pediatric hypertension supervisor : vs. 邱元佑 speaker : int. 謝宜勳

Pediatric hypertension

Supervisor : VS. 邱元佑 Speaker : Int. 謝宜勳

Case information

Patient 1 Patient 2

Age/Gender 13 y/o, male 17 y/o, male

Diagnosis 2003/11

Nephrotic syndrome

2003/11/27

Prednisolone(5) 4# tid

1997: IgA nephropathy

2003/10:

ESRD s/p CAPD

Hypertension

onset2003/12/11 2003/8: hypertension

2003/12/10:

hypertensive crisis

Review:Pediatric hypertension

- Definition

- Etiology

- Clinical manifestation

- Treatment

Definition

Task Force on Blood Pressure Control in Children

( National Heart, Lung, and Blood Institute & National Institutes of Health)

Age, sex and height

Obesity important independent risk

Measurement of BP in Children

Measurement

standard mercury sphygmo-manometer

right arm

bladder width: 40% of the circumference of

the arm

cuff size covered 80% to 100% of the

circumference of the arm

Pediatrics 1996, 98(4): 649-58

systolic or diastolic BP

Normal < 90th%

High normal / borderline blood pressure

90th ~ 95th%

Hypertension > 95th%

Etiology

Primary hypertension Secondary hypertension

Primary hypertension

Essential hypertension Often in adolescent family history Multi-factorial cause:

- heredity, obesity, diet and stress

- genetic alterations in Ca & Na transport

- insulin resistance

- vascular smooth muscle reactivity

- renin- angiotensin system dysfunction

Prenatal cause

(1) children with intrauterine growth retardation (IUGR) had significantly higher mean values of systolic, diastoli

c, and mean blood pressure Fattal-Valevski A, Bernheim J, Leitner Y, et al.: Blood pressure values in children with intrauterine gr

owth retardation. Isr Med Assoc J 2001;3:805–808.

(2) intrauterine environment In women: resting SBP↓4.27 mm Hg and DBP↓ 2.18 mm

Hg per kilogram increase in birth weight in men: no associations! Loos RJ, Fagard R, Beunen G, et al.: Birth weight and blood pressure in young adults: a prospective

twin study. Circulation 2001;104:1633–1638

Secondary hypertension

Most common in the period of infant and younger children

Underlying disease:

- Renal and renovascular disease

- coarctation of the aorta

- endocrine disorder

- medication

Conditions Associated with

Transient or Intermittent Hypertension

in Children

RENAL Acute postinfectious glomerulonephritis Anaphylactoid (Henoch-Schönlein) purpura with nephritis Hemolytic-uremic syndrome Acute tubular necrosis After renal transplantation After blood transfusion in patients with a

zotemia Hypervolemia After surgical procedures on the genitourinary tract Pyelonephritis Renal trauma Leukemic infiltration of the kidney Obstructive uropathy associated with Crohn disease

DRUGS AND POISONS Cocaine Oral contraceptives Sympathomimetic agents Amphetamines Phencyclidine Corticosteroids and adrenocorticotropic hormone Cyclosporine or sirolimus treatment post-transplantation Licorice (glycyrrhizic acid) Lead, mercury, cadmium, thallium Antihypertensive withdrawal (clonidine, methyldopa, propr

anolol) Vitamin D intoxication

CENTRAL AND AUTONOMIC NERVOUS SYSTEM Increased intracranial pressure Guillain-Barré syndrome Burns Familial dysautonomia Stevens-Johnson syndrome Posterior fossa lesions Porphyria Poliomyelitis Encephalitis

Conditions Associated with

Chronic Hypertension in Children

RENAL

Chronic pyelonephritis Chronic glomerulonephritis Hydronephrosis Congenital dysplastic kidney Multicystic kidney Solitary renal cyst Vesicoureteral reflux nephropathy Segmental hypoplasia (Ask-Upmark kidney) Ureteral obstruction Renal tumors Renal trauma Rejection damage following transplantation Postirradiation damage Systemic lupus erythematosus (other connective tissue disease

s)

VASCULAR Coarctation of thoracic or abdominal aorta Renal artery lesions (stenosis, fibromuscular dysplasia, th

rombosis, aneurysm) Umbilical artery catheterization with thrombus formation Neurofibromatosis (intrinsic or extrinsic narrowing of vasc

ular lumen) Renal vein thrombosis Vasculitis Arteriovenous shunt Williams-Beuren syndrome Moyamoya disease

ENDOCRINE

Hyperthyroidism Hyperparathyroidism Congenital adrenal hyperplasia (11 β-hydroxylase and 17-hydroxylas

e defect) Cushing syndrome Primary aldosteronism Dexamethasone-suppressible hyperaldosteronism Pheochromocytoma Other neural crest tumors (neuroblastoma, ganglioneuroblastoma, ga

nglioneuroma) Diabetic nephropathy Liddle syndrome

CENTRAL NERVOUS SYSTEM Intracranial mass Hemorrhage Residual following brain injury Quadriplegia

Clinical manifestation

Essential HTN:

- asymptomatic

- mild BP elevation

- mild to moderate obesity

Secondary HTN:

- mild to severe BP elevation

- not usually produce symptoms (headache, dizziness,

epistaxis, anorexia, visual change)

- underlying disease

- hypertensive encephalopathy:

vomiting, temperature↑, ataxia, stupor and seizure

- End-organ (cardiac and renal ) dysfunction

Treatment

Goal:

Blood pressure below 95 th percentile

according to age, sex and height

Treatment of essential HTN

Non-pharmacologic therapy:

- weight reduction

- sodium intake reduction

- aerobic exercise

- No tobacco and alcohol

Treatment of essential HTN

Pharmacologic therapy diuretics

volume-dependent HTN β-blocking agent

high-renin high cardiac output HTN CCB ACE-I

Treatment of secondary HTNOveractivity of RAAS β-blocking agent

ACE-I

Aldosterone antagonist

Renovascular or renal parenchymal dz

ACE-I

Renal vessel thrombus

angio

Captopril

Neural crest tumor α+ β-blocking agent

Labetalol

High dose of cocaine labetalol

Treatment of hypertensive crisis

Stepwise reduction:

first 6 hr 1/3 total planned reduction BP

following 48-72 hr 2/3

Intravenous administration Labetalol Nitroprusside Sublingual nifedipine

Reference

1. Nilson 17th ed. Novaritis; 1997 : p1592-1598

2. Joseph D. Kay, Alan R. Sinaiko. Pediatric hypertension. Am Heart J 2001;142:422-

3

3. National High Blood Pressure Education Program Working Group on Hypertension

Control in Children and Adolescents. Update on the 1987 task force report on high

blood pressure in children and adolescents: a working group report from the Nation

al High Blood Pressure Education Program. Pediatrics 1996;98:649-58.

4. Albert P. Rocchini. Pediatric hypertension 2001. Current Opinion in Cardiology 200

2, 17:385–389

5. Loos RJ, Fagard R, Beunen G, et al.: Birth weight and blood pressure in young ad

ults: a prospective twin study. Circulation 2001;104:1633–1638.

6. Umbereen S. Nehal and Julie R. Ingelfinger. Pediatric hypertension: recent literatur

e. Current Opinion in Pediatrics 2002, 14:189–196