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Clinical guidelines

National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people Second edition

Childhood kidney disease

Author Dr Jenny James
Expert reviewer Dr Hasantha Gunesekara

Background

Aboriginal and Torres Strait Islander adults have very high rates of end stage renal disease (ESRD) and there is evidence it is increasing.4,110,111 Renal disease can start in utero and has been linked with low birthweight.112 Aboriginal and Torres Strait Islander children have higher rates of urinary tract infection (UTI), renal calculi and glomerulonephritis than non-Indigenous children, though much of the current evidence for this comes from the more remote parts of Australia. There is a lack of studies into incidence rates of these diseases from urban areas. The vast majority of these children will make a full clinical recovery from these renal illnesses.24,113–117

There is mixed evidence as to whether renal disease occurring in childhood contributes to high rates of chronic kidney disease (CKD) in Aboriginal and Torres Strait Islander adults. Risk factors for CKD seen in children, such as haematuria and proteinuria, are often transient116,118–120 with the exception of microalbuminuria in children with pre-pubertal and pubertal onset diabetes.121,122 Single estimations of urinary blood and protein in children vary according to posture, illness, exercise and time of day. Screening urinalysis is costly to the community, may result in physical and psychological costs to the patients and their families, and is prone to misinterpretation. Baseline CKD risk factors are frequent in both Aboriginal and non-Aboriginal primary school aged children, though there is evidence that, at a single test, Aboriginal children have a greater risk of haematuria than non-Aboriginal children. Higher rates of transient haematuria may reflect the higher incidence of transient disease seen in Indigenous children, such as post-infectious glomerulonephritis.23,42,81,116,118,119,123,124

Though most children make an apparent full recovery from acute post-streptococcal glomerulonephritis (APSGN), in some Aboriginal and Torres Strait Islander communities children who had APSGN have six times greater risk of developing renal disease as an adult. Thus it is not clear whether the link between APSGN and adult onset CKD is causative or associative. However, the possibility of a causative link makes the prevention of streptococcal skin disease an important issue for Aboriginal and Torres Strait Islander children. There is good evidence that prevention and treatment of skin infections may be helpful in prevention of APSGN. Children with skin sores and household contacts of such children should be given targeted treatment with anti-scabetics and benzathine penicillin. However, there are different recommendations regarding the extent of chemoprophylaxis coverage that is required in the community. At a population level, regular community based programs may be useful to screen and treat all children in a target age group (eg. ages 0–3 years) for both scabies and infected sores. Simultaneous treatment of the whole community to remove scabies (a common precursor to streptococcal skin infection) followed by regular ongoing surveillance and treatment of scabies and skin sores (at least three times per year) may prevent streptococcal skin infections.115,120,125 There is good evidence that improvements in housing to reduce overcrowding and promotion of regular washing for children will also help prevent skin sores.113,117,125,126

There is a similar lack of certainty around the link between childhood UTI and adult ESRD. It is not clear what the true rate of ESRD caused by pyelonephritic scarring/reflux nephropathy is, nor is it clear what proportion of these people had a UTI in childhood.127 The lack of certainty surrounding this link is reflected in the recommendations, where there is mixed evidence for the use of antibiotic prophylaxis routinely following first time UTI. Some studies show that even in children with vesicoureteric reflux, antibiotic prophylaxis is not superior to supportive care in preventing subsequent UTIs or renal parenchymal injury, and in fact can produce harm.122,127 Other studies support the use of prophylactic antibiotics following a first-time UTI at least until any imaging studies are completed.128,129 However, asymptomatic bacteriuria in infants and children should not be treated with prophylactic antibiotics,127 though it is reasonable to consider antibiotic prophylaxis in infants and children who have had recurrent UTI.127 Some behavioural and environmental preventive activities for children who have had one UTI can decrease the chances of further UTIs. However, there is no evidence that long term outcomes, after a first-time typical UTI, are improved by the use of investigations in children over the age of 6 months.24,127,130 

While high grade vesicoureteric reflux (VUR) is associated with kidney damage, there is no evidence that continuous antibiotic prophylaxis in children with this condition is effective in reducing the rate of pyelonephritis recurrence and the incidence of renal damage in children with VUR.131–133 Some of the kidney damage caused by high grade VUR occurs prenatally.134 Even though the incidence of VUR is increased in the siblings and children of those with VUR, there is no evidence that screening for VUR in these subgroups will result in any benefit as the value of identifying and treating VUR is unproven.133 Circumcision reduces the risk of UTI in boys but has a significant complication rate of haemorrhage and infection, so is not recommended routinely to prevent UTIs. However, in boys with recurrent UTI or high grade VUR there may be a possibility of a net clinical benefit from circumcision given this particular subset of boys has a higher chance of UTI recurrence.135 

Renal calculi in Aboriginal children are predominantly radiolucent uric acid stones and present on average at 24 months of age, though some have been apparent in children as young as 8 months. They usually occur in the upper renal tract and are rare in children living in urban areas. They have been linked with chronic diarrhoea and environmental induced enteropathy.114,136 There is no evidence linking childhood renal calculi to the higher rates of ESRD seen in Aboriginal and Torres Strait Islander adults.

There is mixed evidence as to whether blood pressure screening to detect renal disease should be performed in children. Some evidence supports screening children yearly from the age of 3 years, and younger if there are risk factors for high blood pressure such as obesity.123,137 However, this screening is not primarily recommended for purposes of screening for renal disease in children, nor is it solely recommended so that treatment can prevent renal damage: rather it is primarily targeting prevention of cardiovascular disease. Other evidence either makes no comment about screening for blood pressure in children,78 or supports explicit recommendations for not using blood pressure to screen for renal disease. This is particularly so when blood pressure screening is discussed with regards to being a marker of undiagnosed kidney disease in children.81,116,118,119 Screening recommendations include much discussion about the importance of taking blood pressure correctly and interpreting the findings carefully. This includes recommendations for:

  • auscultation to be used in conjunction with mercury or aneroid sphygmomanometers rather than use of automated devices
  • correct positioning of the child
  • correct cuff size according to the size of the child’s arm
  • being particular in interpretation of blood pressure values according to age, gender and height
  • repeat measurements of blood pressure to validate an abnormal finding followed by referral for appropriate work-up if hypertension is confirmed.

The measurement of blood pressure in all young children has not been linked to strong evidence of improvements in diagnosis and treatment of renal disease, and may be problematic on different fronts. The practice of measuring blood pressure to ensure accuracy of readings and the interpretation of values is more complicated in children than for adults and is thus vulnerable to a fair degree of equipment and practitioner error. It may make community based screening unnecessarily difficult, and divert efforts into directions where the evidence of gain for the child is only mixed and not validated for Aboriginal and Torres Strait Islander populations.

Recommendations: Childhood kidney disease
Preventive intervention typeWho is at risk?What should be done?How often?Level/strength of evidence
Screening All children without a high risk condition Routine urinalysis or blood pressure screening for kidney disease is not recommended unless there is a clinical indication N/A IA23,42,81,116,118,119,123,124
Children living in areas with high rates of infectious skin disease (scabies and impetigo) Check the skin for scabies and impetigo and treat according to management guidelines Opportunistic and as part of an annual health assessment GPP64,120
Children with first episode UTI Assess need for imaging tests based on treatment response within 48 hours and whether atypical features are present (see Table 2.2) As needed IB133
Children with pre-pubertal and pubertal onset diabetes Check albumin to creatinine ratio (ACR) using single voided specimen, morning specimen preferred 5 years after diagnosis or at age 11 years, or at puberty (whichever is earlier), then annually thereafter IA121,122
Behavioural Children who have had at least one episode of UTI Identify and correct predisposing factors for recurrence (including constipation, dysfunctional elimination syndromes, poor fluid intake and delays in voiding) As needed IA127
Chemoprophylaxis Children living in areas with high rates of infectious skin disease (scabies and impetigo) Treat household contacts of someone with scabies with 5% permethrin cream if over 2 months old and sulphur 5% or crotamiton cream if <2 months of age
In communities where there are outbreaks of infected scabies, offer all household contacts of people with impetigo a single dose of benzathine penicillin G (see Resources)
As needed IIIC113,117,120
Environmental Children living in areas with high rates infectious skin disease (scabies and impetigo) Promote good hygiene practices at home
Refer to relevant housing support services to promote access to adequate washing facilities and toilets
Opportunistic IA113,120
Community based interventions that use screening and immediate treatment for skin sores and scabies in targeted age groups should be combined with simultaneous treatment of the whole community for scabies (see Resources) N/A IA113,117,120
Table 2.2. Recommended imaging following first presentation with UTI
Infants younger than 6 months
TestResponds well to treatment within 48 hoursAtypical UTI*
Ultrasound during the acute infection No Yes
Ultrasound within 6 weeks Yes No
DMSA 4–6 months following the acute infection No Yes
MCUG No Yes
Children aged 6 months to 3 years
TestResponds well to treatment within 48 hoursAtypical UTI*
Ultrasound during the acute infection No Yes
Ultrasound within 6 weeks No No
DMSA 4–6 months following the acute infection No Yes
MCUG No No
Children aged 6 months to 3 years
TestResponds well to treatment within 48 hoursAtypical UTI*
Ultrasound during the acute infection No Yes
Ultrasound within 6 weeks No No
DMSA 4–6 months following the acute infection No No
MCUG No No
DMSA = dimercaptosuccinic acid scan (an intravenous radionuclide scan for assessing renal function), MCUG = micturating cystourethrogram
* Atypical UTI features include: the patient is seriously ill, poor urine flow, abdominal or bladder mass, raised creatinine, septicaemia, failure to respond to treatment with suitable antibiotics within 48 hours, infection with non-E. coli organisms
† MCUG should not be performed routinely but should be considered if any of the following features are present: dilatation on ultrasound, poor urine flow, non-E. coli infection, family history of VUR
Source: National Collaborating Centre for Women’s and Children’s Health, 2007.127 Refer to this resource for imaging recommendations for recurrent UTI

Resource

Guidelines for community control of scabies, skin sores and crusted scabies in the Northern Territory (Northern Territory Department of Health and Families)
www.health.nt.gov.au/ library/scripts/objectifyMedia.aspx?file=pdf/ 10/83.pdf&siteID=1&str_title=Healthy+ Skin+Program.pdf.

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