Saudi Journal of Kidney Diseases and Transplantation

: 2017  |  Volume : 28  |  Issue : 3  |  Page : 589--592

Pediatric nephrology practice in Jordan

Kamal Akl1, Issa Hazza2,  
1 Department of Pediatrics, Jordan University Hospital; Department of Pediatrics, Faculty of Medicine, College of Medicine, University of Jordan, Amman, Jordan
2 Department of Pediatrics, Section of Pediatric Nephrology, Queen Rania Children Hospital, Amman, Jordan

Correspondence Address:
Kamal Akl
Department of Pediatrics, Jordan University Hospital, Amman


The practice of pediatric nephrology in a developing country such as Jordan is governed by social, cultural, and economic issues. The prevalence of consanguinity contributes to the emergence of rare heredofamilial disorders and congenital anomalies of the kidneys and urinary tract. Epigenetic factors modify underlying genetic defect predisposing to symptomatic crystalluria. Future research should be directed at prevention.

How to cite this article:
Akl K, Hazza I. Pediatric nephrology practice in Jordan.Saudi J Kidney Dis Transpl 2017;28:589-592

How to cite this URL:
Akl K, Hazza I. Pediatric nephrology practice in Jordan. Saudi J Kidney Dis Transpl [serial online] 2017 [cited 2020 Sep 21 ];28:589-592
Available from:

Full Text


The pediatric renal disease is different from adults. Children are not small adults. One major difference is impact of diseases on growth. Any longstanding disease affecting children will result in growth failure, deformities and may be psychomotor delay. Furthermore, acute kidney injury in childhood may be the harbinger of chronic kidney disease (CKD) in adulthood. Even a low birthweight small for gestational age may lead to hypertension and CKD as an adult.

One hundred years ago, the specialty of pediatrics was not yet conceived in the developed world. Caring for children was part of the service of internal medicine. Adult nephro- logists cared for both adults and children. The pediatric nephrology subspecialty started developing in the late 60’s in the Western countries.

In Jordan, the first academic Department of Pediatrics was initiated in 1975 at the Jordan University Hospital, which was the only such department for the next 10–15 years before other universities followed suit. At that time, Bashir government hospital had a nonacademic pediatric department.

 The Beginnings of Pediatric Nephrology Practice in Jordan

In the 70’s of the last century, there was one pediatric nephrologist at the University of Jordan. In the 80’s, there were two pediatric nephrologists.

In 2016, the number exceeded 15. The distribution of pediatric nephrologists was as follows: Four in universities, one in Ministry of Health, four in the Armed Forces, and five in the private sector.

 Renal Diseases Encountered in Clinical Practice


The major causes in Jordan include urinary tract infection, crystalluria, and glomerular disease. Compared to the Western countries, hypercalciuria is less common than hyper- uricosuria and hyperoxaluria as a cause of hematuria.[1]

Glomerular disease: Primary and secondary

Immunoglobulin A nephropathy is not common in children in Jordan, which most likely reflects less population genetic susceptibility.[2]

Henoch-Schonlein purpura (HSP) is common and it is on the increase. While most cases are benign, few are severe[3] which is similar to childhood HSP in Qatar.[4] HSP may be the presentation of familial Mediterranean fever.[3],[4],[5]

Nephrotic syndrome is the most common cause of steroid-sensitive nephrotic syndrome is minimal change. The most common non minimal change cause of steroid resistance is focal segmental glomerulosclerosis (FSGS).[6] This is similar to other parts of the Middle East such as Qatar.[7]

A study of biopsy-proven steroid dependent/ resistant nephrotic syndrome cases at a Jordanian hospital showed minimal change disease in 27%, FSGS in 21%, mesangial pro- liferative glomerulonephritis in 12.7%, and IgA nephropathy in 7.3%.[6]

Urinary tract infections is very common. Dimercaptosuccinic acid scans uncovered a large number of atrophic kidneys from renal dysplasia secondary to antenatal vesicoureteral reflux.

Acute kidney injury

Acute kidney injury is common.

Currently, hemolytic uremic syndrome (HUS) is not the major cause of acute kidney injury (AKI) in Jordan.[8]

In contrast to industrialized countries, HUS follows Shigella dysenteriae type 1 rather than Escherichia coli O 157:H7. In places where cardiac surgery is performed, postcardiac surgery acute renal failure is common, especially if there is delay on the cardiopulmonary pump. Other causes of AKI include drugs such as nonsteroidal antipyretics given to child who is dehydrated. Nephrotoxicity is an important cause of AKI, especially in neonatal intensive care units.

Chronic renal failure

The most common causes of end-stage renal failure (ESRF) in Jordan include congenital anomalies of the kidney and urinary tract (CAKUT) 56%, hereditary nephropathy 23.2%, and glomerular disease 22.9%. CAKUT includes reflux nephropathy, neurogenic bladder (NB), and posterior urethral valves. Hyperoxaluria accounted for 8% of ESRF cases, and FSGS 10.2%.[9]

 Facilities for Renal Replacement Therapy

Acute peritoneal dialysis is available in the private sector, universities, and government. Chronic peritoneal dialysis in the form of automated peritoneal dialysis (APD) is available at Hamzeh Government Hospital and the Armed Forces Hospitals.

The main facilities for pediatric maintenance HD are found at the University Hospitals and the Armed Forces. Main vascular access is through a permcath. Arteriovenous fistula is performed in older children. Continuous renal replacement therapy is available at the cancer center.

 Causes of Death of End-stage Renal Patients

Sudden death at home is usually due to noncompliance, hyperkalemia, exhaustion of vascular access, and fluid overload.[9]

Late referral is common. People believe that patient still has urine, so why dialyze.

Noncompliance with dialysis and medication is common. Patients usually resort to alternative medicine, including herbs and prayer therapy.

 Renal Transplantation

The vast majority of pediatric renal transplants are from living donors, and most are performed at the Pediatric Armed Forces Hospital. Between 2004 and 2014, more than 100 living related kidney transplants were done at Queen Rania Children Hospital. Mothers were donors in 39.4%. It was preemptive in 32.4%.[10],[11],[12]

The 1- and 5-year graft survival were 96% and 88%, which compares with international data.[13]

Hypertension: The most common causes below and above the age of 10 years are renal/endocrine, and essential, respectively. Voiding disorders include bladder bowel dysfunction which is very common due to improper feeding habits.[14],[15]

The prevalence of nocturnal enuresis is higher than Asian or European countries.[16]

In the treatment of nocturnal enuresis, there is no compliance with behavioral therapy as parents do not have the patience to wait for three to four months. Desmopressin is used instead, but frequently it fails in children who consume caffeine-containing drinks such as tea and colas.

 Factors Peculiar to Jordan Affecting Nephrourologic Conditions

Increased rate of consanguinity and inbreeding results in the finding of rare genetic diseases with renal involvement.

Cultural beliefs: Salting the neonate which is practice in Southern Turkey and Jordan is a 3000 years old custom.[17]

It may result in skin burns and hypernatremic dehydration with morbidity and mortality. Toxicity from salting depends on the concentration of the salt, duration of immersion, and skin thickness.[17] Recent-acquired habits include abuse of antibiotics and antipyretics, especially nonsteroidals. When a child presents with fever and found to have pyuria, it need not be UTI. It could be crystalluria. In a febrile child with NB, a positive urine culture is usually asymptomatic bacteriuria, and the fever may be due to an overlooked pharyngitis.

 Geographic Factors

The hot climate along with decreased water intake promotes crystalluria/stone clinical manifestations, which may mimic various disease states.

 Negative Factors Affecting the Practice of Pediatric Nephrology in Jordan

Besides cultural beliefs and habits, there is noncompliance with doctors’ advice in addition to poor recall. In general, compliance with the consultation is poor. Once patients improve, they quit taking their medicines.

Doctor shopping: Patients in this part of the world not only seek a second opinion but several.

 Pediatric Nephrology Research

Pediatric nephrology research is limited to universities, mainly for the purpose of promotion. It is clinical in the form of retrospective medical record review. Laboratory research is minimal.

Prospective studies are limited, mainly because of parental consent reluctance.

Future directions: Fellowship training and clinical research should be geared toward the prevention of prevalent conditions.

Conflict of interest: None declared.


1Akl K, Ghawanmeh R. The clinical spectrum of idiopathic hyperuricosuria in children: Isolated and associated with hypercalciuria/ hyperoxaluria. Saudi J Kidney Dis Transpl 2012;23:979-84.
2Kiryluk K, Li Y, Sanna-Cherchi S, Rohaniza- degan M, Suzuki H, Eitner F, et al. Geographic differences in genetic susceptibility to IgA nephropathy: GWAS replication study and geospatial risk analysis. PLoS Genet 2012;8: e1002765.
3Albaramki J. Henoch-Schonlein purpura in childhood a fifteen-year experience at a tertiary hospital. J Med Liban 2016;64:13-7.
4Dawod ST, Akl KF. Henoch-Schöenlein syndrome in Qatar: The effects of steroid therapy and paucity of renal involvement. Ann Trop Paediatr 1990;10:279-84.
5Akl K. Childhood Henoch Schonlein purpura in Middle East countries. Saudi J Kidney Dis Transpl 2007;18:151-8.
6Eltohami EA, Akl KF. Primary nephrotic syndrome in Qatar (Arabian Gulf). Br J Clin Pract 1989;43:366-8.
7Hadidi R, Hadidi M, alDabbas M. Spectrum of biopsy-proven kidney disease in children at a Jordanian Hospital. Saudi J Kidney Dis Transpl 2014;25:680-3.
8Akl K. Pediatric nephrology consultations in a tertiary academic center in Jordan. Saudi J Kidney Dis Transpl 2008;19:456-60.
9Akl KF, Albaramki JH, Hazza I, Haddidi R, Saleh SH, Haddad R, et al. Aetiology of paediatric end-stage renal failure in Jordan: A multicentre study. West Indian Med J 2015;65:263-6.
10Hazza I, Al-Mardini R, Salaita G. Pediatric renal transplantation: Jordan’s experience. Saudi J Kidney Dis Transpl 2013;24:157-61.
11Shilbayeh S, Hazza I. Pediatric renal transplantation in the Jordanian population: The clinical outcome measures during long- term follow-up period. Pediatr Neonatol 2012;53:24-33.
12Sacca E, Hazza I. Pre-emptive pediatric renal transplantation. Saudi J Kidney Dis Transpl 2006;17:549-58.
13Kim JJ, Marks SD. Long-term outcomes of children after solid organ transplantation. Clinics (Sao Paulo) 2014;69 Suppl 1:28-38.
14Altamimi E. Clinical characteristics of pediatric constipation in South Jordan. Pediatr Gastroenterol Hepatol Nutr 2014;17:155-61.
15Akl K. Occult chronic functional constipation: An overlooked cause of reversible hydro- nephrosis in childhood. West Indian Med. In Press.
16Hazza I, Tarawneh H. Primary nocturnal enuresis among school children in Jordan. Saudi J Kidney Dis Transpl 2002;13:478-80.
17Peker E, Kirimi E, Tuncer O, Ceylan A. Severe hypernatremia in newborns due to salting. Eur J Pediatr 2010;169:829-32.