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Khanam;citation_title=Ocular Fundus Abnormalities in Pre-Dialytic Chronic Kidney Disease Patients;citation_pages=20-35;citation_volume=07;citation_year=2019"/><meta name="citation_reference" content="citation_journal_title=Ophthalmic Epidemiol;citation_author=R. Mehta;citation_author=A. Hodakowski;citation_author=X. Cai;citation_title=Serum Phosphate and Retinal Microvascular Changes: The Multi-Ethnic Study of Atherosclerosis and the Beaver Dam Eye Study;citation_pages=371-80;citation_volume=24;citation_year=2017;citation_pmid=28402694"/><title>Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study | BMJ Paediatrics Open</title><meta name="description" content="Background Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p<0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p<0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p<0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings."/><meta name="DC.Contributor" content="Amit Kumar Datta"/><meta name="DC.Contributor" content="Afroza Begum"/><meta name="DC.Contributor" content="Ranjit Ranjan Roy"/><meta name="DC.Contributor" content="Tahmina Jesmin"/><meta name="DC.Contributor" content="Abdullah Al Mamun"/><meta name="DC.Contributor" content="Mohammad Afzal Mahfuzullah"/><meta name="DC.Contributor" content="Faisal Chowdhury"/><meta name="DC.Contributor" content="Mohammad Azmain Iktidar"/><meta name="DC.Format" content="text/html"/><meta name="DC.Identifier" content="10.1136/bmjpo-2024-002777"/><meta name="DC.Language" content="en"/><meta name="DC.Publisher" content="BMJ Publishing Group Ltd"/><meta name="DC.AccessRights" content="open-access"/><meta name="DC.Title" content="Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study"/><meta name="DC.Description" content="Background Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p<0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p<0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p<0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings."/><meta name="DC.Date" content="2024-11-19"/><meta name="DC.Type" content="journal-article"/><meta name="DC.Rights" content="This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license"/><meta name="citation_title" content="Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study"/><meta name="citation_abstract" content="Background Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p<0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p<0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p<0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings."/><meta name="citation_journal_title" content="BMJ Paediatrics Open"/><meta name="citation_publisher" content="BMJ Publishing Group Ltd"/><meta name="citation_publication_date" content="2024-11-19"/><meta name="citation_volume" content="8"/><meta name="citation_issue" content="1"/><meta name="citation_doi" content="10.1136/bmjpo-2024-002777"/><meta name="citation_mjid" content="bmjpo;8/1/e002777"/><meta name="citation_id" content="8/1/e002777"/><meta name="citation_public_url" content="https://bmjpaedsopen.bmj.com/content/8/1/e002777"/><meta name="citation_full_html_url" content="https://bmjpaedsopen.bmj.com/content/8/1/e002777"/><meta name="citation_pdf_url" content="https://bmjpaedsopen.bmj.com/content/8/1/e002777.full.pdf"/><meta name="citation_issn" content="2399-9772"/><meta name="citation_journal_abbrev" content="bmjpo"/><meta name="citation_pmid" content="10.1136/bmjpo-2024-002777"/><meta name="citation_article_type" content="research-article"/><meta name="citation_section" content="Nephrology"/><meta name="citation_access" content="open-access"/><link rel="canonical" href="/content/8/1/e002777" /><link rel="alternate" type="application/pdf" href="/content/8/1/e002777.full.pdf" /><meta property="og:title" content="Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study"/><meta property="og:description" content="Background Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p<0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p<0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p<0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings."/><meta property="og:url" content="https://bmjpaedsopen.bmj.com/content/8/1/e002777"/><meta property="og:site_name" content="BMJ Paediatrics Open"/><meta property="og:locale" content="en_GB"/><meta property="og:image" content="https://bmjpaedsopen.bmj.com/content/bmjpo/8/1/e002777/F1.medium.gif"/><meta property="og:image:width" content="800"/><meta property="og:image:height" content="600"/><meta property="og:image:alt" content="Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study"/><meta property="og:image" content="https://bmjpaedsopen.bmj.com/content/bmjpo/8/1/e002777/F1.large.jpg"/><meta property="og:image:width" content="1800"/><meta property="og:image:height" content="1600"/><meta property="og:image:alt" content="Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study"/><meta property="og:type" content="website"/><meta name="twitter:card" content="summary_large_image"/><meta name="twitter:site" content="@bmj_latest"/><meta name="twitter:title" content="Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study"/><meta name="twitter:description" content="Background Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p<0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p<0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p<0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings."/><meta name="twitter:image" content="https://bmjpaedsopen.bmj.com/content/bmjpo/8/1/e002777/F1.medium.gif"/><meta name="twitter:image:alt" content="Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study"/><script src="/_next/static/chunks/polyfills-78c92fac7aa8fdd8.js" noModule=""></script><script> window.dataLayer = window.dataLayer || []; function parseCookies() { let cookieHeader = document.cookie || ""; let cookies = Object.fromEntries( cookieHeader.split("; ").map((c) => c.split("=")) ); for (let key in cookies) { if (cookies[key] === "undefined") { cookies[key] = undefined; } } return cookies; } function uuidv4() { var d = new Date().getTime(); //Timestamp var d2 = (typeof performance !== "undefined" && performance.now && performance.now() * 1000) || 0; //Time in microseconds since page-load or 0 if unsupported return "xxxxxxxx-xxxx-4xxx-yxxx-xxxxxxxxxxxx".replace(/[xy]/g, function (c) { var r = Math.random() * 16; //random number between 0 and 16 if (d > 0) { //Use timestamp until depleted r = (d + r) % 16 | 0; d = Math.floor(d / 16); } else { //Use microseconds since page-load if supported r = (d2 + r) % 16 | 0; d2 = Math.floor(d2 / 16); } return (c === "x" ? r : (r & 0x3) | 0x8).toString(16); }); } function handleCookie() { let cookies = parseCookies(); let bmj_uuid = cookies.bmj_uuid; if (!bmj_uuid) { bmj_uuid = uuidv4(); cookies.bmj_uuid = bmj_uuid; } return { bmj_uuid }; } let { bmj_uuid } = handleCookie(); let bmj_ppid = parseCookies().bmj_ppid; const anonMailId = "e3b0c44298fc1c149afbf4c8996fb92427ae41e4649b934ca495991b7852b855"; let nonAnonMailId = window.dataLayer.find((item) => item.user)?.user?.mail === anonMailId ? null : window.dataLayer.find((item) => item.user)?.user?.mail; let userId = dataLayer.find((item) => item.user)?.user?.["data-ics"] ?? 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focus-visible:outline-bmj-silver-500 block h-[44px] w-full rounded-lg md:hidden"><span class="flex h-full items-center justify-center text-sm font-bold leading-6 text-white">Article options</span></span><span class="share-cite-rights-tooltip bg-share-icon-bg hidden h-[44px] w-[44px] rounded-[8px] pb-[12px] pl-[16px] pr-[16px] pt-[12px] md:block lg:block"><img src="/next-resources/tooltip.svg" alt="Tooltip icon" class="m-auto h-full" /></span></button></div></div><div class="grid grid-cols-[3fr_1fr] gap-x-4 gap-y-4 md:grid-cols-[auto_332px]"><div class="col-span-2 mb-2 pt-[40px] md:mb-6 lg:col-span-1"><div><div xmlns="http://www.w3.org/1999/xhtml" class="article fulltext-view flex flex-col -mb-6"><div class="abstract-section" id="abstract-1"><h2>Abstract</h2><div id="sec-1" class="subsection"><p id="p-2"><strong>Background</strong> Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.</p></div><div id="sec-2" class="subsection"><p id="p-3"><strong>Methods</strong> We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.</p></div><div id="sec-3" class="subsection"><p id="p-4"><strong>Results</strong> The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p<0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p<0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p<0.001).</p></div><div id="sec-4" class="subsection"><p id="p-5"><strong>Conclusion</strong> This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings.</p></div><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="section notes text-bmj-silver-800 border-bmj-silver-100 [&_h3]:text-bmj-silver-800 mb-[40px] border-[1px] px-[24px] pt-[8px] pb-[16px] [&_p]:my-[8px] [&_ul]:m-0 [&_ul]:list-none [&_ul]:p-0 [&_li]:m-0 [&_li]:p-0 [&_h3]:mb-0 [&_h3]:mt-[16px] [&_h3]:text-[1.25rem] [&_h3]:font-normal"><div data-testid="article-notes-content" class="article-notes-content"><div class="" id="boxed-text-1"><div id="sec-5" class="subsection"><h3>What is already known on this topic</h3><ul class="list-unord " id="list-1"><li id="list-item-1"><p id="p-6">Ocular manifestations are prevalent among paediatric patients with chronic kidney disease (CKD), especially with advancing stages. The spectrum of ocular symptoms can be extensive and permanent visual impairment may result from failure to detect and treat the disease in an expedient manner.</p></li></ul></div><div id="sec-6" class="subsection"><h3>What this study adds</h3><ul class="list-unord " id="list-2"><li id="list-item-2"><p id="p-7">In the context of Bangladesh, this is the first study to investigate the ocular manifestations of paediatric CKD patients in relation to potential clinical and biochemical risk factors. Ocular manifestations were most prevalent among children in the final stages of CKD. In advanced CKD, hypertensive retinopathy was prevalent and significantly associated with elevated serum phosphate and calcium phosphate products as well as a decline in estimated glomerular filtration rate and haemoglobin levels.</p></li></ul></div><div id="sec-7" class="subsection"><h3>How this study might affect research, practice or policy</h3><ul class="list-unord " id="list-3"><li id="list-item-3"><p id="p-8">Due to the paucity of prior research, this study sheds light on a relatively neglected but critical aspect of the paediatric CKD population in Bangladesh. The results indicate that ocular manifestations are relatively prevalent among paediatric patients with CKD. It also emphasises the significance of clinical vigilance, routine screening and additional research into the prevention and early treatment of this condition.</p></li></ul></div></div></div></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-8"><h2 class="">Introduction</h2><p id="p-9">Chronic kidney disease (CKD) is a significant global public health issue associated with considerable morbidity and mortality.<a id="xref-ref-1-1" class="xref-bibr" href="#ref-1">1</a> CKD often goes undetected and undiagnosed until it reaches an advanced stage and leads to kidney failure. The prevalence of CKD among children under the age of 16 is between 1.5 and 3.0 cases per million children,<a id="xref-ref-2-1" class="xref-bibr" href="#ref-2">2</a> which can result in multiorgan dysfunction, including various ocular complications.<a id="xref-ref-3-1" class="xref-bibr" href="#ref-3">3</a> In advanced CKD stages, ocular problems may result from uraemia, biochemical abnormalities, hypertension or inadequate haemodialysis treatment.<a id="xref-ref-4-1" class="xref-bibr" href="#ref-4">4</a></p><p id="p-10">The ocular manifestation of advanced CKD results from interactions of multiple factors including underlying risk factors, metabolic aberrations, uraemia and anaemia and treatment induced.<a id="xref-ref-5-1" class="xref-bibr" href="#ref-5">5</a> Hypertensive retinopathy (HR) is the most frequent cause of visual disturbance in these patients, which may initially be asymptomatic but can progress to permanent visual loss if not promptly diagnosed and treated (Ignat et al., 1999; Bajracharya et al., 2008 Contrarily, in CKD with severe anaemia (hemoglobin≤5 gm/dL), retinal arterioles may be pale and optic disc pallor (ischaemic optic neuropathy) may occur.<a id="xref-ref-6-1" class="xref-bibr" href="#ref-6">6</a> In patients with poorly regulated blood pressure, CKD further worsens retinopathy. Thus, treating hypertension in end-stage renal failure may stabilise vision and reduce cataracts.<a id="xref-ref-7-1" class="xref-bibr" href="#ref-7">7</a> Among the biochemical parameters, hypercalcemia and secondary hyperparathyroidism may cause corneal and conjunctival calcifications.<a id="xref-ref-8-1" class="xref-bibr" href="#ref-8">8</a> On the other hand, chronic dialysis patients may develop subsequent cataract due to lens fluid variations,<a id="xref-ref-9-1" class="xref-bibr" href="#ref-9">9</a> whereas inadequate haemodialysis can result in ocular manifestation due to alteration of lacrimal secretion.<a id="xref-ref-10-1" class="xref-bibr" href="#ref-10">10</a> There has also been reported instances of posterior subcapsular cataracts in patients receiving steroid therapy for chronic glomerulonephritis.<a id="xref-ref-9-2" class="xref-bibr" href="#ref-9">9</a> Urea accumulation in lens can also cause chronic water buildup, resulting in osmotic cataract. Furthermore, severe optic nerve injury can result from high intraocular pressure.<a id="xref-ref-11-1" class="xref-bibr" href="#ref-11">11</a></p><p id="p-11">While it is established that individuals with CKD are at higher risk for ocular issues, these complications vary across CKD stages and depend on multiple factors. For instance, while Nusinovici <em>et al</em><a id="xref-ref-5-2" class="xref-bibr" href="#ref-5">5</a> found that ocular complications significantly increase as CKD progresses to end stage, leading to prominent visual impairment, Bajracharya <em>et al</em><a id="xref-ref-12-1" class="xref-bibr" href="#ref-12">12</a> identified maculopathy as the predominant issue in a different cohort. These discrepancies in findings underscore the complexity of CKD-related ocular manifestations and highlight the need for further investigation. The data are particularly sparse regarding the paediatric population, with very few studies exploring the prevalence and potential contributing factors of ocular complications in children.<a id="xref-ref-13-1" class="xref-bibr" href="#ref-13">13</a> Given the lack of comprehensive studies focused on paediatric patients, especially in South Asia, our study aims to address this gap by systematically evaluating the ophthalmological changes in paediatric CKD patients in Bangladesh. This study seeks to provide a clearer understanding of the prevalence, severity and underlying mechanisms of these ocular complications, thereby emphasising the importance of regular screening and early intervention to improve the quality of life for these patients.<a id="xref-ref-6-2" class="xref-bibr" href="#ref-6">6–10 10–12</a></p></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-9"><h2 class="">Materials and methods</h2><p id="p-12">This cross-sectional study was conducted over a period of 1 year, from June 2020 to July 2021 at Department of Pediatric Nephrology of a tertiary-level hospital in Bangladesh. @@@This site was selected since it is situated in the capital city and serves patients from across the entire country.</p><div id="sec-10" class="subsection"><h3>Study participants</h3><p id="p-13">Paediatric patients aged 5–18 of both sexes with advanced CKD (stage III, IV, V and VD dialysis dependent) and consenting parents/legal guardians were included in the study. Acute or chronic eye disorders, ocular trauma within 3 months, CKD owing to cystinosis, oxalosis, Alport syndrome and non-co-operative children were excluded from the study. Each paediatric patient with advanced CKD who visited the department during the study period was consecutively assessed for eligibility. A total of 196 patients were assessed for eligibility and 92 patients were included in final analysis (<a id="xref-fig-1-1" class="xref-fig" href="#F1">figure 1</a>).</p><div id="F1" class="flex items-center justify-center"><section class="my-4"><img id="F1" class="mb-2 mt-[20px] max-h-full max-w-full cursor-pointer object-contain" src="/content/bmjpo/8/1/e002777/F1.medium.gif" alt="Figure 1" height="400" /></section></div><div class="mb-4"><a id="request-permissions" data-testid="request-permissions" target="_blank" rel="noreferrer" class="focus-visible:border-bmj-silver-500 [&_span]:focus-visible:text-bmj-silver-800 hover:text-bmj-blue-700 inline-flex items-center rounded-md text-sm no-underline focus:outline-none focus-visible:border-[1px]" href="https://s100.copyright.com/AppDispatchServlet?publisherName=BMJ&publication=bmjpo&oa=CC-BY-NC-4.0&title=Ophthalmological%20changes%20in%20children%20with%20advanced%20stage%20of%20chronic%20kidney%20disease:%20a%20hospital-based%20study&publicationDate=2024-11-19&author=&contentID=10.1136/bmjpo-2024-002777&volumeNum=8&issueNum=1&startPage=&endPage=&numPages=&copyright=Copyright%20%C2%A9%20:YEAR:,%20The%20Author(s).%20Published%20by%20BMJ%20Publishing%20Group%20Ltd.&orderBeanReset=true"><span data-testid="request-permissions-text" class="request-permissions-text text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 text-[14px] font-bold leading-[20px]">Request permission</span><img data-testid="request-permissions-img" src="/next-resources/vector.svg" alt="request permission icon" class="my-0 ml-[5.88px] h-[16.25px] w-[16.25px]" /></a></div><section class="fig-caption"><span>Figure 1</span><p>Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) diagram of flow of participants at different stages of the study.</p></section></div><div id="sec-11" class="subsection"><h3>Study procedure</h3><p id="p-15">After obtaining consent from the patients’ parents/legal guardians, a semistructured questionnaire was filled out for each case containing detailed history, clinical examination and lab report findings. Blood obtained through aseptic precautions was transported to the institution’s Clinical Pathology Laboratory and Biochemistry Department for measurement. Alport syndrome was ruled out by checking for familial hematuria, sensorineural deafness, anterior lenticonus, macular and perimacular retinopathy and corneal erosion. CKD diagnosis was based on patients’ previous prescription. Allergic conjunctivitis was ruled out during eye examination. To rule out cystinosis, corneal cystine crystal was inspected with slit lamp examination, and retinal pigmentation for oxalate crystal was checked for oxalosis exclusion.</p><p id="p-16">CKD occurs when there is gradual decline in renal function, causing a progressive decrease in glomerular filtration rate (GFR). It also comprises a range of pathophysiologic processes that are linked to abnormal kidney function.<a id="xref-ref-14-1" class="xref-bibr" href="#ref-14">14</a> Grading of CKD was done following KDIGO guidelines 2012. Estimated GFR (eGFR) was calculated by revised Schwartz formula as follows—eGFR=0.413 × (height/S. creatinine), where height was expressed in centimetre and serum creatinine in mg/dL.<a id="xref-ref-15-1" class="xref-bibr" href="#ref-15">15</a> After measurement of eGFR, each patient was categorised as stage I, II, III, IV, V and V(D).<a id="xref-ref-15-2" class="xref-bibr" href="#ref-15">15 16</a></p><p id="p-17">An experienced ophthalmologist performed the ophthalmological examination. Visual acuity was measured with a Snellen chart.<a id="xref-ref-17-1" class="xref-bibr" href="#ref-17">17</a> Schirmer tear test strips measured dry eye; Schirmer I: <10 mm in 5 min.<a id="xref-ref-18-1" class="xref-bibr" href="#ref-18">18</a> Slit lamp bio microscopy (Appasamy, India) examined eyelids, cornea, conjunctiva and lens. L-5110 applanation tonometer (Inami & Co, Japan) assessed intraocular pressure. For posterior segment eye examination, pupils were dilated with tropicamide eye drops (trophen–tropicamide 0.8% and phenylephrine HCL) with fundus evaluation using (a) direct ophthalmoscopy (HEINE Beta-200, HEINE Optotechnik GmbH & Co KG, Germany) and (b) indirect ophthalmoscopy+20 diopter lens. Colour fundus photography was done for HR patients and graded according to Keith and Wagener classification.<a id="xref-ref-19-1" class="xref-bibr" href="#ref-19">19</a> Visual acuity that was measured by using Snellen chart converted to quantitative variable with LogMAR visual acuity conversion chart.<a id="xref-ref-20-1" class="xref-bibr" href="#ref-20">20</a> The patient was diagnosed with visual impairment if their VA LogMAR was <0.50, according to WHO guidelines.<a id="xref-ref-21-1" class="xref-bibr" href="#ref-21">21</a> The parameters for biochemical testing included the possible associated factors, which has been shown to influence the ocular manifestation in CKD patients, including haemoglobin,<a id="xref-ref-6-3" class="xref-bibr" href="#ref-6">6</a> urea,<a id="xref-ref-5-3" class="xref-bibr" href="#ref-5">5</a> triglyceride and cholesterol,<a id="xref-ref-22-1" class="xref-bibr" href="#ref-22">22</a> blood sugar,<a id="xref-ref-22-2" class="xref-bibr" href="#ref-22">22</a> calcium and phosphate and parathyroid hormone.<a id="xref-ref-8-2" class="xref-bibr" href="#ref-8">8</a></p></div><div id="sec-12" class="subsection"><h3>Statistical analysis</h3><p id="p-18">After data collection, it was thoroughly checked for inaccuracies and analysed using Stata V.16. Categorical data were displayed by frequency and relative percentage, whereas continuous variables were shown by mean and SD. Pearson’s χ<sup>2</sup> test, two independent sample t-test and Analysis of Variance(ANOVA) were used to examine two variables’ correlations. A two-tailed p<0.05 considered statistically significant.</p></div><div id="sec-13" class="subsection"><h3>Ethics</h3><p id="p-19">The Institutional Review Board at BSMMU granted ethical approval for this study; reference number: BSMMU/2020/4108. Wherever possible, adherence to the 1964 Declaration of Helsinki and its revisions, as well as similar ethical principles, was ensured. Each participant or their guardians have provided informed consent.</p></div><div id="sec-14" class="subsection"><h3>Patient and public involvement</h3><p id="p-20">Members of the public were involved in several stages of the study including design and conduct. We received input from children and their parents during the pilot and implemented them in our study design. We intend to disseminate the main results to study participants and will seek public involvement in the development of an appropriate method of dissemination.</p></div></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-15"><h2 class="">Results</h2><p id="p-21">Out of 92 patients, 61 were men and 31 women. Male to female ratio in CKD was 1.97:1, with a mean age of 12.1±3.68 years. The highest prevalence was 41.3% for CKD stage VD. Hypoplastic kidney was the predominant cause of CKD, comprising 39.13% of the cases (<a id="xref-table-wrap-1-1" class="xref-table" href="#T1">table 1</a>). <a id="xref-table-wrap-2-1" class="xref-table" href="#T2">Table 2</a> highlights CKD stage correlations with clinical and laboratory parameters. CKD progression led to a substantial increase in average systolic blood pressure (SBP) and diastolic blood pressure (DBP) (p<0.05). As CKD advanced, serum creatinine, urea, phosphate, Ca × PO4, and parathyroid levels increased. Conversely, the average eGFR, haemoglobin and serum calcium decreased. All indicators showed statistical significance (p<0.05), with CKD V and VD showing displaying the most pronounced shift. At advanced CKD, the eGFR dropped significantly and serum urea nearly doubled. The average intraocular pressure in stage VD chronic renal disease patients was 12.8±2.5 mm Hg. 29 (31.5%) patients had impaired vision, 9 in CKD V and 20 in stage VD. Lid oedema (12 in CKD V, 3 in VD), conjunctival pallor (21 in V, 18 in VD) and dry eyes (nine in VD) were also more common in later stages. 15 (16.30%) patients had HR, 1 in CKD V and 14 in VD. Each of these correlations was statistically significant and suggests that worsening CKD increases ophthalmological symptoms. Patients with HR had raised mean serum phosphate and Ca × PO4 levels. These patients also had decreased mean haemoglobin and eGFR. In contrast, conjunctival congestion patients had significantly higher serum phosphate and calcium phosphate products (<a id="xref-table-wrap-3-1" class="xref-table" href="#T3">table 3</a>).</p><div class="border-bmj-silver-50 my-[40px] w-full border-t border-b" data-testid="table-component" id="T1"><div class="mt-[24px] flex flex-col justify-between md:flex-row md:items-center lg:justify-between" data-testid="table-header"><strong class="text-bmj-silver-800 flex-1 text-[1.25rem] !font-bold" data-testid="table-title">Table 1</strong><div class="my-2 flex content-center items-center md:my-0" data-testid="table-controls"><button type="button" tabindex="0" aria-expanded="false" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md">View inline</button><span class="text-bmj-blue-800 mx-2 text-sm">|</span><button class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md" data-testid="popup-open-button">View popup</button></div></div><div data-testid="table-description" class="text-bmj-silver-800 !mt-2 !mb-[24px]">Background characteristics of the study participants (n=92)</div></div><div class="border-bmj-silver-50 my-[40px] w-full border-t border-b" data-testid="table-component" id="T2"><div class="mt-[24px] flex flex-col justify-between md:flex-row md:items-center lg:justify-between" data-testid="table-header"><strong class="text-bmj-silver-800 flex-1 text-[1.25rem] !font-bold" data-testid="table-title">Table 2</strong><div class="my-2 flex content-center items-center md:my-0" data-testid="table-controls"><button type="button" tabindex="0" aria-expanded="false" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md">View inline</button><span class="text-bmj-blue-800 mx-2 text-sm">|</span><button class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md" data-testid="popup-open-button">View popup</button></div></div><div data-testid="table-description" class="text-bmj-silver-800 !mt-2 !mb-[24px]">Clinical parameters of study subjects at different stages of CKD (n=92)</div></div><div class="border-bmj-silver-50 my-[40px] w-full border-t border-b" data-testid="table-component" id="T3"><div class="mt-[24px] flex flex-col justify-between md:flex-row md:items-center lg:justify-between" data-testid="table-header"><strong class="text-bmj-silver-800 flex-1 text-[1.25rem] !font-bold" data-testid="table-title">Table 3</strong><div class="my-2 flex content-center items-center md:my-0" data-testid="table-controls"><button type="button" tabindex="0" aria-expanded="false" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md">View inline</button><span class="text-bmj-blue-800 mx-2 text-sm">|</span><button class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 focus:text-bmj-silver-800 focus-visible:border-bmj-silver-500 text-sm outline-none focus:border-[1px] focus-visible:rounded-md" data-testid="popup-open-button">View popup</button></div></div><div data-testid="table-description" class="text-bmj-silver-800 !mt-2 !mb-[24px]">Comparison of laboratory parameters in relation to retinopathy and conjunctival congestion in the study subjects (N=92)</div></div></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-16"><h2 class="">Discussion</h2><p id="p-32">To the researchers’ knowledge, this is Bangladesh’s first comprehensive research evaluating ophthalmological changes of paediatric CKD patients. Since the study institution was a specialist tertiary care hospital, 22.8% and 41.3% of patients sent from other hospitals had stage V and stage VD CKD. The most common cause of CKD was congenital abnormalities of the kidney and urinary tracts (CAKUT), which includes hypoplastic kidneys and obstructive uropathies. Our findings support the global consensus that infections and CAKUT cause most paediatric CKD.<a id="xref-ref-23-1" class="xref-bibr" href="#ref-23">23</a> We also found that CAKUT is the leading cause of CKD in children in South Asia also, including India,<a id="xref-ref-24-1" class="xref-bibr" href="#ref-24">24</a> Pakistan<a id="xref-ref-25-1" class="xref-bibr" href="#ref-25">25</a> and Nepal.<a id="xref-ref-26-1" class="xref-bibr" href="#ref-26">26</a> Due to a lack of diagnostic facilities, CAKUT was less common in Bhutan.<a id="xref-ref-27-1" class="xref-bibr" href="#ref-27">27</a></p><p id="p-33">Our research used clinical and laboratory parameters to correlate with CKD classifications. SBP and DBP increased significantly with CKD progression. Hypertension is the primary clinical indicator of CKD, and higher levels suggest a worse prognosis.<a id="xref-ref-28-1" class="xref-bibr" href="#ref-28">28</a> Mean haemoglobin, eGFR, serum creatinine, urea, calcium, phosphate, calcium-phosphate product and parathyroid hormone correlated significantly with CKD advancement. Value changes in our study indicate accelerating CKD and may indicate deteriorating prognosis.<a id="xref-ref-29-1" class="xref-bibr" href="#ref-29">29 30</a></p><p id="p-34">Based on visual acuity, 29 patients (31.5%) in our study exhibited visual impairment, with 20 (69.0%) having CKD V. This association was statistically significant and suggests advanced-stage patients with CKD experience greater vision impairment. A complete assessment of ocular health requires consideration of the cornea, lens and retina as well as decreasing visual acuity.<a id="xref-ref-31-1" class="xref-bibr" href="#ref-31">31</a> 15 of 29 visually impaired patients had HR as their primary cause. This group had 14 (93.3%) stage VD patients. This finding supports Nusinvoici <em>et al</em>’s<a id="xref-ref-5-4" class="xref-bibr" href="#ref-5">5</a> finding that retinopathy severity is correlated with renal impairment. Additionally, eGFR values below 30 mL/min/1.73/m<sup>2</sup> triple the risk of retinopathy.<a id="xref-ref-5-5" class="xref-bibr" href="#ref-5">5</a> Furthermore, CKD resulting from chronic glomerulonephritis caused a posterior subcapsular cataract in one patient, impairing vision. Another research of adult patients with CKD identified maculopathy to be the main cause of visual impairment.<a id="xref-ref-12-2" class="xref-bibr" href="#ref-12">12</a></p><p id="p-35">Progression in CKD cause increasingly severe ophthalmological symptoms. Most (15, 79.0%) of the 19 patients with eyelid oedema were in CKD V and VD stages. Our findings match Mansour <em>et al</em>’s,<a id="xref-ref-4-2" class="xref-bibr" href="#ref-4">4</a> who found eyelid oedema in 56.8% of end-stage renal disease (ESRD) patients. 56 patients (60.9%) had conjunctival pallor, indicating clinically evident anaemia and low haemoglobin. These findings align with Thulasidas and Amin,<a id="xref-ref-32-1" class="xref-bibr" href="#ref-32">32</a> who found conjunctival pallor in 56.9% of patients with CKD. 9 (9.98%) stage VD patients reported dry eyes. Dry, red and irritated eyes are common in ESRD patients due to an altered blink reflex, shortened tear breakup times and decreased goblet cell density. CKD’s high vitamin A levels further accelerate the transition from secretory conjunctival mucosa to non-secreting keratinised epithelium.<a id="xref-ref-33-1" class="xref-bibr" href="#ref-33">33</a> Akinci <em>et al</em><a id="xref-ref-34-1" class="xref-bibr" href="#ref-34">34</a> observed 15.8% of paediatric CKD patients had dry eye symptoms, matching our findings. In addition, El-Ghany <em>et al</em><a id="xref-ref-13-2" class="xref-bibr" href="#ref-13">13</a> identified dry eyes in 6.7% of haemodialysis patients compared with early CKD. One patient with chronic glomerulonephritis-related CKD stage VD and long-term steroid therapy had a posterior subcapsular cataract. A study also found 4.7% cataracts in paediatric ESRD patients with CKD VD due to CKD and dialysis complications.<a id="xref-ref-35-1" class="xref-bibr" href="#ref-35">35</a> Stage VD CKD patients had an average intraocular pressure (IOP) of 12.8 mm Hg and an SD of 2.5. This measurement is within the usual 12-to-22-mm Hg IOP range. The finding matches with other studies. Both Mansour <em>et al</em><a id="xref-ref-4-3" class="xref-bibr" href="#ref-4">4</a> and Thulasidas and Amin<a id="xref-ref-32-2" class="xref-bibr" href="#ref-32">32</a> found that the IOP of the study populations was 12.68±1.92 mm Hg and 13.4±2.2 mm Hg, respectively.</p><p id="p-36">Conjunctival congestion was strongly correlated with serum phosphate and calcium phosphate levels in seven individuals (7.6%), six of whom were in stage VD. Calcium phosphate product buildup in the cornea and conjunctiva surpasses their solubility limit and causes persistent inflammatory changes, resulting in conjunctival congestion.<a id="xref-ref-9-3" class="xref-bibr" href="#ref-9">9 36</a> In 2016, Malleswari and Rahmathunnisa<a id="xref-ref-37-1" class="xref-bibr" href="#ref-37">37</a> found conjunctival congestion in 25.6% of haemodialysis patients with CKD. The medical goal for dialysis patients is to keep calcium-phosphate below 55 mg/dL .<a id="xref-ref-9-4" class="xref-bibr" href="#ref-9">9</a></p><p id="p-37">The most important results that potentially threaten vision in advanced CKD are posterior segment abnormalities. 45.7% of our patients had hypertension, and 16.3% had HR. All HR cases were in CKD VD patients. HR is rarer in children than adults, although renal insufficiency considerably increases it.<a id="xref-ref-38-1" class="xref-bibr" href="#ref-38">38</a> The possible explanation for the connection between retinopathy and kidney function could be that retinal microvascular abnormalities resulting from hypertension, inflammation, and other processes may share a common pathophysiological link in the development and progression of CKD.<a id="xref-ref-37-2" class="xref-bibr" href="#ref-37">37</a> In a study by El-Ghany <em>et al</em>,<a id="xref-ref-13-3" class="xref-bibr" href="#ref-13">13</a> 13.3% of Egyptian paediatric patients with CKD developed retinal abnormalities. Diabetes was common in ESRD adult research populations.<a id="xref-ref-4-4" class="xref-bibr" href="#ref-4">4</a> However, none of the study participants had diabetes.</p><p id="p-38">Ahsan <em>et al</em><a id="xref-ref-39-1" class="xref-bibr" href="#ref-39">39</a> found a strong link between low haemoglobin, high blood pressure, severe eGFR decline, and retinopathy risk. We also found that stage VD haemodialysis patients had high blood pressure, low haemoglobin and low eGFR. Comparing patients in different stages of CKD, these differences were significant (p<0.001). Most patients with HR were among haemodialysis group. Moreover, retinopathy patients had substantially low haemoglobin and eGFR. A strong correlation (p<0.001) was found between serum phosphate and calcium-phosphate product in HR patients. Increased blood phosphate levels may cause calcification in medium and large blood vessels, causing endothelial dysfunction and vascular disease in CKD patients. Retinopathy severity in CKD patients was independently associated to blood phosphate levels.<a id="xref-ref-40-1" class="xref-bibr" href="#ref-40">40</a> Serum calcium and phosphate are also predictive markers for chronic renal disease-related ocular symptoms.<a id="xref-ref-39-2" class="xref-bibr" href="#ref-39">39</a> CKD often causes secondary hyperthyroidism, which is exacerbated by mineral metabolism disruption. Therefore, these issues must be monitored routinely.</p><div id="sec-17" class="subsection"><h3>Limitations</h3><p id="p-39">This study had some limitations. It was a hospital-based study with no national sample. Due to COVID-19, sample size was limited. Additionally, the study did not assess intraobserver variation. Patients’ ophthalmological changes could not be assessed more extensively due to the study’s cross-sectional nature. Another limitation of our study is that Snellen’s criterion was translated to logMAR for visual acuity measurements. Scientifically, this conversion is imperfect since the two scales lack equivalent steps. This may have incorporated flaws into our data, affecting the precision of our visual acuity findings. Future study should consider using a single, uniform visual acuity test to avoid such differences. Expressing blood pressure in z-scores would have provided a more standardised comparison across different age groups. As a result, the observed increase in blood pressure may partially reflect the fact that advanced CKD stages are more common in older children, who naturally have higher normal blood pressure values.</p></div></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><div class="article-body-sections wrap-urls md:[&_h2]:text-[2.125rem]" data-testid="article-body-section"><section id="sec-18"><h2 class="">Conclusion</h2><p id="p-40">Paediatric CKD patients often had ophthalmological symptoms, which increased with disease progression. Patients with CKD VD had the highest HR prevalence. Conjunctival congestion and HR were strongly linked to serum and calcium phosphate levels. If neglected, these disorders can cause permanent visual impairment, thus ophthalmological awareness and routine exams can help to detect and prevent them.</p></section><button data-testid="back-to-top-button" class="visible-link text-bmj-blue-600 hover:text-bmj-blue-700 focus-visible:border-bmj-silver-500 mt-[16px] rounded-md focus-visible:border-[1px] focus-visible:outline-none">Back to top</button></div><section class="article-body-sections order-2 mb-0"><section id="fn-group-1" class="!mt-0"><div class="wrap-urls accordion-wrapper border-bmj-silver-50 border-t"><button type="button" aria-expanded="false" tabindex="0" class="text-bmj-blue-800 my-[24px] flex w-full items-center justify-between text-left text-[28px] font-normal leading-10 md:text-[34px]" data-testid="accordion-toggle-button"><span data-testid="accordion-title">Footnotes</span><img class="m-0" src="/next-resources/AccordionArrowDown.svg" alt="Open accordion" /></button></div></section></section><section class="section 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class="m-0 list-none p-0" data-testid="overview-list"><li class="mx-0 pl-0 hidden lg:block"><a href="#abstract-1" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 leading-6 no-underline" data-testid="overview-list-1">Abstract</a></li><li class="mx-0 pl-0 hidden lg:block"><a href="#sec-8" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 leading-6 no-underline" data-testid="overview-list-2">Introduction</a></li><li class="mx-0 pl-0 hidden lg:block"><a href="#sec-9" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 leading-6 no-underline" data-testid="overview-list-3">Materials and methods</a></li><li class="mx-0 pl-0 hidden lg:block"><a href="#sec-15" class="text-bmj-blue-600 hover:text-bmj-blue-700 active:text-bmj-blue-800 leading-6 no-underline" data-testid="overview-list-4">Results</a></li><li class="mx-0 pl-0 hidden lg:block"><a href="#sec-16" class="text-bmj-blue-600 hover:text-bmj-blue-700 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changes in children with advanced stage of chronic kidney disease: a hospital-based study\",\"licenseUrl\":\"http://creativecommons.org/licenses/by-nc/4.0/\",\"accessType\":\"open-access\",\"isOpenAccess\":\"true\",\"publicationDateTimestamp\":\"2024-11-19\",\"authorList\":\"Amit Kumar Datta, Afroza Begum, Ranjit Ranjan Roy, Tahmina Jesmin, Abdullah Al Mamun, Mohammad Afzal Mahfuzullah, Faisal Chowdhury, Mohammad Azmain Iktidar\",\"volume\":\"8\",\"issue\":\"1\",\"firstPage\":\"\",\"lastPage\":\"\"}\n1c:{\"title\":\"Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study\",\"authorDisplay\":\"Amit Kumar Datta, Afroza Begum, Ranjit Ranjan Roy, Tahmina Jesmin, Abdullah Al Mamun, Mohammad Afzal Mahfuzullah, Faisal Chowdhury, Mohammad Azmain Iktidar\",\"elocationId\":\"e002777\",\"journalName\":\"BMJ Paediatrics Open\",\"publicationYear\":\"2024\",\"volume\":\"8\"}\n1d:{\"title\":\"Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study\",\"articleUrl\":\"https://bmjpaedsopen.bmj.com/content/8/1/e002777\"}\n1f:[[\"Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh\",1],[\"Chittagong Medical College Hospital, Chittagong, Bangladesh\",2],[\"Directorate General of Health Services, Dhaka, Bangladesh\",3],[\" School of Research, Chattogram, Bangladesh\",4]]\n23:T526, highlights CKD stage correlations with clinical and laboratory parameters. CKD progression led to a substantial increase in average systolic blood pressure (SBP) and diastolic blood pressure (DBP) (p\u003c0.05). As CKD advanced, ser"])</script><script>self.__next_f.push([1,"um creatinine, urea, phosphate, Ca × PO4, and parathyroid levels increased. Conversely, the average eGFR, haemoglobin and serum calcium decreased. All indicators showed statistical significance (p\u003c0.05), with CKD V and VD showing displaying the most pronounced shift. At advanced CKD, the eGFR dropped significantly and serum urea nearly doubled. The average intraocular pressure in stage VD chronic renal disease patients was 12.8±2.5 mm Hg. 29 (31.5%) patients had impaired vision, 9 in CKD V and 20 in stage VD. Lid oedema (12 in CKD V, 3 in VD), conjunctival pallor (21 in V, 18 in VD) and dry eyes (nine in VD) were also more common in later stages. 15 (16.30%) patients had HR, 1 in CKD V and 14 in VD. Each of these correlations was statistically significant and suggests that worsening CKD increases ophthalmological symptoms. Patients with HR had raised mean serum phosphate and Ca × PO4 levels. These patients also had decreased mean haemoglobin and eGFR. In contrast, conjunctival congestion patients had significantly higher serum phosphate and calcium phosphate products (25:T412,This study had some limitations. It was a hospital-based study with no national sample. Due to COVID-19, sample size was limited. Additionally, the study did not assess intraobserver variation. Patients’ ophthalmological changes could not be assessed more extensively due to the study’s cross-sectional nature. Another limitation of our study is that Snellen’s criterion was translated to logMAR for visual acuity measurements. Scientifically, this conversion is imperfect since the two scales lack equivalent steps. This may have incorporated flaws into our data, affecting the precision of our visual acuity findings. Future study should consider using a single, uniform visual acuity test to avoid such differences. Expressing blood pressure in z-scores would have provided a more standardised comparison across different age groups. As a result, the observed increase in blood pressure may partially reflect the fact that advanced CKD stage"])</script><script>self.__next_f.push([1,"s are more common in older children, who naturally have higher normal blood pressure values.27:T641,\u003chtml\u003e\u003chead\u003e\u003c/head\u003e\u003cbody\u003e\u003cdiv class=\"section fn-group\" id=\"fn-group-1\"\u003e\u003cul\u003e\u003cli class=\"fn-other\" id=\"fn-8\"\u003e\u003cp id=\"p-42\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eX:\u003c/span\u003e @@azmain_iktidar\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-9\"\u003e\u003cp id=\"p-43\"\u003eAKD and MAI contributed equally.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-10\"\u003e\u003cp id=\"p-44\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eContributors:\u003c/span\u003e Study conception and design: AKD and MAI; data collection: AB, RRR, TJ, AAM. Analysis and interpretation of results: MAM, FC; Draft manuscript preparation: AKD, MAI and FC,\u003c/p\u003e\u003cp id=\"p-45\"\u003eGuarantor of the study: AKD\u003cspan class=\"named-content \" id=\"named-content-1\"\u003e. All authors reviewed the results and approved the final version of the manuscript.\u003c/span\u003e\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-11\"\u003e\u003cp id=\"p-46\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eFunding:\u003c/span\u003e The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-conflict\" id=\"fn-12\"\u003e\u003cp id=\"p-47\"\u003e\u003cspan class=\"fn-label font-bold\"\u003eCompeting interests:\u003c/span\u003e None declared.\u003c/p\u003e\u003c/li\u003e\u003cli class=\"fn-other\" id=\"fn-13\"\u003e\u003cp id=\"p-48\"\u003e\u003cspan class=\"fn-label font-bold\"\u003ePatient and public involvement:\u003c/span\u003e Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. 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The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.\"]}]}],[\"$\",\"div\",\"3\",{\"id\":\"sec-3\",\"className\":\"subsection\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-4\",\"children\":[[\"$\",\"strong\",\"0\",{\"children\":\"Results\"}],\" The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p\u003c0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p\u003c0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p\u003c0.001).\"]}]}],[\"$\",\"div\",\"4\",{\"id\":\"sec-4\",\"className\":\"subsection\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-5\",\"children\":[[\"$\",\"strong\",\"0\",{\"children\":\"Conclusion\"}],\" This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings.\"]}]}]],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"$19\",\"3\",{}],[\"$\",\"div\",null,{\"className\":\"section notes text-bmj-silver-800 border-bmj-silver-100 [\u0026_h3]:text-bmj-silver-800 mb-[40px] border-[1px] px-[24px] pt-[8px] pb-[16px] [\u0026_p]:my-[8px] [\u0026_ul]:m-0 [\u0026_ul]:list-none [\u0026_ul]:p-0 [\u0026_li]:m-0 [\u0026_li]:p-0 [\u0026_h3]:mb-0 [\u0026_h3]:mt-[16px] [\u0026_h3]:text-[1.25rem] [\u0026_h3]:font-normal\",\"children\":[\"$\",\"div\",null,{\"data-testid\":\"article-notes-content\",\"className\":\"article-notes-content\",\"children\":[\"$\",\"div\",null,{\"className\":\"\",\"id\":\"boxed-text-1\",\"children\":[[\"$\",\"div\",\"0\",{\"id\":\"sec-5\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"What is already known on this topic\"}],[\"$\",\"ul\",\"1\",{\"className\":\"list-unord \",\"id\":\"list-1\",\"children\":[\"$\",\"li\",null,{\"id\":\"list-item-1\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-6\",\"children\":\"Ocular manifestations are prevalent among paediatric patients with chronic kidney disease (CKD), especially with advancing stages. The spectrum of ocular symptoms can be extensive and permanent visual impairment may result from failure to detect and treat the disease in an expedient manner.\"}]}]}]]}],[\"$\",\"div\",\"1\",{\"id\":\"sec-6\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"What this study adds\"}],[\"$\",\"ul\",\"1\",{\"className\":\"list-unord \",\"id\":\"list-2\",\"children\":[\"$\",\"li\",null,{\"id\":\"list-item-2\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-7\",\"children\":\"In the context of Bangladesh, this is the first study to investigate the ocular manifestations of paediatric CKD patients in relation to potential clinical and biochemical risk factors. Ocular manifestations were most prevalent among children in the final stages of CKD. In advanced CKD, hypertensive retinopathy was prevalent and significantly associated with elevated serum phosphate and calcium phosphate products as well as a decline in estimated glomerular filtration rate and haemoglobin levels.\"}]}]}]]}],[\"$\",\"div\",\"2\",{\"id\":\"sec-7\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"How this study might affect research, practice or policy\"}],[\"$\",\"ul\",\"1\",{\"className\":\"list-unord \",\"id\":\"list-3\",\"children\":[\"$\",\"li\",null,{\"id\":\"list-item-3\",\"children\":[\"$\",\"p\",null,{\"id\":\"p-8\",\"children\":\"Due to the paucity of prior research, this study sheds light on a relatively neglected but critical aspect of the paediatric CKD population in Bangladesh. The results indicate that ocular manifestations are relatively prevalent among paediatric patients with CKD. It also emphasises the significance of clinical vigilance, routine screening and additional research into the prevention and early treatment of this condition.\"}]}]}]]}]]}]}]}],[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls md:[\u0026_h2]:text-[2.125rem]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-8\",{\"id\":\"sec-8\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Introduction\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-9\",\"children\":[\"Chronic kidney disease (CKD) is a significant global public health issue associated with considerable morbidity and mortality.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-1-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-1\",\"children\":\"1\"}],\" CKD often goes undetected and undiagnosed until it reaches an advanced stage and leads to kidney failure. The prevalence of CKD among children under the age of 16 is between 1.5 and 3.0 cases per million children,\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-2-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-2\",\"children\":\"2\"}],\" which can result in multiorgan dysfunction, including various ocular complications.\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-3-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-3\",\"children\":\"3\"}],\" In advanced CKD stages, ocular problems may result from uraemia, biochemical abnormalities, hypertension or inadequate haemodialysis treatment.\",[\"$\",\"a\",\"7\",{\"id\":\"xref-ref-4-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-4\",\"children\":\"4\"}]]}],[\"$\",\"p\",\"2\",{\"id\":\"p-10\",\"children\":[\"The ocular manifestation of advanced CKD results from interactions of multiple factors including underlying risk factors, metabolic aberrations, uraemia and anaemia and treatment induced.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-5-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-5\",\"children\":\"5\"}],\" Hypertensive retinopathy (HR) is the most frequent cause of visual disturbance in these patients, which may initially be asymptomatic but can progress to permanent visual loss if not promptly diagnosed and treated (Ignat et al., 1999; Bajracharya et al., 2008 Contrarily, in CKD with severe anaemia (hemoglobin≤5 gm/dL), retinal arterioles may be pale and optic disc pallor (ischaemic optic neuropathy) may occur.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-6-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-6\",\"children\":\"6\"}],\" In patients with poorly regulated blood pressure, CKD further worsens retinopathy. Thus, treating hypertension in end-stage renal failure may stabilise vision and reduce cataracts.\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-7-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-7\",\"children\":\"7\"}],\" Among the biochemical parameters, hypercalcemia and secondary hyperparathyroidism may cause corneal and conjunctival calcifications.\",[\"$\",\"a\",\"7\",{\"id\":\"xref-ref-8-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-8\",\"children\":\"8\"}],\" On the other hand, chronic dialysis patients may develop subsequent cataract due to lens fluid variations,\",[\"$\",\"a\",\"9\",{\"id\":\"xref-ref-9-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-9\",\"children\":\"9\"}],\" whereas inadequate haemodialysis can result in ocular manifestation due to alteration of lacrimal secretion.\",[\"$\",\"a\",\"11\",{\"id\":\"xref-ref-10-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-10\",\"children\":\"10\"}],\" There has also been reported instances of posterior subcapsular cataracts in patients receiving steroid therapy for chronic glomerulonephritis.\",[\"$\",\"a\",\"13\",{\"id\":\"xref-ref-9-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-9\",\"children\":\"9\"}],\" Urea accumulation in lens can also cause chronic water buildup, resulting in osmotic cataract. Furthermore, severe optic nerve injury can result from high intraocular pressure.\",[\"$\",\"a\",\"15\",{\"id\":\"xref-ref-11-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-11\",\"children\":\"11\"}]]}],[\"$\",\"p\",\"3\",{\"id\":\"p-11\",\"children\":[\"While it is established that individuals with CKD are at higher risk for ocular issues, these complications vary across CKD stages and depend on multiple factors. For instance, while Nusinovici \",[\"$\",\"em\",\"1\",{\"children\":\"et al\"}],[\"$\",\"a\",\"2\",{\"id\":\"xref-ref-5-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-5\",\"children\":\"5\"}],\" found that ocular complications significantly increase as CKD progresses to end stage, leading to prominent visual impairment, Bajracharya \",[\"$\",\"em\",\"4\",{\"children\":\"et al\"}],[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-12-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-12\",\"children\":\"12\"}],\" identified maculopathy as the predominant issue in a different cohort. These discrepancies in findings underscore the complexity of CKD-related ocular manifestations and highlight the need for further investigation. The data are particularly sparse regarding the paediatric population, with very few studies exploring the prevalence and potential contributing factors of ocular complications in children.\",[\"$\",\"a\",\"7\",{\"id\":\"xref-ref-13-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-13\",\"children\":\"13\"}],\" Given the lack of comprehensive studies focused on paediatric patients, especially in South Asia, our study aims to address this gap by systematically evaluating the ophthalmological changes in paediatric CKD patients in Bangladesh. This study seeks to provide a clearer understanding of the prevalence, severity and underlying mechanisms of these ocular complications, thereby emphasising the importance of regular screening and early intervention to improve the quality of life for these patients.\",[\"$\",\"a\",\"9\",{\"id\":\"xref-ref-6-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-6\",\"children\":\"6–10 10–12\"}]]}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls md:[\u0026_h2]:text-[2.125rem]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-9\",{\"id\":\"sec-9\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Materials and methods\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-12\",\"children\":\"This cross-sectional study was conducted over a period of 1 year, from June 2020 to July 2021 at Department of Pediatric Nephrology of a tertiary-level hospital in Bangladesh. @@@This site was selected since it is situated in the capital city and serves patients from across the entire country.\"}],[\"$\",\"div\",\"2\",{\"id\":\"sec-10\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Study participants\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-13\",\"children\":[\"Paediatric patients aged 5–18 of both sexes with advanced CKD (stage III, IV, V and VD dialysis dependent) and consenting parents/legal guardians were included in the study. Acute or chronic eye disorders, ocular trauma within 3 months, CKD owing to cystinosis, oxalosis, Alport syndrome and non-co-operative children were excluded from the study. Each paediatric patient with advanced CKD who visited the department during the study period was consecutively assessed for eligibility. A total of 196 patients were assessed for eligibility and 92 patients were included in final analysis (\",[\"$\",\"a\",\"1\",{\"id\":\"xref-fig-1-1\",\"className\":\"xref-fig\",\"href\":\"#F1\",\"children\":\"figure 1\"}],\").\"]}],[\"$\",\"$L22\",\"2\",{\"attributes\":{\"id\":\"F1\",\"className\":\"fig pos-float odd\"},\"highQualityImageUrl\":\"/content/bmjpo/8/1/e002777/F1.large.jpg\",\"thumbnailImageUrl\":\"/content/bmjpo/8/1/e002777/F1.medium.gif\",\"title\":\"Figure 1\",\"description\":\"Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) diagram of flow of participants at different stages of the study.\",\"rightsAndPermissionsData\":{\"id\":\"bmjpo\",\"title\":\"Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study\",\"licenseUrl\":\"http://creativecommons.org/licenses/by-nc/4.0/\",\"accessType\":\"open-access\",\"isOpenAccess\":\"true\",\"publicationDateTimestamp\":\"2024-11-19\",\"authorList\":\"Amit Kumar Datta, Afroza Begum, Ranjit Ranjan Roy, Tahmina Jesmin, Abdullah Al Mamun, Mohammad Afzal Mahfuzullah, Faisal Chowdhury, Mohammad Azmain Iktidar\",\"volume\":\"8\",\"issue\":\"1\",\"firstPage\":\"\",\"lastPage\":\"\"},\"doi\":\"10.1136/bmjpo-2024-002777\",\"oa\":\"CC-BY-NC-4.0\"}]]}],[\"$\",\"div\",\"3\",{\"id\":\"sec-11\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Study procedure\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-15\",\"children\":\"After obtaining consent from the patients’ parents/legal guardians, a semistructured questionnaire was filled out for each case containing detailed history, clinical examination and lab report findings. Blood obtained through aseptic precautions was transported to the institution’s Clinical Pathology Laboratory and Biochemistry Department for measurement. Alport syndrome was ruled out by checking for familial hematuria, sensorineural deafness, anterior lenticonus, macular and perimacular retinopathy and corneal erosion. CKD diagnosis was based on patients’ previous prescription. Allergic conjunctivitis was ruled out during eye examination. To rule out cystinosis, corneal cystine crystal was inspected with slit lamp examination, and retinal pigmentation for oxalate crystal was checked for oxalosis exclusion.\"}],[\"$\",\"p\",\"2\",{\"id\":\"p-16\",\"children\":[\"CKD occurs when there is gradual decline in renal function, causing a progressive decrease in glomerular filtration rate (GFR). It also comprises a range of pathophysiologic processes that are linked to abnormal kidney function.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-14-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-14\",\"children\":\"14\"}],\" Grading of CKD was done following KDIGO guidelines 2012. Estimated GFR (eGFR) was calculated by revised Schwartz formula as follows—eGFR=0.413 × (height/S. creatinine), where height was expressed in centimetre and serum creatinine in mg/dL.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-15-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-15\",\"children\":\"15\"}],\" After measurement of eGFR, each patient was categorised as stage I, II, III, IV, V and V(D).\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-15-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-15\",\"children\":\"15 16\"}]]}],[\"$\",\"p\",\"3\",{\"id\":\"p-17\",\"children\":[\"An experienced ophthalmologist performed the ophthalmological examination. Visual acuity was measured with a Snellen chart.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-17-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-17\",\"children\":\"17\"}],\" Schirmer tear test strips measured dry eye; Schirmer I: \u003c10 mm in 5 min.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-18-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-18\",\"children\":\"18\"}],\" Slit lamp bio microscopy (Appasamy, India) examined eyelids, cornea, conjunctiva and lens. L-5110 applanation tonometer (Inami \u0026 Co, Japan) assessed intraocular pressure. For posterior segment eye examination, pupils were dilated with tropicamide eye drops (trophen–tropicamide 0.8% and phenylephrine HCL) with fundus evaluation using (a) direct ophthalmoscopy (HEINE Beta-200, HEINE Optotechnik GmbH \u0026 Co KG, Germany) and (b) indirect ophthalmoscopy+20 diopter lens. Colour fundus photography was done for HR patients and graded according to Keith and Wagener classification.\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-19-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-19\",\"children\":\"19\"}],\" Visual acuity that was measured by using Snellen chart converted to quantitative variable with LogMAR visual acuity conversion chart.\",[\"$\",\"a\",\"7\",{\"id\":\"xref-ref-20-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-20\",\"children\":\"20\"}],\" The patient was diagnosed with visual impairment if their VA LogMAR was \u003c0.50, according to WHO guidelines.\",[\"$\",\"a\",\"9\",{\"id\":\"xref-ref-21-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-21\",\"children\":\"21\"}],\" The parameters for biochemical testing included the possible associated factors, which has been shown to influence the ocular manifestation in CKD patients, including haemoglobin,\",[\"$\",\"a\",\"11\",{\"id\":\"xref-ref-6-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-6\",\"children\":\"6\"}],\" urea,\",[\"$\",\"a\",\"13\",{\"id\":\"xref-ref-5-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-5\",\"children\":\"5\"}],\" triglyceride and cholesterol,\",[\"$\",\"a\",\"15\",{\"id\":\"xref-ref-22-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-22\",\"children\":\"22\"}],\" blood sugar,\",[\"$\",\"a\",\"17\",{\"id\":\"xref-ref-22-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-22\",\"children\":\"22\"}],\" calcium and phosphate and parathyroid hormone.\",[\"$\",\"a\",\"19\",{\"id\":\"xref-ref-8-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-8\",\"children\":\"8\"}]]}]]}],[\"$\",\"div\",\"4\",{\"id\":\"sec-12\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Statistical analysis\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-18\",\"children\":[\"After data collection, it was thoroughly checked for inaccuracies and analysed using Stata V.16. Categorical data were displayed by frequency and relative percentage, whereas continuous variables were shown by mean and SD. Pearson’s χ\",[\"$\",\"sup\",\"1\",{\"children\":\"2\"}],\" test, two independent sample t-test and Analysis of Variance(ANOVA) were used to examine two variables’ correlations. A two-tailed p\u003c0.05 considered statistically significant.\"]}]]}],[\"$\",\"div\",\"5\",{\"id\":\"sec-13\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Ethics\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-19\",\"children\":\"The Institutional Review Board at BSMMU granted ethical approval for this study; reference number: BSMMU/2020/4108. Wherever possible, adherence to the 1964 Declaration of Helsinki and its revisions, as well as similar ethical principles, was ensured. Each participant or their guardians have provided informed consent.\"}]]}],[\"$\",\"div\",\"6\",{\"id\":\"sec-14\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Patient and public involvement\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-20\",\"children\":\"Members of the public were involved in several stages of the study including design and conduct. We received input from children and their parents during the pilot and implemented them in our study design. We intend to disseminate the main results to study participants and will seek public involvement in the development of an appropriate method of dissemination.\"}]]}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls md:[\u0026_h2]:text-[2.125rem]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-15\",{\"id\":\"sec-15\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Results\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-21\",\"children\":[\"Out of 92 patients, 61 were men and 31 women. Male to female ratio in CKD was 1.97:1, with a mean age of 12.1±3.68 years. The highest prevalence was 41.3% for CKD stage VD. Hypoplastic kidney was the predominant cause of CKD, comprising 39.13% of the cases (\",[\"$\",\"a\",\"1\",{\"id\":\"xref-table-wrap-1-1\",\"className\":\"xref-table\",\"href\":\"#T1\",\"children\":\"table 1\"}],\"). \",[\"$\",\"a\",\"3\",{\"id\":\"xref-table-wrap-2-1\",\"className\":\"xref-table\",\"href\":\"#T2\",\"children\":\"Table 2\"}],\"$23\",[\"$\",\"a\",\"5\",{\"id\":\"xref-table-wrap-3-1\",\"className\":\"xref-table\",\"href\":\"#T3\",\"children\":\"table 3\"}],\").\"]}],[\"$\",\"$L24\",\"2\",{\"title\":\"Table 1\",\"description\":\"Background characteristics of the study participants (n=92)\",\"children\":[[\"$\",\"table\",\"0\",{\"frame\":\"hsides\",\"rules\":\"groups\",\"id\":\"table-1\",\"children\":[[\"$\",\"thead\",\"0\",{\"id\":\"thead-1\",\"children\":[\"$\",\"tr\",null,{\"id\":\"tr-1\",\"children\":[[\"$\",\"td\",\"0\",{\"align\":\"left\",\"valign\":\"bottom\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-1\",\"className\":\"table-left 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table-vtop\",\"children\":\"12.1±3.68\"}]]}],[\"$\",\"tr\",\"1\",{\"id\":\"tr-3\",\"children\":[[\"$\",\"td\",\"0\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-6\",\"className\":\"table-left table-vtop\",\"children\":\"Sex\"}],[\"$\",\"td\",\"1\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-7\",\"className\":\"table-left table-vtop\",\"children\":null}],[\"$\",\"td\",\"2\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-8\",\"className\":\"table-left table-vtop\",\"children\":null}]]}],[\"$\",\"tr\",\"2\",{\"id\":\"tr-4\",\"children\":[[\"$\",\"td\",\"0\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-9\",\"className\":\"table-left table-vtop\",\"children\":\" Male\"}],[\"$\",\"td\",\"1\",{\"align\":\"left\",\"valign\":\"top\",\"rowSpan\":\"1\",\"colSpan\":\"1\",\"id\":\"td-10\",\"className\":\"table-left 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Since the study institution was a specialist tertiary care hospital, 22.8% and 41.3% of patients sent from other hospitals had stage V and stage VD CKD. The most common cause of CKD was congenital abnormalities of the kidney and urinary tracts (CAKUT), which includes hypoplastic kidneys and obstructive uropathies. Our findings support the global consensus that infections and CAKUT cause most paediatric CKD.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-23-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-23\",\"children\":\"23\"}],\" We also found that CAKUT is the leading cause of CKD in children in South Asia also, including India,\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-24-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-24\",\"children\":\"24\"}],\" Pakistan\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-25-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-25\",\"children\":\"25\"}],\" and Nepal.\",[\"$\",\"a\",\"7\",{\"id\":\"xref-ref-26-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-26\",\"children\":\"26\"}],\" Due to a lack of diagnostic facilities, CAKUT was less common in Bhutan.\",[\"$\",\"a\",\"9\",{\"id\":\"xref-ref-27-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-27\",\"children\":\"27\"}]]}],[\"$\",\"p\",\"2\",{\"id\":\"p-33\",\"children\":[\"Our research used clinical and laboratory parameters to correlate with CKD classifications. SBP and DBP increased significantly with CKD progression. Hypertension is the primary clinical indicator of CKD, and higher levels suggest a worse prognosis.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-28-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-28\",\"children\":\"28\"}],\" Mean haemoglobin, eGFR, serum creatinine, urea, calcium, phosphate, calcium-phosphate product and parathyroid hormone correlated significantly with CKD advancement. Value changes in our study indicate accelerating CKD and may indicate deteriorating prognosis.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-29-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-29\",\"children\":\"29 30\"}]]}],[\"$\",\"p\",\"3\",{\"id\":\"p-34\",\"children\":[\"Based on visual acuity, 29 patients (31.5%) in our study exhibited visual impairment, with 20 (69.0%) having CKD V. This association was statistically significant and suggests advanced-stage patients with CKD experience greater vision impairment. A complete assessment of ocular health requires consideration of the cornea, lens and retina as well as decreasing visual acuity.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-31-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-31\",\"children\":\"31\"}],\" 15 of 29 visually impaired patients had HR as their primary cause. This group had 14 (93.3%) stage VD patients. This finding supports Nusinvoici \",[\"$\",\"em\",\"3\",{\"children\":\"et al\"}],\"’s\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-5-4\",\"className\":\"xref-bibr\",\"href\":\"#ref-5\",\"children\":\"5\"}],\" finding that retinopathy severity is correlated with renal impairment. Additionally, eGFR values below 30 mL/min/1.73/m\",[\"$\",\"sup\",\"7\",{\"children\":\"2\"}],\" triple the risk of retinopathy.\",[\"$\",\"a\",\"9\",{\"id\":\"xref-ref-5-5\",\"className\":\"xref-bibr\",\"href\":\"#ref-5\",\"children\":\"5\"}],\" Furthermore, CKD resulting from chronic glomerulonephritis caused a posterior subcapsular cataract in one patient, impairing vision. Another research of adult patients with CKD identified maculopathy to be the main cause of visual impairment.\",[\"$\",\"a\",\"11\",{\"id\":\"xref-ref-12-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-12\",\"children\":\"12\"}]]}],[\"$\",\"p\",\"4\",{\"id\":\"p-35\",\"children\":[\"Progression in CKD cause increasingly severe ophthalmological symptoms. Most (15, 79.0%) of the 19 patients with eyelid oedema were in CKD V and VD stages. Our findings match Mansour \",[\"$\",\"em\",\"1\",{\"children\":\"et al\"}],\"’s,\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-4-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-4\",\"children\":\"4\"}],\" who found eyelid oedema in 56.8% of end-stage renal disease (ESRD) patients. 56 patients (60.9%) had conjunctival pallor, indicating clinically evident anaemia and low haemoglobin. These findings align with Thulasidas and Amin,\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-32-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-32\",\"children\":\"32\"}],\" who found conjunctival pallor in 56.9% of patients with CKD. 9 (9.98%) stage VD patients reported dry eyes. Dry, red and irritated eyes are common in ESRD patients due to an altered blink reflex, shortened tear breakup times and decreased goblet cell density. CKD’s high vitamin A levels further accelerate the transition from secretory conjunctival mucosa to non-secreting keratinised epithelium.\",[\"$\",\"a\",\"7\",{\"id\":\"xref-ref-33-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-33\",\"children\":\"33\"}],\" Akinci \",[\"$\",\"em\",\"9\",{\"children\":\"et al\"}],[\"$\",\"a\",\"10\",{\"id\":\"xref-ref-34-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-34\",\"children\":\"34\"}],\" observed 15.8% of paediatric CKD patients had dry eye symptoms, matching our findings. In addition, El-Ghany \",[\"$\",\"em\",\"12\",{\"children\":\"et al\"}],[\"$\",\"a\",\"13\",{\"id\":\"xref-ref-13-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-13\",\"children\":\"13\"}],\" identified dry eyes in 6.7% of haemodialysis patients compared with early CKD. One patient with chronic glomerulonephritis-related CKD stage VD and long-term steroid therapy had a posterior subcapsular cataract. A study also found 4.7% cataracts in paediatric ESRD patients with CKD VD due to CKD and dialysis complications.\",[\"$\",\"a\",\"15\",{\"id\":\"xref-ref-35-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-35\",\"children\":\"35\"}],\" Stage VD CKD patients had an average intraocular pressure (IOP) of 12.8 mm Hg and an SD of 2.5. This measurement is within the usual 12-to-22-mm Hg IOP range. The finding matches with other studies. Both Mansour \",[\"$\",\"em\",\"17\",{\"children\":\"et al\"}],[\"$\",\"a\",\"18\",{\"id\":\"xref-ref-4-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-4\",\"children\":\"4\"}],\" and Thulasidas and Amin\",[\"$\",\"a\",\"20\",{\"id\":\"xref-ref-32-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-32\",\"children\":\"32\"}],\" found that the IOP of the study populations was 12.68±1.92 mm Hg and 13.4±2.2 mm Hg, respectively.\"]}],[\"$\",\"p\",\"5\",{\"id\":\"p-36\",\"children\":[\"Conjunctival congestion was strongly correlated with serum phosphate and calcium phosphate levels in seven individuals (7.6%), six of whom were in stage VD. Calcium phosphate product buildup in the cornea and conjunctiva surpasses their solubility limit and causes persistent inflammatory changes, resulting in conjunctival congestion.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-9-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-9\",\"children\":\"9 36\"}],\" In 2016, Malleswari and Rahmathunnisa\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-37-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-37\",\"children\":\"37\"}],\" found conjunctival congestion in 25.6% of haemodialysis patients with CKD. The medical goal for dialysis patients is to keep calcium-phosphate below 55 mg/dL .\",[\"$\",\"a\",\"5\",{\"id\":\"xref-ref-9-4\",\"className\":\"xref-bibr\",\"href\":\"#ref-9\",\"children\":\"9\"}]]}],[\"$\",\"p\",\"6\",{\"id\":\"p-37\",\"children\":[\"The most important results that potentially threaten vision in advanced CKD are posterior segment abnormalities. 45.7% of our patients had hypertension, and 16.3% had HR. All HR cases were in CKD VD patients. HR is rarer in children than adults, although renal insufficiency considerably increases it.\",[\"$\",\"a\",\"1\",{\"id\":\"xref-ref-38-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-38\",\"children\":\"38\"}],\" The possible explanation for the connection between retinopathy and kidney function could be that retinal microvascular abnormalities resulting from hypertension, inflammation, and other processes may share a common pathophysiological link in the development and progression of CKD.\",[\"$\",\"a\",\"3\",{\"id\":\"xref-ref-37-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-37\",\"children\":\"37\"}],\" In a study by El-Ghany \",[\"$\",\"em\",\"5\",{\"children\":\"et al\"}],\",\",[\"$\",\"a\",\"7\",{\"id\":\"xref-ref-13-3\",\"className\":\"xref-bibr\",\"href\":\"#ref-13\",\"children\":\"13\"}],\" 13.3% of Egyptian paediatric patients with CKD developed retinal abnormalities. Diabetes was common in ESRD adult research populations.\",[\"$\",\"a\",\"9\",{\"id\":\"xref-ref-4-4\",\"className\":\"xref-bibr\",\"href\":\"#ref-4\",\"children\":\"4\"}],\" However, none of the study participants had diabetes.\"]}],[\"$\",\"p\",\"7\",{\"id\":\"p-38\",\"children\":[\"Ahsan \",[\"$\",\"em\",\"1\",{\"children\":\"et al\"}],[\"$\",\"a\",\"2\",{\"id\":\"xref-ref-39-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-39\",\"children\":\"39\"}],\" found a strong link between low haemoglobin, high blood pressure, severe eGFR decline, and retinopathy risk. We also found that stage VD haemodialysis patients had high blood pressure, low haemoglobin and low eGFR. Comparing patients in different stages of CKD, these differences were significant (p\u003c0.001). Most patients with HR were among haemodialysis group. Moreover, retinopathy patients had substantially low haemoglobin and eGFR. A strong correlation (p\u003c0.001) was found between serum phosphate and calcium-phosphate product in HR patients. Increased blood phosphate levels may cause calcification in medium and large blood vessels, causing endothelial dysfunction and vascular disease in CKD patients. Retinopathy severity in CKD patients was independently associated to blood phosphate levels.\",[\"$\",\"a\",\"4\",{\"id\":\"xref-ref-40-1\",\"className\":\"xref-bibr\",\"href\":\"#ref-40\",\"children\":\"40\"}],\" Serum calcium and phosphate are also predictive markers for chronic renal disease-related ocular symptoms.\",[\"$\",\"a\",\"6\",{\"id\":\"xref-ref-39-2\",\"className\":\"xref-bibr\",\"href\":\"#ref-39\",\"children\":\"39\"}],\" CKD often causes secondary hyperthyroidism, which is exacerbated by mineral metabolism disruption. Therefore, these issues must be monitored routinely.\"]}],[\"$\",\"div\",\"8\",{\"id\":\"sec-17\",\"className\":\"subsection\",\"children\":[[\"$\",\"h3\",\"0\",{\"children\":\"Limitations\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-39\",\"children\":\"$25\"}]]}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"div\",null,{\"className\":\"article-body-sections wrap-urls md:[\u0026_h2]:text-[2.125rem]\",\"data-testid\":\"article-body-section\",\"children\":[[\"$\",\"section\",\"sec-18\",{\"id\":\"sec-18\",\"children\":[[\"$\",\"h2\",\"0\",{\"className\":\"\",\"children\":\"Conclusion\"}],[\"$\",\"p\",\"1\",{\"id\":\"p-40\",\"children\":\"Paediatric CKD patients often had ophthalmological symptoms, which increased with disease progression. Patients with CKD VD had the highest HR prevalence. Conjunctival congestion and HR were strongly linked to serum and calcium phosphate levels. If neglected, these disorders can cause permanent visual impairment, thus ophthalmological awareness and routine exams can help to detect and prevent them.\"}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}],[\"$\",\"$19\",\"10\",{}],[\"$\",\"$19\",\"11\",{}],[\"$\",\"$19\",\"12\",{}],[\"$\",\"section\",\"13\",{\"className\":\"article-body-sections order-2 mb-0\",\"children\":[\"$\",\"section\",null,{\"id\":\"fn-group-1\",\"className\":\"!mt-0\",\"children\":[\"$\",\"$L26\",null,{\"ids\":[\"fn-group-1\"],\"title\":\"Footnotes\",\"children\":[\"$\",\"div\",null,{\"data-testid\":\"article-footnotes\",\"children\":[\"$\",\"div\",null,{\"data-testid\":\"footnotes\",\"children\":[[\"$\",\"div\",null,{\"className\":\"[\u0026_p]:text-bmj-silver-800 list-none[\u0026_ul]:m-0 m-0 [\u0026_ul]:list-none 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mb-6\",\"children\":[[\"$\",\"p\",null,{\"data-testid\":\"ethics-title\",\"className\":\"mb-4 text-base font-bold\",\"children\":\"Ethics statements\"}],[\"$\",\"section\",null,{\"className\":\"m-0 mt-2\",\"children\":[[\"$\",\"section\",null,{\"data-testid\":\"ethics-consent-section\",\"className\":\"mb-[16px]\",\"children\":[\"Patient consent for publication: \",[\"$\",\"span\",null,{\"data-testid\":\"ethics-consent-text\",\"className\":\"font-bold\",\"dangerouslySetInnerHTML\":{\"__html\":\"\u003cp id=\\\"p-51\\\" class=\\\"ethics-consent-to-publish\\\"\u003eConsent obtained from parent(s)/guardian(s)\u003c/p\u003e\"}}]]}],[\"$\",\"section\",null,{\"data-testid\":\"ethics-approval-section\",\"className\":\"m-0\",\"children\":[\"Ethics approval: \",[\"$\",\"span\",null,{\"data-testid\":\"ethics-approval-text\",\"className\":\"m-0 font-bold\",\"dangerouslySetInnerHTML\":{\"__html\":\"\u003cp id=\\\"p-52\\\" class=\\\"ethics-approval\\\"\u003eThis study involves human participants and was approved by Bangabandhu Sheikh Mujib Medical University, Dhaka, Reference ID: BSMMU/2020/4108 Participants gave informed consent to participate in the study before taking part.\u003c/p\u003e\"}}]]}]]}]]}],[\"$\",\"div\",null,{\"className\":\"wrap-urls mb-6\",\"children\":[[\"$\",\"p\",null,{\"data-testid\":\"acknowledgements-title\",\"className\":\"m-0 mb-4 text-base font-bold\",\"children\":\"Acknowledgements\"}],[\"$\",\"section\",null,{\"data-testid\":\"acknowledgements-text\",\"className\":\"[\u0026_a]:text-bmj-blue-600 [\u0026_a]:hover:text-bmj-blue-700 [\u0026_a]:active:text-bmj-blue-800 [\u0026_a]:focus:text-bmj-silver-800 [\u0026_a]:focus-visible:border-bmj-silver-500 m-0 [\u0026_a]:outline-none [\u0026_a]:focus-visible:rounded-md [\u0026_a]:focus-visible:border-[1px]\",\"dangerouslySetInnerHTML\":{\"__html\":\"\u003chtml\u003e\u003chead\u003e\u003c/head\u003e\u003cbody\u003e\u003cdiv class=\\\"section ack\\\" id=\\\"ack-1\\\"\u003e\u003cp id=\\\"p-41\\\"\u003eThe authors would like to thank Dr. Ariful Haque for his contribution in this project.\u003c/p\u003e\u003c/div\u003e\u003c/body\u003e\u003c/html\u003e\"}}]]}]]}]]}],[\"$\",\"$L21\",null,{\"targetId\":\"article-title-1\"}]]}]}]}]}]}],[\"$\",\"$19\",\"14\",{}],[\"$\",\"section\",\"15\",{\"className\":\"section ref-list 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leading-[24px]\",\"children\":[[\"$\",\"span\",null,{\"className\":\"absolute left-0 h-100\",\"children\":[[\"$\",\"a\",null,{\"href\":\"#xref-ref-1-1\",\"className\":\"visible-link text-bmj-blue-600 hover:text-bmj-blue-700 mr-[1px]\",\"data-testid\":\"reference-link\",\"children\":[\"$\",\"img\",null,{\"src\":\"/next-resources/circle-arrow-up.svg\",\"alt\":\"close\",\"className\":\"inline h-4 mt-1\",\"data-testid\":\"citation-arrow-img\"}]}],\" \"]}],[[[\"$\",\"span\",\"0\",{\"className\":\"text-bmj-silver-800\",\"data-testid\":\"author-0\",\"children\":[\"Halle MP\",\", \"]}],[\"$\",\"span\",\"1\",{\"className\":\"text-bmj-silver-800\",\"data-testid\":\"author-1\",\"children\":[\"Takongue C\",\", \"]}],[\"$\",\"span\",\"2\",{\"className\":\"text-bmj-silver-800\",\"data-testid\":\"author-2\",\"children\":[\"Kengne AP\",\", \"]}]],[\"$\",\"span\",null,{\"data-testid\":\"authors-etal\",\"className\":\"text-bmj-silver-800\",\"children\":\"et al. 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\"]}],[\"$\",\"span\",\"2\",{\"className\":\"text-bmj-silver-800\",\"data-testid\":\"author-2\",\"children\":[\"Hari P\",\", \"]}]],[\"$\",\"span\",null,{\"data-testid\":\"authors-etal\",\"className\":\"text-bmj-silver-800\",\"children\":\"et al. \"}]],[\"$\",\"span\",null,{\"className\":\"text-bmj-silver-800 wrap-urls\",\"data-testid\":\"reference-title\",\"dangerouslySetInnerHTML\":{\"__html\":\"Pediatric Kidney Transplantation: Experience over Two Decades. \"}}],[\"$\",\"span\",null,{\"className\":\"text-bmj-silver-800\",\"children\":[[[\"$\",\"$19\",\"0\",{\"children\":[[\"$\",\"span\",null,{\"children\":\"Asian J Pediatr Nephrol\"}],false]}]],\" \",[\"$\",\"span\",null,{\"children\":[\"2018\",\"; \"]}],[\"$\",\"span\",null,{\"children\":[\"1\",\":\",\"22–8\"]}],\". 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uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p\u003c0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p\u003c0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p\u003c0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings.2c:T7a9,Background Ocular disorders can arise in the advanced stages of chronic"])</script><script>self.__next_f.push([1," kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p\u003c0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p\u003c0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p\u003c0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings.2d:T7a9,Background Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnor"])</script><script>self.__next_f.push([1,"malities, hypertension and inadequate haemodialysis treatment.Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p\u003c0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p\u003c0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p\u003c0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings.2e:T7a9,Background Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.Methods We conduc"])</script><script>self.__next_f.push([1,"ted a cross-sectional study at the Pediatric Nephrology Department, both inpatient and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p\u003c0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p\u003c0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p\u003c0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings.2f:T7a9,Background Ocular disorders can arise in the advanced stages of chronic kidney disease (CKD) for various reasons, including uraemia, biochemical abnormalities, hypertension and inadequate haemodialysis treatment.Methods We conducted a cross-sectional study at the Pediatric Nephrology Department, both inpati"])</script><script>self.__next_f.push([1,"ent and outpatient, of from January 2020 to July 2021. The study aimed to identify and compare ophthalmological changes among children at different stages of CKD to assess potential visual threats. A total of 92 children with advanced-stage CKD, aged 5–18 years, meeting the inclusion and exclusion criteria, were included in the study. Comprehensive assessments, including medical history, physical examinations, relevant tests and detailed ophthalmological examinations, were conducted.Results The mean age of the participants was 12.1±3.68 years. Most of the children were boys (66%). Twenty-nine patients exhibited impaired visual acuity, children with (6/60–6/24) scores in Snellen’s chart Lid oedema and conjunctival pallor were observed in 20.7% and 60.9% of cases, respectively, which were found to statistically significant with advancing CKD stages (p\u003c0.001). Dry eyes were found in 9.8% of CKD stage V patients receiving dialysis (VD) (p=0.003). One patient had a posterior subcapsular cataract, and 7.6% had conjunctival congestion. Patients with conjunctival congestion and hypertensive retinopathy had significantly higher levels of serum phosphate and calcium phosphate product (p\u003c0.001). Hypertensive retinopathy was present in 16.3% of cases, with a significantly higher proportion in the haemodialysis group (93%). Haemodialysis patients exhibited higher blood pressure, lower haemoglobin levels, and a more severe reduction in estimated glomerular filtration rate (p\u003c0.001).Conclusion This study highlights the significant ocular complications associated with CKD, underscoring the need for regular ophthalmological screenings."])</script><script>self.__next_f.push([1,"d:[[\"$\",\"meta\",\"0\",{\"name\":\"viewport\",\"content\":\"width=device-width, initial-scale=1\"}],[\"$\",\"meta\",\"1\",{\"charSet\":\"utf-8\"}],[\"$\",\"title\",\"2\",{\"children\":\"Ophthalmological changes in children with advanced stage of chronic kidney disease: a hospital-based study | BMJ Paediatrics Open\"}],[\"$\",\"meta\",\"3\",{\"name\":\"description\",\"content\":\"$2b\"}],[\"$\",\"meta\",\"4\",{\"name\":\"DC.Contributor\",\"content\":\"Amit Kumar Datta\"}],[\"$\",\"meta\",\"5\",{\"name\":\"DC.Contributor\",\"content\":\"Afroza Begum\"}],[\"$\",\"meta\",\"6\",{\"name\":\"DC.Contributor\",\"content\":\"Ranjit Ranjan 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