Chronic kidney disease among children in Guatemala

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1 Investigción originl / Originl reserch Pn Americn Journl of Public Helth Chronic kidney disese mong children in Guteml Alejndro Cerón, 1 Meredith P. Fort, 2 Chris M. Morine, 1 nd Rndll Lou-Med 3 Suggested cittion Cerón A, Fort MP, Morine CM, Lou-Med R. Chronic kidney disese mong children in Guteml. Rev Pnm Slud Public. 2014;36(6): bstrct Key words Objective. To describe the distribution of peditric chronic kidney disese (CKD) in Guteml, estimte incidence nd prevlence of peditric end-stge renl disese (ESRD), nd estimte time to progress to ESRD. Methods. This study nlyzed the registry of the only peditric nephrology center in Guteml, from Incidence nd prevlence were clculted for nnul periods. Morn s index for sptil utocorreltion ws used to determine significnce of geogrphic distribution of incidence. Time to progress to ESRD nd ssocited risk fctors were clculted with multivrite Cox regression. Results. Of ptients from birth to less thn 20 yers of ge, 432 hd chronic renl filure (CRF). Prevlence nd incidence of ESRD were 4.9 nd 4.6 per million ge-relted popultion, respectively. Incidence ws higher for the Pcific cost nd Guteml City. The cuse of CRF ws undetermined in 43% of ptients. Averge time to progress to ESRD ws 21.9 months; fctors ssocited with progression were: older ge, dignosis of glomerulopthies, nd dvnced-stge CKD t consulttion. Conclusions. Prevlence nd incidence of ESRD in Guteml re lower thn in other countries. This my reflect poor ccess to dignosis. Ares with higher incidence nd lrge proportion of CKD of undetermined cuse re comptible with other studies from the geogrphic subregion. Findings on progression to ESRD my reflect delyed referrl. Kidney diseses; kidney filure, chronic; renl insufficiency, chronic; risk fctors; child helth; epidemiology; Guteml. The epidemiology of chronic kidney disese (CKD) in children outside developed countries is not well-described. The Ltin Americn Registry of Peditric Renl Trnsplnttion is the min 1 University of Denver, Deprtment of Anthropology, Denver, Colordo, United Sttes of Americ. Send correspondence to Alejndro Cerón, emil: [email protected] 2 Institute of Nutrition of Centrl Americ nd Pnm (INCAP), INCAP Reserch Center for the Prevention of Chronic Diseses, Guteml City, Guteml. 3 Fundción pr el Niño Enfermo Renl (FUNDANIER), Hospitl Roosevelt, Guteml City, Guteml. source for dt in Ltin Americ (1). In Guteml, s is the cse for most countries with limited resources, this type of dt hs not been previously reported (2). CKD prevlence nd incidence rtes mong individuls less thn 20 yers of ge vry from 10 to > 100 per millionge-relted popultion (PMARP), nd 2 6 PMARP, respectively (2 14). Previous studies hve reported tht the lrgest proportions of CKD cses in children re cused by: congenitl nomlies of the kidney nd urinry trct (CAKUT), 30% 60%; hereditry nephropthies, 10% 35%; nd glomerulopthies, 3% 25% (2, 10, 14 18). In studies tht hve nlyzed progression to end-stge renl disese (ESRD), fctors ssocited with progression to stge 5 were dvncedstge CKD t dignosis nd hving glomerulr disese (10, 19). Nturl nd socil environmentl exposures hve been reported to be ssocited with CKD in dults (20). In the Mesomericn re extending pproximtely from centrl Mexico to Belize, Guteml, El Slvdor, Hondurs, Nicrgu, nd northern Cost 376 Rev Pnm Slud Public 36(6), 2014

2 Cerón et l. Chronic kidney disese in Gutemln children Originl reserch Ric number of studies hve reported tht such environmentl exposures my be ssocited with geogrphic loction (21 26). A lrge proportion of cses re of undetermined cuse nd the term Mesomericn Nephropthy hs been coined (27 30). Guteml hs only recently hd the cpcity to comprehensively tret children with CKD through its public helth cre system. In 2003, the Fundción pr el Niño Enfermo Renl (Foundtion for Children with Kidney Disese; Guteml City, Guteml; FUNDANIER) ws founded by prents of children with CKD. The cretion of FUNDANIER is described in detil elsewhere (31, 32). FUNDANIER supported the development nd mintennce of Peditric Nephrology Unit t the Roosevelt Hospitl, one of the country s tertiry-level referrl hospitls in Guteml City. The foundtion estblished the country s only exclusively peditric renl replcement therpy (RRT) progrm in 2007 nd creted dtbse to trck ll of its ptients. FUNDANIER s Peditric Nephrology Unit sees inptients nd outptients from ll of Guteml, nd lso runs generl renl clinic. Ptients do not py ny fees or dontions in order to be dmitted nd cn be referred by ny helth cre provider or wlk in on their own inititive. The min brriers to ccess re geogrphic (with ssocited costs) nd linguistic, since there re no indigenous lnguge interprettion services offered. FUNDANIER sometimes covers lodging costs for fmilies in need. It cn be ssumed tht mny common renl problems re seen by generl prctitioners nd peditricins throughout the country, but tht lmost ll complicted cses re eventully seen in FUNDANIER s Peditric Nephrology Unit. The following is n nlysis of the dt vilble from the FUNDANIER clinicl dtbse. The study objectives were to describe the distribution of CKD in Guteml, its cuses nd ge distribution, provide estimtes of incidence nd prevlence rtes of peditric ESRD, the distribution of therpeutic modlities, nd provide estimtes of the time to progression to ESRD nd its ssocited fctors. This nlysis represents the first effort to chrcterize peditric CKD in Guteml. The dt my provide n insight into the cuses of CKD in Centrl Americ. MATERIALS AND METHODS Dt Dt were collected from the ll ptient records of the FUNDANIER dtbse from My 2004 April 2013, nd exported to Stt /MP12.1 (SttCorp LP, College Sttion, Texs, United Sttes) for sttisticl nlysis. A totl of peditric ptients hd been seen by the Peditric Nephrology Clinic t lest once during the study period, including inptients nd outptients. Of these, 432 ptients were clssified s hving chronic renl filure (CRF) or CKD stge 2 or more severe, indicted by n estimted glomerulr filtrtion rte (egfr) < 90 ml/min/1.73m 2 recorded in the ptient record. Popultion The study popultion included individuls who were < 1 yer to 20 yers of ge when presenting for cre t FUNDANIER. All were residents of Guteml nd hd been referred to FUNDANIER, either by the peditric wrd of Roosevelt Hospitl in Guteml City or from nother clinic or hospitl within the country. The study ws pproved by ethicl reviewers t FUNDANIER. The compiled dt mde individul identities indistinguishble, thus protecting their privcy. Vribles Vribles cptured in the dtbse were: nme, birthdte, child plce of residence, weight, height, blood pressure, serum cretinine, hemtocrit, egfr through Schwrtz formul, syndrome t presenttion/referrl, definitive dignosis, nd type of therpy received. Plce of residence ws documented t the deprtment level. Guteml is officilly orgnized in 22 deprtments (counties), which re grouped into eight dministrtive regions: Metropolitn, Centrl, Northwest, Northest, Southwest, Southest, North, nd Petén. The egfr ws used to clssify ptients s hving CKD nd its severity (stge 2 5). The CKD ctegories were clssified using the Guidelines of the Ntionl Kidney Foundtion s Kidney Disese Outcomes Qulity Inititive (33), clssified by egfr in ml/min/1.73m 2. Stge 2 is egfr of 60 < 90; stge 3: 30 < 60; stge 4: 15 < 30; stge 5: < 15 or renl replcement therpy. All ptients with egfr < 90mL/min/1.73m 2 were clssified s hving CRF nd ll ptients with egfr of <15 ml/min/1.73m 2 or on RRT were clssified s hving ESRD. Anlysis The ptient popultion chrcteristics re described with frequencies nd percentges for ll the vribles. Incidence ws clculted s new cses per yer, nd the nnul period prevlence included ll ptients tht hd t lest one consulttion in given yer. Both incidence nd prevlence were estimted in the corresponding ge group s PMARP. The study popultion under 20 yers of ge (used s the denomintor) ws the verge from , s projected by the Gutemln Ntionl Sttistics Institute (34), using the following 5-yer ge groups: 0 4 yers, 5 9 yers, yers, nd yers). The syndrome t presenttion/referrl nd definitive dignosis or cuse of CKD were summrized for ll ptients nd presented s percentge. Incidence rtes were imported into ArcMp 10.2 (Environmentl Systems Reserch Institute, Redlnds, Cliforni, United Sttes), nd were then merged with shpe-file of Guteml. Ech deprtment ws given different hue, reflecting the incidence rte s stndrd devition. In order to determine if the sptil pttern ws sttisticlly significnt, test of sptil utocorreltion ws used. Sptil utocorreltion ws used to determine if incidence rtes for ech deprtment were reltive to their proximity to one nother (35). Morn s Index (34), n index of sptil utocorreltion, ws used with both Rook s nd Queen s contiguity sptil weights for the 22 Gutemln deprtments. The time of progression from dignosis of CKD to ESRD, nd the significnce of risk fctors for progression, were clculted using multivrite Cox regression, using the P < 0.05 significnce level. All ptients in the FUNDANIER dtset with t lest one clinic visit while in stges 2, 3, or 4, nd subsequent followup egfr reding, were included in the survivl nlysis. The co-vrites used in the nlysis were ge ctegory, sex, residence, CKD stge t dignosis/referrl, definitive dignosis (undetermined cuse, CAKUT, Rev Pnm Slud Public 36(6),

3 Originl reserch Cerón et l. Chronic kidney disese in Gutemln children glomerulopthies, or other dignoses), nd dte of cpture (before/fter 2008, bsed on the strt of the exclusively peditric RRT progrm). Stt /MP12.1 (SttCorp LP, College Sttion, Texs, United Sttes) ws used to conduct descriptive sttisticl nlysis nd multivrite Cox regression. RESULTS Tble 1 presents sociodemogrphic vribles, syndrome t presenttion/ referrl, nd stge of CKD t presenttion/referrl. The dtset cptured ptients from My 2004 April The men ge ws 6.19 yers, with stndrd devition (SD) of 4.66 yers; 49.5 % were mle; nd 58% cme from the Metropolitn re (Guteml City); 13% from the Southwest; 10% from the Centrl; 8% from the Southest; nd the remining 11%, from the Northwest, Northest, North, nd the Petén. Of the ptients, 432 were clssified s hving CKD stge 2 or greter (CRF) bsed on the most recent vilble egfr. Of these, 52% were mle, 35% were yers of ge, nd 29% were 5 9 yers of ge. Fifty percent of the ptients were from the Metropolitn re nd 35% cme from the Centrl, Southest nd Southwest regions of the country. Tble 2 shows the totl ptients seen t FUNDANIER, by ge nd CKD stge t their most recent visit. Although percentges of ptients with CKD stges 2 4 re similr for ll ge groups, the number of ptients with ESRD is noticebly higher in the group bove 10 yers of ge. TABLE 1. Sociodemogrphic nd clinicl chrcteristics of peditric ptients with chronic kidney disese (CKD) seen t the Foundtion for Children with Kidney Disese (FUNDANIER) in Guteml, My 2004 April 2013 Vrible Ptients with CKD Stge All ptients 2 5 (lst vilble egfr) No. % No. % Totl Sex Mle Femle Age (yers) < to < to < to < Age not reported Residence Metropolitn re South Other prts of the country CKD Stge t presenttion/referrl Syndrome t presenttion/referrl Urinry trct infection Chronic renl filure Asymptomtic urinry trct nomlies Nephrotic syndrome Nephritic syndrome Nephrolithisis Acute renl filure Other syndrome t presenttion/referrl b Dte of presenttion/referrl Estimted Glomerulr Filtrtion Rte. b Includes: obstructive uropthy, tubulopthy, nd hypertension. Tble 3 presents the definitive dignoses of ptients with CKD stge 2 or greter. Of the finl dignoses, 43% correspond to n undetermined cuse of CKD, followed by 28% due to CAKUT, nd 12% due to glomerulopthies. Kidney disese of undetermined cuse ws higher mong femle ptients. Four of the country s regions hve proportions of ptients with dignoses of undetermined cuses tht re higher thn the ntionl verge: Southwest, 49.2%; Metropolitn, 46.8%; Northwest, 46.4%; nd Centrl, 43.9%; while the rest hve the following: Petén, 37.5%; Southest, 34.9%; Northest, 25%; nd North, 0.0%. Of the 432 ptients with CRF, 193 ptients hd CKD stge 5 (ESRD). The mjority received peritonel dilysis (40.4%), followed by hemodilysis (26.4%), trnsplnt, (12.4%), nd no renl replcement therpy (conservtive mngement; 17.6%). Averge prevlence of ESRD ws estimted to be 4.9 per million people less thn 20 yers of ge. The prevlence is notbly higher mong those yer of ge, with 23.4 per million people under the ge of 20 during the sme period. The verge incidence rte of ESRD ws clculted to be 4.6 per million inhbitnts less thn 20 yers of ge (4.7 for girls nd 4.5 for boys). The incidence rte is notbly higher in the popultion yers of ge: 10.1 per million for the study period. Figure 1 shows incidence rtes of ESRD by deprtment. These dt were clssified into four discreet clsses: SD < 0.5; SD ; SD ; nd SD , with 2.4 being the lrgest SD from the men within the 22 deprtments of Guteml. Vrying shdes were used to illustrte the different clsses of stndrd devition, vrying from light gry (for SD < 0.5) to blck (for SD ). The incidence rte PMARP ws higher thn the ntionl verge in the deprtments of Sctepéquez, 14.5; Guteml, 12.4; Retlhuleu, 11.6; Escuintl, 7.9; Jlp, 7.8; Jutip, 7.6; nd Zcp, 5.4. Using Rook s sptil weights, Morn s Index ws 0.24 with Z-score of Queen s sptil weights lso gve similr results with Morn s Index of 0.20 nd Z-score of Descriptive sttistics show tht progression to ESRD ws relted to CKD stge t dignosis/referrl. Of the 87 ptients cptured with Stge 2 CKD, none 378 Rev Pnm Slud Public 36(6), 2014

4 Cerón et l. Chronic kidney disese in Gutemln children Originl reserch TABLE 2. Number of peditric ptients seen t Foundtion for Children with Kidney Disese (FUNDANIER), by ge group nd stge of chronic kidney disese (CKD) t lst reported visit, Guteml, My 2004 April 2013 Age No CKD or Stge 1 Stge 2 (egfr 60 89) Stge 3 (egfr 30 59) Stge 4 (egfr 15 29) Stge 5 (egfr <15) Totl No. % No. % No. % No. % No. % No. % Not identified < 1 yer yers yers yers > 14 yers Totl Estimted Glomerulr Filtrtion Rte. TABLE 3. Definitive dignosis of ptients with chronic renl filure/stges 2 5 of chronic kidney disese (CKD) t Foundtion for Children with Kidney Disese (FUNDANIER), Guteml, My 2004 April 2013 Dignosis progressed to ESRD, while 15 of 99 (15%) cptured t Stge 3 progressed to ESRD, nd 22 of 57 (39%) cptured t Stge 4 progressed to ESRD. Tble 4 presents results of the nlysis of progression to ESRD. The time of progressing from CKD stges 2, 3, nd 4 to ESRD (CKD stge 5) ws on verge 21.9 months, with SD of 18.7 months, nd rnge of months. The risk of progression to ESRD ws greter in ptients 20 yers of ge compred to the 0 5 yer reference group (hzrd rtio [HR]: 12.8, P = 0.02) nd less in those not coming from the Metropolitn or southern cost regions (HR: 0.20, P = 0.04) s compred to the reference group (Metropolitn re). The vrible tht ws ssocited most significntly with progression to ESRD ws the CKD stge when first dignosed. Ptients beginning in stge 3 rther thn stge 2 were significntly more likely to progress to stge 5 (HR: 20.5, P = 0.005). Ptients beginning in stge 4 s compred to stge 2 were mrkedly more Femle Mle Totl No. % No. % No. % CKD Undetermined cuse Congenitl nomlies (CAKUT) Glomerulopthies Miscellneous cuses Dysfunctionl voiding Nephrolithisis Hereditry nephropthies Tubulopthies No dignosis reported Totl Cogenitl nomlies of the kidney nd urinry trct. likely to progress to stge 5 (HR: , P < 0.001). Ptients with dignosis of glomerulopthies s compred to those with dignosis of CAKUT were significntly more likely to progress to stge 5 (HR: 4.84, P = 0.02). DISCUSSION This study hs chrcterized peditric CKD in Guteml from My 2004 April The prevlence nd incidence rtes reported for ESRD in Gutemln children re notbly lower thn wht hs been reported in the literture in other countries with prevlence rtes between 10 nd > 100 PMARP nd incidence rtes for the sme popultion rnging from 2 16 per million people (2 14). The prevlence nd incidence rtes reported here my indicte tht the true prevlence nd incidence rtes in the country re lower thn in other countries or, more likely, tht lrger number of cses re not dignosed nd referred by the helth system. The fct tht the mjority of the reported cses come from the metropolitn (50% of CRF nd 47% of ESRD) re suggests bis due to disprity in ccess to helth cre, nd my support the ltter explntion. Given tht ESRD prevlence nd incidence rtes were clculted over period of 4 yers ( ), insted of point prevlence, both rtes re very similr in mgnitude (4.9 nd 4.6), reflecting tht the number of deths nd new cses were very similr in ech of the 4 yers included in the nlysis. In the geogrphic nlysis, the mp shows clustering in the southern prt of the country, with higher incidence rtes of peditric ESRD especilly in the districts of Escuintl, Guteml, nd Sctepéquez. Lower incidences re observed in the deprtments t the center of the mp, including Huehuetenngo, Quiché, Bj Verpz, Alt Verpz, nd Izbl. As shown by the Morn s Index test, the clustering of CKD tht is visible on the mp is sttisticlly significnt nd is due to something other thn complete sptil rndomness. Other reports (27 30) hve pointed to the Pcific Cost of Centrl Americ s n re endemic for CKD, chrcterizing Mesomericn Nephropthy s occurring predominntly in men nd presenting clinicl mnifesttions in the third decde of life, with lbortory results showing low-grde proteinuri nd tubulr injury (27 29), nd biopsy presenting extensive glomerulosclerosis, tubulr trophy, nd interstitil fibrosis (30). Identified risk fctors include higher environmentl tempertures, dehydrtion, nd exposure to contminnts (27 29). However, t this moment there is no evidence tht the fctors ssocited with Mesomericn Nephropthy explin our findings; further reserch is needed. Rev Pnm Slud Public 36(6),

5 Originl reserch Cerón et l. Chronic kidney disese in Gutemln children FIGURE 1. Mp of peditric end-stge renl disese incidence rtes by deprtment, Guteml, Upon referrl to FUNDANIER, ptients with CRF undergo renl nd bldder ultrsound to identify possible urinry trct mlformtions. Those ptients with ESRD re lso routinely evluted with voiding cystourethrogrm. Kidney biopsy is performed in cses with Nephritic or Nephrotic syndrome, but not in ll cses with CFR, due to limited ccess to the method. Given tht the mjority of ptients with undetermined cuses did not hve clinicl evidence of Nephritic/Nephrotic syndrome, biopsy ws not performed. Similr to previous studies in other settings, our study found tht hving dvnced stge CKD nd older ge upon referrl, were significntly ssocited with progression to ESRD. These findings my be explined by lck of ccess or delyed referrl to specilized helth cre fcilities. Ptients with definitive dignosis of glomerulopthies were t higher risk of progression to ESRD. Study limittions The strength of this nlysis is tht it ws conducted using the FUNDANIER dtset, which cptures ptients t the ntionl referrl hospitl, nd it is the first to describe CKD in children in Guteml. However, there re number of limittions. The results presented in this rticle re bsed on dt nlysis of hospitl prevlence nd incidence, nd re therefore sub-estimtes of the true incidence nd prevlence in the popultion. It should be noted tht for the geogrphic nlysis, only 22 deprtments were nlyzed, wheres idelly, 30 or more units would be used; s Guteml only hs 22 deprtments, the dt set ws smller thn wht is optiml. Incidence rtes per million-ge-relted popultion, by four clsses of stndrd devitions SAC = Sctepéquez. In ddition, 43% percent of the CRF cses cptured in the dtset were clssified to be of undetermined cuse. The percentge of unclssified dignoses is higher thn wht hs been documented in the literture. We consider tht there re two possible explntions: first, there my be limited dignostic cpcity t FUNDANIER for some entities, such s hereditry nephropthies; or the lrge number of cses in which the cuse is undetermined my hve origins similr to those documented in dults, i.e., Mesomericn Nephropthy (27 30). Conclusions This study points to the importnce of continued reserch nd dt collection on CKD in children in Guteml nd in other countries of Ltin Americ (1, 36, 37). New reserch should nlyze the differences in incidence rtes by residence, for which disprities in ccess to nd utiliztion of services nd dignostics re likely to be importnt vribles. The high incidence of ESRD found long the southern cost is notble, therefore, more focused study of possible explntions is recommended. We lso would encourge greter tten- 380 Rev Pnm Slud Public 36(6), 2014

6 Cerón et l. Chronic kidney disese in Gutemln children Originl reserch TABLE 4. Anlysis of progression from chronic kidney disese (CKD) stges 2 4 to End-Stge Renl Disese, Guteml, My 2004 April 2013 Vrible No. Hzrd rtio 95% Confidence Intervl P vlue 254 Sex Mle Femle (0.60, 2.84) 0.50 Age (yers) < to < (0.84, 23.00) to < (0.45, 5.04) to < (0.36, 5.46) (1.45, ) 0.02 Residence Metropolitn re South (0.45, 2.37) 0.93 Other prts of the country (0.04,.90) 0.04 Stge t which presented (2.54, ) (14.69, ) <0.001 Dignosis Congenitl nomlies (CAKUT) 96 1 Chronic kidney filure of undetermined cuse (0.87, 5.79) 0.10 Glomerulopthies (1.31, 17.91) 0.02 Other dignosis (0.85, 10.32) 0.09 Dte of presenttion (0.23, 1.32) 0.18 Congenitl nomlies of the kidney nd urinry trct. tion on dignosing CKD in children to estblish whether there re, in fct, more cses tht hve non-trditionl cuses, or if dignoses of undetermined cuse re recorded becuse it hs not been possible to dismiss other cuses. Finlly, we recommend continued efforts to mintin the FUNDANIER dtbse with specific emphsis on improved stndrdiztion of the dt cptured on ech individul. Acknowledgments. The Associzione per il Bmbino Nefroptico (Miln, Itly) provided the softwre nd funds to set up the dtbse. The Pn Americn Helth Orgniztion Office in Guteml provided the funding for the study (GU/CNT/ ). The uthors wish to thnk Victori Rodríguez Btres for her support with dt entry; to Pedro Ambrocio from the Pn Americn Helth Orgniztion Office in Guteml for his technicl support in trnsferring files tht permitted this nlysis; nd John C. Christenson for his comments on the mnuscript. Conflicts of interest. None. REFERENCES 1. Grci C, Delucchi A, Ort N, Goulrt P, Koch P, Medin-Pestn J, et l. Ltin Americn Registry of Peditric Renl Trnsplnttion Peditric Trnsplnt. 2010;14(6): doi: /j Wrdy BA, Chdh V. Chronic kidney disese in children: the globl perspective. Peditr Nephrol. 2007;22: doi: /s Vchvnichsnong P, Dissneewte P, McNeil E. Childhood chronic kidney disese in developing country. Peditr Nephrol. 2008;23: doi: /s Bek K, Akmn S, Bilge I, Toploğlu R, Çlıșkn S, Peru H, et l. Chronic kidney disese in children in Turkey. Peditr Nephrol. 2008;24: doi: /s Gheissri A, Hemmtzdeh S, Merrikhi A, Fdei Tehrni S, Mdihi Y. Chronic kidney disese in children: A report from tertiry cre center over 11 yers. J Nephropthol. 2012;1: doi: / nephropthol Huong NTQ, Long TD, Bouissou F, Liem NT, Truong DM, Ng DK, et l. Chronic kidney disese in children: The Ntionl Peditric Hospitl experience in Hnoi, Vietnm. Nephrology. 2009;14: doi: /j x. 7. Hri P, Singl IK, Mntn M, Knitkr M, Btr B, Bgg A. Chronic renl filure in children. Indin Peditr. 2003;40: Anochie I, Eke F. Chronic renl filure in children: report from Port Hrcourt, Nigeri ( ). Peditr Nephrol Berl Ger. 2003;18: doi: /s Mdni K, Otoukesh H, Rstegr A, Vn Why S. Chronic renl filure in Irnin children. Peditr Nephrol. 2001;16: doi: / s Peco-Antic A, Bogdnovic R, Pripovic D, Pripovic A, Kocev N, Golubovic E, et l. Epidemiology of chronic kidney disese in children in Serbi. Nephrol Dil Trnsplnt. 2011;27: doi: /ndt/gfr Bhimm R, Adhikri M, Ashrm K, Connolly C. The spectrum of chronic kidney disese (stges 2 5) in KwZulu-Ntl, South Afric. Peditr Nephrol. 2008;23: doi: /s Hmed RMA. The spectrum of chronic renl filure mong Jordnin children. J Nephrol. 2002;15: Hijzi R, Abitbol CL, Chndr J, Seeherunvong W, Freundlich M, Zilleruelo G. Twenty-five yers of infnt dilysis: single center experience. J Peditr. 2009;155: doi: /j. jpeds Hrmbt J, Strlen KJ, Kim JJ, Tizrd EJ. Epidemiology of chronic kidney disese in children. Peditr Nephrol. 2011;27: doi: /s Piedrhit Echeverry VM, Prd Mez MC, Vnegs Ruiz JJ, Vélez Echeverry C, Sern Higuit LM, Serrno Gyubo AK. Cuss de enfermedd renl crónic en niños tendidos en el Servicio de Nefrologí Pediátric del Hospitl Universitrio Sn Vicente de Púl, de Medellín, Colombi, entre 1960 y Ltrei. 2011;24: Mong Hiep TT, Ismili K, Collrt F, Dmme- Lomberts R, Godefroid N, Ghuysen M-S, et l. Clinicl chrcteristics nd outcomes of children with stge 3 5 chronic kidney disese. Peditr Nephrol. 2010;25: doi: /s Gupt A, Mittl S, Shrm RK, Gulti S. Etiology nd outcome of chronic renl filure in Indin children. Peditr Nephrol. 1999;13: doi: /s Şirin A, Emre S, Alpy H, Nyir A, Bilge I, Tnmn F. Etiology of chronic renl filure in Turkish children. Peditr Nephrol. 1995;9: doi: /BF Sores CM, Diniz JSS, Lim EM, Oliveir GR, Cnhestro MR, Colosimo EA, et l. Predictive fctors of progression to chronic kidney disese stge 5 in predilysis interdisciplinry progrmme. Nephrol Dil Trnsplnt. 2008;24: doi: /ndt/ gfn547. Rev Pnm Slud Public 36(6),

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Hoboken, New Jersey: John Wiley & Sons; Ort-Sibu N, Lopez M, Moriyon JC, Chvez JB. Renl diseses in children in Venezuel, South Americ. Peditr Nephrol. 2002;17: doi /s Cusumno A, Di Giol C, Hermid O, Lvorto C. The Ltin Americn dilysis nd renl trnsplnttion registry nnul report Kidney Int. 2005;97(suppl): Mnuscript received on 25 July Revised version ccepted for publiction on 31 December resumen Enfermedd renl crónic en niños de Guteml Plbrs clve Objetivo. Describir l distribución de enfermedd renl crónic en niños en Guteml, y clculr l incidenci y l prevlenci de nefroptí terminl en niños, sí como el tiempo de progresión hst l nefroptí terminl. Métodos. Este estudio nlizó el registro del único centro de nefrologí pediátric de Guteml, del 2004 l L incidenci y l prevlenci se clculron por períodos nules. Se utilizó el índice de Morn como medid de l utocorrelción espcil con objeto de determinr l significción de l distribución geográfic de l incidenci. El tiempo de progresión l nefroptí terminl, sí como los fctores de riesgo socidos, se clculron medinte l regresión de Cox de vribles múltiples. Resultdos. De pcientes menores de 20 ños, 432 pdecín insuficienci renl crónic. L prevlenci y l incidenci de nefroptí terminl fueron de 4,9 y 4,6 por millón de hbitntes de es mism edd, respectivmente. L incidenci fue myor en l cost del Pcífico y en l Ciudd de Guteml. En 43% de los pcientes l cus de l insuficienci renl crónic er indetermind. El tiempo promedio de progresión un nefroptí terminl fue de 21,9 meses; los fctores socidos con es progresión fueron: l edd myor, el dignóstico de glomeruloptí y l enfermedd renl crónic en etp vnzd en el momento de l consult. Conclusiones. L prevlenci y l incidenci de l nefroptí terminl en Guteml son inferiores ls de otros píses. Ello podrí reflejr un cceso limitdo l dignóstico. L myor incidenci y l mpli proporción de enfermedd renl crónic de cus indetermind en lguns zons son comptibles con ls de otros estudios de l subregión geográfic. Los resultdos en cunto progresión un nefroptí terminl podrín ser el reflejo de l trdnz en l derivción. Enfermeddes renles; fllo renl crónico; insuficienci renl crónic; fctores de riesgo; slud del niño; epidemiologí; Guteml. 382 Rev Pnm Slud Public 36(6), 2014