Presenter: Kaitlin Alexander, MSN, APRN, CPNP-AC/PC, Inpatient Pediatric Nephrology Nurse Practitioner, Children's Health/UT Southwestern Medical Center, Dallas
Event: 2025 Pediatric Virtual Symposium Live on October 10, 2025
Access: Through December 31, 2025
Disclosure: Nothing to disclose
Learning Objectives
Define prehypertension and hypertension in children and adolescents.
Identify two additional diagnostic tests to order in the setting of proteinuria.
Recognize three situations that would require nephrology evaluation.
Hypertension
Statistics
Approximately 16% of school-aged children are prehypertensive.
2-5% of children are hypertensive.
Hypertension ranks third among chronic pediatric diseases.
More common in boys than girls.
More prevalent among Hispanic and African American children compared to non-Hispanic white children.
Definition of Hypertension
Hypertension is defined as systolic or diastolic blood pressure consistently higher than the 95th percentile for age, gender, and height on at least three separate occasions.
Blood Pressure Categories
For Children Aged 1–<13 Years
Normal BP: <90th percentile
Elevated BP (Prehypertension): ≥90th percentile to <95th percentile
Elevated BP (Prehypertension): 120/<80 to 129/<80 mm Hg
Stage 1 HTN: 130/80 to 139/89 mm Hg
Stage 2 HTN: ≥140/90 mm Hg
Accurate Measurements
Measurement Technique
Patients should sit for at least 3 minutes before measurement.
The right arm should be supported, with the cubital fossa at heart level.
Automatic vs Manual Measurements
Automatic measurements calculate mean arterial BP; systolic and diastolic values may be higher than manual measurements due to measurement technique.
Bladder Size for Cuff
Length: ≥80% of arm circumference.
Width: ≥40% of arm circumference between olecranon and acromion.
Incorrect cuff size can result in false readings.
AAP Monitoring Recommendations
Annual BP measurements in low-risk patients aged ≥3 years.
Every encounter for patients with risk factors (e.g., obesity, medications increasing BP, renal disease, history of aortic arch obstruction/coarctation, diabetes).
Types of Hypertension
Primary Hypertension
No identifiable cause.
Often seen in obese children, associated with hyperinsulinism or insulin resistance, high sodium intake.
Most common form in children over 12, increasing in prevalence among younger children.
Secondary Hypertension
Related to acute or chronic diseases; includes:
Renal parenchymal disease
Vascular disorders (e.g., coarctation of the aorta, renal artery stenosis)
Neurological, endocrinological causes, or catecholamine-secreting tumors.
White Coat Hypertension
Elevated blood pressure in a clinical setting, normal outside of that environment.
Diagnosed with an ambulatory blood pressure monitor.
Previously deemed benign; now studied as an intermediate state between normal BP and hypertension.
Hypertensive Urgency vs Emergency
Hypertensive Urgency
Symptomatic blood pressure >99th percentile with no evidence of secondary organ injury.
Requires treatment to prevent target organ damage if left untreated.
Hypertensive Emergency
Symptomatic with blood pressure >99th percentile and evidence of target-organ injury.
Requires prompt treatment to avoid further damage or death.
Hypertensive Encephalopathy
A serious complication of severe hypertension leading to cerebral hypoperfusion.
Clinical Signs and Symptoms
Mild to moderate hypertension: often asymptomatic.
Severe hypertension: can present with headache, vomiting, visual disturbances, epistaxis, palpitations, flushing.
Secondary hypertension: may be asymptomatic, can have varied severity.
Evidence of Target Organ Injury
Ocular: Papilledema.
Cardiac: Left ventricular hypertrophy, observed in 15-40% of children with HTN, indicates need for initiation or intensification of antihypertensive regimen.
Neurological: Seizures, stroke.
Renal: Urinalysis showing proteinuria and hematuria.
Initial Clinical Evaluation of Hypertension
Evaluation of identifiable causes includes:
History and physical exam
BUN, creatinine, electrolytes, urinalysis with microscopy, CBC, renal ultrasound.
Evaluation for comorbidities includes:
Fasting lipid panel and glucose, drug screen, sleep study.
Evaluation for target-organ damage includes:
Echocardiogram, retinal examination.
Management Goals
Prevent or improve acute BP-related complications.
Prevent long-term complications such as cardiovascular disease, stroke, and progressive loss of kidney function.
Aim for blood pressure less than the 85th percentile.
Target <50th percentile for patients with comorbidities.
Management Strategies
Prehypertension
Lifestyle modifications encouraged:
Weight reduction
Regular physical activity.
Dietary modification, including salt restriction.
Stage I Hypertension
Lifestyle modifications are required.
Drug therapy indicated if:
No response to lifestyle modifications,
Symptoms present,
Comorbidities exist,
Target organ damage is present.
Referral to nephrology or cardiology may be considered.
Stage II Hypertension
Determine underlying cause.
Initiate drug therapy alongside lifestyle modifications.
Non-Pharmacologic Management
Recommendations include:
Reduce intake of sugars, soft drinks, saturated fats, and sodium; promote fruits, vegetables, and whole grains.
Moderate to vigorous aerobic activity for at least 40 minutes, at least 3 times per week.
Involve parents/families in the behavioral change process.
Establish realistic goals; generally do not restrict participation in competitive sports except for uncontrolled stage II hypertension.
Pharmacological Management
Recommendations from the National High Blood Pressure Education Program
D: Diuretics: includes loop (Lasix) and thiazide (HCTZ) diuretics; frequently used to enhance the effect of other antihypertensives.
Note: Beta blockers are not typically used as first-line agents in children.
Clinical Guidelines
Relevant recommendations and blood pressure tables can be located in the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents from the National High Blood Pressure Education Program.
Hematuria
Statistics
Microscopic hematuria is more common than gross hematuria; prognosis typically favorable depending on the etiology.
Presence of concurrent proteinuria may suggest significant kidney disease, necessitating renal specialist evaluation.
Definition
Hematuria is defined as the presence of red blood cells (RBCs) in the urine.
Microscopic hematuria: RBC present without visible discoloration, detectable via microscopy.
Gross hematuria: visibly bloody urine, ranging from bright red to brown (similar to tea or cola).
If urine appears red without RBCs, consider hemolysis (hemoglobinuria) or rhabdomyolysis (myoglobinuria).
Baseline Hematuria Evaluation
Conduct urinalysis with microscopy; generally performed in specialized labs with minimal capability in independent practices.
Etiologies of Hematuria
Glomerular Causes
Include:
Acute postinfectious glomerulonephritis
IgA Nephropathy
Membranoproliferative glomerulonephritis (MPGN)
Focal segmental glomerulosclerosis (FSGS)
Benign familial hematuria
Alport syndrome
Systemic diseases, immunological disorders.
Non-Glomerular Causes
Include:
Nephrolithiasis & hypercalciuria
Infection
Tumors/malignancy
Hematologic conditions
Vascular anomalies
Certain medications
Physiological trauma.
Other Causes Mimicking Dark Urine
Medications such as rifampin and nitrofurantoin can cause discoloration.
Physiological pigments (hemoglobin, myoglobin, bilirubin), and certain nutrients (beets, blackberries) can also mimic hematuria.
Poststreptococcal Glomerulonephritis (APSGN)
Overview
A common form of acute glomerulonephritis in children, notably linked to Group A streptococcus (GAS).
Peaks in children aged 2-15 years; less commonly reported in infants under 2 years.
Epidemiology
Over 80% of APSGN cases are related to pharyngitis, with peaks in winter and spring; skin infection-related APSGN peaks in summer and fall, particularly in developing countries.
Clinical Features
Presentation typically occurs 7-14 days post-pharyngitis or up to 6 weeks after impetigo.
Classic triad of symptoms:
Edema
Hypertension
Hematuria (often painless, cola or tea-colored urine in 50% of cases).
Severe hypertension may lead to hypertensive encephalopathy (Posterior Reversible Encephalopathy Syndrome - PRES).
~50% of patients may develop pulmonary edema.
Evaluation
Urinalysis with microscopy to check for hematuria and proteinuria (RBCs and casts)
Complement levels: C3 typically low with normal C4, normalizing within 6-12 weeks post-presentation.
Bacterial/viral studies via swabs or serology (e.g., anti-streptolysin titer, anti-Dnase B).
Nephrology Referral
Urgent referral needed for:
Persistent hematuria/proteinuria beyond 12 weeks.
Worsening renal function.
Persistently low serum C3 after 12 weeks.
Nephritogenicity of Streptococci
Not all strains of GAS cause nephritis; nephritogenic strains do not cause rheumatic fever.
Complement activation is a hallmark feature of APSGN.
Treatment
Primarily symptomatic.
Patients with normal BP and mild renal failure may be managed as outpatient, while those with significant hypertension or oligoanuria may require urgent nephrology referral and possible hospitalization.
Prognosis
Excellent long-term prognosis, with >95% recovery rate of renal function in 3-4 weeks.
<1% transition to chronic or progressive kidney disease.
Recurrence of APSGN is rare due to specific immunity against nephritogenic strains.
Henoch-Schönlein Purpura (HSP) Nephritis
Overview
Most common vasculitis in children, with peak incidence in early childhood.
Associated with purpura/petechiae, abdominal pain, joint involvement, and nephritis.
Clinical Features
Urinalysis may be normal early in the condition; nephritis can ensue after non-renal symptoms resolve.
Signs of Nephritis
Microscopic or gross hematuria.
Transient mild proteinuria to nephrotic syndrome; usually resolves within months but should be monitored.
Evaluation and Monitoring
Blood Tests
Assess renal function, complete blood count, complement levels, and albumin.
Urine Analysis
Urinalysis with microscopy and urine protein/creatinine ratio when protein present.
Monitoring
Weekly urinalysis for 1 month, biweekly for the next 5 months.
Favorable renal outcomes; those developing chronic kidney disease typically present with nephrotic-nephritic syndrome.
Proteinuria
Introduction
Evaluation aims to differentiate between physiologically insignificant and clinically significant proteinuria.
Transient or functional proteinuria may arise from fever, exercise, stress, seizures, or congestive heart failure without indicating renal disease.
Clinical Signs and Symptoms
Often asymptomatic; urine appearance may be frothy, bubbly, or dark yellow.
Nephrotic range proteinuria is associated with peripheral edema and indications of underlying glomerular disease.
Urinalysis for Proteinuria
Should be examined promptly:
False-positive results may occur due to concentrated or alkaline urine, prolonged immersion, or presence of gross hematuria.
False negatives can arise from very dilute or acidotic urine, or low molecular weight proteinuria.
Idiopathic Nephrotic Syndrome
Overview
More prevalent in boys than girls; commonly presents between ages 2 and 8.
Up to 80% respond favorably to steroids; long-term prognosis is typically good.
Defining Features
Large proteinura:
Positive dipstick (3-4+)
Protein/creatinine ratio >2g/g
24-hour urine protein excretion >4mg/m²/hr.
Hypoalbuminemia and generalized edema, often starting periorbitally and becoming generalized over days to weeks.
Additional Features
Microscopic hematuria occurs in ~1/3 of cases; gross hematuria is unusual and indicative of another primary diagnosis.
Hypertension due to intravascular volume depletion, activation of renin-angiotensin system, and overall fluid overload.
Management
Initial care is typically overseen by a pediatric nephrologist, with initiation by a primary care provider if necessary.
Initial steroid dose: 2mg/kg/day for 6 weeks, tapering thereafter, with second courses for relapses.
Nephrology may include additional medications such as ACE inhibitors, calcineurin inhibitors, or immunosuppressive agents.
Long-term Management and Nutrition
Baseline dietary changes are unnecessary; salt restriction advised during relapses.
Monitor and manage weight gain associated with steroid use, encouraging physical activity.
Ensure compliance with immunization schedules, being cautious of live vaccines in immunosuppressed patients (CDC guidelines for pneumococcal vaccine).
Complications to Monitor
Infection risk raises due to urinary loss of IgG and complement components; broad-spectrum antibiotics may be necessary.
Electrolyte disturbances such as hyponatremia and hypocalcemia.
Monitor for hypercoagulability due to loss of antithrombin III; renal vein thrombosis and acute kidney injury risks are increasing in sedentary or fluid-depleted patients.
Final Thoughts
Common relapses triggered by viral infections with significant rates: 70% of steroid-sensitive patients experience at least one relapse, potential lasting into adulthood.
Steroid sensitivity remains the most significant prognostic indicator for patient outcomes.