Aortic Pulse Wave Velocity in Healthy Children and Adolescents: Reference Values for the Vicorder Device and Modifying Factors

Physical activity and its impact on cardiovascular health in pediatric kidney transplant recipients

BACKGROUND

Cardiovascular (CV) morbidity after kidney transplantation (KTx) in childhood is of increasing importance. In light of a high prevalence of CV risk factors, protective measures such as physical activity (PA) come into focus. Our aim was to comprehensively assess PA in pediatric KTx recipients and evaluate its impact on CV health.

METHODS

Forty-eight patients were assessed for frequency, duration, intensity, and setting of PA using the "Motorik-Modul" PA questionnaire. Walking-based activity was measured by accelerometer in a subgroup (n = 23). CV risk factors and subclinical CV organ damage were determined. The impact of PA on CV parameters was analyzed using linear regression models.

RESULTS

Fifty-two percent of pediatric KTx recipients did not reach WHO recommended PA level; 54% did not engage in PA with vigorous intensity (VPA). Twenty-nine percent indicated an extremely inactive lifestyle (< 120 min/week of moderate to vigorous intensity PA, MVPA). Compared to the healthy German KiGGS cohort, KTx recipients specifically lacked engagement in sport activities (KTx: 129 min/week; 95%CI, 97-162 vs. KiGGS, 242 min/week; 95%CI, 230-253). VPA was associated with lower systolic blood pressure (p = 0.024) and resting heart rate (p = 0.005), MVPA with fewer components of the post-transplant metabolic syndrome (p = 0.037), and better left ventricular diastolic function (p = 0.006).

CONCLUSIONS

A considerable lack of PA, especially VPA, exists in young KTx recipients. PA was positively associated with important parameters of CV health. While long-term CV protection through PA seems promising in pediatric KTx recipients, specific educational approaches are most likely needed to increase patients' engagement in sport activities.

Maternal Seafood Consumption during Pregnancy and Cardiovascular Health of Children at 11 Years of Age

Nutrition is critical during pregnancy for the healthy growth of the developing infant, who is fully dependent on maternal dietary omega-3 supply for development. Fatty fish, a main dietary source of omega-3, is associated with decreased cardiovascular risk in adults. We conducted a longitudinal study based on a mother-offspring cohort as part of the project Infancia y Medio Ambiente (INMA) in order to assess whether fish intake during pregnancy relates to cardiovascular health in children. A total of 657 women were included and followed throughout pregnancy until birth, and their children were enrolled at birth and followed up until age 11-12. A semi-quantitative food frequency questionnaire was used to assess the daily intake of foods during the 1st and 3rd trimesters of pregnancy. Cardiovascular assessments included arterial stiffness (assessed by carotid-femoral pulse wave velocity [PWV]) and retinal microcirculation (photographic assessment of central retinal arteriolar and venular equivalent [CRAE and CRVE]). The association between maternal fish consumption and cardiovascular outcomes of offspring at 11 years of age was evaluated using multivariable linear regression models. There were no statistically significant differences in any cardiovascular endpoint in children whose mothers had a higher fish consumption during pregnancy compared to those with a lower fish consumption. We found a slightly higher PWV (β = 0.1, 95% CI = 0.0; 0.2, p for trend = 0.047) in children whose mothers had a higher consumption of canned tuna during the 1st trimester of pregnancy. Fish intake during pregnancy was found to be unrelated to the offspring's cardiovascular health at 11 years of age. The beneficial cardiovascular effects of fish consumption during pregnancy on the offspring are still inconclusive.

Translating scientific recommendations into reality: a feasibility study using group-based high-intensity functional exercise training in adolescents with cerebral palsy

PURPOSE

To examine the feasibility and effects of a functional high-intensity exercise intervention performed in a group-setting on functionality, cardiovascular health and physical performance in adolescents with cerebral palsy (CP).

METHODS

Ten adolescents with a diagnosis of CP (2 females; 16.6 ± 3.4 years; GMFCS: I-II) participated in a 12-week training intervention, containing progressive resistance training using free weights and high-intensity workouts twice a week. The six-minute walking test, arterial stiffness and physical performance (strength and power tests) were measured before and after the intervention.

RESULTS

No adverse events were reported. We measured small increases in the six-minute walking test (Δ = 28.8 m, 95% CI [-1.78;52.7]; g = 0.34 [-0.04;0.72]) and a small reduction in arterial stiffness (Δ = -4.65% [-10.90;1.25]; g = -0.46 [-1.36;0.21]). All measures of physical performance increased (0.24 ≤ g ≤ 0.88).

CONCLUSION

Functional training with free weights in high-functioning adolescents with CP is safe and effective in increasing parameters of physical performance and cardiovascular health. Positively influenced indicators of everyday independence (i.e. strength parameters) showed a transfer into movements of daily life. Concerns about adverse events through high-intensity training in adolescents with CP appear unjustified when training is performed progressively, following basic training principles.

Pulse wave velocity during re-feeding and with weight gain in underweight female adolescents with anorexia nervosa

Anorexia Nervosa (AN) causes harmful underweight and important cardiovascular acute complications however less is known about longer-term cardiovascular risk. We measured carotid femoral pulse wave velocity (PWV) in a group of underweight young women with AN at baseline and weekly as they were refed and gained weight. PWV decreased over time and was negatively associated with increasing BMI and calorific meal content suggesting potential positive cardiovascular benefits for refeeding and weight gain in AN and supports current consensus for the importance of weight gain in underweight young women with AN.

Vascular ageing: moving from bench towards bedside

Prevention of cardiovascular disease (CVD) remains one of the largest public health challenges of our time. Identifying individuals at increased cardiovascular risk at an asymptomatic, sub-clinical stage is of paramount importance for minimizing disease progression as well as the substantial health and economic burden associated with overt CVD. Vascular ageing (VA) involves the deterioration in vascular structure and function over time and ultimately leads to damage in the heart, brain, kidney, and other organs. Vascular ageing encompasses the cumulative effect of all cardiovascular risk factors on the arterial wall over the life course and thus may help identify those at elevated cardiovascular risk, early in disease development. Although the concept of VA is gaining interest clinically, it is seldom measured in routine clinical practice due to lack of consensus on how to characterize VA as physiological vs. pathological and various practical issues. In this state-of-the-art review and as a network of scientists, clinicians, engineers, and industry partners with expertise in VA, we address six questions related to VA in an attempt to increase knowledge among the broader medical community and move the routine measurement of VA a little closer from bench towards bedside.

Cardiovascular health and potential cardiovascular risk factors in young athletes

Introduction

Cardiovascular disease remains the most common cause of death worldwide, and early manifestations are increasingly identified in childhood and adolescence. With physical inactivity being the most prevalent modifiable risk factor, the risk for cardiovascular disease is deemed low in people engaging in regular physical exercise. The aim of this study was to investigate early markers and drivers of cardiovascular disease in young athletes pursuing a career in competitive sports.

Methods

One hundred and five athletes (65 males, mean age 15.7 ± 3.7 years) were characterized by measurement of body impedance to estimate body fat, blood pressure (BP), carotid femoral pulse wave velocity (PWV) to evaluate arterial elasticity, ergometry to assess peak power output, echocardiography to calculate left ventricular mass, and blood tests.

Results

Systolic BP was elevated in 12.6% and thereby more than twice as high as expected for the normal population. Similarly, structural vascular and cardiac changes represented by elevated PWV and left ventricular mass were found in 9.5% and 10.3%. Higher PWV was independently associated with higher systolic BP (β = 0.0186, p < 0.0001), which in turn was closely correlated to hemoglobin levels (β = 0.1252, p = 0.0435). In this population, increased left ventricular mass was associated with lower resting heart rate (β = -0.5187, p = 0.0052), higher metabolic equivalent hours (β = 0.1303, p = 0.0002), sport disciplines with high dynamic component (β = 17.45, p = 0.0009), and also higher systolic BP (β = 0.4715, p = 0.0354).

Conclusion

Despite regular physical exercise and in the absence of obesity, we found an unexpected high rate of cardiovascular risk factors. The association of PWV, systolic BP, and hemoglobin suggested a possible link between training-induced raised hemoglobin levels and altered vascular properties. Our results point toward the need for thorough medical examinations in this seemingly healthy cohort of children and young adults. Long-term follow-up of individuals who started excessive physical exercise at a young age seems warranted to further explore the potential adverse effects on vascular health.

Pulse wave velocity in early-treated children living with perinatal HIV infection is similar to uninfected children

INTRODUCTION

HIV is associated with accelerated cardiovascular disease, due to HIV-associated metabolic abnormalities, antiretroviral therapy (ART), and HIV itself. Carotid-femoral pulse wave velocity (PWV) is the noninvasive gold standard measurement of arterial stiffness, and associated with incident vascular events in adults. It is unclear if arterial stiffness is accelerated in children living with perinatal HIV (CHIV) who initiate ART early in life. We compared the longitudinal trajectory of PWV in CHIV to children unexposed to HIV. A secondary comparison compared HIV exposed uninfected children (CHEU) to unexposed children.

METHODS

Four hundred and sixty-five children (141 CHIV, 160 CHEU, 164 unexposed) previously in the children with HIV early antiretroviral therapy (ART) (CHER) and P1060 trials were followed annually at Tygerberg Children's Hospital, South Africa between 2014 and 2020. CHIV initiated ART in infancy or early childhood, with excellent ART adherence and largely sustained viral suppression. The primary outcome was PWV, measured using the Vicorder system, and evaluated using linear mixed effects models.

RESULTS

Median (interquartile range) age at first PWV measurement was 8.64 (7.7-9.1) years, and median follow-up time 2.9 (1.6-4.0) years. Adjusted analyses showed no significant mean difference in PWV in CHIV and CHEU compared to unexposed [CHIV: 0.101 m/s, 95% confidence interval (CI) -0.012 to 0.214; CHEU: 0.068 m/s, 95% CI -0.047 to 0.183], after adjusting for gender, age, ethnicity, mean arterial pressure, resting average heart rate and family history of cardiovascular disease.

CONCLUSIONS

Early-treated CHIV with sustained viral suppression have similar PWV to unexposed children. Excellent adherence and early ART initiation may protect against cardiovascular disease.

Oscillometric pulse wave velocity estimated via the Mobil-O-Graph shows excellent accuracy in children, adolescents and young adults: an invasive validation study

AIMS

Increased arterial stiffness, measured as arterial pulse wave velocity (PWV) is associated with an elevated cardiovascular risk. Although noninvasive PWV measurement methods have been validated by invasive measurement, there is little such data on pediatric patients. The purpose of this study was to 'fill the gap' by validating PWV obtained by Mobil-O-Graph in children, adolescents in comparison to young adults.

METHODS

Sixty patients (25 male, mean age 16.6 years; range 3-35 years) were included in this study. Fifty-one patients underwent cardiac catheterization after a heart transplantation (HTX) and nine for interventional atrial septal defect-closure. Specific invasive pulse wave velocities were assessed for the ascending aorta (aPWV) and entire central aorta (cPWV). These invasive PWV results were compared to simultaneously measured brachial cuff readings using Mobil-O-Graph (oPWV) stratified by age in two groups (PEDIATRICS <18 years|ADULTS ≥18 years).

RESULTS

Correlation analysis showed a positive linear relation between both invasive PWV measurements and the oPWV in all ages (cPWV/oPWV: r  = 0.417, aPWV/oPWV: r  = 0.628; P  < 0.001). The oPWV data agreed better with the aPWV in mean-value comparisons and correlations with mean difference in PEDIATRICS was 0.41 ± 0.41 m/s (95% confidence interval 0.27-0.55). We also found the cPWV to be faster than the aPWV particularly in adults. In addition, cPWV correlated closer with age ( r  = 0.393, P  < 0.05).

CONCLUSION

Estimated oPWV using the Mobil-O-Graph demonstrated excellent accuracy in adults and pediatric patients. Therefore, the Mobil-O-Graph can be implemented as an ambulatory PWV measuring tool for pediatric cardiovascular risk stratification.

CLINICAL TRIAL REGISTRATION

German clinical trial registration, DRKS00015066.

Arterial stiffness indices, pulse wave velocity and central systolic blood pressure, are able to discriminate between obese and non-obese children

The objectives of this study were to verify, first, if arterial stiffness indices can discriminate between obese and healthy children. Second, to evaluate arterial stiffness index predictors and hemodynamic parameters in obese children. Arterial stiffness indices evaluated were pulse wave velocity (PWV), central systolic blood pressure (SBPc), and central pulse pressure (PPc). A cross-sectional, descriptive, comparative study design was used. The sample consisted of 78 normal-weight children (8.1 ± 1.96 years) and 58 obese children (9.0 ± 1.87 years). PWV, PPc, and SBPc were significantly higher in the group of obese children than in the control group. The ROC curve analysis showed that maximum PWV and SBPc sensitivity and specificity in differentiating obese from non-obese children occurred at 4.09 m/s and 86.17 mmHg, respectively. PPc did not exhibit a discriminatory capacity between the two groups. Peripheral systolic blood pressure (SBPp), peripheral pulse pressure (PPp), and PPc (R² = 0.98) were predictors of increased PWV. Augmentation pressure, PPp, and reflection coefficient (R² = 0.873) were predictors of PPc. Age, augmentation index, total vascular resistance, cardiac index, and mean fat percentage (R² = 0.801) were predictors of SBPc.

CONCLUSION

This study shows for the first time that PWV > 4.09 m/s and SBPc > 86.17 mmHg are cut-off points associated with a higher risk of obesity. These results indicate that the simple, rapid, and noninvasive measurement of arterial stiffness adds prognostic information regarding cardiovascular risk, in addition to increased body mass index.

WHAT IS KNOWN

• Overweight and obesity are strongly associated with comorbidities que contribute to the development of cardiovascular diseases.

WHAT IS NEW

• This is the first study to show that PWV and SBPc can discriminate obese from non-obese children. These results show that, in addition to an increased BMI, a simple, rapid, and noninvasive measurement of arterial stiffness adds prognostic information on cardiovascular risk.

The significance of central blood pressure for cardiovascular target organ damage in children and adolescents after kidney transplantation

BACKGROUND

Cardiovascular (CV) complications are important causes of morbidity and mortality in children after kidney transplantation (KTx). In adults, central blood pressure (cBP) is an accepted predictor of CV sequelae. We aimed to assess the prognostic value of cBP over peripheral blood pressure (pBP) for existing CV damage.

METHODS

We measured cBP and pBP in 48 pediatric KTx recipients (mean age: 13.5 ± 4.2 years). Assessment of left ventricular mass index (LVMI) and aortic pulse wave velocity (PWV) allowed detection of CV target organ damage. LVMI and PWV were used as endpoints in multivariable linear regression models, in which cBP and pBP were compared for their predictive value.

RESULTS

Using cBP z-scores, we identified a larger number of patients with uncontrolled or untreated hypertension compared to pBP (36% vs. 7%). Central systolic blood pressure (cSBP) was a significant independent predictor of LVMI, while peripheral systolic blood pressure (pSBP) was not. Comparing central (cDBP) and peripheral (pDBP) diastolic blood pressure for their predictive value on PWV revealed a greater estimate for cDBP (0.035 vs. 0.026 for pDBP) along with a slightly better model fit for cDBP.

CONCLUSIONS

Our data in a small group of patients provide first evidence that cBP measurements in pediatric KTx recipients might be helpful in identifying patients at risk for the development of CV sequelae. Investigating a larger patient number, ideally repeatedly, is needed to create further evidence supporting our findings. In light of available devices measuring cBP noninvasively, the implementation of such clinical studies post-KTx care should be feasible. A higher resolution version of the Graphical abstract is available as Supplementary information.

Arterial stiffness and blood pressure increase in pediatric kidney transplant recipients

BACKGROUND

Pulse wave velocity (PWV) is a measure of arterial stiffness. We investigated PWV and blood pressure (BP) to determine to what extent BP changes contribute to arterial stiffness, and secondly, to identify influencing factors on BP in children after kidney transplantation.

METHODS

Seventy children ≥ 2.5 years post-transplantation with at least two PWV measurements were included. Changes of systolic (Δ SBP) and diastolic BP (Δ DBP) were classified into "stable/decreasing," "1-10 mmHg increase," and " > 10 mmHg increase." Linear mixed modeling for PWV z-score (PWVz) adjusted either for Δ SBP or Δ DBP was performed. An extended dataset with monthly entries of BP, immunosuppression, and creatinine was obtained in 35 participants over a median of 74 months to perform linear mixed modeling for SBP and DBP.

RESULTS

PWVz increased with a rate of 0.11/year (95% CI 0.054 to 0.16). Compared to participants with stable BP, those with 1-10-mmHg SBP and DBP increase showed a higher PWVz of 0.59 (95% CI 0.046 to 1.13) and 0.86 (95% CI 0.43 to 1.30), respectively. A > 10-mmHg BP increase was associated with an even higher PWVz (SBP β = 0.78, 95% CI 0.22 to 1.34; DBP β = 1.37, 95% CI 0.80 to 1.94). Female sex and participants with lower eGFR showed higher PWVz. In the extended analysis, DBP was positively associated with cyclosporin A and everolimus trough levels.

CONCLUSIONS

A higher increase of PWV is seen in patients with greater BP increase, with higher cyclosporin A and everolimus trough levels associated with higher BP. This emphasizes the role of BP as a modifiable risk factor for the improvement of cardiovascular outcome after transplantation. A higher resolution version of the Graphical abstract is available as Supplementary information.

Bone Mineral Density and Vascular Calcification in Children and Young Adults With CKD 4 to 5 or on Dialysis

Introduction

Older adults with chronic kidney disease (CKD) can have low bone mineral density (BMD) with concurrent vascular calcification. Mineral accrual by the growing skeleton may protect young people with CKD from extraosseous calcification. Our hypothesis was that children and young adults with increasing BMD do not develop vascular calcification.

Methods

This was a multicenter longitudinal study in children and young people (5-30 years) with CKD stages 4 to 5 or on dialysis. BMD was assessed by tibial peripheral quantitative computed tomography (pQCT) and lumbar spine dual-energy X-ray absorptiometry (DXA). The following cardiovascular imaging tests were undertaken: cardiac computed tomography for coronary artery calcification (CAC), ultrasound for carotid intima media thickness z-score (cIMTz), pulse wave velocity z-score (PWVz), and carotid distensibility for arterial stiffness. All measures are presented as age-adjusted and sex-adjusted z-scores.

Results

One hundred participants (median age 13.82 years) were assessed at baseline and 57 followed up after a median of 1.45 years. Trabecular BMD z-score (TrabBMDz) decreased (P = 0.01), and there was a nonsignificant decrease in cortical BMD z-score (CortBMDz) (P = 0.09). Median cIMTz and PWVz showed nonsignificant increase (P = 0.23 and P = 0.19, respectively). The annualized increase in TrabBMDz (ΔTrabBMDz) was an independent predictor of cIMTz increase (R ² = 0.48, β = 0.40, P = 0.03). Young people who demonstrated statural growth (n = 33) had lower ΔTrabBMDz and also attenuated vascular changes compared with those with static growth (n = 24).

Conclusion

This hypothesis-generating study suggests that children and young adults with CKD or on dialysis may develop vascular calcification even as their BMD increases. A presumed buffering capacity of the growing skeleton may offer some protection against extraosseous calcification.

Pulse Wave Velocity Measurements by Magnetic Resonance Imaging in Neonates and Adolescents: Methodological Aspects and Their Clinical Implications

Pulse wave velocity (PWV) by cardiovascular magnetic resonance (CMR) lacks standardization. The aim of this study was to investigate methodological aspects of PWV measurements by CMR in neonates and adolescents. A computer phantom was created to validate the temporal resolution required for accurate PWV. Fifteen neonates and 71 adolescents underwent CMR with reference standard 3D angiography and phase-contrast flow acquisitions, and in a subset coronal overview images. Velocity and flow curves, transit time methods (time-to-foot (TTF), maximum upslope, and time-to-peak (TTP)), and baseline correction methods (no correction, automatic and manual) were investigated. In neonates, required timeframes per cardiac cycle for accurate PWV was 42 for the aortic arch and 41 for the thoracic aorta. In adolescents, corresponding values were 39 and 32. Aortic length differences by overview images and 3D angiography in adolescents were - 16-18 mm (aortic arch) and - 25-30 mm (thoracic aorta). Agreement in PWV between automatic and manual baseline correction was - 0.2 ± 0.3 m/s in neonates and 0.0 ± 0.1 m/s in adolescents. Velocity and flow-derived PWV measurements did not differ in either group (all p > 0.08). In neonates, transit time methods did not differ (all p > 0.19) but in adolescents PWV was higher for TTF (3.8 ± 0.5 m/s) and maximum upslope (3.7 ± 0.6 m/s) compared to TTP (2.7 ± 1.0 m/s; p < 0.0001). This study is a step toward standardization of PWV in neonates and adolescents using CMR. It provides required temporal resolution for phase-contrast flow acquisitions for typical heartrates in neonates and adolescents, and supports 3D angiography and time-to-foot with automatic baseline correction for accurate PWV measurements.

Arterial Stiffness and Chronic Kidney Disease Progression in Children

BACKGROUND AND OBJECTIVES

CKD has been linked to increased arterial stiffness in adults, but data in children with CKD remain conflicting. We aimed to investigate the longitudinal dynamics and determinants of pulse wave velocity in children with CKD and its association with CKD progression.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We performed an analysis of the Cardiovascular Comorbidity in Children with Chronic Kidney Disease (4C) study, which prospectively followed children aged 6-17 years with CKD stages 3-5. Follow-up was censored at the time of KRT initiation. Two separate analyses were performed: with absolute pulse wave velocity (primary outcome) and with pulse wave velocity standardized to height (z score; restricted to participants ≤17 years) as a sensitivity analysis.

RESULTS

In total, 667 patients with a mean baseline eGFR of 27 ml/min per 1.73 m2 were included. Pulse wave velocity above the 95th percentile was observed in 124 (20%) patients at baseline. Absolute pulse wave velocity increased gradually over the median follow-up of 2.7 (interquartile range, 0.7-4.4) years, whereas pulse wave velocity z score remained relatively stable. Absolute pulse wave velocity over time associated with time; older age; higher mean arterial pressure, LDL cholesterol, and albuminuria; and lower ferritin. Pulse wave velocity z score (n=628) was associated with the same variables and additionally, with higher diastolic BP z score, lower height z score, younger age, and girls. Of 628 patients, 369 reached the composite end point of CKD progression (50% eGFR loss, eGFR <10 ml/min per 1.73 m2, or the start of KRT) during a median follow-up of 2.4 (interquartile range, 0.9-4.6) years. Pulse wave velocity z score did not associate with CKD progression by univariable or multivariable proportional hazard analysis correcting for the established predictors eGFR, proteinuria, and BP.

CONCLUSIONS

Pulse wave velocity is increased in children with CKD but does not associate with eGFR or CKD progression.

A Mother-Child Dyadic Approach to Evaluating Subclinical Cardiovascular Disease in Young Children: A Feasibility Study

BACKGROUND

Cardiovascular (CV) risk factors can be transmitted from mothers to their children. However, it is challenging to measure and identify subclinical CV risk in young children using traditional CV risk methods and metrics.

OBJECTIVE

The purpose of this study was to determine the feasibility of recruiting mother-child dyads and measuring arterial stiffness (pulse wave velocity, augmentation index/pressure), blood pressure (BP), BP circadian pattern, specifically nocturnal BP dipping, and CV health metrics in mothers and in children aged 1 to 5 years.

METHODS

All BP and arterial stiffness measures were obtained using the noninvasive automated oscillometric Mobil-O-Graph device. Also measured were blood cholesterol level; glucose level; body mass index (BMI); and smoking, diet, and physical activity history. Descriptive statistics were used for assessing recruitment feasibility and Pearson correlations for mother-child associations.

RESULTS

Thirty-five mother-child dyads completed the protocol. Recruitment reach was 89% and retention rate was 80%. Mothers were 34.3 ± 5.4 years old with a mean systolic BP (SBP) of 114.6 ± 9.5 mm Hg and BMI of 26.0 ± 6.5. Children were 3 ± 1.4 years old with a mean SBP of 103.3 ± 9.4 mm Hg and BMI z-scores of -0.3 ± 1.5. Arterial stiffness parameters were within normal ranges for mothers and children. Twenty-three percent of mothers did not exhibit nocturnal dipping (<10% decrease between day and nighttime SBP). Maternal SBP was positively correlated with child BMI z-scores (r = 0.42, P = .022) as well as mother-child augmentation pressure (r = 0.51, P = .010).

CONCLUSIONS

Our findings support using a mother-child approach and novel noninvasive approaches to assess and target CV risk in mothers and their young children.

Fibroblast Growth Factor 23 Level and Cardiovascular Parameters in Children with Chronic Kidney Disease

OBJECTIVE

To find out the serum fibroblast growth factor 23 (FGF-23) levels in different grades of CKD, and the prevalence of abnormal left ventricular mass index (LVMI), carotid intima-medial thickness (cIMT), and central pulse wave velocity (cPWV) and the risk factors including FGF-23 for these abnormalities.

METHODS

Fifty-nine patients of CKD with G2 to G5, aged 2-18 y were included. The LVMI, cIMT, and cPWV were measured using standard techniques, and serum intact FGF-23 levels were estimated at enrollment.

RESULTS

Median FGF-23 levels were significantly raised in all the grades of CKD than controls (p < 0.001), and also in G4 and G5 in comparison to G2&3 and in G5D than G5. Increased LVMI in 42 (71.2%), elevated cIMT in 30 (57.7%), and cPWV in 14 (26.9%) patients were found. The FGF-23 showed significant negative correlation with eGFRcr and positive with serum iPTH, phosphate and alkaline phosphatase levels, but had no correlations with LVMI, cIMT SDS, and cPWV SDS. Only systolic BP SDS (odds ratio 1.5, 95% CI 1.008-2.231, p = 0.046) was observed as a significant predictor for increased cIMT, while no variables had any association with abnormal LVMI and cPWV.

CONCLUSIONS

Serum FGF-23 showed higher levels with increasing grades of CKD, but no significant association with cardiovascular parameters. Systolic BP SDS was found as a significant risk factor for increased cIMT in children with CKD.

Vascular biomarkers in the prevention of childhood cardiovascular risk: From concept to clinical implementation

Vascular biomarkers allow for non-invasive assessment of vascular structure and function and have been shown to be surrogates for cardiovascular (CV) outcome in adults. They reflect the cumulative risk of a plethora of single CV risk factors, such as obesity and hypertension, on the arterial wall. The process of atherosclerosis oftentimes has its origin in childhood and tracks into adulthood. Obesity-related CV risk in childhood is a main determinant of manifest CV disease and adverse outcome in adulthood. To date, prevention strategies are directed toward the detection and reduction of CV disease in adulthood. This review updates and puts into perspective the potential use of vascular biomarkers in children. With reference to the concept of early vascular aging in adults, it elaborates on the role of vascular biomarkers for CV risk stratification in children. The concept of primordial vascular aging implies that young children be screened for vascular health, in an attempt to timely detect subclinical atherosclerosis and initiate treatment strategies to reverse vascular damage in a period of life with high probability for risk regression. The evidence for the validity of macro- and microvascular candidate biomarkers as screening tools of CV risk in children is reviewed, and limitations as well as remaining research gaps are highlighted. Furthermore, an overview on the effects of exercise treatment on vascular biomarkers is given. Vascular biomarkers susceptible to lifestyle or drug treatment have the potential to qualify as monitoring tools to guide clinicians. This review discusses evidence for vascular biomarkers to optimize screening of childhood CV risk from initial concepts to potential future clinical implementation in cardiovascular prevention.

Arterial stiffness precedes hypertension and metabolic risks in youth: a review

Arterial stiffness is a strong predictor of cardiovascular events and all-cause mortality in middle-aged and old adults. Arterial stiffness has been limited to being an intermediate marker of atherosclerotic cardiovascular events in adolescents and young adult studies. The paucity of normative longitudinal data and repeated gold-standard assessments of arterial stiffness among the young population has occasioned a huge knowledge gap in its clinical utility. This review summarizes recent longitudinal evidence in a large adolescent population, supporting the value of arterial stiffness as a novel risk factor for hypertension, overweight/obesity and insulin resistance. Preventing or decreasing arterial stiffness during adolescence may confer cardiometabolic health benefits in later life, but further pathological and mechanistic research is needed. The review also offers suggestions for incorporating arterial stiffness measures into routine paediatric and young adult clinical practice.

Disparities between determinants of impaired vascular structure and function in young people with primary hypertension: a systematic review

OBJECTIVE

Early effects of primary hypertension on arterial structure and function in children and young people (CYP) and their determinants remain elusive. We aimed to review independent determinants of carotid intima-media thickness (cIMT), carotid wall cross-sectional area (WCSA) and carotid-femoral pulse wave velocity (cfPWV) in CYP with primary hypertension.

METHODS

We performed a systematic review of studies reporting multivariable analysis of cfPWV, cIMT and WCSA in CYP (up to 25 years of age) with primary hypertension. Literature search was performed in PubMed database and 13, 12 and two articles including 3860 (age range 4-25 years, 50% male individuals), 2038 children (5-25 years, 55% male individuals) and 136 children (5-17 years, 85% male individuals) were selected for final analysis of cfPWV, cIMT and WCSA, respectively.

RESULTS

Ninety and 86% of the studies reported higher cfPWV and cIMT in CYP with elevated blood pressure (BP) compared with normotensive controls. Different indices of BP were positively associated with cfPWV in 92% of studies, whereas BMI showed association in 31%. Carotid IMT associated with BP indices in 50% and with BMI in 25% of the studies. WCSA was studied longitudinally and its improvement associated with decrease in measures of central obesity.

CONCLUSION

We found a disparity between the determinants of structural and functional impairment of arterial tree in CYP with primary hypertension. In contrast to cIMT and WCSA, increase of cfPWV is almost exclusively determined by BP.

Cardiovascular Burden Is High in Pediatric Lung Transplant Recipients

BACKGROUND

Cardiovascular morbidity is common in adults after lung transplantation (LTx) but has not been described for pediatric LTx recipients. Early subclinical cardiovascular damage is reflected by increases in pulse wave velocity (PWV; indicating arteriosclerosis), intima-media thickness (IMT; indicating atherosclerosis), and left ventricular mass index (LVMI; indicating left ventricular hypertrophy).

METHODS

We annually assessed 47 pediatric LTx recipients in a prospective longitudinal study (144 observations, mean 3.1 visits/patient, range of 1-4 visits, mean follow-up 2.2 y).

RESULTS

At inclusion, increased PWV and IMT were detected in 13% and 30%, respectively, and elevated LVMI was detected in 33%. Higher PWV was associated with male sex, longer time since LTx, higher diastolic blood pressure, and lower glomerular filtration rate. Male sex and lower hemoglobin levels were associated with higher IMT, and the presence of diabetes was associated with higher LVMI.

CONCLUSIONS

Pediatric LTx recipients suffer from a high and sustained burden of subclinical cardiovascular damage. In light of improving long-term outcomes, cardiovascular morbidity needs to be addressed. Our analysis identified classical and nonclassical risk factors to be associated with the measures for cardiovascular damage, which could serve as targets for intervention.

The burden of subclinical cardiovascular disease in children and young adults with chronic kidney disease and on dialysis

Background

Cardiovascular disease (CVD) is a common cause of morbidity and mortality even in young people with chronic kidney disease (CKD). We examined structural and functional CV changes in patients ˂30 years of age with CKD Stages 4 and 5 and on dialysis.

Methods

A total of 79 children and 21 young adults underwent cardiac computed tomography for coronary artery calcification (CAC), ultrasound for carotid intima-media thickness (cIMT), carotid–femoral pulse wave velocity (cfPWV) and echocardiography. Differences in structural (CAC, cIMT z-score, left ventricular mass index) and functional (carotid distensibility z-score and cfPWV z-score) measures were examined between CKD Stages 4 and 5 and dialysis patients.

Results

Overall, the cIMT z-score was elevated [median 2.17 (interquartile range 1.14–2.86)] and 10 (10%) had CAC. A total of 16/23 (69.5%) patients with CKD Stages 4 and 5 and 68/77 (88.3%) on dialysis had at least one structural or functional CV abnormality. There was no difference in the prevalence of structural abnormalities in CKD or dialysis cohorts, but functional abnormalities were more prevalent in patients on dialysis (P < 0.05). The presence of more than one structural abnormality was associated with a 4.5-fold increased odds of more than one functional abnormality (95% confidence interval 1.3–16.6; P < 0.05). Patients with structural and functional abnormalities [cIMT z-score >2 standard deviation (SD) or distensibility <−2 SD) had less carotid dilatation (lumen:wall cross-sectional area ratio) compared with those with normal cIMT and distensibility.

Conclusions

There is a high burden of subclinical CVD in young CKD patients, with a greater prevalence of functional abnormalities in dialysis compared with CKD patients. Longitudinal studies are required to test these hypothesis-generating data and define the trajectory of CV changes in CKD.

Protective Effects of Appropriate Amount of Nuts Intake on Childhood Blood Pressure Level: A Cross-Sectional Study

OBJECTIVE

Increased blood pressure (BP) is a major risk factor for cardiovascular disease (CVD) in adults. Regular consumption of nuts may improve some BP in adults whereas evidence in children is relatively lacking. This study aimed to determine the efficacy of nuts intake on BP in children.

METHODS

Stratified cluster sampling was performed to include a total of 15,268 primary school children aged 6-12 years in urban and rural areas in Southwest China. The daily nuts intake dosage was collected by questionnaires, and generalized linear model (GLM) and logistic regression were used to analyze the relationship between nuts intake and BP.

RESULTS

For the total subjects, 11,130 (72.9%) participants consumed <35 g/day of nuts, 1,145 (7.5%) participants consumed 35 g/day ≤ nut <50 g/day of nuts, 2,053 (13.4%) participants consumed 50~100 g/day of nuts, and 940 (6.2%) participants consumed over 100 g/day of nut. For sex subgroup, 1,074 (13.53%) boys and 979 (13.35%) girls consumed 50~100 g/day of nuts. Compared with the 50~100 g/day of nuts intake group, systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure (MAP) were significantly different in <35 g/day, 35g/day ≤ nut <50 g/day, and >100 g/day nuts intake groups (all p < 0.001). The logistic regression showed that compared with the 50~100 g/day group, the other three groups are more likely associated with childhood hypertension (all p < 0.001). Therefore, a U-shaped relationship between nuts intake and BP level was identified.

CONCLUSIONS

The finding suggests that intake of 50~100 g/day nuts is the recommended dose of nuts intake to control childhood hypertension, as well as for cardioprotection purposes.

The Determinants of Adolescent Glycolipid Metabolism Disorder: A Cohort Study

BACKGROUND

The increased prevalence of glycolipid metabolism disorders (GLMD) in childhood and adolescents has a well-established association with adult type 2 diabetes and cardiovascular diseases; therefore, determinants of GLMD need to be evaluated during this period.

OBJECTIVES

To explore the prevalence of and risk factors for GLMD from the prenatal period through childhood and adolescence.

METHODS

A bidirectional cohort study which was established in 2014 and followed between March 1 and July 20, 2019, was used to illustrate the impact factors for GLMD. Stratified cluster sampling in urban-rural areas was used to include subjects from four communities in Chongqing. 2808 healthy children aged between 6 and 9 years in 2014 entered the cohort in 2014 and followed in 2019 with a follow-up rate of 70%. 2,136 samples (aged 11.68 ± 0.60 years) were included.

RESULTS

The prevalence rates of insulin resistance (IR), prediabetes/diabetes, and dyslipidemia were 21.02%, 7.19%, and 21.61%, respectively. Subjects with an urban residence, no pubertal development, dyslipidemia in 2014, higher family income, and higher parental education had significantly elevated fasting insulin (FI) or homeostasis model assessment of insulin resistance (HOMA-IR) levels; subjects with female sex, no pubertal development, dyslipidemia in 2014, obesity, gestational hypertension, maternal weight gain above Institute of Medicine guidelines, and single parents had increased triglyceride or triglyceride/high-density lipoprotein (HDL). Adolescents with rural residence had higher HbA1c level.

CONCLUSION

We observed that the prevalence of GLMD was high in childhood and adolescents, and rural-urban areas, sex, pubertal development, dyslipidemia in a younger age, maternal obesity, and hypertension were associated with increased GLMD risk, suggesting that implementing the community-family intervention to improve the GLMD of children is essential.

Pulse Wave Velocity as a Marker of Vascular Dysfunction and Its Correlation with Cardiac Disease in Children with End-Stage Renal Disease (ESRD)

One of the main markers of arterial stiffness is pulse wave velocity (PWV). This parameter is well studied as a marker for end-organ damage in the adult population, being considered a strong predictor of major cardiovascular events. This study assessed PWV in children with chronic kidney disease (CKD) as a marker of cardiovascular risk. We conducted a prospective observational single-center cohort study of 42 consecutively pediatric patients (9–18 years old) with terminal CKD and dialysis, at the Hemodialysis Department of the “M. S. Curie” Hospital, Bucharest. We measured PWV by echocardiography in the ascending aorta (AscAo) and the descending aorta (DescAo), and we correlated them with left ventricular hypertrophy (LVH). Fifteen patients (35.7%) presented vascular dysfunction defined as PWV above the 95th percentile of normal values in the AscAo and/or DescAo. Cardiac disease (LVH/LV remodeling) was discovered in 32 patients (76.2%). All patients with vascular damage also had cardiac disease. Cardiac damage was already present in all patients with vascular disease, and the DescAo is more frequently affected than the AscAo (86.6% vs. 46.9%). Elevated PWV could represent an important parameter for identifying children with CKD and high cardiovascular risk.

Endothelial Dysfunction in Childhood Cancer Survivors: A Narrative Review

Assessment of endothelial dysfunction in cancer survivors may have a role in the early identification of non-communicable diseases and cardiovascular late effects. Oncological therapies may impair endothelial function. Therefore, in patients such as childhood cancer survivors who could benefit from early cardioprotective pharmacological interventions, it is essential to monitor endothelial function, even if the optimal methodology for investigating the multifaceted aspects of endothelial dysfunction is still under debate. Biochemical markers, as well as invasive and non-invasive tools with and without pharmacological stimuli have been studied. Human clinical studies that have examined lifestyle or cancer treatment protocols have yielded evidence showing the involvement of lipid and lipoprotein levels, glycemic control, blood pressure, adiposity, inflammation, and oxidative stress markers on the state of endothelial health and its role as an early indicator of cardiometabolic risk. However, with regards to pharmacological interventions, cautious interpretation of the result attained whilst monitoring the endothelial function is warranted due to methodological limitations and substantial heterogeneity of the results reported in the published studies. In this narrative review, an overview of evidence from human clinical trials examining the effects of cancer therapies on endothelial disease is provided together with a discussion of endothelial function assessment using the different non-invasive techniques available for researchers and clinicians, in recent years.

Insights from the 4C-T Study suggest increased cardiovascular burden in girls with end stage kidney disease before and after kidney transplantation

Mortality in children with kidney failure is higher in girls than boys with cardiovascular complications representing the most common causes of death. Pulse wave velocity (PWV), a measure of vascular stiffness, predicts cardiovascular mortality in adults. Here, PWV in children with kidney failure undergoing kidney replacement therapy was investigated to determine sex differences and potential contributing factors. Two-hundred-thirty-five children (80 girls; 34%) undergoing transplantation (150 pre-emptive, 85 with prior dialysis) having at least one PWV measurement pre- and/or post-transplantation from a prospective cohort were analyzed. Longitudinal analyses (median/maximum follow-up time of 6/9 years) were performed for PWV z-scores (PWVz) using linear mixed regression models and further stratified by the categories of time: pre-kidney replacement therapy and post-transplantation. PWVz significantly increased by 0.094 per year and was significantly higher in girls (PWVz +0.295) compared to boys, independent of the underlying kidney disease. During pre-kidney replacement therapy, an average estimated GFR decline of 4ml/min/1.73m² per year was associated with a PWVz increase of 0.16 in girls only. Higher diastolic blood pressure and low density lipoprotein were independently associated with higher PWVz during pre-kidney replacement therapy in both sexes. In girls post-transplantation, an estimated GFR decline of 4ml/min/1.73m² per year pre-kidney replacement therapy and a longer time (over 12 months) to transplantation were significantly associated with higher PWVz of 0.22 and of 0.57, respectively. PWVz increased further after transplantation and was positively associated with time on dialysis and diastolic blood pressure in both sexes. Thus, our findings demonstrate that girls with advanced chronic kidney disease are more susceptible to develop vascular stiffening compared to boys, this difference persist after transplantation and might contribute to higher mortality rates seen in girls with kidney failure.

Risk Assessment and Clinical Management of Children and Adolescents with Heterozygous Familial Hypercholesterolaemia. A Position Paper of the Associations of Preventive Pediatrics of Serbia, Mighty Medic and International Lipid Expert Panel

Heterozygous familial hypercholesterolaemia (FH) is among the most common genetic metabolic lipid disorders characterised by elevated low-density lipoprotein cholesterol (LDL-C) levels from birth and a significantly higher risk of developing premature atherosclerotic cardiovascular disease. The majority of the current pediatric guidelines for clinical management of children and adolescents with FH does not consider the impact of genetic variations as well as characteristics of vascular phenotype as assessed by recently developed non-invasive imaging techniques. We propose a combined integrated approach of cardiovascular (CV) risk assessment and clinical management of children with FH incorporating current risk assessment profile (LDL-C levels, traditional CV risk factors and familial history) with genetic and non-invasive vascular phenotyping. Based on the existing data on vascular phenotype status, this panel recommends that all children with FH and cIMT ≥0.5 mm should receive lipid lowering therapy irrespective of the presence of CV risk factors, family history and/or LDL-C levels Those children with FH and cIMT ≥0.4 mm should be carefully monitored to initiate lipid lowering management in the most suitable time. Likewise, all genetically confirmed children with FH and LDL-C levels ≥4.1 mmol/L (160 mg/dL), should be treated with lifestyle changes and LLT irrespective of the cIMT, presence of additional RF or family history of CHD.

A Bayesian meta-analysis on early tobacco exposure and vascular health: From childhood to early adulthood

BACKGROUND

Smoking has been consistently associated with increased cardiovascular risk in adults. Although exposure to tobacco products often starts in early life, evidence for the possible adverse effects on the cardiovascular system of the young is scarce. We sought to derive pooled estimates of smoking effects on indices of early vascular damage in children and adolescents.

DESIGN AND METHODS

We performed a systematic review and meta-analysis of clinical studies involving young individuals up to 21 years old that provided data on smoking exposure (active or passive) and flow-mediated dilatation, carotid to femoral pulse wave velocity and maximum carotid intima-media thickness. We employed three distinct methodologies of random-effects data synthesis, including the Sidik-Jonkman estimator, the Hartung and Knapp correction and a Bayesian method with a well-informed prior on the level of between-study variance.

RESULTS

In 12 studies and 5279 individuals in total, smoking exposure was related to deterioration in all three outcomes (mean adjusted flow-mediated dilatation decrease: -0.77%, 95% confidence interval -1.38--0.15, mean adjusted pulse wave velocity increase: 0.1 m/s, 95% confidence interval 0.02-0.17 and mean adjusted carotid intima-media thickness increase: 0.35 mm, 95% confidence interval 0.16-0.55, for the Sidik-Jonkman estimator). No difference was established between active and passive smoking on associations with arterial damage.

CONCLUSIONS

Exposure to tobacco products is associated with subclinical vascular damage early in life, even from childhood. Public health initiatives should target these very young age groups to prevent early smoking exposure and associated arterial damage and its sequelae.

NT-proBNP as a Potential Marker of Cardiovascular Damage in Children with Chronic Kidney Disease

Assessing cardiovascular disease (CVD) in children with chronic kidney disease (CKD) is difficult. Great expectations have been associated with biomarkers, including the N-terminal pro-brain natriuretic peptide (NT-proBNP). This study aimed to determine the correlation between NT-proBNP and cardiovascular complications in children with CKD. Serum NT-proBNP, arterial stiffness, common carotid artery intima-media thickness (cIMT), echocardiographic (ECHO) parameters (including tissue Doppler imaging), and biochemical and clinical data were analyzed in 38 pediatric patients with CKD (21 boys, 12.2 ± 4.2 years). Mean NT-proBNP in CKD patients was 1068.1 ± 4630 pg/mL. NT-proBNP above the norm (125 pg/mL) was found in 16 (42.1%) subjects. NT-proBNP correlated with glomerular filtration rate (GFR) (r = −0.423, p = 0.008), and was significantly higher in CKD G5 (glomerular filtration rate grade) patients compared to CKD G2, G3, and G4 children (p = 0.010, p = 0.004, and p = 0.018, respectively). Moreover, NT-proBNP correlated positively with augmentation index (AP/PP: r = 0.451, p = 0.018, P2/P: r = 0.460, p = 0.016), cIMT (r = 0.504, p = 0.020), and E/E’ in ECHO (r = 0.400, p = 0.032). In multivariate analysis, logNT-proBNP was the only significant predictor of cIMT Z-score (beta = 0.402, 95CI (0.082–0.721), p = 0.014) and P2/P1 (beta = 0.130, 95CI (0.082–0.721), p = 0.014). Conclusions: NT-proBNP may serve as a possible marker of thickening of the carotid artery wall in pediatric patients with CKD. The final role of NT-proBNP as a biomarker of arterial damage, left ventricular hypertrophy, or cardiac diastolic dysfunction in CKD children needs confirmation in prospective studies.

Vascular Ageing in Youth: A Call to Action

Extensive evidence shows that risk factors for cardiovascular disease (CVD) begin to develop early in life. Childhood obesity and elevated blood pressure (BP) have become overwhelmingly challenging, with 57% of today's children predicted to be obese by the age of 35 years, and global rates of hypertension in children and adolescents increasing by 75% from 2000 to 2015. Thus, there is an urgent need for tools that can assess early CVD risk in youth, which may lead to better risk stratification, preventative intervention, and personalised medicine. Vascular ageing (the deterioration in vascular structure and function) is a pivotal progenitor of health degeneration associated with elevated BP. Exposure to adverse environmental and genetic factors from fetal life promotes the development and accumulation of subclinical vascular changes that direct an individual towards a trajectory of early vascular ageing (EVA)-an independent predictor of target organ damage in the heart, brain, and kidneys. Therefore, characterising vascular ageing from youth may provide a window into cardiovascular risk later in life. However, vascular ageing measurements only have value when techniques are accurate/validated and when reliable thresholds are available for defining normal ranges and ranges that signal increased risk of disease. The aim of this paper is to summarise current evidence on the importance of vascular ageing assessment in youth and the impact of interventions to prevent or delay EVA, to highlight the need for standardisation and validation of measurement techniques in children and adolescents, and the importance of establishing reference values for vascular ageing measures in this population.

Youth Vascular Consortium (YVC) Protocol: Establishing Reference Intervals for Vascular Ageing in Children, Adolescents and Young Adults

BACKGROUND

In the last two decades, the global prevalence of paediatric hypertension increased by approximately 75%. Nearly 25% of children are now classified as obese or overweight. Substantial evidence suggests that risk factors for cardiovascular disease (CVD) begin to develop in childhood, thus warranting the need for tools to better screen for early CVD risk in youth. Vascular ageing, the deterioration of vascular structure and function, may be a potentially useful tool for detecting the early and asymptomatic signs of CVD burden. However, it is currently unclear what differentiates normal from pathological ageing in youth as existing reference values for vascular ageing in youth are limited by small sample size or homogenous populations. The international Youth Vascular Consortium (YVC) has been established to address these issues.

AIMS

The primary aim of the YVC is to develop reference intervals of normal vascular ageing in children, adolescents, and young adults. The secondary, exploratory, aim is to perform head-to-head comparisons of vascular ageing biomarkers to determine which biomarker is most strongly related to cardiometabolic health.

STUDY DESIGN

The YVC is a retrospective, multicentre study and will collate data on vascular ageing in children (5-12 years), adolescents (13-18 years) and young adults (19-40 years), as well as routine clinical biochemistry, lifestyle, sociodemographic factors and parental health.

CONCLUSION

To date, 31 research groups from 19 countries have joined the YVC. To our knowledge, this will be the largest study of its kind to investigate vascular ageing in youth.

Exercise Training Duration and Intensity Are Associated With Thicker Carotid Intima-Media Thickness but Improved Arterial Elasticity in Active Children and Adolescents

Even though exercise generally has a positive effect on health, intensive exercise can have adverse effects on the vascular system of adults. This study aimed to investigate the association between training duration and intensity and vascular structure and function in 427 physically active children and adolescents (14.0 ± 1.94 years). In this study, we examined carotid intima-media thickness (cIMT), carotid diameter, and cIMT:diameter-ratio as parameters of carotid arterial structure and arterial compliance (AC), stiffness index β (β), elastic modulus (Ep), and carotid pulse wave velocity (PWVβ) as parameters of carotid arterial function with high-resolution ultrasound. We collected central systolic blood pressure (cSBP) and aortic pulse wave velocity (aPWV) as parameters of central arterial stiffness with an oscillometric device. We used the MoMo Physical Activity Questionnaire to record training duration and intensity. Training duration (p = 0.022) and intensity (p = 0.024) were associated with higher cIMT. Further, training duration was associated with lower central arterial stiffness (cSBP: p = 0.001; aPWV: p = 0.033) and improved AC (p < 0.001). Higher training intensity was related to improved AC (p < 0.001) and larger carotid diameter (p = 0.040). Boys presented thicker cIMT (p = 0.010), improved AC (p = 0.006), and lower central arterial stiffness (cSBP: p < 0.001; aPWV: p = 0.016) associated with higher training duration. Girls presented improved AC (p = 0.023) and lower Ep (p = 0.038) but higher β (p = 0.036) associated with higher training duration. Only boys demonstrated thicker cIMT (p = 0.016) and improved AC (p = 0.002) associated with higher training intensity. A quintile analyses of the training duration revealed thicker cIMT of children and adolescents in Q1 and Q5 than that in Q4 and Q5. Besides, Q1 showed lower cSBP compared to Q4 and Q5. Regarding training intensity, Q5 had thicker cIMT than Q2 and Q3. Although a higher training load is associated with thicker cIMT, the common carotid artery is also more elastic. This suggests that a higher training load leads to a functional adaptation of the carotid artery in youth.

Pathophysiology and consequences of arterial stiffness in children with chronic kidney disease

Changes in arterial structure and function are seen early in the course of chronic kidney disease (CKD) and have been causally associated with cardiovascular (CV) morbidity. Numerous potential injuries encompassing both traditional and uremia-specific CV risk factors can induce structural arterial changes and accelerate arterial stiffening. When the buffering capacity of the normally elastic arteries is reduced, damage to vulnerable microcirculatory beds can occur. Moreover, the resultant increase to cardiac afterload contributes to the development of left ventricular hypertrophy and cardiac dysfunction. Adult studies have linked arterial stiffness with increased risk of mortality, CV events, cognitive decline, and CKD progression. Pulse wave velocity (PWV) is currently the gold standard of arterial stiffness assessment but its measurement in children is challenging due to technical difficulties and physiologic aspects related to growth and poor standardization between algorithms for calculating PWV. Nevertheless, studies in pediatric CKD have reported increased arterial stiffness in children with advanced CKD, on dialysis, and after kidney transplantation. Development of arterial stiffness in children with CKD is closely related to mineral-bone disease and hypertension, but other factors may also play a significant role. The clinical relevance of accelerated arterial stiffness in childhood on cardiovascular outcomes in adult life remains unclear, and prospective studies are needed. In this review we discuss mechanisms leading to arterial stiffness in CKD and its clinical implications, along with issues surrounding the technical aspects of arterial stiffness assessment in children.

Asthma and high-intensity interval training have no effect on clustered cardiometabolic risk or arterial stiffness in adolescents

PURPOSE

Cardiometabolic risk, including arterial stiffness, is increasing in youth. Those with asthma are suggested to be particularly at risk of cardiovascular disease. Efficient and effective strategies are required to prevent the atherosclerotic process in youth. The purpose of this study was to investigate the effect of 6 months high-intensity interval training (HIIT) on cardiometabolic risk in youth with and without asthma.

METHODS

65 adolescents (31 mild asthma; 34 non-asthma) were recruited, 32 (16 asthma) of whom were randomly allocated to receive HIIT three times per week for 6 months. At baseline, mid-intervention, post-intervention and at a 3-month follow-up, anthropometric, metabolic and vascular determinants of cardiometabolic risk were assessed. Following principal component analysis (PCA), linear mixed models were used to assess the influence of asthma, HIIT and their interaction.

RESULTS

Seven factors were identified which explained 88% of the common variance shared among the parameters. Those with asthma demonstrated lower arterial stiffness factor scores mid-intervention (P = 0.047) and lower cholesterol factor scores post-intervention (P = 0.022) but there was no effect of the intervention, or interaction effects, on any PCA-identified factor, at any time-point. HIIT was associated with a lower low-density lipoprotein and diastolic blood pressure at mid-intervention.

DISCUSSION

Neither arterial stiffness nor clustered cardiometabolic risk are influenced by HIIT in adolescents with or without asthma, despite important changes in blood lipid and pressure profiles. Blood pressure, augmentation and pulse wave velocity should be considered physiologically distinct constructs and as potential markers of cardiovascular health.

Cardiovascular disease in childhood and adolescence: Lessons from children with chronic kidney disease

Children suffering from chronic kidney disease (CKD) have the apparent highest risk for the development of cardiovascular disease (CVD) at a young age. While symptoms of CVD are characteristically absent in childhood and adolescence, remodelling of the myocardium, medium and large-sized arteries and of the microcirculation is clinically significant and can be assessed with non-invasive technology. Kidney disease and its progression are the driver of CVD, mediated by an unparalleled accumulation of risk factors converging on several comorbid conditions including hypertension, anaemia, dyslipidaemia, disturbed mineral metabolism and chronic persistent inflammation. Large prospective paediatric cohorts studies have provided valuable insights into the pathogenesis and the progression of CKD-induced cardiovascular comorbidity and have characterised the cardiovascular phenotype in young patients. They have also provided the rationale for close monitoring of risk factors and have defined therapeutic targets. Recently discovered new biomarkers could help identify the individual risk for CVD. Prevention of CVD by aggressive therapy of modifiable risk factors is essential to enable long-term survival of young patients with CKD.

Cardiometabolic risk factors and early indicators of vascular dysfunction: a cross-sectional cohort study in South African adolescents

OBJECTIVES

Prevalence of child and adolescents' overweight and obesity in low- and middle-income countries has increased dramatically. Simultaneously, the incidence of pre-hypertension/hypertension is also increasing in children, which, in turn, predisposes these children to the risk of cardiovascular disease (CVD) in later life. The present study assessed cardiometabolic risk factors and early indicators of vascular dysfunction in adolescents from a low socio-economic rural area in South Africa.

DESIGN

Cross-sectional cohort study.

SETTING

The study was conducted in public schools in Mthatha, OR Tambo district municipality, Eastern Cape Province, South Africa.

PARTICIPANTS

A total of 244 adolescents (188 females) of African ancestry aged 13-16 years were enrolled.

PRIMARY AND SECONDARY OUTCOME MEASURES

Anthropometric and haemodynamic measures and pulse wave velocity (PWV) were related to overweight/obesity and hypertension. Blood markers of cardiometabolic syndrome were assessed as well as vascular function (via PWV).

RESULTS

One-third (33.0%) of the adolescents exceeded the age and sex-specific body mass index percentiles for overweight (≥85th) or obesity (>95th) with a prevalence of 61.1% pre-hypertensives in this group. Overweight/obesity and hypertension were associated with higher triglycerides (lean:overweight: 0.79<1.01 mmol/L; normotensive:hypertensive: 0.82<0.89 mmol/L). Fasting glucose was higher in hypertensive as compared to normotensive adolescents (4.85>4.69 mmol/L, p<0.05). PWV was elevated in 25.9% of the children and significantly correlated with asymmetric dimethylarginine and systolic blood pressure (p<0.001).

CONCLUSION

Overweight/obesity and hypertension show a high prevalence in rural South African youth. Almost half of the studied adolescents are at risk for developing CVD. The high association between cardiometabolic risk factors and PWV further suggests that hypertension in adolescents may promote the progression of CVD in adulthood. Early detection of those at risk and the implementation of preventive strategies in underprivileged young people is urgently needed to stop the progression of vascular damage and manifestation of CVD in rural African children.

Interleukin-8 is increased in chronic kidney disease in children, but not related to cardiovascular disease

Introduction:

In this study, we aimed to detect the cytokine that is involved in the early stage of chronic kidney disease and associated with cardiovascular disease.

Methods:

We included 50 patients who were diagnosed with predialytic chronic kidney disease and 30 healthy pediatric patients in Ege University Medical Faculty Pediatric Clinic, İzmir/Turkey. Interleukin-8 (IL-8), interleukin-10 (IL-10), interleukin-13 (IL-13), and transforming grow factor-β1 (TGF-β1) levels (pg/mL) were measured by ELISA. Carotid-femoral pulse wave velocity (PWV), augmentation index (Aix), carotid intima media thickness (cIMT), and left ventricular mass index (LVMI) were evaluated as markers of cardiovascular disease. The presence of a cardiovascular disease marker was defined as an abnormality in any of the parameters (cIMT, PWV, Aix, and left ventricular mass index (SVKI)). The patient group was divided into two groups as with and without cardiovascular disease.

Results:

Mean Aix and PWV values were higher in CKD patients than controls (Aix: CKD 32.8±11.11%, healthy subjects: 6.74±6.58%, PWV CKD: 7.31±4.34m/s, healthy subjects: 3.42±3.01m/s, respectively; p=0.02, p=0.03). The serum IL-8 levels of CKD were significantly higher than of healthy subjects 568.48±487.35pg/mL, 33.67±47.47pg/mL, respectively (p<0.001). There was no statistically significant difference between IL-8, IL-10, IL-13, TGF-1, in CKD patients with and without cardiovascular disease (p> 0.05).

Discussion:

IL-8 is the sole cytokine that increases in pediatric patients with chronic kidney disease among other cytokines (IL-10, IL-13 and TGF-β1). However, we did not show that IL-8 is related to the presence of cardiovascular disease.

Early Vascular Aging in Children With Type 1 Diabetes and Ambulatory Normotension

Background: Preliminary data suggest that target organ damage (TOD) and early vascular aging (EVA) may occur in children with normal blood pressure (BP). Objectives: To analyze TOD and EVA in normotensive (BP <95th percentile on ambulatory BP monitoring) type 1 diabetes children (T1D) in comparison to healthy controls (C). Subjects: 25 T1D aged 13.9 ± 2.6 years and 22 C aged 14.0 ± 3.4 years. Methods: We analyzed age- and height-related pulse wave velocity (PWV) Z-scores and expected PWV based on age, height, and mean arterial pressure (MAP). Expected vascular age based on measured PWV was calculated from pooled pediatric and adult PWV norms. Left ventricular mass index (LVMI), estimated glomerular filtration rate (eGFR), and urinary albumin/creatinine ratio (ACR) were obtained as markers of TOD. Results: T1D and C groups did not differ in anthropometry, ambulatory, LVMI, and ACR. However, median age- and height-related PWV Z-scores were higher in T1D compared to C (1.08 vs. 0.57, p = 0.006; 0.78 vs. 0.36, p = 0.02, respectively). Mean (±SD) difference between measured and expected PWV was 0.58 ± 0.57 in T1D vs. 0.22 ± 0.59 in C, p = 0.02. The mean (±SD) difference between chronological and expected vascular age was 7.53 ± 7.74 years in T1D vs. 2.78 ± 7.01 years in C, p = 0.04. Conclusion: Increased arterial stiffness and increased intraindividual differences between expected and measured PWV as well as between chronological and expected vascular age indicate that EVA may develop in T1D children even at normal ambulatory BP levels.

Early Vascular Aging in Children With Tuberous Sclerosis Complex

Objectives: Experimental data indicate that activating mutations in the mTOR (mammalian target of rapamycin) pathway may lead to abnormal arterial wall structure. Vascular anomalies like arterial stenoses are reported in pediatric patients with tuberous sclerosis complex (TSC). In addition, large renal lesions (angiomyolipoma-AML and cysts) are risk factors for arterial hypertension in adult patients with TSC. This study aimed to assess blood pressure, including central blood pressure and arterial damage (early vascular aging-EVA) in children with TSC. Materials and Methods: In a group of 33 pediatric patients with TSC (11.13 ± 4.03 years, 15 boys, 18 girls), we evaluated peripheral and central office blood pressure, 24-h ambulatory blood pressure, and arterial damage: aortic pulse wave velocity (aPWV) [m/s], [Z-score], augmentation index (AIx75HR [%]), common carotid artery intima-media thickness (cIMT) [mm], [Z-score], stiffness of common carotid artery (E-tracking), renal lesions in magnetic resonance and ultrasonography, and selected biochemical parameters. The control group consisted of 33 healthy children (11.23 ± 3.28 years, 15 boys, 18 girls). Results: In TSC group 7 (21.2%) children had arterial hypertension, 27 (81.8%) children had renal angiomyolipomas, 26 (78.8%)-renal cysts, and 4 (12.1%) patients were treated with mTOR inhibitors (2 patients with everolimus and 2 patients with sirolimus) at the moment of evaluation. Children with TSC had higher central systolic blood pressure (AoSBP) (98.63 ± 9.65 vs. 90.45 ± 6.87 [mm Hg], p < 0.001), cIMT (0.42 ± 0.05 vs. 0.39 ± 0.03 [mm], p = 0.011), cIMT Z-score (0.81 ± 1.21 vs. 0.16 ± 0.57, p = 0.007), aPWV (4.78 ± 0.81 vs. 4.25 ± 0.56 [m/s], p = 0.003) and aPWV Z-score (-0.14 ± 1.15 vs. -0.96 ± 0.87, p = 0.002) compared to healthy children, without differences in AIx75HR (8.71 ± 15.90 vs. 5.24 ± 11.12 [%], p = 0.319) and stiffness of common carotid artery. In children with TSC AoSBP correlated positively with serum cystatin C concentration (r = 0.377, p = 0.030) and with maximum diameter of renal cyst (R = 0.419, p = 0.033); mean arterial pressure (MAP) 24 h Z-score correlated with serum cystatin C concentration (R = 0.433, p = 0.013); and aPWV Z-score with daily urinary albumin loss [mg/24 h] (R = 0.412, p = 0.029). Conclusions: Children with tuberous sclerosis complex are at risk of elevated central blood pressure and early vascular aging. In children with TSC, blood pressure and arterial stiffness are related to renal involvement.

An Overview of Vascular Dysfunction and Determinants: The Case of Children of African Ancestry

The balance between dilatory and constrictive factors is important as it keeps blood vessels in a homeostatic state. However, altered physiological processes as a result of obesity, hypertension, oxidative stress, and other cardiovascular risk factors may lead to vascular damage, causing an imbalance of vasoactive factors. Over time, the sustained imbalance of these vasoactive factors may lead to vascular dysfunction, which can be assessed by non-invasive methods, such as flow-mediated dilation, pulse wave velocity, flow-mediated slowing, retinal vessel analysis, peripheral vascular reactivity, and carotid intima-media thickness assessment. Although there is increasing prevalence of cardiovascular risk factors (obesity and hypertension) in children in sub-Saharan Africa, little is known about how this may affect vascular function. This review focuses on vasoactive factors implicated in vascular (dys)function, highlighting the determinants and consequences of vascular dysfunction. It further describes the non-invasive methods used for vascular (dys)function assessments and, last, describes the impact of cardiovascular risk factors on vascular dysfunction in children of African ancestry.

Vascular Effects of ACE (Angiotensin-Converting Enzyme) Inhibitors and Statins in Adolescents With Type 1 Diabetes

An increased albumin-creatinine ratio within the normal range can identify adolescents at higher risk of developing adverse cardio-renal outcomes as they progress into adulthood. Utilizing a parallel randomized controlled trial and observational cohort study, we characterized the progression of vascular phenotypes throughout this important period and investigated the effect of ACE (angiotensin-converting enzyme) inhibitors and statins in high-risk adolescents. Endothelial function (flow-mediated dilation and reactive hyperemia index) and arterial stiffness (carotid-femoral pulse wave velocity) were assessed in 158 high-risk participants recruited to a randomized, double-blind placebo-controlled 2×2 factorial trial (randomized, placebo-controlled trial) of ACE inhibitors and/or statins in adolescents with type 1 diabetes (AdDIT [Adolescent Type 1 Diabetes cardio-renal Intervention Trial]). Identical measures were also assessed in 215 lower-risk individuals recruited to a parallel observational study. In the randomized, placebo-controlled trial, high-risk patients randomized to ACE inhibitors had improved flow-mediated dilation after 2 to 4 years of follow-up (mean [95% CI]: 6.6% [6.0-7.2] versus 5.3% [4.7-5.9]; P=0.005), whereas no effect was observed following statin use (6.2% [5.5-6.8] versus 5.8% [5.1-6.4]; P=0.358). In the observational study, patients classed as high-risk based on albumin-creatinine ratio showed evidence of endothelial dysfunction at the end of follow-up (flow-mediated dilation=4.8% [3.8-5.9] versus 6.3% [5.8-6.7] for high-risk versus low-risk groups; P=0.015). Neither reactive hyperemia index nor pulse wave velocity were affected by either treatment (P>0.05 for both), but both were found to increase over the duration of follow-up (0.07 [0.03-0.12]; P=0.001 and 0.5 m/s [0.4-0.6]; P<0.001 for reactive hyperemia index and pulse wave velocity, respectively). ACE inhibitors improve endothelial function in high-risk adolescents as they transition through puberty. The longer-term protective effects of this intervention at this early age remain to be determined. Registration- URL: https://www.clinicaltrials.gov; Unique identifier NCT01581476.

Echocardiographic strain analysis reflects impaired ventricular function in youth with pediatric-onset systemic lupus erythematosus

BACKGROUND

Strain analysis with speckle-tracking echocardiography shows promise as a screening tool for silent myocardial dysfunction in pediatric-onset systemic lupus erythematosus (pSLE). We compared left ventricular (LV) systolic deformation (measured by strain) in children and adolescents with pSLE to controls, and assessed the relationship between strain, disease activity, and other noninvasive measures of cardiovascular health.

METHODS

Twenty pSLE subjects ages 9-21 underwent comprehensive cardiovascular testing, including 2D speckle-tracking echocardiography, ambulatory blood pressure monitoring (ABPM), peripheral endothelial function testing, pulse wave velocity and analysis, and carotid ultrasound. Longitudinal apical-4 chamber (LS_A4C ) and midpoint circumferential strain (CS_mid ) were compared to that of 70 healthy controls using multivariable linear regression. Among pSLE subjects, Pearson correlation coefficients were calculated to evaluate relationships between global longitudinal or circumferential strain and other measures of cardiovascular health.

RESULTS

Average SLE disease duration was 3.2 years (standard deviation [SD] 2.1). 2/20 pSLE subjects had persistent disease activity, and only one met criteria for hypertension by ABPM. LS_A4C was significantly reduced in pSLE subjects compared to controls (mean -18.3 [SD 3.2] vs -21.8% [SD 2.2], P-value <.001). There was no significant difference in CS_mid (-24.8 [SD 3.7] vs -25.7% [SD 3.4], P = .29). Among pSLE subjects, decreased nocturnal blood pressure dipping on ABPM was associated with reduced global circumferential strain (r -0.59, P = .01).

CONCLUSIONS

Longitudinal myocardial deformation is impaired in pSLE patients despite clinical remission and may represent early myocardial damage. Strain analysis should be considered in addition to standard echocardiographic assessment during follow-up of patients with pSLE.

Metabolically Healthy Obesity: Presence of Arterial Stiffness in the Prepubescent Population

Aim: Arteriosclerotic cardiovascular disease, one of the world’s leading causes of death, first manifests itself at an early age. The identification of children who may have increased cardiovascular risk in the future could be an important prevention strategy. Our aim was to assess the clinical, analytical, and dietary variables associated with arterial stiffness (AS), measured by carotid-femoral pulse wave velocity (cfPWV) in a prepubescent population with metabolically healthy obesity (MHO). Subjects and Methods: A cross-sectional study in prepubescent subjects with obesity who had ≤1 metabolic syndrome criteria (abdominal perimeter and blood pressure ≥90th percentile, triglycerides >150 mg/dL, HDL-cholesterol <40 mg/dL, fasting plasma glucose ≥100 mg/dL) was conducted. Adherence to Mediterranean Diet, blood pressure, BMI, waist/height ratio (WHtR), glycemic status, lipid profile, and cfPWV were analyzed. 75 MHO children (boys: 43; girls: 32; p = 0.20) (age = 10.05 ± 1.29 years; BMI = 25.29 ± 3.5 kg/m2) were included. Results: We found a positive correlation between cfPWV and weight (r = 0.51; p < 0.0001), BMI (r = 0.44; p < 0.0001), WHtR (r = 0.26; p = 0.02), fasting insulin levels (r = 0.28; p = 0.02), and insulin resistance (Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) index) (r = 0.25; p = 0.04). Multiple linear regression analysis identified BMI and HOMA-IR as independent parameters associated with cfPWV. Conclusions: Prepubescent children with obesity who were shown to be metabolically healthy presented with arterial stiffness, which is closely related to BMI and the state of insulin resistance.

Is the burden of late hypertension and cardiovascular target organ damage in children and adolescents with coarctation of the aorta after early successful repair different to healthy controls?

OBJECTIVE

Cardiovascular morbidity is high in patients with coarctation of aorta even after successful repair. This study aimed to assess the frequency of late hypertension and the relationship between ambulatory hypertension and cardiovascular target organ damage in children and adolescents after early and successful repair of coarctation of the aorta.

METHODS

Twenty-five children and adolescents (mean age 13.5 ± 3.43 years) with repaired coarctation of the aorta (median age at repair 4 months, arm-leg gradient <20 mmHg) and 16 healthy controls were included. Office and ambulatory blood pressure, pulse wave velocity, and left ventricular mass index were assessed.

RESULTS

Both day- and night-time systolic blood pressure standard deviation score and left ventricular mass index were significantly higher in patients compared to controls (p ≤ 0.001 for all), whereas pulse wave velocity did not differ. The prevalence of masked hypertension, isolated nocturnal hypertension, and left ventricular hypertrophy were 40, 28, and 24%, respectively. Left ventricular mass index was higher in patients with sustained hypertension, masked hypertension, and normotension compared to controls (p < 0.05). In multivariate analysis, higher night-time systolic blood pressure standard deviation score was the only independent predictor of left ventricular mass index.

CONCLUSION

The present study reveals a high prevalence of masked hypertension, isolated nocturnal hypertension, and left ventricular hypertrophy in children and adolescents with coarctation of the aorta even after early and successful repair. Ambulatory blood pressure monitoring should be considered to diagnose hypertension. All coarctation of aorta patients should be followed up lifelong and encouraged to establish a healthy lifestyle starting from childhood.

Metformin use in obese mothers is associated with improved cardiovascular profile in the offspring

BACKGROUND

Maternal obesity increases the risk for pregnancy complications and adverse neonatal outcome and has been associated with long-lasting adverse effects in the offspring, including increased body fat mass, insulin resistance, and increased risk for premature cardiovascular disease. Lifestyle interventions in pregnancy have produced no or modest effects in the reduction of adverse pregnancy outcomes in obese mothers. The Metformin in Obese Pregnant Women trial was associated with reduced adverse pregnancy outcomes and had no effect on birthweight. However, the long-term implications of metformin on the health of offspring remain unknown.

OBJECTIVE

The purpose of this study was to assess whether prenatal exposure to metformin can improve the cardiovascular profile and body composition in the offspring of obese mothers.

STUDY DESIGN

In 151 children from the Metformin in Obese Pregnant Women trial, body composition, peripheral blood pressure, and arterial pulse wave velocity were measured. Central hemodynamics (central blood pressure and augmentation index) were estimated with the use of an oscillometric device. Left ventricular cardiac function and structure were assessed by echocardiography.

RESULTS

Children were 3.9±1.0 years old, and 77 of them had been exposed to metformin prenatally. There was no significant difference in peripheral blood pressure, arterial stiffness, and body composition apart from gluteal and tricep circumferences, which were lower in the metformin group (P<.05). The metformin group, compared with the placebo group, had lower central hemodynamics (mean adjusted decrease, -0.707 mm Hg for aortic systolic blood pressure, -1.65 mm Hg for aortic pulse pressure, and -2.68% for augmentation index; P<.05 for all) and lower left ventricular diastolic function (adjusted difference in left atrial area, -0.525 cm², in isovolumic relaxation time, -0.324 msec, and in pulmonary venous systolic wave, 2.97 cm/s; P<.05 for all). There were no significant differences in metabolic profile between the groups.

CONCLUSION

Children of obese mothers who were exposed prenatally to metformin, compared with those who were exposed to placebo, had lower central hemodynamic and cardiac diastolic indices. These results suggest that the administration of metformin in obese pregnant women potentially may have a beneficial cardiovascular effect for their offspring.

Updated and revised normal values of aortic pulse wave velocity in children and adolescents aged 3-18 years

Measurement of aortic pulse wave velocity (PWV_ao) is recommended for stratifying individual cardiovascular (CV) risk in adults. Diseases in children and adolescents might influence aortic stiffness. It is necessary to exclude overweight (OW), obese (O) subjects, and individuals with increased systolic (SBP) and/or diastolic blood pressure (DBP) from the population, when creating normal values of PWV_ao in children and adolescents. Body mass index (BMI), SBP/DBP cut-off values have remarkably changed in this population during the last decade. Aims of our study were to expand our previously published PWV_ao database and to revise it by using the recently determined normal values. PWV_ao was measured by an occlusive-oscillometric device (Arteriograph, TensioMed Ltd, Budapest, Hungary) in a healthy population aged 3-18 years. 7940 (4374 boys) participants were recruited, 1912 OW/O subjects and 1368 individuals with high SBP/DBP were excluded. Finally, n = 4690 (2599 boys) participants were enrolled. Mean PWV_ao values increased from 5.4 ± 0.6 to 6.4 ± 0.5 m/s (p < 0.05) in boys and from 5.5 ± 0.6 to 6.4 ± 0.5 m/s (p < 0.05) in girls. Mean PWV_ao values were significantly lower in our new study, in boys in age groups of 9-16, in girls in age groups of 11-17. This is the largest and widest age-ranged database of PWV_ao published to date. Due to the change of BMI and SBP/DBP reference values during the last decade, the "old" database of PWV_ao needed to be revised. As a result of this, normal values of PWV_ao decreased significantly in both sexes.

Isolated nocturnal and isolated daytime hypertension associate with altered cardiovascular morphology and function in children with chronic kidney disease: findings from the Cardiovascular Comorbidity in Children with Chronic Kidney Disease study

INTRODUCTION

Prevalence of isolated nocturnal hypertension (INH) and isolated daytime hypertension (IDH) is around 10% in adults. Data in children, especially in chronic kidney disease (CKD), are lacking. The aim of this cross-sectional multicenter cohort study was to define the prevalence of INH and IDH and its association with cardiovascular morphology and function, that is, pulse wave velocity (PWV), carotid intima-media thickness (cIMT), or left ventricular mass index (LVMI) in children with CKD.

METHODS

Ambulatory blood pressure (BP) monitoring profiles were analyzed in 456 children with CKD stages III-V participating in the Cardiovascular Comorbidity in Children with Chronic Kidney Disease Study (64.3% males, 71.3% congenital anomaly of the kidney and urinary tract, age 12.5 ± 3.2 years, estimated glomerular filtration rate 29 ± 12 ml/min per 1.73 m). Baseline PWV, cIMT, and LVMI were compared in normotension, INH, IDH, or sustained 24-h hypertension.

RESULTS

Prevalence of sustained hypertension was 18.4%, of INH 13.4%, and of IDH 3.7%. PWV SDS (SD score) and cIMT SDS were significantly higher in sustained hypertension and INH, and PWV SDS was significantly higher in IDH, compared with normotension. LVMI was significantly increased in sustained hypertension, but not in INH or IDH. Determinants of INH were smallness for gestational age, older age, higher height SDS and parathyroid hormone, and shorter duration of CKD. In logistic regression analysis, day/night-time hypertension or ambulatory BP monitoring pattern (normal, INH, IDH, sustained hypertension) were independently associated with cardiovascular outcome measures: elevated night-time BP was associated with increased cIMT, PWV, and left ventricular hypertrophy; INH was associated with cIMT.

CONCLUSION

INH is present in almost one out of seven children with predialysis CKD; INH and nocturnal hypertension in general are associated with alterations of arterial morphology and function.

Nocturnal blood pressure dipping as a marker of endothelial function and subclinical atherosclerosis in pediatric-onset systemic lupus erythematosus

Background

Loss of the normal nocturnal decline in blood pressure (BP), known as non-dipping, is a potential measure of cardiovascular risk identified by ambulatory blood pressure monitoring (ABPM). We sought to determine whether non-dipping is a useful marker of abnormal vascular function and subclinical atherosclerosis in pediatric-onset systemic lupus erythematosus (pSLE).

Methods

Twenty subjects 9–19 years of age with pSLE underwent ABPM, peripheral endothelial function testing, carotid-femoral pulse wave velocity/analysis for aortic stiffness, and carotid intima-media thickness. We assessed the prevalence of non-dipping and other ABPM abnormalities. Pearson or Spearman rank correlation tests were used to evaluate relationships between nocturnal BP dipping, BP load (% of abnormally elevated BPs over 24-h), and vascular outcome measures.

Results

The majority (75%) of subjects had inactive disease, with mean disease duration of 3.2 years (± 2.1). The prevalence of non-dipping was 50%, which occurred even in the absence of nocturnal or daytime hypertension. Reduced diastolic BP dipping was associated with poorer endothelial function (r 0.5, p = 0.04). Intima-media thickness was significantly greater in subjects with non-dipping (mean standard deviation score of 3.0 vs 1.6, p = 0.02). In contrast, higher systolic and diastolic BP load were associated with increased aortic stiffness (ρ 0.6, p = 0.01 and ρ 0.7, p < 0.01, respectively), but not with endothelial function or intima-media thickness.

Conclusion

In a pSLE cohort with low disease activity, isolated nocturnal BP non-dipping is prevalent and associated with endothelial dysfunction and atherosclerotic changes. In addition to hypertension assessment, ABPM has a promising role in risk stratification and understanding heterogeneous mechanisms of cardiovascular disease in pSLE.