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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2010  |  Volume : 21  |  Issue : 3  |  Page : 555-558
Isolated non diabetic renal disease in diabetic patients: A moroccan report


1 Unit of Nephrology, Dialysis and Renal Transplantation, Ibn Sina University Hospital, Rabat, Morocco
2 Unit of Anatomopathology, Children Hospital, Ibn Sina University Hospital, Rabat, Morocco

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Date of Web Publication26-Apr-2010
 

   Abstract 

The occurrence of non-diabetic renal disease (NDRD) in diabetic patients is well established, with different frequencies from all around the world. We report 13 cases of isolated NDRD in diabetic patients diagnosed in our unit and present our biopsy criteria in these patients. From January 2000 to December 2008, 13 diabetic patients with suspected NDRD underwent renal biopsy. The case records of these patients were retrospectively analysed. Nine were males and the mean age was 51 years (10-75). Two had a type I diabetes and 11 had a type II diabetes. The mean duration of diabetes was 36 and 30 months in type I and II respectively. Indications for renal biopsy included: absent retinopathy in 11 cases (84%), heavy proteinuria in four cases (30%), acute renal failure (ARF) in three cases (23%), rapidly progressive renal failure (RPRF) in one case (7%), hematuria in five cases (38%), extra-renal signs in four cases (30,7%), short duration of diabetes in all cases. In conclusion, NDRD was observed in our study in patients with a short duration of diabetes and atypical clinical or biological findings.

How to cite this article:
Haddiya I, Hamzaoui H, Hamany ZA, Radoui A, Rhou H, Benamar L, Bayahia R, Ouzeddoun N. Isolated non diabetic renal disease in diabetic patients: A moroccan report. Saudi J Kidney Dis Transpl 2010;21:555-8

How to cite this URL:
Haddiya I, Hamzaoui H, Hamany ZA, Radoui A, Rhou H, Benamar L, Bayahia R, Ouzeddoun N. Isolated non diabetic renal disease in diabetic patients: A moroccan report. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2019 May 21];21:555-8. Available from: http://www.sjkdt.org/text.asp?2010/21/3/555/62726

   Introduction Top


Diabetic Nephropathy (DN) is a major cause of end stage renal disease. It affects approxi­mately 40% of patients who have had diabetes for more than 20 years. [1],[2]

The diagnosis is supported by a long history of diabetes, evidence of target organ damage and proteinuria preceding azotemia. The cha­racteristic pathologic findings in (DN) are di­ffuse or nodular mesangial sclerosis and glo­merular basement membrane (GBM) thicke­ning, accompanied by chronic tubular atrophy, interstitial fibrosis, and prominent arterioscle­rosis. However, non-diabetic renal disease in diabetic patients (NDRD), either isolated or superimposed on an underlying diabetic glo­merulosclerosis, has been reported with diffe­rent spectrum of diseases identified in different series. Nonetheless, isolated NDRD is not widely documented. We report 13 cases of isolated NDRD in diabetic patients with renal biopsy diagnosed in our unit and present our biopsy criteria in these patients.


   Patients and Methods Top


Between January 2000 and December 2008, we analyzed 13 diabetic patients, as defined by the world heath organisation (WHO). Our pa­tients were divided into two groups: Group 1: type 1 diabetes, Group 2: type 2 diabetes.

Percutaneous renal biopsy was performed in these patients after obtaining informed consent since they were suspected to have NDRD due to short duration of diabetes (< 5 years), and/or absence of diabetic retinopathy (Diabetic reti­nopathy was diagnosed using direct ophthal­moscopy and fluorescein angiography by an ophthalmologist) and/or presence of micros­copic hematuria or any other atypical clinical finding. Tissue samples were routinely proces­sed by light microscopy, and immunofluores­cence for light microscopy, tissue sections were stained with hematoxylineosin, Schiff's perio­dic acid, methenamine silver, Masson trichrome and Congo red. Immunofluorescence examina­tions for immunoglobulin (Ig) G, IgM, IgA, C3, C4, C1q, fibrinogen, were performed.

Data including sex, age, type of diabetes, dura­tion of diabetes, hypertension, extra-renal signs, presence of renal failure, urinary protein excre­tion and microscopic findings of urinary sedi­ment were assessed. Microscopic hematuria was defined as > 10 red blood cells/mL on phase contrast urine microscopy.


   Results Top


Our 13 diabetic patients had NDRD: [Table 1]shows the clinical and laboratory findings in each group. Two patients belonged to group 1 (type 1 diabetes) and 11 patients to group 2 (type 2 diabetes). Group 1 patients had an ave­rage age of 13 ± 3 (10-16) years old while in the second group 51 ± 21 (33-75) years old. Males outnumbered females (9M/4 F). The mean duration of diabetes was short in both groups with a mean of 36 ± 4 and 30 ± 23 months respectively. Diabetic retinopathy was present in one case in each group. One patient had hypertension and microscopic hematuria in the first group while seven patients had hyperten­sion and six had hematuria in the second group. Proteinuria was in nephrotic range in both groups, but, it was heavier in the second group with a mean of 5 ± 2.2 g/24H. Extrarenal signs (skin lesions, joint pain) advocating systemic disease and myeloma were noticed in both, while renal failure at admission was mostly seen in group 2 patients.

All our patients underwent renal biopsy du­ring the study period. The histological lesions identified in group 1 and 2 are presented in [Table 2]. The diagnosis included a case each of lupus nephritis and minimal change disease in the first group; whereas group 2 comprised three cases of membranous nephropathy, two cases of minimal change syndrome, one case of amyloidosis, one case of crescentreic glo­merulonephritis, one case of acute tubular nec­rosis, one case of thrombotic microangiopthy and hemolytic uremic syndrome and two cases of myeloma.

Indications for renal biopsy, as reported in [Table 3], included predominantly the short du­ration of diabetes, absence of retinopathy, and heavy nephrotic syndrome in three cases of minimal change and three other cases of mem­branous nephropathy. Acute renal failure (ARF) and American Rheumatologic Association (ARA) criteria in one case of lupus nephritis. Rapidly progressive renal failure (RPRF) in one case of crescentric glomerulopathy. Heavy proteinuria in a case of amyloidosis. ARF and extrarenal signs in one case of hemolytic and uremic syndrome and two cases of myeloma. In one case, the biopsy indication was an anu­ric ARF.


   Discussion Top


In the present study, we performed renal biop­sy in 13 cases highly suspected to have NDRD. Usual criteria for suspecting and carrying out renal biopsy in type 1 diabetes mellitus are microhematuria, absence of diabetic retinopa­thy, uncharacteristic change in renal function or immunological abnormalities. [3] However, the validity of these clinical conditions is not well established for type 2 diabetes mellitus. [3]

In our study, males outnumbered females. Se­cond group patients were older than group 1 patients. Duration of diabetes was short, though least in the first group. Kahn [4] also reported that diabetic duration in the patients with NDRD was significantly shorter than in those with DN. Moreover, a Korean study by Choi et al [5] concluded that a short duration of diabetes was significantly associated with NDRD. Our fin­ding is consistent with this report, since the mean duration of diabetes was around 30 ± 4 months, and suggests that short duration of dia­betes could be a useful predictor for NDRD in diabetic patients.

In our study, patients without retinopathy ac­counted for 84% of all patients. Several stu­dies [1],[3],[6] and our result suggest the absence of retinopathy is a strong predictor of NDRD.

Mak et al [7] reported that microscopic hema­turia predicts the presence of NDRD in type 2 diabetic patients because significantly more patients with NDRD had microscopic hema­turia. In our study five patients (38%) had mic­roscopic hematuria.

In addition to these clinical parameters, more detailed analyses of onset pattern of proteinuria and clinical symptoms are important in distin­guishing NDRD.

Tone et al [1] also showed that the combination of absence of retinopathy with nephrotic pro­teinuria constitutes a more sensitive marker for NDRD (76.7%) and is thus, a strong indicator for biopsy. A study by Wong et al [8] also showed that the association of hematuria or proteinuria with the absence of retinopathy constitutes the strongest indication for a non-diabetic lesion (positive predictive values of 94%). Thus, com­bination of indications constitute a more sensi­tive predictor of NDRD than any of the indi­cations alone. [9]

In the present study, the most common ND­RD were minimal change nephrotic syndrome (23%) and membranous nephropathy (23%). IgA nephropathy is reported as the most fre­quent NDRD in diabetic patients, [2],[3] but no case of IgA nephropathy was diagnosed in our pa­tients. The most encountered NDRD in a re­cent Saudi Arabian study is membranous neph­ropathy, which is similar to our findings. [10] Crescentric glomerulonephritis has been rarely reported, [11] only one case was found in our study.

In conclusion, we observed in our retrospec­tive study that the absence of diabetic retino­pathy, short duration of diabetes, heavy protei­nuria. and the presence of any unusual charac­teristic clinical or biological symptom might be useful indications for renal biopsy in diabetic patients.

 
   References Top

1.Tone A, Shikata K, Matsuda M, et al. Clinical features of non-diabetic renal diseases in pa­tients with type 2 diabetes. Diabetes Res Clin Pract 2005;69:237-42.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]  
2.Olsen S. Identification of non-diabetic glome­rular disease in renal biopsies from diabetics: a dilemma. Nephrol Dial Transplant 1999;14: 1846-9.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]  
3.Serra A, Romero R, Bayes B. Lopez D, Bonet J. Is there a need for changes in renal biopsy criteria in proteinuria in type 2 diabetes? Diabetes Res Clin Pract 2002;58:149-53.  Back to cited text no. 3      
4.Kahn S. Correlates of diabetic and non-diabetic renal disease (NDRD) in NIDDM. J Am Soc Nephrol 1995;6:451.  Back to cited text no. 4      
5.Lee EY, Chung CH, Choi SO. Non-diabetic renal disease in patients with non-insulin dependent diabetes mellitus. Yonsei Med J 1999;40: 321-6.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]  
6.Christensen PK, Larsen S, Horn T, Olsen S, Parving HH. Causes of albuminuria in patients with type 2 diabetes without diabetic retino­pathy, Kidney Int 2000;58:1719-31.  Back to cited text no. 6      
7.Mak SK, Gwi E, Chan KW, et al. Clinical pre­dictors of non-diabetic renal disease inpatients with non-insulin dependent diabetes mellitus, Nephrol Dial Transplant 1997;12:2588-91.  Back to cited text no. 7      
8.Wong TY, Choi PC, Szeto CC, et al. Renal outcome in type 2 diabetic patients with or without coexisting nondiabetic nephropathies. Diabetes Care 2002;25:900-5.  Back to cited text no. 8  [PUBMED]  [FULLTEXT]  
9.Soni SS, Gowrishankar S, Kishan AG, Raman A. Non diabetic renal disease in type 2 dia­betes mellitus. Nephrology 2006;11(6):533-7.  Back to cited text no. 9      
10.Jalalah SM. Non-diabetic renal disease in dia­betic patients. Saudi J Kidney Dis Transpl 2008;19(5):813-6.  Back to cited text no. 10      
11.Ramesh N, Mowaffaq S. Diabetic woman with massive proteinuria and acute renal failure. Am J Kidney Dis 2005;46(2):362-6.  Back to cited text no. 11      

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Correspondence Address:
Intissar Haddiya
Villa No. 7, Bloc E, Secteur 21, Rue Assoufairaa, Hay Riad 10100, Rabat
Morocco
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PMID: 20427893

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    Tables

  [Table 1], [Table 2], [Table 3]

This article has been cited by
1 Evaluation of renal biopsies in type 2 diabetic patients with kidney disease: A clinicopathological study of 216 cases
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[Pubmed]



 

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    Abstract
    Introduction
    Patients and Methods
    Results
    Discussion
    References
    Article Tables
 

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