NEPHROLOGY 2009; 14, 722–727 doi:10.1111/j.1440-1797.2009.01142.

x
nep_1142 722..727

Original Article

Chronic kidney disease in children: The National Paediatric

Hospital experience in Hanoi, Vietnam
NGUYEN THI QUYNH HUONG,1,2 TRAN DINH LONG,1,2 FRANÇOIS BOUISSOU,3
NGUYEN THANH LIEM,4 DINH MINH TRUONG,5 DO KIM NGA,1,2 TRAN THI CHIEN1,2 and
JEAN-LOUP BASCANDS6,7

1
Department of Paediatric Nephrology, Paediatric National Hospital, 2Hanoi Medical University, Dong Da,
4
Department of Paediatric Surgery, Paediatric National Hospital, and 5Biostatistic HIV Training and Research
Centre, Hanoi Medical University, Hanoi, Vietnam; 3Department of Paediatric Nephrology, Children’s Hospital,
6
INSERM U858, Rangueil Institute of Molecular Medicine, Department of Renal and Cardiac Remodelling-Team
5, and 7Toulouse III Paul Sabatier University, Toulouse, France

SUMMARY: nep_1142 722..727

Aim: The goal of this descriptive study was to evaluate the aetiology and the socioeconomic status in
hospitalized children in Hanoi and propose solutions to improve prevention and basic health care of patients with
chronic kidney disease in Hanoi City.
Methods: The records of all 152 hospitalized children with chronic kidney disease in the National Paediatric
Hospital in Hanoi from January 2001 to December 2005 were analyzed.
Results: The incidence of paediatric chronic kidney disease native to Hanoi City was estimated to be 5.1/
million-child population (pmcp). Median age was 11.29 years; 60.5% were boys and 39.5% were girls; 65% of
patients were in end-stage renal disease. Causes of chronic kidney disease included glomerulonephritis (66.4%)
and congenital/hereditary anomalies (13%). In 19.8% of children, the aetiology was unavailable. During hospi-
talization, five patients died and 76 patients (50%) refused the treatment although beneficiaries of health
insurance. Thirty patients (19.74%) received peritoneal dialysis and haemodialysis, and seven patients received
renal transplantation with a familial living donor.
Conclusion: Late referral, and limited facilities for renal replacement therapy explain the poor outcome in this
study. We need a program to delineate the burden of chronic kidney disease and improve primary health care for
health promotion and prevention of paediatric chronic kidney disease.

KEY WORDS: chronic kidney disease, end-stage renal disease, glomerular filtration rate, health care,
renal transplantation, socioeconomic status.

Chronic kidney disease (CKD) represents a major health
problem worldwide.1 Children with end-stage renal disease
(ESRD) in industrialized countries have much better pro-
gnoses than their counterparts in developing countries,
as access for the latter to dialysis and transplantation is
limited.2 One of the first steps to improve the health status
Correspondence: Dr Nguyen Thi Quynh Huong, Department of
Paediatric Nephrology, Paediatric National Hospital, 18/879 De La
Thanh Street, Hanoi, Vietnam. Email: ntqhuong18@yahoo.com;
Dr François Bouissou, Department of Paediatric Nephrology, Hôpital
des Enfants, 330 Avenue de Grande Bretagne, Toulouse 31059, France.
Email: bouissou.f@chu-toulouse.fr
Accepted for publication 24 February 2009.
© 2009 The Authors
Journal compilation © 2009 Asian Pacific Society of Nephrology
of CKD children in developing countries is to evaluate the
status of CKD children in these countries or areas (e.g.
number of patients, first diagnosis, incidence of the pathol-
ogy, behaviour of the patient facing this pathology, costs).
This has been recently done for the South of Vietnam.3
However, data in North Vietnam describing the paediatric
population with CKD is still lacking.
Vietnam is a country of 85 154 900 habitants with 37%
of the population under the age of 18 years.4 Hanoi City is
the most important economic pole in the north of Vietnam.
In 2007, the Hanoi population density was officially
estimated4 at 3 289 300, however, due to the migration of
irregular workers from the countryside, this number is
underestimated and is probably close to 5–6 million.
Paediatric nephrology services and renal replacement
therapy units are only available in the National Paediatric
CKD in Vietnamese children
Hospital in Hanoi City. It receives not only CKD patients
from Hanoi but also all patients with CKD coming from the
north and the centre of Vietnam.
The aims of this study were: (i) to estimate the number of
annually hospitalized children diagnosed with CKD; (ii) to
describe the associated symptoms at entry; (iii) to present
how the economic condition of the patient is an important
limiting factor for the acceptance of dialysis and/or trans-
plantation; (iv) to identify risk factors of treatment refusal
by the family patients; and (v) to suggest simple ideas to
improve both the prevention of CKD and health care of
paediatric patients with CKD in Vietnam.
METHODS
Patients
In this retrospective study, all 152 patients up to 18 years hospitalized in
the National Paediatric Hospital in Hanoi City with CKD from the 1
January 2001 to 31 December 2005 were included. After approval from
the ethics committee and director of the National Paediatric Hospital
(Professor Nguyen Thanh Liem), informed consent was obtained from
the parents of all participants.
Clinical parameters studied
Demographic data (address, age, sex), medical history (birth weight,
uronephrology history), anthropometric characteristics (weight,
height), clinical features (blood pressure, primary nephropathy, associ-
ated congenital anomalies and related symptoms to renal insufficiency),
standard biochemical tests (serum and urine) and prescribed treatment
were collected, when available, from medical files. Growth and weight
retardations were defined as standardized values of the height and
weight to less than 2 standard deviations. As there is no existing growth
chart for Vietnamese children, we used the American Centre for
Disease Control and Prevention (CDC) chart.5
Glomerular filtration rate evaluation
Among the 152 patients included in our study, 142 patients had their
height measured, enabling us to estimate glomerular filtration rate
(GFR) according to Schwartz.6
To estimate the GFR in the group of patients (n = 10) for which
height was unavailable, we used the charts of relationship between
serum creatinine and GFR established by Dechaux.7 Serum creatinine
was assessed by the Jaffé method using an Olympus AU 400 (Olympus,
Tokyo, Japan).
Chronic renal disease and end-stage renal
disease criteria
Diagnosis of CKD was based on clinical features; creatininaemia above
150 mmol/L for more than 3 months or, in case of a unique value of
creatininaemia, we added the presence of bilateral contracted kidneys
that was confirmed using ultrasound (performed in 125 patients). Renal
size was compared with normal standard renal dimensions on ultra-
sound.8 ESRD was defined according to the National kidney Founda-
tion Kidney Disease Outcomes Quality Initiative (K/DOQI)9 as GFR
being less than 15 mL/min per 1.73 m2.
© 2009 The Authors
Journal compilation © 2009 Asian Pacific Society of Nephrology
723
Patients with CKD were subdivided in four aetiological subgroups.
Glomerulonephritis (GN) was based clinically on the presence of a
long history of oedema, nephrotic proteinuria and/or haematuria before
the onset of CKD, hypertension and/or urinary protein excretion of
more than 1 g/m2 per day at the time of diagnosis. Proteinuria was
determined by 24 h urine collection. Congenital renal dysplasia with or
without associated uropathies was assessed by ultrasound, voiding cys-
tourethrography and past history of urinary tract infection. Hereditary
renal disorders were assessed by biological parameters, ultrasound
and/or family history. The fourth group was made by CKD of unknown
origin.
Economical study
A precise study was done in all families (n = 37) receiving renal
replacement therapies (dialysis and transplantation) where the cost of
transport (home to hospital including the accompanying parent) and
diet were collected.
Assessment of health-care costs was carried out using the detailed
invoices (medical consultation, drugs, bed, biological test and radio-
logical examination) of each patient.
Statistical methods
The annual number of paediatric cases with CKD was defined as the
number per year of patients native to Hanoi City younger than 18 years
at their first admission during the period 2001–2005. We received all
paediatric patients with CKD of the north and the centre of Vietnam.
Prognostic values of biological indicators were determined by
univariate analysis using Student’s t-test, with P < 0.05 considered as
statistically significant. Analyses were performed using SPSS ver. 12.0
for Windows (SPSS, Chicago, IL, USA).
RESULTS
Demographic characteristics (Table 1)
Among 131 patients originating from the provinces, 36
(23.7%) were from five provinces in the centre of Vietnam
and 95 (62.5%) were from the 19 provinces located in the
north; 13.8% (n = 21) were native to Hanoi City. The mean
population in Hanoi City younger than 18 years is 82 1734.
Thus, the incidence of CKD in this age range of the popu-
lation could be estimated to be 5.1 million-child population
(pmcp).
Sixty-seven percent (102/152) of patients were older
than 10 years. The mean age at the time of discovery of
CKD was 11.29 years (range, 4.5 months to 17 years) and
60.5% of the cases were boys.
Primary renal diseases (Table 2)
Aetiological diagnosis was not available in 19.8% patients.
Approximately 36% of the patients were cases of GN.
Three patients were admitted with acute glomerulonephri-
tis. Congenital structural anomalies represented 11.2%.
724 NTQ Huong et al.

Stage of CKD (Table 3) Symptoms related to CKD at entry (Table 3)

Regarding the stage of CKD, it is noteworthy to observe that Table 3 shows clinical and biochemical parameters. Weight
at entry the median GFR was 14.9 mL/min per 1.73 m2. In retardation was found in 73.7% and growth retardation was
the group of ten patients where GFR was estimated by the present in 77.3% of cases. Ninety percent of the patients
Dechaux charts, four had ESRD. In total, 99 of 152 (65.1%) were anaemic; 78% of these patients had moderate or severe
patients had ESRD at hospital admittance. More than a half anaemia; and 82.5% had a metabolic acidosis as defined by
of the patients (66.9%) had a GFR below 15 mL/min per Philippe et al.11 (Ph <7.38, HCO3– <22, PCO2 <36).
1.73 m2 and only 2.1% patients had a GFR of more than
50 mL/min per 1.73 m2.
Among the 73 patients with a GFR of less than 10 mL/ Treatment refusal (Table 4)
min per 1.73 m2, 37 (51%) received renal replacement
therapy. The treatment’s refusal rate was 50% (76/152) especially in
patients without health insurance (72.4%, P < 0.05). Inter-
estingly, 39% of the patients with health insurance refused
Table 1 Epidemiology of the 152 admitted paediatric chronic treatment and was equivalent between Hanoi City (47.6%)
kidney disease patients in the National Paediatric Hospital, and other provinces (50.4%). The refusal rate was no dif-
Hanoi City, Vietnam
ferent according to aetiology, metabolic or geographical
n % status (P > 0.05).
Place of residence
Hanoi City 21 13.8 Economic study (Table 5)
Twenty-four other provinces 131 86.2
Five provinces in the centre 36 23.7 The average cost of chronic haemodialysis (20 patients)
19 provinces in the north 95 62.5 was $US469/month and chronic ambulatory peritoneal
Age (years)
dialysis (ten patients) was $US485/month. The average
1–4 20 13.2
cost of erythropoietin was $US180/month. In renal trans-
5–9 30 19.7
plantation (seven patients), the cost of immunosuppres-
10–14 70 46.1
15–18 32 21.0
sion with basic triple immunosuppressive drugs for renal
Sex transplantation (cyclosporine, mycophenolate mofetil, cor-
Boys 92 60.5 ticosteroid) was $US158/month. The health insurance
Girls 60 39.5 pays for 80% of the cost and the patient pays for 20%.
Race Transplanted patients received a supplemental help from
Kinh 141 92.8 our hospital foundation. Our patient’s family average
Five other ethnicities 11 7.2 income varied between $US30 and $US113/month in
rural and urban areas, respectively.

Table 2 Primary renal diseases at the origin of chronic kidney disease (CKD) in the 152 cases
Sex
n Male
1. Glomerulonephritis 101 60
Corticosteroid-resistant nephrotic syndrome 33 25
Chronic glomerulonephritis 53 32
Acute glomerulonephritis 3 2
Systemic lupus erythematosus 11 0 11
Henoch–Schonlein purpura 1 1
2. Congenital structural anomalies 17 12
Uropathies/pyelonephritis as a result of 10 7 3
Obstruction without valve 4 3
Urethral valve 1 1
Vesicoureteric reflux 1 1
Neurogenic bladder 4 2
Congenital hypoplasia/dysplasia 7 5
3. Hereditary renal disorders 4 2
Nephrocalcinosis 2 1
Polycystic kidney disease 2 1
4. Unknown origin 30 15
Female %
41 66.4
8 21.7
21 34.9
1 2.0
6.5
0 0.7
5 11.2
6.5
1 2.6
0 0.7
0 0.7
2 2.6
2 4.6
2 2.6
1 1.3
1 1.3
15 19.8

© 2009 The Authors

Journal compilation © 2009 Asian Pacific Society of Nephrology
CKD in Vietnamese children 725

Table 3 Clinical and biochemical data in the 152 chronic underestimated and not truly representative of the overall
kidney disease patients Vietnamese paediatric population.
n % As a general point of view it is now well admitted that
the main cause of CKD in developing countries is chronic
GFR† (mL/min per 1.73 m2) (n = 142) glomerulonephritis and nephrotic syndrome, which is
0–15 95 66.9 usually explained by a higher prevalence of bacterial, viral
0–5 24 16.9 and parasitic infections affecting the kidney.18 This high
>5–10 49 34.5 prevalence may also be related to a better diagnosis rate due
>10–15 22 15.5 to obvious symptoms (oedema, hypertension, respiratory
>15–30 28 19.7 distress) and a worse progression. Consistent with Barsoum18
>30–60 16 11.3 and Warady,12 the main cause of CKD in our hospital was
>60–90 3 2.1
GN (66.4% patients) which is similar to the observation
Standardized weight‡ (n = 152)
in China (52.7%),19 Nigeria (58.3%)20 and South Africa
22 SD 112 73.7
(56.4%) in children more than 5 years of age.13 Surprisingly,
>2 SD 40 26.3
Standardized height‡ (n = 141) the number of GN was lower in the Ho Chi Minh study
22 SD 109 77.3 (30.3%),3 which can be explained by the higher number of
>2 SD 32 22.7 cases of unknown origin.
Hypertension§ (n = 142) 62 43.7 Congenital anomalies and hereditary nephropathies are
Cardiopulmonary disease 15 9.9 predominant in developed countries.12,18 Indeed, in Italy,
Nausea, vomiting 25 16.4 renal congenital hypodysplasia with or without urinary tract
Convulsion 7 4.6 malformation represents 57.6% of patients,14 39.5% in Swe-
Anaemia 137 90.1 den21 and 52% in India.22 Not surprisingly, we only found
Mild anaemia (Hb 9–11 g/dL) 30 19.7 11.2% of the patients with hypodysplasia, which is lower
Moderate anaemia (Hb 6–8.9 g/dL) 70 46.1 than in Ho Chi Minh City (24.2%).3 This could be partially
Severe anaemia (Hb < 6 g/dL) 37 24.3 explained by the slower evolution of CKD and symptomless
Metabolic acidosis¶ (n = 80) 66 82.5 disease in the early stages. The percentage of hereditary
Small kidney on ultrasound (n = 125) 70 56.0 nephropathies is more prevalent in countries where con-
sanguinity is common like Jordania23 and Iran,24 or founder
†Estimation of the glomerular filtration rate according to Schwartz effect as in Finland.25 In our study, we found 2.6% of the
formula.6 ‡Standardized for age and sex using American Centre for
Disease Control and Prevention growth charts.5 §Blood pressure >97.5
patients with hereditary nephropathies whereas it is 12.8%
percentile in Nancy charts by Andre et al.10 ¶Metabolic acidosis in UK15 and 16.6% in Italy.14
(Ph <7.38, HCO3– <22, PCO2 <36) by Philippe et al.11 SD, standard Compared to more developed countries, the number of
deviations. diagnosed CKD cases of unknown origin is very high and
varies from 50% in Mexico City26 and Ho Chi Minh3 to
19.8% in our study. This is mainly due to the very late
DISCUSSION diagnosis in most of the patients but also the lack of available
investigation facilities, such as renal biopsy and imagery.
Although we provided an estimate for paediatric CKD in At their arrival at hospital, the majority of the patients
Hanoi City, the precise incidence of CKD in this retrospec- are already in an advanced stage of CKD as exemplified by
tive study could not be determined because of the absence of their very low GFR. The main reason of this late referral can
a register. This is a recurrent problem in most developing be attributed to traditional habits. Most of our patients have
countries. A second reason why we can only give an estimate been either first treated by traditional healers or have
of the incidence of CKD is because most of the patients are received no treatment at all. Moreover, we have to take into
never hospitalized. Therefore, and consistent with reports of account the lack of specialized education on CKD symptoms
other developing countries, our data are probably underesti- by health-care personal working in dispensaries or in some
mated.12 Indeed, we found a CKD incidence of 5.1 pmcp, of the provincial hospitals. In the Vietnamese health pre-
which is comparable to that observed in Ho Chi Minh City ventive system only bodyweight is determined, while height
(4.8 pmcp).3 The underestimation is more flagrant in Africa is rarely measured. In addition, urine dipstick analysis is not
at 1–2 pmcp.13 As expected, the incidence in more developed routinely performed. For these reasons, many urinary tract
countries is higher, namely 12.1 pmcp in Italy14 and 8.0 pmcp infections are not detected and treated. In addition, system-
in the UK.15 Comparisons remain difficult because of dispari- atic antenatal ultrasonography to screen for urinary tract
ties in the definition of CKD where the GFR lower limits vary anomalies is only available in big cities. We also have to
from 75 to 35 mL/min. take into account that children with chronic renal disease
Data about ESRD are more reliable due to the clear are managed at different levels of the Vietnamese health
end-point. Recent studies show an ESRD incidence rate of system but the final decision to transfer a patient to our
9.9 pmcp in Europe,16 and 14.6 pmcp in the USA.17 In our hospital depends mainly on the families’ capability to afford
study, the number is much lower at 3.18 pcmp, consistent the cost of travel and treatment. As shown in Table 5, the
with that of Ho Chi Minh City (4.08 pcmp).3 As treatment of CKD remained difficult to achieve, mainly by
stated above for CKD, it is evident that our number is the impossibility for the families to cover the financial

© 2009 The Authors

Journal compilation © 2009 Asian Pacific Society of Nephrology
726 NTQ Huong et al.

Table 4 Treatment refusal and relationship with other parameters in 152 patients
Treatment refusal
Number total n (%) P OR 95% CI
Health insurance
Yes 87 34 (39.1) P = 0.022* OR = 2.25 1.171
No 58 42 (72.4) 4.334
Place of residence
Hanoi City 21 10 (47.6) P = 1.000 OR = 1.17 0.444
Province 131 66 (50.4) 2.809
Aetiology
Congenital/hereditary 21 5 (23.8) P = 0.143
Acquired 100 55 (55.0)
Unknown 31 16 (51.6)
Metabolic acidosis (n = 80) 66 42 (63.6) P = 0.147 OR = 2.92 0.856; 9.972
Standardized weight (n = 152)
22 SD 112 59 (52.7) P = 0.57 OR = 0.75 0.361
>2 SD 40 17 (42.5) 1.578
Standardized height (n = 141)
22 SD 109 56 (51.4) P = 0.841 OR = 0.851 0.387
>2 SD 32 16 (50.0) 1.872
Death 5 2 (40.0) P = 1.000 OR = 1.52 0.247; 9.367

*P < 0.05. CI, confidence interval; OR, odds ratio; SD, standard deviation.

Table 5 Economic study of renal replacement therapy

Average cost Health insurance Family charge†
Replacement therapies (number of patients studied) ($US/month) ($US/month) ($US/month)
Haemodialysis (n = 20)
Twelve sessions (single session: $US39.1) 469.2 375.4 93.8‡
Other drugs per month 8.6 8.6
Travels for 1 month (one session: $US4.6) 55.2 55.2
Peritoneal dialysis at home (n = 10)
Connecting system and dialysis liquid 484.8 387.9 96.9
Other drugs per month 8.6 8.6
Travel for 1 month 8.2 8.2
Erythropoietin ($US7.6 per 1000 ui) 180.0 144.0 36.0
Renal transplantation (n = 7)
Drugs for first month 393.9 315.0 78.9‡
Drugs for second month 333.3 266.6 66.7‡
Drugs for third month 212.1 169.7 42.4‡
Drugs for each next month 157.6 126.1 31.5‡

†Average family income ($US/month): rural areas 30.3 (6.4–64.1) and urban areas 113.6 (25.6–192.3). ‡Plus 20% afforded by the foundation of
our hospital.

charge. Although health insurance and our hospital covered
100% of haemodialysis sessions and 80% of the cost of
medication, the patients cannot afford the remaining cost
(travel to the hospital and accommodation, active vitamin
D, iron and the remaining 20% for erythropoietin). Even if
the coverage by health insurance reduces the refusal rate, it
remains very high. This explains the limited number of
patients treated by replacement renal therapy. Renal trans-
plantation remains the cheapest treatment for ESRD.
Of note, the hospital mortality appears very low but is
probably underestimated because most of the patients died
outside. These data are consistent with those reported in
Ho Chi Minh City.3
In Vietnam, chronic paediatric haemodialysis was
initiated in 1998 but only started in 2004 in our hospital.
There are only ten patients treated by chronic peri-
toneal dialysis due to the cost of this therapeutic
treatment. The first renal transplantation case in Vietna-
mese children occurred in our hospital in 2004 with the
help of French experts. Since that time, seven paediatric
renal transplantations from living donors have been
performed.

© 2009 The Authors

Journal compilation © 2009 Asian Pacific Society of Nephrology
CKD in Vietnamese children
Currently, in Vietnam, there is no degree or education
for paediatric nephrologists. We only have to perform 66 h
for a paediatric nephrologist certificate, which does not
allow for serious treatment of paediatric patients with renal
diseases. In our hospital, there are only six paediatric neph-
rologists and among them only four have received 6 month
or 2 year training in developed countries: one in Russia
(3 years), one in France (1 year), one in Singapore (1 year),
one in Australia (6 months), while the other two have
received a Vietnamese paediatric nephrology certificate.
Because of the absence of a renal registry in Vietnam,
there is no reliable information on the epidemiology of
children with CKD and as a consequence the true magni-
tude of CKD/ESRD remains unknown.
In conclusion, this is the first report on CKD of Viet-
namese children in the north and the centre of Vietnam.
CKD in Vietnamese children carries a poor prognosis due to
late referral and the limited availability and high cost of
renal replacement therapy. Besides the continuing educa-
tion for nephrologists, family doctors and other health pro-
fessionals, very simple things could be undertaken to rapidly
improve the outcome of children with CKD. Family doctors
should routinely use cheap urinary dipsticks for the easy and
early detection of patients with kidney diseases allowing
rapid referral to a paediatric nephrologist. For patients with
ESRD on dialysis, transport, housing and food gratuity for
both the patient and the accompanying person will greatly
improve the acceptance of treatment.
ACKNOWLEDGEMENTS
Nguyen Thi Quynh Huong is supported by grant from the
French-vietnamese intergovernmental agreement. We wish
to thank the Medical Manager of the National Paediatric
Hospital for permission to publish and also to thank Profes-
sor Michel Huguier (Paris) and Joost P. Schanstra (U858,
Inserm, Toulouse) for their assistance.
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