Modifiable Cardiovascular Risk Factors in Pediatric Patients on Hemodialysis

Individuals with chronic kidney disease have a high risk of cardiovascular disease (CVD) morbidity and mortality; CVD is the leading cause of death for patients receiving dialysis. To learn more about the impact of potentially modifiable risk factors of hypertension and left ventricular hypertrophy (LVH) in patients on dialysis, a team of researchers led by Dagmara Borzych-Dużałka conducted a study of the largest pediatric patient cohort on maintenance hemodialysis (HD) to date. Their results were published in KI Reports.

There were 910 patients included in the analysis; all were receiving HD or hemodiafiltration (HDF). Patient demographics, underlying kidney disease, clinical data, and information regarding vascular access were recorded at enrollment. Data were recorded in the International Pediatric Hemodialysis Network (IPHN), including 2758 follow-up observations recorded every 6 months. Median patient age was 13.5 years (interquartile range, 9.3-16.2), and 507 (55%) participants were male.

Uncontrolled hypertension was found in 55% of observations; 27% of patients had continually elevated predialysis blood pressure (BP). Systolic and diastolic age- and height-standardized BP (BP-SDS) were independently associated with the number of antihypertensive medications used (odds ratio [OR], 1.47; 95% CI, 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<.0001). IDWG was related to urine production (OR, 0.27 [0.23-0.32]) and dialysate sodium (1.06 [1.01-1.10]; all P<.0001). Masked hypertension occurred among 24% of patients. Having HD versus HDF was an independent risk factor of elevated age- and height-standardized mean arterial pressure (OR, 2.28 [1.18-4.41]; P=.01).

Among 1135 echocardiograms recorded, 51% showed LVH. Modifiable risk factors included HD versus HDF (1.09 [1.02-1.18]; P=.01), predialysis systolic BP-SDS (OR, 1.06 [1.04-1.09]; P<.0001), blood hemoglobin (0.97 [0.95-0.99]; P=.004), and IDWG (1.02 [1.02-1.03]; P=.04). Receiving HD rather than HDF increased the risk of LVH progression (OR, 1.23 [1.03-1.48]; P=.02). Intradialytic hypotension was prevalent in patients progressing to LVH; it was also independently associated with predialysis BP-SDS below the 25th percentile, use of fewer antihypertensives, having HD versus HDF, ultrafiltration rate, and urine production.

Limitations of the study included potential selection bias due to participation in the IPHN registry being voluntary, methodological variability that may have limited sensitivity when identifying correlates of BP and left ventricular mass, and potential residual confounding after adjusting for regional differences in HD populations.

“In conclusion,” the authors wrote, “the largest analysis in pediatric patients on HD or HDF, to date, demonstrates that hypertension and LVH, predominant cardiovascular risk factors in patients on dialysis, are still prevalent in the majority of individuals. The intensity of pharmacologic treatment was associated with worse BP control, indicating that inadequate dialytic fluid and salt control is the key underlying mechanism.” They recommended that clinicians implement actions to help improve cardiovascular outcomes, such as the use of HDF and volume control by reducing IDWG.

Source: KI Reports