| Abstract|| |
Sixty two children aged 12 years or below, with chronic renal failure (CRF) were admitted to Asir Central Hospital, Saudi Arabia, in the period from June 1990 to June 1995. Of them, 39 (63%) were in CRF while 23 (37%) were in end-stage renal failure (ESRF) at the time of presentation giving a mean annual incidence for CRF of 15.6 and for ESRF of 9.2 per million children. The male to female ratio was 1.8:1. The mean age of the children was 5.5 years (age range 20 days to 12 years). Urinary system anomalies (including urinary tract anomalies) were the leading cause of CRF (64.5%) followed by gloraerulopathies (17.7%). In those who presented before the age of six years, SO.9% had CRF caused by urinary system anomalies (including inherited kidney anomalies such as polycystic disease) while such anomalies accounted for only 30% of CRF in children older than six years. Glomerulopathies were the leading cause (45%) of CRF in this latter group. We conclude that our mean annual incidence of CRF and ESRF is high and urinary system anomalies constitute the commonest cause among children in our region. Early diagnosis should therefore be encouraged to ensure early treatment of these anomalies, thus decreasing the incidence of CRF.
Keywords: Chronic renal failure, End-stage renal failure, Children, Asir region, Saudi Arabia.
|How to cite this article:|
Al Harbi N. Chronic Renal Failure in Children in Asir Region of Saudi Arabia. Saudi J Kidney Dis Transpl 1997;8:294-7
| Introduction|| |
Chronic renal failure (CRF) is a major health problem in children and epidemiological studies are important in providing the necessary medical care for these children. The Asir Central Hospital is the only referral center in the Asir region, located in the southern part of Saudi Arabia. Thus, all cases of CRF are referred to this hospital for further management.
This study was conducted to determine the incidence and causes of CRF in children in this region since such a study had not been performed before.
| Patients and Methods|| |
A retrospective review of the records of children (aged 12 years or below) with CRF, defined as persistent elevation (for 3 months or longer) of serum creatinine to a value greater than 132 umol/L in children under two years and 177 jimoI/L in children above two years of age was performed  . The names and hospital record numbers of such children were obtained from the biochemistry laboratory register and the following data were extracted from their hospital records: age at presentation with high serum creatinine, sex, the cause of renal failure, serum creatinine level, result of relevant radiological studies, renal biopsy and management regime. Review of records revealed that all the study children had kidney and bladder ultrasound at admission; 29 children in addition underwent voiding cystourethrograra and six underwent intravenous pyelogram. Seven children with suspected glomerulopathies were subject to renal biopsy.
Chronic renal failure was defined as a stage wherein serum creatinine was elevated as defined above but had not reached end-stage renal failure (ESRF). Terminal or end-stage renal failure was defined as creatinine clearance persistently below or equal to 10 ml/min/1.73 m 2 .
| Results|| |
During the 5-year period between June 1990 and June 1995, 62 children were admitted to the Asir Central Hospital with CRF. This included 23 children with ESRF and 39 with CRF not requiring dialysis giving a mean annual incidence for ESRF of 9.2 and for CRF of 15.6 per million children (the population of children in Asir region is about half a million according to latest census). Their age at presentation ranged between 20 days and 12 years (mean age 5.5 years). There were 40 males and 22 females giving a male to female ratio of 1.8:1. Forty two patients (68%) were younger than six years.
The etiology of CRF in the study children is summarized in [Table - 1]. Urinary system anomalies caused CRF in 40 patients (64.5%). They included urinary tract anomalies in 24 (38.7%), hereditary renal anomalies in seven (11.3%) and renal hypoplasia/dysplasia in nine (14.5%). Vesicoureteric reflux, seen in 11 children and posterior urethral valve, seen in six children were the commonest urinary tract anomalies encoun tered. Four patients (6.4%) had bilateral ureteric obstruction (three had uretero-pelvic obstruction and one had ureterovesical obstruction) while neurogenic bladder occurred in two children and Prune-belly syndrome in one. Urinary system anomalies were more frequent in children younger than six years of age amongst whom they were responsible for 80.9% of CRF cases in contrast to 30% in older children [Table - 2]. Seventy percent of the patients with CRF caused by urinary system anomalies were boys. Hereditary kidney anomalies were the cause of CRF in seven children (11.3%). Poly cystic disease occurred in four and Laurence-moonbardet-biedl syndrome in three children.
Glomerulopathies were the cause of CRF in 11 children (17.7%). Of them, three (4.8%) each had mesangial proliferative glomerulonephritis and Henoch-Schoenlein nephritis, two (3.2%) children each had poststrepto-coccal rapidly progressive glomerulonephritis and hemolytic uremic syndrome and one child had focal glomerulosclerosis (FGS). All glomerulopathies occurred in children older than six years except in two, one with FGS which progressed to ESRF at the age of four years and required CAPD, and the other with chronic glomerulonephritis at six years of age. Glomerulopathies were the cause of CRF in 45% of children older than six years in contrast to 4.8% in younger children. Renal biopsy was performed on seven patients to establish the diagnosis, two each with HenochSchoenlein nephritis, post-streptococcal rapidly progressive glomerulonephritis and mesangial proliferative glomerulonephritis and one patient with FGS. Three patients (4.8%) had CRF following irreversible acute renal failure. Two of these patients probably had cortical necrosis after prolonged renal hypoperfusion (road traffic accident in one and severe dehydration in the other). The third patient developed CRF as a complication of chemotherapy. Eight children had CRF of undetermined cause (12.9%).
The 23 (37.1%) children with ESRF were started on chronic ambulatory peritoneal dialysis (CAPD) when first seen.
| Discussion|| |
The mean age of 5.5 years, and the fact that 67.7% of our study patients were younger than six years at the time of presentation conforms with the study of Mattoo, et al from Riyadh  . It however, differs from what has been reported by Aldrees, et al  whose patients were found to be older with a mean age of 12 years. This was, however, a questionnaire study involving 36 hospitals; furthermore, the reported ages were not the ages at presentation, but at the time the study was conducted. More males were found to have CRF in our study (male to female ratio of 1.8:1), which is similar to other studies from Saudi Arabia ,, and elsewhere  . This could be explained by the high incidence of urinary system anomalies in boys  ; we found that 70% of children with congenital urinary system anomalies were males.
Estimation of the true incidence of CRF in children is very difficult because these patients are usually asymptomatic. In such cases, CRF can only be detected by chance. Estimation of the incidence of ESRF is however, easier and more accurate. During the last five years we had a mean annual incidence of CRF of 15.6 per million children which is higher than reported from Sweden  Germany , and France  wherein, the reported incidence rates are 6.9, 6.0 and 10.5 per million children respectively. However, even these figures are probably underestimates of the true incidence of CRF. The mean annual incidence of ESRF in our area is 9.2 per million children which is higher than that in USA and European countries wherein the incidence ranges between 4.4 and 8 per million children ,,,,, . However, the patients included in those studies were older (<16 years). Our results are similar to that reported from Canada  . In our study, there is a small possibility that some of the children with ESRF might have been missed due to direct referral to higher centers in Riyadh. However, this number is unlikely to be large because such children are usually sent back to us for follow-up care.
Urinary tract anomalies were the major cause of CRF in our patients (38.7%). This is slightly higher than the reported incidence (28-34%) from other parts of Saudi Arabia, , from Sweden (29%)  and much higher than that reported from France (16%)  . This could be explained by a high incidence of consanguineous marriage in our region.
Hereditary kidney anomalies including polycystic disease caused 11.3% of CRF in our series. This is less than the previously reported figures from Saudi Arabia (17.5%)  , and 18%  as well as international reports (16-27%) ,,,, . This difference could be due to a relative lack of facilities in our region to determine the cause of CRF as eight of our cases with CRF had undetermined cause and some of them could possibly have had hereditary anomalies. Hypoplastic/ dysplastic kidney was responsible for CRF in 14.5% of the children which is similar to other reports (13-17%) ,,, and higher than what was reported in Sweden by Helen and Winberg (9%)  .
Glomerulopathies (hemolytic-uremic syndrome excluded) were responsible for CRF in 14.5% of our children. This agrees with the 14-26% incidence reported by other workers ,,,, . Hemolytic uremic syndrome was the cause of CRF in two patients (3.2%) which is comparable to other reports ,, . It appears that the pattern of causes of CRF in our area is similar to that in other countries but the relative frequency of each is different, which is in agreement with the observation of Abdurrahman, et al  .
Glomerulopathies were the most common cause of CRF (45%) in those who were older than six years at the time of presentation. In children younger than six years, urinary system anomalies were the major cause of CRF (80.9%). These findings are similar to those reported from other parts of the world  . This emphasizes the importance of early detection and management of these anomalies in preventing CRF altogether or its progression to ESRF. In this context, a thorough screening of young children presenting with urinary tract infection cannot be overemphasized.
Thirty-seven percent of our patients were in end-stage renal failure at the time of presentation and were started on CAPD. This is in accordance with the three reports of CRF in children from Riyadh, Saudi Arabia (22-71%) ,, .
| Conclusion|| |
This first study from Asir region of Saudi Arabia suggests that CRF in children is a major problem in our region. The incidence of ESRF in our region compares with some of the highest reported incidence in literature. Congenital anomalies of the urinary system constitute the commonest cause of CRF and their contribution in our region is much higher than in Western countries.
| Acknowledgment|| |
I thank Dr. F. Abbag and Dr. Abiodun P. for their help in preparing this paper.
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N Al Harbi
Assistant Professor of Child Health, College of Medicine, King Saudi University, P.O. Box 641, Abha
[Table - 1], [Table - 2]