Effects of Hemodiafiltration versus Conventional... : Journal of the American Society of Nephrology (original) (raw)

Clinical Research

Effects of Hemodiafiltration versus Conventional Hemodialysis in Children with ESKD: The HDF, Heart and Height Study

Shroff, Rukshana1,2; Smith, Colette3; Ranchin, Bruno4; Bayazit, Aysun K.5; Stefanidis, Constantinos J.6; Askiti, Varvara6; Azukaitis, Karolis7; Canpolat, Nur8; Ağbaş, Ayşe8; Aitkenhead, Helen1; Anarat, Ali5; Aoun, Bilal9; Aofolaju, Daley1; Bakkaloglu, Sevcan Azime10; Bhowruth, Devina2; Borzych-Dużałka, Dagmara11; Bulut, Ipek Kaplan12; Büscher, Rainer13; Deanfield, John2; Dempster, Claire1; Duzova, Ali14; Habbig, Sandra15; Hayes, Wesley1; Hegde, Shivram16; Krid, Saoussen17; Licht, Christoph18; Litwin, Mieczyslaw19; Mayes, Mark1; Mir, Sevgi12; Nemec, Rose18; Obrycki, Lukasz19; Paglialonga, Fabio20; Picca, Stefano21; Samaille, Charlotte22; Shenoy, Mohan23; Sinha, Manish D.24; Spasojevic, Brankica25; Stronach, Lynsey1; Vidal, Enrico26; Vondrák, Karel27; Yilmaz, Alev28; Zaloszyc, Ariane29; Fischbach, Michel29; Schmitt, Claus Peter30; Schaefer, Franz30

1Nephrology Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, United Kingdom and

2Vascular Physiology Unit, University College London Institute of Child Health, Gower Street, London, United Kingdom;

3Statistics Department, Institute for Global Health, University College London, London, United Kingdom;

4Renal Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France;

5Nephrology Unit, Cukurova University, Adana, Turkey;

6Nephrology Unit, Kyriakou Children’s Hospital, Athens, Greece;

7Nephrology Unit, Clinic of Pediatrics, Vilnius University, Vilnius, Lithuania;

8Nephrology Unit, Cerrahpasa School of Medicine, Istanbul, Turkey;

9Nephrology Unit, Armand Trousseau Hospital, Paris, France;

10Nephrology Unit, Gazi University Hospital, Ankara, Turkey;

11Nephrology Unit, Medical University of Gdansk, Gdansk, Poland;

12Nephrology Unit, Ege University Faculty of Medicine, Izmir, Turkey;

13Nephrology Unit, University Children Hospital Essen, Essen, Germany;

14Nephrology Unit, Hacettepe University, Ankara, Turkey;

15Nephrology Unit, University Hospital Cologne, Cologne, Germany;

16Nephrology Unit, University Hospital of Wales, Cardiff, United Kingdom;

17Nephrology Unit, Hôpital Necker-Enfants Malades, Paris, France;

18Nephrology Unit, The Hospital for Sick Children, Toronto, Canada;

19Nephrology Unit, Children’s Memorial Health Institute, Warsaw, Poland;

20Nephrology Unit, Fondazione Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy;

21Nephrology Unit, Bambino Gesù” Children Research Hospital, Rome, Italy;

22Nephrology Unit, Hôpital Jeanne De Flandre, Lille Cedex, France;

23Nephrology Unit, Royal Manchester Children’s Hospital, Manchester, United Kingdom;

24Nephrology Unit, Kings College London, Evelina London Children’s Hospital, London, United Kingdom;

25Nephrology Unit, University Children’s Hospital, Belgrade, Serbia;

26Nephrology Unit, Pediatric Dialysis and Transplant Unit, Padova, Italy;

27Nephrology Unit, University Hospital Motol, Prague, Czech Republic;

28Nephrology Unit, Istanbul University Faculty of Medicine, Istanbul, Turkey;

29Nephrology Unit, Children’s Dialysis Center, Strasbourg, France; and

30Nephrology Unit, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany

C.P.S. and F.S. contributed equally to this work.

Correspondence: Dr. Rukshana Shroff, Great Ormond Street Hospital for Children National Health Service Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK. Email: [email protected]

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Abstract

Significance Statement

Although studies suggest that hemodiafiltration (HDF) may reduce cardiovascular mortality in adults, data in children are sparse. In this observational multicenter study, the authors compared HDF and hemodialysis (HD) in children with ESKD, finding that annualized changes in well validated subclinical markers of cardiovascular disease, including carotid intima-media thickness SD scores, were lower in HDF and associated with lower 24-hour ambulatory BP and intradialytic weight gain. Height increased only in the HDF cohort. Compared with the HD cohort, the HDF cohort also had better self-reported outcomes, with fewer headaches, less dizziness or cramps, and shorter recovery time after dialysis sessions. The study provides proof-of-concept data that HDF is a safe treatment that may have benefits over conventional HD in children. A randomized trial is required to confirm these findings.

Background

Hypertension and cardiovascular disease are common in children undergoing dialysis. Studies suggest that hemodiafiltration (HDF) may reduce cardiovascular mortality in adults, but data for children are scarce.

Methods

The HDF, Heart and Height study is a nonrandomized observational study comparing outcomes on conventional hemodialysis (HD) versus postdilution online HDF in children. Primary outcome measures were annualized changes in carotid intima-media thickness (cIMT) SD score and height SD score.

Results

We enrolled 190 children from 28 centers; 78 on HD and 55 on HDF completed 1-year follow-up. The groups were comparable for age, dialysis vintage, access type, dialysis frequency, blood flow, and residual renal function. At 1 year, cIMT SD score increased significantly in children on HD but remained static in the HDF cohort. On propensity score analysis, HD was associated with a +0.47 higher annualized cIMT SD score compared with HDF. Height SD score increased in HDF but remained static in HD. Mean arterial pressure SD score increased with HD only. Factors associated with higher cIMT and mean arterial pressure SD-scores were HD group, higher ultrafiltration rate, and higher _β_2-microglobulin. The HDF cohort had lower _β_2-microglobulin, parathyroid hormone, and high-sensitivity C-reactive protein at 1 year; fewer headaches, dizziness, or cramps; and shorter postdialysis recovery time.

Conclusions

HDF is associated with a lack of progression in vascular measures versus progression with HD, as well as an increase in height not seen in the HD cohort. Patient-related outcomes improved among children on HDF correlating with improved BP control and clearances. Confirmation through randomized trials is required.

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