Chronic Pediatric Hypertension

Transcription

1 Chronic Pediatric Hypertension Nephrology Grand Round 3/13/2015 Mahmoud Kallash M.D Outline Definition of hypertension (HTN) Challenges in diagnosing HTN Epidemiology Causes and evaluation of HTN Management of HTN Investigated therapy Case 1 19 year old male with no significant PMH Weight kg, and BMI 39.9 kg/m2 PCP office November: 170/96 Asymptomatic March 2013: 148/78 Urgent care August 2013: 159/90 Blood work, renal US, Echo, Thyroid: WNL Our office December: 160/78 Definition of HTN Publication Date: August 2004 Definition 3 Measurements (auscultation) Appropriate way in the right arm Definition BP; 50-90% Pre-hypertension; 90-95% Stage 1 HTN; 95-99% plus 5 value. Stage 2 HTN; >99% plus 5 value. Adolescents (12-16); if BP is >120/80 but less than the 95%; Pre- HTN 1

2 Definition Definition - Neonates 17years- older adults guidelines BP <120/80 Oscillometric BP Pre-HTN / Stage 1 HTN /90-99 Stage 2 HTN 160/100 Zubrow et al, J Perinatology, 1995 HTN- Neonates HTN-Neonates Dionne et al, Ped Neph 2012; 27: Dionne et al, Ped Neph 2012; 27: Challenges and Limitations BP references; Single BP measurement Statistically defined Not uniform world wide; UK and Germany have higher values Snap shot (wrong diagnosis?)** Average BP >95% for age, sex and height OR BP load >25% 2

3 Blood Pressure Elevated Elevated Blood Pressure Blood Pressure Masked hypertension* Elevated White Coat Hypertension* *Kavey et al. J Pediatrics 2007 Risk of LVH: White Coat Elevated 20% and similar to stage 1 HTN McNiece et al, Hypertension 2007 Not significantly different between MHT (OR 4.1) and confirmed HTN (OR 4.3) Mitsnefes et al, CKiD *Advanced study, JASN kidney 2010 disease: Susan M et al, J Pediatri 2012 *DM: Ben-Hamouda Chihaoul et al, Ann Cardiol Angeiol 2011 *Obesity: Westerstahl et al, Acta Pædiatrica 2013 Elevated Blood Pressure White Coat Hypertension Masked hypertension Confirmed/ sustained hypertension Bobrie et al, JAMA

4 Back to ca1e 1 White Coat HTN Case 2 8 yo WF with NF1 and bilateral RAS Got surgical correction in March 2014 Jan 30: 160/104 Feb 12: 149/94 April 16: 93/65 July 16: 105/67 Nov 26: 107/62 February 16: Masked HTN Case 3 17 yo WF with CKD stage 3 On Norvasc 10 mg Q day June 26 : 123/83 July 17: 139/92 October 1: 121/82 October 15: 4

5 Uncontrolled HTN Challenges and Limitations SBP; casual BP and (N=198 pts) Challenges and Limitations DBP; casual BP and (N=198) Mitsnefes et al, CKiD study, JASN 2010 Mitsnefes et al, CKiD study, JASN 2010 Benefits of The most reliable way to diagnose HTN. The GS for diagnosing white coat HTN and nocturnal/ masked HTN. Better correlation with LVH*, vascular injury** and progression of renal disease***. Evaluate treatment response. No operational bias or technique error Availability Cost?* is not perfect Age Patient tolerance **Over estimation of blood pressure *Belsha et al. Am J Hypertension 1998 **Lande et al. Hypertension 2006 ***Lubrano et al, Pediatr Nephrol ** Swartz et al, Pediatrics

6 Home BP measurements Some studies showed that they are superior to casual BP measurements in diagnosing HTN* Help in diagnosing WCH and Masked HTN Improve compliance Less sensitive than Do not diagnose non-dippers. Epidemiology Incidence of HTN is increasing; In 1996; 1-2% Over the last decade; 3.7 % Adolescents; up to 5% Obese kids; up to 11-30% White Coat hypertension: 40% Masked HTN; about 7-35% in kids (McNiece et al, 592 subjects, 2007) *Wuhl et al, Pediatr Res 2004;55: Obesity AA and Hispanics Na intake Sleep Apnea Risk Factors Uric acid* Recurrent futi and AKI, low birth weight and prematurity** *Loeffler et al, Hypertension, 2012 Apr;59(4):811-7 Clinical Presentation Most often asymptomatic Symptoms of HTN could be vague; 3 most common symptoms* headache difficulty initiating sleep daytime tiredness Work up When HTN is confirmed; 1) R/O secondary HTN (28% vs 1-2%) 2) Is there any end organ damage? 3) Any indication for anti-htn therapy? Infants; agitation, poor weight gain *Pediatr Nephrol 2006 Apr;21(4):

7 Causes of hypertension Suspension based Age based Basic workup ; CBC and BMP Evaluation UA Renal US with Doppler Echo Further/Endocrine workup? Pheochromocytoma; Metanephrines Thyroid, Adrenal Urine drug screen Evaluation Renal Artery Stenosis Plasma Renin Activity good screening for RAS and familial HTN. value is altered by several antihypertensive agents 15% of children with confirmed RAS have normal PRA value. limited value in neonates and small infants (age specific values) Familial HTN Familial HTN M.Vehaskari Pediatr Nephrol (2009) 24:

8 Evaluation 2-End Organ Damage; Astherosclerosis* LVH; 34-47% of cases, could resolve with appropriate treatment Retina; arteriolar narrowing in up to 50% Microalbuminuria; rare Treatment Targets of HTN treatment; Aim therapy for <95% BP. < 90% if pt has co-morbidities*, such as: DM, end organ damage or renal insufficiency/ proteinuria. *ESCAPE study: Effect of strict blood pressure control and ACEI on the progression of chronic renal failure in pediatric patients. NEJM Prehypertension Treatment Stage 1 hypertension Life modifications All pts Set measurable targets (BP, Wt) Whole family Treatment Treatment Indications for medication Secondary HTN Stage 2 HTN Stage 1 HTN not responding to life style modifications HTN associated with end organ damage or DM HTN associated with severe symptoms Choice of antihypertensive meds Best medication and model to choose? suspected pathophysiology Timing of taking drug? considerer SE/ contraindications. Thiazides in pts with DM and dyslipidemia Hermida et al JASN 2011 Beta Blockers in asthma and peripheral vascular and cardiac disease ACEI and ARBs combination for HTN? ACEI in pregnancy ACEI/ARBs in neonates and The premis ONTARGET study, NEJM

9 Investigated treatment 45 adult patients Resistant hypertension (3+ drugs) egfr 45 cc/min TdFaSk Hypertension 2011 Points to take home Pediatric HTN incidence is increasing and underdiagnosed Appropriate BP measurements on multiple occasions are required for diagnosis Casual BP will miss masked HTN (7-33%) End organ damage; 30-50% Major risk factor for adult hypertension Lancet 2010, 376 Thank you 9