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Table of Contents
EDITORIAL COMMENTARIES
Year : 2022  |  Volume : 25  |  Issue : 3  |  Page : 334-335
 

Peripheral neuropathy in children with chronic kidney disease: Are we looking enough? An Editorial


Department of Neurology, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia

Date of Submission11-Apr-2022
Date of Acceptance19-Apr-2022
Date of Web Publication25-Jun-2022

Correspondence Address:
Shanthi Viswanathan
Department of Neurology, Kuala Lumpur Hospital, Wilayah Persekutuan Kuala Lumpur
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aian.aian_333_22

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How to cite this article:
Viswanathan S. Peripheral neuropathy in children with chronic kidney disease: Are we looking enough? An Editorial. Ann Indian Acad Neurol 2022;25:334-5

How to cite this URL:
Viswanathan S. Peripheral neuropathy in children with chronic kidney disease: Are we looking enough? An Editorial. Ann Indian Acad Neurol [serial online] 2022 [cited 2022 Dec 4];25:334-5. Available from: https://www.annalsofian.org/text.asp?2022/25/3/334/347876




In this issue of AIAN, Ahibhushan et al.[1] described the occurrence of subclinical uremic polyneuropathy in a cohort of children between the ages of 2 and 14 years with chronic kidney disease (CKD) ranging from stage III to stage V. Peripheral neuropathy in these children is possibly under-recognized, under-reported, and under-treated, especially in resource-limited settings. Therefore, this article is timely. It explores the commonest phenotypes and electrophysiological characteristics of uremic polyneuropathies among children with CKD at a tertiary hospital in India and compares the findings to existing literature regionally as well as globally.[1] The exact prevalence of uremic polyneuropathy in children with CKD is unknown and limited reports have suggested that this group usually is asymptomatic.[2],[3]

The main highlights emerging from this study on childhood polyneuropathies in CKD are that subclinical polyneuropathy exists in children with CKD, predominantly of motor axonal type affecting the peroneal and tibial motor nerves with rarer sensory and sensorimotor polyneuropathies.[1] Similarly, another report on childhood CKD-induced neuropathies showed 52% had uremic polyneuropathies (95% confidence interval 37.65, 66.34).[2] The majority (80.8%) of the children had axonal neuropathy, and 11.5% had demyelinating neuropathy.[2] Isolated motor neuropathy was identified in 92.3% of the children, and sensorimotor neuropathy was identified in 7.6%.[2] However, in adults, a recent systematic review suggested the commonest type to be distal symmetric sensorimotor polyneuropathy which occurs due to the accumulation of uremic toxins associated with an oxidative stress-related free radical activity.[2],[3] Therein lies possibly the differences between childhood CKD polyneuropathies and adult types.

The authors were not able to find any relationship between biochemical parameters, CKD severity, or gender and the occurrence of subclinical polyneuropathies. Most studies before this have shown the presence of clinical or subclinical polyneuropathies at stages IV and V. This current study highlights an important point about the presence of polyneuropathy as a premonitory subclinical finding in patients with CKD even at stage III. The most susceptible nerves to injury were the peroneal and tibial motor nerves in the lower limbs followed by the ulnar motor nerves in the upper limbs. Similarly, many authors have reported mean peroneal conduction velocities to be significantly reduced in mild renal failure (serum creatinine concentration, 1.5 to 2.9 mg/dL, normal range: 0.8–1.2 mg/dL), while ulnar motor nerve conduction velocity (MNCV) was significantly decreased only when the serum creatinine value was at least 9 mg/dL.[2],[3],[4],[5] Transplantation seems to have some effect on the reversibility of the mild childhood uremic polyneuropathies. One year post renal transplantation, some rare reports have suggested ulnar motor nerve conduction velocity (MNCS) tends to return to normal values, and it takes 3 years for peroneal MNCV to go back to baseline values.[1],[2],[3],[4]

Consequently, earlier prospective screening of children with CKD, once they achieve critical threshold levels biochemically (as monitored by serum urea, creatinine, and estimated glomerular filtration rate (eGFR)) to identify early CKD induced polyneuropathy, may be important to identify those at risk of long-term disability. Therefore, the periodic measurement of nerve conduction velocity is not useful to follow CKD neuropathies in children with mild CKD or undergoing chronic hemodialysis, however, it may be useful in selected patients once they reach stage III CKD as shown in the current author's study.[1],[2],[3],[4],[5]

There remain unresolved issues with regard to whether early initiation of renal replacement therapy may improve, prevent, or reduce the prevalence of uremic polyneuropathies though as mentioned in many isolated studies some reversibility is seen post-transplant.[2] In the current study, no relationship between dialysis and the occurrence of polyneuropathy was observed.

To conclude, the early demonstration and screening of children with CKD for uremic polyneuropathies are important to establish thresholds wherein intervention with vitamins, micronutrients, and other strategies may be helpful. Plausibly in the future, it may be wise to investigate potential interventions including earlier initiation of renal replacement therapy that possibly may be preventive or produce therapeutic benefits thus reducing long-term physical disabilities in children with CKD-induced polyneuropathies. In the future, more well-planned prospective studies on CKD in children and the occurrence of polyneuropathies may be important.



 
   References Top

1.
Sonbhadra A, Reddy BV, Saini AG, Tiewsoh K, Paria P, Kesavan S, et al. Peripheral neuropathy in children with chronic kidney disease: Are we looking enough? Annals of Indian Academy of Neurology 2022;25:389-93.  Back to cited text no. 1
    
2.
Yoganathan S, Bagga A, Gulati S, Toteja GS, Hari P, Sinha A, et al. Prevalence of electrophysiologically defined peripheral neuropathy in children with chronic kidney disease stage IV and V: A cross sectional study. Muscle Nerve 2018;57:792-8.  Back to cited text no. 2
    
3.
Said G. Uremic neuropathy. Handb Clin Neurol 2013;115:607-12.  Back to cited text no. 3
    
4.
Kandil MR, Darwish ES, Khedr EM, Sabry MM, Abdulah MA. A community-based epidemiological study of peripheral neuropathies in Assiut, Egypt. Neurol Res 2012;34:960-6.  Back to cited text no. 4
    
5.
Abd El Naby SA, Bahbah WA, Kasemy ZA, Mahmoud AA. Neurophysiological and neuroradiological changes in children with chronic kidney disease. Front Pediatr 2020;8:570708.  Back to cited text no. 5
    




 

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