ABSTRACT Renal artery variations are recognized as potential contributors to hypertension through altered renal perfusion and activation of renin–angiotensin system. However, their clinical and hemodynamic significance in children remains unclear. This retrospective study included 14 pediatric patients (0–18 years) with hypertension and renal artery variations. Demographic, laboratory, echocardiographic and ambulatory blood pressure monitoring (ABPM) data were analyzed at baseline and follow‐up. Patients were stratified according to serum renin levels (elevated vs. normal). Accessory renal arteries and early branching were identified in 78.4% and 42.8% of patients, respectively. At baseline, 38.4% of patients had left ventricular hypertrophy and most exhibited nocturnal hypertension with impaired dipping patterns. Although daytime, nighttime blood pressure (BP) SDS values tended to decrease during follow‐up; 24‐h, daytime, nighttime systolic, diastolic BP and mean arterial pressure values did not change significantly in either group. Patients with elevated renin levels showed persistently higher nocturnal BP‐SDS values and more pronounced non‐dipping patterns. In the high‐renin group, left ventricle relative wall thickness (RWT) decreased significantly from 0.41(0.36–0.43)–0.31(0.27–0.35) ( p = 0.03), whereas left ventricular mass index (LVMI) remained unchanged [33(30–40] vs. 37(34–45) g/m 2 · 7 , p = 0.56]. In the normal‐renin group, LVMI showed nonsignificant tendency to decrease [34(32–55) vs. 30(29–51) g/m 2 · 7 , p = 0.06], while the reduction in RWT did not reach statistical significance ( p = 0.12). Renal artery variations in children should not be considered purely anatomical findings. Persistent nocturnal hypertension and impaired dipping patterns, particularly in patients with elevated renin levels, may contribute to ongoing target organ damage. Although ABPM parameters remained largely unchanged during follow‐up, cardiac remodeling showed distinct patterns according to renin status.
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