|Year : 2015 | Volume
| Issue : 2 | Page : 55-60
Etiological Spectrum of Chronic Kidney Disease in Young: A Single Center Study from South India
Putta Rajasekar, Vaddera Sameeraja, Beldari Poornima
Department of General Medicine, Government General Hospital, Kurnool Medical College, Kurnool, Andhra Pradesh, India
|Date of Web Publication||24-Apr-2015|
Department of General Medicine, Government General Hospital, Kurnool, Andhra Pradesh - 518 002
Source of Support: None, Conflict of Interest: None
Background and objectives: Chronic kidney disease (CKD) is an important, chronic, noncommunicable disease epidemic that affects the world. Lack of registries precludes an accurate estimation of the number of patients with CKD. Only a few studies are done in our country to assess etiology of CKD in young patients. This study was aimed to assess the etiology of CKD in young patients. Materials and Methods: Data were collected from 50 patients of CKD between 15 and 40 years age who presented to Government General Hospital, Kurnool from July 2012 to June 2013. They were clinically evaluated and underwent relevant investigations including renal biopsy in indicated cases. Results: Of the 50 patients studied, there was an overall male preponderance over all age groups with a mean age of 27.6 ± 4.9 years. Small kidneys were seen in 70% of patients. 92% of patients had proteinuria. Most common symptoms of presentation were related to gastrointestinal disturbances, breathlessness, easy fatigability, and urinary disturbances. Pallor, pedal edema, and facial puffiness were major clinical features. Majority (62%) had CKD of unknown etiology. In this unknown etiology patients, majority were found to have glomerular disease (42%) based on clinical presentation and other supporting investigations. 92% presented in stage IV or stage V CKD. Histopathologically etiology was proven among 19 patients (38%) with renal biopsy. Conclusion: It is concluded that male patients in the third and fourth decades were in the majority requiring medical care. Chronic Glomerulonephritis of unknown causes constitutes a major etiology among the young presenting in late stages of CKD.
Keywords: Chronic glomerulonephritis, chronic kidney disease, etiology, young patients
|How to cite this article:|
Rajasekar P, Sameeraja V, Poornima B. Etiological Spectrum of Chronic Kidney Disease in Young: A Single Center Study from South India. J Integr Nephrol Androl 2015;2:55-60
|How to cite this URL:|
Rajasekar P, Sameeraja V, Poornima B. Etiological Spectrum of Chronic Kidney Disease in Young: A Single Center Study from South India. J Integr Nephrol Androl [serial online] 2015 [cited 2019 Jun 16];2:55-60. Available from: http://www.journal-ina.com/text.asp?2015/2/2/55/155776
| Introduction|| |
Chronic kidney disease (CKD) has become a major cause of morbidity and mortality in developing countries. CKD patients commonly experience a long asymptomatic phase before showing clinical symptoms. The major outcomes of CKD, regardless of the specific diagnosis (i.e., type of kidney disease), include progression to kidney failure, complications from decreased kidney function, and development of cardiovascular disease. Increasing evidence shows that early detection and treatment often can prevent or delay some of these adverse outcomes and prevent end-stage renal disease (ESRD) occurrence. CKD is of diverse etiology like diabetic nephropathy, hypertensive nephrosclerosis, glomerulonephritis, chronic interstitial nephritis, obstructive uropathy, renovascular, genetic mediated. A comprehensive understanding of the prevalence of CKD and its risk factors is, therefore, necessary in different people from different areas. However, there is still paucity on much data regarding spectrum of renal disease in India, and it places an immense strain on health care system in any society.
The kidney disease outcomes quality initiative of National Kidney Foundation  defines CKD as either kidney damage or decreased glomerular filtration rate <60 mL/min/1.73 m 2 for 3 or >3 months. Kidney damage is defined as pathological abnormalities or markers of damage, including abnormalities in blood or urine tests or imaging studies. Kidney failure is defined as either (1) a level of glomerular filtration rate (GFR) to <15 mL/min/1.73 m 2 , which is accompanied in most cases by signs and symptoms of uremia, or (2) a need for initiation of kidney replacement therapy (dialysis or transplantation) for treatment for complications of decreased GFR, which would otherwise increase the risk of mortality and morbidity.  Some patients may need dialysis or transplantation at GFR 15 mL/min/1.73 m 2 because of symptoms of uremia.
Chronic kidney disease is an important, chronic, noncommunicable disease epidemic that affects the world, including India. Because of the absence of a renal registry in India, the true magnitude of CKD/ESRD is unknown. Two community-based studies, although methodologically different, have shown a prevalence of chronic renal failure of 0.16% and 0.79%.  For some reason, once kidneys have been damaged, they may continue to get worse over months and years, even long after the disease that caused the damage has gone. This is more likely if you have high blood pressure and if there is much protein leaking into the urine. Renal failure that requires dialysis or a kidney transplant to keep you alive is known as end-stage renal failure. 
Patients with CKD stage III or lower (GFR ≥30 mL/min) generally are asymptomatic and do not experience clinically evident disturbances in water or electrolyte balance or endocrine or metabolic derangements. In general, these disturbances clinically manifest with CKD stages IV and V (GFR <30 mL/min). Female patients with advanced CKD commonly develop menstrual irregularities. Women with ESRD are typically amenorrheic and infertile. Pregnancy in CKD can be associated with accelerated renal decline. In advanced CKD and ESRD, pregnancy is associated with markedly decreased fetal survival. It has been suggested that intrauterine malnutrition and decreased birth weight is associated with a decrease of the number of nephrons and increase the risk of CKD in adults. If such observations are confirmed, primary prevention of CKD will also require great attention to women's health and nutrition during pregnancy. Patients with CKD generally progress to ESRD. The rate of progression depends on the underlying diagnosis, on the successful implementation of secondary preventive measures and the individual patient.
| Materials and Methods|| |
A prospective study of 50 adult patients between 15 and 40 years age group with chronic renal failure was undertaken after ethical clearance and with informed consent at government general hospital, Kurnool. Studied from July 2012 to June 2013. Patients with age <15 and >40 and with acute kidney injury were excluded. After obtaining a detailed history, general physical examination, systemic examination, patients were subjected to relevant investigations. Random blood sugar, blood urea, serum creatinine, complete blood picture, serum electrolytes, complete urine examination, serum calcium, phosphorus, total proteins, albumin, ultrasound abdomen, HIV antibodies, hepatitis B surface antigen (HBsAg), hepatitis C virus (HCV), chest X-ray, electrocardiography, and renal biopsy were done wherever indicated.
In subjects with clinical features of CKD, 5 mL of the blood sample is drawn in a plain sterile bottle for estimation of serum creatinine, serum electrolytes, serum calcium. 2 mL of blood in oxalate bottles for blood glucose estimation. Early morning midstream urine was collected in sterile containers for complete urine analysis which included specific gravity, albumin, pus cells, epithelial cells, red blood cells (RBC's), casts and crystals. 2 mL of blood with ethylenediaminetetraacetic acid was collected for complete blood picture, HIV 1 and 2 antibodies (tridot method), HBsAg, HCV were tested in microbiology department. Ultrasonogram of abdomen and chest X-ray were done in the radiology department. Creatinine clearance (CrCl) can be calculated using Cockcroft-Gault formla  and modification of diet in renal disease study formula.  In this study, Cockcroft-Gault formula is used for calculating creatinine clearance. Antinuclear antibodies (ANA), double - stranded DNA antibody levels, serum complement levels were performed in suspected patients. Renal biopsy was performed in our institution and was sent for analysis to outside lab in view of inavailability of immunofluorescence and other stains in our institution and results were interpreted.
| Results|| |
A total of 50 patients fulfilling inclusion criteria were studied over a period of 1-year. Age group included was 15-40 years with the majority of the affected in second and third decade. Mean age group affected was 27.6 ± 4.9. Male:female ratio was 2.3: 1 showing males affected more than females. Gastrointestinal tract disturbances (58%), breathlessness (50%), easy fatigability (44%), and oliguria (30%), nocturia (24%) were the most common symptoms of presentation. Among signs of chronic renal failure, pallor (72%) was seen in majority followed by pedal edema (26%), facial puffiness (20%), pericarditis (13%), pulmonary edema (12%). Anemia was noted in 88% of subjects with mean hemoglobin of 6.78 ± 2 (g/dL). Serum creatinine is >2 mg/dL in 100% patients. Complete urine analysis showed proteinuria in 92%, decreased specific gravity in 72%. Epithelial cells, pus cells, RBC, casts, crystals were present in less percentage. Based on CrCl, most of them were in stage III (46%) and stage IV (46%) of CKD. Small-sized kidneys were present in 70% of patients, large size in 14% based on ultrasonography. Hyperkalemia was found in 74% patients with mean serum potassium of 5.2 ± 0.79 meq/L. Hypocalcemia was noted in 70% of patients with mean serum calcium being 7.7 ± 0.8 mg/dL [Table 1] shows the complete details of the study group.
Among 50 patients, etiology of CRF was proved histopathologically by renal biopsy in 19 patients (38%) which showed etiologies like lupus nephritis (8%), membranoproliferative glomerulonephritis (MPGN) (8%), diabetic nephropathy (8%), IgA nephropathy (6%), focal segmental glomerulosclerosis (FSGS) (6%), HIV-associated nephropathy (2%). In the remaining 31 patients, renal biopsy was not done as they had contracted kidneys at presentation and among these unproven patients, based on anemia, hypertension, edema, urinary disturbances, and other clinical parameters grouped into chronic glomerulonephritis (67.7%) and chronic interstitial nephritis (32.2%). Obstructive uropathy 4 (8%), renal artery stenosis 3 (6%), polycystic CKD (PCKD) 2 (4%), neurogenic bladder 2 (4%), reflux nephropathy 2 (4%) are some of the etiologies in biopsy unproven patients.
| Discussion|| |
The present study was done over a period of 1-year, included 50 patients of <40 years and >15 years of age with CKD and were assessed clinically and histopathologically to establish the etiology of CKD. Among the 50 subjects, the etiology was proven histopathologically in 19 patients (38%) which was of diverse etiologies ultimately leading to chronic glomerulonephritis. In the remaining 31 patients, biopsy (62%) was not done as they had contracted kidneys at presentation, and this histopathologically unproven group were further classified based on presence or absence of anemia, hypertension, oliguria, and edema patients 21 patients (42%) had chronic glomerulonephritis (CGN) and 10 patients (20%) had cervical intraepithelial neoplasia which has shown that chronic glomerulonephritis due to unknown causes was the predominant etiology
United States Renal Data System 2004 annual data report revealed that the incidence rate of ESRD is higher for males with 409/million population compared to 276 for females.  Varma and Raman conducted a cross-sectional study that showed predominance in males (66.04%) than females (33.96%).  Present study was comparable showing majority of affected were males (70%) and females (30%) [Table 2]. Rajapurkar and Dabhi (2010) has observed CKD had a higher frequency in males, whereas those with CKD of unknown etiology were younger and had more females. 
National Health and Nutrition Examination Survey III estimated prevalence of CKD in adults of which 4.3% were in stage III which was not comparable with the present study because it included subjects only <40 years of age.  Rajapurkar and Dabhi (2010) observed that in CKD of unknown etiology, the majority were in stage V which is comparable with the present study that showed majority to be in stage IV and stage V  [Table 3].
Ohsawa et al. observed that young metabolic persons with both preserved estimated GFR and albuminuria should be considered as a very high-risk population for all-cause death.  In the present study, 92% had proteinuria which is comparable. Keller et al.  concluded that there was an association between CKD and ureteric calculus regardless of location which was present in the present study as obstructive uropathy lead to CKD in 8% of our patients. Siddappa et al. conducted a retrospective analysis which showed a prevalence of 7.8% of IgA nephropathy leading to varying degree of renal insufficiency.  The present study had 6% of patients with IgA nephropathy which is comparable. Jung et al.  in a retrospective analysis observed that HIV-associated renal disease were predominant in olden days but since introduction of highly active antiretroviral therapy, renal disease not directly related to HIV has become the predominant cause, in our study only one patient (2%) had HIV-associated nephropathy and variation could be because of increased awareness and prompt initiation of therapy.
Landau et al.  studied etiology of CKD in pediatrics in Israel. The main etiologies were hypoplasia 35%, obstructive uropathy 13%; genetic renal disease 28%; and glomerulonephritis 15%. Rajapurkar et al.  observed etiology to be diabetic nephropathy 31%, undetermined etiology 16%, chronic glomerulonephritis 14% and hypertensive nephrosclerosis 13% in adults. Neild  has observed that congenital anomalies of the kidney and urinary tract account for 20% and predominant glomerulonephritis (histologically not examined) accounted for 28-36%. Present study showed obstructive uropathy 8%, lupus nephritis in 8%, diabetic nephropathy in 8%, MPGN in 8%, IgA nephropathy in 6%, renal artery stenosis in 6%, FSGS in 6%, PCKD in 4%, reflux nephropathy in 4%, neurogenic bladder in 4%, HIV nephropathy in 2%. [Table 4] compares the etiology with other studies.
IgA nephropathy and obstructive uropathy are comparable with other studies. Diabetic nephropathy is not comparable with Rajapurkar et al. as it included different population in a large number, and the present study included patients only <40 years of age. Glomerulonephritis is comparable with Neild. Genetic renal disease and congenital anatomic disorders are not comparable with Daniel et al. since the present study includes young adults, and this was a small group, no definite conclusions were drawn. The incidence of glomerulonephritis in the present study is much higher than any other study as socioeconomic living conditions, streptococcal infections are possibly related to this.
| Conclusion|| |
Chronic kidney disease is a worldwide public health problem, both for the number of patients and cost of treatment involved. Globally, CKD is the 12 th cause of death and the 17 th cause of disability, respectively.  In spite of nephrology being a specialty since seventies, there is a paucity of data regarding spectrum of renal diseases in India. Male patients in the third and fourth decade were in the majority requiring medical care. Young patients have a lower income and more advanced CKD. According to the first annual report published by the CKD registry of India involving 13,151 patients, diabetes and hypertension were major causes of CKD in India accounting for 28.5% and 16.2%, respectively, as in other parts of the world.  However, unlike the other registry data, although hypertension prevalence is declining compared to previous years, chronic glomerulonephritis remains the second common cause of CKD and accounts for 16.2%. Chronic glomerulonephritis constitutes a major etiology among the young though diabetes is the leading etiology in the general population. Etiologies like diabetes, poststreptococcal glomerulonephritis are preventable, and early intervention can retard the progression to CKD. The CKD population in the public sector hospitals was comprised of a higher proportion of younger patients from poorer socioeconomic classes presenting in stages V CKD. , Hence, more preventive measures should be undertaken to prevent treatment burden.
Low birth weight, malnutrition, low socioeconomic status, and low educational status are risk factors of CKD in young. As CKD affects young patients who are in the highly productive age group, with its social and economic implications in the Indian context, one must gear up to organize ourselves for providing the best possible care to the needy, the patients considering the limited resources available. More data on the spectrum of renal diseases, especially in young patients need to be collected all over the country for better management.
| References|| |
National Kidney Foundation. K/DOQI clinical practice guidelines for chronic kidney disease: Evaluation, classification, and stratification. Am J Kidney Dis 2002;39:S1-266.
Agarwal SK. Chronic Kidney Disease and its prevention in India. Kidney International, Supplement 98 (2005), Vol. 68, pp. S41-S5.
Stevens LA, Greene T, Kusek JW. Simplified equation to predict glomerular filtration rate from serum creatinine. J Am Soc Nephrol 2000;11:A828.
Varma PP, Raman DK. Prevalence of early stages of chronic kidney disease in apparently healthy central government employees in India. Nephrol Dial Transplant 2010;25:3011-7.
Rajapurkar M, Dabhi M. Burden of disease-Prevalence and incidence of renal disease in India. Clin Nephrol 2010;74 Suppl 1:S9-12.
Ohsawa M, Fujioka T, Ogasawara K, Tanno K, Okamura T, Turin TC, et al.
High risks of all-cause and cardiovascular deaths in apparently healthy middle-aged people with preserved glomerular filtration rate and albuminuria: A prospective cohort study. Int J Cardiol 2013;170:167-72.
Keller JJ, Chen YK, Lin HC. Association between chronic kidney disease and urinary calculus by stone location: A population-based study. BJU Int 2012;110:E1074-8.
Siddappa S, Kowsalya R, Mythri KM. IgA nephropathy in a tertiary care center from south India. Indian J Nephrol 2011;21:230-4.
Jung O, Haack HS, Brodt HR, Grützmacher P, Geiger H, Amann K, et al.
Changing spectrum of renal disease in HIV infection. Dtsch Med Wochenschr 2013;138:1887-91.
Landau D, Schreiber R, Kleinman A, Vodonos A, Shalev H. Pediatric chronic kidney disease rates in Southern Israel are higher than reported. F1000Res 2013;2:186.
Neild GH. What do we know about chronic renal failure in young adults? I. Primary renal disease. Pediatr Nephrol 2009;24:1913-9.
Veerappan I, Abraham G. Chronic kidney disease: Current status, challenges and management in India. Ch. 130, Sec. 17:apiindia.org/medicine_update_2013. p. 593-7.
Prabahar MR, Chandrasekaran V, Soundararajan P. Epidemic of chronic kidney disease in India-what can be done? Saudi J Kidney Dis Transpl 2008;19:847-53.
Rajapurkar MM, John GT, Kirpalani AL, Abraham G, Agarwal SK, Almeida AF, et al.
What do we know about chronic kidney disease in India: First report of the Indian CKD registry. BMC Nephrol 2012;13:10.
Vijayan M, Ravi R, Abraham G, Ravi R, Mathew M. Chronic kidney disease, a herculean task. Open Urol Nephrol J 2014;7:56-9.
[Table 1], [Table 2], [Table 3], [Table 4]