Hypertension in Children With Chronic Kidney Disease and Dialysis: State of the Art

Hypertension is a highly prevalent and clinically significant complication in childhood chronic kidney disease (CKD), contributing substantially to cardiovascular morbidity, progression of kidney dysfunction, and long-term health risks extending into adulthood. Management of hypertension remains suboptimal with missed opportunities in its accurate detection, monitoring, and subsequent risk stratification to improve clinical outcomes. Evidence consistently demonstrates that sustained hypertension accelerates decline in glomerular filtration rate and increases the risk of left ventricular hypertrophy and other forms of target organ injury. Early and effective intervention, therefore, is essential. Nonpharmacological strategies, including dietary sodium restriction, optimization of fluid balance, and promotion of healthy lifestyle habits, form the foundation of management. Pharmacological therapy, particularly with agents that block the renin-angiotensin-aldosterone system, remains the cornerstone of treatment due to their dual antihypertensive and renoprotective effects. Randomized controlled trials have informed treatment thresholds and targets for those with predialysis CKD. Several knowledge gaps remain including blood pressure targets for earlier stages of CKD especially in those with non-proteinuric kidney disease, longer term safety data for antihypertensive medications, and studies highlighting successful implementation treatment strategies that improve achievement of tretament targets and outcomes require further investigation. Early recognition, routine use of ambulatory monitoring, and comprehensive, individualized management are essential to slow kidney disease progression and reduce cardiovascular risk, ultimately improving long-term outcomes for this vulnerable population.