Blood pressure in children with chronic kidney disease: a report from the Chronic Kidney Disease in Children study

Hypertension in pediatric long-term hemodialysis patients in the United States

BACKGROUND AND OBJECTIVES

Data are limited regarding BP distribution and the prevalence of hypertension in pediatric long-term dialysis patients. This study aimed to examine BP distribution in U.S. pediatric long-term hemodialysis patients.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

This cross-sectional study of all U.S. pediatric (aged 0-< 18 yr, n = 624) long-term hemodialysis patients was performed as part of the Centers for Medicare & Medicaid Services End-Stage Renal Disease (ESRD) Clinical Performance Measures Project. BP and clinical information were collected monthly in October, November, and December 2001. Hypertension was defined as the mean of pre- and postdialysis systolic or diastolic BP above the 95th percentile for age, height, and sex, or antihypertensive medication use. Results were calculated by age, sex, race, ethnicity, ESRD duration, body mass index percentile, primary cause of ESRD, and laboratory data.

RESULTS

Hypertension was present in 79% of patients; 62% used antihypertensive medication. Five percent of patients were prehypertensive (mean BP at 90th to 95th percentile). Hypertension was uncontrolled in 74% of treated patients. Characteristics associated with hypertension included acquired kidney disease, shorter duration of ESRD, and lower mean hemoglobin and calcium values. Characteristics associated with uncontrolled hypertension were younger age and shorter duration of ESRD.

CONCLUSIONS

Hypertension is common in U.S. pediatric long-term hemodialysis patients, uncontrolled in 74% of treated patients, and untreated in 21% of hypertensive patients. It is concluded that a more aggressive approach to treatment of hypertension is warranted in pediatric long-term hemodialysis patients.

Cardiovascular disease in CKD in children: update on risk factors, risk assessment, and management

In young adults with onset of chronic kidney disease in childhood, cardiovascular disease is the most common cause of death. The likely reason for increased cardiovascular disease in these patients is a high prevalence of traditional and uremia-related cardiovascular disease risk factors during childhood chronic kidney disease. Early markers of cardiomyopathy, such as left ventricular hypertrophy and left ventricular dysfunction, and early markers of atherosclerosis, such as increased carotid artery intima-media thickness, carotid arterial wall stiffness, and coronary artery calcification, frequently are found in this patient population. The purpose of this review is to provide an update of recent advances in the understanding and management of cardiovascular disease risks in this population.

Current advances in chronic kidney disease in children: growth, cardiovascular, and neurocognitive risk factors

Linear growth and neurocognitive development are two of the most important differences between adults and children, in terms of clinical issues that must be addressed in patients with chronic kidney disease (CKD). Correction of metabolic acidosis, nutritional deficiency, and renal osteodystrophy improve linear growth, but many children require administration of growth hormone to achieve normal growth. A variety of neurocognitive deficits occur in children with CKD, although there has been an improvement in outcome via improved dialysis, correction of malnutrition, and decreased aluminum exposure. Although growth and neurocognitive development are delayed, cardiovascular complications are accelerated in children with CKD, and are reflected in a dramatic increase in cardiovascular mortality compared with healthy children. Other early cardiovascular complications in children with CKD include left ventricular hypertrophy, cardiac dysfunction, and vascular calcifications.

Cardiovascular disease in children with CKD or ESRD

Cardiovascular disease accounts for 40% of all deaths among pediatric patients with end-stage renal disease (ESRD). ESRD has a particularly large influence on the cardiovascular system in children, as indicated by the more than 700-fold increased risk of cardiac death in affected individuals compared with healthy children of the same age. The prevalence of ESRD is low in children, however, and, consequently, few cardiac deaths occur. As a result, prospective follow-up studies of cardiac risk factors in the pediatric setting are lacking. Nevertheless, cross-sectional data on cardiac disease in children with ESRD have started to emerge. Arterial medial calcification is more prominent in children than classic atherosclerotic intimal calcification. Current data suggest that endothelial dysfunction appears early in renal failure in children, and is followed by arterial medial calcification. This calcification causes arterial wall stiffening and subsequently left ventricular hypertrophy. High systolic blood pressure and serum concentrations of intact parathyroid hormone, calcium and phosphate, as well as long-term dialysis, seem to be important risk factors for cardiovascular disease in pediatric patients with ESRD. These features are important targets for preventive intervention. This Review summarizes the currently available data on cardiovascular disease in children with renal failure.