Impact of the 2022 ambulatory blood pressure monitoring guidelines on blood pressure phenotypes in pediatric kidney transplant recipients

Background: The American Academy of Pediatrics Clinical Practice Guidelines (AAPCPG) recommend 24-h ambulatory blood pressure monitoring (ABPM) for diagnosing hypertension (HTN) in pediatric kidney transplant recipients. The ABPM guidelines were updated in 2022 to incorporate the 2017 AAPCPG thresholds for those ≥ 13 years and exclude blood pressure loads. The effect of the 2022 update on ABPM phenotype and its association with end-organ damage in this population remains unexplored. Method: We retrospectively evaluated pediatric kidney transplant recipients (age < 22 years) who underwent 24-h ABPM for HTN surveillance between 1/2021 and 9/2024. We grouped ABPM phenotypes into two categories: HTN (masked, ambulatory, and 2014-specific severe ambulatory) and no HTN (normal, white-coat, and 2014-specific uncategorized). We assessed systematic differences between the two guidelines using McNemar’s test and agreement using Cohen’s Kappa coefficient. Results: Our cohort included 105 recipients. Compared to 2014, the 2022 guidelines identified more recipients with HTN (49.5% vs. 36.2%; McNemar’s p < 0.001); however, the overall agreement remained substantial (kappa: 0.73, 95% CI: 0.61, 0.86). Among the 10 recipients with elevated ambulatory arterial stiffness index (AASI), the 2022 guidelines identified 80.0% as abnormal compared to only 30.0% under the 2014 guidelines (McNemar’s p = 0.025), reflecting no significant agreement (Kappa: 0.19; 95% CI: -0.1, 0.49). Conclusion: Compared to the 2014 criteria, the 2022 guidelines identified a higher proportion of pediatric kidney transplant recipients with HTN and more effectively identified abnormalities in recipients with elevated AASI. Our findings indicate that 2022 guidelines are better aligned with markers of arterial stiffness and cardiovascular risk.