On 4 – 7 October, Malaysia played host to the 13th Asian Congress of Paediatric Nephrology (ACPN), held in conjunction with the 39th Malaysian Paediatric Association (MPA) Annual Congress at Shangri-La Hotel, Kuala Lumpur. The event also incorporated the 2nd International Paediatric Nephrology Association (IPNA)/Asian Paediatric Nephrology Association (AsPNA) Junior Masterclass.

Bringing together over 865 healthcare professionals from over 20 countries, the four-day event showcased an extensive and insightful programme, featuring over 35 sessions and presentations delivered by more than 70 experts, both local and international.

The scientific committee took great care to finalise an intensive programme that was organised into three tracks according to the level of care. Two tracks focused on aspects of paediatric nephrology, which drew interest among those involved in the care of children with basic kidney disease such as acute glomerulonephritis and urinary tract infections – both, at the level of primary and secondary care. The other was aimed at paediatric nephrology specialists and trainees, as well as those with interest in paediatric nephrology.

(Left – right): Dr Yam-Ngo Lim, Co-Chair of the ACPN 2017; Professor Dr Goh Bak Leong, President of the Malaysian Society of Nephrology; Dr Yap Hui Kim, Secretary-General of the Asian Paediatric Nephrology Association; Professor Pierre Cochat, President of the International Paediatric Nephrology Association and Dr Thiyagar Nadarajaw, President of the Malaysia Paediatric Association officiating the opening of the ACPN 2017 & 39th MPA Annual Congress.
(Left – right): Dr Yam-Ngo Lim, Co-Chair of the ACPN 2017; Professor Dr Goh Bak Leong, President of the Malaysian Society of Nephrology; Dr Yap Hui Kim, Secretary-General of the Asian Paediatric Nephrology Association; Professor Pierre Cochat, President of the International Paediatric Nephrology Association and Dr Thiyagar Nadarajaw, President of the Malaysia Paediatric Association officiating the opening of the ACPN 2017 & 39th MPA Annual Congress.

An event that provides great networking opportunities, the delegates also had the opportunity to showcase their work through oral and poster presentations, where over 190 papers were featured.

“It is gratifying to know that the scientific programme of the congress covers a wide range of very interesting topics, especially those directly related to aspects of Malaysia,” expressed Dr Thiyagar Nadarajaw, President of MPA, in his welcoming speech.

“Back-to-back symposiums, featuring expert sessions, plenaries, free papers and posters will be taking place over these three days. I hope you will gain up-to-date knowledge, and at the same time, meet up with friends,” he added.

“Prevention is priority”

Dr Yap Hui Kim, Secretary-General of the Asian Paediatric Nephrology Association, presenting the AsPNA Lifetime Achievement Award 2017 to Professor Pierre Cochat, President of the International Paediatric Nephrology Association for his outstanding accomplishments and contributions in the field of paediatric nephrology.
Dr Yap Hui Kim, Secretary-General of the Asian Paediatric Nephrology Association, presenting the AsPNA Lifetime Achievement Award 2017 to Professor Pierre Cochat, President of the International Paediatric Nephrology Association for his outstanding accomplishments and contributions in the field of paediatric nephrology.

The event kicked off with IPNA/AsPNA’s Junior Masterclass sessions, where young nephrologists presented their work.. These sessions focused on the etiology and management of chronic kidney disease, and the complications and advancements of peritoneal dialysis.

President of the IPNA, Professor Pierre Cochat provided more insights into the strategies of paediatric nephrology through the first plenary lecture, and advocated that “prevention is a priority” as “around 80% of people die because of renal replacement therapy (RRT) shortage.” In addition, RRT is an expensive treatment that most countries cannot afford.

Professor Pierre Cochat delivering his plenary lecture titled Prevention is Better than Cure: Strategies in Paediatric Nephrology after the Opening Ceremony.
Professor Pierre Cochat delivering his plenary lecture titled Prevention is Better than Cure: Strategies in Paediatric Nephrology after the Opening Ceremony.

Professor Cochat, who was the recipient of this year’s AsPNA Lifetime Achievement Award, highlighted the World Health Organisation’s (WHO) model of tri-level prevention care – primary, secondary and tertiary. The specification, implemented since 1950, states that primary prevention should focus on populations, stand before the disease and include actions on incidence of diseases, system-wide interventions and broad community focus.

Secondary prevention on the other hand, should be devoted to targeted groups, at the onset of diseases, including action and prevalence of diseases, especially those at risk of contracting the disease. Finally, tertiary prevention should be adapted to individuals after the occurrence of the disease, including intensive intervention and control and avoidance of complications.

Professor Cochat cited examples of such prevention measures in multiple countries, including the implementation of the Dietary Approaches to Stop Hypertension (DASH) diet amongst schoolchildren in the US to curb chronic kidney disease. However, he urged that most importantly, prevention should fit the local background of each country.

This can be done through tools like effective communication, good nutritional support, good infection control and providing information and support for children and families. Other tools included the training of physicians and nurses – including education of primary care health professionals – regarding the importance of urinalysis and blood pressure measurement in children and their interpretations.

Tackling vaccine controversies head-on

Highlighting the importance of kidney disease – not only to paediatric nephrologists working in tertiary institutions, but to all physicians who care for children – this year’s theme discussed Paediatric Nephrology: Office Paediatrics to Tertiary Care, zooming into current topics such as vaccinations, hypertension in children, and the importance of imaging after urinary tract infections (UTI).

Dr Musa Mohd Nordin, Consultant Paediatrician & Neonatologist at KPJ Damansara Specialist Hospital, delivering his lecture titled New Vaccines in Asia, animatedly on the second day of the event.
Dr Musa Mohd Nordin, Consultant Paediatrician & Neonatologist at KPJ Damansara Specialist Hospital, delivering his lecture titled New Vaccines in Asia, animatedly on the second day of the event.

Delivering his talk on New Vaccines in Asia, Dr Musa Mohd Nordin, Consultant Paediatrician & Neonatologist at KPJ Damansara Specialist Hospital, shared that “About six million children die before their fifth birthday… half in the neonatal period and the other half in the post-natal period.”

Elaborating further, he stated that one million children die from pneumonia, while approximately 650,000 deaths are due to the rotavirus—both of which are vaccine preventable diseases.

In a complementary session titled Vaccine Controversies, Dr Zulkifli Ismail, Consultant Paediatrician & Paediatric Cardiologist at KPJ Selangor Specialist Hospital, stated that this is due to the rise of refusals of vaccinations, particularly in Malaysia in the past two years. In turn, this has resulted in a rise of diphtheria cases, especially in rural states.

“The reason (for refusal of vaccines) in Malaysia is very clear. This Is because of Muslims who wrongly think that it is not permissible – not halal,” said Dr Musa, exasperatedly. “Unfortunately, the National Fatwa Council on its e-fatwa, actually said that it was haram.”

“There are doubts about the content as anti-vaccine lobbies have been saying that vaccines contain anything from horse urine to amniotic fluid and so on,” elaborated Dr Zul.

Dr Zulkifli Ismail, Consultant Paediatrician & Paediatric Cardiologist at KPJ Selangor Specialist Hospital provided insights to the high rates of refusal of vaccines in Malaysia through his talk titled Vaccine Controversies.
Dr Zulkifli Ismail, Consultant Paediatrician & Paediatric Cardiologist at KPJ Selangor Specialist Hospital provided insights to the high rates of refusal of vaccines in Malaysia through his talk titled Vaccine Controversies.

Listing other reasons that contribute to vaccine refusal, Dr Zul also mentioned the public was concerned about vaccine safety as anti-vaccine lobbies popularise the idea that “adverse events might follow immunisations, including vaccines-induced disorders such as autism, microcephaly and the risk of full-blown disease by voluntary exposure to antigens.”

Other factors include the beliefs that homeopathy or naturopathy being sufficient for the immune system of a child, or religious beliefs that the vaccines contain ‘haram’ ingredients, or that vaccines are the contrary to God. Conspiracy theories such as the manipulation of safety data by the Big Pharma, the influence of Big Pharma on doctors and possibility of doctors prescribing to increase profits were also mentioned.

Dr Musa detailed that the MPA wrote in to rationalise and said that vaccinations were permissible, but the Fatwa did not budge on their opinion – making the issue controversial and pressing.

As such, efforts such as a tripartite collaboration for vaccine advocacy was launched through the national programme, Immunise4Life.

“The government provides credibility to the programme, the professional bodies provide the technical input and the industry provides the financial assistance,” asserted Dr Zulkifli.

A book titled Immunisation controversies: What you need to know – edited by Dr Musa – was also introduced to educate anti-vaccination parents. It contains the fatwa of almost all the countries in the world, as well as answers the question of vaccine safety.

Immunisation controversies:  What you really need to know was edited by Dr Musa and introduced to educate anti-vaccination parents. The book is available at Dr Musa and Dr Zulkifli’s clinics, as well as Klinik Pakar Kanak-kanak Yong at Mutiara Damansara. Other online distribution points are also available at their Facebook page.
Immunisation controversies: What you really need to know was edited by Dr Musa and introduced to educate anti-vaccination parents. The book is available at Dr Musa and Dr Zulkifli’s clinics, as well as Klinik Pakar Kanak-kanak Yong at Mutiara Damansara. Other online distribution points are also available at their Facebook page.

Hypertension in children: An underdiagnosed reality

The lack of focus on hypertension in children was one of the key topics discussed at the congress.

Professor Vera Hermina Kalika Koch, head of the medical Paediatric Methodology Unit in the Children Institute University of Sao Paulo Medical School, began her session with Are We Missing Hypertension in Children?—citing “unfortunately, we have more adult data on hypertension, because it’s more checked in adults than children.”

Drawing reference from the WHO statistics, Professor Koch highlighted that there is a higher prevalence of hypertension (as of 2014) – in adults above 18 years of age – in Africa (30%) compared to the lower region of the Americas (18%). She also mentioned that 46% of the 17.5 million deaths in 2012, were due to non-communicable diseases (NCDs), while more than 42% of deaths were due to coronary heart disease. Of these, highest incidence is reported in Africa and Asia.

Professor Vera Hermina Kalika Koch, the head of the medical Paediatric Methodology Unit in the Children Institute University of Sao Paulo Medical School, highlighting the importance of the early diagnosis of hypertension in children through her session titled, Are We Missing Hypertension in Children?
Professor Vera Hermina Kalika Koch, the head of the medical Paediatric Methodology Unit in the Children Institute University of Sao Paulo Medical School, highlighting the importance of the early diagnosis of hypertension in children through her session titled, Are We Missing Hypertension in Children?

“Since 2004, we have been using normative data from the US, from studies including 17,000 children,” said Professor Koch. However, she added that this data is derived from only one, in general measurement, from each child.

“Another problem with the study was that in the original data, it was contaminated with overweight and obese healthy children, so that the normative values overestimate the normal blood pressure,” she explained. Therefore, in consequence, “we were under-diagnosing hypertension” in children.

She attributes this to the inadequate techniques and equipment, as well as the lack of awareness and professional medical training. She urged paediatricians not to read diagnoses with one measurement.

“You have to give the child the chance of multiple measurements, ideally in multiple visits and see what happens,” she suggested.

This is because several factors such as the nervousness of the child or being in stressful conditions can affect blood pressure readings, reminded Dr Joseph Flynn, a Paediatric Nephrologist at Seattle Children’s Hospital, in his related sessions Hypertension and the Obesity Epidemic and New Guidelines.

Dr Joseph Flynn, a Paediatric Nephrologist at Seattle Children’s Hospital, spoke about the relation of hypertension and the obesity epidemic, as well as the new paediatric hypertension clinical guidelines issued by the American Academy of Paediatrics in his related sessions Hypertension and the Obesity Epidemic and New Guidelines. Dr Flynn is among the co-authors of the guidelines and served as co-chair on the subcommittee.
Dr Joseph Flynn, a Paediatric Nephrologist at Seattle Children’s Hospital, spoke about the relation of hypertension and the obesity epidemic, as well as the new paediatric hypertension clinical guidelines issued by the American Academy of Paediatrics in his related sessions Hypertension and the Obesity Epidemic and New Guidelines. Dr Flynn is among the co-authors of the guidelines and served as co-chair on the subcommittee.

“Early identification of hypertension and all those severe risks is mandatory, as childhood and adolescent BMI, blood pressure measurements, family history of severe risk factors, genetic polymorphisms, are independent predictors of adult obesity, hypertension, dyslipidemia, arteriosclerosis, metabolic syndrome,” elaborated Professor Koch.

In addition, in certain diseases such as chronic kidney diseases, especially staged chronic kidney in children hypertension is very difficult to control – not to mention, there is a proven rate of prevalence of hypertension that is above 50%. Paediatric cancer survivors tend to suffer metabolic syndromes – especially those who have undergone nephrectomy. Renal dysfunction and hypertension are also expected in these children – therefore, should be diagnosed as early as possible.

“We have to be resilient. We have to be used to taking “No” as an answer, and always keep encouraging and educating,” emphasised Professor Koch, advocating the education and awareness of measuring blood pressure in children amongst healthcare professionals and parents.

Tailoring treatments and procedures for ultimate patient care

Addressing the importance of tertiary care in patients who contracted UTI, Professor Dieter Haffner, Paediatrician and Physician at Hannover Medical School Children’s Hospital and the current Treasurer of the European Society for Paediatric Nephrology (ESPN), urged delegates to “keep in mind that it is not all about imaging—but, the goal of the overall management and prevention of renal scarring and development of CKD.”

“The question is, would it change the management and outcome of the patient,” he added. “Sometimes, if you do a lot of imaging, it is a burden on the patient and you may miss your goal of making it about your patient.”

Professor Haffner then addressed imaging studies after the first febrile UTI. This may include ultrasound, cystouretography and late technetium dimercaptosuccinic acid scan, of which the guidelines may differ for boys and girls; yet, there is no consensus in the importance of these scans.

“We want to detect if there is an abstract malformation, if there is reflux and kidney damage. However, there is no consensus on the malrotations, rate of reflux and degree of damage that are important to detect. That is the question: Is it important to detect a low-grade reflux?” asked Professor Haffner, as he discussed the importance of identifying, firstly, the necessity to these imaging studies.

Professor Haffner next elaborated on the lack of consensus depends, mainly, on the poor correlation between the severity of UTI, the presence or absence of reflux, the debated role of reflux and the presence of renal scars, the trend of reflux on the spontaneous resolution, the psychological stress that may arise in patients, and the unclear need of imaging which may affect the overall health of the patient.

Guidelines on imaging also differ between countries; where all countries agree on ultrasound after the first febrile UTI, except the UK. Some suggest ultrasound in younger children only, while some do not recommend it at all.

Ultimately, “it is also important to bear in mind that if a guideline is perfectly valid in one country, it may not be valid in another country… so, you have to decide by yourself. You are responsible for the patient,” echoed Professor Haffner.

He urged paediatric nephrologists to question “What is good in my setting?” – clarifying that “‘in my setting’ means it is not about getting no scar or reflux,” – rather, the necessary steps required to secure the relevant information to treat a patient.

“Always keep in mind: will the results of imaging make an impact on your treatment decisions?” he concluded. MIMS