HYPERTENSION IN ESRD

Oleh : Muhammad Haris

Stase Nefrologi Pediatric

PPDS Ilmu Penyakit Jantung dan Kedokteran Vaskuler

FK UGM

INTRODUCTION

Pediatric hypertension widely observed. Major cause of morbidity and mortality in United States and other countries

The true incidence of hypertension in children is not known

Standart of Blood Pressure for Children was made by NHLBI by using 11 surveys of more than 83.000 infants and children

Last, widely used The Fourth Report

Category : Pre hypertension : above 9oth percentile & below 95th percentile

Stage 1 hypertension : above 95th percentile & below 95th percentile plus 5 mmHg

Stage 2 hypertension : above 95th percentile plus 5 mmHg

CKD stage 1 65 % affected hypertension

CKD stage 4 & 5 80 %

And more than 50 % children with ESRD have uncontrolled hypertension

WORK UP

Laboratory studies : CBC (anemia Chronic Renal Disease), Creatinine (Renal Disease), Hypokalemia (Hyperaldosteronism), Blood hormone (high plasma renin renal vascular hypertension), Urine dipstick (+proteinuria problem in renal)

Echocardiography : LVH from chronic hypertension start for therapy (usually concentric morphology

Abdominal USG may reveal tumors or structural anomalies of kidneys or renal vasculare

Angiography to reveal the structure of renal vessels

PATTERN OF HYPERTENSION IN ESRD

Very common in all stages of CKD

Generally : Fluid overload

Activation of renin-angiotensin system

Symphatetic activation

Endhotelial dysfunction

Chronic hyperparathyroidism

Therapy : ACE inhibitor

ARB

DIuretics

PATHOFISIOLOGY

Mechanisme of muscle sympathomimetic in elevated BP still unclear

Maybe connected with afferent afferent signal, dopaminergic abnormalities & accumulation of leptin in CKD

Another postules about renal ischemia

Renalase (amino oxidase expressed in kidney) activity usually reduced in patients with ESRD. Lower blood pressure and heart rate

In uremic patients, reduced NO stimulation leads to reduced agonist endhotelium-dependent vasodilatation

Corelated with higher concentration of ADMA

(Hadstein, 2007)

DRUG ASSOCIATED WITH HT

Erythropoietin cause elevated BP for several weeks

Related with arterial wall remodeling causing vascular resistance (Schiffl H et al 1998) and voltage independent calcium channel in smooth muscle activity sensitivity NO decreased (Vaziri et al, 1999)

Glucocoticoid lead to fluid retention by their mineralocorticoid effect

Cyclosporine A causes vasoconstriction of glomerular afferent arterioles and hyperplasia of juxtaglomerular apparatus

MANAGEMENT

PHARMACOTHERAPY

Based on epidemiology : 75% children with CKD stages 2-4 can reduces blood pressure (<95th percentile) with monotheraphy oh antihypertensive

More aggressive therapy needed if targetted <50th percentile

Start with single dose and titrate upward

ACE inhibitorand ARB is the most useful drug not only reduce BP but also slow down the progession of renal failure

Mechanism : Reduced proteinuria

Lower intaglomerular pressure

Anti inflamatory

Anti fibrotic

PHARMACOTHERAPY (2)

Diurretics used when hypervolemia

Thiazides are a popular first line therapy in mild to moderate CKD but less efective when GFR falls below 60 ml/min per 1.73 m2 body surface area

Not efective when below 30 ml/min . Shoul used furosemide when the status is ESRD

CCB very potent vasodilators and do not have cardiac side effect (have side effect proteinuria and increase intaglomerular pressure)

Beta Blocker can be used as a second line therapy for renal hypertension in children. Contraindications in asthma and can cause fatigue.

TERIMA KASIH & MOHON ASUPAN