|Year : 2020 | Volume
| Issue : 1 | Page : 57-61
Microalbuminuria among acutely ill febrile children
Ibrahim Aliyu1, Godpower Chinedu Michae2, Bukar Alhaji Grema2, Bashir Mariat Zubayr3
1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Family Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Paediatrics, Institute of Human Virology, Abuja, Nigeria
|Date of Submission||01-Oct-2018|
|Date of Decision||08-Nov-2019|
|Date of Acceptance||11-Nov-2019|
|Date of Web Publication||13-Jan-2020|
Dr. Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University, Kano
Source of Support: None, Conflict of Interest: None
INTRODUCTION: Microalbuminuria has been studied in some acute and chronic illnesses such as urinary tract infection (UTI), heart failure, and diabetes mellitus, but nothing much has been said about children with malaria and pneumonia which are most common in the tropics. Therefore, this study seeks to establish how common microalbuminuria is among acute febrile children.
MATERIALS AND METHODS: This was a prospective longitudinal study. One hundred and eighty-nine febrile children admitted for febrile illnesses who met the inclusion criteria were recruited consecutively between November 2017 and January 2018. Five milliliters of urine was tested for proteinuria using ComboStik 10 strips (DFI Co. Ltd., Gyung-Nam, Korea); positive cases were excluded from the study. Another 5 ml of urine was tested for the presence of microalbumin using ComboStik 2AC strips (DFI Co. Ltd., Gyung-Nam, Korea).
RESULTS: The age ranged from 1 year to 14 years, whereas the mean age was 5.54 ± 3.37 years. There were 138 (73%) males and 51 (27%) females, with a male-to-female ratio of 2.7:1. Most patients with malaria (57.8%), bacterial sepsis (62.5%), bronchopneumonia (42.8%), meningitis (100%), and UTI (72.0%) had high abnormal ratio; however, among the various subgroups, this was observed mostly among those with meningitis, UTI, and bacterial sepsis. The mean values and standard deviations of the age, urine creatinine, microalbumin, and the ratio of microalbumin/creatinine for the various illnesses showed higher values for UTI (age, microalbumin, and microalbumin/creatinine ratio) and bacterial sepsis (creatinine).
CONCLUSION: Microalbuminuria is common in children with febrile illnesses such as malaria, bronchopneumonia, and meningitis; therefore, usage as a screening tool for microalbuminuria should be in afebrile children.
Keywords: Acute febrile illness, bronchopneumonia, malaria, microalbuminuria, sepsis
|How to cite this article:|
Aliyu I, Michae GC, Grema BA, Zubayr BM. Microalbuminuria among acutely ill febrile children. Int J Health Allied Sci 2020;9:57-61
|How to cite this URL:|
Aliyu I, Michae GC, Grema BA, Zubayr BM. Microalbuminuria among acutely ill febrile children. Int J Health Allied Sci [serial online] 2020 [cited 2020 Jan 17];9:57-61. Available from: http://www.ijhas.in/text.asp?2020/9/1/57/275657
| Introduction|| |
The kidneys maintain normal body homeostasis; therefore, loss of renal function may result in profound morbidities or death. Illnesses such as bacterial sepsis, trauma, heart failure, diabetes mellitus, sickle cell anemia, and human immunodeficiency disease over time may progress to renal failure.,,,,
The normal functioning kidneys prevent the filtration of large molecular weight proteins such as albumin (60,000 Daltons); therefore, the presence of protein in the urine serves as a surrogate marker of renal disease. However, proteinuria may be transient or persistent; common causes of transient proteinuria include fever, exercise, and orthostasis, whereas persistent proteinuria is indicative of persistent renal disease.
Microalbuminuria detects early renal disease. This is defined as the presence of moderately increased concentration of albumin in the urine. Prolonged periods of microalbuminuria usually precede significant proteinuria, therefore giving enough time to institute measures that can regress or interrupt progression to established renal failure. Although Kwak et al. had documented significant microalbuminuria in children with acute illness such as urinary tract infection (UTI); and similarly Anil et al. and Basu et al. in their various reports described microalbuminuria as a novel biomarker in sepsis, furthermore increased mortality was associated with elevated values, however nothing much has been said about children with malaria and pneumonia which are most common in tropical climates. Therefore, this study seeks to establish how common microalbuminuria is among children with common acute febrile illnesses in our pediatric emergency.
The objective was to determine the presence of microalbuminuria among febrile ill children seen in the pediatric emergency.
- To determine the presence of microalbuminuria during common acute febrile illnesses seen in our pediatric emergency unit
- To determine if the microalbuminuria persists after the acute febrile illness
- To determine the urine microalbumin/creatinine ratio among acute febrile ill children.
| Materials and Methods|| |
Sample size shall be determined using the formula:
Z1-a/2= standard normal variate, which at 95% confidence interval is 1.96
P = expected proportion of microalbuminuria in a population, which based on previous study was 20.3%.
d = margin of error, which was chosen as 5 based on findings from previous studies
For a population <10,000, therefore, the sample size was nf = 245/1 + n/N, where
N = the population of participants for which the sample was selected from (going through the admission register, based on previous records of an average admission rate of 10 patients/day in our pediatric emergency, over a 12-week period, an estimated admission of 900 was anticipated)
N = 900
nf = 245/1 + 245/900
Therefore, the sample size was 188.
This study was prospective. One hundred and eighty-nine febrile children admitted into the Pediatric Emergency Unit of Aminu Kano Teaching Hospital, Kano, with febrile illnesses who met the inclusion criteria were recruited consecutively over 3 months (November 2017–January 2018). All children with temperature of >37.5°C were enrolled after obtaining consent from the caregivers; relevant information such as the duration of illness, sex, age, clinical symptoms, and diagnosis were entered into a pro forma.
Approval of the Ethics and Research Committee of Aminu Kano Teaching Hospital, Kano, was obtained for this study. Written informed consent was sought from the parents or guardians of the participants before enrollment into the study, and assent was also obtained from children aged 7 years and above.
- All febrile children with axillary temperature >37.5°C
- Acutely ill children: This was defined “as single or repeated episodes of illness characterized by rapid onset with short duration of which the patient usually returns to a normal or previous state of health'',
- Those whose caregivers/parents had consented to the study.
- Children with established clinical signs and/or symptoms of acute or chronic cardiac, renal disease
- Those with abnormal electrolyte, urea, and creatinine on admission
- Those with proteinuria on dipstick test
- Those resident at more than 1 h drive from the hospital.
Definition of terms
- Fever was defined as axillary temperature >37.5°C
- Microalbuminuria was defined as increased urine excretion of albumin between 30 and 300 mg/g of microalbumin/creatinine ratio in a spot urine sample (this is usually not detectable by routine urinalysis strips).
Urine sample was collected in a universal bottle upon admission and after making a clinical diagnosis; 5 ml of urine was tested for the presence of proteinuria using ComboStik 10 strips (DFI Co. Ltd., Gyung-Nam, Korea), and those who tested positive were excluded from the study. Another 5 ml of urine was collected and tested for the presence of microalbumin using ComboStik 2AC strips (DFI Co. Ltd., Gyung-Nam, Korea) on days 2 and 5; the test result was classified as normal, high, and abnormally high based on the color codes of 2AC test strips. This test was repeated 14 days later after resolution of fever for those who tested positive for microalbuminuria; this was to establish the presence of persistent microalbuminuria. Patients and caregivers/parents were counseled appropriately, and those with persistent microalbuminuria were planned for referral to the nephrology clinic for close follow-up care. All expenses for this research were borne by the researchers.
Data were analyzed using the Statistical Package for the Social Sciences SPSS version 16 (SPSS Inc., Chicago, Illinois, USA). Qualitative data were summarized using frequencies and percentages. Quantitative data were summarized using mean and standard deviation. Fisher's exact test was used to assess relationship among qualitative variables with P < 0.05 considered to be statistically significant.
| Results|| |
There were 138 (73%) males and 51 (27%) females, with a male-to-female ratio of 2.7:1.
The age ranged from 1 year to 14 years, whereas the mean age was 5.54 ± 3.37 years; the urine creatinine ranged between 10 mg/dl and 200 mg/dl, and the mean urine creatinine was 29.8 ± 12.3 mg/dl, whereas the urine microalbumin ranged from 10 mg/dl to 150 mg/dl, with a mean value of 59.58 ± 15.51 mg/dl; however, the urine microalbumin/creatinine ratio ranged between 0.10 and 15.0, and the mean value was 5.21 ± 2.29 mg/dl.
Malaria (47.6%) was the most common illness among the participants; this was followed by bacterial sepsis, whereas meningitis (1.6%) was the least [Table 1].
High abnormal microalbumin/creatinine ratio (61.4%) was common on day 2 among admitted patients, whereas 31.7% were normal; however, the values showed a decline with the normal group increasing to 74.1% by day 5 of admission [Table 2].
Most of malaria (57.8%), bacterial sepsis (62.5%), bronchopneumonia (42.8%), meningitis (100%), and UTI (72.0%) had high abnormal ratio [Table 3]; however, among the various subgroups, this was observed mostly among those with meningitis, UTI, and bacterial sepsis. This observation was statistically significant (Fisher's exact = 19.382; P = 0.017).
|Table 3: Comparing the diseases with the microalbumin/creatinine ratio of the study group|
Click here to view
The mean values and standard deviations of the age, urine creatinine, microalbumin, and the ratio of microalbumin/creatinine for the various illnesses showed higher values for UTI (age, microalbumin, and microalbumin/creatinine ratio) and bacterial sepsis (creatinine) [Table 4].
|Table 4: The mean age, urine creatinine and microalbumin, and microalbumin/creatinine ratio for the various diseases among the study group|
Click here to view
Furthermore, all participants in this study had a favorable outcome, with no documented mortality or protracted morbidity; all repeated electrolyte, urea, and creatinine were normal for all participants [Table 5].
|Table 5: The mean electrolyte, urea, and creatinine with associated illnesses after resolution of fever|
Click here to view
| Discussion|| |
This study showed that there were more males than females; this observation was similar to that of Ndukwu and Onah, Anyanwu et al., and Ibeziako and Ibekwe but differed from that of Buntsma et al. who recorded females accounting for 56% of admission in an Australian hospital. Malaria was the most common disease encountered in this study; this was followed by respiratory infection. This pattern was also reported by Ndukwu and Onah, Sa'ad et al., and Bilkisu et al. but was at variance with that reported by Anyanwu et al. who reported more of diarrhea disease.
Majority of the participants had abnormal and highly microalbumin/creatinine ratio at the first testing; this observation was similar to that reported by Kwak et al., but this was also noticed mostly among children with UTI and meningitis in our study. The mean microalbumin/creatinine ratio for the spot urine was lower in our study when compared to those of Kwak et al.; the observed difference may be attributed to the disparity in the study groups, while they studied children with only UTI, our study included subjects with other febrile infectious illnesses which probably had lower risk of renal endothelial injury, hence a lower microalbumin excretion rate. Microalbuminuria results from the imbalance between filtered albumin and reabsorbed albumin; pro-inflammatory mediators alter endothelial function resulting in leaky membranes; therefore, massive glomerular filtration exceeding the capacity of the proximal tubular cells to reabsorb may result in protein excretion in the urine.
This test was repeated on day 5 of admission and subsequently 2 weeks after resolution of fever; there was progressive fall in microalbuminuria on day 5, and subsequently, all the spot urine microalbumin/creatinine ratios were within the normal category 2 weeks after resolution of fever. Microalbuminuria is a screening test for early detection of renal and vascular complications in patients with metabolic disease such as diabetes; however, this study has shown that acute illnesses may result in transient microalbuminuria; therefore, common febrile illnesses such as malaria, bronchopneumonia, meningitis, and septicemia may result in microalbuminuria.,, Hence, a report test is necessary after resolution of signs and symptoms of acute illness. Furthermore, microalbuminuria has prognostic value in acute illnesses; Abid et al. reported that a rising level of microalbuminuria among intensive care patients with severe sepsis, bronchopneumonia, and cerebrovascular accident was associated with increasing risk of mortality, whereas a decreasing microalbuminuria level had a better outcome, and this observation was also witnessed in this study because all the cases had complete resolution of microalbuminuria within 2 weeks after resolution of fever without any mortality recorded. Similarly, Roine reported that microalbuminuria could serve as an index of severity in childhood meningitis, increasing levels of microalbuminuria resulting in poor outcome.
| Conclusion|| |
Microalbuminuria is associated with common acute febrile illnesses seen in children on admission, such as severe malaria, bacterial sepsis, meningitis, and bronchopneumonia; however, this is transient without any residual renal impairment.
We acknowledge the contributions of the research assistants who participated in data collection.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dharnidharka VR, Dabbagh S, Atiyeh B, Simpson P, Sarnaik S. Prevalence of microalbuminuria in children with sickle cell disease. Pediatr Nephrol 1998;12:475-8.
Okpere AN, Anochie IC, Eke FU. Prevalence of microalbuminuria among secondary school children. Afr Health Sci 2012;12:140-7.
Eke CB, Okafor HU, Ibe BC. Prevalence and correlates of microalbuminuria in children with sickle cell anaemia: Experience in a tertiary health facility in Enugu, Nigeria. Int J Nephrol 2012;2012:1-7. Available from: http://dx.doi. org/10.1155/2012/240173
Bertilla Uzoma E, Henrietta Uchenna O, Anthony Nnaemeka I, Tagbo O. Screening for Microalbuminuria in HIV-positive children in Enugu. Int J Nephrol 2012;2012:805834.
Carter JL, Tomson CR, Stevens PE, Lamb EJ. Does urinary tract infection cause proteinuria or microalbuminuria? A systematic review. Nephrol Dial Transplant 2006;21:3031-7.
Mosten IK, Hamel BC, Kinabo GD. Prevalence of persistent microalbuminuria and associated factors among HIV infected children attending a Tertiary hospital in Northern Tanzania: A cross sectional, analytical study. Pan Afr Med J 2015;20:251.
Imuetinyan BA, Okoeguale MI, Egberue GO. Microalbuminuria in children with sickle cell anemia. Saudi J Kidney Dis Transpl 2011;22:733-8.
] [Full text]
Herbert D, Fish AJ. Renal manifestation of systemic disorder. In: Posltethwaite RJ, editor. Clinical Paediatric Nephrology. Bristol: Wright; 1986. p. 146.
Kwak BO, Chung S, Kim KS. Microalbuminuria in children with urinary tract infection. Korean J Pediatr 2010;53:840-4.
Anil AB, Anil M, Yildiz M, Kamit Can F, Bal A, Gokalp G, et al
. The importance of microalbuminuria in predicting patient outcome in a PICU. Pediatr Crit Care Med 2014;15:e220-5.
Basu S, Bhattacharya M, Chatterjee TK, Chaudhuri S, Todi SK, Majumdar A. Microalbuminuria: A novel biomarker of sepsis. Indian J Crit Care Med 2010;14:22-8.
] [Full text]
Araoye MO. Research Methodology with Statistics for Health and Social Sciences. Ilorin, Nigeria: Nathadex; 2004. p. 123-9.
World Health Organization. Glossary of Terms for Community Health Care and Services for Older Persons who Centre for Health Development Ageing and Health Technical Report. Vol. 5. World Health Organization. Available from: http://www.who.int/kobe_centre/ageing/ahp_vol5_glossary.pdf
. [Last assessed on 2016 Dec 31].
Afifi S, Earhart K, Azab MA, Youssef FG, El Sakka H, Wasfy M, et al
. Hospital-based surveillance for acute febrile illness in Egypt: A focus on community-acquired bloodstream infections. Am J Trop Med Hyg 2005;73:392-9.
Pusic MV. Clinical management of fever in children younger than three years of age. Paediatr Child Health 2007;12:469-72.
Oviasu E, Oviasu SV. Urinary abnormalities in asymptomatic adolescent Nigerians. West Afr J Med 1994;13:152-5.
Ndukwu CI, Onah SK. Pattern and outcome of postneonatal pediatric emergencies in Nnamdi Azikiwe University Teaching Hospital, Nnewi, South East Nigeria. Niger J Clin Pract 2015;18:348-53.
] [Full text]
Anyanwu OU, Ezeanosike OB, Ezeonu CT. Pattern and outcome of admissions at the children emergency room at the federal teaching hospital Abakaliki. Afr J Med Health Sci 2014;13:6-10. [Full text]
Ibeziako SN, Ibekwe RC. Pattern and outcome of admissions in the children's emergency room of the University of Nigeria teaching hospital, Enugu. Nig J Paediatr 2002;29:103-7.
Buntsma D, Lithgow A, O'Neill E, Palmer D, Morris P, Acworth J, et al
. Patterns of paediatric emergency presentations to a tertiary referral centre in the Northern Territory. Emerg Med Australas 2017;29:678-85.
Sa'ad YM, Hayatu A, Al-Mustapha II, Orahachi YM, Hauwa MU. Morbidity and mortality of childhood illnesses at the emergency pediatric unit of a tertiary hospital, North-Eastern Nigeria. Sahel Med J 2015;18:1-3.
Bilkisu GI, Aminu MS, Sunday OO, Bassey E, Smart A, Muyideen AB. Pattern of medical childhood and mortality in a new specialist hospital in Gusau, Nigeria. Ann Nigerian Med 2014;8:15-9. [Full text]
Kim MS. Proteinuria. Clin Lab Med 1988;8:527-40.
Rein P, Vonbank A, Saely CH, Beer S, Jankovic V, Boehnel C, et al
. Relation of albuminuria to angiographically determined coronary arterial narrowing in patients with and without type 2 diabetes mellitus and stable or suspected coronary artery disease. Am J Cardiol 2011;107:1144-8.
Hanh Tien NT, Lam PK, Duyen HT, Ngoc TV, Ha PT, Kieu NT, et al
. Assessment of microalbuminuria for early diagnosis and risk prediction in dengue infections. PLoS One 2013;8:e54538.
Drumheller BC, McGrath M, Matsuura AC, Gaieski DF. Point-of-care urine albumin: Creatinine ratio is associated with outcome in emergency department patients with sepsis: A pilot study. Acad Emerg Med 2012;19:259-64.
Roine I. Microalbuminuria: An index of severity in childhood meningitis. Pediatr Infect Dis J 1993;12:584-8.
Abid O, Sun Q, Sugimoto K, Mercan D, Vincent JL. Predictive value of microalbuminuria in medical ICU patients: Results of a pilot study. Chest 2001;120:1984-8.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]