The current status of kidney transplantation in Nigerian children: still awaiting light at the end of the tunnel.

BACKGROUND: Kidney transplantation (KT) is the gold standard treatment for children with chronic kidney disease stage 5 (CKD5). It is easily accessible in well-resourced countries, but not in low/middle-income countries (LMICs). We present, a multicentre experience of paediatric KT of children domiciled in Nigeria. We aim to highlight the challenges and ethical dilemmas that children, their parents or guardians and health care staff face on a daily basis. METHODS: A multicentre survey of Nigerian children who received KTs within or outside Nigeria from 1986 to 2019 was undertaken using a questionnaire emailed to all paediatric and adult consultants who are responsible for the care of children with kidney diseases in Nigeria. Demographic data, causes of CKD5, sources of funding, donor organs and graft and patient outcome were analysed. Using Kaplan-Meier survival analysis, we compared graft and patient survival. RESULTS: Twenty-two children, aged 4-18 years, received 23 KTs, of which 12 were performed in Nigeria. The male-to-female ratio was 3.4:1. Duration of pre-transplant haemodialysis was 4-48 months (median 7 months). Sixteen KTs were self-funded. State governments funded 3 philanthropists 4 KTs. Overall differences in graft and patient survival between the two groups, log rank test P = 0.68 and 0.40, respectively were not statistically significant. CONCLUSIONS: The transplant access rate for Nigerian children is dismal at < 0.2%. Poor funding is a major challenge. There is an urgent need for the federal government to fund health care and particularly KTs. Graphical Abstract.

IPNA clinical practice recommendations for the diagnosis and management of children with steroid-resistant nephrotic syndrome.

Idiopathic nephrotic syndrome newly affects 1-3 per 100,000 children per year. Approximately 85% of cases show complete remission of proteinuria following glucocorticoid treatment. Patients who do not achieve complete remission within 4-6 weeks of glucocorticoid treatment have steroid-resistant nephrotic syndrome (SRNS). In 10-30% of steroid-resistant patients, mutations in podocyte-associated genes can be detected, whereas an undefined circulating factor of immune origin is assumed in the remaining ones. Diagnosis and management of SRNS is a great challenge due to its heterogeneous etiology, frequent lack of remission by further immunosuppressive treatment, and severe complications including the development of end-stage kidney disease and recurrence after renal transplantation. A team of experts including pediatric nephrologists and renal geneticists from the International Pediatric Nephrology Association (IPNA), a renal pathologist, and an adult nephrologist have now developed comprehensive clinical practice recommendations on the diagnosis and management of SRNS in children. The team performed a systematic literature review on 9 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, formulated recommendations and formally graded them at a consensus meeting, with input from patient representatives and a dietician acting as external advisors and a voting panel of pediatric nephrologists. Research recommendations are also given.

Factors associated with substance use among secondary school adolescents in gwagwalada area council, Abuja, Nigeria

Adolescents use substances for various reasons such as for pleasure, stress and anger management. Many factors have been reported to influence adolescent substance use. However, there is paucity of reports from this part of Nigeria.AIM/OBJECTIVES: To identify the socio-demographic factors associated with substance use among secondary school adolescents in Gwagwalada Area Council.MATERIALS AND METHODS: A cross-sectional, descriptive, questionnaire-based, study was carried out in secondary schools among adolescents aged 10 years to 18 years who met the inclusion criteria and after appropriate ethical approval had been obtained.RESULTS: One thousand, one hundred and ninety-six student-filled questionnaires were analysed. The mean age of the students was 14.54 years ± SD 2.28. The students' religion, family structure, residence and type of school were associated with licit substance use while their religion, family structure and residence were associated with illicit substance use (P =<0.05). There was also statistically significant relationships between frequency in participation in religious activities and tobacco use (P = <0.01) and birth order and cocaine andhallucinogen use at P = 0.014 and P = 0.018, respectively.CONCLUSION AND RECOMMENDATION: Several factors were associated with adolescent substance use in this study. It is recommended that more in-depth studies be done to determine causality

Factors Associated with Bacteraemia in Febrile; Non-Neonatal Children 5 Years Old at the Paediatric Outpatient Clinic of the University of Port Harcourt Teaching Hospital; Nigeria

Background. Fever is one of the most common presenting symptoms in the emergency room. Bacteraemia can be a cause of febrile illness in children and can have a fatal outcome if untreated. Therefore; it is important to identify factors associated with bacteraemia in febrile children in order to aid its early diagnosis and prompt treatment. Objectives. To determine the factors associated with bacteraemia among febrile; non-neonatal; under-five children seen in the Children's Clinic of the University of Port Harcourt Teaching Hospital; Nigeria. Methods. Febrile children aged 29 days - 59 months who presented at the outpatient clinic and whose parents gave consent were recruited between September 2010 and January 2011. Information on their age; gender; weight; symptoms; physical examination and blood culture results was collected and analysed.Results. A total of 362 children were studied. The prevalence rate of bacteraemia was 11.5% and 22.2% in moderately and severely malnourished children; respectively (p=0.010). Children with systemic inflammatory response syndrome (SIRS) had the highest bacteraemia prevalence rate (66.7%; p0.001); while children with focal infection and children with fever without other symptoms or signs had bacteraemia rates of 7.1% and 3.7%; respectively. There was no significant relationship between the magnitude of fever and bacteraemia (p0.050).Conclusion. Blood cultures should be performed in febrile children who are malnourished or who have SIRS. Antibiotics should also be commenced while blood culture results are awaited

Weight status of adolescents in secondary schools in port Harcourt using Body Mass Index (BMI).

BACKGROUND: Adolescent weight status is a cumulative effect of health and nutritional problems. Adolescent weight problems often go unnoticed as weight assessment is not considered a priority in adolescents. OBJECTIVES: To determine the weight status of adolescents using BMI and to identify the contributing factors to adolescent weight problems. METHODS: In April 2010, 960 adolescents aged 10-19 years in secondary schools in Port Harcourt were selected for the study using a stratified multi-staged sampling method. Structured questionnaires were filled by the investigators while weight and height were measured. BMI was calculated using the formula weight/height2 (kg/m2). RESULTS: The prevalence of underweight, overweight, obesity and stunting were 6.4%, 6.3%, 1.8% and 5.4% respectively. Factors which were commoner in overweight adolescents were high socioeconomic class, higher maternal education, spending > 3 hours a day watching television and frequent ingestion of snacks. CONCLUSION: There is a need for periodic weight assessment of adolescents and health education to promote healthy eating habits and regular physical exercise as part of the School Health Programme.

Childhood acute glomerulonephritis in Port Harcourt, Rivers State, Nigeria.

BACKGROUND: Acute glomerulonephritis (AGN) is an important cause of renal morbidity and mortality in children. The incidence varies across the countries with lower rates in developed countries due to improved environmental hygiene and socio-economic status. METHODS: A prospective study of patients admitted with the diagnosis of AGN was carried out in the Department of Paediatrics, University of Port Harcourt Teaching Hospital (UPTH) from June 2006 to June 2008. The patients' demographic data, presenting complaints; antecedent history of sore throat or skin infections, clinical findings including blood pressure; investigations, management and outcome were obtained. Data was compared with a previous study done in UPTH 14 years ago and in other countries. RESULTS: A total of 31 patients aged 3 to 16 years had AGN, giving an annual incidence of 15.5 cases. They comprised 16 (51.6%) males and 15 (48.4%) females with a M:F ratio of 1.1:1. There is no significant change in the annual incidence of AGN when compared with the 14.5 cases per year reported in our centre 14 years ago. Fourteen (45.2%) of the patients were between 5-10 years. The highest incidence occurred during the dry cold windy (harmattan) season of October to February in 19 (61.3%) patients. Twenty-four (77.4%) of the patients were from low socio-economic classes (social class IV and V). Sore throat was the commonest infection preceeding AGN (66.6%). Hypertensive encephalopathy with seizure occurred in 5 (16.1%) patients. There were 4 (12.9.1%) patients with nephrotic range proteinuria, and 12 (38.7%) patients had renal failure. Urinary tract infection occurred in 7 (22.6%) patients; klebsiella being the commonest organism isolated. All patients received conservative treatment while dialysis was done in 5 patients; one peritoneal dialysis (PD) and 4 haemodialysis. The recovery rate was 83.9% and a hospital mortality of 3 (9.7%). CONCLUSION: The annual incidence of AGN has remained almost the same in Port Harcourt despite the increased urbanization and overcrowding in this oil rich state of Nigeria.

Human immunodeficiency virus-associated nephropathy (HIVAN) in Nigerian children.

Human immunodeficiency virus-associated nephropathy (HIVAN) has rarely been reported in African children. In this single-center study, we analyzed ten children diagnosed with HIVAN from January 2000 to October 2006. There were eight boys and two girls, with a male:female ratio of 4:1. Their ages were from 5 months to 15 years (mean 6.8+/-6.2 years), with a peak age of 5-9 years. The presenting complaints included generalized edema (60%) and hypertension (50%). All patients had proteinuria on urine dipstick, with four (40%) at nephrotic range (proteinuria >or=500 mg/dl). Nine (90%) patients were in renal failure, with elevated serum creatinine (6.3-24 mg/dl) and serum urea (70-120 mg/dl). Renal disease was the first manifestation of HIV infection in six patients, whereas the diagnosis was made on autopsy in three. The duration from HIV infection to development of HIVAN ranged from 5 months to 10 years. CD4(+) cell count, done in only three patients due to financial constraints, was below 200/mm(3). The kidneys were hyperechoic on abdominal ultrasound in all patients, and three (30%) showed grossly enlarged kidneys. Histology of renal tissues available by autopsy in three patients showed mainly collapsing focal segmental glomerulosclerosis. Treatments given were angiotensin-converting enzyme (ACE) inhibitors and highly active antiretroviral therapy (HAART) in four and two patients, respectively, and one patient underwent peritoneal dialysis. On outcome analysis, seven (70%) patients died, two were lost to follow-up, and one was alive on HAART therapy at the writing of this article. In conclusion, HIVAN occurs in Nigeria children, and the mortality is very high from uremia.

Spontaneous enterocutaneous fistula--A rare presentation of enteric fever.

BACKGROUND: Enterocutaneous fistulae (ECFs) after typhoid perforation have been previously recorded postoperatively due to repair leak or new perforation. Spontaneous ECF formation due to primary intra-abdominal pathologic processes has been attributed to infectious diseases such as tuberculosis and Crohn's disease. A review of the literature has shown no previous report of spontaneous ECF caused primarily by salmonella typhi infection. OBJECTIVE: To report a case of spontaneous ECF due to salmonella typhi infection. CASE REPORT: An eight-year-old female presented with high fever and weight loss of two weeks' duration and a one-week history of a foul-smelling umbilical discharge. She was ill looking, wasted, with evidence of peritonitis. An emergency exploratory laparotomy revealed multiple perforations at the antimesenteric border of the ileocecal valve. With intestinal resection and anastomosis and the use of broad spectrum antibiotics, her clinical state improved. Tissue biopsy showed hemorrhagic necrosis with infiltration by mononuclear inflammatory cells. CONCLUSION: ECF is a rare complication of enteric fever, Enteric fever should therefore be considered in ill children presenting with ECF in the absence of a history of previous surgery, or blunt or penetrating trauma.

Childhood nephrotic syndrome: change in pattern and response to steroids.

BACKGROUND: In our center, childhood nephrotic syndrome (NS) had been reported for over a decade to be steroid sensitive contrary to reports in other parts of Nigeria. The purpose of this study was to determine if there are changes in presentation and response to steroids, with reviews of the literature on NS. METHODS: Analysis of 28 patients seen at the University of Port Harcourt Teaching Hospital, Nigeria, from 1999-2004 with the diagnosis of NS was performed. RESULTS: There were 14 girls and 14 boys with NS. The peak age was 1-4 years. Twenty (71.4%) children had idiopathic nephrotic syndrome (INS). Four had chronic renal failure, one had sickle cell disease (HbSS), two were positive to human immunodeficiency virus (HIV) 1 and 2, and one had pulmonary tuberculosis. Anemia was found in 13 patients, while 17 had Plasmodium falciparum. Plasmodium malariae and hepatitis-B surface antigen were not isolated. Renal biopsy was performed in four patients and revealed minimal-change disease in one child, focal segmental glomerulosclerosis in two and no conclusive result in one patient. Oral prednisolone was used in INS. After one month of therapy, 16 of 20 responded, of which 12 (75%) were <5 years. The NS relapsed in 15 of 16 steroid-sensitive patients. Cyclophosphamide and levamisole were used in four and one patients with FRNS, respectively. Four (14.3%) patients died; all were secondary NS. CONCLUSION: INS remains common in our center, and the majority respond to steroid therapy

Kocher-Debre-Semelaigne syndrome: a case report.

BACKGROUND: Kocher-Debre-Semelaigne (KDS) syndrome is a myopathy of hypothyroidism associated with pseudohypertrophy in infancy or childhood. There are few reported cases of KDS syndrome in the literature. STUDY DESIGN: We present a 5-year-old boy with poor growth and delayed dental and motor development. There was no family history. On examination he had coarse facies, large protruding tongue, athletic build, short stature and mental retardation. The diagnosis of KDS syndrome was based on laboratory and radiologic evidence of congenital hypothyroidism and muscle enlargement. He was started on L-thyroxine at the dose of 4ug/kg/day, and he has shown marked increase in alertness with regressing muscle bulk after 4 weeks of treatment. A short review of the literature is also presented.

Acute renal failure in Nigerian children: Port Harcourt experience.

Acute renal failure (ARF) is a significant cause of morbidity and mortality in children. It may be pre-renal, intrinsic, or post-renal (obstructive) in aetiology. ARF was investigated in children in the south-southern part of Nigeria to determine the prevalence, aetiology, management and outcome of ARF. A retrospective review of data from all children from birth to 16 years of age admitted into the Department of Paediatrics, University of Port Harcourt Teaching Hospital (UPTH), with the diagnosis of ARF over an 18 year period (January 1985 to December 2003) was performed. Information was obtained about the age, sex, clinical features, blood pressure, laboratory and radiological investigations, aetiology, and treatment received including dialysis. Information on the outcome, factors influencing outcome, and possible causes of death were reviewed. There were 211 patients, 138 (65.4%) males and 73 (34.6%) females (M:F, 1.9:1), with a hospital prevalence of 11.7 cases/year. The patients were aged 5 days to 16 years (mean 5.6+/-4.7 years). Oliguria was the most common clinical presentation in 184 (87.2%) patients. Hypertension was seen in only 39 (18.5%) patients. The causes were age-related. The neonates had ARF from severe birth asphyxia 27 (35.5%), septicaemia 17 (22.4%), with tetanus 4 (5.3%) and congenital malformations 11 (14.5%). Sixty-one (28.9%) and 29 (13.7%) patients had ARF from gastroenteritis and malaria respectively. The patients with leukaemia were all more than 10 years old and had acute lymphoblastic leukaemia. Two patients (1.9%) had Burkitts lymphoma involving the abdomen and 3 patients had HIVAN. 112 (53%) patients had anaemia with a mean haematocrit of 20.25+/-6.9%. Dialysis was indicated in 108 patients, but only 24 patients (22.2%) had peritoneal dialysis (PD), because of financial constraints and lack of dialysis equipment. Mortality rate was 40.5%. The causes of death were uraemia 60 (70.6%), overwhelming infection 5 (5.9%), and recurrent anaemia 20 (23.5%). Hypertension (X2 15.7, P<0.001) and lack of dialysis (X2 7.96, P<0.01) significantly affected outcome. Other factors associated with demise were delayed presentation (58.8%), use of herbal treatment (35%), and unaffordability of treatment (40%). ARF is a significant cause of mortality in Nigerian children. The patients are not adequately managed because of poverty and lack of facilities for dialysis. The causes of ARF in our environment are preventable, and should be expected.

Renal vein thrombosis in the neonate: a case report and review of the literature.

We report a case of bilateral renal vein thrombosis in a neonate, and reviewed available literature. The neonate was a macrosomic male born to a mother with glycosuria in pregnancy. There was delay in commencing breasttfeeding for up to 36 hours due to lack of lactation by themother. Clinical and laboratory examination showed enlarged palpable kidneys and azotemia. Diagnosis of bilateral renal vein thrombosis was confirmed by renal ultrasonography. The child is being managed conservatively. Measures aimed at prevention of the disease because of its poor outcome were highlighted.

Chronic renal failure in children: a report from Port Harcourt, Nigeria (1985-2000).

A 15-year review of children who presented with chronic renal failure (CRF) to the University of Port Harcourt Teaching Hospital, Rivers State of Nigeria, was carried out. Forty-five children (28 boys, 17 girls) with CRF, defined as a glomerular filtration rate below 30 ml/min per 1.73 m(2) body surface area or a rise in serum creatinine above 120 micro mol/l for at least 6 months, often accompanied by other biochemical abnormalities, were identified. The median annual incidence of CRF was 3.0 per million children. The prevalence of CRF increased from 12.5 in the 1985-1990 periods to 15 per million children after 1995. Acquired disorder was the major cause of CRF. Glomerulopathies were the cause in 53.3% of patients, mainly chronic glomerulonephritis (56.5%) and nephrotic syndrome (30.4%). Hepatitis B surface antigen was positive in 2 patients. Congenital disorders accounted for 28.9% of all cases of CRF, which is lower than data from other countries. Posterior urethral valve was the only congenital disorder causing CRF in the study. No child with hereditary renal disorder as a cause of CRF was identified. Children with congenital disorders were diagnosed at an earlier age. The mortality rate was high (46.7%), as most patients were managed conservatively, since there were no permanent facilities for chronic dialysis or renal transplantation in Nigeria. The study shows that CRF is common in Nigerian children, and there is an urgent need for the establishment of facilities for renal replacement therapy.

Effects of pyrimethamine versus proguanil in malarial chemoprophylaxis in children with sickle cell disease: a randomized, placebo-controlled, open-label study.

BACKGROUND: Malarial chemoprophylaxis is essential for patients with homozygous sickle cell disease (SCD) who live in areas where malaria is endemic. Endemic regions include most sub-Saharan African countries and Southeast Asia. OBJECTIVE: This study compared the efficacy and tolerability of pyrimethamine with that of proguanil and placebo in the prevention of malaria and the complications of Plasmodium falciparum infection (hepatomegaly, splenomegaly, bone pain crisis, hemolytic crisis) in children with SCD. METHODS: In this single-center, open-label study conducted in Nigeria, children aged 1 to 16 years with SCD were randomly assigned to receive tablets of pyrimethamine (0.5 mg/kg·wk), proguanil (1.5 mg/kg·d), or placebo (vitamin C, 7 mg/kg·d) for 9 months as prophylaxis from February to December (which includes the rainy season), the period of greatest malarial transmission. The clinical and laboratory features of malaria (presence of parasitemia, parasite count and density, hepatomegaly and/or splenomegaly, symptomatic malarial infection [fever, rigors], bone pain crises, and hemolytic crises) were assessed. RESULTS: A total of 97 patients completed the study (49 boys, 48 girls; mean [SD] age, 7.8 [4.3] years). The pyrimethamine group comprised 36 patients (mean [SD] age, 8.1 [4.3] years; range, 2-16 years); the proguanil group, 32 patients (mean [SD] age, 9.5 [3.7] years; range, 3-16 years); and the placebo group, 29 patients (mean age, 5.9 years; range, 1-14 years). The male:female ratio was 1.1:1 in the pyrimethamine group, 1:1.7 in the proguanil group, and 1.6:1 in the placebo group. Parasitemia was noted in 7 patients (19.4%) in the pyrimethamine group, 6 (18.8%) in the proguanil group, and 7 (24.1%) in the placebo group at the start of the study. P falciparum was the only isolate. The mean parasite density over the 9-month period was significantly lower with proguanil compared with pyrimethamine (P = 0.045) and placebo (P<0.05). The incidence of splenomegaly was least with pyrimethamine, but this group had the most patients clinically diagnosed with malaria. Hospitalizations and episodes of bone pain and hemolytic crisis occurred most frequently with placebo. One patient in the placebo group died of septicemia. CONCLUSIONS: Proguanil and pyrimethamine both reduced parasitemia; however, proguanil significantly decreased mean parasite density more effectively than pyrimethamine. Pyrimethamine and proguanil may protect children with SCD from the complications of P falciparum infection despite persistent parasitemia. Proguanil may be more useful than pyrimethamine in the prevention of bone pain crises among patients with SCD.