| Abstract|| |
This survey was performed on children with renal diseases admitted to Shiraz Pediatric Nephrology Unit from October 1993 to March 2000. There was a total of 1358 children, of whom 709 (52%) were boys, with age range of 1 month to 16 years and a mean of 6.5 ± 4.7 years. Thirty percent of children were below age of 2 years. Admission diagnosis was acute nephritis in 312 (23%) patients, urinary tract infection in 259(19.1%), nephrotic syndrome in 252 (18.6%), chronic renal failure in 202 (14.9%), urologic problems in 101 (7.5%), acute renal failure in 99 (7.3%), metabolic disorders in 47 (3.5%) and hypertension in 39 (2.9%). Acute poststreptococcal nephritis was the most common disease in the acute nephritis group. Minimal change nephrotic syndrome was the most common in the nephrotic syndrome group (64.2%). Chronic renal failure was mainly due to congenital urological malformations (46%). Acute renal failure (ARF) was caused mainly by gastroenteritis. There were six cases of ARF due to scorpion sting and 12 cases due to various malignancies and associated tumorlysis syndrome. Persistent hypertension was caused mainly by reflux nephropathy (50%). We conclude that the patterns of renal diseases found in the Iranian children were similar to those reported from other developing countries with predominance of infection related diseases.
Keywords: Epidemiology, Renal disease, Children, Iran
|How to cite this article:|
Derakhshan A, Al Hashemi GH, Fallahzadeh MH. Spectrum of In-patient Renal Diseases in Children "A Report from Southern part Islamic Republic of Iran". Saudi J Kidney Dis Transpl 2004;15:12-7
|How to cite this URL:|
Derakhshan A, Al Hashemi GH, Fallahzadeh MH. Spectrum of In-patient Renal Diseases in Children "A Report from Southern part Islamic Republic of Iran". Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2013 Dec 11];15:12-7. Available from: http://www.sjkdt.org/text.asp?2004/15/1/12/32960
| Introduction|| |
There are differences in the patterns and management of renal diseases in children compared to adults. The pediatric renal patients form 8.7% of all pediatric admissions to hospitals. 
With the initiation of pediatric nephrology fellowship program in 1989, the care of renal patients has improved dramatically in our country. There have been reports from Iran on renal diseases in children. ,,,,, However, major geographical differences in patient referral patterns for renal diseases do exist due to the wide geographic area of the country.
We are reporting our experience on the spectrum of our inpatient renal diseases in a referral center in southern Iran.
| Patients and Methods|| |
We evaluated all children admitted to Shiraz pediatric nephrology unit between October 1993 and March 2000. We reviewed them for age, gender, clinical and laboratory findings, and final diagnosis. We categorized them on the basis of the final diagnosis with the same method used by Chan et al.  Readmissions were excluded and renal events ending in chronic and/ or end- stage renal failure were included in the chronic renal failure (CRF) group.
We categorized the CRF group according to another study from Iran with the same definitions used for chronic renal failure in different age groups. 
| Results|| |
The total number of the study patients was 1358. There were 709 (52%) boys and 649 (48%) girls with a mean age of 6.5 ± 4.7 years. The spectrum of renal disease in our population is summarized in [Table - 1].
Percutaneous kidney biopsy was performed in 348 children; half of these had nephrotic syndrome, glomerulopathies, HUS, nephronophthisis, interstitial nephritis and transplant dysfunction.
There were 312 patients under the category of glomerulonephritis 23%, of whom 161 presented as acute nephritic syndrome, nephriticnephrotic feature or a rapidly progressive glomerulonephritis (RPGN) course; 128 patients belonged to this latter group had features of acute poststreptococcal glomerulonephritis (APSGN).
Kidney biopsy was performed in 14 cases with rapid deterioration of renal function. All of whom had more than 70% crescents. RPGN complicated APSGN in six cases, while the remaining eight cases were idiopathic.
There were 54 (4%) children with lupus nephritis (40 girls and 14 boys) with a mean age of 11.66 ± 3.17 years. The renal histology revealed class II, III, IV, V, in 8, 7, 32 and 3 children, respectively; biopsy was not done in four cases.
There were 253 (18.6%) children (167 boys and 86 girls) in the category of nephrotic syndrome with the mean age of 7.11 ± 4.05 years. Of these patients 101 (40%) were steroid responsive and 48 (19%) had biopsy proven minimal change nephrotic syndrome (MCNS) with a mean age of 6.02 ± 3.56 years. The mean ages for the biopsy proven cases of focal segmental glomerulosclerosis (FSGS), mesangioproliferative glomerulonephritis (MESPGN) and membranoproliferative glomerulonephritis (MPGN) were 7.52 ± 4.15, 5.27
± 4.16 and 11.52 ± 2.55 years, respectively. The group with congenital and infantile nephrotic syndrome was not included for calculation of the mean age.
There were 99 (7.3%) children with acute renal failure of whom 34 (34%) had clinical and paraclinical features of prerenal azotemia. There were 61/99 (61%) cases of acute tubular necrosis (ATN) of whom 21 (34%) were due to acute gastroenteritis, 12 (20%) secondary to various malignancies, six (10%) due to scorpion sting, 13 (21%) due to sepsis, three by hemolysis, two by post cardiac surgery and burn, one congenital heart disease, one poisoning and one gentamicin toxicity. There were four cases of postrenal acute renal failure due to stones, two of which were in a single kidney and two in bilateral ureteropelvic junction.
There were 202 (14.9%) children with CRF. Their age distribution was as follows: 1 month2 years, 25; 3- 6 years, 31; 7- 10 years, 58 and 11- 16 years, 88.
The etiology of CRF included glomerulopathies in 30/202 (14.9%); 16/30 (53%) cases of FSGS, five cases of RPGN, five cases of MPGN and four cases of other glomerulonephritis. Hereditary nephropathies as a cause of CRF included 36 (17.8%) children with nephronophthisis, polycystic kidney disease, primary hyperoxaluria, cystinosis, LaurenceMoon- Biedl syndrome and others.
The congenital urological malformations group with CRF included 93 (46%) children; 37 with reflux nephropathy without neurogenic bladder, 16 with neurogenic bladder with or without reflux, eight with posterior urethral valve, 20 with hypoplastic- dysplastic or ectopic kidneys, 12 with other diagnoses. Multisystem disease and hypertension were the cause of CRF in 6 cases, stone and nephrocalcinosis in 12, chronic interstitial nephritis in 10 and unknown etiology in 15. Kidney transplantation was performed after variable periods of chronic dialysis in 46 children.
Urinary tract infection (UTI) accounted for 260 (19.1%) admissions; 193 (74%) girls with a mean age of 4.34 and 67 (26%) boys with a mean age of 3.63 years.
The age distribution of the boys with UTI was 32 cases in less than 1 year, 10 in 1-2 years and 25 in more than 3 years old. Circumcision was not performed in 37 boys less than 2 years old with UTI. In the group of girls with UTI, 66, 25, 55 and 47 cases were less than one year, 1- 2 years, 3- 7 years and more than 8 years old, respectively.
UTI was diagnosed with suprapubic urine culture in the majority of children 75% and in the remaining group with two or more positive urine cultures of midstream or urine bag. E. coli was the causative organism in 210 (80%) of cases.
The majority of children in this group had one or more imaging studies; sonography in 98% of cases and voiding cystourethrography (VCUG) in 70%. About 52% of children had abnormalities on sonography ranging from minimal unilateral or bilateral caliectasis and thickening of bladder mucosa to frank abnormalities. Furthermore, the VCUG revealed reflux of grade I-IV in 50% of the cases who had this test. The correlation between sonography and VCUG was high (63%).
Persistent hypertension was the cause of referral in 40 (2.9%) children. About half of this group had unilateral small kidney with or without reflux.
Isolated urine abnormalities such as gross hematuria, persistent microscopic hematuria and/or proteinuria were the reason for referral in 17 (1.2%) children.
| Discussion|| |
There are many reports on renal diseases in children from developing or developed countries.  Reports from our country are limited to some specific topics. ,,,,, Here, we are reporting our experience with inpatient profile of renal diseases in children. However, the neonatal age group and outpatient data are not included.
There have been about equal number of admissions of both genders. Thirty percent of children were below two years of age as in other studies.  Glomerulonephritis and nephrotic syndrome were as common in our study as the other studies from Iran. ,
With the exclusion of congenital and infantile nephrotic syndrome and by considering all steroid responders as minimal change, the male to female ratio was found to be 2:1 with a still lower percentage of MCNS than that reported in other studies. , Though high percentage of FSGS was reported in another study this was not seen in ours.  We found low percentage of children with MGN as has been reported before. 
We had more cases of acute and chronic renal failure than Chan et al found.  However, the profile of CRF was very similar to the previous studies, with congenital urological malformation being the most common cause of CRF, followed by hereditary nephropathies and glomerulonephritis. ,,, Our findings also revealed a higher percentage of patients with neurogenic bladder and stone disease.
Kidney transplantation was performed in 46 children and the results appeared in two previous reports. , As in other developing countries, gastroenteritis and associated dehydration were the common causes for prerenal azotemia and ATN, followed by sepsis, malignancy and scorpion sting.
Acute renal failure due to scorpion sting and associated hemolysis has been reported from Iran previously. 
Hemolytic uremic syndrome (HUS) is a common cause of acute renal failure in infants and young children.  The children with HUS in our study presented with glomerulonephritis rather than acute renal failure.
In our study, UTI was three times more common in girls than in boys and E. coli was the most common causative organism. The majority of the cases of UTI in boys occurred in those less than 1 year old as in other studies  and circumcision was a major risk factor for it. ,
Neurogenic bladder was a more common urologic problem in our study than other studies, though a high percentage of 6.7% has been previously reported from Iran. 
Reflux nephropathy was the most common cause of persistent hypertension in our study as was found in other studies. , We found limited number of cases of urinary abnormalities due to outpatient handling of such cases.
| Acknowledgements|| |
The authors thank the vice chancellor for research in Shiraz University of Medical Sciences for his support and the Pediatric Nephrology fellows for their cooperation.
| References|| |
|1.||Sadeghi E. Spectrum of Pediatric diseases in South Islamic Republic of Iran: Eastern Mediterranean Health Journal 1997;103: 519-29. |
|2.||Chan JC. Lessons from 20 years of leading a Pediatric Nephrology Program. Nephron 1998;78:378-88. [PUBMED] [FULLTEXT]|
|3.||Madani K, Otoukesh H, Rastegar A, Van Why S. Chroinc renal failure in Iranian children. Pediatr Nephrol 2001;16:140-4. [PUBMED] [FULLTEXT]|
|4.||Bodaghi E, Vazirian S, Madani A, Shamsa AM, Afzali HM, Elmi F. Primary nephrotic syndrome in Iran: clinicopathological study of 310 cases. Int J Pediatr Nephrol 1986;7: 127-30. |
|5.||Bodaghi E, Vazirian S, Abtahi M, Honarmand MT, Madani A, Zia Shamsa AM. Glomerular diseases in children. The Iranian Experience. Pediatr Nephrol 1989; 3:213- 7. |
|6.||Ahmad E, Malek Hosseini SA, Nezakatgoo N, et al. A report of 26 cases of renal transplantation in children. Transplant Proc 1995;27:2570. [PUBMED] |
|7.||Derakhshan A, Malek Hosseini SA, Hashemi Gh, Fallahzadeh MH, Ghahramani N. Experience with pediatric renal transplantation in Nemazee Hospital transplantation center. Abstract book of VIIth International Congress of the Middle East Society for Organ Transplantation 2000;P 166. |
|8.||Hashemi Gh, Fallahzadeh MH. Analysis of prognostic features in children with HUS. Med J Islamic Rep Iran 1994; 7: 259-61. |
|9.||Pediatric Nephrology around the world. In: Barrat TM, Avner ED, Harmon WE (eds). Pediatric Nephrology. 4th edn. Lippincott: Williams and Wilkins 1999;PP 1349-72. |
|10.||International study of Kidney Disease in Children. Nephrotic Syndrome in children: prediction of histopathology from clinical and laboratory characteristics at time of diagnosis. Kidney Int 1978;13:159-65. [PUBMED] |
|11.||White RH, Glasgow EF, Mills RJ. Clinicopathological study of nephrotic syndrome in childhood. Lancet 1970;1:1353-9. [PUBMED] |
|12.||Srivastava T, Simon SD, Alon US. High incidence of focal segmental glomerulosclerosis in nephrotic syndrome of childhood. Pediatr Nephrol 1999;13:13-18. [PUBMED] [FULLTEXT]|
|13.||Kleinknecht C, Habib R. Membranous glomerulonephritis. In: Holiday MA, Barrat TM, Vernier RL (eds). Pediatric Nephrology. 3rd edn. Baltimore: Williams and Wilkins, 1987; PP 462-70. |
|14.||Lagomarsimo E, Valenzuela A, Cavagnaro F, Solar E. Chronic renal failure in Pediatrics 1996. Chilean survey. Pediatr Nephrol 1999;13:288-91. |
|15.||Gulati S, Mittal S, Sharma RK, Gupta A. Etiology and outcome of chronic renal failure in Indian children. Pediatr Nephrol 1999;13:594-6. [PUBMED] [FULLTEXT]|
|16.||Malhotra KK, Mirdehghan M, Tandon HD. Acute renal failure following scorpion sting. Am J Trop Med Hyg 1978;27:623-6. |
|17.||Meyers KEC, Kaplan BS. Hemolyticuremic syndrome. In: Barrat TM, Avner ED, Harmon WE (eds). Pediatric Nephrology. 4th edn. Lippincott: Williams and Wilkins, 1999; PP 811-22. |
|18.||Hansson S, Jodal U. Urinary tract infection. In: Holliday MA, Barrat TM, Vernier RL (eds). Pediatric Nephrology. 4th edn. Lippincott: Williams and Wilkins 1999; P 839 (Fig. 52.1). |
|19.||Wiswell TE, Roscelli JD. Corroborative evidence for the decreased incidence of urinary tract infections in circumcised male infants. Pediatrics 1989;78: 96-9. |
|20.||Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases incidence and casts of urinary tract infections during the first year of life. Pediatrics 2000;105:789-93. [PUBMED] [FULLTEXT]|
|21.||Farhud DD, Walizadeh GR, Kamali MS. Congenital malformations and genetic diseases in Iranian infants. Hum Genet 1986;74:382-5. [PUBMED] |
|22.||Daniels SR, Loggie JM, McEnery PT, Towbin RB. Clinical spectrum of intrinsic renovascular hypertension in children. Pediatrics 1987;80:698-704. [PUBMED] |
|23.||Burke GL, Voors AW, Shear CL, et al. Cardiovascular risk factors from birth to 7 years of age: the Bogalusa Heart Study. Blood pressure. Pediatrics 1987;80:784-6. |
Division of Pediatric Nephrology, Nemazee Hospital, P.O. Box 71937, Shiraz University of Medical Sciences, Shiraz
[Table - 1]