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Perinatal risks to renal functional reserve in low birthweight [LWB], very low birthweight [VLBW] and extremely low birthweight [ELBW] babies
AJH–April 2001–VOL. 14, NO. 4, PART 2
POSTERS: Pediatric Hypertension
P-624 PERINATAL RISKS TO RENAL FUNCTIONAL RESERVE IN LOW BIRTHWEIGHT [LWB], VERY LOW BIRTHWEIGHT [VLBW] AND EXTREMELY LOW BIRTHWEIGHT [ELBW] BABIES Julie R. Ingelfinger, Michelle Ramirez, Jean L. McAuliffe, Elizabeth A. Catlin. 1Pediatrics, Massachusetts General Hospital, Boston, MA, United States Humans form nephrons through week 34 of gestation [range 32-36 weeks]. Thus, nephrogenesis is still occurring within the kidneys when infants are born early. Compelling data suggest that renal endowment is markedly influenced by perinatal factors, and that interference with nephrogenesis at such a time will result in a higher incidence than expected of cardiorenal disease in adult life. Given the complex course of very small infants during their first weeks of extrauterine life, during which they are in neonatal intensive care units, it is clear that many, if not most, such infants are exposed to nephrotoxic medications and also suffer from periods of less-than-optimal nutrition. The renal functional reserve of NICU survivors, as they grow and develop through childhood and beyond, has not been explored, though considerable epidemiological data [Barker hypothesis] has correlated low birthweight with a high frequency of hypertension and cardiovascular problems in later life. We examined exposure to potentially nephrotoxic medications in a cohort of 20 LBW [⬍2.5 kg],VLBW [⬍1.5 kg], and ELBW [⬍1kg] infants in the NICU during an 8 week period. The average number of medications to which each neonate was exposed was 14 [range 10-21], as shown in Table below. This quite straightforward information points out the need for caution with respect to nephrotoxin exposure in premature infants who are still forming new nephrons. We hypothesize that the final weeks of nephrogenesis are impaired in this situation and that renal functional reserve in such individuals is impaired as well. Nephrotoxic Potential Gentamicin
Potential Tubular Effect
Other Renal Effects
Aldactone
Aldactone
Amoxicillin
Bactroban Cefazolin Dilantin Furosemide MSO4 NaHCO3 Pavulon Phenobarbital Versed Meds in 1st 2 columns
Chlorothiazide DTO Fer-in-Sol Furosemide Glycerine Oxacillin
Ampicillin Albuterol Atrovent Contrast Media Decadron Dobutamine Dopamine Fentanyl Heparin Hydrocortisone
Nephrotoxic in Caution in Combination LBW Babies
Bacitracin [if absorbed] Tobramycin Cefazolin Vancomycin Cefotaxime Indomethacin Chlorothiazide HCTZ Zantac
Neosynephrine
Key Words: cardiorenal reserve, hypertension, perinatal programming
P-625 SIGNIFICANCE OF BODY MASS INDEX IN PRIMARY AND SECONDARY PEDIATRIC HYPERTENSION Renee F. Robinson, Donald D. Batisky, Milap C. Nahata, John D. Mahan. 1Division of Pharmacy Practice and Administration, The Ohio State University College of Pharmacy, Columbus, OH, United States, 2 Nephrology, Children’s Hospital Research Institute, Columbus, OH, United States, 3Nephrology, The Ohio State University College of Medicine, Columbus, OH, United States The objectives of this study were to 1)determine the relationship between body mass index and primary and secondary hypertension; and, 2) to assess body mass index at the age of onset of primary and secondary hypertension in children and adolescents. Patient demographics, age, race, gender, body mass index, family history, presentation of disease, etiology of hypertension, date of diagnosis, medication therapy received, laboratory measures and other pro-
239A
cedures were recorded for the 321 patients seen in the Nephrology Clinic at Children’s Hospital over a 4 year period. A total of 321 patients were studied: 220 with primary hypertension, 97 with secondary hypertension. Our patient population(172 males,149 females)was diverse in age (⬍ 11 years (32%), ⬎ 11 years (69%)) and ethnicity (237 Caucasians, 54 African Americans). Body mass index was found to be significantly greater in patients with primary hypertension versus secondary hypertension (p⫽0.002). The age of onset (10.5 ⫾2.6)in primary hypertension was related to increased body mass index (p ⫽ 0.00); however, there was no relationship between body mass index and age of onset of secondary hypertension. Conclusion 1)increased body mass index was more prevalent in children with primary hypertension and 2) earlier onset of primary hypertension in the pediatric population was associated with increased body mass index. Key Words: body mass index, primary and secondary hypertension, pediatric hypertension
P-626 CHARACTERISTICS OF CHILDREN WITH PRIMARY HYPERTENSION REFERRED TO A TERTIARY CENTER Joseph T. Flynn. 1 Pediatric Hypertension Program, C.S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI, United States The characteristics of primary hypertension (PH) in children (C) were studied by retrospectively reviewing the records of our pediatric hypertension (HTN) program. Of 157 C seen over a 5-year period, 58 (36.9%) had PH, defined as sustained blood pressure (BP) ⬎95th percentile for age/gender/height. 11 additional C (7%) had borderline HTN, defined as BP between 90-95th percentiles. Mean age of these 69 C was 13.3⫾4 years (mean⫾SD), range 1.1-18.5y. 24/69 (34.8%) were female. Family history (FH) of HTN in a parent or grandparent was present in 56/65 C (86.2%) for whom FH was available. Mean BMI of all C was 27⫾7 and was slightly higher in older teens. Initial BP was 132⫾18/74⫾13 mmHg for C ⬍12y, and was 144⫾11/78⫾12 mmHg for C ⬎12y. All C underwent a standard evaluation to exclude secondary HTN. Renal function, electrolytes and urinalysis were normal in all C. Echocardiography was obtained in 57/69 C (83%); left ventricular hypertrophy (LVH) was present in 13/57 C (22.8%). Ambulatory BP monitoring (ABPM) was performed in 35 C (50%). Mean 24h systolic BP load was 52⫾24%; mean diastolic BP load was 18⫾16%. 33/69 C (47.8%) received antihypertensive drug therapy; the remaining C were instructed in lifestyle modifications. Indications for drug therapy were LVH in 11 C, abnormal ABPM in 9 C, persistent casual BP elevation in 5 C, & other reasons in 8 C. Medications used included calcium antagonists (17 C), ACE inhibitors (9 C), beta blockers (4 C) and others (3 C). Follow up BP’s were available for 48 C; drug therapy produced a significant decrease in BP whereas lifestyle modifications did not: Group Medication Lifestyle
SBP DBP SBP DBP
Initial
Follow-up
P*
146 ⫾ 12 83 ⫾ 13 135 ⫾ 14 72 ⫾ 9
132 ⫾ 11 67 ⫾ 9 136 ⫾ 12 72 ⫾ 9
⬍0.0001 ⬍0.0001 NS NS
*two-way, paired t test From these data we conclude that PH is commonly seen in specialized pediatric HTN clinics. Characteristics of PH in this series included positive FH, mild obesity and systolic HTN on ABPM. Indications for drug therapy were present in a greater percentage of C with PH than previously reported, and ABPM played a key role in determining the need for drug therapy. Long-term, prospective studies are needed to further define the natural history of childhood PH and to further examine
POSTERS: Pediatric Hypertension
P-624 PERINATAL RISKS TO RENAL FUNCTIONAL RESERVE IN LOW BIRTHWEIGHT [LWB], VERY LOW BIRTHWEIGHT [VLBW] AND EXTREMELY LOW BIRTHWEIGHT [ELBW] BABIES Julie R. Ingelfinger, Michelle Ramirez, Jean L. McAuliffe, Elizabeth A. Catlin. 1Pediatrics, Massachusetts General Hospital, Boston, MA, United States Humans form nephrons through week 34 of gestation [range 32-36 weeks]. Thus, nephrogenesis is still occurring within the kidneys when infants are born early. Compelling data suggest that renal endowment is markedly influenced by perinatal factors, and that interference with nephrogenesis at such a time will result in a higher incidence than expected of cardiorenal disease in adult life. Given the complex course of very small infants during their first weeks of extrauterine life, during which they are in neonatal intensive care units, it is clear that many, if not most, such infants are exposed to nephrotoxic medications and also suffer from periods of less-than-optimal nutrition. The renal functional reserve of NICU survivors, as they grow and develop through childhood and beyond, has not been explored, though considerable epidemiological data [Barker hypothesis] has correlated low birthweight with a high frequency of hypertension and cardiovascular problems in later life. We examined exposure to potentially nephrotoxic medications in a cohort of 20 LBW [⬍2.5 kg],VLBW [⬍1.5 kg], and ELBW [⬍1kg] infants in the NICU during an 8 week period. The average number of medications to which each neonate was exposed was 14 [range 10-21], as shown in Table below. This quite straightforward information points out the need for caution with respect to nephrotoxin exposure in premature infants who are still forming new nephrons. We hypothesize that the final weeks of nephrogenesis are impaired in this situation and that renal functional reserve in such individuals is impaired as well. Nephrotoxic Potential Gentamicin
Potential Tubular Effect
Other Renal Effects
Aldactone
Aldactone
Amoxicillin
Bactroban Cefazolin Dilantin Furosemide MSO4 NaHCO3 Pavulon Phenobarbital Versed Meds in 1st 2 columns
Chlorothiazide DTO Fer-in-Sol Furosemide Glycerine Oxacillin
Ampicillin Albuterol Atrovent Contrast Media Decadron Dobutamine Dopamine Fentanyl Heparin Hydrocortisone
Nephrotoxic in Caution in Combination LBW Babies
Bacitracin [if absorbed] Tobramycin Cefazolin Vancomycin Cefotaxime Indomethacin Chlorothiazide HCTZ Zantac
Neosynephrine
Key Words: cardiorenal reserve, hypertension, perinatal programming
P-625 SIGNIFICANCE OF BODY MASS INDEX IN PRIMARY AND SECONDARY PEDIATRIC HYPERTENSION Renee F. Robinson, Donald D. Batisky, Milap C. Nahata, John D. Mahan. 1Division of Pharmacy Practice and Administration, The Ohio State University College of Pharmacy, Columbus, OH, United States, 2 Nephrology, Children’s Hospital Research Institute, Columbus, OH, United States, 3Nephrology, The Ohio State University College of Medicine, Columbus, OH, United States The objectives of this study were to 1)determine the relationship between body mass index and primary and secondary hypertension; and, 2) to assess body mass index at the age of onset of primary and secondary hypertension in children and adolescents. Patient demographics, age, race, gender, body mass index, family history, presentation of disease, etiology of hypertension, date of diagnosis, medication therapy received, laboratory measures and other pro-
239A
cedures were recorded for the 321 patients seen in the Nephrology Clinic at Children’s Hospital over a 4 year period. A total of 321 patients were studied: 220 with primary hypertension, 97 with secondary hypertension. Our patient population(172 males,149 females)was diverse in age (⬍ 11 years (32%), ⬎ 11 years (69%)) and ethnicity (237 Caucasians, 54 African Americans). Body mass index was found to be significantly greater in patients with primary hypertension versus secondary hypertension (p⫽0.002). The age of onset (10.5 ⫾2.6)in primary hypertension was related to increased body mass index (p ⫽ 0.00); however, there was no relationship between body mass index and age of onset of secondary hypertension. Conclusion 1)increased body mass index was more prevalent in children with primary hypertension and 2) earlier onset of primary hypertension in the pediatric population was associated with increased body mass index. Key Words: body mass index, primary and secondary hypertension, pediatric hypertension
P-626 CHARACTERISTICS OF CHILDREN WITH PRIMARY HYPERTENSION REFERRED TO A TERTIARY CENTER Joseph T. Flynn. 1 Pediatric Hypertension Program, C.S. Mott Children’s Hospital, University of Michigan Health System, Ann Arbor, MI, United States The characteristics of primary hypertension (PH) in children (C) were studied by retrospectively reviewing the records of our pediatric hypertension (HTN) program. Of 157 C seen over a 5-year period, 58 (36.9%) had PH, defined as sustained blood pressure (BP) ⬎95th percentile for age/gender/height. 11 additional C (7%) had borderline HTN, defined as BP between 90-95th percentiles. Mean age of these 69 C was 13.3⫾4 years (mean⫾SD), range 1.1-18.5y. 24/69 (34.8%) were female. Family history (FH) of HTN in a parent or grandparent was present in 56/65 C (86.2%) for whom FH was available. Mean BMI of all C was 27⫾7 and was slightly higher in older teens. Initial BP was 132⫾18/74⫾13 mmHg for C ⬍12y, and was 144⫾11/78⫾12 mmHg for C ⬎12y. All C underwent a standard evaluation to exclude secondary HTN. Renal function, electrolytes and urinalysis were normal in all C. Echocardiography was obtained in 57/69 C (83%); left ventricular hypertrophy (LVH) was present in 13/57 C (22.8%). Ambulatory BP monitoring (ABPM) was performed in 35 C (50%). Mean 24h systolic BP load was 52⫾24%; mean diastolic BP load was 18⫾16%. 33/69 C (47.8%) received antihypertensive drug therapy; the remaining C were instructed in lifestyle modifications. Indications for drug therapy were LVH in 11 C, abnormal ABPM in 9 C, persistent casual BP elevation in 5 C, & other reasons in 8 C. Medications used included calcium antagonists (17 C), ACE inhibitors (9 C), beta blockers (4 C) and others (3 C). Follow up BP’s were available for 48 C; drug therapy produced a significant decrease in BP whereas lifestyle modifications did not: Group Medication Lifestyle
SBP DBP SBP DBP
Initial
Follow-up
P*
146 ⫾ 12 83 ⫾ 13 135 ⫾ 14 72 ⫾ 9
132 ⫾ 11 67 ⫾ 9 136 ⫾ 12 72 ⫾ 9
⬍0.0001 ⬍0.0001 NS NS
*two-way, paired t test From these data we conclude that PH is commonly seen in specialized pediatric HTN clinics. Characteristics of PH in this series included positive FH, mild obesity and systolic HTN on ABPM. Indications for drug therapy were present in a greater percentage of C with PH than previously reported, and ABPM played a key role in determining the need for drug therapy. Long-term, prospective studies are needed to further define the natural history of childhood PH and to further examine