Pediatric hypertension,Supervisor : VS. 邱元佑 Speaker : Int. 謝宜勳,Case information,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 heightObesity 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,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, diastolic, and mean blood pressureFattal-Valevski A, Bernheim J, Leitner Y, et al.: Blood pressure values in children with intrauterine growth retardation. Isr Med Assoc J 2001;3:805808.(2) intrauterine environment In women: resting SBP4.27 mm Hg and DBP 2.18 mm Hg per kilogram increase in birth weightin 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;104:16331638,Secondary hypertension,Most common in the period of infant and younger childrenUnderlying 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-Schnlein) 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,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,CENTRAL AND AUTONOMIC NERVOUS SYSTEM Increased intracranial pressure Guillain-Barr 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 diseases),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,ENDOCRINE Hyperthyroidism Hyperparathyroidism Congenital adrenal hyperplasia (11 -hydroxylase and 17-hydroxylase defect) Cushing syndrome Primary aldosteronism Dexamethasone-suppressible hyperaldosteronism Pheochromocytoma Other neural crest tumors (neuroblastoma, ganglioneuroblastoma, ganglioneuroma) 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 therapydiuretics volume-dependent HTN -blocking agent high-renin high cardiac output HTN CCB ACE-I,Treatment of secondary HTN,Treatment of hypertensive crisis,Stepwise reduction: first 6 hr 1/3 total planned reduction BPfollowing 48-72 hr 2/3Intravenous administration Labetalol Nitroprusside Sublingual nifedipine,Reference,