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Hemodiafiltration maintains a sustained improvement in blood pressure compared to conventional hemodialysis in children—the HDF, heart and height (3H) study

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Abstract

Background

Hypertension is prevalent in children on dialysis and associated with cardiovascular disease. We studied the blood pressure (BP) trends and the evolution of BP over 1 year in children on conventional hemodialysis (HD) vs. hemodiafiltration (HDF).

Methods

This is a post hoc analysis of the “3H – HDF-Hearts-Height” dataset, a multicenter, parallel-arm observational study. Seventy-eight children on HD and 55 on HDF who had three 24-h ambulatory BP monitoring (ABPM) measures over 1 year were included. Mean arterial pressure (MAP) was calculated and hypertension defined as 24-h MAP standard deviation score (SDS) ≥95th percentile.

Results

Poor agreement between pre-dialysis systolic BP-SDS and 24-h MAP was found (mean difference − 0.6; 95% limits of agreement −4.9–3.8). At baseline, 82% on HD and 44% on HDF were hypertensive, with uncontrolled hypertension in 88% vs. 25% respectively; p < 0.001. At 12 months, children on HDF had consistently lower MAP-SDS compared to those on HD (p < 0.001). Over 1-year follow-up, the HD group had mean MAP-SDS increase of +0.98 (95%CI 0.77–1.20; p < 0.0001), whereas the HDF group had a non-significant increase of +0.15 (95%CI −0.10–0.40; p = 0.23). Significant predictors of MAP-SDS were dialysis modality (β = +0.83 [95%CI +0.51 − +1.15] HD vs. HDF, p < 0.0001) and higher inter-dialytic-weight-gain (IDWG)% (β = 0.13 [95%CI 0.06–0.19]; p = 0.0003).

Conclusions

Children on HD had a significant and sustained increase in BP over 1 year compared to a stable BP in those on HDF, despite an equivalent dialysis dose. Higher IDWG% was associated with higher 24-h MAP-SDS in both groups.

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Acknowledgments

RS is funded by a National Institute for Health Research (NIHR), Career Development Fellowship for this research project. This publication presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. A part of the work took place in the Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London.

Funding

The 3H study was sponsored by Kidney Research UK. Part sponsorship was obtained from Fresenius Medical Care, who approved the study protocol, but had no role in data collection, data analysis or drafting the manuscript.

Author information

Authors and Affiliations

  1. University College London Great Ormond Street Hospital for Children and Institute of Child Health, London, UK

    Francesca De Zan & Rukshana Shroff

  2. Institute of Global Health, University College London, London, UK

    Colette Smith

  3. Hacettepe University, Ankara, Turkey

    Ali Duzova

  4. Cukurova University, Adana, Turkey

    Aysun Bayazit & Ali Anarat

  5. A & P Kyriakou Children’s Hospital, Athens, Greece

    Constantinos J Stefanidis & Varvara Askiti

  6. Clinic of Pediatrics, Faculty of Medicine, Vilnius University, Vilnius, Lithuania

    Karolis Azukaitis

  7. Cerrahpasa School of Medicine, Istanbul, Turkey

    Nur Canpolat & Ayse Agbas

  8. Armand Trousseau Hospital, Paris, France

    Bilal Aoun

  9. Gazi University Hospital, Ankara, Turkey

    Sevcan A. Bakkaloglu

  10. Medical University of Gdańsk, Gdańsk, Poland

    Dagmara Borzych-Dużałka

  11. Ege University Faculty of Medicine, Izmir, Turkey

    Ipek Kaplan Bulut

  12. University Hospital Cologne, Cologne, Germany

    Sandra Habbig

  13. Hôpital Necker-Enfants Malades, Paris, France

    Saoussen Krid

  14. The Hospital for Sick Children, Toronto, ON, Canada

    Christoph Licht

  15. Children’s Memorial Health Institute, Warsaw, Poland

    Mieczyslaw Litwin & Lukasz Obrycki

  16. Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy

    Fabio Paglialonga

  17. Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France

    Bruno Ranchin

  18. CHU Lille, Service de Néphrologie Pédiatrique, Lille, France

    Charlotte Samaille

  19. Royal Manchester Children’s Hospital, Manchester, UK

    Mohan Shenoy

  20. Kings College London Evelina London Children’s Hospital, London, UK

    Manish D Sinha

  21. University Children’s Hospital, Belgrade, Serbia

    Brankica Spasojevic

  22. Istanbul University Faculty of Medical, Istanbul, Turkey

    Alev Yilmaz

  23. Children’s Dialysis Center, Strasbourg, France

    Michel Fischbach

  24. Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany

    Claus Peter Schmitt & Franz Schaefer

  25. Division of Pediatrics, Department of Medicine, University of Udine, Udine, Italy

    Enrico Vidal

  26. Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK

    Rukshana Shroff

Authors
  1. Francesca De Zan
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  2. Colette Smith
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  3. Ali Duzova
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  4. Aysun Bayazit
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  5. Constantinos J Stefanidis
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  6. Varvara Askiti
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  7. Karolis Azukaitis
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  8. Nur Canpolat
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  9. Ayse Agbas
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  10. Ali Anarat
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  11. Bilal Aoun
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  12. Sevcan A. Bakkaloglu
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  13. Dagmara Borzych-Dużałka
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  14. Ipek Kaplan Bulut
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  15. Sandra Habbig
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  16. Saoussen Krid
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  17. Christoph Licht
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  18. Mieczyslaw Litwin
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  19. Lukasz Obrycki
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  20. Fabio Paglialonga
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  21. Bruno Ranchin
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  22. Charlotte Samaille
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  23. Mohan Shenoy
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  24. Manish D Sinha
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  25. Brankica Spasojevic
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  26. Alev Yilmaz
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  27. Michel Fischbach
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  28. Claus Peter Schmitt
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  29. Franz Schaefer
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  30. Enrico Vidal
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  31. Rukshana Shroff
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Contributions

RS is the Principal Investigator and obtained funding. RS, EV, CPS and FS designed the study. RS, FDZ and CS drafted the paper. CS performed the statistical analyses. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Rukshana Shroff.

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Conflict of interest

RS has an investigator-initiated study funded by Fresenius Medical Care and has received speaker honoraria from Fresenius Medical Care and Amgen. CPS and FS received funding for investigator-initiated research from Fresenius Medical Care, and CPD also from Amgen.

All authors to declare COI.

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The study was performed according to the principles of the declaration of Helsinki. It has been approved by the NRES (National Research Ethics Service) Committee London—Bloomsbury, a Research Ethics Committee established by the Health Research Authority, England. Approval from local Institutional Review Boards was obtained for each participating site.

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Full written informed consent has been obtained from all parents or caregivers, and assent from children, where applicable.

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ESM 1

Supplemental Fig. 1. Pre-dialysis systolic blood pressure SDS by treatment modality and age groups at baseline (1A) and 12 months (1B). Supplemental Fig. 2. Pre-dialysis diastolic blood pressure SDS by treatment modality and age groups at baseline (2A) and 12 months (2B). Supplemental Fig. 3. Distribution of hypertension in HD and HDF patients based on systolic and diastolic blood pressure at baseline (3A) and 12 months (3B). The Y-axis indicates the percentage of patients in each category. Striped columns represent BP < 95th percentile and filled columns represent BP > 95th percentile. (PDF 265 kb)

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De Zan, F., Smith, C., Duzova, A. et al. Hemodiafiltration maintains a sustained improvement in blood pressure compared to conventional hemodialysis in children—the HDF, heart and height (3H) study. Pediatr Nephrol 36, 2393–2403 (2021). https://doi.org/10.1007/s00467-021-04930-2

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  • DOI: https://doi.org/10.1007/s00467-021-04930-2

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