Microalbuminuria in Children With Primary Hypertension

Clinical guidelines for the diagnosis, evaluation, and management of hypertension for Korean children and adolescents: the Korean Working Group of Pediatric Hypertension

Pediatric hypertension (HTN) is a significant, growing health concern worldwide and also in Korea. Diagnosis, evaluation, and treatment of HTN in Korean children and adolescents are uncertain due to limitations in using the current international guidelines, since the recommendations by the American Academy of Pediatrics (AAP) and European Society of Hypertension (ESH) guidelines differ. Furthermore, these are guidelines for Western youth, who are racially and ethnically different from Koreans. In addition, reference blood pressure values for all pediatric age groups, which are essential for the diagnosis of HTN according to these two guidelines, are absent in Korea. Therefore, HTN guidelines for Korean children and adolescents should be established. The Korean Working Group of Pediatric Hypertension established clinical guidelines for the diagnosis, evaluation, and management of HTN in Korean children and adolescents. These guidelines were based on reported clinical evidence, expert recommendations, and AAP and ESH guidelines. The characteristics of Korean youth and the Korean medical and insurance system were considered during the establishment of the guidelines. By providing recommendations suitable for Korean youth, these guidelines will help in the prevention and management of childhood HTN, thus relieving the burden of cardiovascular disease in adulthood in Korea.

Hypertension in children with congenital anomalies of the kidney and urinary tract

BACKGROUND

Congenital anomalies of the kidney and urinary tract (CAKUT) are the most common cause of childhood chronic kidney disease (CKD). We hypothesized that hypertension varies across CAKUT categories and increases the risk of CKD.

METHODS

This was a retrospective cohort study and included cases with a multicystic dysplastic kidney (MCDK, n = 81), unilateral kidney agenesis (UKA, n = 47), kidney hypoplasia (KH, n = 130), and posterior urethral valves (PUV, n = 75). Hypertension was defined as systolic or diastolic blood pressure ≥ 95th percentile for age, sex and height, and CKD as an estimated glomerular filtration rate < 60 ml/min/1.73 m2, both at 2 consecutive clinic visits at least 3 months apart.

RESULTS

Sixty-two (19%) out of 333 cases developed hypertension, with significant difference according to CAKUT type. Patients with smaller kidney size (7.7 vs. 8.3, p = 0.045), kidney anomalies in addition to the primary diagnosis (aCAKUT) (53 vs. 38%, p = 0.03), proteinuria (46 vs. 12%, p < 0.001), and CKD (51 vs. 23%, p < 0.001) were more likely to develop hypertension. When adjusted for kidney size, the diagnoses of PUV (OR 10.9, 95%CI 3.0, 40.5), UKA (OR 6.4, 95%CI 1.6, 24.9) and KH (OR 4.2, 95%CI 1.1, 16.1), and aCAKUT (OR 2.1, 95%CI 1.2, 3.9) were independent risk factors for hypertension. Hypertension increased the risk of developing CKD by twofold (HR 1.9, 95%CI 1.19, 2.94).

CONCLUSION

Hypertension is common in children with CAKUT and increases the risk of CKD. These findings will aid in the development of a standardized clinical pathway for the care of hypertensive children with CAKUT.

Increasing trend in hypertension prevalence among Korean adolescents from 2007 to 2020

BACKGROUND

The purpose of this study was to examine the prevalence of hypertension in Korean adolescents, its long-term trends, and factors associated with the development of hypertension.

METHODS

Data of the Korea National Health and Nutrition Examination Survey (KNHANES) from 2007 to 2020 were combined into three time periods (2007-2011, 2012-2016, and 2017-2020). A total of 11,146 Korean adolescents aged 10-18 were included in the analysis. The definition of hypertension was based on the 2017 American Academy of Pediatrics guidelines for hypertension.

RESULTS

The age-adjusted prevalence of hypertension was 5.47%, 7.85%, and 9.92% in 2007-2011, 2012-2016, and 2017-2020, respectively. Long-term trend analysis using Joinpoint analysis over the observation period showed a significantly increasing trend in hypertension prevalence with a mean annual percentage change of 6.4%. Boys, those aged 13-15, those aged 16-18, overweight/obese, and those living in urban areas were more likely to develop hypertension (OR 1.980, 1.492, 3.180, 2.943, and 1.330, respectively).

CONCLUSION

The prevalence of hypertension in Korean adolescents was higher than the global prevalence of hypertension and showed an increase over a 13-year period. Targeted strategies for prevention and early detection of hypertension are needed in this population.

Prevalence of Pediatric Masked Hypertension and Risk of Subclinical Cardiovascular Outcomes: A Systematic Review and Meta-Analysis

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.

Hypertension in children and adolescents

Definition and management of arterial hypertension in children and adolescents are uncertain, due to different positions of current guidelines. The European Society of Cardiology task-force, constituted by Associations and Councils with interest in arterial hypertension, has reviewed current literature and evidence, to produce a Consensus Document focused on aspects of hypertension in the age range of 6-16 years, including definition, methods of measurement of blood pressure, clinical evaluation, assessment of hypertension-mediated target organ damage, evaluation of possible vascular, renal and hormonal causes, assessment and management of concomitant risk factors with specific attention for obesity, and anti-hypertensive strategies, especially focused on life-style modifications. The Consensus Panel also suggests aspects that should be studied with high priority, including generation of multi-ethnic sex, age and height specific European normative tables, implementation of randomized clinical trials on different diagnostic and therapeutic aspects, and long-term cohort studies to link with adult cardiovascular risk. Finally, suggestions for the successful implementation of the contents of the present Consensus document are also given.

High blood pressure in children and adolescents: current perspectives and strategies to improve future kidney and cardiovascular health

Hypertension is one of the most common causes of preventable death worldwide. The prevalence of pediatric hypertension has increased significantly in recent decades. The cause of this is likely multifactorial, related to increasing childhood obesity, high dietary sodium intake, sedentary lifestyles, perinatal factors, familial aggregation, socioeconomic factors, and ethnic blood pressure (BP) differences. Pediatric hypertension represents a major public health threat. Uncontrolled pediatric hypertension is associated with subclinical cardiovascular disease and adult-onset hypertension. In children with chronic kidney disease (CKD), hypertension is also a strong risk factor for progression to kidney failure. Despite these risks, current rates of pediatric BP screening, hypertension detection, treatment, and control remain suboptimal. Contributing to these shortcomings are the challenges of accurately measuring pediatric BP, limited access to validated pediatric equipment and hypertension specialists, complex interpretation of pediatric BP measurements, problematic normative BP data, and conflicting society guidelines for pediatric hypertension. To date, limited pediatric hypertension research has been conducted to help address these challenges. However, there are several promising signs in the field of pediatric hypertension. There is greater attention being drawn on the cardiovascular risks of pediatric hypertension, more emphasis on the need for childhood BP screening and management, new public health initiatives being implemented, and increasing research interest and funding. This article summarizes what is currently known about pediatric hypertension, the existing knowledge-practice gaps, and ongoing research aimed at improving future kidney and cardiovascular health.

Relationship between High Blood Pressure and Microalbuminuria in Children Aged 6-9 Years in a South African Population

Though the association between high blood pressure and microalbuminuria is well established in adults, there is a paucity of information on microalbuminuria in children. This study investigated the relationship between high blood pressure and microalbuminuria in 6-9-year-old children. A cross-sectional study, which included 306 primary school children of age 6-9 years old from urban areas (n = 154) and rural areas (n = 152) of the Eastern Cape Province of South Africa, was conducted. Participants' anthropometric data were determined and systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were measured and converted to BP percentiles for age, sex and height. Creatinine and albumin concentrations were assayed in early morning midstream urine and the albumin to creatinine ratio (ACR) was calculated. There was a 42.8% prevalence of elevated blood pressure/high blood pressure (E-BP/H-BP) and a 10.1% prevalence of microalbuminuria. Among the 131 children with E-BP/H-BP, 17 had elevated ACR with a prevalence of 13.95%. SBP and HR increased with increasing range of ACR and, furthermore, SBP was significantly (p < 0.05) higher in children with moderately and severely increased ACR. SBP was associated with ACR and increased SBP predicted microalbuminuria (R2 = 0.42, adj R2 = 0.039, B: 0.120, p = < 0.05). In conclusion, microalbuminuria was present in 6-9-year-old South African children of African Ancestry and a weak association was observed with SBP in children.

Are My Pediatric Patients at Increased Risk of Developing Chronic Kidney Disease?

Chronic kidney disease (CKD) is an underrecognized and often undiagnosed cause of morbidity and mortality. Many children and adolescents are at increased risk of developing CKD as they mature and age, secondary to conditions commonly cared for by pediatric health professionals. Prematurity, diabetes mellitus, hypertension, congenital heart disease, sickle cell disease and trait, severe obesity, cancer chemotherapy, other drug toxicities, and systemic situations that may cause acute kidney injury such as sepsis or extracorporeal membrane oxygenation therapy predispose to potential CKD. Clinicians should be aware of these conditions in order to screen for CKD, choose non-nephrotoxic treatments for these children whenever possible, and treat or refer those who have early signs of CKD.

Cross-Sectional Relationship between Carotid-Femoral Pulse Wave Velocity and Biomarkers in Vascular-Related Diseases

Objectives

The present study was done to investigate the relationship between carotid-femoral pulse wave velocity (CFPWV) and biomarkers such as homocysteine (Hcy), N-terminal pro-brain natriuretic peptide (NT-proBNP), and urine albumin (microalbumin) (UAE) in vascular-related diseases.

Methods

656 subjects were enrolled into our study. There were 377 patients with hypertension, 231 with coronary heart disease, 154 with diabetes mellitus, and 186 healthy subjects. They were divided into four groups according to the number of suffered diseases: group 1 had only one of three diseases, group 2 had two, and group 3 had all of three diseases. CFPWV was measured by Complior apparatus.

Results

CFPWV was significantly higher in group 3 than in the healthy group, group 1, and group 2 (12.71 ± 2.38 vs 10.11 ± 2.28, 10.70 ± 2.12, and 11.92 ± 2.55, all p < 0.05). The level of Hcy was significantly higher in group1, group 2, and group 3 than in healthy subjects, respectively. Levels of Log NT-proBNP and Log UAE were significantly higher in group 3 than in group 1 (2.27 ± 0.4 vs 2.10 ± 0.4, 1.00 ± 0.65 vs 0.68 ± 0.56, both p < 0.05). Positive correlation between CFWV and Hcy, Log UAE, and Log NT-proBNP was found in the entire study group (r = 0.109, 0.196, and 0.119, all p < 0.05). Multivariate analysis showed that pulse pressure, age, fasting plasma glucose, diastolic blood pressure, body mass index, and Log UAE were independent associating factors of CFPWV in all subjects (β = 0.334, p < 0.001; β = 0.333, p < 0.001; β = 0.126, p=0.004; β = 0.137, p=0.003; β = −0.142, p=0.002; and β = 0.098, p=0.031).

Conclusions

CFPWV was significantly higher in subjects with hypertension, CHD, and DM. There was correlation between CFPWV and biomarkers such as NT-proBNP, Hcy, and urine albumin (microalbumin).

Early Markers of Sickle Nephropathy in Children With Sickle Cell Anemia Are Associated With Red Cell Cation Transport Activity

The early stages of sickle cell nephropathy (SCN) manifest in children with sickle cell anemia (SCA) as hyperfiltration and proteinuria. The physiological conditions of the renovascular system are among the most conducive to hemoglobin S polymerization in the body and will magnify small changes in red cell volume thus crucially modulating intracellular concentrations of hemoglobin S. This large cross-sectional study of children with sickle cell anemia measured glomerular filtration rates and microalbuminuria to report prevalence, clinical correlates and uniquely, association with key red cell cation transport mechanisms. One hundred and twelve patients (mean age 10.7 ± 4.1) were recruited. The prevalence of hyperfiltration and microalbuminuria was 98% and 15.1%, respectively. Glomerular filtration rates did not vary with age, but proteinuria became more prevalent with increasing age. Both features associated with markers of hemolysis, while elevated hemoglobin F was protective, but no association was seen with systolic or diastolic blood pressure. In multivariate analysis, both Gardos channel (β = 0.476, P < 0.001) and KCl co-transporter (KCC; β = -0.216, P = 0.009) activity, alongside age (β = 0.237, P = 0.004), remained independently predictive for microalbuminuria. Increased activity of Gardos channel and P_sickle positively associated with microalbuminuria, while increased KCC activity associated with a reduction in microalbuminuria. This study demonstrates a direct link between the abnormally active red cell cation transport systems in sickle cell disease and sickle organopathy. Small variations in the activity of these transport mechanisms predict for SCN and measurement of them may help identify those at risk, while pharmaceutical manipulation of these excessively active systems may ameliorate their risk.

Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents

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.