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Ahlmann C, Stronach L, Waters K, Walker K, Oh J, Schmitt CP, Ranchin B, Shroff R. Hemodiafiltration for children with stage 5 chronic kidney disease: technical aspects and outcomes. Pediatr Nephrol 2024; 39:2611-2626. [PMID: 38347283 DOI: 10.1007/s00467-024-06285-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/31/2023] [Accepted: 01/02/2024] [Indexed: 07/26/2024]
Abstract
Despite significant medical and technical improvements in the field of dialysis, the morbidity and mortality among patients with chronic kidney disease (CKD) stage 5 on dialysis remains extremely high. Hemodiafiltration (HDF), a dialysis method that combines the two main principles of hemodialysis (HD) and hemofiltration-diffusion and convection-has had a positive impact on survival when delivered with a high convective dose. Improved outcomes with HDF have been attributed to the following factors: HDF removes middle molecular weight uremic toxins including inflammatory cytokines, increases hemodynamic stability, and reduces inflammation and oxidative stress compared to conventional HD. Two randomized trials in adults have shown improved survival with HDF compared to high-flux HD. A large prospective cohort study in children has shown that HDF attenuated the progression of cardiovascular disease, improved bone turnover and growth, reduced inflammation, and improved blood pressure control compared to conventional HD. Importantly, children on HDF reported fewer headaches, dizziness, and cramps; had increased physical activity; and improved school attendance compared to those on HD. In this educational review, we discuss the technical aspects of HDF and results from pediatric studies, comparing outcomes on HDF vs. conventional HD. Convective volume, the cornerstone of treatment with HDF and a key determinant of outcomes in adult randomized trials, is discussed in detail, including the practical aspects of achieving an optimal convective volume.
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Affiliation(s)
- Charlotte Ahlmann
- University College London Great Ormond Street Hospital and Institute of Child Health, London, WC1N 3JH, UK
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lynsey Stronach
- University College London Great Ormond Street Hospital and Institute of Child Health, London, WC1N 3JH, UK
| | - Kathryn Waters
- University College London Great Ormond Street Hospital and Institute of Child Health, London, WC1N 3JH, UK
| | - Kate Walker
- University College London Great Ormond Street Hospital and Institute of Child Health, London, WC1N 3JH, UK
| | - Jun Oh
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Claus Peter Schmitt
- Centre for Pediatric and Adolescent Medicine, University of Heidelberg, Heidelberg, Germany
| | - Bruno Ranchin
- Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Université de Lyon, Lyon, France
| | - Rukshana Shroff
- University College London Great Ormond Street Hospital and Institute of Child Health, London, WC1N 3JH, UK.
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Borzych-Dużałka D, Shroff R, Ranchin B, Zhai Y, Paglialonga F, Kari JA, Ahn YH, Awad HS, Loza R, Hooman N, Ericson R, Drożdz D, Kaur A, Bakkaloglu SA, Samaille C, Lee M, Tellier S, Thumfart J, Fila M, Warady BA, Schaefer F, Schmitt CP. Prospective Study of Modifiable Risk Factors of Arterial Hypertension and Left Ventricular Hypertrophy in Pediatric Patients on Hemodialysis. Kidney Int Rep 2024; 9:1694-1704. [PMID: 38899176 PMCID: PMC11184401 DOI: 10.1016/j.ekir.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2024] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 06/21/2024] Open
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.
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Affiliation(s)
- Dagmara Borzych-Dużałka
- Department for Pediatrics, Nephrology and Hypertension, Medical University of Gdansk, Gdansk, Poland
| | - Rukshana Shroff
- UCL Great Ormond Street Hospital and Institute of Child Health, London, UK
| | - Bruno Ranchin
- Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Lyon, France
| | - Yihui Zhai
- Children’s Hospital of Fudan University, Shanghai, China
| | - Fabio Paglialonga
- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Jameela A. Kari
- King Abdulaziz University Hospital, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Yo H. Ahn
- Department of Pediatrics, Seoul National University Children’s Hospital, Seoul National University College of Medicine, Republic of Korea
| | - Hazem S. Awad
- Aljalila Children’s Specialty Hospital, Department of Pediatric Nephrology, Dubai, United Arab Emirates
| | | | | | | | - Dorota Drożdz
- Jagellonian University Medical College, Kraków, Poland
| | - Amrit Kaur
- Royal Manchester Children’s Hospital, Manchester, UK
| | | | | | - Marsha Lee
- The University of California, San Francisco, California, USA
| | | | - Julia Thumfart
- Department of Pediatric Gastroenterology, Nephrology and Metabolic Diseases, Charité Universitätsmedizin Berlin, Germany
| | - Marc Fila
- Department of Pediatric Nephrology, CHU de Montpellier, Montpellier, France
| | | | - Franz Schaefer
- Centre for Pediatric and Adolescent Medicine, University of Heidelberg, Germany
| | - Claus P. Schmitt
- Centre for Pediatric and Adolescent Medicine, University of Heidelberg, Germany
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The effects of hospital and dialysis unit characteristics on hospitalizations for access-related complications among children on maintenance dialysis: a European, multicenter, observational, cross-sectional study. Pediatr Nephrol 2023:10.1007/s00467-022-05842-5. [PMID: 36595069 DOI: 10.1007/s00467-022-05842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 11/23/2022] [Accepted: 11/28/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Previous studies investigating hospitalizations in dialysis patients have focused primarily on patient-centered factors. We analyzed the impact of hospital and dialysis unit characteristics on pediatric dialysis patients' hospitalizations for access-related complications (ARCs). METHODS This cross-sectional study involved 102 hemodialysis (HD) and 163 peritoneal dialysis (PD) patients. Data between July 2017 and July 2018 were analyzed. RESULTS Children's hospitals (CHs) had more pediatric nephrologists and longer PD experience (years) than general hospitals (GHs) (p = 0.026 and p = 0.023, respectively). A total of 53% of automated PD (APD) and 6% of continuous ambulatory PD (CAPD) patients were in CHs (p < 0.001). Ninety-three percent of APD and 69% of CAPD patients were treated in pediatric-specific PD units (p = 0.001). CHs had a higher prevalence in providing hemodiafiltration (HDF) than GHs (83% vs. 30%). Ninety-seven percent of HDF vs. 66% for conventional HD (cHD) patients, and 94% of patients with arteriovenous fistula (AVF) vs. 70% of those with central venous catheters (CVC), were dialyzed in pediatric-specific HD units (p = 0.001 and p = 0.016, respectively). Eighty patients (51 PD and 29 HD) had 135 (84 PD, 51 HD) hospitalizations. CAPD was an independent risk factor for hospitalizations for infectious ARCs (I-ARCs) (p = 0.009), and a health center's PD experience negatively correlated with CAPD patient hospitalizations for I-ARCs (p = 0.041). cHD and dialyzing in combined HD units significantly increased hospitalization risk for non-infectious (NI-)ARCs (p = 0.044 and p = 0.017, respectively). CONCLUSIONS CHs and pediatric-specific dialysis units have higher prevalence of APD and HDF use. Hospitalizations for I-ARCs in CAPD are lower in centers with longer PD experience, and pediatric HD units are associated with fewer hospitalizations due to NI-ARCs. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Reducing the burden of cardiovascular disease in children with chronic kidney disease: prevention vs. damage limitation. Pediatr Nephrol 2021; 36:2537-2544. [PMID: 34143301 DOI: 10.1007/s00467-021-05102-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 10/21/2022]
Abstract
Cardiovascular disease (CVD) is a life-limiting condition in patients with chronic kidney disease (CKD) and is rapidly progressive, especially in those with stage 5 CKD and on dialysis. Cardiovascular mortality, although reducing, remains at least 30 times higher than in the general pediatric population. The American Heart Association guidelines for cardiovascular risk reduction in high-risk pediatric patients has stratified pediatric CKD patients in the "high risk" category for the development of CVD, with associated pathological and/or clinical evidence for manifest coronary disease before 30 years of age. While improving patient survival is a key priority, other patient-related outcomes, such as psychosocial development, quality of life and growth are of major importance to children and their caregivers. Once vascular damage or calcification has developed, there are no data to suggest that they can be reversed. Treatments such as intensified dialysis and transplantation may attenuate the progression of subclinical cardiovascular disease, but no treatment to date has shown that the inexorable progression of CVD in CKD can be reversed. Thus, our management must focus on early diagnosis and robust preventative strategies to give our patients the best chance of optimal cardiovascular health and survival. In this review, the pathophysiology and importance of preventing the development of CVD in CKD is discussed.
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