Kidney diseases in children: Early identification is the key

Dear Editor,

In our tertiary care centre, a 2-year-old male child patient got admitted with high grade fever and history of dribbling of urine. Investigations showed that he had features of sepsis due to urinary tract infection and chronic kidney disease V secondary to bladder outlet obstruction due to posterior urethral valves. Another 5-year-old female child patient was admitted with history of swelling around the eyes off and on for almost one year. She later developed swelling all over the body with high blood pressure and developed seizures when she was diagnosed to have nephrotic syndrome with posterior reversible encephalopathy syndrome. These and many other kidney diseases, some by birth (i.e., congenital) and rest acquired in later life, are seen in childhood but unfortunately many a times, the symptoms of kidney disease are easily missed due to lack of awareness not only among the general population but also among primary care physicians. This further gets aggravated by the socioeconomic and cultural mores in low-income countries and combined with difficult and often expensive healthcare; over 50% of patients with chronic kidney disease (CKD) are first seen in advanced stages where the treatment is difficult both due to the complications of the disease and costs involved.¹

CKD has been defined by Kidney Disease: Improving Global Outcomes (KDIGO) guidelines persistence of as abnormalities of kidney structure or function for more than 3 months, with implications to health.² This definition was formulated for the adult population and adapted for pediatric age group and is recommended to be used for the sake of uniformity.

In a study conducted in 2017 across 195 countries across the world including the low-income countries of Asia and Africa, total number of deaths due to CKD was estimated to be 1·2 million between 1990 and 2017. This study estimated the global prevalence of CKD to be approximately 9%.³ Data regarding prevalence of CKD from the Armed Forces in India are lacking with a study conducted more than a decade back reporting it to be 9.54% with BMI >23, diabetes mellitus and hypertension as independent risk factors for CKD.⁴

Studies on prevalence of CKD in pediatric age group are mostly from the developed countries with very few studies from developing countries. The prevalence of pediatric CKD in the western literature is reported to be between 55 and 75 patients per million populations.⁵

Children are vulnerable to CKD due to certain factors unique to the pediatric age group including congenital anomalies of the kidney and urinary tract (CAKUT), various cystic and renal tubular disorders and cilliopathies which may occur in isolation or as part of various syndromes, some of which have well elucidated genetic etiology and in others the same is still under evaluation. Also the children who have suffered acute kidney injury due to any cause in the neonatal period or who were preterm and/or small for gestational age (SGA), are at high risk for developing CKD and its stigmata in form of hypertension, proteinuria, and cardiovascular complications along with progression in stage of CKD later in life.⁶ Apart from these genetic and congenital disorders, children may develop host of acquired renal disorders like nephrotic or nephritic syndrome, urinary tract infections and pyelonephritis, stone disease (which may have metabolic cause in more than half the cases), kidney diseases as part of multi system diseases like autoimmune disorders, and so on.

So what is the way forward? Awareness of kidney diseases and their symptoms will go a long way in early identification and timely management of underlying kidney disease especially in children and reduce the overall burden of kidney diseases on our health care system. Table 1 lists the symptoms which may point towards an underlying kidney disease and those children who are at high risk for developing CKD along with symptoms/biochemical/radiological abnormalities for which referral to Pediatric nephrologist is warranted.

Table 1.

Symptoms which may point toward kidney disease in children and which require referral to pediatric nephrologist.

Symptoms which may point towards kidney disease in children •Poor growth •Frequent high fever without a cause •Poor urinary stream •Swelling around the eyes or on face •Blood in urine •Frothy urine •Anemia •High blood pressure Children who are at high risk of kidney disease •Preterm babies •Newborn or children requiring ICU admission or major surgery •Children with any congenital kidney anomaly •Children with kidney stones •Children on prolonged treatment for chronic diseases Symptoms/biochemical/radiological abnormalities which warrant referral to Pediatric nephrologist •Poor urinary stream •Recurrent culture positive urinary tract infections •Any congenital anomaly of the kidney or urinary tracta •Syndromic children with renal anomalies •Gross or persistent hematuria •Proteinuria •Hypertension •Acute kidney injury except pre-renal which is completely resolved •Any derangement in renal function test with low Glomerular filtration rate (GFR) or persistent biochemical or structural renal anomaly beyond 3 months •Children on chronic therapy with nephrotoxic drugs for other conditions Children with CKD IV & beyond need initiation of renal replacement therapy and work up for transplant and should be managed at nephrology/pediatric nephrology center

^aIf not previously evaluated/or follow up as advised.

Children with CKD require close monitoring for progression and development of complications for institution of timely management. Proteinuria and hypertension are the two modifiable risk factors reported to significantly predict the progression of CKD.⁷ Therefore, it is imperative that all pediatricians and health workers assess these children carefully at each visit for the same as well as their growth, nutrition, and immunization which often get neglected but actually impact their long-term outcomes significantly.⁸ Table 2 summarizes the periodic evaluation required in children with CKD. Informed consent from patients/ parents/ guardian was obtained for publication of data.

Table 2.

Periodic evaluation required in children with CKD (I-III) [adapted from CKD KDIGO guidelines].²

Monthly: •Weight •Blood pressure (if known hypertensive) Quarterly: •Height •Hemoglobin and Peripheral blood smear if known to have anemia Six monthly: Blood pressure (if normal blood pressure previously) Annual: •Hemoglobin and Peripheral blood smear •renal function test •Urine protein creatinine ratio •Ultrasonography of the kidneys, ureters and urinary bladder if primarily a structural disease Additional tests may be recommended by nephrologist/pediatric nephrologist depending on underlying etiology and clinical condition of the child Evaluation required once •Viral markers: HBsAg, Anti HCV antibody, HIV 1&2 •Thyroid function test Immunization: age appropriate routine immunization to continue unless special contraindication and additional vaccines in consultation with the Pediatric Nephrologist

The old proverb of prevention being better than cure is nowhere more relevant than in chronic kidney disease and promoting a healthy lifestyle in children with emphasis on balanced diet with avoidance of high salt junk food and sweetened drinks, adequate physical activity to prevent obesity, discouraging the teenagers and young adults from smoking and drug abuse, is a shared responsibility of parents and doctors alike. Also, extremely crucial is to strictly avoid any over the counter treatment and avoidance of unnecessary painkillers, antibiotics and other medications which may be harmful for the kidneys.

To emphasize the above, World Kidney Day is celebrated every year on the second Thursday of March and the theme for the year 2023 is “Kidney Health for All: Preparing for the unexpected, supporting the vulnerable.”

Therefore, through this letter, in your esteemed journal, we would like to reemphasize the importance of making awareness our ally in the battle against kidney diseases in patients of all ages including children and support each other to achieve “Kidney Health for All.”

Patients/ Guardians/ Participants consent

Patients informed consent was obtained.

Ethical clearance

Not Applicable.

Source of support

Nil.

Disclosure of competing interest

The authors have none to declare.