| Abstract|| |
Renal disease in hospitalized children can be difficult to diagnose early as it may exhibit few symptoms, unlike in adults. This study reports the epidemiological data, percentages and types of renal disorders in children seen at the pediatric nephrology center of the AlKadhymia Teaching Hospital, Baghdad, Iraq. A retrospective review of the charts of all patients, aged between one month and 14 years, who were admitted and followed-up for a period of three years from January 2009 till January 2012 were studied. The presence of renal disease based on their clinical records, laboratory tests and final diagnosis were noted. A total of 4785 children were admitted during the study period, of whom 326 renal disorders were observed in 281 children (5.8%). The affected children included 158 males (56.2%) and 123 females (43.7%). Majority of the cases were above two years of age (n = 181; 64.4%). Among them, urinary tract infection, seen in 60 patients (18.4%), was the most common renal disease, followed by nephrotic syndrome (n = 52; 15.9%), renal stone disease (n = 49; 15%), congenital malformations (n = 46; 14.1%), acute renal failure (n = 37; 11.3%), chronic renal failure (n = 22; 6.7%), glomerulonephritis (n = 16; 4.9%), isolated hematuria (n = 14; 4.2%), hypertension (n = 8; 2.4%), tubular disorders [renal tubular acidosis (n = 8; 2.4%), isolated hypercalciuria (n = 7; 2.1%), Bartter syndrome (n = 1; 0.3%)] and Wilm's tumor in six (1.8%) patients. The spectrum of renal disorders in Iraq is wide, and is similar to those reported from other developing countries with a predominance of infectious diseases.
|How to cite this article:|
Ali SH, Hussien FS, Abd Al-Amer H. Profile of renal diseases in Iraqi children: A single-center report. Saudi J Kidney Dis Transpl 2015;26:613-8
|How to cite this URL:|
Ali SH, Hussien FS, Abd Al-Amer H. Profile of renal diseases in Iraqi children: A single-center report. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 May 24];26:613-8. Available from: http://www.sjkdt.org/text.asp?2015/26/3/613/157422
| Introduction|| |
The prevalence and pattern of pediatric renal disorders have been poorly defined in developing countries. This is because renal diseases are masked by the prevailing endemic diseases. , Renal disease constitutes 4.5-8.7% of all pediatric admissions to hospitals. ,,
The pattern of renal disease is different in developing countries as compared with developed countries. Also, there are differences in the pattern and management of renal diseases in children compared with adults; during infancy and early childhood, unexplained fever or failure to thrive might be the only manifestation of underlying renal disease.  Studying the profile of renal diseases in children in our environment may provide data that could guide health planners in the future to prevent these diseases. It is becoming increasingly evident that preventive nephrology holds the key to effective management of common childhood renal diseases in developing economies, including Iraq. In order to make this feasible, we have to initially understand the pattern and prevalence of renal diseases in Iraq. This will create increased awareness among medical practitioners in the country. This study was undertaken to meet this need.
| Patients and Methods|| |
In this retrospective study, case records of all patients admitted to the Pediatric Department or those who had been followed-up at the Pediatric Nephrology Clinic in Al-Kadhymia Teaching Hospital over a period of three years from January 2009 to January 2012 were reviewed. Data were collected from the record files of these patients, which were obtained from the Department of Statistics of the hospital. The evaluation included history, physical examination and relevant investigations. In cases where there was more than one renal disorder, each disorder was assessed as a separate episode.
Initial investigations that had been performed included complete blood count, erythrocyte sedimentation rate, urine analysis, urine culture and sensitivity, serum electrolytes, blood urea and serum creatinine. Subsequent investigations were carried out as needed and included renal ultrasonography, intravenous urogram, micturating cystourethrography, serum cholesterol and protein, 24-h urinary protein estimation, dsDNA and renal biopsy. Other tests performed in some cases included arterial blood gases (ABG), throat swab culture and sensitivity, anti-streptolysin O (ASO) titer, serum complement (C3, C4), anti-nuclear antibody (ANA), 24-h urine for calcium, uric acid, oxalate and cystine.
The diagnosis of urinary tract infection (UTI) was based on clinical manifestations and a positive urine culture. , The urinary tract was evaluated by renal ultrasonography. Other studies such as voiding cystourethrography (VCU) and intravenous pyelography were performed in selected cases.
Nephrotic syndrome (NS) was diagnosed on the basis of proteinuria >40 mg/h/m 2 body surface area, edema, hypoproteinemia and hypercholesterolemia. ,
Hypercalciuria was diagnosed in children with a urinary calcium/creatinine ratio >0.2 mg/mg in two first void-morning urine samples. , In children over four years of age, the diagnosis was confirmed by a 24-h urinary calcium excretion above 4 mg/kg/day.
Acute glomerulonephritis (GN) was diagnosed on the basis of presence of a clinical picture of hematuria, edema and hypertension. ,
Renal tubular acidosis (RTA) was considered by the presence of hyperchloremic metabolic acidosis, with normal anion gap (between 8 and 16 mEq/L).  Bartter syndrome is characterized by growth failure, metabolic alkalosis and renal potassium wasting. 
Acute renal failure (ARF) was diagnosed on the basis of increase in serum creatinine levels by >0.3 mg/dL in 48 h or decreased urine output to <0.5 mL/kg within six hours.  Children with either systolic or diastolic blood pressure (BP) falling above the 95th percentiles, based on gender, height and age, were regarded as hypertensive. 
Chronic renal failure (CRF) was defined as glomerular filtration rate of <60 mL/min/1.73 m 2 body surface areas as estimated by Schwartz's formula  or on the basis of serum creatinine persistently above 2.0 mg/dL for children less than two years of age, 2.5 mg/dL for children three to 10 years old and 3.0 mg/dL for older children. 
Neonates below the age of one month were excluded from the study. Patients who were re-admitted were excluded from the study.
| Results|| |
The total number of patients with renal diseases in this study was 281; they constituted 5.8% of the total pediatric admissions (4785) during the study period. Among patients with renal disease, 158 (56.2%) were males and 123 (43.8%) were females. Forty-five cases (16.1%) were below one year of age, 55 cases (19.5%) between one and two years of age and 181 cases (64.4%) were above two years of age.
Three hundred and twenty-six renal disorders occurred in 281 children, and the distribution of these renal disorders is shown in [Table 1]; 45 patients had more than one renal disorder as shown in [Table 2]. Each disorder was considered as a separate entity.
The most common renal disease in this study was UTI, seen in 60 patients (18.4%), either as isolated UTI or associated with other renal diseases. The most common anomalies associated with UTI included vesicoureteric reflux (VUR), followed by pelvi-ureteric junction (PUJ) obstruction, neurogenic bladder, hypoplastic-dysplastic kidneys, posterior urethral valve (PUV), ectopic, single kidney and polycystic kidney disease (PCKD). More females had UTI (n = 38) than males (n = 22), with a ratio of 1.7:1. UTI was caused by E. coli in 23 patients (38.4%), Staphylococcus aureus in 13 (21.6%), Klebsiella in 10 (16.6%), Proteus in eight (13.4%) and Pseudomonas in six patients (10%).
The second most common renal disease in this study was NS, seen in 52 patients (15.9%). Four of them were below one year of age, 34 patients ranged from one to eight years and the other 14 patients were above eight years of age. Steroid responsiveness was seen in the majority of cases (n = 38; 73%). Renal biopsy was performed in 17 patients, which revealed minimal change disease (MCD) in eight patients, focal and segmental glomerulosclerosis (FSGS) in five patients, membranoproliferative GN (MPGN) in two cases and congenital NS of the Finnish type in two patients.
Urolithiasis (UL) occurred in 49 patients (15%); hypercalciuria was found to be the most common metabolic abnormality, followed by hyper-oxaluria, hyper-uricosuria and cystinuria. The upper urinary tract system was the most common site for stone location. Bilateral renal involvement was seen in more than one-third of the cases.
Calcium oxalate was the most common type of stone. Etiology of UL was established in majority of the cases (56.3%) to be metabolic with an early onset of symptoms. Family history of UL and multiple and bilateral stones were observed in this group compared with the other etiologic groups. Infection-related stones and anatomical anomalies constituted the other causes of UL, seen in 21.8% and 16.7% of the patients, respectively.
Congenital anomalies were observed in 46 patients (14.1%) in this study. The most common anomaly was VUR, seen in 11 cases (23.9%), followed by PUJ in seven (15.2%) and PUV, hypoplastic-dysplastic kidney and neurogenic bladder in five cases each (10.8%). Other anomalies included ectopic kidney in five patients, single kidney in three and ureterocele, PCKD and duplex system in two cases each; Prune belly syndrome was reported in one patient.
ARF occurred in 37 patients (11.3%), mainly in children below aged two years. Gastroenteritis and dehydration were the main causes, seen in 21 patients (56.7%), followed by sepsis in six patients, hemolytic uremic syndrome (HUS) in five patients and birth asphyxia in three patients, while two patients had GN complicated by ARF. Most of them were treated conservatively and a few required acute intermittent peritoneal dialysis (PD).
CRF was seen in 22 patients (6.7%); of them, eight cases (36.3%) were related to structural and anatomical anomalies, including dysplatichypoplastic kidneys. Other causes of CRF included FSGS in five patients and hereditary diseases including PCKD and cystinosis in four patients. In five patients (22.7%), no cause could be identified.
GN was observed in 16 patients (4.9%); poststreptococcal GN was the main cause, seen in 10 cases (62.5%). This was preceded by upper respiratory tract infection in 40% and impetigo in 20%. In 40%, there was no obvious antecedent factor. Other types of GN included lupus nephritis and IgAN in two cases each and Henoch Schonlein purpura (HSP) and rapidly progressive GN in one case each. Isolated hematuria was seen in 14 patients (4.3%). In the majority, it was simple infrequent microscopic hematuria while in four, macroscopic hematuria was seen. All patients had normal BP, renal function and normal ultrasound; none had associated UTI. Persistent hypertension was detected in eight children (2.4%). Half of this group had unilateral small kidney with reflux.
Tubular disorders were seen in 16 cases. Eight of them (2.4%) had renal tubular acidosis (RTA); distal type 1 was the most common variety, seen in four patients, proximal type 2 was seen in three patients and one patient had type 4 RTA. Other tubular disorders included idiopathic hypercalciuria seen in seven patients (2.1%) and one patient with Bartter syndrome (0.3%).
Wilm's tumor was seen in six patients (1.8%); all were treated in the oncology department.
| Discussion|| |
The pattern of diseases recorded in this study is similar to that observed by other workers around the world. ,,,, In a study from Nepal, 6.3% of the children admitted in the pediatric hospital had renal disease, while in Libya it was 3%. , In our study, the percentage was 5.8%.
UTI was the most common renal problem, similar to the South American report  as well as reports from other developing countries. ,, The majority of patients in our series had VUR as the most frequent associated urinary tract abnormality, similar to other reported studies. ,,
Urolithiasis was seen in 15% of our study patients. This is a frequent disorder among our population, and is similar to previous reports from Iraq.  Metabolic UL accounted for more than a half of these cases. Genetic and/or dietary factors could play a role in this disorder, although definitive evidence is still lacking.  Most of the children with NS were steroid sensitive (73%), which is similar to reports from other developing countries,  and different from other developed countries.  It has been reported that in this age group, even patients with steroid-dependent and steroidresistant NS showed MCD on renal biopsy.  Dehydration, due to gastrointestinal disorders, was the most common cause of ARF in our patients, as has been reported from many other developing countries. , This emphasizes the necessity of a reinforcing program of preventive medicine, such as oral rehydration. The profile of CRF was similar to previous studies, with congenital urological malformations being the most common cause of CRF, followed by hereditary nephropathies and GN. ,,, Late presentation and lack of interventional measures including renal replacement therapy, such as continuous peritoneal dialysis, were the main constraints among these patients.
In developing countries, acute GN is reportedly more frequently associated with streptococcal pharyngeal infection (40%) than streptococcal skin infection (20%). , In contrast, in developed countries with a high socio-economic standard, the incidence of acute GN is decreasing. 
Hypertension was seen in eight patients (2.4%), similar to figures reported from other regions. , The presence of VUR as an associated finding in children with hypertension was highlighted by a study from Iran that indicated the presence of VUR in 50% of the studied cases. 
Interestingly, we encountered 16 patients with tubular disorders; this is higher than the study from Libya, in which only three patients with tubular disorders were observed.  This may be attributed to the high rate of consanguineous marriage in our community leading to these inherited disorders. Bartter syndrome was reported in one patient in a study from Saudi Arabia,  which is similar to our study. As reported in other studies, our study found that renal tumors were seen in a range of 0.4-6.2%. ,,, The Al Kadhymia Teaching Hospital is a tertiary referral center; this might reflect the relatively high rate of tumors in this study.
In conclusion, the spectrum of renal disorders in one center in Iraq is wide and shares similarities with epidemiological studies from other countries of both the developed and the developing world.
| References|| |
Hamed R. Childhood renal disorders in Jordan. J Nephrol 1995;8:162-6.
Adedoyin OT, Adeniyi A. Preventive nephrology - a proposed option in childhood nephropathy. Niger J Pediatr 2001;28:46-9.
Sadeghi E. Spectrum of Pediatric diseases in South Islamic Republic of Iran. East Mediterr Health J 1997;103:519-29.
Bhatta NK, Shrestha P, Budathoki S, et al. Profile of renal diseases in Nepalese children. Kathmandu Univ Med J (KUMJ) 2008;6:191-4.
Michael IO, Gabriel OE. Pattern of Renal Disease in Children in Midwestern Zone of Nigeria. Saudi J Kidney Dis Transplant 2003; 14:539-44.
Barbosa-Cesnik C, Brown MB, Buxton M, Zhang L, DeBusscher J, Foxman B. Cranberry juice fails to prevent recurrent urinary tract infection: Results from a randomized placebocontrolled trial. Clin Infect Dis 2011;52:23-30.
Brady PW, Conway PH, Goudie A. Duration of inpatient intravenous antibiotic therapy and treatment failure in infants hospitalized with UTI. Pediatrics 2010;126:196-203.
Mao J, Zhang Y, Du L, et al. NPHS1 and NPHS2 gene mutations in Chinese children with sporadic nephrotic syndrome. Pediatr Res 2007;61:117-22.
Niaudet P, Boyer O. Idiopathic nephrotic syndrome in children: Clinical aspects Germany: Springer-Verlag; 2009. p. 667-702.
Elder JS. Urologic Disorders in Infants and Children, Nelson Textbook of pediatrics, 18th Edition, Vol. 537. USA: Saunders; 2007. p. 2221-71.
Rodriguez-Soriano J. New insights into the pathogenesis of renal tubular acidosis. Pediatr Nephrol 2000;14:1121-36.
Hisano S, Matsushita M, Fujita T, Takeshita M, Iwasaki H. Activation of the lectin complement pathway in post-streptococcal acute glomerulonephritis. Pathol Int 2007;57:351-7.
Rodriguez-Iturbe B, Batsford S. Pathogenesis of post streptococcal glomerulonephritis. Kidney Int 2007;71:1094-104.
Davis ID, Avner ED. Nephrology, In: Kliegman, behrman Nelson Textbook of pediatrics. 18th Edition, Vol. 508. USA: Saunders; 2007. p. 2163-219.
Edmondson JD, Maizels M, Alpert SA, et al. Multi-institutional experience with PIC cystography-incidence of occult vesicoureteral reflux in children with febrile urinary tract infection. Urology 2006;67:608-11.
Seikaly MG, Ho PL, Emmett L, Fine RN, Tejani A. Chronic renal insufficiency in children. Pediatr Nephrol 2003;18:796-804.
Orta-Sibu N, Lopez M, Moriyon JC, Chavez JB. Renal diseases in children in Venezuela, South America. Pediatr Nephrol 2002;17:566-9.
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.
Elzouki AY, Amin F, Jaiswal OP. Prevalence and pattern of renal disease in eastern Libya. Arch Dis Child 1983:58;106-9.
Goldriach N. Urinary tract infection, vesico ureteric reflux and related conditions. 3rd ed. Pediatr Nephrol 1994;2:1424-9.
Eke FU, Eke NN. Renal disorders in children: A Nigerian study. Pediatr Nephrol 1994;8:383-6.
Bratalavsky G. Recurrence risk in infants with urinary tract infections and a negative radiographic evaluation. J Urol 2004;172:1610-3.
Steele RN. Epidemiology and clinical presentation of urinary tract infections in children. Pediatr Ann 1999;28:653-8.
Ali SH, Rifat UN. Etiological and clinical patterns of childhood urolithiasis in Iraq. Pediatr Nephrol 2005;20:1453-7.
Scheimann S. New insights into causes and treatment of kidney stones. Hosp Pract 2000; 35:49-68.
Thomson P. Renal problems in black South African children. Pediatr Nephrol 1997;11: 508-12.
Bazina M, Galvaina-Durdov M. Epidemiology of renal disease in children in the region of Southern Croatia. Med Sci Monit 2007;13: CR172-6.
Srivastav RN, Bagga A. Pediatric Nephrology 4th ed. New Delhi, India: Jaypee Brothers Medical Publishers; 2005. p. 58.
Velásquez-Jones L, Muñoz-Arispe R. Acute renal insufficiency. Bol Med Hosp Infant Mex 1993;50:678-90.
Gokcay G, Emre S, Tanman F, Sirin A. An epidemiological approach to acute renal failure in children. J Trop Pediatr 1999;37:191-3.
Chan JC. Lessons from 20 years of leading a Pediatric Nephrology Program. Nephron 1998; 78:378-88.
Madani K, Otoukesh H, Rastegar A, Van Why S. Chroinc renal failure in Iranian children. Pediatr Nephrol 2001;16:140-4.
Lagomarsimo E, Valenzuela A, Cavagnaro F, Solar E. Chronic renal failure in Pediatrics 1996. Chilean survey. Pediatr Nephrol 1999;13:288-91.
Gulati S, Mittal S, Sharma RK, Gupta A. Etiology and outcome of chronic renal failure in Indian children. Pediatr Nephrol 1999;13: 594-6.
Malla T, Malla KK, Thapalial A, Sharma MS. An Overview of Renal Disease in Children in Pokhara: J Nepal Paediatr Soc 2007;27:75-8.
Santos Diniz JS. Aspects of Brazilian pediatric nephrology. Pediatr Nephrol 1988;2:271-6.
Al-Rasheed SA, Al-Mugeiren MM, Al-Salloum AA, Al-Sohaibani MO. Childhood renal diseases in Saudi Arabia. A Clinico-patholgical study of 167 cases. Int Urol Nephrol 1996;28:607-13.
Etuk IS, Anah MU, Ochighs SO, Eyong M. Pattern of paediatric renal disease in inpatients in Calabar, Nigeria. Trop Doct 2006;36:256.
Dr. Shatha Hussain Ali
Department of Pediatrics, College of Medicine, Al-Nahrain University, Al-Kadhymia, P. O. Box 70074, Baghdad
[Table 1], [Table 2]