Hypertension in Children and Adolescents: A Position Statement From a Panel of Multidisciplinary Experts Coordinated by the French Society of Hypertension

What to Expect on the Long-term Follow-up of Pediatric Pyeloplasty: Critical Time Intervals and Risk Factors

BACKGROUND

Standard protocol for post-pyeloplasty monitoring in children and natural course of hydronephrosis resolution have not been well defined. We aimed to analyze critical time intervals and risk factors in the long-term clinical outcomes of children who were operated for ureteropelvic junction obstruction.

METHODS

Files of patients who underwent open dismembered pyeloplasty between January 2000 and December 2012 and had a ≥10 years follow-up were retrospectively reviewed. Changes in SFU hydronephrosis grade, pelvis anteroposterior diameter (APD), renal parenchymal thickness, split renal functions (SRF) on MAG-3 scan as well as development of hypertension and proteinuria were noted. Complete resolution was defined as SFU grade 0-1 or APD≤10 mm or ≥50 % APD decrease.

RESULTS

Overall, 223 patients (161 boys, 72.1 %) with a median age of 9 (range 1-185) months underwent unilateral pyeloplasty, whereas 14 patients (13 boys, 92.8 %) with a median age of 4 (range 2-39) months underwent bilateral pyeloplasty. Median follow-up was 13 (range 10-22) years. Complete resolution was observed in 190 patients (85.2 %). None of the cases required re-do pyeloplasty. Regarding unilateral cases, postoperative changes in hydronephrosis reached a plateau at the 60th month. Also, there was no significant difference regarding SRF between the 12th month and the 60th month (p > 0.05). Hypertension developed after a median period of 12 years in 13 (5.4 %) of the patients, while proteinuria developed in four (1.6 %) patients. Bilateral disease (HR: 2.518, p = 0.034) was found to be a significant determinant for development of hypertension and/or proteinuria.

CONCLUSIONS

Our results indicated that ultrasonographic findings stabilized after the 60th month postoperatively, and SRF remained stable between the postoperative 12th and the 60th months. The risk of developing hypertension and/or proteinuria was 2.5 times greater in bilateral cases.

LEVEL OF EVIDENCE

Level II.

A rare cause and an even rarer treatment of hypertension in a 5-year-old boy: Mid-aortic syndrome

Renal artery stenosis is one of the common vascular diseases that cause hypertension in children. However, renal artery aneurysms and abdominal aortic aneurysms, which may be components of mid-aortic syndrome, are rarely associated with renal artery stenosis. Despite its rarity, early diagnosis and treatment are critical to prevent fatal complications. Currently, non-surgical invasive techniques are considered the first choice for treatment, but in some cases, surgery is inevitable. Here, we present a 5-year-old boy with a mid-aortic syndrome. The patient presented with a history of severe headache and epistaxis 5-6 times a day and was diagnosed with hypertension. A 9 × 9 mm saccular aneurysm on the anterior surface of the abdominal aorta at the level of the left renal artery ostium, and a 12 mm aneurysm in the left renal artery after a stenotic segment at the hilum level was detected in the doppler USG and contrast-enhanced imaging techniques. The patient was operated on electively. We used a PTFE patch to repair the abdominal aorta and, saphenous vein which was taken from his father to repair the renal artery. The patient recovered well and was discharged on the 18th day.

Blood Pressure Pattern and Prevalence of Hypertension amongst Apparently Healthy Primary School Pupils in Abuja, Nigeria

OBJECTIVES

The objective of this study was to determine the blood pressure (BP) pattern and prevalence of hypertension amongst apparently healthy primary school pupils in Abuja.

METHODOLOGY

This was a descriptive, cross-sectional study carried out on apparently healthy primary school children aged 6-12 years. BP was measured using a standard mercury sphygmomanometer according to standard guidelines. Data were analysed using SPSS version 17.0. Pearson's correlation coefficient (r) and analysis of variance were used to determine the relationship between BP and various variables where applicable. P = 0.05 was considered statistically significant.

RESULTS

Out of 1011 pupils recruited for the study, 457 (42.2%) were male. The mean systolic and diastolic BP (SBP and DBP) increased significantly with age from 94.5 mmHg to 101.0 mmHg and from 61.5 mmHg to 65.3 mmHg from 6 to 12 years for SBP and DBP, respectively (P < 0.05). The prevalence of high BP was 9.1%. Age was the only predictor of SBP (β = -0.629, 95% confidence interval [CI] -1.115, -0.142), while age, height and body mass index (BMI) were the predictors of DBP (β = -0.686, 95% CI of -1.152, -0.221; β = 0.490, 95% CI of 0.172, 0.809; β = 1.753, 95% CI of 0.374, 3.160) for age, height and BMI, respectively, at P < 0.05.

CONCLUSION

The predictors of SBP and DBP as shown in this study support the recommendations by various reports for taking body size into consideration in developing reference values for various populations. Age and body size are important determinants of BP in children. Its measurement should be encouraged in schools.

Etiology, risk factors and management of hypertension post liver transplantation

BACKGROUND

Cardiovascular events are one of the most important causes of morbidity and mortality in the long-term follow-up of liver transplant recipients. Hypertension is a significant cardiovascular risk factor that occurs frequently after pediatric liver transplantation. Chronic use of immunosuppressants - mainly calcineurin inhibitors - plays a major role in the development of post-transplant hypertension and circadian disturbances such as flattening of the nocturnal blood pressure dip. This requires special attention in children given the long timeframe during which immunosuppressive therapy is necessary. Careful and structured blood pressure monitoring and adequate treatment of hypertension are essential to optimize the quality of life and life expectancy of pediatric liver transplant patients. However, evidence-based guidelines for monitoring and management of post-transplant hypertension and its complications are lacking.

METHODS

We conducted a comprehensive review of the current knowledge and practices concerning post-transplant hypertension. The databases Pubmed, Embase, Web of Science and Google Scholar were scanned with the following keywords: pediatric liver transplantation, immunosuppression, tacrolimus, cardiovascular effects, hypertension, heart function, kidney function, circadian rhythm, mechanism, monitoring, and management.

RESULTS

In this review, we describe the incidence and etiology of hypertension in pediatric liver transplant recipients, the underlying mechanisms and characteristics of calcineurin inhibitor-induced hypertension, and the consequences of and risk factors for post-transplant hypertension. We hereby present an overview of the current practices in blood pressure monitoring and antihypertensive treatment as well as an algorithm for the evaluation and management of hypertension post liver transplantation. Finally, we discuss knowledge gaps and suggestions for future research.

Association of the Protective Dietary Pattern for Blood Pressure with Elevated Blood Pressure and Hypertension among Chinese Children and Adolescents Aged 6-17 Years Old: Data from China Nutrition and Health Surveillance (2015-2017)

Studies focused on the association between dietary patterns and elevated blood pressure (BP) and hypertension (HTN) among children and adolescents remain insufficient. This study aimed to explore a dietary pattern that could be helpful for the prevention of abnormal BP and to investigate the association between this dietary pattern and elevated BP and HTN among Chinese children and adolescents. A total of 52,080 Chinese children and adolescents aged 6~17 years old from the China Nutrition and Health Surveillance (CNHS) 2015-2017 were included in the current study. The reduced rank regression (RRR) method was applied to derive a dietary pattern that is associated with BP. Multivariable logistic regression was used to assess the association between dietary pattern (DP) and elevated BP and HTN. The Dietary Approach to Stop Hypertension (DASH) score was also calculated for each participant as a comparative method to validate the dietary pattern derived with the RRR method. A protective dietary pattern (PDP) for BP among Chinese children and adolescents was derived, which was characterized by high intakes of dairy products, mushrooms/edible fungi, fresh vegetables, fresh fruits, fresh eggs, aquatic products, mixed legumes, soybeans and related products, offal, dried fruits, and coarse cereals, with low intakes of refined grains. After multiple adjustments, there were significant inverse associations between PDP scores and the odds of elevated BP and HTN (elevated BP: Q5 vs. Q1, OR = 0.849, 95%CI = 0.755-0.931, P-trend < 0.05; HTN: Q5 vs. Q1, OR = 0.795, 95%CI = 0.694-0.911, P-trend < 0.05). The DASH diet was also observed to have protective effects on elevated BP in model I (Q5 vs. Q1, OR = 0.899, 95%CI = 0.828-0.975, P-trend < 0.05), but was not observed to have protective effects on HTN (HTN: Q5 vs. Q1, OR = 0.958, 95%CI = 0.876-1.048, P-trend > 0.05). The current study suggested that greater adherence to the PDP for BP among Chinese children and adolescents might be associated with lower odds of elevated BP and HTN.

Undiagnosed Pediatric Elevated Blood Pressure Is Characterized by Induction of Proinflammatory and Cytotoxic Mediators

BACKGROUND

Inflammatory processes have been suggested as a culprit of vascular damage in pediatric hypertension. We aimed to investigate transcriptional changes of immune modulators and determine their association with office blood pressure in adolescents who were not diagnosed with hypertension at the time of the study visit.

METHODS

Office blood pressure measurements and blood samples were taken from adolescents of 2 German birth cohorts, GINIplus (The German Infant Study on the Influence of Nutrition Intervention Plus Air Pollution and Genetics on Allergy Development; discovery cohort, n=1219) and LISA (Influences of Lifestyle-related factors on the Immune System and the Development of Allergies in Childhood; validation cohort, n=809), during the 15-year follow-up visit and categorized based on the European Society of Hypertension Guideline. Hs-CRP (high-sensitivity C-reactive protein) and expression of 51 genes encoding cytokines/receptors and transcription factors were analyzed.

RESULTS

The prevalence of elevated systolic blood pressure (overweight/obese) was 14.0% (5.1%) and 16.4% (5.2%) in the discovery and validation cohorts, respectively. An enhanced cytotoxic (GZMB, PRF1, IL2RB) and proinflammatory (FOS, IL1B, hs-CRP) immune profile was observed in association with the hypertension class in both cohorts. Expression of hs-CRP and IL1B was driven by overweight with IL1B being identified as a mediator between body mass index and elevated systolic blood pressure (adj.β/95% CI, 0.01/0.0002-0.02). The association of GZMB (adjusted odds ratio/95% CI, 1.67/1.26-2.21; P=0.0004) and PRF1 (adjusted odds ratio/95% CI, 1.70/1.26-2.29; P=0.0005) in the hypertension class remained significant in normal-weight individuals without parental predisposition. These effects were confirmed in LISA.

CONCLUSIONS

Adolescent hypertension is not limited to known risk groups. As adolescents in the hypertension class show an inflammatory profile similar to that of established hypertension in adults, blood pressure monitoring at a young age is critical to ensure early intervention and prevention of adverse sequelae.

Efficacy of fosinopril and amlodipine in pediatric primary hypertension: a single-center observational study

Objective

Fosinopril and amlodipine are commonly prescribed as first-line pharmacotherapeutic agents for pediatric hypertension, but there is a lack of comparative studies regarding the efficacy of these two drugs. We aimed to evaluate and compare the efficacy of fosinopril and amlodipine monotherapy in pediatric primary hypertension.

Methods

This was a single-center, bidirectional observational study. A total of 175 children and adolescents with primary hypertension receiving antihypertensive monotherapy from July 2020 to February 2023 were enrolled. According to antihypertensive drugs, they were divided into the fosinopril group (n = 96) and the amlodipine group (n = 79). Subgroup analysis was performed to compare the efficacy of the two groups in terms of blood pressure (BP) control rates and reductions following a 4-week treatment.

Results

After 4 weeks of treatment, both groups achieved significant reductions in systolic BP (SBP) and diastolic BP (DBP) by more than 18 mmHg and 6 mmHg, respectively, with BP control rates of 61.5% in the fosinopril group and 59.5% in the amlodipine group, revealing no significant differences in the antihypertensive efficacy between the two groups except for DBP control rate (FDR adjusted P > 0.05). Further subsequent subgroup analyses revealed that the reductions in SBP and DBP in the fosinopril group were significantly greater than those in the amlodipine group in patients of females and hypo-HDL-cholesterolemia (FDR adjusted P < 0.05), and there was a trend of difference, although not significant, in patients with central obesity and insulin resistance (IR) (FDR adjusted 0.05 < P ≤ 0.1). However, there were no significant differences in treatment efficacy in patients without these characteristics. Furthermore, hypertriglyceridemia did not exhibit a significant association with the difference in treatment efficacy between the two medications (FDR adjusted P > 0.05).

Conclusions

Fosinopril and amlodipine monotherapy were both effective in pediatric primary hypertension during a short-term follow-up. Fosinopril may be particularly effective in reducing BP in hypertensive patients of females, central obesity, IR, and hypo-HDL-cholesterolemia. These findings indicate that optimizing antihypertensive medication selection based on the individualized characteristics of children with hypertension may improve the efficacy of antihypertensive treatment.

Efficacy of Different Dietary Patterns in the Treatment of Functional Gastrointestinal Disorders in Children and Adolescents: A Systematic Review of Intervention Studies

Functional gastrointestinal disorders (FGIDs) are common in children and adolescents. In recent years, interest in the role of diet in the treatment of FGIDs has increased. Currently, interest focuses on the low-FODMAP diet (LFD), the fructose- or lactose-restricted diet (FRD or LRD), the gluten-free diet (GFD), and the Mediterranean diet (MD). In this review, we focus on the role of these dietary patterns in the FGIDs most commonly diagnosed in clinical practice, namely irritable bowel syndrome (IBS), functional abdominal pain (FAP), functional dyspepsia (FD), and functional constipation (FC). Fifteen clinical trials were systematically reviewed (both RCTs and single-arm clinical trials). We demonstrated the lack of high-quality intervention trials. Based on current evidence, low-FODMAP diet, LRD, FRD, and GFD have no place in daily clinical practice for the management of children and adolescents with FGIDs. Nevertheless, some patients with IBS or RAP may experience some benefit from the use of a low-FODMAP diet or FRD/LRD. Limited data suggest that MD may be promising in the management of FGIDs, especially in IBS patients, but more data are required to investigate the mechanisms of its protective effects.

Primary and secondary paediatric hypertension

High blood pressure (BP) or hypertension is a well known risk factor for developing heart attack, stroke, atrial fibrillation and renal failure. Although in the past hypertension was supposed to develop at middle age, it is now widely recognized that it begins early during childhood. As such, approximately 5-10% of children and adolescents are hypertensive. Unlike that previously reported, it is now widely accepted that primary hypertension is the most diffuse form of high BP encountered even in paediatric age, while secondary hypertension accounts just for a minority of the cases. There are significant differences between that outlined by the European Society of Hypertension (ESH), the European Society of Cardiology (ESC), and the last statement by the American Academy of Pediatrics (AAP) concerning the BP cut-offs to identify young hypertensive individuals. Not only that, but the AAP have also excluded obese children in the new normative data. This is undoubtedly a matter of concern. Conversely, both the AAP and ESH/ESC agree that medical therapy should be reserved just for nonresponders to measures like weight loss/salt intake reduction/increase in aerobic exercise. Secondary hypertension often occurs in aortic coarctation or chronic renal disease patients. The former can develop hypertension despite early effective repair. This is associated with significant morbidity and is arguably the most important adverse outcome in about 30% of these subjects. Also, syndromic patients, for example those with Williams syndrome, may suffer from a generalized aortopathy, which triggers increased arterial stiffness and hypertension. This review summarizes the state-of-the-art situation regarding primary and secondary paediatric hypertension.

Assessment of Cardiovascular Risk Factors in Patients with Juvenile Idiopathic Arthritis

Introduction: The aim of this study was to assess the exposure to cardiovascular disease (CVD) risk factors in patients with juvenile idiopathic arthritis (JIA). Intima–media complex thickness (IMT), selected metabolic parameters and health behaviors were assessed in the course of the study. Methods: The study included study group, which consisted of 45 patients with JIA and 37 healthy age- and sex-matched children in the control group. Analyses in both groups included anthropometric parameters, laboratory tests, IMT and a questionnaire on exposure to modifiable CVD risk factors. Results: The study confirmed that CVD risk factors were present in both groups of patients. Significantly more children with JIA had abnormal BMI (p = 0.006) compared to the control group. Children in the study group were more likely to consume fruit regularly (p = 0.021) and less likely to consume fast food (p = 0.011) and sweetened beverages (p = 0.042) than children in the control group. Only 1 patient with JIA met criteria for ideal cardiovascular health. Dietary habits were not associated with IMT values, BMI, presence of joint pain or biochemical parameters in the study group. Conclusions: Patients with JIA are exposed to cardiovascular risk factors equally to their healthy peers. Ideal cardiovascular health should be pursued in the pediatric population with particular attention paid to patients with chronic diseases (i.e., JIA). The application of carotid artery IMT measurement in the assessment of CVD risk requires studies on a larger group of patients.

Pharmacological Treatment of Arterial Hypertension in Children and Adolescents in Lithuania

The global prevalence of arterial hypertension (AH) in the pediatric population is increasing, but therapeutic approaches and the choice of the most suitable antihypertensive medications remains challenging. The study aimed to estimate the prevalence, treatment rates, and pharmacological treatment patterns of children and adolescents with AH in Lithuania during 2019 using real-world data. The study population consisted of citizens of Lithuania aged 0 to 17 years, who were diagnosed with AH according to the International Classification of Diseases (ICD). The analysis of reimbursed antihypertensive medication prescriptions was performed according to AH etiology and age. The overall prevalence of AH by diagnostic ICD codes in 2019 was 0.29%:0.24% for primary and 0.05% for secondary. Treatment rates were 39.8% for primary AH and 66.3% for secondary AH. Angiotensin-converting enzyme inhibitors (ACEi) were the most popular medications irrespective of the etiology of AH or age. Beta-blockers were in the second place and used more often in older children. Calcium channel blockers were the third and angiotensin receptor blockers were the fourth most frequent choices. Enalapril was the most popular agent in the ACEi group and metoprolol in the beta-blocker group. Nearly forty percent of Lithuanian children with primary AH receive pharmacological therapy compared to two-thirds with secondary AH. Although ACEi are the predominant class of antihypertensive medications, discordances with available guidelines are evident, particularly in the overuse of beta-blockers and underuse of diuretics.

Teenagers and young adults with a past of allogenic hematopoietic stem cell transplantation are at significant risk of chronic kidney disease

BACKGROUND

Allogenic hematopoietic stem cell transplantation (aHSCT) remains the treatment of choice for some malignant hemopathies in children, albeit with the risk of long-term consequences, including chronic kidney disease (CKD).

METHODS

In our single tertiary referral center, we retrospectively assessed the long-term renal outcome in a cohort of children and adolescents who had undergone aHSCT for malignant hemopathies between 2003 and 2017. We distinguished glomerular and tubular dysfunctions and assessed the accuracy of the most common formula(s) to estimate glomerular filtration rate (GFR) during standard clinical follow-up.

RESULTS

Among the 166 patients who had received aHSCT, 61 underwent kidney functional assessment 1 to 10 years post-transplantation. Twenty-seven patients (44.3%) had a CKD with glomerular impairment, including 20 patients with a GFR < 90 mL/min/1.73 m², and among these, 5 patients < 60 mL/min/1.73 m². Patients with tubular signs had a significantly higher baseline GFR: 112 mL/min/1.73 m² [100; 120] versus 102 [99.0; 112.5] for patients without kidney involvement, and 76 [61; 86] for patients with CKD (p < 0.01). Schwartz, CKiDU25, and EKFC formulas significantly overestimated mGFR, with a P30% ≤ 30%, which could lead to overlooking CKD diagnosis in this population. No patient reached kidney failure.

CONCLUSIONS

In conclusion, our study shows that CKD represents an important long-term sequela for children and adolescents who undergo aHSCT for malignant hemopathies, either with glomerular dysfunction or with the more insidious tubular dysfunction which could potentially impact growth. These patients could benefit from specialized long-term nephrology follow-up. A higher resolution version of the Graphical abstract is available as Supplementary information.

Safety and Efficacy of the Nit-Occlud® Coil for Percutaneous Closure of Various Sizes of PDA

Most interventionalists use the Amplatzer Duct Occluder (ADO) or the Nit-Occlud® Coils (NOC) to close patent ductus arteriosus (PDA). Data regarding the success and effect of NOCs in the occlusion of large PDAs are insufficient. We aimed to investigate whether the PDA occlusion of large PDAs using NOC is safe and efficient for all ages. This was a retrospective study involving 361 pediatric and adult patients who underwent the transcatheter closure of PDA using NOC over the past 21 years for all PDA sizes and ages. The sizes of PDA were classified as small, moderate, and large. A comparison of the aortic pressure before and after PDA occlusion using NOC showed significant differences in terms of systolic and pulse pressures for all age groups (p < 0.05). The rate of the residual shunts of NOC was 2%, while the rate of complete occlusions of NOC was 98% at 12 months after occlusion regardless of the shape of PDA. The complication rate with PDA occlusion using NOC was 5%. PDA occlusion using NOC is as effective and safe as ADO for the occlusion of PDA of all sizes. Therefore, PDA occlusion using NOC can be a safe and feasible procedure to close various sizes and types of PDA without complications.

Prevalence of hypertension and related risk factors among children and adolescents at three separate visits: A large school-based study in China

OBJECTIVE

We aimed to demonstrate characteristics of hypertension at three separate visits and its risk factors among children and adolescents based on a large school-based study in China.

MATERIALS AND METHODS

Based on a large-scale ongoing monitoring program conducted in Suzhou, China, 59,679 children and adolescents aged 7-17 years from 60 public schools were enrolled during 2020 to 2021. Height, weight, and blood pressure (BP) were measured. Additional BP would be measured for hypertensive students at least 2 weeks later. Confirmed hypertension was defined as simultaneously BP meeting above or equal to 95th percentile for age, sex, and height at three separate visits. Odds ratio (ORs), and 95% CIs were calculated by logistic regression to identify risk factors for hypertension.

RESULTS

Prevalence of hypertension at three separate visits were 20.4, 6.3, and 3.1%, respectively. Prevalence of confirmed isolated systolic hypertension, isolated diastolic hypertension, and systolic and diastolic hypertension were 1.9, 0.3, and 0.9%, respectively. Hypertension prevalence for stages 1 and 2 were 2.6 and 0.6%. Different hypertension prevalence were found among various age and gender groups. Boys [OR, 1.137 (95% CI, 1.033-1.251)], high age [OR, 3.326 (95% CI, 2.950-3.751)], urban residents [OR, 1.579 (95% CI, 1.417-1.760)], high-socioeconomic status [OR, 1.156 (95% CI, 1.039-1.286)] and body mass index category including overweight [1.883 (95% CI, 1.665-2.129)], obesity [4.049 (95% CI, 3.625-4.523)], and thinness [OR, 0.457 (95% CI, 0.306-0.683)] were associated with confirmed hypertension.

CONCLUSION

A single BP measurement would overestimate hypertension prevalence, about 3% Chinese children were hypertensive, early, and effective intervention around risk factors for hypertension should be taken.

Evaluation of Health-Promoting Behaviors in the Prevention of Cardiovascular Diseases in the Preschool Children of Polish Health Care Professionals

BACKGROUND

The aim of the study was to evaluate the health-promoting behavior of the preschool children (aged 3-6 y) of Polish health care professionals (HCPs).

METHODS

The study was conducted by means of quantitative research on a group of 386 individuals, using an Internet-based survey.

RESULTS

The ideal cardiovascular health model was determined in the case of 22 children (5.6%). The collected data revealed that, when regarding the recommended level of physical activity, children from HCP families meet the American Heart Association criteria much more often than their peers from other study populations (56.5% vs. 16.6%). In our study, more girls than boys participated in organized activities (60.2% vs. 50.3%, p = 0.05). There was no correlation between achieving adequate levels of physical activity and the BMI (p > 0.1). Overweight children had a more balanced diet than children with a normal body weight (p = 0.009).

CONCLUSIONS

The obtained results allowed us to make the conclusion that there is a need to implement educational and preventive measures on a large scale, while some health-promoting behaviors, especially those concerning proper nutrition, require major modifications, even in HCP families.