Treatment of hypertension in children and adolescents

The treatment of hypertension in children and adolescents has been markedly changed in recent years by several factors, including the publication of new consensus recommendations, the obesity epidemic, and the increased availability of information on efficacy and safety of antihypertensive medications in the young. In this review we present an updated approach to the outpatient management of hypertension in the child or adolescent, utilizing representative cases to illustrate important principles as well as possible controversies

Neonatal hypertension: diagnosis and management

Hypertension in the term or preterm neonate may be seen in up to 2% of all infants cared for in the modern neonatal intensive care unit. Although the definition of hypertension in this age group has not been completely standardized, recent studies have provided new normative data that may be used to facilitate identification of such infants. Common causes of hypertension in neonates include thromboembolic events related to umbilical catheterization, congenital problems such as aortic coarctation, structural renal malformations and renovascular disease, as well as acquired renal disease and certain medications. A careful history and physical examination will usually identify the probable cause in most cases without the need for extensive laboratory or radiologic testing. Therapy of neonatal hypertension should be tailored to the severity of the blood pressure elevation, and to the underlying cause of hypertension as appropriate. A wide range of therapeutic agents are now available for management of neonatal hypertension in both the acute and chronic settings. In most cases hypertension will resolve, but some infants may require prolonged treatment.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/42300/1/467-14-4-332_00140332.pd

Pretransplant varicella vaccination is cost-effective in pediatric renal transplantation

Because of the severe complications that may result from varicella zoster virus (VZV) infection following renal transplantation (Tx), transplanted varicella-susceptible children exposed to varicella are typically given varicella zoster immunoglobulin (VZIG) as prophylaxis or are admitted and treated with parenteral acyclovir if VZIG prophylaxis fails. As both VZIG and hospitalization are costly, prevention of varicella infection by vaccination could potentially result in significant cost savings in addition to decreasing morbidity and mortality. To test this hypothesis, we developed a decision-analysis model to evaluate the cost-effectiveness of vaccinating patients with chronic renal failure (CRF) against varicella prior to renal transplant. Under baseline assumptions, vaccination for varicella pretransplant was a cost-effective strategy, with a cost of $211 per patient vaccinated compared with$1,828 per patient not vaccinated. The magnitude of cost savings from vaccination was sensitive to variations in the cost of varicella vaccine, the percentage of patients hospitalized for treatment with acyclovir, and the percentage of patients exposed to varicella infection. One- and two-way sensitivity analyses confirmed that vaccination was the dominant cost-effective strategy under all conditions examined. We conclude that vaccination for varicella pretransplant is cost-effective for patients with CRF, and that the magnitude of cost savings is sensitive to the cost of hospitalization, the percentage of patients exposed to varicella, and the cost of varicella vaccination. Pending results of ongoing studies of the safety and efficacy of VZV vaccine in children with CRF, we recommend that VZV vaccine be given to all children with CRF.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/73184/1/j.1399-3046.2001.00032.x.pd

Isradipine treatment of hypertension in children: a single-center experience

Many children with hypertension, particularly those with new-onset hypertension related to glomerulonephritis, organ transplantation, or other forms of secondary hypertension, require treatment with a short-acting antihypertensive in order to quickly achieve blood pressure (BP) control. We administered isradipine, a short-acting, second-generation calcium antagonist, to 72 such children. Retrospective data collection was undertaken to determine the effects of isradipine treatment. The mean age of children treated with isradipine was 74±55 months (mean±SD). Nearly all of these children had secondary hypertension and were initially treated as hospital inpatients for newly diagnosed hypertension. Mean isradipine dose was 0.36±0.17 mg/kg per day, with no significant variation in dose according to patient age. Isradipine was administered three times per day in most instances, but 21% of the time it was administered four times per day. An extemporaneous isradipine suspension was used in 62% of treatment courses. BP control was achieved with isradipine alone in 38 children; the remainder received isradipine in combination with additional antihypertensives. Comparison of pre-treatment BP with BP obtained 8±9 days later demonstrated a significant BP reduction with isradipine treatment, with a mean reduction of 14±13 mmHg for systolic BP and 13±15 mmHg for diastolic BP. There was no effect of isradipine treatment on heart rate. Adverse effects occurred in 9.5% of treatment courses, and included headache, flushing, dizziness, and tachycardia. We conclude that isradipine successfully lowers BP in hypertensive children with secondary forms of hypertension. Use of isradipine suspension allows infants and young children to be treated as readily as older children.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/42307/1/467-17-9-748_s00467-002-0939-6.pd

Familial, atypical hemolytic-uremic syndrome in a premature infant

The hemolytic-uremic syndrome (HUS) typically presents in toddlers or older children after an episode of bloody diarrhea caused by Escherichia coli 0157:H7. However, numerous ’’atypical’’ presentations have been described, including familial cases. Here we describe what we believe to be the first report of familial HUS in a premature infant during the neonatal period.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/42298/1/467-12-9-782_80120782.pd

Calcium channel blockers: pharmacology and place in therapy of pediatric hypertension

The calcium channel blockers (CCBs) are a diverse group of antihypertensive medications with variable pharmacokinetics and clinical effects. Although CCBs have been widely applied to the treatment of hypertensive children, data regarding the pharmacokinetics, efficacy and safety of these agents in children are extremely limited. In this review we briefly summarize the mechanism of action of CCBs and then summarize pertinent pharmacokinetic information on each of the CCBs commonly used in children, including amlodipine, diltiazem, felodipine, isradipine, intravenous nicardipine, nifedipine and verapamil. Clinically important drug interactions and adverse effects are discussed, as well as the potential role of CCBs in renal protection. Available pediatric efficacy and safety data are summarized, and recommendations made regarding the rational use of CCBs in the management of pediatric hypertension.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/42303/1/467-15-3-4-302_00150302.pd

Blood pressure in children with chronic kidney disease: Lessons learned from the Chronic Kidney Disease in Children Cohort Study

Cardiovascular disease (CVD) is common amongst children and adolescents with chronic kidney disease (CKD) and end-stage kidney disease (ESRD). However, the early accrual of CVD risk factors in children with CKD has not been well studied. The Chronic Kidney Disease in Children (CKiD) Study, a multicenter, prospective cohort study of children with mild-to-moderate CKD at study entry counts among its primary aims investigation of the drivers of CVD risk in this population. As the most prevalent CVD risk factor in children with CKD, blood pressure (BP) has been a major focus of investigation for the CKiD Study Group. Over the first 15 years of the study, landmark publications have better defined the prevalence of hypertension, the frequency with which it is under-recognized and thus undertreated, and the consequences of elevated BP in this cohort. The purpose of this review is to summarize the contributions made by the CKiD Study in advancing knowledge of BP in this high-risk population, and to highlight areas in need of further study

Hypertension, Chronic Kidney Disease, and Renal Pathology in a Child with Hermansky-Pudlak Syndrome

We report a child with Hermansky-Pudlak Syndrome (HPS) and chronic kidney disease (stage II) with histological diagnosis of focal segmental glomerulosclerosis (FSGS). A 15-year-old male of Puerto Rico ancestry with history of HPS, hypertension (HTN), asthma, obesity, and chronic kidney disease (CKD) stage II presented with new-onset proteinuria without edema. His blood pressure had been controlled, serum creatinine had been 0.9–1.4 mg/dL, and first morning urine protein/creatinine ratio (UPC) ranged from 0.2 to 0.38. Due to persistent nonorthostatic proteinuria with CKD, renal biopsy was performed and FSGS (not otherwise specified) with chronic diffuse tubulopathy (tubular cytoplasmic droplets) and acute tubular injury was reported. Ceroid-like material is known to infiltrate tissues (i.e., lungs, colon, and kidney) in HPS, but the reason for the renal insufficiency is unknown. Nonspecific kidney disease and in one adult case IgA nephropathy with ANCA-positive glomerulonephritis have previously been reported in patients with Hermansky-Pudlak syndrome. To our knowledge, we report the first pediatric renal pathology case of HPS associated with CKD. This paper discusses presentation and management of renal disease in HPS