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Blood pressure management in children on dialysis

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Abstract

Hypertension is a leading cause of cardiovascular complications in children on dialysis. Volume overload and activation of the renin–angiotensin–aldosterone system play a major role in the pathophysiology of hypertension. The first step in managing blood pressure (BP) is the careful assessment of ambulatory BP monitoring. Volume control is essential and should start with the accurate identification of dry weight, based on a comprehensive assessment, including bioimpedance analysis and intradialytic blood volume monitoring (BVM). Reduction of interdialytic weight gain (IDWG) is critical, as higher IDWG is associated with a worse left ventricular mass index and poorer BP control: it can be obtained by means of salt restriction, reduced fluid intake, and optimized sodium removal in dialysis. Optimization of peritoneal dialysis and intensified hemodialysis or hemodiafiltration have been shown to improve both fluid and sodium management, leading to better BP levels. Studies comparing different antihypertensive agents in children are lacking. The pharmacokinetic properties of each drug should be considered. At present, BP control remains suboptimal in many patients and efforts are needed to improve the long-term outcomes of children on dialysis.

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References

  1. Kramer A, Stel VS, Tizard J, Verrina E, Ronnholm K, Palsson R, Maxwell H, Jager KJ (2009) Characteristics and survival of young adults who started renal replacement therapy during childhood. Nephrol Dial Transplant 24:926–933

    Article  PubMed  Google Scholar 

  2. Chesnaye NC, Schaefer F, Groothoff JW, Bonthuis M, Reusz G, Heaf JG, Lewis M, Maurer E, Paripović D, Zagozdzon I, van Stralen KJ, Jager KJ (2016) Mortality risk in European children with end-stage renal disease on dialysis. Kidney Int 89:1355–1362

    Article  PubMed  Google Scholar 

  3. US Renal Data System: USRDS 2015 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States, Bethesda, MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2015

  4. 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 16:318–323

    Article  CAS  PubMed  Google Scholar 

  5. Bakkaloglu SA, Borzych D, Soo Ha I, Serdaroglu E, Büscher R, Salas P, Patel H, Drozdz D, Vondrak K, Watanabe A, Villagra J, Yavascan O, Valenzuela M, Gipson D, Ng KH, Warady BA, Schaefer F, International Pediatric Peritoneal Dialysis Network (2011) Cardiac geometry in children receiving chronic peritoneal dialysis: findings from the International pediatric peritoneal dialysis Network (IPPN) registry. Clin J Am Soc Nephrol 6:1926–1933

    Article  PubMed  PubMed Central  Google Scholar 

  6. Chavers BM, Solid CA, Daniels FX, Chen SC, Collins AJ, Frankenfield DL, Herzog CA, Haskin O, Wong CJ, McCabe L, Begin B, Sutherland SM, Chaudhuri A (2009) Hypertension in pediatric long- term hemodialysis patients in the United States. Clin J Am Soc Nephrol 4:1363–1369

    Article  PubMed  PubMed Central  Google Scholar 

  7. Kramer AM, van Stralen KJ, Jager KJ, Schaefer F, Verrina E, Seeman T, Lewis MA, Boehm M, Simonetti GD, Novljan G, Groothoff J (2011) Demographics of blood pressure and hypertension in children on renal replacement therapy in Europe. Kidney Int 80:1092–1098

    Article  PubMed  Google Scholar 

  8. Halbach SM, Martz K, Mattoo T, Flynn J (2012) Predictors of blood pressure and its control in pediatric patients receiving dialysis. J Pediatr 160:621–625

    Article  PubMed  Google Scholar 

  9. Chaudhuri A, Sutherland SM, Begin B, Salsbery K, McCabe L, Potter D, Alexander SR, Wong CJ (2011) Role of twenty-four-hour ambulatory blood pressure monitoring in children on dialysis. Clin J Am Soc Nephrol 6:870–876

    Article  PubMed  PubMed Central  Google Scholar 

  10. Goldstein SL, Smith CM, Currier H (2003) Noninvasive interventions to decrease hospitalization and associated costs for pediatric patients receiving hemodialysis. J Am Soc Nephrol 14:2127–2131

    Article  PubMed  Google Scholar 

  11. Ozkahya M, Ok E, Toz H, Asci G, Duman S, Basci A, Kose T, Dorhout Mees EJ (2006) Long-term survival rates in haemodialysis patients treated with strict volume control. Nephrol Dial Transplant 21:3506–3513

    Article  PubMed  Google Scholar 

  12. VanDeVoorde RG, Barletta GM, Chand DH, Dresner IG, Lane J, Leiser J, Lin JJ, Pan CG, Patel H, Valentini RP, Mitsnefes MM (2007) Blood pressure control in pediatric hemodialysis: the Midwest pediatric Nephrology consortium study. Pediatr Nephrol 22:547–553

    Article  PubMed  Google Scholar 

  13. Paglialonga F, Consolo S, Galli MA, Testa S, Edefonti A (2015) Interdialytic weight gain in oligoanuric children and adolescents on chronic haemodialysis. Pediatr Nephrol 30:999–1005

    Article  PubMed  Google Scholar 

  14. Haskin O, Wong CJ, McCabe L, Begin B, Sutherland SM, Chaudhuri A (2015) 44-h ambulatory blood pressure monitoring: revealing the true burden of hypertension in pediatric hemodialysis patients. Pediatr Nephrol 30:653–660

    Article  PubMed  Google Scholar 

  15. Tkaczyk M, Nowicki M, Bałasz-Chmielewska I, Boguszewska-Baçzkowska H, Drozdz D, Kołłataj B, Jarmoliński T, Jobs K, Kiliś-Pstrusińska K, Leszczyńska B, Makulska I, Runowski D, Stankiewicz R, Szczepańska M, Wierciński R, Grenda R, Kanik A, Pietrzyk JA, Roszkowska-Blaim M, Szprynger K, Zachwieja J, Zajaczkowska MM, Zoch-Zwierz W, Zwolińska D, Zurowska A (2006) Hypertension in dialysed children: the prevalence and therapeutic approach in Poland—a nationwide survey. Nephrol Dial Transplant 21:736–724

    Article  PubMed  Google Scholar 

  16. Van Buren PN, Inrig JK (2012) Hypertension and hemodialysis: pathophysiology and outcomes in adult and pediatric populations. Pediatr Nephrol 27:339–350

    Article  PubMed  Google Scholar 

  17. Hadtstein C, Schaefer F (2008) Hypertension in children with chronic kidney disease: pathophysiology and management. Pediatr Nephrol 23:363–371

    Article  PubMed  Google Scholar 

  18. Agarwal R, Andersen MJ, Bishu K, Saha C (2006) Home blood pressure monitoring improves the diagnosis of hypertension in hemodialysis patients. Kidney Int 69:900–906

    Article  CAS  PubMed  Google Scholar 

  19. Agarwal R, Brim NJ, Mahenthiran J, Andersen MJ, Saha C (2006) Out-of-hemodialysis-unit blood pressure is a superior determinant of left ventricular hypertrophy. Hypertension 47:62–68

    Article  CAS  PubMed  Google Scholar 

  20. Mitsnefes M, Flynn J, Cohn S, Samuels J, Blydt-Hansen T, Saland J, Kimball T, Furth S, Warady G, CKiD Study Group (2010) Masked hypertension associates with left ventricular hypertrophy in children with CKD. J Am Soc Nephrol 21:137–144

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. Barletta GM, Flynn J, Mitsnefes M, Samuels J, Friedman LA, Ng D, Cox C, Poffenbarger T, Warady B, Furth S (2014) Heart rate and blood pressure variability in children with chronic kidney disease: a report from the CKiD study. Pediatr Nephrol 29:1059–1065

    Article  PubMed  PubMed Central  Google Scholar 

  22. Mitsnefes MM, Pierce C, Flynn J, Samuels J, Dionne J, Furth S, Warady B, CKiD study group (2016) Can office blood pressure readings predict masked hypertension? Pediatr Nephrol 31:163–166

    Article  PubMed  Google Scholar 

  23. Wühl E, Witte K, Soergel M, Mehls O, Schaefer F, German Working Group on Pediatric Hypertension (2002) Distribution of 24-h ambulatory blood pressure in children: normalized reference values and role of body dimensions. J Hypertens 20:1995–2007

    Article  PubMed  Google Scholar 

  24. Ulinski T, Genty J, Viau C, Tillous-Borde I, Deschênes G (2006) Reduction of left ventricular hypertrophy in children undergoing hemodialysis. Pediatr Nephrol 21:1171–1178

    Article  PubMed  Google Scholar 

  25. Litwin M, Wühl E, Jourdan C, Trelewicz J, Niemirska A, Fahr K, Jobs K, Grenda R, Wawer ZT, Rajszys P, Tröger J, Mehls O, Schaefer F (2005) Altered morphologic properties of large arteries in children with chronic renal failure and after renal transplantation. J Am Soc Nephrol 16:1494–1500

    Article  PubMed  Google Scholar 

  26. The ESCAPE Trial Group (2009) Strict blood-pressure control and progression of renal failure in children. N Engl J Med 361:1639–1650

    Article  Google Scholar 

  27. Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work Group (2012) KDIGO clinical practice guideline for the management of blood pressure in chronic kidney disease. Kidney Int Suppl 2:337–414

    Article  Google Scholar 

  28. Roszkowska-Blaim M, Skrzypczyk P, Jander A, Tkaczyk M, Bałasz-Chmielewska I, Żurowska A, Drożdż D, Pietrzyk JA (2015) Effect of hypertension and antihypertensive medications on residual renal function in children treated with chronic peritoneal dialysis. Adv Med Sci 60:18–24

    Article  PubMed  Google Scholar 

  29. Zaloszyc A, Schaefer B, Schaefer F, Krid S, Salomon R, Niaudet P, Schmitt CP, Fischbach M (2013) Hydration measurement by bioimpedance spectroscopy and blood pressure management in children on hemodialysis. Pediatr Nephrol 28:2169–2177

    Article  PubMed  Google Scholar 

  30. Hothi DK, Rees L, Marek J, Burton J, McIntyre CW (2009) Pediatric myocardial stunning underscores the cardiac toxicity of conventional hemodialysis treatments. Clin J Am Soc Nephrol 4:790–797

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Oh G, Wong C, Begin B, Salsbery K, Sutherland S, Chaudhuri A (2014) Whole-body single-frequency bioimpedance analysis in pediatric hemodialysis patients. Pediatr Nephrol 29:1417–1423

    Article  PubMed  Google Scholar 

  32. Paglialonga F, Ardissino G, Galli MA, Scarfia RV, Testa S, Edefonti A (2012) Bioimpedance analysis and cardiovascular status in pediatric patients on chronic hemodialysis. Hemodial Int 16:S20–S25

    Article  PubMed  Google Scholar 

  33. Allinovi M, Saleem M, Romagnani P, Nazerian P, Hayes W (2016) Lung ultrasound: a novel technique for detecting fluid overload in children on dialysis. Nephrol Dial Transplant. doi:10.1093/ndt/gfw037

    Google Scholar 

  34. Allinovi M, Saleem MA, Burgess O, Armstrong C, Hayes W (2016) Finding covert fluid: methods for detecting volume overload in children on dialysis. Pediatr Nephrol 31:2327–2335

    Article  PubMed  PubMed Central  Google Scholar 

  35. Candan C, Sever L, Civilibal M, Caliskan S, Arisoy N (2009) Blood volume monitoring to adjust dry weight in hypertensive pediatric hemodialysis patients. Pediatr Nephrol 24:581–587

    Article  PubMed  Google Scholar 

  36. Patel HP, Goldstein SL, Mahan JD, Smith B, Fried CB, Currier H, Flynn JT (2007) A standard, noninvasive monitoring of hematocrit algorithm improves blood pressure control in pediatric hemodialysis patients. Clin J Am Soc Nephrol 2:252–257

    Article  PubMed  Google Scholar 

  37. Fadel FI, Makar SH, Eskander AE, Aon AH (2014) Decreasing intra-dialytic morbid events and assessment of dry weight in children on chronic hemodialysis using non-invasive changes in hematocrit. Saudi J Kidney Dis Transpl 25:1030–1037

    Article  PubMed  Google Scholar 

  38. Kayikcioglu M, Tumuklu M, Ozkahya M, Ozdogan O, Asci G, Duman S, Toz H, Can LH, Basci A, Ok E (2009) The benefit of salt restriction in the treatment of end-stage renal disease by haemodialysis. Nephrol Dial Transplant 24:956–962

    Article  PubMed  Google Scholar 

  39. McCausland FR, Waikar SS, Brunelli SM (2012) Increased dietary sodium is independently associated with greater mortality among prevalent hemodialysis patients. Kidney Int 82:204–211

    Article  CAS  Google Scholar 

  40. National Kidney Foundation (2004) K/DOQI clinical practice guidelines on hypertension and antihypertensive agents in chronic kidney disease. Am J Kidney Dis 43:S1–S290

    Google Scholar 

  41. Jackson SL, King SM, Zhao L, Cogswell ME (2016) Prevalence of excess sodium intake in the United States—NHANES, 2009–2012. MMWR Morb Mortal Wkly Rep 64:1393–1397

    Article  PubMed  Google Scholar 

  42. Hui WF, Betoko A, Savant JD, Abraham AG, Greenbaum LA, Warady B, Moxey-Mims MM, Furth SL (2016) Assessment of dietary intake of children with chronic kidney disease. Pediatr Nephrol. doi:10.1007/s00467-016-3491-5

    Google Scholar 

  43. Grimes CA, Campbell KJ, Riddell LJ, Nowson CA (2011) Sources of sodium in Australian children’s diets and the effect of the application of sodium targets to food products to reduce sodium intake. Br J Nutr 105:468–477

    Article  CAS  PubMed  Google Scholar 

  44. Wise PM, Hansen JL, Reed DR, Breslin PA (2007) Twin study of the heritability of recognition thresholds for sour and salty taste. Chem Senses 32:749–754

    Article  PubMed  PubMed Central  Google Scholar 

  45. Fischbach M, Schmitt CP, Shroff R, Zaloszyc A, Warady BA (2016) Increasing sodium removal on peritoneal dialysis: applying dialysis mechanics to the peritoneal dialysis prescription. Kidney Int 89:761–766

    Article  CAS  PubMed  Google Scholar 

  46. Davies D, Carlsson O, Simonsen O, Johansson AC, Venturoli D, Ledebo I, Wieslander A, Chan C, Rippe B (2009) The effects of low-sodium peritoneal dialysis fluids on blood pressure, thirst and volume status. Nephrol Dial Transplant 24:1609–1617

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  47. Fischbach M, Terzic J, Laugel V, Escande B, Dangelser C, Helmstetter A (2003) Measurement of hydrostatic intraperitoneal pressure: a useful tool for the improvement of dialysis dose prescription. Pediatr Nephrol 18:976–980

    Article  CAS  PubMed  Google Scholar 

  48. Fischbach M, Terzic J, Becmeur F, Lahlou A, Desprez P, Battouche D, Geisert J (1996) Relationship between intraperitoneal hydrostatic pressure and dialysate volume in children on PD. Adv Perit Dial 12:330–334

    CAS  PubMed  Google Scholar 

  49. Rousso S, Banh TM, Ackerman S, Piva E, Licht C, Harvey EA (2016) Impact of fill volume on ultrafiltration with icodextrin in children on chronic peritoneal dialysis. Pediatr Nephrol 31:1673–1679

    Article  PubMed  Google Scholar 

  50. Fischbach M, Desprez P, Donnars F, Hamel G, Geisert J (1994) Optimization of CCPD prescription in children using peritoneal equilibration test. Adv Perit Dial 10:307–309

    CAS  PubMed  Google Scholar 

  51. Zaloszyc A, Schmitt CP, Schaefer B, Doutey A, Terzic J, Menouer S, Higel L, Fischbach M (2016) Peritoneal equilibration test: conventional versus adapted. Preliminary study. Nephrol Ther. doi:10.1016/j.nephro.2016.07.444

    PubMed  Google Scholar 

  52. Rippe B, Öberg CM (2016) Is adapted APD theoretically more efficient than conventional APD? Perit Dial Int. doi:10.3747/pdi.2015.00144

    PubMed  Google Scholar 

  53. Fischbach M, Issad B, Dubois V, Taamma R (2011) The beneficial influence on the effectiveness of automated peritoneal dialysis of varying the dwell time (short/long) and fill volume (small/large): a randomized controlled trial. Perit Dial Int 31:450–458

    Article  PubMed  Google Scholar 

  54. Thein H, Haloob I, Marshall MR (2007) Associations of a facility level decrease in dialysate sodium concentration with blood pressure and interdialytic weight gain. Nephrol Dial Transplant 22:2630–2639

    Article  CAS  PubMed  Google Scholar 

  55. Munoz Mendoza J, Arramreddy R, Schiller B (2015) Dialysate sodium: choosing the optimal hemodialysis bath. Am J Kidney Dis 66:710–720

    Article  CAS  PubMed  Google Scholar 

  56. Marsenic O, Anderson M, Couloures KG, Hong WS, Kevin Hall E, Dahl N (2016) Effect of the decrease in dialysate sodium in pediatric patients on chronic hemodialysis. Hemodial Int 20:277–285

    Article  PubMed  Google Scholar 

  57. Hwang KS, Choi EY, Park JS, Lee CH, Kang CM, Kim GH (2013) Postdialysis serum sodium changes and systolic blood pressure in patients undergoing online hemodiafiltration and high-flux hemodialysis. Kidney Res Clin Pract 32:62–65

    Article  PubMed  PubMed Central  Google Scholar 

  58. Fischbach M, Terzic J, Laugel V, Dheu C, Menouer S, Helms P, Livolsi A (2004) Daily on-line haemodiafiltration: a pilot trial in children. Nephrol Dial Transplant 19:2360–2367

    Article  PubMed  Google Scholar 

  59. Goldstein SL, Silverstein DM, Leung JC, Feig DI, Soletsky B, Knight C, Warady BA (2008) Frequent hemodialysis with NxStage system in pediatric patients receiving maintenance hemodialysis. Pediatr Nephrol 23:129–135

    Article  PubMed  Google Scholar 

  60. Hoppe A, von Puttkamer C, Linke U, Kahler C, Booss M, Braunauer-Kolberg R, Hofmann K, Joachimsky P, Hirte I, Schley S, Utsch B, Thumfart J, Briese S, Gellermann J, Zimmering M, Querfeld U, Muller D (2011) A hospital-based intermittent nocturnal hemodialysis program for children and adolescents. J Pediatr 158:95–99

    Article  PubMed  Google Scholar 

  61. Thumfart J, Puttkamer CV, Wagner S, Querfeld U, Müller D (2014) Hemodiafiltration in a pediatric nocturnal dialysis program. Pediatr Nephrol 29:1411–1416

    Article  PubMed  Google Scholar 

  62. Thumfart J, Hilliger T, Stiny C, Wagner S, Querfeld U, Müller D (2015) Is peritoneal dialysis still an equal option? Results of the Berlin Pediatric Nocturnal Dialysis Program. Pediatr Nephrol 30:1181–1187

    Article  PubMed  Google Scholar 

  63. Flynn JT, Mitsnefes M, Pierce C, Cole SR, Parekh RS, Furth SL, Warady BA, Chronic Kidney Disease in Children Study Group (2008) Blood pressure in children with chronic kidney disease: a report from the chronic kidney disease in children study. Hypertension 52:631–637

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Kupferman JC, Aronson Friedman L, Cox C, Flynn J, Furth S, Warady B, Mitsnefes M, CKiD Study Group (2014) BP control and left ventricular hypertrophy regression in children with CKD. J Am Soc Nephrol 25:167–174

    Article  PubMed  Google Scholar 

  65. Lin JJ, Mitsnefes MM, Smoyer WE, Valentini RP (2009) Antihypertensive prescription in pediatric dialysis: a practitioner survey by the Midwest pediatric Nephrology consortium study. Hemodial Int 13:307–315

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Commenda 9, 20122, Milan, Italy

    F. Paglialonga, S. Consolo, A. Edefonti & G. Montini

  2. Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy

    G. Montini

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  1. F. Paglialonga
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  2. S. Consolo
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  3. A. Edefonti
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  4. G. Montini
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1. c; 2. a; 3. c; 4. e; 5. d

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Paglialonga, F., Consolo, S., Edefonti, A. et al. Blood pressure management in children on dialysis. Pediatr Nephrol 33, 239–250 (2018). https://doi.org/10.1007/s00467-017-3666-8

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