Diagnosis and treatment of hypertension in children

A Deep Insight Into Regulatory T Cell Metabolism in Renal Disease: Facts and Perspectives

Kidney disease encompasses a complex set of diseases that can aggravate or start systemic pathophysiological processes through their complex metabolic mechanisms and effects on body homoeostasis. The prevalence of kidney disease has increased dramatically over the last two decades. CD4⁺CD25⁺ regulatory T (Treg) cells that express the transcription factor forkhead box protein 3 (Foxp3) are critical for maintaining immune homeostasis and preventing autoimmune disease and tissue damage caused by excessive or unnecessary immune activation, including autoimmune kidney diseases. Recent studies have highlighted the critical role of metabolic reprogramming in controlling the plasticity, stability, and function of Treg cells. They are also likely to play a vital role in limiting kidney transplant rejection and potentially promoting transplant tolerance. Metabolic pathways, such as mitochondrial function, glycolysis, lipid synthesis, glutaminolysis, and mammalian target of rapamycin (mTOR) activation, are involved in the development of renal diseases by modulating the function and proliferation of Treg cells. Targeting metabolic pathways to alter Treg cells can offer a promising method for renal disease therapy. In this review, we provide a new perspective on the role of Treg cell metabolism in renal diseases by presenting the renal microenvironment、relevant metabolites of Treg cell metabolism, and the role of Treg cell metabolism in various kidney diseases.

Effect of Comprehensive Interventions Including Nutrition Education and Physical Activity on High Blood Pressure among Children: Evidence from School-Based Cluster Randomized Control Trial in China

Childhood hypertension has increasingly become a public health problem globally. However, limited literature research examined the effect of comprehensive interventions including nutrition education and physical activity on blood pressure among children. A total of 6764 children aged 7–13 years were analyzed based on a multicenter randomized controlled trial for comprehensive interventions in 30 primary schools in China to evaluate the effects on blood pressure, which lasted for two semesters. The standards used for the diagnosis of high blood pressure were the cut-off points based on age and sex for Chinese children. Compared with the control group, the intervention effects were −0.5 mm Hg (95% confidence interval (CI): −1.1, 0; p = 0.064) for diastolic blood pressure and −0.9 mmHg (95% CI: −1.5, −0.3; p = 0.005) for systolic blood pressure. For the incidence of high blood pressure, the changes were −1.4% in the intervention group and 0.4% in the control group (1.8% difference between the two groups, p = 0.015) after trial. The school-based comprehensive interventions appeared to have moderate effects on high blood pressure prevention among children in China.

Diagnostic Errors in Primary Care Pediatrics: Project RedDE

OBJECTIVE

Diagnostic errors (DEs), which encompass failures of accuracy, timeliness, or patient communication, cause appreciable morbidity but are understudied in pediatrics. Pediatricians have expressed interest in reducing high-frequency/subacute DEs, but their epidemiology remains unknown. The objective of this study was to investigate the frequency of two high-frequency/subacute DEs and one missed opportunity for diagnosis (MOD) in primary care pediatrics.

METHODS

As part of a national quality improvement collaborative, 25 primary care pediatric practices were randomized to collect 5 months of retrospective data on one DE or MOD: elevated blood pressure (BP) and abnormal laboratory values (DEs), or adolescent depression evaluation (MOD). Relationships between DE or MOD proportions and patient age, gender, and insurance status were explored with mixed-effects logistic regression models.

RESULTS

DE or MOD rates in pediatric primary care were found to be 54% for patients with elevated BP (n = 389), 11% for patients with abnormal laboratory values (n = 381), and 62% for adolescents with an opportunity to evaluate for depression (n = 400). When examining the number of times a pediatrician may have recognized an abnormal condition but either knowingly or unknowingly did not act according to recommended guidelines, providers did not document recognition of an elevated BP in 51% of patients with elevated BP, and they did not document recognition of an abnormal laboratory value without a delay in 9% of patients with abnormal laboratory values.

CONCLUSIONS

DEs and MODs occur at an appreciable frequency in pediatric primary care. These errors may contribute to care delays and patient harm.

[Blood pressure values in adolescents in the Community of Madrid: Tables based on the MEPAFAC Study]

INTRODUCTION

High blood pressure (HBP) is a modifiable cardiovascular risk factor and its detection at early ages may allow strategies to be designed to reduce cardiovascular risk in adulthood.

OBJECTIVES

To provide blood pressure (BP) values in a sample of adolescents using an electronic oscillometric device.

MATERIAL AND METHODS

BP was measured according the European Society of Hypertension guidelines using an oscillometric device. Height and weight were also measured. Four height groups were used in order to associate the 90, 95, and 99 percentiles with systolic BP (pSBP) and diastolic BP percentiles (pDBP) for sex and age: H150 (≤ 150cm), H160(151-160cm), H170(161-170cm), and H180(≥171cm).

RESULTS

Data from 2,758 students aged 12-17 years were included in the analysis. BP increases with age, with differences of up to 11mmHg in boys vs. 3mmHg in girls for SBP and 3mmHg vs. 1mmHg for DBP. In high SBP, for the younger adolescents, the difference related to height was 15mmHg in boys vs. 8mmHg in girls, with no significant increase in the older ones in either gender. The high BDP varied depending on the height, 10mmHg in younger boys and 3mmHg in older ones, while in girls the variation was 3mmHg for all ages.

CONCLUSIONS

SBP/DBP in adolescents increases with age and also with height, giving similar figures in the taller ones, regardless of age.

Obesity as a Mediator between Cardiorespiratory Fitness and Blood Pressure in Preschoolers

OBJECTIVES

To analyze the relationships between body mass index (BMI), cardiorespiratory fitness (CRF), and blood pressure (BP), and to examine whether obesity acts as a mediator between fitness and BP in children.

STUDY DESIGN

A cross-sectional analysis using a population-based sample of 1604 school children aged 4-7 years attending 21 schools from the provinces of Ciudad Real and Cuenca, Spain, was undertaken. Data on anthropometric variables, BP measurements, and CRF were collected. The relationships between body composition (BMI, percent body fat, and waist circumference), CRF, and mean arterial pressure was estimated using Pearson correlation coefficients. ANCOVA tested the differences in BP measurements by categories of BMI and CRF, controlling for different sets of confounders. The PROCESS macro developed by Preacher and Hayes was used for mediation analysis.

RESULTS

BP values were significantly higher in school children with excess weight and poorer CRF. In addition, BMI acts as a full mediator in the association between CRF and mean arterial pressure in boys at 62.28% (z = -5.433; P ≤ .001) and a partial mediator in girls at 35.24% (z = -5.246; P ≤ .001).

CONCLUSIONS

BMI mediates the relationship between CRF and mean arterial pressure. These findings highlight the importance of maintaining a healthy weight for the prevention of high BP levels in childhood.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01971840.

Predictors of renal replacement therapy and mortality in children with chronic kidney disease

Objectives:

To study the epidemiology of chronic kidney disease (CKD) in children, and to look for risk factors to predict renal replacement therapy (RRT) and mortality.

Methods:

This is a retrospective cohort study conducted at King Abdulaziz University Hospital, Jeddah, Saudi Arabia between 2006 and 2014, where the files of 1,000 children with CKD were reviewed. We determined the effect of consanguinity and hypertension, and being a Saudi indigene on mortality and RRT. We compared children with congenital versus non-congenital causes of CKD.

Results:

The mean±standard deviation age at presentation was 4.9±4.3 years. The median duration of follow up was 1.5 (interquartile range [IQR]: 0.4-4.0) years. Only 9.7% of children received RRT, and 8.3% died. The underlying etiology for CKD was congenital in 537 children. The congenital CKD group presented at a younger age group (3.5±4.0 versus 6.6±3.9 years, p<0.0001), had more advanced stages of CKD (p<0.0001), higher rates of consanguinity (75.4% versus 47.1%, p<0.0001), and RRT (p<0.004) than children with non-congenital CKD. Risk factors for RRT among children with CKD include being a Saudi indigene (relative risk [RR]=1.49, 95% confidence interval (CI): 1.01-2.21), and hypertensive (RR=5.29, 95% CI: 3.54-7.91). The risk factor for mortality was hypertension (RR=2.46, 95% CI: 1.66-3.65).

Conclusion:

Congenital causes of CKD represent the main etiology of CKD in children living in the western province of Saudi Arabia. Significant risk factors for RRT include congenital CKD, Saudi nationality, and hypertension. Hypertension is also a predictor of mortality in children with CKD.

Association between anthropometry and high blood pressure in a representative sample of preschoolers in madrid

INTRODUCTION AND OBJECTIVES

Program SI! is a multi-level, school-based intervention for the promotion of cardiovascular health from early childhood. The aim of this paper is to characterize the prevalence of obesity and high blood pressure in the preschoolers enrolled in the study, and to compare various criteria for classifying obesity.

METHODS

The study was a cluster-randomized controlled intervention trial including 24 state schools in Madrid (Spain). Weight, height, triceps and subscapular skinfold thicknesses, waist circumference, and systolic and diastolic blood pressure were measured in 2011 children (1009 boys and 1002 girls) aged 3 to 5 years (3.7 [0.9]). Body mass index and blood pressure were classified by corresponding task force criteria. Obesity was studied by 6 different criteria. Associations of body mass index, body weight, body fat, and waist circumference on blood pressure were examined, and the risk of high blood pressure in relation to tertiles of body mass index was calculated.

RESULTS

The prevalence of obesity according to the International Obesity Task Force varied from 2% at age 3 to 8% at age 5, and the overall prevalence of high blood pressure (≥ 90th percentile) was 20%. Sex- and age-specific criteria for obesity showed better agreement with the reference than a single generalized cutoff. The risk of high blood pressure was higher for the highest tertile of body mass index distribution.

CONCLUSIONS

The highest prevalence of obesity and high blood pressure was found among older children. The classification of obesity in children was more accurate using sex- and age-specific cutoffs.

Hypertension in the teenager

Over the last two decades, essential hypertension has become common in adolescents, yet remains under-diagnosed in absence of symptoms. Diagnosis is based on normative percentiles that factor in age, sex and height. Evaluation is more similar to adult essential hypertension than childhood secondary hypertension. Modifiable risk factors such as obesity, sodium consumption and low exercise should be addressed first. Many anti-hypertensive medications now have specific regulatory approval for children. Sports participation need not be limited in mild or well-controlled cases. Primary care physicians play an important role in reduction of cardiovascular mortality by early detection and referral when needed.

Screening for hypertension in children and adolescents to prevent cardiovascular disease

BACKGROUND AND OBJECTIVE

The prevalence of hypertension is increasing in children, and may persist into adulthood. This systematic review was conducted for the US Preventive Services Task Force recommendation on the effectiveness of screening asymptomatic children and adolescents for hypertension in order to prevent cardiovascular disease.

METHODS

Eligible studies were identified from Medline and the Cochrane Library (through July 2012). We included trials and controlled observational studies in asymptomatic children and adolescents on the effectiveness and harms of screening and treatment, as well as accuracy of blood pressure measurement. One author extracted study characteristics and results, which were checked for accuracy by a second author.

RESULTS

No studies evaluated the effects of screening for hypertension on health outcomes. Two studies of screening tests for elevated blood pressure reported moderate sensitivities (0.65, 0.72) and specificities (0.75, 0.92). Sensitivities and specificities of child hypertension for the later presence of adult hypertension (7 studies) were wide ranging (0-0.63 and 0.77-1.0, respectively), and associations between child hypertension and carotid intima media thickening and proteinuria in young adults (3 studies) were inconsistent. Seven studies reported that drug interventions effectively lowered blood pressure in adolescents over short follow-up periods. No serious treatment-related adverse effects were reported.

CONCLUSIONS

There is no direct evidence that screening for hypertension in children and adolescents reduces adverse cardiovascular outcomes in adults. Additional studies are needed to improve diagnosis and risk stratification of children with elevated blood pressure and to quantify risks and benefits of interventions.

Hypertension in children and adolescents: epidemiology and pathogenesis

High blood pressure is one among the leading contributors to burden of disease globally. Approximately 54 % of stroke and 47 % of ischemic heart disease events worldwide were attributable to high blood pressure in the year 2001. There is deficiency of data on the long-term outcome of hypertension in children. In spite of this, there is sufficient evidence to suspect that the health risks of hypertension in pediatric patients are substantial. Hypertension in childhood is known to result in hypertension in young adulthood. The epidemiology of hypertension in children is well represented from various studies conducted across continents. Factors like methodological issues in measurement, socio demographic differences, adiposity levels and ethnicity appear to influence the distribution of blood pressure as well as prevalence of hypertension in children. The etio-pathogenesis of essential (primary) hypertension is multi-factorial in origin. Obesity, insulin resistance, activation of sympathetic nervous system, alterations in sodium homeostasis, renin-angiotensin system changes, changes in vascular smooth muscle structure and reactivity, high serum uric acid levels, genetic factors and fetal programming have been reported to contribute to this disorder. The causes of secondary hypertension vary with age. Renal disorders and coarctation of the aorta are the most common causes of hypertension in children up to age 6 y. In older children, renal parenchymal disease remains the most frequent cause of increased blood pressure. Other causes of hypertension in children are relatively rare and include systemic arteritis and certain tumours, endocrine dysfunction, and neurologic disorders.

Prematurity-related hypertension in children and adolescents

Due to the functional and structural immaturity of different organ systems, preterms have a higher rate of morbidity and mortality. The prevention and treatment of the complications of prematurity is a major challenge in perinatal health care. Recently, there have been several multicenter research trials analysing the impact of prematurity or low birth weight on the health problems of children and adolescents. Many of these studies deal with the issue of pediatric hypertension. An analysis of 15 studies conducted in the years 1998–2011, in which blood pressure values in ex-preterm children were measured, was performed. Comparison was based on several issues: measurement method, cohorts age, size, and birthweight. It has been proven that hypertension occurs more often in former preterm infants; however the etiologic pathways that cause this condition still remain unclear. Moreover, pediatric hypertension is a significant problem, because of its transformation into adult hypertension and increased cardiovascular risk later in life. Therefore it is crucial to introduce wide-spread screening and detection of elevated blood pressure, especially among prematurely born children.