Secondary hypertension How to approach?

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1 Secondary hypertension How to approach? Tomáš Seeman Department of Pediatrics and Transplantation Center, University Hospital Motol, 2 nd Faculty of Medicine, Charles University Prague, Czech Republic

2 Forms of secondary hypertension Prevalence of secondary forms of hypertension Screening tests for detection of secondary hypertension Diagnostic tests for secondary hypertension

3 Forms of hypertension acc. the etiology Hypertension Primary - essential Secondary Renal Cardiovascular Endocrine Other Renoparenchymal Renovascular

4 Causes of hypertension in children (0-18 years) Cardiac 2% Primary 23% Endocrine 4% Other 4% Renovasc. 9% Renoparench. 58% (n = 132) (Arar et al. Pediatr Nephrol 1994, 8: 186-9)

5 Primary 43% (15-18 (UT, Houston, years) Tx, USA) (0-19 years) Secondary 57%

6 Causes of hypertension in adolescents (15-18 years) Endocrine 5% Other 1% Renoparenchym 14% Primary 75% Renovasc. Cardiac 4% 1% (n=378 /1025) (Wyszynska et al. Acta Paediatr 1992, 81: 244-6)

7 (15-18 (UT, Houston, years) Tx, USA) (0-19 years) 6 yr!

8 Presence of different forms of HT depends mainly on the: - age of the child (newborns, infants, todlers,., adolescents) In general: the younger the child the more probable is secondary HT

9 Severity of hypertension - nighttime (%) p< p< Secondary HT Primary HT 0 systolic BP load diastolic BP load

10 Severity of hypertension - daytime (%) p<0.05(!?!) systolic BP load NS diastolic BP load Secondary HT Primary HT

11 (% of children) Reduced nocturnal BP dip on ABPM 100 % specificity for secondary HT p< p< Secondary HT Primary HT 5 0 systolic BP 0 % 0 % diastolic BP

12 Presence of different forms of HT depends mainly on the: - age of the child (newborns, infants, todlers,., adolescents) - severity of nighttime hypertension In general: the younger the child and the more severe the nighttime HT the more probable is secondary HT

13 Causes of persistent hypertension 1.renoparenchymal: renal diseases that often cause HT (>50%): chronic GN (IgA-N, membranoprolif.gn, FSGN, systemic GN (lupus-n), chronic PN, after HUS, RPGN, Henoch-Schoenlein-N, reflux nephropathy, segmental renal hypoplasia, polycystic kidney disease (AR, AD) multicystic dysplastic kidney. chronic renal insufficiency, after renal transplantation

14 severe reflux nephropathy severe hypertension

15 2.Renovascular hypertension Lesion of the renal artery/arteries: 1)fibromuscular dysplasia (FMD) neurofibromatosis, arteritis (Takayasu), injury, external compression Lesion of renal veins: thrombosis of renal vessels (venous prevails, particularly in newborns)

17 3.Cardiovascular causes of hypertension 1. Coarctation of aorta 2. a-v shunts (Botall) 3. thrombosis of umbilical artery

18 4. Endocrine causes of HT a) adrenal medulla: catecholamines: - pheochromocytoma (in 30% familial, male gender prevails) - paraganglioma (extra-adren.pheo.) neuroblastoma ganglioneuroma

19 b) adrenal cortex: 1)mineralocorticoids: CAH (deficiency of 11ß- and 17α hydroxylasis) primary hyperaldosteronism (adenoma, hyperplasia, glucocorticoid-remediable aldosteronism) 2) glucocorticoids: Cushing syndrome (centr., periph.) steroid medication

20 c) thyreoid hormones: hyperthyreodism: systol. HT

21 5. Other causes Central nervous system: intracranial tumors, hemorrhage, hypertension, post intracranial injuries (polytrauma) Drug-induced corticoids, CyA/Tacro, liquorice, contraceptives, psychostimulants, opiods, Monogenic forms of hypertension GRA (=FHA-1), FHA-2, AME, Liddle sy., Gordon sy., CAH 11-beta or 17-alpha hydroxylase defic.

22 Diagnostic algorithm for a child with elevated BP 1. Confirm chronic elevation of BP (3x office BP, ABPM) 2. Exclude/Diagnose secondary causes of hypertension = potential causal treatable 3. Determine the presence of target organ damage (TOD) heart, kidney (eye) 4. Search for other cardiovascular risk factors family and past medical history, physical and laboratory examination

Work-up of a pediatric patient with hypertension to diagnose/exclude secondary HT 1)Medical history Family history: hypertension, CVE (MI, stroke, death), diabetes, dyslipidemia Past

23 Work-up of a pediatric patient with hypertension to diagnose/exclude secondary HT 1)Medical history Family history: hypertension, CVE (MI, stroke, death), diabetes, dyslipidemia Past medical history: renal diseases, cardiac diseases, endocrinopathies, systemic diseases (SLE), BP in the past Snoring and sleep apnea history (OSAS) Drug intake (steroids, ) 2)Physical examination

24 2)Physical examination 2016 ESH Guidelines

25 3)Laboratory investigation 1 st step: - basic evaluation Should be performed in all children with hypertension!! Urine: Urinalysis, +event. culture +microalbuminuria (albumin/creatinine ratio), proteinuria Blood: Serum creatinine, urea, electrolytes, uric acid, total cholesterol, HDL- and LDL chol., triglycerides +glycaemia Imaging studies: Renal ultrasound Echocardiography (Guidelines of the Europ.Society Hypert., J Hypert 2016)

26 Should 24-hour Ambulatory Blood Pressure Monitoring (ABPM) be a part a the basic evaluations in a child with newly diagnosed (office) hypertension?

27 Sept. 2017

28 =prehypertens.

29 2155 $ saved by performing ABPM as initial test just after 3 clinic BP and before laboratory tests!

30 ==

31 Sept online first

32 (% of children) Reduced nocturnal BP dip on ABPM 100 % specificity for secondary HT p< p< Secondary HT Primary HT 5 0 systolic BP 0 % 0 % diastolic BP

33 2 nd step - targeted examination: Only in children with suspicion on secondary HT from medical history, physical examination or 1 st step tests: 2016 ESH guidelines

34 Dif. dg. of the monogenic forms of hypertension 2016 ESH guidelines

35 Which evaluation do they need?

36 Summary

37 Summary

Conclusions All children with hypertension must be examined with the aim to detect/exclude secondary etiology of hypertension - possible causal treatable.

38 Conclusions All children with hypertension must be examined with the aim to detect/exclude secondary etiology of hypertension - possible causal treatable. The examinations include medical history physical examination laboratory and imaging tests In children since birth secondary hypertension prevails - 60% of them are due to renoparenchymal or renovascular disease In adolescents (since 12 years (6 in USA)) primary hypertension prevails.

40 2015 US Guideline: In adults

Pediatric Hypertension. Alisa A. Acosta, MD, MPH Asst. Professor, Renal Section April 5, 2019

Pediatric Hypertension. Alisa A. Acosta, MD, MPH Asst. Professor, Renal Section April 5, 2019 Pediatric Hypertension Alisa A. Acosta, MD, MPH Asst. Professor, Renal Section April 5, 2019 Objectives Recognize the importance of accurate blood pressure measurement in pediatric patients Define pediatric