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This study aimed to determine the causes of chronic kidney disease (CKD) in Iranian children. In this
systematic review and meta-analysis study, international (PubMed, Web of Science, Scopus, and Google
Scholar) and national (SID, Magiran) databases were searched for articles published through December 30,
2017. The quality of the studies was determined using the Hoy instrument. Out of 2,117 initial studies,
13 studies performed on a total of 3,596 children were included in the final stage of the study. Based on
the results of the random effects method (95% CI), the main causes of chronic kidney disease in stages
1–4 (CKD) were CAKUT (37%) and glomerulonephritis (19.96%); in stage 5 (ESRD) they were CAKUT
(40.82%) and urological disorders (27.44%). Considering the high prevalence of CAKUT, glomerulonephri-
tis and urinary problems, the use of comprehensive approaches can be very effective in enhancing the
knowledge of patients about the causes of kidney disease. The results obtained from the present study
can assist policymakers in more accurately planning screenings of the causes of CKD in Iranian children.
Center, Ali-Ebne Abitaleb Hospital, Zahedan University of reduce the costs incurred to the health system of Iran (as
Medical Sciences, Zahedan, IR a developing country), where a large portion of the health
¶
Nursing Department, Faculty of Nursing and Midwifery, Birjand system resources is allocated to chronic diseases, such as
University of Medical Sciences, Birjand, IR CKD. This study aimed to identify the causes of CKD in
Corresponding author: Salehoddin Bouya (hresearchh@gmail.com) Iranian children as an understudied population.
Art. 34, page 2 of 9 Shahdadi et al: Causes of Chronic Kidney Disease in Iranian Children
disorders was 27.38% (95% CI: 13.90, 40.86; I2 = 98.22%) glomerulonephritis and hereditary nephropathy, which
(Figures 2 and 3). indeed have been placed in the classification of CAKUT in
the present study and are considered important causes of
3.1.4. Meta-regression CKD in children.
The results of univariate meta-regression analyses showed Causes of CKD in different regions of Iran were differ-
that participant’s mean age, gender (male-to-female ratio), ent, which may be due to different levels of health liter-
and year of publication did not contribute significantly acy among the people in the studies. The most common
to the heterogeneity of CAKUT and glomerulonephritis cause of CKD was CAKUT, which showed genetic diseases,
(p-value > 0.05) (Figure 4). including hereditary diseases and congenital malforma-
tions, are an important cause of the high incidence of CKD
4. Discussion among Iranian children. Another important cause of the
4.1. Causes of CKD among children high incidence of CAKUT is the lateness of visits and refer-
This systematic review of publications through 30 rals to the nephrologist due to latent CKD progress and
December 2017 aimed to determine the causes of CKD in high rates of consanguineous marriage [26, 31].
Iranian children. A total of 13 studies conducted on a total Unlike the present study, CKD in children in Italy and
of 3,596 Iranian children were included in the meta-analy- Belgium had miscellaneous causes [6, 10]. Furthermore,
sis. The overall main causes were CAKUT (38.4%), urologi- the prevalence of each cause differed from country to
cal disorders (22.28%), and glomerulonephritis (14%). The country, suggesting a difference in the pattern of causes of
results of sub-group analysis of stages 1–4 (CKD) and stage CKD across different countries. In the East Mediterranean
5 (ESRD) showed that the main causes in stages 1–4 of Region, such as Turkey, CAKUT is again the most impor-
CKD were CAKUT (37%) and glomerulonephritis (19.96%). tant cause of CKD in children, confirming the results of
Due to a shortage of information on the CKD epidemi- the present study, but due to some differences between
ology in children, no study was found that examined the Iran and Turkey, we should interpret them with caution
causes of CKD in children around the world through a [12]. Although the general pattern is the same across
meta-analysis. Registry-based studies have indicated that various countries, the prevalence of each cause is differ-
the most common causes of CKD in the U.S. were CAKUT ent. In this regard, the prevalence of CAKUT in American
(48%), miscellaneous (21%), and glomerulonephritis and European countries [6, 10] was 48–59%, but in the
(14%) (US) [9]; in Italy, they were CAKUT (58%), hereditary present study, the prevalence of congenital causes and
nephropathy (15%), and miscellaneous (10%) [6]; and in CAKUT was around 37%. The prevalence of causes lead-
Belgium, they were CAKUT (59%), hereditary nephropa- ing to nephropathy, including glomerulonephritis and
thy (19%), and cystic kidney disease (9%) [10]. As with hereditary causes, in European countries and the U.S. was
the present study, all other studies identified CAKUT as 10–14% [6, 9, 10]. However, in the present study, the prev-
the most important cause of CKD in children around the alence of glomerulonephritis was 19.96%, which may be
world. Other important causes in Iran were included: due to the methodology of the studies, including the place
Table 1: Summary of included studies.
First Author (year) Province Design Stage of CKD Setting Sample Size Study Duration Risk of bias
Ahmadzadeh, A., et al. (2009) [29] Khuzestan Retrospective Stage 1–4 Hospital 139 10(y) Low
Ataei, N., et al. (2016) [14] Tehran Retrospective Stage 1–5 Hospital 363 24(y) Moderate
Art. 34, page 4 of 9
Azarfar, A., et al. (2017) [15] Khorasan Razavi Cross-sectional Stage 1–5 Hospital 326 7(y) Low
Derakhshan, A., et al. (2003) [16] Fars Retrospective Stage 1–4 Hospital 1358 6.5(y) Low
Fallahzadeh, M. H. (2001) [24] Fars Prospective Stage 1–4 Hospital 170 10(y) Moderate
Gheissari, A., et al. (2012) [25] Isfahan Retrospective Stage 1–4 Hospital 268 11(y) Low
Gheissari, A., et al. (2013) [26] Isfahan Cross-sectional Stage 1–5 School 712 1(y) Low
Madani, K., et al. (2001) [23] Tehran Cross-sectional Stage 1–4 Hospital 166 9(y) Low
Mortazavi, F., et al. (2006) [27] East Azerbaijan Retrospective Stage 1–4 Hospital 55 4.5(y) Moderate
Mortazavi, F., et al. (2010) [28] East Azerbaijan Retrospective Stage 1–5 Hospital 115 10(y) Low
Otukesh, H., et al. (2001) [21] Tehran Retrospective Stage 1–4 Hospital 245 1(y) Moderate
Sharifian, M., et al. (2016) [22] Tehran Cross-sectional Stage 1–5 Hospital 104 1(y) Low
Sorkhi, H. (2001) [30] Mazandaran Cross-sectional Stage 1–5 Hospital 85 1(y) Low
Shahdadi et al: Causes of Chronic Kidney Disease in Iranian Children
Table 2: Prevalence of causes based on stage of CKD.
First author (Year) Glomerulonephritis CAKUT Urological disorders Urinary calculi Unknown
ES Weight ES Weight ES Weight ES Weight ES Weight
(95% CI for ES) (95% CI for ES) (95% CI for ES) (95% CI for ES) (95% CI for ES)
Stage 1–4
Ahmadzadeh, A. 6.47 (3.44, 11.85) 7.94 67.63 (59.46, 74.84) 9.06 10.79 (6.65, 17.04) 10.03
(2009) [29]
Derakhshan, A. 22.97 (20.82, 25.29) 8.14 0.96 (0.56, 1.63) 9.23 7.58 (6.29, 9.12) 25.91
(2003) [16]
Fallahzadeh, M.H. 15.29 (10.66, 21.47) 7.74 15.29 (10.66, 21.47) 9.15 24.12 (18.30, 31.07) 29.63 13.53 (9.19, 19.48) 10.06
(2001) [24]
Gheissari, A. 42.57 (35.96, 49.47) 7.48 34.16 (27.97, 40.94) 9.11
(2012) [25]
Madani, K. 10.24 (6.49, 15.79) 7.87 46.99 (39.55, 54.56) 9.07 8.43 (5.09, 13.66) 10.45
(2001) [23]
Mortazavi, F. 23.48 (16.67, 32.0) 7.29 58.26 (49.12, 66.86) 9.01 2.61 (0.89, 7.39) 34.69 9.57 (5.43, 16.32) 9.92
(2006) [27]
Otukesh, H. 20.41 (15.84, 25.89) 7.80 36.73 (30.95, 42.93) 9.13 3.67 (1.94, 6.83) 11.11
Shahdadi et al: Causes of Chronic Kidney Disease in Iranian Children
(2001) [21]
Sub-total random 19.96 (12.61, 27.31) 54.26 37.00 (15.63, 58.36) 63.76 8.84 (4.91, 12.77) 51.53
pooled ES
Stage 5 (ESRD)
Ataei, N. 20.11 (16.31, 24.54) 7.94 59.50 (54.38, 64.43) 9.16 19.56 (15.81, 23.95) 10.51
(2016) [14]
Azarfar, A. 3.68 (2.12, 6.32) 8.16 38.34 (33.23, 43.73) 25.30 2.76 (1.46, 5.16) 35.68 20.86 (16.80, 25.60) 10.37
(2017) [15]
Gheissari, A. 35.07 (29.61, 40.96) 7.69 34.33 (28.90, 40.20) 9.14 21.64 (17.13, 26.95) 10.13
(2013) [26]
Mortazavi, F. 25.45 (15.81, 38.3) 6.40 61.82 (48.61, 73.48) 8.78 12.73 (6.30, 24.02) 8.12
(2010) [28]
Sharifian, M. 8.65 (4.62, 15.63) 7.74 8.65 (4.62, 15.63) 9.15 14.42 (8.94, 22.44) 24.91
(2016) [22]
Sorkhi, H. 5.88 (2.54, 13.04) 7.81 29.41 (20.79, 39.82) 23.89 10.59 (5.67, 18.91) 9.33
(2001) [30]
Sub-total random 16.13 (6.28, 25.98) 45.74 40.82 (15.40, 66.24) 36.23 27.44 (11.78, 43.11) 74.09 17.94 (14.10, 21.78) 48.47
pooled ES
Art. 34, page 5 of 9
Random pooled ES 18.21 (12.04, 24.39) 100 38.40 (21.19, 55.61) 100 22.28 (5.51, 39.06) 100 9.04 (0.87, 17.20) 100 13.11 (8.44, 17.78) 100
Art. 34, page 6 of 9 Shahdadi et al: Causes of Chronic Kidney Disease in Iranian Children
where the research was conducted, sample size, sampling 4.2. Limitations
method, or the socioeconomic causes of health status, The limitations of the present study were different clas-
including a poor level of knowledge about CKD among sifications of CKD causes in some included studies, a lack
the parents of children, less access to health services, and of information in some studies where the authors were
delayed referral to a nephrologist. The high prevalence of contacted, and the design type of studies, most of which
glomerulonephritis could suggest a greater prevalence of were retrospective. Another limitation was the scope of
viral and bacterial infections in developing countries, such the studies, which were performed in only 7 provinces
as Iran [32–34]. (from a total of 31 provinces). One limitation was the tar-
The results also revealed that in the ESRD group get population; we included studies conducted on Iran as
(stage 5), the most common causes of CKD were CAKUT the study aim, but it was better for determining the CKD
(40.82%) and urological disorders (27.44%). Studies have causes in the Middle East and children around the globe.
indicated that the causes of CKD prevalence in children The most important limitation of the present study was
in the ESRD stage in Australia and New Zealand include a majority of the studies were conducted in hospital set-
CAKUT (34%) and glomerulonephritis (29%) [35], CAKUT tings, which may affect the generalizability of results. It
(36%) and hereditary nephropathy (22%) in Europe [36], seems due to the lack of a national screening program for
CAKUT (43%) and glomerulonephritis (18%) in England early detection of CKD, a lack of community-based CKD
[37], and CAKUT (36%) and glomerulonephritis (22%) in related research and necessary required infrastructure,
Asian countries, including Japan [38]. As with the present and the low number of community-based research cent-
study, CAKUT was identified by other studies as the most ers in Iran, despite a lot of progress in national medical
common cause of CKD in children at the ESRD stage. The research toward general population health concerns in
prevalence of CAKUT is higher in Iran than in other Asian the last decade, the main focus of research is on hospital-
counties, such as Japan, which may suggest a higher rate ized patients. The planning and implementation of pro-
of genetic diseases, late diagnosis of pediatric diseases, grams related to early detection of CKD in children can
and poorer health conditions in Iranian children com- lead to prevention and the minimization of costs for man-
pared to Japanese children. aging ESRD in child patients.
Shahdadi et al: Causes of Chronic Kidney Disease in Iranian Children Art. 34, page 7 of 9
Figure 4: Meta-regression of age, gender (male-to-female ratio), year of publication, and prevalence of congenital
causes (CAKUT) and glomerulonephritis in Iranian children.
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Shahdadi et al: Causes of Chronic Kidney Disease in Iranian Children Art. 34, page 9 of 9
How to cite this article: Shahdadi H, Sheyback M, Rafiemanesh H, Balouchi A, Bouya S and Mahmoudirad G. Causes of Chronic
Kidney Disease in Iranian Children: A Meta-Analysis and Systematic Review. Annals of Global Health. 2019; 85(1): 34, 1–9. DOI:
https://doi.org/10.5334/aogh.2391
Copyright: © 2019 The Author(s). This is an open-access article distributed under the terms of the Creative Commons Attribution
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