RENAL DATA FROM ASIA-AFRICA
|Year : 2013 | Volume
| Issue : 4 | Page : 844-852
|Clinical analysis of hypertension in children: An urban Indian study
Sunil K Kota1, Siva K Kota2, Lalit K Meher3, Jammula Sruti4, Gayatri Kotni5, Sandip Panda6, Prabhas R Tripathy7, Kirtikumar Modi1
1 Department of Endocrinology, Medwin Hospital, Hyderabad, Andhra Pradesh, India
2 Department of Anesthesia, Central Security Hospital, Riyadh, Saudi Arabia
3 Department of Medicine, MKCG Medical College, Berhampur, Orissa, India
4 Department of Pharmaceutics, Roland Institute of Pharmaceutical Sciences, Berhampur, Orissa, India
5 Department of Obstetrics and Gynecology, Riyadh Care Hospital, Riyadh, Saudi Arabia
6 Department of Cardiology, JIPMER, Puducherry, India
7 Department of Anatomy, Kalinga Institute of Medical Sciences, Bhubaneswar, Orissa, India
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|Date of Web Publication||24-Jun-2013|
| Abstract|| |
Hypertension in children, although an uncommon entity, is associated with end-organ damage. We tried to study the clinical profile of hypertension in children presented to our hospital. The medical records from January 1990 to December 2010 of all children aged 18 years and younger with hypertension were studied. The patients were divided into four age groups (infants, pre-school age, school age and adolescents) Presenting symptoms and other clinical parameters were thoroughly evaluated. The results were compared with previous studies on hypertension in children. A total of 135 patients were selected (male:female 103:32), with mean age of 0.4 ± 2.1 years (range: six months to 17 years). The most common age group affected was the adolescents group (42.9%). The most common clinical feature at presentation was dizziness (30.3%), followed by headache and chest discomfort (22.9%). Transient hypertension was detected in 34 patients (25.2%), and was most common in the adolescent age group, whereas sustained hypertension was noticed in 101 patients (74.8%) and was the most common in the school age group (36/45, 80%). Forty-two patients (31.1%) presented with hypertensive crisis. Nine patients were considered to have essential hypertension. The chief causes included chronic glomerulonephritis in 56 (41.5%), endocrine disorders in 21 (15.5%), obstructive uropathy in 16 (11.8%), reflux nephropathy in 12 (8.8%) and renovascular disease in 5 (3.7%). Takayasu's disease was the most common cause of renovascular hypertension. Coarctation of aorta was the most common cause of hypertension in infancy, being present in 40% of the cases. Hypertension in children may be easily underestimated but is a potentially life-threatening problem. Most of them are asymptomatic and a large chunk has an underlying etiology. Primary care clinicians should promptly identify patients with hypertension and treat them immediately and appropriately to prevent damage to the cardiovascular organs.
|How to cite this article:|
Kota SK, Kota SK, Meher LK, Sruti J, Kotni G, Panda S, Tripathy PR, Modi K. Clinical analysis of hypertension in children: An urban Indian study. Saudi J Kidney Dis Transpl 2013;24:844-52
|How to cite this URL:|
Kota SK, Kota SK, Meher LK, Sruti J, Kotni G, Panda S, Tripathy PR, Modi K. Clinical analysis of hypertension in children: An urban Indian study. Saudi J Kidney Dis Transpl [serial online] 2013 [cited 2020 Jun 2];24:844-52. Available from: http://www.sjkdt.org/text.asp?2013/24/4/844/113919
| Introduction|| |
Hypertension in children is a relatively rare disease. The incidence of hypertension in children is gradually increasing with prevalence of obesity, salt intake and dyslipidemia.  Childhood hypertension is a risk factor for early cardiovascular morbidity and mortality  along with other end-organ damage and hypertensive encephalopathy. In a majority of children, hypertension accompanies an underlying disorder. However, hypertension may manifest for the first time without obvious features of a renal or cardiovascular disorder.
The common causes of hypertension in childhood include chronic glomerulonephritis (GN), reflux nephropathy and obstructive uropathy. ,, The etiologies vary with different age groups. Most hypertensive children over the age of six years suffer from primary hypertension; in those with hypertension over the age of 15 years, 90% suffer from primary hypertension. , Essential hypertension is being increasingly recognized among school going children in India. , Hypertension in these cases is usually mild and most children are asymptomatic. Also, data on the causes of hypertension in Indian children is low. We hereby retrospectively studied the demography, etiology and clinical manifestations of hypertension in 135 patients at a tertiary care center in south India.
| Patients and Methods|| |
All the children <18 years presenting to our hospital from January 1990 to December 2010 with a diagnosis of hypertension were retrospectively analyzed. Patients were categorized as per their age of presentation, infant (<1 year old), pre-school age (≥1-6 years old), school age (>6-12 years old) and adolescent (>12-18 years old).
Blood pressure measurement
All children above three years old were subjected to blood pressure (BP) measurement. For bedridden infants and infants who could not sit, BP was checked while they were in a seated position with their back supported, feet placed on the floor, right arm supported and cubital fossa at the level of the heart. An appropriate cuff size was used with an inflatable bladder width that was at least 40% of the arm circumference at a point midway between the olecranon and the acromion. The cuff bladder length covered 80-100% of the circumference of the arm. If the systolic blood pressure (SBP) or diastolic blood pressure (DBP) was high, it was re-measured at the other limbs. Ambulatory BP monitoring was used to measure the BP every hour in 37 patients who presented with unstable BP requiring close observation.
Hypertension in children more than 12 months old was defined according to the BP standards based on sex, age and height as stipulated in the updated classification of hypertension by the National Blood Pressure Education Program Working Group on Hypertension in Children and Adolescents. , Hypertension was identified as SBP or DBP greater than or equal to the 95 th percentile; stage-1 hypertension was an SBP or DBP within the range of the 95 th percentile to the 99 th percentile plus 5 mmHg; stage-2 hypertension was SBP or DBP greater than the 99 th percentile plus 5 mmHg. For patients younger than 12 months old, hypertension was defined as SBP or DBP greater than the 95 th percentile for infants of similar age, size and sex. Hypertension was defined as transient when the BP was higher than the 95 th percentile only once or twice, but returned to less than the 95 th percentile on the second or third measurement without the use of antihypertensive medication. Sustained hypertension was defined as SBP or DBP above the 95 th percentile for height by age and sex that persisted for at least four weeks. 
Clinical and laboratory evaluation of the patients
The patients were subjected to evaluation of clinical parameters like age, sex, weight, height, body mass index (BMI), clinical features at presentation, family history of hypertension and BP. All patients initially underwent urinalysis and culture, complete blood counts and blood levels of sodium, potassium, urea, creatinine, calcium and phosphorus. Chest roentgenogram, electrocardiogram and abdominal ultrasound were obtained in all cases. Echocardiogram, urinary catecholamine levels, nuclear or radiocontrast voiding cystourethrogram (VCUG), intravenous pyelogram (IVP), 99mTc-diethylenetriamine pentaacetic acid (DTPA) renal scans, percutaneous renal biopsy, digital subtraction angiography and aortography were performed whenever indicated. Essential hypertension was diagnosed only if a detailed evaluation did not show an identifiable etiology.
Analysis of the whole data was performed pertinent to demographic and etiologic variables. The study results were compared with previously published studies on childhood hypertension.
| Results|| |
Of the 12,650 patients' records, both outpatient and inpatient during the study period, 135 (1.06%) [male:female 103:32 (3.2:1)] patients had hypertension. The mean age of the study group was 8.4 ± 2.1 years (range: six months to 17 years). The number of patients under the different age groups was: infant - 5, pre-school - 27, school - 45 and adolescent - 58.
Transient hypertension was detected in 34 patients (25.2%), and was the most common in the adolescent age group (19/58, 32.7%). The mean age group was 9.8 ± 2.9 years. The common causes included acute GN, corticosteroid toxicity and encephalopathy with raised intracranial hypertension. Other causes included emotional, painful or uncomfortable events. 
Sustained hypertension was noticed in 101 patients (74.8%), and was most common in the school age group (36/45, 80%). The mean age group was 8.3 ± 2.2 years, with a male:female ratio of 89:12. Majority of the cases (110, 81.5%) presented with stage-2 hypertension, with highest prevalence in the school age children. Stage-1 hypertension was maximally seen in the adolescent age group patients. [Table 1] depicts the comparison between the transient and the sustained hypertension group patients.
Forty-two patients (31.1%) presented with hypertensive crisis. Twenty-one patients had hypertensive emergency defined as hypertension in combination with acute or ongoing target-organ lesions, or hypertension associated with an immediate life-threatening event requiring immediate intervention to reduce BP; 15 patients had hypertensive crisis defined as an elevation in DBP higher than 120 mmHg with no evidence of target-organ lesion; ,, and six patients had hypertensive encephalopathy defined as severe hypertension in conjunction with symptoms such as headache, altered mental status, seizure or visual disturbances and the presence of reversible posterior abnormalities on T2-weighted brain magnetic resonance images.  Endocrine disorders were more likely to induce hypertensive crisis.
Demographic variables [Table 2]
Overall, the most common age group affected was the adolescent group (58/135, 42.9%). Most males were in the adolescent age group, while most females were in the pre-school age group. The most common clinical feature at presentation was dizziness (30.3%), followed by headache and chest discomfort (22.9%). According to age groups, nausea and vomiting was the most common presentation in infants (60%); nausea and vomiting, chest discomfort and altered sensorium (11.1% each) was the most common presentation in the pre-school age group; and dizziness was the most common presentation in both the school (40%) and the adolescent (34.5%) age groups.
A family history was elicited in 36 (26.6%) cases. The adolescents were most commonly found to have a family history. Twenty-four patients presented with congestive heart failure (17.7%), most commonly in the pre-school age group was affected. Visual symptoms were noticed in seven cases, and the school age children were the worst sufferers. Encephalopathy was observed in nine cases, the most common age group affected being the pre-school age group.
Etiologic variables [Table 3]
Hypertension was associated with an underlying cause in 126 patients (93.3%), whereas it was essential in nine cases. Overall, the most common cause was intrinsic renal disease. However, the most common cause of hypertension in the infant group was coarctation of aorta, found in two of five (40%) patients. All the other three age groups were found to have intrinsic renal disease as the most common cause of hypertension.
- Intrinsic renal diseases: A total of 99 patients (73.3%) had intrinsic renal disease as the cause of hypertension. The male:female ratio was 78:21.
- Glomerulonephritis (GN): Overall, 56 patients had GN. The mean age at presentation was 6.8 ± 2.9 years. The most common clinical presentations were edema (44 cases), microscopic hematuria (30 cases), nephritic syndrome (26 cases) and azotemia (ten cases). The renal biopsy results of 80 patients were available and the pathologic lesions were found to be membranoproliferative GN in 22 cases (27.5%), focal segmental glomerulosclerosis in 17 cases (21.2%) and crescentic GN in 11 cases (13.8%).
- Obstructive uropathies: A total of 16 patients had obstructive uropathies. The pre-school age group was the most commonly affected. The most common abnormality was posterior urethral valve in 12 cases. Other causes included renal calculi, vesico ureteric junction obstruction, neurogenic bladder and urethral stricture, with a prevalence of one case each.
- Reflux nephropathies: Twelve patients had reflux nephropathies. School age children were mostly affected. Most common lesion was vesicoureteric reflux in ten patients, which was bilateral in all cases. Six patients had recurrent urinary tract infection. The most common manifestation was oliguria and anasarca, and this was seen in ten patients.
- Thrombotic microangiopathies: Seven patients had thrombotic microangiopathies, and adolescents were the most commonly affected age group. The patients presented with gradual-onset oliguria, anemia, variable thrombocytopenia, hypertension and severe azotemia. There was a history of preceding diarrheal illness in two patients. Renal biopsy confirmed thrombotic microangiopathy with variable glomerular involvement.
- Renovascular causes: A total of five patients had renovascular pathologies as the etiology for hypertension and the most common age group affected was the adolescents age group. Takayasu's arteritis was found in four patients and two patients had isolated renal artery stenosis. The patients with Takayasu's disease had palpitation, dyspnea with limb claudication in two patients and asymmetric pulses in four patients. Angiogram revealed involvement of the abdominal aorta in four patients, renal artery stenosis in three and aortic arch involvement in two patients. f) Others: Two adolescents had nephronophthisis and one infant had hypoplastic kidney.
- Endocrine diseases: Twenty-one patients (15.5%) had hypertension attributable to endocrine causes. The most common age group affected was the adolescent age group, with a male:female ratio of 14:7. The lesions found were pheochromocytoma in 17 cases, paragangliomas in two cases and adrenal adenoma and carcinoma (one case each).
- Cardiovascular diseases: Coarctation of aorta was found in five cases. Majority of them were school age children with a male: female ratio of 3:2. Three patients presented with congestive heart failure. The associated vascular abnormalities were bicuspid aortic valve in three cases, ventricular septal defect in two cases and patent ductus arteriosus in one case.
- Central nervous system diseases: In one infant, encephalopathy with epilepsy was associated with transient hypertension.
- Essential hypertension: Despite applying all the investigational modalities at disposal, no underlying cause could be identified in nine patients. Majority of them were school age children with a male:female ratio of 7:2. They were classified as essential hypertension.
| Discussion|| |
In adults with hypertension, the essential variety accounts for 2-10% of the cases and the secondary variety accounts for 5-10% of the cases.  But, in children, hypertension is most often secondary. Wide variations in BP  and non-specific symptomatology are responsible for underdetection of hypertension in children. In a study of healthy school going children from north India, the prevalence of hypertension was 11.7%.  A secondary cause was found in 4.1% of the hypertensive children and the rest were considered to have primary hypertension. An Indian study  has demonstrated a prevalence of 1.1% for sustained hypertension. In our study, the combined prevalence of transient and sustained hypertension was 1.06%.
We examined the etiology of sustained hypertension in 135 children. An underlying cause was found in 93.3% of the patients. Renal parenchymal disease was most common among all age groups (73.3%) except infancy, when coarctation of aorta was seen in 40% of the patients. The principal renal disorders were GN, obstructive uropathy and reflux nephropathy. Our observations are comparable to those from other groups. ,,,, Two Indian studies have demonstrated intrinsic renal parenchymal disease as the most common etiology of chronic persistent hypertension. , Chronic GN is the most common cause of sustained hypertension [Table 4]. Reflux nephropathy has also emerged as a frequent cause of pediatric hypertension in children, accounting for 16-33% of the cases. ,,,,, In our study group, GN accounted for 41.4% and reflux nephropathy for 8.9% of the cases.
|Table 4: Comparison of different studies with regard to the etiology of hypertension.|
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Contrary to earlier view,  in a recent study,  younger hypertensive children were found to have more severe symptoms including endorgan damage and altered mental status. Only half of the patients with hypertensive crisis had underlying causes, and only 16% of these had a family history of hypertension. This led to the suggestion that BP should be measured in younger children with acute, non-specific problems. Similarly, in our study, majority of the patients were asymptomatic or presenting with non-specific complaints but with an evident family history in 26.6% cases.
In our study, among patients with stage-2 hypertension, 42 presented with DBP greater than 120 mmHg, and six of these patients developed hypertensive encephalopathy. In another study among patients with stage-2 hypertension, 12 patients presented with DBP greater than 120 mmHg, and three (25%) of these patients developed hypertensive encephalopathy.  This calls for awareness on the part of primary clinicians to pay more attention toward patients presenting with stage-2 hypertension and initiate treatment early.
Renal artery stenosis and thrombosis result in renovascular hypertension. , In the present study, however, the most common cause of reno-vascular disease was Takayasu's disease, which is similar to that reported in another Indian study.  The arteritis is of undetermined etiology involving the aorta and the proximal portion of its major branches, the thoraco-abdominal aorta being the most common site. One or both renal arteries may be affected in more than two-thirds of the patients, with tubercular etiology elucidated in 50% of the cases.  Absent or feeble peripheral pulses are typically present and the diagnosis is confirmed on arteriography. Hemolytic uremic syndrome is characterized by occlusive thrombotic micro-angiopathy of interlobular arteries and arterioles on renal biopsy. The disorder manifests with azotemia, severe hypertension, heavy proteinuria and edema resembling rapidly progressive GN. Renal biopsy establishes the diagnosis. Two of our patients had diarrheal illness preceding the onset of hemolytic uremic syndrome. Unlike previous study results, , we found a higher prevalence of endocrine-related etiologies for our group of patients, with majority of them presenting with hypertensive crisis. The incidence of essential hypertension is also high (6.7% vs 1.6%), and this may be attribute to the higher prevalence of obesity with adverse lifestyle practices. Similar to another study,  all the patients with hypertensive crisis in our study nearly met the criteria for stage-2 hypertension. , It was suggested that the upper BP limit should be set at the 99 th percentile level plus 5 mmHg. 
The age of onset of hypertension was correlated with the etiology of hypertension. The most common etiology in the infant group was coarctation of aorta, found in two of five (40%) patients. All the other three age groups were found to have intrinsic renal disease as the most common cause of hypertension. Central nervous system or neurologic disorder was the cause for hypertension in one infant only. The incidence of hypertension caused by cardiovascular disease seemed to decrease with age. Therefore, clinicians should try to identify the underlying causes to manage hypertension in children, particularly in children at or younger than six years of age. Endocrine disorders, renal diseases and essential hypertension played major roles in patients with hypertensive crisis. The prevalence of essential hypertension was increasing with age. The results were similar to those of other studies. , The most common clinical feature at presentation was dizziness (30.3%), followed by headache and chest discomfort (22.9%). According to age groups, nausea and vomiting was the most common presentation in infants (60%); nausea and vomiting, chest discomfort and altered sensorium (11.1% each) were the most common presentations in the pre-school age group; and dizziness was the most common presentation in both the school (40%) and the adolescent (34.5%) age groups. A previous study  has reported that in children of pre-school age, nausea/vomiting followed by headache were the most common symptoms, while dizziness and headache comprised the majority of clinical symptoms in children greater than six years of age. Abdominal pain was the most common clinically presented symptom associated with transient hypertension in all age groups in our study, similar to the results from a previous study. 
The incidence of essential hypertension in children varies from 1% to 45% in various hospital-based studies from developed countries. ,,, Arar et al  found primary hypertension in 30 (22.7%) cases. Hypertension in these patients is usually mild. An infrequent diagnosis of essential hypertension in the present study could be due to selective referral of symptomatic and severe hypertension to the hospital. Screening studies for essential hypertension in school going children in India show a prevalence of 0.46-11.7%. ,, In another study,  untreated primary hypertension was the main etiology of hypertension (65.3%) and hypertensive crisis (45.5%); primary hypertension rarely resulted in hypertensive emergency, and no cases contributed to hypertensive encephalopathy. This reflects primary hypertension as a relatively benign cause of hypertension. In addition, changes in consciousness and endorgan damage were more prevalent in infants and pre-school-aged children than in older children. The limitations of our study are: (1) small sample size, (2) study population from a single hospital might not be representative of the whole population; and (3) absence of treatment and proper follow-up data. However, we still consider that preliminary observations from our study would pave the way for further large-scale, multicenter prospective studies involving a larger number of patients reflecting the general populace with long follow-up periods.
Pediatric hypertension may be an underestimated entity, with most affected children found to be having underlying etiologies. Most patients are asymptomatic and detected incidentally upon evaluation of associated morbidities. All children with hypertension should undergo screening studies, which would guide toward definitive investigation to establish the underlying etiology as per prevalence of hypertension across all age groups. Appropriate treatment is mandatory to prevent uncontrolled hypertension-induced end-organ damage and cardiovascular morbidity.
| Acknowledgments|| |
All the authors would like to express their heartfelt thanks to Dr. Jagadeesh Tangudu, M Tech, MS, PhD and Sowmya Jammula, M Tech for their immense and selfless contribution toward manuscript preparation, language editing and final approval of text.
| References|| |
|1.||Wu YT, Chen YH, Lue HC, Chen CH. Relationship between the levels of blood pressure and the age, body mass in school children. Acta Cardiol Sin 1986;2:95-101. |
|2.||Pan WH, Chen JW, Fann C, Jou YS, Wu SY. Genetic epidemiology study of young-onset hypertension in Taiwan. Hum Genet 2000; 107:210-5. |
|3.||Wyszynska T, Cichocka E, Wieteska-Kimczak A, Januszewicz P. A single pediatric center experience with 1025 children with hypertension. Acta Paediatr 1992;81:244-6. |
|4.||Gill DG, Mendis da Costa B, Cameron JD, Joseph MC, Ogg CS, Chantler C. Analyses of 100 children with severe and persistent hypertension. Arch Dis Child 1976;51:951-6. |
|5.||Arar MY, Hogg RJ, Arant Jr BS, Seikaly MG. Etiology of sustained hypertension in children in the southwestern United States. Pediatr Nephrol 1994;8:186-9. |
|6.||Flynn JT. Evaluation and management of hypertension in childhood. Prog Pediatr Cardiol 2001;12:177-88. |
|7.||Seeman T, Dusek J, Vondrichová H, et al. Ambulatory blood pressure correlates with renal volume and number of renal cysts in children with autosomal dominant polycystic kidney disease. Blood Press Monit 2003;8:107-10. |
|8.||Anand NK, Tandon L. Prevalence of hypertension in school going children. Indian Pediatr 1996;33:377-81. |
|9.||Chadha SL, Tandon R, Shekhawat S, Gopinath N. An epidemiological study of blood pressure in school children (5_14 years) in Delhi. Indian Heart J 1999;51:178-82. |
|10.||National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 2004;114(2 Suppl 4th Report):555-76. |
|11.||Reich A, Muller G, Gelbrich G, Deutscher K, Godicke R, Kiess W. Obesity and blood pressure: Results from the examination of 2365 schoolchildren in Germany. Int J Obes Relat Metab Disord 2003;27:1459-64. |
|12.||Update on the 1987 Task Force Report on Blood Pressure in Children and Adolescents: A Working Group Report From the National High Blood Pressure Education Program. Pediatrics 1996;98:649-58. |
|13.||Martin JF, Higashiama E, Garcia E, Luizon MR, Cipullo JP. Hypertensive crisis profile: Prevalence and clinical presentation. Arq Bras Cardiol 2004;83:131-6. |
|14.||Patel HP, Mitsnefes M. Advances in the pathogenesis and management of hypertensive crisis. Curr Opin Pediatr 2005;17:210-4. |
|15.||Norwood VF. Hypertension. Pediatr Rev 2002; 23:197-208. |
|16.||Pavlakis SG, Frank Y, Chusid R. Hypertensive encephalopathy, reversible occipitoparietal encephalopathy, or reversible posterior leukoencephalopathy: Three names for an old syndrome. J Child Neurol 1999;14:277-81. |
|17.||Chobanian AV, Bakris GL, Black HR, et al. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension 2003;42:1206-52. |
|18.||Belsha CW. Pediatric hypertension in the emergency department. Ann Emerg Med 2008; 51:S21-3. |
|19.||Hari P, Bagga A, Srivastava N. Sustained Hypertension in children. Indian Pediatr 2000; 37:268-74. |
|20.||Uhari M, Koskimies O. A survey of 164 Finnish children and adolescents with hypertension. Acta Pediatr Scand 1979;68:193-8. |
|21.||Still JL, Cottom D. Severe hypertension in childhood. Arch Dis Child 1967;42:34-42. |
|22.||Khalil A, Singh TP, Arora R, Puri RK. Pediatric hypertension: Clinical profile and etiology. Indian Pediatr 1991;28:141-6. |
|23.||Stewart JN, McGillivary D, Sussman J, Foster B. The value of routine blood pressure measurement in children presenting to the emergency department with non-urgent problems. J Pediatr 2008;153:478-83. |
|24.||Yang WC, Wu HP. Clinical Analysis of Hypertension in Children Admitted to the Emergency Department. Pediatr Neonatol 2010;51:44-51. |
|25.||Srivastava S, Srivastava RN, Tandon R. Idiopathic obstructive aortoarteritis in children. Indian Pediatr 1986;23:403-10. |
|26.||Bhuyan UN, Bagga A, Srivastava RN. Acute renal failure and severe hypertension in children with renal thrombotic microangiopathy. Nephron 1994;66:302-6. |
|27.||Verma M, Chhatwal J, George SM. Obesity and hypertension. Indian Pediatr 1994;31:1065-74. |
Sunil K Kota
Department of Endocrinology, Medwin Hospital, Chiragh Ali Lane, Nampally, Hyderabad - 500 001, Andhra Pradesh
[Table 1], [Table 2], [Table 3], [Table 4]
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