| Abstract|| |
To document the pattern of childhood renal diseases in the mid-western zone of Nigeria, we evaluated 195 children in the pediatric in-patient service at the University of Benin Teaching Hospital (UBTH) from 1997-2002. There were 250 renal disease episodes that occurred in 195 children. Renal disease accounted for 4.5% of total pediatric admissions. Urinary tract infection (UTI) was found in 82 (32.8%) cases caused largely by Escherichia coli in 39 (47.6%) followed by Staphylococcus aureus in 21 (25.6%). Other morbidities were nephrotic syndrome 61(24.4%), characterized by high incidences of associated UTI and steroid resistance; acute glomerulonephritis (AGN) in 50 (20.0%), complicated commonly by UTI and congestive cardiac failure; chronic renal failure in 24 (9.6%), resulting mainly from obstructive uropathy and glomerulonephritidis and nephroblastoma in 17 (6.8%). Rare conditions included acute renal failure, urethral prolapse, vesico-ureteric reflux, polycystic kidney disease, urolithiasis and meatal stenosis among others. We conclude that potentially preventable renal diseases are still highly prevalent in our society to warrant community-based interventions. Preventive measures are advocated.
Keywords: Pattern, Renal diseases, Children.
|How to cite this article:|
Michael IO, Gabriel OE. Pattern of Renal Diseases in Children in Midwestern Zone of Nigeria. Saudi J Kidney Dis Transpl 2003;14:539-44
|How to cite this URL:|
Michael IO, Gabriel OE. Pattern of Renal Diseases in Children in Midwestern Zone of Nigeria. Saudi J Kidney Dis Transpl [serial online] 2003 [cited 2019 Jul 17];14:539-44. Available from: http://www.sjkdt.org/text.asp?2003/14/4/539/32996
| Introduction|| |
Medical audit of morbidity pattern is an invaluable tool in health planning in any given community.  It is important in healthcare research and resource allocation particularly in economies where financial allocation to healthcare sector falls short of minimum requirement. 
Though an audit outcome of a locality may be extrapolated for another, the emerging trend is for each locality to have its peculiarities regarding disease prevalence. Previously, Abdurahman et al  and Henrickse et al  carried out evaluations of childhood renal diseases prevalent in Northern Nigeria and Ibadan. Similar studies have been replicated in Port Harcourt  and Enugu.  These workers noted the relative importance of such morbidities as urinary tract infection (UTI) and glomerulonephritidis. The same reasons of paucity of facilities for renal replacement therapy and poor socio-economic situations that formed part of the bases of previous endeavors remain valid even today.
Thus an audit of renal diseases in children in our environment may provide data that could guide health planners in future to prevent diseases. It is becoming increasingly evident that preventive nephrology holds the key to effective management of common childhood renal diseases in the developing economies including Nigeria. In this study therefore, we report the pattern of childhood renal diseases seen in our medical center.
| Patients and Methods|| |
We evaluated 195 children admitted to the pediatric in-patient service at the University of Benin Teaching Hospital (UBTH) from 1997-2002. UBTH is the only teaching and research tertiary centre in the Midwestern region of Nigeria now comprising Edo and Delta States with a projected population of 7.5 million and pediatric population of about 3.5 million. It is located in the tropical rainforest belt with two distinct weather conditions of wet and dry seasons. A substantial proportion of the population is peasant farmers of the low socio-economic class.
The evaluation of the children included history, physical examination and relevant investigations. In cases with more than one renal morbidity, each morbidity was assessed as separate episode.
The initial investigations routinely carried out in the unit included complete blood count (CBC), erythrocyte sedimentation rate (ESR), urinalysis, urine culture and sensitivity, serum electrolytes, urea and creatinine. Further investigations that were carried out as needed included renal ultrasonography, intravenous urogram, micturating cysto-urethrography, serum cholesterol and proteins, anti-streptolysin O titer, 24-hour urinary protein estimation, renal biopsy and Hepatitis B surface antigen. The renal service in our center included hemo and peritoneal dialysis that were carried out in a very limited number of cases. The patients were followed up for variable periods as outpatients.
| Results|| |
Two hundred and fifty renal disease episodes occurred in 195 children seen over six years. They formed 4.5% of the 4298 pediatric inpatients in our center.
Urinary tract infection (UTI) either as an isolated diagnosis or in conjunction with other morbidities was seen in 82 (32.8%) patients; 6 (7.3%) were isolated cases and 76 (92.7%) occurred in association with other morbidities. The majority of these cases were detected during routine work up of the patients. The causal organisms were Escherichia More Details coli in 39 (47.6%) patients, Staphylococcus aureus in 21 (25.6%) and Klebsiella pneumoniae in 18 (22.0%). Others were Proteus mirabilis, Pseudomonas aeruginosa, Alkaligenes faecalis and Monganella morgani involving a case (1.2%) each. UTI complicated renal diseases such as nephrotic syndrome and acute glomerulonephritis (AGN) more commonly in children aged 6 years and above in comparison with those younger children who had malaria and acute respiratory tract infection.
There were 61(31.3%) cases of nephrotic syndrome (NS); 41 (67.2%) males and 20 (32.8%) females. The mean age was five years (range 2-15 years); 21 (34.4%) children aged 1-5 years, 17 (27.9%) aged 6-9 years, 20 (32.8%) aged 10-14 years and 3 (4.9%) were over 15 years. Twenty-six (42.6%) patients had concomitant urinary tract infection caused largely by Escherichia coli, Klebsiella pneumoniae and Staphylococcus aureus. Only one (1.6%) case had primary peritonitis. Thirty (49.2%) patients were hypertensives on admission. Of the 51 in whom steroid was used 35 (68.6%) responded to a 6 week course of prednisolone; 15 (42.9%) of them achieving response by 3 weeks of therapy. The remaining 16 (26.2%), who were steroid resistant, eventually received low dose prednisolone and six weeks course of cyclophosphamide with variable response. Only 4 (6.6%) patients, all 10 years and above, had renal tissue histology prior to commencement of treatment and three of the four, had minimal change lesion. One had membrano-proliferative disease.
Fifty cases (25.6%) of children had AGN. They were 23 (46.0%) males and 27 (54.0%) females. The mean age was 3 years (range 1.25-15 years); 24 (48.0%) aged five years or below, 14 (28.0%) were aged 6-9 years, 9 (18.0%) 10-14 years, while only 3 (6.0%) were older than 14 years. Antecedent infection was recorded in about 26 (52%) of cases; 10 (38.5%) had sore throat, while 14 (53.8%) had infected scabies or impetigo and two (7.7%) had both sore throat and pyoderma. Clinical findings included hypertension in 39 (78.0%) patients; congestive cardiac failure in 15 (30.0%) and acute renal failure in five (10.0%). The mean duration of hospital stay was 14.8 + 6.8 days (range 2-28 days). Complications of AGN included UTI in 17 (34.0%), hypertensive encephalopathy in three (6.0%) and death in three (6.0%).
Twenty-four (12.3%) patients had chronic renal failure (CRF); at presentation, all 24 patients had GFR below 25ml/1.73 /minute. There were 14 (58.3%) males and 10 (41.7%) females. Age ranged from 0.8 - 16.0 years; 9 (37.5%) were aged 10 years or below and 15 (62.5%) were over 10 years. Causes included obstructive uropathy (posterior urethral valve in 9 (37.5%); bilateral urolithiasis, meatal stenosis and vesico-ureteric reflux, 1 (4.2%) case each. Glomerulonephritidis were suspected in 11 (45.8%) patients, while recurrent UTI accounted for 1 (4.2%) case only. Characteristic features included late presentation to hospital, missed diagnosis at referral clinics, high incidence of associated UTI, poor socioeconomic conditions of parents coupled with inability to afford any form of renal replacement therapy and erythropoetin, high case fatality rate of 73.7% and increased incidence of discharge against medical advice.
Seventeen cases of nephroblastoma were seen during the six years period. They consisted of 10 (58.8%) males and 7 (41.2%) females. At presentation, the mean age was 4 years (range, 0.92 - 8 years). Late presentation was a common problem with 11 (64.7%) cases presenting in stages III and IV. Hematuria (as a feature) was seen in 4 (23.5%) cases while associated hypertension was absent in these cases.
There were 7 (4.1%) cases of acute renal failure (ARF); 3 (42.9%) cases occurred in male children less than three years who had suspected AGN. The causes included hemolytic uremic syndrome, severe dehydration and severe malaria. Case fatality rate was 42.9%.
There were miscellaneous group that included patients with uretheral prolapse involving two females aged 12 months and 4 years with vesico-ureteric reflux, polycystic kidney disease and hydrocolpos. Other cases included a case each of bilateral urolithiasis (involving a 15 years old male), papillary necrosis seen in a 14-year-old male following prolonged use of systemic steroids and sickle cell nephropathy in a 13-year-old male.
| Discussion|| |
The spectrum of childhood renal diseases in this study had slight variation of spectrum from that reported from similar centers in Nigeria, [Table - 1]. ,,,
The leading role of UTI found in this study had been noted in a previous study.  The majority of cases of UTI occurred in patients with other renal morbidities including NS, AGN and CRF. Other workers have also reported the relationship between UTI and these disorders. ,, Impairment of local immunity in the renal system due to these primary diseases may predispose individuals to UTI. Organisms implicated in these cases of UTI were similar to what had been noted in some other series in Nigeria. , Nonetheless, the emergence of new organisms with increased virulence is noted in this study.
Following UTI, NS was the second common morbidity encountered. This was in conformity with the findings in the Port Harcourt series.  In the Eastern part of Nigeria  however, AGN, rather than NS was more commonly encountered. It is uncertain to why there is local variation in the relative prevalence of NS. Substantial number of cases of NS had associated UTI - a relationship that had been noted in some series. , Rarity of thrombo-embolic phenomena and peritonitis noted in the study was at variance with reports from the Europe and America. ,
Differences in diet may explain the variations noted in the incidence of such complications. It is however, not readily apparent why peritonitis, as a complication should be rare, in the study location. Hypertension was also common amongst such patients. Our patients are comparatively older children and it is postulated that many of them could have secondary nephrosis with probable membranous or membrano-proliferative histological patterns. These could explain the high incidences of hypertension in this series. Comparable to the findings of the other Nigerian series, , the response to steroid was moderate and this may also be related to the histological patterns that are perhaps dominant in our environment.
Unlike its prominence in the Eastern Nigeria, AGN was the third most common renal disorder seen. In contrast with reports from other centers in Nigeria, female predilection was more in our study. , Antecedent infection was noted in less than half of the study subjects, suggesting perhaps, that a sizable number may not be ascribable to streptococcal infection. That a large pool of AGN is still seen at the close of twentieth century under-scores the poor state of our health care delivery and environmental sanitation. It is noteworthy, however, that the case fatality rate was low, due perhaps to early presentation to hospital. Over 30% of our cases also had concomitant UTI. Higgins had also reported this trend. 
Nephroblastoma was the second commonest solid malignancy in our center after Burkett's lymphoma. The mean age was similar to those noted in literatures from the Middle East.  It is noteworthy, however, that the majority of our patients presented late to hospital, due most likely to parental ignorance.
About 3.0% of the patients with renal diseases seen in our study had chronic renal failure with majority of them in the second decade of life. Unlike reports on CRF from Middle East  and Western world,  structural urologic malformations played a very dominant role in our study. Even more intriguing was the finding that congenital lesion like posterior urethral valve (PUV), a surgically amenable condition accounted for a sizeable number of cases. Late presentation and inability to afford interventional measures including renal replacement therapy were the bane of these patients. These factors could explain the high case fatality rates noted among patients with CRF in the study.
Finally, conditions such as IgA nephropathy and renal tubular acidosis were not encountered in our study. It is possible that such conditions are very rare or undiagnosed in our setting. Non-availability of appropriate diagnostic tools remains a formidable hindrance to be surmounted in the quest to establish true prevalence of such diseases.
| Acknowledgement|| |
We deeply appreciate the contributions of all our health staff that were involved in the care of the children with renal diseases.
| References|| |
|1.||Snow RW, Craig M, Deichmann U, Marsh K. Estimating mortality, morbidity and disability due to malaria among Africa's non-pregnant population. Bull World Health Org 999;77 (8): 624-40. |
|2.||Isah AO, Isah EC, Okojie OH, OhajuObodo JO. Morbidity pattern in out-patient clinics in Edo and Delta States of Nigeria. Ann Biomed Sci 2002; 1: 70-6. |
|3.||Abdurrahman MB, Babaoye FA, Akhionbare HA. Childhood renal disorders in Nigeria. Pediatr Nephrol 1990; 4: 88-93. |
|4.||Hendrickse RG, Gilles HM. The nephrotic syndrome and other renal diseases in children in Western Nigeria. East Afr Med J 1963; 40: 186-201. [PUBMED] |
|5.||Eke FU, Eke NN. Renal disorders in children: a Nigerian study. Pediatr Nephrol 1994;8:382-6. |
|6.||Okoro BA, Okafor HU. Pattern of childhood renal disorders in Enugu. Nig J Paediatr 1999;26:14-8. |
|7.||Ibadin MO. The prevalence of urinary tract infection in childhood nephrotic syndrome. Nig J Paediatr 1997; 24: 40-4. |
|8.||Ibadin MO, Abiodun PO. Urinary tract infection in children with acute nephritic syndrome. Ann Biomed Sci 2002; 1: 23-9. |
|9.||McVicar M, Policastro A, Nicastri AD, Gort D. Incidence of bacteuria in the nephritic syndrome in children. J Pediatr 1973;82:166-7. |
|10.||Adeyemo AA, Gbadegesin RA, Onyemenem TN, Ekweozor CC. Urinary tract pathogen and anti-microbial sensitivity patterns in children in Ibadan, Nigeria. Ann Trop Paediatr 1994; 14: (4): 271-4. |
|11.||Azubike CN, Nwamadu OJ, Oji RU, Uzoije N. Prevalence of urinary tract infection among school children in a Nigerian rural community. West Afr J Med 1994;13(1): 48-52. |
|12.||Andrew M, Brooker LA. Hemostatic complications in renal disorders of the young. Paediatr Nephrol 1996; 10: 88-99. |
|13.||Krensky AM, Ingelfinger JR, Grupe WE. Peritonitis in childhood nephrotic syndrome 1970-1980. Am J Dis Child 1982;136:732-6. [PUBMED] |
|14.||Okafor HU, Okoro BA, Ugwu GI. Acute glomerulonephritis in Enugu. Nig J Paediatr 1995; 22: 31-5. |
|15.||Akhiobare HA, Abdurrahman MB. Acute glomerulonephritis in Zaria. Nig J Paediatr 1984; 11: 59-62. |
|16.||Higgins PM. Acute post-streptococcal glomerulonephritis in general practice: the contribution of infection to its onset and course. Epidemiol Infect 1996;116 (2):193-201. |
|17.||Haddadin I, Issa H. Wilms' tumour experience at king Hussein medical center. Saudi J Kidney Dis Transplant 2000;11 (1): 35-9. |
|18.||Hamed RM. The spectrum of chronic renal failure among Jordanian children. J Nephrol 2002; 15: 130-5. [PUBMED] [FULLTEXT]|
|19.||Pistor K, Scharer K, Olbing H, TamminenMobius T. Children with chronic renal failure in the Federal Republic of Germany: Primary renal diseases, age and intervals from early renal failure to death. Clin Nephrol 1985; 23: 278-84. |
Ibasdin Okoeguale Michael
Department of Child Health, University of Benin Teaching Hospital, Benin City
[Table - 1]