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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2016  |  Volume : 27  |  Issue : 2  |  Page : 371-376
Pattern of renal diseases in children: A developing country experience


1 Department of Pediatrics and Adolescent Medicine, B. P. Koirala Institute of Health Sciences, Dharan, Nepal
2 Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Biochemistry, B. P. Koirala Institute of Health Sciences, Dharan, Nepal

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Date of Web Publication11-Mar-2016
 

   Abstract 

Spectrum of renal disease varies in different ethnic population, geographical location, and by environmental factors. The purpose of this study was to find out the clinical spectrum and occurrence of different pediatric renal diseases at a teaching hospital in the Eastern part of Nepal. All cases of renal diseases from one month to 15 years of age, attending the pediatric renal outpatient department and/or were admitted to the wards during the period of February 2012 to January 2013, were included in the study. Detailed clinical and laboratory evaluations were performed on all patients. Diseases were categorized as per standard definitions and managed with hospital protocols. Renal diseases accounted to be 206 cases (6.9%) of total annual pediatric admissions, of which (58%) were male and (42%) female. Acute glomerulonephritis (AGN) was the most common disorder (37.7%) followed by nephrotic syndrome (26.1%), urinary tract infection (21.3%), acute kidney injury (AKI) (17.9%), obstructive uropathy (1.9%), chronic kidney disease (CKD) (1.2%), and others. In AGN group, the most common cause was post-infectious glomerulonephritis (PIGN) (32.9%) followed by lupus nephritis (4%) and Henoch-Schonlein purpura nephritis (0.8%). Urine culture was positive in (9.22%) and the most common organism was Escherichia coli (57.9%). The causes of AKI were urosepsis, septicemia, and AGN (18.9%) each, followed by dehydration (13.5%). Mortality was found in 5% of cases and the etiologies were AKI in (72.7%), PIGN (18.1%), and CKD (9%). Renal diseases are a significant problem among children and are one of the common causes of hospital admission. These patients need comprehensive services for early identification and management.

How to cite this article:
Yadav SP, Shah GS, Mishra OP, Baral N. Pattern of renal diseases in children: A developing country experience. Saudi J Kidney Dis Transpl 2016;27:371-6

How to cite this URL:
Yadav SP, Shah GS, Mishra OP, Baral N. Pattern of renal diseases in children: A developing country experience. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Mar 20];27:371-6. Available from: http://www.sjkdt.org/text.asp?2016/27/2/371/178565

   Introduction Top


The pattern of childhood renal disease varies from one geographic region to another even within the same country. [1],[2],[3] This variation is influenced by factors such as genetic predisposition, environmental background, and to a large extent the level of awareness. The causes are different in developing countries as compared to developed ones. In general, pediatric renal disease accounts about 4.5-8.7% of total pediatric admissions. [4],[5] The diagnosis of renal disease among hospitalized children can often be missed. During infancy and early childhood, unexplained fever or failure to thrive may be the only manifestations. Data describing the spectrum of renal diseases in hospitalized children in Nepal is scanty. [6] Previously, the prevalence of renal diseases in asymptomatic school children was found to be 0.71% in our country. [7] Since there is a marked paucity of data from our country, this study was conducted to find out the pattern, clinical spectrum, and outcome of patients of renal diseases at a tertiary care teaching hospital in the Eastern region of Nepal.


   Methods Top


This was a prospective study conducted over a period of one-year from February 2012 to January 2013. All the cases of renal disorders in the age group of one month to 15 years, reporting to pediatric renal clinic and/or were admitted to pediatric wards were included in the study. Data regarding information about demography, clinical features, examinations, investigations, hospital discharge diagnoses, final outcome, and referral were recorded in a predesigned proforma. All the children coming with features suggestive of renal system involvement were subjected to a detail history, clinical examination, and investigations to trace out any renal disease. After detailed clinical examination and investigation, those cases without features of renal involvement were excluded from the study. The investigations included were complete blood count, erythrocyte sedimentation rate, gross and microscopic examination of urine and culture, 24 h urinary protein, serum total protein, albumin, cholesterol, urea, creatinine, sodium, potassium, calcium, and phosphate. Serum anti-streptolysin O, C3, C4, anti-nuclear antibodies and Anti-Ds DNA were done wherever required. Radiological investigations included ultrasonography of kidney, ureter and bladder, and voiding cystourethrogram as indicated. Renal biopsy could be performed only in 16 cases and tissue was examined under light microscopy at our center. The patients requiring detailed immunofluorescence examination were referred to other center. The cases were categorized into: acute glomerulonephritis (AGN), nephrotic syndrome (NS), urinary tract infection (UTI), postinfectious glomerulonephritis (PIGN), lupus nephritis, Henoch-Schonlein purpura nephritis (HSP nephritis), acute kidney injury (AKI), chronic kidney disease (CKD), hemolytic uremic syndrome (HUS), and others, using standard definitions. [8]9],[10],[11] Each patient was followed from admission to discharge on a daily basis and they were kept under regular follow-up in pediatric renal clinic during their future course. The study protocol was approved by the Institute Ethics Committee. Informed written consent was taken for enrollment and procedure.


   Statistical Analysis Top


The data were analyzed using SPSS 20.0 version (IBM Corp. Armonk, New York, USA). The variables showing normal distribution were analyzed using Student's t-test and ANOVA for multiple comparisons. The Chi-square test was applied to compare the data of proportions. A P <0.05 was considered as significant.


   Results Top


A total of 206 cases were detected to have renal disease during the study duration. This accounted to be 6.98% of total pediatric admissions. Age and gender distribution of cases are presented in [Table 1]. One hundred and twenty cases (58%) were male. Most of the cases belonged to the age group of 6-10 year (44.1%); with mean of 8.3 years. Edema was the most common symptom (78.2%) at presentation followed by fever (57.3%), hypertension (53.4%), oliguria (38.8%), hematuria (26.7%), and pain abdomen (23.3%). History of sore throat and pyoderma were present in 18.9% and 9.7%, respectively.
Table 1: Age and gender distribution of cases.

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Urine examination showed proteinuria in 73.3% of the cases. Hematuria, pyuria, and proteinuria >2+ (Dipstick method) were found 55%, 37.4%, and 34%, respectively. Urine culture was positive in 9.2%. Escherichia coli was the most common organism (57.9%), followed by enterococcus (15.8%), acinetobacter (15.8%), and streptococcus (10.5%). Renal function test showed high urea (43.2%) and creatinine (44.6%).

As shown in [Table 2] most common renal disease was AGN (37.1%), followed by NS (26%), UTI (21.3%), and AKI (17.9%). Obstructive uropathy and CKD were seen in 1.9% and 1.2%, respectively. Other cases were polycystic kidney disease, nephrolithiasis, IgA nephropathy, and HUS seen in one case each.
Table 2: Pattern of renal diseases.

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Among AGN, PIGN accounted to 33% followed by lupus nephritis (4%) and HSP nephritis (0.8%). The common age group for AGN was 10-15 year, with mean age nine years, and the youngest patient was three-year-old. Hypertension was present in 86.1%, hematuria in 96%, proteinuria (>2+ by Dipstick), and pyuria was seen 34% in each. Serum creatinine level was raised in 41% of cases. Complications were present 31% of cases at presentation, of which hypertensive encephalopathy in 9.5%, left ventricular failure in 8.5% and AKI in 6.3% of children. The common age of presentation of NS was 5-10 years with mean age of 7.7 years and the youngest was 1.5 year. The male: female ratio was 2.3:1. Hypertension was seen in 30.8%. Serum mean cholesterol, albumin, and proteinuria levels were 398 mg/dL, 1.8 g/dL, and 2.1 g/m 2 /24 h, respectively. Raised serum creatinine was found in 26.2% and hematuria 15.4% of patients. Among NS, first episode was present in 37%, infrequent relapser in 29%, frequent relapser in 9%, steroid dependent in 20%, and steroid resistant in 5%. The comparative analysis between NS and AGN is depicted in [Table 3]. The mean age at presentation was significantly lower in NS and the male gender was significantly affected as compared to AGN. Significantly higher number of AGN cases presented with fever, hematuria, pyoderma, encephalopathy, joints pain, and hypertension. On the other hand, edema and oliguria were significantly more common in NS. Serum creatinine level and hematuria were significantly higher in AGN group.
Table 3: Comparative analysis of nephritic syndrome and acute glomerulonephritis.

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There were total 37 (18.4%) cases of AKI. Septicemia, urosepsis, and AGN were in 18.9% of cases each. Prerenal cause included severe dehydration following acute gastroenteritis (14%). Other causes of AKI were diabetic ketoacidosis, dapsone poisoning, severe malaria, 5.4% each and wasp bite (2.7%).

Renal biopsy could be performed in total of 17 cases (8.25%) only. Lack of immunofluorescence microscopy facility and reluctance on the part of parents to give the written consent were the major limitations in performing renal biopsy. The findings found in renal biopsy are depicted in [Figure 1] and the minimal change disease (58.82%) was the most common histopathological lesion seen.
Figure 1. Histopathological findings in renal biopsy.

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One hundred ninety-one cases (93%) improved, 5% expired, and about 2% cases required referral for surgical intervention and further treatment to higher nephrology centers. The non-survivors had AKI and mostly due to sepsis causing multiorgan dysfunction syndrome.


   Discussion Top


The occurrence of renal diseases reporting to a tertiary care center of a teaching hospital in the present study was found to be 6.9% of annual pediatric admissions. In previous reports, it varied ranging from 3% to 8.7%. [4],[5],[12] The triad of edema (78.2%), oliguria (39%), and hematuria (27%) was the main presenting features in addition to fever, which was present in 57.3% of cases. Hypertension and microscopic hematuria were found in about half of the patients. Malla et al [6] reported edema and hypertension in lower percentage of their cases, thus, initial clinical presentation may vary from center to center and it mainly depends on the stage of disease and underlying etiologies.

Among various etiologies, AGN was the most common renal disease (37.7%). A relatively lower percentage (30.7%) of AGN has been reported by another center in our country. [6] The difference could be due to the type of referral cases received as many postinfectious glomerulonephritis reported to our center from nearby rural regions. However, our observation of AGN was similar to the study reported from Nigeria. [13]

NS (26.1%) was the second most common renal disease in our study. Etuk et al [14] found the incidence of nephrotic syndrome to be 30.7%. The age of presentation is usually before the first decade mainly around five years of age. The mean age of the patient of NS in our study was 7.4 years, which is similar to the findings of previous reports. [12],[13] In contrast, other authors reported that majority of cases of NS were <5 years. [6],[14] The UTI accounted for 21.3% of cases. The other studies [6],[15] reported relatively higher incidence of UTI and the difference is due to that we get complicated UTI being a referral center and many patients of lower UTI did not come for medical treatment and treated at peripheral health posts. However Ocheke et al [13] reported a relatively lower frequency of UTI (11.6%), as the study embarked search for UTI in children with strong suspicion on clinical ground irrespective of any underlying medical condition. Therefore, some of their cases might have been missed. E. coli was the most common cause of symptomatic UTI; similar to many reviews of renal diseases in children from other parts of the world. [12]

There were 18.4% of cases presenting with AKI at presentation in our study. Sepsis (40%) was found to be most common etiology followed by AGN and severe dehydration after gastroenteritis. Poisoning, insect bites, and obstructive uropathy were other causes of AKI. Other studies reported AKI as one of the renal disease contributing to significant morbidity. [6],[12] However, the incidence and outcome depend on the facilities to treat patients of AKI. We provide renal replacement therapy (peritoneal dialysis and hemodialysis) to these patients, so many sick cases of AKI are referred to us for management. We found three cases (1.4%) of CKD and four cases of obstructive uropathy (1.9%). The CKD cases were in stage IV and V and the causes were polycystic kidney disease in one and obstructive uropathy in two cases. Elzouki et al [12] reported CKD in 0.8% and Malla et al [6] in 3.5% of cases. The reported cases of CKD were found to be congenital renal malformation, obstructive uropathy, and glomerulonephritis. [16],[17],[18],[19] The incidence of CKD reporting to a center varies and it mainly depends on the facilities of renal replacement therapy and transplantation. As many centers in the developing countries are not providing these therapies due to shortage of financial resources and the fact that dialysis centers, equipment, and trained personnel are simply not available. Therefore, patients are referred to other advanced centers or another country where patients can be adequately managed.

The early detection of renal diseases in childhood leads to better therapy and reduction in the morbidity and mortality. This study was an attempt to find out the burden of renal diseases, their relative occurrence, clinical profile, and outcome. The difficulty in determining prevalent renal problems relates to under diagnosis, late presentation and nonavailability of investigations and/or treatment in the developing countries. The implication of this study is that there is a need for routine screening for renal diseases in children so that children with evidence of kidney disease can be identified early and treated appropriately.

Conflict of interests: None declared.

 
   References Top

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Ocheke IE, Okolo SN, Thomas FB, Agaba EI. Pattern of childhood renal diseases in Jos, Nigeria: A preliminary report. J Med Trop 2010;12:52-5.  Back to cited text no. 13
    
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Etuk IS, Anah MU, Ochighs SO, Eyong M. Pattern of paediatric renal disease in inpatients in Calabar, Nigeria. Trop Doct 2006;36:256.  Back to cited text no. 14
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Eke FU, Eke NN. Renal disorders in children: A Nigerian study. Pediatr Nephrol 1994;8: 383-6.  Back to cited text no. 15
    
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Chan JC. Lessons from 20 years of leading a pediatric nephrology program. Nephron 1998;78:378-88.  Back to cited text no. 16
    
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Madani K, Otoukesh H, Rastegar A, Van Why S. Chronic renal failure in Iranian children. Pediatr Nephrol 2001;16:140-4.  Back to cited text no. 17
    
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Lagomarsimo E, Valenzuela A, Cavagnaro F, Solar E. Chronic renal failure in pediatrics 1996. Chilean survey. Pediatr Nephrol 1999; 13:288-91.  Back to cited text no. 18
    
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Gulati S, Mittal S, Sharma RK, Gupta A. Etiology and outcome of chronic renal failure in Indian children. Pediatr Nephrol 1999;13: 594-6.  Back to cited text no. 19
    

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Correspondence Address:
Gauri Shankar Shah
Department of Pediatrics and Adolescent Medicine, B. P. Koirala Institute of Health Sciences, Dharan
Nepal
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DOI: 10.4103/1319-2442.178565

PMID: 26997393

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