A Win for Children on Dialysis: New National Standards for Blood Pressure Measurements

For children battling chronic kidney disease, the threat of heart disease looms large.

Heart disease is the leading cause of death for children with kidney failure. However, newly established national standards for measuring blood pressure during dialysis have set a foundation for reducing the risk. 

Dialysis replaces some functions of the kidneys, including filtering out waste and extracting water from the blood. Some children receive dialysis at home, but many others require long in-clinic sessions three times per week using a hemodialysis machine. Until the child can receive a kidney transplant, dialysis keeps them alive.

“Children with non-functional kidneys suffer from hard-to-manage blood pressure, largely from fluid gains between dialysis sessions. They have significantly increased risk for cardiovascular diseases,” says Marsha Lee, MD, professor of pediatrics in the Division of Nephrology and director of the pediatric dialysis program at UC San Francisco Benioff Children’s Hospitals.

In response to this risk, the SCOPE Collaborative, a national initiative of over 50 centers dedicated to improving the health of these children, began to examine blood pressure and fluid management practices in pediatric hemodialysis units nationwide. Lee was chosen to head the project alongside Audrey Anaya, MSN, RNN, CN, the clinical nurse supervisor of pediatric dialysis at UCSF Benioff Children’s Hospital San Francisco.

Why Standardization Matters

“To start, we surveyed for blood pressure measurement practices and found substantial inconsistencies. Comparing the data across centers was like apples to oranges,” says Anaya. “A crucial first step to improving cardiovascular outcomes was to align the data by widely implementing a best practice.”

Some centers required patients to sit quietly for five minutes to calm them down. In other centers, sitting wasn’t ever required or only sometimes was. Different triggers were used to alert when blood pressure needed to be closely monitored, which was done using various devices.

Fundamentally, there were so many hidden variables in the existing blood pressure data that it couldn’t be trusted to see trends or which interventions effectively reduce cardiovascular stress. National studies using a large population of patients were simply not feasible.

Working with other centers in the collaborative, the project team established best practices and successfully implemented them at 85% of participating centers, as detailed in their Current Hypertension Reports publication.

“Change in the medical field is difficult, especially when attempting to improve a seemingly mundane process like blood pressure measurement,” says Lee. “We’ve now collected three years of standardized data providing key insights into the prevalence of blood pressure issues in these children.”

Next Steps: Fluid Management

As children with failed kidneys cannot remove excess fluids from their blood naturally, managing their fluid intake is a vital part of reducing the stress on their cardiovascular systems. In addition, removing the extra fluids through dialysis can cause rapid changes in blood pressure and heart rate. A temporary weakness of the heart, known as cardiac stunning, can also happen if the fluid removal is too rapid.

“While we teach our patients to limit sodium to minimize thirst, staying under the recommended 1 liter of fluid per day is difficult when you’re a child surrounded by foods high in salt,” says Anaya. “The impact can be silent but devastating.”

Healthcare teams make critical decisions during hemodialysis on fluid removal, but it’s been unclear what can be done to control blood pressure most effectively. Now that the SCOPE Collaborative has trustworthy data on blood pressure, the group plans to leverage it to establish best practices for fluid removal and management.

“The fluid management group includes over 50 interdisciplinary hemodialysis team members, showing the significant interest and momentum in finding ways to improve the cardiovascular health of these children into adulthood,” says Lee.