Diagnóstico, evaluación y tratamiento de la hipertensión arterial en niños y adolescentes / Diagnosis, evaluation and treatment of arterial hypertension in children and adolescents

La perspectiva clínica de la presión arterial en edad pediátrica ha cambiado en los últimos años como consecuencia de la medida regula de la presión arterial y de un mejor conocimiento de los valores de normalidad que son variables a lo largo del crecimiento y desarrollo. El diagnóstico de hipertensión arterial debe basarse en varias mediciones de la presión arterial, realizadas en la consulta en distintos momentos. Si bien deben tomarse como referencia las mediciones de la presión arterial realizadas en la consulta, los valores de presión arterial obtenidos fuera de la consulta pueden contribuir a realizar una evaluación más precisa de los individuos. El abordaje terapéutico de la hipertensión arterial debe contemplar no sólo el uso de fármacos sino también la aplicación de medidas no farmacológicas. La consideración de su uso, fármacos y/o medidas no farmacológicas, se realizará en función de los valores de presión arterial, de la presencia de una etiología definida, y de la evaluación de los posibles factores de riesgo asociados (AU)

The clinical perspective of arterial blood pressure in pediatric age has changed in recent years due to the regular measurement of blood pressure and better knowledge about the normality values that are variable during growth and development. The diagnosis of arterial hypertension should be based on several measurements of blood pressure performed in the medical office at different times. Although the measurements of blood pressure made in the medical office should be used as reference, the blood pressure values obtained outside of the office can contribute to making a more precise evaluation of the individuals. The therapeutic approach to arterial hypertension should not only contemplate the use of drugs but also the application of non-pharmacological measures. The consideration of its use, drugs and/or non-pharmacological measures, will be made based on the blood pressure values, the presence of a defined etiology, and the evaluation of the possible associated risk factors (AU)

Beneficios de la medida de la masa ventricular en adolescentes con hipertensión arterial / Benefits of the measurement of ventricular mass in adolescents with high blood pressure

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Birth weight influences blood pressure values and variability in children and adolescents.

The objective of the present study was to assess the relationships between birth weight and the values and variability of ambulatory blood pressure. Six hundred thirty healthy children (369 girls) age 4 to 18 years (mean, 9.9 years) born at term after a normotensive pregnancy were included. The subjects were divided into 5 groups according to birth weight. For each subject, a 24-hour ambulatory blood pressure monitoring was performed according to the protocol designed. Average and variability (estimated as the standard deviation) of ambulatory blood pressure and heart rate were calculated separately for 24-hour, daytime, and nighttime periods. When values were adjusted for gender, current age, weight, and height, children with the lowest birth weights had the highest ambulatory blood pressure values and variability, whereas no differences in heart rate were observed. Multiple regression analysis showed that although current weight was the strongest predictor for 24-hour systolic blood pressure (P<0.001), there was also an independent and significant inverse relationship for birth weight (P<0.002) after controlling for gender, current age, and height. Likewise, birth weight was independently and inversely correlated with 24-hour systolic blood pressure variability (P<0.03). In conclusion, children who had lower birth weights tended to have not only the highest blood pressure values but also the highest blood pressure variability, independent of the increases in ambulatory blood pressure values. Knowing that high blood pressure variability is at least partially independent of blood pressure values, the importance of this variability on further blood pressure rises and/or on vascular damage later in life needs to be assessed in future studies.

Obesity modifies the relationship between ambulatory blood pressure and natriuresis in children.

BACKGROUND: The objective in the present study was to evaluate if obesity beginning in the first two decades of life influences the relationship between ambulatory blood pressure and urinary sodium excretion. DESIGN AND METHODS: Eighty-five obese and 88 non-obese children aged 3-19 years were included in the study. For each subject, a 24h ambulatory blood pressure monitoring and a complete urine collection were simultaneously performed according to the protocols designed. The averages of ambulatory blood pressure and of the urinary excretion rates for sodium, potassium and creatinine were calculated separately for 24-h, awake and sleep periods as defined by a mini-diary. RESULTS: Weight and sodium excretion are directly associated with systolic blood pressure; however, the relationship between blood pressure and sodium excretion seems to be modified in obese children as compared to controls. The interaction between sodium excretion and weight was negative indicating that the rate of change of systolic blood pressure by sodium unit is smaller for the obese than for the non-obese, even though at the same urinary sodium excretion level the obese children had higher ambulatory systolic blood pressure. CONCLUSIONS: Obesity during the first two decades of life seems to restrict sodium excretion, leading to higher blood pressure values. The capacity to excrete sodium seems to be heterogeneous, the lowest capacity being at the highest blood pressure values. Subsets of the obese, those with the lowest ability to excrete sodium, may be further protected by low sodium intake in order to prevent a rise in blood pressure.

[Remediable glucocorticoid hyperaldosteronism: molecular diagnosis]. / Hiperaldosteronismo remediable con glucocorticoides: diagnóstico genético.

BACKGROUND: The first family diagnosed in Spain of glucocorticoid remediable aldosteronism (GRA) is reported. SUBJECTS AND METHODS: We described the phenotype, biochemical values and genetic diagnosis of a GRA pedigree. DNA analysis was performed by using Southern-blot and polymerase chain reaction. RESULTS: We reported a 14-year-old boy who presented with severe hypertension, and strong family history of early-onset hypertension. His suppressed plasmatic renin activity, family history and failure to respond to conventional antihypertensive therapy raised GRA as a potential etiology. The diagnosis was confirmed by genetic testing, in the index case and in one of family members, which demonstrated the chimeric gene duplication, which was a resultant of a crossing-over between the proximal portion of 11 beta-hydroxylase gen, CYP11B1, and the distal portion of aldosterone synthetase gene CYP11B2. Two other family members, who died, suffered hyporeninemic severe hypertension. The cause of death in one of them was hemorrhagic stroke. Amiloride, which blocks sodium transport in the distal nephron, plus hydroclorothiazide was an effective treatment option. CONCLUSIONS: The role of molecular diagnosis techniques is essential for the rapid diagnosis of cases of arterial hypertension secondary to familial glucocorticoid remediable aldosteronism.

[Circadian rhythms variability of arterial pressure: methodological aspects for the measurement]. / Variabilidad circadiana de la presión arterial: aspectos metodológicos para su estimación.

BACKGROUND: To study the differences among the methods used for estimating daytime and nighttime ambulatory blood pressure values, and to analyze their determinant factors. SUBJECTS AND METHODS: In 402 individuals mean values of systolic and diastolic blood pressure (SBP and DBP) during 24 h, daytime and nighttime, were calculated by three different methods: a) real-time, following a minidiary; b) long-time, having a nighttime period from 23:00 to 07:00 h, and a daytime one from 08:00 to 22:00 h, and c) short-time, having a nighttime period from midnight to 6:00 h, and a daytime one from 08:00 to 22:00 h. RESULTS: Daytime mean values of SBP and DBP were similar for the three methods. Nighttime mean values of SBP and DBP calculated using the long-time were significantly higher than those calculated with the real-time ((SBP -2.25 [5.3] mmHg, p < 0.05; DBP -1.17 [3.4] mmHg, p < 0.05). No differences were observed for both SBP and DBP with the real-time. The number of sleeping hours was the main determinant of the differences observed between the long-time and the real-time methods. The percentage of subjects with a non-dipping pattern were 17, 26 and 18% for real, long and short time methods, respectively. CONCLUSIONS: Daytime mean BP values are reproducible whatever the method used, but for estimating nighttime mean BP values short-time is the best of the fixed-time methods. Minidiary should be used if more accurate values are necessary or if the subjects sleep habits do not fit into the standard patterns.

The impact of obesity and body fat distribution on ambulatory blood pressure in children and adolescents.

To assess the relationship between obesity, body fat distribution, and blood pressure in children and adolescents, various measures of obesity and the waist-to-hip circumference ratio were related to casual and ambulatory blood pressure as measured using a SpaceLabs 90207 monitor during a regular school day. Seventy obese and 70 nonobese children aged 6 to 16 years were included in the study. Regardless of the time period analyzed (24 h, daytime, or nighttime), ambulatory blood pressure and casual blood pressure were significantly higher among the obese children. The differences in systolic blood pressure observed between the groups were attributable to the presence of obesity as estimated by the ponderal index and by skinfold thickness. Similarly, systolic and diastolic loads, as an assessment of high blood pressure values over 24 h, were significantly higher in the obese children when compared to the loads for the nonobese children. Waist-to-hip circumference ratio was independently associated, (in multiple regression analysis) with systolic blood pressure, whether during 24 h, daytime, or nighttime periods, after controlling for age, sex, current height, ponderal index, and tricipital skinfold thickness. This study demonstrates that obesity is a determinant of ambulatory and casual blood pressure. Since obese children with a predominantly abdominal fat mass show higher blood pressure values, evaluation of body fat distribution in children may help to identify subjects more susceptible to developing hypertension later in life.

Current and birth weights exert independent influences on nocturnal pressure-natriuresis relationships in normotensive children.

The objective was to study the impact of birth weight on the relationship between ambulatory blood pressure and urinary sodium excretion in children and adolescents. The study included 134 healthy children (61 boys), all Caucasians, who were born at term after a normotensive pregnancy. For each subject, a 24-hour ambulatory blood pressure monitoring and a complete urine collection were simultaneously performed according to the protocols designed. Average ambulatory blood pressure (BP) and the urinary excretion rates for sodium, potassium, and creatinine were calculated separately for 24-hour, awake, and sleep periods defined by a mini-diary. The excretion rate of sodium during sleep time was positively correlated with ambulatory systolic BP; such a positive relationship was not found for waking hours. Consequently, the impact of birth weight on the relationship between blood pressure and the urinary sodium excretion rate was analyzed during sleeping hours. Stepwise multiple regression analysis shows that although current weight was the strongest predictor for the sodium excretion rate during sleep (P<.001), there was also an independent significant direct relationship for birth weight (P<.04) after controlling for age, sex, and the average of systolic BP during sleep. Adjusted for current weight, a significant difference in the regression slopes relating urinary sodium excretion rate and systolic BP during sleep exists between children in the lowest (<3.100 kg) and the highest tertiles (>3.500 kg) of birth weight (P<.02). Differences in sodium excretion rates, adjusted for current weight, between the two extreme tertiles of birth weight became significant at the highest systolic BP (P<.04). The children who had the lowest birth weight tended to excrete less sodium during sleep. The results of the present study show a blunted pressure natriuresis curve in children and adolescents with the lowest birth weight. Whether this abnormal renal sodium handling may be present as an initial or as an intermediate mechanism leading to higher BP values must be assessed in additional studies.

Spectrofluorimetric determination of vitamin K3 by a solid-phase zinc reactor immobilized in a flow injection assembly.

The spectrofluorimetric determination of vitamin K3 (menadione) using a flow injection (FI) assembly provided with a solid-phase reactor with immobilized zinc is described. The naphthohydroquinone was produced by means of two coupled steps in the FI system: hydrolysis of the sodium sulfite derivative of the menadione in a basic medium and reduction of the generated menadione in the zinc reactor in an acidic medium. The fluorescent product was monitored spectrofluorimetrically (lambda ex 325 nm; lambda em 425 nm). The calibration graph was linear over the range 0.1-18 micrograms ml-1 with a reproducibility of 1.6%; the limit of detection was 0.005 microgram ml-1 and the sample throughput was 70 h-1. The influence of foreign compounds was studied and the procedure was applied to the determination of vitamin K3 in three different pharmaceutical formulations.

Lepidoglyphus destructor acarus in the urban house environment.

To assess the presence of Lepidoglyphus destructor in the household environment of sensitized children living in an urban environment, samples of house dust were collected at the homes where two groups of patients were living, as well as in two bakeries in the city of Valencia, which were taken as a reference. Patients were divided into two groups. Group A included atopic children suffering from rhinitis and/or asthma, who were sensitized to L. destructor, as proven by prick test and specific IgE (CAP). Group B included children with the same features as those included in Group A, who were sensitized to Dermatophagoides pteronyssinus, with prick and CAP tests showing no significant sensitization to L. destructor. The samples of dust were analyzed, and the amounts of Der p I, Der f I, Der II and Lep d I per gram of dust were assessed through a solid-phase ELISA with monoclonal antibodies. In Group A, all patients but two showed a sensitization to D. pteronyssinus by prick test and serum IgE. At the homes of the patients from both groups, significant levels of Dermatophagoides were found. In Group A, only three houses showed levels of L. destructor which were comparable to those found in bakeries. Lep d I was not found in the houses of Group B patients. This means that a sensitization to L. destructor, as assessed with full extracts, is not always an indicator of its presence at the patient's house environment; it may rather refer to cross-reactivity to Dermatophagoides. Thus, availability of the main antigen Lep d I seems necessary to increase the specificity of the allergologic study.

Intolerance to sodium metabisulfite in children with steroid-dependent asthma.

Oral challenge tests were carried out with sodium metabisulfite solution doses of 5, 10, 25, 50 and 100 mg, dissolved in 20 ml of citric acid, and administered to 20 children aged 7-14 years with steroid-dependent bronchial asthma. A single-blind challenge protocol was performed initially and the positive responses were confirmed by double-blind challenge. Initially, 6 of 20 presented a positive reaction, confirmed in 4 of 20 by double-blind challenge. Only 1 child was clinically suspected of exhibiting intolerance to this agent. The prevalence of the challenge test using sodium metabisulfite in children with steroid-dependent bronchial asthma was 20%.

[Factors modifying late bronchial response in the bronchial provocation test in asthmatic children]. / Factores modificadores de la respuesta bronquial tardía en el test de provocación bronquial en niños asmáticos.

When the test of bronchial provocation with inhalant allergens is performed in atopic asthmatics, we may find an immediate response (IR), a late response (LR) or a dual response (IR-LR). The immediate response occurs between 10 to 30 minutes after the allergenic exposition and it is resolved spontaneously in about one to two hours. A proportion of these patients, estimated around 47-73% presented a LR. The LR is manifested 3 or 5 hours after the inhalation test, maximum at 6-12 hours and may persist until 24 hours. The late response serves as a clinical model of asthma because the bronchial response is more prolonged and severe than the immediate response. This is best controlled with corticosteroids while bronchial reversibility is difficult with sympathomimetics only, a fact commonly observed in the natural course of asthma. The early response was observed to be in relation with multiple factors more predictable than the late response. The object of this work was to evaluate if the LR was related with factors such as the degree of obstruction previous to the test, the intensity of immediate bronchial response and the maximum dose of inhaled allergen. The present study was performed in 34 children of both sexes with ages ranging between 6 and 14 years, diagnosed with bronchial asthma caused by Dermatophagoides (26 patients), and Alternaria (8 patients) through the score of Foucard with positive bronchial provocation test with the allergen. The BPT was performed according to the method described for Cockcroft, utilizing a continuous pressured nebulizer, inhaling for two minutes at current volume. We employed the De Villbis 646 model nebulizer with flow of air at 6 l/min and output at 0.13-0.16 ml/min. The inhaled concentrations of allergen progressively increased by ten fold, in Dermatophagoides 0.01; 0.1; 1 and 10 BU/ml, and for Alternaria 1/1,000,000, 1/100,000 and 1/10,000 P/V. Ten minutes after each dose a spirometric function with pneumoscreen Jaeger was performed. If the FEV1 was decreased by 20% from the control value, we considered the IR positive. The late response was evaluated through an hourly control of the peak respiratory flow rate (PEFR) with a Mini Wright within a 24 hours period after the test, respecting nocturnal sleep. We considered positive (LR) if PEFR fall was equal or superior to 40% of the basal value and the presence of bronchial symptoms.(ABSTRACT TRUNCATED AT 400 WORDS)