An Overview of Renal Diseases in Children in Pokhara

Objective: To determine the current pattern and prevalence of renal diseases in childhood in this region of Nepal. Material and Methods: A retrospective study of the renal diseases in children attending the Pediatric OPD and those hospitalised in Manipal Teaching Hospital, Pokhara was done over a period of 6 years (September 2000September 2006). A detailed clinical and laboratory evaluation was performed at baseline. The children were managed according to disease diagnosed. These cases are under follow up and some have undergone surgical treatment. Results: 228 children (123 boys & 105girls) were diagnosed to have renal disease. Among them 39.5% had urinary tract infection (UTI), 30.7 % were suffering from acute glomerulonephritis (AGN), 17.5% were cases of nephrotic syndrome (NS) and 12 % had some other problems for example, 6.14% had genetic defects, 2.63% had renal Stone, 2.2% had pre-renal acute renal failure, unexplained recurrent hematuria in 1.3%. All the cases of UTI underwent through investigation and were treated accordingly. All cases of AGN are planned for follow up for 11⁄2 yrs and among them 3 required biopsy till date. All cases of NS are under regular follow-ups and 2 have undergone biopsy. Renal stone was operated successfully. All cases of acute and chronic renal failures had required dialysis. Out of 5 (2.5%) chronic renal failures, 2 with end stage renal disease expired after repeated hemodialysis and three are still requiring dialysis. Among the obstructive uropathies, 43 % had renal stone, 36 % had posterior urethral valve and 21% VUR. Conclusion: It can be concluded that renal disease is not uncommon in children. It can be completely cured with proper and adequate treatment. Sometimes it has a bad prognosis when it reaches end stage renal disease. Early recognition, timely treatment and regular follow up are mandatory in management of children with renal diseases.


Introduction
Childhood Renal Diseases (CRD) are commonly associated with few or no specifi c symptoms 1 .This fraction of patients may not be managed adequately, hence the diagnosis of these cases are important.This study therefore evaluates the current pattern and prevalence of renal diseases in childhood.This study also points out the relative public health problems of renal diseases in childhood.

Materials and Methods
This was a retrospective study carried out for a period of 6 years from September 2000 to September 2006.All children attending the Paediatric Outpatient Department and those admitted in the paediatrics ward of Manipal Teaching Hospital were included in this study.All the children had come with symptoms related to the renal system.Every case was subjected to a detailed clinical examination, followed by relevant investigations.The children were divided in to four age groups; 0-1 yr, >1-5 yr, >5-10 yr and over 10 years.The renal problems were classifi ed as Urinary Tract Infections (UTI), Acute Glomerulo Nephritis (AGN), Nephrotic Syndrome (NS), & Others.The investigations included routine urine examination, renal function tests, ultrasonogram (USG) abdomen, Micturating Cystourethrogram (MCU), Intravenous Pyelography (IVP) and other scans as required.

Discussion
Children with renal disease are brought to the hospital with a variety of symptoms, regardless of being related to the symptoms of kidney diseases or not 2 .In our study out of all the children who attended the paediatric OPD in a period of 6 years, 250 were found to have signifi cant fi ndings that warranted a full pattern of investigations related to kidney disease, including urine routine examination, urine culture and sensitivity, renal function tests, ultra sonogram etc.Out of these 228 were fi nally labelled to have renal problems.In the general population, about 30 people in every 100,000 develop kidney failure each year.In the paediatric population of the age group 19 and under; the annual rate is only 1 or 2 new cases in every 100,000 children 3 .The number of urinary tract infections (UTIs) were the highest accounting for 39.5% of cases and then 30.7 % were of acute glomerulonephritis (AGN) followed by 17.5 % of nephritic syndrome ( NS).Throughout childhood, the risk of a UTI is two percent for boys and eight percent for girls 4 .
Incidence and prevalence of nephritis in the paediatric population is not known 5 .However in a study by Zhongguo Dang Dai Er Ke Za Zh 29.09% were diagnosed as nephrotic syndrome, 22.00% as acute nephritis syndrome, 17.21% as isolated hematuria, 15.87% as purpura nephritis, and 7.30% as hepatitis B virus-associated nephritis.6This pattern is different from the pattern seen in our study.In the developed countries Acute post infectious (most often post streptococcal) GN has almost been wiped out but in Asia it still accounts for a large number of cases 7 .The overall prevalence of NS in childhood is approximately 2-5 cases per 100,000 children.The cumulative prevalence rate is approximately 15.5/100,000 8 .The type of symptoms that should be of signifi cance include edema, oliguria, hematuria, anuria and even evidence of renal failure.In older children presence of fever, hypertension, are some modes of presentations 9 .These features were noted in our study also.Hematuria is one of the most common urinary fi ndings that bring children to the attention of the paediatric nephrologists 10 .Thirty eight percent of our cases also presented with hematuria.Acute renal failure is a serious condition in critically ill patients, but less literature is available on acute renal failure in critically ill children 11 .The incidence rate of acute renal failure in PICU was 4.5% 11 .In our study 3.9% of the patients presented with ARF.The most common causes in our case was due to prerenal conditions like Post Diarrhoeal conditions, Septicemia followed by Post-Streptococcal Glomerulonephritis, Hepato-renal failure and Posterior Urethral Valve.While in another study the main cause of ARF was hemolytic uraemic syndrome in 18.2%, oncologic pathologies in 18.2% and cardiac surgery 11.4% 11 .
In a study by Kari JA sixty-six children had chronic renal failure (CRF) over a period of 4 years whereas we had only 8 cases over 6 years.Congenital abnormalities of the renal system were the major cause of CRF (50%) followed by neurogenic bladder (19.6%), either idiopathic (6%) or associated with neural tube defects (13.6%).Hereditary conditions were the cause in 12% and glomerular disease in 13.6% 12 .In our study Glomerulonephritis, Obstructive Uropathy and Nephrotic Syndrome were the causes of CRF.
Coming to management part the cost of investigations and treatment of these children is expensive and many patients in the developing world cannot afford it.Children with renal disease may require simple treatment in the outpatient department or may be so serious that they may require treatment in a paediatric renal or intensive care (PICU) unit, or may require continuous renal replacement therapies such as haemofi ltration (HF).The special procedures that was carried out was micturating cystourethrogram (MCU) in 5.3% cases which helped us to diagnose obstructive uropathy.Renal biopsy was done only in 5 (2.2%) cases probably due to the expensive cost and also due to lack of a good histopathological support.Other specialized procedures are not available in this part of the country.Many of our cases were managed in the outpatient department and the inpatient ward of the paediatric department.Some required PICU care and a 12 (5.3%)cases required dialysis.In a study by Kari JA 10.6% received hemodialysis and 21.2% cases had received peritoneal dialysis 12 .Yet in another study peritoneal dialysis (PD) was done in 23%, hemodialysis (HD) in 15%, HF in 28% 13 .With recent advances, stone management has changed from an open surgical approach to a less invasive procedure such as extracorporeal shock-wave lithotripsy and endoscopic techniques.Herein, in our study all cases of renal stone underwent successful surgery.Finally 4 (1.8%) cases were referred to higher centers for management in a nephrology unit.Five patients (2.2 %) died.Mortality reported by others were from 18%-20% 12,13 .

Conclusion
The early detection of renal diseases in childhood leads to better treatment and reduction in the mortality and morbidity.Our study, which is the fi rst from the western region in Pokhara attempts to show the incidence and prevalence of renal disease in children.The diffi culty of determining these relates to frequent under diagnosis.Many tests are available but in developing countries most cannot be done as these are unavailable or are too expensive.This constitutes a big public health problem and as facilities for treatment are expensive or not available, many children die before getting optimal treatment.

Table 1 :
Age and Sex Distribution at Presentation

Table 2 :
Pattern of Renal Diseases All cases of AGN are planned for follow up for 1-½ yrs and among them three patients required biopsy till date.All cases of NS are under regular follow-ups out of which two have undergone biopsy.Renal stones were operated successfully.All cases of acute and chronic renal failures had required dialysis.Out of 3 (25%) chronic renal failures 2 with End stage renal disease expired after repeated hemodialysis and one is still requiring dialysis.

Table 3 :
Causes of Renal Failure

Table 4 :
Signs and Symptoms at Presentation

Table 5 :
Special Procedures and Management Required