Waist-to-height ratio, body mass index, and cardiovascular risk profile
in children with chronic kidney disease
Anthony A. Portale
Received: 19 February 2018 / Revised: 10 May 2018 /Accepted: 21 May 2018
Background Cardiovascular (CV) risk is high in children with chronic kidney disease (CKD), and further compounded in those
who are overweight. Children with CKD have a unique body habitus not accurately assessed by body mass index (BMI). Waist-to-
height ratio (WHr), a better predictor of CV risk in populations with short stature, has not been investigated in children with CKD.
Methods Analysis of 1723 visits of 593 participants enrolled in the Chronic Kidney Disease in Children (CKiD) study was
conducted. CKiD participants had BMI and WHr measured and classified as follows: (1) lean (WHr ≤ 0.49, BMI < 85th percen-
tile); (2) WHr-overweight (WHr > 0.49, BMI < 85th percentile); (3) BMI-overweight (WHr ≤ 0.49, BMI ≥ 85th percentile); or (4)
overweight by both BMI and WHr. Left ventricular mass index (LVMI), fasting lipids, fibroblast growth factor 23 (FGF23),
blood pressure, and glucose were measured as markers of CV risk. Linear mixed-effects regression was used to evaluate
differences in CV markers between overweight and lean groups.
Results Participants were 12.2 years old, 60% male, and 17% African-American. Approximately 15% were overweight by WHr
but not by BMI. Overweight status by WHr-only or both WHr and BMI was associated with lower high-density lipoprotein
(HDL) and higher LVMI, triglycerides, and non-HDL cholesterol compared to lean. CV markers of participants overweight by
BMI-only were similar to those of lean children.
Conclusions WHr-adiposity is associated with an adverse CV risk profile in children with CKD. A significant proportion of
children with central adiposity are missed by BMI. WHr should be utilized as a screening tool for CV risk in this population.
Body mass index
Left ventricular mass index
Fibroblast growth factor 23
Chronic kidney disease (CKD) is a lifelong chronic illness in
which risks to cardiovascular (CV) health begin early in the
course of the disease. Major CV events are rare in children,
and early abnormalities are not easily detectable by conven-
tional monitoring. By the time children with CKD reach
young adulthood, their risk of CV mortality is 30-fold higher
compared to their healthy peers , indicating the need for
better predictors and monitoring.
Obesity and abdominal adiposity, in particular, have been
strongly associated with higher CV risk [2, 3]. It is known that
obesity-related morbidity is more closely linked to central, or
visceral, fat distribution rather than total body fat [3, 4].
Although body mass index (BMI) is the most common mea-
sure of anthropometrics used in clinical practice, it has inher-
ent limitations that can lead to misdiagnosis of obesity.
Specifically, the inability of BMI to differentiate between lean
and fat mass can result in the misclassification of lean, mus-
cular individuals as overweight while those with excess fat
mass and low muscle mass can have a BMI in the healthy
range [5, 6]. To this point, a recent study showed that 55%
* Kristen Sgambat
Department of Nephrology, Children’s National Health System, 111
Michigan Avenue NW, Washington, DC 20010, USA
Johns Hopkins Bloomberg School of Public Health, Baltimore, MD,
Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
University of California, San Francisco, CA, USA
The Children’s Hospital of Philadelphia, Department of Pediatrics,
Philadelphia, PA, USA
Children’s Mercy Kansas City, Kansas City, MO, USA