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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 5
| Issue : 2 | Page : 86-90 |
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The poor outcome of pediatric chronic kidney disease in a resource-limited country
Tochi Ada Uchenwa, Ifeoma Comfort Anochie
Department of Paediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
| Date of Submission | 08-Apr-2022 |
| Date of Acceptance | 17-Jun-2022 |
| Date of Web Publication | 31-Dec-2022 |
Correspondence Address:
Tochi Ada Uchenwa
Department of Paediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt
Nigeria
 Source of Support: None, Conflict of Interest: None
Introduction: There is a global rise in the incidence of chronic kidney disease (CKD), with the implication of increased demand for kidney replacement therapy (KRT). In resource-limited countries where there is a large deficit in renal support for such patients, this translates into poor clinical outcomes. Materials and Methods: This was a retrospective review of the prevalence, clinical outcomes of CKD patients that were managed in the renal unit of the University of Port Harcourt Teaching Hospital from June 2016 to June 2019. Results: Findings from the study showed a male preponderance of 1:0.6. Of all patients with kidney disease, CKD comprised 24.6% of cases, and among these, 75.6% had ESKD. Of 34 (75.6%) patients who required KRT, 10 (29.4%) patients received at least one session of hemodialysis; however, only one patient (2.9%) continued to receive once weekly sessions of hemodialysis, sustained for a year. Mortality among the patients with CKD was 60%, with 28.9% lost to follow-up, signed against medical advice, or absconded. Conclusion: Considering the burden of CKD in Nigeria, much is desired with regards to available KRT options. Government regulation is needed to improve access to available KRT.
Keywords: Africa, children, kidney failure, outcome
How to cite this article:
Uchenwa TA, Anochie IC. The poor outcome of pediatric chronic kidney disease in a resource-limited country. Asian J Pediatr Nephrol 2022;5:86-90 |
| Introduction | |  |
Chronic kidney disease (CKD) is emerging as a public health problem worldwide[1],[2] and is well recognized as an important contributor to global mortality and morbidity.[3] Trends suggest an increase in the proportion of persons with CKD worldwide.[4],[5] However, the reported rates in resource-limited countries represent a fraction of the actual figures, since estimates in these settings are biased, reflecting chiefly hospital records. Previous studies in hospitals had reported CKD in 15-48 children per million.[6],[7],[8] and kidney failure in 7.5 children per million childhood population annually.[9],[10] In Nigeria, CKD accounts for about 4.8%–20.3% of renal disorders seen in hospitals.[11],[12],[13],[14],[15] The rising trend in the global population of children with CKD may relate to poor preventive practices,[16] including delayed diagnosis and management of posterior urethral valves (PUVs), chronic glomerulonephritis (CGN), HIV-associated nephropathy (HIVAN), and sickle-cell nephropathy. In Nigeria, late presentation is a common experience,[17],[18] which, together with the coexistence of communicable and noncommunicable diseases, illicit use of (over the counter and prescription) medications, and the injudicious use of herbal remedies, might be responsible for the high rates of CKD.[19],[20] The high CKD burden in resource-limited countries has numerous implications, including increased demand for the available support services and resources, dire financial implications for families of patients, and increased mortality rates among these patients.
Kidney failure has high mortality in the absence of affordable renal support for these patients and poor outcomes among patients.[17],[21] Even on dialysis, the mortality rate for children is 30-150 times that of the pediatric population,[22],[23] and the expected survival is ~ 20 years.[22] Dialysis in Nigeria is expensive and unaffordable to majority of patients at the cost of 72.2-84.2 USD in Port Harcourt Southern Nigeria in relation to the monthly income with about 70% of the population living below the 1USD per day poverty line in Nigeria.[24] Such economic factors often interplay to deprive patients of kidney replacement therapy (KRT), leading to preventable death. In Nigeria, currently, there are more than 80 established hemodialysis centers and 5–10 functional kidney transplantation centers.[25],[26] While this indicates considerable improvement over two decades,[25] these options remain nonaffordable and inaccessible, chiefly due to the high cost of maintenance of equipment, dearth of manpower, and lack of government intervention and regulation. This results in dire clinical outcomes, including loss to follow-up and death when families cannot keep up with cost of care.
Chronic KRT in children is almost nonexistent because of high costs of care and lack of health insurance; in absence of governmental support, patients pay out of pocket unlike in developed countries where functional health insurance schemes help bear the cost of care.[27],[28] The aim of this review was to study the burden and short- and long-term outcome of CKD and to highlight the challenges in the management of patients with CKD in a resource-limited country.
| Materials and Methods | | |
We retrospectively reviewed all cases of kidney disease managed in the Nephrology Unit of the University of Port Harcourt Teaching Hospital (UPTH), Port Harcourt, Nigeria, over a 3-year period between June 2016 and June 2019. This tertiary health institution is one of the referral centers for the south geopolitical zone of Nigeria. While the nephrology unit of the hospital offers hemodialysis and acute peritoneal dialysis, facilities for chronic peritoneal dialysis and kidney transplantation are lacking.
Data were extracted from the renal register to collect sociodemographic details (age and gender), clinical profile, probable cause of CKD, results of laboratory investigations (kidney function test, complete blood count, serum calcium and phosphate, and serology), therapies, and outcome. Estimated glomerular filtration rate (eGFR) was calculated using the modified Schwartz formula, and CKD was defined and classified into five stages using the Kidney Disease: Improving Global Outcomes guideline.[2] Ethical approval was obtained from the University of Port Harcourt Teaching Hospital Research and Ethics committee. Data was analyzed using Statistical Package for Social Sciences (SPSS) version 25 (IBM. SPSS, Chicago; USA).
| Results | | |
During the study period, 169 children with renal diseases were seen. The more commonly diagnosed renal diseases included AKI (52, 28.4%), CKD (45, 24.6%), nephrotic syndrome (26, 14.2%), CAKUT (21, 11.5%), and HIVAN (18, 9.8%) [Figure 1]. Less commonly diagnosed conditions were sickle cell nephropathy, pyelonephritis, lupus nephritis, and hepatitis C nephropathy. Among patients with CKD, 27 (60%) were boys, and the median (range) age was 8.0 years (1 month to 17 years). Most (75.6%) patients with CKD had CKD stage 5 (kidney failure) at presentation [Table 1]. Thirty-six (80%) had hypertension, 30 (66.7%) edema, and 28 (62.2%) had severe anemia. | Figure 1: Etiology of kidney disease. AKI: Acute kidney injury, CAKUT: Congenital anomalies of kidneys and urinary tract, CKD: Chronic kidney disease, HIVAN: Human immunodeficiency virus associated nephropathy
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 | Table 1: Presenting features in patients with chronic kidney disease stages
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The leading causes of CKD were PUV (13, 28.9%), HIVAN (10, 22.2%), CGN (7, 15.6%), nephrotic syndrome (6, 13.3%), and sickle cell nephropathy (4, 8.9%) [Figure 2]. The cause was unknown in 5 (11.1%) cases [Figure 2]. The mean±standard deviation and median serum creatinine at presentation was 617.8±340.9 μmol/l 595μmol/l respectively [Table 1]. Most patients could not access KRT due to financial constraints and out-of-pocket expenses. Out of 10 (25.7%) patients who accessed dialysis, only one child was able to maintain once weekly dialysis [Figure 3]. Adequate dialysis was not received by any of the children, and none could afford renal transplant. | Figure 2: Etiology in cases with chronic kidney disease. HIVAN: Human immunodeficiency virus associated nephropathy
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Outcomes in the patients with CKD were poor, with death in 27 (60%) cases, and either loss to follow-up or left against medical advice in 13 cases. Five (11.1%) patients are still on follow-up [Figure 4]. Among patients who died, 9 (33.3%) had PUV, 5 (18.5%) HIVAN, 6 (22.2%) had CGN, and 2 (7.4%) sickle cell nephropathy.
| Discussion | | |
This study highlights the high burden of CKD, comprising one-fourth of all patients with kidney disease managed at one center, with kidney failure accounting for over two-thirds of the cases. The reported proportion of patients with CKD is comparable to a previous report from Jos, Nigeria (20.3%),[15] Cameroon (15.5%),[29] and Pakistan (29%),[30] but higher than prior reports from the Abia state University Teaching Hospital, Lagos University Teaching Hospital and University of Abuja Teaching Hospital, Nigeria, which found CKD in 4.8%–6.7% of cases.[11],[12],[13] This enormous burden of CKD and kidney failure poses challenges for populations globally,[31] but has dire consequences in emerging countries lacking resources to manage such patients. The present study similarly found that only one-fifth of the patients had access to the available KRT (dialysis), and over one-half died due to inability to afford ongoing care.
The relative preponderance of boys over girls with CKD is similar to previous reports and might reflect the male predilection for CKD secondary to structural anomalies of the urinary tract.[18],[32] This study found PUV as the leading cause of CKD, other common causes were HIVAN, CGN, and nephrotic syndrome, while sickle cell nephropathy was the least common cause. However, Odetunde et al.,[17] Adekanmbi et al.,[33] and Michael and Gabriel[18] observed that glomerulonephritis was the leading cause in their study. The high proportion of HIVAN (22.2%) in this review contrasts with the low prevalence of 2% reported by Odetunde et al.[17]
Hypertension, edema, and anemia were common presentations as has been observed in Nigeria in previous reports.[17],[18] The mean eGFR was 16.8 ± 16.9 L/min/1.73 m2 with most of the patients in kidney failure at presentation. This was similar to reports from Enugu[17] and Benin.[18]
Mortality rates associated with kidney failure in children on dialysis are at least 30 times higher than that in the general population,[34] particularly in children lacking access to KRT. The high mortality rate of 60% in this study agrees with previous reports from Benin (58%)[18] but higher than the rates reported from Sagamu in Western Nigeria (21%)[33] and Enugu in Eastern Nigeria (8.2%).[17] The latter study reported a much higher proportion (40.8%) of patients that were lost to follow-up, compared to 28.9% in our study.
One case received at least one weekly session of dialysis, but none received adequate dialysis, which is similar to the experience by several authors in Nigeria.[17],[18],[33] Reasons for inadequate dialysis were chiefly financial constraints and inadequate facilities for KRT. This is in contrast to developed countries, where most children have adequate dialysis, and access to chronic KRT has improved outcomes of children with kidney failure leading to long-term survival rates of ~ 79% at 10 years and ~ 66% at 20 years.[23],[35],[36],[37]
CKD is an important cause of mortality and morbidity among children in resource-limited regions with its management being a great challenge due mainly to late presentation, poor socioeconomic conditions, out-of-pocket expenses (lack of health insurance schemes covering care for kidney diseases), inadequate health infrastructure, poor government support, and the near absence of KRT options other than dialysis, which is often impoverishing,[9] as highlighted in this review. Access to chronic KRT has improved outcomes of patients with kidney failure in developed countries, with deaths occurring mainly due to infections and cardiovascular diseases rather than kidney failure.[35],[36] There is, therefore, an urgent need for governmental and nongovernmental bodies to increase support for children with CKD and expand the national health insurance scheme to include care of these children.
| Conclusion | | |
The prevalence of CKD was high among patients with kidney disease managed at a tertiary care center in Nigeria. The high rates of kidney failure and mortality reflect the lack of preventive practices, delays in diagnosis, and inadequacy of available KRT among this population. Government regulation of cost of KRT, expansion of the scope of available health insurance schemes to include kidney diseases, awareness creation on the need for healthy lifestyles, and practices are required to improve the outcomes among these patients.
Ethical clearance
The ethical approval is a generic approval so has no approval number because the study was a retrospective review.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1]
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