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Pinto-Silva C, Correia-Costa A, Moura C, Mota C, Guerra A, Areias JC, Schaefer F, Afonso AC, Wühl E, Azevedo A, Correia-Costa L. Cardiovascular rhythmicity in overweight and obese children. J Bras Nefrol 2023; 45:449-457. [PMID: 37527530 PMCID: PMC10726656 DOI: 10.1590/2175-8239-jbn-2022-0138en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 05/17/2023] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION Obesity is thought to play a role in the disruption of cardiac rhythmicity in obese children, but this is mostly an unexplored field of investigation. We aimed to evaluate the impact of overweight and obesity on circadian and ultradian cardiovascular rhythmicity of prepubertal children, in comparison with normal weight counterparts. METHODS We performed a cross sectional study of 316 children, followed in the birth cohort Generation XXI (Portugal). Anthropometrics and 24-hour ambulatory blood pressure were measured and profiles were examined with Fourier analysis for circadian and ultradian blood pressure (BP) and heart rate (HR) rhythms. RESULTS Overweight/obese children presented more frequently a non-dipping BP pattern than normal weight counterparts (31.5% vs. 21.6%, p = 0.047). The prevalence of 24-hour mean arterial pressure (MAP) and 8-hour HR rhythmicity was significantly lower in obese children (79.3% vs. 88.0%, p = 0.038 and 33.3% vs. 45.2%, p = 0.031, respectively). The prevalence of the remaining MAP and HR rhythmicity was similar in both groups. No differences were found in the median values of amplitudes and acrophases of MAP and HR rhythms. DISCUSSION The alterations found in rhythmicity suggest that circadian and ultradian rhythmicity analysis might be sensitive in detecting early cardiovascular dysregulations, but future studies are needed to reinforce our findings and to better understand their long-term implications.
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Affiliation(s)
- Catarina Pinto-Silva
- Centro Hospitalar Universitário de Coimbra, Divisão de Pediatria, Coimbra, Portugal
| | - Ana Correia-Costa
- Universidade do Porto, Faculdade de Medicina da Universidade do Porto, Divisão de Pediatria, Porto, Portugal
- Centro Hospitalar e Universitário de São João, Divisão de Cardiologia Pediátrica, Porto, Portugal
| | - Cláudia Moura
- Universidade do Porto, Faculdade de Medicina da Universidade do Porto, Divisão de Pediatria, Porto, Portugal
- Centro Hospitalar e Universitário de São João, Divisão de Cardiologia Pediátrica, Porto, Portugal
| | - Cláudia Mota
- Universidade do Porto, Faculdade de Medicina da Universidade do Porto, Divisão de Pediatria, Porto, Portugal
| | - António Guerra
- Centro Hospitalar e Universitário de São João, Divisão de Cardiologia Pediátrica, Porto, Portugal
- Centro Hospitalar Universitário de São João, Serviço de Pediatria, Unidade de Nutrição Pediátrica, Porto, Portugal
| | - José Carlos Areias
- Universidade do Porto, Faculdade de Medicina da Universidade do Porto, Divisão de Pediatria, Porto, Portugal
- Centro Hospitalar e Universitário de São João, Divisão de Cardiologia Pediátrica, Porto, Portugal
| | - Franz Schaefer
- Universidade de Heidelberg, Centro de Pediatria e Medicina do Adolescente, Divisão de Nefrologia Pediátrica, Heidelberg, Alemanha
| | - Alberto Caldas Afonso
- Centro Hospitalar Universitário de Santo António, Centro Materno-Infantil do Norte, Unidade de Nefrologia Pediátrica, Porto, Portugal
- Universidade do Porto, Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
- Universidade do Porto, Instituto de Saúde Pública, Unidade de Investigação em Epidemiologia, Porto, Portugal
| | - Elke Wühl
- Universidade de Heidelberg, Centro de Pediatria e Medicina do Adolescente, Divisão de Nefrologia Pediátrica, Heidelberg, Alemanha
| | - Ana Azevedo
- Universidade do Porto, Instituto de Saúde Pública, Unidade de Investigação em Epidemiologia, Porto, Portugal
- Universidade do Porto, Faculdade de Medicina, Saúde Pública e Ciências Forenses, Departamento de Educação Médica, Porto, Portugal
| | - Liane Correia-Costa
- Centro Hospitalar Universitário de Santo António, Centro Materno-Infantil do Norte, Unidade de Nefrologia Pediátrica, Porto, Portugal
- Universidade do Porto, Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
- Universidade do Porto, Instituto de Saúde Pública, Unidade de Investigação em Epidemiologia, Porto, Portugal
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Kovačević A, Vidatić I, Škorić I, Valent Morić B. Does the Body Mass Index Category Influence Ambulatory Blood Pressure Parameters in Office Normotensive Obese Children? Pediatr Cardiol 2023; 44:599-606. [PMID: 35809123 DOI: 10.1007/s00246-022-02963-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/22/2022] [Indexed: 10/17/2022]
Abstract
The aim of our study was to investigate the influence of the degree of obesity on ambulatory blood pressure parameters in selected group of office normotensive obese children and adolescents. Our study involved 119 obese patients (55 males, 46.2%) aged 7-18 years divided into 3 groups based on their body mass index Z-score, who underwent ambulatory blood pressure monitoring. Our results show that obese patients, even when office normotensive, have alterations in blood pressure values obtained by ambulatory blood pressure monitoring. We found a positive correlation between systolic and diastolic blood pressure and body mass index in our patients (p [Formula: see text] 0.001). Daytime blood pressure load correlated with rising body mass index and was higher in groups II and III compared to group I (p < 0.001). Body mass index category did not influence the dipping pattern in our subjects although most of our subjects (66.4%) showed non-dipping pattern for systolic blood pressure. The difference in blood pressure variability was confirmed only for daytime systolic and diastolic values between groups I and II (p = 0.019 and p = 0.002, respectively). In conclusion, our study showed that in office normotensive obese children and adolescents, systolic and diastolic blood pressure values obtained by ambulatory blood pressure monitoring are higher in subjects with higher body mass index. Patients with increased body mass index also have higher percentage of blood pressure readings above 95th percentile and increased daytime blood pressure variability. Obese patients show non-dipping pattern, independently of the rising body mass index category.
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Affiliation(s)
- Ana Kovačević
- Department of Pediatrics, Sestre Milosrdnice University Hospital Center, Vinogradska cesta 29, 10000, Zagreb, Croatia.
| | - Ines Vidatić
- Department of Pediatrics, Sestre Milosrdnice University Hospital Center, Vinogradska cesta 29, 10000, Zagreb, Croatia
| | - Iva Škorić
- Department of Pediatrics, Sestre Milosrdnice University Hospital Center, Vinogradska cesta 29, 10000, Zagreb, Croatia
| | - Bernardica Valent Morić
- Department of Pediatrics, Sestre Milosrdnice University Hospital Center, Vinogradska cesta 29, 10000, Zagreb, Croatia
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Abstract
Childhood obesity is, according to the WHO, one of the most serious challenges of the 21st century. More than 100 million children have obesity today. Already during childhood, almost all organs are at risk of being affected by obesity. In this review, we present the current knowledge about diseases associated with childhood obesity and how they are affected by weight loss. One major causative factor is obesity-induced low-grade chronic inflammation, which can be observed already in preschool children. This inflammation-together with endocrine, paracrine, and metabolic effects of obesity-increases the long-term risk for several severe diseases. Type 2 diabetes is increasingly prevalent in adolescents and young adults who have had obesity during childhood. When it is diagnosed in young individuals, the morbidity and mortality rate is higher than when it occurs later in life, and more dangerous than type 1 diabetes. Childhood obesity also increases the risk for several autoimmune diseases such as multiple sclerosis, Crohn's disease, arthritis, and type 1 diabetes and it is well established that childhood obesity also increases the risk for cardiovascular disease. Consequently, childhood obesity increases the risk for premature mortality, and the mortality rate is three times higher already before 30 years of age compared with the normal population. The risks associated with childhood obesity are modified by weight loss. However, the risk reduction is affected by the age at which weight loss occurs. In general, early weight loss-that is, before puberty-is more beneficial, but there are marked disease-specific differences.
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Affiliation(s)
- Claude Marcus
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Danielsson
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Emilia Hagman
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Bakhoum CY, Vuong KT, Carter CE, Gabbai FB, Ix JH, Garimella PS. Proteinuria and nocturnal blood pressure dipping in hypertensive children and adolescents. Pediatr Res 2021; 90:876-881. [PMID: 33504962 PMCID: PMC8313642 DOI: 10.1038/s41390-020-01315-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 11/17/2020] [Accepted: 11/22/2020] [Indexed: 01/30/2023]
Abstract
BACKGROUND The absence of nocturnal blood pressure dipping is associated with adverse cardiovascular outcomes in adults, and proteinuria is a risk factor for non-dipping in this population. Risk factors for non-dipping in children are largely unknown. METHODS We retrospectively identified patients aged 5-19 years who underwent 24-h ambulatory blood pressure monitoring (ABPM) from August 2018 to January 2019 and had a spot urine protein-to-creatinine ratio (PCR) within 1 year of their ABPM. Dipping was defined as ≥10% reduction in systolic and diastolic blood pressure from day to night. Multivariable logistic and linear regression models evaluated the association of proteinuria with non-dipping. RESULTS Among 77 children identified, 27 (35.1%) were non-dippers. Each two-fold higher urine PCR was associated with 38% higher odds of non-dipping, after adjusting for body mass index (BMI). Higher urine PCR was also associated with a lower diastolic dipping percentage by 1.33 (95% confidence interval 0.31-2.34), after adjusting for BMI, age, and estimated glomerular filtration rate. CONCLUSIONS Limitations of this study include its retrospective design and the time lapse between urine PCR and ABPM. Proteinuria appears to be associated with blood pressure non-dipping in children. This finding needs to be confirmed in prospective studies. IMPACT Our study demonstrates the association of proteinuria with non-dipping of blood pressure in children. This association has been explored in adults, but to our knowledge, this is the first time it is evaluated in children referred for evaluation of elevated blood pressure. Non-dipping is a modifiable risk factor for kidney function decline and cardiovascular disease in adulthood, and thus early identification in children is important. The association between proteinuria and non-dipping in children will allow us to more readily identify those at risk, with a future focus on interventions to modify blood pressure dipping patterns.
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Affiliation(s)
- Christine Y. Bakhoum
- Division of Pediatric Nephrology, Rady Children’s Hospital, San Diego, California,Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Kim T. Vuong
- Department of Pediatrics, University of California San Diego, La Jolla, California
| | - Caitlin E. Carter
- Division of Pediatric Nephrology, Rady Children’s Hospital, San Diego, California,Department of Pediatrics, University of California San Diego, La Jolla, California,Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California
| | - Francis B. Gabbai
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California.,Nephrology Section, Medicine Service, Veterans Affairs San Diego Healthcare System, La Jolla, California
| | - Joachim H. Ix
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California.,Nephrology Section, Medicine Service, Veterans Affairs San Diego Healthcare System, La Jolla, California
| | - Pranav S. Garimella
- Division of Nephrology and Hypertension, Department of Medicine, University of California San Diego, La Jolla, California
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Fredric D, Greenberg JH, Parikh CR, Devarajan P, Chui H, Cockovski V, Pizzi M, Palijan A, Hessey E, Jia Y, Thiessen-Philbrook HR, Zappitelli M. 24-hour ambulatory blood pressure monitoring 9 years after pediatric cardiac surgery: a pilot and feasibility study. Pediatr Nephrol 2021; 36:1533-1541. [PMID: 33411068 PMCID: PMC10942669 DOI: 10.1007/s00467-020-04847-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 09/30/2020] [Accepted: 10/30/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Children undergoing cardiac surgery are at risk of high blood pressure (BP), a risk factor for cardiovascular and kidney disease. Twenty-four-hour ambulatory BP monitoring (ABPM) is a reference standard hypertension (HTN) test. Little data exist on ABPM abnormalities in children several years post cardiac surgery. This study aimed to (a) determine ABPM feasibility; (b) describe and compare ABPM measures and abnormalities (percent load, masked HTN [MH]; non-dipping, mean systolic/diastolic BP > 95th percentile; pre-HTN (ABPM); white-coat HTN [WCH]) to casual BP; and (c) compare BP in patients with and without acute kidney injury (AKI). METHODS Prospective, follow-up pilot study of children (0-18 years) who underwent cardiac surgery from 2007 to 2009 at Montreal Children's Hospital. We recorded if participants had post-operative AKI and assessed the following outcomes at 9-year follow-up: casual BP classified by three single-visit measures (normal; elevated BP [eBPSingleVisit]; HTNSingleVisit); ABPM. Bivariable analyses were used to compare characteristics between groups. RESULTS Twenty-three patients (median [interquartile range], 8.6 [8.0, 9.0] years post cardiac surgery) were included; 16 (70%) male. Six participants (26%) had eBPSingleVisit or higher. On ABPM, 11 (48%) had ≥ 1 abnormality: 9 (39%) had non-dipping; 3 (13%) had pre-HTN; 3 (13%) had WCH; none had HTN or MH. There were no differences in ABPM according to AKI status. CONCLUSION Our pilot study determined that ABPM was feasible in children years after cardiac surgery and frequently identified ABPM abnormalities. Future research in larger populations is needed to define specific risk factors for HTN in children after cardiac surgery.
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Affiliation(s)
- Daniel Fredric
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Room 11.9722, Toronto, ON, M5G 0A4, Canada
| | - Jason H Greenberg
- Section of Nephrology, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Chirag R Parikh
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Prasad Devarajan
- Department of Nephrology and Hypertension, Cincinnati Children's Hospital, University of Cincinnati, Cincinnati, OH, USA
| | - Hayton Chui
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Room 11.9722, Toronto, ON, M5G 0A4, Canada
| | - Vedran Cockovski
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Room 11.9722, Toronto, ON, M5G 0A4, Canada
| | - Michael Pizzi
- McGill University Health Centre Research Institute, Montreal, QC, Canada
| | - Ana Palijan
- McGill University Health Centre Research Institute, Montreal, QC, Canada
| | - Erin Hessey
- Faculty of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Yaqi Jia
- Division of Nephrology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Michael Zappitelli
- Department of Pediatrics, Division of Nephrology, Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, 686 Bay Street, 11th floor, Room 11.9722, Toronto, ON, M5G 0A4, Canada.
- McGill University Health Centre Research Institute, Montreal, QC, Canada.
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Hagman E, Danielsson P, Lindberg L, Marcus C. Paediatric obesity treatment during 14 years in Sweden: Lessons from the Swedish Childhood Obesity Treatment Register-BORIS. Pediatr Obes 2020; 15:e12626. [PMID: 32074662 DOI: 10.1111/ijpo.12626] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/28/2020] [Accepted: 01/31/2020] [Indexed: 01/07/2023]
Abstract
BACKGROUND Treatment of paediatric obesity has been offered customarily and free of charge for more than 15 years in Sweden. The Swedish Childhood Obesity Treatment Register (BORIS) is a prospective register of children and adolescents undergoing obesity treatment. OBJECTIVES To investigate how patient characteristics and treatment efficacy has changed over 14 years on a national scale. METHODS All subjects in BORIS with data from 2004 until 2017 were included, n = 21 499. Outcomes were age and BMI SDS at treatment initiation, dropout rates and treatment outcome up to 3 years after treatment initiation. RESULTS Age and BMI SDS at treatment initiation have decreased during the years (both P < .0001). Of the patients who started treatment before 2009, more than 80% had at least 1-year follow-up. This number has decreased to about 60% in 2017. Since 2004, no trend in improvement of treatment results was observed when evaluating change in either BMI SDS or proportion of obesity remission. There was no difference between the sexes. CONCLUSION Although children in Sweden receive treatment at an earlier age, which is a major determinant of treatment success, and at a lower degree of obesity at treatment initiation, the effect of childhood obesity treatment on standard anthropometric measures has not improved over the investigated years.
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Affiliation(s)
- Emilia Hagman
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Pernilla Danielsson
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Louise Lindberg
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Claude Marcus
- Division of Pediatrics, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
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Nocturnal blood pressure dipping as a marker of endothelial function and subclinical atherosclerosis in pediatric-onset systemic lupus erythematosus. Arthritis Res Ther 2020; 22:129. [PMID: 32493472 PMCID: PMC7268394 DOI: 10.1186/s13075-020-02224-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 05/21/2020] [Indexed: 01/20/2023] Open
Abstract
Background Loss of the normal nocturnal decline in blood pressure (BP), known as non-dipping, is a potential measure of cardiovascular risk identified by ambulatory blood pressure monitoring (ABPM). We sought to determine whether non-dipping is a useful marker of abnormal vascular function and subclinical atherosclerosis in pediatric-onset systemic lupus erythematosus (pSLE). Methods Twenty subjects 9–19 years of age with pSLE underwent ABPM, peripheral endothelial function testing, carotid-femoral pulse wave velocity/analysis for aortic stiffness, and carotid intima-media thickness. We assessed the prevalence of non-dipping and other ABPM abnormalities. Pearson or Spearman rank correlation tests were used to evaluate relationships between nocturnal BP dipping, BP load (% of abnormally elevated BPs over 24-h), and vascular outcome measures. Results The majority (75%) of subjects had inactive disease, with mean disease duration of 3.2 years (± 2.1). The prevalence of non-dipping was 50%, which occurred even in the absence of nocturnal or daytime hypertension. Reduced diastolic BP dipping was associated with poorer endothelial function (r 0.5, p = 0.04). Intima-media thickness was significantly greater in subjects with non-dipping (mean standard deviation score of 3.0 vs 1.6, p = 0.02). In contrast, higher systolic and diastolic BP load were associated with increased aortic stiffness (ρ 0.6, p = 0.01 and ρ 0.7, p < 0.01, respectively), but not with endothelial function or intima-media thickness. Conclusion In a pSLE cohort with low disease activity, isolated nocturnal BP non-dipping is prevalent and associated with endothelial dysfunction and atherosclerotic changes. In addition to hypertension assessment, ABPM has a promising role in risk stratification and understanding heterogeneous mechanisms of cardiovascular disease in pSLE.
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Miazgowski T, Taszarek A, Miazgowski B. Visceral fat, cardiometabolic risk factors, and nocturnal blood pressure fall in young adults with primary hypertension. J Clin Hypertens (Greenwich) 2019; 21:1406-1414. [PMID: 31369205 DOI: 10.1111/jch.13639] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/04/2019] [Accepted: 06/21/2019] [Indexed: 01/21/2023]
Abstract
The aims of this study were to assess associations of body fat levels and distribution with metabolic profiles and 24-hour blood pressure in young adults with primary hypertension. Visceral fat (VF) was estimated using dual-energy X-ray absorptiometry. VF was highly significantly associated with a high frequency of overweight/obesity, impaired fasting glucose, increased levels of triglycerides and LDL-cholesterol, and lowered level of HDL-cholesterol. The value of systolic blood pressure (SBP) nocturnal fall was similar between patients receiving RAAS inhibitors, beta-blockers, and calcium channel blockers. In multiple regression, the VF/weight ratio after adjusting for age, gender, total fat, and chronotherapeutic drug delivery was associated with the percentage SBP nocturnal fall (β = -.3108; 95% CI: -0.5923; -0.0980; P = .013). In males, excess VF increased the odds by 2.3 times for non-dipping blood pressure. Our results suggest that in young adult hypertensives, the VF/weight ratio might be associated with non-dipping blood pressure.
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Affiliation(s)
- Tomasz Miazgowski
- Department of Hypertension & Internal Medicine, Pomeranian Medical University, Szczecin, Poland
| | - Aleksandra Taszarek
- Center for Innovation in Medical Education, Pomeranian Medical University, Szczecin, Poland.,Doctoral Study, Pomeranian Medical University, Szczecin, Poland
| | - Bartosz Miazgowski
- Center for Innovation in Medical Education, Pomeranian Medical University, Szczecin, Poland.,Doctoral Study, Pomeranian Medical University, Szczecin, Poland
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The effect of weight loss and weight gain on blood pressure in children and adolescents with obesity. Int J Obes (Lond) 2019; 43:1988-1994. [PMID: 31152153 DOI: 10.1038/s41366-019-0384-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 03/04/2019] [Accepted: 04/19/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Obesity in childhood is a profound risk factor for hypertension, and weight loss has positive effects on blood pressure (BP). However, the expected effect size on BP from weight reduction in children with obesity is insufficiently described. Therefore, the aim was to investigate the association between changes of degree of obesity and BP levels. SUBJECTS This prospective cohort study examined subjects receiving behavioral lifestyle modification treatment who were registered in the Swedish national registry for treatment of childhood obesity (BORIS). A total of 5279 obese subjects (51.3% boys) had repeated BP measurements. The average follow-up time was 32 months. Degree of obesity was expressed as BMI standard deviation score (SDS) and BP as BP SDS. RESULTS The mean age at treatment initiation was 10.3 years. The prevalence of hypertensive BP was 15.3% for systolic and 5.5% for diastolic pressure. Both systolic and diastolic BP SDS decreased when a lower BMI SDS was achieved; systolic BP SDS decreased 0.41 [0.33-0.49] and diastolic BP SDS decreased 0.26 [0.20-0.32] per BMI SDS unit reduction. The impact of BMI SDS reduction on BP SDS was greater in subjects with hypertensive levels at treatment initiation, but behavioral modification was an insufficient treatment for 27% of them. Obesity treatment failure increased the risk of developing hypertensive levels; HR = 1.81 [1.38-2.37] (systolic BP) HR = 3.82 [2.34-6.24] (diastolic BP), per unit increase in BMI SDS. CONCLUSIONS Weight loss is a key factor for hypertension prevention and treatment in children with obesity. However, its limited effect suggests that additional pharmacological antihypertensive treatment more readily should be considered.
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Prevalence and Risk Factors for Arterial Hypertension Development in Childhood Acute Lymphoblastic Leukemia Survivors. J Pediatr Hematol Oncol 2019; 41:175-180. [PMID: 30475300 DOI: 10.1097/mph.0000000000001349] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Childhood acute lymphoblastic leukemia (ALL) survivors are at an increased risk of cardiovascular disease including arterial hypertension (AH). The objectives of this study were to assess the prevalence of AH using 24-hour ambulatory blood pressure monitoring, explore characteristics of AH, and define risk factors for the development of AH in childhood ALL survivors. PATIENTS AND METHODS The study comprised 81 childhood ALL survivors (5 to 25 y of age) after a median follow-up time of 5 years. The control group consisted of 52 healthy children (5 to 17 y of age) without any known severe or chronic medical condition. Ambulatory blood pressure monitoring was performed in all patients and controls. Serum lipids were measured in all patients and controls. RESULTS ALL survivors were more likely to have AH than controls (odds ratio, 2.47; 95% confidence interval, 1.08-5.63; P=0.0315). The mean time from ALL diagnosis until diagnosis of AH was 5.1±2.97 years. Day-time diastolic SDS and day-time mean arterial pressure SDS were significantly higher in ALL cohort compared with the controls (-0.3±1.43 vs. -0.76±0.95; P=0.04 and 1.44±1.64 vs. 0.92±1.03; P=0.047). Childhood ALL survivors with AH were more likely to be systolic extreme dippers and reverse systolic/diastolic dippers compared with those with normal blood pressure (P<0.05). There was no association of AH with leukemia subtype, leukemia risk group, sex, central nervous system irradiation, and obesity. CONCLUSIONS The prevalence of AH in childhood ALL survivors may be as high as 37%. We recommend regular monitoring of blood pressure in childhood ALL survivors early in the follow-up.
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Wühl E. Hypertension in childhood obesity. Acta Paediatr 2019; 108:37-43. [PMID: 30144170 DOI: 10.1111/apa.14551] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 06/23/2018] [Accepted: 08/21/2018] [Indexed: 01/09/2023]
Abstract
AIM The prevalence of childhood hypertension is rising in parallel with global increases in the prevalence of overweight and obesity. We looked at key papers and documents covering three decades. METHODS This mini review examined a wide range of material published in English, with the main focus on 1993-2018, including clinical trials, meta-analyses, guidelines and data produced by the World Health Organization and the World Obesity Federation. RESULTS The literature showed that body weight and blood pressure are closely correlated and obesity-related hypertension contributes further to the clustering of cardiovascular risk factors in obesity. Because the duration of hypertension affects the risk of end-organ damage, timely diagnosis and initiation of treatment are important. First-line interventions should aim for blood pressure control and weight reduction. However, lifestyle modifications are often not successful with regard to attaining and maintaining long-term blood pressure and weight control, despite a multidisciplinary approach. Antihypertensive treatment is recommended for all hypertensive children with failure of nonpharmacological treatment, diabetes, secondary hypertension, stage 2 hypertension or target organ damage. CONCLUSION We found that obesity-related hypertension was associated with a significantly increased cardiovascular morbidity and mortality, and early diagnosis and treatment for blood pressure control and weight reduction is essential.
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Affiliation(s)
- Elke Wühl
- Center for Child and Adolescent Medicine Heidelberg University Hospital Heidelberg Germany
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12
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Grisaru S, Yue M, Samuel SM, Chaput KH, Hamiwka LA. Blood pressure in children with attention deficit/hyperactivity disorder. Paediatr Child Health 2018; 23:e102-e108. [PMID: 30455580 DOI: 10.1093/pch/pxx207] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objectives Children with attention deficit/hyperactivity disorder (ADHD) are frequently treated with psycho-stimulant agents causing a modest but significant increase in blood pressure and heart rate. The objective of this study was to define blood pressure characteristics in children with ADHD treated with a variety of medications in a community setup. Methods Children registered at a large paediatric clinic in Calgary, AB with documented histories of ADHD were randomly contacted. Consenting participants had standardized office BP measurements, ambulatory blood pressure monitoring (ABPM) studies and were asked to complete the sleep disturbance scale for children (SDSC) questionnaire. Findings were compared with data from the Canadian Health Measures Survey (CMHS). Results Fifty-five children (47 males) aged 7 to 17 years (average 11.6 ± 2.5 years) with an average BMI z-score of -0.37 ± 1.22 completed the study. All children were medicated, the majority (82%), with various types of stimulant agents. Elevated office BP values were more prevalent than in the CMHS; >90th percentile in 5 (9.1%) and >95th percentile in 3 (5.5%). ABPM confirmed 'white coat hypertension' in 3 (5.5%), masked hypertension in 2 (3.6%) and nondipping in 28 (51%). The SDSC score suggested that 43 (78%) children had disturbed sleep. Logistic regression modelling indicated that nondipping correlated with disturbed sleep. Conclusion The 'white coat' phenomenon may be responsible for increased prevalence of elevated rest/office BP values in children with ADHD. Prevalent sleep 'non-dipping' in this population is associated with sleep disturbances but clinical significance of this finding requires further investigation.
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Affiliation(s)
- Silviu Grisaru
- Department of Pediatrics, Cumming Section of Medicine, University of Calgary, Calgary, Alberta
| | - Melissa Yue
- Werklund School of Education, University of Calgary, Calgary, Alberta
| | - Susan M Samuel
- Department of Pediatrics, Cumming Section of Medicine, University of Calgary, Calgary, Alberta
| | - Kathleen H Chaput
- Departments of Pediatrics and Community Health Sciences, University of Calgary, Calgary, Alberta
| | - Lorraine A Hamiwka
- Department of Pediatrics, Cumming Section of Medicine, University of Calgary, Calgary, Alberta
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13
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Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics 2017; 140:peds.2017-1904. [PMID: 28827377 DOI: 10.1542/peds.2017-1904] [Citation(s) in RCA: 1839] [Impact Index Per Article: 262.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
These pediatric hypertension guidelines are an update to the 2004 "Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents." Significant changes in these guidelines include (1) the replacement of the term "prehypertension" with the term "elevated blood pressure," (2) new normative pediatric blood pressure (BP) tables based on normal-weight children, (3) a simplified screening table for identifying BPs needing further evaluation, (4) a simplified BP classification in adolescents ≥13 years of age that aligns with the forthcoming American Heart Association and American College of Cardiology adult BP guidelines, (5) a more limited recommendation to perform screening BP measurements only at preventive care visits, (6) streamlined recommendations on the initial evaluation and management of abnormal BPs, (7) an expanded role for ambulatory BP monitoring in the diagnosis and management of pediatric hypertension, and (8) revised recommendations on when to perform echocardiography in the evaluation of newly diagnosed hypertensive pediatric patients (generally only before medication initiation), along with a revised definition of left ventricular hypertrophy. These guidelines include 30 Key Action Statements and 27 additional recommendations derived from a comprehensive review of almost 15 000 published articles between January 2004 and July 2016. Each Key Action Statement includes level of evidence, benefit-harm relationship, and strength of recommendation. This clinical practice guideline, endorsed by the American Heart Association, is intended to foster a patient- and family-centered approach to care, reduce unnecessary and costly medical interventions, improve patient diagnoses and outcomes, support implementation, and provide direction for future research.
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Affiliation(s)
- Joseph T Flynn
- Dr. Robert O. Hickman Endowed Chair in Pediatric Nephrology, Division of Nephrology, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington;
| | - David C Kaelber
- Departments of Pediatrics, Internal Medicine, Population and Quantitative Health Sciences, Center for Clinical Informatics Research and Education, Case Western Reserve University and MetroHealth System, Cleveland, Ohio
| | - Carissa M Baker-Smith
- Division of Pediatric Cardiology, School of Medicine, University of Maryland, Baltimore, Maryland
| | - Douglas Blowey
- Children's Mercy Hospital, University of Missouri-Kansas City and Children's Mercy Integrated Care Solutions, Kansas City, Missouri
| | - Aaron E Carroll
- Department of Pediatrics, School of Medicine, Indiana University, Bloomington, Indiana
| | - Stephen R Daniels
- Department of Pediatrics, School of Medicine, University of Colorado-Denver and Pediatrician in Chief, Children's Hospital Colorado, Aurora, Colorado
| | - Sarah D de Ferranti
- Director, Preventive Cardiology Clinic, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Janis M Dionne
- Division of Nephrology, Department of Pediatrics, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Bonita Falkner
- Departments of Medicine and Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Susan K Flinn
- Consultant, American Academy of Pediatrics, Washington, District of Columbia
| | - Samuel S Gidding
- Cardiology Division Head, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Celeste Goodwin
- National Pediatric Blood Pressure Awareness Foundation, Prairieville, Louisiana
| | - Michael G Leu
- Departments of Pediatrics and Biomedical Informatics and Medical Education, University of Washington, University of Washington Medicine and Information Technology Services, and Seattle Children's Hospital, Seattle, Washington
| | - Makia E Powers
- Department of Pediatrics, School of Medicine, Morehouse College, Atlanta, Georgia
| | - Corinna Rea
- Associate Director, General Academic Pediatric Fellowship, Staff Physician, Boston's Children's Hospital Primary Care at Longwood, Instructor, Harvard Medical School, Boston, Massachusetts
| | - Joshua Samuels
- Departments of Pediatrics and Internal Medicine, McGovern Medical School, University of Texas, Houston, Texas
| | - Madeline Simasek
- Pediatric Education, University of Pittsburgh Medical Center Shadyside Family Medicine Residency, Clinical Associate Professor of Pediatrics, Children's Hospital of Pittsburgh of University of Pittsburgh Medical Center, and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vidhu V Thaker
- Division of Molecular Genetics, Department of Pediatrics, Columbia University Medical Center, New York, New York; and
| | - Elaine M Urbina
- Preventive Cardiology, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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14
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Lebensburger JD, Cutter GR, Howard TH, Muntner P, Feig DI. Evaluating risk factors for chronic kidney disease in pediatric patients with sickle cell anemia. Pediatr Nephrol 2017; 32:1565-1573. [PMID: 28382567 PMCID: PMC5628098 DOI: 10.1007/s00467-017-3658-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Revised: 03/09/2017] [Accepted: 03/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND Patients with sickle cell anemia (SCA) have an increased prevalence of nephropathy and mortality from chronic kidney disease (CKD). METHODS We evaluated the association of hyperuricemia and nocturnal hypertension with lower estimated glomerular filtration rate (eGFR) using cystatin-C in patients aged 10-21 years with the HbSS or HbSB0 form of the disease during a non-acute clinic visit. eGFR and uric acid measurements were obtained in 83 and 81 participants, respectively, and 24-h ambulatory blood pressure monitoring (ABPM) was performed in 44 participants. Annual testing included vital signs, complete blood count, comprehensive metabolic panel, medications, urine microalbumin/creatinine, and lactate dehydrogenase measurements. Hyperuricemia was defined as a uric acid level of ≥5.5 mg/dL. Nocturnal hypertension was defined as >25% of nocturnal readings at >95th percentile according to norms established by the American Heart Association Statement on ABPM in children and adolescents. RESULTS The mean eGFR was statistically significantly lower in patients with hyperuricemia than in those with normal uric acid levels (143 vs. 161 mL/min/1.73 m2, respectively). Of the 44 participants for whom ABPM data were available, 14 (32%) had systolic nocturnal hypertension and 12 (27%) had diastolic nocturnal hypertension. The mean eGFR was statistically significantly lower in participants with nocturnal systolic and diastolic hypertension than in those with normal nocturnal blood pressure. In a regression model, nocturnal hypertension and hyperuricemia were associated with a lower eGFR. CONCLUSIONS Two risk factors for CKD, i.e., nocturnal hypertension and hyperuricemia, were associated with lower eGFR in older children and adolescent patients with SCA. Long-term studies on their association with progression to CKD in this population are warranted. KEY POINT Nocturnal hypertension and hyperuricemia are established risk factors for nephropathy in other diseases and may play a role in SCA nephropathy.
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Affiliation(s)
- Jeffrey D Lebensburger
- Pediatric Hematology and Oncology, University of Alabama at Birmingham, 1600 7th Ave South, Lowder 512, Birmingham, AL, 35233, USA.
| | - Gary R Cutter
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Thomas H Howard
- Pediatric Hematology and Oncology, University of Alabama at Birmingham, 1600 7th Ave South, Lowder 512, Birmingham, AL, 35233, USA
| | - Paul Muntner
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Daniel I Feig
- Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
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15
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Macumber IR, Weiss NS, Halbach SM, Hanevold CD, Flynn JT. The Association of Pediatric Obesity With Nocturnal Non-Dipping on 24-Hour Ambulatory Blood Pressure Monitoring. Am J Hypertens 2016; 29:647-52. [PMID: 26310663 DOI: 10.1093/ajh/hpv147] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 08/01/2015] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Obesity has been linked with abnormal nocturnal dipping of blood pressure (BP) in adults, which in turn is associated with poor cardiovascular outcomes. There are few data regarding abnormal dipping status in the obese pediatric population. The goal of this study was to further describe the relationship between obesity and non-dipping status on ambulatory blood pressure monitor (ABPM) in children. METHODS We conducted a cross-sectional study using a database of patients aged 5-21 years who had undergone 24-hour ABPM at Seattle Children's Hospital from January 2008 through May 2014. Subjects were grouped by body mass index (BMI) into lean (BMI 15th-85th percentile) and obese (BMI >95th percentile) groups. RESULTS Compared to lean subjects (n = 161), obese subjects (n = 247) had a prevalence ratio (PR) for non-dipping of 2.15, adjusted for race (95% confidence interval (CI) = 1.25-3.42). Increasing severity of obesity was not further associated with nocturnal non-dipping. Nocturnal non-dipping was not associated with left ventricular hypertrophy (PR = 1.01, 95% CI = 0.71-1.44). CONCLUSIONS These results suggest that in children, just as in adults, obesity is related to a relatively decreased dipping in nocturnal BP.
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Affiliation(s)
- Ian R Macumber
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA;
| | - Noel S Weiss
- Department of Epidemiology, University of Washington, Seattle, Washington, USA
| | - Susan M Halbach
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Coral D Hanevold
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Joseph T Flynn
- Division of Nephrology, Seattle Children's Hospital, Seattle, Washington, USA
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16
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Correia-Costa L, Sousa T, Morato M, Cosme D, Afonso J, Moura C, Mota C, Areias JC, Guerra A, Schaefer F, Caldas Afonso A, Barros H, Albino-Teixeira A, Azevedo A. Association of myeloperoxidase levels with cardiometabolic factors and renal function in prepubertal children. Eur J Clin Invest 2016; 46:50-9. [PMID: 26541603 DOI: 10.1111/eci.12564] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 11/01/2015] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Myeloperoxidase (MPO), an enzyme linking obesity and cardiovascular (CV) risk in adults, has rarely been studied in young children and no studies assessed its association with renal function. We sought to explore a possible association between serum MPO levels, obesity, CV risk factors and renal function in prepubertal children. MATERIALS/METHODS Cross-sectional evaluation of 309 children aged 8-9 years (161 normal weight, 148 overweight/obese), members of the birth cohort Generation I (Portugal). Anthropometrics (body mass index (BMI), waist-to-height ratio (WHtR) and % body fat mass (%BFM) by bioelectrical impedance analysis), 24-h ambulatory blood pressure monitoring and pulse wave velocity (PWV) were measured. Insulin resistance was estimated by the HOMA index (considering serum fasting glucose and insulin determinations). Serum MPO levels were assessed by immunoenzymatic assay. RESULTS MPO levels were positively associated with obesity indices (BMI z-score, WHtR and %BFM). Higher MPO levels were associated with higher 24-h and night-time mean arterial pressure, with nondipping and with higher values of insulin resistance. In normal weight children, the endothelial function, as evaluated indirectly by PWV, was an independent predictor of MPO levels. In overweight/obese children, estimated glomerular filtration rate increased significantly across tertiles of MPO (Ptrend = 0·031) and this association held after adjustment for age, sex, neutrophil and monocyte counts and CV risk factors. CONCLUSIONS Our results reinforce the role of MPO as a risk marker in obesity and related CV morbidities in young children. MPO levels associate with the dipping pattern and PWV and, among overweight/obese children, an association exists between MPO and renal function.
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Affiliation(s)
- Liane Correia-Costa
- EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal.,Division of Pediatric Nephrology, Integrated Pediatric Hospital, Centro Hospitalar São João, Porto, Portugal
| | - Teresa Sousa
- Department of Pharmacology and Therapeutics, Faculty of Medicine of University of Porto, Porto, Portugal.,MedInUP - Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
| | - Manuela Morato
- Department of Pharmacology and Therapeutics, Faculty of Medicine of University of Porto, Porto, Portugal.,MedInUP - Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal.,Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy of Porto, REQUIMTE, University of Porto, Porto, Portugal
| | - Dina Cosme
- EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal.,Department of Pharmacology and Therapeutics, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Joana Afonso
- Department of Pharmacology and Therapeutics, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Cláudia Moura
- Division of Pediatric Cardiology, Integrated Pediatric Hospital, Centro Hospitalar São João, Porto, Portugal
| | - Cláudia Mota
- Division of Pediatric Cardiology, Integrated Pediatric Hospital, Centro Hospitalar São João, Porto, Portugal
| | - José Carlos Areias
- Division of Pediatric Cardiology, Integrated Pediatric Hospital, Centro Hospitalar São João, Porto, Portugal
| | - António Guerra
- Division of Pediatric Nutrition, Integrated Pediatric Hospital, Centro Hospitalar São João, Porto, Portugal
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Alberto Caldas Afonso
- EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal.,Division of Pediatric Nephrology, Integrated Pediatric Hospital, Centro Hospitalar São João, Porto, Portugal
| | - Henrique Barros
- EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal.,Department of Clinical Epidemiology, Predictive Medicine and Public Health, Faculty of Medicine of University of Porto, Porto, Portugal
| | - António Albino-Teixeira
- Department of Pharmacology and Therapeutics, Faculty of Medicine of University of Porto, Porto, Portugal.,MedInUP - Center for Drug Discovery and Innovative Medicines, University of Porto, Porto, Portugal
| | - Ana Azevedo
- EPIUnit - Institute of Public Health, University of Porto, Porto, Portugal.,Department of Clinical Epidemiology, Predictive Medicine and Public Health, Faculty of Medicine of University of Porto, Porto, Portugal
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17
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Nishimoto M, Fujita T. Renal mechanisms of salt-sensitive hypertension: contribution of two steroid receptor-associated pathways. Am J Physiol Renal Physiol 2015; 308:F377-87. [DOI: 10.1152/ajprenal.00477.2013] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Although salt is a major environmental factor in the development of hypertension, the degree of salt sensitivity varies widely among individuals. The mechanisms responsible for this variation remain to be elucidated. Recent studies have revealed the involvement of two important signaling pathways in renal tubules that play key roles in electrolyte balance and the maintenance of normal blood pressure: the β2-adrenergic stimulant-glucocorticoid receptor (GR)-with-no-lysine kinase (WNK)4-Na+-Cl− cotransporter pathway, which is active in distal convoluted tubule (DCT)1, and the Ras-related C3 botulinum toxin substrate (Rac)1-mineralocorticoid receptor (MR) pathway, which is active in DCT2, connecting tubules, and collecting ducts. β2-Adrenergic stimulation due to increased renal sympathetic activity in obesity- and salt-induced hypertension suppresses histone deacetylase 8 activity via cAMP/PKA signaling, increasing the accessibility of GRs to the negative GR response element in the WNK4 promoter. This results in the suppression of WNK4 transcription followed by the activation of Na+-Cl− cotransporters in the DCT and elevated Na+ retention and blood pressure upon salt loading. Rac1 activates MRs, even in the absence of ligand binding, with this activity increased in the presence of ligand. In salt-sensitive animals, Rac1 activation due to salt loading activates MRs in DCT2, connecting tubules, and collecting ducts. Thus, GRs and MRs are independently involved in two pathways responsible for renal Na+ handling and salt-sensitive hypertension. These findings suggest novel therapeutic targets and may lead to the development of diagnostic tools to determine salt sensitivity in hypertensive patients.
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Affiliation(s)
- Mitsuhiro Nishimoto
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
| | - Toshiro Fujita
- Division of Clinical Epigenetics, Research Center for Advanced Science and Technology, The University of Tokyo, Tokyo, Japan
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