Blood pressure lowering for kidney transplant recipients: systematic review with network meta-analysis

J Hypertens. 2024 May 1;42(5):848-855 doi: 10.1097/HJH.0000000000003663.

Hypertension affects 50-90% of kidney transplant recipients and is associated with cardiovascular disease and graft loss. We aimed to evaluate the comparative benefits and harms of blood pressure lowering agents in people with a functioning kidney transplant.


We conducted a systematic review with network meta-analysis of randomized controlled trials (RCTs). We searched MEDLINE, Embase, and CENTRAL through to October 2023. RCTs evaluating blood pressure lowering agents administered for at least 2 weeks in people with a functioning kidney transplant with and without preexisting hypertension were eligible. Two reviewers independently extracted data. The primary outcome was graft loss. Treatment effects were estimated using random effects network meta-analysis, with treatment effects expressed as an odds ratio (OR) for binary outcomes and mean difference (MD) for continuous outcomes together with their 95% confidence interval (CI). Confidence in the evidence was assessed using GRADE for network meta-analysis.


Ninety-four studies (7547 adults) were included. Two studies were conducted in children. No blood pressure-lowering agent reduced the risk of graft loss, withdrawal because of adverse events, death, cardiovascular or kidney outcomes compared with placebo/other drug class. Angiotensin-converting enzyme inhibitors and angiotensin receptor blocker therapy may incur greater odds of hyperkalemia compared with calcium channel blockers [odds ratio (OR) 5.48, 95% confidence interval (CI) 2.47-12.16; and OR 8.67, 95% CI 2.65-28.36; low certainty evidence, respectively).


The evidentiary basis for the comparative benefits and safety of blood pressure lowering agents in people with a functioning kidney transplant is limited to guide treatment decision-making.

CET Conclusion
Reviewer: Reshma Rana Magar, Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences University of Oxford
Conclusion: The aim of this systematic review was to examine the role of blood pressure lowering agents in transplant patients with a functioning kidney allograft. A large number of studies were included (94 studies), including a total of 7547 adults, all of which were randomised controlled studies. The authors found that none of the blood pressure-lowering agents reduced the risk of graft loss nor did they show significant differences in terms of all-cause death, cardiovascular death and withdrawal because of adverse events, in comparison to placebo or other drug class. Although only RCTs were included, some of them were of poor quality and/or were publish over 20 years ago—these factors may have influenced the certainty of the findings. This study also highlights the insufficient reporting of data on important variables such as donor type (living versus deceased), time after transplantation and quality of life, which may have restricted the authors from performing a more granular analyses of the outcomes. Hence, the authors concluded that the evidence basis for this topic is poor that cannot be used to inform clinical decision-making.
Study Details
Aims: This study aimed to assess the benefits and harms associated with blood pressure lowering agents in renal transplant recipients with a functioning graft.
Interventions: Three electronic databases including MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched. Two reviewers independently selected studies for inclusion and extracted data. The Cochrane Risk of Bias Tool was used to assess the risk of bias.
Participants: 94 studies were included in the review.
Outcomes: The primary effectiveness outcome was graft loss, and safety outcome was withdrawal due to adverse events. The secondary outcomes were death (all-cause and cardiovascular), cardiovascular disease, acute rejection, acute kidney injury, acute dialysis, estimated glomerular filtration rate (eGFR), creatinine clearance, systolic blood pressure (SBP) and diastolic blood pressure (DBP), mean arterial pressure (MAP), adverse events and quality of life.
Follow Up: N/A
Funding: Funding not described
Publication type: Meta-Analysis, Systematic Review
Review registration: PROSPERO - CRD42019134147
Organ: Kidney
Language: English
MeSH terms: Child; Adult; Humans; Blood Pressure; Kidney Transplantation; Network Meta-Analysis; Hypertension; Angiotensin-Converting Enzyme Inhibitors; 0 (Angiotensin-Converting Enzyme Inhibitors)