Clinical assessment of primary and secondary hypertension in children and adolescents

Çakıcı, Evrim Kargın; Yazılıtaş, Fatma; Kurt-Şükür, Eda Didem; Güngör, Tülin; Çelikkaya, Evra; Karakaya, Deniz; Bülbül, Mehmet

doi:10.1016/j.arcped.2020.06.005

Cited by 7 publications

(12 citation statements)

References 29 publications

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“…Hyperuricemia has been associated with hypertension in large epidemiological studies and the mechanism of action is thought to involve uric acid–mediated endothelial dysfunction and activation of the renin-angiotensin system . Although serum uric acid concentration was useful for differentiating primary vs secondary hypertension in the 2 single-center studies in this meta-analysis, and small trials have suggested that interventions to lower uric acid can improve blood pressure in adolescents with hypertension, the current guidelines state that the evidence is insufficient to recommend routine measurement of uric acid without large-scale, multicenter studies to confirm these findings.…”

Section: Discussionmentioning

confidence: 80%

“…The individual study methods, study populations, inclusion and exclusion criteria, and proportions of children and adolescents with secondary hypertension are described in eTable 2 in the Supplement. Most studies were retrospective cohorts of consecutive children and adolescents referred to pediatric nephrology or pediatric hypertension clinics. Five studies were retrospective cohorts of children and adolescents who had 24-hour ambulatory blood pressure monitoring.…”

Section: Resultsmentioning

confidence: 99%

“…Five studies evaluated 24-hour ambulatory blood pressure monitoring for identifying secondary hypertension in children and adolescents, including 3 studies with evidence levels 1 to 3 (Table 3). A combination of daytime diastolic blood pressure load of 25% or greater and nocturnal systolic blood pressure load of 50% or greater was associated with an increased likelihood of secondary hypertension (sensitivity, 0.40; specificity, 0.82; LR, 4.8 [95% CI, 1.2-20]).…”

Section: Resultsmentioning

confidence: 99%

“…Even though all children and adolescents with hypertension should have serum electrolytes checked as part of their diagnostic evaluation, no literature were found on the utility of specific electrolyte abnormalities such as hypokalemia and metabolic alkalosis, which can be seen in renovascular or monogenic causes of hypertension, for predicting secondary hypertension. Serum uric acid concentration greater than 5.5 mg/dL was associated with primary hypertension in 2 studies, and was also used to distinguish primary hypertension from white coat hypertension . It is important to note that all children and adolescents in these 2 studies had normal kidney function because impaired glomerular filtration will cause hyperuricemia.…”

Section: Discussionmentioning

confidence: 99%

“…Individual studies have found that patient characteristics such as age, body mass index, family history, degree of blood pressure elevation, diastolic hypertension, and presence of symptoms associated with hypertension such as headache, chest pain, and edema may help differentiate between primary and secondary hypertension. For clinicians who opt to screen children and adolescents for hypertension, the purpose of this systematic review and meta-analysis was to determine the utility of the clinical history, physical examination, and 24-hour ambulatory blood pressure monitoring for differentiating primary hypertension from secondary hypertension in children and adolescents (aged ≤21 years).…”

Section: Introductionmentioning

confidence: 99%

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ImportanceGuidelines recommend that all children and adolescents with hypertension undergo evaluation for secondary causes. Identifying clinical factors associated with secondary hypertension may decrease unnecessary testing for those with primary hypertension.ObjectiveTo determine the utility of the clinical history, physical examination, and 24-hour ambulatory blood pressure monitoring for differentiating primary hypertension from secondary hypertension in children and adolescents (aged ≤21 years).Data Sources and Study SelectionThe databases of MEDLINE, PubMed Central, Embase, Web of Science, and Cochrane Library were searched from inception to January 2022 without language limits. Two authors identified studies describing clinical characteristics in children and adolescents with primary and secondary hypertension.Data Extraction and SynthesisFor each clinical finding in each study, a 2 × 2 table was created that included the number of patients with and without the finding who had primary vs secondary hypertension. Risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies tool.Main Outcomes and MeasuresRandom-effects modeling was used to calculate sensitivity, specificity, and likelihood ratios (LRs).ResultsOf 3254 unique titles and abstracts screened, 30 studies met inclusion criteria for the meta-analysis and 23 (N = 4210 children and adolescents) were used for pooling in the meta-analysis. In the 3 studies conducted at primary care clinics or school-based screening clinics, the prevalence of secondary hypertension was 9.0% (95% CI, 4.5%-15.0%). In the 20 studies conducted at subspecialty clinics, the prevalence of secondary hypertension was 44% (95% CI, 36%-53%). The demographic findings most strongly associated with secondary hypertension were family history of secondary hypertension (sensitivity, 0.46; specificity, 0.90; LR, 4.7 [95% CI, 2.9-7.6]), weight in the 10th percentile or lower for age and sex (sensitivity, 0.27; specificity, 0.94; LR, 4.5 [95% CI, 1.2-18]), history of prematurity (sensitivity range, 0.17-0.33; specificity range, 0.86-0.94; LR range, 2.3-2.8), and age of 6 years or younger (sensitivity range, 0.25-0.36; specificity range, 0.86-0.88; LR range, 2.2-2.6). Laboratory studies most associated with secondary hypertension were microalbuminuria (sensitivity, 0.13; specificity, 0.99; LR, 13 [95% CI, 3.1-53]) and serum uric acid concentration of 5.5 mg/dL or lower (sensitivity range, 0.70-0.73; specificity range, 0.65-0.89; LR range, 2.1-6.3). Increased daytime diastolic blood pressure load combined with increased nocturnal systolic blood pressure load on 24-hour ambulatory blood pressure monitoring was associated with secondary hypertension (sensitivity, 0.40; specificity, 0.82; LR, 4.8 [95% CI, 1.2-20]). Findings associated with a decreased likelihood of secondary hypertension were asymptomatic presentation (LR range, 0.19-0.36), obesity (LR, 0.34 [95% CI, 0.13-0.90]), and family history of any hypertension (LR, 0.42 [95% CI, 0.30-0.57]). Hypertension stage, headache, and left ventricular hypertrophy did not distinguish secondary from primary hypertension.Conclusions and RelevanceFamily history of secondary hypertension, younger age, lower body weight, and increased blood pressure load using 24-hour ambulatory blood pressure monitoring were associated with a higher likelihood of secondary hypertension. No individual sign or symptom definitively differentiates secondary hypertension from primary hypertension.

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Section: Discussionmentioning

confidence: 80%

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%