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Restructuring the Ikeda City school urinary screening system: report of a screening survey

Restructuring the Ikeda City school urinary screening system: report of a screening survey Background: Annual urinary screening is conducted at municipal kindergartens, elementary schools, and junior high schools in Ikeda City, Osaka, Japan (Ikeda City School System), and the results are reviewed by a general physician, but standards for when to recommend specialist referral have not been clear. Methods: In all children attending the Ikeda City School System in 2012, dipstick urinalysis of a first-morning urine specimen was recommended once or twice, and if a second urinalysis showed proteinuria (≥1+), the urinary protein/creatinine ratio was measured. If this showed ≥0.2 g/g of creatinine (g/gCr), it was recommended that the child be evaluated by a specialist at Ikeda City Hospital. Results: Urinary screening was performed in about 20% (388) of kindergarten, about 90% (5363) of elementary school, and about 86% (2523) of junior high school children living in Ikeda City. Urine samples were obtained from 387, 5349, and 2476 children, respectively. The urinary protein/creatinine ratio was ≥0.2 g/gCr in 13 children, including 1 elementary and 12 junior high children. In these 13 children, chronic nephritic syndrome (CNS) was suspected in 6 junior high school children, and of these, this was a new finding in 5, and renal biopsy was indicated in 3. In Ikeda City, the prevalence of CNS in elementary school children was <0.03%, the prevalence of CNS in junior high school children was 0.29%, and a renal biopsy was indicated in 0.14%. By eliminating the costs associated with assessment of the results by the Ikeda Medical Association, and by directly contracting with the testing company, the expenses paid by Ikeda City for the system itself decreased from 2,508,619 yen to 966,157 yen. Conclusions: Incorporating the urinary protein/creatinine ratio into the school urinary screening system in the Ikeda City School System and clarifying standards for specialist referral has enabled restructuring of the system so that is efficient and its effectiveness can be assessed. Keywords: Chronic glomerulonephritis, Chronic nephritic syndrome, Prevalence, Renal biopsy, School urinary screening, Urinary protein/creatinine ratio Background consultation have not been clear, the number of children Annual urinary screening has been conducted in the who have undergone renal biopsy and aggressive treat- Ikeda City School System based on revisions in the En- ment such as steroid therapy is unknown, and it has not forcement Ordinance and Enforcement Regulations of been possible to assess effectiveness. the School Health Law in 1973. The school urinary The objective of the school urinary screening has re- screening results are evaluated by general physicians cently been focused on the detection of chronic neph- who are members of the local medical association. ritic syndrome (CNS). Measurement of the urinary However, standards for when to refer for specialty protein/creatinine ratio on secondary testing has been introduced, and a system for referral of all children with proteinuria, defined as a urinary protein/creatinine ratio * Correspondence: nkajiwara@ams.odn.ne.jp Department of Nephrology, Ikeda City Hospital, Ikeda, Osaka, Japan ≥0.2 g/gCr, for consultation at Ikeda City Hospital, a Full list of author information is available at the end of the article © 2013 Kajiwara et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 2 of 6 http://www.apfmj.com/content/12/1/6 core medical institution in the region, has been estab- guardians were advised to seek treatment at Ikeda City lished. The results are now reported. In addition to con- Hospital. An appointment with the pediatric or nephrol- sidering the efficiency of the system, the morbidity rate ogy outpatient department at Ikeda City Hospital was ar- of CNS was estimated, and the costs of the screening ranged by the health education teacher. system were considered. If the urinary protein/creatinine ratio was <0.2 g/gCr but either of the two urinalyses showed occult blood (≥1+) Methods or urinary glucose (≥ ±), the test results and a letter Urinary screening by dipstick urinalysis of a first- recommending consultation with the school doctor or a morning urine sample was performed once or twice in family practitioner (hereinafter referred to as “school all children attending the Ikeda City School System. In doctor”) were sent to the parents/guardians. In this children with either urinary protein (≥1+) or occult letter, to exclude acute nephritic syndrome, congenital blood (≥1+) on the first urinalysis, a second urinalysis of urological disease, and so on, the doctor was asked to a first-morning urine sample was performed. If dipstick “Please check the child’s blood pressure and whether urinalysis at this time showed urinary protein (≥1+), the the child has pretibial edema, and take appropriate urinary protein/creatinine ratio was measured using that blood tests or abdominal ultrasonography as needed.” urine. For children with urinary protein (≤ ±) and a urinary In addition, if the second urinalysis showed either protein/creatinine ratio <0.2 g/gCr on second urinalysis, urinary protein (≥1+) or occult blood (≥1+), the urinary and with occult blood (≤ ±) and urinary glucose (−)on sediment was then also examined, and the results for the either of the two urinalyses, only the test results were sent number of white blood cells (cells/hpf), the number of to the parents/guardians. The above protocol is shown in red blood cells (cells/hpf), and the presence or absence Table 1. Children who were referred to Ikeda City Hospital of cellular casts were recorded. In children with a urin- were examined by a pediatrician or nephrologist. ary protein/creatinine ratio ≥0.2 g/gCr (regardless of the Because most of the children going to elementary presence or absence of occult blood), their parents/ school and junior high school go to the municipal Table 1 School urinary screening protocol and results 1st Urinalysis 2nd Urinalysis Direction Number Protein OB Protein OB Uprot/Ucr ratio -or± -or± None 8093 - + or + −or++ Not submitted 11 -or± + + -or± ≥0.2 Ikeda City Hospital 0 -or± + + + ≥0.2 0 + -or± + -or± ≥0.2 11 + -or± + + ≥0.2 0 + + + -or± ≥0.2 0 ++ + + ≥0.2 2 -or± + + + <0.2 School doctor or family practitioner 40 + -or± + + <0.2 + + + + <0.2 -or± + -or± + + -or± -or± + + + -or± + -or± + + -or± <0.2 + + + -or± <0.2 -or± + -or± -or± + + -or± -or± + -or± + -or± <0.2 Observation 55 + -or± -or± -or± Total 8212 OB: occult blood. Uprot/Ucr ratio: urinary protein/creatinine ratio. Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 3 of 6 http://www.apfmj.com/content/12/1/6 schools, it is possible to estimate the morbidity of CNS students, 108 (90.8%) submitted a sample (elementary in elementary and junior high school age children from school 26, junior high school 82). The sample submission the numbers of children with suspected CNS found by rate for the second urinary screening was 89.7% in elemen- this system, using the expression below. tary school and 91.1% in junior high school students The morbidity rate = the number of elementary (junior (Table 2). None of the children had urinary glucose (≥ ±). high) school children with suspected CNS ÷ {number of The subsequent protocol is shown in Table 1. all children in the municipal elementary (junior high) In 13 children who had urinary protein (≥1+) on a sec- schools × participation rate for the first urinalysis}. ond dipstick urinalysis, the urinary protein/creatinine ra- For children who never underwent a second urinalysis tio was measured using that urine. The urinary protein/ despite repeated recommendations, the calculation was creatinine ratio was ≥0.2 g/gCr in 13 children, including revised from the rate of children with suspected CNS in 1 elementary school and 12 junior high school students children who underwent a 2nd urinalysis. The revised (Table 3). Of these 13 children, 1 junior high school stu- method of calculation is mentioned in the results. dent had proteinuria/hematuria syndrome since elemen- The ethical committee of Ikeda City Hospital approved tary school; CNS was suspected, the child was being the research proposal and granted permission for the re- seen at another hospital, and renal biopsy was being search. Written informed consent was obtained from the considered. Follow-up evaluation at Ikeda City Hospital patient/guardian prior to taking the first urinalysis. was recommended for the other 12 children. CNS was suspected in 3 children based on proteinuria and Results hematuria syndrome, and renal biopsy was considered in The population of Ikeda City as of April 1, 2012 was 1 child. In addition, CNS was suspected in 2 children 103,199. This included 938 4-year-old children, 917 chil- based on proteinuria syndrome, and renal biopsy was dren with an age corresponding to the first grade of considered in 1 child. elementary school (age 6 years), and 981 children with CNS was suspected in 6 children (all junior high an age corresponding to the first grade of junior high school students), and this was a newly discovered finding school (age 12 years). The numbers of these children at- in 5 cases. Of the 6 children with suspected CNS, renal tending the Ikeda City School System were 192 (20.5%), biopsy was judged to be indicated by a specialist in 3 829 (90.4%), and 842 (85.8%), respectively. Because chil- cases. Other diagnoses included postural proteinuria in dren usually continue at the same school where they 1 child (elementary school), a urinary tract infection (re- were first-year students until their graduation, among solved) in 1 child, and no abnormalities on evaluation at children living in Ikeda City, about 88% attend a munici- Ikeda City Hospital in 4 children, who were thus diag- pal elementary school or a municipal junior high school nosed as having only a transient abnormality at the time in Ikeda City. The remainder, 12% of children, goes to of school urinary screening. One child never received private, national, and Osaka prefectural kindergartens further evaluation despite repeated recommendations. and schools. In April 2012, a first urinary screening was 40 children had urinary protein (≤ ±) or a urinary pro- recommended in all 8274 children attending the Ikeda tein/creatinine ratio <0.2 g/gCr on the second urinary City School System, including 388 kindergarten, 5363 screening, but with occult blood (≥1+) on either of the elementary school, and 2523 junior high school students. two urinalyses; consultation with the school doctor was In response to the recommendations, urine samples recommended. A total of 55 children had urinary protein were submitted from a total of 8212 children (99.3%), in- (≤ ±) or a urinary protein/creatinine ratio of <0.2 g/gCr on cluding 387 kindergarten, 5349 elementary school, and the second urinary screening, and with occult blood (≤ ±) 2476 junior high school students. and urinary glucose (−) on both urinalyses; these test re- Dipstick urinalysis showed urinary protein (≥1+) or oc- sults were reported, but no recommendation for further evaluation was made (Table 1). cult blood (≥1+) in 119 (1.4%) of these children (kindergar- ten 0, elementary school 29, junior high school 90), and a School urinary screening in the Ikeda City School System second urinary screening was recommended. Of these in 2012 found no children in kindergarten or elementary Table 2 Children who were subjects of urinary examination Kindergarten Elementary Junior high Total All children in municipal kindergartens and schools 388 5363 2523 8274 Participated in 1st urinalysis 387 5349 2476 8212 Recommended for 2nd urinalysis 0 29 90 119 Participated in 2nd urinalysis 0 26 82 108 Urinary protein/creatinine ratio ≥0.2 g/gCr 0 1 12 13 Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 4 of 6 http://www.apfmj.com/content/12/1/6 Table 3 Children with a urinary protein/creatinine ratio ≥0.2 g/gCr School Age (y) Sex Result Junior high 15 M Chronic nephritic syndrome (renal biopsy considered) Proteinuria & hematuria Junior high 15 M Junior high 15 M Proteinuria Junior high 13 M Chronic nephritic syndrome (observation) Proteinuria & hematuria Junior high 13 F Junior high 12 F Proteinuria Elementary 11 F Posture proteinuria Junior high 12 M Urinary tract infection Junior high 13 M Within normal limit Junior high 13 M Junior high 13 F Junior high 12 F Junior high 15 M Did not come for consultation school with proteinuria/hematuria syndrome or proteinuria with the testing company, even with additional measure- syndrome that was suspicious of CNS. Attendance at kin- ment of the urinary protein/creatinine ratio, the cost dergarten is not part of compulsory educationinJapan.In was decreased to 966,157 yen. Ikeda City, children going to municipal kindergartens are in theminority, so theCNS morbidityof childrengoing to Discussion kindergartens was not estimated. If there was one elemen- It is desirable to compare the efficiency of the old and tary school child with CNS, based on the calculation new systems. However, in the old system, there were no 1÷(5349 × 0.897) = 0.00021, the prevalence of CNS among clear criteria for specialist referral, and it is not possible about the 5300 elementary school children in Ikeda City to know the numbers of children diagnosed with CNS. was estimated at 0.021%. In fact, there was no such child, Therefore, the morbidity rate of CNS was estimated so the prevalence of CNS among about 5300 elementary using the new system and compared with previously re- school children in Ikeda City was estimated at <0.03%. ported morbidity estimates. Of about 2500 junior high school students, 6 children In a report by Utsunomiya et al. on the effectiveness of had suspected CNS based on proteinuria/hematuria syn- school urinary screening in elementary and junior high drome or proteinuria syndrome. This was a new finding school students in Yonago City [1], of 688 children re- in 5 of the 6 children. In particular, 3 of these children quiring consultation for further evaluation based on might have had progressive CNS based on findings such renal screening at elementary and junior high schools, as proteinuria ≥0.5 g/gCr, and a renal biopsy was consid- 29 (4.2%) underwent renal biopsy; 2 had normal find- ered. If the 1 child who did not have further evaluation ings, and 27 (3.9%) had a histopathologic diagnosis such despite recommendations for consultation is counted as as IgA nephropathy. On school urinary screening in the 0.5 persons with suspected CNS and 0.25 persons in Ikeda City School System, 108 children had a second whom renal biopsy is indicated, then based on the calcu- urinalysis, and in 3 (2.8%) of these children, a renal bi- lations 6.5÷(2476 × 0.911) = 0.00288 and 3.25÷(2476 × opsy was indicated. Thus, the frequency of an indication 0.911) = 0.00144, the prevalence of CNS in about 2500 for renal biopsy in children with abnormal urinary junior high school students in Ikeda City was 0.29%, and screening results is about the same in Yonago City and a renal biopsy was judged to be indicated by a specialist Ikeda City. in 0.14% of these junior high school students. In a report by Shoji et al. on urinary screening at In 2011, the cost paid by Ikeda City for school urinary Osaka Prefectural schools using the urinary protein/cre- screening, including costs associated with assessment of atinine ratio mainly in senior high school students [2], the results by the Ikeda Medical Association, was the incidence in 2007 of newly diagnosed chronic glom- 2,508,619 yen, and the cost of urinary examination from erulonephritis was 7.6 per 100,000 persons (0.0076%). the local medical association to the testing company was This is a fairly low incidence, only about 1/18 of the esti- 1,465,926 yen. However, in 2012, there were no costs as- mated 0.14% prevalence of junior high school children sociated with assessment of the results, but only the in Ikeda City in whom renal biopsy was indicated. The costs of urinary screening. Because of the direct contract reasons for this difference may be: new onset cases of Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 5 of 6 http://www.apfmj.com/content/12/1/6 chronic glomerulonephritis from 2005 were ascertained finding, and intermittent or persistent proteinuria is a in Osaka Prefectural schools, and children with onset by frequent finding, but a small number of patients may 2006 were not included; only children who were diag- have IgA nephropathy without proteinuria [6]. By nosed with chronic glomerulonephritis based on renal recommending specialty referral only for children with a biopsy were counted; and differences between children urinary protein/creatinine ratio ≥0.2 g/gCr, it may not be in senior high school and children in junior high school possible to diagnose IgA nephropathy without protein- and lower grades. uria. However, the “Clinical guidelines for Immuno- In Korea, school children have undergone urine globulin A (IgA) nephropathy in Japan, third version” screening tests since 1998. Between 1999 and 2008, a state that the renal prognosis in clinical severity C- total of 47,047,545 school children, including elementary Grade I (urinary protein <0.5 g/day) is relatively good. school children (6–11 years old), middle school children Furthermore, renal biopsy in children positive only for (12–14 years old), and high school children (15–17 years hematuria but with a urinary protein/creatinine ratio old) participated in a mass school urine screening pro- <0.2 g/gCr increases medical costs. In addition, in Japan, gram. Through this process, 5114 children (0.010%) which has led the world in conducting school urinary were referred to pediatric nephrologists, all members of screening nationwide for about 30 years, microscopic the Korean Study Group of School Urinalysis Screening, hematuria in elementary and junior high school children at seven hospitals nationwide. Percutaneous renal biop- is almost always associated with a good prognosis [8]. sies were performed on 1478 children (28.9% of referred Therefore, in children with a urinary protein/creatinine children), and chronic glomerulonephritis was detected ratio <0.2 g/gCr, a recommendation for specialty referral in 25% of referred children [3]. Due to the difference in is probably not necessary. referral criteria, it is difficult to compare their results In children not seen by specialists, the possibility for with those of the present study. presenting with symptoms of CNS in the future exists. A cut-off value of 0.2 g/gCr for the urinary protein/ This is clear from the higher morbidity of CNS in junior creatinine ratio in children aged ≥2 years has previously high schools than in elementary schools. To address this been reported [4,5], but use of the urinary protein/ issue, annual urinalysis should be continued in schools. creatinine ratio in screening systems such as school urinary In Japan, after graduation from junior high school, 96.6% screening has seldom been reported. In the report from of children go to senior high school (15–17 years old), Osaka Prefectural schools, the urinary protein/creatinine where they also undergo urinalyses. ratio was introduced for school urinary screening start- In the new system, the cost of the urinary screening ing in 2006, and the number of children in whom fur- system itself was reduced. However, since referrals were ther detailed evaluation was deemed necessary decreased recommended for 53 children (13 children were recom- from 2436 children in 2005 to 268 children in 2007. mended to see specialists, and 40 children were recom- However, the number of children newly diagnosed with mended to see school doctors), there is a possibility that chronic glomerulonephritis did not decrease from 2005 medical expenses increased. Further consideration of (7 children) to 2007 (9 children) [2]. Thus, the report ways to decrease recommendations for referrals for chil- concluded that the burden on children themselves, their dren who do not need them is required. parents/guardians, the schools, and medical institutions was reduced, but without a decrease in diagnostic effi- Conclusions ciency. In the case of the Ikeda City School System, al- In conclusion, incorporating the urinary protein/creatin- though diagnostic efficiency could not be compared, ine ratio into the school urinary screening system in the because the number of cases of CNS up to 2011 could Ikeda City School System and clarifying standards for re- not be ascertained, the costs of the urinary screening ferral to specialty consultation has enabled restructuring system could be reduced. of the system so that it is efficient and its effectiveness In Japan, IgA nephropathy accounts for ≥30% of cases can be assessed. of chronic glomerulonephritis in adults and ≥20% of Competing interests cases in children [6]. We also consider early detection of The authors have no conflicts of interest to disclose. There is nothing to IgA nephropathy to be an important objective of school declare with respect to this article. urinary screening. It has been reported that about 62% Authors’ contributions of IgA nephropathy in children in Japan is discovered NK drafted the manuscript. NK, KH, SY, and IM examined the children at based on microscopic hematuria and/or asymptomatic Ikeda City Hospital. NK, TF, KS, SM, TK, and TU designed the study. NK, SH, proteinuria [7], and school urinary screening has played and SA contributed to data analysis. MI contributed as a representative of school doctors and family practitioners in Ikeda City. SH and KS contributed a contributory role. In the “Clinical guidelines for Im- as representatives of the Ikeda City Board of Education. MY and SA munoglobulin A (IgA) nephropathy in Japan, third ver- contributed as representatives of health education teachers in Ikeda City. All sion,” persistent microscopic hematuria is a necessary authors read and approved the final manuscript. Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 6 of 6 http://www.apfmj.com/content/12/1/6 Acknowledgements The authors would like to express their gratitude to Prof. Yoshiharu Tsubakihara at the Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, and to Dr. Tatsuya Shoji at the Department of Kidney Disease and Hypertension, Osaka General Medical Center, for their advice in restructuring the school urinary screening system in the Ikeda City School System. Author details Department of Nephrology, Ikeda City Hospital, Ikeda, Osaka, Japan. Department of Nephrology and Artificial Kidney, Matsushita Memorial Hospital, Moriguchi, Osaka, Japan. Department of General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan. Inoue Clinic Medical Corporation, Ikeda, 5 6 Osaka, Japan. Ikeda City Board of Education, Ikeda, Osaka, Japan. Ikeda City Ishibashi Elementary School, Ikeda, Osaka, Japan. Ikeda City Fushiodai Elementary School, Ikeda, Osaka, Japan. Department of Pediatrics, Ikeda City Hospital, Ikeda, Osaka, Japan. Received: 10 December 2012 Accepted: 6 December 2013 Published: 13 December 2013 References 1. Utsunomiya Y, Koda T, Kado T, Okada S, Hayashi A, Kanzaki S, Kasagi T, Hayashibara H, Okasora T: Incidence of pediatric IgA nephropathy. Pediatr Nephrol 2003, 18:511–515. 2. Shoji T, Onishi M, Suzuki A, Kaneko T, Mori K, Satomura K, Tsubakihara Y: Poor utilization of results from school urinalysis screening. Sogorinsho 2009, 58:1176–1180. Japanese. 3. Byoung-Soo C, Won-Ho H, Hae Il C, Inseok L, Cheol Woo K, Su-Young K, Dae-Yeol L, Tae-Sun H, Jin-Soon S: A nationwide study of mass unine screening tests on Korean school children and implications for chronic kidney disease management. Clin Exp Nephrol 2013, 17:205–210. 4. Houser M: Assessment of proteinuria using random urine samples. J Pediatr 1984, 104:845–848. 5. Yoshimoto M, Tsukahara H, Saito M, Hayashi S, Haruki S, Fujisawa S, Sudo M: Evaluation of variability of proteinuria indices. Pediatr Nephrol 1990, 4:136–139. 6. Special Study Group (IgA Nephropathy) on Progressive Renal Diseases: Clinical guides for immunoglobulin A (IgA) nephropathy in Japan, third version. Nihon Jinzo Gakkai Shi 2011, 53:123–135. Japanese. 7. Yoshikawa N, Tanaka R, Iijima K: Pathophysiology and treatment of IgA nephropathy in children. Pediatr Nephrol 2001, 16:446–457. 8. Committee for Diagnostic Guidelines of Hematuria: Guidelines for diagnosis of hematuria. Nihon Jinzo Gakkai Shi 2006, 48(Suppl):1–34. Japanese. doi:10.1186/1447-056X-12-6 Cite this article as: Kajiwara et al.: Restructuring the Ikeda City school urinary screening system: report of a screening survey. Asia Pacific Family Medicine 2013 12:6. 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Restructuring the Ikeda City school urinary screening system: report of a screening survey

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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: Annual urinary screening is conducted at municipal kindergartens, elementary schools, and junior high schools in Ikeda City, Osaka, Japan (Ikeda City School System), and the results are reviewed by a general physician, but standards for when to recommend specialist referral have not been clear. Methods: In all children attending the Ikeda City School System in 2012, dipstick urinalysis of a first-morning urine specimen was recommended once or twice, and if a second urinalysis showed proteinuria (≥1+), the urinary protein/creatinine ratio was measured. If this showed ≥0.2 g/g of creatinine (g/gCr), it was recommended that the child be evaluated by a specialist at Ikeda City Hospital. Results: Urinary screening was performed in about 20% (388) of kindergarten, about 90% (5363) of elementary school, and about 86% (2523) of junior high school children living in Ikeda City. Urine samples were obtained from 387, 5349, and 2476 children, respectively. The urinary protein/creatinine ratio was ≥0.2 g/gCr in 13 children, including 1 elementary and 12 junior high children. In these 13 children, chronic nephritic syndrome (CNS) was suspected in 6 junior high school children, and of these, this was a new finding in 5, and renal biopsy was indicated in 3. In Ikeda City, the prevalence of CNS in elementary school children was <0.03%, the prevalence of CNS in junior high school children was 0.29%, and a renal biopsy was indicated in 0.14%. By eliminating the costs associated with assessment of the results by the Ikeda Medical Association, and by directly contracting with the testing company, the expenses paid by Ikeda City for the system itself decreased from 2,508,619 yen to 966,157 yen. Conclusions: Incorporating the urinary protein/creatinine ratio into the school urinary screening system in the Ikeda City School System and clarifying standards for specialist referral has enabled restructuring of the system so that is efficient and its effectiveness can be assessed. Keywords: Chronic glomerulonephritis, Chronic nephritic syndrome, Prevalence, Renal biopsy, School urinary screening, Urinary protein/creatinine ratio Background consultation have not been clear, the number of children Annual urinary screening has been conducted in the who have undergone renal biopsy and aggressive treat- Ikeda City School System based on revisions in the En- ment such as steroid therapy is unknown, and it has not forcement Ordinance and Enforcement Regulations of been possible to assess effectiveness. the School Health Law in 1973. The school urinary The objective of the school urinary screening has re- screening results are evaluated by general physicians cently been focused on the detection of chronic neph- who are members of the local medical association. ritic syndrome (CNS). Measurement of the urinary However, standards for when to refer for specialty protein/creatinine ratio on secondary testing has been introduced, and a system for referral of all children with proteinuria, defined as a urinary protein/creatinine ratio * Correspondence: nkajiwara@ams.odn.ne.jp Department of Nephrology, Ikeda City Hospital, Ikeda, Osaka, Japan ≥0.2 g/gCr, for consultation at Ikeda City Hospital, a Full list of author information is available at the end of the article © 2013 Kajiwara et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 2 of 6 http://www.apfmj.com/content/12/1/6 core medical institution in the region, has been estab- guardians were advised to seek treatment at Ikeda City lished. The results are now reported. In addition to con- Hospital. An appointment with the pediatric or nephrol- sidering the efficiency of the system, the morbidity rate ogy outpatient department at Ikeda City Hospital was ar- of CNS was estimated, and the costs of the screening ranged by the health education teacher. system were considered. If the urinary protein/creatinine ratio was <0.2 g/gCr but either of the two urinalyses showed occult blood (≥1+) Methods or urinary glucose (≥ ±), the test results and a letter Urinary screening by dipstick urinalysis of a first- recommending consultation with the school doctor or a morning urine sample was performed once or twice in family practitioner (hereinafter referred to as “school all children attending the Ikeda City School System. In doctor”) were sent to the parents/guardians. In this children with either urinary protein (≥1+) or occult letter, to exclude acute nephritic syndrome, congenital blood (≥1+) on the first urinalysis, a second urinalysis of urological disease, and so on, the doctor was asked to a first-morning urine sample was performed. If dipstick “Please check the child’s blood pressure and whether urinalysis at this time showed urinary protein (≥1+), the the child has pretibial edema, and take appropriate urinary protein/creatinine ratio was measured using that blood tests or abdominal ultrasonography as needed.” urine. For children with urinary protein (≤ ±) and a urinary In addition, if the second urinalysis showed either protein/creatinine ratio <0.2 g/gCr on second urinalysis, urinary protein (≥1+) or occult blood (≥1+), the urinary and with occult blood (≤ ±) and urinary glucose (−)on sediment was then also examined, and the results for the either of the two urinalyses, only the test results were sent number of white blood cells (cells/hpf), the number of to the parents/guardians. The above protocol is shown in red blood cells (cells/hpf), and the presence or absence Table 1. Children who were referred to Ikeda City Hospital of cellular casts were recorded. In children with a urin- were examined by a pediatrician or nephrologist. ary protein/creatinine ratio ≥0.2 g/gCr (regardless of the Because most of the children going to elementary presence or absence of occult blood), their parents/ school and junior high school go to the municipal Table 1 School urinary screening protocol and results 1st Urinalysis 2nd Urinalysis Direction Number Protein OB Protein OB Uprot/Ucr ratio -or± -or± None 8093 - + or + −or++ Not submitted 11 -or± + + -or± ≥0.2 Ikeda City Hospital 0 -or± + + + ≥0.2 0 + -or± + -or± ≥0.2 11 + -or± + + ≥0.2 0 + + + -or± ≥0.2 0 ++ + + ≥0.2 2 -or± + + + <0.2 School doctor or family practitioner 40 + -or± + + <0.2 + + + + <0.2 -or± + -or± + + -or± -or± + + + -or± + -or± + + -or± <0.2 + + + -or± <0.2 -or± + -or± -or± + + -or± -or± + -or± + -or± <0.2 Observation 55 + -or± -or± -or± Total 8212 OB: occult blood. Uprot/Ucr ratio: urinary protein/creatinine ratio. Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 3 of 6 http://www.apfmj.com/content/12/1/6 schools, it is possible to estimate the morbidity of CNS students, 108 (90.8%) submitted a sample (elementary in elementary and junior high school age children from school 26, junior high school 82). The sample submission the numbers of children with suspected CNS found by rate for the second urinary screening was 89.7% in elemen- this system, using the expression below. tary school and 91.1% in junior high school students The morbidity rate = the number of elementary (junior (Table 2). None of the children had urinary glucose (≥ ±). high) school children with suspected CNS ÷ {number of The subsequent protocol is shown in Table 1. all children in the municipal elementary (junior high) In 13 children who had urinary protein (≥1+) on a sec- schools × participation rate for the first urinalysis}. ond dipstick urinalysis, the urinary protein/creatinine ra- For children who never underwent a second urinalysis tio was measured using that urine. The urinary protein/ despite repeated recommendations, the calculation was creatinine ratio was ≥0.2 g/gCr in 13 children, including revised from the rate of children with suspected CNS in 1 elementary school and 12 junior high school students children who underwent a 2nd urinalysis. The revised (Table 3). Of these 13 children, 1 junior high school stu- method of calculation is mentioned in the results. dent had proteinuria/hematuria syndrome since elemen- The ethical committee of Ikeda City Hospital approved tary school; CNS was suspected, the child was being the research proposal and granted permission for the re- seen at another hospital, and renal biopsy was being search. Written informed consent was obtained from the considered. Follow-up evaluation at Ikeda City Hospital patient/guardian prior to taking the first urinalysis. was recommended for the other 12 children. CNS was suspected in 3 children based on proteinuria and Results hematuria syndrome, and renal biopsy was considered in The population of Ikeda City as of April 1, 2012 was 1 child. In addition, CNS was suspected in 2 children 103,199. This included 938 4-year-old children, 917 chil- based on proteinuria syndrome, and renal biopsy was dren with an age corresponding to the first grade of considered in 1 child. elementary school (age 6 years), and 981 children with CNS was suspected in 6 children (all junior high an age corresponding to the first grade of junior high school students), and this was a newly discovered finding school (age 12 years). The numbers of these children at- in 5 cases. Of the 6 children with suspected CNS, renal tending the Ikeda City School System were 192 (20.5%), biopsy was judged to be indicated by a specialist in 3 829 (90.4%), and 842 (85.8%), respectively. Because chil- cases. Other diagnoses included postural proteinuria in dren usually continue at the same school where they 1 child (elementary school), a urinary tract infection (re- were first-year students until their graduation, among solved) in 1 child, and no abnormalities on evaluation at children living in Ikeda City, about 88% attend a munici- Ikeda City Hospital in 4 children, who were thus diag- pal elementary school or a municipal junior high school nosed as having only a transient abnormality at the time in Ikeda City. The remainder, 12% of children, goes to of school urinary screening. One child never received private, national, and Osaka prefectural kindergartens further evaluation despite repeated recommendations. and schools. In April 2012, a first urinary screening was 40 children had urinary protein (≤ ±) or a urinary pro- recommended in all 8274 children attending the Ikeda tein/creatinine ratio <0.2 g/gCr on the second urinary City School System, including 388 kindergarten, 5363 screening, but with occult blood (≥1+) on either of the elementary school, and 2523 junior high school students. two urinalyses; consultation with the school doctor was In response to the recommendations, urine samples recommended. A total of 55 children had urinary protein were submitted from a total of 8212 children (99.3%), in- (≤ ±) or a urinary protein/creatinine ratio of <0.2 g/gCr on cluding 387 kindergarten, 5349 elementary school, and the second urinary screening, and with occult blood (≤ ±) 2476 junior high school students. and urinary glucose (−) on both urinalyses; these test re- Dipstick urinalysis showed urinary protein (≥1+) or oc- sults were reported, but no recommendation for further evaluation was made (Table 1). cult blood (≥1+) in 119 (1.4%) of these children (kindergar- ten 0, elementary school 29, junior high school 90), and a School urinary screening in the Ikeda City School System second urinary screening was recommended. Of these in 2012 found no children in kindergarten or elementary Table 2 Children who were subjects of urinary examination Kindergarten Elementary Junior high Total All children in municipal kindergartens and schools 388 5363 2523 8274 Participated in 1st urinalysis 387 5349 2476 8212 Recommended for 2nd urinalysis 0 29 90 119 Participated in 2nd urinalysis 0 26 82 108 Urinary protein/creatinine ratio ≥0.2 g/gCr 0 1 12 13 Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 4 of 6 http://www.apfmj.com/content/12/1/6 Table 3 Children with a urinary protein/creatinine ratio ≥0.2 g/gCr School Age (y) Sex Result Junior high 15 M Chronic nephritic syndrome (renal biopsy considered) Proteinuria & hematuria Junior high 15 M Junior high 15 M Proteinuria Junior high 13 M Chronic nephritic syndrome (observation) Proteinuria & hematuria Junior high 13 F Junior high 12 F Proteinuria Elementary 11 F Posture proteinuria Junior high 12 M Urinary tract infection Junior high 13 M Within normal limit Junior high 13 M Junior high 13 F Junior high 12 F Junior high 15 M Did not come for consultation school with proteinuria/hematuria syndrome or proteinuria with the testing company, even with additional measure- syndrome that was suspicious of CNS. Attendance at kin- ment of the urinary protein/creatinine ratio, the cost dergarten is not part of compulsory educationinJapan.In was decreased to 966,157 yen. Ikeda City, children going to municipal kindergartens are in theminority, so theCNS morbidityof childrengoing to Discussion kindergartens was not estimated. If there was one elemen- It is desirable to compare the efficiency of the old and tary school child with CNS, based on the calculation new systems. However, in the old system, there were no 1÷(5349 × 0.897) = 0.00021, the prevalence of CNS among clear criteria for specialist referral, and it is not possible about the 5300 elementary school children in Ikeda City to know the numbers of children diagnosed with CNS. was estimated at 0.021%. In fact, there was no such child, Therefore, the morbidity rate of CNS was estimated so the prevalence of CNS among about 5300 elementary using the new system and compared with previously re- school children in Ikeda City was estimated at <0.03%. ported morbidity estimates. Of about 2500 junior high school students, 6 children In a report by Utsunomiya et al. on the effectiveness of had suspected CNS based on proteinuria/hematuria syn- school urinary screening in elementary and junior high drome or proteinuria syndrome. This was a new finding school students in Yonago City [1], of 688 children re- in 5 of the 6 children. In particular, 3 of these children quiring consultation for further evaluation based on might have had progressive CNS based on findings such renal screening at elementary and junior high schools, as proteinuria ≥0.5 g/gCr, and a renal biopsy was consid- 29 (4.2%) underwent renal biopsy; 2 had normal find- ered. If the 1 child who did not have further evaluation ings, and 27 (3.9%) had a histopathologic diagnosis such despite recommendations for consultation is counted as as IgA nephropathy. On school urinary screening in the 0.5 persons with suspected CNS and 0.25 persons in Ikeda City School System, 108 children had a second whom renal biopsy is indicated, then based on the calcu- urinalysis, and in 3 (2.8%) of these children, a renal bi- lations 6.5÷(2476 × 0.911) = 0.00288 and 3.25÷(2476 × opsy was indicated. Thus, the frequency of an indication 0.911) = 0.00144, the prevalence of CNS in about 2500 for renal biopsy in children with abnormal urinary junior high school students in Ikeda City was 0.29%, and screening results is about the same in Yonago City and a renal biopsy was judged to be indicated by a specialist Ikeda City. in 0.14% of these junior high school students. In a report by Shoji et al. on urinary screening at In 2011, the cost paid by Ikeda City for school urinary Osaka Prefectural schools using the urinary protein/cre- screening, including costs associated with assessment of atinine ratio mainly in senior high school students [2], the results by the Ikeda Medical Association, was the incidence in 2007 of newly diagnosed chronic glom- 2,508,619 yen, and the cost of urinary examination from erulonephritis was 7.6 per 100,000 persons (0.0076%). the local medical association to the testing company was This is a fairly low incidence, only about 1/18 of the esti- 1,465,926 yen. However, in 2012, there were no costs as- mated 0.14% prevalence of junior high school children sociated with assessment of the results, but only the in Ikeda City in whom renal biopsy was indicated. The costs of urinary screening. Because of the direct contract reasons for this difference may be: new onset cases of Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 5 of 6 http://www.apfmj.com/content/12/1/6 chronic glomerulonephritis from 2005 were ascertained finding, and intermittent or persistent proteinuria is a in Osaka Prefectural schools, and children with onset by frequent finding, but a small number of patients may 2006 were not included; only children who were diag- have IgA nephropathy without proteinuria [6]. By nosed with chronic glomerulonephritis based on renal recommending specialty referral only for children with a biopsy were counted; and differences between children urinary protein/creatinine ratio ≥0.2 g/gCr, it may not be in senior high school and children in junior high school possible to diagnose IgA nephropathy without protein- and lower grades. uria. However, the “Clinical guidelines for Immuno- In Korea, school children have undergone urine globulin A (IgA) nephropathy in Japan, third version” screening tests since 1998. Between 1999 and 2008, a state that the renal prognosis in clinical severity C- total of 47,047,545 school children, including elementary Grade I (urinary protein <0.5 g/day) is relatively good. school children (6–11 years old), middle school children Furthermore, renal biopsy in children positive only for (12–14 years old), and high school children (15–17 years hematuria but with a urinary protein/creatinine ratio old) participated in a mass school urine screening pro- <0.2 g/gCr increases medical costs. In addition, in Japan, gram. Through this process, 5114 children (0.010%) which has led the world in conducting school urinary were referred to pediatric nephrologists, all members of screening nationwide for about 30 years, microscopic the Korean Study Group of School Urinalysis Screening, hematuria in elementary and junior high school children at seven hospitals nationwide. Percutaneous renal biop- is almost always associated with a good prognosis [8]. sies were performed on 1478 children (28.9% of referred Therefore, in children with a urinary protein/creatinine children), and chronic glomerulonephritis was detected ratio <0.2 g/gCr, a recommendation for specialty referral in 25% of referred children [3]. Due to the difference in is probably not necessary. referral criteria, it is difficult to compare their results In children not seen by specialists, the possibility for with those of the present study. presenting with symptoms of CNS in the future exists. A cut-off value of 0.2 g/gCr for the urinary protein/ This is clear from the higher morbidity of CNS in junior creatinine ratio in children aged ≥2 years has previously high schools than in elementary schools. To address this been reported [4,5], but use of the urinary protein/ issue, annual urinalysis should be continued in schools. creatinine ratio in screening systems such as school urinary In Japan, after graduation from junior high school, 96.6% screening has seldom been reported. In the report from of children go to senior high school (15–17 years old), Osaka Prefectural schools, the urinary protein/creatinine where they also undergo urinalyses. ratio was introduced for school urinary screening start- In the new system, the cost of the urinary screening ing in 2006, and the number of children in whom fur- system itself was reduced. However, since referrals were ther detailed evaluation was deemed necessary decreased recommended for 53 children (13 children were recom- from 2436 children in 2005 to 268 children in 2007. mended to see specialists, and 40 children were recom- However, the number of children newly diagnosed with mended to see school doctors), there is a possibility that chronic glomerulonephritis did not decrease from 2005 medical expenses increased. Further consideration of (7 children) to 2007 (9 children) [2]. Thus, the report ways to decrease recommendations for referrals for chil- concluded that the burden on children themselves, their dren who do not need them is required. parents/guardians, the schools, and medical institutions was reduced, but without a decrease in diagnostic effi- Conclusions ciency. In the case of the Ikeda City School System, al- In conclusion, incorporating the urinary protein/creatin- though diagnostic efficiency could not be compared, ine ratio into the school urinary screening system in the because the number of cases of CNS up to 2011 could Ikeda City School System and clarifying standards for re- not be ascertained, the costs of the urinary screening ferral to specialty consultation has enabled restructuring system could be reduced. of the system so that it is efficient and its effectiveness In Japan, IgA nephropathy accounts for ≥30% of cases can be assessed. of chronic glomerulonephritis in adults and ≥20% of Competing interests cases in children [6]. We also consider early detection of The authors have no conflicts of interest to disclose. There is nothing to IgA nephropathy to be an important objective of school declare with respect to this article. urinary screening. It has been reported that about 62% Authors’ contributions of IgA nephropathy in children in Japan is discovered NK drafted the manuscript. NK, KH, SY, and IM examined the children at based on microscopic hematuria and/or asymptomatic Ikeda City Hospital. NK, TF, KS, SM, TK, and TU designed the study. NK, SH, proteinuria [7], and school urinary screening has played and SA contributed to data analysis. MI contributed as a representative of school doctors and family practitioners in Ikeda City. SH and KS contributed a contributory role. In the “Clinical guidelines for Im- as representatives of the Ikeda City Board of Education. MY and SA munoglobulin A (IgA) nephropathy in Japan, third ver- contributed as representatives of health education teachers in Ikeda City. All sion,” persistent microscopic hematuria is a necessary authors read and approved the final manuscript. Kajiwara et al. Asia Pacific Family Medicine 2013, 12:6 Page 6 of 6 http://www.apfmj.com/content/12/1/6 Acknowledgements The authors would like to express their gratitude to Prof. Yoshiharu Tsubakihara at the Department of Comprehensive Kidney Disease Research, Osaka University Graduate School of Medicine, and to Dr. Tatsuya Shoji at the Department of Kidney Disease and Hypertension, Osaka General Medical Center, for their advice in restructuring the school urinary screening system in the Ikeda City School System. Author details Department of Nephrology, Ikeda City Hospital, Ikeda, Osaka, Japan. Department of Nephrology and Artificial Kidney, Matsushita Memorial Hospital, Moriguchi, Osaka, Japan. Department of General Medicine, Ikeda City Hospital, Ikeda, Osaka, Japan. Inoue Clinic Medical Corporation, Ikeda, 5 6 Osaka, Japan. Ikeda City Board of Education, Ikeda, Osaka, Japan. Ikeda City Ishibashi Elementary School, Ikeda, Osaka, Japan. Ikeda City Fushiodai Elementary School, Ikeda, Osaka, Japan. Department of Pediatrics, Ikeda City Hospital, Ikeda, Osaka, Japan. Received: 10 December 2012 Accepted: 6 December 2013 Published: 13 December 2013 References 1. Utsunomiya Y, Koda T, Kado T, Okada S, Hayashi A, Kanzaki S, Kasagi T, Hayashibara H, Okasora T: Incidence of pediatric IgA nephropathy. Pediatr Nephrol 2003, 18:511–515. 2. Shoji T, Onishi M, Suzuki A, Kaneko T, Mori K, Satomura K, Tsubakihara Y: Poor utilization of results from school urinalysis screening. Sogorinsho 2009, 58:1176–1180. Japanese. 3. Byoung-Soo C, Won-Ho H, Hae Il C, Inseok L, Cheol Woo K, Su-Young K, Dae-Yeol L, Tae-Sun H, Jin-Soon S: A nationwide study of mass unine screening tests on Korean school children and implications for chronic kidney disease management. Clin Exp Nephrol 2013, 17:205–210. 4. Houser M: Assessment of proteinuria using random urine samples. J Pediatr 1984, 104:845–848. 5. Yoshimoto M, Tsukahara H, Saito M, Hayashi S, Haruki S, Fujisawa S, Sudo M: Evaluation of variability of proteinuria indices. Pediatr Nephrol 1990, 4:136–139. 6. Special Study Group (IgA Nephropathy) on Progressive Renal Diseases: Clinical guides for immunoglobulin A (IgA) nephropathy in Japan, third version. Nihon Jinzo Gakkai Shi 2011, 53:123–135. Japanese. 7. Yoshikawa N, Tanaka R, Iijima K: Pathophysiology and treatment of IgA nephropathy in children. Pediatr Nephrol 2001, 16:446–457. 8. Committee for Diagnostic Guidelines of Hematuria: Guidelines for diagnosis of hematuria. Nihon Jinzo Gakkai Shi 2006, 48(Suppl):1–34. Japanese. doi:10.1186/1447-056X-12-6 Cite this article as: Kajiwara et al.: Restructuring the Ikeda City school urinary screening system: report of a screening survey. Asia Pacific Family Medicine 2013 12:6. 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Asia Pacific Family Medicine – Springer Journals

Published: Dec 13, 2013

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