associated with subclinical cardiovascular disease and adult-onset hypertension. In children with chronic kidney disease (CKD), hypertension is also a strong risk factor for progression to kidney failure. Despite these risks, current rates of pediatric BP screening, hypertension detection, treatment, and control remain suboptimal. Contributing to these shortcomings are the challenges of accurately measuring pediatric BP, limited access to validated pediatric equipment and hypertension specialists, complex interpretation of pediatric BP measurements, problematic normative BP data, and conflicting society guidelines for pediatric hypertension. To date, limited pediatric hypertension research has been conducted to help address these challenges. However, there are several promising signs in the field of pediatric hypertension. There is greater attention being drawn on the cardiovascular risks of pediatric hypertension, more emphasis on the need for childhood BP screening and management, new public health initiatives being implemented, and increasing research interest and funding. This article summarizes what is currently known about pediatric hypertension, the existing knowledge-practice gaps, and ongoing research aimed at improving future kidney and cardiovascular health. Kidney Int Rep (2022) 7, 954–970; https://doi.org/10.1016/j.ekir.2022.02.018 KEYWORDS: blood pressure; cardiovascular health; children; hypertension; kidney disease; pediatric ª 2022 International Society of Nephrology. Published by Elsevier Inc. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). Hypertension is one of the most common causes of preventable global disease and death.1–3 Global hypertension prevalence has doubled from 1990 to 2019, but less than half of the patients with hypertension are diagnosed and less than one-quarter are adequately controlled.2 Significant global disparities exist, with lower rates of hypertension diagnosis, treatment, and control in low- and middle-income countries.2,4 There is strong evidence that pediatric hypertension tracks into adulthood and is associated with premature cardiovascular and kidney diseases.5–12 Therefore, early detection and adequate management of pediatric hypertension should be prioritized. Hypertension Prevalence The prevalence of pediatric hypertension has increased in recent decades, contributed partly by rising childhood obesity.13,14 However, rates of pediatric hypertension depend on the definition used, which have changed over time and vary globally (Table 1).5,15,16,17 Without direct evidence linking specific BP thresholds to cardiovascular outcomes, pediatric hypertension is defined using normative distributions. Between 3% and 5% of children and adolescents have hypertension and 10% and 14% have elevated BP levels (“prehypertension”).13,14,18–20 In a global meta-analysis, the pooled prevalence of hypertension was 4.0% and Correspondence: Rahul Chanchlani, Division of Pediatric Nephrology, Department of Pediatrics, McMaster Children’s Hospital, 1280 Main Street West, Hamilton, Ontario L8N 3Z5, Canada. E-mail: chanchlr@mcmaster.ca Received 28 November 2021; revised 15 February 2022; accepted 21 February 2022; published online 1 March 2022 954 Kidney International Reports (2022) 7, 954–970 REVIEW prehypertension was 9.7%.14 Hypertension prevalence increased from 1.3% (1990–1999) to 6.0% (2010–2014). State of Pediatric Hypertension Care Despite the high prevalence, pediatric hypertension care remains suboptimal (Figure 1). There are conflicting recommendations on pediatric BP screening. Although the most recent guidelines of the American Academy of Pediatrics, European Society of Hypertension, and Hypertension Canada recommend yearly BP screening for healthy children $ 3 years old (Table 1),5,15,21 both the United States Preventative Services Taskforce and the United Kingdom National Screening Committee do not recommend screening.22,23 In theory, a good screening test should be safe, inexpensive, widely available, and able to detect preclinical disease with effective treatment.2 All of these characteristics apply to pediatric office-based BP measurement. Pediatric BP screening may also help detect hypertension comorbidities and causes of secondary hypertension. BP screening and follow-up are incomplete. In 2 Canadian studies of 9667 and 378,002 children, respectively, only 15% to 33% of children had annual BP measurement.19,24 Only 5% to 56% of children have appropriate follow-up after elevated BP level measurement.19,24–27 Less than 25% of children with hypertension are accurately diagnosed, less than half receive lifestyle counseling, and only 6% are prescribed antihypertensive medication.19,25,26,28–30 Clear challenges and knowledge-practice gaps exist in pediatric hypertension care (Figure 1). Determinants of Pediatric Hypertension The cause of increasing pediatric hypertension is multifactorial. Primary hypertension accounts for 50% to 90% of cases and is more common in older children and adolescents.31–33 However, secondary causes should be excluded after hypertension diagnosis, particularly in treatment-resistant and young