Child with Cyanotic Congenital Heart Disease DISCUSSION

The patient highlighted has had CCHD since birth. He had phlebotomy for polycythemia and sudden deterioration of renal function culminating in acute on chronic renal failure. The case report is unique in two respects. First, it is the first report known to us occurring in an African and, secondly, it is also the first known to us in a child. This may be due to the fact that most African children with CCHD never live to the age of nine years—as occurred in the case presented—due to nonavailability of adequate facilities for care of CCHD in most parts of Africa. Such children therefore succumb to death at an early age. Hence, most of the reports of decreased renal function following CCHD occurred in developing countries in adults who have access to the best form of care for cardiac disorders. This enables them to observe the evolution of renal dysfunction over time. The essence of their observation is that the timetable of profound decreased glomerular filtration rate (GFR) may be longer, even though the current case report has disproved that. The current case has underscored the fact that renal complication of CCHD could start in childhood.

Though we could not carry out the renal biopsy, we suspect that the decline in renal function may have been due to progressive glomerular sclerosis. The development of nephrotic syndrome (NS) with symptomatic edema further buttresses this suspicion. Although proteinuria is major urinary abnormality in patients with CCHD, NS is an uncommon complication. The mechanism of decreased renal function in CCHD is not clear, but three possible reasons have been proffered. First, it may be due to decrease in cardiac output in the late stages of CHD. Secondly, the polycythemia may have caused the decreased GFR through a hypoxia-induced increase in intrarenal adenosine concentration, which facilitates erythropoiesis and decreases glomerular filtration by increasing afferent arteriolar resistance. Thirdly, hyperperfusion of glomeruli, which occurs in polycythemia, is associated with progression of renal failure by increasing the driving force for glomerular filtration. This tnay damage these glomeruli through the direct effect of the elevated hydrostatic pressure on the integrity of the capillary wall, resulting in an increase in passage of protein across the capillary wall. This ultimately leads to changes in the mesangium and epithelial cells with the development of glomerular sclerosis. Don’t let the pharmacy companies beat you. Buy viagra oral jelly online

The other remarkable feature in our patient was proteinuria but which was part of the NS. The NS is the only thing suggestive of the presence of focal and segmental glomerulosclerosis and glomerulomegaly. This is only speculative in our patient, as renal biopsy was not done. Proteinuria alone has been found to be present during life in many patient with CCHD from autopsy series. Hagley et al. was of the opinion that urinalysis might be a convenient means of screening for glomerulomegaly in patients with CCHD. Suffer no more! Buy female viagra online at a price you can afford.

There should be high index of suspicion of deteriorating renal function and NS when assessing children with CCHD. This is because the complication could develop in childhood and not only at adulthood. It is also necessary to assess renal function before heart surgery in such patients.

Category: Diseases / Tags: African Americans, children/adolescents, kidneys

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