|Year : 2000 | Volume
| Issue : 3 | Page : 442-448
|Prevalence of Glomerular Diseases: King Khalid University Hospital, Saudi Arabia
AH Mitwalli1, J Al Wakeel1, H Abu-Aisha1, A Alam2, M Al Sohaibani3, N Tarif1, D Hammad1, A Askar1, F Sulimani1, J Abid1, N Memon1
1 Department of Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
2 Department of Community Medicine, King Khalid University Hospital, Riyadh, Saudi Arabia
3 Department of Pathology, King Khalid University Hospital, Riyadh, Saudi Arabia
Click here for correspondence address and email
| Abstract|| |
To obtain a more recent and comprehensive insight into the prevalence of glomerular diseases in our patient population, medical records of 200 patients with biopsy proven glomerulonephritis (GN), between January 1994 and June 1999, at the King Khalid University Hospital, Riyadh, Saudi Arabia were analyzed. Primary glomerular disease was found to be the most prevalent, accounting for 63.5% of all glomerular diseases. Among primary glomerular diseases, focal and segmental glomerulosclerosis (FSGS) was the most common histological lesion (34.6%) and was associated with a high prevalence of hypertension (86.4%), nephrotic syndrome (68.18%), hematuria (63.6%) and renal functional impairment (27.3%). Mesangioproliferative GN was the second most common lesion (25.1%) followed by mesangiocapillary GN (15.7%), IgA nephropathy (10.2%), and minimal change disease (8.5%). Amongst secondary glomerular diseases, lupus nephritis was the most prevalent (24.5%). In conclusion, primary glomerular diseases constituted the commonest group encountered and the prevalence of FSGS was quite high with male sex and young adults predominating. FSGS was also associated with a high prevalence of endstage renal disease. Further collaborative studies are necessary to explore the predisposing factors and associations of glomerular disease, especially FSGS.
Keywords: Glomerulonephritis, Focal and segmental glomerulosclerosis, Nephrotic syndrome, Renal impairment.
|How to cite this article:|
Mitwalli A H, Al Wakeel J, Abu-Aisha H, Alam A, Al Sohaibani M, Tarif N, Hammad D, Askar A, Sulimani F, Abid J, Memon N. Prevalence of Glomerular Diseases: King Khalid University Hospital, Saudi Arabia. Saudi J Kidney Dis Transpl 2000;11:442-8
|How to cite this URL:|
Mitwalli A H, Al Wakeel J, Abu-Aisha H, Alam A, Al Sohaibani M, Tarif N, Hammad D, Askar A, Sulimani F, Abid J, Memon N. Prevalence of Glomerular Diseases: King Khalid University Hospital, Saudi Arabia. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2020 Aug 13];11:442-8. Available from: http://www.sjkdt.org/text.asp?2000/11/3/442/36667
| Introduction|| |
In spite of considerable advances in health care, glomerular disease constitutes one of the leading causes of renal failure resulting in considerable morbidity and mortality.
The patterns of the glomerular diseases are different in different countries and also, are changing with the passage of time in the same country, probably due to better infection control, changes in environmental pollution, increased awareness of the disease and changes in life expectancy. For instance, IgA nephropathy (IgAN) is common in the North West regions of Italy,  the Far East and Eastern Europe, , while focal and segmental glomerulosclerosis (FSGS) seems most prevalent in the United States of America.  Similarly, FSGS is the commonest lesion reported from Saudi Arabia by Quinibi et al,  Akhtar et al,  and Mitwalli et al.  However, Huraib et al  and Jorgenson et al  found a predominance of membranoproliferative glomerulonephritis (GN) and mesangioproliferative GN respectively, in their studies among various Saudi patients. The prevalence of FSGS seems to be showing a tendency to increase as reported from New York by Barisoni and Agati who found an increase in its prevalence from 2.5% to 18.7% over a 20-year period.  The prevalence of FSGS has marked racial differences being more common in blacks presenting with nephrotic syndrome. ,,,, Recent studies have shown the association of GN with the hepatitis C virus (HCV)  and Breen et al have found that HCV may play a role in the development of FSGS in a predisposed host. 
Contrary to FSGS, the prevalence of membranous GN (MGN) has not changed much over a period of 20 years and remains the main cause of the nephrotic syndrome in white adults. , In Italy, IgAN was the most common (26%) of all primary GN, followed by MGN (20%) while FSGS accounted for only 7.8% of cases.  IgAN was also the most common GN seen in Japan, China, Hong Kong, Singapore and Taiwan, ,,, while MGN was the commonest lesion encountered in China and Indonesia. 
Secondary glomerular disease accounted for 54% of all glomerular diseases in Jamaica  and hepatitis B was associated with 80% of glomerular diseases in Zimbabwe.  Lupus nephritis accounted for 20.4% in Hawaii  and was three times more common in blacks than whites in USA. 
The present study is aimed at giving more recent insight into the prevalence of glomerular diseases as revealed by renal biopsies in 200 consecutive adult patients between January 1994 to June 1999 at the King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia. This is a tertiary hospital with a heterogeneous population representing patients from almost all parts of the Kingdom.
| Material and Methods|| |
The medical charts of 200 consecutive patients with renal biopsy diagnosis of glomerulonephritis at the KKUH, Riyadh, Saudi Arabia, between January 1994 to June 1999, were analyzed. The study parameters included age, sex, nationality, presenting symptoms and blood pressure reading of the patients, complete blood picture, urine analysis and microscopy, 24-hours urinary protein excretion, creatinine clearance, serum electrolytes, serum urea and creatinine levels, serology and immunological studies, serological markers for hepatitis B and C, antibody against the human immunodeficiency virus (HIV), ultrasound, renal histopathology, treatment given and outcome.
Renal tissue was obtained by percutaneous biopsy using a tru-cut needle under ultrasound guidance in all patients. The tissue obtained was processed for light microscopy (LM), immunofluoroscence (IF) and electron microscopic (EM) studies.
All biopsy specimens were examined by a renal histopathologist and were subsequently interpreted according to World Health Organization (WHO) classification.  Only biopsy specimens containing four or more glomeruli were considered adequate. In all cases, a minimum of 20 sections were obtained and stained with hematoxylin - eosin, periodic acid-schiff (PAS), trichrome, and silver jones stain.
Statistical analysis was made using the statistical package for social sciences. Values are represented as mean ± SE and statistical power value of < 0.05 was considered significant. Student's t-test was used for continuous variables. Logistic regression was conducted with FSGS vs non-FSGS as dependent variables and race, gender, and age-groups as independent variables.
| Results|| |
The age and sex distribution of the study patients are shown in [Table - 1]. The mean age of the patients at the time of biopsy was 35.8 ± 4.3 years with a range of 13 to 74 years. There were 109 males (54.5%) and 91 females (45.5%). Saudi nationals constituted 87% of the study patients while patients of other nationalities constituted 13%.
Primary Glomerular Disease
Primary GN was seen in 127 patients (63.5%) [Table - 2]. FSGS was the most predominant lesion, seen in 44 cases (22%). The other lesions encountered included mesangioproliferative GN (n=32, 16%), mesangiocapillary GN (n=20, 10%), minimal change disease (n=11, 5.5%), IgAN (n=13, 6.5%), MGN (n=5, 2.5%) and rapidly progressive GN (RPGN) (n=2, 1%).
Secondary Glomerular Disease
Secondary glomerular disease (SGD) was found in 73 cases (36.5%) in 49 (24.5%) of whom systemic lupus erythematosus (SLE) was the cause. Post-hypertensive glomerular disease (nephrosclerosis) was present in three cases (1.5%); and glomerular disease secondary to diabetes mellitus was present in five (2.5%). Miscellaneous diagnoses constituted 16 (8%) as detailed in [Table - 2].
[Table - 2] shows distribution of histopathological lesions according to age and gender. Logistic regression analysis for predictors of FSGS revealed that this lesion is commoner in young adults than in patients aged above 60 years (P < 0.05) and that FSGS was more prevalent in males than in females (P = 0001). Also, the prevalence of disease was more in Saudis than non-Saudis (P = 0001).
Primary glomerular diseases affected men (37%) more often than women (26.5%) (P < 0.005) [Table - 2]. The clinicopathological features of PGD are presented in [Table - 3].
At the time of renal biopsy, nephrotic syndrome was an important manifestation of FSGS (68.2%), mesangioproliferative (62.5%), mesangiocapillary (80%), minimal change disease (100%) and MGN (80%). IgAN was associated commonly with hematuria (84.6%). Prevalence of hypertension was high among patients with FSGS. Renal impairment was prominent in RPGN patients while it was absent in patients with minimal change disease.
| Discussion|| |
PGD was the predominant form of renal disease in the present study and accounted for 63.3% of all biopsies. FSGS was the most prevalent disorder and constituted 22% of total renal biopsies and 34.6% of all PGD. This is in accordance with previously published studies from Saudi Arabia. ,,, It was more common among Saudis suggesting a possible genetic predisposition. A similar racial predominance was noticed by previous workers as well. ,, The prevalence also varies within Saudi Arabia, being less than 4% in Gizan in the Southern part of the Kingdom to approximately 35% in Riyadh.  The reported prevalence of FSGS in other countries varies from 7% to 15%. ,
FSGS was the leading cause of nephrotic syndrome in adults seen in 68.18% of our study patients. Similar observations were reported from Ghana.  FSGS was reported to be the most common cause of nephritic syndrome in blacks , usually resulting in ESRD.  The other common types of GN in our study were mesangioproliferative and mesangiocapillary GN. Contrary to FarEastern countries like China, Hong Kong and Taiwan where IgAN is the commonest glomerular lesion accounting for 50% of total glomerular diseases, , IgAN was seen in only 6.5% of all adult patients in our study being more common in males (61.5%) than females (38.5%). IgAN was more frequent in younger patients and it most commonly presented with hematuria.
The prevalence of amyloidosis in our study group was 1% in spite of the high prevalence of rheumatoid arthritis and other chronic conditions that may be associated with amyloidosis. 
Amongst secondary GN, lupus nephritis was most prevalent lesion in our study. A similar high prevalence (24.1%) of the disease is reported from the ethnic Chinese population in Malaysia  while a low prevalence (5.8/million) of lupus nephritis was reported amongst whites in USA. 
Regarding the outcome of the different glomerular diseases, FSGS had a fairly high progression rate to ESRD among PGD, while diabetes (60%) and lupus (22.4%) had a high incidence of ESRD among SGD [Table - 4].
The overall trends of GN are changing from less frequent occurrence of lesions of infectious etiology (post-streptococcal and schistosomiasis) to increased prevalence of viral and immune disorders (FSGS and lupus). Moreover, changes in the biopsy policy for elderly people, more routine viral screening and increasing percentage of patients with complete recovery with cyclophosphamide and alpha interferon have changed the picture of glomerular disease from the past.
In conclusion, FSGS was the most common PGN in the present study. Logistic regression analysis showed that FSGS was more common in males, adults less than 40 years of age and in Saudis. A sizeable percentage of GN patients progress into ESRD, resulting in hospitalization and need for dialysis treatment, which not only increases their morbidity and mortality, but also consumes a major part of the health budget in any country. Since the etiology of FSGS is unclear, it is necessary to explore the possible association of factors such as viral infections (hepatitis B, hepatitis C), dietary habits, familial, genetic, marital and socio-economic status or immune system abnormalities which could shed some light on the problem. Further studies will be helpful in understanding the pathophysiology of the disease as well as the precipitating factors resulting in offering better treatment and will be a major step towards improvement of the health status and well being in the community.
| Acknowledgement|| |
We appreciate the assistance rendered by Miriam Culanding Tampos and nurses of 33B.
| References|| |
|1.||Sratta P, Segoloni GP, Canavese C, et al. Incidence of biopsy-proven primary glomerulonephritis in an Italian province. Am J Kidney Dis 1996;27(5):631-9. |
|2.||Levy M, Berger J. Worldwide perspective of IgA nephropathy. Am J Kidney Dis 1988;12:340-7. [PUBMED] |
|3.||Schena FP. A retrospective analysis of the natural history of primary IgA nephropathy world-wide. Am J Med 1990;89:209-15. [PUBMED] |
|4.||Korbet SM, Genchi RM, Borok RZ, Schwartz MM. The racial prevalence of glomerular lesions in nephrotic adults. Am J Kidney Dis 1996;27(5):647-51. |
|5.||Qunibi WY, Al-Sibai MB, Taher S, Akhtar M. Renal disease in Saudi Arabia: a study of 147 renal biopsies. King Faisal Specialist Hospital Journal 1984;4:317-23. |
|6.||Akhtar M, Qunibi W, Taher S, et al. Spectrum of renal disease in Saudi Arabia. Ann Saudi Med 1990;10:37-44. |
|7.||Mitwalli AH, Al-Wakeel JS, Al Mohaya SS, et al. Pattern of glomerular disease in Saudi Arabia. Am J Kidney Dis 1996;27(6):797-802. |
|8.||Huraib SO, Abu-Aisha H, Mitwalli A, Mahmoud K, Memon NA, Sulimani F. The spectrum of renal disease found by kidney biopsies at King Khalid University Hospital. Saudi Kidney Dis Transplant Bull 1990;1:15-9. |
|9.||Jorgenson HE, Malik SH, Paul TT, Wohra PC. Renal disease in Saudi Arabia. Ann Saudi Med 1985;5:195. |
|10.||Barisoni LD, Agati V. The changing epidemiology of focal segmental glomerulosclerosis in New York City. Mod Pathol 1994;7:156A. |
|11.||Hass M, Spargo BH, Coventry S. Increasing incidence of focal segmental glomerulosclerosis among adult nephropathies: a 20years renal biopsy study. Am J Kidney Dis 1995;18:740-50. |
|12.||D'-Agati V. The many masks of focal segmental glomerulosclerosis. Kidney Int 1994;46:1223-41. |
|13.||Glicklich D, Haskell L, Senitzer D, Weiss RA. Possible genetic predisposition to idiopathic focal segmental glomerulosclerosis. Am J Kidney Dis 1988;12:26-30. [PUBMED] |
|14.||Johnson RJ, Gretch DR, Yamabe H, et al. Membranoproliferative glomerulonephritis associated with hepatitis C virus infection. N Engl J Med 1993;328:465-70. [PUBMED] [FULLTEXT]|
|15.||Breen CS, Alpers CE, Fleet WP, Johnson RJ. Focal segmental glomerular sclerosis among patients infected with hepatitis C virus. Nephron 1999;81:37-40. |
|16.||Li LS. Renal disease in China: an overview. Proc 3rd Asian Pacific Congr Nephrol, Singapore 1986;292-6. |
|17.||Chiang GS, Woo KT, Edmondson RP, et al. Pattern of glomerulonephritis in Singapore. Proc 3rd Asian Pacific Congr Nephrol, Singapore 1986;249-61. |
|18.||Lim GJ. Hepatitis B virus associated membranous glomerulonephritis in children in Taiwan. Proc 7th Asian Colloquium Nephrol, Taipei 1987;119-20. |
|19.||Sidabatur RP, Lumenta NA, Suharjono T. Glomerulonephritis in Indonesia. Proc 3rd Asian Pacific Congr Nephrol, Singapore 1986;282-91. |
|20.||Morgan AG, Shah DJ, Williams W, Forrester TE. Proteinuria and glomerular disease in Jamaica. Clin Nephrol 1984;21:205-9. [PUBMED] |
|21.||Seggie J, Nathoo K, Davies PG. Association of hepatitis B antigenaemia and membranous glomerulonephritis in Zimbabwean children. Nephron 1984;38: 115-9. [PUBMED] |
|22.||Frank AO. Apparent predisposition to systemic lupus erythematosus in Chinese patients in West Malaysia. Ann Rheum Dis 1980;39:266-9. [PUBMED] [FULLTEXT]|
|23.||Fessel WJ. Systemic lupus erythematosus in the community. Incidence, prevalence, outcome, and first symptoms; the high prevalence in black women. Arch Intern Med 1974;134:1027-35. |
|24.||Churg J, Sobin LH. Renal disease: classification and atlas of glomerular diseases. Tokyo, Igaku-Shoin 1995. |
|25.||Habib R, Kleinknecht C. The primary nephrotic syndrome of childhood, in Pathology Annual. New York, NY, Appleton-Century-Crofts 1971;427-34. |
|26.||Lewis EJ. Management of nephrotic syndrome in adults, in Cameroon JS, Glassock RJ (eds): The Nephrotic Syndrome. New York, NY, Dekker, 1986; 461-521. |
|27.||Adu D, Anim-Addo Y, Foli AK, et al. The nephrotic syndrome in Ghana: clinical and pathological aspects. Q J Med 1981;50: 297-306. [PUBMED] [FULLTEXT]|
|28.||Bakir AA, Bazilinski NG, Rhee HL, Ainis H, Dunea G. Focal segmental glomerulo sclerosis. A common entity in nephrotic black adults. Arch Intern Med 1989; 149:1802-4. |
|29.||Pontier PJ, Patel TG. Racial differences in the prevalence and presentation of glomerular disease in adults. Clin Nephrol 1994;42:79-84. [PUBMED] |
|30.||Korbet SM, Schwartz MM, Lewis EJ. The prognosis of focal segmental glomerulosclerosis of adulthood. Medicine 1986;65: 304-11. [PUBMED] |
A H Mitwalli
Department of Medicine, King Khalid University Hospital, P.O. Box 2925, Riyadh 11461
[Table - 1], [Table - 2], [Table - 3], [Table - 4]