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