Ambulatory hypertension and left ventricular hypertrophy in pediatric chronic kidney disease: a systematic review and meta-analysis

Clinical Snapshot

Key Findings

• P Value: Not explicitly reported but CI excludes null

• Effect Size: Mean difference 5.15 g/m2.7 higher LVMI in hypertensive group

• Primary Outcome: Left ventricular mass index (LVMI) difference between hypertensive and normotensive pediatric CKD patients

• Nnt Or Sensitivity: Odds ratio for LVH: 2.82 (95% CI 2.18, 3.65) - approximately 1 in 5 hypertensive children will develop LVH attributable to elevated BP

• Confidence Interval: 95% CI 3.16 to 7.15 g/m2.7

Clinical Application

Requires access to 24-hour ambulatory blood pressure monitoring and echocardiography, available in most Australian pediatric tertiary centres Aligns with RACGP guidelines emphasizing cardiovascular risk reduction in CKD. May inform PBS subsidy decisions for pediatric antihypertensive medications and support Medicare funding for ABPM in high-risk children Australian children and adolescents with CKD stages 1-5, particularly those under nephrology care

Abstract

UNLABELLED: Cardiovascular disease is the leading cause of mortality in pediatric patients with chronic kidney disease (CKD). In the general pediatric population, hypertension is associated with an increased risk of left ventricular hypertrophy (LVH); however, the strength of this association varies in the pediatric CKD literature. A lack of consensus on optimal blood pressure (BP) targets for this population contributes to variability in clinical practice. This study aims to determine the association between ambulatory hypertension and LVH in pediatric CKD. A systematic literature search was conducted on five databases from 1974 to 2025. The mean left ventricular mass index (LVMI) and odds of LVH was compared between normotensive and hypertensive groups. The association between LVMI and 24-h systolic/diastolic blood pressure, day/night systolic/diastolic blood pressure, and 24-h mean arterial pressure (MAP), was determined. Fifty-one full text studies (n = 6509 children) were eligible for inclusion in the meta-analysis. Pediatric CKD patients with ambulatory hypertension demonstrated increased LVMI (mean difference 5.15 g/m2.7 (95% CI 3.16, 7.15) and increased risk of LVH odds ratio 2.82 (95% CI 2.18, 3.65) to normotensive controls. LVMI was significantly lower among children with a 24-h MAP < 50th percentile (- 8.2 g/m2.7, 95% CI - 16.0, - 0.4) and 24-h SBP between the 50 and 90th percentiles (- 10.8 g/m2.7, 95% CI - 20.8, - 0.8) compared to those with 24-h MAP or 24 h SBP > 90th percentile, respectively. CONCLUSION: In children with CKD, ambulatory hypertension is associated with elevated risk of LVH and increased LVMI. However, there was significant heterogeneity among the included studies with respect to study design and definition of outcomes. Timely detection of hypertensive target organ injury is imperative to mitigate future cardiovascular disease in pediatric CKD patients.Prospero Registration: CRD 42023426891. WHAT IS KNOWN: • Hypertension is a critical predictor of adverse cardiovascular outcomes in children with CKD. Hypertension-induced target organ damage such as LVH may predict future cardiovascular outcomes in high-risk populations. Despite this, there remains considerable variability in clinical blood pressure targets and monitoring practices. Our findings highlight the importance of ambulatory blood pressure monitoring (ABPM) in detecting subclinical cardiovascular injury, supporting its integration into routine CKD care to improve risk stratification and treatment decisions. WHAT IS NEW: • This meta-analysis establishes a robust association between ambulatory hypertension and left ventricular hypertrophy (LVH) in children with CKD, demonstrating that higher blood pressure burden is linked to increased left ventricular mass index (LVMI). Notably, children with 24-h mean arterial pressure (MAP) and systolic blood pressure (SBP) above the 90th percentile exhibited significantly greater LVMI, reinforcing the impact of sustained hypertension on cardiac remodelling in pediatric CKD. • The strong association between ambulatory hypertension and LVH underscores the urgent need for evidence-based BP thresholds that minimize cardiovascular risk in pediatric CKD. Early identification of hypertensive target organ damage may enable timely therapeutic interventions to prevent long-term cardiovascular complications. Future studies should focus on defining optimal BP targets and evaluating the efficacy of antihypertensive strategies tailored to pediatric CKD. Standardizing BP measurement approaches may further refine hypertension management and improve cardiovascular outcomes in this vulnerable population.

References

1. 1.Chung, J., Yu, A., Robinson, C., Dionne, J. M., Ewusie, J., Lawson, D. O., Mitsnefes, M., Noone, D. G., Parekh, R. S., Sinha, M., South, A. M., Thabane, L., Chung, Z., & Chanchlani, R. (2026). Ambulatory hypertension and left ventricular hypertrophy in pediatric chronic kidney disease: A systematic review and meta-analysis. European Journal of Pediatrics. https://doi.org/10.2215/CJN.10130819