Description
Background: Around 1.7 billion cases of childhood diarrhoea occur annually. Exposure to unclean water, malnutrition, poverty, poor access to education and inadequate access to preventive health care and vaccinations all contribute to increased risk of infectious diarrhoea. Diarrhoea increases the risk of malnutrition, other infections, growth failure and poor school performance. Diarrhoea risk is increasing with climate change, and in people experiencing mass displacement. A One Health approach and achievement of the sustainable development goals are crucial reduce the burden of childhood diarrhoea and its consequences globally.
Diarrhoea is frequently associated with dehydration which contributes to mortality. Since the introduction of Oral Rehydration Solution in 1978 many lives have been saved, but around 525 000 children still die from diarrhoea annually. Diarrhoea is an underrecognized cause of acute kidney injury (AKI), due to dehydration, sepsis and/or associated hemolytic uremic syndrome (HUS). Due to poor awareness, lack of access to basic diagnostics, and non-specific symptoms, AKI is significantly underdiagnosed and undertreated. Children with AKI have increased mortality especially where dialysis is not accessible, and are at risk of developing long-term chronic kidney disease, which not only impacts the individual, but also creates long terms costs for health systems.
Data is urgently required to understand the burden of AKI associated with diarrhoea.
Methods: Systematic literature review of studies describing AKI and diarrhoea in children published since 2000. Studies published in English were identified through MEDLINE, Web of Science, African Index Medicus, and the WHO library.
Results: After screening titles and abstracts of 1896 articles, 228 full text articles were evaluated and 97 articles were included for analysis. Studies were stratified into 3 categories: children hospitalized with AKI following diarrheal disease (Diarrhoea/AKI, n=8, 8.5%); presence of diarrhoea in children with AKI (AKI/Diarrhoea, n=15, 16.5%); and diarrhoea with HUS (D+-HUS, n=74, 75%). Studies were mostly single-center, retrospective. Most studies (50%) originated from high income countries (HICs), middle-income (MICs) and low income (LICs) countries contributed 25% each.
The mean proportion of patients with Diarrhoea/AKI was higher in LICs (43.2%, range from 10-86%) compared to HICs (12.5%, range from 0.8-24.6%). In patients with AKI, the mean proportion with diarrheal disease (AKI/Diarrhoea) was similar across country income categories (HICs 16.15%, range 12-20% vs. LICs 23.8%, range 10-43%). Data was not robust enough to draw conclusions on outcomes in children with AKI and Diarrhoea. In children with D+HUS, mean dialysis requirement ranged between 45-56%. The proportion of children progressing to CKD was similar across country income groups (14.3 – 16.3%). Mortality was highest in LICs (mean 31.5%, range 17-52%) compared to MICs (6.2%) and HICs (4.2%).
Conclusion: Diarrhea is an important cause of AKI and death in children. The short and long term consequences are very underreported especially from lower resource settings. More awareness is required to permit early diagnosis and treatment and reduce the long term consequences for individuals and health systems. A One Health approach and achievement of the Sustainable Development Goals could significantly reduce the burden of childhood diarrhoea and its consequences globally.
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