Urinary Screening in Primary School Children in Yazd, Iran

authors:

avatar Abd Al-Hamid Jafari Nodoshan 1 , avatar Ahmad Shajari 2 , avatar Azam Golzar 3 , * , avatar Mehrdad Shakiba 1

Department of Pediatrics, Children Growth Disorder Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran
Yazd Islamic Azad University Of Medical Sciences, Yazd, IR Iran
Children Growth Disorder Research Center, Shahid Sadoughi University of Medical Sciences, Yazd, IR Iran
Shiraz E-Medical Journal: Vol.16, issue 1; e23866
published online: January 17, 2015
article type: Research Article
received: December 25, 2014
accepted: December 29, 2014
DOI: https://doi.org/10.17795/semj23866

how to cite: Jafari Nodoshan A A, Shajari A, Golzar A, Shakiba M. Urinary Screening in Primary School Children in Yazd, Iran. Shiraz E-Med J. 2015;16(1):e23866. https://doi.org/10.17795/semj23866.

Abstract

Background:

Urinary screening program for asymptomatic urinary abnormalities among primary school children may facilitate preventing, halting, and deferring the progression of some diseases.

Objectives:

To describe the urine examination findings in healthy primary school beginners in Yazd (Iran).

Patients and Methods:

A complete physical examination in the morning with a midstream urine sample collection obtained from 3014 students in two educational areas of Yazd, Iran. Students with positive test results in the first screening were retested. The urine samples of those with two abnormal results were analyzed using dipstick and microscope concurrently.

Results:

Children (1527 girls, 1487 boys) were screened and urinary abnormalities were detected in 94 (3.1%) subjects at the first screening. Proteinuria was the most common abnormality, detected in 54 (1.79%), and next, hematuria was present in 16 subjects. Of these children, 24 (0.79%) cases were positive in the second screening. In the third analysis of samples, abnormal findings in the patients included one isolated hematuria, eight isolated proteinuria, and two combined hematuria and proteinuria. 19 out of 3014 (0.63%) had a familiar history of renal diseases and three of them had renal disease.

Conclusions:

Urinary screening can detect chronic renal disease in its earliest stages that may help to prevent the deterioration of future renal function. In addition, a long-term follow-up of the children with hematuria and proteinuria is suggested.

1. Background

In the last three decades, urinary screening to diagnose asymptomatic renal disease in children is widespread in the developed countries (1, 2). In Asia, a program involving annual screening of primary school children is regularly conducted in Japan(1), Taiwan (3), and Korea (4). Dipstick urinalysis (DUA) remains a cornerstone to evaluate the kidney function at relatively low cost (5). Asymptomatic hematuria or proteinuria is commonly detected by a routine dipstick with a reported prevalence between 1%-10% for proteinuria, and 0.5%-2% for hematuria (6, 7). Isolated hematuria, as well as proteinuria, is usually benign, however persistent hematuria and/or proteinuria may be associated with serious underlying renal diseases or systemic disorders that require workup and referral to the nephrologists. School urinalysis screening allows early detection of the disease in its early stages and prevents the onset of renal insufficiency.

2. Objectives

The current study aimed to screen the urine of healthy primary school beginners in Yazd, Iran, for hematuria and proteinuria.

3. Patients and Methods

A cross-sectional study was conducted on 3014 subjects randomly selected from the first grade students of a primary school in Yazd from October 2007 to February 2008. The study was approved by the Ethics Committee of Yazd University of Medical Sciences. The students` parents were instructed to complete a questionnaire on the relevant demographic information and a sample of midstream urine was collected. They returned the questionnaires along with the urine specimens the following day. General physical examination (including controlling the weight, height, blood pressure, edema and paleness) was also carried out on each student by general practitioners. The first morning urine was examined by urine strips (dip sticks) (LABodia Co., Germany). In this screening program, the dipstick consisted of 10 reagents: pH, specific gravity, protein, blood, glucose, leukocytes, nitrites, urobilinogen, bilirubin, and ketones. A high-power field (HPF), when used in r elation to microscopy, references the area visible under the maximum magnification power of the objective being used. Children with abnormal findings called for the second urinary screening and if positive results were confirmed, a urine microscopic analysis was performed to examine the third urine sample. Those with persistent urinary abnormalities were referred to specialists for further evaluation. One hundred-sixty-five students were excluded due to the recent history of antibiotic therapy. Informed consent letters were obtained from the children's parents and school managers. The data were analyzed by SPSS 12. A P < 0.05 was considered statistically significant.

4. Results

A total of 3014 students (1479 boys and 1535 girls) were enrolled in the study, of whom 1484 (49.2 %) were from zone one, and 1530 (50.8 %) from zone two of Yazd city, Iran. Body Mass Index (BMI) of the subjects ranged between 10.23 and 25.02. There was no significant correlation between BMI and urinary abnormalities. At the first screening, 94 (3.1%) school children had urinary abnormalities. Proteinuria was the most common form of urinary abnormality found in 54 (1.79%) subjects. 15 cases showed positive results for blood, 10 for leukocyte estrase, 12 for ketones, and 21 for nitrite (Table 1). The prevalence of urinary abnormalities was higher in girls; however, no significant difference was observed in the prevalence of proteinuria between boys and girls. In the second stage of the study 24 (0.79%) abnormal urine samples were found (two isolated hematuria, 11 isolated proteinuria, 2 combined hematuria and proteinuria) (Table 2). In the final samples, after microscopic examination of urine, 18 students showed abnormal findings, including: Hematuria, nitrite+ and leukocyturia (n = 2), hematuria and proteinuria (n = 2), isolated hematuria (n = 1), nitrite (n = 4), leukocyturia (n = 1), isolated proteinuria (n = 8). Among eight students with positive results for protein, one was diagnosed with nephritic syndrome, five showed persistent proteinuria and were kept on follow-up, and two had hypertension. In one out of six children with hematuria in the second screening, the calcium-creatinine ratio was more than 0.21, which showed nephrolithiasis by ultrasonography during the follow-up. In the follow-up,12 new cases of renal diseases (0.5%) were found: Nephrolithiasis (n = 1), hypertension (blood pressure > 95th percentile for age), (n = 2), glomerulonephritis (n = 2), ectopic kidney (n = 1), and 6 patients with UTI (positive urine culture). Urinary symptoms were found in 33 questionnaires. Anorexia was the most common symptom in the subjects (11.24%) (Table 3). In the current study, urine specific gravity was more than 1.020 in 2427 cases (80.6%) due to inadequate water intake. The calculated cost for initial screening with a dipstick urinalysis was 0.001 Dollars per patient.

Table 1.

Urinary Findings in the First Screening

Urinary FindingBoysGirlsTotal
Proteinuria183654
Hematuria41115
Nitrite+02121
Leukocyte esterase01010
Ketone4812
Table 2.

Abnormal Urinary Test Results in the Second Stage

Urinary FindingBoysGirlsTotal
Isolated Hematuria112
Isolated Proteinuria4711
Combined hematuria and proteinuria112
Leukocyte esterase011
Nitrite+055
Any urine abnormality a033
Total61824

adipstick-positive protein, blood, leukocyte and nitrite in combination.

Table 3.

Prevalence of Symptoms in the Study Group (General and Urinary)

SymptomGirlsBoysTotal
Anorexia203136339
Poor weight gain148105253
Nocturia104151255
Lower abdominal pain231336
Dysuria341347
Incontinency261541
Flank pain393473

5. Discussion

Early diagnosis and prevention of renal diseases is the only way to prevent kidney failure, however, individuals with renal diseases often do not experience symptoms until reaching an advanced stage. Mass urinary screening helps to determine the prevalence of renal diseases in asymptomatic children. In the present study, only 3.1% of the school children had urinary abnormalities at the first screening, which was similar to the study by Hajar et al. (8) who screened 870 students in Lebanon and reported the prevalence of 2.9% at the first screening. However, it was lower than those of Shajari et al. (9) in Iran who reported a prevalence of 4.7% in the first screening and higher than 2.5% and 1.3% were reported in the Northern Iran and Egypt, respectively (10, 11). This higher prevalence could be due to the fact that more urine abnormalities than only the proteinuria and hematuria were tested in the current study where the prevalence of asymptomatic proteinuria, hematuria, nitrite and leukocyte esterase were 1.79%, 0.5%, 0.69%, and 0.29%, respectively. The prevalence of urine abnormality persisted in 0.79% on further testing in the second screening. It is compatible with the results of other studies that showed a prevalence of 0.72% and 0.71%, respectively (11, 12). Proteinuria is relatively common in children, with a reported prevalence of 1%-10%, while persistent proteinuria is much less common (13). In the current study, isolated proteinuria was the most common urinary abnormality with a prevalence of 1.79% in the first screening, which was lower than the 3.5% and 3.6% reported from different geographic regions of the world (9, 10). A cross-sectional study conducted in Lebanon reported that the prevalence of isolated proteinuria was 0.1%(8). Nepal, Malaysia, Egypt, and Shanghai reported prevalences of 0.22%, 0.12%, 0.12%, and 0.51%, respectively (11, 12, 14, 15). Akor et al. demonstrated that proteinuria was the most common urinary abnormality 3.5%, followed by hematuria 1.5% and both hematuria and proteinuria 0.2% on screening the children in Nigeria (16). There were other reports on the prevalence of hematuria and proteinuria among school children in various studies from different parts of the world (16-18). In some studies hematuria was the most common form of urinary abnormality (11, 19). The prevalence of asymptomatic microscopic hematuria among school-age children was estimated at 0.5% to 2.0% depending on the population screened (13). It was comparable to the current study results that showed a prevalence of 0.5%. Nigerian and Xiamen cities reported a prevalence of 1.5% and 1.21%, respectively (16, 20). On the contrary, hematuria had a lower prevalence in Malaysia, Egypt, and China 0.21%, 0.36% and 0.46%, respectively (11, 14, 15). Rao et al. conducted a study to determine the prevalence of urine abnormalities in school children in China. Proteinuria, occult blood, and glucosuria were detected in about 0.07%, 0.51%, and 0.06 % of the subjects, respectively (15). The current study reported that nitrituria was 0.69% at the first screening, which was lower than what was found by El-Abden et al. (1.6%) (13). Both findings of nitrituria and CHN (combined hematuria and nitrituria) increase the risk of urinary tract infections. In addition, the prevalence of proteinuria and/or hematuria may be related to different age groups. The findings of the current study were consistent with those of Parakh et al. who found that urinary abnormalities were more common in girls than boys (12). Other authors (21-23) also showed that urinary abnormalities were more frequent in girls compared with boys. Nitrituria was significantly higher in girls than boys due to their shorter urethra which makes them susceptible to ascending bacterial infection (24). Several studies indicated that urinary abnormalities are a common problem among boys and girls (25). Bakr et al. found that gender, age, or socioeconomic status had no effect on the prevalence of urinary abnormalities (11). In contrast, Lin et al. showed that microscopic urinary abnormalities were more common in males than females (26). Urine specific gravity was more than 1.020 in the present study that may indicate a relative dehydration. Ideally, the normal range for specific gravity of human urine is 1.002 to about 1.030. However, if specific gravity is above > 1.010, this can indicate mild dehydration which becomes more severe as the number increases. Two children had features of glomerulonephritis in the present study. Parakh et al. (12) from Nepal and Bakr et al. (11) from Egypt reported glomerulonephritis in respectively 50% and 66.6% of their subjects with confirmed urinary abnormalities. There are some controversies over the value of urine screening in school children. In the United States, mass screening of asymptomatic individuals is not found cost effective (27). Simonetti and Konrad also suggested that urine screening is not very useful and should be performed only at the age of five years or in sexually active adolescents (28). In another study Hanif et al. (29) suggested that urine analysis should be performed in all patients to identify the presence of unrecognized renal diseases, which may benefit from simple therapeutic measures. It is suggested that routine urine screening programs are implemented in school-age children, which is beneficial to the patients and, in many cases, cost-effective.

Acknowledgements

References

  • 1.

    Murakami M, Yamamoto H, Ueda Y, Murakami K, Yamauchi K. Urinary screening of elementary and junior high-school children over a 13-year period in Tokyo. Pediatr Nephrol. 1991;5(1):50-3. [PubMed ID: 2025538].

  • 2.

    Hagan JF, Shaw JS, Duncan PM. Bright futures: Guidelines for health supervision of infants, children, and adolescents. Elk Grove Village: American Academy of Pediatrics; 2008.

  • 3.

    Lin CY, Hsieh CC, Chen WP, Yang LY, Wang HH. The underlying diseases and follow-up in Taiwanese children screened by urinalysis. Pediatr Nephrol. 2001;16(3):232-7. [PubMed ID: 11322370].

  • 4.

    Cho BS, Kim SD, Choi YM, Kang HH. School urinalysis screening in Korea: prevalence of chronic renal disease. Pediatr Nephrol. 2001;16(12):1126-8. [PubMed ID: 11793113]. https://doi.org/10.1007/s004670100043.

  • 5.

    Campbell TL. Routine Urinalysis: Is the Dipstick Enough? J Am Med Assoc. 1985;254(13):1723. https://doi.org/10.1001/jama.1985.03360130055025.

  • 6.

    Hogg RJ, Portman RJ, Milliner D, Lemley KV, Eddy A, Ingelfinger J. 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. 2000;105(6):1242-9. [PubMed ID: 10835064].

  • 7.

    Assadi FK. Value of urinary excretion of microalbumin in predicting glomerular lesions in children with isolated microscopic hematuria. Pediatr Nephrol. 2005;20(8):1131-5. [PubMed ID: 15942787]. https://doi.org/10.1007/s00467-005-1928-3.

  • 8.

    Hajar F, Taleb M, Aoun B, Shatila A. Dipstick urine analysis screening among asymptomatic school children. N Am J Med Sci. 2011;3(4):179-84. [PubMed ID: 22540088]. https://doi.org/10.4297/najms.2011.3179.

  • 9.

    Shajari A, Fallah Zadeh Shajari MH. Screening of renal diseases in the first primary school children in Shiraz. Acta Med Iran. 2007;45(3):215-8.

  • 10.

    Badeli H, Heidarzadeh A, Ahmadian MR. Prevalence of hematuria and proteinuria in healthy 4 to 6 year old children in daycare Centers of Rasht (Northern Iran). Iran J Pediatr. 2009;19(2):169-72.

  • 11.

    Bakr A, Sarhan A, Hammad A, Ragab M, Salama OS, Al-Husseni F, et al. Asymptomatic urinary abnormalities among primary school children in Egypt. World J Pediatr. 2007;3(3):214-7.

  • 12.

    Parakh P, Bhatta NK, Mishra OP, Shrestha P, Budhathoki S, Majhi S, et al. Urinary screening for detection of renal abnormalities in asymptomatic school children. Nephrourol Mon. 2012;4(3):551-5. [PubMed ID: 23573484]. https://doi.org/10.5812/numonthly.3528.

  • 13.

    El-Abden MYZ, Abo-ElKheir OI, El-Sadek SM, El-Said AM, Awaad MA. Screening of renal diseases by urine analysis in primary school aged children at El-Gharbiya governorate-Egypt. Egypt J Hosp Med. 2013;50:24-33.

  • 14.

    Zainal D, Baba A, Mustaffa BE. Screening proteinuria and hematuria in Malaysian children. Southeast Asian J Trop Med Public Health. 1995;26(4):785-8. [PubMed ID: 9139395].

  • 15.

    Rao J, Zhou L, Shen Q, Sun L, Fang XY, Liu HM, et al. School urinalysis screening in Shanghai. World J Pediatr. 2006;3:195-8.

  • 16.

    Akor F, Okolo SN, Agaba EI, Okolo A. Urine examination findings in apparently healthy new school entrants in Jos, Nigeria. South Afr J Child Health. 2009;3(2).

  • 17.

    Ikimalo FE, Eke FU, Nkanginieme K, Ikimalo J. Urinary screening for detection of asymptomatic haematuria and proteinuria in children in urban and periurban schools in Port Harcourt. Niger J Paediatr. 2003;30(1):1-6. https://doi.org/10.4314/njp.v30i1.12013.

  • 18.

    Trihono PP, Timan IS, Bektiwibowo S, Aulia D, Edwar L. Screening urinalysis for proteinuria in schoolchildren. Paediatr Indones. 2001;41(9-10):231-3.

  • 19.

    Yap HK, Quek CM, Shen Q, Joshi V, Chia KS. Role of urinary screening programmes in children in the prevention of chronic kidney disease. Ann Acad Med Singapore. 2005;34(1):3-7. [PubMed ID: 15726213].

  • 20.

    Shen T, Peng G, Zhang HF, Hung ZQ, Zhang JY, Wang ZZ, et al. Urine routine screening of 34455 school children in Xiamen city.[J]. Chin J Child Health Care. 2009;1:40.

  • 21.

    Park YH, Choi JY, Chung HS, Koo JW, Kim SY, Namgoong MK, et al. Hematuria and proteinuria in a mass school urine screening test. Pediatr Nephrol. 2005;20(8):1126-30. [PubMed ID: 15947990]. https://doi.org/10.1007/s00467-005-1915-8.

  • 22.

    Oviasu E, Oviasu SV. Urinary abnormalities in asymptomatic adolescent Nigerians. West Afr J Med. 1994;13(3):152-5. [PubMed ID: 7841104].

  • 23.

    Sadeghi MS, Hadian MA, Rakhshani F. Prevalence of asymptomatic hematuria and proteinuria among school children in Zahedan. Tabib-E-Shargh. 2008;10(1):59-64.

  • 24.

    Ahmed SM, Swedlund SK. Evaluation and treatment of urinary tract infections in children. Am Fam Physician. 1998;57(7):1573-80. 1583-4.

  • 25.

    Vehaskari VM, Rapola J. Isolated proteinuria: analysis of a school-age population. J Pediatr. 1982;101(5):661-8. [PubMed ID: 7131137].

  • 26.

    Lin CY, Sheng CC, Chen CH, Lin CC, Chou P. The prevalence of heavy proteinuria and progression risk factors in children undergoing urinary screening. Pediatr Nephrol. 2000;14(10-11):953-9. [PubMed ID: 10975305].

  • 27.

    Patel HP. The abnormal urinalysis. Pediatr Clin North Am. 2006;53(3):325-37. v. [PubMed ID: 16716783]. https://doi.org/10.1016/j.pcl.2006.02.004.

  • 28.

    Simonetti GD, Konrad M. [Examination of urine in the child]. Ther Umsch. 2006;63(9):579-84. [PubMed ID: 17048172]. https://doi.org/10.1024/0040-5930.63.9.579.

  • 29.

    Hanif R, Ally SH, Jalal ud D, Khan K. Effectiveness of routine urine analysis of patient attending rural health centers in Abbottabad. J Ayub Med Coll Abbottabad. 2006;18(3):63-4. [PubMed ID: 17348317].