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Litwin M. Pathophysiology of primary hypertension in children and adolescents. Pediatr Nephrol 2024; 39:1725-1737. [PMID: 37700113 PMCID: PMC11026201 DOI: 10.1007/s00467-023-06142-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 08/13/2023] [Accepted: 08/14/2023] [Indexed: 09/14/2023]
Abstract
The progress in research on the physiology of the cardiovascular system made in the last 100 years allowed for the development of the pathogenesis not only of secondary forms of hypertension but also of primary hypertension. The main determinants of blood pressure are described by the relationship between stroke volume, heart rate, peripheral resistance, and arterial stiffness. The theories developed by Guyton and Folkow describe the importance of the volume factor and total peripheral resistance. However, none of them fully presents the pathogenesis of essential hypertension. The multifactorial model of primary hypertension pathogenesis developed by Irving Page in the 1940s, called Page's mosaic, covers most of the pathophysiological phenomena observed in essential hypertension. The most important pathophysiological phenomena included in Page's mosaic form a network of interconnected "nodes". New discoveries both from experimental and clinical studies made in recent decades have allowed the original Page mosaic to be modified and the addition of new pathophysiological nodes. Most of the clinical studies confirming the validity of the multifactorial pathogenesis of primary hypertension concern adults. However, hypertension develops in childhood and is even perinatally programmed. Therefore, the next nodes in Page's mosaic should be age and perinatal factors. This article presents data from pediatric clinical trials describing the most important pathophysiological processes associated with the development of essential hypertension in children and adolescents.
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Affiliation(s)
- Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
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Massengale K, Xu Y, Snieder H, Su S, Wang X. A longitudinal study of blood pressure circadian rhythm from childhood to early adulthood. J Hum Hypertens 2024; 38:437-443. [PMID: 38627604 DOI: 10.1038/s41371-024-00911-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 03/19/2024] [Accepted: 04/02/2024] [Indexed: 05/09/2024]
Abstract
Altered blood pressure (BP) circadian rhythmicity has been increasingly linked with cardiovascular risk. However, little is known about BP circadian rhythm change with age and its possible sociodemographic, anthropometric, and genetic moderators. Twenty-four-hour ambulatory BP was measured up to 16 times over a 23-year period in 339 European Americans (EAs) and 293 African Americans (AAs), with an average age of 15 years at the initial visit. BP circadian rhythms were indexed by amplitude and percent rhythm (a measure of rhythm integrity) and calculated using Fourier analysis. BP amplitude and percent rhythm increased with age and average BP (BP mesor). AAs were more likely to have lower BP amplitude and percent rhythm than their EA counterparts. BP amplitude and percent rhythm also decreased with adiposity (BMI and waist circumference). The summer season was associated with lower BP amplitude in AAs and lower percent rhythm in both AAs and EAs. Sex, height, socioeconomic status, physical activity, and family history of essential hypertension did not have an independent impact on BP amplitude or percent rhythm. The results of the present study suggest that BP circadian rhythm increases with age and BP mesor from childhood to young adulthood, decreases with adiposity, and that AAs are more likely to have lower circadian rhythm than EAs. Furthermore, we demonstrated that the summer season is associated with lower BP rhythmicity.
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Affiliation(s)
| | - Yanyan Xu
- Department of Biostatistics and Informatics, University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Harold Snieder
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Georgia Prevention Institute, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Shaoyong Su
- Georgia Prevention Institute, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Xiaoling Wang
- Georgia Prevention Institute, Medical College of Georgia, Augusta University, Augusta, GA, USA.
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Pinto-Silva C, Correia-Costa A, Moura C, Mota C, Guerra A, Areias JC, Schaefer F, Afonso AC, Wühl E, Azevedo A, Correia-Costa L. Cardiovascular rhythmicity in overweight and obese children. J Bras Nefrol 2023; 45:449-457. [PMID: 37527530 PMCID: PMC10726656 DOI: 10.1590/2175-8239-jbn-2022-0138en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/17/2023] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION Obesity is thought to play a role in the disruption of cardiac rhythmicity in obese children, but this is mostly an unexplored field of investigation. We aimed to evaluate the impact of overweight and obesity on circadian and ultradian cardiovascular rhythmicity of prepubertal children, in comparison with normal weight counterparts. METHODS We performed a cross sectional study of 316 children, followed in the birth cohort Generation XXI (Portugal). Anthropometrics and 24-hour ambulatory blood pressure were measured and profiles were examined with Fourier analysis for circadian and ultradian blood pressure (BP) and heart rate (HR) rhythms. RESULTS Overweight/obese children presented more frequently a non-dipping BP pattern than normal weight counterparts (31.5% vs. 21.6%, p = 0.047). The prevalence of 24-hour mean arterial pressure (MAP) and 8-hour HR rhythmicity was significantly lower in obese children (79.3% vs. 88.0%, p = 0.038 and 33.3% vs. 45.2%, p = 0.031, respectively). The prevalence of the remaining MAP and HR rhythmicity was similar in both groups. No differences were found in the median values of amplitudes and acrophases of MAP and HR rhythms. DISCUSSION The alterations found in rhythmicity suggest that circadian and ultradian rhythmicity analysis might be sensitive in detecting early cardiovascular dysregulations, but future studies are needed to reinforce our findings and to better understand their long-term implications.
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Affiliation(s)
- Catarina Pinto-Silva
- Centro Hospitalar Universitário de Coimbra, Divisão de Pediatria, Coimbra, Portugal
| | - Ana Correia-Costa
- Universidade do Porto, Faculdade de Medicina da Universidade do Porto, Divisão de Pediatria, Porto, Portugal
- Centro Hospitalar e Universitário de São João, Divisão de Cardiologia Pediátrica, Porto, Portugal
| | - Cláudia Moura
- Universidade do Porto, Faculdade de Medicina da Universidade do Porto, Divisão de Pediatria, Porto, Portugal
- Centro Hospitalar e Universitário de São João, Divisão de Cardiologia Pediátrica, Porto, Portugal
| | - Cláudia Mota
- Universidade do Porto, Faculdade de Medicina da Universidade do Porto, Divisão de Pediatria, Porto, Portugal
| | - António Guerra
- Centro Hospitalar e Universitário de São João, Divisão de Cardiologia Pediátrica, Porto, Portugal
- Centro Hospitalar Universitário de São João, Serviço de Pediatria, Unidade de Nutrição Pediátrica, Porto, Portugal
| | - José Carlos Areias
- Universidade do Porto, Faculdade de Medicina da Universidade do Porto, Divisão de Pediatria, Porto, Portugal
- Centro Hospitalar e Universitário de São João, Divisão de Cardiologia Pediátrica, Porto, Portugal
| | - Franz Schaefer
- Universidade de Heidelberg, Centro de Pediatria e Medicina do Adolescente, Divisão de Nefrologia Pediátrica, Heidelberg, Alemanha
| | - Alberto Caldas Afonso
- Centro Hospitalar Universitário de Santo António, Centro Materno-Infantil do Norte, Unidade de Nefrologia Pediátrica, Porto, Portugal
- Universidade do Porto, Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
- Universidade do Porto, Instituto de Saúde Pública, Unidade de Investigação em Epidemiologia, Porto, Portugal
| | - Elke Wühl
- Universidade de Heidelberg, Centro de Pediatria e Medicina do Adolescente, Divisão de Nefrologia Pediátrica, Heidelberg, Alemanha
| | - Ana Azevedo
- Universidade do Porto, Instituto de Saúde Pública, Unidade de Investigação em Epidemiologia, Porto, Portugal
- Universidade do Porto, Faculdade de Medicina, Saúde Pública e Ciências Forenses, Departamento de Educação Médica, Porto, Portugal
| | - Liane Correia-Costa
- Centro Hospitalar Universitário de Santo António, Centro Materno-Infantil do Norte, Unidade de Nefrologia Pediátrica, Porto, Portugal
- Universidade do Porto, Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
- Universidade do Porto, Instituto de Saúde Pública, Unidade de Investigação em Epidemiologia, Porto, Portugal
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Rus RR, Pac M, Obrycki Ł, Sağsak E, Azukaitis K, Sinha MD, Jankauskiene A, Litwin M. Systolic and diastolic left ventricular function in children with primary hypertension: a systematic review and meta-analysis. J Hypertens 2023; 41:51-62. [PMID: 36453653 DOI: 10.1097/hjh.0000000000003298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE Evaluation of left ventricular function provides early evidence of target-organ damage in children with primary hypertension. We performed a systematic review and meta-analysis of left ventricular systolic and diastolic function in children and adolescents with primary hypertension. METHODS Literature search was performed in PubMed database and out of 718 articles (published between 2000 and 2021) 22 studies providing comparison of left ventricular function parameters between children with primary hypertension and normotensive controls were selected. RESULTS Overall, 3460 children (5-21 years) with primary hypertension were analyzed. Meta-analysis showed that hypertensive patients when compared with normotensives, had an increased heart rate (mean difference [MD] 5.59; 95% confidence interval [CI] 3.28, 7.89; 10 studies) and increased fractional shortening (MD 1.04; 95% CI 0.48, 1.60; 9 studies) but did not differ in ejection fraction (MD -0.03; 95% CI -1.07, 1.02; 12 studies). Stroke volume was higher in one out of three studies, whereas no differences in cardiac output were found in two studies with available data. Hypertensive children had also lower E/A values (MD -0.21; -0.33, -0.09; 14 studies), greater values of E/e' (MD 0.59; 0.36, 0.82; 8 studies) and greater global longitudinal stress (MD 2.50; 2.03, 2.96; 4 studies) when compared to those with normotension. CONCLUSION Our results indicate that hypertensive children and adolescents present with signs of hyperkinetic function of the left ventricle, demonstrate evidence of increased left ventricular strain and impaired diastolic function compared to normotensive controls.
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Affiliation(s)
- Rina R Rus
- Pediatric Nephrology Department, Children's Hospital, University Medical Centre Ljubljana, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Michał Pac
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Łukasz Obrycki
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Elif Sağsak
- Yeditepe University, Department of Pediatric Endocrinology, Istanbul, Turkey
| | - Karolis Azukaitis
- Clinic of Pediatrics, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Manish D Sinha
- King's College London, Department of Paediatric Nephrology, Evelina London Children's, Hospital, London, UK
| | - Augustina Jankauskiene
- Clinic of Pediatrics, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
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Xu Y, Su S, Brown M, Snieder H, Harshfield G, Wang X. Ethnic differences and heritability of blood pressure circadian rhythm in African and European American youth and young adults. J Hypertens 2022; 40:163-170. [PMID: 34857708 PMCID: PMC8646444 DOI: 10.1097/hjh.0000000000002988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The aim of this study was to investigate whether blood pressure (BP) circadian rhythm in African Americans differed from that in European Americans. We further examined the genetic and/or environmental sources of variances of the BP circadian rhythm parameters and the extent to which they depend on ethnicity or sex. METHOD Quantification of BP circadian rhythm was obtained using Fourier transformation from the ambulatory BP monitoring data of 760 individuals (mean age, 17.2 ± 3.3; 322 twin pairs and 116 singletons; 351 African Americans). RESULTS BP circadian rhythm showed a clear difference by ethnic group with African Americans having a lower amplitude (P = 1.5e-08), a lower percentage rhythm (P = 2.8e-11), a higher MESOR (P = 2.5e-05) and being more likely not to display circadian rhythm (P = 0.002) or not in phase (P = 0.003). Familial aggregation was identified for amplitude, percentage rhythm and acrophase with genetic factors and common environmental factors together accounting for 23 to 33% of the total variance of these BP circadian rhythm parameters. Unique environmental factors were the largest contributor explaining up to 67--77% of the total variance of these parameters. No sex or ethnicity difference in the variance components of BP circadian rhythm was observed. CONCLUSION This study suggests that ethnic differences in BP circadian rhythm already exist in youth with African Americans having a dampened circadian rhythm and better BP circadian rhythm may be achieved by changes in environmental factors.
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Affiliation(s)
- Yanyan Xu
- Georgia Prevention Institute, Department of Medicine
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta, Georgia, USA
| | - Shaoyong Su
- Georgia Prevention Institute, Department of Medicine
| | | | - Harold Snieder
- Georgia Prevention Institute, Department of Medicine
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | | | - Xiaoling Wang
- Georgia Prevention Institute, Department of Medicine
- Center for Biotechnology and Genomic Medicine, Medical College of Georgia, Augusta, Georgia, USA
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Litwin M, Kułaga Z. Obesity, metabolic syndrome, and primary hypertension. Pediatr Nephrol 2021; 36:825-837. [PMID: 32388582 PMCID: PMC7910261 DOI: 10.1007/s00467-020-04579-3] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 04/08/2020] [Accepted: 04/16/2020] [Indexed: 12/15/2022]
Abstract
Primary hypertension is the dominant form of arterial hypertension in adolescents. Disturbed body composition with, among other things, increased visceral fat deposition, accelerated biological maturation, metabolic abnormalities typical for metabolic syndrome, and increased adrenergic drive constitutes the intermediary phenotype of primary hypertension. Metabolic syndrome is observed in 15-20% of adolescents with primary hypertension. These features are also typical of obesity-related hypertension. Metabolic abnormalities and metabolic syndrome are closely associated with both the severity of hypertension and the risk of target organ damage. However, even though increased body mass index is the main determinant of blood pressure in the general population, not every hypertensive adolescent is obese and not every obese patient suffers from hypertension or metabolic abnormalities typical for metabolic syndrome. Thus, the concepts of metabolically healthy obesity, normal weight metabolically unhealthy, and metabolically unhealthy obese phenotypes have been developed. The risk of hypertension and hypertensive target organ damage increases with exposure to metabolic risk factors which are determined by disturbed body composition and visceral obesity. Due to the fact that both primary hypertension and obesity-related hypertension present similar pathogenesis, the principles of treatment are the same and are focused not only on lowering blood pressure, but also on normalizing body composition and metabolic abnormalities.
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Affiliation(s)
- Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
| | - Zbigniew Kułaga
- grid.413923.e0000 0001 2232 2498Department of Public Health, The Children’s Memorial Health Institute, Warsaw, Poland
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Abstract
Although relatively rare in childhood, primary hypertension (PH) is thought to have originated in childhood and may be even determined perinatally. PH prevalence increases in school-age children and affects 11% of 18-year-old adolescents. Associated with metabolic risk factors, elevated blood pressure in childhood is carried into adulthood. Analysis of the phenotype of hypertensive children has revealed that PH is a complex of anthropometric and neuro-immuno-metabolic abnormalities, typically found in hypertensive adults. Children with elevated blood pressure have shown signs of accelerated biological development, which are closely associated with further development of PH, metabolic syndrome, and cardiovascular disease in adulthood. At the time of diagnosis, hypertensive children were reported to have significant arterial remodelling expressed as significantly increased carotid intima-media thickness, increased stiffness of large arteries, lower area of microcirculation, and decreased endothelial function. These changes indicate that their biological age is 4 to 5 years older than their normotensive peers. All these abnormalities are typical features of early vascular aging described in adults with PH. However, as these early vascular changes in hypertensive children are closely associated with features of accelerated biological development and neuro-immuno-metabolic abnormalities observed in older subjects, it seems that PH in childhood is not only an early vascular aging event, but also an early biological maturation phenomenon.
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8
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Falkner B. The Childhood Role in Development of Primary Hypertension. Am J Hypertens 2018; 31:762-769. [PMID: 29648569 DOI: 10.1093/ajh/hpy058] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 04/09/2018] [Indexed: 12/25/2022] Open
Abstract
Primary hypertension is not just an adult disorder. Current US population data on children and adolescents demonstrate a prevalence of elevated blood pressure (BP) and hypertension combined of over 10%. Recent reports from prospective cohort studies describe an association of high BP in childhood with hypertension in young adulthood. Excess adiposity is strongly associated with higher BP in childhood and increases risk for hypertension in adulthood. In addition to overweight/obesity, other exposures that raise the risk for high BP include low birthweight, dietary sodium, and stress. Using intermediate markers of cardiovascular injury, studies on hypertensive children report findings of cardiac hypertrophy, vascular stiffness, and early atherosclerotic changes. Impaired cognitive function has also been demonstrated in hypertensive children. Recent advances in clinical and translational research support the concept that the evolution of primary hypertension begins in childhood.
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Affiliation(s)
- Bonita Falkner
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA
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9
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Massella L, Mekahli D, Paripović D, Prikhodina L, Godefroid N, Niemirska A, Ağbaş A, Kalicka K, Jankauskiene A, Mizerska-Wasiak M, Afonso AC, Salomon R, Deschênes G, Ariceta G, Özçakar ZB, Teixeira A, Duzova A, Harambat J, Seeman T, Hrčková G, Lungu AC, Papizh S, Peco-Antic A, De Rechter S, Giordano U, Kirchner M, Lutz T, Schaefer F, Devuyst O, Wühl E, Emma F. Prevalence of Hypertension in Children with Early-Stage ADPKD. Clin J Am Soc Nephrol 2018; 13:874-883. [PMID: 29674338 PMCID: PMC5989684 DOI: 10.2215/cjn.11401017] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/27/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Autosomal dominant polycystic kidney disease is the most common inheritable kidney disease, frequently thought to become symptomatic in adulthood. However, patients with autosomal dominant polycystic kidney disease may develop signs or symptoms during childhood, in particular hypertension. Although ambulatory BP monitoring is the preferred method to diagnose hypertension in pediatrics, data in children with autosomal dominant polycystic kidney disease are limited. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Our retrospective multicenter study was conducted to collect ambulatory BP monitoring recordings from patients with autosomal dominant polycystic kidney disease age <18 years old. Basic anthropometric parameters as well as data on kidney function, BP treatment, and kidney ultrasound were also collected. RESULTS Data from 310 children with autosomal dominant polycystic kidney disease with a mean age of 11.5±4.1 years old were collected at 22 European centers. At the time when ambulatory BP monitoring was performed, 95% of children had normal kidney function. Reference data for ambulatory BP monitoring were available for 292 patients. The prevalence rates of children with hypertension and/or those who were treated with antihypertensive drugs were 31%, 42%, and 35% during daytime, nighttime, or the entire 24-hour cycle, respectively. In addition, 52% of participants lacked a physiologic nocturnal BP dipping, and 18% had isolated nocturnal hypertension. Logistic regression analysis showed a significant association between a categorical cyst score that was calculated on the basis of the number of cysts >1 cm per kidney and daytime hypertension (odds ratio, 1.70; 95% confidence interval, 1.21 to 2.4; P=0.002), nighttime hypertension (odds ratio, 1.31; 95% confidence interval, 1.05 to 1.63; P=0.02), or 24-hour hypertension (odds ratio, 1.39; 95% confidence interval, 1.08 to 1.81; P=0.01). Kidney length, expressed as SD score, was also significantly associated with nighttime hypertension (odds ratio, 1.23; 95% confidence interval, 1.06 to 1.42; P=0.10). CONCLUSIONS These data indicate high prevalence of hypertension in children with autosomal dominant polycystic kidney disease starting at young ages.
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Affiliation(s)
- Laura Massella
- Division of Nephrology, Department of Pediatric Subspecialties, and
| | - Djalila Mekahli
- Polycystic Kidney Disease Research Group, Laboratory of Pediatrics, Department of Development and Regeneration, Gynaecology Pediatrics and Urology (G-PURE), Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Dušan Paripović
- Nephrology Department, University Children’s Hospital, Belgrade, Serbia
| | - Larisa Prikhodina
- Department of Inherited and Acquired Kidney Diseases, Research and Clinical Institute for Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Nathalie Godefroid
- Department of Pediatrics, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Anna Niemirska
- Department of Nephrology, Kidney Transplantation and Arterial Hypertension, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Ayşe Ağbaş
- Department of Pediatric Nephrology, Cerrahpasa Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Karolina Kalicka
- Department of Pediatric Nephrology, Medical University in Lublin, Lublin, Poland
| | | | | | - Alberto Caldas Afonso
- Centro Materno Infantil do Norte, Centro Hospitalar do Porto, Abel Salazar Biomedical Sciences Institute, University of Porto, Porto, Portugal
| | - Rémi Salomon
- Department of Pediatric Nephrology, Assistance Publique Hôpitaux de Paris, Necker Enfant Malades, Descartes University, Paris, France
- Reference Centre of Hereditary Renal Diseases of the Child and Adult, Assistance Publique Hôpitaux de Paris, Necker Enfants Malades, Paris, France
| | - Georges Deschênes
- Division of Pediatric Nephrology, Assistance Publique Hôpitaux de Paris, Robert Debré, Sorbonne University, Paris, France
| | - Gema Ariceta
- Pediatric Nephrology Service, University Hospital Vall d’Hebrón, Universidad Autonoma de Barcelona, Barcelona, Spain
| | - Z. Birsin Özçakar
- Division of Pediatric Nephrology and Rheumatology, Department of Pediatrics, Ankara University Medical School, Ankara, Turkey
| | - Ana Teixeira
- Pediatric Nephrology Unit, Centro Hospitalar São João, Porto, Portugal
| | - Ali Duzova
- Division of Pediatric Nephrology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Jérôme Harambat
- Pediatric Nephrology Unit, Bordeaux University Hospital, Institut National de la Santé et de la Recherche Médicale Unité Mixte de Recherche 1219, Bordeaux, France
| | - Tomáš Seeman
- Department of Pediatrics, 2nd Medical Faculty, University Hospital Motol, Charles University Prague, Prague, Czech Republic
| | - Gabriela Hrčková
- Department of Pediatrics of the Faculty of Medicine, Comenius University in Bratislava and the University Children’s Hospital Bratislava, Bratislava, Slovakia
| | | | - Svetlana Papizh
- Department of Inherited and Acquired Kidney Diseases, Research and Clinical Institute for Pediatrics, Pirogov Russian National Research Medical University, Moscow, Russia
| | - Amira Peco-Antic
- Nephrology Department, University Children's Hospital and School of Medicine, University of Belgrade, Serbia
| | - Stéphanie De Rechter
- Polycystic Kidney Disease Research Group, Laboratory of Pediatrics, Department of Development and Regeneration, Gynaecology Pediatrics and Urology (G-PURE), Katholieke Universiteit Leuven, Leuven, Belgium
- Department of Pediatric Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ugo Giordano
- Arterial Hypertension Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children’s Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Marietta Kirchner
- Department of Medical Biometry, Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Teresa Lutz
- Pediatric Nephrology Division, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Franz Schaefer
- Pediatric Nephrology Division, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Olivier Devuyst
- Institute of Physiology, University of Zurich, Zurich, Switzerland; and
- Division of Nephrology, Cliniques Universitaires Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Elke Wühl
- Pediatric Nephrology Division, Center for Pediatrics and Adolescent Medicine, Heidelberg University Hospital, Heidelberg, Germany
| | - Francesco Emma
- Division of Nephrology, Department of Pediatric Subspecialties, and
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10
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Litwin M. Why should we screen for arterial hypertension in children and adolescents? Pediatr Nephrol 2018; 33:83-92. [PMID: 28717934 PMCID: PMC5700235 DOI: 10.1007/s00467-017-3739-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 06/23/2017] [Indexed: 01/11/2023]
Affiliation(s)
- Mieczysław Litwin
- Department of Nephrology and Arterial Hypertension, The Children's Memorial Health Institute, 04-730 Aleja Dzieci Polskich, 20, Warsaw, Poland.
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11
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Abstract
Largely due to the childhood obesity epidemic, there has been an increase in the prevalence of hypertension in children and adolescents. Obesity associated hypertension is the most common hypertension phenotype among adolescents. Approximately 30% of obese adolescents have elevated blood pressure (BP) or hypertension. Updated definitions of elevated BP and hypertension in adolescents are now similar to definitions of BP status in adults. For adolescents ≥13 years of age, elevated BP is 120 to 129/<80 mm Hg. Hypertension, stage 1, is ≥130 to 139/80 to 89 mm Hg, and hypertension, stage 2, is ≥140/90 mm Hg. BP measurements over separate clinic visits are necessary to verify the diagnosis of elevated BP or hypertension. Ambulatory BP monitoring, when available, provides confirmatory data on BP status. Causal mechanisms for obesity associated hypertension include increased sympathetic nervous system activity, increased renal sodium retention secondary to insulin resistance/hyperinsulinemia, and obesity mediated inflammation. The primary treatment for obesity associated hypertension is weight reduction with lifestyle changes in diet and physical activity. Although difficult to achieve, even modest weight reduction can be beneficial. The diet should be rich in fruits, vegetables, fiber, and low-fat dairy with reduction in salt intake. When lifestyle changes are insufficient to achieve BP control, pharmacologic therapy is indicated to achieve a goal BP of <130/80 mm Hg or <90th percentile, whichever is lower. Regular BP monitoring is necessary for ongoing management of obesity associated hypertension in adolescents.
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Affiliation(s)
- Bonita Falkner
- Department of Medicine and Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA
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12
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Saner C, Simonetti GD, Wühl E, Mullis PE, Janner M. Circadian and ultradian cardiovascular rhythmicity in obese children. Eur J Pediatr 2016; 175:1031-8. [PMID: 27240757 DOI: 10.1007/s00431-016-2736-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 04/21/2016] [Accepted: 05/16/2016] [Indexed: 10/21/2022]
Abstract
UNLABELLED Altered circadian and ultradian blood pressure (BP) and heart rate (HR) rhythmicity have been described in diseases with increased cardiovascular risk. We analyzed cardiovascular rhythmicity in obese children. BP and HR rhythmicity was assessed with Fourier analysis from 24-h ambulatory BP measurements in 75 obese children and compared with an age- and gender-matched, lean healthy reference group of 150 subjects. Multivariate regression analysis was applied to identify significant independent factors explaining variability of rhythmicity. Prevalence of 24- and 6-h BP rhythmicity in the obese group was lower (p = 0.03 and p = 0.02), whereas the prevalence of HR rhythmicity was comparable in both groups. Excluding hypertensive participants, the results remained similar. Twenty-four-hour BP and HR acrophase were delayed in obese children (p = 0.004, p < 0.0001), 24-h BP amplitude did not differ (p = 0.07), and 24-h HR amplitude was blunted (p = < 0.0001). BP Mesor in the obese group was higher (p = 0.02); HR Mesor did not differ (p = 0.1). Multivariate regression analysis failed to identify a single anthropometric or blood pressure parameter explaining the variability of BP and HR rhythmicity. CONCLUSION Prevalence and parameters of circadian and ultradian BP and HR rhythmicity in obese children are altered compared to a healthy reference group, independent of preexisting hypertension. WHAT IS KNOWN • Altered cardiovascular rhythmicity has been described in children with different diseases such as primary hypertension or chronic renal failure. What is New: • This study reveals altered cardiovascular rhythmicity in obese children compared to an age and gender-matched healthy reference group independent from preexisting hypertension.
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Affiliation(s)
- Christoph Saner
- University Children's Hospital UKBB, Spitalstrasse 33, CH-4056, Basel, Switzerland
| | - Giacomo D Simonetti
- Division of Pediatric Nephrology, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH-3010, Bern, Switzerland. .,Pediatric Department of Southern Switzerland, Via Ospedale, CH-6500, Bellinzona, Switzerland.
| | - Elke Wühl
- Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Im Neuenheimer Feld 430, D-69120, Heidelberg, Germany
| | - Primus E Mullis
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH- 3010, Bern, Switzerland
| | - Marco Janner
- Division of Pediatric Endocrinology, Diabetology and Metabolism, Department of Pediatrics, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 15, CH- 3010, Bern, Switzerland
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13
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Abstract
The assessment of blood pressure (BP) can be challenging in children, especially in very young individuals, due to their variable body size and lack of cooperation. In the absence of data relating BP with cardiovascular outcomes in children, there is a need to convert absolute BP values (in mmHg) into age-, gender- and height appropriate BP percentiles or Z-scores in order to compare a patient's BP with the BP of healthy children of the same age, but also of children of different ages. Traditionally, the interpretation of BP has been based mainly on the assessment of the BP level obtained by office, home or 24-h BP monitoring. Recent studies suggest that it is not only BP level (i.e. average BP) but also BP variability that is clinically important for the development of target organ damage, including the progression of chronic kidney disease. In this review we describe current methods to evaluate of BP level, outline available methods for BP variability assessment and discuss the clinical consequences of BP variability, including its potential role in the management of hypertension.
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14
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Primary hypertension is a disease of premature vascular aging associated with neuro-immuno-metabolic abnormalities. Pediatr Nephrol 2016; 31:185-94. [PMID: 25724169 PMCID: PMC4689752 DOI: 10.1007/s00467-015-3065-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/19/2015] [Accepted: 02/03/2015] [Indexed: 02/07/2023]
Abstract
There is an increasing amount of data indicating that primary hypertension (PH) is not only a hemodynamic phenomenon but also a complex syndrome involving abnormal fat tissue distribution, over-activity of the sympathetic nervous system (SNS), metabolic abnormalities, and activation of the immune system. In children, PH usually presents with a typical phenotype of disturbed body composition, accelerated biological maturity, and subtle immunological and metabolic abnormalities. This stage of the disease is potentially reversible. However, long-lasting over-activity of the SNS and immuno-metabolic alterations usually lead to an irreversible stage of cardiovascular disease. We describe an intermediate phenotype of children with PH, showing that PH is associated with accelerated development, i.e., early premature aging of the immune, metabolic, and vascular systems. The associations and determinants of hypertensive organ damage, the principles of treatment, and the possibility of rejuvenation of the cardiovascular system are discussed.
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15
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Feber J, Ruzicka M, Geier P, Litwin M. Autonomic nervous system dysregulation in pediatric hypertension. Curr Hypertens Rep 2014; 16:426. [PMID: 24633841 DOI: 10.1007/s11906-014-0426-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Historically, primary hypertension (HTN) has been prevalent typically in adults. Recent data however, suggests an increasing number of children diagnosed with primary HTN, mainly in the setting of obesity. One of the factors considered in the etiology of HTN is the autonomous nervous system, namely its dysregulation. In the past, the sympathetic nervous system (SNS) was regarded as a system engaged mostly in buffering major acute changes in blood pressure (BP), in response to physical and emotional stressors. Recent evidence suggests that the SNS plays a much broader role in the regulation of BP, including the development and maintenance of sustained HTN by a chronically elevated central sympathetic tone in adults and children with central/visceral obesity. Consequently, attempts have been made to reduce the SNS hyperactivity, in order to intervene early in the course of the disease and prevent HTN-related complications later in life.
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Affiliation(s)
- Janusz Feber
- Division of Nephrology, Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, Ontario, K1H 8 L1, Canada,
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16
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Flynn JT, Daniels SR, Hayman LL, Maahs DM, McCrindle BW, Mitsnefes M, Zachariah JP, Urbina EM. Update: ambulatory blood pressure monitoring in children and adolescents: a scientific statement from the American Heart Association. Hypertension 2014; 63:1116-35. [PMID: 24591341 PMCID: PMC4146525 DOI: 10.1161/hyp.0000000000000007] [Citation(s) in RCA: 388] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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17
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Affiliation(s)
- Joseph T. Flynn
- From the Department of Pediatrics, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, WA
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18
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Niemirska A, Litwin M, Feber J, Jurkiewicz E. Blood pressure rhythmicity and visceral fat in children with hypertension. Hypertension 2013; 62:782-8. [PMID: 23959553 DOI: 10.1161/hypertensionaha.113.01292] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Primary hypertension is associated with disturbed activity of the sympathetic nervous system and altered blood pressure rhythmicity. We analyzed changes in cardiovascular rhythmicity and its relation with target organ damage during 12 months of antihypertensive treatment in 50 boys with hypertension (median, 15.0 years). The following parameters were obtained before and after 12 months of antihypertensive treatment: 24-hour ambulatory blood pressure, left ventricular mass, carotid intima-media thickness, and MRI for visceral and subcutaneous adipose tissue. Amplitudes and acrophases of mean arterial pressure and heart rate rhythms were obtained for 24-, 12-, and 8-hour periods. After 1 year of treatment, 68% of patients were normotensive, and left ventricular mass and carotid intima-media thickness decreased in 60% and 62% of patients, respectively. Blood pressure and heart rate rhythmicity patterns did not change. Changes in blood pressure amplitude correlated with the decrease of waist circumference (P=0.035). Moreover, the decrease of visceral fat correlated with the decrease of 24-hour mean arterial pressure and heart rate acrophases (both P<0.05). There were no differences in changes of blood pressure and heart rate rhythms between patients who achieved or did not achieve normotension and regression of left ventricular mass and carotid intima-media thickness. It was concluded that abnormal cardiovascular rhythmicity persists in children with primary hypertension despite effective antihypertensive treatment, which suggests that it may be the primary abnormality. The correlation between changes in cardiovascular rhythmicity and visceral obesity may indicate that the visceral fat plays an important role in the sympathetic activity of adolescents with hypertension.
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Affiliation(s)
- Anna Niemirska
- Department of Nephrology, Kidney Transplantation, and Arterial Hypertension, The Children's Memorial Health Institute, Warsaw, Poland.
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Wolfenstetter A, Simonetti GD, Pöschl J, Schaefer F, Wühl E. Altered cardiovascular rhythmicity in children born small for gestational age. Hypertension 2012; 60:865-70. [PMID: 22733461 DOI: 10.1161/hypertensionaha.112.196949] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Low birth weight is frequently associated with a disproportionately high incidence of cardiovascular disease, diabetes mellitus, and kidney disease in adulthood. Epidemiological studies have identified an inverse association between low birth weight or being small for gestational age and hypertension in adulthood. We hypothesized that children born with low birth weight might have altered circadian and ultradian cardiovascular rhythmicity independent of the prevailing blood pressure level. Twenty-four-hour ambulatory blood pressure and heart rate rhythmicity was prospectively evaluated by Fourier analysis in a cohort of healthy children born with low birth weight and compared with normative pediatric data. Seventy-five children born small for gestational age (mean age, 8.1±2.2 years) and 139 controls matched for age and sex were investigated. In addition to increased 24-hour, daytime, and especially nighttime blood pressure levels (P<0.05), children born small for gestational age exhibited blunted circadian (24-hour) and ultradian (12-, 8-, and 6-hour) blood pressure rhythmicity (P<0.05). In a multivariate analysis including children born with low birth weight and controls, being born with low birth weight independently influenced ultradian blood pressure rhythmicity, whereas in a multivariate analysis including children born with low birth weight only, circadian and ultradian rhythms were independently influenced by catch-up growth, gestational age, and blood pressure level. This study demonstrates blunted circadian and ultradian cardiovascular rhythmicity in prepubertal children born small for gestational age, independent from the presence of arterial hypertension. Circadian and ultradian rhythms may be sensitive indicators for detecting subtle early abnormalities of cardiovascular regulation.
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Affiliation(s)
- Ann Wolfenstetter
- Center for Pediatric and Adolescent Medicine, Division of Pediatric Nephrology, University of Heidelberg, Heidelberg, Germany
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