Investigations for diagnosis of secondary hypertension in children: yield and costs

BACKGROUND: Screening for secondary hypertension is not recommended for all hypertensive patients, but missing these cases is critical. We aimed to (i) assess hypertension causes in a cohort of hypertensive children, (ii) determine the costs and contributions of an extended diagnostic work-up to screen for secondary hypertension, and (iii) compare the performance of a "short diagnostic work-up" with the protocols of the American Academy of Pediatrics (AAP) and European Society of Hypertension (ESH). METHODS: We conducted a retrospective, single-center study of 70 hypertensive patients aged 1-18 years. All underwent an extended work-up to exclude secondary hypertension. Diagnostic findings, test counts, and costs were analyzed. A short work-up (serum creatinine, fasting glucose, electrolytes, urinalysis, kidney ultrasound (US), and renal artery Doppler US), as well as the AAP and ESH protocols, was evaluated for performance and costs. RESULTS: Secondary hypertension was identified in 29 patients (41.4%). The extended protocol identified or excluded secondary causes in all patients. Kidney US had the highest diagnostic yield (37.1%). The short work-up and ESH protocol identified all secondary cases, whereas the AAP protocol missed 15 diagnoses. The extended protocol cost € 17,715.60 (€ 253.08 per patient). Direct cost savings were 64.3% with the short work-up, 92.4% with the AAP protocol, and 76.2% with the ESH protocol. CONCLUSIONS: Primary is more common than secondary hypertension in children, with kidney parenchymal disease being the leading secondary cause. As recommended by guidelines, a simplified, focused work-up may offer a cost-effective alternative to extensive screening while maintaining diagnostic accuracy.