Page 1108 - TNFlipTest

P74 Pediatrics
Nephrology Toronto Notes 2019
Prognosis
• generallygood:80%ofchildrenresponsivetocorticosteroids
• upto2/3experiencerelapse,oftenmultipletimes;sustainedremissionwithnormalkidneyfunction
usually by adolescence
• complications: h risk of infections (spontaneous peritonitis, cellulitis, sepsis); hypercoagulability
due to decreased intravascular volume and antithrombin III depletion (PE, renal vein thrombosis); intravascular volume depletion, leading to hypotension, shock, renal failure; side effects of drugs
Hypertension in Childhood
Definition
• HTN:sBPand/ordBP≥95thpercentileforsex,age,andheighton≥3occasions
• pre-HTN:sBPand/ordBP≥90thpercentilebut<95thpercentileorBP≥120/80irrespectiveofage,
gender, and height
Table 35. 95th Percentile Blood Pressures (mmHg)
Age (Yr)
1 6 12
17
Female
50th Percentile for Height
104/58 111/74 123/80
129/84
75th Percentile for Height
105/59 113/74 124/81 130/85
Male
50th Percentile for Height
103/56 114/74 123/81 136/87
75th Percentile for Height
104/57 115/75 125/82 138/87
Adapted from: the Fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. National Heart, Lung and Blood Institute. National Institutes of Health. May 2004.
Epidemiology
• prevalence:3-5%forHTN,7-10%forpre-HTN;M>F • increasingprevalenceofpre-HTNoverthelast25+yr
Etiology
• primaryHTN
■ diagnosis of exclusion
■ most common in older children (≥10 yr), especially if positive family history, overweight, and only
mild HTN
■ responsible for ~90% of cases of HTN in adolescents, rarely in young children
• secondaryHTN
■ identifiable cause of HTN (most likely etiology depends on age) ■ responsible for majority of childhood HTN
• alwaysconsiderwhitecoatHTNforallages
Table 36. Etiology of Secondary HTN by Age Group
System
Endocrine/ Metabolic
Renal Vascular Drugs
Neonates
CAH
Congenital renal disease
Coarctation of the aorta Renal artery thrombosis
1 mo-6 yr
Wilms’ tumour (hrenin) Neuroblastoma
(h catecholamines)
Renal parenchymal disease
Coarctation of the aorta RAS
Corticosteroids Cyclosporine and tacrolimus
7-12 yr
Endocrinopathies*
Renal parenchymal disease
Renovascular abnormalities
Corticosteroids OCP Cyclosporine and tacrolimus
>13 yr
Endocrinopathies*
Renal parenchymal disease
Corticosteroids
OCP
Cyclosporine and tacrolimus Recreational drugs (amphetamines, cocaine, etc.)
Signs of Secondary HTN
• Edema (renal parenchymal disease)
• Abdominal or renal bruit (RAS)
• Differential 4 limb BP/diminished femoral
pulses (coarctation)
• Abdominal mass (Wilms’, neuroblastoma)
• Goitre/skin changes (hyperthyroidism)
• Ambiguous genitalia (CAH)
*Note: may include hyperthyroidism, hyperparathyroidism, Cushing’s syndrome, primary hyperaldosteronism/Conn’s syndrome, pheochromocytoma
Risk Factors
• primaryHTN:malegender,positivefamilyhistory,obesity,obstructivesleepapnea,AfricanAmerican, prematurity/LBW
• secondaryHTN:historyofrenaldisease,abdominaltrauma,familyhistoryofautoimmunediseases, umbilical artery catheterization