting list for kidney donors increases every year. Elevated blood pressure (BP) is one of the exclusion criteria for living kidney donation.
The definition of BP evolved over time. For the kidney donors, it is better to define the hypertension as that level of BP in which the benefits of treatment out-weight the risks of inaction, if this is possible. As this allows appropriately individualize the care plan.
Current Living Kidney Donation Guidelines
High BP has been one of the main contraindications to living kidney donation, but the donation risks in mild, well-controlled hypertension are not well understood. This leads to the development of several different guidelines that try to define hypertension. Despite these guidelines, most transplant centers adhere to their own standards while evaluating donors with hypertension.
2017 high blood pressure clinical practice guidelines by ACC/AHA, defines an elevated BP is 120—129 mm Hg systole and stage 1 is 130—139 mmHg systole or 80—89 mmHg diastole. The effects of these guidelines remain to be seen. Old guidelines have raised concerns about donors with systolic BP > 140 mmHg, and some even for systolic BP > 130 mmHg, especially in younger donors. Also, treatment goals of these donors remains a question in light of these newer guidelines.
The SPRINT clearly found that a BP goal < 120/80 mmHg is associated with a decrease in cardiovascular events in individuals with mean age of 68 years, not diabetic, and an e GFT of about 72ml/min/1.73m2. But, it does not provide evidence that lower systolic BP goals are important in delaying the progression of kidney disease, and because the mean GFR in SPRINT study participants is not different from that observed in kidney donors there may be reason to believe that kidney donors might need lower BP targets, especially in young age, obesity, and African.
Evaluation and Assessment of BP Predonation
Screening for hypertension in potential donors should include 2 measurements on 2 separate occasions by trained clinical staff with calibrated equipment. If high or high normal especially in young age, overweight, or African then BP should be measured with ambulatory BP monitoring (ABPM) or repeated standard BP measurements. Patients with easily controlled hypertension with 1 or 2 drugs and no evidence of end organ damage may be accepted as low risk kidney donors on a case-by-case basis. Donors with borderline hypertension may require imaging studies. KDIGO working group advice to counsel donors that BP may accelerate post-donation, and there may be need to more antihypertensive drugs.
Preexisting Hypertension in Kidney Donor
As response to decreasing supply of donor organs and increase demand, many centers are relaxing their criteria to include donors with well-controlled hypertension.
In summary, donors with well-controlled BP (BP <140/90) controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension, strengthening the support for their inclusion into, and consequent expansion of, the living kidney donor pool. Yet, the available studies are of short duration, and there are phenotypes, such as obese, or people with African heritage who may be at more risk, and genotypes such as APOL1 which may confer more risk over time.
Development of Hypertension in Kidney Donors Postdonation
It is important to consider risk factors (African American and Hispanic descent, BMI, and age) when
evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation. Donors with risk factors for hypertension may require earlier and more intensive strategies to control BP.
Management of BP and Hypertension Postdonation in Living Kidney Donors
in the early post-donation period, it is allowed to maintain high BP < 160/90 mm Hg for optimal kidney perfusion. This can be maintained by short acting agents like calcium channel blocker or clonidine. Treatment of BP elevation on the long-term should be individualized according to comorbidities, drug-drug interaction, drug side effect, and kidney function.
In addition to pharmacological therapy, donors should have positive life style modifications. Such as regular exercise, decrease salt intake, ideal body weight, avoid smoking, and moderate alcohol intake.
KDIGO guidelines suggest that postdonation BP should be measured annually. Hypertensive donors should have more frequently than normotensive donors, also should have laboratory, and urinary albumin:creatinine ratio test and cardiovascular risks modifications.
Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
Office BP measurement should be carried out as recommended. If there is another concerns about a donor’s BP or young age, over-weight, or African origin then ABPM should be considered.
According to ACC/AHA guidelines, patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (LVH, albuminuria), or is taking 2 antihypertensive medications, then they should be excluded from kidney donation.
This study raises a concernabout patients with an average office BP reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive medication, who has obstructive sleep apnea or African origin, or has obesity (waist circumference of ≥94cm for men and ≥80cm for women) which are risk for ESRD. These donors should have an ABPM and lose weight. If ABPM BP <125/75 mm Hg can be considered for donation. If donor’s 24 hrs ABPM reading is ≥125/75 mm Hgm they should receive drug and lifestyle interventions to control their BP and weight; when their BP becomes < 125/75 mmHg on a subsequent 24 hrs ABPM reading or office measurements, they could then be reevaluated for living kidney donation.
Postdonation BP is suggested to maintained ≤130/80 mmHg clinic measurement, which is in line with current guidelines for general populations. ABPM is best than office BP in predicting the prognosis of high BP, but no data to support its use for all potential donors, because of cost, and availability.
Conclusion
Currently, some of the guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, when hypertensive donors are allowed to donate, they do not seem to be at a significantly increased risk of developing renal or cardiovascular health issues.
the demand for kidney donations much more than the supply of deceased donor allografts
outcome of Live kidney Transplant is much better than deceased donors.
live kidney donations can be used as preemptive or early interventional treatment
overall decline in number of living kidney donations since 2004, while the waiting list for kidney donors increases every year. This decline could be due to the medical unsuitability of potential donors
Elevated blood pressure (BP) is one of the most important cause of rejection of the donor due to the dual adverse effect and outcome on the recipient and the donor
The review will discuss the following:
Current Living Kidney Donation Guidelines
· most guidelines have raised concerns about donors with systolic BP >140 mm Hg, or systolic blood pressure >130 mm Hg, especially in younger donors.
· SPRINT (Systolic Blood Pressure Intervention Trial) clearly demonstrated that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events in a population with a mean age of 68 years, no evidence of diabetes, and an estimated glomerular filtration rate (GFR) of approximately 72mL/min/1.73 m2 ><120/80 mm Hg) was associated with a reduction in cardiovascular events in a population
· Of note, the mean GFR in the SPRINT study participants of ~70mL per minute which is equivalent to those who donated a kidney.
· kidney donors might need lower BP targets, especially if they are younger, overweight, or have African ancestry.
Evaluation and Assessment of BP Pre-donation
· screening for hypertension in potential donors should include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated
· if high then do ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements
· earlier hypertensives were not accepted as donor however as the demand of the donors increased , patients with mild controlled hypertensives were accepted as kidney donors.
· The KDIGO working group report of 2017 suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy. This is especially true in younger donors, overweight or have African ancestry
Preexisting Hypertension in Kidney Donor Candidates
· The Observational studies or retrospective studies showed controversies in their results , some reported decline in kidney function while others have maintained their kidney function .
· This could be due to difference in the duration of follow up , and sample size in addition to the definition of hypertension in each study.
· pre-donation BP has a small effect on ESRD risk compared with other factors, such as increased proteinuria or reduced GFR.
· Studies showed older donors with hypertension had a higher risk of ESRD but not mortality for 15 years post-donation.
· In summary, donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension.
· However there are certain individual who carries higher risk such as
· Obese
· people with African heritage
· genotypes such as APOL1
they are not ideal candidate despite a BP of 115/70 mm Hg.
However, proper counseling on the risks (increased BP and potential end organ damage), should be conducted.
Development of Hypertension in Kidney Donors Post-donation
· Even though kidney donation often leads to physiological alterations (kidney hyperfiltration, upregulation of renin-angiotensin-aldosterone system, and changes in vascular tone) that may elevate BP, it is not considered to be a risk factor in developing hypertension postdonation.
· Studies comparing donor and non donor did not show a significant difference in developing hypertension in both groups.
· studies often fail to compare their study population with age matched controls.
· The long-term risk of hypertension were studied in living kidney donors showed statistically significant increase in BP postdonation, with 21% of the donors developed hypertension that required AHM use. However, the increase in BP was from 113/75 to 116/77 mm Hg, values that are well below the normal benchmarks for hypertension. But there was no comparison of these statistics with that of the normal population,
· Another study showed that the risk of developing hypertension, defined as >140/90 mm Hg, increased 3.64-fold 1-year post-donation. However, the mean predonation systolic and diastolic BP values of the normotensive donors who were hypertensive after 1 year postdonation were significantly higher than those donors who were normotensive after 1 year postdonation.
· This suggests that these patients may have been prehypertensive or more susceptible to developing hypertension.
· While those who remained normotensive after 1 year and 5 years, there was only a modest and nonsignificant increase in risk of developing hypertension.
· Thus, this study suggests that kidney donation itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP, and if your predonation systolic BP is 135 mm Hg, you are more likely to reach 140mm Hg than if your BP was 125 mm Hg over the course of several years.
· African American donors had a 37% higher relative likelihood of any antihypertensive medication use after donation compared with Caucasian living donors. This is due to the fact that African American patients with hypertension have resistant hypertension and higher rates of incident ESRD than European Americans.
· MYH9 and APOL1 loci on Chromosome 22 have been linked with nondiabetic kidney disease in several recent studies.
· Two alleles of the APOL1 gene, G1, and G2, are associated with higher risk of focal glomerulosclerosis and hypertension-attributed kidney disease.
· the risk allele frequency in African Americans for G1 or G2 is ~30%, it is much lower in Hispanics with African admixture and extremely low in European Americans.
· These variants may explain 70% of the excess focal segmental glomerulosclerosis, HIV-associated nephropathy, and hypertensive kidney disease in African Americans.
· Screening for APOL1 susceptibility variants in kidney donors before surgery may have an important impact on outcomes for kidney transplant recipients.
· Donors with 2 APOL1 variants convey higher risk of allograft failure to recipients.
· Current consensus guidelines have contraindicated donors with a BMI >30–35. And these group is more likely to have predonation hypertension and each increase in year of donor age was associated with a 5%–7% higher likelihood of hypertension.
· frequency of hypertension increased by 10% for each 1-unit increase in BMI, with higher BMI being associated with higher rates of hypertension 5 years postnephrectomy.
· BMI status at time of evaluation determines one’s postdonation prognosis.
· In summary, it is important to keep these risk factors (African American and Hispanic descent, BMI, and age) in mind when evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation. As discussed below, donors with risk factors for hypertension may require earlier and more intensive strategies to control BP.
Management of BP and Hypertension Postdonation in Living Kidney Donors
· Early after donation, it is suggested to allow BP (<160/90 mm Hg) to be elevated to allow for optimal kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
· Long-term control of BP in kidney must be individualized according to comorbidities, drug-drug interactions, drug side effects, and kidney function. It is recommend that angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
· living kidney donors also need to make positive lifestyle changes, including weight control, modest dietary sodium reduction and regular exercise, smoking avoidance, and modest alcohol intake.
· They should also receive proper education on taking home BP for self-BP monitoring and management.
· The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of postdonation follow-up care.
· Hypertensive living kidney donors (whether the hypertension developed pre or postdonation) should be followed more frequently than the average, normotensive donor and to have regular BP, laboratory, and urinary albumin:creatinine ratio tests conducted.
· They should also have their other cardiovascular risk factors well controlled.
· However, these recommendations are somewhat unrealistic, given frequent lack of follow-up of living kidney donors. Ideally, there should be a systematic approach. Moreover, higher risk patients may also require lower BP targets for treatment.
Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
Based on the current literature, we suggest the following protocol in evaluating potential living kidney donors on the basis of their BPs
· Office readings should be carried out as recommended in most guidelines:
· patient will rest 5 minutes before readings are conducted.
· BP should be measured with a properly sized BP cuff.
· The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading.
· If there are additional concerns about a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered and measurements take place every 15– 30 minutes during the daytime and 30–60 minutes at night for 24 hours with measurements.
· Based on the most recent ACC/AHA guidelines, if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling.
· If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.
· In the absence of any available clinical data, we raise concern about patients with an average office BP reading ≥130/80 mm Hg but <160/100 mm Hg, and is taking 2 or fewer antihypertensive medication.
· Patients who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94cm for men and ≥80cm for women as obesity has been shown to be a risk factor for ESRD.
· They should have an ABPM and preferably try to lose some weight. If the patient’s 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation.
· Other wise they should be counseled then reevaluated for living kidney donation.
· With respect to BP assessment post-donation, we suggest maintaining a clinic BP ≤130/80 mm Hg, which is in line with current guidelines, not only for living kidney donors but for the general population.
· Whether patients who are obese or possibly carry high risk APOL1 variants require lower BP targets is an intriguing question.
· However this proposal does not take into account “masked hypertension,” defined as normal BP in the office with elevated BP in nonoffice settings, as the prevalence of masked hypertension in the healthy population has not been clearly elucidated.
· In addition, there is currently not enough data to support the use of ABPM for all potential donors, as we have to be mindful of the cost, availability, and expertise needed to perform ABPM correctly.
· We recommend that ideally all potential donors should monitor their BP with home BP readings.
CONCLUSIONS
living kidney donors is the possibility of developing hypertension after kidney donation, especially if they are younger, overweight, or of African heritage. Studies have shown that in healthy, well-selected donors with no known risk factors, living kidney donation does not significantly predispose them to developing hypertension postdonation.
Personalized pharmacotherapy along with beneficial lifestyle changes and more follow-up appointments should be utilized to manage BP and hypertension after kidney donation.
level of evidence , it is a review article -level 5
Introduction
No doubt renal transplantation is considered the best successful solution for ESRD patients ,even living donation has the best outcome rather than the deceased donation outcomes regarding both patient and graft survival ,however a list of considerable obstacles face living donation especially donor clinical dilemmas. Living donation also can widen the option of timing for donation whether pre emptive or interventional after the establishment of dialytic support.
Among the discussed exclusion criteria for renal donation hypertension, obesity, diabetes, and impaired kidney function. The definition of hypertension has been evolving over the years. For living renal donors, hypertension represents a clinical conflict and our role as transplant nephrologists is how best to assess this balance between BP and long-term outcomes.
Current Living Kidney Donation Guidelines
Most guidelines have concerns regarding donors with systolic BP >140 mm Hg. the SPRINT (Systolic blood Pressure Intervention Trial) stated that the lower BP goal (<120/80 mm Hg), the more associated reduction in cardiovascular events. Kidney donors might need lower BP targets, particularly if they are young in age, overweight, or of African background.
Evaluation and Assessment of BP Predonation
Screening for hypertension must include BP measurement on 2 separate occasions by experienced clinical personnel. Cases with suspected elevated blood pressures ought to perform ambulatory BP monitoring (ABPM) for further evaluation.
A study conducted by Armanyous et al referring to daytime ABPM as a gold standard revealed a 16% prevalence of hypertension in candidate renal donors. They also detected a substantial percentage of patients having masked hypertension, determined with ABPM.
Historically, HTN per se was considered as a contraindication for donation, however in this era patients with easily controlled hypertension with 1 or 2 agents and without evidence of target organ damage can be accepted as low-risk candidate donors.
According to Lentine et al study a conclusion of predonation hypertension was not associated with any increased risk of any perioperative complications, like gastrointestinal, bleeding, respiratory, and surgical injuries was established.
However, the KDIGO recommended that donors ought to be counseled that donation might accelerate the rise in their BP and increase the need for more antihypertensive therapy.
Preexisting Hypertension in Kidney Donor Candidates
Some studies stated that donors with predonation hypertension have a decline in renal function (evidenced by increasing serum creatinine and decreased estimated GFR), whereas other studies concluded that there were no difference in renal function between normotensive and hypertensive donors. These studies had many limitations varying between follow-up duration, study population, hypertension definitions as well as sample size.
According to Lenihan et al there was marked glomerulopenia in hypertensive donors, but not associated with significant difference in GFR, hyperfiltration capacity, or compensatory renocortical hypertrophy later on.
In fact older donors with hypertension had a higher potential risk of ESRD but not mortality for 15 years post donation. Furthermore, donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and with no evidence of target organ damage) are considered of minimal risk of occurrence of worsening kidney function or hypertension.
Thus, these previously discussed data augments the expansion of living donor pool.
Development of Hypertension in Kidney Donors Post donation
Kasiske et al conducted a study of 3 year donation concerned with systolic and diastolic BP in renal donors which increased slightly and significantly over time in both donors and controls, with conclusion that no significant differences between both groups.
This study highlights that kidney donation itself is not associated with significant increase in the risk of occurrence of hypertension, rather than other factors that might cause progressive rise in BP, as if the predonation systolic BP is 135 mm Hg, this is more likely to reach 140 mm Hg than if the BP was 125 mm Hg over the course of several years.
Hypertension was estimated by 41% of African American donors in a study compared with 30% of Caucasians on follow up of 7 years duration. African American donors present a 37% higher relative tendency for the use of antihypertensive medication post donation compared to those Caucasian living donors.
The fact that African Americans have higher rates of development of ESRD than European Americans due to their genetic background as MYH9 and APOL1 loci on Chromosome 22 have been clearly linked to occurrence of nondiabetic kidney disease in several recent studies. The presence of the APOL1 gene, G1, and G2 explains the potential higher risk of focal glomerulosclerosis and hypertension renal diseases.
This genetic background explains 70% of the progression to focal segmental glomerulosclerosis, HIV-associated nephropathy, and hypertensive renal disease in African Americans. So it is preferred to apply screening for APOL1 susceptibility variants in donors prior to donation. Even donors with 2 APOL1 variants confront higher risk of allograft failure in renal transplant recipients afterwards.
Lentine et al recommended refusing obese donors as they are more prone to hypertension as well as each increase in year of donor age was accompanied by a 5%–7% higher likelihood of hypertension. The frequency of hypertension increases by 10% for each 1-unit increase in BMI; the higher the BMI, the higher rates of hypertension 5 years post nephrectomy, the more associated ESRD risk probability. Hip-to-waist ratio is a promising tool which may be more sensitive prognostic tool for determining health outcomes than BMI.
Management of BP and Hypertension Post donation in Living Kidney Donors
Townsend et al suggest the avoidance of both angiotensin converting enzyme inhibitors, angiotensin receptor blockers as well as diuretics perioperatively for proper adaptive hyperfiltration and expected shifts in volume.
Living donors need to adopt healthy lifestyle with special emphasis on weight control, modest dietary sodium reduction, regular exercise and smoking cessation. They must also perform frequent BP monitoring and management if needed.
The KDIGO Clinical Practice Guidelines recommend for donors follow up to be carried on annual basis including regular BP, laboratory, and urinary albumin: creatinine ratio tests.
CONCLUSIONS
Hypertensive donors are allowed to donate based on the absence of significant risk for developing renal or cardiovascular health issues. More strict strategies to evaluate BP in candidate living donors and maintain proper BP control post donation ought to be adopted finally.
Level of evidence 5.
Current Living Kidney Donation Guidelines
2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA definition
Elevated BP is 120–129 mm Hg systolic
Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg
Most guidelines for donor evaluation contraindicate kidney donation with blood pressure more than 140/90mmHg
The authors of the study have the following guidelines:
Level of evidence
Level V
Blood Pressure and Living Kidney Donors: A Clinical Perspective
Elevated blood pressure (BP) is one of the leading exclusion criteria for living kidney donation, as it is a risk factor for renal and cardiovascular disease.
The most current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation.
This review, have examined the current living kidney donation guidelines with respect to HTN, the impact of living kidney donation on “hypertensive” donors, the risk of and factors contributing to the development of “hypertension” postdonation in normotensive donors, and medical and lifestyle management of BP in living kidney donors.
Current Living Kidney Donation Guidelines
The defnitions of HTN have been revised with the recent release of the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA. Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or
diastolic 80–89 mm Hg.
Evaluation and Assessment of BP Predonation
Screening for HTN in potential donors should include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated.
If BP is determined to be high, or high normal, then BP should be evaluated with ambulatory BP monitoring (ABPM) or repeated with standardized BP measurements.
Preexisting Hypertension in Kidney Donor Candidates
Some transplant centers are relaxing their selection criteria to include donors
with well-regulated hypertension
Donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension. Yet, the available studies are of short duration, and there are phenotypes, such as obese,
or people with African heritage who may be at more risk, and genotypes such as APOL1 which may confer more risk over time.
Development of Hypertension in Kidney Donors Postdonation
It is important to keep these risk factors (African American and Hispanic descent, BMI, and age) in mind when evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation.
Management of BP and Hypertension Postdonation in Living Kidney Donors
Early after donation, it is suggested to allow BP (<160/90 mm Hg) to be elevated to allow for optimal kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
Long-term control of BP in kidney donors depends on the individual patient and lifestyle changes (weight control, modest dietary sodium reduction and regular exercise, smoking avoidance, and modest alcohol intake). They should also receive proper education on taking home BP for self-BP monitoring and management.
The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of postdonation follow-up care. Hypertensive living kidney donors should:
i. Be followed more frequently
ii. Have regular BP, laboratory, and urinary albumin: creatinine ratio tests conducted.
iii. Have their other cardiovascular risk factors well controlled.
CONCLUSIONS
Currently, some of the guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, hypertensive donors do not seem to be at a significantly increased risk of developing renal or CVD.
Another concern for living kidney donors is the possibility of developing HTN after kidney donation, especially if they are younger, overweight, or of African heritage.
Studies have shown that in healthy, well-selected donors with no known
risk factors, living kidney donation does not signifcantly predispose them to developing HTN postdonation; however, certain risk factors, such as being African American or Hispanic, obese, or older, are associated with higher likelihoods of developing hypertension postdonation.
Personalized pharmacotherapy along with beneficial lifestyle changes and more follow-up appointments should be utilized to manage BP and HTN after kidney donation.
Q1- Please summarise this article in your own words.
Abstract
The guidelines state that a BP >140/90 mm Hg with 1–2 AHM or evidence of end-organ damage to be excluded from living kidney donation.
But , the definitions of “hypertension” have changed according to American guidelines suggesting that 120–129 mm Hg is elevated BP and Stage 1 hypertension is 130 mm Hg.
There is a fact that the kidney function (eGFR) of “hypertensive” donors does not significantly worse postdonation compared to that of “normotensive” donors and the kidney donation itself is not considered to be a risk factor for developing hypertension, but other risk factors play a role (African American or Hispanic descent, obesity, age).
The choice of BP targets and medications should be individualized. In general, a BP target of <130/80 mm Hg is needed, with lifestyle modifications.
In general there is an increase in the numbers of ESRD patients but with adecrease in donor pool , this usually because of the high prevelance of disease in donors like HT,DM , renal impairment .
Current Living Kidney Donation Guidelines
Previously high BP considered as a contraindications to kidney donation.
Although the new BP guideline has changed according to ACC/AHA,
the definitions also are changed
Elevated BP is 120–129 mm Hg systolic and
Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg.
Even though the most guidelines concerns about donors with systolic BP >140 mm Hg, although some raised questions about systolic blood pressure >130 mm Hg, especially in younger donors.
SPRINT demonstrated that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events but SPRINT study does not provide evidence that lower systolic pressure goals are important in delaying the progression of kidney disease.
Evaluation and Assessment of BP Predonation
screening should include BP measurement on 2 separate occasions ( by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated ).
If BP is high, or high normal, if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with (ABPM) .
In the past , a BP >140/90 mm Hg and/or use of (AHMs) was considered as contraindications to donation. However, patients with easily controlled hypertension with 1 or 2 agents and no evidence of target organ damage may be accepted as low-risk kidney donors.
The KDIGO working group report of 201711 suggested that potential donors with hypertension should be individualized should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy. , especially if they are overweight or have African ancestry.
Preexisting Hypertension in Kidney Donor Candidates
more transplant centers are relaxing their selection criteria to include donors with well-regulated hypertension in response to decreasing supply of donor organs .
Kiberd noted that a 5-mm Hg increase in systolic BP had a very small effect on ESRD risk compared with other factors, such as increased proteinuria or reduced GFR.
In summary, donors with well-controlled BP (BP <140/90 controlled with 1–2 AHM and no evidence of target organ damage) seem to be at minimal risk of develop ing worsening kidney function or hypertension,
Development of Hypertension in Kidney Donors Postdonation
although kidney donation leads to physiological alterations (kidney hyperfiltration, upregulation ofrenin-angiotensin-aldosterone system, and changes in vascular tone) that may elevate BP, it is not considered to be a risk factor in developing hypertension postdonation.
Study by Kim et al study the long-term risk of hypertension in living kidney donors and found that there was a statistically significant increase in BP postdonation, with 21% of the donors developing hypertension that required AHM use. However, the increase in BP was from 113/75 to 116/77 mm Hg .
A study Thiel et al by suggests that kidney donation itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP .
In One study Hypertension was identified in 41% of African American donors compared with 30% of Caucasians. African American and Hispanic donors are at about a 50% increased relative risk of developing hypertension post donation.
Current consensus guidelines have contraindicated donors with a BMI >30–35.
obese donors (BMI >30) had higher mean systolic and diastolic BPs than non obese donors. studies have also shown that hip-to-waist ratio may be a more sensitive prognostic for determining health outcomes than BMI.
In summary, it is important to keep these risk factors (African American and Hispanic descent, BMI, and age) in mind when evaluating potential living kidney donors, as they seem to pose a higher risk of developing hypertension and other long-term medical complications as a result of donation.
Management of BP and Hypertension Postdonation in Living Kidney Donors
Early after donation, to allow BP (<160/90 mm Hg) to allow kidney perfusion, which can be controlled by calcium channel blocker or clonidine .
Long-term control of BP in kidney donors should be individualized . Townsend et al recommend that ACEI , ARBS , and diuretics should be avoided perioperatively .
The KDIGO Guidelines suggest that proper BP measurements should be performed annually , or more frequently in Hypertensive living kidney.
Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
Office readings needs
· patient will rest 5 minutes before readings are conducted.
· BP should be measured with a properly sized BP cuff.
· The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading.
If there are additional concerns , then ABPM will be considered.
Based on the ACC/AHA guidelines,
· if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation.
· If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage or is taking >2 antihypertensive medication,
then they should be excluded from kidney donation.
In the absence of any available clinical data, we raise concern about patients with an average office BP reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive
medication, who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women as obesity has been shown to be a risk factor for ESRD.
They should have an ABPM and preferably try to lose some weight.
· If the patient’s 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation.
· If the patient’s 24 hour ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight.
The author suggest maintaining post donation clinic BP ≤130/80 mm Hg .
Q2- What is the level of evidence provided by this article?
Level of evidence – 5
# Please summarise this article in your own words
# The objective:
*This study, estimate the recent living kidney donation guidelines with respect to “HTN,” the impact of living kidney donation on HTN donors, the risk of and factors contributing to the development of “HTN” postdonation in normotensive donors, and medical and lifestyle management of BP in living kidney donors.
#Current Living Kidney Donation Guidelines
High BP has long been considered as contraindications to live kidney donation, but the risks of donation in mild, well-controlled HTN are not well clarified.
*With the curent release of the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA, the definitions of HTN have been revised. Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg.
*The implications of these new guidelines on other published guidelines regarding kidney donation and HTN remain to be seen.
*The SPRINT clearly conducted that a lower BP goal (<120/80 mm Hg) was associated with a low cardiovascular events in a population with a mean age of 68 years, no evidence of DM, and e -GFR 72 mL/min/1.73 m2.
* Thus, kidney donors might need lower BP targets, especially if they are younger, obese, or have African ancestry.
# Evaluation and Assessment of BP Predonation
*The BP measurement accurately on 2 separate occasions by clinical staff, with equipment that has been calibrated.
* If BP is high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with (ABPM) or repeated with standardized BP measurements.
*The KDIGO working group report of 201711 suggested that potential donors with hypertension should be individualized in relation to the transplant programs, the donors should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
*So we can add that this is also a concern in younger donors, especially if they are overweight or have African ancestry, or both.
# Preexisting Hypertension in Kidney Donor Candidates
*Some studies have found that donors with predonation HTN have a decline in kidney function, while others have maintained that there is no significant difference in kidney function between normotensive and hypertensive donors.
*The discrepancy between these studies could be explained by the variance in follow-up length, study population, hypertension definitions, and sample size.
*In summary, donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension.
# Development of Hypertension in Kidney Donors Postdonation
*The risk factors (African American and Hispanic descent, BMI, and age) should be consider when evaluating potential living kidney donors, as they seem to pose a higher risk of developing HTN and other long-term medical complications as a result of donation.
*Donors with risk factors for hypertension may require earlier and more intensive strategies to control BP.
# Management of BP and Hypertension Postdonation in Living Kidney Donors
*Early after donation, to allow BP (<160/90 mm Hg) and to allow for optimal kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
*Townsend et al recommend that ACEI,ARBs, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
*Lifestyle changes are important (wt control, modest dietary sodium reduction and regular exercise, avoidance smoking and alcohol intake).
*The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of postdonation follow-up care laboratory, and urinary albumin:creatinine ratio tests conducted.
# Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
*Based on the current literature, the suggestion are:
Office readings should be carried out at rest 5 minutes before readings are conducted. The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading.
*If the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation.
* If the average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.
*If the average office BP reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer antihypertensive medication, who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women as obesity has been shown to be a risk factor for ESRD they should have an ABPM and preferably try to lose some weight.
* If the 24 hour ABPM BP reading is <125/75 mm Hg, they should be considered for donation. If the ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight; when their BP becomes <125/75 mm Hg on a subsequent 24 hour ABPM reading or over multiple office measurements, they could then be reevaluated for living kidney donation.
# What is the level of evidence provided by this article?
*The level of evidence is 5
Despite all the advantages and potential of living kidney donation, since 2004 there has been a general fall in the number of such donations.
Increased likelihood of negative outcomes for both kidney transplant recipients and living kidney donors makes elevated blood pressure (BP) one of the most common exclusion criteria for living kidney donation.
Potential donors should have their blood pressure checked twice to check for hypertension by clinical staff that has been trained to measure blood pressure reliably and with calibrated equipment.
In the past, antihypertensive drug use or a blood pressure level more than 140/90 mm Hg were regarded as contraindications to donation. On the other hand, low-risk kidney donors may be accepted in some cases for patients whose hypertension can be effectively managed with one or two medications and who show no signs of target organ damage.
Although some studies have found a decline in kidney function in predonation hypertensive donors (as shown by rising serum creatinine and falling estimated GFR), other studies have maintained that there is no appreciable difference in kidney function between normotensive and hypertensive donors.
Donors with well-controlled blood pressure (BP 140/90 controlled with 1-2 antihypertensive drugs and no signs of target organ damage) appear to be at low risk of developing worsening kidney function or hypertension, supporting their inclusion in, and consequent expansion of, the living kidney donor pool. However, the studies that are now available are of limited duration, and there are phenotypes, such as obesity or people with African ancestry, as well as genotypes, such as APOL1, that may increase risk over time.
When assessing potential living kidney donors, it’s crucial to keep these risk variables in mind because they seem to pose a higher chance of developing hypertension and other long-term medical issues. These risk factors include age, BMI, and people of African American and Hispanic heritage.
This is a narrative review (level 5 evidence)
It was discussed with evidenced from different guideline(AHA/ACC, SPRINT) that the pre donation hypertension, American African donors, obesity, BMI >30, and APOL1 gens are at higher risk developing hypertension post donation.
The new definition of hypertension has changed now >129/79 systolic is stage 1 hypertension, and hypertension is one of the main exclusion criteria for living donation.
Those with higher waist (male >94, female >80) BP at three different occasion higher then 140 systolic are at higher risk of developing hypertension post donation. so its strongly advised to reduce wait, BP control with lifestyle modification, and single medication can be individualized for donation.
level of evidence 5
Summary:
Hypertension is one of the main exclusion criteria for living kidney donation, as it is a risk factor for renal and cardiovascular disease.
The effect of elevated BP in living kidney donors is not well studied or understood.
The most current living kidney donation guidelines advocate donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation.
Though, the definitions of “hypertension” have changed with the release of the American Heart Association (AHA)/American College of Cardiology (ACC) clinical practice guidelines suggesting that 120–129 mm Hg is elevated BP and Stage 1 hypertension is 130 mm Hg.
However, the kidney function of hypertensive living kidney donors does not fare significantly worse post donation compared with that of normotensive donors.
In addition, even though living kidney donation itself is not considered to be a risk factor for developing hypertension, there exist certain risk factors African American or Hispanic descent, obesity, age.
The choice of BP targets and medications needs to be carefully individualized.
Level of evidence: 5
Hypertension,” is one of the main exclusion criteria for living kidney dona-
tion. The effect of hypertension in living donors is not known. Hypertension is a risk factor for renal and cardiovascular disease. Donors with a BP >140/90 mm Hg with 1–2 antihypertensive drugs or evidence of end-organ damage should be excluded from living donation (as per guidelines). According to the American Heart Association (AHA)/American College of Cardiology (ACC) a BP 120–129 mm Hg is an elevated and a BP of 130 mmHg is considered stage 1 hypertension.
Some studies have shown that donors with pre-donation hypertension have a decline in kidney function while others have demonstrated no significant difference in kidney function between living donors with normal BP and donors with hypertension.
However, the majority of the studies have shown that after the donation the kidney function of the living donors with hypertension does not progress significantly compared to the living donors with a normal BP.
Moreover, there are factors which increase the risk of developing hypertension in living kidney donors with normal BP after donation, such as obesity, age and ethnicity (African American or Hispanic descent).
Obese donors were more likely to have pre-donation hypertension and each increase in the year of donor age was associated with a 5%–7% higher likelihood of hypertension.
BP less than 130/80 mmHg is considered acceptable together with lifestyle adjusted to the individual.
This is a review article (Level 5)
This review article { Evidence level V} explores the hypertension and intervention prior to transplant.
Hypertension is one of exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both recipients and donors.
Current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded.
The impact of hypertension on donor has not been as well studied. The definitions of “hypertension” are variable depending on the guidelines.
Current LKD Guidelines
Risks of donation in mild, well-controlled “hypertension” are not well understood and most transplant centres adhere to their own standards when evaluating for hypertension in living donors
2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA, elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg
SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events in a population with a mean age of 68 years, no evidence of diabetes, and an estimated glomerular filtration rate (GFR) of approximately 72mL/min/1.73 m2 . mean GFR in the SPRINT study participants of ~70mL per minute is not different than observes in donors.so, kidney donors might need lower BP targets, especially if they are younger, overweight, or have African ancestry.
Evaluation and Assessment of BP pre-donation
Blood pressure in donors include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated.
If BP is determined to be high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ABPM or repeated with standardized BP measurements
Armanyous et al using daytime ABPM as a gold standard found a 16% prevalence of hypertension in kidney donors.
KDIGO WG report suggested that donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counselled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
Pre-existing Hypertension in Kidney Donor Candidates
Transplant centres are relaxing their selection criteria to include donors with well controlled hypertension.
Observational studies of hypertensive donors have shown heterogeneous results, Some studies found that donors with predonation hypertension have a decline in kidney function ,while some ither studies showed no significant difference .
The discrepancy between these studies could be explained by the variance in follow-up length, study population, hypertension definitions, and sample size.
Observational study of 24 533 older donors (≥50 y of age), including 2265 with predonation hypertension, demonstrated that older donors with hypertension had a higher risk of ESRD but not mortality for 15 years after donation.
It is suggested that donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at negligible risk of developing worsening kidney function or hypertension.
Kidney donation leads to physiological alterations (kidney hyperfiltration, upregulation of RAAS, and changes in vascular tone)
Studies done with follow-up for short period didn’t find significant increase in bp post donation
it was suggested that LKD itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP includes obesity, African American, smoking, older age.
Current consensus guidelines have contraindicated donors with a BMI >30–35. Lentine et al confirmed that obese donors were more likely to have predonation hypertension and each increase in year of donor age was associated with a 5%–7% higher likelihood of hypertension.
Study also demonstrated that the frequency of hypertension increased by 10% for each 1-unit increase in BMI, with higher BMI being associated with higher rates of hypertension 5 years post nephrectomy.
obese donors (BMI >30) had higher mean systolic and diastolic BPs than nonobese donors, leading to a significant increase in ESRD risk.
Management of BP and Hypertension Postdonation in Living Kidney Donors
Early after donation, it is suggested to allow BP (<160/90 mm Hg) to be elevated to keep kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
Townsend et al recommend that ACEi, ARB, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
KDIGO suggest that proper BP measurements annually as part of postdonation follow-up care.
Hypertensive living kidney donors should be followed more frequently than the average, normotensive donor and to have regular BP, laboratory, and urinary albumin: creatinine ratio tests examined.
When There is concerns about donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered, and measurements take place every 15– 30 minutes during the daytime and 30–60 minutes at night for 24 hours with measurements.
ACC/AHA guidelines stated that if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation
If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as LVH, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.
Current Living Kidney Donation Guidelines:
With the recent release of the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA, the definitions of hypertension have been revised. The implications of these new guidelines on other published guidelines regarding kidney donation and hypertension remain to be seen.
SPRINT study does not provide evidence that lower systolic pressure goals are important in delaying the progression of kidney disease.
Evaluation and Assessment of BP Pre-donation:
Screening for hypertension in potential donors should include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated.
If BP is determined to be high or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ambulatory BP monitoring.
Pre-existing Hypertension in Kidney Donor Candidates:
Observational studies of hypertensive donors have produced conflicting results. Some studies have found that donors with pre-donation hypertension have a decline in kidney function (evidenced by increasing serum creatinine and decreased eGFR while others have maintained that there is no significant difference in kidney function between normotensive and hypertensive donors.
Development of Hypertension in Kidney Donors Post-donation:
Physiological changes that happened post-donation are not considered a risk factor for HTN post-donation.
There may be an inherent factor that may contribute to the development of elevated BP aside from living kidney donation.
Pre-hypertension is a risk factor for post-donation HTN.
African American and Hispanic donors are also at about a 50% increased relative risk of developing HTN post-donation.
Obese donors were more likely to have pre-donation hypertension and each increase in the year of donor age was associated with a 5%–7% higher likelihood of hypertension.
Management of BP and Hypertension Post-donation in Living Kidney Donors:
personalized medication regimen.
positive lifestyle changes
proper education on taking home BP for self-BP monitoring and management.
Level 5 ( review article ).
Please summarize this article in your own words
This review explores current guidelines of Live related kidney transplant with respect to Hypertension in Donors, impact of kidney donation on Hypertensive donors, contributory factors of post donation Hypertension in Normotensive donors and lifestyle management to control BP in living kidney donors
Suggestions/Considerations made by Authors:
BP recording:
a. Office BP recording: Rest for 5 mins and average of 3 readings at 1 min gap each.
b. Ambulatory 24-hour BP measurement: Day recording every 15-30 mins and night recording 30-60 mins in 24 hours.
Consider ABPM in following subsets of patients
i. if BP≥130/80 on averaged office readings
ii. Obese patient
iii. African or Hispanic descent
iv. Use of 1 or 2 Anti-hypertensive drugs
v. Obstructive Sleep Apnea
Consideration for Donor selection with respect to BP:
· If office readings/24 hours ABPM <130/80, consider for donation.
· If office/24hour ABPM ≥ 130/80 but <160/100, taking ≤ 2 Antihypertensives(AHT), OSA, African/Hispanic Descent and Obese, advise lifestyle and Pharmacological interventions and should be revaluated for live kidney donation if 24 hour ABPM becomes < 125/75.
· If office reading>160/100, End-organ Damage (LVH, Albuminuria, Hypertensive retinopathy), use of 3+ AHT, exclude from Donor’s list.
Management of BP and Hypertension Post donation:
· Early after donation, elevated BP (<160/90) allowed for optimal kidney perfusion and filtration
· Preferred AHTs are short acting and selective (CCB or clonidine)
· Avoid ACEI, ARB, Diuretics perioperatively due to adaptive hyperfiltration and expected shifts in volume.
· BP measurement and Urine Albumin: Creatinine ratio annually
· Educate for Positive Lifestyle changes:
o Weight management
o Exercise Regularly
o Modest sodium reduction in diet
o Avoid smoking
o Modest Alcohol Intake
o Proper education on measuring home BP for self-Monitoring
What is the level of evidence provided by this article?
It’s a Review article and level of evidence in 5.
Review article level 5
Summary:
Hypertension is a contraindication for donation as it is associated with poor outcome for donor and recipient. SPRINT show that low blood pressure <120/80 was associated with less CV events in elderly without DM and eGFR ~70ml/min/m. The mean of eGFR in SPRINT was approximate to kidney donor so the donor may need to have lower blood pressure level especially if they are young aged , over weight or African .BP should be estimated properly in different 2 occasions.
KDOGO guideline suggest that acceptance of donor with hypertension should be individualized following transplant program acceptable risk profile threshold and donor information regarding risk of acceleration of hypertension and need for more anti-hypertensive medications.
Studies showed conflicting results of outcomes of LKD with pre-existing hypertension. Some showed deterioration of renal function after donation while others showed maintained normal renal function with non significant differences between normotensive and hypertensive donors. This could be explained by variability in follow up duration , population, hypertension definition and sample size.
LKD can cause hyperfiltration, up-regulation of RAS system in addition to change in vascular tone, which can lead to development of hypertension. Several studies showed that SBP & DBP can be increased slightly post donation but insignificantly when compared to control. The risk of HT development post LKD increased with risk factors as African American descend( APOL1 diversity), obesity and elderly.
Early post donation, it is better to maintain blood pressure <160/90 for adequate kidney perfusion with selective short acting drugs as CCB or clonidine.
Long term BP control relies on individual factors and co-morbidities.
BP evaluation:
_Office reading of average BP<130/80 on 3 occasions is considered suitable for donation. BP equal or more than160/100, signs of end organ damage or use >2 antihypertensive drugs not to proceed for donation. Post donation target is equal or less than 130/80. AMBP: if BP >130/80 but <160/100, on more than 2 antihypertensive medications, OSA, African American descent, waist >96cm(male) or >80cm(female) not to donate. If AMBP <125/80 precede with donation but if >125/80 control BP with drugs and ABPM repeated.
III. Blood Pressure and Living Kidney Donors: A Clinical Perspective
Hypertension has been a challenge and an issue for many pathologies and continues to be. It causes cardiovascular diseases and other complications. It is no difference when it comes to kidney transplantation. It is still a current issue and can be contraindication for kidney transplant. There are guidelines that is being created to help to control BP and allow kidney transplantation.
The definition of hypertension is BP reading of greater than 140/90 mmHg. So due to the number of patients with kidney failure, the donor pool needs to be increased, and as such, donor with mild HTN and on mono therapy or two AHM with no end organ failure then the patient can be a donor. Individuals must follow the guidelines especially if the pressure is elevated or high, overweight, based on ethnic group, etc.
Most guidelines concerned about BP greater than 140/90 and others especially in young donor a BP greater than 130 mmHg.
Based on the AHA/ACC, BP in this range 120-129 systolic and stage 1 HTN 130-139 are considered elevated.
Based on SPRINT a BP lower than 120/80 should be the goal.
Once the donor is decided to donate, he or she must be evaluated to ensure that:
1) The blood pressure of the potential donor must be measured on 2 separate occasions.
2) To ensure BP is determined to be high or high normal, ABPM should be considered especially in patients who are overweight, younger age and ethnic group especially the black race,
3) Blood pressures that is controlled on one or two medications with no end organ damage, is considered low risk kidney donors.
There have been studies, that has shown discrepancy and contradiction as it regards to HTN and in LKD. Some studies have proven that pre donation blood pressure has related to decrease in kidney function while others do not prove the same.
Once the patient has been transplanted, there can be appearance of HTN post transplantation. The blood pressure post-transplant depends on:
1) Alteration of kidney physiology that is related to hyper filtration, upregulation or renin angiotensin aldosterone system.
2) There has been studies that shows increase of blood pressures post donation but fails to compare their study population with age matched control and an increase in BP was from 113/75 to 116/77 mmHg.
3) There was a poor donor size.
4) The follow up percentage was small.
There are certain risk factors for elevated BP post-donation and they are:
1) African and Hispanic
2) Obesity
3) Older donors or elderly
4) Genetic
Once the patient has BP and HTN post donation, it must be monitored and treated. In situation like:
1) Post donation the BP must try to maintain a BP less than 160/90 to allow proper kidney perfusion.
2) Individuals with high risk of BP their pressure needs to maintain low
3) Treatment for BP must be individualized
4) Proper patient education must be considered
5) Guidelines like KDIGO ensures that BP be monitored annually.
The suggested BP for living donors are as follows:
1) Resting period before BP is taken
2) A reading of more than 3 times and a BP of less than 130/80 is considered adequate for transplantation
3) Patients with elevated pressure greater than 160/90, organ damage and is taking more than 2 antihypertensive medications is not to be considered.
4) A blood pressure of 125/75 is accepted if ABPM is used.
The article reviewed is a level 5.
Summary : a clinical perspective of blood pressure and living kidney donor
This article is about a crucial and recurrent theme among live donors, i.e., prevalence of hypertension. Hypertension in certain conditions becomes an exclusion criteria for donors.
Living kidney donation guidelines indicate that donors with well controlled BP under 140/90 mm Hg with 1-2 anti-hypertensive medications with no evidence of end organ damage. If not, the donor should be excluded from live donation.
Certain characters can become risk factors for hypertension in the donor. These include :
Lifestyle modifications form an important part of management in these donors. These modifications include :
Level of evidence
This is a narrative review, and thus level of evidence is 5.
– Studies have shown that recipients who received allografts from living donors survive longer and perform significantly better than those who received grafts from deceased donors.
– Elevated blood pressure (BP) is one of the leading exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both kidney transplant recipients and living kidney donors alike
– Despite hypertension affecting both kidney recipients and donors, the impact of hypertension on the latter has not been as well studied and understood. The definitions of “hypertension” are variable depending on the guidelines. The definitions have also evolved over time. If one were to define “hypertension” as that level of BP in which the benefits of treatment outweigh the risks of inaction, then one could more appropriately individualize the care plan. For kidney donors, this is the clinical conundrum: how best to assess this balance between BP and long-term outcome
– In this review, we will examine the current living kidney donation guidelines with respect to “hypertension,” the impact of living kidney donation on “hypertensive” donors, the risk of and factors contributing to the development of “hypertension” postdonation in normotensive donors, and medical and lifestyle management of BP in living kidney donors. Understanding “hypertension” in living kidney donors will improve not only patient education during the donor recruitment process but also patient care postdonation. With this knowledge, it may be possible to delineate more specific and standardized guidelines for living kidney donation, which may very well be what we need to narrow the gap between the supply and demand for living kidney transplants
Current Living Kidney Donation Guidelines
– Elevated bl.p. is one of the exclusion criteria for kidney donation .
– Many guidelines like KDIGO , excluding donors with bl.p.>140/90 with 1-2 anti hypertensive medications or evidence of end organ damage, however , Each centre is adhering to his limit of bl.p.
– The new ACC/AHA guidelines defines elevated bl.p. : 120-129 systolic &
stage 1 Hypertension : 130-139 / 80-89 .
– The SPRINT trial clearly demonstrated that lower bl.p. goal < 120/80 is associated with low cardiovascular events in population with no evidence of diabetes , aged 86 ys & eGFR approximately 72 ml/m
– Based on this data , may be a reason to believe that lower bl.p. target in kidney donors is needed especially if young , obese or African ethnicity
Evaluation and Assessment of BP Predonation
– Bl.p. measurements in 2 separate occasions with trained persons with calibrated equipments , if bl.p. < 130/80 , none obese & no African heritage >>can proceed for transplantation
– Otherwise , if bl.p.>130/80 especially in younger or obese or African heritage >>then 24 hrs ambulatory bl.p. monitoring should be considered .
– Patient with easily controlled hypertension with 1-2 medications with no end organ damage like LVH or albuminuria , can be considered for donation .
– Kdigo 2017 suggested that hypertensive donors should be individualized as case by case & as per centre acceptable risk profile & tat they should be counselled that donation may accelerate theier hypertension or increase need for anti hypertensive medications & here we can add special concern regarding younger , obese & African heritage donors .
Preexisting Hypertension in Kidney Donor Candidates
– Data may be conflicting if pre hypertensive doors is at increased risk of rapid GFR decline , reaching ESRD or worsening of HTN .
– In summary of many results , easily controlled hypertension with bl.p. < 130/80 on 1-2 AHM with no EOD carry low risk but special concern should be given in younger , obese & African heritage .
development of Hypertension in Kidney Donors Postdonation
– Again the studies are giving avconflicting data regarding increased risk of developing post donation HTN between that showing no difference between donors & the control groups & others showing increased risk of developing HTN post donation .
– But there are risk factors should be kept in mind for increasing the risk which are ypunger , obese ( BMI >30 ) , African heritage ( donors with 2 APOLI 1 variants carry high risk ) .
Management of BP and Hypertension Postdonation in Living Kidney Donors
– Early post donation : highr target is better < 160/90 , to allow optimal kidney perfusion , can achieved using short acting drugs like CCB or clonidine .
– ACE I , ARBS , diuretics should to be avoided perioperatively due to hyperfiltration & expected shift in volume .
– Life style modifications , low salt diet , regular exercise , avoid smoking & alcohol & regular monitoring of BL.P at home & at regular visits post donation with follow up of alb./cr. Ratio & control of other CV risk factors should be obtained .
Our Suggestions for Living Kidney Donor Evaluation With Respect to BP
This literature suggest that :
1- Office bl.p. measurement for all donors ( after 5 minutes rest with calibrated equibment , 3 readings with 1 minute rest in between each & average of these readings ) >>if bl.p. < 130/80 can be considered for donation .
2- If office bl.p. > 160/100 , EOD ( LVH or albuminuria) or use of 3 or more AHM >>>should be excluded from donation .
3- If bl.p. > 130/80 or obese ( BMI >30 , waist circumference > 94 cm in males or > 80 cm in females ) or African heritage or obstructive sleep apnea , then ABPM should be obtained
4- If ABPM < 130/ 80 ( even after weight loss or 1-2 AHM ) so can be considered for donation .
5- Special concern for younger , obese & African heritage should be given
level of evidence >> level 5
This is a review study (level of evidence V) discussing the risk of hypertension post-donation.
Hypertension is one of the common contraindications of kidney donation, but the definition of Hypertension and the best method for measuring BP is still there is no standardization and it differs from one center to another.
· Caring for Australasians with Renal Impairment (CASI), British Transplantation Society (BTS), Canadian Council for Donation and Transplantation (CCDT): exclude donors with blood pressure >140/90 mm Hg on 3 occasions.
· European Association of Urology (EAU), European Best Practice Guidelines (EBPG): exclude donors with uncontrolled hypertension.
· Organ Procurement and Transplantation Network (OPTN): exclude donors with blood pressure >130/85 mm Hg (in donors>50 y old).
Measurement of BP
There are 3 main methods for evaluation of BP
1. Office blood pressure (OBP): 1st patient will rest 5 minutes before readings then BP should be measured with a properly sized BP cuff by well-trained staff. The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading.
2. Home blood pressure monitoring (HBPM): recording at least twice the daily average of two home blood pressure readings over a minimum of 4 days. HBPM is better correlated to 24-h ABPM, and superior to OBP when predicting hard outcomes
3. Ambulatory 24h blood pressure monitoring (ABPM): considered the best way the evaluation of BP and showed a better correlation with clinical outcomes. Best it’s not the standard practice in donor evaluation as its expensive but ABPM should be considered If there are concerns about a potential donor’s BP or younger age, overweight, or African heritage, and measurements take place every 15–30 minutes during the daytime and 30–60 minutes at night for 24 hours
Suggestions for Living Kidney Donor by the author:
· Evaluation with Respect to OBP readings should be carried out as recommended
· Evaluation with Respect to ABPM is indicated for patients (in the gray zone) with
If the patient’s 24-hour ABPM reading is ≥125/75 mm Hg, they should afford pharmacological and non-pharmacological lifestyle management and when their BP becomes <125/75 mm Hg in 24-hour ABPM follow-up: donation can be allowed otherwise donation is not allowed.
Management of BP and Hypertension Post-donation
-all living kidney donors should make lifestyle changes like weight control, dietary sodium reduction, regular exercise, smoking cessation, and decreased alcohol intake to decrease the risk of development of post-donation hypertension.
-They should also receive proper education regarding self- BP monitoring and proper BP measurements should be performed annually as part of post-donation follow-up care.
-if pharmacological intervention is needed: ACEi, ARBs, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
risk factors for developing post-donation hypertension such as
This review study was conducted to assess the potential influence of donor hypertension severity on suitability for donation and the consequent effect of donation on the donor hypertension.
It’s a telling truth that expanding the living donor pool effort was facing an ever-increasing difficulty, leading to massive limitation of Kidney transplantation rate and enlarging the waiting list. In order to overcome this hurdle and increases the living donor pool, one of the possible options, was to loosen the criteria for selecting the suitable donors. Hypertensive patients were always an accessible pool for kidney donation, and the criteria for selecting the hypertensive donors was expressing number of changes over the recent years with conflicting data on the suitability for donation and the potential consequences on hypertension progress thereafter.
definition of hypertension was changed recently, and the ACA noticed a blood pressure limit of 130/80 as stage 1 hypertension. Prior guideline defined hypertension as 140/90.
The hypertensive donors were categorized as acceptable living donors if they meet certain features including:
Blood pressure less than 140/80
No end organ damage.
On 2 anti-hypertensive medications maximum.
Hypertensive patients are at an escalating risk of renal and cardiovascular disease, therefore donating kidneys are theoretically linked to this hazard and proper selection is crucial. The landmark SPRINT study revealed improved cardiovascular outcome with blood pressure limit below 120/80. However, there was no renal assessment and outcome with this level of blood pressure control. Nevertheless, some transplant centers advocated the cut off 130/80 as a baseline blood pressure for kidney donation.
Several studies investigated the long-term effect of kidney donation on hyper with conflicting results. Special patients’ categories, such as African American, Hispanic, obese, old age and those with APOL 1 genotype are prone to have progressed hypertension post donation, even when its within normal range before transplantation.
Early blood pressure reaction post donation is usually elevated due to activation of RAAS system and vascular changes, which will be normalized thereafter.
Of note, as highlighted by more than one study is to avoid RAASi post transplantation, to improve the renal perfusion and support renal function.
My conclusion for this review article, is that each patient has to be taken as per his own merits, looking at him holistically in a way that in addition for having well controlled blood pressure without end organ damage, obesity, ethnicity and age have to take a very important part in deciding upon proceed with a hypertensive kidney donation.
This is a Narrative Review – Level 5
It is a study to evaluate blood pressure intervention in living kidney donor patients. The objective is to evaluate the impact of hypertension on the organ donor and its evolution over time. Despite several different protocols around the world, some similarities can be discussed, especially in young, overweight patients with African ancestry.
In these higher risk patients, the need for continuous outpatient measurement is more indicated.
Higher blood pressure, use of antihypertensive drugs prior to transplantation and target organ damage decrease the chance of organ donation, increasing the need for monitored outpatient evaluation and pre-transplant care.
However, blood pressures controlled with one or two antihypertensive drugs can be included as donors by expansion criteria.
Expected relative risk for those of African ancestry is 50% for hypertension after donation, likely due to a higher frequency of MYH9 and APOL1 at the Chromosome 22 loci, increasing focal segmental glomerusclerosis, nephropathy, and kidney disease. Even those with two APOL 1 variants have a high risk of rejection in recipients.
Another important risk factor is obesity, especially with a BMI greater than 30 or 35.
The appropriate choice of antihypertensive drug and the best time (avoiding diuretics in the perioperative period, for example) are important to minimize the risk of kidney damage, and consequently, organ rejection for the recipient and induction of hypertension for the donor.
For these reasons, donor counseling is essential, emphasizing the need for metabolic control (glycemia, weight, dyslipidemia, albuminuria), blood pressure control (values below 130 x 80), pre and post transplant care. Blood pressure monitoring and drug intervention when necessary should be performed.
Kidney transplant with a living donor is the best form of treatment for patients with ESRD. The article deals with living kidney donation guidelines with respect to hypertension, the impact of donation on hypertensive donors, the risk of hypertension development post-donation, and the management of hypertension in renal donors.
Living kidney donation guidelines with respect to blood pressure:
According to most guidelines, high blood pressure or hypertension is a contraindication for donation if the BP is more than 140/90 mm Hg on 1-2 antihypertensives or is associated with target-organ damage.
SPRINT trial concluded that BP<120/80 in patients with eGFR~70 ml/min reduced cardiovascular events. The GFR post-donation is similar to the SPRINT study participants, hence extrapolating those results, a renal donor should have target BP of <120/80.
BP assessment prior to donation:
BP should be measured by well trained staff using well calibrated instruments on 2 separate occasions (average of 3 readings, 1 minute apart and after 5-minute rest). If BP is found high (>130/80), and the donor is young, overweight or African-American, or if the donor has obstructive sleep apnea, increased waist circumference (>94 cm in males and > 80 cm in females) or uses 1-2 antihypertensives, then Ambulatory BP monitoring (ABPM) should be performed. The donor can be allowed to donate only if ABPM is within normal limits (BP<125/75). If 24 hour ABPM is high, pharmacological and non-pharmacological interventions including losing weight should be undertaken and once BPis <125/75, the donor should be reassessed.
KDIGO guidelines suggest individualization of donor evaluation with respect to hypertension and counselling regarding rise of BP and increased requirement of anti-hypertensives post-donation should be done.
Pre-existing hypertension in living kidney donor:
The study of impact of hypertension on kidney donation has shown conflicting results with some studies showing deterioration in renal function post-donation while others did not show any such decline, mainly on account of short-term follow-up and unrepresentative patient population. Overall, donors with well controlled BP (<140/90) on 1-2 antihypertensives and no target organ damage have been shown to have minimal risk of developing renal function worsening or hypertension, but there is increased risk in obese, African-Americans and those with genotype APOL1.
Hypertension development post-donation:
Hyperfiltration, upregulation of RAAS and changes in vascular tone may increase BP post-donation. Studies have shown slight increase in systolic and diastolic BP in donors as well as controls oner time, with no difference in ABPM 3 years post-donation form control group. Obese patients are more likely to have pre-donation hypertension. Increase in BMI by 1 increase the risk of hypertension by 10%. Increase in age by 1 year increases risk of hypertension by 507%. So risk factors for hypertension like African-American ancestry, Hispanics, BMI and age should be kept in mind.
Management of BP in donor post-donation:
Avoid ACE inhibitors/ ARBs or diuretics in peri-operative period.
Keep BP<160/90 using calcium channel blockers or clonidine in early post-operative period to allow optimal renal perfusion. Emphasize on lifestyle modifications including diet, weight control, avoiding smoking, regular exercise etc. More frequent follow-up and management of other cardiovascular risk factors is important.
Donor evaluation with respect to BP:
All potential donors should monitor their BP at home. The BP evaluation should be done as per the protocol mentioned above. Those with BP > 160/100 or target organ damage like LVH or albuminuria, or using 3 or more antihypertensives should undergo 24 hour ABPM.
Level of evidence: Level 5: Narrative review
Elevated blood pressure (BP), or “hypertension,” has been one of the main exclusion criteria for living kidney donation, as it is a risk factor for renal and cardiovascular disease. The most current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihypertensive medications or evidence of end-organ damage should be excluded from living kidney donation
The choice of BP targets and medications needs to be carefully individualized. In general, a BP <130/80 mm Hg is needed, along with lifestyle modifications.
Elevated blood pressure (BP) is one of the leading exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both kidney transplant recipients and living kidney donors alike. Despite hypertension affecting both kidney recipients and donors, the impact of hypertension on the latter has not been as well studied and understood
Understanding “hypertension” in living kidney donors will improve not only patient education during the donor recruitment process but also patient care postdonation.
donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension, strengthening the support for their inclusion into, and consequent expansion of, the living kidney donor pool. Yet, the available studies are of short duration, and there are phenotypes, such as obese, or people with African heritage who may be at more risk, and genotypes such as APOL1 which may confer more risk over time. For example, as 25-year-old overweight male homozygous for APOL1 risk variants may not be an ideal candidate despite a BP of 115/70 mm Hg. However, proper counseling on the aforementioned risks (increased BP and potential endorgan damage), albeit small, should be conducted
Hypertension criteria have changed substantially in the last few years. The goal of being more inclusive for kidney donors with elevated BP may be considered given the opportunity to control BP in an effective manner. No longer should they be considered “marginal” donors. Currently, some of the guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, when hypertensive donors are allowed to donate, they do not seem to be at a significantly increased risk of developing renal or cardiovascular health issues. Another concern for living kidney donors is the possibility of developing hypertension after kidney donation, especially if they are younger, overweight, or of African heritage. Studies have shown that in healthy, well-selected donors with no known risk factors, living kidney donation does not significantly predispose them to developing hypertension postdonation;
however, certain risk factors, such as being African American or Hispanic, obese, or older, are associated with higher likelihoods of developing hypertension postdonation. Personalized pharmacotherapy along with beneficial lifestyle changes and more follow-up appointments should be utilized to manage BP and hypertension after kidney donation. Lastly, we have put forth suggestions for evaluating BP in potential living kidney donors and maintaining BP control postdonation.
Evidence level V
This review explores and examine hypertension and the living kidney donation in different aspects: starting with the guidelines with respect to hypertension the impact of living kidney donation on hypertensive donors, the risk of and factors contributing to the development of hypertension post donation in normotensive donors, and medical and lifestyle management of BP in living kidney donors.
Guidelines and their contraindications to donation for hypertension:
According to Kidney Disease Improving Global Outcomes (KDIGO) BP >140/90 mm Hg on <2 anti-hypertensive medications, end-organ damage or predicted lifetime ESRD risk exceeding transplant centre’s acceptable risk threshold is contraindication for donation
British Transplantation Society (BTS), Blood pressure must be assessed on at least two separate occasions, Potential donors with mild-moderate hypertension that is controlled to <140/90 mmHg (and/or 135/85 mmHg with ABPM or home monitoring) with one or two antihypertensive drugs and who have no evidence of end organ damage may be acceptable for donation
Pre-existing Hypertension in Kidney Donor Candidates:
Observational studies of hypertensive donors have produced conflicting results Some studies have found that donors with predonation hypertension have a
decline in kidney function while others have maintained that there is no significant difference in kidney function between normotensive and hypertensive donors. The discrepancy between these studies could be explained by the variance in follow-up length, study population, hypertension definitions, and sample size. Other existing retrospective studies have also been limited by short follow-up times, unrepresentative patient populations, and low rates of follow up.
· Tsinalis et al: 1 y,No change in BP or UACR, eGFR4mL/min lower in H donors
· Gracida et al: Mean 80.7 ± 32-month Creatinine 1.37 H vs 1.1 mg/dL N, (P < 0.001)
· Textor et al, 6–12 month No effect on BP, eGFR, or UACR
· Tent et al,1 and 5 y, systolic blood pressure higher in H, eGFR without difference
· Lenihan et al: 6 months No difference in eGFR or BP more glomerular in H
· Srivastava et:21 ± 1 months, increase in creatinine of 0.5 ± 0.2 mg/dL in H Vs N, no proteinuria
· Sofue et al: 2 y No change in BP. No significant change in eGFR although higher UACR associated with lower eGFR
Development of Hypertension in Kidney Donors Post donation:
An important prospective study: Kasiske et al followed living kidney donors over a 3-year period. systolic and diastolic BP increased slightly and significantly over time in both donors and controls, but there were no significant differences between the 2 groups; in addition, after 3 years, the 24-hour ABPM of both groups was not statistically significant either. Kim et al studied the long-term risk of hypertension in living kidney donors and found that
there was a statistically significant increase in BP postdonation, with 21% of the donors developing hypertension that required AHM use. However, the increase in BP was from 113/75 to 116/77 mm Hg; in addition, the total sample size of donors whose hypertension histories could be obtained was 43, with only 11% of the total sample size having a follow-up of >1 year.
Thiel et al found that the risk of developing hypertension, defined as >140/90 mm Hg, increased 3.64-fold 1-year postdonation. However, the mean predonation systolic and diastolic BP values of the normotensive donors who were hypertensive after 1 year postdonation were significantly higher than those donors who were normotensive after 1 year postdonation. This suggests that these patients may have been prehypertensive or more susceptible to developing hypertension.
There have been a few studies that have looked at these at risk groups to see how they fare postdonation. Hypertension was identified in 41% of African American donors in a study with an average follow up length of 7 years, compared with 30% of Caucasians.
African American and Hispanic donors are also at about a 50% increased relative risk of developing hypertension postdonation
Lentine et al confirmed that obese donors were more likely to have predonation
hypertension and each increase in year of donor age was associated with a 5%–7% higher likelihood of hypertension. Another study demonstrated that the frequency of hypertension increased by 10% for each 1-unit increase in BMI, with higher BMI being associated with higher rates of hypertension 5 years postnephrectomy.
Management of BP and Hypertension Post donation in Living Kidney Donors:
· Early after donation: allow BP (<160/90 mm Hg) to be elevated to allow for optimal kidney perfusion, which can be maintained with selective, short-acting
hypertensive agents (such as calcium channel blocker or clonidine).
· Long-term control of BP in kidney donors depends on the individual patient.
· The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of postdonation follow-up care.
Level 5, narrative review article.
Summary of the article
-Studies have shown that recipients who received allografts from living donors survive longer than deceased donors.
-Elevated blood pressure (BP) is one of exclusion criteria for living kidney donation, as it increases the risk for detrimental outcomes for both recipients and donors most current living kidney donation guidelines state that donors with a BP >140/90 mm Hg with 1–2 antihy-pertensive medications or evidence of end-organ damage should be excluded from living kidney donation.
– the impact of hypertension on donor has not been as well studied.
-definitions of “hypertension” are variable depending on the guidelines.
▪︎Current Living Kidney Donation Guidelines
-the risks of donation in mild, well-controlled “hypertension” are not well understood and most transplant centers adhere to their own standards when evaluating for hypertension in liviing donors
-the recent release of the 2017 High Blood Pressure Clinical Practice Guidelines by ACC/AHA, the definitions of hypertension have been revised.
Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg
– SPRINT (Systolic Blood Pressure Intervention Trial) demonstrated that a lower BP goal (<120/80 mm Hg) was associated with a reduction in cardiovascular events in a population with a mean age of 68 years, no evidence of diabetes, and an estimated glomerular filtration rate (GFR) of approximately 72mL/min/1.73 m2
the mean GFR in the SPRINT study participants of ~70mL per minute is not different than observes in donors.
so it is believed that kidney donors might need lower BP targets, especially if they are younger, overweight, or have African ancestry.
▪︎ Evaluation and Assessment of BP Predonation
– screening for hypertension in donors include BP measurement on 2 separate occasions by clinical staff who are trained to measure BP accurately, with equipment that has been calibrated.
– If BP is determined to be high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ABPM or repeated with standardized BP measurements
-Armanyous et al using daytime ABPM as a gold standard found a 16% prevalence of hypertension in kidney donors.
-The KDIGO working group report suggested that donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
▪︎Preexisting Hypertension in Kidney Donor Candidates
-more transplant centers are relaxing their selection criteria to include donors with well-regulated hypertension.
Observational studies of hypertensive donors have produced conflicting results ,Some studies found that donors with predonation hypertension have a decline in kidney function ,while other studies showed no significant difference .
– The discrepancy between these studies could be explained by the variance in follow-up length, study population, hypertension definitions, and sample size.
-A recent observational study of 24 533 older donors (≥50 y of age), including 2265 with predonation hypertension, demonstrated that older donors with hypertension had a higher risk of ESRD but not mortality for 15 years postdonation.
-it was suggested that donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing worsening kidney function or hypertension.
– kidney donation often leads to physiological alterations (kidney hyperfiltration, upregulation of
renin-angiotensin-aldosterone system, and changes in vascular tone)
– most studies done with follow-up for short period didn’t found significant increase in bp post donation
-And it was suggested that kidney donation itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP.
-risk factors includes obesity, African American, smoking, older age .
-Current consensus guidelines have contraindicated donors with a BMI >30–35.2 Lentine et al confirmed that obese donors were more likely to have predonation hypertension and each increase in year of donor age was associated with a 5%–7% higher likelihood of hypertension.
– Another study demonstrated that the frequency of hypertension increased by 10% for each 1-unit increase in BMI, with higher BMI being associated with higher rates of hypertension 5 years postnephrectomy.
obese donors (BMI >30) had higher mean systolic and diastolic BPs than nonobese donors, leading to a significant increase in ESRD risk.
▪︎Management of BP and Hypertension Postdonation in Living Kidney Donors
-Early after donation, it is suggested to allow BP (<160/90 mm Hg) to be elevated to keep kidney perfusion, which can be maintained with selective, short-acting hypertensive agents (such as calcium channel blocker or clonidine).
Townsend et al recommend that angiotensin converting enzyme inhibitors, angiotensin receptor blockers, and diuretics should be avoided perioperatively due to adaptive hyperfiltration and expected shifts in volume.
-KDIGO Guidelines suggest that proper BP measurements annually as part of postdonation follow-up care.
-Hypertensive living kidney donors should be followed more frequently than the average, normotensive donor and to have regular BP, laboratory, and urinary albumin:creatinine ratio tests conducted.
additional concerns about donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered and measurements take place every 15– 30 minutes during the daytime and 30–60 minutes at night for 24 hours with measurements.
-Based on the most recent ACC/AHA guidelines, if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation
If the patient has an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.
Evidence level V
1-Summary of Blood Pressure and Living Kidney Donors: A Clinical PerspectiveHTN is the one of exclusion criteria for living kidney donation as increase the risk for both kidney transplant recipients and living kidney donor alike.
In this review, highlight living donation guide line with respect to HTN, include develop of post donation HTN and management of HTN in living kidney donors.
Current living kidney donation guide lines for donor with HTN:
CAST, BTS, CCDT and American society of transplantation CAST is contra indication to donation of BP > 140/90 mm Hg on 3 occasions.
European Associations of urology and European Best practice Guide lines uncontrolled HTN is contra indicated.
Organ procurement and transplantations network donations is contraindication of BP > 130/85 mm Hg ( in donors < 50y old).
Kidigo guide lines donations is contraindicated if BP > 140/90 mm Hg or < 2 AHMs ,end organ damage as predicted lifetime ESRD risk.
The kidney working group report of 2017 suggest that potential donors with HTN should be individualized in relation the transplant programs acceptable risk profile threshold and that they should recounseled that donation may accelerate the risk in BP and increase the need for more anti hypertension therapy.
Observation study of older donor > 50y of age including 2265 with pre donation hypertension had a higher risk of ESRD but not mortality far 15 years post donation but no significant effect an BP or change in AHM use in hypotensive donor post donation
development of HTN in Kidney donors post donation:
Kidney donations lead to Kidney hyper filtration, upregulation of Renin- angiotensin aldosterone and change in vascular tone.
Kasiske etal prospective study felling living donors are a – 3yers period. Theirs observed systolic and diastolic BP increased slightly and significantly one time in both donors and control, but there is no significant different between two group management if BP and HTN post donation in living Kidney donors.
Early after donation HIS suggested to allow BP < 160/90 mmHg to be elevated to allow far optional kidney perfusion using calcium channel blacker or clonidine.
Avoid ACE and diuretics should be avoid perioperative due to adaptive hyper filtration and expected shifts in volume.
2- level 5
Please summarise this article in your own words
The LKD is best option in renal transplantation. The transplant waiting list in increasing but the donor pool on decreasing trend. The main reason for this is the medical co morbidities. Elevated blood pressure is one of the leading exclusion criteria. Donation with hypertension in associated with poor outcomes for donor and recipient.
In this review they examined current living donation guidelines as regards hypertension, impact of living kidney donation on hypertensive donors the risks and factors contributing t o the development of hypertension , post donation in normotensive donors and lifestyle management of hypertension in living donors.
SPRINT study ( systolic blood pressure intervention trial) concluded than blood pressure less than 120/80 was associated with less cardiovascular events. So it was concluded that kidney donors may need lower blood pressure targets if they are younger, overweight or have African ancestry.
Blood pressure measurements.
Measure blood pressure by trained staff at 2 occasions in a week
Ambulatory blood pressure monitoring in young hypertensives, overweight, or Africans.
Kidney donation with hypertension can be dealt with case to case by individual transplant programme . The donor can be warned to acceleration in hypertension post donation and need for medical therapy.
Pre existing hypertension in kidney donor candidates
Observational studies have produced conflicting results. Some studies have shown that pre donation hypertension does not affect post donation decline in renal function while others have shown decline in GFR.
This variability can be due to different sample size, methodology and population.
Post Donation Development of Hypertension
Despite risks associated with donation many transplant centres are relaxing criteria for donation by well controlled suitable hypertensives. Post donation there is hyperfilteration , alteration in vascular tone and activation of renin and angiotensin system which can lead to development of hypertension. This development of hypertension post donation can be precipitated by high risk factors like high BMI, old age and african race.
Management of hypertension Post donation
Post donation a blood pressure of 160/90 mm Hg is permitted to allow graft perfusion. It can be maintained by calcium channel blockers and clonidine. Long term management is individualized according to patients condition. KDIGO practice guidelines recommends assessment of blood pressure annually post donation.
LKD evaluation with regards to blood pressure
On three measurements if the blood pressure is <130/80- proceed with donation
Exclude from donation-
BP>160/90
Use of two antihypertensive drugs
End organ damage
24 hour ABPM BP reading is <125/80 – Proceed
ABPM >130/80 , on 2 medications, African or American descent- Donor proceed with donation
What is the level of evidence provided by this article?
Review article
Level V
ABPM >130/80 , on 2 medications, African or American descent- Donot proceed with donation ( Sorry there was typo above)
HTN in living kidney donation is one of the most important topics as its the leading cause of exclusive criteria
as the living donation is the management of choice in ESRD and number of potential donors needed in increasing year after year so the impact of living kidney donation on “hypertensive” donors, the risk of and factors contributing to the development of hypertension” post donation in normotensive donors, and medical and lifestyle management of BP in living kidney donors should be studied well .
there is to fixed definition of HTN and it is variable according to differant studies or guild lines and the threshold to accept the donor with HTN its also differentiate from one center to other
Office readings should be carried out as recommended in most guidelines , If there are additional concerns about a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered .
according to ACC/AHA
with appropriate individualization and counseling.
If the
Donors with well-controlled BP (BP <140/90 controlled with 1–2 antihypertensive drugs and no evidence of target organ damage) seem to be at minimal risk of developing
worsening kidney function or hypertension, strengthening the support for their inclusion into, and consequent expansion of, the living kidney donor pool. Yet, the available studies are of short duration, and there are phenotypes, such as obese, or people with African heritage who may be at more risk, and genotypes such as APOL1 which may confer more risk over time.
.Post donation HTN could be due to glomerular hyperfiltration, upregulated renin-angiotensin-aldosterone system and cahnges in vascular tone, African have higher incidence of HTN and ESRD than other population, supposed to be related to MYH9 and APOL1 loci in chromosome 22.
With respect to BP assessment postdonation, we suggest maintaining a clinic BP ≤130/80 mm Hg, which is in line with current guidelines, not only for living kidney donors but for the general population. Whether patients who are obese or possibly carry high risk APOL1 variants require lower BP targets is an intriguing question.
High blood pressure is one of the leading exclusion criteria for living kidney donation. Current KDIGO guideline suggests BP > 140/90 mmhg on <2 antihypertesive medicine, end organ damage are contraindicated for donation.
BP <130/80 mmhg on office, non obese, no African heritage allowed for donation.
BP < 130/80 mmhg and either obese or African heritage, > or equal 130/80 mmhg on office, use of 1 or 2 AHMs, obstructive sleep apnoea – ask for 24 hour ambulatory BP measurement- if normal allow for donations.
BP > or equal 160/100mmhg , end organ damage( left ventricular hypertrophy, albuminuria) and use of 3 anti hypertensive medicines- 24 hour ABPM- lifestyle and pharmacologic interventions- re evaluate for donations after attaining normal BP.
The KDIGO 2017 suggests, potential donors with hypertension should be indivisualized and they should be counseled that donation may accelerate the rise of BP.
Study suggests that kidney donation itself does not significantly increase the risk developing hypertension, but there are factors that lead to progressive rise in BP. Risk factors are: African American and Hispanic descent, BMI and age.
KDIGO suggests, proper BP measurement should be performed annually as part of post donation follow up care.
While the BP has been one of the exclusion criteria of live kidney donation, as the risk of future CKD and CVD, most common current living kidney donation guidelines, stated that; donors of BP > 140/90 and those taking 1-2 AHM, or there is any evidence end organ damage, should be excluded.
Kidney function (eGFR) of hypertensive living kidney donors does not significantly worse post donation compared to that of normotensive donors, in addition, live kidney donation it self not considered to be a risk factor of developing HTN, with a risk factor that increase the risk of HTN; African American, Hispanic descent, obesity, and age .
Current living kidney donation guidelines;
HTN is considered one of the main CI to live kidney donation, different guidelines BP level of which donors can be excluded.
Excluding BP level from donation according to ;
SPRINT trial:
SPRINT; systolic BP intervention trial; clearly demonstrated that; lower BP level < 120/80 is associated with decrease of CV event in mean age of 68 , with no evidence of DM, and eGFR of approximately 72 ml/min/1.73m2
So SPRINT does not, provide evidence that law systolic BP is important in delaying the progression of kidney disease .
Evaluation and assessment of BP pre donation;-
Armanyous et al.; using day time ABPM is the gold standard way of assessing BP , found that 16% prevelance of HTN in live kidney donors, using Joint National Commission definition, while found that 34% in live kidney donors having HTN pre donation. using ACC/AHA, concluded that; easily controlled HTN on 1-2 drugs, with no evidence of end organ damage , may be acceptef as law risk live kidney donor, and may need additional examination and imaging study.
Lentile et al.; concluded that predonation HTN, is not associated with increase risk of any perioperative complications.
KDIGO 2017; stated that potential donors with HTN should be individualized , provide counselling to donors that BP may rise and may need post donation medication.
Pre existing HTN in live kidney donors, although HTN may increase risk of renal and CVD, more centers include donors with well regulated HTN.
Observational studies produce conflict results;
Development of HTN in kidney donors post donation;-
Kidney donation lead to physiological alteration ;
The 2 changes increase BP but it’s not considered to be a risk for inducing HTN post donation.
Important prospective studies , post donation follow up for BP;-
Management of BP and HTN post donation in live kidney donors;
Early post donation allow BP < 160/90 to be increase to allow optimium kidney perfusion , maintained with Ca channel blocker, .
Townsend et al.; recommend ACE-i ,ARB, diuretics, should be avoided perioperatively due to adaptive hyperfiltration and expected shift in volume, plus treatment , advice to change life style, diet, weight control, smoking cessation.
KDIGO suggest proper BP measurement performed annually, and more frequently in hypertensive donors, and more microalbuminurea testing plus controll of CV risk factor.
Suggestion of live kidney donor evaluation for HTN;
Level of doanation ((5)).
Please summarise this article in your own words:
Hypertension is one of concern in evaluation and exclusion criteria for kidney dononrs, because is associated with increased cardiovascular risk and mortality, and graft loss in recipients.
The definition of hypertension is variable and changing according to guidelines.
Current ACC/AHA guidelines: elevated blood pressure 120-129 mmHg, stage1 HTN 130-139 mmHg systolic/80-89 mmHg diastolic. the B/p should be measured twice if high then ABPM is mandatory, in obese, young and Africans ABPM is better, the prevalence of HTN among kidney donor is 16% according to JNC7, and 34% using ACC/AHA guidelines. Thus the KDIGO working group report of 201711 suggested that potential donors with hypertension should be individualized.
Preexisting Hypertension in kidney donor candidates: in the face of increased need for kidney transplantation to meet the increase in ESRD, make some centers to be flexible in inclusion criteria for donation, as there is conflicting results from the studies regarding the decline in kidney function post donation, so the donors with B/P <140/90 mmHg controlled with one or two antihypertensives and no end organ damage, are at minimal risk for developing HTN and worsening kidney function.
Post donation HTN could be due to glomerular hyperfiltration, upregulated renin-angiotensin-aldosterone system and cahnges in vascular tone, African have higher incidence of HTN and ESRD than other population, supposed to be related to MYH9 and APOL1 loci in chromosome 22.
They suggest Office readings should be carried out as recommended in most guidelines: BP should be measured with a properly sized BP cuff. The final BP will be averaged over 3 readings conducted with a minimum of a 1-minute rest in between each reading. If there are additional concerns about a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered for 24 hours.
patient with BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling. in patients with an average office BP reading ≥160/100 mm Hg, evidence of end-organ damage (such as left ventricular hypertrophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation, other comorbidities should be evaluated and treated(ie obesity,OSA,,,etc).
Conclusion:
pre and post donation evaluation of HTN and management is a must, as there is increased cardiovascular disease risk and risk for worsening kidney function after donation.
special concern to African, obese and older population, because of increased of the above mentioned risks.
Personalized pharmacotherapy along with beneficial lifestyle changes and more follow-up appointments should be utilized to manage BP and hypertension after kidney donation.
What is the level of evidence provided by this article?
Level V erratic review.
Blood Pressure and Living Kidney Donors: A Clinical Perspective
summary
HTN was considered as a contraindication to living kidney donor transplantation for long time, currently there are different guidelines being created with respect to mild and controlled HTN in the field of kidney donation.
Current Living Kidney Donation Guidelines
1) Most guidelines have raised concerns about donor with SBP > 140 mmHg and some guidelines have concern about SBP >130 especially in younger donors.
2) ACC/AHA 2017 guidelines: Elevated BP is 120–129 mm Hg systolic and Stage 1 hypertension is 130–139 mm Hg or diastolic 80–89 mm Hg (implications of these revision remain to be seen).
3) A lower BP goal(<120/80) is clearly demonstrated by the SPRINT:
i) SPRINT study does not provide evidence that lower systolic pressure goals are important in delaying the progression of kidney disease.
ii) the mean GFR in the SPRINT study participants of ~70 mL per minute is not substantially different than what one observes in people who have donated a kidney.
4) There may be reason to believe that kidney donors might need lower BP targets, especially if they are younger, overweight, or have African ancestry.
Evaluation and Assessment of BP Pre-donation
1) BP measurement in potential donor on 2 separate occasions.
2) ABPM should be considered when BP is determined to be high or high normal, especially in the presence of variability, younger age, overweight or African heritage.
3) The variability and phenotype differences(white coat HTN and masked HTN) have not been prospectively studied in kidney donors.
4) Easily controlled hypertension with 1 or 2 agents and no evidence of target organ damage may be accepted as low-risk kidney donors.
5) The KDIGO working group report of 201711 suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy.
Preexisting Hypertension in Kidney Donor Candidates
1) There were discrepancy and contradiction between previous studies on HTN in the LKD. Some studies stated that pre-donation HTN is associated with a decline in kidney function, while other studies showed that there is no significant difference in kidney function between normotensive and hypertensive donors. . The discrepancy between these studies could be explained by:
i) the variance in follow-up length.
ii) Study population.
iii) hypertension definitions.
iv) sample size.
2) Compounding that may confer more risk over time:
i. Obese.
ii. People with African heritage.
iii. genotypes such as APOL1.
3) Lenihan et al discovered that although there was marked glomerulopenia in hypertensive donors, there was a nonsignificant difference in GFR, hyper- filtration capacity, or compensatory renocortical hypertrophy.
4) A recent observational study of 24 533 older donors (≥50 y of age), including 2265 with predonation hypertension, demonstrated that older donors with hypertension had a higher risk of ESRD but not mortality for 15 years postdonation.
Development of Hypertension in Kidney Donors Postdonation
1. Physiological alterations after kidney donation:
i. Kidney hyperfiltration.
ii. Upregulation of renin-angiotensin-aldosterone system.
iii. Changes in vascular tone.
2. There were reports suggested an increased risk of developing hypertension post-donation:
i. These studies failed to compare their study population with age-matched controls.
ii. The increase in BP was from 113/75 to 116/77 mm Hg, values that are well below the normal benchmarks for hypertension.
iii. The sample size of the donors was small.
iv. Small percentage (11%) had follow-up > 1y.
3. Thiel et al found that the risk of developing hypertension(>140/90), increased 3.64-fold 1-year post-donation.
i. the mean pre-donation systolic and diastolic BP values of the normotensive donors who were hypertensive after 1year post-donation were significantly higher than those donors who were normotensive after 1year post-donation. This suggest pre-donation HTN or more susceptibility to developing HTN.
ii. In 5years follow-up, there was only a modest and nonsignificant increase in risk of developing hypertension.
iii. This study suggests that kidney donation itself does not significantly increase the risk of developing hypertension, but there are factors that lead to a progressive rise in BP.
4. Risks for HTN post-donation:
i. African American and Hispanic descent.
ii. Obese donors.
iii. Elderly donors.
iv. MYH9 and APOL1 loci on Chromosome 22 have been linked with nondiabetic kidney disease in several recent studies.
v. Two alleles of the APOL1 gene, G1, and G2, are associated with higher risk of focal glomerulosclerosis and hypertension-attributed kidney disease.
Management of BP and Hypertension Postdonation in Living Kidney Donors
1. Early after donation, it is suggested to allow BP (<160/90 mm Hg) to be elevated to allow for optimal kidney perfusion.
2. Higher risk patients may require lower BP targets for treatment.
3. Long-term control of BP in kidney donors depends on the individual patient Specific pharmacotherapy must be individualized according to comorbidities, drug-drug interactions, drug side effects, and kidney function.
4. Living kidney donors also need to make positive lifestyle changes, including weight control, modest dietary sodium reduction and regular exercise, smoking avoidance, and modest alcohol intake.
5. Proper education on taking home BP for self-BP monitoring and management.
6. The KDIGO suggest that proper BP measurements should be performed annually as part of post-donation follow-up care.
Suggestions for Living Kidney Donor Evaluation With Respect to BP
1. Office readings as recommended in most guidelines after rest of 5minutes.
2. BP reading <130/80 mm Hg over 3 measurements, should be considered for donation with appropriate individualization and counseling.
3. To exclude from kidney donation list if:
i. The patient has an average office BP reading ≥160/100 mm Hg.
ii. Evidence of end-organ damage.
iii. On more than 2 antihypertensive medications.
4. ABPM BP <125/75 mm Hg, should be considered for donation.
What is the level of evidence provided by this article?
Review article
level of evidence; 5
1-Office readings should be carried out as recommended in most guidelines:
The final BP will be averaged over 3 readings conducted.
2-a potential donor’s BP or younger age, overweight, or African heritage, then ABPM should be considered.
3-Based on the most recent ACC/AHA guidelines recommend ;
1- if the patient has an average office BP reading <130/80 mm Hg over 3 measurements, then they should be considered for donation with appropriate individualization and counseling.
2-If the patient has an average office BP reading ≥160/100 mm Hg,evidence of end-organ damage (such as left ventricular hyper trophy, albuminuria), or is taking >2 antihypertensive medication, then they should be excluded from kidney donation.-
3- patients with an average office BP reading ≥130/80 mm Hg but <<160/100 mm Hg, and is taking 2 or fewer anti- hypertensive medication, who has obstructive sleep apnea or African heritage, or has a waist circumference of ≥94 cm for men and ≥80 cm for women as obesity has been shown to be a risk factor for ESRD. They should have an ABPM and preferably try to lose some weight.
4-If the patient’s 24 hour ABPM BP reading is ;
1- <125/75 mm Hg, they should be considered for donation.
2-If the patient’s 24 hour ABPM reading is ≥125/75 mm Hg, they should be given pharmacologic and lifestyle interventions to control their BP and weight; when their BP becomes <125/75 mm Hg on a subsequent 24 hour ABPM reading or over multiple office measurements, they could then be reevaluated for living kidney donation.
The KDIGO working group report of 2017;
suggested that potential donors with hypertension should be individualized in relation to the transplant program’s acceptable risk profile threshold and that they should be counseled that donation may accelerate the rise in BP and increase the need for more antihypertensive therapy. We agree with these statements and would add that this is also a concern in younger donors, especially if they are overweight or have African ancestry, or both.
Guidelines and their contraindications to donation for hypertension
1-Caring for Australasians with Renal Impairment (CASI), British Transplantation Society (BTS), Canadian Council for Donation and Transplantation (CCDT).
If the BP is >140/90 mm Hg on 3 occasions ,the donation is contra indicated
2-Amsterdam Forum, American Society of Transplantation (AST)
If the BP is >140/90 mm Hg, the donation is contra indicated
3-European Association of Urology (EAU), European Best Practice Guidelines (EBPG) Uncontrolled hypertension Organ Procurement and Transplantation Network (OPTN).
If the BP is >130/85 mm Hg (in donors <50 y old) ,the donation is contra indicated
4-Kidney Disease Improving Global Outcomes (KDIGO) >140/90 mm Hg on <2 AHMs, end-organ damage or predicted lifetime ESRD risk exceeding transplant center’s acceptable risk threshold.
Development of Hypertension in Kidney Donors Post donation;
The risk factors include ;
1- African American and Hispanic descent.
2- Increased BMI
3- Age ( old age has increased risk )
1- The KDIGO Clinical Practice Guidelines suggest that proper BP measurements should be performed annually as part of post donation follow-up care.
2- Hypertensive living kidney donors (whether the hypertension developed pre or post donation) should be followed more frequently than the average, normotensive donor and to have regular BP, laboratory, and urinary albumin:creatinine ratio tests conducted.They should also have their other cardiovascular risk factors well controlled.
What is the level of evidence provided by this article?
Level V
Global standard definition of hypertension is BP reading of >140/90 . Generally as part of increase the donor pools ,and donor with mild HTN and on mono therapy or two AHM with no end organ faluier can donate his kidney ,and he has to know the risk of developing high bp and kidney injury. The donor should be of life long follow up program .
if BP is determined to be high, or high normal, especially if there is variability, or the patient is younger, overweight, or has African heritage, then BP should be evaluated with ambulatory BP monitoring or repeated with standardized BP measurements Despite hypertension being a known risk factor for renal and cardiovascular disease,15-17 more and more transplant centers are relaxing their selection criteria to include donors with well-regulated hypertension in response to decreasing supply of donor organs and increasing demand for kidney transplants
post donation HTN:
An important prospective study by Kasike et al followed up living kidney donors for a period of threes years. he found no statistically significant difference between the donors and controls in both SBPs and DBPs
Other studies have shown that the risk is higher in developing elevated BPs post-donation. The major risk factor was a higher BP pre-donation. Most of these studies excluded marginal donors, donors with an African-American heritage, the obese donors and the elderly donors.
Donor who have an African American heritage have a higher risk of developing post-donation HTN than caucasians. The risk is thought to be high due to the higher presence of the APOL 1 gene. Presence of the APOL1 gene in the donor can also have an impact on graft outcome in the recipient
Donor after donation will be treated and monitored regularly and his bp specially in young donor not >130/90 and in early post operative period preferable to be 160/90 not to affect kidney perfusion .
Generally,CCB,Beta blocker and central acting medications can be used in patient after donation better to avoid ARB,ACEI.
the level of evidence of this article is systemic view ,level V.
Living kidney donation has several advantages as it increase the donor pool, associated with better graft and patient outcome than deceased donor transplant and can be used preemptive, but the medical unfitness of donors remains as a barrier against living donation.
HTN is the commonest cause of exclusion of kidney donors.
Current living kidney donation guidelines:
Different guidelines are available.
The recent guidelines by ACC/AHA define stage1 HTN as systolic BP 130-139 or diastolic BP 80-89, so concerns were raised about donors with systolic BP>130 and their target BP after donation.
The SPRINT showed that keeping BP<120/80 is associated with less cardiovascular events in patients with mean age 68 years, nondiabetic and with eGFR approximately 72, so kidney donors may benefit from lower BP targets after donation.
Evaluation of BP pre-donation:
Screening should include standardized BP measurement on 2 separate occasions.
ABPM should be considered in donors with high or high normal BP, overweight, young age or Africans.
Phenotypes as masked HTN and white coat HTN should be considered during assessment.
KDIGO guidelines suggest that accepting donor with HTN should be individualized according to the risk of having accelerated HTN after donation.
Preexisting HTN in kidney donor candidates:
Most centers include donors with controlled HTN to increase donor pool.
Results of studies on hypertensive donors and associated risk of having renal impairment were controversial.
Most retrospective studies showed that hypertensive donors had no significant increase in BP or antihypertensive agents after donation.
Patients with controlled HTN on 1 or 2 medications with no evidence of target organ damage are accepted for donation after proper counseling about risk of elevated BP and potential end organ damage.
Young, obese or Africans could be at increased risk and should be included on individual basis.
Development of HTN in kidney donors post-donation:
Physiologic alterations after donation are not considered a risk factor for developing HTN after donation.
A prospective study showed that both donors and controls have the same increase in BP after 3 years of follow up.
A trial showed that patients with untreated HTN developed stage 1 HTN over 4 years while those treated with candesartan had lower incidence of HTN suggesting the possibility of modifying BP after donation.
Few studies included marginal donors who are at higher risk of developing HTN before donation.
African Americans have higher relative risk for developing HTN and higher incidence of having ESRD post-donation than Caucasians, several small studies suggest association between presence of donor variants and adverse outcomes of recipients of kidneys with APOL1 susceptibility.
Potential donors with BMI >30-35 are excluded as they have increased risk for having HTN and for developing ESRD after donation, BMI during evaluation can predict prognosis post donation.
African Americans, obese and young age donors require earlier and more intensive treatment to control BP after donation.
Management of BP and HTN post-donation in living kidney donors:
Early after donation: BP is kept elevated <160/90 to keep optimal kidney perfusion.
Long term control: should be individualized according to comorbidities, drug interaction, side effects and kidney function, control should include lifestyle changes, medications and education about self BP monitoring
ACEI, ARB and diuretics are not recommended in perioperative period.
KDIGO guidelines suggest annual follow up after donation and more frequent follow up in hypertensive donors.
Other cardiovascular risk factors should be well controlled.
Suggestions for living kidney donor evaluation with respect to BP:
Standardized BP measurement during evaluation.
High risk potential donors as African Americans, obese and young age should have ABPM
Patients with BP<130/80 can be included with proper individualization and counseling counseling.
Patients with BP >160/100, evidence of end organ damage or taking >2 antihypertensive agents should be excluded.
Those with BP between 130/80 and 160/100, taking 1 or 2 antihypertensive medications, have obstructive sleep apnea, African American or have waist circumference >94cm in men and >80cm in women should have ABPM and if BP<125/75 they can be considered for donation
If BP >125/75, BP should be controlled with lifestyle changes and pharmacologic agents, then to be reevaluated for donation.
Post donation BP should be kept <130/80
Those suggestions are limited as they didn’t consider masked HTN, ABPM is expensive and not widely available and need several studies to determine its role.
Level of evidence: 5 (Review article)
Please summarise this article in your own words
Guidelines & their contraindications to donation for hypertension:
1. CASI, BTS, CCDT: >140/90 mm Hg on 3 occasions.
2. Amsterdam Forum, AST: >140/90 mm Hg
3. EAU, EBPG: Uncontrolled hypertension
4. OPTN: >130/85 mm Hg (in donors <50 years old)
5. KDIGO: >140/90 mm Hg on <2 AHMs, end-organ damage or predicted lifetime ESRD risk exceeding transplant center’s acceptable risk threshold
Contraindications to donation for hypertension in different studies:
1. 24 h ABPM with >15% of SBP>140/90 mm Hg (Moore et al)
2. >130/90 mm Hg in someone <50 year old, end-organ damage, non-Caucasian, or 3+ AHMs (Lapasia et al)
3. >140/90 mm Hg (Haghighi et al; Nagib et al; Sofue et al; Perlis et al)
4. >140/90 mm Hg or AHMs use (Clayton et al; Lagou et al; Lentine et al; Thiel et al; Mjoen et al)
Summary:
Donors with BP <140/90 controlled with 1–2 drugs & no end-organ damage are at minimal risk of worsening kidney function or HTN following donation; however, the available studies are of short duration, & some pheno-or geno-types (obese, African heritage, or APOL1) may be at more risk.
Data comparing influence of BP on renal outcomes in LKDs:
Prospective studies:
1. Tsinalis et al: 46 HTN, 75 Normotensive (BP >150/99 mm Hg or medication use) followed for 1 year.
Outcome: No change in BP or UACR, eGFR 4 mL/min lower in HTN donors.
2. Gracida et al: 16 HTN, 422 Normotensive
(MAP of H 107.8 mm Hg) followed for a mean 80.7 ± 32 months.
Outcome: Creatinine 1.37 in HTN versus 1.1 mg/dL in Normotensives (P < 0.001).
3. Textor et al: 24 HTN, 124 Normotensive (Clinic BP >140/90 mm Hg or ABPM >135/ 85 mm Hg) followed for 6–12 month.
Outcome: No effect on BP, eGFR, or UACR.
4.Tent et al: 47 HTN, 94 Normotensive (Medication use) followed for 1 & 5 years. Outcome:
Early (2 mo) SBP higher in HTN
1 & 5 y eGFR without difference
5. Lenihan et al: 10 HTN, 10 Normotensive (ABPM >140/90 mm Hg or medication use)
Followed for 6 months
Outcome: No difference in eGFR or BP more glomerular in HTN.
Retrospective studies:
1.Srivastava et al: 18 HTN, 64 Normo-tensive ( BP <140/90 mm Hg with medication use)followed for 21 ± 1 months.
Outcome: Mean increase in creatinine 0.5 ± 0.2 mg/dL in HTN versus Normotensive, no proteinuria.
2.Sofue et al: 14 HTN, 38 Normotensive(BP level not defined) followed for 2 years.
Outcome: No change in BP. No significant change in eGFR although higher UACR associated with lower eGFR.
Suggestions based on the current literature:
1. Office readings as recommended in most guidelines:
– Rest 5 min before readings.
– A properly sized BPcuff.
– Final BP averaged from >3 readings with a minimum of a 1-min rest in between each reading.
– ABPM –in certain situations (e.g, younger age, overweight, or African heritage)
2. Based on ACC/AHA guidelines:
– If an average office BP <130/80 mm Hg over 3 measurements, donation is considered.
– If average office BP≥160/100 mm Hg, end-organ damage (LVH, albuminuria), or on >2 antihypertensive medication, then exclude from donation.
-Office BP ≥130/80mm Hg but <<160/100 mm Hg, & on 2 or fewer medication: no available clinical data.
– Postdonation: suggested clinic BP ≤130/80 mm Hg (in line with current guidelines, not only for LKDs but for the general population).
Caveats to the above suggestions:
– “masked hypertension” (BP normal in office, elevated BP in non-office) is not considered.
– Currently no enough data to support the use of ABPM for all potential donors (cost, availability, & expertise needed to perform ABPM correctly).
– No evidence-based guidelines currently available for identifying levels of BP which would pose risk from kidney donation, especially if they are obese, African heritage, or have an APOL1 high risk variant.
– Nor any data on an optimal BP target or treatment plan.
Conclusions
Some guidelines recommend that a 24-hour ABPM BP reading >140/90 mm Hg or use of AHMs be a contraindication to donation. However, when allowed to donate, there is no significantly increased risk of developing renal or CV disease.
There is a concern for LKDs of developing HTN after donation, especially if younger, overweight, or of African heritage.
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What is the level of evidence provided by this article?
Level V