Transcript Pediatric Hypertension

Pediatric Hypertension
Matthew Grinsell, MD, PhD
Disclosure

I have no financial disclosures.
Outline

Focus will be outpatient HTN in children and
adolescents.
 Definition of HTN in children and adolescents.
 Blood pressure measurement.
 Epidemiology.
 Etiology.
 Diagnosis.
 Evaluation.
 Therapy.
 Monitoring.
Definition of Hypertension
HTN-Adult vs. Pediatrics
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HTN is defined as the BP above which there is increased
risk of morbidity and mortality.
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In adults, HTN is relatively clearly defined by outcome data
such as:
 Mortality.
 CVD.
 Stroke.
This is why 120/80 is considered pre-HTN.
140/90 is HTN.
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Hypertension-Adult vs. Pediatrics
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In children and teens, there are very limited outcomes
data, so we use a statistical standard defined by BP
tables.
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Use of blood pressure tables available from:
(www.nhlbi.nih.gov/ guidelines/hypertension/childtbl. pdf
Easy
way is to type in “pediatric blood pressure tables” in
Google.
Pediatric BP Tables
We will come back to BP tables shortly
(www.nhlbi.nih.gov/ guidelines/hypertension/childtbl. pdf
Pediatric HTN
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Approximately 3-5% of children HTN and that number is
likely increasing.
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Hypertension is an average SBP and/or diastolic BP
(DBP) that is above the 95th percentile for gender, age,
and height on three separate occasions.
 Systolic and diastolic are of equal importance.

Regardless of the charted 95% BP for age, gender and
height, any pediatric patient with BP above 120/80 mm
Hg should be considered prehypertensive and
evaluated.
Pediatrics 2004;114;555
HTN Classification in Children and
Adolescents
Pediatrics 2004;114;555
HTN as a Global Health Issue
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HTN was the leading attributable cause of death
worldwide in 2004 according to the WHO.
In the United States:
 33% of adults 20 years and older had HTN.
 HTN in 2007 was the 13th leading cause of death in
the US but is a known risk factor or complication of:
 #1 Heart disease
 #4 Cerebrovascular diseases/Stroke
 #7 Diabetes Mellitus
 #9 Kidney disease
http://www.who.int/healthinfo/global_burden_disease/global_health_risks/en/index.html
http://www.cdc.gov/nchs/fastats/lcod.htm
HTN as a Pediatric Health Issue
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Patients 10-17 years with elevated SBP on admission to
hospital in Reykjavik, Iceland, 1950 to 1967.
126 individuals (54 men) invited for a follow-up in 2008.
Median BP was 125/80 mmHg 1950-1967
Median BP 133/75 mmHg 2008
49/126 had been diagnosed with HTN (23 men)
12/126 with coronary artery disease (10 men).
Significant correlation (P = 0.03) between the diagnosis
of coronary artery disease in adulthood and elevated
childhood systolic BP.
Pediatr Nephrol. 2010 Feb;25(2):323-8
HTN and Early Atherosclerosis
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Pathobiological Determinants of Atherosclerosis in Youth
(PDAY).
 Autopsies of 629 males age 15-34 who died of trauma.
 Normal cholesterol (< 160) and HDL (> 35).
Hypertensive males had more raised aortic plaque lesions
than normotensive males.
Obese males had more extensive fatty streaks in the
abdominal aorta and the left anterior descending coronary
artery.
HTN may impact the extent and severity of coronary artery
disease and aortic atherosclerosis in adolescents and young
adults.
JAMA. 1990 Dec 19;264(23):3018-24
Circulation. 2001 Mar 20;103(11):1546-50.
Measurement of Blood
Pressure
BP Measurement
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Who should have BP measured?
Selection of correct cuff size.
Oscillometry vs. auscultation.
Confirmation of elevated blood pressures.
Who Should Have BP Measured?
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AAP recommends:
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Children 3 years and older who are seen in a medical
setting should have their BP measured at least once during
that visit.
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Children under 3 years should have BP measured if they
have certain risk factors.
Pediatrics 2004;114;555
When to Measure BP in Children
< 3 yrs
• History of NICU stay, Prematurity, or VLBW.
•Congenital Heart Disease
•Recurrent urinary tract infections, hematuria,
proteinuria
•Known renal disease or urologic malformations
•Family history of congenital renal disease
•Solid organ transplant
•Malignancy or bone marrow transplant
•Treatment with drugs known to raise BP
•Systemic illness with high blood pressure such as
TS or NF
•Evidence of elevated intracranial pressure
When to Measure BP in Children
< 3 yrs
• History of NICU stay, Prematurity, or VLBW.
•Congenital Heart Disease
•Recurrent urinary tract infections, hematuria,
proteinuria
•Known renal disease or urologic malformations
•Family history of congenital renal disease
•Solid organ transplant
•Malignancy or bone marrow transplant
•Treatment with drugs known to raise BP
•Systemic illness with high blood pressure such as
TS or NF
•Evidence of elevated intracranial pressure
When to Measure BP in Children
< 3 yrs
• History of NICU stay, Prematurity, or VLBW.
•Congenital Heart Disease
•Recurrent urinary tract infections, hematuria,
proteinuria
•Known renal disease or urologic malformations
•Family history of congenital renal disease
•Solid organ transplant
•Malignancy or bone marrow transplant
•Treatment with drugs known to raise BP
•Systemic illness with high blood pressure such as
TS or NF
•Evidence of elevated intracranial pressure
When to Measure BP in Children
< 3 yrs
• History of NICU stay, Prematurity, or VLBW.
•Congenital Heart Disease
•Recurrent urinary tract infections, hematuria,
proteinuria
•Known renal disease or urologic malformations
•Family history of congenital renal disease
•Solid organ transplant
•Malignancy or bone marrow transplant
•Treatment with drugs known to raise BP
•Systemic illness with high blood pressure such as
TS or NF
•Evidence of elevated intracranial pressure
BP-Measurement
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Obtain patient’s height percentile.
Select cuff appropriate for child’s size.
 Appropriate size cuff : bladder width = 40% upper arm
circumference.
 Or, bladder length should encircle 80-100% upper
arm circumference.
 A cuff too small may lead to high BP values.
 When in doubt use a larger cuff.
Pediatric Nephrology Clinic Cuffs
BP-Measurement
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No stimulant drugs or foods for 24 hours.
Sitting quietly for 5 minutes with back supported, and
feet on the floor.
Right arm supported with cuff placed at the level of the
heart.
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Right arm is preferred because standardized measurements are based
on right arm BP.
Stethoscope placed over the brachial artery below the
bottom edge of the cuff.
Inflate cuff to 99% + 20 initially (in kids 140-150 works).
SBP = 1st Korotkoff sound “opening snap”.
DBP = 5th Korotkoff sound or disappearance of sounds.
BP-Measurement
BP-Measurement
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Once BP is obtained, plot on BP charts as a function of:
 Gender.
 Age.
 Height percentile.
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For example: A 7y/o female who is 125 cm tall (75%).
 Measured BP is 105/65.
Use of Pediatric Tables
A 7y/o female who is 125 cm tall.
Measured BP is 105/65.
(www.nhlbi.nih.gov/ guidelines/hypertension/childtbl. pdf
Use of Pediatric Tables
A 7y/o female who is 125 cm tall.
Measured BP is 105/65.
(www.nhlbi.nih.gov/ guidelines/hypertension/childtbl. pdf
Use of Pediatric Tables
A 7y/o female who is 125 cm tall.
Measured BP is 105/65.
(www.nhlbi.nih.gov/ guidelines/hypertension/childtbl. pdf
Use of Pediatric Tables
A 7y/o female who is 125 cm tall.
Measured BP is 105/65.
(www.nhlbi.nih.gov/ guidelines/hypertension/childtbl. pdf
Questions About BP Measurement
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Is there a significant difference between auscultation and
oscillometric (Automated) measurements?
Do stimulants used for ADD/ADHD significantly affect BP
in children?
Auscultation vs Oscillometry
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Ausculatation is the preferred method of BP
measurement as tables are based on auscultation.
Oscillometric measurement
 Reduces inter-observer variability.
 Highly reproducible.
Oscillometric devices work by measuring MAP and using
an algorithm to calculate SBP/DBP.
 Proprietary information.
 Makes standardization impossible.
Auscultation vs Oscillometry
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2001: Auscultation and oscillometric BP measurements
on 7,208 school children age 5-17 years in San Antonio,
TX.
 Dinamap 8100
Cross-over design: Children randomized to either
auscultation or Dinamap as first measurement
technique, then measured with alternate technique.
On average, Oscillometry had a 10 mmHg higher SBP
and 4.7 mmHg DBP.
The difference was more pronounced in younger
children.
Arch Pediatr Adolesc Med/Vol 155,Jan 2001.
Stimulants and BP
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Placebo controlled studies have found small but
statistically significant increases in BP with stimulants.
 Generally 2-4 mmHg for SBP.
 1-3 mmHg for DBP.
The clinical significance of these findings remains
unclear.
One study did find a sustained BP > 95% in 2.5% of
subjects following discontinuation of stimulants.
On a population level, modest BP effect, but certain
individuals may be sensitive.
If needed, continue stimulants.
Child Adolesc Psychiatr Clin N Am. 2009 April 1
Biol Psychiatry 2007;61:706–712
Epidemiology of
Hypertension
HTN-Epidemiology
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Pre-HTN and HTN have been increasing in children and
adolescents over last 2-3 decades.
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How much?
% Children with Pre-HTN (BP 90%-95%)
Pre-HTN Increase 8-17 y/o
Between the 2 time periods, Pre-HTN increased in all groups.
Adapted from Circulation 2007, 116:1488-1496
HTN-Increase Over Time
The prevalence HTN in 8-17 year olds in the US has
increased over the last 20-25 years.
5
% Children with HTN (BP > 95%)
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4.5
4
3.5
3
2.5
1988-1994
2
1999-2002
1.5
1
2012?
0.5
0
Non-Hispanic blacks
Non-Hispanic whites
Mexican Americans
Adapted from Circulation 2007, 116:1488-1496
HTN in the Pediatric Age Group
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Between 1988-1994 and 1999-2002 in 8-17 y/o patinets:
 Pre-HTN and HTN increased significantly in
Hispanics, Caucasians and African-Americans of both
genders.
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So what has caused the increase in adolescent HTN?
 Likely mulitfactorial.
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However, I would like to go on a brief tangent……
Obesity-BMI and HTN in Children
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As BMI increases, so does HTN.
So has pediatric BMI been increasing over time?
Hypertension 2002, 40:441-447
Yes, Obesity and BMI are Rising
There are some interesting if not outright causative chronologic
associations with rising childhood BMI and obesity.
Adapted from: http://www.cdc.gov/obesity/childhood/prevalence.html.
Yes, Obesity and BMI are Rising
1971: Legislation signed allowing
use of high fructose corn syrup
in lieu of cane sugar.
Adapted from: http://www.cdc.gov/obesity/childhood/prevalence.html.
Yes, Obesity and BMI are Rising
1971: Legislation signed allowing
use of high fructose corn syrup
in lieu of cane sugar.
1976: High Fructose corn
syrup enters widespread use.
Adapted from: http://www.cdc.gov/obesity/childhood/prevalence.html.
High Fructose Corn Syrup
Use of High Fructose Corn Syrup
Yes, Obesity and BMI are Rising
1980’s:
Anything
else?
1971: Legislation signed allowing
use of high fructose corn syrup
in lieu of cane sugar.
1976: High Fructose corn
syrup enters widespread use.
Adapted from: http://www.cdc.gov/obesity/childhood/prevalence.html.
1985 and the Link to Obesity
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Boris Becker becomes the youngest Wimbledon
champion at 17 years old.
Television series The Dukes of Hazzard goes off the air.
Microsoft Corporation releases the first version of
Windows, Windows 1.0.
These are all exciting, but likely did not contribute to
obesity.
Had to be something else………
Obesity and Nintendo
Not the only cause, but certainly a part of the bigger picture.
Obesity and HTN
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Obesity and Hypertension are linked.
 These health problems do track into adulthood.
Bogalusa Heart Study:
 Overweight children were 4.5 times and 2.4 times as
likely to have elevated SBP and DBP, respectively.
Possibility related to:
 Sympathetic overactivity.
 Insulin resistance.
 Altered vascular structure.
 Increased salt sensitivity.
Etiology of HTN
Etiology of HTN in Pediatrics
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Primary (essential) - no identifiable underlying cause.
This has increased with obesity epidemic.
 Diagnosis of exclusion.
Thought to be a complex interplay of environmental and
genetic factors.
Etiology of HTN in Pediatrics
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Secondary - Identifiable cause, potentially curable. Can
be placed in a few broad categories.
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Renal parenchymal
diseases. (most
common)
Aortic coarctation.
Renovascular: FMD.
Single Gene
Disorders: Liddles,
Gordons.
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Endocrine disorders.
Malignancies: pheo.
neuroblastoma
Miscellaneous disorders:
Ingestions, Williams
syndrome.
Secondary HTN-Etiology
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University of Texas Southwestern MC, 1994.
132 children 0-18 years with sustained HTN.
89 (67%) had secondary HTN due to kidney or
renovascular disease.
Most common causes of secondary HTN were:
 Glomerulonephritis.
 Reflux nephropathy.
Renal Vein Thrombosis most common in neonatal
period.
Pediatr Nephrol 1994; 8:186.
Secondary HTN-Etiology
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Children’s Hospital, Warsaw, Poland.
1,025 patients 1 month to 18 years old referred for HTN.
636 diagnosed with sustained HTN.
351 (55%) patients with secondary HTN.
Age
Group
(years)
0-5
6-14
Total
Patients with
Patients Kidney/Renovascular
disease.
105
83 (79%)
153
129 (84%)
15-18
93
66 (71%)
Secondary HTN-Big DDx
Pediatr Nephrol (2009) 24:2137–2146
White Coat HTN
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HTN in medical setting likely due to nerves/anxiety.
Actually is a risk factor for sustained HTN with 30-40% of
individuals with WCH developing sustained HTN after 10
years.
 Possibly related to increased sympathetic activity.
Diagnosis of HTN
HTN-Diagnosis
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Unlike adults, no outcomes data to identify a single cutoff
value like 140/90.
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Diagnosis of HTN is made when there are 3 readings
above the 95% or if patient is symptomatic.
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Stage 2 or symptomatic HTN does not need 3 readings
for diagnosis.
 For example a 6 y/o with 170/110.
Symptoms of HTN
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Headache.
Blurry vision.
Epistaxis.
Nausea/vomiting.
Poor feeding.
Flushing.
Cough.
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Abdominal pain.
Shortness of breath.
Heart palpitations.
Slurred speech.
Confusion.
Seizures.
Evaluation of HTN
HTN-Evaluation
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If elevated BP is noted during medical visit:
Prehypertension - Recheck in six months.
Stage 1 HTN - Recheck within 1-2 weeks/ABPM.
Stage 2 HTN - Evaluation for HTN should proceed
within 5-7 days or immediately if the patient is
symptomatic.
 In conjunction with drug therapy.
Goal of evaluation is to differentiate primary from
secondary HTN to identify potentially curable cause.
HTN Evaluation-Historical Clues
Primary (essential)
 Adolescent.
 Usually Stage 1 HTN.
 Strong family history.
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HTN.
Cardiovascular disease.
Obesity.
Diabetes.
History of sleep
disorders/apnea/snoring.
Secondary
 Prepubertal.
 Thin.
 Usually severe HTN
(defined as stage 2 HTN)
 Acute rise from normal
baseline.
 History of UTI.
 Edema (swole), rash,
gross hematuria.
 C/O headache, sweating,
tachycardia, feeling hot,
and nausea.
HTN-Other History
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Family history-ADPKD, transplantation, early CVD or
HTN.
Diet: Soda intake, fast food, processed foods.
Medical history: Prematurity +/- UAC, urinary tract
infections, other medical issues.
Alcohol and tobacco exposure.
Review of medications, illicit drugs, herbal or dietary
supplements.
Physical activity history.
Screen time
HTN-Medications
HTN-Physical Exam
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Confirm HTN manual BP measurement.
BMI – Obesity.
4 extremity BP - aortic coarctation, LE BP generally 1020 mm Hg higher than arms.
Edema-Fluid overload, renal disease.
Abdominal: Bruit.
Rash-SLE, HSP, vasculitis.
Fundoscopy – operator dependent.
Tachycardia-catecholamine excess.
Skin: Stigmata of NF1 or TSC.
Lab Workup-Stage 1 HTN
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BMP/RFP- Kidney function.
CBC-CKD.
UA and culture (if indicated)-proteinuria, hematuria.
 Microscopy of urine sediment for casts, dysmorphic
RBC’s.
Urine protein/creatinine ratio-GN.
TSH, Free T4.
Lipid panel, fasting glucose, HgbA1c.
Drug Screen if index of suspicion.
Lab Workup-Stage 2 HTN
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CMP/RFP.
CBC.
UA, Urine culture, urine protein/creatinine ratio.
Renin and Aldosterone.
Complement components 3 & 4.
Lab Workup-Other Studies
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Renal vein Renin sampling.
ANA, anti-dsDNA.
ANCA, MPO + PR3 titers.
Anti-GBM.
Plasma fractionated metanephrines/24 hour urine
metanephrines, HVA & VMA.
Imaging
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Renal US-Renal size and anatomy, cystic
disease/dysplasia, hydronephrosis, blood flow.
Echocardiogram - to assess for LVH which is by far the
most common end organ damage.
 Also picks up Coarctation.
Some reports show LVH in up to 35% of children with
even mild HTN.
 Percentage of children with LVH increases with
severity of HTN.
Imaging
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Other studies:
 MAG3 scan to assess renal perfusion, obstruction
and differential function.
 DMSA to assess for renal scarring due to recurrent
pyelonephritis.
 VCUG to assess for reflux and posterior urethral
valves.
 CT angiogram to assess for renal artery stenosis and
can also assess for coarctation.
These imaging studies can be done after therapy is
initiated.
MAG3
Left
Right
Renal Damage-DMSA
VCUG
CT Angiogram of RAS
www.learningradiology.com/caseofweek
Other Evaluation Options
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Sleep Study
Ophthalmology assessment for retinal damage.
Ambulatory Blood Pressure Monitoring.
 Helpful in identifying individuals with white-coat HTN.
Pediatr Nephrol 2009; 24:707–719.
Therapy of HTN
HTN-Therapy
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Therapy for HTN in adults has proven benefits in
reducing cardiovascular morbidity and mortality.
Data in children only evaluate ability of therapies to lower
BP, no data on long term clinical outcomes.
 Unique research opportunity in Utah with a large
population that tends to stay local.
Growing body of evidence that preventing/treating
pediatric HTN will have long term benefits into
adulthood.
HTN-Non Pharmacologic Therapy
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DASH (Dietary Approaches to Stop Hypertension)
 Salt Restriction-1200-2000 mg/day
 High intake of fruits, vegetables, low fat or nonfat dairy,
whole grains, lean meats, fish and poultry; nuts and
beans.
 Small amounts of red meats, saturated fats, sweets, and
sugar-containing beverages.
DASH diet has been shown to reduce SBP 10-13 points
and DBP 4-7 points.
Exercise-Aerobic +/- resistance training.
Limiting screen time to < 2 hrs per day (less Nintendo).
http://www.kidney.org/professionals/kdoqi/guidelines_bp/guide_6.htm
Weight Loss and HTN
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In adults, weight loss = 1-2 mm Hg per pound lost.
72 obese children and adolescents, 10-17 years old.
Pre-randomization BP’s averaged 127/78.
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Group A: Diet and behavior change x 8 weeks
Group B: Diet, behavior change and 1 hour exercise thrice
weekly x 8 weeks.
Group C: No intervention x 8 weeks.
Group A: wt - 2 kg, BP from 127/80 to 117/68
Group B: wt - 3 kg, BP from 129/79 to 113/66
Group C: wt + 4 kg, BP from 126/78 to 130/77
Weight loss reduces BP in obese adolescents.
 Long term benefit?
PEDIATRICS Vol. 82 No.1 July 1988
HTN-Non Pharmacologic Therapy
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We routinely encourage:
 Salt restriction with a no-added-salt diet.
 Restriction of sugar-sweetened beverages.
 Including Sports Drinks.
 Exercise.
 More fruits and veggies.
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Compliance is a definite struggle with individuals and
families.
Pharmacologic Therapy-Who Gets
Treated?
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Stage 2 HTN.
Symptomatic HTN.
Insufficient response to non-pharmacologic interventions.
 Usually try a 3-6 month trial.
Pre-HTN or Stage 1 HTN in patients with diabetes mellitus,
CKD, or proteinuria.
Evidence of end-organ damage, most importantly LVH.
Stage 1 HTN with dyslipidemia.
Pharmacologic Therapy-Goals
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Reduce BP to <95%.
< 90% with other comorbid conditions.
 LVH, or diabetes.
< 50% in children with CKD.
Start lowest possible dose with single med and titrate up
to desired effect or side-effects.
 Then start second med.
As nearly all classes of anti-HTN medications have
shown efficacy in lowering pediatric BP, choice of initial
medication is at discretion of treating physician.
N Engl J Med 2009;361:1639-50.
Anti-Hypertensive Medications
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Due to patent protection provided by 1997 Food and
Drug Administration Modernization Act (FDAMA) and the
2002 Best Pharmaceuticals for Children Act, more
medications studied and approved for children.
Commonly Used:
 Dihydropyridine Calcium Channel Blockers.
 ACE inhibitors/Angiotensin Receptor Blockers.
 Beta-Blockers.
 Diuretics.
Less commonly used
 Clonidine, Doxasin, Prazosin, Hydralazine, Minoxidil.
Calcium Channel BlockersDihydropyridine Class
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Amlodipine, Nifedipine, Nicardipine
Extensive history of safety and efficacy in children.
Relax smooth muscle.
Low side effect profile, may cause peripheral edema and
orthostatic symptoms.
ACE inhibitors/Angiotensin
Receptor Blockers
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Safe and effective in children/adolescents.
Long term use may protect from chronic kidney disease.
Possible side effects include increased creatinine,
hyperkalemia, and chronic cough due to bradykinin excess.
Teratogenic.
Counseling required regarding use of ACEI/ARB with
NSAIDS or dehydration.
Preferred antihypertensive medication for athletes.
Beta Blockers
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Among earliest and widely used anti-HTN medications in
pediatrics.
Well tolerated with few side effects.
Contraindicated in asthma and heart block.
Should be avoided in athletes.
Diuretics
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Thiazides-HCTZ, Metolazone, Chlorthalidone
 Complications include hypokalemia, hyperglycemia.
 May elevate cholesterol and triglycerides.
Loop diuretics – furosemide, bumetanide
 Also cause hypokalemia.
Potassium sparing-Spironolactone, Eplerenone,
Triamterene, Amiloride.
 Block action of Aldosterone.
Other Medications
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Clonidine, central alpha-blocker.
 May cause sedation, rebound HTN.
Doxazosin, Prazosin
 Used for treatment of pre-op HTN with
pheochromocytoma.
Hydralazine - Direct vasodilator.
Minoxidil - Very potent direct vasodilator, promotes hair
growth.
 Not a good long term option.
Therapy Monitoring
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Once pharmaceutical therapy is initiated, check labs in
1-2 weeks.
 Assess for renal function, potassium.
 Particularly patients on ACEI/ARB and/or diuretics.
Clinical follow-up frequent following initiation of meds.
 Every 2-4 weeks until stable, then space visits out.
 Maintenance visits every 3-6 months
 Continue to encourage lifestyle changes.
 Ongoing vigilance for medication side effects, end
organ damage.
ABPM to assess response to therapy every 6-12
months.
Questions About BP
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Is sports participation safe in children and adolescents
with HTN?
HTN and Sports
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AAP Policy Statement, 2010
The presence of pre-HTN should not limit eligibility for
competitive athletics.
Encourage lifestyle modifications:
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Weight management.
Daily physical activity.
Well-balanced diet.
BP should be measured every 6 months.
Pediatrics 2010;125;1287
HTN and Sports
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Stage 1 HTN in the absence of end organ damage
should not limit eligibility for competitive athletics.
 Recheck BP in 1-2 weeks or sooner if symptomatic.
 Appropriate referrals to pediatric medical
subspecialists if patients have persistent HTN, are
symptomatic, have LVH or concomitant heart
disease.
 Require evaluation for lifestyle modification or drug
therapy.
Pediatrics 2010;125;1287
HTN and Sports

Stage 2 HTN in the absence of end organ damage
should be restricted from high-static sports (classes IIIA
to IIIC) until their blood pressure is in normal range after
lifestyle modification and/or drug therapy.

These athletes should be promptly referred and
evaluated by a qualified pediatric medical subspecialist
within 1 week if they are asymptomatic or immediately if
they are symptomatic.

801-662-1000 Ask for Pediatric Nephrologist on call.
Pediatrics 2010;125;1287
High Static Sports
Pediatrics 2010;125;1287
Summary
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Pre-HTN and HTN are increasing in pediatric population.
SBP and DBP are equally important in diagnosis of HTN
If you have a patient with HTN, check for kidney
disease.
If you suspect kidney disease, check for HTN.
Regardless of the charted 95% BP for age, gender and
height, any adolescents with BP above 120/80 mm Hg
should be considered prehypertensive and evaluated.
Summary
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Stage 2 or symptomatic HTN requires immediate therapy
and evaluation.
Initiate dietary counseling early.
 Avoid the potato chip aisle, chef Boyardee aisle and
buildings with drive through windows.
Consider referral to subspecialty care for pre-HTN.
Recommend referral for stage 1 and 2 HTN.
Thank you