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Peak blood pressure and prediction of posterior reversible encephalopathy syndrome in children

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Abstract

Background

Hypertension is a risk factor for posterior reversible encephalopathy syndrome (PRES), but the timing and severity of hypertension relative to PRES are unknown. The objective was to identify a clinically meaningful blood pressure (BP) threshold that predicts PRES development in high-risk children.

Methods

We recorded peak systolic BP, diastolic BP, BP z-scores, and mean arterial pressure over the 14 days preceding clinical concern for PRES in 35 subjects who developed PRES, compared to 14 controls who had normal brain magnetic resonance imaging and similar underlying disease, renal function, and medications. We used multivariable logistic regression models adjusted for fluid overload and obesity to estimate the association of peak BP with PRES. We used receiver operating characteristic curves to determine which peak BP thresholds best predicted PRES and calculated the corresponding sensitivity, specificity, and positive and negative predictive values.

Results

Peak systolic BP z-score was most strongly associated with PRES (OR 3.97, 95% CI 1.62–9.74), and peak systolic BP z-score ≥ 3.0 predicted PRES (area under the curve 0.95, 95% CI 0.88–1.0) with 91% sensitivity and 85% specificity, indicating 94% positive predictive value and 79% negative predictive value.

Conclusions

We demonstrated that peak systolic BP z-score ≥ 3.0 in the preceding 14 days predicted PRES development in cases compared with controls in children at high risk. Our study suggests that stage 2 hypertension, corresponding to a z-score ≥ 3.0, could help define hypertensive emergency in high-risk children and indicate when more aggressive treatment is warranted to prevent neurologic injury.

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Acknowledgments

We would like to thank Scott Sutherland, MD, at Stanford University School of Medicine for his assistance in conceptualizing this study and Julia Rushing and Tim Craven, M. Stat., at Wake Forest School of Medicine for their assistance with data analysis.

Data sharing statement

The datasets generated and analyzed during the current study are available from the corresponding author on reasonable request.

Funding

This study was funded by the Spectrum Stanford Center for Clinical and Translational Research and Education (NIH/NCATS TL1 TR001084 [to AMS]), the Wake Forest Clinical and Translational Science Award (NIH/NCATS UL1 TR001420), and Wake Forest School of Medicine Department of Pediatrics research funds [to AMS]. The study originally took place at Stanford School of Medicine.

Author information

Authors and Affiliations

  1. Department of Otolaryngology-Head and Neck Surgery, Tufts University School of Medicine, Boston, MA, USA

    Emily Gall

  2. Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA

    Abanti Chaudhuri

  3. Section of Nephrology, Department of Pediatrics, Wake Forest School of Medicine and Brenner Children’s Hospital, One Medical Center Boulevard, Winston Salem, NC, 27157, USA

    Andrew M. South

  4. Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC, USA

    Andrew M. South

  5. Cardiovascular Sciences Center, Wake Forest School of Medicine, Winston Salem, NC, USA

    Andrew M. South

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  1. Emily Gall
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  2. Abanti Chaudhuri
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Contributions

Dr. Gall assisted with data interpretation, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. Chaudhuri conceptualized and designed the study, assisted with data interpretation, and reviewed and revised the manuscript. Dr. South conceptualized and designed the study, collected data, analyzed and interpreted the data, and reviewed and revised the manuscript. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

Corresponding author

Correspondence to Andrew M. South.

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Conflict of interest

The authors declare that they have no conflicts of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (Stanford School of Medicine Institutional Review Board IRB27787 and Wake Forest School of Medicine Institutional Review Board IRB00046847) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

The IRB determined that this retrospective analysis did not require informed consent.

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Gall, E., Chaudhuri, A. & South, A.M. Peak blood pressure and prediction of posterior reversible encephalopathy syndrome in children. Pediatr Nephrol 35, 1967–1975 (2020). https://doi.org/10.1007/s00467-020-04577-5

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  • DOI: https://doi.org/10.1007/s00467-020-04577-5

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