Proteinuria in South Asian children: prevalence and determinants

Abstract

Proteinuria in children is a marker of kidney disease and atherosclerosis, both which are known predictors of cardiovascular mortality. Recent evidence suggests that migrant South Asian populations living in the West may be at higher risk of kidney disease than native Caucasians. However, the determinants of proteinuria in South Asian children have not been explored. Previously, we reported ethnic variation in the prevalence of proteinuria in the adult population of Pakistan. However, it is not known whether ethnic predisposition to proteinuria appears during childhood or whether it is acquired later in life as a result of prolonged exposure to undiagnosed diabetes and hypertension.

Analyses were based on a subset of data for 4977 children aged 5 to less than 15 years collected as part of the broad National Health Survey of Pakistan, conducted between 1990 and 1994. Proteinuria was defined as a dipstick positive for protein on a random urine sample. Ethnicity was reported as “mother-tongue”, which is specific for each of the five major ethnic subgroups of Pakistan: Muhajir, Punjabi, Sindhi, Pashtun, and Baluchi.

The overall prevalence (95% CI) of proteinuria in the children was 3.3% (2.7–3.9%). It was 6.2% in Sindhis, 3.6% in Muhajirs, 2.8% in Punjabis, 2.8% in Baluchis, and 1.0% in Pashtuns (p<0.001). In multivariable analyses, proteinuria was associated with greater height (p=0.007), urban dwelling (p=0.03), lower socioeconomic status (p=0.02), and certain ethnicities (p=0.005).

The ethnic variation in proteinuria in South Asian children mirrors variation among ethnic groups in adults. This suggests variations in susceptibility or early exposure to causes of chronic kidney disease, rather than long-term exposure to undiagnosed diabetes or hypertension. Further studies are needed to determine factors in early life that may differentially predispose certain ethnic groups to proteinuria.

This is a preview of subscription content, log in to check access.

References

  1. 1.

    Grimm RH J, Svendsen KH KB, Keane WF, Wahi MM (1997) Proteinuria is a risk factor for mortality over 10 years of follow-up. MRFIT Research Group. Multiple risk factor intervention trial. Kidney Int Suppl 63:S10–14

    PubMed  Google Scholar 

  2. 2.

    Sarnak MJ, Levey AS, Schoolwerth AC, et al (2003) Kidney disease as a risk factor for development of cardiovascular disease: a statement from the American Heart Association Councils on Kidney in Cardiovascular Disease, High Blood Pressure Research, Clinical Cardiology, and Epidemiology and Prevention. Circulation 108(17):2154–69

    Article  PubMed  Google Scholar 

  3. 3.

    Hogg RJ, Portman RJ, Milliner D, Lemley KV, Eddy A, Ingelfinger J (2000) Evaluation and management of proteinuria and nephrotic syndrome in children: recommendations from a pediatric nephrology panel established at the National Kidney Foundation conference on proteinuria, albuminuria, risk, assessment, detection, and elimination (PARADE). Pediatrics 105(6):1242–9

    Article  CAS  PubMed  Google Scholar 

  4. 4.

    Muntner P, He J, Hamm L, Loria C, Whelton PK (2002) Renal insufficiency and subsequent death resulting from cardiovascular disease in the United States. J Am Soc Nephrol 13(3):745–53

    PubMed  Google Scholar 

  5. 5.

    Wingen AM, Fabian-Bach C, Schacfer F, Mehls O (1997) Randomised multicenter study of a low protein diet on the progression of renal failure in children. Lancet 349:1117–1123

    Article  CAS  PubMed  Google Scholar 

  6. 6.

    Portman RJ, Hawkins E, Verani R (1991) Premature artherosclerosis in pediatric renal patients: report of the Southwest Pediatric Nephrology Study Group. Pediatr Res 29:349A

    Google Scholar 

  7. 7.

    Dodge WF, West EF, Smith EH, Bruce H, 3rd (1976) Proteinuria and hematuria in schoolchildren: epidemiology and early natural history. J Pediatr 88(2):327–47

    CAS  PubMed  Google Scholar 

  8. 8.

    Mueller PW, Caudill SP (1999) Urinary albumin excretion in children: factors related to elevated excretion in the United States population. Ren Fail 21(3–4):293–302

    Google Scholar 

  9. 9.

    Loghman-Adham M (1998) Evaluating proteinuria in children. Am Fam Physician 58(5):1145–52, 1158–9

    CAS  PubMed  Google Scholar 

  10. 10.

    Ramirez SP, Hsu SI, McClellan W (2001) Low body weight is a risk factor for proteinuria in multiracial Southeast Asian pediatric population. Am J Kidney Dis 38(5):1045–54

    CAS  PubMed  Google Scholar 

  11. 11.

    Chandie Shaw PK, Vandenbroucke JP, Tjandra YI, et al (2002) Increased end-stage diabetic nephropathy in Indo-Asian immigrants living in the Netherlands. Diabetologia 45(3):337–41

    Google Scholar 

  12. 12.

    Fischbacher CM, Bhopal R, Rutter MK, Unwin NC, Marshall SM, White M, Alberti KG (2003) Microalbuminuria is more frequent in South Asian than in European origin populations: a comparative study in Newcastle, UK. Diabet Med 20(1):31–6

    Article  CAS  PubMed  Google Scholar 

  13. 13.

    Mather HM, Chaturvedi N, Kehely AM (1998) Comparison of prevalence and risk factors for microalbuminuria in South Asians and Europeans with type 2 diabetes mellitus. Diabet Med 15(8):672–7

    Article  CAS  PubMed  Google Scholar 

  14. 14.

    Fava S, Azzopardi J, Watkins PJ, Hattersley AT (2001) Adult height and proteinuria in type 2 diabetes. Nephrol Dial Transplant 16(3):525–8

    Google Scholar 

  15. 15.

    Rossing P, Tarnow L, Nielsen FS, Boelskifte S, Brenner BM, Parving HH (1995) Short stature and diabetic nephropathy. BMJ 310(6975):296–7

    CAS  PubMed  Google Scholar 

  16. 16.

    Olivarius Nde F, Vestbo E, Andreasen AH, Mogensen CE (2001) Renal involvement is related to body height in newly diagnosed diabetic women aged 40 years or over. Diabetes Metab 27(1):14–8

    PubMed  Google Scholar 

  17. 17.

    Jafar TH, Chaturvedi N, Gul A, Khan AQ, Schmid CH, Levey AS (2003) Ethnic differences and determinants of proteinuria among South Asian subgroups in Pakistan. Kidney Int 64(4):1437–1444

    Article  PubMed  Google Scholar 

  18. 18.

    Jafar TH, Levey AS, Jafary FH, White F, Gul A, Rahbar MA, Kahn AQ, Hattersley A, Schmid CH, Chaturvedi N (2003) Ethnic subgroup differences in hypertension in Pakistan. J Hypertens 21(5):905–12

    Article  CAS  PubMed  Google Scholar 

  19. 19.

    Banuazizi A (1986) The state, religion, and ethnic politics: Afghanistan, Iran, and Pakistan. Syracuse University Press, Syracuse, NY

  20. 20.

    Hussain R (1999) Community perceptions of reasons for preference for consanguineous marriages in Pakistan. J Biosoc Sci 31(4):449–61

    Article  CAS  PubMed  Google Scholar 

  21. 21.

    Pakistan Medical Research Council (1998) National Health Survey of Pakistan 1990–1994: Pakistan Medical Research Council, Islamabad, Pakistan, p 50

  22. 22.

    Mallick MD (1992) Sample design for the National Health Survey of Pakistan. Pakistan J Med Res 31(Suppl):289–290

    Google Scholar 

  23. 23.

    Midhet F, Karim MS, Berendes H (1997) Situation of women and children’s health in rural areas of North-West Frontier Province and FATA, Pakistan. National Institute of Child Health and Human Development, Bethesda and Department of Community Health Sciences, The Aga Khan University, Karachi

  24. 24.

    Pasha O, Luby SP, Khan AJ, Shah SA, McCormick JB, Fisher-Hoch SP (1999) Household members of hepatitis C virus-infected people in Hafizabad, Pakistan: infection by injections from health care providers. Epidemiol Infect 123(3):515–8

    Article  CAS  Google Scholar 

  25. 25.

    Khan TS, Rizvi F, Rashid A (2003) Hepatitis C seropositivity among chronic liver disease patients in Hazara, Pakistan. J Ayub Med Coll Abbottabad 15(2):53–5

    Google Scholar 

  26. 26.

    McQuillan GM, Townsend TR, Fields HA, Carroll M, Leahy M, Polk BF (1989) Seroepidemiology of hepatitis B virus infection in the United States, 1976 to 1980. Am J Med 87(3A):5S–10S

    Article  CAS  Google Scholar 

  27. 27.

    Gust ID (1996) Epidemiology of hepatitis B infection in the Western Pacific and South East Asia. Gut 38(Suppl 2):S18–23

    PubMed  Google Scholar 

  28. 28.

    Tariq WU, Hussain AB, Karamat KA, Ghani E, Hussain T, Hussain S (1999) Demographic aspects of hepatitis C in northern Pakistan. J Pak Med Assoc 49(8):198–201

    CAS  PubMed  Google Scholar 

  29. 29.

    Horner D, Fliser D, Klimm HP, Ritz E (1996) Albuminuria in normotensive and hypertensive individuals attending offices of general practitioners. J Hypertens 14(5):655–60

    CAS  PubMed  Google Scholar 

  30. 30.

    Lee PA, Guo SS, Kulin HE (2001) Age of puberty: data from the United States of America. Apmis 109(2):81–8

    Article  CAS  PubMed  Google Scholar 

  31. 31.

    Vestbo E, Olivarius Nde F, Mogensen CE (2001) Is renal involvement related to birth weight and adult height? Diabetes Metab 27(1):9–12

    CAS  PubMed  Google Scholar 

  32. 32.

    Alebiosu CO (2003) An update on “progression promoters” in renal diseases. J Natl Med Assoc 95(1):30–42

    CAS  PubMed  Google Scholar 

  33. 33.

    Zoccali C (2002) Nephropathy associated with arterial hypertension: genes and Barker’s hypothesis. Giornale Italiano di Nefrologia 19(5):517–22

    CAS  PubMed  Google Scholar 

  34. 34.

    Kistner A, Celsi G, Vanpee M, Jacobson SH (2000) Increased blood pressure but normal renal function in adult women born preterm. Pediatr Nephrol 15(3–4):215–20

    Google Scholar 

  35. 35.

    Rose G (1985) Sick individuals and sick populations. Int J Epidemiol 14(1):32–38

    CAS  PubMed  Google Scholar 

  36. 36.

    Polito C, La Manna A, Olivieri AN, Di Toro R (1988) Proteinuria and statural growth. Child Nephrol Urol 9(5):286–9

    PubMed  Google Scholar 

  37. 37.

    Davies AG, Postlethwaite RJ, Price DA BJ, Houlton CA, Fielding BA (1984) Urinary albumin excretion in school children. Arch Dis Child 59(7):625–30

    CAS  PubMed  Google Scholar 

  38. 38.

    el Hag AI, el Seed AM, Mustafa MD (1984) Proteinuria in Sudanese children. Ann Trop Paediatr 4(2):99–102

    PubMed  Google Scholar 

  39. 39.

    Huttunen NP, Kaar ML, Pietilainen M, Vierikko P, Reinila M (1981) Exercise-induced proteinuria in children and adolescents. Scand J Clin Lab Invest 41(6):583–7

    CAS  PubMed  Google Scholar 

  40. 40.

    Muraguri PW, McLigeyo SO, Kayima JK (1997) Proteinuria, other selected urinary abnormalities and hypertension among teenage secondary school students in Nairobi, Kenya. East Afr Med J 74(8):467–73

    CAS  PubMed  Google Scholar 

  41. 41.

    Kalter-Leibovici O, Van Dyk DJ, Leibovici L, Loya N, Erman A, Kremer I, Bauer G, Rosenfeld JB, Karp M, Laron Z (1991) Risk factors for development of diabetic nephropathy and retinopathy in Jewish IDDM patients. Diabetes 40(2):204–10

    CAS  PubMed  Google Scholar 

  42. 42.

    Weng C, Coppini DV, Sonksen PH (2000) Geographic and social factors are related to increased morbidity and mortality rates in diabetic patients. Diabet Med 17(8):612–7

    Article  CAS  PubMed  Google Scholar 

  43. 43.

    Hogg RJ, Furth S, Lemley KV, Portman R, Schwartz GJ, Coresh J, Balk E, Lau J, Levin A, Kausz AT, Eknoyan G, Levey AS (2003) National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative clinical practice guidelines for chronic kidney disease in children and adolescents: evaluation, classification and stratification. Pediatrics 111:1416–1421

    Article  PubMed  Google Scholar 

  44. 44.

    Rothman K, Greenland S (1998) Precision and validity in epidemiological studies. In: Modern epidemiology, 2nd edn. Lippincott-Raven, Philadelphia, PA, pp 115–134

  45. 45.

    Iyer RS, Shailaja SN, Bhaskaranand N, Baliga M, Venkatesh A (1991) Quantitation of proteinuria using protein-creatinine ratio in random urine samples. Indian Pediatr 28(5):463–7

    CAS  PubMed  Google Scholar 

  46. 46.

    Davidson MB, Smiley JF (1999) Relationship between dipstick positive proteinuria and albumin:creatinine ratios. J Diabetes Complications 13:52–55

    Article  CAS  PubMed  Google Scholar 

  47. 47.

    Jones CA, Francis ME, Eberhardt MS, et al (2002) Microalbuminuria in the US population: third National Health and Nutrition Examination Survey. Am J Kidney Dis 39(3):445–59

    PubMed  Google Scholar 

  48. 48.

    Zainal D, Baba A, Mustaffa BE (1995) Screening proteinuria and hematuria in Malaysian children. Southeast Asian J Trop Med Public Health 26(4):785–8

    CAS  PubMed  Google Scholar 

  49. 49.

    Murakami M (1990) Screening for proteinuria and hematuria in school children—methods and results. Acta Paediatr Jpn 32(6):682–9

    CAS  PubMed  Google Scholar 

  50. 50.

    Sakhuja V, Sud K (2003) End-stage renal disease in India and Pakistan: burden of disease and management issues. Kidney Int Suppl 83:S115–8

    Article  PubMed  Google Scholar 

  51. 51.

    Mykkanen L, Zaccaro DJ, Wagenknecht LE, Robbins DC, Gabriel M, Haffner SM (1998) Microalbuminuria is associated with insulin resistance in nondiabetic subjects: the insulin resistance atherosclerosis study. Diabetes 47:793–800

    CAS  PubMed  Google Scholar 

Download references

Author information

Affiliations

Authors

Corresponding author

Correspondence to Tazeen H. Jafar.

Additional information

Supported by grants from Fogarty International Center, NIH RO3 TWO5657–01A1 (Drs. Levey/Jafar//Schmid/Chaturvedi), and NIDDK RO1 DK53869 (Dr. Levey)

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Jafar, T.H., Chaturvedi, N., Hatcher, J. et al. Proteinuria in South Asian children: prevalence and determinants. Pediatr Nephrol 20, 1458–1465 (2005). https://doi.org/10.1007/s00467-005-1923-8

Download citation

Keywords

  • Proteinuria
  • Kidney disease
  • Epidemiology
  • South Asians
  • Ethnicity