INTRODUCTION:
Chronic kidney disease is an insidious and
irreversible condition that eventually progresses to end stage renal failure
and is now a worldwide crisis. According
to the Global Burden of Disease (GBD) study, disability-adjusted life-years
(DALYs) for CKD has risen from 29th in 1990 to 18th in
2019.1 Chronic
kidney disease (CKD) remains an alarming disease and constitutes a major public
health challenge among children too, with a global prevalence of 15–74.7
cases/million children.2 Kidney disease often goes undetected
in the general population, but children are at an even greater risk.
The main aim of the World Kidney Day 2016 with the
theme “Kidney Disease and Children: Act early to prevent it” was to
combat the increase of preventable kidney diseases in children which directed
the investigator to do something on early detection of kidney disease in
children.
In children, asymptomatic urinary findings like
proteinuria as well as hematuria may be sometimes the only early signs of renal
diseases like membranous nephropathy, membrano-proliferative
glomerulonephritis.3 Detection of early proteinuria, hematuria,
proteinuria with hematuria, hypertension, body mass index (BMI) abnormalities,
and a composite data analysis in children may be more helpful in diagnosing
renal disease earlier and initiating measures to slow progression to advanced
stages of CKD. Hence, Urine examination is perhaps the most important, easiest
and simplest test, which should be considered as the part of physical
examination in all children being screened for Kidney diseases. The basic
dip-stick method of urine analysis is the most rapid screening procedure that
could be helpful in the early detection of renal or urinary tract diseases. The
purpose of this study was to screen school children for the presence of urine
abnormalities.
OBJECTIVES OF THE STUDY:
1.
To detect urine
abnormalities among school children of 10- 14 years
2.
To find association
between presence of urinary abnormalities with the selected baseline variables
of children.
MATERIALS AND METHODS:
Operational definition:
Urine abnormalities: In this study, “urine abnormalities” refer to the
presence of protein, blood, glucose, ketones, nitrite, leukocytes, bilirubin,
urobilinogen and abnormalities in pH and specific gravity as assessed by using
urine dip-strips (Aspen Diagnostics Private Limited). The change in colour on
the urine dip-strip was interpreted as per the instructions given by the
manufacturing company.
Research approach:
Quantitative approach
Research design:
descriptive survey design
Research variable:
Presence of urinary abnormalities among school
children.
Population:
School
children between 10 to 14 years of age.
Sample:
The study was done on 235 school children
between 10 to 14 years of age. The sample size was calculated using the
equation N= 4pq/ D2
Sampling technique:
Purposive sampling
Setting of the study:
Four selected schools (under Dy. DE, Pathanamthitta
District)
Inclusion criteria:
School children between 10 – 14 years of age who were
present at the time of data collection and were willing to participate
in the study
Exclusion criteria:
· Female school children who were having
their menstrual periods or were within seven days of their LMP during the time
of data collection
· School children who were currently on any
medications
· School children already diagnosed with
kidney diseases
Tools and Technique:
Tool 1: This tool had two sections. Section A- Baseline proforma was
used to collect baseline details like age, sex, place of residence and relevant
history of child with respect to urinary abnormalities which was to be filled
by their parents using Self-report by parents of the child. Section B-
Physical examination proforma consisted a chart for recording anthropometric
measurements, vital signs and the head to foot examination in order to screen
children for the risk factors related to urine abnormalities using Observation
and Bio-physical measures.
Tool 2: consisted of a record of the results of urine dip strip test of the
study samples following the guidelines given by the manufacturing company
(Aspen Diagnostics Private Limited). The urine dip strips were read and
interpreted as follows:
· Each sample was assessed within one hour of
collection of samples.
· Each parameter was read following 60
seconds of dipping the dip-strip in urine and was interpreted within the
prescribed time for each parameter as mentioned by the manufacturer.
· Repeat testing was done for those who with
a positive test.
Content Validity of the tool:
The prepared tools along with objectives, criteria
checklist were submitted to nine experts that included two nephrologists, one
pediatrician, one expert from community medicine and five child health nursing
experts. Their valuable suggestions were included for the modification of the
tool.
Reliability:
Reliability of the dip-strip analysis was found using
inter-observer method, where the researcher and her colleague separately
analyzed the urine samples taken from 10 school students’ using separate
dip-strips of the same brand, and reliability coefficient ‘r’ was
calculated using the formula: r = (no. of agreements)/ (no. of agreements + no.
of disagreements); The reliability of the tool was 0.8 which indicated that the
tool was reliable.
The weighing machine, BP apparatus and mercury
thermometer were calibrated by Biomedical Engineering Department of a Tertiary
Care Centre at Tiruvalla.
Pilot study: was conducted on 10% of the sample size in Feb. 2017
in a selected High School of Pathanamthitta
Data collection:
The data collection for the main study was done over a
4wks period in Feb-March 2017. After getting the ethical clearance from the
Institutional Ethics Committee, the schools were identified as per the planned
sampling technique. Permission from the school authorities was obtained and a
convenient time for data collection was identified. Based on the time allotted
for data collection, the investigator went to the selected schools. The purpose
of the study was explained to the students with the help of a power point
presentation. Consent forms (including information about the study, parental
consent and student assent) and tool 1 were distributed and they were asked to
get it filled by the parents and return it on the next allotted day. On the
next day, the height and weight measurements (taken by a colleague of the
investigator) and blood pressure measurement and physical examination (done by
the investigator herself) were done for those children who got their parental
consent and also gave their assent. Following this their BMI was calculated and
BP levels were classified and the investigator performed urine analysis. Repeat
urine examinations were performed on those children with abnormal urine
findings. Around 25children were assessed in a day and the data was coded and
entered onto the master sheet. The analysis was done using descriptive
(frequency and percentages) and inferential statistics (Chi- square test and
Fisher’s exact test) with the help of SPSS 20th version.
The above table 1(a) shows that out of the 235
samples, 68.9% (162) were in the age group of 12-14 years, 54% (127) were
females, 84.3% (198) reported to belong to rural area, most of the samples i.e.
90.2% (212) were born at term and none of them were found to have any kidney
related disease since birth and 5.1% (12) had frequent infections since birth
and also had a history of medication intake in the previous years. Among the
symptoms of kidney disease within the past six months, the most common urinary
symptom reported is burning sensation, in 4.3% (10). Among the other symptoms
majority i.e. 7.2% (17) had unexplained fever.
Table 1b: Frequency and percentage distribution of
samples based on physical examination findings. (N= 235)
|
Sl. No.
|
Physical
Examination Findings
|
F
|
%
|
|
1.
|
Body Mass
Index
|
|
|
|
|
Underweight
|
033
|
14.0
|
|
|
Normal
|
173
|
73.6
|
|
|
Overweight
|
019
|
08.1
|
|
|
Obese
|
010
|
04.3
|
|
2.
|
Blood pressure
|
|
|
|
|
Normal
|
122
|
51.9
|
|
|
Prehypertension
|
107
|
45.5
|
|
|
Stage 1
hypertension
|
005
|
2.10
|
|
|
Stage 2
hypertension
|
001
|
0.40
|
|
3.
|
Body built
|
|
|
|
|
Lean
|
080
|
34.0
|
|
|
Moderate
|
145
|
61.7
|
|
|
Heavy
|
010
|
04.3
|
|
4.
|
Activity
|
|
|
|
|
Active
|
235
|
100.0
|
|
|
Dull
|
000
|
00,0
|
|
5.
|
Skin
|
|
|
|
|
Normal
|
219
|
93.2
|
|
|
Dry skin
|
015
|
06.4
|
|
|
Rashes
|
001
|
00.4
|
|
6.
|
Flank pain
|
|
|
|
|
Yes
|
002
|
00.9
|
|
|
No
|
233
|
99.1
|
The above table 1(b) shows that out of the 235
samples, 34% appeared lean, but only 14% were underweight, 8.1% were overweight
and a few i.e. 4.3% were obese. Also 45.5% were found to have pre-hypertension,
2.1% had stage 1 hypertension and 0.4% had stage 2 hypertension. All of them
were found to be active and the head to foot examination showed that 6.4% had
dry skin, 0.4% had rashes and 0.9% had flank pain.
Section B: Urinary Abnormalities among School
Children (N= 235)
Fig 1: Pie diagram on total number of students detected
to have a urine abnormality
The figure 1 shows that urine abnormality was present
in majority i.e. 90.2% (212) of the samples and a few i.e. 9.8% (23) of the
samples did not have any urine abnormalities.
Table 2: Distribution of samples based on urine
abnormalities detected among school children (N= 235)
|
S. No.
|
Urine
characteristics
|
F
|
%
|
|
1.
|
Colour of
urine
|
|
|
|
|
Normal (straw
coloured)
|
164
|
69.80
|
|
|
Abnormal (dark
yellow, brownish, red)
|
071
|
30.20
|
|
2.
|
Clarity
|
|
|
|
|
Clear
|
235
|
100.0
|
|
|
Turbid
|
0
|
0
|
|
3.
|
Urine
abnormalities detected
|
|
|
|
|
Hypersthenuria
|
210
|
89.36
|
|
|
Bilirubinuria
|
008
|
03.40
|
|
|
Leukocyturia
|
004
|
01.70
|
|
|
Alkaline pH
|
003
|
01.27
|
|
|
Proteinuria
|
001
|
00.42
|
The above table 2 shows that all had clear urine but
more than a quarter i.e. 30.2% had dark yellow urine, and 90.2% had urine
abnormalities. The most common urine abnormality detected was hypersthenuria/
increased specific gravity i.e. 89.36%, followed by bilirubinuria in 3.4%,
leukocyturia in 1.7% and 1.27% had alkaline ph. The least detected urine
abnormality was proteinuria (0.42%). None of them had urobilinogenuria,
ketonuria, nitrituria, glycosuria and hematuria respectively.
Section C: Association between presence of urinary
abnormalities and selected baseline variables of children
Table 3 Association between the number of school
children detected to have urinary abnormalities with their selected baseline
variables such as age, sex, family history, type of birth, place of residence,
medication history, blood pressure and BMI (N= 235)
|
Variables
|
Urine
abnormality
|
ᵡ2 value
|
p value
|
|
Present
|
Absent
|
|
f
|
f
|
|
Age
|
|
|
|
|
|
10-<12 years
|
061
|
12
|
12.801
|
0.001**
|
|
12-14 years
|
151
|
11
|
|
|
|
Sex
|
|
|
|
|
|
Male
|
099
|
09
|
0.478
|
0.489
|
|
Female
|
113
|
14
|
|
|
|
Family history
|
|
|
|
|
|
Yes
|
005
|
01
|
0.330*
|
0.465
|
|
No
|
207
|
22
|
|
|
|
Type of birth
|
|
|
|
|
|
Term
|
189
|
23
|
2.766*
|
0.140
|
|
Preterm
|
023
|
00
|
|
|
|
Place of
residence
|
|
|
|
|
|
Urban
|
028
|
09
|
10.511
|
0.001**
|
|
Rural
|
184
|
14
|
|
|
|
Medication
history
|
|
|
|
|
|
Yes
|
012
|
00
|
1.372*
|
0.613
|
|
No
|
200
|
23
|
|
|
|
Blood pressure
|
|
|
|
|
|
Normal
|
108
|
14
|
1.274
|
0.735
|
|
Pre-hypertension
|
098
|
09
|
|
|
|
Stage 1and 2 hypertension
|
006
|
00
|
|
|
|
BMI
|
|
|
|
|
|
Underweight
|
030
|
03
|
2.360
|
0.501
|
|
Normal
|
154
|
19
|
|
|
|
Overweight or
obese
|
028
|
01
|
|
|
|
|
|
|
|
|
(*Fisher’s exact test, ** Significant at ≤ 0.05
level of significance)
Table 3 reveals that an association exists between
presence of urinary abnormalities with age and place of residence at ≤
0.05 level of significance. No association was found with family history, type
of birth and Medication history which was analyzed using Fisher’s exact test.
DISCUSSION:
Section 1: Discussion related to distribution of
samples based on baseline variables:
In the present study, of the 235 samples, the highest
prevalence of urine abnormalities was seen in children aged 12 to 14years
(68.9%). This finding agrees with P. N. Vinoth et al who conducted a similar
study on screening for asymptomatic renal disease among school children in
Chennai.(3) The
current study had nearly half (54%) of the samples as females which is same as
in the studies conducted by F. Akor et al(4), A. N. Okpere et al5, and Ramadan A.
Mahmoud et al.6
When analyzing the frequency and percentage
distribution of the samples based on relevant health history of the child with
respect to urine abnormalities, only 1.7% (4) of the samples had reported a
history of chronic illness requiring hospitalization in the past which included
appendicitis (0.4%), asthma (0.4%), headache (0.4%) and oophorectomy procedure
(0.4%). Six (2.6%) of the study samples reported to have a family history of
renal disease which was reported to be either in grandfather, father, aunt or
nephew. Only 12(5.1%) of them reported to have frequent infections since birth,
which included dust allergy (0.4%), eczema(0.9%), headache(0.4%), itching and
pus formation(0.4%), occasional breathing difficulty (0.4%), occasional
fever(0.4%), skin lesions(0.4%), sneezing(0.4%), skin lesions on leg(0.4%),
throat pain during fever(0.4%) and tonsillitis(0.4%). Among the children with
fever and frequent throat infections in the past, only 0.8% of the children
reported to have a urine abnormality i.e. increased specific gravity.
Concerning the medication history, only 12 (i.e. 5.1%) of the students were on
medications which was for allergic sneeze, asthma, dry skin, hair loss,
seizure, skin disease, thyroid, nasal block and as iron supplements. All
children who were on medications were found to have a urine abnormality i.e.
increased specific gravity. The frequency and percentage distribution of the
samples based on their reporting of symptoms related to urinary abnormalities
over the past six months revealed that 23(9.78%) children reported of urinary
symptoms. Among those with urinary symptoms, the most common symptom reported
was burning sensation (indicative of UTI) which was of 4.3% (10) in the
samples. The next common urinary symptom reported was frothy urine (which could
be related proteinuria), reported by 2.6% (6), followed by increased frequency
of micturition i.e. 2.1% (5). Only 0.9% (2) of the samples mentioned a history
of difficulty in passing urine and none of them reported to have hematuria. The
investigator couldn’t find any study supporting or contradicting these details.
Gender-wise comparison shows that urinary symptoms
were commonly verbalized by males while the other symptoms show somewhat equal
representation in both genders. This fact is contradicted by a study conducted
by C .S. V. Kumar et al.7
Renal disease, particularly in children, may present
in a subtle manner such as failure to thrive, unexplained fevers, vague pains,
gastrointestinal symptoms, anemia, abdominal mass, edema, and hypertension.8
In this study, the investigator looked for the above presented symptoms and
found that 66(28.08%) children had reported of having had other symptoms (other
than urinary symptoms) related to urinary abnormalities within past six months.
Among them, a few i.e. 7.2% (17) mentioned that they had unexplained fever,
6.4% (15) each of the subjects verbalized of having fatigue and dry skin in the
past six months, 4.7% (11) had weight loss and nausea, vomiting and diarrhoea
were reported by 1.7% (4) each of the samples.
The frequency and percentage distribution of the
samples based on their physical examination findings shows that a major portion
of them i.e. 73.6% (173) had normal BMI, while some i.e. 8.1% (19) were
overweight, 14% (33) were underweight and a few i.e. 4.3% (10) were obese.
Further, of the 235 samples, more than half i.e. 61.7% (145) of school children
were of moderate built, some i.e. 34% (80) of the children were lean and a few
i.e. 4.3% (10) of them were overweight. More than half of the school children
i.e. 51.9% (122) had normal BP, while almost equivalent number i.e. 45.5% (107)
had pre-hypertension, a few i.e. 2.1% (5) had stage 1 hypertension and one of
them i.e. 0.4% had stage 2 hypertension. All of the 235(100%) school children
were active. Pallor, cyanosis, clubbing and generalized body edema were not
found in any of them. 6.4% (15) of the 235 school children had dry skin, only
two of them (i.e. 0.9%) had flank pain and one (i.e. 0.4%) of the students had
icterus and skin rashes. Other aspects of assessment related to head/ face,
eyes mouth and extremities revealed normal findings in all of the 235 school
children. The investigator couldn’t find any study supporting these details.
Section 2: Discussion related to urinary abnormalities
among school children:
On analyzing the distribution of the samples based on
the presence of urine abnormalities, it was found that more than half i.e.
69.8% (164) of school children had normal straw coloured urine but 30.2% (71)
had dark yellow coloured urine which indicated possible dehydration. On
enquiring further out of curiosity, the investigator got the report of a low
fluid intake. None of them had brownish or red coloured urine which may be
found in liver, kidney or hematologic disorders, or related to certain medications,
food or trauma. All of the 235 school children had clear urine with no
turbidity.
A majority of the school children i.e. 90.2% (212) of
the sample of school children were detected to have some or the other of the
ten urine abnormalities when assessed by the urine dip strip test.
It is a well-known fact that the most common urinary
abnormalities found among children are hematuria and proteinuria.9
Hematuria, which is known to be a significant finding indicating kidney disease
and is caused following urinary tract infection, bladder or kidney stone,
kidney injury, kidney infections like glomerulonephritis, inherited diseases
like sickle cell anemia, trauma and menstrual bleeding, was not seen in any of
the samples. Opposing this finding many other studies conducted in Karnataka,10
Egypt,11 Nigeria4 and Sudan12 showed a
prevalence of hematuria as 5%, 9.8%, 1.5% and 9.5% respectively. Proteinuria,
which is known to be caused by hyper-infiltration or kidney injury or due to
kidney disease with reduced nephron mass13 is commonly seen in
nephrotic syndrome, renal dysplasia, diabetes or hypertension. Only one sample
(i.e. 0.42%) in the present study had proteinuria. Supporting this finding,
studies conducted in Karnataka,10 Kashmir,14 Egypt,11
Chennai,3 Nigeria4 and Sudan12 also show a
prevalence of proteinuria as 16%, 2.17%, 2.6%, 2.5%, 1.5% and 7.1%
respectively. The reduced prevalence in this study could be probably due to the
small sample size or due to the differences in the geographic area in which the
study took place.
In the present study, even though only one (i.e. 0.4%)
of the student were found to be icteric, urobilinogen was not detected in any
of the urine samples whereas bilirubinuria was seen in 3.4% (8) of the samples.
Contradictory to this, a study conducted in Nigeria(4) reports the prevalence of urobilinogen as 1.8% and
1.7% (11) had bilirubinuria. Urobilinogenuria and bilirubinuria are urine
abnormalities which do not reflect any kidney related diseases and these are
usually found in conditions like biliary tract disease, hepatitis, gall stones,
liver disease and tumours of liver or gall bladder.15 Since the
presence of bilirubin in urine is an early indicator of liver disease even
before clinical symptoms appear, the students may require repeat testing and
further evaluation. This was suggested to the school authorities.
Glycosuria and Ketonuria are typically found in
association with diabetes and kidney disease. In the present study, neither
glycosuria nor ketonuria was detected in any of the samples. Contradictory to
this finding, a similar study conducted by Francis Akor et al4
reported presence of ketones as 0.6% and a study conducted by P. N. Vinoth et
al3 showed the prevalence of glycosuria as 0.3%.
Nitrites in urine usually indicate UTI, cystitis etc.
and leukocyturia, also may be due to kidney infections, children holding urine
for too long or due to any blockage in the urinary tract.(16) In
the present study, nitrites were not detected in urine of any of the 235 school
students but 1.7% (4) of the students had leukocyturia. Related studies which
showed a presence of nitrituria, were carried out among pre-schoolers and
primary school children where the prevalence was 0.45%17 and 2%.18
Similarly, the prevalence of leukocyturia was 1%.18
In this study, majority of the samples i.e. 89.36%
(210) had increased urine specific gravity (hypersthenuria). Hyperesthenuria is
known to be found in case of dehydration, emesis, diarrhoea, excessive sweating
or urinary tract infection.19 The investigator couldn’t find any
supporting or contradicting studies related to this data. The pH findings in
the present study detected that 1.27% (3) had alkaline urine. As per
literature, alkaline urine is present in cases like renal tubular acidosis,
urinary tract infections and vomiting as per literature review.19
The investigator couldn’t find any supporting study related to this finding.
Section 3: Discussion related to association between
presence of urinary abnormalities with selected baseline variables of children
In the present study, Chi-square test and Fisher’s
exact test (used in case >20% of the cells had a value less than five) were
done to assess the association between presence of urinary abnormalities and
selected baseline variables of the children such as age, sex, place of
residence, type of birth, family history, medication history, blood pressure
and BMI. A highly significant association was between the presence of urinary
abnormality and the age of children (p=0.001) which can be supported by a study
conducted by Rotimi Williams et al20 where the p-value was
<0.0001. A significant association was also found between the presence of
urine abnormality and the place of residence (p= 0.001) of the samples at a
significance level of ≤0.05. At the same time, no association was found
between the presence of urinary abnormalities and other selected baseline
variables like sex, type of birth, family history, medication history and BMI.
Whereas a study conducted by Rotimi Williams et al20 showed an
association of leukocyturia and proteinuria with hypertension having a p value
< 0.0001.
CONCLUSION:
Detection of certain urine abnormalities could
sometimes be the only early finding of a kidney disease, which if identified on
time would help in preventing the dreaded disease. The current study findings
revealed that majority of the school children (90.2%) had urinary abnormalities
and that there is highly significant association between presence of urinary
abnormality and age of children (p= 0.001); and between urinary abnormality and
place of residence (p= 0.001) at ≤0.05 level of significance. As many of
the school children had urinary abnormalities, the results were informed to the
Principal/concerned Headmaster or Headmistress of the school and it was made
clear to them to communicate about the abnormal findings directly to the
children’s parents without fail so that further evaluation could be done to
identify the presence of life-threatening disease. It was clearly explained to
them that the present study uses just a screening method which can have false
positive results but the findings must be followed up to ensure that the child
has a healthy future.
CONFLICT OF INTEREST:
The authors have no conflicts of interest
regarding this investigation.
ACKNOWLEDGMENTS:
The authors would like to thank the selected school
managements for their kind support during the study.
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