| Abstract|| |
To evaluate the patterns of chronic renal failure in children in our center, we studied prospectively the etiology and outcome of all the cases referred to us as renal disease between 1997-2002. There were 24 children;14 (58.3%) males and 10 (41.7%) females with a mean age of 11.2 + 0.97 years (range; 0.08-16.0 years). The estimated incidence was 1.7 new cases per million-child population and the prevalence was 4 per million populations. The leading causes of renal failure were glomerulonephritidis in 14 (58.3%) children and posterior urethral valve in 8 (33.3%). Most of the patients came from poor socio-economic background. Generalized body swelling 11 (45.8%), abdominal swelling 9 (37.5%) and paleness 7 (29.2%) were the commonest presenting complaints. Late presentation and severely compromised renal function were common features. The mortality rate was 58.3%. We conclude that there is an increased mortality rate in children with renal disease in our country due to the dearth of facilities for renal replacement therapy coupled with poverty and late referrals.
Keywords: Chronic renal insufficiency, Epidemiology, Outcome, Children.
|How to cite this article:|
Michael IO, Gabreil OE. Chronic Renal Failure in Children of Benin, Nigeria. Saudi J Kidney Dis Transpl 2004;15:79-83
| Introduction|| |
Chronic renal failure (CRF) that signifies marked steady and irreversible deterioration in kidney function is not very common in the pediatric population.  It represents a common pathway for varied morbidities as they progress inexorably towards end-stage renal disease (ESRD). The causes and course of CRF have been studied extensively in adults but in children literature on CRF are almost restricted to those emanating from Europe, North America and Middle East. ,,,, Recently, some cases of CRF were reported from Nigeria suggesting an increasing role for CRF in children morbidity and mortality. 
CRF demands the availability of modalities of renal replacement therapy (RRT) as definitive management.  RRT is expensive and relatively unavailable in Nigeria. Furthermore, substantial proportion of CRF in children is preventable. ,
We studied the children with CRF referred for evaluation in our facility to define the etiology and outcome in them in order to lay down a strategy for management in this population.
| Patients and Methods|| |
We prospectively enrolled in the study all children managed for CRF at the University of Benin Teaching Hospital (UBTH), Benin City, Nigeria from October 1997 to September 2002. UBTH is a tertiary healthcare center that receives patients mainly from Edo and Delta states of Nigeria with estimated combined population of 6.5 million.
Evaluation of each child entailed medical history, physical examination, radiological and laboratory studies. Laboratory evaluations included urine and serum creatinine; serum urea, electrolytes, serum protein, blood cell count, urinalysis and urine culture. All the study patients had glomerular filteration rate (GFR) less than 25ml/min/1.73m 2 body surface area, as estimated by using the Schwartz formula.  Diagnosis of the urologic abnormalities was based on history and radiologic and sonographic findings, while that of glomerulonephritidis was empirical, relying mainly on history. We did not routinely perform renal biopsy in our patients because of inadequate facilities. Family socio-economic status was determined in accordance with the methods described by Olusanya et al. 
All patients had some conservative management including calcium carbonate, antihypertensives (mainly hydralazine, α-methyldopa, angiotensin converting-enzyme-inhibitors and calcium channel blockers). Though recombinant erythropoietin was prescribed for most patients, only two could afford it. One patient had a week long course of dialysis. Calcium supplementation and alkali were given as needed to optimize growth potential. Restriction of protein intake was not enforced because access to protein was generally poor in our patients. We did not give 1,25 dihydroxy vitamin D. We did not monitor parathormone levels, as facilities for measurement were not routinely available. The need to ensure adequate calories was taken into consideration. Our center also did not have set-up for renal transplantation.
On discharge or demise the parameters already outlined were documented and formed the database for this study.
| Results|| |
Twenty-four children with CRF were managed at the children's ward of UBTH over five years. Fourteen (58.3%) were males with male to female ratio of 1.4:1. The mean + SD age of the children was 11.2 + 0.97 years (range of 0.08 - 16 years). Approximately 62 percent of these children were over 10 years of age. The estimated prevalence of CRF in the Edo/Delta States according to our data is 4 per million populations. The estimated incidence of CRF is 1.7 new cases per million-child population per year (45% of the entire population is under 16 years).
The leading causes of renal failure were glomerulonephritidis in 14 (58.3%) children and posterior urethral valve in 8 (33.3%), [Table - 1]. The majority of the children were from families of low-socio-economic status (SES), while 3 (12.5%) were from middle to high SES. The parents of most patients were either subsistent farmers or petty traders with estimated family annual income falling short of 1000 US dollars. Twenty-one out of 24 (87.5%) mothers and 17 of 24 (70.8%) fathers had only primary school education.
The spectrum of clinical presentations is shown in [Table - 2]. Generalized body swelling, abdominal swelling, paleness and weakness were the commonest complaints occurring in 11 (45.8 %), 9 (37.5 %), 7 (29.2%) and 7 (29.2%) cases respectively. Others included vomiting and difficulty in breathing found in 6 (25.0 %) cases each. Mean duration of symptoms before presentation was 21.2 + 5.8 weeks (range of 2 weeks-2 years). Mean duration of hospital stay was 17.2 + 2.4 days (range of 3-42 days). Only two (8.3%) patients could afford one-week maximum treatment with erythropoetin due to financial constraints. One of these two patients had a week course of hemodialysis; the rest could not be dialyzed for reasons that included financial insufficiency, inappropriate age and very short duration of stay in hospital.
Management before referral to our hospital included repeated transfusion to 5 (20.8 %) patients blood transfusion for presumed hematological diseases in private health facilities. Ten (41.7%) children had diuretics and varying doses of prednisolone for presumed nephrotic syndrome. Three (37.5%) children with antecedent problem of posterior urethral valve (PUV) presented with abdominal masses, which formed the bases of referral for consideration of abdominal malignancy.
Of the 24 patients, 14 (58.3%) died, five (20.8%) were discharged against medical advice, while one child was referred to another center due to lack of facility. The remaining four (16.7%) were lost to follow-up.
| Discussion|| |
In this study, the estimated incidence of 1.7 new cases per million child population per year is a much lower number than the 68 per million in some developed countries  and 10.7 reported from the middle East.  Similarly, the prevalence of CRF in this study was lower than the 32.4 and 51 per million population reported respectively from Jordan  and Europe. This disparity can be attributed to a number of factors such as too late recognition or referrals of the cases of CRF by families or primary physicians to nephrologists. Poor facilities of renal replacement therapy (RRT) are also an additive factor.
More male than female children had CRF in this series. This finding is in conformity with those from related studies that noted male predilection in childhood CRF or CRF. , This may be due to the more common structural anomalies of the urogenital system in males that predispose to CRF.
Glomerulonephritis was the major cause of CRF in this study. This finding is at variance with what is reported in some other countries where urologic abnormalities were the leading cause of CRF. ,, The reason for this variation is not readily obvious. However, prevalence of preventable causes of glomerulonephritis such as post streptococcal cases may be higher in our population. Posterior urethral valve was responsible for over 90% of urologic abnormalities seen in this study. This is a potentially preventable condition by early referral and surgical correction.
Only one case of primary vesico-ureteric reflux was seen in this study in contradiction to the 25% noted by Hamed et al.  The dearth of relevant investigative tools for urologic abnormalities and late referrals may account for this low figure.
The mortality rate of 58% in our study is unacceptably high due to inadequate facilities for RRT, pervasive poverty and negative socio-cultural health awareness and attitudes. Most of our patients' families could not afford erythropoetin or cost of longterm dialysis (cost about 150 US dollars a week). Only one of the families of children involved could afford chronic dialysis or renal transplantation.
We conclude that there is an increased mortality rate in children with renal disease in our country due to the dearth of facilities for renal replacement therapy coupled with poverty and late referrals. We need reform of the health system and to set the priorities for management of renal diseases in our country.
| Acknowledgement|| |
We thank the resident doctors and nurses in renal unit who were involved in the care of these children.
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Ibadin Okoegual Michael
Department of Child Health, University of Benin Teaching Hospital, Benin City
[Table - 1], [Table - 2]