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