Table 1.
Secondary causes of hypertension by organ system with clinical and laboratory findings.
| Organ system | Differential diagnosis | Findings/workup |
|---|---|---|
| Renal | ||
| Renal parenchyma | Acute and chronic glomerulonephritis | Hematuria, proteinuria, edema |
| Acute and chronic renal failure | Use KDIGO, pRIFLE, or AKIN guidelines for diagnosis | |
| Congenital renal malformationsa | Prenatal/postnatal renal US findings of dysplasia, obstructive uropathy | |
| Polycystic kidney disease | Hepatosplenomegaly (ARPKD) | |
| Systemic vasculitis | ||
| SLE | Low C3, C4, CH50, +ds-DNA, +anti-Smith, joint pain/swelling, rash, edema | |
| ANCA | Normal to +ANCA, ↑ CRP, ↑ ESR, joint pain/swelling, rash, edema | |
| HSP | Hematuria, proteinuria, purpuric rash | |
| PAN | Arteriography, ↑ liver enzymes, livedo reticularis | |
| Parenchymal scar from pyelonephritis, VUR, HUS | DMSA scan; VCUG and history of UTIs; hemolysis, uremia, +/− diarrhea, AKI | |
| Reno-vascular | Renal vein thrombosisa | Hematuria, thrombocytopenia, flank mass |
| Renal artery stenosis | Abdominal bruit, angiogram, and renal vein sampling | |
| Fibromuscular dysplasia | ||
| Syndromes | ||
| Williams | Elfin facies, short stature, hypercalcemia, supravalvular aortic stenosis, “cocktail party” personality, CAKUT | |
| Turners | Webbed neck, widely spaced nipples, short stature, ovarian failure, cardiac malformation, CAKUT | |
| NF1 | Neurofibromas, café-au-lait spots, axillary freckling, Lisch nodules, optic gliomas, bone and CNS abnormalities | |
| Arteritis | ||
| Takayasu’s | Bruit, angiogram | |
| Kawasaki Moyamoya |
Conjunctival injection, strawberry tongue, erythema of the extremities, cervical lymphadenopathy, polymorphous rash, ↑ WBCs and platelets, ↑ liver enzymes, ↑ ESR, ↑ CRP TIA, stroke, epilepsy, EEG, head CT/MRI, angiogram | |
| Renal transplant artery stenosis | Bruit, angiogram | |
| Tumors compressing on renal vessels | Angiogram | |
| Endocrine | Catecholamine excess | |
| Pheochromocytoma/paraganglioma | Flushing, diaphoresis, tachycardia, abdominal mass | |
| Neuroblastoma Sympathomimetic drugs: phenylpropanolamine (decongestant), cocaine, amphetamine, phencyclidine, epinephrine, phenylephrine, terbutaline, monoamine oxidase-inhibitor with tyramine containing foods |
Tachycardia, abdominal mass, CT/MRI, ↑ urine and serum catecholamines, biopsy | |
| Corticosteroid excess | ||
| Cushing syndrome: | ||
| ACTH dependent | ||
| ACTH independent | ||
| Mineralocorticoid excess | Truncal obesity, moon facies, abdominal striae, hirsutism | |
| Congenital adrenal hyperplasia | ↑ ACTH; brain MRI | |
| Aldosterone-secreting tumors | ↓ ACTH; CT/MRI abdomen | |
| Thyroid disease Hyperthyroidism Hypothyroidism |
Ambiguous genitalia/virilization (girls), phallic enlargement/scrotal hyperpigmentation (boys); ↑ 17-hydroxyprogesterone (21-hydroxylase deficiency); hyponatremia, hyperkalemia, FTT (boys) ↑ Aldosterone, ↓ PRA, hypokalemia, metabolic alkalosis Nervousness, exophthalmos (Graves’ disease), muscle tremors, weight loss, heat intolerance, thinning skin/fine hair, frequent bowel movements; ↓ TSH, ↑ T4 |
|
| Hypercalcemia (primary or secondary to malignancy, hyperparathyroidism, vitamin D intoxication) | Fatigue, muscle cramps/weakness, weight gain, dry/coarse skin and thinning hair, cold intolerance, constipation; ↑TSH, ↓T4 | |
| Cardiac | Coarctation of the aortaa Mid aortic syndromea |
Radio-femoral delay of pulses, normal/low blood pressure in legs, heart murmur |
| Pulmonary | Obstructive sleep apnea | Snoring |
| Bronchopulmonary dysplasiaa | Supplemental oxygen requirement for >28 days in neonates (see ATS diagnostic criteria) | |
| Central nervous system | Elevated intracranial pressure Seizures |
Bradycardia |
| Medications | Steroids | Moon facies, abdominal striae |
| Immunosuppressants | ||
| Cyclosporine | Hypertriglyceridemia, hypertrichosis, gingival hyperplasia, hirsutism, headache, tremors, aphthous ulcers | |
| Tacrolimus | Hyperkalemia, hypomagnesemia, tremors, hyperglycemia | |
| Sirolimus | Impaired wound healing, dyslipidemia, myopathy, liver dysfunction | |
| Oral contraceptives Anesthetics: ketamine Erythropoietin |
||
| Monogenic HTN | Liddle’s syndrome | Hypokalemia, metabolic alkalosis, low PRA and aldosterone |
| Gordon’s syndrome (pseudohypoaldosteronism type II) | Hyperkalemia, low/low normal PRA and aldosterone | |
| Syndrome of apparent mineralocorticoid excess | Hypokalemia, metabolic alkalosis, low PRA and aldosterone, FTT, elevated ratio of urinary tetrahydrocortisol + allotetrahydrocortisol/tetrahydrocortisone, hypercalciuria | |
| Glucocorticoid remediable aldosteronism (aka familial hyperaldosteronism type I) | Hypokalemia, metabolic alkalosis, normal/high urinary aldosterone, 18-oxo-tetrahydrocortisol/tetrahydrocortisol >1 | |
| Miscellaneous | Post ECMOa | |
| Cyclical vomiting syndrome | Vomiting, hyponatremia, migraines | |
aCommon etiology of HTN in neonates and infants.
ACTH, adenocorticotrophic hormone; ANCA, antineutrophil cytoplasmic antibody; ATS, American thoracic society; CAKUT, congenital anomalies of the kidney and urinary tract; CRP, C-reactive protein; CT, computed tomography; ECMO, extra-corporeal membrane oxygenation; ESR, erythrocyte sedimentation rate; FTT, failure to thrive; HSP, henoch schonlein purpura; HUS, hemolytic uremic syndrome; MRI, magnetic resonance imaging; PAN, polyarteritis nodosa; PRA, plasma renin activity; SLE, systemic lupus erythematosus; TIA, transient ischemic attack; VUR, vesico-ureteral reflux; WBC, white blood cell.