Improving the Management of Hypertension in Pediatric Hematopoietic Stem Cell Transplantation

Hypertension (HTN) is a known complication of pediatric hematopoietic stem cell transplant (HSCT). Historically, the risks for developing HTN depend on a variety of factors which may include use of calcineurin inhibitors, the presence of graft versus host disease requiring steroid therapy, total body irradiation, and standardized chemotherapy delivered during HSCT.  Uncontrolled HTN in pediatric HSCT patients may lead to significant life threatening complications that often affect long term cardiac and renal outcomes. Managing pediatric HSCT associated HTN is often a challenge due to the range of patients ages, heights and weights which determine normal and target blood pressure. Using a multidisciplinary approach, we collected pilot data from 6 pediatric patients who had received allogeneic HSCTs from day +0 to day +5. The focus was to look at their hypertension management within the first days following their stem cell infusions.  The data consisted of blood pressure parameters ordered, documented blood pressures, the response time for reporting HTN and the antihypertensive medications given to patients during that period.   The table below lists the data obtained.  We found 3 areas to focus improvements on. One was to educate staff on the use of the individualized blood pressure parameters (<95% for age and height, Pediatrics 2004; 114; 555-576, infants birth -12 months parameters, Pediatric Nephrology (2012) 27:17-32) in the initial order set.  A second area was to educate staff on the process of taking blood pressures according to the published guidelines followed by our nephrology and HTN clinics.  A third improvement opportunity was to decrease the time to initiation of antihypertensive therapy.   Overall the goal is to protect the pediatric patients throughout HSCT.  This is a process that the multidisciplinary HSCT team continues to focus and improve upon, thus impacting the outcomes for our pediatric BMT population. 

Table: Pediatric HSCT Blood Pressure Data (Day +0 to Day +5)

Number of pediatric HSCT patients	6
Patients age	6 month-14 years
Type of HSCT	allogeneic  matched  unrelated donor
Number of myeloablative HSCT	2 of 6
Number of reduced intensity HSCT	4 of 6
Number of patients with initial BP parameters ordered that were above >95% for age and height or above age specific percentiles for birth to 12 months of age	3/6
Total number of blood pressure (BP) data points (Day +0 to Day +5)	458
Median number of elevated systolic BPs documented before a BP medication was  first ordered	30
Median number of diastolic BPs documented before a BP medication as first ordered	16
Median Time in hours to Initial antihypertensive medication delivery  after elevated BPs were documented	64.5
Most frequently used antihypertensive medications	Hydralazine (as needed) Nicardipine (as needed) Amlodipine (1-2 times daily) Enalaprilat (every 8 hours)