How is severe hypertension managed in acute poststreptococcal glomerulonephritis (APSGN)?

Updated: Dec 05, 2018
  • Author: Rajendra Bhimma, MBChB, MD, PhD, DCH (SA), FCP(Paeds)(SA), MMed(Natal); Chief Editor: Craig B Langman, MD  more...
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Answer

Severe hypertension, or that associated with signs of cerebral dysfunction, demands immediate attention. Debate exists regarding the agent that is most effective in patients with severe hypertension.

Three drugs are commonly cited as having a high benefit-to-risk ratio: labetalol (0.5-2 mg/kg/h intravenously [IV]), diazoxide, and nitroprusside (0.5-2 mcg/kg/min IV; in patients with severe hypertension that is refractory to the previous agents). Recently, sodium nitroprusside has been replaced by the use of nicardipine in the United States and much of Western Europe (start at 5 mg/h intravenously [IV], increase by 2.5 mg/h every 5-15 min as needed, maximum dose 15 mg/h). Discontinue if hypotension or tachycardia is present (may restart at 3-5 mg/h IV). In combination with any of these agents, the simultaneous IV administration of furosemide at doses of 2 mg/kg may be merited. Diazoxide use for blood pressure (BP) control is limited because, once administered, no further control of pressure is possible, unlike labetalol or nitroprusside.

Severe hypertension without encephalopathy can be treated in the manner described above or, more commonly, by administration of vasodilator drugs, such as hydralazine or nifedipine.

The doses of these drugs can be administered either by injection or by mouth and can be repeated every 10-20 minutes until a suitable response is obtained. For most children, the need for more than 2-3 doses is unusual.


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