Nocturnal hypertension in kidney transplant recipients: epidemiology, pathophysiology, prognostic significance, and management

Kidney transplantation markedly improves survival and quality of life in patients with kidney failure; however, cardiovascular disease remains the leading cause of morbidity and mortality among kidney transplant recipients (KTRs). Hypertension after kidney transplantation is very common and is strongly associated with adverse cardiovascular as well as graft-related outcomes. Notably, hypertension in this population exhibits distinct features, including exceptionally high rates of masked hypertension; this is largely driven by the frequent occurrence of elevated nocturnal blood pressure (BP) and abnormal dipping patterns, which were observed in up to 95% of KTRs. Observational studies consistently demonstrate that higher nocturnal BP and abnormal dipping profiles are linked to accelerated graft function loss, cardiovascular events, and hypertension-mediated target-organ damage, frequently with stronger prognostic value than office or daytime BP measurements. In this review, we summarize the current evidence on circadian BP phenotypes and nocturnal hypertension in KTRs, focusing on epidemiology, underlying mechanisms, prognostic implications for cardiovascular and graft outcomes, and contemporary strategies for diagnosis and management.