ESPN 51th Annual Meeting

ESPN 2018


 
Haemodiafiltration (HDF) improves the cardiovascular risk profile compared to conventional haemodialysis (HD) through improved BP and PTH control – the HDF, Heart and Height (3H) trial
RUKSHANA SHROFF 1 Aysun Bayazit 2 Constantinos J Stefanidis 3 Varvara Askiti 3 Karolis Azukaitis 4 Nur Canpolat 5 Sevcan Bakkaloglu 6 Fabio Paglialonga 7 Mohan Shenoy 8 Bruno Ranchin 9 Colette Smith 1 Devina Bhowruth 1 Saoussen Krid 10 Claus P Schmitt 4 Franz Schaefer 4

1- GREAT ORMOND STREET HOSPITAL FOR CHILDREN
2- Cukurova University, Adana, Turkey
3- A & P Kyriakou Children’s Hospital, Athens, Greece
4- Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
5- Cerrahpasa School of Medicine, Istanbul
6- Gazi University Hospital, Ankara, Turkey
7- Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
8- Royal Manchester Children’s Hospital, Manchester, UK
9- Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
10- Hôpital Necker-Enfants Malades, Paris, France
 
Introduction:

Fluid overload, hypertension and cardiovascular disease are common in children on dialysis. In adults, HDF is shown to reduce cardiovascular mortality, but causes for this are not clear and data in children are scarce.

Material and methods:

We performed a non-randomized parallel-arm clinical trial within the International Pediatric Hemodialysis Network registry to assess changes in fluid status, BP, biochemistry and cardiovascular measures in children on HDF compared with conventional HD. The primary outcome measure was change in carotid intima media thickness standard deviation score (cIMT SDS) at 1-year. (ClinicalTrials.gov: NCT02063776)

Results:

190 children (from 28 centres across Europe and North America) were recruited, and 177 fulfilled inclusion criteria. 133 children (78 on HD and 55 on HDF) completed one-year follow-up. There was no difference between HD and HDF groups in age, gender, underlying renal disease, comorbidities, dialysis vintage, access type, blood flow or presence of residual renal function. There were 44 dropouts, mainly (79%) due to transplantation; there were no deaths. The median convective volume achieved in the HDF group was 13.33 (inter-quartile range 12.4 to 14.5) ml/m2/session. At 1-year, children on HDF had lower cIMT SDS and lower pulse wave velocity-SDS compared to those on conventional HD (1.88 vs 2.64; p=0.007 and 0.77 vs 1.99, p<0.001 respectively). 24-hour mean arterial pressure (MAP) SDS and left ventricular mass index were significantly lower on HDF (p<0.01 for all). HDF patients had lower serum PTH, high-sensitivity CRP and beta2-microglobulin levels compared to HD (p<0.05 for all). Annualised change in cIMT SDS was 10-fold lower in HDF compared to HD (0.013 vs 0.48; p=0.002). The HDF vs HD group, PTH, MAP SDS and dialysate water quality significantly associated with cIMT SDS. On propensity scoring analysis, after adjusting for potential confounders, children on HD had 0.38 greater increase in cIMT SDS compared to those on HDF (95%CI 0.01 to 0.74). All data were adjusted for country and baseline cIMT-SDS. Importantly, the type of vascular access, blood flow rate and residual renal function did not correlate with cIMT SDS, suggesting that convective clearance is a significant determinant of outcome.

Conclusions:

In children, HDF halts the progression of vascular changes compared to conventional HD. This may be due to improved fluid and BP control and reduced PTH levels in HDF compared to HD patients.