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23/8/50
An 8-year-old Thai boy was
admitted due to severe progressive
headache and severe hypertension.
History
Present Illness
• He had episodes of headache of few times per
month for 1 year. The characteristic was a
throbbing frontal headache aggravated from
exercise and relieved by resting or analgesic
drug such as paracetamol.
• 2 days prior to admission, his headache became
progressively severe.
History (2)
Present illness
• No nausea, vomiting, dyspnea, and orthopnea
• Vision was normal.
• No fever, cough, or sore throat recently
• Normal urination, no dysuria, hematuria, or oliguria
• No edema, rash, oral ulcer, anemia, abnormal
bleeding, or arthralgia
• No history of previous hypertension or urinary tract
infection.
History (3)
• No family history of hypertension or renal
disease
• Development was normal.
• Complete vaccination as scheduled
• No history of any drug allergy
• No ingestion of any medications
Physical Examination
Vital signs: T 37.5 o C, P 76 /min, no delayed pulse
and equal all extremities, RR 24 / min,
Blood pressure
Right arm: 170/120 mmHg
Left arm:
165/110 mmHg
Right leg: 170/105 mmHg
Left leg:
170/110 mmHg
BW 23 kg (P10-25) Ht 126.5 cm (P 50)
BMI 14.37 kg/m2
Physical Examination (2)
General appearance: alert and cooperative,
not pale, no jaundice, no dyspnea, no
orthopnea, no puffy eyelids, no edema, and
no cyanosis
Skin: no rash, no petechiae , no ecchymoses,
no alopecia, no café au lait spots
HEENT: normal
Physical examination (3)
CVS: PMI at left 5th intercostals space, lateral to
midclavicular line, no heaving or thrill, normal
first and second heart sound, no murmur
RS: normal
Abdomen: soft, not tender, no palpable mass,
liver and spleen not palpable, normal bowel
sound , no abdominal bruit
Nervous system : Normal
No superficial lymphadenopathy
Problem list
1. Chronic headache for 1 yr with severe
progressive headache for 2 days
2. Severe hypertension
3. Cardiomegaly
Hypertension in childhood
What is hypertension?
• Hypertension=average SBP and/or DBP ≥ 95th
percentile for gender, age, and height on ≥ 3
separate occasions
• Prehypertension : BP 90th -95th or BP ≥ 120/80
• Normotension : SBP and DBP ≤ 90th by age,
gender, and height or BP ≤ 120/80
• Hypertension stage I : SBP and/or DBP 95th -99th
• Hypertension stage II : SBP and/or DBP ≥ 99th
Clinical manifestations
of hypertension
• Most of the patients do not have symptom
related to hypertension at the presentation.
• Chronic headache (10 %)
• Hypertensive encephalopathy (6.8%)
• Epistaxis (1.4%)
• Visual disturbance (1.4 %)
[ The Study of persistent hypertension in Thai children etiologies and outcome in J med association Thai 2006 ]
Hypertensive Emergency
• No specific level of BP
• Defined as a blood pressure high enough
to cause acute injury to target organs
• Children are more prone to hypertensive
encephalopathy than adults
Complication of hypertensive
emergency
• The most common complications are
- Hypertensive encephalopathy
- Cerebral infarction and hemorrhage
- Facial palsy
- Visual symptoms
- Cardiac failure
- Renal failure
Hypertension etiology
• Primary or early onset of essential
hypertension
• Secondary hypertension
The Causes of Secondary Hypertension in
Children and Adolescents
Cause
Acute hypertension
Chronic hypertension Etiology
Renal
Acute glomerulonephritis
Congenital defects
Tumors of the kidney
Acute renal failure
Chronic pyelonephritis
Hypoplastic kidney
Hemolytic-uremic
syndrome
Hydronephrosis
Collagen vascular
disease
-
Pheochromocytoma
Primary
aldosteronism
Hyperthyroidism
Neuroblastoma
Coarctation of the aorta
Renal arteriovenous
fistula
Renal artery stenosis
Neurofibromatosis
Takayasu arteritis
Tuberous sclerosis
Dysautonomia
-
Endocrine
Vascular
Neurogenic
Renovascular trauma
Increased intracranial
pressure
Guillain-Barré syndrome
Metabolic
Hypercalcemia
Adapted from Daniels SR, Loggie JM: Essential hypertension. Adolesc Med State Art Rev 2:555, 1991.
Hypernatremia
The Causes of Secondary Hypertension in
Children and Adolescents (2)
Cause
Acute hypertension
Chronic hypertension Etiology
Metabolic
Hypercalcemia
-
-
Cocaine
Nonsteroidal
Anabolic steroids
Phencyclidine
anti-inflammatory drugs
Corticosteroids
Amphetamines
Oral contraceptives
Alcohol
Burns
Leg traction
Heavy metal poisons
-
Hypernatremia
Drugs
Others
Adapted from Daniels SR, Loggie JM: Essential hypertension. Adolesc Med State Art Rev 2:555, 1991.
Etiology of Secondary
Hypertension in Pediatrics
•
•
•
•
•
78%
12%
2%
0.5%
7.5%
renal parenchymal
renovascular
coarctation of the aorta
pheochromocytoma
others
Ronald Portman,MD professor and director,division of pediatric nephrology and hypertension, University of Texus Houston, 2003
Cause of the persistent hypertension
according to age group in Thailand
Age
6-12 yr
Cause
No. of patient(%)
lupus nephritis
36.1
chronic renal failure
22.2
idiopathic nephrotic syndrome 5.6
IgA nephropathy
2.8
renovascular disase
13.9
drug induced
11.1
coarctation of aorta
2.8
Essential hypertension
2.8
unknown
2.8
[ The Study of persistent hypertension in Thai children etiologies and outcome in J med association Thai 2006 ]
How to approach hypertension
Diagnostic work up & Evaluation
for target organ damage
The Causes of Secondary Hypertension as
Suggested by History
History
Suggests
Known urinary tract infection; recurrent abdominal or flank
pain with frequency, urgency, dysuria; secondary enuresis
Renal disease
Joint pains, rash, fever, edema
Renal disease, vasculitis
Complicated neonatal course, umbilical artery catheter
Renal artery stenosis
Renal trauma
Renal artery stenosis
Drug use (e.g., sympathomimetics, anabolic steroids, oral
contraceptives, illicit drugs)
Drug-induced hypertension
Aberrant course or timing of secondary sexual
characteristics; virilization
Adrenal disorder
Muscle cramping, constipation, weakness
Hyperaldosteronism (primary or secondary)
Excessive sweating, episodes of pallor and flushing
Pheochromocytoma
Adapted from Hiner LB, Falkner B: Renovascular hypertension in children. Pediatr Clin North Am 40:128-129, 1993.
The Causes of Secondary Hypertension as
Suggested by Physical Examination
Physical finding
Possible secondary cause
Blood pressure
>140/100 at any age
Multiple secondary causes
Leg < arm blood pressure
Coarctation of the aorta
Poor growth
Chronic renal disease
Short stature, features of Turner syndrome
Coarctation of the aorta
Multiple café-au-lait spots or neurofibromas
Renal artery stenosis, pheochromocytoma
Decreased or delayed pulse in leg
Coarctation of the aorta
Vascular bruits
Over large vessels
Arteritis
Over upper abdomen, flank
Renal artery stenosis
Flank or upper quadrant mass
Renal malformation, renal or adrenal tumor
Excessive virilization or secondary sex characteristics
inappropriate for age
Adrenal disorder
Extremities
Adapted from Hiner LB, Falkner B: Renovascular hypertension in children. Pediatr Clin North Am 40:128-129, 1993.
Edema
Renal disease
Excessive sweating
Pheochromocytoma
Adapted from Hiner LB, Falkner B: Renovascular hypertension in children. Pediatr Clin North Am 40:128-129, 1993.
Investigation
The first line
•
•
•
•
Urinalysis
Urine culture
BUN , creatinine
24 hr. urine for
vanillymandelic acid
• Renal ultrasound
including Doppler
study of renal ateries
•
•
•
•
•
•
Complete blood count
Electrolyte
Calcium, Phosphate
Chest x- ray
EKG
Retinal examination
Investigation
The second line
• urine catecholamine
• plasma renin and aldosterone
• CT angiography
• ESR and ANA
Investigation in this
patient
Investigation
• CBC : Hb 12.1 g/dl Hct 35.3 % WBC
3890 cell/mm3 ( N 46%, L 39%, Mo 9%)
Plt 187,000 cell/mm3
• UA : pH 6, Sp.gr. 1.015, protein 2+ ,ketone
negative WBC 0-1 cell/HP , RBC 0-1
cell/HP, no dysmorphic RBC, no cast
• Urine protein/creatine : 0.8
• 24 hr. urine protein : 9 mg/kg/day
Investigation
• Blood chemistry : BUN 13.0 mg/dl, Cr
0.7 mg/dl, Na 137 mmol/L, K 3.1 mmol/L,
Cl 102 mmol/L, HCO3 22 mmol/L
• Lipid profile : Chol 203 mg/dl, TG 68
mg/dl, HDL 66 mg/dl, LDL 123.4 mg/dl
• EKG : LVH by voltage criteria
• Fundoscopic examination : atherosclerosis
grade II BE
• CXR : Cardiomegaly, CT ratio 0.53, no pulmonary infiltration.
Investigation
• Echocardiogram :
no coarctation of aorta, no irregularity
or aneurysmal dilatation of abdominal
aorta.
concentric LVH without LVOT
obstruction.
good LV systolic function.
no structural heart disease.
Investigation
•
•
•
•
Throat swab culture : normal flora
Anti-streptolysin O : 576 IU/ml
AntiDNAse B : 79.1 U/ml
C3 : 105 mg/dl
• U/S : Bilateral hydronephrosis and hydroureter UVJ,
possibly related with stricture at UVJ from megaureter
or stenosis related with ectopic ureter.
VCUG : bilateral vesicoureteric reflux grade 5,
suspected bilateral primary megaureter
• Tc-99m MAG3 : hydronephrosis and hydroureter
both kidneys with no evidence of obstruction. Mild
impair function of left kidney.
Investigation
• Tc-99m DMSA : multiple small renal
infarction (function right: left = 51%: 49%)
Renal parenchymal disease
• Acute glomerulonephritis •
• Lupus nephritis
• Acute or chronic renal
failure
•
• Nephrotic syndrome
•
• IgA nephropathy
• Henoch-Schonlein
nephritis
Coarse renal scarring
(reflux nephropathy,
obstructive uropathy,
neuropathic bladder)
Polycystic kidney disease
Hemolytic uraemic
syndrome.
VESICOURETERAL REFLUX
VESICOURETERAL REFLUX
• The retrograde passage of urine from the
bladder into the upper urinary tract
• Incidence : 1 % of children
• 2 categories : primary and secondary
• Screening with a radionuclide cystogram of all
sibling < 3 year and any sibling with a UTI is
appropriate.
older sibling may undergo renal U/S and if an
abnormality is found, VCUG is recommended
The length of the
submucosal
segment of the
distal ureter is an
important factor in
determining the
effectiveness of the
ureteral valvular
mechanism in
preventing VUR.
Clinical manifestation
• Prenatal presentation :
hydronephrosis via U/S (80% are male)
• Postnatal presentation : UTI
• In other children, VCUG is performed during
evaluation for pathology of urinary tract
International system of radiographic grading of VUR
Treatment
• Goal of treatment are to prevent
complication
• Surgery for severe VUR
• ATB prophylaxis for mild to moderate
VUR
Treatment of hypertension
Nonpharmacologic treatment
•
•
•
•
•
dietary salt restriction
mineral supplementation
weight control
regular exercise
life style modification
Indications for Antihypertensive drugs
•
•
•
•
Symptomatic hypertension
Secondary hypertension
Hypertensive target-organ damage
Persistent hypertension despite
nonpharmacologic measure
• DM?
Antihypertensive drugs
• ACEI and Ca channel blocker are
commonly prescribed in children
• Diuretics are usually adjunct therapy.
• Need regular long term follow up with
special attention to target organ injury and
underlying disease
Antihypertensive drugs for
hypertensive emergency
Most useful
• Esmolol : IV 100-150 ug/kg/min
• Hydralazine : IV or IM 0.2-0.6 mg/kg/dose
• Labetalol : IV 0.2-1.0 mg/kg/dose
• Nicardipine : IV 1-3 mg/kg/min
• Sodium nitroprusside : IV 0.53-10 ug/kg/min
Management in this patient
Management
• Antihypertensive drug :
Enalapril (5 mg) ½ tab oral bid
Adalat CR (30 mg) 1 tab oral OD
Atenolol (50 mg) ½ tab oral bid pc
• ATB prophylaxis :
Bactrim (80 mg of TMP) 1 tab oral hs
• At ward , BP 100-130 / 80-90 mmHg ,
UA : protein 2+ , wc 0-1/HP
Home medications:
•
•
•
•
Bactrim (80 mg of TMP) 1 tab oral hs
Enalapril (5 mg) ½ tab oral bid
Adalat CR (30 mg) 1 tab oral OD
Atenolol (50 mg) ½ tab oral bid pc
Progression
Progress Note
Surgery: bilateral re-implantation
(Cohen Cross trigone)
After surgery : no anti-hypertensive medications
(BP 117/80 mmHg)
Medications:
– Bactrim (80 mg of TMP) ½ tab oral bid
– Paracetamol (500) ½ tab oral prn for pain
q 4-6 hrs
VCUG 1 month after surgery
Tc-99m DMSA : no significant change of bilateral renal
cortex compare to the previous study
Special thank
ศ.พญ. อัจฉรา สั มบุณณานนท์
Thank you