|Year : 2019 | Volume
| Issue : 1 | Page : 53-60
The pattern and outcomes of childhood renal diseases at University of Abuja Teaching Hospital, Abuja, Nigeria: A 4 year retrospective review
Emmanuel Ademola Anigilaje, Temilade Christianah Adesina
Nephrology Unit, Department of Paediatrics, University of Abuja Teaching Hospital, Gwagwalada, Abuja, Nigeria
|Date of Web Publication||12-Mar-2019|
Emmanuel Ademola Anigilaje
Nephrology Unit, Department of Paediatrics, University of Abuja Teaching Hospital, Gwagwalada, Abuja
Source of Support: None, Conflict of Interest: None
Introduction: Renal disorders contribute to childhood morbidity and mortality in developing countries. Therefore, the knowledge of the burden of childhood renal diseases is required for preventive and management purposes. This article determines the pattern and the outcomes of childhood renal diseases seen at the University of Abuja Teaching Hospital (UATH), Gwagwalada, Abuja, Nigeria. Materials and Methods: This was a retrospective review of children aged 1 month to 17 years, who were seen at the paediatric nephrology clinic, emergency paediatric unit and paediatric ward of the UATH over 4 years from January 2013 to December 2016. Results: A total of 4327 children were seen during the study period, with 163 of them having renal disorders, including 95 (58.3%) males and 68 (41.7%) females (mean age of 5.9 ± 4.7 years) giving a prevalence of 3.8% (38 cases per 1000 children). There was a progressive increase in the diagnoses of renal diseases during the study period, from 3.1% in 2013 to 5.4% in 2016. The most common disorders were urinary tract infection (UTI) 50 (30.7%) and acute kidney injury (AKI) 50 (30.7%). Others included nephrotic syndrome (11.7%), congenital anomalies of the kidney and the urinary tract (9.2%), acute glomerulonephritis (7.9%), chronic kidney disease (CKD, 6.7%), nephroblastoma (3.7%) and urolithiasis (2.5%). Twenty-three children died (mortality rate of 14.1%), resulting mostly from AKI (7.8%) and CKD (9.1%). Conclusion: UTI and AKI are the leading renal disorders in this study. Concerted efforts are needed to promote preventive nephrology in the face of high cost of treating acute kidney disease and CKD in Nigeria.
Keywords: Abuja, children, Nigeria, renal diseases
|How to cite this article:|
Anigilaje EA, Adesina TC. The pattern and outcomes of childhood renal diseases at University of Abuja Teaching Hospital, Abuja, Nigeria: A 4 year retrospective review. Niger Postgrad Med J 2019;26:53-60
|How to cite this URL:|
Anigilaje EA, Adesina TC. The pattern and outcomes of childhood renal diseases at University of Abuja Teaching Hospital, Abuja, Nigeria: A 4 year retrospective review. Niger Postgrad Med J [serial online] 2019 [cited 2019 Mar 24];26:53-60. Available from: http://www.npmj.org/text.asp?2019/26/1/53/253978
| Introduction|| |
In developing countries, childhood renal diseases constitute an important cause of morbidity and mortality.,, The knowledge of the epidemiology of childhood renal diseases is important because it assists in health planning, allows for adequate resource allocation and enables adequate renal services provision.,,
Data from hospital-based studies have reported the burden of paediatric kidney diseases to range from 1.1% to 8.9% in Nigeria.,,,,,,,,, Documented diseases include acute glomerulonephritis (AGN), nephrotic syndrome (NS), acute kidney injury (AKI), congenital anomalies of the kidney and the urinary tract (CAKUT), chronic kidney diseases (CKDs) and renal malignancies, with varying rates.,,,,,,,,, Elsewhere, in Eastern Libya, renal diseases accounted for 2.8% of paediatric admissions, compared to 6.3% in Dubai. In Libya AGN was most common, whereas in Dubai and Nepal, NS ranked the highest.
The variations in the patterns of renal diseases amongst the paediatric population in Nigeria,,,,,,,,, and in those of other countries,, are related to differences in genetic predisposition, environmental risk factors for renal diseases, definitions of renal pathologies, clinical and laboratory capacities to diagnose renal diseases, methodological variations relating to the type of study (retrospective or prospective), duration of the study and sample size.,,,,,,,,,,,,
A delay in the diagnosis of acute kidney disease and CKDs and the limited resources available for their management often contribute to the poor treatment outcomes seen in the developing countries, highlighting the imperativeness of preventive nephrology for childhood renal diseases., In the light of this, knowing the pattern of prevailing renal diseases in a particular setting allows for a more focused preventive nephrology that is aimed at reducing the burden of renal diseases in the same locality.
To the best of the investigators' knowledge, there has been no report on the prevalence and pattern of childhood renal disorders in Abuja, the Federal Capital Territory (FCT) of Nigeria.
The aim of this article is to report a 4-year review of the pattern and the outcomes of renal disorders amongst children aged 1 month to 17 years at the University of Abuja Teaching Hospital (UATH), Gwagwalada, Abuja, Nigeria, between January 2013 and December 2016.
| Materials and Methods|| |
Ethical approval to conduct the study was obtained from the Health Research and Ethics Committee of the UATH, P. M. B. 226, Gwagwalada, FCT, Abuja, Nigeria. This study was approved on 3 July 2018 with protocol number UATH/HREC/PR/2018/007/129.
The UATH is a tertiary 350-bed hospital. It serves as a referral centre for other hospitals within the Abuja metropolis and the surrounding states of Benue, Kogi, Kaduna Nasarawa and Niger.
A retrospective analysis of records of children (aged 1 month to 17 years) diagnosed with renal disorders over 4 years (January 2013 to December 2016) at the paediatric nephrology clinic, emergency paediatric unit and paediatric medical ward of the UATH, Gwagwalada, Abuja. The necessary information for the study was extracted from the patients' record files and from the renal register of the paediatric nephrology unit. Children aged <1 month who are routinely seen by the neonatologists were excluded. Patients who did not have records of information required for the study were also excluded. Children re-admitted for the same renal disorder were only counted once at the first presentation. A study pro forma was used to extract information that included demographic characteristics, types of renal diseases, presenting symptoms and signs and outcomes of management of the renal diseases. These outcomes included discharge, discharge against medical advice (DAMA), loss to follow-up and death.
Definitions of some renal diseases
Each diagnosis was based on the primary disease. For example, children with urinary tract infection (UTI) and background NS were classified as NS and those with AGN and AKI were classified as AGN.
AKI was defined as an abrupt decline in renal excretory function characterised by a reversible increase in the blood concentration of creatinine and nitrogenous waste products, often with a decrease in urine output and by the inability of the kidneys to regulate fluid and electrolyte homeostasis in a child., Its severity and outcomes were described by paediatric-Risk, Injury, Failure, Loss of kidney function, End-stage kidney disease (pRIFLE) criteria using the elevated serum creatinine estimation measured by Jaffe's method. Estimation of glomerular filtration rate (eGFR) was by the Schwartz's formula, and adequacy of urinary output was based on the body weight.
NS was diagnosed in the presence of oedema, massive proteinuria of urine protein creatinine ratio of ≥200 mg/mmol and hypoalbuminaemia ≤2.5 g/dl (≤25 g/l).
AGN was diagnosed in children manifesting with sudden onset of features of glomerular injury, which include haematuria, mild-to-moderate proteinuria, hypertension, oedema, oliguria and varying degrees of renal insufficiency.
UTI was defined as an isolation of a bacterium in the urine sample obtained via supra-pubic aspiration or at least 50 000 colony-forming units (CFU) per mL of a uropathogen in urine obtained via catheterisation or the presence of ≥100,000 CFU per mL of a uropathogen from mid-stream urine sample., A mid-stream, clean-catch urine specimen was obtained from children who have urinary control. In an infant or child unable to void on request, the specimen for culture was obtained by suprapubic aspiration or urethral catheterisation and the procedures followed the standard sterile technique.
CKD was based on the National Kidney Foundation-Kidney Disease Outcomes Qualitative Initiative definition as kidney damage lasting for at least 3 months with or without a decrease in GFR or any patient who has a GFR <60 ml/min/1.73 m2 for 3 months with or without kidney damage.
CAKUTs including posterior urethral valve (PUV), renal dysplasias and pelvic-ureteric junction (PUJ) obstruction were diagnosed by micturating cystourethrogram (MCUG), ultrasound scan (USS) and intravenous urography (IVU).
PUV is an obstructing membrane in the posterior male urethra as a result of abnormal development in utero. It is diagnosed with MCUG when there are dilatation and elongation of the posterior urethra with a linear radiolucent band corresponding to the valve.
Multicystic renal dysplasia is a condition that results from the malformation of the kidney during foetal development. The kidney consists of irregular cysts of varying sizes. USS findings comprise lobulated renal contour with multiple internal cysts of varying sizes and shapes; the renal parenchyma is usually fibrous and echogenic. The cysts cluster and are non-communicating. It is usually confirmed as a non-excretory kidney during IVU.
PUJ obstruction refers to a dilated renal pelvis with a collapsed proximal ureter caused by abnormal anatomical muscle arrangement, anomalous collagen collar, ischaemic insult, urothelial ureteral fold or extrinsic ureter compression by crossing vessels at the PUJ obstruction, usually diagnosed with USS and IVU.
Outcome measures could be (a) discharge (due to full recovery or significant recovery of renal function); (b) DAMA or loss to follow-up; (c) referral (to other hospitals usually due to long geographical distance from the place of abode to UATH) and (d) death.
Analysis of the data was performed using SPSS version 15.0 (SPSS Inc, 233 South Wacker Drive, 11th Floor, Chicago, IL 60606-6412, Patent No. 7,023,453, USA). The age of the cases were summarised as means and standard deviations. Other clinical features (demographic characteristics, the type of renal diseases, and the presenting signs and symptoms) were presented as counts and percentages. Chi-square test was applied to test the association of the renal diseases and gender. The prevalence of renal diseases was calculated based on the renal diseases counts per all the paediatric diagnoses seen, expressed as percentages and as per 1000 children per-year(s). P < 0.05 was regarded as statistically significant.
| Results|| |
Of the 4327 children seen during the study period, 163 had renal disorders giving a prevalence of 3.8% (a prevalence of 38 renal cases per 1000 children seen). The 163 children comprised 95 (58.3%) males and 68 (41.7%) females with a male-to-female ratio of 1.4:1. The cases were between 1 month and 17 years of age. The mean age was 5.9 ± 4.7 years. Forty-six per cent of the children were <5 years of age [Table 1].
There was a progressive increase in the proportion of the diagnoses of renal diseases during the study period, increasing from 3.1% in 2013 (31 renal cases/1000 children) to 5.4% in 2016 (54 renal cases/1000 children). This increment was statistically significant between 2015 and 2016 (P = 0.0083) [Table 2]. The trends of admission are as shown in [Figure 1].
With regard to clinical presentations, most presented with a history of fever 65 (40.0%) and vomiting 65 (40.0%), while abdominal tenderness 75 (46.0%) and pallor 73 (44.8%) were the most common signs [Table 3] and [Table 4].
UTI and AKI were the most common diagnosis, each accounting for 30.7% of the renal cases. UTI occurred more in males (54%) than females (46%). This gender difference was not statistically significant (P = 0.46) [Table 5]. Escherichia More Details coli 24 (48%), Staphylococcus aureus 10 (20%) and Klebsiella spp. 9 (18%) were the most common bacteria isolated. While good (97%–100%) sensitivity to quinolones and ceftriaxone was observed, resistance to the first-line antimicrobials including amoxicillin, gentamycin, nalidixic acid and nitrofurantoin was also common. UTI was also common among children with AKI and AGN.
Of the 50 cases with AKI, the causes were sepsis 27 (54%), hypovolaemia from diarrhoea 10 (20%), acute tubular necrosis from severe malaria 6 (12%), haemolytic-uraemic syndrome 2 (4%), acute pyelonephritis 2 (4%), infiltration by nephroblastoma 2 (4%) and a case (2%) of non-steroidal analgesic (ibuprofen) nephritis in a background of hypovolaemia/diarrhoeal disease. Eight (61.5%) of the children with AGN also had AKI. The mean age at presentation of AKI was 7.4 ± 4.7 years. Mortality in subjects with AKI was 22% (1 of the eight children with AKI from AGN also died from pulmonary oedema) and the majority (98%) died from uraemic encephalopathy, congestive heart failure and pulmonary oedema. Eight infants with AKI were referred to another hospital (before 2015, when the UATH was lacking the capacity to do peritoneal dialysis). The mean age of the subjects with AGN was 7.3 ± 1.33 years, and majority occurred more in male (61.5%) than in female (38.5%) gender, albeit, not statistically significant (P = 0.819) [Table 5] and [Table 6].
NS constituted 11.7% of the cases. It affected more males (73.7%) than females (26.3%) although this was not significant (P = 0.147) [Table 5]. The mean age at diagnosis was 8.3 ± 0.97 years. A majority 17 (89.5%) responded primarily to steroid. The two adolescents (13- and 15-year-old males) were steroid resistant and they progressed to end-stage kidney disease (ESKD) within 14 and 36 months of the initial diagnosis. Histopathology was focal segmental glomerulosclerosis in one of the two who had renal biopsy done. Renal biopsy was declined by the parent of the other child. Mortality was recorded in 4 (21.1%) cases of NS [Table 6].
The diagnosis of CKD was made in 11 (6.7) cases [Table 5]. Aetiology of CKD could not be determined in three subjects. Two were caused by HIV nephropathy while one was caused by chronic glomerulonephritis. PUV and steroid-resistant NS accounted for three and two cases, respectively. Mortality was recorded in 9 (81.8%) cases [Table 6]. One of the nine cases that died, a 14-year-old girl in ESKD, was perinatally infected with HIV, in addition to having a left congenital solitary kidney. She died shortly after receiving live-donor transplantation (from her senior brother) from acute graft rejection.
Six (3.7%) cases of nephroblastoma were seen [Table 5]. Nephroblastoma occurred significantly more in females 5 (83.3%) than in male 1 (16.7%), P = 0.035. Three (50%) had unilateral nephrectomy and chemotherapy and are still alive 2 years after treatment. One (16.7%) died during therapy from overwhelming sepsis/septic shock and two (33.3%) were lost to follow-up after the first course of chemotherapy.
Fifteen (9.2%) cases presented with CAKUT [Table 5]. The pattern was 12 (80%) with PUV, 1 (6.7%) with unilateral left dysplastic kidney, 1 (6.7%) with right congenital solitary kidney and 1 (6.7%) with bilateral ureteropelvic junction obstruction. Of the 12 cases with PUV, 3 (25%) presented in CKD (with eGFR <60 ml/min/1.73 m2); the other 9 (75%) cases presented early within the first 12 weeks of life, with 6 (50%) having been diagnosed with antenatal USS.
Other renal disease was seen in 4 (2.5%) cases of urolithiasis in male children [Table 5].
In general, regarding the outcome, 68.1% of the patients were discharged, 14.1% died, 10.4% DAMA, while 7.4% were referred. The highest mortality was among patients with AKI (47.8%) followed by those with CKD (39.1%) [Table 6].
| Discussion|| |
We documented a prevalence of 3.8% (38 renal cases per 1000 children seen) over a period of 4 years. While the prevalence of 3.8% compares similarly with 3.2% in Calabar, South-South Nigeria, 3.2% in Gusau, North-West Nigeria, and 3.9% in Lagos, South-West Nigeria; it was higher than 1.1% in Port-Harcourt, South-South Nigeria, and 2.9% in Jos, North-Central Nigeria. Our prevalence of 3.8% was, however, lower than 4.5% in Benin, South-South Nigeria, and 8.9% that was also reported in another study in Lagos, South-West Nigeria. Elsewhere, the prevalence of 3.8% in this study also compares with 3.0% in Libya and 3.3% in Pakistan but lower than 6.3% that was reported by Bhatta et al. in Nepal. In this study, the major childhood diseases were AKI (30.7%) and UTI (30.7%), with NS (11.7%) coming at a distant third position. In agreement with our study, Ocheke et al. in Jos also reported AKI to be the predominant renal disorder in contrast to other Nigerian studies, whereby NS and AGN were the leading diagnoses.,,,,,,, The reasons for the difference in the prevalence and pattern of renal diseases in this study and those of others,,,,,,,,,,,, could be related to differences in genetic predisposition, environmental risk factors for renal diseases, clinical and laboratory capacities to diagnose renal diseases, methodological variations relating to the type of study (retrospective or prospective), duration of the study and sample size. While the study by Okoro and Okafor identified local conditions such as malnutrition, poor environmental and personal hygiene and poverty to be associated with the development of renal diseases in Nigerian children, this retrospective study did not access for the same risk factors.
In this study, the data support a rising incidence of childhood kidney diseases. This is reflected in the progressive increase in the proportion of cases of paediatric renal diseases from 3.1% in 2013 (31 renal cases/1000 children) to 5.4% in 2016 (54 renal cases/1000 children). In actual fact, there was a statistically significant increase in the cases of renal diseases seen in 2015 compared to 2016. This increasing burden of childhood renal diseases was also observed in Lagos, where the prevalence of renal disease was 3.9% in 1991–2002 compared to 8.9% in 2008–2011. Bhimma and Kalo had earlier notified a general increase in childhood renal diseases in developing countries. In this study, a higher index of suspicion occasioned by the availability of a paediatric nephrologist at the UATH from 2015 to 2016 may partly explain the increasing frequency of diagnosis of renal diseases seen. Further, in recent times, the International Society of Nephrology and International Paediatric Nephrology Association have embarked on increasing the awareness of childhood renal diseases in developing countries, plausibly, accounting for an increase in health care-seeking behaviours for renal diseases among the populace. Furthermore, a higher sensitivity of pRIFLE in identifying early cases of AKI might have contributed to the higher frequency of AKI diagnoses. Mortality from AKI is still unacceptably high at 22% (47.8% of all renal deaths). Similar trend of high mortality among AKI cases was also reported by other researchers.,, Deaths from AKI also resulted from uraemic encephalopathy, congestive heart failure and pulmonary oedema, mostly as a result of the late presentation to the hospital and the inability to commence dialysis promptly.
While variations exist for the causes of paediatric AKI within countries and across continents, the finding of sepsis, hypovolaemia/diarrhoeal disease and severe falciparum malaria as the major causes of AKI in our study is not greatly different from what has been reported earlier.,,,,,,
In Congo-Brazzaville, gastroenteritis (25.7%), NS (14.7%), sepsis (15.23%), malaria (12.38%) and AGN were reported to be the main causes of AKI. Anochie and Eke reported gastroenteritis (28.9%) and malaria (13.7%) as the major causes of AKI in Port-Harcourt, Nigeria. In Ile Ife, Nigeria, malaria (42.53%), renal Burkitt's lymphoma (29%), sepsis(28.73%), AGN (27.8%), NS (16.7%) and HUS (5.5%) accounted for the majority of AKI in that study. Esezobor et al. in Lagos, Nigeria, revealed that primary kidney disease (AGN, NS, HUS and pyelonephritis) caused 38.6% of AKI, while sepsis (25.7%) and malaria (11.4%) explained the others. Halle et al. in Cameroon reported sepsis (57.5%), severe malaria (21.8%), hypovolaemia (16.1%) and use of herbal concoctions (6.9%) to be the main causes in their cohort. Antwi et al. in Ghana also reported haemoglobinuria, obstructive uropathy, tumour infiltration, gastroenteritis and glomerulonephritis. In Libya and India, NS was also the predominant cause of AKI.
In general, given that most of the causes of AKI in our study and those of others,,,, appear to be of preventable causes, the role of preventive nephrology cannot therefore be over-emphasised.
The preponderance of UTI as one of the leading causes of childhood renal diagnosis in this study is similar to the reports from Benin and Port-Harcourt. UTI was also the predominant childhood renal disorder in the studies in Pakistan, Sudan and Venezuela.
In this study, UTI was screened for in all under-fives presenting with fever. This practice may explain why the prevalence of UTI is high in this study. UTI has a propensity of causing a permanent renal parenchymal scarring (RPS) in up to 10%–15% of cases. A substantial RPS is also a precursor of poor renal growth, hypertension, and CKD that may be seen later in adulthood., Thus, a successful treatment of UTI is important to prevent RPS.
In this study, the bacterial isolates of UTI were sensitive to the quinolones and ceftriaxone while being resistant to the first-line antimicrobials: amoxicillin, gentamycin, nalidixic acid, and nitrofurantoin. The preserved sensitivity to quinolone and ceftriaxone may be explained by the fact that the quinolones are rarely prescribed for children and the parenteral routes of ceftriaxone reduce its abuse. Some of the common reasons for the emergence of resistance to the first line antimicrobials include low patient compliance to a prescribed antibiotic regimen; self-medication by patients who procure antibiotics over the counter without a medical prescription; the menace of substandard antibiotics and a subtherapeutic prescription by health workers.
NS accounted for 11.7% of the cases and it affected more males (73.7%) than females (26.3%). NS has also been reported to be commoner in male than in female gender by other authors in Nigeria.,,,,, However, no particular explanation has been offered for this male preponderance. Recently, Ladapo et al. had also reported a high steroid sensitivity among children with NS in Lagos. We suggest that initial steroid therapy is ideal for all NS patients as our study and that of Ladapo et al., maybe suggesting a high initial steroid sensitivity among children with NS in the tropics in recent times.
The prevalence of nephroblastoma in this study was 3.7%, which compared with 3.1% in Zaria North-West Nigeria but was lower than 15.3% and 22.2% reported in two studies in Lagos, and 7.2% in Jos. The reason for this discrepancy remains unclear and future research efforts may unravel it. Nephroblastoma occurred significantly more in females than in male in this study, in keeping with the known slight female preponderance (male-to-female ratio of 0.92:1 in unilateral nephroblastoma and 0.60:1 in bilateral nephroblastoma) in children with nephroblastoma. However, no reason has been adduced for this female preponderance.
PUV was the most common CAKUT in this study and three subjects with PUV also contributed to the cases of CKD seen due to their late presentation in ESKD. While CKD was reported in 11 (6.7%) cases, many more might have been lost in peripheral health centres amidst non-recognition or misdiagnosis. The high mortality associated with CKD in this study is also similar to reports from other studies.,,, Various reasons will explain the high mortality including financial constraints on the part of parents, unavailability of health insurance scheme to care for CKD, inadequate facilities for renal replacement therapy and very limited access to renal transplantation.
However, most (68.1%) cases of renal diseases in this study were discharged with good renal function.
The overall mortality of 14.1% in this study was higher than <1.0%, 6.8% and 10% that were reported in Libya, Sudan and Gusau, Nigeria, respectively. The mortality rate was however lower than 17.7% reported in Lagos and 14.6% reported in Calabar. Differences in renal mortality can be explained from various reasons including the promptness of presentation at the hospital, awareness about renal diseases, difference in availability of diagnostic tool, the appropriateness of treatment and access to free renal healthcare services to mention a few.
Seventeen (10.4%) children also DAMA or were lost to follow-up in this study. The remarkable rate of DAMA in this study was higher than the 6% in Gusau, and the 6.8% in Umahia but was lower than the 12.9% reported in Asaba by other Nigerian researchers. DAMA in this study and in other places in Nigeria,, is often caused by financial constraint in accessing health care services as payment is often out of pocket by poor parents and/or caregivers. In addition, there is a contending belief in supernatural causes of chronic diseases (like renal diseases) and parents often seek unorthodox medicine for these diseases.
This study is limited by its retrospective design.
| Conclusion|| |
UTI and AKI (occurring due to preventable causes) are the leading renal disorders in this study and mortality was high at 14.1%. Concerted efforts are needed to promote preventive nephrology in the face of an existing high cost of treating acute kidney disease and CKDs in Nigeria.
We are grateful to the parents and the children who populated this study
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]