Prospective Study of Modifiable Risk Factors of Arterial Hypertension and Left Ventricular Hypertrophy in Pediatric Patients on Hemodialysis

Dagmara Borzych-Dużałka; Rukshana Shroff; Bruno Ranchin; Yihui Zhai; Fabio Paglialonga; Jameela A Kari; Yo H Ahn; Hazem S Awad; Reyner Loza; Nakysa Hooman; Robin Ericson; Dorota Drożdz; Amrit Kaur; Sevcan A Bakkaloglu; Charlotte Samaille; Marsha Lee; Stephanie Tellier; Julia Thumfart; Marc Fila; Bradley A Warady; Franz Schaefer; Claus P Schmitt

doi:10.1016/j.ekir.2024.03.016

Prospective Study of Modifiable Risk Factors of Arterial Hypertension and Left Ventricular Hypertrophy in Pediatric Patients on Hemodialysis

Kidney Int Rep. 2024 Mar 18;9(6):1694-1704. doi: 10.1016/j.ekir.2024.03.016. eCollection 2024 Jun.

Authors

Dagmara Borzych-Dużałka¹, Rukshana Shroff², Bruno Ranchin³, Yihui Zhai⁴, Fabio Paglialonga⁵, Jameela A Kari⁶, Yo H Ahn⁷, Hazem S Awad⁸, Reyner Loza⁹, Nakysa Hooman¹⁰, Robin Ericson¹¹, Dorota Drożdz¹², Amrit Kaur¹³, Sevcan A Bakkaloglu¹⁴, Charlotte Samaille¹⁵, Marsha Lee¹⁶, Stephanie Tellier¹⁷, Julia Thumfart¹⁸, Marc Fila¹⁹, Bradley A Warady²⁰, Franz Schaefer²¹, Claus P Schmitt²¹

Affiliations

¹ Department for Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland.
² UCL Great Ormond Street Hospital and Institute of Child Health, London, UK.
³ Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France.
⁴ Children's Hospital of Fudan University, Shanghai, China.
⁵ Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
⁶ King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia.
⁷ Department of Pediatrics, Seoul National University Children's Hospital, Seoul National University College of Medicine, Republic of Korea.
⁸ Aljalila Children's Specialty Hospital, Department of Pediatric Nephrology, Dubai, United Arab Emirates.
⁹ Cayetano Heredia Hospital, Lima, Peru.
¹⁰ Iran University of Medical Sciences, Tehran, Iran.
¹¹ Starship Children's Hospital, Auckland, New Zealand.
¹² Jagellonian University Medical College, Kraków, Poland.
¹³ Royal Manchester Children's Hospital, Manchester, UK.
¹⁴ Gazi University Hospital, Ankara, Turkey.
¹⁵ Hôpital Jeanne de Flandre, Lille, France.
¹⁶ The University of California, San Francisco, California, USA.
¹⁷ Dialyse Pediatricue CHU, Toulouse, France.
¹⁸ Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité Universitätsmedizin Berlin, Germany.
¹⁹ Department of Pediatric Nephrology, CHU de Montpellier, Montpellier, France.
²⁰ Children's Mercy Kansas City, Kansas City, Missouri, USA.
²¹ Centre for Pediatric and Adolescent Medicine, University of Heidelberg, Germany.

Abstract

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.

Keywords: blood pressure; hemodialysis; left ventricular hypertrophy.