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INVITED COMMENTARY
Hypertension in Nephrotic Syndrome: A Pressing Concern

TANVI BINDAL, ARVIND BAGGA*
Division of Nephrology, Department of Pediatrics, All India Institute of Medical Sciences, New Delhi.
[email protected]
H
igh blood pressure is often detected in patients recorded values, and hypertension was defined as per
with nephrotic syndrome, at the onset of the standard guidelines [7]. The authors found that almost
illness, following therapy with prednisolone, one-third (32.5%) of patients had hypertension during
and/or during long-term follow-up. A review disease relapse, which persisted in one-quarter of cases
of cardiovascular outcomes in proteinuric glomerulo- (8.6%) following 4-weeks of prednisolone therapy.
pathies showed that the prevalence of hypertension ranges Amongst hypertensive patients, 29% had a family history
from 7% to 41% in steroid sensitive nephrotic syndrome, of hypertension, and ~50% had history of hypertension at
compared to 13% to 58% in patients with steroid resis- disease onset or during a previous relapse. While a propor-
tance [1]. In patients with steroid sensitive disease, high tion of patients showed abnormal left ventricular geo-
blood pressure was found in 65% to 95% of patients with metry, concentric left ventricular hypertrophy was unco-
edema, which persisted in 19% to 34% following steroid- mmon. These findings are noteworthy, since clinic hyper-
induced remission [2,3]. The prevalence of hypertension is tension was found in ~30% patients with active disease,
highest in patients with frequent relapses or steroid depen- compared to an estimated population prevalence of ~4%
dence, and in those with family history of essential hyper- for primary hypertension [8]. However, it would be impor-
tension [1,3]. Masked hypertension, which is in itself asso- tant to emphasize few issues of relevance for practicing
ciated with adverse cardiovascular outcomes, is reported clinicians and researchers.
in 16% to 40% of such patients. [4,5].
The eligibility criteria state that inclusion was limited
Hypertension in nephrotic syndrome may be attributed to patients who were receiving antihypertensive medi-
to intrinsic renal and non-renal causes, as well as extrinsic cations for 3-months or longer. In order to determine the
reasons. The chief renal causes include primary salt and prevalence of hypertension in infrequent relapsers, it
water retention, fluid overload, glomerulosclerosis related would have been appropriate to include all patients with
decline in glomerular filtration rate, and proliferative infrequent relapses, irrespective of antihypertensive
glomerulonephritis. Important extrarenal factors contri- therapy. While the use of antihypertensive medications
buting to hypertension are therapy with corticosteroids or might have led to underestimation of the prevalence of
calcineurin inhibitors, and dyslipidemia [1]. Hypertension hypertension, the true prevalence might indeed have been
has long-term cardiovascular consequences, including left lower were all the patients with infrequent relapses
ventricular hypertrophy and atherosclerosis, and leads to included. Secondly, patients with hypertension appear to
end-organ injury, such as retinopathy and progressive have had more severe relapses, as indicated by serum and
kidney disease. Almost one-third of children with primary urine biochemistry. A prolonged duration of disease and
hypertension show echocardiographic evidence of left delayed therapy of relapse might influence the severity of
ventricular hypertrophy, underscoring the importance of relapse and result in hemodynamic aberrations, including
detection and appropriate management of hypertension in hypertension. Thirdly, in order to negate the influence of
children [6]. corticosteroid therapy on hypertension, repeat blood
pressure values should have been estimated a few months
A prospective single center observational study, pub-
remote from the relapse. Further, the value of detecting
lished in this issue of the Journal, aimed to evaluate the
transient hypertension is uncertain, since persistent
prevalence of hypertension in 83 children with infre-
hypertension is more likely to correlate with cardio-
quently relapsing nephrotic syndrome during a relapse and
vascular outcomes than acute hypertension associated
following 4-weeks of prednisolone therapy. The authors
with a relapse.
also evaluated if hypertension was associated with family
history, dyslipidemia, or end organ damage. Blood pre- Compared to casual clinic blood pressure records,
ssure was measured in the clinic as the mean of three ambulatory blood pressure monitoring (ABPM) is a
INDIAN PEDIATRICS 1 APRIL 20, 2023 [E-PUB AHEAD OF PRINT]

INVITED COMMENTARY
comprehensive technique to detect abnormal blood REFERENCES

pressure in adults and children [9]. Its advantages include
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In conclusion, findings of this and other reports AE, Daniels SR, et al. Clinical practice guideline for screen-
suggest that acute but transient hypertension is common ing and management of high blood pressure in children and
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Prospective studies on prevalence of hypertension should
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Published online: April 20, 2023; PII: 097475591600526 in the diagnosis and treatment of hypertension: A systematic
review. Am J Hypertens. 2011;24:123-34.
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INVITED COMMENTARY

Hypertension in Nephrotic Syndrome: A Pressing Concern

INDIAN PEDIATRICS 1 APRIL 20, 2023 [E-PUB AHEAD OF PRINT]

comprehensive technique to detect abnormal blood REFERENCES

INDIAN PEDIATRICS 2 APRIL 20, 2023 [E-PUB AHEAD OF PRINT]

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