surgical kidney ailment induced hypertension and management

1. Renal Hypertension in Children
Dr. Faheem ul Hassan
Pediatric & Neonatal Surgery
IGICH Banglore
Dr. Vinay Jadhav
Assoc. Professor
Pediatric & Neonatal Surgery
IGICH Banglore

2. Definition
Hypertension is defined as systolic or diastolic BP
95th percentile for age, gender and height, on at least
3 separate occasions,
1-3 weeks apart.

3. Stages
Systolic or diastolic BP
> 95th percentile and up to 5 mm above the 99th percentile.
Blood pressures in this range should be
rechecked twice in the next 1-3 weeks, or
sooner if symptomatic
Stage 1 hypertension:

4. Stages
SBP or DBP values 5 mm or more above the 99th percentile.
The presence of stage 2 hypertension should be confirmed
on a repeat measurement, at the same visit.
These patients require further evaluation within one week
or immediately if they are symptomatic.
Stage 2 hypertension:

5. White coat hypertension
Blood pressure higher than the 95th percentile in clinic or
hospital setting, while it is below 90th percentile in familiar
environments.
Require monitoring over the next 12 months
No pharmacological therapy

6. Screening
Prematurity
Very LBW or interventions in NICU
CHD
seizures,

7. Screening
Also advised in
of kidney or heart disease,
Altered sensorium and headache or visual complaints.
conditions associated with hypertension,
e.g., neurofibromatosis, tuberous sclerosis

8. Screening
Surgical Patients
of kidney or heart disease,
recurrent UTI
known renal or urological diseases, hematuria or proteinuria;
family history of congenital renal disorders
malignancy, post organ transplant
and ambiguous genitalia.

9. Screening

10. Measurement devices
continues to be the preferred method for blood pressure
estimation.
It should be regularly calibrated and validated,
mercury is a major environmental pollutant
Mercury sphygmomanometer

11. Measurement devices
infants (auscultation is difficult) and
in ICU (frequent BP measurements are needed)
However normative data is not based on these readings
values > 90th percentile must be cross checked
Oscillometric devices

12. Measurement devices
based on spring technology
Include wrist or finger band oscillometry
Their use should be discouraged
Aneroid and other devices:

13. Measurement devices
Continuous recordings over 12- or 24-hr
more reproducible and
correlate with TOD
Limitation is lack of availability of these instruments
Ambulatory blood pressure monitoring (ABPM):

14. Technique
BP is recorded once the child has rested for 5-10 minutes.
supine position is preferred for younger children.
The right arm is used for consistency and for comparison

15. Technique
the cubital fossa should be at heart
observer's eye at the level of the mercury column.
The width of the cuff bladder should be 40%
length should be 80-100% of the arm circumference.

16. Technique
stethoscope on the brachial artery
mercury column is lowered 2 mm per second
high reading should be confirmed after the child has rested for 5
minutes
average of 2-3 readings is taken

17. Cuff size
Age Width cm Length cm
Newborn, infant 4 8
Child 9 18
Adolescent 10 24
Adult 13 30
Thigh 20 42

18. Transient hypertension
acute glomerulonephritis
GBS
raised ICP,
Corticosteroid administration,
anxiety and hyperthyroidism.

19. Persistent Hypertension
Primary (essential) hypertension
Cardiovascular disease: Coarctation of aorta
Renal parenchymal disease:
Chronic glomerulonephritis,
reflux nephropathy,
obstructive uropathy,
Polycystic kidney disease,
Renal dysplasia

20. Persistent Hypertension
Renovascular hypertension:
renal artery stenosis,
renal artery thrombosis
Tumours
Wilms
Neuroblastoma

21. Persistent Hypertension
Endocrine
Pheochromocytoma,
Cushing syndrome,
CAH,
Primary hyper-aldosteronism,
Glucocorticoid

22. Hypertensive Crisis
hypertensive encephalopathy,
Intracerebral bleeding,
acute left ventricular failure and
Renal failure

23. Chronic Hypertension
eyes (hypertensive retinopathy),
heart (increased left ventricular mass, diastolic
dysfunction),
kidneys (albuminuria),
brain and blood vessels (increased initimal and
medial thickness).
Can lead to

24. Clinical evaluation
Facial puffiness,
edema,
abdominal pain,
dysuria,
hematuria,
frequency,
polyuria;
history of urinary tract infections
abdominal mass
Renal disease

25. Clinical evaluation
Asymmetric pulses,
abdominal/neck bruit,
weak femoral artery pulses,
café au lait spots,
neurofibromatosis
Renovascular, COA

26. Clinical evaluation
Arthritis,
arthralgias,
unexplained fever,
polymorphic rash
Connective tissue disease

27. Clinical evaluation
Muscle weakness, cramps; episodic fever, pallor, sweating,
flushing, tachycardia;
polyuria, polydipsia, failure to thrive; abdominal mass;
ambiguous genitalia/ virilization
Endocrine

28. Investigations

29. Investigations

30. Investigations
Secondary hypertension must be considered in every patient
< 6 years with elevated BP
majority of patients with secondary hypertension have a renal
or renovascular etiology

31. Management
Lifestyle modifications.
Weight reduction
Increased physical activity
Dietary changes (2.6-3.8 g salt).

32. Principles of treatment
The goal for treatment is reduction of blood pressure to
levels <95th percentile
reduction of blood pressure to levels <90th percentile in
comorbid conditions or target-organ damage

33. Principles of treatment
Commonly used medications in children include
ACEI,
CCB
β blockers and thiazide diuretics

34. Principles
Medications with a longer duration of action (once, twice
daily dosing) are preferred for better compliance and less
side effects.
Dose adjustment of antihypertensive medications need not be
made more frequently than every 2-3 days.

35. Stages

36. Medication
Nifedipine and amlodipine are effective CCB for children.
Captopril, chiefly used in young infants,
Beyond infancy, enalapril is preferred
Newer ACEI (lisinopril, ramipril) require once daily dosing
and have fewer side effects.

37. Medication
ARB used in children include losartan, valsartan and
irbesartan.
Labetalol (α- and β-blocker) is useful in refractory
Hypertension

38. Acute glomerulonephritis
Hypertension in postinfectious AGN is of short duration due
salt and water retention
Treatment is
Fluid & sodium restriction
Loop diuretics

39. Chronic kidney disease
The target blood pressure in these patients is <90th
percentile
CKD stage I-III (GFR >30 mL/min/1.73 m2)--- ACEI is
DOC
CKD stage IV-V; GFR <30 mL/min/1.73 m2--- Avoid ACEI

40. ACEI
reduce proteinuria & retard progression of CKD
Needs monitoring of serum K+ and creatinine (initially at 7-
14 days and then every 1-3 months)
The dose of ACEI is reduced if Creatinine exceeds 35%
from the baseline
ACEI avoided in sexually active females-

41. RAAS
Angiotensinogen
Angiotensinogen I
Renin
Angiotensinogen II
ACE
Na+ absorption,K
excretion , water
retention
arteriolar
vasoconstriction
Increased Blood
pressure
ADH- Water Retention
Aldosterone

42. Hypertension in CKD

43. Hypertension on CKD

44. Hypertension in CKD

45. Hypertension in CKD

46. Hypertension in CKD
HTN, loss of nephron mass, and proteinuria are the three
main risk factors for CKD progression
Loss of nephron mass leads to Hyperfiltration and hence
proteinuria
Proteinuria is also caused by damage to capillaries

47. End organ damage
Hypertensive retinopathy
LVH
CIMT (Carotid intimal muscle thickness) correlates with left LVH
Around 60% of patients with CKD will have LVH
Hypertensive management regresses LVH
ECHO and Ophthalmoscopy is recommended

48. End organ damage

49. End organ damage

50. Target BP
AAP Fourth Report----below the 90th percentile.
European Society of Hypertension--- <75th percentile for
non-proteinuric CKD and <50th for proteinuric CKD
KDIGO--- <50th percentile for children with CKD and
proteinuria

51. Treatment
ACE inhibition can slow the progression of CKD
ACEI along with ARB improve cardiovascular and kidney
outcomes. (proteinuria)
Around 50% of patients require multidrug treatment for
achieving target BP
ACE+ Thiazide may be a good combination

52. Treatment
ACE+ Thizide may be a good combination
RAAS Blockade (ACEI)– Hyperkalemia
Thiazides--- Hypokalemia
Thiazides are ineffective in GFR below 60 mL/min/1.73 m2,
In CKD stages IV and V, furosemide is a better choice.

53. Treatment

54. Renovascular hypertension
hypertension resulting from a lesion that impairs blood flow
to one or both kidneys.
RVH is the second most common cause of correctable
hypertension in children second only to coarctation

55. RVH
fibromuscular dysplasia (FMD)
Renal Artery Stenosis
Takayasu
Etiology
Bilateral renal artery disease is more common than unilateral

56. RVH
behavioral changes or failure to thrive
headache and lethargy
fever, weight loss, diffuse myalgias,
Café-au-lait spots
bruit over the abdomen or other larger vessels.
Clinical features

57. RVH
Investigations
Conventional renal arteriography is the gold standard but it is invasive.

58. RVH
Plasma Renin Activity
PRA is raised in a majority of cases with of renovascular
disease or pyelonephritic scarring.
However, 15% of children with unilateral and 40% with
bilateral renal artery stenosis may have normal PRA
Investigations

59. RVH
Captopril DPTA renogram Scans
reduced uptake distal to stenosis
Renal Vein Renin Assays (R/Rc > 1.5)
Investigations

60. RVH
Captopril DPTA renogram Scans
Investigations

61. RVH
Doppler Ultrasonography (pulsus tardus)
A peak systolic velocity greater than 180 or 200 cm/s and is
suggestive of renovascular hypertension
Investigations

62. RVH
MRI

63. RVH
Percutaneous transluminal angioplasty

64. Stages

65. Stages

66. Stages

67. Stages

68. S. Uric acid levels

69. Introduction
High UA levels are associated with the new development of hypertension

70. Plasma Renin Activity
Primary hyperaldosteronism is associated with low PRA levels
Low PRA levels also rule out renal hypertension

71. Doses of oral antihypertensives

72. Doses of oral antihypertensives

73. Tulip Garden Srinagar
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