AUTONOMIC NERVOUS SYSTEM DYSFUNCTTION(AD)IN CHILDREN WITH END STAGE RENAL DISFASE: OOMPARISON OF HEMD-(HD) AND PFRTIONEAL(PD)DIALYSIS

Abstract

Symptomatic hypotension complicated 53-87% of all treatments in 7 of our pediatric HD patients (HDP) despite modest ultrafiltration (<6% of estimated dry weight). The possible relationship of AD to this problem was evaluated in 12 dialysis patients (DP) aged 8.1-19.8 yrs, 5 of whom were receiving peritoneal dialysis(PDP),and in 7 controls (C) aged 8.0-16.5 yrs, using the heart rate (HR) response to the Valsalva Maneuver (VM) (straining to 40 mm Hg × 10 sec)and degree of beat-to-beat variability in the resting heart rate (BVHR). Studies were performed using a standard electrocardiograph; the Valsalva Ratio(VR)was calculated as the maximal RR interval following÷minimal RR interval during VM. BVHR was determined as the coefficient of variation(CV)of 150 successive RR intervals recorded during recumbency. All DP had normal cardiac function by echocardiography, and none had orthostatic hypotension. The mean VR for C (2.06±.23) was significantly higher than that for HDP(1.54±.19,p<.001),PDP (1.68±.18,p<.02),and the group as a whole (1.60±.19,p<.001). In most DP the abnormally low VR was due to a failure to develop adequate reflex bradycardia following the release of straining. The mean CV for C (.103±.034) was significantly higher than that for HDP (.042±.015,p<.001) but not PDP (.072±.015,p<.10). Moreover, the mean CV for HDP was significantly lower than that for PDP (p<.01). Mean hemoglobin concentrations were not significantly different in HDP (7.1±1.5 g/dl)vs. PDP(7.6±.94 g/dl,p>.40), nor were the observed disturbances attributable to differences in resting HR, supine mean arterial pressure,months on dialysis, or age. The data indicate that AD occurs commonly among pediatric DP. The observed pattern of disturbances is consistent with defective cardiac parasympathetic innervation, with HDP more severely affected than PDP. AD also may be 'unmasked' more readily in HDP, since the higher ultrafiltration rates associated with HD require more effective cardiovascular reflex compensation. AD should be considered as a possible cause of recurrent, symptomatic hypotension in pediatric DP.

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