| Abstract|| |
To evaluate the etiology and prognosis of acute renal failure (ARF) in Moroccan children, we retrospectively studied 120 cases of ARF that presented to two centers in Casablanca, Morocco between 1982 and 1999. There were 72 (60%) boys and 48 (40%) females with age that ranged between six months and 15 years with a mean of 6.8 ± 5.0 years. All patients received appropriate medical treatment, while 76 (74%) patients required dialysis; peritoneal dialysis in 31 (40%) patients and hemodialysis in 45 (60%). Emergency dialysis was performed in 37 (48.7%) patients due to severe sodium and water overload and/or severe hyperkalemia, while dialysis was initiated in 39 (51.3%) because of high blood urea and creatinine levels. Predialysis serum urea nitrogen (BUN) exceeded 33 mmol/l in all of these cases and the mean was 51 mmol/l. The causes of ARF included acute glomerulonephritis (GN) in 61 (50.8%), hemolytic uremic syndrome (HUS) in 18 (15%), renal hypoperfusion in 12 (10%), acute interstitial nephritis in 9 (7.5%), urinary tract obstruction in 7 (5.9%) and the cause was not identified in 13 (10.8%). Mortality rate was 17%; recovery rate was higher in the non-oliguric patients. Outcome was favorable in 65% of the patients with glomerular disease. Most patients in this study did not require intensive care and none had neonatal ARF, which is known to carry poor prognosis.
Keywords: Acute renal failure, Child, Dialysis, Morocco.
|How to cite this article:|
Bourquia A, Chakib F, Jennah A, Boughnama A. Acute Renal Failure in Moroccan Children. Saudi J Kidney Dis Transpl 2002;13:66-70
|How to cite this URL:|
Bourquia A, Chakib F, Jennah A, Boughnama A. Acute Renal Failure in Moroccan Children. Saudi J Kidney Dis Transpl [serial online] 2002 [cited 2020 Jan 18];13:66-70. Available from: http://www.sjkdt.org/text.asp?2002/13/1/66/33207
| Introduction|| |
Acute renal failure (ARF) is not uncommon in young children. The prognosis in this group of patients has remarkably improved since the introduction of peritoneal dialysis in the 1970s. However, we still see mortality due to the underlying causes of renal failure. ,,
The aim of this study was to evaluate the etiology and prognosis of ARF in Moroccan children.
| Patients and Methods|| |
We retrospectively studied 120 children who presented with ARF to the Ibn Rochd hospital and Al Amal center in Casablanca, Morocco between 1980 and 1999.
There were 72 (60%) boys and 48 (40%) females with age that ranged between six months and 15 years with a mean of 6.8 ± 5.0 years.
ARF was defined as elevated blood urea nitrogen (BUN) higher than 16 mmol/L and/or serum creatinine more than 150 µmol/L with or without oliguria. The decrease of urine output less than 1 ml/kg/hour (25 ml/kg/24h) was considered as oliguria.
All patients received appropriate medical treatment including, restriction of fluids (20 ml/kg), restriction of sodium and potassium intake, restriction of protein and provision of appropriate calorie intake. There were six (5%) patients who required removal of urinary obstruction. Despite these measures, 76 (74%) patients required dialysis; peritoneal dialysis in 31 (40%) patients and hemodialysis in 45 (60%). Central catheterization was used in the hemodialysis patient; jugular vein catheterization was used in 37 (48.7%) patients. Emergency dialysis was performed in 37 (48.7%) patients due to severe sodium and water overload and/or severe hyperkalemia, while dialysis was initiated in 39 (51.3%) because of high blood urea and creatinine levels. Predialysis BUN exceeded 33 mmol/l in all the cases that needed dialysis and the mean was 51 mmol/l.
| Results|| |
[Table - 1] shows the causes of ARF in the study patients. They included glomerulonephritis (GN) in 61 (50.8%) of the patients, hemolytic uremic syndrome (HUS) in 18 (15%), renal hypoperfusion in 12 (10%), acute interstitial nephritis in 9 (7.5%), urinary tract obstruction in 7 (5.9%), and the cause was not identified in 13 (10.8%) patients.
In the GN group, acute GN was found in 48/61 (78.6%) patients, especially those who were older than five years. There were 31 (50.8%) patients who presented with severe hypertension and fluid retention. Of these patients, seven (22.5%) had pulmonary edema and four (12.9%) had hypertensive encephalopathy. There were 33/61 (54%) patients who required dialysis therapy. Of those who were treated by peritoneal dialysis three had peritonitis secondary to the procedure. There were 7/61 (11.4%) patients who died of pulmonary edema due to late referral. Chronic renal failure was a complication secondary to ARF in four children. The biopsy in these patients revealed diffuse GN and crescents.
There were 13/61 (21.3%) patients in the GN group who presented with severe nephrotic syndrome. The age of the patients ranged between 10 months and 13 years with a mean of seven years. Renal biopsy was performed in 10/13 (76.9%) patients, which revealed membranoproliferative GN in five (50%), amyloidosis in two (20%), focal segmental GN in two (20%) and lupus nephritis in one (10%). Sepsis and renal ischemia was found in 6/13 (46%) patients; 5/6 (83.3%) required dialysis. Steroids were used in 9/13 (69.2%). Two out of 13 patients died; one secondary to tuberculosis, and the other secondary to renal vein thrombosis. The rest of the patients recovered.
There were 18 patients with HUS (13 boys and five girls) with a mean age of 3.2 years. Sepsis was present in 11 (61%) patients with palor and vomiting in 9/11 (81.8%). Edema was present in 4/18 (22.2%). There was no oliguria in 17/18 (95%). Severe anemia with hemoglobin of less than six grams was present in all the cases. Fourteen (77.7%) patients required dialysis. Prognosis was favorable in 15 (83.3%) patients who regained renal function within 16 days. However, two (11%) patients had hypertension for the following three years.
There were 12 patients who had prerenal azotemia due to dehydration secondary to diarrhea in 10 (83.3%), osmotic diuresis in one and hyperthermia in one. Dialysis was used in six (50%) patients. Mortality rate was 41.4% (5/12) due to respiratory distress syndrome and severe electrolyte disturbances.
Acute tubular necrosis (ATN) was found in 10 patients. Four (40%) patients had renal failure as a complication of shock associated with sepsis, hemorrhage or toxemia. Two (20%) patients had the renal failure secondary to gentamycin toxicity; both patients required dialysis and one of them died. Two (20%) had rhabdomyolysis; one was a Marathon runner and the other ingested paraphenylene diamine (hair dye) in a suicidal attempt and both patients recovered after a 5-session course of dialysis. Two patients had acute on top of chronic nephropathy; the cause was urinary tract infection in one (10%) and unknown in the other (10%).
There were seven patients with urinary tract obstruction associated with ARF; five (71.4%) patients had nephrolithiasis and two (28.5%) had oxalosis. Of the patients with nephrolithiasis, three patients had solitary kidney and had bilateral pelvi-ureteric junction syndrome. The prognosis was favorable in 5 (71.4%) patients.
There were thirteen cases of ARF with unknown etiology. With hemodialysis the prognosis was favorable in seven (53.8%) patients with full recovery of renal function in four (30.7%). Four (30.7%) patients died after few hours of admission to hospital due to severe hemodynamic disturbances.
| Discussion|| |
Our study demonstrated an annual incidence of ARF in Moroccan children of 7.8 cases, which was similar to that of Colon et al,  more than that of Hudson et al 3 and much less than the 45 cases reported by Bouvier et al.  This difference can be attributed to the methods of referral of patients.
The clinical presentation differs according to age. ,, Excessive weight gain, nausea, vomiting gastrointestinal hemorrhage, neurological disturbances and severe sepsis occur more frequently in older children,  while fetal distress, oliguria, severe hypertension and renal vein thrombosis are more frequently encountered in neonates. 
ARF is usually classified into prerenal, renal, and postrenal. Prerenal azotemia was diagnosed in 13.4% of our study patients according to fractional sodium excretion and/or fluid challenge. ,, Delay in diagnosis and appropriate management led to increased mortality in this group of our study patients who should have had favorable outcome.
Broyer et al  found that glomerular injury accounted for 92% of the renal parenchymal causes of acute failure and 65.5% of all the causes of renal failure in children. Glomerular injury is associated with sepsis in children older than four years and results in ARF in 70% of the cases.  The prognosis is usually good according to the published data by others. ,,,, In our study, survival was excellent in this subgroup (94.2%). Late referral to a specialized center can result in complications. In the cases of the nephrotic syndrome, the renal failure was functional in nature and dialysis was rarely needed. This is consistent with reports that the renal failure usually responds to conservative therapy in this group.  The hemolytic uremic syndrome is usually a major cause of ARF in young children. ,,,, In our study, 7/18 patients with HUS were under three years of age. The prognosis was excellent in our study and the patients required dialysis. The mortality was low (0.6%) in the study of Bouvier et al,  4.6% in the study of Broyer et al,  and 7.4% in the study of Loirat et al.  The use of dialysis decreased mortality remarkably according to Habib et al  from 62% to 23% within ten years.
Obstructive ARF is rare in children. , and is usually due to nephrolithiasis and congenital anomalies of the urinary tract. Oxalosis has a bad prognosis with rare recovery and it is unfortunately common in our country.
The prognosis of the ARF depends on many factors including the urine output. Recovery of renal function is better in the absence of oliguria. , In our study, we had similar findings of better prognosis in the absence of oliguria.
The mortality rate in our study was low in comparison with the other studies. ,,,
This may be due to the difference in the studied population, since we excluded the inpatients in the intensive care unit and the neonates with cardiac surgery.
In conclusion, the pattern and prognosis of ARF in the Moroccan children was similar to that noted in many other populations around the world.
| References|| |
|1.||Bouvier P. L'insuffisance renale aigue de l'enfant. A Propos de 25 observations reunionnaises. These Med, Grenoble 1, 1986;n° 5004. |
|2.||Broyer M, Loirat C, Guesnu M. L'insuffisance renale aigue de l'enfant. In: Nephrologie Pediatrique 3eme ed. Paris, Flammarion, Medecine-Sciences 1983;41524. |
|3.||Hodson EM, Kjellstrand CM, Mauer SM. Acute renal failure in infants and childrens: outcome of 53 patients requiring hemodialysis treatment. J Pediatr 1978;93:756-61. |
|4.||Colome MF, Boudaillez B, Dremp O, Canarelli JP, Piussan CH. Insuffisance renale aigue chez l'enfant et en periode neonatale. Aspects etiologiques et therapeutiques (42 observations). Med Hyg 1987;45:520-6. |
|5.||Beaufils F, Schegel N, Pillion G. La thrombose des veines renales du nouveau ne et son traitement. Journees Parisiennes de Pediatrie. Paris, Flammarion 1982;41-51. |
|6.||Cameroun CB, Browns JS. L'insuffisance renale aigue de l'enfant. In: Nephrologie, Paris, Flammarion, Medecine-Sciences 1979; 1:257-86. |
|7.||Lopez-Herce J, Dorao P, Delgado MA, Espinosa L, Ruza F, Martinez MC. Continuous arteriovenous hemofiltration in children. Intensive Care Med 1989;15:224-7. |
|8.||Habib R, Gonzales BG. Glomerulonephrite aigue post-infectieuse. In: Nephrologie Pediatrique. 3e ed. Paris, Flammarion, Medecine-Sciences 1983;401-11. |
|9.||Kleinkecht D, Jungers P, Chanard J, Barabanel C, Ganeval D, Rondon NM. Les facteurs du pronostic immediat dans les insuffisances renales aigues, influence des hemodialyses prophylactiques. Actualites Nephrologiques de l'Hopital Necker. Fammarion medecine sciences, Paris 1971; 215-41. |
|10.||Counahan R, Cameron JS, Ogg CS, et al. Presentation, management, complications and outcome of acute renal failure in chidhood: five years experience. Br Med J 1977;1:599-602. |
|11.||Habib R, Levy M, Gagnadoux MF, Broyer M. Le pronostic du syndrome hemolytique et uremique chez l'enfant. In : Actualites Nephrologiques de l'Hopital Necker. Paris, Flammarion, Medecine-Sciences 1981;245-67. |
|12.||Haddad L. La dialyse peritoneale chez l'enfant a propos de 55 cas. These Med, Tunis, 1982. |
|13.||Loirat C, Sonsino E, Varga MA. Syndrome hemolytique et uremique chez l'enfant. Journees Parisiennes de pediatrie. Paris, Flammarion, Medecine-Science 1982;52-63. |
|14.||Barry C, Debachez C, Etiennem. Rhabdomyolyse aigue avec myoglobinurie a propos d'un cas presume d'origine virale. Ann pediatr (Paris) 1986;33:351-53. |
|15.||Kleinknecht D. L'insuffisance renale aigue. In: Principes de Reanimation Medicale. 3 ed. Paris, Flammarion, Medecine-Sciences 1982;pp. 174-209. |
|16.||Larbre F. Les glomerulonephrites aigues de l'enfant dans la pathologie digestive. In: David M. Nephrologie Pediatrique. Flammarion, Medecine-Sciences 1986;p1450-54. |
|17.||Reznik VM, Griswold WR, Peterson BM, Rodarte A, Ferris ME, Mendoza SA. Peritoneal dialysis for acute renal failure in children. Pediatr Nephrol 1991;5:715-7. |
|18.||Ezouki AY, Amin F, Jaiswal OP. Primary nephrotic syndrome in Arab children. Arch Dis Child 1984;59:253-5. |
127, Bd Victor Hugo, Casablanca
[Table - 1]