Department of Child Health

Nephrology Division
FKUI RSCM
Jakarta

Hypertensive crisis:
uncommon

Hypertension stage 1:
2.6%

medical emergency

Hypertension stage 2:
0.6%

Diagnosis and rapid treatment prevent

irreversible brain damage or death

2004
The fourth report on the diagnosis, evaluation, and
treatment of high blood pressure in children and
adolescents:
Hypertension:
Stage 1 hypertension: BP 95th percentile to 5 mmHg above 99th percentiles

for gender, age, and height

Stage 2 hypertension: BP > 5 mmHg above 99 th percentile for gender, age,
and height

National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and
Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in
children and adolescents. Pediatrics 2004;114:555-76.

Hypertensive crisis
(Joint National committee on Detection, Evaluation and
Treatment of Hypertension, JNC7)

-SBP > 180 mmHg

-DBP > 120 mmHg
-Hypertension (BP < 180/120 mmHg) with
encephalopathy, heart failure, retinopathy

Hypertensive crisis:
Hypertensive urgency

Without organ target damage

Clinical manifestations: headache, vomiting
Possibility progressive to a hypertensive
emergency
Perioperative hypertension

Hypertensive emergency:

Severe Hypertension with end-organ injury of

the brain, heart, kidney

Hypertensive emergency
(organ target damage: +)
Hypertensive encephalopathy
Congestive heart failure
Pulmonary edema
ARF/CRF
Adrenergic crisis
Head trauma
Stroke
Myocardial infarction
Dissecting aortic aneurysm

Hypertensive urgency
(organ target damage:-)
Accelerated hypertension
Malignant hypertension
Peri-operative hypertension

Etiology
1.

Renal parenchymal disease

a. Glomerulonephritis
b. Systemic vasculitis with renal

involvement
c. Hemolytic uremic syndrome
d. Interstitial nephritis (chronic
pyelonephritis)
e. Hereditary diseases

2. Renovascular
a. Intrinsic renal artery disease:
Fibromuscular dysplasia
Arteritis (Kawasaki, Takayasu, Moyamoya disease)
Renal transplant artery stenosis
Newborn with umbilical vessel catheters
Renal transplant renal artery or venous thrombosis
Renal trauma
b. Extrinsic compression
Neoplasia: Wilms tumor, neuroblastoma,
pheochromocytoma, paraganglioma, neurofibroma,
lymphoma
Perirenal hematoma, trauma
Retroperitoneal fibrosis

3. Cardiovascular
a. Coarctation of aorta
b. Middle aortic syndrome
c. Williams syndrome
d. Turner syndrome

4. Endocrine abnormalities
a. Tumor secreting vasoactive substance (cathecholamines, renin)
b. Thyroid disorders
c. Cushing syndrome
d. Hyperaldosteronism
e. Congenital adrenal hyperplasia
f. Hypercalcemia

5. Miscellaneous causes
a. Neurologic abnormalities
- Elevated intracranial pressure
- Recent seizure, status epilepticus
- Familial dysautonomia
b. Cyclic vomiting syndrome
c. Polycythemia, recombinant erythropoietin therapy
d. Anesthetic drugs : ketamine, naloxone
e. Drug abuse: cocaine, amphetamine, methamphetamine,
phencyclidine, methylphenidate

Pathophysiology
Renin angiotensin system

Fluid overload
Sympathetic stimulation
Endothelial dysfunction

Medication and other substances

Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12

Clinical Presentation
Confirm Blood pressure with proper size cuff and
technique
Depend on organ target damage
CNS findings
Weakness
Nausea and vomiting
Severe headache
Seizures
Altered mental status
Loss of vision
Neurologic deficits

 Heart failure symptoms : Tachypnea,

Shortness of breath, edema

Suggest renal disease: hematuria, flank
pain, cola colored urine
Exophtalmos : hyperthyroidism
Abdomial mass: Wilms tumor, polycystic
kidney, neuroblastoma
Important !! sign of child abuse with CNS

trauma

Retinopathy hypertension
Encepalopathy hypertension
Seizure
Left Ventrikel hypertrophy
Facial Palsy
Vision Changes
Hemiplegia
Cranial bruits
BP >99 without organ damage

: 27%
: 25%
: 25%
: 13%
: 12%
: 9%
: 8%
: 5%
: 24%

Management
Antihypertensive drugs
Evaluation for target organ damage
Investigation of causes
Supportive management

a. Antihypertensive drugs
Should be initiated prior to obtaining the results of

laboratory and radiologic

Preferably in intensive care setting with
continuous cardiac monitor
Goal of therapy: BP to normal or near normal
level as quickly as possible
Target :<95th percentiles

 BP measure:

@ 5 minute ( First 15 minute)

@ 15 minute ( First hour)
@ 30 minute until Diastolic BP 100

@ 1-3 hour
Intravenous or Oral anti hypertensive
Lowering BP
25-30% in 8-12 hour

25-30% in 24-36 hour

b. Investigation of causes
Evaluations:

- causes
- co-morbidity
- target organ damage
Evaluation should be individualized
Majority causes: renoparenchym or renovascular
screening to this condition
Diagnostic tests:
Urinalysis
BUN,SC
CBC

c. Evaluation for target organ damage

Abnormality of brain, heart, kidney, eyes

d. Supportive management

Antihypertensive for hypertensive crisis

Drug of choice:

Short acting

Can be titrated
Indonesia:

Nifedipine, Na nitroprusside, clonidine,

nicardipine

Nifedipine
Calcium-channel blockers
Direct vasodilators by inhibiting vascular smooth muscle

contraction by interfering with cellular calcium influx

Sublingually: start 0,1 mg/kg max 10 mg/dosage or 120

mg/day
Effective within 10 minutes with peak effect in 30 - 40 min.
Sublingual more rapid than oral for 10 to 15 minutes

Side effects: headache, flushing, dizziness, tachycardia

Scheme: Treatment of crisis/encephalopathy hypertension

with nifedipine
Nifedipine sublingually 0.1 mg/kgbw
Increased 0.1 mg/kgbw/dose every 30 minutes
Max. dose: 10 mg/dose
+ Furosemide 1 mg/kgbw/dose, 2 x per day i.v.
(Orally: in good condition)
Diastolic
90 100 mmHg

If blood pressure is not decreased,

+ Captopril 0.3 mg/kgbw/dose 2-3 x per day
(max. 2 mg/kgbw/dose)

STABILE
MAINTENANCE NIFEDIPINE
0.2 mg 1 mg/kgbw/day, 3-4 x
Alatas H. Naskah simposium dan workshop sehari: Kegawatan pada penyakit ginjal anak.
Makasar, 27-28 Mei, 2006,17-28.

Nitroprusside
Nitric oxide donor vasodilatory effect on venous and

arteriolar
renal blood flow

Continuous infusion
Dose: begin at 0.3 g/kg/min,

and titrated to a max. dose of 8 g/kg/min

Requires continuous BP monitoring
Toxic metabolites: cyanide, thiocyanate

Nitroprusside
Side effects:

Cyanide/thiocyanate toxicity:
- anxiety, headache, dizziness, confusion, jaw stiffness,
seizures,
- metabolic acidosis and hypoxemia
Hypotension, methemoglobinemia, hypothyroidism, tinnitus,
visual disturbances, tachyphylaxis
> 72 hours or renal failure:
- monitor cyanide levels
- co-administer with Na-thiosulfate
(infusion of nitroprusside to thiosulfate: 10 : 1)
Contraindicated:
- intracranial pressure
- caution in aorta coarctation
Solution should be protected from light

Rust RS, Chun RWM. IPediatric Neurology, Principles & Practice, 4th ed., Philadelphia, Mosby Elsevier,
2006,p.2233-83
Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.1199-1220
Li SPS, Wong SN. Practical Paediatric Nephrology, 1st ed., Hong Kong, Medcom Limited, 2005;p.89-95

2. Clonidine
Central agonist
Useful when intensive care monitoring facilities are not available
Side effects:- drowsiness

- decreased alertness
- elevations in liver enzymes
- muscle or joint pain, weight gain, and rash.
Clonidine difficult to follow the course of hypertensive
encephalopathy
Cause rebound hypertension if suddenly withdrawn

Brazy PC. Primer on Kideny Diseases, 1st ed, San Diego, Academic Press, 1994;p. 355-61
Alatas H. Naskah simposium dan workshop sehari: Kegawatan pada penyakit ginjal anak, Makasar, 27-28 Mei, 2006,17-28.
Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.1199-1220.

Scheme. Treatment of crisis/encephalopathy hypertension

with clonidine
Clonidine drip 0.002 mg/kgbw/8 hours
in 100 cc dextrose 5% (12 drops micro)
Inceased every 30 minutes until max. dose
0.006 mg/kgbw/8 hours

+ Furosemide 1 mg/kgbw/dose IV

Diastolic 90-100 mmHg

Captopril orally 0.3 mg/kgbw/dose

(max. 2 mg/kgbw/dose), 2-3 times/day
STABILE
Clonidine stop
Captopril continue
Alatas H. Naskah simposium dan workshop sehari: Kegawatan pada penyakit ginjal anak.
Makasar, 27-28 Mei, 2006,17-28.

Nicardipine
Calcium channel blockers
Direct vasodilators by inhibiting vascular smooth muscle contraction by

interfering with cellular calcium influx

Rapid, safe, effective
Continuous infusion: 0,5 to 5,0 g/kg/min (max. = 5 mg/hour)
Cause tachycardia, headache, flushing, dizziness
Contraindicated: head trauma, intracranial haemorrhage
Alternative to nitroprusside or intravenous labetalol

Diazoxide
Nondiuretic thiazide
Potent arteriole vasodilator
Dose: 1 to 3 mg/kg per dose
IV infusion over 5 to 10 minutes and may be given every 10 to 15 minutes
Max. dose: 10 mg/kg or 150 mg

Causes sodium retention and requires diuretic: furosemide

Side effects: = other systemic vasodilators

- hyperglycemia, hyperuricemia, nausea, vomiting, constipation,

- hypertrichosis, skin rash, fever, leucopenia, thrombocytopenia
Contraindicated:
-intracerebral hemorrhage
-dissecting aortic aneurysm
-acute myocardial infarction
-coarctation of the aorta

Labetalol
-blocker or -adrenergic antagonist with peripheral -adrenergic

antagonism vasodilatation of peripheral vasculature

antihypertensive effect
blood pressure by reducing heart rate and myocardial contractility,

and reduce cardiac output

Is not cardioselective and does not have intrinsic symphatomimetic

activity
Dose: 0,2-1,0 mg/kg/dose IV push over 2 minutes

If no response, may redose q5-10 minutes incrementally to max. dose

= 60 mg, or 0,25-2,0 mg/kg/hour IV continuous infusion

Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.11991220.
Rust RS, Chun RWM. Pediatric Neurology, Principles & Practice, 4th ed., Philadelphia, Mosby Elsevier,
2006,p.2233-83
Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12

Hydralazine
Induces relaxation of vascular smooth muscles arteriolar

vasodilatation
Short half-life
Tachycardia, plasma renin activity, sodium retention

Best used with diuretic and -blocker

IV bolus or IM: 0,2-0,5 mg/kg/dose q4-6 hr

(max. 3,5 mg/kg/day)

Side effects: headache, palpitation, sweating, nausea,

dizziness.
Hydralazine (> 200 mg/day) lupus-like syndrome

Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.1199-1220.
Brazy PC. Primer on Kideny Diseases, 1st ed, San Diego, Academic Press, 1994;p. 355-61
Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12

Fenoldopam
Dopamine-1 receptor agonist
0,5-2 g/kg/min
Contraindicated: glaucoma

Cause headaches, tachycardia

Li SPS, Wong SN. Practical Paediatric Nephrology, 1st ed., Hong Kong, Medcom Limited, 2005;p.89-95
Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12

Esmolol, Enalaprilat
Rare used in children
Esmolol:

Cardioselective adrenoreceptive -blocker

IV bolus: 100-500 g/kg over 1-2 min,
then

50-500 g/kg/min

Enalaprilat:

ACE inhibitor
IV: 0,005-0,01 mg/kg/dose q8-24hr
up to 1,25
mg/dose

Vogt BA, Davis ID. Pediatric Nephrology, 5th edition, Philadelphia, Lippincott Williams & Wilkins,.2004;p.1199-1220.
Flynn JT, Tullus K. Pediatr Nephrol 2009;24:1101-12

Summary
Hypertensive crisis may lead to encephalopahty, heart

failure, and retinopathy

Secondary hypertension is commonest causes and

investigations is necessary to identify the etiology

Management consisted of antihypertensive agents,

evaluation for target organ damage, investigation of

causes, and supportive management