Nigerian Journal of Paediatrics

Renal abnormalities among children with sickle cell anaemia

Niger J Paediatr 2018; 45 (2):112 - 117

ORIGINAL

Olorukooba AA

CC – BY Renal abnormalities among

Akuse RM

Ogunrinde GO

children with sickle cell anaemia

Mamman AI

Yusuf R

Kajogbola G

DOI:http://dx.doi.org/10.4314/njp.v45i2.7

Accepted: 3rd May 2018

Abstract : Introduction: Sickle

Results: Eleven (10.3%) children

cell anaemia (SCA) is a non-

with SCA had haematuria while

Olorukooba AA (

)

communicable disease of public

6.5% had overt proteinuria. Chil-

Akuse RM, Ogunrinde GO

health significance. SCA is char-

dren with SCA who had proteinu-

Department of Paediatrics,

acterized by chronic red blood

ria were five times more likely, to

cell haemolysis and vaso-

develop haematuria than the con-

Mamman AI

occlusion which further compli-

trols with proteinuria (p = 0.03).

Department of Haematology and

cated by nitric oxide deficiency,

Microalbuminuria was found in

Blood transfusion services

causes oxidative damage to the

24.3% of children with SCA. The

body organs especially the kid-

mean estimated glomerular filtra-

Yusuf R

neys.

tion rate was normal for both sub-

Department of Chemical Pathology

Objectives: To document the

jects and controls. Only three

prevalence of renal function and

(2.8%) of the SCA subjects had

Kajogbola G

structural abnormalities in chil-

increased renal echogenicity all of

Department of Radiology,

dren with SCA in a teaching hos-

whom had microalbuminuria and

Ahmadu Bello University Teaching

pital in north western Nigeria.

were older than nine years.

Hospital, Zaria, Nigeria

Materials and Methods: One hun-

Conclusion and recommendations:

Email: abiolaira@yahoo.co.uk.

dred and ten subjects with SCA in

Renal abnormalities were found in

steady state without known renal

children with SCA occurring as

or cardiac abnormalities were

early as 4 years of age. Regular

enrolled and matched for age and

screening for renal disease in chil-

sex with controls (haemoglobin

dren with SCA is recommended to

AA).

Interviewer-administered

ensure management modalities are

questionnaires, clinical examina-

instituted early.

tion and renal ultrasound scans

were carried out. Urinalysis, spot

Key words: SCA, Renal abnor-

urine albumin creatinine ratio and

malities, haematuria, proteinuria,

serum creatinine were carried out

renal size, estimated glomerular

using

standardized

laboratory

filtration rate

methods.

Introduction

communicable disease of public health significance

world wide. Progression of CKD to end stage renal dis-

Sickle cell nephropathy encompasses the structural and

ease (ESRD) may be delayed or halted using various

functional abnormalities of the kidney seen in patients

modalities like lifestyle and dietary modifications and

with sickle cell haemoglobinopathy (an autosomal reces-

use of drugs like hydroxyurea and angiotensin convert-

sive genetic disorder ) in the absence of other secon-

1,2

ing enzyme inhibitors (ACEI) and receptor blockers

(ARB). Over the years, there have been advances in the

dary causes of kidney disease. Up to 1 in 5 people with

SCD develop renal abnormalities which may progress to

management of SCA, changes in lifestyle, diet, wide

chronic kidney disease (CKD). The haemodynamic

spread use of non-steroidal anti-inflammatory drugs

changes of chronic anaemia and the consequences of

(NSAID’s), herbs and substandard drugs all of which

may affect the kidney. The aforementioned, coupled

vaso-occlusion which are especially marked within the

renal medulla in SCA results in abnormalities in renal

with the increase in CKD noted worldwide prompted

structure and function that begin in childhood. Func-

this study to detect abnormalities in renal structure and

tional abnormalities include impaired urinary concentra-

function in children with SCA in the locality.

tion, causing hyposthenuria,

enuresis, proteinuria,

nephrotic syndrome, haematuria, hypertension, acute

This study therefore aimed to determine renal function

kidney injury, chronic kidney disease and end-stage re-

and ultrasonographic findings in children with sickle

nal disease. Chronic kidney disease is an emerging non

cell anaemia in a tertiary hospital north western Nigeria.

113

Materials and Methodology

ing Turbilatex a quantitative turbidimetric kit manufac-

tured by Labkit diagnostics limited. Microalbuminuria

A cross sectional study was carried out in the paediatric

was considered as an albumin creatinine ration (ACR) of

haematology and oncology clinic between August 2014

30-300mg/g.

to January 2015 following approval from the Human

Research and Ethics Committee

Abdominal ultrasound scan was carried out using the

Mindray

pro sound model ultrasonography machine

One hundred and ten subjects with SCA in steady state

with Doppler facilities using a convex (curved array)

without any prior known renal or cardiac abnormalities

transducer at 3.75MHz. The kidneys were evaluated in

were consecutively sampled, enrolled and matched for

the supine and prone positions. The longitudinal lengths

age and sex with controls (haemoglobin AA). A struc-

of the kidneys were measured and compared with paedi-

tured interviewer-administered questionnaire was ad-

atric normograms. The ultrasonographic appearance was

ministered and clinical examination carried out. Renal

described based on consensus between two ultrasono-

glomerular function was assessed using urinalysis, mi-

graphers (qualified radiologists) noting the presence of

cro-albuminuria a sensitive marker of renal disease and

increased parenchymal echogenicity, calyceal clubbing,

estimated glomerular filtration rate (eGFR). Renal struc-

renal scarring and other abnormalities. An increase in

ture was assessed using renal ultrasound scans.

reflectivity throughout the kidney and poor/loss cortico-

medullary differentiation was defined as diffusely in-

The first consecutive 10 children who met the inclusion

creased renal echogenicity.

criteria were enrolled for the study each clinic day. Sub-

jects were children with haemoglobin electrophoretic

diagnosis of SCA (Hb SS and Hb SS+F) aged two to 18

years old who were in their steady state. Steady state

Results

was defined as a child with SCA who has remained

symptom-free for the three weeks preceding enrolment

Of the 110 subjects enrolled, five of the subjects did not

into the study. Excluded from the study were subjects

report back following initial screening showing protein-

with known cardiac disease (congenital or acquired) or

uria despite efforts to get across to them (two control

hypertension and those with urinary tract infection (UTI)

and three subjects with sickle cell anaemia). Two urine

or symptoms suggestive of UTI. Urinary tract infection

samples for the controls were lost in the laboratory due

was considered present for this study in subjects with

to spillage. A final population consisting of 107 subjects

positive leucocyte esterase and/or nitrite on urinalysis

with haemoglobin SS and 106 controls with haemoglo-

and/or un-centrifuged urine microscopy of ≥1 leucocytes

bin phenotype AA following haemoglobin electrophore-

per high power field. Also excluded where children with

sis was used. The female: male ratio was 1:1.03. The

known congenital structural renal conditions (posterior

ages ranged from 2 to 17 years for the SCA subjects,

urethral valves, renal artery stenosis and children who

and 2.2 to 18 years for the controls. The mean age for

had been on antibiotics treatment in the last two weeks

the SCA group was 8.9 ± 4.0 years while that for the

preceding the study.

control was 8.2 ± 3.8 years ( p = 0.16).

A spot sample of 10 ml of urine was collected by clean

Thirty-three (30.8%) of the children with SCA had pro-

catch method in a universal specimen bottle for urinaly-

teinuria. These included 26 (24.3%) who had microalbu-

sis at the clinic; Urine was tested immediately with

minuria while the rest had overt proteinuria ( ≥1+). The

prevalence of proteinuria was significantly more ( χ =

Combi 11

dipstix. Only children with samples that

tested negative to nitrites and leucocyte esterase were

6.59, p = 0.01) than that in the control group who had an

recruited. In those with proteinuria (>+ 1 protein on dip-

overall prevalence of proteinuria of 16 (15.1%).

sticks) or haematuria (>+1 blood on dipsticks), urine

Microalbuminuria was significantly more in subjects

microscopy was carried out to rule out UTI. All samples

(24.3%) than controls ( p = 0.04). Table 1. Sickle cell

that tested negative for proteinuria, nitrite and leucocyte

anaemia subjects were 2.1 times more likely to have

esterase by dipstix and normal urine microscopy was

microalbuminuria than controls. There were 17 (31.5%)

stored at -20 C for quantification of micro-albuminuria

female subjects with SCA who had microalbuminuria,

using a semi-quantitative immunoturbidimetric assay.

they were not significantly more than the 9 (17.0%)

male subjects with SCA who had microalbuminuria ( χ =

Venous blood (2.5ml) was collected via a venepuncture

using a peripheral vein following swabbing of the skin

2.3, p = 0.1). Microalbuminuria apparently increased

with age but this was not statistically significant with χ

with 70% alcohol and povidone iodine and assayed for

creatinine. Serum creatinine was assayed using the Se-

for linear trend = 0.6, p = 0.4. Other biometric and labo-

lectra XL

automated chemistry analyser (ELITech

ratory parameters were not found to significantly affect

group, vital scientific Chicago, IL (USA)) which is

the occurrence of proteinuria in children with SCA in

based on the Jaffe’s reaction. Each assay was validated

this study.

using commercial quality control samples, standards and

previously assayed human sera. Laboratory reference

The overall mean estimated glomerular filtration rate

values for serum creatinine were used and the eGFR was

(eGFR) for subjects with SCA was not significantly

higher (101.4 ± 27.6 ml/min/1.73 m ) than that in the

calculated from the serum creatinine using the original

controls (98.9 ± 26.4 ml/min/1.73 m ; t -test = 0.68, p =

Schwartz formula. Micro-albuminuria was assayed us-

114

0.5). The mean eGFR, increased with age for the fe-

SCA = sickle cell anaemia, SD- standard deviation,

males and males in both the SCA and control groups.

*statistically significant

There was also no significant difference in the mean

eGFR of subjects and controls with proteinuria and

Fig 1: Ultrasound image of the right kidney showing increased

renal echogenicity in a nine-year old girl with sickle cell

those without proteinuria. Table 2

anaemia

Table 1: Prevalence of microalbuminuria in sickle cell anae-

mia and control subjects

Parameter

SCA

Control

Total

n (%)

Microalbuminuria

26 (24.3)

14 (13.2)

40 (18.8)

No microalbuminuria

81 (75.7)

92 (86.8)

164 (81.2)

Total

107 (100.0)

106 (100.0)

213 (100.0)

χ2 = 4.3, df = 1, p= 0.04, OR = 2.1, 95% C.I 1.0 - 4.3

Table2: Mean estimated glomerular filtration rates (eGFR) of

sickle cell anaemia and control subjects by age group and gen-

der

Mean eGFR ± SD (ml/

min/1.73 m2)

Discussion

Age

Gender

(years)

SCA

Control

test

value

The prevalence of proteinuria among sickle cell anaemia

0.19

subjects was 30.8% most of which was from microalbu-

Female

0-4

77.9 ± 13.7

76.3 ± 20.8

0.8

minuria and was significantly more than in the controls.

5-9

90.4 ± 20.4

88.3 ± 16.7

0.37

0.7

This study recorded a prevalence of overt proteinuria

107.9 ±

0.06

10-14

108.4 ± 39.8

23.1

0.9

using dipstix of 6.5% among children with sickle cell

anaemia, this was similar to finding by Ugwu et al in

15-19

127.2 ± 15.1

111.9 ± 9.8

1.94

0.09

Port Harcourt, Anigilage and Adedoyin

Male

0-4

80.1 ± 13.9

80.4 ± 29.2

0.03

0.9

in Ilorin, and

Wigfall et al

5-9

94.2 ± 20.8

89.8 ± 31.3

0.5

0.6

in the USA, who found a prevalence of

108.4 ±

0.12

7%, 6.7% and 6.2% respectively. However, while the

10-14

109.6 ± 20.3

20.6

0.9

finding of overt proteinuria among SCA subjects by

133.9 ±

0.17

Ugwu et al and Wigfall et al were significantly higher in

15-19

136.9 ± 18.8

23.1

0.8

subjects with SCA compared to controls, this was not

SCA = sickle cell anaemia, eGFR= estimated glomerular filtra-

found to be so in this study. The lack of significant dif-

tion

ference in the occurrence of overt proteinuria in subjects

with SCA when compared with controls may be as a

The mean kidney lengths and widths were significantly

result of the controls being drawn from the hospital set-

higher in the SCA groups compared with the controls.

ting and some may have had undocumented risk factors

Table 3. While the mean lengths and widths for the left

for proteinuria.

kidney were more than the right kidney in both SCA and

controls groups, the differences were not found to be

Microalbuminuria was significantly more in subjects

significant ( p >0.05). Three (2.8%) of the subjects with

with SCA compared with controls. SCA subjects were

SCA (two females and one male) had diffuse increased

found to be 2.5 times as likely to have microalbuminuria

renal echogenicity, a non-specific indication of renal

when compared to controls. This is similar to 26.5% of

parenchymal disease. All of the subjects with SCA with

SCA subjects with microalbuminuria recorded by

Dharnidharka et al

increased renal echogenicity were between 9 and 14

in a study in the United States of

years had microalbuminuria though none had proteinuria

America (USA) among 102 SCA subjects. These find-

or haematuria demonstrable on urine dipstix, raised

ings are however, higher than that recorded by Imuet-

inyan et al in Benin and Eke et al

blood pressure or abnormal estimated glomerular filtra-

at Enugu where

tion rates.

20.3% and 18.5% respectively of their SCA subjects had

microalbuminuria. In the studies by Dharnindakar,

Table 3: Mean renal lengths and widths in sickle cell anaemia

and Eke, microalbuminuria was signifi-

Imuetinyan

and controls

cantly higher in children with SCA than controls. The

Mean kidney

SCA

Control

t-test

p value

higher prevalence of micro-albuminuria in this study

measurement

n = 107

n= 106

and Dharnindakar et al

compared to the Benin and

mm (SD)

Enugu findings may be due to the difference in the

Right length

86.2 (13.0)

79.9 (11.1)

-3.76

<0.0001*

method of assay employed. Micral strips which are semi

Left length

87.1 (13.1)

80.2 (10.9)

-4.1

<0.0001*

Benin and

-quantitative

methods

were

used

Right width

36.7 (4.9)

34.0 (3.5)

-4.64

<0.0001*

Enugu whereas a quantitative method was used in this

14 ,

Left width

37.1 (5.0)

34.1 (3.9)

-4.86

<0.0001*

study and in the study by Dharnidharka et al . Preva-

lence of microalbuminuria from the study by Solarin et

al in Lagos using both semi quantitative micral strips

115

(38.8%) and quantitative methods (11.3%) varied. This

controls then studied in Zaria. Both studies like this

disparity is thought to be due to methodology.

The

study did not find a significant difference in the occur-

female preponderance of subjects with microalbuminu-

rence of haematuria between subjects with SCA and

ria in this study was also documented by Imuetinyan ,

HbAA controls. The higher prevalence of haematuria

Solarin and Dharnidhakar et al .

Microalbuminuria

found in this study compared to the studies by Konotey-

was found in children less than five years in this study,

Ahulu and Aikhionbare may be as a result of the long

similar to the study done by Imuetinyan et al in Benin

time that has elapsed between their studies and this

but in contrast with findings by Gusach et al

1 6

who

study allowing for other factors leading to increasing

documented that microalbuminuria was noted in those

prevalence of renal disease noted worldwide, such as

10 years or older and Dharnidharka et al in the USA

increased sensitivity of test materials and changes in

lifestyle. Ugwu et al in Port Harcourt reported a higher

who documented no microalbuminuria under the age of

prevalence of haematuria of 11.1%

seven years. The later occurrence of microalbuminuria

while Anigilaje et

may be as a result of possible effect of diagnosis of SCA

in Ilorin studied 75 subjects with SCA in their

at birth through routine screening in developed countries

steady states and reported prevalence of haematuria of

13.3%.

like the USA and England where screening for sickle

While dipstix method was used in Port Har-

court, Anigilaje et al

cell disease has been recommended for all infants, re-

used urine microscopy in addi-

gardless of ethnic origin. It was found in this study that

tion to urine diptix. The results obtained by Anigilaje et

there was a slight increase in prevalence of MA in those

were higher than what was recorded in this study

and in the study by Ugwu et al , as this may be as a re-

children who were older than 10 years but this apparent

increase of microalbuminuria was not significant. This

sult of the urine sediment microscopy method used in

increase with age was also noted in other studies

11 , 18 ,

the Ilorin study as against urine dipstix used in the latter

and may possibly be as a result of higher number of

two studies.

crisis in these children and disease progression over

time.

There was no significant sex predilection for haematuria

among subjects with SCA in this study though there was

The mean haemoglobin in subjects with SCA with pro-

a female preponderance. This was similar to the pattern

teinuria was significantly lower than controls with pro-

found in the controls in this study. Also, Anigilaje et

and Konotey-Ahulu found no significant sex

al ,

teinuria and lower than in subjects with SCA without

proteinuria. The lower levels of haemoglobin in sickle

predilections in their studies. Female preponderance

cell anaemia subjects may signify the increased severity

may be explained on the background of the anatomy of

of the disease due to resultant sickling which in turn

the female genitalia which predisposes the urethra to

triggers release of prostaglandins and nitric oxide which

trauma and ascending infections that may lead to tran-

sient occult haematuria. Studies have also shown the

cause oxidative damage to the glomerulus, renal vaso-

dilatation and raised glomerular filtration rate (GFR),

prevalence of renal papillary necrosis which is a cause

also anaemia will result in increased cardiac output.

20 , 21 ,

of haematuria was commoner in females.

29,30

This study

22 , 23

noted an apparent increase of haematuria with age simi-

lar to previous studies.

Weight and blood pressure were not associated with the

occurrence of proteinuria in subjects with SCA. How-

The estimated glomerular filtration rate eGFR increased

ever, weight was a factor in controls with proteinuria as

with age in both males and females in the SCA and con-

they had a significantly higher weight than those without

trol groups with no statistically significantly difference

between both groups. Wigfall et al in their study of

proteinuria.

Previous studies have linked proteinuria

with raised body mass index (BMI) and obesity

24,25

children aged 2 to 21 years recorded a higher than ex-

identifying obesity as a major risk factor to renal dis-

pected eGFR in the SCA group in the first decade which

ease. Eke et al found significantly raised BMI in the

declined toward normal in the second decade. This con-

control group with MA but BMI was not found to be

trasted with the findings of this study which found the

significant in SCA group with microalbuminuria. Micro-

eGFR was within low to normal limits in the first decade

albuminuria found in SCA, occurs independent of the

and steadily increased with age similar to findings in

other known factors influencing the prevalence of renal

controls as were also reported by Okoro and Onuwa-

meze

and Olowu et al .

disease in the control population.

The presence of urinary ab-

normalities did not significantly affect the mean eGFR,

and similar to the report by Alvarez et al .

Even though the study found twice as many children

with SCA having haematuria, the prevalence of haema-

turia in SCA subjects in this study may be clinically

The lengths of the right and left kidneys in sickle cell

significant and it is possible that increasing the sample

anaemia group were significantly longer than those in

size of subjects in this study will increase the power to

the control group. This increased renal size was also

documented by Odita et al in Nigeria unlike Ibinayie et

detect differences between the two groups. Some older

al who found 27% of subjects with SCA had shrunken

studies done decades ago showed lower prevalence of

kidney. This study and Odita et al looked at children,

Konotey-Ahulu

haematuria

26 ,27

recorded a prevalence

whereas the study by Ibinaiye et al

3 4

of 2.1% in sickle cell anaemia subjects with haematuria

involved mainly

adults up to 54 years who may have had continuous

at the Korle Bu hospital, Ghana. Aikhionbare et al did

not find haematuria in the 101 subjects with SCA or the

renal damage leading to shrunken kidneys. The mean

116

lengths for the kidneys for the SCA and control groups

within normal. Renal structural abnormalities occur in

where within normal range; this is similar to findings by

lower percentage children with sickle cell anaemia but

Yeboah and Rodrigues in Ghana.

its association with renal glomerular function needs to

be further explored.

Few (2.8%) of the SCA subjects had increased diffuse

echogenicity/loss cortico-medullary differentiation dem-

Authors’ contributions

onstrating structural abnormalities occurring in child-

Olorukooba AA: Conceptualization and design of study,

hood. All subjects with renal abnormalities on ultrasono-

literature search, acquisition of data, analysis and inter-

graphy were nine years or older and all microalbuminu-

pretation of data, drafting the manuscript and revising of

ria though none had proteinuria or haematuria demon-

intellectual content.

strable on urine dipstix, raised blood pressure or abnor-

Akuse RM, Ogunrinde GO, Mamman AI, Yusuf R: De-

mal estimated glomerular filtration rates. Other studies

sign of study, analysis and interpretation of data and

have shown increased prevalence of renal echogenicity

revision of manuscript.

in subjects with SCA this has been attributed to renal

Kajogbola G: Acquisition of data, interpretation of data

papillary necrosis, presence of high concentrations of

and revision of manuscript.

iron deposits within tubular epithelial cells, focal scaring

Conflict of interest: None.

and interstitial fibrosis in the vasa recta system, glome-

Funding: None

rular hypertrophy and renal sclerosis.

36, 37

Recommendation

Conclusion

The use of routine microalbuminuria assay needs to be

encouraged among children with sickle cell anaemia and

There were significant renal glomerular function abnor-

renal ultrasound evaluation should be included in follow

malities occurring in children as low as four years.

up of children with microalbuminuria.

Glomerular filtration rate however appears to remain

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