Abstract
Since the 1970s, when the initial reports of neonatal hypertension related to renal artery thromboembolism were published, other secondary causes of neonatal hypertension have been reported. Those infants with no identifiable cause of hypertension were labeled with a variety of terms. Herein, we describe such infants as having idiopathic neonatal hypertension (INH). Most, but not all, of these hypertensive infants were noted to have bronchopulmonary dysplasia (BPD). More recently, reports described common clinical characteristics seen in INH patients, whether or not they had BPD. This phenotype includes low plasma renin activity, presentation near 40 weeks postmenstrual age, and a favorable response to treatment with spironolactone. A small prospective study in INH patents showed evidence of mineralocorticoid receptor activation due to inhibition of 11β-HSD2, the enzyme that converts cortisol to the less potent mineralocorticoid—cortisone. Meanwhile, phthalate metabolites have been shown to inhibit 11β-HSD2 in human microsomes. Premature infants can come in contact with exceptionally large phthalate exposures, especially those infants with BPD. This work describes a common low-renin phenotype, commonly seen in patients categorized as having INH. Further, we review the evidence that hypertension in INH patients with the low-renin phenotype may be mediated by phthalate-associated inhibition of 11β-HSD2. Lastly, we review the implications of these findings regarding identification, treatment, and prevention of the low-renin hypertension phenotype seen in premature infants categorized as having INH.
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Abbreviations
- BPD:
-
Bronchopulmonary dysplasia
- PRA:
-
Plasma renin activity
- HTN:
-
Hypertension
- INH:
-
Idiopathic neonatal hypertension
- DEHP:
-
Di-2-ethylhexyl phthalate
- 11β-HSD2:
-
11β-Hydroxysteroid dehydrogenase type 2
- MR:
-
Mineralocorticoid receptor
- ENaC:
-
Epithelial sodium channel
References
Adelman RD (1978) Neonatal hypertension. Pediatr Clin N Am 25:99–110
Flynn JT (2000) Neonatal hypertension: diagnosis and management. Pediatr Nephrol 14:332–341
Batisky DL (2014) Neonatal hypertension. Clin Perinatol 41:529–542
Kent AL, Chaudhari T (2013) Determinants of neonatal blood pressure. Curr Hypertens Rep 15:426–432
Sahu R, Pannu H, Yu R, Shete S, Bricker JT, Gupta-Malhotra M (2013) Systemic hypertension requiring treatment in the neonatal intensive care unit. J Pediatr 163:84–88
Sheftel DN, Hustead V, Friedman A (1983) Hypertension screening in the follow-up of premature infants. Pediatrics 71:763–766
VanDeVoorde RG, Mitsnefes MM (2014) Neonatal hypertension. In: Chishti AS, Alam S, Kiessling S (eds) Kidney and urinary tract disease in the newborn. Springer, New York, pp 349–361
Flynn JT (2012) Hypertension in the neonatal period. Curr Opin Pediatr 24:197–204
Friedman AL, Hustead VA (1987) Hypertension in babies following discharge from a neonatal intensive care unit. A 3 year follow-up. Pediatr Nephrol 1:30–34
Singh HP, Hurley RM, Myers TF (1992) Neonatal hypertension, incidence and risk factors. Am J Hypertens 5:51–55
Jenkins RD, Aziz JK, Gievers LL, Mooers HM, Fino N, Rozansky DJ (2017) Characteristics of hypertension in premature infants with and without chronic lung disease: a long-term multi-center study. Pediatr Nephrol 32:2115–2124
Jenkins R, Tackitt S, Gievers L, Iragorri S, Sage K, Cornwall T et al (2019) Phthalate-associated hypertension in premature infants: a prospective mechanistic cohort study. Pediatr Nephrol 34:1413–1424
Farnbach K, Iragorri S, Al-Uzri A, Rozansky D, Forbush R, Jenkins R (2019) The changing spectrum of hypertension in premature infants. J Perinatol 39:1528–1534
Starr M, Wilson A (2022) Systemic hypertension in infants with bronchopulmonary dysplasia. Curr Hypertens Rep 24:193–203
Hjorten R, Flynn JT (2022) Neonatal hypertension. Clin Perinatol 49:27–42
Al Awad E, Yusuf K, Soraisham A, Obaid H, Sundaram A, Samedi V et al (2018) Transient hyperaldosteronism and neonatal hypertension: case series and literature review. J Clin Neonatol 7:185–189
Kotchen TA, Strickland AL, Rice TW, Walters DR (1972) A study of the renin-angiotensin system in newborn infants. J Pediatr 80:938–946
Dillon MJ, Gillin ME, Ryness JM, deSwiet M (1976) Plasma renin activity and aldosterone concentration in the human newborn. Arch Dis Child 51:537–540
Martinerie L, Pussard E, Foix-L’Helias L, Petit F, Cosson C, Boileau P, Lombes M (2009) Physiological partial aldosterone resistance in human newborns. Pediatr Res 66:325–328
Leslie GI, Barr PA, Gallery EDM, Gyory AZ (1984) Role of renin and aldosterone in establishment of electrolyte balance in very low birthweight neonates. Aust Paediatr J 20:209–212
Sulyok E, Nemeth M, Tenyi I, Csaba I, Gyory E, Ertl T et al (1979) Postnatal development of renin-angiotensin-aldosterone system, RAAS, in relation to electrolyte balance in premature infants. Pediatr Res 13:817–820
Zhou H, Satlin LM (2004) Renal potassium handling in healthy and sick newborns. Semin Perinatol 28:103–111
Satlin LM (1999) Regulation of potassium transport in the maturing kidney. Semin Nephrol 19:155–165
New MI, Levine LS (1980) Hypertension of childhood with suppressed renin. Endocr Rev 1:421–430
DiMartino-Nardi J, New MI (1987) Low-renin hypertension of childhood. Pediatr Nephrol 1:99–108
Walker BR, Edwards CR (1994) Licorice-induced hypertension and syndromes of apparent mineralocorticoid excess. Endocrinol Metab Clin North Am 23:359–377
Trasande L, Sathyanarayana S, Spanier AJ, Trachtman H, Attina TM, Urbina EM (2013) Urinary phthalates are associated with higher blood pressure in childhood. J Pediatr 163:747-753.e1
Shiue I (2014) Higher urinary heavy metal, phthalate, and arsenic but not parabens concentrations in people with high blood pressure, U.S. NHANES, 2011–2012. Int J Environ Res Public Health 11:5989–5999
Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM (2017) Subcommittee on screening and management of high blood pressure in clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 2:140
Zhao B, Chu Y, Huang Y, Hardy DO, Lin S, Ge R et al (2010) Structure-dependent inhibition of human and rat 11B-hydroxysteroid dehydrogenase 2 activities by phthalates. Chem Biol Interact 183:79–84
Subotic U, Hannmann T, Kiss M, Brade J, Breitkopf K, Loff S (2007) Extraction of the plasticizers diethylhexylphthalate and polyadipate from polyvinylchloride nasogastric tubes through gastric juice and feeding solution. J Pediatr Gastroenterol Nutr 44:71–76
Loff S, Kabs F, Subotic U, Schaible T, Reinecke F, Langbein M (2002) Kinetics of diethylhexyl-phthalate extraction from polyvinylchloride-infusion lines. J Parenter Enteral Nutr 26:305–309
Loff S, Subotic U, Reinicke F, Wischmann H, Brade J (2004) Extraction of di-ethylhexyl-phthalate from perfusion lines of various material, length and brand by lipid emulsions. J Pediatr Gastroenterol Nutr 39:341–345
Latini G, De Felice C, Del Vecchio A, Barducci A, Ferri M, Chiellini F (2009) Di-(2-ethylhexyl)phthalate leakage and color changes in endotracheal tubes after application in high-risk newborns. Neonatology 95:317–323
Chiellini F, Ferri M, Latini G (2011) Physical-chemical assessment of di-(2-ethylhexyl)-phthalate leakage from poly(vinyl chloride) endotracheal tubes after application in high risk newborns. Int J Pharm 409:57–61
Green R, Hauser R, Calafat AM, Weuve J, Schettler T, Ringer S, Huttner K, Hu H (2005) Use of di(2-ethylhexyl) phthalate-containing medical products and urinary levels of mono(2-ethylhexyl) phthalate in neonatal intensive care unit infants. Environ Health Perspect 113:1222–1225
Weuve J, Sanchez BN, Calafat AM, Schettler T, Green RA, Hu H, Hauser R (2006) Exposure to phthalates in neonatal intensive care unit infants: urinary concentrations of monoesters and oxidative metabolites. Environ Health Perspect 114:1424–1431
Calafat AM, Needham LL, Silva MJ, Lambert G (2004) Exposure to di-(2-ethylhexyl) phthalate among premature neonates in a neonatal intensive care unit. Pediatrics 113:e429-434
Malarvannan G, Onghena M, Verstraete S, Van Puffelen E, Jacobs A, Vanhorebeek I et al (2019) Phthalate and alternative plasticizers in indwelling medical devices in pediatric intensive care units. J Hazard Mater 363:63–72
Genay S, Luciani C, Decaudin B, Kambia N, Dine T, Odou P et al (2011) Experimental study on infusion devices containing polyvinyl chloride: to what extent are they di(2-ethylhexy) phthalate-free? Int J Pharm 412:47–51
Nielsen BS, Andersen DN, Giovalle E, Bjergstrom M, Larsen PB (2014) Alternatives to classified phthalaes in medical devices. Environmental project No 1557. The Danish Environmental Protection Agency. https://www2.mst.dk/udgiv/publications/2014/03/978-87-93178-27-4.pdf
Jenkins R, Ondusko D, Montrose L, Forbush R, Rozansky D (2021) Phthalate exposures in the neonatal intensive care unit. Toxics 9:90
Jenkins R (2021) Reducing toxic phthalate exposures in premature infants. In: Barria RM (ed) Topics on critical issues in neonatal care. Intech Open, London, pp 89–107
Mallow EB, Fox MA (2014) Phthalates and critically ill neonates: device-related exposures and non-endocrine toxic risks. J Perinatol 34:892–897
Jenkins R, Farnbach K, Iragorri S (2021) Elimination of intravenous di-2-ethylhexyl phthalate exposure abrogates most neonatal hypertension in premature infants with bronchopulmonary dysplasia. Toxics 9:75
Ma X, Lian Q-Q, Dong Q, Ge R-S (2011) Environmental inhibitors of 11b-hydroxysteroid dehydrogenase type 2. Toxicology 285:83–89
KochHM BHM, Preuss R, Angerer J (2005) New metabolites of di(2-ethylhexyl)phthalate (DEHP) in human urine and serum after single oral doses of deuterium-labelled DEPH. Arch Toxicol 79:365–376
Meltzer D, Martinez-Arguelles DB, Campioli E, Lee S, Papadopoulos V (2015) In utero exposure to the endocrine disruptor di(2-ethylhexyl) phthalate targets ovarian theca cells and steroidogenesis in the adult female rat. Reprod Toxicol 51:47–56
Bergman A, Heindel JJ et al (2013) State of the science of endocrine disrupting chemicals 2012: summary for decision-makers. World Health Organization, United Nations Environment Programme, Inter-Organization Programme for the Sound Management of Chemicals. https://apps.who.int/iris/handle/10665/78102
Montrose L, Padmanabhan V, Goodrich JM, Domino SE, Treadwell MC, Meeker JD, Watkins DJ, Dolinoy DC (2018) Maternal levels of endocrine disrupting chemicals in the first trimester of pregnancy are associated with infant cord blood DNA methylation. Epigenetics 13:301–309
Stroustrup A, Bragg JB, Andra SS, Curtin PC, Spear EA, Sison DB et al (2018) Neonatal intensive care unit phthalate exposure and preterm infant neurobehavioral performance. PLoS One 13:e0193835
Wang Y, Zhu H, Kannan K (2019) A review of biomonitoring of phthalate exposures. Toxics 7:21
Acknowledgements
We thank A. Stout and M. Jenkins for the editing support and D. Rozansky for the scientific content and graphic support.
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Jenkins, R.D. Phthalates cause a low-renin phenotype commonly found in premature infants with idiopathic neonatal hypertension. Pediatr Nephrol 38, 1717–1724 (2023). https://doi.org/10.1007/s00467-022-05773-1
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DOI: https://doi.org/10.1007/s00467-022-05773-1