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Hypertension in children vevey february 2010

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short review of HTN management, in the light of two cases

short review of HTN management, in the light of two cases

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  • Dear all, It is a pleasure to present to you a topic related to pediatric hypertension. Pediatric hypertension is a growing problem in the busy general pediatric office, as more and more children are diagnosed with HTN. This might be linked to pediatric obesity, although, as we will see, not totally In this hour, I will present you some epidemiological data about pediatric hypertension, and how to approach and investigate a child with HTN
  • Why to get interested in pediatric HTN: First because HTN in children is a growing problem. If we look at the problem just from an epidemiologic point of view, in this slide, you can see that pediatric HTN is recognized as one of the most prevalent chronic condition in children. Of note, obesity is even more important, and this is especially important as there is a strong link between obesity and HTN
  • Why to get interested in pediatric HTN: Second, althought the consequences / death or even morbidity secondary to HTN is very low in the pediatric age, as you know, HTN is a major player of cardiovascular morbidity and mortality in adults. Furthermore, it has been shown that a significant percentage of children with HTN during infancy still have HTN in adulthood (so-called blood pressure tracking). What is not know, and I will come to it later, is if the children with pediatric HTN are the same adults with complication of their sustained HTN.
  • This is the outlined plan for this presentation, I will talk about:
  • Let’s talk about definition:
  • Pediatric hypertension is defined as a blood pressure value superior to the 95 th percentile for age, sex and height. These percentile have been defined by a task force studying several thousand children in the US, with diverse background ethnicity as well. Of note, and this is relevant, only the first value of the blood pressure recording was taken into account to calculate the percentile. We will come back to that later.
  • This enable to derive normal BP values for children according to their Age Sex Heigh
  • HTN has been defined as More than the 95 th percentile for sex, age, and height. Stage one HTN between 95 th to 99 th percentile and stage 2 more than 99 th percentile + 5 mm Hg.
  • As it might be difficult to always have these curves or remember them, an easy method to remember the normal upper limit is the following:
  • Now that we approximately know about the normal values, let’s talk about two cases demonstrating the importance of measuring BP. These examples will also give an insight into the pathophysiology of HTN
  • First case is a mongenic HNT…..
  • The girl was 12 when she was sent from the school nurse, where she was discovered to have severe HTN. She had a history of surgically corrected VUR (and interestingly, she was already hypertensive at that time).
  • Her father suffered from severe HTN as well with headaches and tinitus, he was aged 32
  • Her grand-father died of sub-arachnoid hemorrhage from HTN at the age of 32.
  • Her great grand-father died of sub-arachnoid hemorrhage from HTN at the age of 32.
  • Her great great grand-father died of sub-arachnoid hemorrhage from HTN at the age of 32.
  • An uncle died of sub-arachnoid hemorrhage from HTN, and two ants where suffering from severe HTN, but still alive (treated??).
  • She had a normal physical exam
  • Her labs were remarkable for a hypokalemic metabolic alkalosis, with kaliuresis.
  • Her endocrine studies showed an extremely high aldosterone levels
  • I can therefore summarize the case as follow:
  • Because of very high aldo levels, we can rule out CAH, AME. Gordon syndrome is associated with acidosis, and is ruled out, as is Liddle syndrome, associated with extremely low aldo levels. Therefore, from a physiologic point of view, I thought she must have GRA She was treated with diuretic, inhibiting the salt reabsorbtion, which is the source of her HTN, and did extremely well.
  • This is another, less dramatic case, but maybe even more difficult to manage:
  • Probable essential HTN, Worsened by: Obesity (25% associated hypertensive kids are obese) Salt intake (20% of the general population is salt sensitive)
  • Let’s now talk about pathophysiology of HTN in children
  • In this sketch, you can see how somebody can progress from being normotensive to hypertensive, if he present one or more of the following aspects: In pink : genetic / prenatal riks factors, in one word : programmed determinants In blue: secondary insult during life style, that can induce HTN or worsen a pre-HTN state In green, life style factors, that can induce HTN or worsen a pre-HTN state
  • Let’s briefly talk about the programmed risk factors, such as genetic:
  • Monogenic HTN syndormes are now fairly well known, such as GRA for our family, and help us understand the physiology of HTN (physiology of salt and RAA axis in that example)
  • Birth weight is another programmed determinant for HTN, as I will explain to you now:
  • Barker, in the UK, has now shown for two decades that a low birth weight is associated with : Increased HTN in the adulthood Increased cardiovascular mortality Increased metabolic syndrome In that slide, you can see that a low birth weight is significantly associated with HTN in adulthood
  • In a study we conducted in Lausanne, we studied former premature infants, defined as < 32 weeks, with or without growth retardation, at the age of 15 years, and found that premature infants, with or without growth retardation, had a significantly higher diastolic BP values. This also shows the prematurity has being important in the generation of HTN in children.
  • In another recent study that I am going in greater details later, we were able to show that the prevalence of HTN in 12-year-old schoolchildren in Lausanne was significantly associated with birth weight, with low birth weight infants defined as less than 2.5 kg.
  • Let’s now look at what I called the lifestyle risks for HTN. Of note, these risks are the only one to be (more or less) preventable, avoidable or correctable. Let us look now not at underweight children, but overweight children.
  • We conducted a study in the schools of Lausanne, looking at the prevalence of HTN in children aged approx. 12. We were specifically looking at the relation between HTN and obesity We were also interested in looking at the variation of BP values between the first measure and the subsequent values, either at school or at home. This because a first value only would overestimate the prevalence of HTN in children
  • We therefore measured BP on three visits, three times each time.
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  • You can see on this slide a very very dramatic decrease in the incidence of HTN between the first BP measurement and the third one. If I should convey only one message, this would be it: always always check BP several time before making a diagnosis of HTN in a patient
  • Studying the determinant of HTN in that population, we found that approximately 12 to 15 percent of children were overweight or obest Rate of overweight or obese children are fairly low compared to other European countries such as the UK. Because of volountary participation, we might have underestimated the true prevalence of obesity in our study children
  • Here is another dramatic picture showing an increase in the diastolic and mainly systolic BP with increased BMI
  • This depicts in another way this relationship. The prevalence of HTN was dramatically increased if BMI was more than the 95 th percentile, passing from an average of 2% to an average of 15%.
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  • Let’s talk about the third part of our study: the evaluation of the hypertensive child
  • We can take the same sketch we used for the etiology of HTN in children, and apply that for the clinical approach of the hypertensive child This will allow us not to forget any pathophysiological pathway in the investigation of such children The history should include Birth weight Family history, presence of HTN, especially monogenic HTN, essential hypertension, cardiovascular morbidity Post-natal weight gain Dietary habits, salt intake, smoking
  • Physical exam, in the same way, should concentrate on The presence of obesity The presence of any illness (kidney disease, endocrine diseas, cardiac disease) susceptible to cause or aggravate HTN in a child.
  • Here are some examples of a child with Cushing syndrome and another one with an acute Henoch-Schoenlein Purpura
  • In the same manner, lab investigation will try to look for any acute or chronic injuries causing HTN in the child. Lab investigation will also look for any adverse consequence of HTN in the child (end organ damage).
  • As you can see on that slide, secondary causes are quite common in children, and almost never present in adults. I would almost never diagnose a young child, less than 10, as having essential HTN.
  • Last chapter in our today topic. We have shown the importance of measuring blood pressure, the importance of repeating blood pressure measurement before making a diagnosis of HTN, and we approach the phycisal and laboratory investigation of the child with HTN, but we did not talk about how to clinically, in a practical way, measure the BP in the children This is very important for several reasons: BP can be very difficult to take, especially in premature babies, or sometimes in toddlers Because of the growth of the child, the impact of proper equipment (cuffs, machine) has a bigger impact than in adults There is a lot of literature in the adult world about different BP measurement (office vs home blood pressure measurement vs ambulatory blood pressure measurement). There is not much literature data in children yet, which makes translation from adult HTN studies to pediatric ones difficult.
  • Bladder should not be too narrow. Too narrow a bladder will give you a high BP value. Too big a bladder will sometime give you to low a blood pressure, but the difference is probably not too important.
  • The bladder length should cover approx. 80% of the arm circumference, and the bladder width should be approx. 2/3 of the arm length.
  • Here is a table that you have in your hand out showing the approx. bladder size to use in different categories.
  • Let’s now talk about the different methods of measuring BP
  • Read slide
  • Another question that we asked ourselves was the following: is there any importance or difference if we place the BP cuff on the wrist or on the arm. This is especially important, as more and more automated BP device have wrist cuff instead of arm cuff.
  • We compared the difference between a wrist or an arm cuff, at different inflation values, by measuring on the other arm the finger BP As you can see, in normotensive adult patients, there was no difference between arm or wrist cuff. On the other hand, in hypertensive adult patients, arm cuff induced a significantly higher response that the wrist cuff, at two different inflation pressures. Results in normotensive children showed no significant difference as well.
  • Read slide Role of discomfort ? Would still recommend the arm at the present time in children
  • We talked about -which bladder size to use -where to take blood pressure (arm vs wrist) -the importance of repeating BP measurement in the office Let us know talk about ABPM in children ABPM in children has been used quite routinely for now a decade. It is thought to 1) better represent the true living condition of the patient, 2) avoid white coat HTN, and 3) give additionanl risk factors such as night dipping . Although literature data is less extensive than in adults, there are good data showing a goood relationship between the severity of HTN, the left ventricular hypertrophy, and the values of the ABPM In border line cases, where I can not figure if the child (especially adolescents) have true HTN or not, I do perform an ABPM (or, as we will see later, a self measurement of BP at home)
  • Self Blood pressure measurement at home has been developped during the last 5 years. As with ABPM, it more reflects the real life of the patient, and does not carry the cumberness or noisance of the ABPM that some patients report. Normative values have been developped for adults, not for children. I do not know which method (office vs ABPM vs home BP self-monitoring) is the best, especially in children. It is probably not so important, as:
  • The three methods has been shown to correlate, independently, with cardiovascular risk, morbidity and mortality.
  • Last chapter, a very brief overview of treatment of HTN in children: who to treat, when, and what with??
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  • This approach has not only been validated by the pediatric HTN community, but also by the AAP committee on the prevention or treatment of children at risk for cardiovascular morbidity
  • This is probably the most difficult question to answer: Is there any proven benefits of treating early HTN, in infancy, instead of waiting a few years. There is a lack of studies showing the ultimate outcome of treated or non treated mild HTN in children, on a long term basis!! I am not talking about severe HTN, as in our first example monogenic HTN, or in children with HTN and end organ damage, who are by far the one who will benefit the most of a tight BP control.
  • On this slide is shown the death rate (all causes and not only CV disease), of children and young adults without chronic kidney disease, of children with transplantation or finally children on dialysis. A tight control of the BP in that population will definitely save lives
  • In another example, still in children with chronic kidney disease, a tight control of BP in patients not on dialysis, but with CKD, was able to postpone the renal replacement therapy, therefore to decrease the rate of progression of their renal failure.
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  • Transcript

    • 1. Hypertension in children F. Cachat Pediatrics and Pediatric Nephrology Vevey and Lausanne Switzerland
    • 2. Disease prevalence in childhood
      • Congenital heart disease 1%
      • Epilepsy 3-5%
      • ADHD 3-5%
      • Hypertension 4-5%
      • Asthma 7%
      • Obesity 18-25%
    • 3. HTN is a major killer in adulthood Some HTN originates in childhood Many children with HTN during infancy will still have HTN as adults (blood pressure tracking)
    • 4. PLAN
      • Definition
      • Case presentation
      • Physiology of hypertension in children (some aspects)
      • Evaluation of the child with hypertension (some aspects)
      • Management of the child with hypertension (some aspects)
      • Conclusion
    • 5. Definitions
    • 6.
      • Update on the 1996 and 1987 Task Force Report on High Blood Pressure in Children and Adolescents:
        • 60’000 healthy children
        • M/F: 50/50
        • White: 56%, African-American: 29%, Spanish: 9%, Asian: 3%, Others: 3%
      Definitions
    • 7. Definitions
    • 8. Classification of Hypertension in Children and Adolescents SBP or DBP Percentile Normal <90 th percentile Prehypertension 90 th percentile to <95 th percentile, or if BP exceeds 120/80 mm Hg, even if below the 90 th percentile up to <95 th percentile Stage 1 hypertension 95 th percentile to the 99 th percentile + 5 mm Hg Stage 2 hypertension >99 th percentile + 5 mm Hg
    • 9. How to calculate the 95 th percentile of BP for a child?
        • Systolic BP (1-17 years)
          • 100 + (age in years x 2)
        • Diastolic BP (1-10 years)
          • 60 + (age in years x 2)
        • Diastolic BP (11-17 years)
          • 70 + (age in years)
    • 10. Case presentation
    • 11. Case presentations
      • Case 1 : monogenic hypertension
          • When a rare single genetic disease helps to understand the pathophysiology of HTN in children
          • When HTN treatment benefits are obvious
      • Case 2 : obesity related hypertension
          • A rising epidemic of HTN in children in the Western World
          • When HTN treatment benefits are less obvious (and treatment more difficult)
          • Polygenic, multifactorial HTN
    • 12. HTN Sub-arachn. hemorrhage BP 160/110 mm Hg Hx of surgically-corrected VUR
    • 13. HTN Sub-arachn. hemorrhage BP 160/110 mm Hg Hx of surgically-corrected VUR
    • 14. HTN Sub-arachn. hemorrhage BP 160/110 mm Hg Hx of surgically-corrected VUR Premature death 36 years old Sub-arachn. hemorrhage
    • 15. HTN Sub-arachn. hemorrhage BP 160/110 mm Hg Hx of surgically-corrected VUR Premature death 36 years old Sub-arachn. hemorrhage
    • 16. HTN Sub-arachn. hemorrhage BP 160/110 mm Hg Hx of surgically-corrected VUR Premature death 36 years old Sub-arachn. hemorrhage
    • 17. HTN Sub-arachn. hemorrhage BP 160/110 mm Hg Hx of surgically-corrected VUR Premature death 36 years old Sub-arachn. hemorrhage
    • 18. Physical exam
      • NORMAL except for confirmed severe asymptomatic HTN (discovered during routine school exam)
    • 19. Laboratory values
      • Plasma chemistries : Na 141 mmol/l, K 2.8 mmol/l , creatinine 71  mol/l, bicarbonates 27 mmol/l, BE + 3.2 mmol/l , glucose 5.3 mmol/l, calcium 2.37 mmol/l
      • Urine chemistries : Na 113 mmol/l, K 75 mmol/l , no proteinuria, no glycosuria
      • I 123 -Hippuran scintigraphy : normal, no scars
      • Father’s plasma potassium : 3.2 mmol/l
    • 20. Laboratory values
      • Plasma renin activity: extremely low
      • Plasma aldosterone: extremely high
      • Plasma and urine cortisol : normal values
    • 21. In summary
      • An autosomal dominant form of severe HTN
      • With hypokalemia and alkalosis
      • With very high aldosterone levels and suppressed renin activity
    • 22. Na Intake Kidneys Urinary sodium R e nin Blood volume Blood pressure Na and Cl transport Aldost e rone ACTH GRA Congenital Adrenal hyperplasia Deoxycorticosterone Cortisol Cortisone ENaC (Liddle’s syndrome ) Gordon syndrome AME Monogenic endocrine HTN
    • 23. 15-year-old boy No past medical history No medication Found by the pediatrician to have sustained HTN 140/85 mm Hg Extensive work-up negative Family history positive for both parents having HTN
    • 24. Conservative treatment/ diet No major changes in diet continues to eat salty food (salt sensitivity) Pharmacological treatment Poor compliance with drug treatment (drug compliance) Poor BP (and weight) improvement
    • 25. Pathophysiology
    • 26. Child at risk Birth weight Sex Genetics Adult with ± cardio- vascular risks Physical activity Job/social factors Weight Weight gain Obesity Truncal obesity Food (fat, sodium) Smoking/environmental factors Renal injury Cardiac abnormality (coarctation of the Aorta) Endocrine abnormality Programmed determinants Secondary insults Life style
    • 27. Child at risk Birth weight Sex Genetics Adult with ± cardio- vascular risks Physical activity Job/social factors Weight Weight gain Obesity Truncal obesity Food (fat, sodium) Smoking/environmental factors Renal injury Cardiac abnormality (coarctation of the Aorta) Endocrine abnormality
    • 28. HTN Sub-arachn. hemorrhage BP 160/110 mm Hg Hx of surgically-corrected VUR Premature death 36 years old Sub-arachn. hemorrhage GRA AME Liddle syndrome
    • 29. Child at risk Birth weight Sex Genetics Adult with ± cardio- vascular risks Physical activity Job/social factors Weight Weight gain Obesity Truncal obesity Food (fat, sodium) Smoking/environmental factors Renal injury Cardiac abnormality (coarctation of the Aorta) Endocrine abnormality
    • 30. Relationship between blood pressure values and birth weight Barker DJP Schweiz Med Wochenschrift 1999;129:189-196
    • 31. f/u of BP in former premature infants with or without growth retardation in Lausanne (14-16 years) Systolic BP (mm Hg) Diastolic BP (mm Hg) Controls 123 ±11 71±5 * Premature infants** without growth retardation 129 ±13 86±9 Premature infants** with growth retardation 129 ±17 87±6 *P<0.0001 compared to premature with and without intrauterine growth retardation (unpaired t-test) Premature infants defined as  32 weeks gestational age
    • 32. % with elevated BP at 12 y (at 1st visit) Etude Chiolero-IUMSP Relation between birth weight and blood pressure (systolic blood pressure) 0% 5% 10% 15% 20% <2.5 kg (270) 2.5-4.0 kg (3979) >4.0 kg (405) 16.7 10.6 16.7 11.2
    • 33. Child at risk Birth weight Sex Genetics Adult with ± cardio- vascular risks Physical activity Job/social factors Weight Weight gain Obesity Truncal obesity Food (fat, sodium) Smoking/environmental factors Renal injury Cardiac abnormality (coarctation of the Aorta) Endocrine abnormality
    • 34.
      • Background
      • Obesity is increasingly frequent among children worldwide
      • There is a fear that obesity related conditions might increase, such as hypertension
      • Few data on prevalence of hypertension among children, especially in European countries
      • Most epidemiological studies assessed blood pressure (BP) on one visit , hence BP was overestimated
    • 35.
      • Aims
      • To assess prevalence of hypertension measured on up to three visits in a Swiss pediatric population
      • To assess the relationship between hypertension, being overweight and other factors
    • 36.
      • Methods
      • All children of the 6 th grade of the schools of canton of Vaud (N=6873) were eligible and 5207 participated (76%) .
      • Weight, height, and blood pressure (BP) were measured.
      • At initial visit, three BP readings were obtained with a clinically validated automated device.
    • 37.
      • Methods
      • IOTF criteria for use for overweight/obesity .
      • Elevated BP was defined for average of two last BP readings > 95th sex-, age- and height specific percentiles (US reference).
      • If BP was elevated at the initial visit, BP was measured on up to two additional separate visits.
      • Hypertension is defined for elevated BP on the three visits (recommendation of NHBPEP)
    • 38.
      • Prevalence of elevated BP at each visit
      • Four fold decrease in the prevalence of elevated BP between 1 st and 3 rd visit
      • Probably lower prevalence than in US children (4-9%).
      Results 10.5 12.4 4.0 3.7 2.3 2.0 0 5 10 15 1st visit 2nd visit 3rd visit Boys Girls Hypertension
    • 39.
      • High prevalence of overweight, relatively low compared to other regions of Europe
      • Underestimation as some overweight/obese children did not participate
      Results
    • 40.
      • BP strongly relates to BMI
      • The association between BP and BMI is independent of age and height
      • Blood pressure and body mass index
      BP (mmHg) BMI (kg/m2) Results
    • 41. Results
      • Prevalence of hypertension according to BMI category
      1.7 1.2 2.0 3.8 14.9 0 5 10 15 20 <25th 25th-74th 75th-84th 85th-94th >=95th BMI percentile (CDC) Hypertension (%)
    • 42. Conclusion
      • 1) Prevalence of overweight and obesity in children aged 12 years old was high but relatively low compared to other regions of Europe
      • 2) Prevalence of hypertension was highly dependent on the number of visits at which BP was measured
      • 3) HTN prevalence was low, and increased with increase in BMI
    • 43. Evaluation of HTN in children
    • 44.
      • History taking
      Child at risk Birth weight Sex Genetics Adult with ± cardio- vascular risks Physical activity Job/social factors Weight Weight gain Obesity Truncal obesity Food (fat, sodium) Smoking/environmental factors Renal injury Cardiac abnormality (coarctation of the Aorta) Endocrine abnormality
    • 45.
      • Physical exam
      Child at risk Birth weight Sex Genetics Adult with ± cardio- vascular risks Physical activity Job/social factors Weight Weight gain Obesity Truncal obesity Food (fat, sodium) Smoking/environmental factors Renal injury Cardiac abnormality (coarctation of the Aorta) Endocrine abnormality
    • 46. Cushing syndrome Henoch-Schoenlein purpura
    • 47.
      • Lab investigations
      Child at risk Birth weight Sex Genetics Adult with ± cardio- vascular risks Physical activity Job/social factors Weight Weight gain Obesity Truncal obesity Food (fat, sodium) Smoking/environmental factors Renal injury Cardiac abnormality (coarctation of the Aorta) Endocrine abnormality
    • 48. Children Secondary causes Renal causes (78%) Reno-vascular causes (12%) Coarctation Aorta (2%) Other causes (endocrine causes, phaeo) (8%) (Essential HTN) Adults Essential HTN (Secondary causes) Age Frequency
    • 49. Measurement of blood pressure in children
    • 50. BP measurement : cuff choice Cuff too narrow Good-sized cuff
    • 51. BP measurement : cuff choice American Family Physician 2006; 7(9) 40% of the circumference or 2/3 of the arm lengt ≥ 80% of the arm circumference
    • 52. BP measurement : cuff choice
    • 53. BP measurement methods
      • BP measurement in the office
      • ABPM
      • Self-blood pressure monitoring at home
    • 54. BP measurement in the office
      • Most commonly used
      • Always obtain at least 3 values to diagnose sustained hypertension
      • White coat hypertension:
        • Innocent bystander (?)
        • Adults data makes the f/u of white coat hypertension mandatory, no data in children
    • 55. Single office BP measure
      • Is there any difference between arm and wrist cuff?
    • 56. Blood pressure reactivity in adults Lausanne Study
    • 57. Single office BP measurement
    • 58. ABPM Most commonly used method to confirm HTN Prognostic factor of “dipping” Abnormal ABPM linked to left ventricular hypertrophy
    • 59. Self-measurement of BP at home
      • Advantages:
          • Greater numbers of readings
          • Avoidance of the white-coat syndrome
          • Absence of observer bias
          • Increased compliance with anti-hypertensive therapy
      • Reference values
          • Derived from population studies
          • In adults:
            • Mean + 2 SD: 137/89 mm Hg
            • 95 th percentile: 135/86 mm Hg
    • 60.  
    • 61. Treatment of HTN in children
    • 62. When to treat HTN in children? S/D BP Measure Non-pharm. pharm. treatm. Normal < P90 No measure none none Pre-HTN P90-95 or f/u 6 months low salt diet none unless > 120/80 physical act. CKD or diabetes or cardiac disease
    • 63. When to treat HTN in children? TA S/D Measure Non-pharm. Pharmacol ttt Stage I HTN P95-99 f/u within diet none unless + 5 mmHg 2 weeks physical activity organ damage or symptomatic Stage II HTN > P99 referral diet yes + 5 mmHg physical activity
    • 64. Pharmacologic management
      • Pharmacological approach will allow to control:
        • hormonal aspect of BP ( IEC or ARBs )
        • Vascular reactivity (arterial and venous) ( calcium channel blockers or peripheral  -blockers )
        • Cardiac output (  -blockers )
        • SNC sympathetic activity ( central  -agonists )
    • 65.  
    • 66. Why to treat, does it make a difference?
      • Outcome difficult to assess in children:
          • Rare complications during childhood
          • Classic complications (stroke, heart failure, blindness) occur (very) late
          • Notable exception of children with CKD and HTN:
    • 67. Mortality in children with CKD Death rate per 100,000 0 10 100 1000 10000 0-14 15-19 20-30 Age (years) Adapted from Parekh et al, J Pediatr, 2002 Dialysis Transplant General Population
      • Black
      • White
    • 68. • CrCl < 75ml/min/1.73m 2 • HTN: >95 th % (Task Force) • Normotensive: n=1987 (52%) • Hypertensive: n=1874 (48%) • Endpoint: – CrCl by 10 ml/min/1.73m 2 – Renal replacement therapy P<0.001 Mitsnefes et al, J Am Soc Nephrol 2003 NAPRTCS CRI Database: NAPRTCS CRI Database: 58% 49% Morbidity in children with CKD Non-Hypertension Hypertension % PROGRESSION TO ESRD/CR.CL. DROP 10 0 20 40 60 80 100 MONTHS 0 12 24 36
    • 69. Conclusions
    • 70.
      • BP measurement must be done routinely in all children, as soon as possible, at least for the first time when the child in 3 years old, or earlier in children with associated risk factors for HTN
      • The vast majority of children with HTN are asymptomatic until their BP is significantly high with potential target organ damage
      Conclusions
    • 71. Conclusions
      • Younger children (< 10 years old) often (always) have secondary HTN
      • One single abnormal BP value must always be confirmed, either at the office (first), or with ABPM and/or self-monitored blood pressure at home
    • 72. Conclusions
      • Non-pharmacologic treatment must be started in every child with HTN
      • Pharmacologic treatment will be reserved for children with target organ damage or severe HTN
    • 73. What we know
      • HTN exists in infancy
      • In selected cases (monogenic HTN, severe symptomatic HTN) treatment benefits are obvious
      • Treatment of HTN should not only rely on mere BP readings but also on associated risk factors such as obesity, diabetes, renal failure, microalbuminuria, metabolic syndrome, family history or end-organ damage
    • 74. What we do not know
      • What is the best way of measuring BP in children ? (office? Self blood pressure monitoring? ABPM?)
      • What is the relationship between pediatric HTN and later adult morbidity/mortality in a non selected population?
      • What is the role of biomarkers such as microalbuminuria?
    • 75. References
      • Hypertension in children . Leonard G Feld. Butterworth-Heinemann Ed. Boston, 1997;233p.
          • Excellent review, short, global approach and management of the child with HTN
      • Hypertension: pathophysiology, diagnosis and management . Laragh JH, Brenner BM. Raven Press, New-York, 1990, 2 volumes.
          • One (the) reference in adult HTN medicine
      • The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents . Pediatrics 2004;114:555-576
          • Last recommendations from the AAP regarding investigation and management of HTN in children. The pediatric reference

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