RENAL DATA FROM THE ARAB WORLD
Year : 2006 | Volume
: 17 | Issue : 4 | Page : 581--585
Pediatric End-Stage Renal Disease: Single Center Analysis
Edward Sacca, Issa Hazza
Department of Pediatric Nephrology, King Hussein Medical Center, Amman, Jordan
P.O. Box 143924, Amman 11814
Data describing end stage renal disease in Jordan is very limited, due to the absence of internal center as well as national registry systems. In this retrospective analysis, we define the etiology, prevalence, incidence as well as other demographic features of pediatric end stage renal disease and renal replacement therapy at King Hussein Medical Center. All children who entered the chronic dialysis program in our center from January 2001 to December 2005 were included in the study. Children who were transplanted pre-emptively were also included. A total number of 42 patients were included. The mean age at time of dialysis initiation was 11.10 ± 2.25 years; 19 (45.2%) were males. The prevalence of ESRD in Jordan children was calculated to be 14.5 patients per million. Hemodialysis (HD) was the primary modality of therapy in 40 (95.2%) patients. The most common cause of ESRD in our children was acquired glomerulopathy in 13 (31%) patients, followed by oxalosis in seven (16.7%), and neurogenic bladder in six (14.3 %). Thirteen patients were transplanted; the one and three year graft survival rates were 87.5% and 72.5%, respectively. We conclude that there are some peculiar features for pediatric ESRD in Jordan including the high incidence of oxalosis and neurogenic bladder. A national registry for children with ESRD should be established as this may have serious implications on the choice of renal replacement therapy.
|How to cite this article:|
Sacca E, Hazza I. Pediatric End-Stage Renal Disease: Single Center Analysis.Saudi J Kidney Dis Transpl 2006;17:581-585
|How to cite this URL:|
Sacca E, Hazza I. Pediatric End-Stage Renal Disease: Single Center Analysis. Saudi J Kidney Dis Transpl [serial online] 2006 [cited 2022 May 16 ];17:581-585
Available from: https://www.sjkdt.org/text.asp?2006/17/4/581/32502
End-stage renal disease (ESRD) is a rare condition in children relative to adults; , however it remains a significant cause of mortality and morbidity in the pediatric age group.
There is a paucity of data describing pediatric ESRD in Jordan. Defining the etiology and other demographic features of pediatric ESRD is becoming important for strategies of renal replacement therapy and renal transplantation nationwide.
Children with ESRD have special clinical features that are different from adults including the growth and development of secondary sexual characteristics. 
In this retrospective analysis, we define prevalence, etiology, demographic features and choices of renal replacement therapy in our center.
Patients and methods
This is a retrospective study of children who presented with ESRD to King Hussein Medical Center (KHMC) and related Royal Medical Services (RMS) in Amman, Jordan, from January 2001 to December 2005. We included chronic dialysis patients and all transplanted children whether they were subjected to dialysis or not. Children who received dialysis for acute renal failure were excluded from the study. The charts of all patients were reviewed. The date of dialysis initiation, the cause of ESRD, and other demographic features including age and gender were recorded.
Prevalence was calculated based on the fact that Jordan's population is 5.5 million, of which 50% are children less than 14 years of age. We estimated that 35% of the population is covered by RMS hospitals. All patients with chronic kidney disease (CKD) and ESRD in hospitals related to the RMS are referred to KHMC, as it is the only hospital offering advanced pediatric renal services. The pediatric population covered by the RMS was therefore calculated at 0.96 million. As 52.4% of our patients were not covered by the RMS, another 1.05 million of the child population was added. From this, we estimated that this study covered an estimated population of two million children.
Statistical package for social studies (SPSS) version 10 for Microsoft windows was used for statistical analysis; results are given in mean ± standard deviation (SD) unless otherwise indicated. Actuarial graft survival was calculated using the Kaplan Meier life survival function of the SPSS.
42 patients were included in this analysis (19 (45.2%) males and 23 (54.8%) females). The mean age at the time of dialysis initiation was 11.10 ± 2.25 years. By the end of 2005, 11 (26.2%) patients died, 13 (31%) were transplanted and 18 (42.9%) remained on dialysis. The prevalence of ESRD in Jordan was calculated to be 14.5 patients per million children. There was an increase in the incidence of diagnosed ESRD from 3 patients per million children in 2001 to 7.5 patients per million children in 2005.
The most common cause of ESRD in our study cohort was acquired glomerulopathy in 13 (31%) patients, followed by oxalosis in 7 (16.7%), neurogenic bladder in 6 (14.3%), reflux nephropathy in 5 (11.9%), renal dysplasia/ hypoplasia in 4 (9.5%), autosomal recessive polycystic kidney disease (ARPKD) in 3 (7.1%), nephronephthesis in 2 (4.8%), whereas Alport's syndrome and cystinosis comprised one patient (2.4%) each, [Table 1].
Hemodialysis (HD) was the main modality of therapy in 40 (95.2%) patients, whereas only one patient (2.4%) received peritoneal dialysis.
13 patients were transplanted (8 (61.5%) females and 5 (38.5%) males). Ten (77.0%) patients were transplanted from a live related donor and 3 (27%) patients were transplanted from a live unrelated donor outside of Jordan; one patient (2.4%) was transplanted preemptively.
The one and three year graft survival rates were 87.5% and 72.5%, respectively [Figure 1].
The mean age at the time of dialysis initiation in our children was comparable to what has been reported by others including the United States Renal Data Registry System (USRDS) 2005 annual report, where the mean age at dialysis initiation was 12.1 years.  Children with acquired glomerulopathy usually start dialysis at an older age than those with congenital or hereditary conditions. Acquired glomerulopathy comprised a large group of our patients and explains the relatively older age at time of dialysis initiation.
Worldwide, more than 75% of children on dialysis are currently being dialyzed by peritoneal dialysis, , with automated peritoneal dialysis (APD) being considered the best option for pediatric dialysis with many advantages over HD.  However, in our unit, 95.2% of children received chronic HD. In our center, the option of APD is not well established for chronic dialysis for technical reasons and issues related to parental participation, which is required for peritoneal dialysis (PD). Nevertheless, the 2005 USRDS annual report noted a re-emergence of HD as the modality of choice over PD. Currently, in the United States, more than two thirds of pediatric patients receive HD rather than APD. 
The estimated prevalence of ESRD in Jordan in our study was 14.5 per million children, which is considered low relative to other reports.  However, the youngest age in our study was six indicating that some younger patients were not offered dialysis for technical reasons related to HD in this group. This underestimated ESRD in our group relative to other populations. 
The reported incidence of ESRD varies from one place to another. In the 1991 report of the European Renal Association (ERA), the average incidence of new patients accepted for RRT was reported as 4 - 6 per million children per year for patients less than 15 years of age,  whereas the incidence of pediatric ESRD in the United States was 13 per million children per year in the 0 -19 age group.  In 2005, our estimated incidence was 7.5 patients per million children per year.
The etiology of the primary disease that results in ESRD in children differs substantially from that in the adult population; structural renal disease predominates especially in younger children.  Data from the USRDS annual report shows an increased frequency of acquired primary glomerulonephritis, which is becoming the most common cause of pediatric ESRD in more than 30% of patients.  Our study found acquired glomerulopathy in 31% of the children with ESRD, which is comparable to the above percentages and those from other developed and developing countries.,,
Oxalosis comprised 16.7% of the cases in our children. This is striking but has been reported by others in the region , and probably reflects the high incidence of consanguineous marriages in Jordan, similar to the rest of the Arab world. This also explains the higher than expected percentage of other hereditary diseases.
Another striking feature is the relatively high percentage of patients with neurogenic bladder as a cause of ESRD. This can be explained by late referral of these patients and decreased awareness of the importance of early detection and referral of children with neurogenic bladders.
Other causes of ESRD among our group including reflux nephropathy are comparable to other reports elsewhere.,,,
Renal transplantation in the pediatric age group is considered the best modality of RRT, , and is strongly favored to any form of dialysis., Around 30% of our children were transplanted which is much lower than most reports coming from the western world where more than 66% of children are transplanted. We can explain our low percentage of transplantation by the fact that our first pediatric renal transplant was performed in April 2003 and a relatively high percentage of our patients have oxalosis, which requires combined liver and kidney transplantation, an option that is not available in our center.
That actuarial one and a three year graft survival of 87.5% and 72.5%, respectively, is lower than expected especially when all our patients received transplants from live donors. Although these percentages are similar to many other centers in the developing and developed world, they indicate room for better development of surgical and medical care of transplanted children in our center. We conclude that the incidence and prevalence of ESRD among Jordanian children is generally comparable to other populations. There is a need to establish a national registry system to better define the etiologies and other demographic features of pediatric ESRD in Jordan.
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