What is the management of hypertensive urgency in a child with grade 5 Chronic Kidney Disease (CKD)?

Management of Hypertensive Urgency in a Child with Grade 5 CKD

In a child with grade 5 CKD experiencing hypertensive urgency, an ACE inhibitor or ARB should be used as first-line therapy, with a target 24-hour mean arterial pressure below the 50th percentile for age, sex, and height measured by ambulatory blood pressure monitoring (ABPM). 1

Initial Assessment and Management

• Hypertensive urgency is defined as severe arterial hypertension without evidence of acute organ damage but with nonspecific symptoms such as headache, dizziness, nosebleeds, nausea, or vomiting 2
• Distinguish from hypertensive emergency, which involves severe hypertension with acute organ damage (CNS, heart, kidney, eye) and requires more aggressive management 3
• For hypertensive urgency in CKD, a gradual reduction in blood pressure is recommended, with a target of 25% reduction within the first 8 hours and complete normalization within 24-48 hours 2, 3

Pharmacological Management

First-Line Therapy:

• ACE inhibitors or ARBs are strongly recommended as first-line agents for hypertension in children with CKD 1
• These medications lower proteinuria and are generally well-tolerated in the pediatric population 1
• Monitor serum creatinine and potassium within 2-4 weeks of initiation or dose increase of ACE inhibitors or ARBs 4

Alternative Agents:

• If ACE inhibitors or ARBs are contraindicated or insufficient:
  • Calcium channel blockers (nicardipine, nifedipine) can be used 2, 3
  • Labetalol may be considered, but use with caution due to potential side effects in pediatric patients 5, 6

Route of Administration:

• For hypertensive urgency without organ damage, oral medications can be appropriate 2
• For more severe cases or poor oral intake, intravenous options include:
  • Nicardipine: Administered by slow continuous infusion (0.1 mg/mL) through a central line or large peripheral vein 7, 3
  • Labetalol: Can be given as continuous infusion with careful monitoring 6, 2

Blood Pressure Targets

• The KDIGO guidelines recommend targeting 24-hour mean arterial pressure by ABPM to ≤50th percentile for age, sex, and height in children with CKD 1, 4
• This recommendation is based on the ESCAPE trial, which demonstrated slower progression of CKD in patients treated to a 24-hour mean arterial pressure <50th percentile compared to those treated to <90th percentile 1
• Avoid precipitous drops in blood pressure as they can impair perfusion of vital organs 8

Monitoring and Follow-up

• Use ABPM for accurate assessment of blood pressure control in children with CKD 1, 4
• Monitor for potential adverse effects of medications:
  • For ACE inhibitors/ARBs: Monitor renal function and potassium levels 4
  • For beta-blockers: Watch for bradycardia, hypotension, hypoglycemia (especially in infants), and CNS effects 5
  • For calcium channel blockers: Monitor for hypotension and tachycardia 7
• Continue antihypertensive therapy even when eGFR falls below 30 ml/min per 1.73 m² unless specific adverse effects occur 4

Important Considerations for Grade 5 CKD

• In advanced CKD, medication dosing may need adjustment based on residual renal function 6
• Avoid medications that may worsen renal function or have significant renal clearance 4
• Consider the patient's volume status, as volume overload is common in advanced CKD and may require diuretic therapy in addition to antihypertensive medications 4
• Be vigilant for hyperkalemia with ACE inhibitors or ARBs, which should be managed with measures to reduce potassium rather than immediately stopping the medication 4

Common Pitfalls to Avoid

• Lowering blood pressure too rapidly can lead to organ hypoperfusion; aim for gradual reduction 8, 9
• Failing to monitor for medication side effects specific to pediatric patients 5
• Not adjusting medication doses appropriately for decreased renal function in grade 5 CKD 4
• Overlooking the need for comprehensive evaluation for secondary causes of hypertension 2