1. World Kidney Day 2016: Kidney Disease & Children
World Kidney Day 2016: Kidney Disease & Children. Act Early to Prevent It!

2. World Kidney Day 2016: Kidney Disease & Children
World Kidney Day 2016: Kidney Disease & Children. Act Early to Prevent It!
Kidney disease affects millions of people worldwide, including many children who may be at risk at an early age. It is therefore crucial that we encourage and facilitate education, early detection and a healthy life style in children, to fight the increase of preventable kidney diseases and to treat children with inborn and acquired disorders of the kidneys worldwide.

3. Pediatric Kidney Disease – An Update
Edited by the ASPN Clinical Affairs Committee

4. Hypertension (HTN) Tammy Brady, MD, PhD
Johns Hopkins Children’s Center

5. HTN: Background Health care providers: Do not routinely measure BP
Epidemiology
1970’s and 1980’s: 0.3%-1.2% of children had HTN
Current Estimates:
3-5% of all children have HTN
3-24% of all children are pre-hypertensive
Prehypertension hypertension at a rate of 7% per year
20-47% of obese children are hypertensive
Prevalence of HTN in children increases with increasing BMI percentile
Underestimate of disease?
Providers don’t routinely measure BP
Providers don’t routinely recognize BP elevations
Health care providers:
Do not routinely measure BP
2/3 of the time during WCV
1/3 of the time during sick visits
Under-recognize elevated BP
Over 6 months: 39% pediatric visits had an elevated BP
87% of these encounters were unrecognized by providers

6. HTN: Definition Sustained elevation in BP ≥95th percentile or ≥140/90
Any BP ≥ 90th percentile (or ≥120/80) should be repeated manually x2, with the average recorded
95th percentile
90th percentile
or 120/80
99th percentile
99th percentile + 5 mmHg
NORMAL BP
PRE-HYPERTENSION
STAGE 1 HYPERTENSION
STAGE 2 HYPERTENSION
Children 1-17 years
140/90
120/80
160/100
NORMAL BP
PRE-HYPERTENSION
STAGE 1 HYPERTENSION
STAGE 2 HYPERTENSION
Adolescents ≥18 years
normal blood pressure increases with age, height and BMI
Presence of systemic illness associated with HTN (neurofibromatosis, tuberous sclerosis)

7. HTN: Technique is important!

8. HTN: New developments Update!
Updated guideline for the evaluation of elevated blood pressure in children and adolescents
Sponsored by the American Academy of Pediatrics
Multidisciplinary committee
Increased CVD risk with pre-hypertension?
Need for lower BP thresholds to decrease CVD risk?
SHIP-AHOY
The Population project -> investigate BP thresholds for development of hypertensive target organ damage (TOD)
The Clinical Project -> characterize the ambulatory BP and metabolic phenotype best predicting TOD.
The Basic Project -> investigate epigenetic changes that influence the development of TOD in youth with HTN.

9. HTN: New developments Ability to identify target organ damage
Echocardiography – measure LVMI, RWT
Detect LVH (eccentric and concentric) - > initiate antihypertensive therapy
Detect concentric remodeling
Neurocognitive testing – assess executive function, attention
Radial artery applanation tonometry – measure central vascular pressure
More accurate predictor of CVD outcome than peripheral BP
Peripheral pressure does not accurately reflect central pressure 2/2 pressure amplification
BP meds have different effects on central BP despite similar effect on peripheral BP
Pulse Wave Velocity – measure central arterial stiffness
Augmentation Index – measure peripheral arterial stiffness

10. HTN: New developments Obesity prevalence and role in HTN HYPERTENSION
Prevalence of obesity in 2-19 years olds remains high at 17% and has not changed significantly based on NHANES data.
BP tables: 21% of this normative data comes from obese/ overweight children
Obstructive sleep apnea common
Dysfunctional adipocyte -> imbalance in expression of pro- and anti-inflammatory adipokines -> Hypertension
Adipose Tissue Dysfunction:
Macrophage infiltration
Increased FFA
Hyperleptinemia
Adiponectin deficiency
Increased resistin
RAAS hormone secretion
Mineralocorticoid stimulating factor
RAAS Activation
SNS Activation
Oxidative stress and Inflammation
Endothelial dysfunction
Impaired pressure natriuresis
Vascular hypertrophy
HYPERTENSION
Dorresteijn et al, Obesity Reviews, 2012.

11. HTN: Key Points J Pediatr. 2015 Sep 2. doi: 10.1016
Role of healthy lifestyle - nature and nurture
Resolution of elevated BP in transition from childhood to adulthood appeared to be partially determined by modifiable factors including “fruit and vegetable intake, physical activity, cardiorespiratory fitness, alcohol consumption, smoking, and socioeconomic status”
BP in childhood and the gain in BMI from childhood to adulthood are significant predictors of adult hypertension in both genders.
Genetic risk score in women and risky alcohol consumption in men are independently related with the risk of adult hypertension.
Meeting current physical activity recommendations (≥ 60 minutes/day) is able to attenuate the deleterious effect of genetic polymorphism on systolic blood pressure in European adolescents.
J Pediatr Sep 2. doi:
PLoS One Oct 14;9(10):e

12. HTN: Therapies

13. HTN: Therapies
PEDIATRICS Volume 128, Supplement 5, December 2011
This publication provides comprehensive tables regarding anti-hypertensive medications in children. Example:
The Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents: Summary Report published in Pediatrics in 2011 has two tables of “Antihypertensive Medications with Pediatric Experience”
Likely more to be added to this table with the Food and Drug Association Modernization Act (FDAMA)
- Some medications now have FDA approved pediatric labelling
- New clinical trials have provided needed data regarding drug dosing and metabolism

14. HTN: Summary
Hypertension in children is likely underrecognized due to infrequent and improper measurement
Proper measurement technique is vital!
Studies are underway to better understand the long-term impact of hypertension in children
Appropriate lifestyle modifications and pharmacologic therapy will be the key to limiting long-term health effects

15. Happy World Kidney Day 2016!
Your pediatric nephrology community continues to work hard to improve clinical care, foster education, and advance the science regarding kidney disease in children! We appreciate your support and all you do for children’s health care!