Peak blood pressure and prediction of posterior reversible encephalopathy syndrome in children
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ORIGINAL ARTICLE
Peak blood pressure and prediction of posterior reversible encephalopathy syndrome in children Emily Gall 1 & Abanti Chaudhuri 2 & Andrew M. South 3,4,5 Received: 22 November 2019 / Revised: 6 April 2020 / Accepted: 15 April 2020 # IPNA 2020
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 zscore ≥ 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. Keywords Hypertension . Hypertensive crisis . Hypertensive emergency . Hypertensive encephalopathy . Pediatrics
Introduction
* Andrew M. South [email protected] 1
Department of Otolaryngology-Head and Neck Surgery, Tufts University School of Medicine, Boston, MA, USA
2
Division of Nephrology, Department of Pediatrics, Stanford University School of Medicine, Palo Alto, CA, USA
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
4
Department of Epidemiology and Prevention, Division of Public Health Sciences, Wake Forest School of Medicine, Winston Salem, NC, USA
5
Cardiovascular Sciences Center, Wake Forest School of Medicine, Winston Salem, NC, USA
Posterior reversible encephalopathy syndrome (PRES) is a common complication of hypertensive crisis in children and adults and is characterized clinically by mental status changes, seizures, headaches, and visual changes [1]. The incidence of PRES varies according to the presence of certain high-risk factors: l
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