Prsentation PowerPoint

1
ESPN 2006 Palermo 7-10October
PEADIATRIC NEPHROLOGY
The North African Perspectives
Amal Bourquia Casablanca
2
North Africa

• No single accepted definition
• - UN definition Algeria, Egypt,
• Libya, Tunisia, Morocco, Sudan
• - Afrique du Nord
• Morocco, Algeria, Tunisia
• NA is referred to as white africa
• Inhabitants complexion is more or less white
  compared to
• sub- saharian Africans
• Population
• Doubled since the 60s gt 70 millions
  inhabitants
• Adolescents and young adults gt more than half
  of population

3
North Africa

• Positive changes
• More practitioners than before
• Improvement in immunisation recommended by the
  WHO
• Care during pregnancy
• An obvious decrease in consanguine marriages
• Effective therapy of acute diarrhea with
  rehydratation therapy
• Lower incidence streptococcal, staphylococcal,
  tuberculosis
• Infant and child mortality has fallen 51 to
  21 / last 20 years
• Chronic diseases more important

4
North Africa
What characterises the management of renal
diseases in NA ?
No satisfactory socio-economic conditions

• Poor health spending and poor infrastructure
• Few hospitals specialising in children care
  2/country
• Hardly any units for managing paediatric
  nephrology
• No access to nephrology care for people living
  far from big cities
• Countries leaders non sensitised, little
  motivation
• Seeking medical care in developed countries
• Development of domestic PN units

5
North Africa
Population and Human ressources

• Population
• Illiteracy
• Scarce information
• Health insurance
• Non compliance
• Practitioners
• More and more paediatricians
• Little attention given to PN during training
• Paucity of pediatricians with PN qualifications
• Few qualified nurses

6
North Africa
Epidemiology

• No statistical data / national and regional
  level
• Paediatric renal diseases largely unknown
  entity
• Obstacle to the adoption of preventive measures

Renal diseases seem to be more frequent
High percentage of children less than 15 years
(35)
7
North Africa

• Frequency of infectious diseases / Urinary tract
  infection
• Frequent hereditary diseases / consanguine
  marriages
• Screening and genetic advice blocked by social
  practices
• Toxic products in traditional medicine
• (Takaout PPD, Harmel, Addad)
• Absence of education programs
• Renal diseases are often treated at a late stage
  /
• complicated forms

What diseases and what treatment ?
8
Common diseases
Acute renal failure

• Morbidity and mortality factor of infants and
  children
• Aetiology differs according to age and
  geographical areas
• ARF in Moroccan children

• Retrospective study 1982 and 2004
• 2 centres in Casablanca
• 209 cases of ARF 60 boys and 40 girls
• Age ranged between 06 months and 15 years
• Management
• Dialysis 79 PD 28, HD 72
• Emergency 48.7

9
Common diseases
Acute renal failure

• Causes
• Acute glomerulonephritis 42.8
• Haemolytic uremic syndrome 15
• Renal hypo perfusion 10
• Acute interstitial nephritis 09.5
• Urinary tract obstruction 06.9
• Not identified 10.8
• Outcome
• Normal renal function 49 (65 of GN)
• Higher in non-oliguric group
• Mortality rate 17 CRF 8

10
Common diseases
Acute renal failure

• Low mortality rate with isolated renal failure
• Other areas
• Lack of dialysis facilities
• Unavailability of trained doctors and nurses
• Use of toxic products
• Ignorance, poverty
• Delay in arriving at the specialized centre

High mortality
11
Common diseases
Acute glomerulonephretis

• AGN Post streptococcal (beta haemolytic)
• The peak age ranges from 4 to 9 years
• PSAGN
• A marked decline in the prevalence of PSAGN /
  complications
• Predominance of a pharyngeal infection
  antecedent
• Prognosis good with prompt and proper treatment
• Rural areas PSAGN diagnosed at a late stage
• Present with one or more complications

12
Common diseases
Nephrotic syndrome

• Paucity of studies
• A retrospective study 1990 - 2000
• 176 Moroccan children lt 16 years with INS

Histhopathological spectrum
13
Common diseases
Nephrotic syndrome

• MPGN
• High incidence and remains common in NA
• Seems to appear at an earlier age in NA
• Severe course with rapid progression to ESRF

Lupus nephritis Morocco
Tunisia Patients 27 20 Period/years 16
14 Mean age 8,7 9.3 Nephrotic syndrome
31 25 Renal involvement 78 75 Significant
hypertension 53 45
14
Common diseases
Urinary tract infection

• Most common nephrological problem
• Often undetected
• Investigations
• VUR not a major problem / little reflux
  nephropathy
• Obstructive uropathy is common
• posterior urethral valves
• Characteristics
• Late diagnosis (PUV)
• Frequent ESRF
• All males are circumcised

15
Common diseases
Urinary tract infection

• Neuropathic bladder
• NB due to spina bifida or NNNB important cause
  of CRF
• A threat to the kidneys if not managed
  appropriately
• Clean intermittent catheterization is not
  started early
• Children required dialysis as they were in ESRF

Frequent CRF secondary to uropathy Earlier
diagnosis and treatment could lead to a lower
incidence
16
Common diseases
Urinary tract stone

• Important health problems in NA
• Calcium oxalate composition
• 120 Tunisian children (5 months-15 years)
• Bladder calculi whewellite (69) struvite (22)
• Nucleus of bladder stones ammonium urate (45)
• Nucleus of kidney and ureteral calculi ammonium
  urate (38),
• whewellite (24), carbapatite (13), or struvite
  (11).
• Exclusive metabolic factors 25.

Endemic urolithiasis 40 involving simultaneous
nutritional, metabolic, and infectious factors,
its nucleus composed of ammonium urate
17
Common diseases
Primary hyperoxaluria

• Frequent cause of CRF / consanguinity
• Diagnosis family history, urine oxalate level
• Rarely with AGA activity, DNA
• ESRD starts early
• Death

Morocco Tunisia Nb/ sexe 27 (12 girls) 24
(10) Mean age (years) 4,8 6,3 Consanguinity
rate 76 71 Nephrocalcinosis 91 98 Urolithi
asis 43 44 Delai before diagnosis 1,8
yaers 1.3 year Severe RF in Dg 81 78
18
Common diseases
Chronic renale failure

• No data on the true incidence and prevalence of
  CRF
• Incidence in Tunisia
• ESRF 100 120 pmp per year
• ESRF in children 7/ year / million
• Causes/ Tunisia Morocco
• Glomerulonephretis 19 21
• Hereditary nephropathies 29 08
• Urological anomalies/ PN 16 38
• Hypoplasia / Dysplasia 03 02
• Multisystem diseases 08 05
• Unknown aetiology 25 26

19
Common diseases
Renal remplacement therapy

• Management of CRF significant problem
• Care for children with ESRF major problem
• Delayed diagnosis
• Failure of measures to slow progression of renal
  failure
• Financial problems/ limited resources
• Difficulty to employ key workers
• Failure at school
• Isolated experiences with paediatric
• dialysis programs, personal efforts
• Not always efficient and sufficient

20
Common diseases
Renal transplantation

• 1982 Islamic Ulema (scholars) approved the acts
• of organ donation and transplantation
• 1986 The first LRT in NA
• 2005 LRT 132 Morocco, 147 Algeria, 620 Tunisia
• RT programs not satisfactory
• Socio-economic factors should be evaluated before
  RT

21
Perspectives
Is the promotion of PN justified in NA?

• Humanitarian grounds
• Children with RD exist independently of PN
  services
• Cost / benefits
• The lack of an explicit health care policy of PN
  has delirious consequences
• Improper use and overuse of costly procedures
• hospitalisation and intensive health care
  facilities
• An unequal allocation of resources favouring the
  
• wealthy and socially previligied people

22
Perspectives
How to improve management of RD? What should be
doune?

• The challenge is affordable access to
• Prevention strategies
• Effective medication
• Contemporary techniques
• A permanent conflict
• Is it rational to spend money on high cost
  technologies
• for the treatment of few patients when these
  resources
• could be allocated to basic health service ?
• which should be more beneficial ?

23
Perspectives

• Development of a PN program
• taking into account the specificities of NA
• Adequate planning, management and assessment
• of prevention and treatment of renal diseases
• Infrastructure and equipment
• Adapting the treatment to the context
• Training
• Prevention
• Education

24
Perspectives
Infrastructure and equipement

• Extending health care to rural areas (primary
  care, prevention)
• Improving the units to serve a large number of
  children
• Creating PN units with optimal distribution
• Preventing waste of resources Better
  organisation of services
• Contribution and collaboration of different
  sectors
• Public health, Private practices, NGOs
• Availability of facilities of treatment
• intensive care, dialysis, surgery and
  transplantation
• Twinning to transfer technology

25
Perspectives
Treatement adapted to the context

• Overcome socioeconomic limitations
• Taking into account the communitys culture and
  beliefs
• Using definitive therapies where possible
• Using an effective but inexpensive medications
• Improving a locally adequate RT program / LD
• Favouring PD bridge between ESRD / RT
• Providing data national and regional registries
• Development of national healthcare policies
• appropriate to the epidemiology of these countries

26
Perspectives
Training

• Well-trained paediatric nephrologists
• Locally prevalent of renal diseases
• Preventive aspects and early diagnosis
• Optimum management with available resources
• Taking into consideration the socioeconomic,
  political
• and cultural context
• Cooperation
• Domestic physicians in charge of children with
  KD
• International and regional

27
Perspectives
Prevention

• Prenatal diagnostic / Difficulties
• Developing genetic advice
• Awarness of individual at risk
• Early detection and treatment
• Availability of primary care
• Good management of KD by paediatrician or GP
• Sensitising people about the danger of using
  toxic products

28
Perspectives
Educating programs

• An educational approach centred not only on
  diseases but
• on human beings, families and communities
• Taking into account the culture and beliefs of
  communities
• Involvement of different institutions
• - The ministry of health
• - Community leaders
• - General practitioners/ specialists
• - NGOs

29
Perspectives

• Example of NGOs
• Books and documents

• Media audio,TV, web, magazine..
• Educating and providing information to families
  (mothers)

30
The North African Perspectives
Paediatrician nephrologists are directly involved
in the defence of the rights of patients
Children with kidney diseases are a minority in
society The quality of a society is related to
the way it treats its minorities