Blood Pressure Goals in Pediatric Glomerulonephritis
In children with glomerulonephritis, blood pressure should be lowered to consistently achieve levels at or below the 50th percentile for age, sex, and height, particularly in those with proteinuria. 1
Target Blood Pressure Goals
- For children with glomerulonephritis, the recommended target is a 24-hour mean arterial pressure (MAP) at the 50th percentile or lower for age, sex, and height as measured by ambulatory blood pressure monitoring (ABPM) 1
- Blood pressure-lowering treatment should be initiated when BP is consistently above the 90th percentile for age, sex, and height 1
- For children with proteinuria, achieving systolic and diastolic readings at or below the 50th percentile is particularly important unless limited by symptoms of hypotension 1
- The KDIGO 2021 guidelines specifically recommend targeting the 50th percentile for 24-hour MAP in children with glomerular disease 1
Medication Selection
- An ACE inhibitor (ACEi) or angiotensin receptor blocker (ARB) should be used as first-line therapy for high blood pressure in children with glomerulonephritis 1, 2
- These medications should be used regardless of the level of proteinuria, as they provide renoprotective benefits beyond blood pressure control 1
- Titrate ACEi or ARB to maximally tolerated or allowed dose to achieve optimal blood pressure control and reduction in proteinuria 1
- Monitor for adverse effects including hyperkalemia, acute deterioration in kidney function, and hypotension, especially in pediatric patients 1
Proteinuria Considerations
- In children with proteinuria between 0.5-1 g/day/1.73 m², ACEi or ARB treatment is recommended 1
- For proteinuria >1 g/day/1.73 m², long-term ACEi or ARB treatment with up-titration depending on blood pressure is strongly recommended 1
- Current expert opinion advocates for a target level of proteinuria of 0.5-1 g/day/1.73 m² along with blood pressure control below the 90th percentile 1
- The relationship between proteinuria and blood pressure control is bidirectional - better BP control helps reduce proteinuria, and reducing proteinuria helps improve BP control 1
Monitoring and Follow-up
- Regular monitoring of blood pressure using standardized techniques is essential 1
- When possible, 24-hour ambulatory blood pressure monitoring provides the most accurate assessment of blood pressure control in children with glomerulonephritis 1
- Monitor serum creatinine, potassium, and estimated GFR frequently when using ACEi or ARB medications 1
- Counsel patients/families to temporarily hold ACEi/ARB and diuretics during periods of volume depletion (vomiting, diarrhea, etc.) 1
Additional Considerations
- Employ lifestyle modifications including sodium restriction (<2.0 g/day), weight normalization, and regular exercise as adjunctive measures 1
- In children with nephrotic syndrome, hypertension is common (>90%) during the edematous phase and decreases significantly after remission 3
- A study of children with chronic kidney disease showed that maintaining BP below the 90th percentile was associated with slower CKD progression in both glomerular and non-glomerular CKD 4
- Early increases in blood pressure, even within the "normal" range, may be associated with target organ damage in glomerulonephritis 5
Common Pitfalls and Caveats
- Avoid delaying initiation of antihypertensive therapy when BP consistently exceeds the 90th percentile 1
- Do not use combinations of ACEi and ARB together in children with glomerulonephritis as this increases risk of adverse effects without additional benefits 2
- Be aware that diuretics may be needed for edema management but can cause electrolyte abnormalities and volume depletion in children 1
- Remember that blood pressure goals may need to be adjusted during acute illness or periods of rapid growth 1