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К^ДПребёнка
КлУчна пед1атр1я / Clinical Pediatrics
УДК 616.12-008.331.1-021.3-053.5-056-085
HORLENKO O.M, SOCHKA N.V., DEBRECENI O.V., HORLENKO F.V., PIRIDI V.L., TOMEYA.I., DEBRECENIK.O., KOSSEY G.B.
State Higher Educational Institution «Uzhgorod National University», Medical Faculty, Department of Pediatrics with Infectious Diseases, Uzhgorod
CLINICAL PARACLINICAL PARAMETERS OF PRIMARY ARTERIAL HYPERTENSION IN ADOLESCENTS
Summary. We investigated children with primary arterial hypertension (PAH) from the Transcarpathian region of Ukraine (68 children, middle age 14.68 ± 0.84 years). In patients with arterial hypertension which PAH debuted in adolescence and have changes in lipid profile are formed pathological process in two ways: first way presented increase in total cholesterol associated with lower high-density lipoprotein (HDL) cholesterol indicators, and other is an increase in triglycerides with decreased levels of HDL cholesterol, according to data of M.M. Korenev et al. (2010, 2011). These changes in lipid profile is prognostically unfavorable signs of atherosclerosis which developed in the patients (1st way), in others — development of the metabolic syndrome in the young age (14—15 years), which we observed in our research. Our data are also relevant tendency. In children with PAH increase triglyceride levels (1.96 ± 0.04 mmol/l) associated with significant decrease in HDL cholesterol fraction (1.20 ± 0.31 mmol/l) which predicts development of the metabolic syndrome in the young age. Key words: children, primary arterial hypertension, parameters of homeostasis disorders.
Introduction
Primary arterial hypertension (PAH) comprises 90—95 % of the arterial hypertension in children. 66.0 % of people with hypertension have atherogenic changes in lipid profile, characterized by increased levels of total cholesterol, triglycerides, and have parallel decrease in fractions of antiatherogenic high-density lipoprotein (HDL) cholesterol. Arterial hypertension in the children is characterized by a large prevalence, has not only medical importance, but also social role. This disease is a major cause of morbidity and mortality of the adult population [1-3].
The Aim. To investigate the presentation parameters of children with PAH based on the study of levels of ho-meostasis and their correlation.
Materials and Methods
Clinical characteristic, laboratory study (clinical and biochemical blood tests, ELISA contents of inter-leukins 1, 6 in the blood serum), determining levels of hormones T4, thyroid-stimulating hormone (TSH), micro- and macroelements (phosphorus, potassium, calcium, sodium and chlorine) in the blood serum, statistics methods.
Results
We investigated children with PAH from Transcarpathian region (68 children, middle age 14.68 ± 0.84 years). The control group consisted of 30 healthy children, middle age 13.52 ± 0.22 years. We considered clinical manifestations of PAH in children.
Particularly representational signs in children with PAH were: palpitation (43.59 ± 5.65 %), headache (increased to the end of the day) (30.77 ± 5.26 %), pain in the heart area of short duration (28.21 ± 5.13 %), dizziness (orthostatic) (26.92 ± 5.05 %), as can be seen from Table 1.
We obtained the following data in the study of blood pressure (BP) in the children with PAH (Table 2).
SBP parameters significantly differed in studied children (125.12 ± 0.73 mmHg to 114.73 ± 0.58 mmHg, p < 0.05). Systolic hypertension 3—8 times prevails over diastolic in children according to the literature data. The prevalence of systolic hypertension in adolescence ob© Horlenko O.M., Sochka N.V., Debreceni O.V.,
Horlenko F.V., Piridi V.L., Tomey A.I., Debreceni K.O., Kossey G.B., 2014 © «Здоровье ребенка», 2014 © Заславский А.Ю., 2014
KAiHiHHa пед1атр1я / Clinical Pediatrics
served in all subgroups regardless of race, age and gender was found. This applies mainly to the PAH.
We also conducted biochemical blood serum tests (Table 3).
As shown in the Table 3, the children with PAH had significantly higher specific biochemical parameters, including total bilirubin (11.51 ± 0.49 mmol/l to 8.23 ± 1.02 mmol/l in children from the control group; p < 0.001). Revealed significant differences identified only in the levels of HDL (respectively 1.20 ± 0.31 mmol/l to 1.69 ± 0.01 mmol/l; p < 0.001) by following data. HDL is useful «antiatherogenic» factor which transferred of cholesterol from cells of peripheral organs (including arteries, arteries of the brain, etc.) to the liver where it will be excreted from the body in the form of bile acids. Elevated levels of total cholesterol were determined in 18.76 % of patients — up to 6.12 ± 0.21 mmol/l among children. These children have recorded violations in the increase of total cholesterol by fraction of LDL to 2.78 ± 0.42 mmol/l, when levels HDL fraction and TG were in the reference value. According to our investigation were found significant differences in the levels of
Table 1. Clinical characteristics o;
cholesterol in children with PAH (2.35 ± 0.18 mmol/l to the control group — 0.84 ± 0.03 mmol/l). The rate of LDL more correlated with the risk of atherosclerosis than the total cholesterol level, that this fraction provides access of cholesterol to a blood vessels and organs. Determination of LDL is very informative for child organism. The deviations from the reference of this signs can indicate the risk of atherosclerosis and coronary heart disease in adulthood with high degree of probability.
The data of IA in 2.97 times higher in patients with PAH to the control group (2.67 and 0.90) according to our data. Average values of uric acid (UA) in the blood (0.26 ± 0.02 mmol/l and 0.19 ± 0.01 mmol/l, respectively, p < 0.001) and urine (3.28 ± 0.08 mmol/day and 2.24 ± 0.02 mmol/day, respectively, p < 0.001) in children with PAH were significantly higher than those of children in the control group. Hyperuricemia (> 0.32 mmol/l) was found in 2 girls — 4.80 % in boys, elevated levels of UA were found only in the one case — 2.50 %. We can say that the level of values fractions of cholesterol are the risk of PAH, analyzed of lipid metabolism, which are an indication for the possibility of cor-
ymptoms in the children with PAH
Parameters Children with PAH (n = 68)
Abs. %
Headache (increased to the end of the day) 24 30.77 ± 5.26
Fatigue 21 21.79 ± 4.70
Irritability 17 21.79 ± 4.70
Visual impairment 12 15.38 ± 4.11
Palpitation 34 43.59 ± 5.65
Pain in the heart area of short duration 22 28.21 ± 5.13
Dizziness (orthostatic) 21 26.92 ± 5.05
Table 2. Characteristic of blood pressure (mmHg)
Parameters Children with PAH (n = 68) Control group (n = 30)
Systolic BP 125.12 ± 0.73* 114.73 ± 0.58
Diastolic BP 77.59 ± 0.61 70.90 ± 1.10
Note: Р-liability of the data in children with PAH and in control group: * — p < 0.05.
Table 3. Biochemical tests of venous blood of the children with PAH
Parameters Children with PAH (n = 68) Control group (n = 30)
Total cholesterol, mmol/l 4.44 ± 0.10 2.94 ± 0.17**
HDL cholesterol, mmol/l 1.20 ± 0.31*** 1.69 ± 0.01
LDL cholesterol, mmol/l 2.35 ± 0.18** 0.84 ± 0.03
Atherogenic index 2.67 0.90
Calcium, mmol/l 2.18 ± 0.02 2.31 ± 0.02*
Total bilirubin, mmol/l 11.51 ± 0.49 8.23 ± 1.02
Triglycerides, mmol/l 1.96 ± 0.04 1.49 ± 0.04
Creatinine, pmol/l 94.57 ± 3.36*** 80.05 ± 1.87
Urea, mmol/l 4.57 ± 0.13 4.28 ± 0.16
Glucose, mmol/l 4.95 ± 0.11 4.53 ± 0.21
Uric acid, mmol/l 0.26 ± 0.02 0.19 ± 0.01***
Uricuria, mmol/day 3.28 ± 0.08 2.24 ± 0.02***
Notes: P-liability of the data in children with PAH and in control group: * — р < 0.05; ** — р < 0.001; *** — р < 0.001.
KëiHNHa neAiaTpifl / Clinical Pediatrics
rection. All these next biochemical tests in children with group observation were within the age norm.
Study of hemostasiogram is an important test of the origin and development of PAH and is potentially atherosclerosis and coronary heart disease to. We received the following data as result of research. Changes in hemostasiogram were indicated in 54.00 % of children. Major violations were characterized by reliable estimates an increase of activated recalcification time in the group of children with PAH in comparison with the control group (74.76 ± 5.06 sec to 64.76 ± 2.04 sec, p < 0.05) with increasing concentration of fibrinogen (17.53 ± 1.63 to 11.32 ± 0.77, p < 0.001) too, which may presented a predisposition to thrombogenesis in children with PAH group. The growth of the concentration of fibrinogen in plasma correlate with an increased risk of complications of heart disease within the reference values, according to the literature data even.
In the examined contingent we conducted a survey to for identify disorders of mineral metabolism child's organism. This mineral metabolism data are presented in Table 4.
The levels of all minerals were identified within reference values. Significant difference observed in the level of sodium in children with PAH and the control group (respectively 133.90 ± 1.72 mmol/l and 119.16 ± 2.01 mmol/l, p < 0.001). But all numerical values varied within a reference.
Investigation of hormonal levels, cytokine profile (IL-1, IL-6) in children with PAH presented in the Table 5.
Endothelial cells are active producers of IL-1. Complect of different types of cells which have receptors to IL-1 are numerous and distributed on the all organism systems. Growth stimulatory effect of IL-1 on the B cells is important for the development of the immune answer. Some effects caused by IL-6 are similar to the action of IL-1. The main effect of IL-6 is related to his participation as a cofactor in the differentiation of B lymphocytes and their maturation and transformation
into plasmatic cells, which do immunoglobulin secretion. IL-6 is one of the most active cytokines which participated in the realization of immune answer. These cytokines contribute to the development of endothelial inflammation by activating endothelial cells, macrophages, stimulating production of free radicals, pro-teolytic enzymes and a significant increase coagulation activity. The levels of IL-1 and IL-6 were in the range of reference values with tendency to the lower level, especially IL-1, according to our data This fact indicates decrease of production of interleukins in child's organism of the patients with PAH what confirmed by the above described clinical and laboratory effects. There are a significant decrease in TSH and absolute decrease in the level of T4. Their influence on lipid metabolism caused by inhibition of synthesis and increased fat splitting with the release of glycerol and fatty acids and increase the concentration of cholesterol. These data are consistent with our result (4.44 ± 0.10 mmol/l to 3.21 ± 0.26 mmol/l; p < 0.001). Cortisol has nonpre-sentive mineralocorticoid influence, but high maintenance caused by excessive sodium retention in the child organism (133.90 ± 1.72 mmol/l to the control group — 119.16 ± 2.01 mmol/l; p < 0.001). There is a clear tendency of significant relationships although but our data vary within the reference values.
Correlation analysis of our study data demonstrated a direct relationship between the value of IL-6 which correlated with the level of glucose (r = 0.65). SAT has a high degree of feedback to the level of T4. The value of IL-6 correlated in inverse proportion to the level of TSH (r = -0.31). TSH is also directly dependent from the levels of total protein (r = 0.79), which has negative relationship with sodium (r = -0.89). The level of calcium has negative relationship with the level of sodium (r = -0.85).
Conclusions
In patients with hypertension which PAH debuted in adolescence and have changes in lipid profile are formed
Table 4. Mineral balance in the case of children with PAH
Parameters, mmol/l Children with PAH (n = 68) M ± m Control group (n = 30) M ± m Р
Potassium 4.58 ± 0.18 3.64 ± 0.21 > 0.05
Sodium 133.90 ± 1.72* 119.16 ± 2.01 < 0.05
Chlorine 102.58 ± 1.78 97.5 ± 1.87 > 0.05
Note: * — Р-liability of the data in children with PAH and in control group.
Table 5. Hormonal levels, cytokines profile in children with primary arterial hypertension
Parameters Children with PAH (n = 68) M ± m Control group (n = 30) M ± m
IL-1, pg/ml 0.43 ± 0.03* 0.64 ± 0.05
IL-6, pg/ml 1.05 ± 0.16 1.19 ± 0.15
TSH, mmol/ml 1.22 ± 0.08* 1.92 ± 0.20
T4, nmol/l 14.33 ± 0.42 15.46 ± 0.33
Cortisol, nmol/l 364.29 ± 17.42* 246.80 ± 22.49
Note: Р-liability of the data in children with PAH and in control group: * — p < 0.02.
KAiHiHHa пeдiaтрiя / Clinical Pediatrics
pathological process in two ways: first way presented increase in total cholesterol associated with lower HDL fraction of cholesterol, and other — is an increase of Triglycerides with decreased level of HDL cholesterol, according to data of M.M. Korenev et al. (2010, 2011). These changes in lipid profile is prognostically unfavorable signs of atherosclerosis which formed in the patients (1st way), in others — is development of the metabolic syndrome in the young age (14—15 years), which we observed in our research. In children with PAH increase Triglyceride levels (1.96 ± 0.04 mmol/l) associated with significant decrease in HDL cholesterol fraction
(1.20 ± 0.31 mmol/l) which predicts of development of the metabolic syndrome in the young age.
References
1. Коваленко В.М., Корнацький В.М., Дорогой А.П. та in. Стан серцево-судинног патологи та шляхи його покращення в Украт: Методичный поабник. — К., 2003. — 45 с.
2. Маколкин В.И. Метаболический синдром / В.И. Макол-кин. — М.: МИА, 2010. — 142 с.
3. Collins R.T. Pre-hypertension and hypertension in pediatrics: don't let the statistics hide the pathology / R.T. Collins, B.S. Alpert // J. Pediatr. — 2009. — Vol. 155, № 2. — P. 165-169.
Получено 18.03.14 ■
Горленко О.М., Сочка Н.В., Дебрецен! О.В., Горленко Ф.В., П!р!д! В.Л., Томей А.1., Дебрецен!К.О., Коссей Г.В. ДВНЗ «Ужгородський нацюнальний унверситет», медичний факультет, кафедра пед!атрн та ¡нфекц!йниххвороб
КЛШкО-ПАРАКЛМчт ПАРАМЕТРИ ПЕРВИННОТ АРТЕР|АЛЬН01 ппертензи в тдл1тюв
Резюме. Ми дослщжувади дитячий контингент Закар-патсько! област з первинною артер1альною гшертенз1ею (ПАГ) (68 чол., середнш в1к — 14,68 ± 0,84 року). У тих хворих з артер1альною гшертенз1ею, у яких ПАГ дебюту-вала в пщлггковому вщ, спостеркаються змши в лшщ-ному спектр1 1 патолопчний процес формуеться у двох напрямках. Перший шлях представлений збшьшенням р1вня загального холестерину з бшьш низькими показни-ками фракци холестерину лшопротещв високо1 щшьносп (ЛПВЩ). При другому шляху пщвищення р1вня тригль цервддв асоцшеться з1 зниженням р1вня фракц11 холестерину ЛПВЩ, згщно з даними М.М. Коренева 1 ствавт. (2010, 2011). Щ зм1ни в л1п1дному спектр1 е прогностично несприятливими для розвитку атеросклерозу (1-й шлях розвитку), у д1тей 1з 2-м шляхом формування патолопчно-го процесу оч1куеться розвиток метабол1чного синдрому в молодому в1ц1 (14—15 ротв), що 1 в]дзначено в нашому до-сл1дженн1. У д1тей 1з ПАГ п]двищення р1вня триглщервддв (1,96 ± 0,04 ммоль/л) асоцшоване з1 значним зниженням фракц11 холестерину ЛПВЩ (1,20 ± 0,31 ммоль/л), що вщ-пов]дае прогнозу розвитку метабол1чного синдрому в молодому вщ1
Ключовi слова: д1ти, первинна артер1альна г1пертенз1я, параметри порушень гомеостазу.
Горленко О.М., Сочка Н.В., Дебрецени Е.В., Горленко Ф.В., Пириди В.Л., Томей А.И., Дебрецени К.А., Коссей Г.В. ГВУЗ«Ужгородский национальный университет», медицинский факультет, кафедра педиатрии и инфекционных болезней
КЛИНИКО-ПАРАКЛИНИЧЕСКИЕ ПАРАМЕТРЫ ПЕРВИЧНОЙ АРТЕРИАЛЬНОЙ ГИПЕРТЕНЗИИ У ПОДРОСТКОВ
Резюме. Мы исследовали детский контингент Закарпатской области с первичной артериальной гипертензи-ей (ПАГ) (68 чел., средний возраст — 14,68 ± 0,84 года). У тех больных с артериальной гипертензией, у которых ПАГ дебютировала в подростковом возрасте, наблюдаются изменения в липидном спектре и патологический процесс формируется в двух направлениях. Первый путь представлен увеличением уровня общего холестерина с более низкими показателями фракции холестерина ли-попротеидов высокой плотности (ЛПВП). При втором пути повышение уровня триглицеридов ассоциируется со снижением уровня фракции холестерина ЛПВП, согласно данным М.М. Коренева и соавт. (2010, 2011). Эти изменения в липидном спектре являются прогностически неблагоприятными для развития атеросклероза (1-й путь развития), у детей со 2-м путем формирования патологического процесса ожидается развитие метаболического синдрома в молодом возрасте (14—15 лет), что и представлено в нашем исследовании. У детей с ПАГ повышение уровня триглицеридов (1,96 ± 0,04 ммоль/л) ассоциировано со значительным снижением фракции холестерина ЛПВП (1,20 ±0,31 ммоль/л), что соответствует прогнозу развития метаболического синдрома в молодом возрасте.
Ключевые слова: дети, первичная артериальная гипер-тензия, параметры нарушений гомеостаза.
