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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2016  |  Volume : 27  |  Issue : 3  |  Page : 507-511
Neurological and cardiac complications in a cohort of children with end-stage renal disease

Department of Pediatrics, Jordan University Hospital, College of Medicine, University of Jordan, Amman, Jordan

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Date of Web Publication13-May-2016


Adult patients with chronic kidney disease are at risk of major neurologic and cardiac complications. The purpose of this study is to review the neurological and cardiac complications in children with end-stage renal disease (ESRD). A retrospective review of medical records of children with ESRD at Jordan University Hospital was performed. All neurological and cardiac events were recorded and analyzed. Data of a total of 68 children with ESRD presenting between 2002 and 2013 were reviewed. Neurological complications occurred in 32.4%; seizures were the most common event. Uncontrolled hypertension was the leading cause of neurological events. Cardiac complications occurred in 39.7%, the most common being pericardial effusion. Mortality from neurological complications was 45%. Neurological and cardiac complications occurred in around a third of children with ESRD with a high mortality rate. More effective control of hypertension, anemia, and intensive and gentle dialysis are needed.

How to cite this article:
Albaramki JH, Al-Ammouri IA, Akl KF. Neurological and cardiac complications in a cohort of children with end-stage renal disease. Saudi J Kidney Dis Transpl 2016;27:507-11

How to cite this URL:
Albaramki JH, Al-Ammouri IA, Akl KF. Neurological and cardiac complications in a cohort of children with end-stage renal disease. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2022 Jan 16];27:507-11. Available from: https://www.sjkdt.org/text.asp?2016/27/3/507/182384

   Introduction Top

Neurological complications frequently affect patients with chronic kidney disease (CKD) and are an important cause of morbidity and mortality. Some of these complications are related to the underlying renal disease, or to the CKD itself, whereas others are secondary to dialysis. They affect both the central and peripheral nervous systems. These complica-tions include: dialysis disequilibrium, uremic Correspondence to encephalopathy, intracranial hemorrhage, brain infarction, white matter disease, posterior reversible encephalopathy syndrome (PRES), peripheral neuropathy, cerebral atrophy, and restless leg syndrome.[1]Other neurological pro- blems encountered in CKD include neuro- cognitive dysfunction with defects in attention, language, and memory.[2]

Cardiovascular disease is the most important cause of death in adolescents and young adults with CKD and accounts for a quarter of pedia- tric deaths.[3]In adults, coronary artery disease and cardiomyopathy-associated congestive heart failure are the leading causes of cardiovascular mortality, whereas in children, arrhythmias are the most common underlying cardiac event leading to death.[4]Cardiac complications range from congestive heart failure, left ventricular hypertrophy (LVH), pulmonary hypertension (PHT), and pericardial disease.

In this study, we aim to analyze the neuro- logical and cardiac complications among chil- dren with end-stage renal disease (ESRD).

   Methods Top

Medical records of all children with ESRD (Stage-5 CKD) seen at the Jordan University Hospital over the period 2002-2013 were reviewed. Data collected included sex, age, cause of CKD, and mode and duration of dialysis. All neurological and cardiac compli- cations were recorded. The cause of the neuro- logical events was elicited by reviewing blood pressure, electrolytes, and brain imaging results at the time of the event. Echocardio- graphic and clinical notes were reviewed to detect cardiac complications.

ESRD was defined as Stage-5 CKD which is a glomerular filtration rate <15 mL/1.73 m[2].[5]

   Results Top

A total of 68 children with ESRD were reviewed, mean age was 9 ± 5.6 years, 37 were females. Congenital anomalies of the kidney and the urinary tract were the most common cause of ESRD [Table 1].
Table 1. Clinical demographics of the study patients

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Neurological complications occurred in 22 patients (32%), and cardiac complications occurred in 27 patients (40%). Both neurolo- gical and cardiac complications occurred in six patients (8%).

A total of 94 neurological events occurred in 22 patients. Average age was 10.6 years, female:male ratio was 3.4:1. Seventeen pa- tients were on hemodialysis (HD), four on peritoneal dialysis (PD), and one was not on dialysis because the family had refused dia- lysis treatment. Glomerular disease was the cause of ESRD in 13 patients (59%), conge- nital renal anomalies in seven (32%), and two (9%) had hereditary causes.

Seizures were the most common event [Table 2]. Hypertension was the predominant cause in 77% of events, hypocalcemia in 20%, and a mixed cause was found in 19%. About 53% of events occurred in patients who were on dialysis for <1 year, 41% after 1-5 years, and 6% after five years of dialysis.

The neurological events resulted in death in 45% of patients.
Table 2. Neurological complications seen in the study patients

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Abnormal brain imaging was seen in 25 events (27%). Intra-cerebral hemorrhage was seen in 12 events with localization of the hemorrhage to the temporal, parietal, occipital, and frontal lobes. Basal ganglia hemorrhage was seen in two, one patient had cerebellar hemorrhage, another one had pituitary apo- plexy and manifested with visual disturbances. Intra-ventricular and subarachnoid hemorrhage were also seen in few patients. As a compli- cation of hemorrhage, hydrocephalus was seen in one and porencephalic cyst in two patients. Infarction was seen in 10 events; all were on HD. Four had lacunar infarcts in the basal ganglia, one had a thalamic infarct, and the remaining had frontal, parietal, and occipital lobe infarcts. PRES was seen in one patient, who had edema in the parietotemporal and posterior lobes, and presented with gait ataxia. One of our patients with systemic lupus ery- thematosus developed subacute venous throm- bosis caused by cerebral vasculitis.

Diffuse white matter disease was seen in three patients, basal ganglia calcification in two, and calvarial thickening due to Brown tumor was seen in one.

Twenty-seven patients had a cardiac compli- cation (female:male, 1.7:1); 20 were on PD, six were on HD, and one was off dialysis. Glome- rular disease was the cause of ESRD in 11 pa- tients (41%), congenital renal anomalies in 12 (44%), and four (15%) had hereditary causes. Pericardial effusion was the most common complication occurring in 24 patients; 33.3% had recurrent effusions, six patients required pericardiocentesis, and three required pericar- dial window.

One patient on HD had an intracardiac thrombus [Table 3].
Table 3. Cardiac complications seen in the study patients

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   Discussion Top

Neurological complications are an important cause of morbidity and mortality in ESRD patients. There is scarce data on neurological complications in children.[6]Most of the data is extrapolated from adult studies. The relative risk of cerebral hemorrhage in adult dialysis patients is much higher than the general popu- lation and it occurs at 10 years younger than the general population.[7]Cerebral hemorrhage in these patients is more severe in terms of size, and its clinical outcome.[8],[9]Brain hemor- rhage was seen in 13% of our neurological events.

Risk factors for hemorrhage in these patients include the use of anticoagulant therapy in dia- lysis, defective platelet adhesion and inade- quate control of hypertension.

Infarction and silent infarcts are also seen in these patients. Reports from adults showed four to ten times increase in the incidence of stroke in ESRD compared to controls. Hyper- tension, atherosclerosis, uremia, increased lipoprotein A, and intra-dialytic hypotension are risk factors for infarction.[10]Accumulation of guanidine compounds, oxidative and car- bonyl stress, hyper-homocysteinemia, and dis- turbances of calcium and phosphate metabo- lism are other factors present in renal failure patients that increase their risk of stroke.[9]In our patients, brain infarcts detected on imaging studies, which is a well-known complication of HD, were seen in 10% of events.

PRES is a clinicoradiological diagnosis that presents as altered level of consciousness, sei- zures, and visual disturbances. Magnetic reso- nance imaging typically shows white matter changes in the posterior occipital regions.[11]Seizures and altered level of consciousness were the most common neurological problems in our patients, similar to other studies.[12]We had a patient who presented with pituitary apoplexy similar to a previous report.[13]Uncon- trolled hypertension was the predominant cause, and poor control of hypertension could be attributed to noncompliance with medi- cations, inadequate dialysis, and poor adhe- rence to their restriction of fluid intake.

In a review of pediatric neuroimaging studies in children with CKD, it was found that signs of cerebrovascular disease including deep white matter hyper-intensities, white matter lesions, cerebral microbleeds, and silent cere- bral infarction were present.[6]

In contrast to cardiac events, neurological complications were seen more in children on HD, and this could be due to the use of anti- coagulation and risk of intra-dialytic hypo- tension in HD patients in comparison to PD patients.

Cardiovascular complications occurred in 39.7% of our patients and the current USA renal database confirmed cardiovascular di- sease as one of the major causes of death in children with CKD.[14]The risk factors for cardiovascular disease include hypertension, dyslipidemia, anemia, homocysteinemia, hyper- parathyroidism, and elevated C-reactive pro- tein.[14],[15]Pericardial effusion was the most common cardiac complication found and that was slightly higher than in a study in adults from Saudi Arabia.[16]Pericardial disease in ESRD is usually manifested as acute uremic or inadequate dialysis pericarditis and pericardial effusion. The treatment includes intensive HD and pericardiocentesis.[17]

LVH occurs in 40-75% of pediatric ESRD patients.[4]The important factors contributing to it are hypertension, chronic volume overload, and chronic anemia.

PHT was found 22% of our patients. The exact pathogenesis is still not clearly understood; however, other studies also have reported high incidence of PHT in adult patients on HD.[18],[19]This study is limited by its retrospective nature of reviewing medical records and the relatively small number of patients.


Neurological and cardiac events occurred in around a third of pediatric patients with ESRD resulting in high mortality rate. Strict control of hypertension, gentle HD to avoid blood pressure fluctuation, and meticulous control of electrolytes is advised to decrease these complications.

   References Top

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Gipson DS, Wetherington CE, Duquette PJ, Hooper SR. The nervous system and chronic kidney disease in children. Pediatr Nephrol 2004;19:832-9.  Back to cited text no. 2
Parekh RS, Gidding SS. Cardiovascular com- plications in pediatric end-stage renal disease. Pediatr Nephrol 2005;20:125-31.  Back to cited text no. 3
Chavers BM, Li S, Collins AJ, Herzog CA. Cardiovascular disease in pediatric chronic dialysis patients. Kidney Int 2002;62:648-53.  Back to cited text no. 4
Levey AS, Eckardt KU, Tsukamoto Y, et al. Definition and classification of chronic kidney disease: A position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2005;67:2089-100.  Back to cited text no. 5
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Onoyama K, Ibayashi S, Nanishi F, et al. Cerebral hemorrhage in patients on mainte- nance hemodialysis. CT analysis of 25 cases. Eur Neurol 1987;26:171-5.  Back to cited text no. 8
Brouns R, De Deyn PP. Neurological compli- cations in renal failure: A review. Clin Neurol Neurosurg 2004;107:1-16.  Back to cited text no. 9
Lakadamyali H, Ergün T. MRI for acute neurologic complications in end-stage renal disease patients on hemodialysis. Diagn Interv Radiol 2011;17:112-7.  Back to cited text no. 10
McCoy B, King M, Gill D, Twomey E. Child- hood posterior reversible encephalopathy syndrome. Eur J Paediatr Neurol 2011;15:91-4.  Back to cited text no. 11
Uysal S, Renda Y, Saatci U, Yalaz K. Neuro- logic complications in chronic renal failure: A retrospective study. Clin Pediatr (Phila) 1990; 29:510-4.  Back to cited text no. 12
De la Torre M, Alcázar R, Aguirre M, Ferreras I. The dialysis patient with headache and sudden hypotension: Consider pituitary apoplexy. Nephrol Dial Transplant 1998;13:787-8.  Back to cited text no. 13
Mitsnefes MM. Cardiovascular disease in children with chronic kidney disease. J Am Soc Nephrol 2012;23:578-85.  Back to cited text no. 14
Mitsnefes MM. Cardiovascular complications of pediatric chronic kidney disease. Pediatr Nephrol 2008;23:27-39.  Back to cited text no. 15
Al-Ezzy YA, Al-Barraq AO, Al-Hamaty NA, Haza'a K, Thania SY, Al-Saidy FA. Cardio- vascular manifestations in chronic renal failure patients on hemodialysis. Saudi Med J 2003; 24:652-5.  Back to cited text no. 16
Alpert MA, Ravenscraft MD. Pericardial involvement in end-stage renal disease. Am J Med Sci 2003;325:228-36.  Back to cited text no. 17
Mahdavi-Mazdeh M, Alijavad-Mousavi S, Yahyazadeh H, Azadi M, Yoosefnejad H, Ataiipoor Y. Pulmonary hypertension in hemo- dialysis patients. Saudi J Kidney Dis Transpl 2008;19:189-93.  Back to cited text no. 18
[PUBMED]  Medknow Journal  
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Correspondence Address:
Jumana H Albaramki
Department of Pediatrics, Jordan University Hospital, College of Medicine, University of Jordan, Amman
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DOI: 10.4103/1319-2442.182384

PMID: 27215242

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