Inside Pediatrics, Nephrology

Improving Renal Transplant Outcomes

Blood pressure is one of the most basic biometrics, taken nearly every time someone visits a health care provider. It’s also one of the most important indicators of kidney problems in both native and transplanted kidneys, with studies suggesting a direct benefit of maintaining normal blood pressures on transplant outcomes.

But taking a child’s blood pressure when they’re seen in clinic provides just a snapshot in time in a non-standard environment that can be associated with high anxiety, said Michael E. Seifert, M.D., a pediatric nephrologist at Children’s of Alabama and the University of Alabama at Birmingham (UAB). That’s why the gold standard for assessing blood pressure control is a 24-hour ambulatory blood pressure monitor, which the Pediatric Kidney Transplant Program strives to perform at least once a year in each eligible patient. The device takes and records blood pressure every 30-60 minutes, providing a slew of important information for clinicians. In fact, studies suggest that ambulatory blood pressures are a better predictor of long-term cardiovascular outcomes than clinic blood pressures.

It can also highlight unique blood pressure patterns in children with transplants that can’t be detected with the occasional clinic visit, such as masked hypertension, when blood pressure is normal in the clinic but high the rest of the day. Or nocturnal hypertension, in which it is only high at night or when the patient is asleep. A normal pattern for blood pressure over a 24-hour period is called nocturnal dipping, where the blood pressure is lower during the nighttime and sleep periods than when patients are awake.

However, when the staff dug into its data, they found that only about 20% to 25% of their eligible patients had had an ambulatory blood pressure monitor in the past year. So they launched a quality improvement project as part of the Improving Renal Outcomes Collaborative (IROC), a learning health system of 32 pediatric kidney transplant centers in the U.S. that share data and best practices in an effort to improve transplant outcomes. The quality improvement project was supported by a Quality Improvement Award from the Kaul Pediatric Research Institute at Children’s of Alabama.

The team already had a weekly pre-visit planning meeting in place that helped prepare for each patient’s needs during the next week of clinics. They used that opportunity to generate lists of patients who had not had the ambulatory blood pressure monitor, and systematically made it a part of the transplant anniversary visits. After just six months, placement rates jumped to over 40%, even throughout the pandemic and telehealth visits.

“We are really proud of our team for being able to improve and sustain that during some pretty challenging conditions,” Seifert said.

Even more important, in about three-fourths of the patients, the ambulatory blood pressures turned up a problem that required intervention.

“We assumed we were doing a great job with this because we’re nephrologists and we have hypertension clinics focused on proper blood pressure measurement and control,” Seifert said. “But until you start looking hard at your data, you can’t presume you’re doing as well as you think you are. We didn’t know we needed to improve until we turned the lens on it.” The project has been so successful other solid organ transplant programs at Children’s are also considering implementing it as part of their cardiovascular risk assessments.

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