Abstract
Rationale & Objective: Accurate detection of hypertension is crucial for clinical management of pediatric chronic kidney disease (CKD). The 2017 American Academy of Pediatrics (AAP) clinical practice guideline for childhood hypertension included new normative blood pressure (BP) values and revised definitions of BP categories. In this study, we examined the effect of applying the AAP guideline's normative data and definitions to the Chronic Kidney Disease in Children (CKiD) cohort compared with use of normative data and definitions from the 2004 Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Study Design: Observational cohort study. Setting & Participants: Children and adolescents in the CKiD cohort. Exposure: Clinic BP measurements. Outcome: BP percentiles and hypertension stages calculated using the 2017 AAP guideline and the Fourth Report from 2004. Analytical Approach: Agreement analysis compared the estimated percentile and prevalence of high BP based on the 2017 guideline and 2004 report to clinic and combined ambulatory BP readings. Results: The proportion of children classified as having normal clinic BP was similar using the 2017 and 2004 systems, but the use of the 2017 normative data classified more participants as having stages 1-2 hypertension (22% vs 11%), with marginal reproducibility (κ = 0.569 [95% CI, 0.538-0.599]). Those identified as having stage 2 hypertension by the 2017 guideline had higher levels of proteinuria compared with those identified using the 2004 report. Comparing use of the 2017 guideline and the 2004 report in terms of ambulatory BP monitoring categories, there were substantially more participants with white coat (3.5% vs 1.5%) and ambulatory (15.5% vs 7.9%) hypertension, but the proportion with masked hypertension was lower (40.2% vs 47.8%, respectively), and the percentage of participants who were normotensive was similar (40.9% vs 42.9%, respectively). Overall, there was good reproducibility (κ = 0.799 [95% CI, 0.778-0.819]) of classification by ambulatory BP monitoring. Limitations: Relationship with long-term progression and target organ damage was not assessed. Conclusions: A greater percentage of children with CKD were identified as having hypertension based on both clinic and ambulatory BP when using the 2017 AAP guideline versus the Fourth Report from 2004, and the 2017 guideline better discriminated those with higher levels of proteinuria. The substantial differences in the classification of hypertension when using the 2017 guideline should inform clinical care.
| Original language | English (US) |
|---|---|
| Pages (from-to) | 545-553 |
| Number of pages | 9 |
| Journal | American Journal of Kidney Diseases |
| Volume | 81 |
| Issue number | 5 |
| DOIs | |
| State | Published - May 2023 |
Funding
A list of the CKiD Study Investigators can be found in Table S1. Derek K. Ng, PhD, Megan K. Carroll, MS, Susan L. Furth, MD, MPH, Bradley A. Warady, MD, and Joseph T. Flynn, MD, MS. Research idea and study design: DKN, MKC, JTF; data acquisition: SLF, JTF, BAW; data analysis/interpretation: DKN, MKC, JTF; statistical analysis: DKN, MKC; supervision or mentorship: SLF, BAW. Each author contributed important intellectual content during manuscript drafting or revision and agrees to be personally accountable for the individual's own contributions and to ensure that questions pertaining to the accuracy or integrity of any portion of the work, even one in which the author was not directly involved, are appropriately investigated and resolved, including with documentation in the literature if appropriate. Data in this article were collected by CKiD (www.statepi.jhsph.edu/ckid) with clinical coordinating centers at Children's Mercy Hospital and the University of Missouri–Kansas City (Principal Investigator [PI]: Dr Warady) and Children's Hospital of Philadelphia (PI: Dr Furth), Central Biochemistry Laboratory (PI: George Schwartz, MD) at the University of Rochester Medical Center, and data coordinating center (PIs: Alvaro Muñoz, PhD and Dr Ng) at the Johns Hopkins Bloomberg School of Public Health. CKiD is funded by the National Institute of Diabetes and Digestive and Kidney Diseases, with additional funding from the National Institute of Child Health and Human Development, and the National Heart, Lung, and Blood Institute (U01-DK-66143, U01-DK-66174, U24-DK-082194, and U24-DK-66116). The authors declare that they have no relevant financial interests. Received June 6, 2022. Evaluated by 3 external peer reviewers and a statistician, with editorial input from an Acting Editor-in-Chief (Swapnil Hiremath, MD, MPH). Accepted in revised form October 4, 2022. The involvement of an Acting Editor-in-Chief to handle the peer-review and decision-making processes was to comply with AJKD's procedures for potential conflicts of interest for editors, described in the Information for Authors & Journal Policies. Data in this article were collected by CKiD ( www.statepi.jhsph.edu/ckid ) with clinical coordinating centers at Children’s Mercy Hospital and the University of Missouri–Kansas City (Principal Investigator [PI]: Dr Warady) and Children’s Hospital of Philadelphia (PI: Dr Furth), Central Biochemistry Laboratory (PI: George Schwartz, MD) at the University of Rochester Medical Center, and data coordinating center (PIs: Alvaro Muñoz, PhD and Dr Ng) at the Johns Hopkins Bloomberg School of Public Health. CKiD is funded by the National Institute of Diabetes and Digestive and Kidney Diseases, with additional funding from the National Institute of Child Health and Human Development, and the National Heart, Lung, and Blood Institute (U01-DK-66143, U01-DK-66174, U24-DK-082194, and U24-DK-66116).
Keywords
- Ambulatory blood pressure monitoring (ABPM)
- BP threshold
- blood pressure (BP)
- childhood hypertension
- chronic kidney disease (CKD)
- diagnostic criteria
- guideline implementation
- hypertension prevalence
- hypertension staging
- normative data
- pediatric BP
- pediatric nephrology
ASJC Scopus subject areas
- Nephrology