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

Chapter 3. Child health
Childhood kidney disease
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☰ Table of contents

Recommendations: Childhood kidney disease

Preventive intervention type

Who is at risk?

What should be done?

How often?

Level/ strength of evidence

References

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   IA 2,3,4, 23,38
Children with a highrisk condition (obese/ overweight, renal disease, congenital heart disease, strong family history Routine urinalysis and blood pressure surveillance is advisable. For children with diabetes, refer below Opportunistic GPP 37
Children with asymptomatic proteinuria Routine renal ultrasound examination is not recommended   IA 23
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 (refer to ‘Resources’) Opportunistic and as part of annual health assessment GPP 11, 39
Children with first episode urinary tract infection (UTI) Assess need for imaging tests based on treatment response within 48 hours and whether atypical features are present (Box 2)   IB 34
Children with prepubertal and pubertal onset diabetes Check albumin to creatinine ratio (ACR) using single voided specimen, morning specimen preferred. Abnormal screening tests should be repeated as microalbuminuria may be transient Check blood pressure annually At age 10 years or at puberty (whichever is earlier), after 2–5 years’ diabetes duration, then annually thereafter IA 9, 10

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 IA 23

Chemo-prophylaxis

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 aged >2 months, and sulphur 5% or crotamiton cream if aged <2 months In communities where there are outbreaks of infected scabies, offer all household contacts of people with impetigo a single dose of benzathine penicillin G (refer to ‘Resources’) As needed IIIC 14
Children with recurrent UTIs There is insufficient evidence to routinely recommend probiotic therapy or cranberry products for the prevention of recurrent UTIs   IA 27, 28
Routine prophylactic antibiotics are not required, even if the child has vesicoureteric reflux If used: daily for 12 months, then review IA

 
Children with asymptomatic bacteriuria Antibiotics are not recommended   IA

 

Environmental

 Children living in areas with high rates of infectious skin disease (scabies and impetigo) Promote good hygiene practices at home Refer to relevant housing support services to reduce overcrowding and promote access to adequate washing facilities Recommend the regular use of community swimming pools Opportunistic GPP IB 11, 20
Children living in areas with high rates of infectious skin disease (scabies and impetigo) Community-based interventions that use screening and immediate treatment of skin sores and scabies in targeted age groups should be combined with simultaneous treatment of the whole community for scabies (refer to ‘Resources’)   IA 11, 14

Box 1. Acute management of children with UTI/pyelonephritis*† (CARI guidelines)25,40

Child with asymptomatic bacteriuria (ie bacterial growth in urine with no symptoms)

No treatment is required25,26

Child with presumed UTI (ie symptoms and +ve leucocytes and/or nitrites on urinalysis)

Low risk (not septic, can tolerate oral medications)

Age

No pyelonephritis (ie cystitis)

Pyelonephritis (fever >38oCwith loin pain/tenderness)

<1 month

IV antibiotics

IV antibiotics

≥1 month

Oral antibiotics for 2–4 days

Oral antibiotics for 7–10 days

High risk (septic, cannot tolerate oral medications)

 

No pyelonephritis

Pyelonephritis (fever >38oC with loin pain/tenderness)

All ages

IV antibiotics

IV antibiotics

IV, intravenous; UTI, urinary tract infection

*NICE guidelines23 are very similar, but use a three-month rather than a one-month age cut-off.

†AAP guidelines24 are similar, but recommend a minimum seven-day antibiotic course for all children with UTI.

Box 2. Investigations for children with first UTI/pyelonephritis23

Atypical (any of the following)

  • patient 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–Escherichia coli organisms

Infants aged <6 months: MCUG* if atypical UTI or recurrent UTIs

Children aged <3 years: Renal ultrasound during acute infection + DMSA scan† in 4–6 months

Children aged ≥3 years: Renal ultrasound during acute infection

Typical (ie does not meet any of above atypical criteria)

Infants aged <6 months: Renal ultrasound within six weeks

Children aged ≥6 months: No investigations required

DMSA, dimercaptosuccinic acid; MCUG, micturating cystourethrogram; UTI, urinary tract infection

*MCUG should not be performed routinely, but should be considered if there is dilatation on ultrasound or poor urine flow.

†DMSA scan – an intravenous radionuclide scan for assessing renal function.


Background

The high rate of chronic kidney disease (CKD) is a significant reason for the health gap between Aboriginal and Torres Strait Islander peoples and other Australians. Aboriginal and Torres Strait Islander peoples have very high rates of self-reported long-term kidney disease (1.8%; nearly four times as high as non-Indigenous people based on age-standardised rates).1 CKD accounted for 45% of hospitalisations for Aboriginal and Torres Strait Islander people in 2012–13, mostly for dialysis. Aboriginal and Torres Strait Islander people are admitted for dialysis at 10 times higher rates than non-Indigenous Australians.1 CKD was an underlying cause or associated cause in one in every seven Aboriginal and Torres Strait Islander deaths between 2008 and 2012.1
Given the high rate of CKD in adulthood, there may be opportunities to prevent the trajectory to end-stage renal disease through interventions starting in childhood.2–4 In one study, Aboriginal primary school-aged children had the same prevalence of persistent CKD risk factors (haematuria, proteinuria, obesity and hypertension-systolic or diastolic) as non-Aboriginal children,4 while proteinuria was more common in Aboriginal people aged >20 years than in those aged 5–19 years.5

Prevention of CKD may need to commence from pregnancy. There is international epidemiological and experimental evidence that a predisposition to CKD in adulthood may arise from in-utero influences that result in low birth weight (LBW) (the fetal origins of adult disease hypothesis).6 Mechanisms may be related to a reduced nephron endowment at birth (due to in utero epigenetic mechanisms) that enhances vulnerability to postnatal renal injury over time.7 In an autopsy study, Aboriginal people from a remote community setting had much fewer nephrons and glomeruli than non-Aboriginal people, particularly when there was a history of hypertension, consistent with the finding that they have a susceptibility to renal failure.8 However, this study was subject to selection bias and prenatal prevention strategies need to be complemented with postnatal strategies as described here.
There is mixed evidence on the extent to which childhood renal disease contributes to high CKD rates in Aboriginal and Torres Strait Islander adults. Risk factors for CKD seen in children, such as haematuria and proteinuria, are often transient,2–4 with the exception of microalbuminuria in children with pre-pubertal and pubertal onset diabetes.9,10 Baseline CKD risk factors are frequent in both Aboriginal and Torres Strait Islander and non-Indigenous primary school-aged children, although there is evidence that, at a single test, Aboriginal and Torres Strait Islander children have a greater risk of haematuria than non-Indigenous children.4

Higher rates of transient haematuria may reflect the higher incidence of transient diseases seen in Aboriginal and Torres Strait Islander children, particularly acute post-streptococcal glomerulonephritis (APSGN).2–4 In some Aboriginal and Torres Strait Islander communities, children who had APSGN had six times greater risk of developing renal disease as adults,11 although most children make an apparent full recovery from APSGN. It is not clear whether the link between APSGN and adult onset CKD is causative or associative. Prevention of end-stage kidney disease (ESKD) may be a goal of urinary tract infection (UTI) investigation and management. However, epidemiological data suggest only a very small association between UTI and ESKD, probably not causal,12 and there has been no significant decrease in ESKD attributable to pyelonephritic scarring/reflux nephropathy since more aggressive investigation and treatment in the 1960s.13 The major determinants of ESKD in Aboriginal and Torres Strait Islander adults continue to be cardiovascular disease (CVD) (13% prevalence),1 diabetes (11% prevalence)1 and obesity (37% prevalence)1 rather than infections.


Interventions

Skin infections and kidney disease

There is some evidence that prevention and treatment of skin infections prevents APSGN.14 Therefore, children with skin sores, and household contacts of such children, should be given targeted treatment with anti-scabetics and benzathine penicillin.14
Population-level recommendations for children in communities with a high prevalence of skin conditions are less clear. Regular community-based programs may be useful to screen and treat all children in a target age group (eg ages 0–3 years)11 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.11 These interventions reduce skin sores, scabies and APSGN, and we assume this would reduce ESKD.11,14,15

Housing, overcrowding and swimming pools

There is evidence that dysfunctional housing facilities and overcrowding enhance the risk of skin, ear, respiratory and gastrointestinal infections in Aboriginal children.16,17 The New South Wales Housing for Health program was a collaborative effort between Aboriginal community groups, land councils and NSW Health to upgrade essential housing needs for healthy living. People who received assistance from the Housing for Health program had a 38% reduction in hospitalisations for infections (skin, gut, respiratory and otitis media) in 2008 compared with 1998. This compared to a 3% increase per 10,000 population over the same time period for people who had not received assistance from Housing for Health.18 A study from Bangladesh found that poor-quality housing and lack of electricity were associated with scabies in Bangladesh.19 A reduction in the prevalence of skin sores in Aboriginal children has been reported in several pre–post studies as a beneficial effect of swimming pools and may be due to cleaning of the skin.20,21 Although these are infection-related outcomes, it is likely that improvements in housing and overcrowding would also lead to improved kidney health outcomes, but specific evidence is lacking.

Prevention of recurrent UTI

There is lack of certainty regarding the usefulness of routine antibiotic prophylaxis following the first UTI. A large double-blind placebo-controlled trial found a modest 6% reduction in febrile UTI after one year of prophylactic daily cotrimoxazole and that children with vesico-ureteric reflux (VUR) were no more likely to benefit from prophylactic antibiotics than those without VUR.22 Guidelines from the National Institute for Health and Care Excellence (NICE), Caring for Australians with Renal Impairment and the American
Academy of Pediatrics (AAP) currently do not recommend using prophylactic antibiotics after the first UTI.23–25 Prophylactic antibiotics remain an option for recurrent UTI. However, it is clear that asymptomatic bacteriuria in infants and children should not be treated with prophylactic antibiotics.23,26
There is no current evidence to support the use of cranberry juice27 or probiotics to prevent UTIs.28 Circumcision reduces the risk of UTI in boys29 but is associated with some risk and so is not recommended routinely to prevent UTIs.

Imaging studies after UTIs

Renal ultrasound screening is recommended in children aged <6 months largely because it provides reassurance to families, is cheap and non-invasive. Despite this, there is no evidence that renal ultrasounds after a febrile UTI reduce progression to ESKD.23 The AAP no longer recommends micturating cystourethrograms (MCUGs) after febrile UTIs,30 and NICE only recommends MCUGs in infants aged <6 months with atypical or recurrent UTIs.23 High-grade VUR is associated with kidney damage; however, there is no evidence that continuous antibiotic prophylaxis in children with VUR reduces scarring. The Randomized Intervention for Children with Vesicoureteral Reflux (RIVUR) trial, a randomised placebo-controlled trial involving 607 children with VUR, showed reduced UTI recurrence but no difference in renal scarring in children on prophylaxis.31 A meta-analysis of eight trials, including the Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteric Reflux and Normal Renal Tracts (PRIVENT)22 and RIVUR,31 showed reduced UTI recurrence but no difference in renal scarring rates in children with VUR given prophylactic antibiotics.32 Some of the kidney damage caused by high-grade VUR occurs prenatally.33 The incidence of VUR is increased in siblings and children of those with VUR; however, there is no evidence that screening for VUR in these sub-groups will result in any benefit as the value of identifying and treating VUR is unproven.34

Blood pressure screening

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 three years, and younger if there are risk factors for high blood pressure such as obesity.35 However, this screening is not primarily recommended for the 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. The RACGP Guidelines for preventive activities in general practice (Red Book) makes no specific recommendations about screening for blood pressure in children.36 The most recent AAP statement recommends screening all children aged ≥3 years annually, and those at high risk (obesity, medications known to increase blood pressure, renal disease, a history of aortic arch obstruction or coarctation, or diabetes) at every visit. However, these recommendations are based on grade C quality evidence and classified as only ‘moderate’ strength.37
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 for a variety of reasons. The practice of measuring blood pressure is more complicated in children than in adults. It can be difficult to ensure accurate readings and the correct interpretation of values is vulnerable to equipment and practitioner error. Therefore, community-based blood pressure screening would be difficult and, given the current lack of evidence, it would be better to divert energy into screening practices with a stronger evidence base.
When taking a blood pressure, we recommend:

  • using the manual technique rather than automated devices
  • choosing the correct cuff size
  • referring to the normal ranges based on age, gender and height (refer to ‘Resources’)
  • repeating if abnormal and referring for appropriate work-up if hypertension is confirmed.

Urinalysis screening

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. Urinalysis screening of all children is not recommended.38
 

Resources
 

 

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

 





 
 

 

  1. Australian Institute Health and Welfare. The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples: 2015.  [Accessed 15 November 2017].
  2. Haysom L, Williams R, Hodson E, et al. Risk of CKD in Australian indigenous and nonindigenous children: A population-based cohort study. Am J Kidney Dis 2009;(2):22–37.
  3. Haysom L, Williams R, Hodson E, et al. Early chronic kidney disease in Aboriginal and non-Aboriginal Australian children: Remoteness, socioeconomic disadvantage or race? Kidney Int 2007;(8):787–94
  4. Haysom L, Williams R, Hodson EM, et al. Natural history of chronic kidney disease in Australian Indigenous and non-Indigenous children: A 4-year population-based follow-up study. Med J Aust 2009;190(6):303–06.
  5. Singh GR, White AV, Hoy WE. Renal ultrasound findings in an Australian Aboriginal population with high rates of renal disease. Nephrology 2005;10(4):358–61.
  6. Boubred F, Saint-Faust M, Buffat C, Ligi I, Grandvuillemin I, Simeoni U. Developmental origins of chronic renal disease: An integrative hypothesis. Int J Nephrol 2013.
  7. Newsome AD, Davis GK, Ojeda NB, Alexander BT. Complications during pregnancy and fetal development: Implications for the occurrence of chronic kidney disease. Expert Rev Cardiovasc Ther 2017;15(3):211–20.
  8. Hoy WE, Hughson MD, Singh GR, Douglas-Denton R, Bertram JF. Reduced nephron number and glomerulomegaly in Australian Aborigines: A group at high risk for renal disease and hypertension. Kidney Int 2006;70:104–10.
  9. Donaghue KC, Chiarelli F, Trotta D, Allgrove J, Dahl-Jorgensen K. ISPAD clinical practice consensus guidelines 2006–2007. Microvascular and macrovascular complications. Pediatr Diabetes 2007;8(3):163–70.
  10. N Isbel, F de Looze, M Gallagher, et al. Proteinuria CARI guidelines. Aust Fam Physician 2005;34(11).
  11. Centre for Disease Control. Healthy skin program: Guidelines for community control of scabies, skin sores, tinea and crusted scabies in the Northern Territory. Darwin: Northern Territory Department of Health, 2015. [Accessed 15 November 2017].
  12. Craig JC, Williams GJ. Denominators do matter: It’s a myth – urinary tract infection does not cause chronic kidney disease. Pediatrics 2011;128(5):984–85.
  13. Craig JC, Irwig LM, Knight JF, Roy LP. Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics 2000;105(6):1236–41.
  14. Johnston F, Carapetis J, Patel MS, Wallace T, Spillane P. Evaluating the use of penicillin to control outbreaks of acute poststreptococcal glomerulonephritis. Pediatr Infect Dis J 1999;18(4):327–32.
  15. Heukelbach J, Feldmeier H. Scabies. Lancet 2006;367(9524):1767–74.
  16. Couzos S, Murray R, for the Kimberley Aboriginal Medical Services Council. Aboriginal primary health care: An evidence-based approach. Melbourne: Oxford University Press, 2008.
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  20. Lehmann D, Tennant MT, Silva DT, et al. Benefits of swimming pools in two remote Aboriginal communities in Western Australia: Intervention study. BMJ 2003;327(7412):415–19.
  21. Hendrickx D, Stephen A, Lehmann D, et al. A systematic review of the evidence that swimming pools improve health and wellbeing in remote Aboriginal communities in Australia. Aust N Z J Public Health 2016;40(1):30–36.
  22. Craig J, Simpson J, Williams G, et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med 2009;361(18):1748–58.
  23. National Collaborating Centre for Women’s and Children’s Health Commissioned by the National Institute for Health and Care Excellence. NICE guideline: Urinary tract infection in children diagnosis, treatment and long-term management. London: NICE, 2007.
  24. Roberts KB. Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128(3):595–610.
  25. Williams G, Hewitt I. Diagnosis and treatment of urinary tract infection in children: Long term management – Recurrent urinary tract infection and vesicouretic reflux. KHA-CARI guidelines. Westmead, NSW: Kidney Health Australia, CARI, 2014.   [Accessed 15 November 2017].
  26. Zalmanovici Trestioreanu A, Lador A, Sauerbrun-Cutler M, Leibovici L. Antibiotics for asymptomatic bacteriuria. Cochrane Database Syst Rev 2015(4):CD009534.
  27. Jepson RG, Williams G, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev 2012;10:CD001321.
  28. Schwenger EM, Tejani AM, Loewen PS. Probiotics for preventing urinary tract infections in adults and children. Cochrane Database Syst Rev 2015(12):CD008772.
  29. Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: A systematic review of randomized trials and observational studies. Arch Dis Child 2005;90(8):853–58.
  30. Finnell SM, Carroll AE, Downs SM, Subcommittee on Urinary Tract Infection. Diagnosis and management of an initial UTI in febrile infants and young children. Pediatrics 2011;128(3):e749–70.
  31. Hoberman A, Greenfield SP, Mattoo TK, et al. Antimicrobial prophylaxis for children with vesicoureteral reflux. N Engl J Med 2014;370(25):2367–76.
  32. Wang HS, Gbadegesin RA, Foreman JW, et al. Efficacy of antibiotic prophylaxis in children with vesicoureteral reflux: Systematic review and meta-analysis. J Urol 2015;193(3):963–69.
  33. Zaffanello M, Franchini M, Brugnara M, Fanos V. Evaluating kidney damage from vesico-ureteral reflux in children. Saudi J Kidney Dis Transpl 2009;20(1):57–68.
  34. Skoog SJ, Peters CA, Arant BS Jr, et al. Pediatric vesicoureteral reflux guidelines panel summary report: Clinical practice guidelines for screening siblings of children with vesicoureteral reflux and neonates/infants with prenatal hydronephrosis. J Urol 2010;184(3):1145–51.
  35. Moyer VA. Screening for primary hypertension in children and adolescents: US Preventive Services Task Force recommendation statement. Pediatrics 2013;132(5):907–14.
  36. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edn. East Melbourne, Vic: RACGP, 2016.
  37. Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents. Pediatrics 2017;140(3):e20171904.
  38. Wilkinson J, Bass C, Diem S, et al. Preventive services for children and adolescents. Institute for Clinical Systems Improvement, 2012.
  39. Antibiotic Expert Group. Therapeutic guidelines: Antibiotic. Version 14. Melbourne: Therapeutic Guidelines Ltd, 2010. Trnka P, McTaggart S. Diagnosis and treatment of urinary tract infection in children: Acute management. KHA-CARI guidelines. Westmead, NSW: Kidney Health Australia, CARI, 2014.  [Accessed 15 November 2017].

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