Cause Of Hypertension In Children Research Articles

At the bottom of the differential diagnosis list: unusual causes of pediatric hypertension

Hypertension affects 1–5% of children and adolescents, and the incidence has been increasing in association with obesity. However, secondary causes of hypertension such as renal parenchymal diseases, congenital abnormalities and renovascular disorders still remain the leading cause of pediatric hypertension, particularly in children under 12 years old. Other less common causes of hypertension in children and adolescents, including immobilization, burns, illicit and prescription drugs, dietary supplements, genetic disorders, and tumors will be addressed in this review.

Cold medication containing oral phenylephrine as a cause of hypertension in children

A 5-year-old girl presented hypertension [24-h blood pressure (BP) average 135/80 mmHg, above the 99th BP percentile], as confirmed by ambulatory BP monitoring, following the use of a cold preparation (2.5 ml every 8 h for 4 days) containing phenyephrine (1 mg/ml). There was a clear relationship between the administration of the medication and hypertension, and between normalized BP values (24-h BP average 109/66 mmHg, 90th percentile) and the withdrawal of the medication. Alternative causes of hypertension could not be found. This is the first reported case of children's hypertension related with oral administration of phenylephrine. The potential risk of medicines containing sympathomimetic drugs should not be underestimated, and cold preparations should be included in the differential diagnosis of the etiology of hypertension in children.

Feocromocitoma: uma causa rara de hipertensão arterial na infância

OBJETIVO: Relatar o caso de um adolescente com feocromocitoma, uma causa rara de hipertensão arterial na infância. DESCRIÇÃO: Adolescente internado em unidade de terapia intensiva infantil em decorrência de emergência hipertensiva, conseqüente à presença de feocromocitoma em adrenal esquerda, diagnosticado por meio de tomografia computadorizada do abdome e pela dosagem de adrenalina e noradrenalina urinárias. O paciente foi submetido à adrenalectomia esquerda, após o uso de alfa-bloqueador para controle do quadro hipertensivo. O anatomopatológico confirmou o diagnóstico do tumor. No pós-operatório, o paciente permaneceu estável, possibilitando a suspensão dos anti-hipertensivos. COMENTÁRIOS: Os feocromocitomas são tumores capazes de produzir catecolaminas, especialmente adrenalina e/ou noradrenalina. Cerca de 85 a 95% dos tumores são únicos, benignos e encontrados na medula adrenal. O feocromocitoma é um tumor de incidência rara e apenas 10 a 20% ocorrem na infância, representando uma causa rara de hipertensão arterial. Esta última é um sinal freqüente na maioria das crianças (80%), podendo ser acompanhada por cefaléia e sudorese. A encefalopatia hipertensiva consiste em uma forma de apresentação excepcional da doença. O diagnóstico pode ser realizado, na maioria dos casos, pela tomografia de abdome e pela dosagem das catecolaminas e seus metabólitos produzidos pelo tumor. O tratamento de escolha consiste na ressecção completa do tumor após o preparo farmacológico do paciente com o uso de alfa-bloqueador. No pós-operatório, a maioria dos pacientes evolui com controle do quadro de hipertensão arterial.

Conditions Mimicking Coarctation of the Aorta

Coarctation of the aorta is a cause of right arm hypertension in children and of heart failure in infants after ductal closure. We present two cases with these presentations that were initially thought to be coarctation of the aorta. They were subsequently diagnosed as Takayasu's arteritis in the older child and a large cerebral arteriovenous malformation in the infant. These conditions should be in the differential of right arm hypertension and of aortic flow reversal on echocardiography.

Novel Concepts in the Pathogenesis and Management of Pediatric Hypertension

Hypertension is a major cause of morbidity and mortality throughout the world and an independent risk factor for cardiovascular disease. Although the incidence of hypertension is significantly greater in adults than children, recent trends reveal a rising percentage of children with high blood pressure. Coincident with the dramatic increase of the number of children with hypertension has been a growing field of knowledge regarding novel causes and therapeutic options for children with high blood pressure. Most reviews in pediatric hypertension focus on the many traditional causes of hypertension in children including renovascular disease, renal parenchymal disease, medication usage, endocrine causes (e.g. hyperthyroidism), and cardiovascular causes (e.g. coarctation of the aorta). However, recent research suggests that nontraditional causes of hypertension including chronic inflammation, low nephron number, prematurity/low birth weight, malnutrition, obesity (as part of the metabolic syndrome), hyperinsulinemia/insulin resistance, elevated uric acid, and dietary factors may be more common than previously thought. There are also innovative concepts in the treatment of childhood hypertension, including behavioral and combination drug therapy. In a rapidly evolving field and epidemic of children developing high blood pressure, it is therefore imperative for the generalist and specialist to be cognizant of the many changes occurring in the pathogenesis and management of childhood hypertension.

HYPERTENSIVE ENCEPHALOPATHY INDUCED BY MERCURY POISONING; A REPORT OF 3 CASES (IN AN IRANIAN FAMILY)

Objective Mercury poisoning is one of the important recent causes of mortality and mortality in children worldwide, particularly in industrial environments; mercury is a poisonous metal, especially harmful to the nervous and immune systems and the kidneys and can even be fatal. Elemental mercury is present in thermometers, barometer batteries, sphygmomanometers and latex paints. Inorganic mercury salts are found in antiseptics, pesticides, pigments and explosives and are used as preservatives in medicine. Mercury was once used to stop fever, and this worked because the immune system was so weakened that it could no longer sustain the attack for which the fever was created. Some medical drugs still contain mercury chloride and mercurous chloride and certain forms of mercury are still used in some laxatives. Mercury toxicity of the nervous system causes anorexia, ataxia, lack of ability to coordinate voluntary muscle movements, dementia, depression, dizziness, emotional instability, erethism (abnormal irritability in response to stimulation), incoordination, insomnia, irritability, loss of ability to speak, memory impairment, numbness, saresthesias (sensation of prickling, tingling or creeping on the skin), psychosis, tremors, drowsiness, fatigue and weakness. Other organ damages include kidney failure, headaches, hearing impairment, visual impairment, hypertension, dermatitis, digestive tract problems, colitis, diarrhea, stomatitis and excessive salivation, loss of teeth, metallic taste, chromosomal damage, birth defects and ensuing organ failure. Chronic mercury poisoning can cause Acrodynia (Pink disease). Mercury poisoning is a rare cause of hypertension in children. Herein we report 3 cases, the first a child with hypertensive encephalopathy due to severe mercury poisoning and his two siblings with moderate symptoms. Case report A 10 year old boy was admitted in psychiatric ward of Imam Hossein Hospital with behavioral disorder, irritability, mood change and convulsion. Because of his blood pressure which was 160/120 he was referred and admitted to the Pediatric Nephrology department. On arrival, for his hypotonia and the pink discoloration of his fingers a diagnosis of Acrodynia (Pink disease) was considered; his history showed that he has played with a ball of mercury, taken from a laboratory. He and his 2 siblings received British Anti Lewisite(BAL) and D-penicillamin; at follow-up all symptoms had gradually disappeared and they are well now. Keywords: Mercury poisoning, Children, Renal complications, Hypertensive encephalopathy

Spontaneous intracerebral haemorrhage caused by extra-adrenal phaeochromocytoma

We report an 18-year-old man who presented with a sudden onset of headache followed by left hemianopia. A brain CT scan showed intracerebral haemorrhage in the left frontoparietal area, but a cerebral angiogram and MRI revealed no vascular anomaly. The patient was managed conservatively and his headache and visual loss improved over time. Hypertension in the form of paroxysmal attacks led us to suspect phaeochromocytoma. Subsequently, the patient was diagnosed with an extra-adrenal phaeochromocytoma in the left para-aortic area following endocrinological evaluation, abdominal CT scan and 131I-meta-iodobenzylguanidine (MIBG) scintigraphy. The patient presented here illustrates the importance of a careful search for a remediable cause of hypertension in children and young adults with spontaneous intracerebral haemorrhage.

Multicystic renal dysplasia of lower moiety in a duplicated system causing hypertension

Multicystic renal dysplasia is an extremely uncommon cause of hypertension in children. Ipsilateral duplication anomalies associated with multicystic kidney have rarely been reported. Hypertension associated with multicystic kidney has been reported previously in a few cases but on Medline search no report was found where hypertension was associated with segmental multicystic dysplasia in a duplicated system. We report a one-year-old girl in whom hypertension was associated with left partial duplicated system and lower moiety multicystic dysplasia. After lower pole heminephrectomy the hypertension resolved and remained so at six months follow-up. In our knowledge this is the first report of its type.

Experience with surgical excision in childhood pheochromocytoma.

Pheochromocytoma is one of the potentially fatal causes of childhood hypertension. The study aims to analyze the results of our experiences in pheochromocytomas and the long-term results of its surgical treatment in children. The records of 15 children (11 boys, 4 girls) treated for pheochromocytoma in our unit during the period of 1984 and 2002 were reviewed retrospectively. The average age at surgery was 11.7 yr (range 6 yr 9 months-15 yr 7 months). Localized disease is defined as the cases without the invasion of surrounding tissue, regional disease as the invasion of surrounding tissue and metastatic disease as distant metastases. The mean follow-up after pheochromocytoma excision was 95 months (range 5 to 221 months). Tumors were located in the adrenal gland in 11 (bilaterally in 4) and extra-adrenally in 4. Localized disease occurred in 14 patients and regional disease in one. Only one patient was associated with von Hippel Lindau syndrome. Adrenalectomy or total excision of extra adrenal tumor was performed. Four patients (26.7%) recurred after the first operation (at 2 yr 9 months to 14 yr) and regional disease recurred in one patient three times. Early diagnosis, surgical excision, and long-term follow up are most important for the appropriate treatment of childhood pheochromocytoma.

Hypertension in children and adolescents: definition, pathophysiology, risk factors, and long-term sequelae

Background: Awareness of hypertension as an adult public health issue has increased dramatically during the past 3 decades, leading to substantial decreases in morbidity and mortality related to stroke and coronary artery disease. Awareness of blood pressure issues in the pediatric population also has increased, leading to conceptual changes in the diagnosis and treatment of childhood hypertension. The current focus has shifted to early identification of mild to moderate hypertension in asymptomatic, otherwise healthy children and adolescents. Objective: The purpose of this article was to define hypertension in the pediatric population and describe the secondary causes of childhood hypertension, risk factors and potential pathophysiology of essential hypertension in childhood, and the long-term sequelae for individuals with hypertension identified during childhood. Methods: Information regarding pediatric hypertension was identified through a MEDLINE ® search of the literature from 1985 to 2000. Results: Definitions of pediatric hypertension have been carefully refined over the past 30 years, and normative data are available for children and adolescents, based on age, sex, and height. Childhood hypertension may be identified during evaluation of an acutely ill child, but is increasingly identified during routine blood pressure screening, particularly in adolescents. Although, historically, most pediatric hypertension was believed to be secondary in origin (related to an identifiable underlying disorder), recent data suggest that almost 90% of hypertensive adolescents have essential hypertension. The proposed factors that may be involved in the pathophysiology of essential hypertension include familial and genetic influences, race, and salt sensitivity. Although an essential hypertension gene has not yet been identified, several monogenic forms of hypertension have been described, which may account for a minority of individuals with presumed essential hypertension. In addition, a number of candidate genes that may be involved in the complex genetic susceptibility to hypertension have been described. There is growing evidence concerning adverse long-term consequences of hypertension identified in childhood and adolescence, including increased incidence of cardiovascular and coronary heart disease. Conclusions: Based on the generally accepted concept that essential hypertension begins in childhood, early optimization of blood pressure control in childhood may reduce an individual's lifetime risk of cardiovascular morbidity and mortality. In addition, aggressive treatment of cardiovascular risk factors during childhood and adolescence may have a major impact on the prevalence of adult cardiovascular disease.

Evaluation and management of hypertension in childhood

Hypertension, a relatively uncommon problem in childhood except in certain groups of children, is an important cardiovascular risk factor that can have significant health implications, especially the tendency for an elevated blood pressure in childhood to predict the development of adult hypertension. Common causes of childhood hypertension include renal and cardiac disease, as well as essential hypertension in adolescents. Given these factors, it is usually possible to evaluate the hypertensive child in a focused manner that should reveal not only the underlying cause of hypertension, but also its severity. Treatment should incorporate non-pharmacologic approaches as well as antihypertensive medications, and should take into account other cardiovascular risk factors such as hyperlipidemia. This review highlights these and other important issues in the evaluation and management of hypertensive children, and provides practical guidance to the practitioner involved in caring for such patients.

02-7 Utility of CT renal angiogram in the evaluation of correctable causes of childhood hypertension

02-7 Utility of CT renal angiogram in the evaluation of correctable causes of childhood hypertension

Aldosterone-producing adrenocortical adenoma in childhood: A case report

Aldosterone-producing adrenal tumor is an exceptional cause of hypertension in childhood. The authors describe an 11-year-old girl with hypertension and lower limb weakness who had hyperaldosteronism and left adrenocortical adenoma.

The investigation of renovascular hypertension in children: the accuracy of radio-isotopes in detecting renovascular disease.

Renovascular disease is an important cause of hypertension in children because it is potentially treatable by surgical or angioplasty techniques. The aim of this study was to assess the accuracy of radio-isotopes (DMSA, DTPA and MAG3) combined with the angiotensin converting enzyme inhibitor, captopril, in detecting children with renovascular hypertension. We retrospectively reviewed the ultrasound and pre- and post-captopril radionuclide studies (either DMSA and/or DPTA and/or MAG3) of children with sustained hypertension investigated at our institution. Renal angiography was used as the 'reference technique'. Thirty-nine children, over a period of 10 years, were evaluated: 17 (44%) children had renovascular disease that involved the proximal three divisions of the renal arteries, some of which were amenable to treatment. The overall sensitivity, specificity, positive predictive value and negative predictive value for detecting such renovascular disease, as assessed by changes between pre- and post-captopril radio-isotope studies, were disappointing at 59%, 68%, 59% and 68%, respectively. When considering only abnormalities in post-captopril studies, these indices were 82%, 41%, 52% and 75%, respectively. Three children with potentially treatable renovascular disease were not identified on the captopril studies. We conclude that renal angiography should remain the 'reference technique' in identifying children suspected of renovascular hypertension.

Epidemiology of Hypertension in children in a inner city population. 1637

High blood pressure in children is usually due to secondary causes and deserves further workup. There are very few reports in recent literature on the epidemiology of Pediatric hypertension. We conducted a retrospective analysis to survey the etiology of hypertension in our largely non-Caucasian inner city population and were able to identify 129 children with hypertension. Sex distribution was almost identical with 67 (52%) males and 62(48%) females. Of the 129 children with hypertension 78 (60.5%) were African American, 35 (27%) Hispanic, 12 (9%) Caucasian and 4 (3%) Other. The age distribution was 7% for 0-1 yrs, 24% for 1-6 yrs, 24% for 6-12 yrs, 45% for 12-18 yrs. Glomerulonephritis was the primary diagnosis in 66 (51%) patients followed by Primary Hypertension in 28 (22%) and Renal Dysplasia/ Hypoplasia in 9 (7%). Further analysis of the 66 children with Glomerulonephritis revealed Focal Segmental Glomerulosclerosis to be the commonest lesion found in 25 (36%) patients, Lupus Nephritis in 22 (17%) and IgM Nephropathy in 5(8%). Reno- vascular lesions was the commonest cause of hypertension in children between 0-1 yrs of age. Glomerulonephritis was the most frequent lesion in all other age groups. Primary Hypertension was more prevelant in older children and was frequently associated with obesity and Diabetes Mellitus. Table

Pediatric renovascular hypertension

Renovascular disease is a frequent cause of severe hypertension in children and may result in significant morbidity or mortality. Most children presenting with renovascular hypertension have few if any symptoms, but devastating neurologic injury and congestive heart failure are still too often observed. Several new radiographic techniques have been used to detect renovascular lesions, but none has yet demonstrated consistently superior results when compared with intra-arterial digital subtraction angiography. Renal venous renin sampling, duplex ultrasonography, and captopril-enhanced renal scintigraphy may be useful diagnostic adjuncts. Therapeutic objectives include cure of hypertension and restoration or preservation of renal function. At many institutions, percutaneous transluminal angioplasty has become the treatment of choice for patients with renal transplant artery stenosis and discrete, nonostial stenoses caused by fibromuscular dysplasia. More extensive lesions generally respond well to surgical correction. Chronic pharmacologic therapy is reserved for patients who do not respond to angioplasty or in cases in which the location or extent of involvement of the renal arterial system precludes surgical revascularization. Nephrectomy is usually reserved for kidneys that have minuscule function of irreparable vascular anomalies. An individualized approach to therapy is increasingly emphasized.

Vesicoureteral reflux in children

The association between vesicoureteral reflux and urinary tract infection represents a significant threat to the kidney, in the form of pyelonephritic scarring. The physiopathologic events that allow the upward migration of bacteria and their inoculation in the renal tissue, causing irreversible damage if not adequately treated, are reasonably understood. Reflux nephropathy is a major cause of childhood hypertension and renal insufficiency. Early diagnosis of reflux, and identification of the pyelonephritic aggression are important for successful therapy. Long-term chemoprophylaxis,to prevent urinary tract infection and renal scarring is the adequate form of treating low-grade vesicoureteric reflux, since spontaneous cure is expected in most of these cases. Although the same approach can be employed in high-grade reflux, surgery is a favorable alternative, with high rates of primary success,reducing the need of long-term medication and the exposure of the kidney to recurring pyelonephritic aggression. The retrograde flow of urine from the bladder to the upper urinary tract is an abnormal situation in the human being, known as vesicoureteral reflux (VUR). It results either from an intrinsic anatomical deficiency of the vesicoureteral junction or from an increased bladder pressure, due to mechanical or dysfunctional vesicourethral obstruction. The recognition of the association between VUR, urinary tract infection (UTI) and renal scars has led to an increased study of this disease in the last two decades.

Hypertension artérielle par intoxication au mercure: intérêt diagnostique du captopril

background. - Mercury poisoning is a rare cause of hypertension in children. Urinary excretion sometimes remains low despite severe clinical intoxication. Case report. - A 23 month-old girl was admitted with hypertension, tachycardia, apathy, irritability and excessive sweating. Erythromelalgia and neurologic symptoms permitted the diagnosis of acrodynia. Urine mercury remained normal until chelation. Captopril significantly increased urine mercury concentration but failed to improve clinical manifestations. Clinical improvement required infusions of BAL® for 5 days then oral dimer-captosuccinic acid for 3 months. Metal vapors originated from the mercury which spilled from a broken thermometer onto the carpet. Comments. - Low basal urine mercury could be associated with real mercury poisoning. Small amounts of metal mercury held in a thermometer could produce a high level of mercury vapor leading to intoxication in young children. The binding capacity of metal ions by captopril could be used to increase urine mercury output. Nevertheless, captopril therapy fails to improve acrodynia. Total elimination of mercury requires long-term therapy with BAL® or dimercaptosuccinic acid. Conclusions. - An unexpected mode of intoxication and low basal urine mercury are not decisive arguments against mercury poisoning, which is the only cause of acrodynia.

Aldosteronoma in childhood: A review of clinical features and management

Primary hyperaldosteronism is rare in children and usually results from bilateral adrenocortical hyperplasia. Adrenal adenoma causing primary hyperaldosteronism (aldosteronoma) in children is even rarer, with only eight reported cases in children under 18 years of age. Aldosteronoma is a very rare, correctable cause of childhood hypertension. A review of all the reported cases, including that of the authors, is presented. Also discussed are the available biochemical and radiological investigations, the preoperative medical management, the surgical treatment, and the postoperative management.

Etiology of sustained hypertension in children in the southwestern United States.

We reviewed the records of 132 children with persistent hypertension who were evaluated by our pediatric nephrology services between 1987 and 1991. Eighty-nine (67%) of these children were found to have renal or renovascular disease, 30 (23%) had primary hypertension and 13 (10%) had a non-renal cause for their hypertension. Glomerulonephritis (n = 37) and reflux nephropathy (n = 26) were the most frequent renal disorders identified. Renal artery thrombosis was the most common cause of hypertension in the neonatal period (in 6 of 12 neonates, 50%) whereas cystic kidney disease was the most common cause of hypertension in the 1st year of life (in 9 of 30 infants, 30%). The prevalence of primary hypertension increased with age; this diagnosis was made in 16 of 46 (35%) hypertensive patients between 12 and 18 years of age and, more surprisingly, in 8 of 27 (30%) children between 7 and 11 years of age. These data confirm that secondary hypertension is the most common cause of hypertension in children but suggest that primary hypertension is more prevalent than previously recognized in patients between 7 and 18 years of age.