Pediatric Nephrology

, Volume 27, Issue 5, pp 741–751 | Cite as

Hypertensive crisis in children

Educational Review

Abstract

Hypertensive crisis is rare in children and is usually secondary to an underlying disease. There is strong evidence that the renin-angiotensin system plays an important role in the genesis of hypertensive crisis. An important principle in the management of children with hypertensive crisis is to determine if severe hypertension is chronic, acute, or acute-on-chronic. When it is associated with signs of end-organ damage such as encephalopathy, congestive cardiac failure or renal failure, there is an emergent need to lower blood pressures to 25-30% of the original value and then accomplish a gradual reduction in blood pressure. Precipitous drops in blood pressure can result in impairment of perfusion of vital organs. Medications commonly used to treat hypertensive crisis in children are nicardipine, labetalol and sodium nitroprusside. In this review, we discuss the pathophysiology, differential diagnosis and recent developments in management of hypertensive crisis in children.

Keywords

Hypertension Hypertension crisis Hypertensive urgency Children Antihypertensive therapy 

Notes

References

  1. 1.
    Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ (2004) Overweight, ethnicity and the prevalence of hypertension in school aged children. Pediatrics 113:475–482PubMedCrossRefGoogle Scholar
  2. 2.
    National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents (2004) The Fourth Report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 114:555–576Google Scholar
  3. 3.
    Lurbe E, Cifkova R, Cruickshank JK, Dillon MJ, Ferreira I, Invitti C, Kuznetsova T, Laurent S, Mancia G, Moralesa-Olivas F, Rascher W, Redon J, Schaefer F, Seeman T, Stergiou G, Wühl E, Zanchetti A (2009) Management of high blood pressure in children and adolescents: recommendations of the European Society of Hypertension. J Hypertens 27:1719–1742PubMedCrossRefGoogle Scholar
  4. 4.
    National Heart, Lung, and Blood Institute (2003) The seventh report of the Joint National Committee on Detection, Evaluation and Treatment of High Blood Pressure. Hypertension 42:1206Google Scholar
  5. 5.
    Roman RJ (2003) Autoregulation of blood flow. In: Izzo JL, Black HR (eds) Hypertension primer: the essentials of high blood pressure, 3rd edn. Council for High Blood Pressure Research, American Heart Association/Lippincott-Williams & Wilkins, Philadelphia, pp 114–117Google Scholar
  6. 6.
    Houston M (1989) Pathophysiology, clinical aspects and treatment of hypertensive crisis. Progr Cardiovasc Dis 32:99–148CrossRefGoogle Scholar
  7. 7.
    Laragh JH, Ulick S, Januszewicw V, Deming QB, Kelly WG, Lieberman S (1960) Aldosterone secretion and primary and malignant hypertension. J Clin Invest 139:1091–1106CrossRefGoogle Scholar
  8. 8.
    Laragh JH, Angers M, Kelly WG, Lieberman S (1960) Hypotensive agents and pressor substances. The effect of epinephrine, Angiotensin II and others on the secretory rate of aldosterone in man. JAMA 174:293–295PubMedCrossRefGoogle Scholar
  9. 9.
    Geise J (1977) The renin angiotensin system and the pathogenesis of vascular disease in malignant hypertension. Clin Sci Mol Med 3:19s–21sGoogle Scholar
  10. 10.
    Fleming S (2000) Malignant hypertension—the role of the paracrine renin-angiotensin system. J Pathol 192:135–139PubMedCrossRefGoogle Scholar
  11. 11.
    Mohring J, Mohring P, Petri M, Hack D (1977) Vasopressor role of ADH in the pathogenesis of malignant DOC hypertension. Am J Physiol 232:F260–F269PubMedGoogle Scholar
  12. 12.
    Madeddu P, Emanueli C, El-Dahr S (2007) Mechanisms of disease: the tissue kallikrein-kinin system in hypertension and vascular remodeling. Nat Clin Pract Nephrol 3:208–221PubMedCrossRefGoogle Scholar
  13. 13.
    Kincaid-Smith P (1980) Malignant hypertension: mechanisms and management. Pharmacol Ther 9:245–269PubMedCrossRefGoogle Scholar
  14. 14.
    Katholi RE, Winternitz SR, Oparil S (1981) Role of the renal nerves in the pathogenesis of one-kidney renal hypertension in the rat. Hypertension 3:404–409PubMedGoogle Scholar
  15. 15.
    Oparil S (1986) The sympathetic nervous system in clinical and experimental hypertension. Kidney Int 30:437–452PubMedCrossRefGoogle Scholar
  16. 16.
    Mathias CJ, Wilkinson A, Lewis P, Peart WS, Sever PS, Snell ME (1983) Clonidine lowers blood pressure independently of renin suppression in patients with unilateral renal stenosis. Chest 83:357–359PubMedGoogle Scholar
  17. 17.
    Zimmerman BG (1981) Adrenergic facilitation by angiotensin: does it serve a physiological function. Clin Sci 60:343–348PubMedGoogle Scholar
  18. 18.
    Whitworth CE, Fleming S, Cumming AD, Morton JJ, Burns NJ, Williams BC, Mullins JJ (1994) Spontaneous development of malignant phase hypertension in transgenic Ren-2 rats. Kidney Int 46:1528–1532PubMedCrossRefGoogle Scholar
  19. 19.
    Montgomery HE, Kiernan LA, Whitworth CE, Fleming S, Unger T, Gohlke P, Mullins JJ, McEwan JR (1998) Inhibition of tissue angiotensin converting enzyme activity prevents malignant hypertension in TGR (mREN2)27. J Hypertens 16:635–643PubMedCrossRefGoogle Scholar
  20. 20.
    Patterson ME, Mouton CR, Mullins JJ, Mitchell KD (2005) Interactive effects of superoxide anion and nitric oxide on blood pressure and renal hemodynamics in transgenic rats with inducible malignant hypertension. Am J Physiol Renal Physiol 289:754–759CrossRefGoogle Scholar
  21. 21.
    Marvar PJ, Thabet SR, Guzek TJ, Lob HE, McCann LA, Weyand C, Gordon FJ, Harrison DG (2010) Central and peripheral mechanisms of T-lymphocyte activation and vascular inflammation produced by angiotensin II-induced hypertension. Circ Res 107:263–270PubMedCrossRefGoogle Scholar
  22. 22.
    Leumann EP, Bauer RP, Slaton PE, Biglieri EG, Holliday MA (1970) Renovascular hypertension in children. Pediatrics 46:362–370PubMedGoogle Scholar
  23. 23.
    Brody MJ, Johnson AK (1980) Role of the antero-ventral third ventricle region in fluid and electrolyte balance, arterial pressure regulation, and hypertension. Front Neuroendocrinol 6:249–292Google Scholar
  24. 24.
    Zhang B, Xing C, Yu X, Sun B, Zhao X, Qian J (2008) Renal thrombotic renal thrombotic microangiopathies induced by severe hypertension. Hypertens Res 31:479–483PubMedCrossRefGoogle Scholar
  25. 25.
    Zubrow AB, Hulman S, Kushner H, Falkner B (1995) Determinants of blood pressure in infants admitted to neonatal intensive care units: a prospective multicenter study. J Perinatol 15:470–479PubMedGoogle Scholar
  26. 26.
    Flynn JT (2000) Neonatal hypertension: diagnosis and management. Pediatr Nephrol 14:332–341PubMedCrossRefGoogle Scholar
  27. 27.
    Calenda E, Richez F, Muraine M (2007) Acute hypertension due to phenylephrine eyedrops in a newborn. Can J Opthalmol 42:486CrossRefGoogle Scholar
  28. 28.
    Baker MD (1986) Theophylline toxicity in children. J Pediatr 109:538–542PubMedCrossRefGoogle Scholar
  29. 29.
    Saland JM, Mahony L, Baum M (2001) Perinatal renal ischemia resulting in hypertensive cardiomyopathy. Pediatrics 107:185–186PubMedCrossRefGoogle Scholar
  30. 30.
    Brody SL, Slovis CM, Wrenn KD (1990) Cocaine related medical problems: Consecutive series of 233 patients. Am J Med 119:226–235Google Scholar
  31. 31.
    Drees JC, Stone JA, Wu AHB (2009) Morbidity involving the hallucinogenic amines MDA and 2C-I. J Forensic Sci 54:1485–1487PubMedCrossRefGoogle Scholar
  32. 32.
    Armstrong EP, Malone DC (2003) The impact of nonsteroidal anti-inflammatory drugs on blood pressure with an emphasis on newer agents. Clin Ther 25:1–18PubMedCrossRefGoogle Scholar
  33. 33.
    Mitsnefes M, Stablein D (2005) Hypertension in pediatric patients on long-term dialysis: A report of the North American Pediatric Renal Transplant Cooperative Study (NAPRTCS). Am J Kidney Dis 45:309–315PubMedCrossRefGoogle Scholar
  34. 34.
    Horl MP, Horl WH (2002) Hemodialysis-associated hypertension: pathophysiology and therapy. Am J Kidney Dis 39(2):227–244PubMedCrossRefGoogle Scholar
  35. 35.
    Vonend O, Rump LC, Ritz E (2008) Sympathetic overactivity—the Cinderella of cardiovascular risk factors in dialysis patients. Semin Dial 21:327–330CrossRefGoogle Scholar
  36. 36.
    Meyers K, Falkner B (2009) Hypertension in children and adolescents: an approach to management of complex hypertension in pediatric patients. Curr Hypertens Rep 11:315–352PubMedCrossRefGoogle Scholar
  37. 37.
    Tullus K, Brennan E, Hamilton G, Lord R, McLaren CA, Marks SD, Roebuck DJ (2008) Renovascular hypertension in children. Lancet 371:1453–1463PubMedCrossRefGoogle Scholar
  38. 38.
    Eklof H, Ahlstrom H, Magnusson A, Anderson LG, Andren B, Hagg A, Bergqvist D, Nyman R (2006) A prospective comparison of duplex ultrasonography, captopril renography, MRA and CTA in assessing renal artery stenosis. Acta Radiol 47:764–774PubMedCrossRefGoogle Scholar
  39. 39.
    Marshalleck F (2010) Pediatric arterial interventions. Tech Vasc Interv Radiol 13:238–243PubMedCrossRefGoogle Scholar
  40. 40.
    Luke RG (1991) Pathophysiology and treatment of post-transplant hypertension. J Am Soc Nephrol 2:S37–S44PubMedGoogle Scholar
  41. 41.
    Kaul A, Sharma RK, Gupta A, Singh U (2010) Spectrum of hypertension in post transplant. J Assoc Physicians India 58:221–224PubMedGoogle Scholar
  42. 42.
    Zarifian A, Meleg-Smith S, O’Donovan R, Tesi RJ, Batuman V (1999) Cyclosporine-associated thrombotic microangiopathy in renal allografts. Kidney Int 55:2457–2466PubMedCrossRefGoogle Scholar
  43. 43.
    Robson M, Côte I, Abbs I, Koffman G, Goldsmith D (2003) Thrombotic micro-angiopathy with sirolimus-based immunesuppression: potentiation of calcineurin-inhibitor-induced endothelial damage? Am J Transplant 3:324–327PubMedCrossRefGoogle Scholar
  44. 44.
    Ozen S, Celik A, Alper H, Simsek DG, Darcan S (2010) Primary hyperparathyroidism in a young adult presenting with severe hypertension. J Pediatr Endocrinol Metab 23:193–196PubMedGoogle Scholar
  45. 45.
    Grinsell MM, Norwood VF (2009) At the bottom of the differential diagnosis list: unusual causes of pediatric hypertension. Pediatr Nephrol 24:2137–2146PubMedCrossRefGoogle Scholar
  46. 46.
    Chan JC, Young RB, Alon U, Mamunes P (1983) Hypercalcemia in children with disorders of calcium and phosphate metabolism during long-term treatment with 1,25-dihydroxyvitamin-D3. Pediatrics 72:225–233PubMedGoogle Scholar
  47. 47.
    Van der Horst-Schrivers ANA, Kerstens MN, Wolffenbuttel BHR (2006) Pre-operative pharmacological management of phaeochromocytoma. Neth J Med 64:290–295PubMedGoogle Scholar
  48. 48.
    Nussberger J (2003) Investigating mineralocorticoid hypertension. J Hypertens Suppl 21(2):S25–S30PubMedGoogle Scholar
  49. 49.
    Abend NS, Bonnemann CG, Licht DJ (2007) Status epilepticus secondary to hypertensive encephalopathy as the presenting manifestation of Guillain barre Syndrome. Pediatr Emerg Care 23:659–661PubMedCrossRefGoogle Scholar
  50. 50.
    Kwon S, Koo J, Lee S (2001) Clinical Spectrum of reversible posterior encephalopathy syndrome. Pediatr Neurol 24:361–364PubMedCrossRefGoogle Scholar
  51. 51.
    Onder AM, Lopez R, Teomete U, Francoeur D, Bhatia R, Knowbi O, Hijazi R, Chandar J, Abitbol C, Zilleruelo G (2007) Posterior reversible encephalopathy syndrome in the pediatric renal population. Pediatr Nephrol 22:1921–1929PubMedCrossRefGoogle Scholar
  52. 52.
    Lee VH, Wijdicks EF, Manno EM, Rabinstain AA (2008) Clinical spectrum of reversible posterior leukoencephalopathy syndrome. Arch Neurol 65:205–210PubMedCrossRefGoogle Scholar
  53. 53.
    Mehta JL, Lopez LM (1987) Rebound hypertension following abrupt cessation of clonidine and metoprolol. Treatment with labetalol. Arch Intern Med 147:389–390PubMedCrossRefGoogle Scholar
  54. 54.
    Piccoli GB, Anania P, Biancone L, Mezza E, Vischi M, Jeantet A, Rabbia C, Savio D, Rossatto D, Gai M, Perin PC, Segoloni GP (2001) Hypertensive rebound after angiotensin converting enzyme inhibitor withdrawal in diabetic patients with chronic renal failure. Nephrol Dial Transplant 16:1084–1085PubMedCrossRefGoogle Scholar
  55. 55.
    Pickering TG, Hall JE, Appel LJ, Falkner BE, Graves J, Hill MN, Jones DW, Kurtz T, Sg S, Roccella EJ (2005) Recommendations for blood pressure measurement in humans and experimental animals: part 1: blood pressure measurements in humans: a statement for professionals from the Subcommittee of Professional and Public Education of the American Heart Association Council on High Blood Pressure Research. Circulation 111:697–716PubMedCrossRefGoogle Scholar
  56. 56.
    Chiolero A, Paradis G, Lambert M (2010) Accuracy of oscillometric devices in children and adults. Blood Press 19:254–259PubMedCrossRefGoogle Scholar
  57. 57.
    McGhee BH, Bridges EJ (2002) Monitoring arterial blood pressure: what you may not know. Crit Care Nurse 22:60–79PubMedGoogle Scholar
  58. 58.
    Colan SD, Fujii A, Borow KM, MacPherson D, Sanders SP (1983) Noninvasive determination of systolic, diastolic and end-systolic blood pressure in neonates, infants and young children: Comparison with central aortic pressure measurements. Am J Cardiol 52:867–870PubMedCrossRefGoogle Scholar
  59. 59.
    Flynn JT, Tullus K (2009) Severe hypertension in children and adolescents: pathophysiology and treatment. Pediatr Nephrol 24:1101–1112PubMedCrossRefGoogle Scholar
  60. 60.
    Flynn JT, Mottes TA, Brophy PB, Kershaw DB, Smoyer WE, Bunchman TE (2001) Intravenous nicardipine for treatment of severe hypertension in children. J Pediatr 139:38–43PubMedCrossRefGoogle Scholar
  61. 61.
    Michael J, Groshong T, Tobias JD (1998) Nicardipine for hypertensive emergencies in children with renal disease. Pediatr Nephrol 12:40–42PubMedCrossRefGoogle Scholar
  62. 62.
    Bunchman TE, Lynch RE, Wood EG (1992) Intravenously administered labetalol for treatment of malignant hypertension in children. J Pediatr 120:140–144PubMedCrossRefGoogle Scholar
  63. 63.
    Thomas CA, Moffett BA, Wagner JL, Mott AR, Feig DI (2011) Safety and efficacy of intravenous labetalol for hypertensive crisis in infants and small children. Pediatr Crit Care Med 12:28–32PubMedCrossRefGoogle Scholar
  64. 64.
    Lopez-Sendon J, Swedberg K, McMurray J, Tamargo J, Maggioni AP, Dargie H, Tendera M, Waagstein M, Kjeckshus J, Philippe L, Torp-Pederson C (2004) Expert consensus document on β adrenergic receptor blockers. Eur Heart J 25:1341–1362PubMedCrossRefGoogle Scholar
  65. 65.
    Weist DB, Garner SS, Uber WE, Sade RM (1998) Esmolol for the management of pediatric hypertension after cardiac operations. J Thorac Cardiovasc Surg 115:890–897CrossRefGoogle Scholar
  66. 66.
    Panacek EA, Bednarczyk EM, Dunbar LM, Foulke GE, Holkslaw TL (1995) Randomized, prospective trial of fenoldapam vs sodium nitroprusside in the treatment of acute severe hypertension. Fenoldapam Study Group. Acad Emerg Med 2:959–965PubMedCrossRefGoogle Scholar
  67. 67.
    Hammer GB, Verghese ST, Drover DR, Yaster M, Tobin JR (2008) Pharmacokinetics and pharmacodynamics of fenoldapam mesylate for blood pressure control in pediatric patients. BMC Anesthesiol 8:6–15PubMedCrossRefGoogle Scholar
  68. 68.
    Gordillo-Paniagua G, Velasquez Jones L, Martini R, Valdez Bolanos E (1975) Sodium nitroprusside treatment of severe arterial hypertension in children. J Pediatr 87:799–802PubMedCrossRefGoogle Scholar
  69. 69.
    Wells TG, Bunchman TE, Kearns GL (1990) Treatment of neonatal hypertension with enalaprilat. J Pediatr 117:664–667PubMedCrossRefGoogle Scholar
  70. 70.
    Gantenbein MH, Bauersfeld U, Baenziger O, Frey B, Neuhaus T, Sennhauser F, Bernet V (2008) Side effects of angiotensin converting enzyme inhibitor (captopril) in newborns and young infants. J Perinat Med 36:448–452PubMedCrossRefGoogle Scholar
  71. 71.
    Towe E, Tobias JD (2010) Preliminary experience with clevidipine in the pediatric population. J Intensive Care Med 25:349–352PubMedCrossRefGoogle Scholar
  72. 72.
    Joynt KE, Moslehi JJ, Baughman KL (2009) Paragangliomas: etiology, presentation, and management. Cardiol Rev 17:159–164PubMedCrossRefGoogle Scholar
  73. 73.
    Rodriguez MA, Kumar SK, De Caro M (2010) Hypertensive Crisis. Cardiol Rev 18:102–107PubMedCrossRefGoogle Scholar
  74. 74.
    Johnson CE, Jacobson PA, Song MH (1997) Isradipine therapy in hypertensive pediatric patients. Ann Pharmacother 31:704–707PubMedGoogle Scholar
  75. 75.
    Miyashita Y, Peterson D, Reese JN, Flynn JT (2010) Isradipine for treatment of acute hypertension in hospitalized children and adolescents. J Clin Hypertens 12:850–855CrossRefGoogle Scholar
  76. 76.
    Blaszak T, Savage JA, Ellis EN (2001) The use of short-acting nifedipine in pediatric patients with hypertension. J Pediatr 139:34–37PubMedCrossRefGoogle Scholar
  77. 77.
    Castenada MP, Walsh CA, Woroniecki RP, Del Rio M, Flynn JT (2005) Ventricular arrhythmia following short acting nifedipine administration. Pediatr Nephrol 20:1000–1002CrossRefGoogle Scholar
  78. 78.
    Wong H, Hadi M, Khoury T, Geary D, Rubin B, Guido F (2006) Management of severe hypertension in a child with tuberous sclerosis-related major vascular abnormalities. J Hypertens 24:597–599PubMedCrossRefGoogle Scholar
  79. 79.
    Strife CF, Quinlan M, Waldo FB, Fryer CJ, Jackson EC, Welch TR, McEnery PT, West CD (1986) Minoxidil for control of acute blood pressure elevation in chronically hypertensive children. Pediatrics 78:861–865PubMedGoogle Scholar
  80. 80.
    Martin WB, Spodlick DH, Zins GR (1980) Pericardial disorders occurring during open-label study of 1869 severely hypertensive patients treated with minoxidil. J Cardiovasc Pharmacol 2:S217–227PubMedCrossRefGoogle Scholar
  81. 81.
    Chandar JJ, Sfakianakis GN, Zilleruelo GE, Guerra JJ, Georgiou MF, Abitbol CL, Montane BS, Strauss J (1999) ACE inhibition scintigraphy in the management of hypertension in children. Pediatr Nephrol 13:493–500PubMedCrossRefGoogle Scholar
  82. 82.
    Sfakianakis GN, Sfakianaki E, Paredes A, Abitbol C, Zilleruelo G, Goldberg RN, Strauss J (1988) Single-dose captopril scintigraphy in the neonate with renovascular hypertension: prediction of renal failure, a side effect of captopril therapy. Biol Neonate 54:246–253PubMedCrossRefGoogle Scholar
  83. 83.
    Deal JE, Barratt TM, Dillon MJ (1992) Management of hypertensive emergencies. Arch Dis Child 67:1089–1092PubMedCrossRefGoogle Scholar
  84. 84.
    Hulse JA, Taylor DS, Dillon MJ (1979) Blindness and paraplegia in severe childhood hypertension. Lancet 2(8142):553–556PubMedCrossRefGoogle Scholar

Copyright information

© IPNA 2011

Authors and Affiliations

  1. 1.Department of Pediatrics, Division of Pediatric Nephrology, Holtz Children’s HospitalUniversity of Miami Miller School of MedicineMiamiUSA
  2. 2.Division of Pediatric NephrologyUniversity of Miami/ Holtz Children’s HospitalMiamiUSA

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