Improved blood pressure and left ventricular remodelling in children on chronic intermittent haemodialysis: a longitudinal study

  • Nabil Melhem
  • Alex Savis
  • Arran Wheatley
  • Helen Copeman
  • Kay Willmott
  • Christopher J. D. Reid
  • John Simpson
  • Manish D. SinhaEmail author
Original Article
Part of the following topical collections:
  1. What's New in Dialysis



We aimed to examine longitudinal changes in left ventricular (LV) structure and function and evaluate factors associated with LV remodelling in children on chronic haemodialysis.


Retrospective longitudinal study including all children from the start of chronic haemodialysis with two or more m-mode 2D echocardiograms and tissue Doppler studies. Left ventricular mass (LVM) in g/m2.7, geometry and LV function were compared at baseline (dialysis start) with follow-up studies at least 6 months following commencement. Left ventricular hypertrophy (LVH) was defined if greater than 95th percentile as per age-specific centiles. We also defined LVH as indexed LV mass index (LVMI) > 51 g/m2.7 and using LV mass-for-height z-scores greater than the 95th percentile. Biochemical data, interdialytic weight change and blood pressure level were assessed for their association with change in indexed LVM.


Twenty-three of the 32 children < 18 years were included (n = 5, < 5 years) with last follow-up study performed following dialysis after a median (IQR) of 21 (10–34) months. The prevalence of LVH reduced significantly (69.6%, (n = 16/23) vs. 39.1% (n = 9/23), P = 0.002); LV geometry improved (13% concentric and 56.5% eccentric vs. 8.7% and 17.4% respectively) with mean ± SD reduction in indexed LVM (50.8 ± 23.1 g/m2.7 vs. 38.6 ± 14.7 g/m2.7, P = 0.002) and LV mass-for-height z-scores (0.67 ± 1.66 vs. − 0.46 ± 1.88, P = 0.002) from baseline to last follow-up respectively. There was no change in systolic function (LV fractional shortening, 37% vs. 38%, P = 0.39) and diastolic function (mean E/E′ 10.8 vs. 9.0, P = 0.09). Multiple regression analysis identified improved systolic BP control (β = 0.41, P = 0.04) as an independent predictor for change in indexed LVM.


LV structure and function can improve in children despite long-term chronic intermittent haemodialysis. Cardiovascular health in this population does not always deteriorate but can be stabilised and indeed improved with optimal blood pressure management.


Dialysis ESKD Renal replacement therapy Cardiac 


Sources of funding

The authors (JMS and MDS) acknowledges financial support from the Department of Health via the National Institute for Health Research (NIHR) comprehensive Biomedical Research Centre and Clinical Research Facilities awards to Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London and King’s College Hospital NHS Foundation Trust.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflicts of interest.

The results presented in this paper have not been published previously in whole or part.

Ethical approval

The authors confirm that as this was a retrospective analysis evaluating results of clinical investigations; no consent from patients was indicated and ethical approval was not required.


  1. 1.
    Collins AJ, Foley RN, Chavers B, Gilbertson D, Herzog C, Johansen K, Kasiske B, Kutner N, Liu J, St Peter W, Guo H, Gustafson S, Heubner B, Lamb K, Li S, Li S, Peng Y, Qiu Y, Roberts T, Skeans M, Snyder J, Solid C, Thompson B, Wang C, Weinhandl E, Zaun D, Arko C, Chen SC, Daniels F, Ebben J, Frazier E, Hanzlik C, Johnson R, Sheets D, Wang X, Forrest B, Constantini E, Everson S, Eggers P, Agodoa L (2012) United States renal data system 2011 annual data report: atlas of chronic kidney disease & end-stage renal disease in the United States. Am J Kidney Dis 59(1 Suppl 1):A7, e1-420. Google Scholar
  2. 2.
    Mitsnefes MM (2012) Cardiovascular disease in children with chronic kidney disease. J Am Soc Nephrol 23(4):578–585. Google Scholar
  3. 3.
    Groothoff JW, Gruppen MP, Offringa M, Hutten J, Lilien MR, Van De Kar NJ, Wolff ED, Davin JC, Heymans HS (2002) Mortality and causes of death of end-stage renal disease in children: a Dutch cohort study. Kidney Int 61(2):621–629. Google Scholar
  4. 4.
    McDonald SP, Craig JC, Australian, New Zealand Paediatric Nephrology A (2004) Long-term survival of children with end-stage renal disease. N Engl J Med 350(26):2654–2662. Google Scholar
  5. 5.
    Oh J, Wunsch R, Turzer M, Bahner M, Raggi P, Querfeld U, Mehls O, Schaefer F (2002) Advanced coronary and carotid arteriopathy in young adults with childhood-onset chronic renal failure. Circulation 106(1):100–105Google Scholar
  6. 6.
    Mitsnefes MM, Barletta GM, Dresner IG, Chand DH, Geary D, Lin JJ, Patel H (2006) Severe cardiac hypertrophy and long-term dialysis: the Midwest Pediatric Nephrology Consortium study. Pediatr Nephrol 21(8):1167–1170. Google Scholar
  7. 7.
    Mitsnefes MM, Kimball TR, Kartal J, Witt SA, Glascock BJ, Khoury PR, Daniels SR (2006) Progression of left ventricular hypertrophy in children with early chronic kidney disease: 2-year follow-up study. J Pediatr 149(5):671–675. Google Scholar
  8. 8.
    Sozeri B, Mir S, Kara OD, Levent E (2010) When does the cardiovascular disease appear in patients with chronic kidney disease? Pediatr Cardiol 31(6):821–828. Google Scholar
  9. 9.
    Ulinski T, Genty J, Viau C, Tillous-Borde I, Deschenes G (2006) Reduction of left ventricular hypertrophy in children undergoing hemodialysis. Pediatr Nephrol 21(8):1171–1178. Google Scholar
  10. 10.
    Force m A/T, Elliott PM, Anastasakis A, Borger MA, Borggrefe M, Cecchi F, Charron P, Hagege AA, Lafont A, Limongelli G, Mahrholdt H, McKenna WJ, Mogensen J, Nihoyannopoulos P, Nistri S, Pieper PG, Pieske B, Rapezzi C, Rutten FH, Tillmanns C, Watkins H (2014) 2014 ESC guidelines on diagnosis and management of hypertrophic cardiomyopathy: the task force for the diagnosis and management of hypertrophic cardiomyopathy of the European Society of Cardiology (ESC). Eur Heart J 35(39):2733–2779. Google Scholar
  11. 11.
    National High Blood Pressure Education Program Working Group on High Blood Pressure in C, Adolescents (2004) The fourth report on the diagnosis, evaluation, and treatment of high blood pressure in children and adolescents. Pediatrics 114(2 Suppl 4th Report):555–576Google Scholar
  12. 12.
    Fischbach M, Zaloszyc A, Shroff R (2015) The interdialytic weight gain: a simple marker of left ventricular hypertrophy in children on chronic haemodialysis. Pediatr Nephrol 30(6):859–863. Google Scholar
  13. 13.
    Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, Flachskampf FA, Foster E, Goldstein SA, Kuznetsova T, Lancellotti P, Muraru D, Picard MH, Rietzschel ER, Rudski L, Spencer KT, Tsang W, Voigt JU (2015) Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. J Am Soc Echocardiogr 28(1):1–39 e14. Google Scholar
  14. 14.
    Khoury PR, Mitsnefes M, Daniels SR, Kimball TR (2009) Age-specific reference intervals for indexed left ventricular mass in children. J Am Soc Echocardiogr 22(6):709–714. Google Scholar
  15. 15.
    Foster BJ, Mackie AS, Mitsnefes M, Ali H, Mamber S, Colan SD (2008) A novel method of expressing left ventricular mass relative to body size in children. Circulation 117(21):2769–2775. Google Scholar
  16. 16.
    Arques S, Roux E, Luccioni R (2007) Current clinical applications of spectral tissue Doppler echocardiography (E/E′ ratio) as a noninvasive surrogate for left ventricular diastolic pressures in the diagnosis of heart failure with preserved left ventricular systolic function. Cardiovasc Ultrasound 5:16. Google Scholar
  17. 17.
    Mitsnefes MM, Daniels SR, Schwartz SM, Khoury P, Strife CF (2001) Changes in left ventricular mass in children and adolescents during chronic dialysis. Pediatr Nephrol 16(4):318–323Google Scholar
  18. 18.
    Cannella G, La Canna G, Sandrini M, Gaggiotti M, Nordio G, Movilli E, Mombelloni S, Visioli O, Maiorca R (1991) Reversal of left ventricular hypertrophy following recombinant human erythropoietin treatment of anaemic dialysed uraemic patients. Nephrol Dial Transplant 6(1):31–37Google Scholar
  19. 19.
    Chan CT, Floras JS, Miller JA, Richardson RM, Pierratos A (2002) Regression of left ventricular hypertrophy after conversion to nocturnal hemodialysis. Kidney Int 61(6):2235–2239. Google Scholar
  20. 20.
    Hampl H, Sternberg C, Berweck S, Lange D, Lorenz F, Pohle C, Riedel E, Gogoll L, Hennig L (2002) Regression of left ventricular hypertrophy in hemodialysis patients is possible. Clin Nephrol 58(Suppl 1):S73–S96Google Scholar
  21. 21.
    Mitsnefes MM, Daniels SR, Schwartz SM, Meyer RA, Khoury P, Strife CF (2000) Severe left ventricular hypertrophy in pediatric dialysis: prevalence and predictors. Pediatr Nephrol 14(10–11):898–902Google Scholar
  22. 22.
    Seeherunvong W, Abitbol CL, Chandar J, Rusconi P, Zilleruelo GE, Freundlich M (2012) Fibroblast growth factor 23 and left ventricular hypertrophy in children on dialysis. Pediatr Nephrol 27(11):2129–2136. Google Scholar
  23. 23.
    Schaefer F, Doyon A, Azukaitis K, Bayazit A, Canpolat N, Duzova A, Niemirska A, Sozeri B, Thurn D, Anarat A, Ranchin B, Litwin M, Caliskan S, Candan C, Baskin E, Yilmaz E, Mir S, Kirchner M, Sander A, Haffner D, Melk A, Wuhl E, Shroff R, Querfeld U, Consortium CS (2017) Cardiovascular phenotypes in children with CKD: the 4C study. Clin J Am Soc Nephrol 12(1):19–28. Google Scholar
  24. 24.
    Vasu S, Kelly P, Lawson WE (2005) Anemia in heart failure--a concise review. Clin Cardiol 28(10):454–458Google Scholar
  25. 25.
    Matteucci MC, Chinali M, Rinelli G, Wuhl E, Zurowska A, Charbit M, Pongiglione G, Schaefer F, Group ET (2013) Change in cardiac geometry and function in CKD children during strict BP control: a randomized study. Clin J Am Soc Nephrol 8(2):203–210. Google Scholar
  26. 26.
    Mitsnefes M, Flynn J, Cohn S, Samuels J, Blydt-Hansen T, Saland J, Kimball T, Furth S, Warady B, Group CKS (2010) Masked hypertension associates with left ventricular hypertrophy in children with CKD. J Am Soc Nephrol 21(1):137–144. Google Scholar
  27. 27.
    Lindblad YT, Axelsson J, Balzano R, Vavilis G, Chromek M, Celsi G, Barany P (2013) Left ventricular diastolic dysfunction by tissue Doppler echocardiography in pediatric chronic kidney disease. Pediatr Nephrol 28(10):2003–2013. Google Scholar
  28. 28.
    Mitsnefes MM, Kimball TR, Border WL, Witt SA, Glascock BJ, Khoury PR, Daniels SR (2004) Impaired left ventricular diastolic function in children with chronic renal failure. Kidney Int 65(4):1461–1466. Google Scholar
  29. 29.
    Schoenmaker NJ, Kuipers IM, van der Lee JH, Tromp WF, van Dyck M, Gewillig M, Blom NA, Groothoff JW (2014) Diastolic dysfunction measured by tissue Doppler imaging in children with end-stage renal disease: a report of the RICH-Q study. Cardiol Young 24(2):236–244. Google Scholar
  30. 30.
    Bakkaloglu SA, Saygili A, Sever L, Aksu N, Noyan A, Akman S, Ekim M, Doganay B, Yildiz N, Akalin F, Caliskan S, Kara OD, Duzova A, Soylu A, Atalay S (2010) Impact of peritoneal transport characteristics on cardiac function in paediatric peritoneal dialysis patients: a Turkish Pediatric Peritoneal Dialysis Study Group (TUPEPD) report. Nephrol Dial Transplant 25(7):2296–2303. Google Scholar
  31. 31.
    Bakkaloglu SA, Saygili A, Sever L, Noyan A, Akman S, Ekim M, Aksu N, Doganay B, Yildiz N, Duzova A, Soylu A, Alpay H, Sonmez F, Civilibal M, Erdem S, Kardelen F (2009) Assessment of cardiovascular risk in paediatric peritoneal dialysis patients: a Turkish Pediatric Peritoneal Dialysis Study Group (TUPEPD) report. Nephrol Dial Transplant 24(11):3525–3532. Google Scholar
  32. 32.
    Sood MM, Pauly RP, Rigatto C, Komenda P (2008) Left ventricular dysfunction in the haemodialysis population. NDT Plus 1(4):199–205. Google Scholar
  33. 33.
    Johnstone LM, Jones CL, Grigg LE, Wilkinson JL, Walker RG, Powell HR (1996) Left ventricular abnormalities in children, adolescents and young adults with renal disease. Kidney Int 50(3):998–1006Google Scholar
  34. 34.
    Mitsnefes MM (2008) Cardiovascular complications of pediatric chronic kidney disease. Pediatr Nephrol 23(1):27–39. Google Scholar
  35. 35.
    Chinali M, de Simone G, Matteucci MC, Picca S, Mastrostefano A, Anarat A, Caliskan S, Jeck N, Neuhaus TJ, Peco-Antic A, Peruzzi L, Testa S, Mehls O, Wuhl E, Schaefer F, Group ET (2007) Reduced systolic myocardial function in children with chronic renal insufficiency. J Am Soc Nephrol 18(2):593–598. Google Scholar
  36. 36.
    Simpson JM, Rawlins D, Mathur S, Chubb H, Sinha MD (2013) Systolic and diastolic ventricular function assessed by tissue Doppler imaging in children with chronic kidney disease. Echocardiography 30(3):331–337. Google Scholar
  37. 37.
    Navarini S, Bellsham-Revell H, Chubb H, Gu H, Sinha MD, Simpson JM (2017) Myocardial deformation measured by 3-dimensional speckle tracking in children and adolescents with systemic arterial hypertension. Hypertension 70(6):1142–1147. Google Scholar
  38. 38.
    Ie EH, Vletter WB, ten Cate FJ, Nette RW, Weimar W, Roelandt JR, Zietse R (2003) Preload dependence of new Doppler techniques limits their utility for left ventricular diastolic function assessment in hemodialysis patients. J Am Soc Nephrol 14(7):1858–1862Google Scholar

Copyright information

© IPNA 2019

Authors and Affiliations

  1. 1.Department of Paediatric NephrologyEvelina London Children’s Hospital, Guys & St Thomas’ NHS Foundation TrustLondonUK
  2. 2.Department of Paediatric CardiologyEvelina London Children’s Hospital, Guy’s & ST Thomas’ Foundation Hospitals NHS TrustLondonUK
  3. 3.Kings College LondonLondonUK

Personalised recommendations