hemodialysis ( hd ) is the most used renal replacement therapy for children in morocco . if the adult population is the majority of patients followed , many hemodialysis centers host or had hosted children whose care differs from that of adults . the aim of this study was to determine the prevalence of patients who started hemodialysis in childhood and study their characteristics and specificities of their care . this is a multicentric descriptive cross - sectional study achieved during the first quarter of 2012 . we studied all patients undergoing a chronic hemodialysis ( chd ) , who have started dialysis in childhood ( before age of 18 ) and are still hemodialyzed in public or private hemodialysis centers . our survey included all centers in the following regions : meknes - tafilalet , fez - boulemane , taza - al hoceima - taounate , and the oriental regions . a questionnaire was given to patients and to the nephrologists working in these centers by physician investigators belonging to the university hospital hassan ii of fez . these investigators moved to the different centers so as to collect demographic , clinical , and paraclinical data concerning all the patients included in study . the given questionnaire also helped us to collect their opinions on renal transplantation and the reasons for the position they have taken . then , the data collected was processed by the statistical software ( spss statistics version 17.0 ) under the license of faculty of medicine and pharmacy of fez . a total of 2066 patients undergoing dialysis in 39 hemodialysis centers ( 22 public and 17 private centers ) were included . from these patients , we collected only 72 patients ( 3.48% ) who started hemodialysis in childhood : 38 patients in private centers and 34 patients in public centers . we noted a male predominance with a sex ratio of 1.9 ( 47  m/25  f ) . the mean age of our patients was 20.6  6.5 years ( 435 years ) , while the average age concerning the beginning of dialysis was 14.12  3.4 years , with an age extreme ranging from 3 to 18 years ( figure 1 ) . the initial nephropathy is urological abnormalities in 18% of cases , a glomerulopathy in 12.5% of cases , and a systemic disease in 7% of cases . hereditary nephropathy was diagnosed in 4 patients ( 5.5% ) and hypertensive nephropathy in 2 patients only ( 3% ) . the number of dialysis sessions per week was three sessions in 49 patients ( 68% ) and two sessions in 23 patients ( 32% ) . all the patients are hemodialyzed via a native arteriovenous fistula ( avf ) except one child who had a permanent hemodialysis catheter . in 69.40% of cases the percentage of patients having 3 sessions per week has increased from 40% for patients whose age is less than 10 years ( this age is usually characterized by a low weight : less than 30  kg ) to 65% in the 10 to 15 age group and 73% in the age group of patients who are over 15 years old ( table 3 ) . the female patients , who have reached adulthood , suffer from growth retardation in 43.50% of cases with a size  150  cm ( = 2sd ) and a bmi = 2sd in 8.70% of cases , whereas the male patients , who have reached adulthood , suffer from a growth retardation in 60% of cases with a size  160  cm ( = 2sd ) and a bmi = 2sd in 23.2% of cases . among 75% of our patients who have reached the age of 18 years , 2% have a primary level of study and 35% reached a college level , 39% a secondary school , and 17% a high school while 7% are illiterate . two of the 49 patients , who have reached adulthood , are married . concerning the patients on hemodialysis whose age is under 18 ( 25% ) , 22% of them study at a secondary school , 6% of them study in a high school , and 72% are out of school . their main motivation factors were related primarily to fluid restriction and diet constraints ( 52% ) , studies or work difficulties ( 62% ) , marital problems and desire to have children ( 30.50% ) , complications of hemodialysis ( 21% ) , free time ( 17% ) , and travel ( 10% ) . three reasons are associated in 6% of cases and four reasons are associated in 25% of cases . 8.33% of patients refused renal transplantation mainly because of the presumed high cost of the operation . the patients were informed about renal transplantation by their physician in 48% of cases , close contacts in 17% of cases , and the media in 15.5% of cases . once the subject was explained in this investigation , 80.5% of patients agreed kidney transplantation from a living donor , among which 48.2% claim to have a potential related living donor . in 20.68% of cases , in the case of children and adolescents , the registers data of the chronic kidney disease ( ckd ) are limited since there are low reference populations . this means that it is difficult to have direct comparisons of rates of ckd of childhood ( incidence and prevalence ) in different geographical areas of the world because of many reasons among which we find the methodological differences in the age groups of the studies , the characterization of the degree of renal failure , and the classification of disease . the only studies available are those dealing with the prevalence and incidence of ckd in relation to the population of healthy children , which make the comparison with some of our data not applicable . in morocco , according to the census of the population in 2004 published by the high commission for planning , the total population of the four regions covered by the study represents 29.50% of the moroccan population . the pediatric population under 19 years old represents 41.80% in these regions and 24.95% of the pediatric population in morocco . public health services and social benefits available in these 4 regions are similar to the remaining 12 regions in morocco . in addition , at the time of the study , four university hospitals were functional , respectively , in the cities of rabat , casablanca , marrakech , and fez . however , the provision of care in the private sector is larger in some other parts of the country , particularly in the cities of casablanca ( the largest city in morocco ) and rabat ( the capital ) . the magredial register data ( register of the end stage renal disease : morocco - transplant - dialysis ) involving four regions ( those involved in our study are not included ) shows that , in 3112 patients undergoing renal replacement therapy , the age group ranging from 0 to 19 years represents 6.50% of cases . few data are available in the north african countries , in the middle east , or in central african countries since there are no regional registers which could help the authorities to collect and publish valid epidemiological data . the only data ( incidence and prevalence ) that come from these developing countries are mainly derived from reports of tertiary centers of care [ 1 , 4 ] . in different registers , the incidence of esrd varies from 7.2 to 16 new cases per year and per million of the age - related population ( pmarp ) according to the age limit ( 15 to 20 years old ) . according to naprtcs register ( north american pediatric renal trials and collaborative studies ) , esrd mainly affects children between the ages of 6 and 18 years , with the highest incidence in children whose age is between 15 and 19 years old ( 28 pmarp ) [ 5 , 6 ] . however , in our study the largest number of cases was between 10 and 18 years old . in most studies , the prevalence and the incidence of the predialysis stage of ckd or replacement therapy are higher among boys than girls . in morocco , these results can be explained by the high incidence of congenital anomalies of the kidney and urinary tract among boys ( cakut ) [ 1 , 5 , 7 ] . the average age of our patients as they started dialysis was 14.12  3.4 years and only 3% of them were younger than 5 years . the reason behind which we have few children aged less than 5 years old in this study is that they are generally not considered as eligible for dialysis or kidney transplant . from the age of 15 years , children are considered as adults and are then treated more easily . therefore , these data are similar to the initial experience of some countries . arteriovenous fistula ( avf ) has often been done twice at least , probably due to the nonsystematic use of microscope . microsurgery is necessary for the creation of a functional avf for most children , but few surgeons are trained for this technique , which is rarely used even in other countries . conventional hemodialysis is usually performed three times per week with a duration which can not be less than four hours per session . because of the lack of financial resources or dialysis machine available in dialysis centers , 32% of our patients received only two sessions per week or 8 hours of dialysis per week . in this survey , the urological abnormalities represents also the most found etiology in our country ( 34% of cases ) as well as in different countries ( usa 57% of cases , italy 68% of cases , india 47% of cases , and iran 52% of cases ) [ 7 , 1113 ] . glomerular diseases ( 12.5% in this series ) represent the second etiology of esrd , with a very variable rate depending on the country . these diseases are found in europe and the united states in percentages ranging from 7% to 24.5% of cases . in other countries such as vietnam , nigeria , and south africa , glomerulonephritis represents the main cause of esrd with 66.4% , 58.3% , and 56.4% , respectively . this difference is due to a higher prevalence of infectious diseases [ 1 , 3 , 5 , 7 , 11 ] . hereditary nephropathies ( 5.5% ) represent a small percentage in comparison with other studies that found a higher incidence ( we have nationally 17% of cases and iran has 21.7% , tunisia 29% , italy 25% , iraq 21.3% , and jordan 29.7% ) in relation with the frequency of intermarriages in these countries [ 4 , 7 , 8 , 12 ] . the etiologies we have found may be underestimated because of the very high percentage of unknown etiologies ( 54% ) in this study in comparison with other studies . this testifies that the management of the patients ' care is done in late and advanced stages of their kidney disease [ 58 , 11 ] . the establishment of a treatment with the recombinant human growth hormone ( rhgh ) improves growth rate of these children ; however , the recognition and the early treatment of malnutrition , mineral and bone disorders , and electrolyte and acid - base abnormalities should take place before considering a growth hormone ( gh ) treatment [ 10 , 14 , 15 ] . in our study , no patient was treated with growth hormone which reflects an inadequate management of hemodialyzed children in adult hemodialysis centers . the social integration and the quality of life of our patients are poor as it is shown through their low level of education , their social status ( 2/49 are married ) , and their professional status ( 74% have no profession or work ) . the young adults who had a prolonged dialysis in childhood are more likely to be unemployed than the age - matched population and those who are employed have a lower professional qualification [ 14 , 16 ] . many factors contribute to this observation : frequency of hemodialysis sessions , complications of kidney disease and dialysis , and higher incidence of developmental disorders in comparison with the general pediatric population , with an impact on neurodevelopment and psychosocial outcome . in the long term , the risk of mortality of children undergoing dialysis is thirty times higher than normal children [ 14 , 18 ] . in the pediatric population , different studies emphasize on the fact that the younger the age of the patient at the beginning of dialysis is , the higher the mortality is , characterized by a higher incidence of comorbidities . however , mortality is lower in children than adults who are undergoing dialysis [ 14 , 19 , 20 ] . nevertheless , mortality is much higher ( 4 to 10 times ) in children undergoing dialysis than those with kidney transplantation . indeed , the expected remaining life for dialysis children , aged from 0 to 14 years , is only 18.3 years , against 50 years for kidney transplantation children [ 1 , 14 ] . furthermore , renal transplantation provides a better chance of rehabilitation in terms of training and psychosocial functioning . this highly desired therapy by our hemodialyzed patients remains difficult to access despite the expended efforts to develop the field of transplantation in our country . , about 360 kidney transplants have been performed with more than 90% from related living donors . the only transplant center in the four regions of our study is that of the university hospital of fez . one of them was conducted in 2014 in an adolescent under the age of 13 years . a total of about 20 pediatric kidney transplants have been performed to date in morocco , mostly in adolescents . a recent program of the department of health is looking to expanding the supply of transplantation in morocco and provides a pediatric priority . this study has allowed us to achieve initial assessment and observation on the management of pediatric hemodialysis in morocco . it reveals that the hemodialysis centers , which are mainly intended for adults , do not take into consideration the pediatric specificities of hemodialyzed children . the development of pediatric renal transplantation will surely contribute to the improvement of the prognosis and the quality of life of patients who had started hemodialysis in childhood .
hemodialysis is the most used renal replacement therapy for children in morocco . 
 the objective of this study was to determine the prevalence of patients who started hemodialysis in childhood and study their characteristics and specificities of their care . 
 for this we conducted a multicentric descriptive cross - sectional study of all chronic hemodialysis patients who started dialysis in pediatric age , in hemodialysis centers in four of the sixteen regions of morocco . 
 we collected 2066 patients undergoing dialysis in 39 hemodialysis centers ; from these , only 72 patients ( 3.48% ) started hemodialysis in childhood . 
 the average age of patients was 20.64    6.5 years with a sex ratio of 1.9 . 
 duration of dialysis was 78.2    56 months . 
 the cause of end stage renal disease was urological abnormalities in 18% of cases and glomerulopathy in 12.5% of cases ; however , it remains unknown in half of the patients . over 18 years 
 , 74% of patients are without profession , it is active in 13% of cases , and pursuing studies are only in 13% of cases . 
 patients under 5 years and those with a low weight are rarely taken care of in chronic hemodialysis with little individualization of prescription . 
 greater attention should be paid to renal transplantation that is desired by the majority of these patients ( 92% ) .