V. Manikandasamy

Magnitude and clinico-etiological profileof renal disorders in children – a retrospectivestudyin tertiarycarehospital

Maheswari K.¹, Manikandasamy V², Shanmuga Arumugasamy S³, Kiran⁴, Lakshman⁵, Brinda⁶

¹Dr. Maheswari K, AssociateProfessor, ²Dr. Manikandasamy V, Assistant Professor, ³Dr. Shanmuga Arumugasamy S.,Assistant professor, above authors are affiliated with Department of Paediatrics, Velammal Medical College, Madurai, India, ⁴Dr. Kiran, Senior Resident, ⁵Dr. Lakshman, Senior resident, ⁶Dr. Brinda, Senior Resident, above three authors are affiliated with Department of Paediatrics, Sri Venkateshwara Medical College and Research Centre, Puducherry, India.

Address for Correspondence: Dr.V. Manikandasamy, HIG 36, Sector 6, TNHBcolony, KoodalPudhur, Madurai,Tamilnadu, India. Email- bharathi4samy@gmail.com

Abstract

Objectives: This study was undertaken to know about the magnitude, clinical spectrum and etiologyof renal diseases in children in a tertiary care teaching hospital. Materials and Methods: Thisis a hospital based, retrospective, descriptive study, done on children with renaldiseases admitted to pediatric department of Velammal Medical College, Madurai from Jan 2016 – Dec 2016. Results: Renal disorders are contributing to 4.6% of total admissions. Males (61.1%%), outnumbered, females (38.9%) in our study. Children less than 5 years of age were most commonly affected (47%). Most common symptom in children with renal disorders were burning micturition/increased frequency/urgency(36.4%), fever (29.4%), decreased urine output(28.4%), abdomen distension (25.4%), pain abdomen (18.4%), vomiting (17.6%), red/cola coloured urine (11.6%). The most common sign observed wasperi-orbital puffiness (22.3%),pedal edema and ascitis in (18.8%) each, tachypnea in (10.5%) of children. The most common etiologyof renal disorders wasUTI (36.4%), PUJ obstruction (18.8%), Nephrotic syndrome in (16.4%), and renal calculi (14.1%). Conclusion: Our present study has revealed that, the magnitude of childhood renal disorders is in the increasing trend, associated with wide clinical spectrum and predominance of infective etiology. Emphasis is therefore placed on high index of suspicion for atypical presentation of renal disorders andpreventing progression to chronicity.

Keywords: Children;Acute kidney injury, UTI, Chronic kidney disease

Manuscript received: 3rd August 2017, Reviewed: 14th August 2017
Author Corrected: 24th August 2017, Accepted for Publication: 30th August 2017

Introduction

Renal diseases are major causes of morbidity and mortality in hospitalized pediatric patients. Paediatric patients with renal diseases, especially younger ones may present with nonspecific signs and symptoms unrelated to urinary tract. Unexplained fever or failure to thrive may be the only manifestation.Paediatricians, therefore, should be familiar with the modes of presentation of renal disease and should have a high index of suspicion of these conditions [1]. Studies from different geographical areas around the world have reported variable patterns of renal diseases in paediatric population. Theses variations could be related to genetic predisposition, environmental factors, or lack of awareness about importance of early diagnosis of such disorders [2]. The patterns of renal disease in children are different from developing countries as compared to developed countries and paediatric renal disease form about 4.5-8.7% of total paediatric admission. Renal disease in hospitalized children and young adult can be difficult to diagnose early as it may present only with few symptoms, tends to have different course than adult and respond variously to different treatment [3].Renal disease in children is an important group of disorders from both mortality and morbidity point of view,incurring significant expenses on both family and health services[4]. Analysis of various registries indicates that the epidemiology and spectrum of renal disease in the pediatric age group differ from one geographic place to another [5]. Acute kidney injury (AKI), formerly known as acute renal failure is common in children admitted to hospitals. In contrast to developed countries where AKIis more common in older children admitted to intensive care units with multiple co-morbidities and multi-organ failure, previous studies of AKI in children in developing countries, documented single disease entities such as diarrhoeal diseases, malaria, hemolytic uremic syndrome and acute glomerulonephritis as the major causes of AKI [6]. Previous studies have reported that the largest proportions of CKD cases in children are caused by congenital anomalies of the kidney and urinary tract, 30-60%; hereditary nephropathies, 10-35%; and glomerulopathies, 3-25% [7].

Materials and Methods

Study design: This is a retrospective, descriptive study.
Setting: Hospital based study in a tertiary care centre in south India
Participants: Children aged 3 months to 15 years of age admitted and treated in pediatric department from January 2016-December 2016 invelammal medical college, Madurai.

Inclusion Criteria
•   3 months to 15 years old children presenting to the pediatric department with renaldiseases.
•   Complete patient information along with the investigation reports in the medical records.

Exclusion Criteria
•   Children less than 3 months and more than 15 years of age.
•   Medical records with incomplete information/ Evaluation done in other hospitals.

Variables: Magnitude, clinical spectrum, etiology
Data source: The patients needed for this study were identified by reviewing our department nominal register. The hospital records of the children with renal diseases were retrieved from the medical records department following due permission.
Study size: 85 children
Quantitative variable: magnitude
Statistical analysis: simple proportion test.

The following data was collected from the medical records department (MRD) about thechildren included in this study.
•   Age, sex, symptoms and signs of renal diseases.
•   Results of urine tests(culture, microscopy, dipstick test, protein quantitative test) ,blood test(complete blood count, peripheral smear, urea, creatinine, electrolytes, albumin, ASO titers, CRP test, autoimmune antibodies, C3, C4 levels, serum calcium/uric acid levels),imaging studies (abdominal ultrasound,micturatingcystourethrogram, DMSA/DPTA scans)cystoscopy, renalbiopsyreport was noted.

Results

Out of 2259 children, admitted in pediatric ward from Jan 2016- Dec 2016, about 85 children had renal disorders, with 104 admissions (some of the renal cases had repeated admissions) contributing to4.6% of the total number of admissions. The analyses of 85 children with renal disorders are given below.

Table-1: Distribution of children according to demographic data

Demographic data

Number

Percentage

Gender

Male

Female

61.1

38.9

Age group

3 months – 5 years

6-10 years

11-15 years

32.9

According to table 1- it was seen that males 52(61.1%), outnumbered female children 33(38.9%). Renaldisorders was most commonly seen in children less than 5 years of age 40 (47%), followed by, children of6-10 years of age 28 (32.9%) and 11-15 years of age 17 (20%).

Table-2: Distribution of children according to clinical profile of renal disorders

Clinical profile

No.

Percentage

Symptoms

Burning-micturition/increase frequency/urgency

Fever

Decreased urine output

Abdomen distension

Pain abdomen

Vomiting

Red/cola coloured urine

Decreased-appetite/poor feeding

Dribbling of urine

Altered sensorium/irritability

Bed wetting

Deformity of limbs

Headache

Seizures

36.4

29.4

28.4

25.4

18.4

17.6

11.6

10.5

8.2

3.5

2.3

1.1

Signs

Peri orbital puffiness

Pedal edema

Ascitis

Tachypnea

Pallor

Short stature

Renomegaly

22.3

18.8

10.5

5.8

4.7

3.5

According to table -2, it was observed that, most common symptom in children with renal disorderswere, symptoms of UTI in 31 (36.4%), fever in 25(29.4%), decreased urine output24 (28.4), abdomen distension in 22 (25.4%), pain abdomen 16 (18.8%), vomiting 15 (17.6%), red/ cola coloured urine 10 (11.6%).

The most common sign observed was, peri-orbital puffiness in 19 (22.3%), pedal edema in 16 (18.8%), ascites in 16(18.8%), tachypnea in 9(10.5 %), pallor in 5 (5.8 %).

Table-3: Distribution ofchildren according to etiology of renaldisorders

Etiology

No/percentage

UTI

PUJobstruction/hydronephrosis

Nephrotic syndrome

Renal calculi

AGN

Congenital anomalies

Right ureter double moiety

Ureterocele

Ectopic ureter

HUS

Nocturnal enuresis

Renal rickets

VUR

AKI

CKD

Urethral-stricture(posttraumatic)

Wilms tumor

Neuroblastoma

Rhabdomyosarcoma-bladder

31 (36.4)

16 (18.8)

14 (16.4 )

12 (14.1)

5 (5.8)

3 (3.5)

3 ( 3.5)

2 (2.3)

1(1.1)

This table depicted thatthemost common etiology of renal diseases were UTI in 31(36.4%), PUJ Obstruction in 16(18.8%), nephrotic syndrome14 (16.4%), renal calculi in 12 (14.1%), AGN in 5 (5.8%).

Other uncommon etiologywere, post traumatic urethral stricture, wilms tumor, neuroblastoma, rhabdomyosarcoma of bladder in (1.1%) each.

Discussion

The common causes of ARF in children include acute tubular necrosis secondary to various causes (including congestive cardiac failure and sepsis), haemolytic uremic syndrome, and glomerulonephritis and urinary tract obstruction. Ischemia, toxins as well as primary parenchymal disease,have to be considered.
The most common symptom of renal disorders noted in our study was history suggestive of UTI (36.4%), fever (29.4%), decreased urine output (28.4%), abdomen distension (25.4%), pain abdomen (18.8%), vomiting (17.6%). Most common sign noted was periorbital puffiness (22.3%), pedal edema (18.8%), ascitis (18.8%). This is similar to other studies[1,2]. The high incidence of ARF due to infective diarrhoeas and dysentry reflects poor socioeconomic and hygienic conditions, inadequate facilities in rural areas, delayin seeking medical advice [8,9]. Childhood CKD presents clinical features that are specific and totally peculiar to the paediatric age group, such as the impact of the disease on growth. It is an important cause of morbidity and mortality in children worldwide. Congenital disorders, including congenital anomalies of the kidney and urinary tract and hereditary nephropathies, are responsible for about two thirds of all cases of CKD in developed countries, while acquired causes predominate in developing countries [10-12].

It was observed that the magnitude of renal disorders was 4.6% (104 out of 2259 admissions),during the studyperiod of 12 months.Other authors have observed similar observations[13-15]. In contrast, another study has shown that, paediatric renal disorders accounted for only 1.1% of the total outpatients and hospital admissions[19].

In our study it was seen, that males (61.1%) outnumbered female children (38.8%) in prevalence of renaldisorders. Similar results were reported by various authors [16-20].The most common age group affected in our study was children less than 5 years of age (47%), followed by 6-10 years (32.9%), & 11-15 years of age (20%). But, in contrast, study donein Kashmir showed that, 6-12 years of age were most commonly affected by renal disorders [20].

The most common etiology of renal disorders revealed by our study was UTI (36.4%). This was followed by PUJ obstruction with hydronephrosis(18.8%), nephrotic syndrome(16.4%), renal calculi(14.1%), AGN (5.8%), congenital anomalies, HUS and nocturnal enuresis in (3.5%) each. Other etiologies were AKI (pre-renal)& CKD in (2.3%) each. Malignancies such as wilms tumor and neuroblastoma and rhabdomyosarcoma of bladder was seen in (1.1%) each. Similar to our study, UTI was the most common cause of renal disorder observed in various authors [17,18].But, UTI was less common (8.9%) etiology observed in Nigeria [25].In contrast to our study, nephroticsyndrome was the most common cause of paediatric renal admissionsinother countries [22,23,26].Ethiopian studyhas revealed congenital anomalies as the most common (26.8%) cause of renal disorder in children, which was less common (3.5%) in our study.Aretrospective study in contrast, has observed acute glomerulonephritis(36.9%) as the most common childhood renal disorder [25].

As about 2.3% of children in our study, had acute kidney injury (pre-renal), related to volume loss in diarrhea, because of late referral. But HUS complicating bacillary dysentry was the most common cause of acute renal failure in other studies [21,24].

The major limitation of our retrospective study was lack of follow up and analysis of outcome in children withrenal disorders. In addition outpatient records were excluded. The magnitude reported in this study, may therefore be an underestimation.

Conclusion

Our present study has revealed that, the magnitude of childhood renal disorders is in the increasing trend, associated with wide clinical spectrum and predominance of infective etiology. Emphasis is therefore placed on high index of suspicion for atypical presentation of renal disorders andpreventing progression to chronicity. Butsince thisis a retrospective study with small sample size,the authors would like to recommend for further detailed prospective studies in future, with emphasis onmorbidity and mortality point of view, to plan provision ofoptimalhealth care services for children with renal disorders.

Author contribution & Acknowledgement- The first 3 authors contributed to study design and data collection from MRD. The last 3 authors contributed to data analysis and interpretation of results.Wethank all the MRD staffs, for helping us in collection of patient information from medical records.
We are grateful to Dr. Mathevan.G& Dr. Natarajarathinam for encouraging us to do this study.

Abbreviation
UTI- urinary tract infection
PUJ- pelvi-ureteric junction
AGN- acute glomerulonephritis
HUS- hemolytic uremic syndrome
VUR- vesico-ureteric reflux
AKI – acute kidney injury
CKD – chronic kidney disease

Funding: Nil, Conflict of interest: None initiated.
Permission from IRB: Yes

References

1. Mola K, Shimelis D. Pattern and outcome of renal disease in hospitalized children in TikurAnbessaspecialized teaching hospital, Addis Ababa, Ethiopa. Ethiop Med J. 2016;54(3):117-123.

2. Ali el-TM, Rahman AH, Karrar ZA. Pattern and outcome of renal diseases in hospitalized children in Khartoum State, Sudan.Sudan J Paediatr. 2012;12(2):52-9. [PubMed]

3. Bhatta NK, Shrestha P, Budathoki S, Kalakheti BK, Poudel P, Sinha A, Et al. Profile of renal diseases in Nepalese children. Kathmandu Univ Med J (KUMJ) 2008 Apr-Jun;6(2):191-4. [PubMed]

4. Iqbal J, Rehman MA, Khan MA. Pattern of renal disease in children.J Pak Med Assoc. 1994 May;44(5):118-20. [PubMed]

5. Saca E, Hazza I, El-Imam O, Kawar M. Spectrum of biopsy-proven renal disease in the pediatric age group at king Hussein medical center. JRMS 2007Apr;14(1):34-37.

6. Esezobor CI, Ladapo TA, Osinaike B, Lesi FEA. Paediatric Acute Kidney Injury in a Tertiary Hospital in Nigeria: Prevalence, Causes and Mortality Rate. PLoS ONE. 2012;7(12):e51229. http://doi.org/10.1371/journal.pone.0051229.

7. Cerón A, Fort MP, Morine CM, Lou-Meda R.Chronic kidney disease among children in Guatemala.RevPanamSaludPublica. 2014 Dec;36(6):376-82. [PubMed]

8. Filler G. Acute renal failure in children: aetiology and management. Paediatr Drugs.2001;3(11):783-92. [PubMed]

9. Chugh KS, Narang A, Kumar L, Sakhuja V, Unni VN, Pirzada R, . Acute renal failure amongst children in a tropical environment. Int J Artif Organs. 1987 Mar;10(2):97-101. [PubMed]

10. Becherucci F, Roperto RM, Materassi M, Romagnani P. Chronic kidney disease in children.Clin Kidney J. 2016 Aug;9(4):583-91. doi: 10.1093/ckj/sfw047. Epub 2016 Jun 5. [PubMed]

11. Kanitkar M. Chronic Kidney Disease in Children: An Indian Perspective. Med J Armed Forces India. 2009 Jan;65(1):45-9. doi: 10.1016/S0377-1237(09)80055-5. Epub 2011 Jul 21.

12. Harambat J, Van Stralen KJ, Kim JJ, Tizard EJ. Epidemiology of chronic disease in children.Pediatric Nephrology (Berlin, Germany). 2012;27(3);363-373. http://doi.org/10.1007/s00467-011-1939-1

13. Ladapo TA, Esezobor CI, Lesi FE. Pediatric kidney diseases in an African country: prevalence, spectrum and outcome. Saudi J Kidney Dis Transpl. 2014 Sep;25(5):1110-6.

14. Ali SH, Hussien FS, Abd Al-Amer H. Profile of renal diseases in Iraqi children: A single-center report. Saudi J Kidney Dis Transpl. 2015 May-Jun;26(3):613-8. doi: 10.4103/1319-2442.157422. [PubMed]

15. Elzouki AY, Amin F, Jaiswal OP. Prevalence and pattern of renal disease in eastern Libya.Arch Dis Child. 1983 Feb;58(2):106-9. [PubMed]

16. Ugwu G, Nwajei G, Chinemelu U. Pattern of Renal Diseases among children in the Niger Delta Region, Nigeria. Arab J Nephrol Transplant 2014 Jan;7(1):49-50.

17. Cruz FS, Carbera W, Barreto S, Mayor MM, Ba`ez D. Kidney disease in Paraguay. Kidney IntSuppl2005Aug;(97):120-5. [PubMed]

18. Orta-Sibu N, Lopez M, Moriyon JC, Chavez JB. Renal diseases in children in Venezuela, South America.PediatrNephrol. 2002 Jul;17(7):566-9. Epub 2002 Jun 7.

19. Eke FU, Eke NN. Renal disorders in children: a Nigerian study. PediatrNephrol. 1994 Jun;8(3):383-6. [PubMed]

20. Ashraf M, Kumar V, Bano RA, Wani KA, Ahmed J, Ahmed K. Spectrum of Renal and Urinary Tract Diseases in Kashmiri Children. Journal of Clinical and Diagnostic Research : JCDR. 2016 Jun;10(6):SM01-SM02. http://doi.org/10.7860/JCDR/2016/20222.7999

21. Arora P, Kher V, GuptaA, Kohli HS, Gulati S, Rai PK, etal. Pattern of acute renal failure at a referral hospital. Indian pediatr 1994 Sep:31(9);1047-1053. https://www.ncbi.nlm.nih.gov/pubmed/7883359

22. Naicker S. End-stage renal disease in sub-Saharan and South Africa. Kidney Int Suppl. 2003 Feb;(83):S119-22. [PubMed]

23. Muoneke VU, Una AF, Eke CB, Anyanwu OU. The Burden and Outcome of Pediatric Renal Admissions at the Federal Teaching Hospital Abakaliki: A 3-year Review(2011-2013). Ann Med Health Sci Res. 2016 Jul-Aug;6(4):243-250. http://doi.org/10.4103/amhsr.amhsr_342_14

24. Date A, Unni JC, Raghupathy P, Jadhav M, Pereira SM, Richard J, Jacob CK, Kirubakaran MG, Shastry JC. The pattern of medical renal disease in children in a south Indian hospital.Ann Trop Paediatr. 1984 Dec;4(4):207-11.

25. Etuk IS, Anah MU, Ochighs SO, Eyong M. Pattern of paediatric renal disease in inpatients in Calabar, Nigeria.Trop Doct. 2006 Oct;36(4):256.

26. Adedoyin OT, Adesiyun OA, Mark F, Adeniyi A. Childhood renal disorders in llorin, north central Nigeria. Niger Postgrad Med J. 2012 Jun;19(2):88-91. [PubMed]

How to cite this article?

Maheswari K, Manikandasamy V, Shanmuga Arumugasamy S, Kiran, Lakshman, Brinda. Magnitude and clinicoetiological profileof renal disorders in children – a retrospectivestudyin tertiarycarehospital. J PediatrRes. 2017;4(08):519-524.doi:10. 17511/ijpr.2017.08.04.