Antihypertensive treatment for kidney transplant recipients

Background The comparative effects of specific blood pressure (BP) lowering treatments on patient‐important outcomes following kidney transplantation are uncertain. Our 2009 Cochrane review found that calcium channel blockers (CCBs) improved graft function and prevented graft loss, while the evidence for other BP‐lowering treatments was limited. This is an update of the 2009 Cochrane review. Objectives To compare the benefits and harms of different classes and combinations of antihypertensive drugs in kidney transplant recipients. Search methods We contacted the Information Specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 3 July 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. Selection criteria Randomised controlled trials (RCTs) and quasi‐RCTs evaluating any BP‐lowering agent in recipients of a functioning kidney transplant for at least two weeks were eligible. Data collection and analysis Two authors independently assessed the risks of bias and extracted data. Treatment estimates were summarised using the random‐effects model and expressed as relative risk (RR) or mean difference (MD) with 95% confidence intervals (CI). Evidence certainty was assessed using Grades of Recommendation, Assessment, Development and Evaluation (GRADE) processes. The primary outcomes included all‐cause death, graft loss, and kidney function. Main results Ninety‐seven studies (8706 participants) were included. One study evaluated treatment in children. The overall risk of bias was unclear to high across all domains. Compared to placebo or standard care alone, CCBs probably reduce all‐cause death (23 studies, 3327 participants: RR 0.83, 95% CI 0.72 to 0.95; I2 = 0%; moderate certainty evidence) and graft loss (24 studies, 3577 participants: RR 0.84, 95% CI 0.75 to 0.95; I2 = 0%; moderate certainty evidence). CCBs may make little or no difference to estimated glomerular filtration rate (eGFR) (11 studies, 2250 participants: MD 1.89 mL/min/1.73 m2, 95% CI ‐0.70 to 4.48; I2 = 48%; low certainty evidence) and acute rejection (13 studies, 906 participants: RR 10.8, 95% CI 0.85 to 1.35; I2 = 0%; moderate certainty evidence). CCBs may reduce systolic BP (SBP) (3 studies, 329 participants: MD ‐5.83 mm Hg, 95% CI ‐10.24 to ‐1.42; I2 = 13%; low cer