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Chung J, Robinson C, Sheffield L, Paramanathan P, Yu A, Ewusie J, Sanger S, Mitsnefes M, Parekh RS, Sinha MD, Rodrigues M, Thabane L, Dionne J, Chanchlani R. Prevalence of Pediatric Masked Hypertension and Risk of Subclinical Cardiovascular Outcomes: A Systematic Review and Meta-Analysis. Hypertension 2023; 80:2280-2292. [PMID: 37737026 DOI: 10.1161/hypertensionaha.123.20967] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Masked hypertension (MH) occurs when office blood pressure is normal, but hypertension is confirmed using out-of-office blood pressure measures. Hypertension is a risk factor for subclinical cardiovascular outcomes, including left ventricular hypertrophy, increased left ventricular mass index, carotid intima media thickness, and pulse wave velocity. However, the risk factors for ambulatory blood pressure monitoring defined MH and its association with subclinical cardiovascular outcomes are unclear. A systematic literature search on 9 databases included English publications from 1974 to 2023. Pediatric MH prevalence was stratified by disease comorbidities and compared with the general pediatric population. We also compared the prevalence of left ventricular hypertrophy, and mean differences in left ventricular mass index, carotid intima media thickness, and pulse wave velocity between MH versus normotensive pediatric patients. Of 2199 screened studies, 136 studies (n=28 612; ages 4-25 years) were included. The prevalence of MH in the general pediatric population was 10.4% (95% CI, 8.00-12.80). Compared with the general pediatric population, the risk ratio (RR) of MH was significantly greater in children with coarctation of the aorta (RR, 1.91), solid-organ or stem-cell transplant (RR, 2.34), chronic kidney disease (RR, 2.44), and sickle cell disease (RR, 1.33). MH patients had increased risk of subclinical cardiovascular outcomes compared with normotensive patients, including higher left ventricular mass index (mean difference, 3.86 g/m2.7 [95% CI, 2.51-5.22]), left ventricular hypertrophy (odds ratio, 2.44 [95% CI, 1.50-3.96]), and higher pulse wave velocity (mean difference, 0.30 m/s [95% CI, 0.14-0.45]). The prevalence of MH is significantly elevated among children with various comorbidities. Children with MH have evidence of subclinical cardiovascular outcomes, which increases their risk of long-term cardiovascular disease.
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Affiliation(s)
- Jason Chung
- Temerty Faculty of Medicine, University of Toronto, Ontario, Canada (J.C.)
| | - Cal Robinson
- Department of Pediatrics, Division of Nephrology, The Hospital for Sick Children, Toronto, Ontario, Canada (C.R.)
| | - Lauren Sheffield
- Faculty of Sciences, McMaster University, Hamilton, Ontario, Canada (L.S.)
| | - Prathayini Paramanathan
- All Saints University College of Medicine, Kingstown, Saint Vincent and the Grenadines (P.P.)
| | - Andrew Yu
- Faculty of Science, University of Alberta, Edmonton, Canada (A.Y.)
| | - Joycelyne Ewusie
- Department of Health Research Methods, Evidence, and Impact, Research Institute - St Joseph's Healthcare Hamilton, McMaster University, Ontario, Canada (J.E., L.T.)
| | - Stephanie Sanger
- Department of Health Sciences: Health Science Library, McMaster University, Hamilton, Ontario, Canada (S.S.)
| | - Mark Mitsnefes
- Department of Pediatrics, Division of Nephrology, Cincinnati Children's Hospital Medical Center, OH (M.M.)
| | - Rulan S Parekh
- Department of Pediatrics and Medicine, Division of Nephrology, The Hospital for Sick Children, University Health Network and University of Toronto, Ontario, Canada (R.S.P.)
| | - Manish D Sinha
- Department of Paediatric Nephrology, King's College London, Evelina London Childrens Hospital, United Kingdom (M.D.S.)
| | - Myanca Rodrigues
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (M.R.)
| | - Lehana Thabane
- Department of Health Research Methods, Evidence, and Impact, Research Institute - St Joseph's Healthcare Hamilton, McMaster University, Ontario, Canada (J.E., L.T.)
- University of Johannesburg Faculty of Health Sciences, South Africa (L.T.)
| | - Janis Dionne
- Department of Pediatrics, Division of Nephrology, University of British Columbia, Vancouver, Canada (J.D.)
| | - Rahul Chanchlani
- Department of Pediatrics, Division of Pediatric Nephrology, McMaster Children's Hospital, McMaster University, Hamilton, Canada (R.C.)
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Seeman T, Šuláková T, Stabouli S. Masked Hypertension in Healthy Children and Adolescents: Who Should Be Screened? Curr Hypertens Rep 2023; 25:231-242. [PMID: 37639176 PMCID: PMC10491704 DOI: 10.1007/s11906-023-01260-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 08/29/2023]
Abstract
PURPOSE OF REVIEW The goal is to review masked hypertension (MH) as a relatively new phenomenon when patients have normal office BP but elevated out-of-office BP. Firstly, it was described in children in 2004. It has received increased attention in the past decade. RECENT FINDINGS The prevalence of MH in different pediatric populations differs widely between 0 and 60% based on the population studied, definition of MH, or method of out-of-office BP measurement. The highest prevalence of MH has been demonstrated in children with chronic kidney disease (CKD), obesity, diabetes, and after heart transplantation. In healthy children but with risk factors for hypertension such as prematurity, overweight/obesity, diabetes, chronic kidney disease, or positive family history of hypertension, the prevalence of MH is 9%. In healthy children without risk factors for hypertension, the prevalence of MH is very low ranging 0-3%. In healthy children, only patients with the following clinical conditions should be screened for MH: high-normal/elevated office BP, positive family history of hypertension, and those referred for suspected hypertension who have normal office BP in the secondary/tertiary center.
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Affiliation(s)
- Tomáš Seeman
- Department of Pediatrics, Charles University Prague, 2nd Medical Faculty, V Úvalu 84, 15006, Prague, Czech Republic.
- Department of Pediatrics, University Hospital Ostrava, Ostrava, Czech Republic.
| | - Terezie Šuláková
- Department of Pediatrics, University Hospital Ostrava, Ostrava, Czech Republic
- Department of Pediatrics, Medical Faculty, University of Ostrava, Ostrava, Czech Republic
| | - Stella Stabouli
- 1st Department of Pediatrics, School of Medicine, Faculty of Health Sciences, Aristotle University Thessaloniki, Hippokratio Hospital, Thessaloniki, Greece
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Bansal N, Raedi WA, Medar SS, Abraham L, Beddows K, Hsu DT, Lamour JM, Mahgerefteh J. Masked Hypertension in Pediatric Heart Transplant Recipients. Pediatr Cardiol 2023; 44:1003-1008. [PMID: 36656319 DOI: 10.1007/s00246-023-03096-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 01/10/2023] [Indexed: 01/20/2023]
Abstract
BACKGROUND Masked hypertension (HTN), especially, isolated nocturnal HTN (INH) has been shown to be a risk factor for cardiovascular disease (CVD) but is not studied well in pediatric heart transplant (PHT) patients. Ambulatory blood pressure monitoring (ABPM) is known to identify patients with HTN but is not used routinely in PHT. METHODS A single-center, prospective, cross-sectional study of PHT recipients was performed to observe the incidence of masked HTN using 24-h ABPM. The relationship between ABPM parameters and clinical variables was assessed using Spearman correlation coefficient. p value < 0.05 was considered significant. RESULTS ABPM was performed in 34 patients, mean age 14 ± 5 years, median 5.5 years post-PHT. All patients had normal cardiac function, left ventricular mass index and blood pressure measurements in the clinic. Four patients had known prior HTN and on medications, one of them was uncontrolled. Of the remaining 30 patients, 18 new patients were diagnosed with masked HTN, of which 14 had INH. Diurnal variation was abnormal in 82% (28/34) patients. 24-h diastolic blood pressure (DBP) index correlated with glomerular filtration rate (GFR) (r = - 0.44, p = 0.01). There was no correlation between other ABPM parameters with tacrolimus trough levels. CONCLUSIONS ABPM identified masked HTN in 60% of patients, with majority being INH. Abnormal circadian BP patterns were present in 82% and an association was found between GFR and DBP parameters. HTN, especially INH, is under-recognized in PHT recipients and ABPM has a role in their long-term care.
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Affiliation(s)
- Neha Bansal
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave- R1, Bronx, NY, 10467, USA.
| | - Waheed A Raedi
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave- R1, Bronx, NY, 10467, USA
| | - Shivanand S Medar
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave- R1, Bronx, NY, 10467, USA.,Division of Pediatric Critical Care Medicine, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Lincy Abraham
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave- R1, Bronx, NY, 10467, USA
| | - Kimberly Beddows
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave- R1, Bronx, NY, 10467, USA
| | - Daphne T Hsu
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave- R1, Bronx, NY, 10467, USA
| | - Jacqueline M Lamour
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave- R1, Bronx, NY, 10467, USA
| | - Joseph Mahgerefteh
- Division of Pediatric Cardiology, Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Ave- R1, Bronx, NY, 10467, USA
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Flynn JT, Urbina EM, Brady TM, Baker-Smith C, Daniels SR, Hayman LL, Mitsnefes M, Tran A, Zachariah JP. Ambulatory Blood Pressure Monitoring in Children and Adolescents: 2022 Update: A Scientific Statement From the American Heart Association. Hypertension 2022; 79:e114-e124. [PMID: 35603599 DOI: 10.1161/hyp.0000000000000215] [Citation(s) in RCA: 32] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Use of ambulatory blood pressure monitoring in children and adolescents has markedly increased since publication of the last American Heart Association scientific statement on pediatric ambulatory blood pressure monitoring in 2014. In addition, there has also been significant expansion of the evidence base for use of ambulatory blood pressure monitoring in the pediatric population, including new data linking ambulatory blood pressure levels with the development of blood pressure-related target organ damage. Last, additional data have recently been published that enable simplification of the classification of pediatric ambulatory monitoring studies. This scientific statement presents a succinct review of this new evidence, guidance on optimal application of ambulatory blood pressure monitoring in the clinical setting, and an updated classification scheme for the interpretation of ambulatory blood pressure monitoring in children and adolescents. We also highlight areas of uncertainty where additional research is needed.
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Végh A, Bárczi A, Cseprekál O, Kis É, Kelen K, Török S, Szabó AJ, Reusz GS. Follow-Up of Blood Pressure, Arterial Stiffness, and GFR in Pediatric Kidney Transplant Recipients. Front Med (Lausanne) 2021; 8:800580. [PMID: 34977101 PMCID: PMC8716619 DOI: 10.3389/fmed.2021.800580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 11/18/2021] [Indexed: 11/17/2022] Open
Abstract
Pediatric renal transplant recipients (RTx) were studied for longitudinal changes in blood pressure (BP), arterial stiffness by pulse wave velocity (PWV), and graft function. Patients and Methods: 52 RTx patients (22 males) were included; office BP (OBP) and 24 h BP monitoring (ABPM) as well as PWV were assessed together with glycemic and lipid parameters and glomerular filtration rate (GFR) at 2.4[1.0–4.7] (T1) and 9.3[6.3–11.8] years (T2) after transplantation (median [range]). Results: Hypertension was present in 67 and 75% of patients at T1 and T2, respectively. Controlled hypertension was documented in 37 and 44% by OBP and 40 and 43% by ABPM. Nocturnal hypertension was present in 35 and 30% at T1 and T2; 24 and 32% of the patients had masked hypertension, while white coat hypertension was present in 16 and 21% at T1 and T2, respectively. Blood pressure by ABPM correlated significantly with GFR and PWV at T2, while PWV also correlated significantly with T2 cholesterol levels. Patients with uncontrolled hypertension by ABPM had a significant decrease in GFR, although not significant with OBP. Anemia and increased HOMAi were present in ~20% of patients at T1 and T2. Conclusion: Pediatric RTx patients harbor risk factors that may affect their cardiovascular health. While we were unable to predict the evolution of renal function based on PWV and ABPM at T1, these risk factors correlated closely with GFR at follow-up suggesting that control of hypertension may have an impact on the evolution of GFR.
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Affiliation(s)
- Anna Végh
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - Adrienn Bárczi
- Medical Imaging Centre Semmelweis University, Budapest, Hungary
| | - Orsolya Cseprekál
- Department of Transplantation and Surgery Semmelweis University, Budapest, Hungary
| | - Éva Kis
- Gottsegen National Cardiovascular Center, Budapest, Hungary
| | - Kata Kelen
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - Szilárd Török
- Department of Transplantation and Surgery Semmelweis University, Budapest, Hungary
| | - Attila J. Szabó
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
| | - György S. Reusz
- First Department of Pediatrics Semmelweis University, Budapest, Hungary
- *Correspondence: György S. Reusz
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Evaluation of arterial hypertension by ambulatory blood pressure monitoring in pediatric liver transplant recipients. Blood Press Monit 2021; 27:39-42. [PMID: 34267073 DOI: 10.1097/mbp.0000000000000563] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Many cardiovascular complications, including hypertension, are seen in pediatric liver transplantation. The purpose of this study was to analyze the frequency of arterial hypertension of pediatric liver transplant recipients and also to determine the related risk factors. METHODS Thirty-six pediatric liver transplant recipients aged 8-17 years were prospectively studied by manual and ambulatory blood pressure measurement (ABPM) technique. RESULTS The mean age of patients was 12.42 ± 2.74 years and the mean ABPM measurement time after transplantation was 2 years (3 months-5.9 years). Only one (2.7%) patient was detected as hypertensive by casual measurement, but 17 (47.2%) patients were found to be hypertensive when measured through ABPM. Of children that were found to be hypertensive as a result of ABPM, 64.7% were observed to have a nondipper pattern. Considering the time passed after the transplantation, patients were found to be more hypertensive in the first 2 years posttransplant although it was not found statistically significant. CONCLUSIONS In this study, it has been shown that it is possible to diagnose hypertension at an earlier period of transplantation using ABPM in pediatric liver transplant patients. ABPM is needed to detect masked hypertension that may develop following liver transplantation.
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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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Charnaya O, Seifert M. Promoting cardiovascular health post-transplant through early diagnosis and adequate management of hypertension and dyslipidemia. Pediatr Transplant 2021; 25:e13811. [PMID: 32871051 DOI: 10.1111/petr.13811] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/18/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
Despite correction of underlying solid organ failure by transplantation, pediatric transplant recipients still have increased mortality rates compared to the general pediatric population, in part due to increased cardiovascular risk. In particular, pediatric kidney and non-kidney transplant recipients with chronic kidney disease have significant cardiovascular risk that worsens with declining kidney function. Biomarkers associated with future cardiovascular risk such as casual and ambulatory hypertension, dyslipidemia, vascular stiffness and calcification, and left ventricular hypertrophy can be detected throughout the post-transplant period and in patients with stable kidney function. Among these, hypertension and dyslipidemia are two potentially modifiable cardiovascular risk factors that are highly prevalent in kidney and non-kidney pediatric transplant recipients. Standardized approaches to appropriate BP measurement and lipid monitoring are needed to detect and address these risk factors in a timely fashion. To achieve sustained improvement in cardiovascular health, clinicians should partner with patients and their caregivers to address these and other risk factors with a combined approach that integrates pharmacologic with non-pharmacologic approaches. This review outlines the scope and impact of hypertension and dyslipidemia in pediatric transplant recipients, with a particular focus on pediatric kidney transplantation given the high burden of chronic kidney disease-associated cardiovascular risk. We also review the current published guidelines for monitoring and managing abnormalities in blood pressure and lipids, highlighting the important role of therapeutic lifestyle changes in concert with antihypertensive and lipid-lowering medications.
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Affiliation(s)
- Olga Charnaya
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Seifert
- Department of Pediatrics, University of Alabama School of Medicine, Birmingham, AL, USA
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Practical application of ABPM in the pediatric nephrology clinic. Pediatr Nephrol 2020; 35:2067-2076. [PMID: 31732802 DOI: 10.1007/s00467-019-04361-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Revised: 08/07/2019] [Accepted: 09/06/2019] [Indexed: 12/26/2022]
Abstract
The use of 24-h ABPM has become commonplace when diagnosing and managing hypertension in the pediatric population. Multiple clinical guidelines recommend ABPM as the preferred method for identifying white-coat hypertension, masked hypertension, and determining degree of blood pressure (BP) control. Accurate, timely diagnosis and optimal management are particularly important in certain populations, such as children with chronic kidney disease (CKD), diabetes, and other conditions with increased risk for cardiovascular disease. Understanding how best to utilize ABPM to achieve these goals is important for pediatric nephrologists and other hypertension specialists. This review will provide practical information on the equipment, application, interpretation, and documentation of ABPM in the specialty clinic.
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10
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Pais P, Dello Strologo L, Iyengar A, Velusamy V, Greenbaum LA. Nocturnal hypertension and left ventricular hypertrophy in pediatric renal transplant recipients in South India. Pediatr Transplant 2020; 24:e13710. [PMID: 32320120 DOI: 10.1111/petr.13710] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
HTN after renal transplantation is associated with cardiovascular morbidity. ABPM allows diagnosis of masked HTN and isolated nocturnal HTN. Longitudinal ABPM data in children post-transplant are limited. ABPM was performed in children post-transplant and repeated in 6-12 months. BP indices were used to determine the prevalence of masked HTN, masked uncontrolled HTN (masked HTN in patients on antihypertensive medications), and isolated nocturnal HTN. Linear regression determined the association between LVMI and ABPM indices. Thirty children underwent a baseline ABPM. Ambulatory HTN was present in 25 (83%). Masked HTN was present in 18 (60%) and isolated nocturnal HTN in 13 (43%). Nocturnal ambulatory BP was higher than corresponding daytime BPs (P < .001 for systolic and diastolic) and 25 (83%) had a blunted nocturnal dip. Prednisone dose predicted nocturnal DBP index and DBP load (r2 = .40, P = .024 and r2 = .178, P = .02). ABPM was repeated in 18 patients within 11 (±3) months. BP indices decreased with time, but nocturnal BPs remained higher than daytime (P < .001 for SBP and DBP). Blunted nocturnal dip did not improve. LVH was present in 12 (57%). LVMI was directly related to the nocturnal SBP index (r2 = .377, P = .003) and nocturnal DBP index (r2 = .493, P < .001). We found no association between LVMI and daytime BP indices. The prevalence of masked HTN, isolated nocturnal HTN, and blunted nocturnal dip was high in children with kidney transplants. Nocturnal BP predicted LVMI. Ambulatory BP improved on longitudinal follow-up, but the pattern of isolated nocturnal HTN persisted.
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Affiliation(s)
- Priya Pais
- Department of Pediatric Nephrology, St John's Medical College Hospital, St John's National Academy of Health Sciences, Bangalore, India
| | - Luca Dello Strologo
- Pediatric Nephrology and Renal Transplant Unit, Bambino Gesù Children's Hospital-IRCCS, Rome, Italy
| | - Arpana Iyengar
- Department of Pediatric Nephrology, St John's Medical College Hospital, St John's National Academy of Health Sciences, Bangalore, India
| | - Vasanthakumar Velusamy
- Division of Clinical Research and Training, St John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
| | - Larry A Greenbaum
- Division of Pediatric Nephrology, Emory University and Children's Healthcare of Atlanta, Atlanta, GA, USA
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11
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Oreschak K, Wolfel EE, Saba LM, Ambardekar AV, Lindenfeld J, Aquilante CL. Relationship between nocturnal blood pressure patterns and end organ damage and diastolic dysfunction in heart transplant recipients. Clin Transplant 2020; 34:e13842. [PMID: 32090364 DOI: 10.1111/ctr.13842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 02/09/2020] [Accepted: 02/20/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND We assessed the relationship between circadian blood pressure (BP) patterns and clinical outcomes in a contemporary cohort of adult heart transplant recipients. METHODS This retrospective, cross-sectional study included adult heart transplant recipients at least 6 months post-transplant. Ambulatory BP measurements were recorded over 24 hours. Nondippers were defined as a decline in average nighttime BP ≤ 10% compared with daytime. Primary outcomes were the presence of end organ damage, that is, microalbuminuria, chronic kidney disease, and/or left ventricular hypertrophy. Secondary outcomes were measures of diastolic dysfunction (ie, mitral valve deceleration time, e/e', E/A, and isovolumetric relaxation time), microalbumin/creatinine ratio, eGFR, interventricular septal thickness, and left ventricular posterior wall thickness. RESULTS Of 30 patients, 53.3% (n = 16) were systolic nondippers and 40% (n = 12) were diastolic nondippers. Diastolic nondippers had three times higher urine microalbumin/creatinine ratios than diastolic dippers (P = .03). Systolic nondippers had 16.3% lower mitral valve deceleration time (P = .05) than systolic dippers, while diastolic nondippers had 20.4% higher e/e' (P = .05) than diastolic dippers. There were no significant relationships between BP dipping status and any of the primary outcomes. CONCLUSIONS These data suggest that systolic and diastolic nondipping BP patterns are associated with subclinical kidney damage and diastolic dysfunction in heart transplant recipients.
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Affiliation(s)
- Kris Oreschak
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Eugene E Wolfel
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Laura M Saba
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
| | - Amrut V Ambardekar
- Division of Cardiology, University of Colorado School of Medicine, Aurora, CO, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christina L Aquilante
- Department of Pharmaceutical Sciences, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, CO, USA
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12
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Abstract
PURPOSE OF REVIEW This is a review of ambulatory blood pressure monitoring (ABPM) use in pediatrics, summarizing current knowledge and uses of ABPM. RECENT FINDINGS Updated guidelines from the American Academy of Pediatrics have emphasized the value of ABPM. ABPM is necessary to diagnose white coat hypertension, masked hypertension, and nocturnal hypertension associated with specific conditions. There is growing evidence that ABPM may be useful in these populations. ABPM has been demonstrated to be more predictive of end-organ damage in pediatric hypertension compared to office blood pressure. ABPM is an important tool in the diagnosis and management of pediatric hypertension. Routine use of ABPM could potentially prevent early cardiovascular morbidity and mortality in a wide variety of populations.
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Affiliation(s)
- Sonali S Patel
- Department of Pediatrics, Section of Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO, 80045, USA.
| | - Stephen R Daniels
- Department of Pediatrics, Section of Cardiology, Children's Hospital Colorado, University of Colorado School of Medicine, 13123 E 16th Ave, Aurora, CO, 80045, USA
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13
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Severova-Andreevska G, Danilovska I, Sikole A, Popov Z, Ivanovski N. Hypertension after Kidney Transplantation: Clinical Significance and Therapeutical Aspects. Open Access Maced J Med Sci 2019; 7:1241-1245. [PMID: 31049114 PMCID: PMC6490475 DOI: 10.3889/oamjms.2019.264] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2019] [Revised: 04/02/2019] [Accepted: 04/03/2019] [Indexed: 12/14/2022] Open
Abstract
Most of the kidney transplanted patients develop arterial hypertension after renal transplantation. Together with very well-known and usual risk factors, post-transplant hypertension contributes to the whole cardiovascular morbidity and mortality in the kidney transplant population. The reasons of post-transplant hypertension are factors related to donors and recipients, immunosuppressive therapy like Calcineurin Inhibitors (CNI) and surgery procedures (stenosis and kinking of the renal artery and ureteral obstruction). According to Eighth National Committee (JNC 8) recommendations, blood pressure > 140/90 mmHg is considered as hypertension. The usual antihypertensive drugs used for the control of hypertension are Calcium channel blockers (CCB), Angiotensin-converting enzyme (ACE) inhibitors, Angiotensin -II receptor blockers (ARB), B- blockers and diuretics. Follow the KDIGO guidelines the target blood pressure < 140/90 mmHg for patients without proteinuria and < 125/75 mmHg in patients with proteinuria is recommended. Better control of post-transplant hypertension improves the long-term graft and patient's survival.
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Affiliation(s)
- Galina Severova-Andreevska
- University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Ilina Danilovska
- University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Aleksandar Sikole
- University Clinic of Nephrology, Medical Faculty, Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
| | - Zivko Popov
- Macedonian Academy for Science and Arts, Skopje, Republic of Macedonia
- Zan Mitrev Clinic, Skopje, Republic of Macedonia
| | - Ninoslav Ivanovski
- Zan Mitrev Clinic, Skopje, Republic of Macedonia
- Ss Cyril and Methodius University of Skopje, Skopje, Republic of Macedonia
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14
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Steroid withdrawal improves blood pressure control and nocturnal dipping in pediatric renal transplant recipients: analysis of a prospective, randomized, controlled trial. Pediatr Nephrol 2019; 34:341-348. [PMID: 30178240 DOI: 10.1007/s00467-018-4069-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Variable effects of steroid minimization strategies on blood pressure in pediatric renal transplant recipients have been reported, but data on the effect of steroid withdrawal on ambulatory blood pressure and circadian blood pressure rhythm have not been published so far. METHODS In a prospective, randomized, multicenter study on steroid withdrawal in pediatric renal transplant recipients (n = 42) on cyclosporine, mycophenolate mofetil, and methylprednisolone, we performed a substudy in 28 patients, aged 11.2 ± 3.8 years, for whom ambulatory blood pressure monitoring (ABPM) data were available. RESULTS In the steroid-withdrawal group, the percentage of patients with arterial hypertension, defined as systolic and/or diastolic blood pressure values recorded by ABPM > 1.64 SDS and/or antihypertensive medication, at month 15 was significantly lower (35.7%, p = 0.002) than in controls (92.9%). The need of antihypertensive medication dropped significantly by 61.2% (p < 0.000 vs. control), while in controls, it even rose by 69.3%. One year after steroid withdrawal, no patient exhibited hypertensive blood pressure values above the 95th percentile, compared to 35.7% at baseline (p = 0.014) and to 14.3% of control (p = 0.142). The beneficial impact of steroid withdrawal was especially pronounced for nocturnal blood pressure, leading to a recovered circadian rhythm in 71.4% of patients vs. 14.3% at baseline (p = 0.002), while the percentage of controls with an abnormal circadian rhythm (35.7%) did not change. CONCLUSIONS Steroid withdrawal in pediatric renal transplant recipients with well-preserved allograft function is associated with less arterial hypertension recorded by ABPM and recovery of circadian blood pressure rhythm by restoration of nocturnal blood pressure dipping.
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Krmar RT, Ferraris JR. Clinical value of ambulatory blood pressure in pediatric patients after renal transplantation. Pediatr Nephrol 2018; 33:1327-1336. [PMID: 28842790 PMCID: PMC6019432 DOI: 10.1007/s00467-017-3781-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/27/2017] [Accepted: 07/31/2017] [Indexed: 12/19/2022]
Abstract
Hypertension is a highly prevalent co-morbidity in pediatric kidney transplant recipients. Undertreated hypertension is associated with cardiovascular complications and negatively impacts renal graft survival. Thus, the accurate measurement of blood pressure is of the utmost importance for the correct diagnosis and subsequent management of post-renal transplant hypertension. Data derived from the general population, and to a lesser extent from the pediatric population, indicates that ambulatory blood pressure monitoring (ABPM) is superior to blood pressure measurements taken in the clinical setting for the evaluation of true mean blood pressure, identification of patients requiring antihypertensive treatment, and in the prediction of cardiovascular outcome. This Educational Review will discuss the clinical value of ABPM in the identification of individual blood pressure phenotypes, i.e., normotension, new-onset hypertension, white-coat hypertension, masked hypertension, controlled blood pressure, and undertreated/uncontrolled hypertension in pediatric kidney transplant recipients. Finally, we examine the utility of performing repeated ABPM for treatment monitoring of post-renal transplant hypertension and on surrogate markers related to relevant clinical cardiovascular outcomes. Taken together, our review highlights the clinical value of the routine use of ABPM as a tool for identifying and monitoring hypertension in pediatric kidney transplant recipients.
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Affiliation(s)
- Rafael T. Krmar
- Department of Physiology and Pharmacology (FYFA), Karolinska Institute, C3, Nanna Svartz Väg 2, 171 77 Stockholm, Sweden
| | - Jorge R. Ferraris
- Departamento de Pediatría, Hospital Italiano de Buenos Aires, Juan D. Perón 4190, C1199ABB C.A.B.A, Código Argentina
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16
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Barletta GM, Pierce C, Mitsnefes M, Samuels J, Warady BA, Furth S, Flynn J. Is Blood Pressure Improving in Children With Chronic Kidney Disease? A Period Analysis. Hypertension 2018; 71:444-450. [PMID: 29295853 PMCID: PMC5812788 DOI: 10.1161/hypertensionaha.117.09649] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Revised: 05/16/2017] [Accepted: 12/05/2017] [Indexed: 12/18/2022]
Abstract
Uncontrolled hypertension in children with chronic kidney disease (CKD) has been identified as one of the main factors contributing to progression of CKD and increased risk for cardiovascular disease. Recent efforts to achieve better blood pressure (BP) control have been recommended. The primary objective of this analysis was to compare BP control over 2 time periods among participants enrolled in the CKiD study (Chronic Kidney Disease in Children). Casual BP and 24-hour ambulatory BP monitor data were compared among 851 participants during 2 time periods: January 1, 2005, through July 1, 2008 (period 1, n=345), and July 1, 2010, through December 31, 2013 (period 2, n=506). Multivariable logistic regression to model the propensity of a visit record being in period 2 as a function of specific predictors was performed. After controlling for confounding variables (age, sex, race, socioeconomics, CKD duration, glomerular filtration rate, proteinuria, body mass index, growth failure, and antihypertensives), no significant differences were detected between time periods with respect to casual BP status (prehypertension: 15% versus 15%; uncontrolled hypertension: 18% versus 17%; P=0.87). Analysis of ambulatory BP monitor data demonstrated higher ambulatory BP indices, most notably masked hypertension in period 2 (36% versus 49%; P<0.001). Average sleep BP index (P<0.05) and sleep BP loads (P<0.05) were higher in period 2. Despite publication of hypertension recommendations and guidelines for BP control in patients with CKD, this study suggests that hypertension remains undertreated and under-recognized in children with CKD. This analysis also underscores the importance of routine ambulatory BP monitor assessment in children with CKD.
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Affiliation(s)
- Gina-Marie Barletta
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.).
| | - Christopher Pierce
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Mark Mitsnefes
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Joshua Samuels
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Bradley A Warady
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Susan Furth
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
| | - Joseph Flynn
- From the Pediatric Kidney Disease and Hypertension Centers, Phoenix, AZ (G.-M.B.); Johns Hopkins University, Baltimore, MD (C.P.); Cincinnati Children's Hospital, OH (M.M.); McGovern Medical School UT Health, Houston, TX (J.S.); Children's Mercy Hospital, Kansas City, MO (B.A.W.); Children's Hospital of Philadelphia, PA (S.F.); and Seattle Children's Hospital, Seattle, WA (J.F.)
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17
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Ambulatory Blood Pressure Monitoring in Children and Adolescents: a Review of Recent Literature and New Guidelines. Curr Hypertens Rep 2017; 19:96. [DOI: 10.1007/s11906-017-0791-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Updated Guideline May Improve the Recognition and Diagnosis of Hypertension in Children and Adolescents; Review of the 2017 AAP Blood Pressure Clinical Practice Guideline. Curr Hypertens Rep 2017; 19:84. [DOI: 10.1007/s11906-017-0780-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Hamdani G, Nehus EJ, Hanevold CD, VanSickle JS, Hooper DK, Blowey D, Warady BA, Mitsnefes MM. Ambulatory Blood Pressure Control in Children and Young Adults After Kidney Transplantation. Am J Hypertens 2017; 30:1039-1046. [PMID: 28575139 DOI: 10.1093/ajh/hpx092] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 05/10/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ambulatory blood pressure (BP) monitoring (ABPM) is the preferred method to characterize BP status, and its use in kidney transplant recipients is increasing. Data on longitudinal ambulatory BP (ABP) trends in pediatric and young adult kidney transplant recipients are limited. METHODS Retrospective review of a large cohort of children and young adults following kidney transplantation and evaluation of their ABP status over time and its associations with any patient and clinical characteristics. RESULTS Two hundred and two patients had baseline ABPM available for analysis, and 123 of them had a follow up (median time 2.3 years) ABPM. At the time of follow up, more patients were treated for hypertension (80% vs. 72%, P = 0.02), and less patients had ambulatory hypertension (36% vs. 54%, P = 0.005), uncontrolled or untreated, compared with baseline, with 45% of all patients classified as having controlled hypertension (compared to 26% at baseline, P = 0.002). Prevalence of ambulatory hypertension decreased only in patients who were less than 18 years old at baseline. High baseline mean 24-hour systolic BP was independently associated with persistent hypertension. CONCLUSIONS In young kidney transplant recipients followed by ABPM, the prevalence of ambulatory hypertension decreases over time, mainly due to the increased number of patients with controlled hypertension.
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Affiliation(s)
- Gilad Hamdani
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Coral D Hanevold
- Division of Pediatric Nephrology, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Judith S VanSickle
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - David K Hooper
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
| | - Doug Blowey
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - Bradley A Warady
- Division of Pediatric Nephrology, Children’s Mercy Hospital, Kansas City, Missouri, USA
| | - Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA
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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: 1912] [Impact Index Per Article: 273.1] [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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21
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Ambulatory Blood Pressure, Left Ventricular Hypertrophy, and Allograft Function in Children and Young Adults After Kidney Transplantation. Transplantation 2017; 101:150-156. [PMID: 26895218 DOI: 10.1097/tp.0000000000001087] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Hypertension is a common complication and is an important risk factor for graft loss and adverse cardiovascular outcomes in pediatric kidney transplantation. Ambulatory blood pressure monitoring (ABPM) is the preferred method to characterize blood pressure status. METHODS We conducted a retrospective review of a large cohort of children and young adults with kidney transplant to estimate the prevalence of abnormal ambulatory blood pressure (ABP), assess factors associated with abnormal ABP, and examine whether ambulatory hypertension is associated with worse allograft function and left ventricular hypertrophy (LVH). RESULTS Two hundred twenty-one patients had ABPM, and 142 patients had echocardiographic results available for analysis. One third of the patients had masked hypertension, 32% had LVH, and 38% had estimated glomerular filtration rate less than 60 mL/min per 1.73 m. African-American race/Hispanic ethnicity and requirement for more than 1 antihypertensive medication were independently associated with having masked hypertension. In a multivariate analysis, abnormal blood pressure (masked or sustained hypertension combined) was an independent predictor for LVH among patients not receiving antihypertensive treatment (P = 0.025). In a separate analysis, the use of antihypertensive medications was independently associated with worse allograft function (P = 0.002) although abnormal blood pressure was not a significant predictor. CONCLUSIONS In young kidney transplant recipients, elevated ABP is frequently unrecognized and undertreated. The high prevalence of abnormal ABP, including masked hypertension, and its association with LVH supports the case for routine ABPM and cardiac structure evaluation as the standard of care in these patients.
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22
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Charnaya O, Moudgil A. Hypertension in the Pediatric Kidney Transplant Recipient. Front Pediatr 2017; 5:86. [PMID: 28507980 PMCID: PMC5410589 DOI: 10.3389/fped.2017.00086] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 04/07/2017] [Indexed: 12/14/2022] Open
Abstract
Hypertension after kidney transplant is a frequent occurrence in pediatric patients. It is a risk factor for graft loss and contributes to the significant burden of cardiovascular disease (CVD) in this population. The etiology of posttransplant hypertension is multifactorial including donor factors, recipient factors, medications, and lifestyle factors similar to those prevalent in the general population. Ambulatory blood pressure monitoring has emerged as the most reliable method for measuring hypertension in pediatric transplant recipients, and many consider it to be essential in the care of these patients. Recent technological advances including measurement of carotid intima-media thickness, pulse wave velocity, and myocardial strain using specked echocardiography and cardiac magnetic resonance imaging have improved our ability to assess CVD burden. Since hypertension remains underrecognized and inadequately treated, an early diagnosis and an appropriate control should be the focus of therapy to help improve patient and graft survival.
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Affiliation(s)
- Olga Charnaya
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
| | - Asha Moudgil
- Division of Pediatric Nephrology, Children's National Health System, Washington, DC, USA
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23
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Peterson CG, Miyashita Y. The Use of Ambulatory Blood Pressure Monitoring As Standard of Care in Pediatrics. Front Pediatr 2017; 5:153. [PMID: 28713799 PMCID: PMC5492637 DOI: 10.3389/fped.2017.00153] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 06/19/2017] [Indexed: 12/16/2022] Open
Abstract
Hypertension (HTN) is a significant global health problem, responsible for 7.5 million deaths each year worldwide. The prevalence of HTN is increasing in the pediatric population likely attributed to the increase in childhood obesity. Recent work has also shown that blood pressure (BP) tends to track from childhood to adulthood including BP-related target organ damage. In the last 25-30 years, pediatric use of ambulatory blood pressure monitoring (ABPM) has been expanding mainly in the setting of initial elevated BP measurement evaluation, HTN therapy efficacy follow-up, and renal disease. However, there are many clinical areas where ABPM could potentially be used but is currently underutilized. This review summarizes the current knowledge and the uses of pediatric ABPM and explores clinical areas where it can be very useful both to detect HTN and its longitudinal follow-up. And thus, ABPM could serve as a critical tool to potentially prevent early cardiovascular mortality and morbidity in wide variety of populations. With solid data to support ABPM's superiority over clinic BP measurements and these clinical areas for its expansion, ABPM should now be part of standard of care in BP evaluation and management in pediatrics.
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Affiliation(s)
- Caitlin G Peterson
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Yosuke Miyashita
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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24
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Sharma AP. Elective ambulatory blood pressure monitoring to diagnose masked hypertension after kidney transplantation: are we ready for that? Pediatr Transplant 2016; 20:1014-1015. [PMID: 27882685 DOI: 10.1111/petr.12810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Ajay P Sharma
- Division of Nephrology, London Health Sciences Centre, Children's Hospital, Western University, London, ON, Canada.,Department of Pediatrics, London Health Sciences Centre, Children's Hospital, Western University, London, ON, Canada
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25
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Hamdani G, Nehus EJ, Hooper DK, Mitsnefes MM. Masked hypertension and allograft function in pediatric and young adults kidney transplant recipients. Pediatr Transplant 2016; 20:1026-1031. [PMID: 27353352 DOI: 10.1111/petr.12752] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/07/2016] [Indexed: 11/27/2022]
Abstract
Masked hypertension is a common complication of pediatric kidney transplantation. While office hypertension is known to be associated with worse short- and long-term graft function, the role of masked hypertension in allograft dysfunction is not clear. We conducted a retrospective cross-sectional analysis of 77 consecutive pediatric kidney transplant recipients who had routine 24-h ambulatory blood pressure monitoring with the aims to estimate the prevalence of masked hypertension and examine its association with allograft function. Masked hypertension was defined as a 24-h systolic or diastolic blood pressure load ≥25%. Twenty-nine percent of patients had masked hypertension. Patients with masked hypertension had significantly lower allograft function estimated using the creatinine-based Schwartz-Lyon formula, a cystatin C-based formula, and combined cystatin C and creatinine-based formulas than patients with normal blood pressure (all p values <0.05). In a multivariable analysis, masked hypertension remained independently associated with worse allograft function after adjustment for age, sex, race, time post-transplant, rejection history, antihypertensive treatment, and hemoglobin level. We conclude that in young kidney transplant recipients, masked hypertension is common and is associated with worse allograft function. These results support the case for routine ambulatory blood pressure monitoring as the standard of care in these patients to detect and treat masked hypertension.
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Affiliation(s)
- Gilad Hamdani
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Edward J Nehus
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David K Hooper
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mark M Mitsnefes
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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26
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Terrace JD, Oniscu GC. Paediatric obesity and renal transplantation: current challenges and solutions. Pediatr Nephrol 2016; 31:555-62. [PMID: 26018121 DOI: 10.1007/s00467-015-3126-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Revised: 04/27/2015] [Accepted: 04/28/2015] [Indexed: 12/16/2022]
Abstract
The increased incidence of obesity in the paediatric population poses significant challenges to renal transplantation. Whilst the body mass index appears to be widely used as a measure of obesity in adults, there are no standardised definitions in the paediatric population, making comparative analyses difficult. In the paediatric transplant population, obesity is associated with an increased incidence of surgical complications, diabetes, hyperlipidaemia and cardiovascular morbidity, leading to diminished graft function and impacting patient and graft survival. Management of obesity in renal transplantation requires multiple interventions starting with life-style and behavioural modification combined with medical and possibly surgical therapies, representing a unique challenge in the childhood setting. In this review we discuss the current challenges of obesity and potential solutions in the setting of paediatric transplantation.
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Affiliation(s)
- John D Terrace
- Transplant Unit, The Royal Infirmary of Edinburgh, Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK
| | - Gabriel C Oniscu
- Transplant Unit, The Royal Infirmary of Edinburgh, Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.
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Abstract
Renal transplantation in paediatric patients usually provides excellent short-term and medium-term results. Early diagnosis of chronic kidney disease and active therapy of end-stage renal disease before and after transplantation enables the majority of children to grow and develop normally. The adverse effects of immunosuppressive medication and reduced graft function might, however, hamper long-term outcomes in these patients and can lead to metabolic complications, cardiovascular disease, reduced bone health, and malignancies. The neurocognitive development and quality of life of paediatric transplant recipients largely depend on the primary diagnosis and on graft function. Poor adherence to immunosuppression is an important risk factor for graft loss in adolescents, and controlled transition to adult care is of utmost importance to ensure a continued normal life. In this Review, we discuss the outcomes and long-term effects of renal transplantation in paediatric recipients, including consequences on growth, development, bone, metabolic, and cardiovascular disorders. We discuss the key problems in the care of paediatric renal transplant recipients and the remaining challenges that should be the focus of future research.
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