Pediatric hypertension update. Curr Opin Nephrol Hypertens. 2010;19:292-297. [PMID: 20164767 DOI: 10.1097/mnh.0b013e3283373016]

Clinical Characteristics and Factors Associated With Hypertension in 205 Hospitalized Children: A Single-Center Study in Southwest China

Objective: The aim of this study was to investigate the clinical characteristics and factors associated with pediatric hypertension and target organ damage (TOD). Methods: We retrospectively reviewed clinical data from 205 children with hypertension treated in our hospital from 2007 to 2018. The patients were classified based on the type of hypertension (primary, secondary) and presence of TOD (heart, brain, retina). Logistic regression analysis was performed to identify the factors independently associated with hypertension and TOD. Results: There were 107 males, 97 females, and one intersex in this study, with an age range of 0.1-17.9 years. Majority of cases (177, 86.3%) had secondary hypertension, while 13.7% had primary hypertension. The most frequent cause of secondary hypertension was renal disease (59.32%). Elevated serum creatinine level (odds ratio [OR] = 7.22, 95% confidence interval [95% CI] = 1.6-32.62, P = 0.01), blood urea nitrogen (OR = 6.33, 95% CI = 1.81-22.19, P = 0.004), serum uric acid level (OR = 3.66, 95% CI = 1.20-11.22, P = 0.023), and albuminuria (OR = 3.72, 95% CI = 1.50-9.26, P = 0.005) were independently associated with secondary hypertension. Elevated serum uric acid and blood urea nitrogen levels were associated with left ventricular hypertrophy (OR = 6.638, 95% CI = 1.349-32.657, P = 0.02) and hypertensive encephalopathy (OR = 4.384, 95% CI = 1.148-16.746, P = 0.031), respectively. Triglyceride level correlated with hypertensive retinopathy (P = 0.001). Conclusion: Pediatric hypertension was most often secondary, with renal disease as the leading cause. Elevated levels of serum uric acid, blood urea nitrogen, serum creatinine, and albuminuria may indicate secondary hypertension in childhood. Elevated serum uric acid, blood urea nitrogen, and triglyceride levels were associated with left ventricular hypertrophy, hypertensive encephalopathy, and hypertensive retinopathy, respectively.

Primary Pediatric Hypertension: Current Understanding and Emerging Concepts

The rising prevalence of primary pediatric hypertension and its tracking into adult hypertension point to the importance of determining its pathogenesis to gain insights into its current and emerging management. Considering that the intricate control of BP is governed by a myriad of anatomical, molecular biological, biochemical, and physiological systems, multiple genes are likely to influence an individual's BP and susceptibility to develop hypertension. The long-term regulation of BP rests on renal and non-renal mechanisms. One renal mechanism relates to sodium transport. The impaired renal sodium handling in primary hypertension and salt sensitivity may be caused by aberrant counter-regulatory natriuretic and anti-natriuretic pathways. The sympathetic nervous and renin-angiotensin-aldosterone systems are examples of antinatriuretic pathways. An important counter-regulatory natriuretic pathway is afforded by the renal autocrine/paracrine dopamine system, aberrations of which are involved in the pathogenesis of hypertension, including that associated with obesity. We present updates on the complex interactions of these two systems with dietary salt intake in relation to obesity, insulin resistance, inflammation, and oxidative stress. We review how insults during pregnancy such as maternal and paternal malnutrition, glucocorticoid exposure, infection, placental insufficiency, and treatments during the neonatal period have long-lasting effects in the regulation of renal function and BP. Moreover, these effects have sex differences. There is a need for early diagnosis, frequent monitoring, and timely management due to increasing evidence of premature target organ damage. Large controlled studies are needed to evaluate the long-term consequences of the treatment of elevated BP during childhood, especially to establish the validity of the current definition and treatment of pediatric hypertension.

The emerging epidemic of hypertension in Asian children and adolescents

Hypertension has become a serious global public health burden because of its high incidence and concomitant risk of cardiovascular disease. Many studies have verified that risk factors, such as hypertension and obesity which are responsible for cardiovascular disease, start in early childhood. In Asian countries, the prevalence of hypertension in the pediatric age group has become more prevalent than ever before with the increasing obesity epidemic. To tackle the epidemic of cardiovascular disease, a leading cause of death and disability of non-communicable diseases in Asian countries, population-based measures aiming at reducing harmful environmental factors to blood pressure and body weight must be applied to individuals in their early childhood, as early as the fetal stage. This review focused on the prevalence of pediatric hypertension in Asian countries and outlined several considerations for accurate blood pressure (BP) measurement and evaluation, along with an overview of pathophysiology of fetal programming and obesity related with childhood hypertension.

The effects of celecoxib or naproxen on blood pressure in pediatric patients with juvenile idiopathic arthritis

BACKGROUND

Selective and nonselective nonsteroidal anti-inflammatory drugs (NSAIDs) are indicated for the treatment of juvenile idiopathic arthritis (JIA). However, the effect of NSAIDs on blood pressure (BP) in children has not been rigorously examined.

METHODS

In this randomized, double-blind, multicenter, active-controlled, 6-week trial, the safety and efficacy of celecoxib (50 mg twice daily [bid] or 100 mg bid) or naproxen (7.5 mg/kg bid) was evaluated in patients aged 2–17 years with JIA.

RESULTS

The least squares (LS) mean difference (celecoxib – naproxen) in change from baseline to week 6/final visit in systolic BP was 1.10 (90% confidence interval, −0.56, 2.76). No significant LS mean differences in diastolic BP relative to baseline were reported. Treatment-emergent adverse events occurred in 48% of patients in each treatment group.

CONCLUSION

Both celecoxib and naproxen had no impact on BP, and both treatments had comparable safety profiles. Celecoxib, or naproxen, could be seen as suitable treatment options for pediatric patients with JIA.

Cochrane in context: pharmacological interventions for hypertension in children

BACKGROUND

Hypertension is a major risk factor for stroke, coronary artery disease and kidney damage in adults. There is a paucity of data on the long-term sequelae of persistent hypertension in children, but it is known that children with hypertension have evidence of end-organ damage and are at risk of hypertension into adulthood. The prevalence of hypertension in children is increasing, most likely owing to a concurrent rise in obesity. In children with hypertension, nonpharmacological measures are often recommended as first-line therapy, but a significant proportion of children will eventually require pharmacological treatment to reduce blood pressure, especially those with evidence of end-organ damage at presentation or during follow-up. A systematic review of the effects of antihypertensive agents in children has not previously been conducted.

OBJECTIVES

To determine the dose-related effects of different classes of antihypertensive medications, as monotherapy compared with placebo; as combination therapy compared with placebo or as a single medication; or in comparisons of various doses within the same class on systolic or diastolic blood pressure (or both) in children with hypertension.

SEARCH METHODS

We searched the Cochrane Hypertension Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (2013,Issue 9), Ovid MEDLINE (1946 to October 2013), Ovid EMBASE (1974 to October 2013) and bibliographic citations.

SELECTION CRITERIA

The selection criteria were deliberately broad as there are only few clinical trials in children. We included randomized controlled trials of at least 2 weeks duration comparing antihypertensive agents either as monotherapy or as combination therapy with either placebo or another medication, or comparing different doses of the same medication, in children with hypertension. Hypertension was defined as an average (over a minimum of three readings) systolic or diastolic blood pressure (or both) on the 95th percentile or above for age, height and gender.

DATA COLLECTION AND ANALYSIS

Two authors independently selected relevant studies, extracted data and assessed risk of bias. We summarized data, where possible, using a random-effects model. Formal assessment of heterogeneity was not possible because of insufficient data.

MAIN RESULTS

A total of 21 trials evaluated antihypertensive medications of various drug classes in 3454 hypertensive children with periods of follow-up ranging from 3 to 24 weeks. There were five randomized controlled trials comparing an antihypertensive drug directly with placebo, 12 dose-finding trials, two trials comparing calcium channel blockers with angiotensin receptor blockers, one trial comparing a centrally acting ..-blocker with a diuretic and one trial comparing an angiotensin-converting enzyme inhibitor with an angiotensin receptor blocker. No randomized trial was identified that evaluated the effectiveness of antihypertensive medications on target end-organ damage. The trials were of variable quality and most were funded by pharmaceutical companies. Among the angiotensin receptor blockers, candesartan (one trial, n=240), when compared with placebo, reduced systolic blood pressure by 6.50 mmHg (95% confidence interval .9.44 to .3.56) and diastolic blood pressure by 5.50 mmHg (95% confidence interval .9.62 to .1.38) (low-quality evidence). High dose telmisartan (one trial, n=76), when compared with placebo, reduced systolic blood pressure by .8.50 (95% confidence interval .13.79 to .3.21) but not diastolic blood pressure (.4.80, 95% . .9.50 to 0.10) (low-quality evidence). ..-Blocker (metoprolol, one trial, n=140), when compared with placebo, significantly reduced systolic blood pressure by 4.20 mmHg (95% confidence interval .8.12 to .0.28) but not diastolic blood pressure (.3.20 mmHg 95% confidence interval .7.12 to 0.72) (low-quality evidence). ..-Blocker-diuretic combination (bisoprolol/hydrochlorothiazide, one trial, n=94) when compared with placebo did not result in a significant reduction in systolic blood pressure (.4.0 mmHg, 95% confidence interval .8.99 to .0.19), but did have an effect on diastolic blood pressure (.4.50 mmHg, 95% confidence interval .8.26 to .0.74) (low-quality evidence). Calcium channel blocker (extended-release felodipine, one trial, n=133) was not effective in reducing systolic blood pressure (.0.62 mmHg, 95% confidence interval .2.97 to 1.73) or diastolic blood pressure (.1.86 mmHg, 95% confidence interval .5.23 to 1.51) when compared with placebo. Further, there was no consistent dose-response observed among any of the drug classes. The adverse events associated with the antihypertensive agents were mostly minor and included headaches, dizziness and upper respiratory infections. AUTHORS'

CONCLUSIONS

Overall, there are sparse data informing the use of antihypertensive agents in children, with outcomes reported limited to blood pressure and not end-organ damage. Most data are available for candesartan, for which there is low-quality evidence of a modest lowering effect on blood pressure. We did not find evidence of a consistent dose–response relationship for escalating doses of angiotensin receptor blockers, calcium channel blockers or angiotensin-converting enzyme inhibitors. All agents appear safe, at least in the short term.

Epidemiology of elevated blood pressure in youth and its utility for predicting adulthood outcomes: A review

Elevated blood pressure has been demonstrated to track from youth to adulthood and some have demonstrated an association between early-life blood pressure and subsequent atherosclerosis and cardiovascular disease. In addition, reports regarding the strength of tracking are inconsistent and the modifiable risk factors that affect the trajectory of blood pressure from youth to adulthood remain unclear. This paper comprehensively evaluated the existing classifications of youth hypertension and the current trends of youth hypertension. Further, evidence for the consequences of hypertension in youth has been comprehensively evaluated. Importantly, a review of the studies examining tracking from youth to adulthood has been performed and a number of studies investigating the factors affecting tracking has also been investigated. The overall consideration of this body of literature highlights the vital importance of identifying hypertension in youth to prevent complications in adulthood. Adiposity is regarded to be a factor affecting the progression of hypertension from youth to adulthood yet there is little evidence available for other modifiable factors. It is apparent that further research is necessary within this field in order to create effective preventative strategies to target youth hypertension.

Atherosclerotic renal artery stenosis as a cause for hypertension in an adolescent patient

BACKGROUND

Atherosclerosis causing renal artery stenosis (RAS) is one of the most common secondary causes of hypertension in adults, but is rare in children.

CASE-DIAGNOSIS/TREATMENT

RAS associated with coronary artery stenosis was diagnosed in a teenage patient who presented with intermittent chest pain and elevated blood pressures for 6 years. The diagnosis of RAS was suspected after physical examination revealed an abdominal bruit. Renal ultrasound with Doppler revealed normal appearing kidneys with high velocity in the aorta and renal arteries. Computed tomography angiography (CTA) of the chest and abdomen demonstrated generalized calcified atherosclerotic narrowing of the arteries including the renal, celiac, superior mesenteric and coronary arteries in the setting of hyperlipidemia. The lipid panel revealed hypercholesterolemia with elevated serum plant sterol concentrations, suggesting the diagnosis of sitosterolemia. Cardiac catheterization demonstrated left anterior descending artery and left circumflex artery stenosis, which required bypass of the left anterior descending artery and stenting of the left circumflex artery. Aggressive lipid control was recommended and he was treated medically with a beta-blocker, low-dose angiotensin-converting enzyme inhibitor, aspirin, statin, and clopidogrel.

CONCLUSION

Although very rare, generalized atherosclerosis caused by genetic disorders should be considered an underlying cause for severe hypertension in children with hyperlipidemia.

Essential pediatric hypertension: defining the educational needs of primary care pediatricians

BACKGROUND

In order to better understand the educational needs regarding appropriate recognition, diagnosis and management of pediatric hypertension (HTN), we asked practicing pediatricians questions regarding their educational needs and comfort level on this topic.

METHODS

We conducted 4 focus group sessions that included 27 participants representing pediatric residents, adolescent medicine physicians, clinic based pediatricians and office based pediatricians. Each focus group session lasted for approximately an hour and 90 pages of total transcriptions were produced verbatim from audio recordings.

RESULTS

Four reviewers read each transcript and themes were elucidated from these transcripts. Overall, 5 major themes related to educational needs and clinical concerns were found: utilization of resources to define blood pressure (BP), correct BP measurement method(s), co-morbidities, barriers to care, and experience level with HTN. Six minor themes were also identified: differences in BP measurement, accuracy of BP, recognition of HTN, practice pattern of care, education of families and patients, and differences in level of training. The focus group participants were also questioned on their preferences regarding educational methods (i.e. e-learning, small group sessions, self-study, large group presentations) and revealed varied teaching and learning preferences.

CONCLUSIONS

There are multiple methods to approach education regarding pediatric HTN for primary care pediatricians based on provider preferences and multiple educational activities should be pursued to achieve best outcomes. Based on this data, the next direction will be to develop and deliver multiple educational methods and to evaluate the impact on practice patterns of care for children and adolescents with HTN.

Unmet needs in the measurement of blood pressure in primary care

BACKGROUND

Blood pressure (BP) monitoring in UK children at risk of hypertension takes place predominantly in secondary and tertiary care.

OBJECTIVES

To investigate (i) the availability of paediatric BP equipment in primary care (PC) and (ii) the confidence of PC professionals in measuring and interpreting children's BP.

METHODS

103 PC practices were approached to complete a questionnaire. BP equipment availability and confidence with BP measurement and interpretation were recorded (interval scale 1-10). Cuff size and equipment type were documented.

RESULTS

95 (92%) practices responded; 40/95 possessed paediatric BP cuffs. 35/51 devices were validated for paediatric use. Median (IQR) confidence in BP measurement was 7 (2-8). Confidence in BP interpretation was 3 (2-6), though this improved if normal ranges were provided (8 (6-9), p<0.01).

CONCLUSIONS

Investment in appropriate equipment and education is required to allow PC to successfully monitor BP in children.

Auscultatory measured normative blood pressure of korean adolescents: using the korean national health and nutrition examination survey 2001-2007

Background and Objectives

In Korea, there hasn't been any previous literature that describes auscultatory blood pressure (BP) normative tables for adolescents. Using BP data, from the Korean National Health and Nutrition Examination Survey (KNHANES), we created normative auscultatory BP percentile tables for Korean adolescents.

Subjects and Methods

A total of 3508 adolescents (boys 1852, girls 1656), aged 10-17 in 2001, 2005 and 2007 from the KNHANES database years, were included. Auscultatory BP measurement was performed, using a Baumanometer Mercury Gravity Sphygmomanometer.

Results

The mean systolic BP of boys was higher than that of girls in adolescents older than 13 years of age, and the mean diastolic BP of boys was higher than that of girls in those older than 15 years. Systolic and diastolic BP was correlated with weight, height and age. Age-specific normative auscultatory systolic and diastolic BP percentiles for boys and girls were completed. The graph that showed age-specific prehypertensive and hypertensive systolic and diastolic BP for boys and girls was presented. For adolescents, the height-specific auscultatory BP percentiles for boys and girls were completed. A graph that shows the height-specific prehypertensive and hypertensive BP for boys and girls was also made.

Conclusion

The auscultatory age-and height-specific BP percentiles for Korean adolescents are established. These can be useful in screening the prehypertension and hypertension of Korean adolescents in a clinical setting.

Uric acid level and elevated blood pressure in US adolescents: National Health and Nutrition Examination Survey, 1999-2006

Uric acid is associated with cardiovascular disease and cardiovascular disease risk factors in adults, including chronic kidney disease, coronary artery disease, stroke, diabetes mellitus, preeclampsia, and hypertension. We examined the association between uric acid and elevated blood pressure in a large, nationally representative cohort of US adolescents, a population with a relatively low prevalence of cardiovascular disease and cardiovascular disease risk factors. Among 6036 adolescents 12 to 17 years of age examined in the 1999-2006 National Health and Nutrition Examination Survey, the mean age was 14.5 years, 17% were obese (body mass index: ≥95th percentile), and 3.3% had elevated blood pressure. Mean serum uric acid level was 5.0 mg/dL, and 34% had a uric acid level ≥5.5 mg/dL. In analyses adjusted for age, sex, race/ethnicity, and body mass index percentile, the odds ratio of elevated blood pressure, defined as a systolic or diastolic blood pressure ≥95th percentile for age, sex, and height, for each 0.1-mg/dL increase in uric acid level was 1.38 (95% CI: 1.16-1.65). Compared with <5.5 mg/dL, participants with a uric acid level ≥5.5 mg/dL had a 2.03 times higher odds of having elevated blood pressure (95% CI: 1.38-3.00). In conclusion, increasing levels of serum uric acid are associated with elevated blood pressure in healthy US adolescents. Additional prospective studies and clinical trials are needed to determine whether uric acid is merely a marker in a complex metabolic pathway or causal of hypertension and, thus, a potential screening and therapeutic target.

Demographics of blood pressure and hypertension in children on renal replacement therapy in Europe

Hypertension is a well-known complication in children on renal replacement therapy and an important risk factor for cardiovascular disease in later life. In order to define the prevalence of and risk factors for hypertension among children, we enrolled 3337 pediatric patients from 15 countries in the ESPN/ERA-EDTA Registry of whom 464 were on hemodialysis, 851 on peritoneal dialysis, and 2023 had received a renal allograft. Hypertension was defined as either systolic or diastolic blood pressures in the 95th percentile or greater for age, height, and gender or use of antihypertensive medication. Analyses were adjusted for age, gender, duration, and modality of renal replacement therapy. In 10 countries in which information on the use of antihypertensive medication was available, hypertension was present in over two-thirds of hemodialysis, peritoneal dialysis, or transplant patients. Blood pressure values above the 95th percentile were significantly more prevalent in very young patients (under 3 years) compared to 13- to 17-year olds (odds ratio 2.47), during the first year compared to over 5 years of renal replacement therapy (odds ratio 1.80), and in patients on hemodialysis compared to transplant recipients or those on peritoneal dialysis (odds ratios of 2.48 and 1.59, respectively). Over time, mean blood pressures decreased in both hemodialysis and transplant patients, but not in peritoneal dialysis patients. Hence, our findings highlight the extent of the problem of hypertension in children with end-stage renal disease in Europe.

Primary versus secondary hypertension in children followed up at an outpatient tertiary unit

Childhood hypertension has classically been recognized as a secondary disease. However, primary hypertension also occurs in children. The aim of this study was to compare clinical features of pediatric patients with elevated blood pressure, which were referred to an outpatient tertiary unit, and to detect variables associated with the identification of primary hypertension. The records of 220 patients with hypertension followed between 1996 and 2006 were analyzed. The variable of interest was primary hypertension. Logistic regression analysis was applied to identify clinical variables that were independently associated with primary hypertension. Of 220 patients, 33 (15%) had primary hypertension, and 187 (85%) exhibited secondary hypertension. No statistically significant differences were detected in gender, race, age at diagnosis, and systolic/diastolic blood pressure levels between both groups. After adjustment, four variables at baseline remained independently associated with primary hypertension: absence of signs/symptoms (OR 18.87, 95% CI 6.32-56.29), normal serum creatinine (OR 0.02, 95% CI 0.00-0.27), family history of hypertension (OR 3.03, 95% CI 1.04-8.79), and elevated body weight (OR 1.06, 95% CI 1.02-1.10). The absence of signs/symptoms, normal serum creatinine, family history of hypertension, and overweight/obesity at admission are clues to diagnose primary hypertension in childhood.