SURVIVAL OF CHILDREN ON HEMODIALYSIS AT BUEA REGIONAL HOSPITAL; 5 YEAR RETROSPECTIVE RETROSPECTIVE STUDY.

ABSTRACTS

BACKGROUND:

          Over the years, pediatric renal disease has become one of the leading causes of morbidity and mortality worldwide. Estimate of the global burden of disease indicate that the kidney and urinary tract disorders account for approximately 830000 deaths and 18467000 disability-adjusted life years annually, ranking them the 12^th among causes of death (1.4 percent of all death) and 17^th among causes of disability (1.0 percent of all disability-adjusted life years) (6)

         Less than 10 percent of children with kidney failure worldwide actually receive dialysis or a transplant. Kidney failure care consist of conservative treatment or kidney replacement therapy that is maintenance dialysis or kidney transplant. Hemodialysis is the commonest form of kidney replacement therapy in the world, accounting for approximately 69 % of all kidney replacement therapy and 89 % of all dialysis. Over the last six decades since the inception of Dialysis technology and patient access to therapy have advanced considerably, particularly in high-income countries (7). Mortality in children with ESRD in SSA is reported high, mainly because of inaccessibility to dialysis and transplantation. In Cameroon hemodialysis is the sole kidney replacement therapy available and little is known about prognosis of children admitted in chronic hemodialysis (8)

OBJECTIVE.

Evaluating the Survival of children on hemodialysis at BRH

METHODS

A hospital based retrospective study will be carryout at hemodialysis center of Buea Regional hospital from January – May 2023. We will review medical records of all children who underwent or are on hemodialysis at BRH, Data including demographics, clinical status, lab results at presentation and during follow up etc. will be recorded.  Questionaries will be filled for children that fulfil the inclusion criteria.

CONCLUSION: We expected to determine the factors surrounding the survival of children on hemodialysis and factors associated with high mortality. This will contribute to policy makers and health workers and thus help to reduce mortality on children on hemodialysis.

Key words: Survival, Children, Hemodialysis, Buea Regional Hospital

CHAPTER 1 INTRODUCTION.

1.1 BACKGROUND

Pediatric renal disease has become one of the leading causes of morbidity and mortality worldwide. The global burden of the disease indicates that kidney and urinary tract disorders account for approximately for approximately 830000 deaths and 18467000 disability-adjusted life years annually, ranking them the 12^th among causes of death (1.4 percent of all death) and 17^th among causes of disability (1.0 percent of all disability-adjusted life years). Renal disease among pediatric patient varies in different population due to genetic, patient access to health care, socioeconomic status, spectrum of background infection and study setting. The prevalence of kidney disease among pediatric patients varies between 1.2 % and 16.5 % (6)

Over the decades pediatric patient who survive end stage renal disease has improved substantially. Nevertheless, the mortality rate is at least 30 times higher than in healthy peer. Patient survival is multifactorial and dependent on various patient and treatment characteristic and degree of economic welfare of the country in which a patient is treated.  In every 1 million children < 20 years in developed world about nine requires treatment of end stage renal disease with RRT (9)

In the world, the commonest form of kidney replacement therapy is hemodialysis which account for approximately 69 % of RRT and 89 % of all dialysis. since the dialysis technology inception over six decades, access to patient has advanced particularly in high income countries. However, availability, accessibility, cost and outcome of HD across the world vary widely with a high overall rate of morbidity, mortality and impaired quality of life. The major cause of morbidity is from cardiovascular disease which affect more than two third of patient receiving hemodialysis and account for approximately 50 mortality rates. Worldwide, children with kidney disease who receive HD or transplant are less than 10 %. Maintenance dialysis or kidney transplant is considered conservative treatment or renal replacement therapy for care of patient with kidney failure. Although dialysis is lifesaving, the goal of successful pediatric RRT is a quick recovery kidney transplant with either living or deceased donor organs. In the setting of kidney failure, children depend on parents for decision making and the pediatric nephrology team for taking decisions about RRT or conservative management (8)

In Africa, there is limited Literature on pediatric renal disorder due to the slow development of the subspecialty, lack of trained staff and availability of highly technical resources such as renal histopathology, dialysis machines and solution, immunosuppressive drugs and transplantation services. The percentage of renal disease among hospitalized children varies with recent studies reporting a prevalence of up to 8.9 % in certain part of Africa that has pediatric nephrology and some tertiary centers. The most frequent causes of renal disease in sub-region in Africa are malaria, septicemia, HIV, sickle cell anemia, hepatitis B and schistosomiasis (10)

Although 1.9 million patients worldwide are undergoing renal replacement therapy, which yield a usage of 316 per million population and annual initiation of 73 per million population, only about one third (648000) of the patients reside in developing regions, which contribute 85 % of the world’s population. The mortality rate of patients on hemodialysis within the first 3 months after initiation of dialysis is high with annual mortality of 9 % per year and with a 5-year survival of 40-50 %. In many developing countries, there is a shortage of renal replacement services which causes an estimated 2.3-7.1 million premature deaths. ESRD patient in Africa have the lowest access to RRT with only 9-16 % being treated in central and eastern Africa, with an estimated treatment rate to be as low as 1 -3 % (11)

Despite the establishment of renal registries and publication of data about RRT, many African countries due to sustainability issues lack countrywide publication. consequently, less is known about initial survival or the risk factors which cause early mortality in dialysis patients. However, there is high mortality during the first 90 days and modifications might be made during the critical period to impact not only early survival but also, possibly long-term survival of patients on dialysis. Lack of access to dialysis center, financial constraints were the main reasons for late initiation of hemodialysis and frequent discontinuation in Ethiopia.  Electric power fluctuation, frequent breakdown of machines and lack of filtered water were also the main reasons for reduced dialysis session per week and reduced hemodialysis duration per session from the standard (11)

Factors associated with kidney disease mortality in children are age of initiation which is a key determinant of mortality in children as children < 5 years are 4 times at higher risk and children > 5 years are 1.5 times higher. In addition, gender is a risk factor for higher mortality as girls are at higher risk than boys, Race as blacks are 64 percent at higher risk of death than whites. The most common etiologies of renal disease in children which account for at least half pediatric ESRD patient are primary renal disease such as congenital anomalies and urinary tract and glomerulonephritis. Moreover, other factors such as anthropometry measurement, comorbidity, renal replacement modalities, time on RRT initiation, residual renal function at RRT initiation, are factors responsible for high mortality. (9)

 Very little is known about its true burden in children particularly in low resource settings. ESRD is a devastating disorder associated with high morbidity and mortality. The real impact of injuries in children in developing countries is unknown as most children in early stages remain underdiagnosed and many others die without accessing renal replacement therapy which is expensive and difficult to implement in children without necessary health workers capacity and health systems set up apart from select tertiary centers (12)

Mortality in children with ESRD in SSA is reported high, mainly because of inaccessibility to dialysis and transplantation. In Cameroon hemodialysis is the sole kidney replacement therapy available and little is known about prognosis of children admitted in chronic hemodialysis (8)

We aimed at investigating the factors surrounding survival of children on hemodialysis at Buea Regional Hospital.

1.2 PROBLEM STATEMENT.

Kidney failure care in low resource settings has focused mainly on adult patients and does not apply well to children; The lack of unadopted equipment in children, children lack of autonomy to make medical decisions, are inherently vulnerable and are dependent on their caregivers for decision making and for treatment. Moreover, technical failure in the treatment such difficulty in accessing fistula, central line due to lack peritoneal dialysis has led to high mortality of children on hemodialysis. We wish to investigate the factors leading to survival and mortality rate in children on hemodialysis.

1.3 JUSTIFICATION.

Despite similar studies done so far in the world, SSA and part of our setting, many children still come for dialysis treatment and some die in the course of dialysis treatment. Moreover, no study has focused on survival of children on hemodialysis in our certain, studying the factors leading to mortality and survival of children on hemodialysis will help in reducing the mortality and prolonged life.

1.4 RESEARCH GOAL

To investigate the factors leading to survival of children on hemodialysis.     

1.5 RESEARCH QUESTION.

1. What is the number of children diagnosed or admitted for kidney failure at BRH?
2. What is the mortality rate in children on hemodialysis?
3. What are the comorbidities in children undergoing hemodialysis?
4. What are the most predisposing factors to poor survival of children on hemodialysis?

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