Morning blood pressure surge and morning hypertension in kidney transplant recipients

Kidney transplant recipients (KTRs) frequently exhibit abnormal ambulatory blood pressure (BP) patterns, particularly nocturnal hypertension and impaired dipping. However, morning hypertension and morning BP surge (MBPS) remain less well-characterized in this population. This analysis aims to evaluate the prevalence and phenotypes of morning hypertension and ambulatory BP monitoring (ABPM)-derived morning surge indices according to nocturnal BP status and dipping pattern in KTRs. A total of 135 KTRs who underwent 24 h ABPM (ABPMpro device) were included. Morning BP was defined as mean BP during the first two hours after awakening. MBPS was assessed using pre-awakening, sleep-through and rising surge definitions. Morning hypertension was present in 53.3% of KTRs; among those with morning hypertension, 93.1% had sustained nocturnal and morning hypertension. Elevated SBP was equally frequent during morning and nighttime periods (43.7% each), but only half of them had elevated BP during daytime. Office BP underestimated morning BP burden, with masked morning hypertension identified in 18.5%. Participants with nocturnal hypertension had lower pre-awakening systolic MBPS than those without nocturnal hypertension (8.0 ± 12.1 vs. 15.2 ± 12.8 mmHg, p = 0.014), as well as lower sleep-through systolic MBPS (15.6 ± 13.0 vs. 22.2 ± 13.9 mmHg, p = 0.037), while rising MBPS did not differ significantly. Across dipping categories, MBPS indices were consistently higher in dippers and lower in reverse dippers (pre-awakening SBP surge: dippers 24.7 ± 13.1, non-dippers 10.7 ± 9.1, and reverse-dippers 1.1 ± 11.2 mmHg; p < 0.001). Morning hypertension is common in KTRs and is driven predominantly by sustained nocturnal and morning hypertension. Blunted MBPS likely reflects persistent nocturnal BP elevation and impaired dipping status.