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Prospective Study of Modifiable Risk Factors of Arterial Hypertension and Left Ventricular Hypertrophy in Pediatric
Dagmara Borzych-Dużałka1, Rukshana Shroff2, Bruno Ranchin3
1Department for Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland.
Insights
Fluid overload in pediatric dialysis patients causes high blood pressure and left ventricular hypertrophy. Hemodiafiltration (HDF) may improve outcomes compared to hemodialysis (HD), alongside better anemia and interdialytic weight gain control.
Area of Science:
- Pediatric Nephrology
- Cardiovascular Health in Dialysis Patients
- Hypertension Management
Background:
- Fluid and salt overload are significant issues for patients on dialysis, leading to hypertension, left ventricular hypertrophy (LVH), and hemodynamic instability.
- These complications contribute to increased cardiovascular morbidity in dialysis populations.
Purpose of the Study:
- To analyze the prevalence of uncontrolled hypertension and left ventricular hypertrophy (LVH) in pediatric patients undergoing maintenance hemodialysis/hemodiafiltration (HD/HDF).
- To identify risk factors associated with hypertension and LVH in this population.
- To compare the outcomes between HD and HDF modalities.
Main Methods:
- A prospective analysis of 910 pediatric patients on maintenance HD/HDF, with 2758 observations recorded every 6 months.
- Data collected included blood pressure (BP), interdialytic weight gain (IDWG), urine output, dialysate sodium (dNa), hemoglobin levels, and echocardiographic findings for LVH assessment.
- Statistical analysis included odds ratios (OR) to determine associations between variables.
Main Results:
- Uncontrolled hypertension was observed in 55% of patient observations, with 27% having persistently elevated predialysis BP.
- Systolic and diastolic BP-SDS were independently associated with antihypertensive medication use and IDWG.
- Left ventricular hypertrophy (LVH) was present in 51% of echocardiograms. Hemodialysis (HD) modality was an independent risk factor for elevated MAP-SDS and LVH progression compared to hemodiafiltration (HDF).
- Interdialytic weight gain (IDWG) was linked to urine output and dialysate sodium (dNa).
Conclusions:
- Uncontrolled hypertension and LVH are prevalent in pediatric HD patients despite treatment.
- Hemodiafiltration (HDF) may offer improved outcomes compared to hemodialysis (HD).
- Optimizing anemia management and interdialytic weight gain (IDWG) control, potentially by lowering dialysate sodium (dNa), could improve patient outcomes without increasing intradialytic hypotension (IDH).
Introduction:
Fluid and salt overload in patients on dialysis result in high blood pressure (BP), left ventricular hypertrophy (LVH) and hemodynamic instability, resulting in cardiovascular morbidity.
Methods:
Analysis of 910 pediatric patients on maintenance hemodialysis/hemodiafiltration (HD/HDF), prospectively followed-up with 2758 observations recorded every 6-months in the International Pediatric Hemodialysis Network (IPHN).
Results:
Uncontrolled hypertension was present in 55% of observations, with 27% of patients exhibiting persistently elevated predialysis BP. Systolic and diastolic age- and height-standardized BP (BP-SDS) were independently associated with the number of antihypertensive medications (odds ratio [OR] = 1.47, 95% confidence interval 1.39-1.56, 1.36 [1.23-1.36]) and interdialytic weight gain (IDWG; 1.19 [1.14-1.22], 1.09 [1.06-1.11]; all P < 0.0001). IDWG was related to urine output (OR = 0.27 [0.23-0.32]) and dialysate sodium (dNa; 1.06 [1.01-1.10]; all P < 0.0001). The prevalence of masked hypertension was 24%, and HD versus HDF use was an independent risk factor of elevated age- and height-standardized mean arterial pressure (MAP-SDS) (OR = 2.28 [1.18-4.41], P = 0.01). Of the 1135 echocardiograms, 51% demonstrated LVH. Modifiable risk factors included predialysis systolic BP-SDS (OR = 1.06 [1.04-1.09], P < 0.0001), blood hemoglobin (0.97 [0.95-0.99], P = 0.004), HD versus HDF modality (1.09 [1.02-1.18], P = 0.01), and IDWG (1.02 [1.02-1.03], P = 0.04). In addition, HD modality increased the risk of LVH progression (OR = 1.23 [1.03-1.48], P = 0.02). Intradialytic hypotension (IDH) was prevalent in patients progressing to LVH and independently associated with predialysis BP-SDS below 25th percentile, lower number of antihypertensives, HD versus HDF modality, ultrafiltration (UF) rate, and urine output, but not with dNa.
Conclusion:
Uncontrolled hypertension and LVH are common in pediatric HD, despite intense pharmacologic therapy. The outcome may improve with use of HDF, and superior anemia and IDWG control; the latter via lowering dNa, without increasing the risk of IDH.
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