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

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),

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

“…This is in line with the largest interventional study in pediatric patients on HD to date, the 3H-trial, in which 24-hour MAP-SDS was significantly higher in those on HD than in those on HDF, and increased during 12 months on HD but not on HDF. 24 , 25 At present, it is unclear whether these BP effects are due to superior toxin removal, reduced systemic inflammation, and/or increased sodium removal with lower sodium concentration in the substitution fluid. 26 …”

“… 33 , 34 , 35 , 36 In the 3H trial, they improved fluid status; 26 LVMI was higher in patients on HD than in those on HDF; and in children on HDF, it closely correlated with the improved fluid status. 25 …”

Evidencia de la hemodiafiltración en línea de alto volumen en pediatría

“…El índice de masa ventricular izquierda al inicio fue comparable en ambas cohortes y no mostró un aumento significativo luego de 12 meses en ninguno de los dos grupos; sin embargo, fue más alto en los pacientes con HD. 13,14 En un subestudio del 3H se hizo un análisis prospectivo observacional comparando HD de alto flujo contra HVHDF. Al cabo de 3 meses del cambio de terapia de HD a HVHDF se encontró una reducción en los marcadores de inflamación, el perfil de riesgo endotelial y la capacidad antioxidante, lo que podría reflejar una disminución en la progresión del daño cardiovascular.…”

Hemodiafiltration in the pediatric population

“…Hypertension (measured by 24‐h ambulatory blood pressure recording and expressed as the mean arterial pressure [MAP]‐SDS) was significantly more common and increased more rapidly in children on conventional HD compared to HDF 4 . Over a 1‐year follow‐up, the MAP increased by 0.98 SDS in HD patients while there was an attenuated and nonsignificant increase of 0.15 SDS in HDF patients 7 . A significant risk factor that correlated with change in the MAP‐SDS was the interdialytic weight gain (IDWG%), a surrogate for sodium mass removal rate, suggesting that effective volume control is key to managing hypertension in children on dialysis.…”

“…4 Over a 1-year follow-up, the MAP increased by 0.98 SDS in HD patients while there was an attenuated and nonsignificant increase of 0.15 SDS in HDF patients. 7 A significant risk factor that correlated with change in the MAP-SDS was the interdialytic weight gain (IDWG%), a surrogate for sodium mass removal rate, suggesting that effective volume control is key to managing hypertension in children on dialysis. A further study suggests that switching children from nocturnal in-center HD to nocturnal incenter HDF may significantly improve their BP, phosphate, and PTH control.…”