hypertension renal disease

1. HYPERTENSION IN ESRD
Oleh : Muhammad Haris
Stase Nefrologi Pediatric
PPDS Ilmu Penyakit Jantung dan Kedokteran Vaskuler
FK UGM

2. INTRODUCTION
 Pediatric hypertension  widely observed. Major cause of morbidity and
mortality in United States and other countries
 The true incidence of hypertension in children is not known
 Standart of Blood Pressure for Children was made by NHLBI by using 11 surveys of
more than 83.000 infants and children
 Last, widely used The Fourth Report
 Category :
 Pre hypertension : above 9oth percentile & below 95th percentile
 Stage 1 hypertension : above 95th percentile & below 95th percentile plus 5 mmHg
 Stage 2 hypertension : above 95th percentile plus 5 mmHg

3.  CKD stage 1  65 % affected hypertension
 CKD stage 4 & 5  80 %
 And more than 50 % children with ESRD have uncontrolled hypertension

4. WORK UP
 Laboratory studies : CBC (anemia  Chronic Renal Disease), Creatinine (Renal
Disease), Hypokalemia (Hyperaldosteronism), Blood hormone (high plasma renin
 renal vascular hypertension), Urine dipstick (+proteinuria  problem in renal)
 Echocardiography : LVH from chronic hypertension  start for therapy (usually
concentric morphology
 Abdominal USG may reveal tumors or structural anomalies of kidneys or renal
vasculare
 Angiography  to reveal the structure of renal vessels

5. PATTERN OF HYPERTENSION IN ESRD
 Very common in all stages of CKD
 Generally :
 Fluid overload
 Activation of renin-angiotensin system
 Symphatetic activation
 Endhotelial dysfunction
 Chronic hyperparathyroidism
 Therapy :
 ACE inhibitor
 ARB
 DIuretics

6. PATHOFISIOLOGY
 Mechanisme of muscle sympathomimetic in elevated BP still unclear
 Maybe connected with afferent afferent signal, dopaminergic abnormalities &
accumulation of leptin in CKD
 Another postules about renal ischemia
 Renalase (amino oxidase expressed in kidney)  activity usually reduced in
patients with ESRD. Lower blood pressure and heart rate
 In uremic patients, reduced NO stimulation leads to reduced agonist
endhotelium-dependent vasodilatation
 Corelated with higher concentration of ADMA

7. (Hadstein, 2007)

8. DRUG ASSOCIATED WITH HT
 Erythropoietin cause elevated BP for several weeks
 Related with arterial wall remodeling causing vascular resistance (Schiffl H et al
1998) and voltage independent calcium channel in smooth muscle activity 
sensitivity NO decreased (Vaziri et al, 1999)
 Glucocoticoid lead to fluid retention by their mineralocorticoid effect
 Cyclosporine A causes vasoconstriction of glomerular afferent arterioles and
hyperplasia of juxtaglomerular apparatus

9. MANAGEMENT

10. PHARMACOTHERAPY
 Based on epidemiology : 75% children with CKD stages 2-4 can reduces blood
pressure (<95th percentile) with monotheraphy oh antihypertensive
 More aggressive therapy needed if targetted <50th percentile
 Start with single dose and titrate upward
 ACE inhibitorand ARB is the most useful drug  not only reduce BP but also slow
down the progession of renal failure
 Mechanism :
 Reduced proteinuria
 Lower intaglomerular pressure
 Anti inflamatory
 Anti fibrotic

11. PHARMACOTHERAPY (2)
 Diurretics used when hypervolemia
 Thiazides are a popular first line therapy in mild to moderate CKD but less efective when
GFR falls below 60 ml/min per 1.73 m2 body surface area
 Not efective when below 30 ml/min . Shoul used furosemide when the status is ESRD
 CCB  very potent vasodilators and do not have cardiac side effect (have side effect
proteinuria and increase intaglomerular pressure)
 Beta Blocker can be used as a second line therapy for renal hypertension in children.
Contraindications in asthma and can cause fatigue.

12. TERIMA KASIH & MOHON ASUPAN