Olson D L, Lieberman E
Pediatr Clin North Am. 1976 Nov;23(4):795-805. doi: 10.1016/s0031-3955(16)33361-2.
Preliminary results of this retrospective-prospective analysis of renal hypertension in 110 children indicate that hypertension may be secondary to a wide variety of acute progresive, and chronic renal diseases which may be either congenital or acquired. Affected children may be detected at any time from infancy through adolescence. Symptoms usually associated with acute glomerulonephritis (i.e., headache, swelling, nausea, vomiting, anorexia, fatigue, dizziness, and fever) occur in both acute and chronic renal diseases associated with hypertension. Headache and swelling are the most common symptoms in this series. Peripheral edema, rales, and increased heart size were found in between 10 and 25% of these children. Differential diagnosis may be approached by a consideration of causes of acute and chronic hypertension. The child with chronic renal disease usually presents with a long history of fatigability, poor growth, and pallor, and laboratory tests reveal elevation of the creatinine and BUN along with anemia, hypocalcemia, and hyperphosphatemia. In contrast, the child with acute renal disease and hypertension presents with a history of prior good health followed by the abrupt onset of signs and symptoms of renal disease; laboratory tests usually reveal modest elevations of creatinine and BUN, anemia is unusual, an abnormal urinalysis is common, and serum calcium and phosphorous levels are usually normal. Renovascular and asymmetric renal parenchymal disease represent uncommon but important conditions because surgery may be curative. Treatment may be surgical, medical, or combined. Surgical conditions include renal trauma, hydronephrosis, asymmetric renal disease, and renal arterial disease. Adequate blood pressure control without medication can be expected following surgery in instances of unilateral involvement with a normal contralateral kidney. Meticulous assessment of the contralateral kidney is needed to determine that it is normal. If surgery is unsuccessful or is not indicated, pharmacologic therapy is initiated with a stepwise regimen starting with the mildest agent (e.g., thiazides) and then adding additional antihypertensive drugs when adequate blood pressure control has not yet been achieved. The goal of therapy is the lowest, safest, tolerated blood pressure levels. Long-term, carefully designed studies of antihypertensive agents for children with renal hypertension are not available. The need for collection and critical analysis of data concerning the clinical course of children with renal hypertension is evident from a review of the literature and from the preliminary data presented in this series. The presentation of such information and a critique of outcome variables will provide a basis for program planning for affected children and improvement in patient care where indicated.
对110名儿童肾性高血压进行的这项回顾性-前瞻性分析的初步结果表明，高血压可能继发于多种急性进展性和慢性肾脏疾病，这些疾病可能是先天性的，也可能是后天获得的。从婴儿期到青春期的任何时候都可能发现受影响的儿童。与急性肾小球肾炎相关的症状（即头痛、肿胀、恶心、呕吐、厌食、疲劳、头晕和发热）在与高血压相关的急性和慢性肾脏疾病中均会出现。头痛和肿胀是该系列中最常见的症状。在这些儿童中，10%至25%的人出现外周水肿、啰音和心脏增大。鉴别诊断可通过考虑急性和慢性高血压的病因来进行。患有慢性肾脏疾病的儿童通常有长期疲劳、生长发育不良和面色苍白的病史，实验室检查显示肌酐和尿素氮升高，同时伴有贫血、低钙血症和高磷血症。相比之下，患有急性肾脏疾病和高血压的儿童有既往健康史，随后突然出现肾脏疾病的体征和症状；实验室检查通常显示肌酐和尿素氮略有升高，贫血不常见，尿常规异常常见，血清钙和磷水平通常正常。肾血管性和不对称性肾实质疾病虽不常见但很重要，因为手术可能治愈。治疗方法可以是手术、药物治疗或联合治疗。外科治疗的情况包括肾外伤、肾积水、不对称性肾病和肾动脉疾病。单侧受累且对侧肾脏正常的情况下，手术后有望在不使用药物的情况下充分控制血压。需要对侧肾脏进行细致评估以确定其正常。如果手术不成功或不适用，则开始药物治疗，采用逐步治疗方案，从最温和的药物（如噻嗪类）开始，当尚未实现充分的血压控制时再添加其他抗高血压药物。治疗的目标是达到最低、最安全且可耐受的血压水平。目前尚无针对儿童肾性高血压的抗高血压药物的长期、精心设计的研究。从文献综述和本系列呈现的初步数据中可以明显看出，需要收集和批判性分析有关儿童肾性高血压临床病程的数据。提供此类信息并对结果变量进行评估将为受影响儿童的项目规划以及在适当情况下改善患者护理提供依据。
