CME
An Athletic Adolescent Girl with Proteinuria and Hypertension Siddhartha Dante, MD; and Catherine Glunz, MD
Abstract Siddhartha Dante, MD, is a Resident Physician, Internal Medicine-Pediatrics, University of Chicago Medicine. Catherine Glunz, MD, is an Attending Physician, Internal Medicine-Pediatrics, Northshore University Health System. Address correspondence to Siddhartha Dante, MD, University of Chicago Medicine, 5841 South Maryland Avenue, MC 7082, Chicago, IL 60637; email: [email protected]. Disclosure: The authors have no relevant financial relationships to disclose. 10.3928/00904481-20150313-10
© Shutterstock
An 18-year-old athletic adolescent presents with hypertension found during a routine screening. Her prior history includes familial hyperlipidemia. Hypertension in the adolescent is classified based on percentiles for age, sex, and height. The most common secondary cause of hypertension in the pediatric and adolescent patient is renal disease. This patient was found to have nephrotic syndrome and because of her age, a renal biopsy was required to make the diagnosis and to direct subsequent treatment plans. She was diagnosed with C3 glomerulopathy, which is the result of dysregulation and uncontrolled activation of the alternative complement pathway; new therapies are emerging for this disease. In this case, we review the diagnosis and initial assessment of hypertension in the pediatric patient, and the causes of nephrotic syndrome with a focus on C3 glomerulopathy. [Pediatr Ann. 2015;44(3):e58-e61.]
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CME
A
n 18-year-old presents for a follow-up analysis for hypertension that was found during a routine preparticipation military physical examination. A competitive athlete who participated in track and swimming throughout high school, she is currently training for a halfmarathon on the upcoming weekend. During the previous prerequisite check, the urinalysis showed blood and protein; although concerned, the patient believes that the protein and blood findings are the result of menses and that the blood pressure (BP) reading was inaccurate. Two years previously, she had been diagnosed with familial hyperlipidemia after screening was conducted during a health maintenance visit. Screening had been requested by the family because of her father’s recent successful resuscitation from sudden cardiac arrest due to a myocardial infarction. Laboratory tests were taken with a referral to follow up with the Pediatric Genetics department. She was initially treated with statin therapy with improvement but, in discussion with her geneticist, had discontinued therapy in preparation for military boot camp. At this examination, she feels well and denies any chest pain, shortness of breath, dizziness, weakness, or nausea. She notes an approximate 15-pound weight gain over the past 6 months, which she attributes to the stresses of high school graduation and not to a sedentary lifestyle. She completed her menses 2 weeks prior; she describes her menstruation flow as regular and normal. She denies the possibility of pregnancy and any history of sexual activity. PHYSICAL EXAMINATION Initial physical examination reveals a well-appearing athletic female with a manual BP of 144/100 mm Hg at
PEDIATRIC ANNALS • Vol. 44, No. 3, 2015
rest, which is in the 99th percentile for age, sex, and height for both systolic BP (SBP) and diastolic BP (DBP). Review of weight measurements show an increase of 17 pounds from February to the visit in July. Her current body mass index is 22.4 kg/m2. Her heart rate is normal and rhythm is regular. Heart sounds are S1/S2 with no murmurs, rubs, or gallops. Her lungs are clear to auscultation. No renal bruits are heard on auscultation and aorta size is normal. There is no evidence of papilledema on fundoscopic examination, and no periorbital swelling or pedal edema. DISCUSSION Hypertension Hypertension in an adolescent is defined as SBP or DBP that is greater than the 95th percentile for age, sex, and height as averaged over three or more occasions (Table 1).1 In review of her medical record, elevated BP readings from a visit 1 month prior with her gynecologist and 3 months prior during an orthopedic surgery visit for a fractured finger are noted. Classifying her stage of hypertension is also based on percentile with prehypertension defined as between the 90th and 95th percentile, stage 1 hypertension between the 95th and 99th percentile, and stage 2 hypertension for all measurements greater than the 99th percentile.1 Although the prevalence of hypertension in the pediatric population is growing and largely attributed to obesity and sedentary lifestyles, secondary causes must always be considered, especially in patients who present with stage 1 or stage 2 hypertension.2 Renal diseases are the most common cause of secondary hypertension in the pediatric patient and initial laboratory and imaging results are directed toward this organ system (Table 1).1 Echocardiography can also be help-
ful but more for identification of left ventricular hypertrophy as a sign of end-organ damage and/or chronic hypertension. In this patient, evaluation began with repeating her urinalysis and conducting a complete blood count and basic metabolic panel. Because of her history of familial hyperlipidemia and no current therapy, a fasting lipid panel and liver function tests are conducted. Finally, a renal Doppler ultrasound is also performed. RESULTS The first results are 3+ blood and 3+ protein present on her urinalysis (Figure 1). Then, hypoproteinemia and hypoalbuminemia showed on her liver function tests. Her blood urea nitrogen and serum creatinine are remarkably normal despite concern for renal dysfunction. Her lipid panel is notable for a doubling of her total cholesterol from her last check 1 year prior from 267 mg/dL to 494 mg/dL with elevated low-density lipoprotein of 407 mg/dL and triglycerides of 255 mg/dL. Her high-density lipoprotein is low at 36 mg/dL. Before having the patient return for further testing, you note that results from the previously submitted urine sample reveal a random urine protein to creatinine ratio of 5.1, which is indicative of nephrotic range proteinuria. Results from her renal ultrasound show moderate pelvic ascites with normal-sized kidneys with no hydronephrosis or perinephric collections but increased echogenicity compatible with medical renal disease. Doppler evaluation shows normal renal vasculature. For further testing, a 24-hour urine collection is requested, along with additional laboratory work for coagulation studies, thyroid studies, and serologic tests for causes of nephrotic e59
CME TABLE 1.
Pediatric Hypertension: Criteria and Secondary Causes Diagnosing Pediatric Hypertensiona Prehypertension SBP or DBP ≥90th to
An Athletic Adolescent Girl with Proteinuria and Hypertension Siddhartha Dante, MD; and Catherine Glunz, MD
Abstract Siddhartha Dante, MD, is a Resident Physician, Internal Medicine-Pediatrics, University of Chicago Medicine. Catherine Glunz, MD, is an Attending Physician, Internal Medicine-Pediatrics, Northshore University Health System. Address correspondence to Siddhartha Dante, MD, University of Chicago Medicine, 5841 South Maryland Avenue, MC 7082, Chicago, IL 60637; email: [email protected]. Disclosure: The authors have no relevant financial relationships to disclose. 10.3928/00904481-20150313-10
© Shutterstock
An 18-year-old athletic adolescent presents with hypertension found during a routine screening. Her prior history includes familial hyperlipidemia. Hypertension in the adolescent is classified based on percentiles for age, sex, and height. The most common secondary cause of hypertension in the pediatric and adolescent patient is renal disease. This patient was found to have nephrotic syndrome and because of her age, a renal biopsy was required to make the diagnosis and to direct subsequent treatment plans. She was diagnosed with C3 glomerulopathy, which is the result of dysregulation and uncontrolled activation of the alternative complement pathway; new therapies are emerging for this disease. In this case, we review the diagnosis and initial assessment of hypertension in the pediatric patient, and the causes of nephrotic syndrome with a focus on C3 glomerulopathy. [Pediatr Ann. 2015;44(3):e58-e61.]
e58
Copyright © SLACK Incorporated
CME
A
n 18-year-old presents for a follow-up analysis for hypertension that was found during a routine preparticipation military physical examination. A competitive athlete who participated in track and swimming throughout high school, she is currently training for a halfmarathon on the upcoming weekend. During the previous prerequisite check, the urinalysis showed blood and protein; although concerned, the patient believes that the protein and blood findings are the result of menses and that the blood pressure (BP) reading was inaccurate. Two years previously, she had been diagnosed with familial hyperlipidemia after screening was conducted during a health maintenance visit. Screening had been requested by the family because of her father’s recent successful resuscitation from sudden cardiac arrest due to a myocardial infarction. Laboratory tests were taken with a referral to follow up with the Pediatric Genetics department. She was initially treated with statin therapy with improvement but, in discussion with her geneticist, had discontinued therapy in preparation for military boot camp. At this examination, she feels well and denies any chest pain, shortness of breath, dizziness, weakness, or nausea. She notes an approximate 15-pound weight gain over the past 6 months, which she attributes to the stresses of high school graduation and not to a sedentary lifestyle. She completed her menses 2 weeks prior; she describes her menstruation flow as regular and normal. She denies the possibility of pregnancy and any history of sexual activity. PHYSICAL EXAMINATION Initial physical examination reveals a well-appearing athletic female with a manual BP of 144/100 mm Hg at
PEDIATRIC ANNALS • Vol. 44, No. 3, 2015
rest, which is in the 99th percentile for age, sex, and height for both systolic BP (SBP) and diastolic BP (DBP). Review of weight measurements show an increase of 17 pounds from February to the visit in July. Her current body mass index is 22.4 kg/m2. Her heart rate is normal and rhythm is regular. Heart sounds are S1/S2 with no murmurs, rubs, or gallops. Her lungs are clear to auscultation. No renal bruits are heard on auscultation and aorta size is normal. There is no evidence of papilledema on fundoscopic examination, and no periorbital swelling or pedal edema. DISCUSSION Hypertension Hypertension in an adolescent is defined as SBP or DBP that is greater than the 95th percentile for age, sex, and height as averaged over three or more occasions (Table 1).1 In review of her medical record, elevated BP readings from a visit 1 month prior with her gynecologist and 3 months prior during an orthopedic surgery visit for a fractured finger are noted. Classifying her stage of hypertension is also based on percentile with prehypertension defined as between the 90th and 95th percentile, stage 1 hypertension between the 95th and 99th percentile, and stage 2 hypertension for all measurements greater than the 99th percentile.1 Although the prevalence of hypertension in the pediatric population is growing and largely attributed to obesity and sedentary lifestyles, secondary causes must always be considered, especially in patients who present with stage 1 or stage 2 hypertension.2 Renal diseases are the most common cause of secondary hypertension in the pediatric patient and initial laboratory and imaging results are directed toward this organ system (Table 1).1 Echocardiography can also be help-
ful but more for identification of left ventricular hypertrophy as a sign of end-organ damage and/or chronic hypertension. In this patient, evaluation began with repeating her urinalysis and conducting a complete blood count and basic metabolic panel. Because of her history of familial hyperlipidemia and no current therapy, a fasting lipid panel and liver function tests are conducted. Finally, a renal Doppler ultrasound is also performed. RESULTS The first results are 3+ blood and 3+ protein present on her urinalysis (Figure 1). Then, hypoproteinemia and hypoalbuminemia showed on her liver function tests. Her blood urea nitrogen and serum creatinine are remarkably normal despite concern for renal dysfunction. Her lipid panel is notable for a doubling of her total cholesterol from her last check 1 year prior from 267 mg/dL to 494 mg/dL with elevated low-density lipoprotein of 407 mg/dL and triglycerides of 255 mg/dL. Her high-density lipoprotein is low at 36 mg/dL. Before having the patient return for further testing, you note that results from the previously submitted urine sample reveal a random urine protein to creatinine ratio of 5.1, which is indicative of nephrotic range proteinuria. Results from her renal ultrasound show moderate pelvic ascites with normal-sized kidneys with no hydronephrosis or perinephric collections but increased echogenicity compatible with medical renal disease. Doppler evaluation shows normal renal vasculature. For further testing, a 24-hour urine collection is requested, along with additional laboratory work for coagulation studies, thyroid studies, and serologic tests for causes of nephrotic e59
CME TABLE 1.
Pediatric Hypertension: Criteria and Secondary Causes Diagnosing Pediatric Hypertensiona Prehypertension SBP or DBP ≥90th to
![[Bilateral papilledema secondary to intracranial hypertension in an adolescent girl].](/assets/img/hold.png)
