Taiwo Augustina Ladapo

Paediatric Acute Kidney Injury in a Tertiary Hospital in Nigeria: Prevalence, Causes and Mortality Rate

Background The modest decline in child mortality in Africa raises the question whether the pattern of diseases associated with acute kidney injury (AKI) in children in Nigeria has changed. Methods A database of children, aged between one month and 16 years, with AKI (using modified pediatric RIFLE criteria) was reviewed. The cause of AKI was defined as the major underlying disease. The clinical and laboratory features of children with AKI who survived were compared to those who died. Results Of the 4 015 children admitted into Lagos University Teaching Hospital between July 2010 and July 2012, 70 episodes of AKI were recorded equalling 17.4 cases per 1000 children. The median age of the children with AKI was 4.8 (range 0.1–14.4) years and 68.6% were males. Acute kidney injury was present in 58 (82.9%) children at admission with 70% in ‘failure’ category. Primary kidney disease (38.6%), sepsis (25.7%) and malaria (11.4%) were the commonest causes. The primary kidney diseases were acute glomerulonephritis (11) and nephrotic syndrome (8). Nineteen (28.4%) children with AKI died. Need for dialysis [odds ratio: 10.04 (2.94–34.33)], white cell >15 000/mm3 [odds ratio: 5.72 (1.65–19.89)] and platelet <100 000/mm3 [odds ratio: 9.56 (2.63–34.77)] were associated with death. Conclusion Acute kidney injury is common in children admitted to hospitals. The common causes remain primary kidney diseases, sepsis and malaria but the contribution of sepsis is rising while malaria and gastroenteritis are declining. Acute kidney injury-related mortality remains high.

Obesity and elevated blood pressure among adolescents in Lagos, Nigeria: a cross-sectional study

BackgroundChildhood obesity and associated hypertension are major public health concerns globally. This study aimed to determine the prevalence of obesity and the associated risk of high blood pressure among Nigerian adolescents.MethodsA cross-sectional school-based study of 885 apparently healthy adolescents was performed. Weight, height and blood pressure (BP) were measured using standard methods. Body mass index (BMI) was calculated and categorized by age, sex and percentile. Obesity and overweight were defined as: ≥ 95th and 85th to < 95th percentiles, respectively, for age, sex and height. Subjects were sub-categorized into age 10–13 years (A) and 14–17 years (B). The odds ratio for pre-hypertensive and hypertensive range BP by age and BMI were generated. Significance was set at P < 0.05.ResultsThe prevalence of overweight and obesity were 13.8% and 9.4%, respectively. The prevalence of hypertensive range systolic BP in obese versus normal BMI females was 16% versus 23% (p=0.00) and 12.1% versus 6.4% (p=0.27) in males. The prevalence of hypertensive range diastolic BP in obese versus normal BMI females was 12% versus 1.4% (p=0.00) and 15.2% versus 3.5% (p=0.01) in males. BMI in group B was significantly associated with pre-hypertensive and hypertensive range systolic BP in overweight (P = 0.01, P = 0.002) and obese subjects (P = 0.00, P = 0.00) and with hypertensive range diastolic BP (P = 0.00) only in obese subjects. The only significant association in group A was between obesity and pre-hypertensive range diastolic BP (P = 0.00).ConclusionThe prevalence of hypertensive range BP among obese Nigerian adolescents was high. Screening for childhood obesity and hypertension, and long-term follow-up of obese adolescents into adulthood are recommended.

Pediatric kidney diseases in an African country: Prevalence, spectrum and outcome

Insufficient data to guide the authorities responsible for resource allocation and a focus on communicable diseases increase the challenges of care of children with kidney disease in resource-constrained settings like ours. This study was performed with the aim to describe the current spectrum of pediatric nephrology disease in a tertiary hospital in Sub-Saharan Africa and highlight the challenges encountered in their care. A 4-year retrospective review of pediatric renal admissions was carried out and the overall prevalence, disease-specific prevalence and mortality rates were determined. Results were compared with nationwide data. Kidney diseases accounted for 8.9% of pediatric admissions with a prevalence of 22.3 admissions per 1000 child-admissions per year. Nephrotic syndrome, acute kidney injury and nephroblastoma accounted for almost 70% of admissions. The overall mortality was 14.4% with acute kidney injury accounting for 36% of this. Chronic kidney disease was also associated with poor outcome. The spectrum of disease nationwide is similar with a wide variation in disease-specific prevalence between geographic regions. The prevalence of genetic and hereditary conditions was low. The prevalence of pediatric renal disease in our environment is on the increase and associated with significant morbidity and mortality. Late presentation and high treatment costs were limitations to care. Preventive nephrology, training of pediatric nephrologists and strengthening of health insurance schemes are advocated.

High Steroid Sensitivity among Children with Nephrotic Syndrome in Southwestern Nigeria

Recent reports from both Caucasian and black populations suggest changes in steroid responsiveness of childhood nephrotic syndrome. This study was therefore undertaken to determine the features and steroid sensitivity pattern of a cohort of black children with nephrotic syndrome. Records of children managed for nephrotic syndrome from January 2008 to April 2013 were reviewed. Details including age, response to treatment, and renal histology were analysed. There were 108 children (median age: 5.9 years, peak: 1-2 years), 90.2% of whom had idiopathic nephrotic syndrome. Steroid sensitivity was 82.8% among children with idiopathic nephrotic syndrome but 75.9% overall. Median time to remission was 7 days. Median age was significantly lower in steroid sensitive compared with resistant patients. The predominant histologic finding in resistant cases was focal segmental glomerulosclerosis (53.3%). No cases of quartan malaria nephropathy or hepatitis B virus nephropathy were diagnosed. Overall mortality was 6.5%. In conclusion, unusually high steroid sensitivity is reported among a cohort of black children. This is likely attributable to the lower age structure of our cohort as well as possible changing epidemiology of some other childhood diseases. Surveillance of the epidemiology of childhood nephrotic syndrome and corresponding modifications in practice are therefore recommended.

Peritoneal Dialysis for Children with Acute Kidney Injury in Lagos, Nigeria: Experience with Adaptations

♦ Introduction: International professional groups are supporting the training of physicians in developing countries in nephrology, including peritoneal dialysis (PD). This report documents the impact of such efforts in the provision of manual PD for children with acute kidney injury (AKI) in a public hospital in Lagos, Nigeria. ♦ Methods: Medical records of all children with AKI managed with PD between July 2010 and March 2013 were reviewed. ♦ Results: Seventeen children with a mean (SEM) age of 3.8 (0.8) years received PD for 0 - 18 days; about half were infants. PD was provided manually, frequently with intercostal drains as catheters. Blockage of catheters and peritonitis occurred in 4 (23.5%) and 2 (11.8%) children, respectively. Eight (47.1%) of the 17 children had resolution of AKI and were discharged from hospital. In 4 (57.1%) of the 7 children who died, PD was performed for ≤ 2 days. ♦ Conclusion: PD for childhood AKI is feasible in resource-constrained regions with fairly good outcome. Blockage of catheter was the most common complication encountered.

Microsporidiosis in pediatric renal transplant patients in Cape Town, South Africa: Two case reports

Microsporidia are an emerging group of pathogens associated with life‐threatening opportunistic infections in immunocompromised hosts, particularly human immunodeficiency virus (HIV)‐infected individuals. There have, however, been recent reports of infection in adult solid organ transplant recipients. We report two cases in children, to our knowledge the first in the paediatric literature. Two 13‐yr‐old, HIV‐seronegative females received deceased donor renal transplants from the same donor. Both patients suffered acute cell‐mediated rejection and CMV infection reactivation, managed with intensified immunosuppression and ganciclovir. Pyrexia of unknown origin and intermittent diarrhea in both prompted extensive investigations. In both patients, numerous spores of a microsporidial species were demonstrated in renal tissue on biopsy and in the urine, using modified trichrome and quick‐hot Gram‐chromotrope staining. Electron microscopy and PCR confirmed Encephalitozoon cuniculi infections. Both patients were successfully treated with 400 mg twice daily of albendazole, with sustained clinical improvement. We recommend that microsporidiosis be considered in the differential diagnosis of pyrexia of unknown origin in severely immunocompromised pediatric solid organ transplant recipients, particularly when associated with diarrhea.

Successful Treatment of Hepatitis B Virus Associated Nephrotic Syndrome With Oral Lamivudine in a Nigerian Child: A Case Report

Hepatitis B virus is a well described cause of nephrotic syndrome (NS) worldwide, the typical lesion being membranous glomerulonephropathy. HBV associated NS has been successfully treated with intravenous alpha interferon (IFN), an anti-viral agent. In recent times there have been reports of treatment with lamivudine, an orally administered nucleoside analogue inhibitor of HBV DNA polymerase in Caucasian children. Data is however limited and its actual efficacy and safety in children is yet to be determined. We present the case of an 8-year-old Nigerian boy with NS and active hepatitis B virus infection. He went into remission 3 months after commencing oral lamivudine which he had for a year with no significant side effects observed. He remains in remission 3 years later. This, to our knowledge is the first report in literature of successful treatment in an African child.

Frequency of relapse among Nigerian children with steroid-sensitive nephrotic syndrome.

BACKGROUND The clinical course of steroid-sensitive nephrotic syndrome (SSNS) among Nigerian children has rarely been reported; this makes prognostication difficult. OBJECTIVES The objective was to determine the frequency of relapses including frequent relapses (FR) and steroid-dependence (SD) in a cohort of Nigerian children with SSNS. A secondary objective was to identify clinical and demographic factors associated with relapse in these children. METHODS Medical records of children with SSNS in a Tertiary Hospital in Nigeria were reviewed. Children with onset of nephrotic syndrome (NS) at age <1-year, follow-up period <12 months and secondary causes of NS were excluded. The relapse status of each child was determined in the 1st and 2nd year after diagnosis and the proportions with no relapse, FR and SD were calculated. RESULTS Fifty children (68% males; median [range] age at onset of NS 4.8 [1.1-14.9] years) were followed-up for 31.1 (12.1-79.8) months. In the 1st and 2nd year of follow-up, 23 (46%) and 24 (70.6%) children experienced relapse, respectively. In the 1st-year, 0% and 10% had FR and SD while in the 2nd year 2.9% and 11.8% had FR and SD, respectively. Age at onset of NS, gender, time to first remission, serum creatinine or presence of hypertension or microscopic hematuria was not associated with 1st or 2nd year relapse. CONCLUSION About half and two-thirds of children with NS in our center experience relapse in the 1st and 2nd year of follow-up, respectively; much fewer proportions experienced FR and SD in these periods. None of the commonly reported demographic and clinical factors was associated with NS relapse.

Blood pressure to height ratio as a screening tool for prehypertension and hypertension in adolescents

BACKGROUND Current methods of detection of childhood hypertension are cumbersome and contribute to under-diagnosis hence, the need to generate simpler diagnostic tools. The blood pressure to height ratio has recently been proposed as a novel screening tool for prehypertension and hypertension in some populations. We evaluated its applicability in our environment. MATERIALS AND METHODS The weights, heights, and blood pressure measurements of 2364 apparently healthy adolescents were determined. Sex-specific systolic and diastolic blood pressure to height ratios (SBPHR) and (DBPHR) were calculated, and their ability to detect prehypertension and hypertension was determined using receiver operating curves. Discriminatory ability was measured by the area under the curve (AUC) and optimal cutoff points along the curve were determined. P < 0.05 was considered statistically significant. RESULTS The SBPHR and DBPHR were similar across all age groups and sexes. The AUC of SBPHR and DBPHR for diagnosing prehypertension and hypertension by sex was >0.95 for both diastolic and systolic hypertension in both sexes. It ranged between 0.803 and 0.922 for prehypertension and 0.954-0.978 for hypertension indicating higher accuracy for hypertension. Sensitivity was higher for systolic and diastolic hypertension (90-98%) compared with prehypertension (87-98%). Specificity was lower than sensitivity across all categories of hypertension and prehypertension (0.64-0.88%) though higher for hypertension (0.75-0.88) compared with prehypertension (0.64-0.75). CONCLUSION BPHR is a useful screening tool for prehypertension and hypertension in black adolescents. Accuracy increased with higher degrees of hypertension.

Cyclosporine in the treatment of childhood idiopathic steroid resistant nephrotic syndrome: a single centre experience in Nigeria

Introduction Children with steroid resistant nephrotic syndrome usually require treatment with second-line agents and calcineurin inhibitors such as cyclosporine are now recommended as initial therapy. These agents only recently become available in our environment and their impact on care is unknown. We reviewed the short-term treatment outcomes of their use in comparison with previous outcomes. Methods Medical records of children managed for idiopathic steroid resistant nephrotic syndrome over a 5 year period were reviewed. Remission rates and improvement in renal function following use of various agents were compared. Results Of 103 children with idiopathic nephrotic syndrome, 25(24.3%) were steroid resistant, of whom 17 received additional medications. Full remission rate for cyclosporine was 70% (7/10). Remission rates prior to the availability of cyclosporine were 40% (2/5) for cyclophosphamide and 66% (2/3), (partial remission only) with enalapril, an angiotensin converting enzyme inhibitor used in combination with alternate day prednisolone. One child with cyclophosphamide resistance subsequently achieved remission with cyclosporine. Remission was not related to sex (p=0.96), age (p=0.54), serum albumin (p=0.37) or hypertension (p=0.43) but to serum cholesterol (p= 0.02). The estimated glomerular filteration rate (eGFR) among children treated with cyclosporine ranged from 30-167 ml/min/1.73m2 as follows: >90 (5); 60-89 (3); 30-59 (2) while the mean pre and post treatment eGFR in those with eGFR <90 were 60 and 104ml/min/1.73m2 respectively (p=0.03). Mortality rate was 10% (1/10) in children treated with cyclosporine compared with 28.6% (2/7) in those treated with other medications (p=0.54). Conclusion Cyclosporine resulted in improved treatment outcomes in children with idiopathic steroid resistant nephrotic syndrome.