R Akuse, A Ibrahim, M Bugaje, A Yakubu, J Raji, E Ebene, H Eno, H Abdukareem, K Ochube, S Gabaolu, L Daniel
children, chronic kidney disease, nigeria, resource constrained countries, world kidney day
R Akuse, A Ibrahim, M Bugaje, A Yakubu, J Raji, E Ebene, H Eno, H Abdukareem, K Ochube, S Gabaolu, L Daniel. World Kidney Day – Don’t Forget The Children. The Internet Journal of Nephrology. 2012 Volume 6 Number 2.
World Kidney Day (WKD) is an annual global health campaign initiated in 2006 by the International Society of Nephrology and the International Federation of Kidney Foundations . Its purpose is to raise awareness about the importance of kidneys to health and reduce the frequency and impact of kidney disease and its associated problems. This is because increasing numbers of people are being affected by Chronic kidney disease (CKD) which is a strong risk factor for development of cardiovascular disease, the leading cause of mortality worldwide [1-5]. WKD has become a strong tool for advocacy to government officials, healthcare providers and the general public but in most countries, the focus is on adults and not children . Although some organizations involve children in educational activities, few include them in the screening programmes of WKD . Yet renal disease is a significant cause of morbidity in children worldwide .
Estimates of CKD in many resource constrained countries are difficult to obtain because of the lack of renal registries . In Nigeria, (the most populous nation in Sub-Saharan Africa), the incidence of CKD is estimated to occur in 7.5 children per million of the childhood population . These are probably underestimates as they exclude children who have no access to hospital care. Unfortunately renal disease often goes undetected until the patient presents in End Stage Renal Disease (ESRD) [9, 10]. This results in devastating social and financial consequences for the patients and their families as facilities for renal replacement therapy are limited, and too expensive for the majority of patients [3, 10]. Many Nigerian nephrologists recommend screening so as to detect kidney disease early and prevent or slow down progression to ESRD [11-13]. This is necessary because the general public has little awareness about kidney disease  and some people even use urine as treatment for illness . WKD offers opportunities to educate communities which have little awareness about kidney disease and screen them for it. During the 2011 WKD, staff of Ahmadu Bello University Teaching Hospital (ABUTH) Zaria, Nigeria carried out public enlightenment talks and screening of adults and children in Giwa - a nearby semiurban community. This is a report of the screening done among the children.
Subjects And Methods
Giwa is a semiurban community situated in Northern Nigeria 250 kilometres from Abuja, the Federal capital and 10 kilometres from Ahmadu Bello University Teaching Hospital (ABUTH), Zaria. Giwa is the headquarters of Giwa local government which has a population of 286,427. The residents are mainly Hausa/Fulani Muslims who engage in small scale farming . Giwa has a general hospital, and primary health centres but the residents also patronize traditional healers .
Preparation For WKD
Planning and preparation for WKD took approximately six weeks. The first phase involved informing the management of ABUTH about the proposed project and seeking financial support for it. This was followed by meetings with the Chairman, the District head and members of the Giwa Executive Council as well as key political leaders. This was to sensitize them about the objectives of the proposed WKD programme. They granted permission for the WKD team to give talks and screen both adults and children. The Giwa local government health department personnel were also involved.
Some of the equipment used for screening during WKD was obtained from the ABUTH hospital e.g. stethoscopes, sphygmomanometers, weighing scales etc.). Funds were needed to buy consumables (gloves, urine bottles, dipsticks), provide banners, posters and pay for the services of a town crier to publicize the event; payment for interpreters, local theatrical group, transport, refreshments for the team and other logistics. Funding was provided by ABUTH and voluntary donations from members of the WKD team who were keen to start some form of preventive activity for kidney disease in communities near the hospital. The total project cost came to approximately 200,000 naira (US dollars 1,257).
The WKD team consisted of doctors, nurses, health workers from the Nephrolgoy units of the Departments of Medicine and Paediatrics, Community Medicine, dialysis unit and medical students. The town crier went round town in a van using loud speakers to invite all residents to the village square for the program. The WKD coincided with a village market day which meant many people were able to attend the meeting at the village square. The District head, members of the executive council and their families were present. There were also a number of Muslim clerics. A talk was given about risk factors for development of kidney disease and the importance of screening. This was followed by songs and a play performed by a local theatrical troupe. From the discussion that followed, it appeared that the residents had little prior knowledge about kidneys, their function, or the importance of screening. They had no unique cultural or religious views about the kidneys. Activities were carried out in the local language (Hausa). The program lasted from 9am to 4pm. Adults were then invited to go for screening and were asked to bring their children. The results of the adult screening are reported elsewhere.
Children were screened at a separate station in the same locality as the adults. Biodata, family and medical history, information about drug ingestion, use of traditional medication, and symptoms of illness was collected and entered into a proforma. The weights and heights of the children were recorded. Blood pressures (BP) were measured using a mercury sphygmomanometer with an appropriately sized cuff with the child seated. Dipstick analysis was done using Combi 9 (Macherey-Nagel). Abnormal findings were confirmed on a second urine sample. Parents were notified of the results and those whose children had abnormal findings given referral letters to the paediatric nephrology clinic at ABUTH for further evaluation.
Data was analyzed using SPSS version 16 computer package for windows. Proteinuria, hematuria, glycosuria, nitriuria were defined as a reading of 1+ or more on dipstick and Hypertension as systolic and/or diastolic BP greater than 95% for age, gender, and height. Body mass index (BMI) for the children’s gender, weight and height was calculated using a BMI Calculator .Frequencies of all variables were calculated but children with missing information were excluded. Crosstabulation of variables was done. Quantitative variables were presented as mean, standard deviation, range, while qualitative variables as frequencies, percentages and numbers in parenthesis.
A total of 115 children - 93(80.8%) boys and 22(19.1%) girls participated. Their ages ranged from 3 to 15 years (mean 9.97±3 years) (Fig1).
Most 89(77.4%) were students but 26(22.6%) (3-15 years) were not attending school. Details of their history are shown in Table 1.
The BMI of 106 children for whom it was calculated, ranged from 12 to 23kg/m2. Most 79(74.5%) had appropriate BMI, but 16(15.1%) were underweight, 10(9.4%) overweight, and one child was obese.
Proteinuria was detected in 3(2.8%), haematuria in 2(1.9%), glycosuria in 16(14.9%), and nitrituria in none of 107 children whose urine was tested. Children with proteinuria (1+) were all male, aged 8 to 12 years. Two had a history of foamy urine, all of ingestion of analgesics and one of traditional medication. Haematuria was found in two 13 year old boys, one of whom gave a history of passage of bloody urine. Sixteen (13.9%) other children aged 5 to 14 years had glycosuria. Four of these complained of illness (headache and deafness), 2 had a family history of diabetes and 3 were overweight.
Six (6.4%) of 94 children whose BP was measured were hypertensive. They were aged 7 to 12 years and 4(66.7%) were male. Most 4(66.7%) were asymptomatic. One (16.7%) had isolated systolic hypertension, 2(33.3%) isolated diastolic hypertension and 3(50%) combined systolic and diastolic hypertension. None had a family history of hypertension or kidney disease. One child gave a history of scabies and the other of body swelling and foamy urine. All had past history of ingestion of traditional medication and analgesics. Only one child (who had combined systolic and diastolic hypertension) had proteinuria (1+).
Children and parents showed great interest but it took more time, staff and effort to attend to children than to adults. Some of the younger children were unable to produce urine on request.
A total of 26(22.6%) children had abnormal findings. Ten (8.7%) had indicators of possible renal disease (hypertension, proteinuria, haematuria) and 16(13.9%) glycosuria. All were referred for further evaluation but only one went – a boy who had previously been treated for glomerulonephritis in ABUTH
Abnormalities that could indicate possible renal disease were detected during screening, but in most cases the significance of these findings could not be determined because many children were not taken for further evaluation.
The prevalence of proteinuria and haematuria in this study were in the mid-range of that found in other studies in Nigeria which recorded proteinuria in 1% to 7.7% and haematuria in 0.55% to 3.8% of children screened [20-25]. The prevalence of hypertension was similar to that found by another researcher among rural children  but other studies report both higher and lower prevalences (ranging from 3.5% to 9.5%).[27-29]. A surprising high percentage (13.9%) of children had glycosuria. Studies from other parts of the country recorded prevalences of 0 to 2.9% of glycosuria [20, 21]. These variations in prevalence are probably due to differences in age, ratio of males to females and disease patterns of the various populations.
However the apparently low yield of proteinuria and haematuria raises questions about whether urinary screening is cost effective. Screening for hypertension is generally accepted worldwide but there is controversy about the value of urinalysis . In North America and Europe, mass screening using dipstick urinalysis is discouraged because of low diagnostic yield and lack of evidence that it leads to reduction in the number of children who progress to ESRD. In contrast, in the Far East, mass urinalysis of school children is routinely done annually as it is said to be highly effective in detecting kidney disease [30-31]. From this study, it appears that screening for hypertension, proteinuria, haematuria and glycosuria might be beneficial. However the absence of nitrites, which is a marker for urinary tract infection (UTI), implies that mass screening for UTI may not be worthwhile – a view shared by Abdurrahman many years earlier .
The study was limited because renal disease could not be confirmed in most of the children. The reasons why they were not taken for further evaluation could not be ascertained. It is possible that the children were perceived by their parents to be healthy as most were asymptomatic. However other researchers have reported that transportation costs affect use of western medical care in Giwa [32-33]. Evaluation is necessary because abnormalities might be due to other conditions. For example proteinuria could result from fever, exercise, orthostatic proteinuria or UTI while trauma, sickle cell disease, UTI or other conditions could cause haematuria . Transient glycosuria, diabetes mellitus and a low renal threshold must be excluded in children with glycosuria though it could also be due to renal causes like Fanconi syndrome, diabetic nephropathy, UTI or CKD [34-36]. Thus efforts must be made to increase follow up. One method could be by arranging for children to be seen at local health facilities and only those with persistent abnormalities would then be referred to specialist centres. As an alternative, specialists could visit community health facilities at regular intervals.
Non communicable diseases are increasingly becoming important causes of childhood morbidity and mortality . Early detection of renal disease could help reduce morbidity, mortality and associated health costs but most resource constrained countries are yet to develop screening strategies [37-38]. Some researchers have advocated routine screening of school children . It should be noted that almost 23% of the children were not attending school and these children would be missed if screening of school children was done. WKD offers a means of testing children who could otherwise be missed e.g. those who do not go to school and/or those who live in rural areas. Thus it is recommended that National nephrology associations should encourage screening of children during WKD. Their members could collect data in communities in different parts of their countries and the information gathered could then be collated in a national database. This could provide data which could contribute in the development of national screening policies.
Efforts to detect prevent and slow progression of CKD must not be left only to governments or governmental agencies. Non-governmental organizations and communities must be involved . No effort was made to involve traditional healers but it is possible that if they are involved, they may prove to be a means of reaching more people in the community.
WKD offers an opportunity to screen children for kidney disease including those who might otherwise be missed. Data collected could help assist in development of national screening policies but efforts must be made to improve further evaluation of those with detected abnormalities. This calls for cooperation between the government, the health sector and community. Hard work - Possibly, but the next generation is worth it.