3-2. Hypertension in CKD. Francesco Emma (eng)

1,929 views

Published on

Published in: Health & Medicine
  • Be the first to comment

3-2. Hypertension in CKD. Francesco Emma (eng)

  1. 1. Hypertension in CKD: epidemiology, treatment targets, complications Francesco Emma Division of Nephrology and Dialysis Bambino Gesù Children’s Hospital, IRCCS Rome, Italy
  2. 2. Life expectancy, according to CKD stages (Canada) Gansevoort et al. Lancet 2013
  3. 3. Life expectancy, according to age class CKD5 vs Tx (US) USRDS 2005 annual report and OPTN/SRTR 2006 annual report
  4. 4. Causes of death in patients with CKD (Canada) Gansevoort et al. Lancet 2013
  5. 5. Leading causes of death in the general pediatric population and in children on renal replacement therapy Mitsnefes, JASN 2012
  6. 6. Risk of CV mortality at different stages of renal failure Dégi et al, Pediatr Transpl 2012
  7. 7. Common risk factors for CVD in children with CKD Management of HTN in children with CKD needs to be associated with treatment of other risk factors for CVD Mitsnefes MM, JASN 2012
  8. 8. Therapeutic lifestyle changes in hypertensive children  Weight reduction: primary therapy for obesity-related hypertension prevention of weight gain limits future increases in BP  Regular physical activity: improves efforts at weight management may prevent increase in BP over time  Dietary modification: prehypertensive children hypertensive children  Family-based intervention: improve success Source: the 4th report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents
  9. 9. CKD children can develop metabolic syndrome! 38 children with metabolic syndrome: mean LVMI was 48.3 g/m2.7 75 children without metabolic syndrome: mean LVMI was 40.0 g/m2.7 (p = 0.0008) Wilson et al, Ped transpl 2010 Higher risk of death Higher risk of rejection Hanevold et al, Pediatrics 2005
  10. 10. Hypertension is a cause, a consequence, and a symptom of CKD Early CKD Glomerular/interstitial damage Mild/Moderate CKD Sclerosis-fibrosis Severe CKD Gansevoort et al. Lancet 2013 HTN
  11. 11. Atherosclerosis timeline
  12. 12. Assessing CV status in children with CKD Advantages Disadvantages Office BP Easy White coat HTN ABPM Easy and reliable Operator independent Needs equipment Home blood pressure Easy and reliable Parental involvement cIMT Relatively easy Operator dependant PWV Early sign of CV morbidity Special equipment in part operator dependent Ecocardiography Relatively easy In part operator dependent Strain ecocardiography More sensitive Special equipment In part operator dependent Electron beam heart CT Early detection of coronary calcifications Expensive Irradiation
  13. 13. Target Disease State Desired Percentile for Gender, Age, & Height Uncomplicated primary HTN with no target-organ damage BP <95th Percentile Chronic renal disease, diabetes, hypertensive target-organ damage BP <90th Percentile Source: Escape trial and the 4th report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents
  14. 14. Not all children with CKD are treated! Mitsnefes et al, JASN 2003
  15. 15. Small children are more likely to be undertreated
  16. 16. Antihypertensive medications in children • ACE inhibitors • angiotensin receptor blockers • beta-blockers • calcium channel blockers • diuretics
  17. 17. http://www.nhlbi.nih.gov/health/prof/heart/hbp/hbp_ped.pdf
  18. 18. ACEi - ARBs
  19. 19. ACEi - ARBs  contraindicated in pregnancy females of childbearing age should be informed  check serum K and creatinine levels periodically  cough is less common in children and with newer molecules  caution with children advanced CKD or polyuria
  20. 20. ESCAPE trial 385 children, 3 to 18 years of age, with chronic kidney disease (glomerular filtration rate of 15 to 80 ml per minute per 1.73 m2 of body-surface area) received ramipril at a dose of 6 mg per square meter of body surface area per day. Patients were randomly assigned to intensified blood-pressure control (with a target 24hour mean arterial pressure below the 50th percentile) or conventional blood-pressure control (mean arterial pressure in the 50th to 95th percentile), achieved by the addition of antihypertensive therapy that does not target the renin–angiotensin system; patients were followed for 5 years. The primary end-point was the time to a decline of 50% in the glomerular filtration rate or progression to end-stage renal disease.
  21. 21. ESCAPE trial
  22. 22. Target Disease State Desired Percentile for Gender, Age, & Height Uncomplicated primary HTN with no target-organ damage BP <95th Percentile Chronic renal disease, diabetes, hypertensive target-organ damage BP <50th Percentile BP <90th Percentile Source: Escape trial and the 4th report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents
  23. 23. Alfa- and/or beta-blockers and CCB
  24. 24. Alfa- and/or beta-blockers and CCB  Alfa- and/or beta-blockers - contraindicated if asthma or overt heart failure - heart rate is dose-limiting - may impair athletic performance - should not be used in insulin-dependent diabetics  Calcium channel blockers - extended-release nifedipine tablets must be swallowed whole. - may cause tachycardia - may cause or worsen edema - may cause gingival hypertrophy (in particular with CsA)
  25. 25. Step-wise approach  Start with a small dose  Increase progressively to the maximal dose, if tolerated  Add a small dose of a second drug  Increase progressively the second medication NB: do NOT decrease treatment when BP is normal
  26. 26. Target-organ abnormalities in childhood hypertension  Target-organ abnormalities are commonly associated with hypertension in children and adolescents.  Left ventricular hypertrophy (LVH) is the most prominent evidence of target-organ damage.  Pediatric patients with established hypertension should have echocardiographic assessment of left ventricular mass at diagnosis and periodically thereafter.  The presence of LVH is an indication to initiate or intensify antihypertensive therapy. Source: the 4th report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents
  27. 27. Prevalence of left ventricular hypertrophy (LVH) in pre-dialysis patients with CKD Reference Tucker, NDT 1997 n=85 (adults) Prevalence of LVH GFR >30 16% GFR <30 38% Levin, Am J Kidney Dis 1999 n=318 (adults) GFR 50-75 GFR 51-25 GFR<25 Start dialysis 29% 32% 48% 70% Johnstone, Kidney Int 1996 n=32 (age 1.5-16.9 y) Mean plasma creatinine: 1.85 mg/dl (0.53-8.4): 22% Mitsnefes, Kidney Int 2004 n=33 (age 6.4-20.0 y) GFR 20-75 21% Matteucci, JASN 2006 N= 156 (age 3-18) CKD 2-4 33%
  28. 28. Definition of LVH in children Height (m) modified from de Simone JASN 2003
  29. 29. Prevalence of LVH in children with CKD Matteucci et al, JASN 2006
  30. 30. Strain echocardiography Provides data on cardiac function of all three planes of the heart (circumferential, radial and longitudinal).
  31. 31. Strain echocardiography Abnormalities in cardiac mechanics and systolic synchronicity, also in patients with normal traditional cardiac indices.
  32. 32. Improvement of LVH with ACEi (24 months)
  33. 33. Life-threatening LVH
  34. 34. Life-threatening LVH
  35. 35. Nephrectomy has no long-term impact on BP and LVMI in transplanted children Ped Nephrol 2010
  36. 36. Steroid withdrawal improves blood pressure control after pediatric renal transplantation NDT, 2010
  37. 37. Thank you!

×