Optimal Blood Pressure Targets for Kidney Transplant Recipients: Evolution of Research and Best Practices

The optimal blood pressure target for kidney transplant recipients remains a subject of debate. While multiple studies have confirmed that hypertension negatively impacts graft survival, there is still a lack of clear clinical evidence regarding the ideal blood pressure range. Maintaining optimal blood pressure after transplantation is crucial not only for cardiovascular disease prevention but also for the long-term survival of the transplanted kidney. In 2017, the American Heart Association (AHA) and the American College of Cardiology (ACC) revised the hypertension threshold to ≥130/80 mmHg, raising discussions on whether stricter blood pressure control is necessary for kidney transplant recipients.

A recent study from the Collaborative Transplant Study (CTS) (2025, Speer et al.) analyzed data from 62,556 kidney transplant recipients to assess the relationship between different blood pressure levels and graft survival/mortality. This study provides a more detailed perspective on blood pressure management in kidney transplant recipients. This article reviews the evolution of research on this topic, explores optimal blood pressure targets, and discusses future directions for study and clinical application.

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Summary of Research and Blood Pressure Guidelines

 

(a) Good Outcome Group

• This group consists of kidney transplant recipients with no immunological complications and preserved kidney function at 1 year post-transplant.
• Patients were classified into three groups: No Hypertension (No HT, green), Hypertension Stage 1 (HT Stage 1, orange), and Hypertension Stage 2 (HT Stage 2, red).
• Graft survival at year 6:
  • No HT: 95.8%
  • HT Stage 1: 96.3%
  • HT Stage 2: 95.1%
• The statistical significance of the difference was P < 0.001.
• Although the Stage 2 hypertension group (≥140/90 mmHg) showed slightly lower survival rates, the difference was relatively minor within the Good Outcome group.

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(b) Poor Outcome Group

• This group includes kidney transplant recipients who required antirejection treatment or had a serum creatinine level of ≥130 µmol/L at 1 year post-transplant, indicating impaired kidney function.
• Graft survival at year 6:
  • No HT: 88.2%
  • HT Stage 1: 86.4%
  • HT Stage 2: 82.5%
• The Stage 2 hypertension (HT Stage 2) group showed a sharp decline in graft survival, clearly demonstrating the negative impact of hypertension.

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• Hypertension, particularly Stage 2 (≥140/90 mmHg), increases the risk of kidney transplant failure.
• In the Good Outcome group, the impact of hypertension was relatively small, whereas in the Poor Outcome group, survival rates decreased significantly.
• Therefore, kidney transplant recipients with impaired kidney function require more aggressive blood pressure management to improve long-term outcomes.

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Case Studies

Case 1: 55-year-old Male, Uncontrolled Hypertension After Transplant

• Background: A 55-year-old male with diabetes and hypertension underwent a kidney transplant two years ago.
• Blood Pressure Management: His initial BP was 145/95 mmHg, which remained uncontrolled despite antihypertensive medication, persisting above 140/90 mmHg at the 1-year mark.
• Outcome: According to the **CTS study (2025), patients with Stage 2 hypertension (≥140/90 mmHg) at the 1-year mark had a 55% increased risk of graft failure.
• Medical Intervention: More aggressive blood pressure management is necessary, with a target of <130/80 mmHg to improve long-term graft survival.

Case 2: 40-year-old Female, Gradual Blood Pressure Increase

• Background: A 40-year-old female had normal BP (<120/80 mmHg) in the first year post-transplant but later developed Stage 1 hypertension (130-139/80-89 mmHg).
• Blood Pressure Management: Lifestyle changes and additional antihypertensive medication adjustments were recommended.
• Outcome: The CTS study showed that even Stage 1 hypertension (130-139/80-89 mmHg) increased the risk of graft failure by 11%.
• Medical Intervention: Long-term BP control strategies should be implemented to reduce the risk of graft loss.

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Optimal Blood Pressure Targets and Future Directions

Current Recommendations

• <130/80 mmHg appears to be the most appropriate target for improving graft survival.
• ≥140/90 mmHg is significantly associated with an increased risk of graft failure and mortality.
• However, lowering BP aggressively to <120/80 mmHg remains uncertain, as some studies have suggested potential risks, such as acute kidney injury (AKI).

Future Research Needs

1. Randomized Controlled Trials (RCTs)
   • To establish causality and determine the safest and most effective BP target for kidney transplant recipients.
2. Long-term BP Monitoring
   • Studies should track BP over time rather than relying on a single measurement.
3. Personalized BP Targets
   • Optimal BP targets should consider age, gender, cardiovascular history, and graft function.

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Conclusion

The ideal blood pressure target for kidney transplant recipients is becoming clearer with recent research. Current evidence suggests that maintaining BP <130/80 mmHg is beneficial, while ≥140/90 mmHg significantly increases the risk of graft failure. However, further RCTs are needed to determine whether lowering BP to <120/80 mmHg provides additional benefits or potential risks. As new research emerges, personalized BP management strategies will become increasingly important in clinical practice.

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References

1. Speer C, Benning L, Morath C, Zeier M, Frey N, Opelz G, Döhler B, Tran TH. Blood Pressure Goals and Outcomes in Kidney Transplant Recipients in an Analysis of the Collaborative Transplant Study. Kidney Int Rep. 2025;10:780–790.

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