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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2005  |  Volume : 16  |  Issue : 1  |  Page : 84-88
The Major Causes of Chronic Renal Insufficiency in Syrian Children: A One-Year, Single-Center Experience

Pediatric Nephrology Department, Kidney Hospital, P.O. Box: 8292, Damascus, Syria

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Chronic kidney disease (CKD) is a world-wide public health problem, the causes of which differ in children from that reported in adult patients. There is an increased incidence of congenital and hereditary diseases causing chronic renal failure in the pediatric age-group and virtually no diabetic nephropathy. To determine the major causes, clinical expression, course, and outcomes of CKD in Syrian children we conducted a prospective study from February 2002 to February 2003 in the pediatric nephrology department at the Kidney Hospital in Damascus, Syria. Fifty-five patients with varying degrees of renal impairment were involved in the analysis. A total of 31 children (56%) had obstructive nephropathy (ON) as the cause of chronic renal insufficiency and 24 children (44%) had non-obstructive nephropathy (Non-ON). Neurogenic bladder was the commonest cause of ON, seen in 15 patients (27%), nephrolithiasis was seen in 10 patients (18%), urethral stenosis in three (5%), Uretro-Pelvie Junction (UPJ) stenosis in two (3%), and posterior urethral valves in one case (2%). Chronic glomerulonephritis and renal hypoplasia were the commonest causes of non­ON seen in six patients each (11%). Reflux nephropathy was seen in four patients (7%), hereditary nephritis in three (5%), polycystic kidney, nephrocalcinosis and Prune Belly syndrome in one case each (2%), and the cause was unknown in two patients (3%). The study is still ongoing and will be reviewed after two years with a bigger sample and possibly more reliable results.

Keywords: Chronic kidney disease, Obstructive nephropathy, Children, Syria.

How to cite this article:
Saeed MA. The Major Causes of Chronic Renal Insufficiency in Syrian Children: A One-Year, Single-Center Experience. Saudi J Kidney Dis Transpl 2005;16:84-8

How to cite this URL:
Saeed MA. The Major Causes of Chronic Renal Insufficiency in Syrian Children: A One-Year, Single-Center Experience. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2022 Jan 20];16:84-8. Available from: https://www.sjkdt.org/text.asp?2005/16/1/84/32954

   Introduction Top

Chronic renal failure (CRF) is defined by a glomerular filtration rate (GFR) of < 50 ml/ min/1.73m² body surface area (BSA). Below this level of renal function, growth impairment and metabolic abnormalities such as secondary hyperparathyroidism become apparent. Renal replacement therapy (RRT), either by dialysis or transplantation, becomes necessary when the GFR falls below 10 ml/min/1.73 m² BSA.

Approximately 75% of children requiring RRT have a prenatal cause for CRF, which has important implications for genetic coun­seling, antenatal diagnosis and future research. The proportional distribution of primary renal diseases has changed over time mainly as a result of the increasing number of younger children being treated now. Also, the prognosis for children with CRF has changed immeasurably over the past 25 years, from almost certain death to, now, a good prospect of long-term survival and rehabilitation. Technical advances have made it possible to offer dialysis and transplantation to almost all children with end­stage renal disease (ESRD) including the very young, although problems persist particularly in the areas of growth and transplant rejection.

Based on these observations, pediatric nephro­logists in developing countries have made a strong plea for the elimination of discrimi­natory practices against children and claim "the same right for subjects who were living in the same country but with the unique difference of age and size". [1],[2]

   Patients and Methods Top

This prospective study included all children (up to 15 years old) with the diagnosis of CRF who presented to the department of pediatric nephrology at the Kidney Hospital, Damascus, Syria during the period February 2002 to February 2003. This hospital is a tertiary care center, and receives patients from all parts of Syria.

The parameters studied included: gender, age, place of residence, age at the first complaint, age when the diagnosis of CRF was made, age at which the patient reached ESRD (if applicable), family history of similar kidney diseases, consanguinity, cause of CRF, asso­ciated malformations, co-morbidity {recurrent urinary tract infections (UTI), hypertension and its response to therapy, delayed psycho­motor development, etc}, renal function when first seen and patient outcome at the end of the study {transplanted, hemodialysis (HD) peritoneal dialysis (PD) ,CRF ,and death}.

These data were constantly updated during the entire study period. Fifty-five children (34 boys and 21 girls) were seen over a one­year period, and constituted the study group.

   Results Top

[Table - 1] shows the patient categories and the relative frequency of the various diagnostic groups. There were 31 children with obstructive nephropathy and 24 children with non-obstru­ctive nephropathy.

We divided our patients into four age-groups: 0-2 years, 2-5 years, 5-10 years and 10-15 years. There were two boys and three girls in the first group, seven boys and two girls in the second group, 14 boys and six girls in the third group and 11 boys and 10 girls in the fourth group. Out of the 15 cases of neurogenic bladder eight were seen in the fourth group. Nephrolithiasis was seen most frequently in the third group (6 out of 10). Out of the four cases of urethral stenosis, three were seen in the fourth group.

There were 41 patients above five years of age. Seven cases each in the ON and non-ON groups were below five years of age.

We noticed a positive family history of chronic kidney disease in 10 cases; six of them had nephrolithiasis, three had hereditary nephritis and one child had chronic glomerulo­nephritis. It was also noticed that 12 patients had one or more of the following associated malformations congenital cataract, congenital glaucoma, nystagmus, hydrocephalus, micro­cephaly, meningocele, cleft palate, ventricular septal defect, ectopic testis, inguinal hernia, imperforated anus, solitary kidney, bowing legs and/or chondrodysplasia.

Co-morbid conditions were numerous and variable and included recurrent UTI (n = 36), hypertension (n = 25), delayed psycho-motor development (n = 21), convulsions (n = 14), renal osteodystrophy (n = 9), cardiomyopathy (n = 5), major bleeding disorders (n = 4) and hypertensive encephalopathy (n = 2).

There were 36 cases with recurrent UTI (24 cases with ON and 12 cases with Non­ON). Of these, seven cases were below five years of age, 12 cases between the age of 5-10 years, and 17 cases between the age of 10 -15 years. Hypertension was noted in 25 patients (11 cases with ON and 14 cases with Non-ON). It was volume dependent in 16 cases and non­volume dependent in nine. Four of these patients were below five years of age, eight cases between the ages of 5 and 10 years. Consanguineous marriages were reported in the parents of 29 study children (16 ON and 13 Non-ON). We evaluated the renal function at first presentation for each patient. There were 18 patients (7 children with ON and 11 children with non-ON) with established CRF when first seen, of whom 11 patients had ESRD already.

[Table - 2] shows the progression of renal in­sufficiency according to the type of nephro­pathy. It delineates the time elapsed between the first presentation to the development of CRF, between the diagnosis of CRF and onset of ESRD, and between the first presentation and onset of ESRD.

By the end of the study period, three children had received kidney transplants, six children died, and 46 children were being managed with varying degrees of CRF (11 of them were on hemodialysis program and 8 were on peritoneal dialysis).

   Discussion Top

In our study, obstructive nephropathy accounted for the majority of cases of CRF accounting for 56%. This percentage is higher than we see in other studies. In the 1999 annual report of North American Pediatric Renal Trans­plant Cooperative Study (NAPRTCS), [3] obstructive nephropathy accounted for only 12.7% of all pediatric patients receiving a renal transplant in North America. In Sweden, Helin and Winberg (1980), in a retrospective study of CRF in children, reported that obstru­ctive anomalies accounted for 30% of all cases. [4]

Neurogenic bladder was the most common cause of CRF in this study accounting for 27% of all cases and 48% of the cases with ON. Nephrolithiasis was the second common­nest cause accounting for 18% of all cases and 32% of cases with ON. Non-ON causes were found in 44% of all cases; renal hypoplasia and chronic glomerulonephritis were the two most common causes, accounting for 11% of all cases each.

The prevalence of renal hypolplasia in our study did not differ much from that of other studies; being 7.5% in the report of the EDTA pediatric registry (Rizzoni et al,1985), [5] 12% in Helin's study, [5] 15.2% in the NAPRTCS, [4] 22% in the study of Habib et al. 1973, at the Hopital des Enfants Malades in Paris, [6] and 23% in the study of Mongeau at the Hopital Salinte -Justive in Montreal. [8]

The prevalence of chronic glomerulonephritis in this study (11%) was clearly lower than that in the previously mentioned studies, the lowest was 24% in the study of Morgeau [7] and the highest was 31.7% in the 1998 report of the United States Renal Data System (USRDS). [8] Only three cases (6%) of here­ditary / familial nephritis were encountered in our study. We strongly believe that this is an underestimation if we take into consideration the high prevalence of consanguineous marriages in our country.

In our study group, 62% of patients were male. This predominance of male gender has been well established by all the investiga­tors. [9] Males clearly predominated in the age group 2 to 10 years and in all ON patients (68%) except in UPJ stenosis where both cases were female.

We noticed an increasing prevalence of hypertension with age; for example 50% of patients above 10 years were hypertensive as against only 30% of children aged below five years. Interestingly, a decreasing adequacy of blood pressure control with age was also noticed. As much as 75% of young hyper­tensive children (below 5 years) had the blood pressure adequately controlled while only 33% of older hypertensive patients (above 10 years) were adequately controlled.

Parental consanguinity was noted in 53% of all patients. This huge percentage can explain the wide prevalence of many causes of CRF in this series like nephrolithiasis, neurogenic bladder, reflux nephropathy and hereditary nephritis. Unfortunately, we do not have national figures indicating the real prevalence of parental consanguinity in order to be able to make the comparison, but it seems that the percentage in our patients is definitely above that of the general population.

Renal insufficiency was present at the time of first presentation in 33% of all patients (45% in Non ON cases, and 22% of ON cases). ESRD was already present at the time of first presentation in 20% of all cases (25% in non-ON cases and 16% in ON cases). This late detection could be explained by the fact that these patients came from remote areas in addition to their low socio-economic status.

By the end of the study, 62% of all patients were in ESRD (58% of ON patients and 66% of non-ON patients). The rate of progression was faster in patients with neurogenic bladder than those with nephrolithiasis; mean time was 16 months in neurogenic bladder versus 37 months in nephrolithiasis. However, the progression to ESRD, once CRF was well established, was faster in nephrolithiasis than that of neurogenic bladder; the mean time was 5 months versus 42 months in neurogenic bladder. It was obvious that the time from the first complaint to the establishment of ESRD was clearly shorter in non-ON cases (23 months) than that of ON cases (62 months).

We are aware of the small number of patients in our study, which might have resulted in distorted findings. This in turn might have played a role (at least partially) in magnifying the importance of ON as a cause of CKD in Syrian children. A wider sample over a longer duration of time will certainly give us a better understanding of our patients and reflect more accurately the importance of each known cause of CKD in children of our region.

The current study is an ongoing one and hopefully in the next few years, we will be able to review the whole data with a more accurate conclusion.

   Conclusion Top

In our study obstructive nephropathy has been shown to be responsible for a bigger percentage of CKD than we see in the inter­national studies. Whether this is due to a true higher prevalence of some causes of obstructive nephropathy or an insufficient sample size, can only be elucidated with further studies involving larger number of patients.

   References Top

1.Grunberg J. The challenge of care of children with renal disease in developing countries: a Latin American outlook. Indian Pediatr 1996;33:91-4.  Back to cited text no. 1  [PUBMED]  
2.Saieh Andonie C. The management of end­stage renal disease in underdeveloped countries: a moral and an economic problem. Pediatr Nephrol 1990;4:199-201.  Back to cited text no. 2    
3.The 1999 annual report of North American Pediatric Renal Transplant Cooperative Study Kidney Transplantation. Peter J. Morris, 5 th edition Oxford, WB. Saunders Company. 605.  Back to cited text no. 3    
4.Helin I. Winberg J. Chronic renal failure in Swedish children. Acta Paediatr. Scand 1980;69:607-11.  Back to cited text no. 4    
5.Rizzoni G, Broyer M, Brunner H, et al. Combined report on regular dialysis and transplantation of children in Europe, XIV, 1983. Proc Eur Dial Transplant Assoc 1985; 21:22-65.  Back to cited text no. 5    
6.Habib R, Broyer M, Benmaiz H. Chronic renal failure in children. Causes, rate of deterioration and survival data. Nephron 1973;11:209-20.  Back to cited text no. 6    
7.Mongeau JG, Robitaille P, Grall MM. Chronic renal failure in children. Can Med Assoc J 1978;118:907-10.  Back to cited text no. 7    
8.The 1998 report of the USRDS, Kidney Transplantation Peter J. Morris, 5 th edition. Oxford, WB. Saunders Company. 605.  Back to cited text no. 8    
9.European Society for Pediatric Nephrology, ESPN Handbook (2002), P Cochar, France 370.  Back to cited text no. 9    

Correspondence Address:
Mohammed Bassam A Saeed
Pediatric Nephrology Department, Kidney Hospital, P.O. Box: 8292, Damascus
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PMID: 18209463

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