Clinical spectrum of intrinsic renovascular hypertension in children
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S R Daniels1, J M Loggie, P T McEnery
1Department of Pediatrics, Children's Hospital Medical Center, Cincinnati, OH 45229-2899.
Insights
Renal arterial stenosis is a rare cause of hypertension in children, affecting 3% of evaluated patients. Management requires individualized treatment based on the specific cause and severity of the condition.
Area of Science:
- Pediatric Nephrology
- Pediatric Cardiology
- Vascular Biology
Background:
- Elevated blood pressure (BP) in children and adolescents is a growing concern.
- Hypertension services evaluate numerous pediatric patients, but specific causes like renovascular hypertension are less common.
- Intrinsic renal arterial stenosis is an underdiagnosed cause of secondary hypertension in pediatric populations.
Purpose of the Study:
- To identify the prevalence and characteristics of hypertension secondary to intrinsic renal arterial stenosis in children and adolescents.
- To explore the diverse etiologies, clinical presentations, and outcomes of renovascular hypertension in this age group.
- To evaluate the diagnostic utility of standard clinical assessments and the effectiveness of surgical versus medical management.
Main Methods:
- Retrospective study of pediatric patients evaluated for hypertension.
- Identification of cases with intrinsic renal arterial stenosis.
- Analysis of patient demographics, presenting blood pressure, etiologies, end-organ damage, diagnostic methods, and treatment outcomes.
Main Results:
- 27 children (3%) were diagnosed with hypertension secondary to intrinsic renal arterial stenosis, presenting with a mean BP of 171.6/114.2 mm Hg.
- Identified causes included fibromuscular dysplasia, arteritis, Williams syndrome, and trauma, among others.
- End-organ damage like left ventricular hypertrophy was prevalent; standard diagnostic tests were not effective in identifying renovascular lesions.
- Outcomes were variable for both surgical and medical management.
Conclusions:
- Intrinsic renal arterial stenosis is a significant, though infrequent, cause of severe hypertension in children.
- Diagnosis and management require a high index of suspicion and individualized approaches.
- Further research into optimal diagnostic and therapeutic strategies for pediatric renovascular hypertension is warranted.
Abstract:
In the past two decades, 853 children and adolescents have been evaluated for elevated BP as inpatients and outpatients by the hypertension service at Children's Hospital Medical Center, Cincinnati. Most children with hypertension secondary to coarctation of the aorta and all children with glomerulonephritis are managed by other services and are not included in that total. In a retrospective study, 27 children (3%) were identified as having hypertension secondary to intrinsic renal arterial stenosis. The age at presentation ranged from 5 months to 20 years. The mean BP at that time was 171.6/114.2 mm Hg. Ten categories of causes were identified, including fibromuscular dysplasia, arteritis, Williams syndrome, neurofibromatosis, congenital malformations, blunt abdominal trauma, surgical vascular trauma-irradiation, thrombosis, congenital rubella syndrome, and unknown. Overall, symptoms were not common. However, findings of end-organ response, such as left ventricular hypertrophy and retinal vascular abnormalities were prevalent. This is not surprising given the mean BP level at presentation. Physical examination, laboratory tests, and radiologic evaluations (exclusive of renal angiography) were not useful in detecting or identifying the location and extent of the renovascular lesions. Fourteen patients were treated surgically, and 13 were managed medically. The outcome was variable for both treatment modalities. The management of renovascular hypertension in children must be individualized depending on the cause, location, and severity of the lesion, as well as the size of the child. Some forms of renovascular pathology, particularly the arteritides, may resolve spontaneously, and children with these entities should have their BP treated medically until the inflammatory process has subsided.(ABSTRACT TRUNCATED AT 250 WORDS)