1. Pediatric hypertension Supervisor : VS. 邱元佑 Speaker : Int. 謝宜勳

2. Case information Patient 1Patient 2 Age/Gender 13 y/o, male17 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 onset 2003/12/112003/8: hypertension 2003/12/10: hypertensive crisis

3. Review: Pediatric hypertension - Definition - Etiology - Clinical manifestation - Treatment

4. 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

5. Measurement of BP in Children

6. 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

7. Pediatrics 1996, 98(4): 649-58

9. systolic or diastolic BP Normal< 90th% High normal / borderline blood pressure 90th ~ 95th% Hypertension> 95th%

10. Etiology Primary hypertension Secondary hypertension

11. 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

12. Prenatal cause (1) children with intrauterine growth retardation (IUGR)  had significantly higher mean values of systolic, diastolic, and mean blood pressure Fattal-Valevski A, Bernheim J, Leitner Y, et al.: Blood pressure values in children with intrauterine growth 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

13. 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

14. Conditions Associated with Transient or Intermittent Hypertension in Children

15. 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 azotemia Hypervolemia After surgical procedures on the genitourinary tract Pyelonephritis Renal trauma Leukemic infiltration of the kidney Obstructive uropathy associated with Crohn disease

16. 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, propranolol) Vitamin D intoxication

17. CENTRAL AND AUTONOMIC NERVOUS SYSTEM Increased intracranial pressure Guillain-Barré syndrome Burns Familial dysautonomia Stevens-Johnson syndrome Posterior fossa lesions Porphyria Poliomyelitis Encephalitis

18. Conditions Associated with Chronic Hypertension in Children

19. 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 diseases)

20. VASCULAR Coarctation of thoracic or abdominal aorta Renal artery lesions (stenosis, fibromuscular dysplasia, thrombosis, aneurysm) Umbilical artery catheterization with thrombus formation Neurofibromatosis (intrinsic or extrinsic narrowing of vascular lumen) Renal vein thrombosis Vasculitis Arteriovenous shunt Williams-Beuren syndrome Moyamoya disease

21. ENDOCRINE Hyperthyroidism Hyperparathyroidism Congenital adrenal hyperplasia (11 β-hydroxylase and 17- hydroxylase defect) Cushing syndrome Primary aldosteronism Dexamethasone-suppressible hyperaldosteronism Pheochromocytoma Other neural crest tumors (neuroblastoma, ganglioneuroblastoma, ganglioneuroma) Diabetic nephropathy Liddle syndrome

22. CENTRAL NERVOUS SYSTEM Intracranial mass Hemorrhage Residual following brain injury Quadriplegia

23. Clinical manifestation Essential HTN: - asymptomatic - mild BP elevation - mild to moderate obesity

24. 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

25. Treatment Goal: Blood pressure below 95 th percentile according to age, sex and height

26. Treatment of essential HTN Non-pharmacologic therapy: - weight reduction - sodium intake reduction - aerobic exercise - No tobacco and alcohol

27. Treatment of essential HTN Pharmacologic therapy diuretics  volume-dependent HTN β-blocking agent  high-renin high cardiac output HTN CCB ACE-I

28. Treatment of secondary HTN Overactivity of RAASβ-blocking agent ACE-I Aldosterone antagonist Renovascular or renal parenchymal dz ACE-I Renal vessel thrombus  angio Captopril Neural crest tumorα+ β-blocking agent Labetalol High dose of cocainelabetalol

29. 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

31. 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 National High Blood Pressure Education Program. Pediatrics 1996;98:649-58. 4.Albert P. Rocchini. Pediatric hypertension 2001. Current Opinion in Cardiology 2002, 17:385–389 5.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. 6.Umbereen S. Nehal and Julie R. Ingelfinger. Pediatric hypertension: recent literature. Current Opinion in Pediatrics 2002, 14:189–196