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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2015  |  Volume : 26  |  Issue : 5  |  Page : 1064-1069
Acute glomerulonephritis in children of the Niger Delta region of Nigeria


Department of Pediatrics, Delta State University Teaching Hospital, PMB O7, Oghara, Delta State, Nigeria

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Date of Web Publication7-Sep-2015
 

   Abstract 

A three-year retrospective study was conducted to determine the incidence, pattern of presentation and other clinical and biochemical features as well as outcome of treatment of patients admitted with acute glomerulonephritis at the Delta State University Teaching Hospital, Oghara and GN Children's Clinic, Warri. The case notes of all the children who presented with renal diseases from January 2010 to December 2012 were retrieved and those with acute glomerulonephritis were analyzed. A total of 20 patients (13 male and seven female) with acute glomerulonephritis were seen during the three-year period under review. Twelve patients (60%) were from the low socioeconomic class, six (30%) from the middle class and only two (10%) were from the high-income group. The presentation of the illness was most common between October and January. The age range of the patients was three to 13 years, with an average age of eight years. Seventeen (85%) of the patients were in the school-going age group (>5 years to 10 years). The most common symptom/sign noted was anemia in 90% of the patients, followed by oliguria/anuria and edema seen in 80% of the patients. Seventy percent of the patients had cola-colored urine, while 55% had hypertension. Some patients gave a history suggestive of previous streptococcal infection. More patients had sore throat (25%) than skin infection (10%). All the patients had proteinuria, while 90% had hematuria. The most common complication was acute kidney injury, seen in eight (40%) of the patients, followed by hypertensive encephalopathy, which occurred in three (15%) patients. Most patients (60%) were hospitalized for one to two weeks. The outcome of the management of these patients showed 14 (70%) of the patients recovered fully while three (15%) had persistent hematuria and two (10%) had persistent proteinuria. Ninety-five percent of the patients recovered from the acute illness and one patient (5%), a boy aged nine years old, died.

How to cite this article:
McGil Ugwu G I. Acute glomerulonephritis in children of the Niger Delta region of Nigeria. Saudi J Kidney Dis Transpl 2015;26:1064-9

How to cite this URL:
McGil Ugwu G I. Acute glomerulonephritis in children of the Niger Delta region of Nigeria. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2022 Nov 29];26:1064-9. Available from: https://www.sjkdt.org/text.asp?2015/26/5/1064/164618

   Introduction Top


Dr. Bright initially described acute glomerulonephritis in 1927. [1] It comprises a specific set of renal diseases in which an immunologic mechanism triggers inflammation and proliferation of the glomerular tissue that can result in damage to the basement membrane, mesangium or capillary endothelium. [2] Hippocrates originally described the manifestation of back pain and hematuria that lead to oliguria or anuria. [3] Langhans was able to describe the pathophysiological glomerular changes. [4] The archetype of acute glomerulonephritis is acute post-streptococcal glomerulonephritis (APSGN) and, usually, an unqualified acute glomerulonephritis used to mean APSGN. It usually follows a streptococcal sore throat or skin infection by various types or strains of streptococcus. It is a disease that depicts the hygienic state of the area/ county, being more common in developing countries, and the incidence has dropped dramatically in the United States of America in the last few decades. [5] Some centers have reported seasonal variations. [6] However, the incidence varies from place to place, which cannot be explained by environmental cleanliness alone. There may even have a racial undertone, being more common in blacks than Indians and Caucasians in the USA. [7]

This study was conducted to determine the incidence and pattern of presentation of acute glomerulonephritis at the Delta State University Teaching Hospital, Oghara and GN Children's Clinic, Warri, the only pediatric nephrology hospital in the area. The study is a three-year retrospective study from January 2010 and December 2012, as the teaching hospital was started in January 2010.


   Materials and Methods Top


The case notes of all the children who presented with renal diseases from January 2010 to December 2012 were retrieved and those with acute glomerulonephritis were analyzed. Information obtained among other things included age and gender of the patient. Others included presenting symptoms and signs, the socioeconomic status of the parents of the children according to the Olusanya et al study in 1985, [8] the month of occurrence, investigations, diagnosis, treatment given, progress made and outcome of the management, including follow-up up to Week 12. The data collected were then analyzed.


   Results Top


Acute glomerulonephritis accounted for about 18.2% of all the renal patients seen during the period under review. A total of 20 patients with acute glomerulonephritis were seen during the three-year period under review. Thirteen of them were male and seven were female, giving a male to female ratio of approximately 2:1. Twelve of the patients (60%) were in the low socio-economic class, six (30%) were in the middle economic class and only two (10%) were from the high-income group. The presentation of the illness was most common between October and January. The age range of the patients was three to 13 years, with an average age of eight years. [Figure 1] shows the age distribution of the children studied.
Figure 1: Distribution according to age ranges.

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No neonate was seen with acute glomerulonephritis while only one patient aged three years was seen in the pre-school age group (>1 month to 5 years), representing 5% of the total number of patients seen. Seventeen (85%) of the patients were in the school-going age group (>5 years to 10 years), while two (10%) were aged >10 years up to 16 years (adolescence). [Table 1] shows the clinical presentation of the patients.
Table 1: Clinical presentation of the patients.

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The data show that the most common symptom/sign observed was anemia, with up to 90% of the patients having this condition. This was followed by oliguria/anuria and edema, which was seen in 80% of the patients. Seventy percent of the patients had cola-colored (dark) urine, while 55% had hypertension. Among the findings, the lowest finding was tender hepatomegaly (10%), which occurred in two patients with congestive cardiac failure. Some patients gave history suggestive of possible previous streptococcal infection. More patients had sore throat (25%) than skin infection (10%).

[Table 2] shows the results of various investigations that were carried out. The table shows that all the patients had proteinuria, while 90% had hematuria. When compared with those with macroscopic hematuria (cola-colored urine), only 20% had microscopic hematuria. Urinary casts (red cell or granular) were found in 65% of the patients. The ASO titer was raised in only 30% of the patients and a throat culture for Streptococcus pyogenes was positive in only one patient. Evidence of kidney enlargement on ultrasonography was seen in eight (40%) of the patients. Two patients had cardiomegaly and they who also had congestive cardiac failure.
Table 2: Laboratory/radiological results of the patients.

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The most common complication was acute kidney injury. Eight (40%) of the patients had this at the time of presentation. Of these, three needed dialysis, one peritoneal and two hemodialysis, and all of them survived. This was followed by hypertensive encephalopathy, which occurred in three patients, representing 15% of the population. Two patients (10%) had congestive cardiac failure while one (5%) had acute pulmonary congestion [Figure 2].
Figure 2: The complications observed among the patients.

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The duration of stay ranged from two to 28 days. [Table 3] shows the duration of stay in weeks and the percentage of the patients. Most patients (60%) were hospitalized for one to two weeks.
Table 3: Duration of stay in weeks of the patients.

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The outcome of the management of these patients showed that 14 (70%) of the patients recovered fully while three (15%) had persistent hematuria (defined as hematuria >12 weeks) and two (10%) had persistent proteinuria (defined as proteinuria >12 weeks). No patient was discharged against medical advice, while only one patient (5%), a boy aged nine years old, died. Ninety-five percent of the patients recovered from their acute illnesses.


   Discussion Top


A total of 20 patients were seen over a threeyear period, giving a yearly incidence of about seven per annum. This is far smaller than the yearly incidence documented by Anochie in Port Hacourt [9] but similar to the study in Calabar, [6] both of which are in the Niger Delta region. In the Calabar study, 76 patients were seen over a 10-year period. The incidence showed a singular peak between October and January, similar to the study in Port Harcourt, [9] and did not show a twice-a-year peak as in Calabar [6] . There is a male preponderance similar to the Port Harcourt, [9] Calabar, [6] Enugu, [10] Zaria, [11] Ibadan [12] and Ilorin [13] studies. But, the ratio of 2:1 is much higher than in these studies, where the ratio is 1.1:1 in favor of the male patients. [6],[9] This is however in contrast to the findings by Ibadin and colleagues, who found a higher incidence in females in Benin, [14] which used to be in the same state with Oghara and Warri.

Studies published as Board Review Course and Update 2013 in the Journal of the American Society of Nephrology, showed that the incidence is lesser in India and Thailand than in Nigeria and Morroco, and far lesser in the developed world countries such as the United States of America and Australia. [15] This may reflect the hygienic state of the various countries as studies, including our study, have shown that it is mainly a disease of the low socio-economic group. Etuk in Calabar [6] documented that 82% of their patients were in the low socio-economic class compared with our finding of 60%. Acute glomerulonephritis is the second most common renal pathology in our study, which is similar to the study by Adedoyin and colleagues in Ilorin [16] and Enugu. [10] However, studies in Jos [17] and Libya [18] showed it to be the most common renal pathology in children. In fact, an initial study in Enugu [19] and a study in Benin [14] showed that it is the third most common childhood renal disease. In a study in the Kingdom of Saudi Arabia, it is a declining disease, reflecting the improved hygienic state and tremendous leap in the socioeconomic parameters. [20]

The data obtained showed that the disease is more common in the school-going age group (>5 years to 10 years), and this is the finding in other parts of Nigeria and even in the United States of America [5],[21] and elsewhere in the developed countries, [5] but surprisingly different from Ibadin and Adiodun's study in Benin, [14] which used to be in the same state within the area of this study. In the Benin study, acute glomerulonephritis was found to be most common in the pre-school age group (>1 month to 5 years). [14] Clinical presentation showed that the most common finding was anemia, which the laboratory findings proved to be dilutional. Edema and oligo-anuria were the second most common clinical signs at 80%, which is similar to the findings in Calabar, [6] but in that study edema was found in 98.5%. Cola-colored urine was present in 85.5% of the patients compared with 70% in our study. [6] Hypertension in our study was seen in 55% of our patients compared with 92.3% in Jos, [17] 86.8% in Calabar [6] and 78% in Benin. [14] No obvious explanation for these marked differences can be given.

Laboratory investigations showed that proteinuria was present in all our patients, similar to the findings in Enugu [10] and Calabar. However, while hematuria was present in all the 68 patients in Calabar, it was present in 90% of our patients. Previous history of sore throat was documented in 25% of our patients and skin infection in 10%. The incidence of previous history of sore throat was similar to the study in Calabar [6] at 14.7%, but in that study infection of the skin as the cause of acute glomerulonephritis was more common at 22.1% compared with 19% in our study. Ibadin documented a significant history of antecedent infections in 52% of patients, 53.8% of which came from sore throat and 7.7% from skin infections, showing as in our study that the APSGN is predominantly from sore throat when documented. [14]

The most common complication observed in our study was acute kidney injury, occurring in eight (40%) of our patients. This is a very large percentage compared with that reported from Benin and Calabar. In Benin, [14] it occurred in only 10% of the patients and 5.9% in Calabar. [6] But, in Ife, Olowu noted that it is the second most common cause of acute kidney injury in that center, at a rate of 27.8%. [22] This disparity cannot be explained by just the method of measuring the blood pressure. Fifteen percent of the patients had hypertensive encephalopathy. This, was reported to be far lower (4.4%) in the studies in Calabar [6] and in Benin, [14] but lower than the findings in Ilorin, where it was 23.1%, and in Jos. [17]

Logically, the incidence of hypertensive encephalopathy and the incidence of hypertension should be correspondingly related and one would have expected hypertensive encephalopathy to be higher where hypertension is found. However, the incidence of hypertension was higher in Port Harcourt, but with a lower incidence of hypertensive encephalopathy. [9] The incidence of congestive heart failure was similar to our study, as in Calabar. [6] Most of our patients were hospitalized for one to two weeks, which is similar to Ibadin's study in Benin. [14] All the patients who were dialyzed recovered and in fact the total recovery rate from the acute phase was 95%, which is higher than the study in Calabar [6] and Port Harcourt. [9] But, this is similar to an American study where the recovery rate was put at as much as 100%, with an incidence of 10-15%, which has fallen dramatically in the last few decades. [5] In Sudan, it is the most common cause of chronic renal disease in children. [23] No patient was discharged against medical advice compared with Okechukwu's study, [24] Eke and Opara in Port Harcourt [25] and in Calabar, [6] where 5% were discharged against medical advice. The mortality rate of 5% is similar to the findings in Calabar [6] and 6% in Benin, [14] as only one patient died and he was a boy.

This study has shown the pattern of acute glomerulonephritis in the Niger Delta region of Nigeria. It also showed that some of the characteristics vary from studies in and outside Nigeria, and even in the same locality.


   Acknowledgment Top


The authors wish to sincerely appreciate the invaluable help from Lady Eunice Ugwu, Dr. Martin Aso, T. K. Ugwu and I. K. Ugwu.

 
   References Top

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Jackson SJ, Steen AC, Campbell H. Systemic review. Estimation of global burden of nonsupporative sequaelle of upper respiratory tract infection, rheumatic fever, poststreptococcal acute glomerulonephritis. Trop Med Int Health 2011;16:2-11.  Back to cited text no. 3
    
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Luo C, Chen D, Tang Z, et al. Clinicopathological features and prognosis of Chinese patients with acute post-streptococcal glomerulonephritis. Nephrology (Carlton) 2010;15:625-31.  Back to cited text no. 4
    
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Acute Glomerulonephritis in the United States: Overview. Available from: http://www.emedicine.medscape.com/article/239278-overview#ao156. [Last accessed on 14 May 2013].  Back to cited text no. 5
    
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Wesley AG, Scragg JN, Rubidge CJ, Wallace HL. The racial incidence of disease in hospital children in Durban. S Afr Med J 1967;41:332-5.  Back to cited text no. 7
    
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Anochie I, Eke F, Okpere A. Childhood acute glomerulonephritis in Port Harcourt, Rivers State, Nigeria. Niger J Med 2009;18:162-7.  Back to cited text no. 9
    
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Ibadin PO, Abiodun PO. Childhood acute glomerulonephritis in Benin City. Nig J Paediatr 2003;30:45-9.  Back to cited text no. 14
    
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Adedoyin OT, Adesiyun OA, Mark F, Adeniyi A. Childhood renal disorders in Ilorin, north central Nigeria. Niger Postgrad Med J 2012;19:88-91.  Back to cited text no. 16
    
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Ocheke IE, Okolo SN, Bode-Thomas F, Agaba EI. Pattern of childhood renal diseases in Jos, Nigeria: A preliminary report. J Med Trop 2010;12:52-5.  Back to cited text no. 17
    
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Elzouki AY, Amin F, Jaiswal OP. Prevalence and pattern of paediatric renal diseases in Eastern Libya. Arch Dis Child 1983;58:313-23.  Back to cited text no. 18
    
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Rodriguez-Iturbe B, Musser JM. The current state of poststreptococcal glomerulonephritis. J Am Soc Nephrol 2008;19:1855-64.  Back to cited text no. 21
    
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Olowu WA, Adelusola KA. Pediatric acute renal failure in southwestern Nigeria. Kidney Int 2004;66:1541-8.  Back to cited text no. 22
    
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Aliel TM, Abdelraheem MB, Mohamed RM, Hassan EG, Watson AR. Chronic renal failure in Sudanese children: Aetiology and outcomes. Pediatr Nephrol 2009;24:349-53.  Back to cited text no. 23
    
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Okechukwu AA. Discharge against medical advice in children at the university of Abuja Gwagwalada Nigeria. J Med Med Sci 2011;2:947-52.  Back to cited text no. 24
    
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Eke GK, Opara PI. Discharge against medical advice amongst patients admitted into the paediatric wards of the University of Port Harcourt Teaching Hospital. Nig J Paediatr 2013;40:40-4.  Back to cited text no. 25
    

Top
Correspondence Address:
G I McGil Ugwu
Department of Pediatrics, Delta State University Teaching Hospital, PMB O7, Oghara, Delta State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.164618

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    Figures

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