Editorial

This editorial is structured as a series of tentative questions and answers. We consider that this is appropriate for a subject that has received only limited attention in the literature but which is now gaining ground:

(1) What is the value of reporting on paediatric nephrology in low- and middle-income countries?

It is a topic with its own identity and specificity because, globally, there are differences in terms of geography, climate, population, economy, socio-political environments and genetics that may explain the varied epidemiology of renal and urinary tract diseases and their different clinical picture, morbidity and mortality rate in low- and middle-income countries (LMIC) compared with high-income countries (HIC) [1,2]. Medical and non-medical factors determine the clinical presentation and outcome of renal diseases in LMICs and account for their poorer prognosis [3].

The articles in this special issue include many examples of such a pattern, ranging from post-infectious glomerulonephritis [4] and nephrotic syndrome [5,6] to neurogenic bladder [7] and acute kidney injury [8]. Experience gleaned from long-term cooperation between the paediatric nephrology units in Milan, Italy and Managua, Nicaragua [9] have confirmed that the complications associated with renal disease are more severe and the mortality rate higher in LMIC than in an HIC such as Italy.

While climatic and genetic differences cannot be eliminated, it is possible to overcome socio-economic and political difficulties, although only in an unpredictable manner and not in the short-to-medium term [10]. This issue is of great importance because the majority of children worldwide live in LMIC and therefore paediatric nephrology in LMIC deserves more attention in the literature and by scientific institutions. This special issue is a concrete step in the right direction.

(2) What is the aim of this special issue?

The aim is to provide health workers in LMIC and HIC who are interested in cooperative projects with a diagnostic and therapeutic tool for dealing with the most common renal diseases, concentrating, especially in LMIC, on the best use of available resources, which also heavily influences short- and long-term prognoses [3].

Most of the articles are written by paediatric nephrologists working in both LMIC and HIC, which ensures plurality of views.

(3) What are the most common kidney and urinary tract diseases in LMIC and what is their relationship to chronic kidney disease and end-stage renal disease?

Knowledge and understanding of the epidemiology of kidney diseases in LMIC is of the utmost importance if the progression of chronic kidney disease (CKD) is to be reduced or prevented. It is very difficult to obtain reliable data from registries or databases [11] in LMIC and much depends on the efficiency and coverage of hospital networks and the competence of the personnel responsible. Before reliable epidemiological data on the main kidney diseases leading to CKD in LMIC can be obtained, many years of fine tuning of the network of central and peripheral hospitals and healthcare units and of the registry or database is required.

As most human and economic resources for renal healthcare are spent on the management of CKD and end-stage renal disease (ESRD), noticeably on dialysis and transplantation programmes, it is becoming increasingly evident that, on clinical grounds, data pertaining to kidney diseases should identify the factors which lead to CKD and its diagnosis [12]. On epidemiological grounds, data collection should be limited to the diseases which more frequently cause CKD. This special issue provides examples of such a clinical approach, particularly the idiopathic and secondary forms of steroid-resistant nephrotic syndrome [5,6], neurological bladder [7] and acute kidney injury [8]. Also, more common diseases, for example, urinary tract infections [13] and post-infectious glomerulonephritis [4], should be diagnosed and treated bearing in mind the possibility of renal damage secondary to congenital kidney and urinary tract malformations and the persistence of kidney disease marked by the presence of proteinuria and haematuria, respectively.

(4) Which kidney diseases and non-medical factors are most responsible for, respectively, CKD and death in LMIC?

Data from the Nicaraguan Paediatric CKD Registry demonstrate a different incidence and prevalence of CKD and a different aetiology from those reported in HIC [11]. Some cases, for instance the higher frequency of neurological bladder and lupus nephritis in Nicaragua, can be linked to real data such as low folic acid intake during pregnancy and genetic factors; in other cases such as kidney and urinary tract malformations they relate to the scarce availability of prenatal ultrasound, particularly for women living in poverty and far from the main hospitals. The fact remains, however, that, because of late diagnosis of CKD, frequently at stages IV and V when dialysis and/or transplantation are already required, more than 30% of the causes of CKD in children in Nicaragua are still unknown. This is more because of the limited availability of diagnostic tools, particularly in outlying parts of the country, than to health workers having insufficient knowledge. Moreover, in children with CKD, a direct correlation between high mortality rates and being lost to follow-up, low socio-economic status and, more importantly, a low level of parental education have been demonstrated [3].

This underlines the difficulty of reducing mortality rates based only on medical, organisational (networks) and economic (charitable foundations) tools. Even if available, complex treatment modalities, such as dialysis and transplantation, can be refused by the family for various reasons, including cultural ones [12]. This can be frustrating for health workers involved in cooperative projects because improving the survival rate of children with CKD is a slow process which relates to socio-economic development and cannot be easily predicted.

(5) Is a special issue on paediatric kidney diseases the only way to aid the development of paediatric nephrology in LMIC?

There are many other ways in which we can contribute to the development of paediatric nephrology in LMIC. Structured, long-term cooperation between paediatric nephrologists in HIC and LMIC is a well known modality that involves not only joint clinical and educational activities but also managerial and financial aid through sustainable projects agreed with local health authorities [14]. Some examples are Sudan [8,15], Nicaragua [9] and Guatemala [16], to name but a few. For the HIC nephrologist, this type of initiative is an opportunity to provide high-quality training in evidence-based medicine while, for the LMIC nephrologist it provides the educational and in most cases financial support for improved diagnostic and therapeutic practice which otherwise would be impossible to obtain and thus promotes confidence.

Basic training in paediatric nephrology for LMIC paediatric nephrologists is regularly provided by most of the international paediatric nephrology societies, both in LMIC and as internships in recognised HIC units [17].

Access to the international computerised dialysis databases which have been created in recent years [18] represents yet another important opportunity for the cultural growth of LMIC, permitting nephrologists to transmit centre/patient clinical and laboratory data to the central registry and compare their results with a benchmark, thus identifying any weaknesses in patient care.

Finally, it is hoped that editorial initiatives such as this special issue will help to ensure that HIC diagnostic and treatment models and protocols will not be slavishly applied to LMIC children, but considered in a realistic and practical manner.

Alberto Edefonti and Giovanni Montini
Paediatric Nephrology, Dialysis and Transplant Unit, Fondazione Cà Granda IRCCS, Ospedale Maggiore Policlinico, Milano, Italy
Mabel Sandoval Diaz
Department of Paediatric Nephrology and Urology, Hospital Infantil Nacional Manuel Jesus de Rivera, Managua, Nicaragua