| Abstract|| |
To obtain a recent and comprehensive insight into the pattern of glomerular diseases in the Bangladeshi population, we studied 95 adequate renal biopsies done during July 2008 to June 2009, by light and direct immunofluorescence microscopy in the Department of Pathology, Rajshahi Medical College, Northern Region of Bangladesh. Of these, 38 (40%) were males and 57 (60%) were females, with a male to female ratio of 1:1.5. The most frequent clinical presentation was nephrotic syndrome (67.37%). Primary glomerular disease accounted for 91.25% of all glomerular disease and, of them, focal and segmental mesangial proliferative glomerulonephritis was the most common histological lesion in 29.47%. Diffuse mesangial proliferative glomerulonephritis (GN) was the second most common lesion (15.79%), followed by focal segmental GN (11.58%), minimal change disease (10.53%), membranous GN (7.37%), IgA nephropathy (6.85%), chronic sclerosing GN (2.11%) and crescentic GN (2.11%). Lupus nephritis was the most prevalent among secondary GN.
|How to cite this article:|
Habib M A, Badruddoza S M. Pattern of glomerular diseases among adults in Rajshahi, the Northern Region of Bangladesh. Saudi J Kidney Dis Transpl 2012;23:876-80
|How to cite this URL:|
Habib M A, Badruddoza S M. Pattern of glomerular diseases among adults in Rajshahi, the Northern Region of Bangladesh. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2019 Jun 27];23:876-80. Available from: http://www.sjkdt.org/text.asp?2012/23/4/876/98195
| Introduction|| |
Glomerular disease is a common cause of end-stage renal disease (ESRD) and comprises 25-45% cases of ESRD in developing nations, including Bangladesh.  The pattern of glomerulonephritis (GN) varies widely from country to country and also in different regions of the same country, reflecting the possible effects of socioeconomic status and genetic and environmental factors. The current study reports the frequency of glomerular diseases in Rajshahi, the Northern region of Bangladesh.
| Material and Methods|| |
Renal biopsy (needle biopsy) specimens of all clinically suspected GN patients submitted to the Pathology Department from the Nephrology Department of Rajshahi Medical College Hospital, since March 2008 to August 2009 (1 year six months), were studied. Two renal biopsy samples from each patient were processed, one for light microscopy (LM) and another for immunofluorence microscopy (IM). The specimen for LM preserved in 10% formalin was processed subsequently for paraffin impregnation. The paraffin blocks were sectioned serially at 2-3-μm thickness and one slide was stained with hematoxylin and eosin (H&E) and another with Periodic acid Schiff (PAS). The other specimen for direct immunofluorescence (DIF) study, preserved in normal saline, was immediately processed for frozen section. Sections were cut in a -20°C cooled chamber of cryostat (Leica CM 1100, Heidelberger Strasse, Nussloch, Germany) at a thickness of 4-5 μm, and the sections were air dried and stained with FITC conjugated rabbit antisera against human IgG, IgM and IgA (Astra, Italy) separately. The sections were examined under an immunofluorescence microscope (Carl Zeiss Axioster plus HBO 50 fluorescent lamp, Gottingen, Germany). All biopsy specimens were interpreted according to the World Health Organization (WHO) classification.  Statistical analysis was made using the statistical package for social sciences.
| Results|| |
A total of 95 histopathologically adequate renal biopsy (needle biopsy) specimens were studied. Of these, 38 were male (40%) and 57 were female (60%). The male-female ratio was 1:1.5. The age range of patients was 18- 70 years, with a mean age of 30.29 years. The age and sex distribution of the study patients are shown in [Table 1].
|Table 1: Age and sex distribution of the study group (according to decades).|
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The most frequent clinical presentation was nephrotic syndrome [64 (67.37%)], followed by nephritic syndrome [15 (15.79%)] and hematuria [8 (8.42%)] [Table 2].
|Table 2: Relation of various patterns of glomerulonephritis with clinical presentation.|
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Among 95 cases, 86 (91.25%) cases were primary GN; the remaining nine (8.75%) cases were due to systemic diseases and infection. Regarding pattern of GN, it was observed that focal and segmental mesangial proliferative glomerulonephritis (FSPGN) (29.47%) (28 of 95 cases) is the most frequent pattern of primary GN in the study group [Figure 1] and [Figure 2], followed by diffuse mesangial proliferative glomerulonephritis (DMesPGN), which is 15.79% (15 of 95 cases). Of secondary GN, six (6.32%) cases were lupus nephritis, one case was chronic glomerulosclerosis due to amyloidosis, one case was due to diabetes mellitus, and one case was due to hepatitis B virus infection. Among the lupus nephritis patients, there was one male and five females, and all patients had been clinically and immunologically diagnosed as systemic lupus erythematosus (SLE) at the time of biopsy [Table 3]. Among 95 cases, DIF study was done in 86 adequate cases, of which 55 (63.95%) were DIF positive and 31 (36.05%) were DIF negative. The most frequent combination of depo sition of immunoglobulins was IgG + IgA, followed by IgG + IgA + IgM. The most frequent single deposition of immunoglobulin was IgG, followed by IgM [Table 4].
|Figure 1: Photomicrograph of histological section showing mild focal segmental proliferation of mesangial cells and matrix, FSPGN (PAS stain ×1600).|
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|Figure 2: Photomicrograph of DIF showing a glomerulus with scattered and granular deposition of IgG in the mesangium of mild to moderate degree. Histologically, this case was diagnosed as FSPGN (DIF with polyclonal rabbit anti-human IgG-FTT conjugate, ×1600).|
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|Table 3: Distribution of various histopathological types of glomerulonephritis of adult age.|
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|Table 4: Frequency of immunoglobulin IgG, IgA and IgM in DIF-positive cases (n = 55).|
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| Discussion|| |
Primary glomerular disease comprised 91.25% and secondary GN 8.75% of all the cases of GN in the present study, and the maximum number of cases, 45 (47.37%), were found in the age group of 21-30 years. FSPGN was the most frequent pattern of GN in adults, constituting 29.47%, which was followed by DMesPGN 16.84%. In a study, Nabiruddin et al  showed that FSPGN 23.49% was the most common pattern of GN in Bangladesh, followed by DMesPGN 16%, which was very much closer to the present study. But, in the western region of Saudi Arabia, the most frequent primary GN is MGN (25.7%), followed by FSGS at 21.3%. 
The most common clinical presentation was nephrotic syndrome (67.37%), similar to the 59.1% cases of nephrotic syndrome studied by Hossain. 
The present study showed that among 86 adequate cases for DIF, 55 (63.95%) cases were found to be DIF positive. But, 50% DIF positive cases were observed by two other studies done in Bangladesh. , It was observed that IgG alone and in various combinations was found in 45 (81.82%) cases (highest deposits). The highest frequency of IgG deposition in the mesangium of glomeruli strongly suggests evidence of immune complex deposition. Tabassum  showed a similar deposition of IgG in 73.33% cases.
In the present study, MGN were found as 7.37%, which is similar to the study of Rahman et al.  FSGS in the current study was found as 11.58%, and 22.22% showed mild deposition of IgM in DIF. But, Rahman  found a lower incidence of FSGS as 02.80%. IgA nephropathy was found in 6.32% cases, which was very close to 7% and 4.6% studied by different the Bangladeshi authors Rashid et al  and Rahman,  respectively. It is the most common form of primary glomerular disease in Asia, accounting for up to 30-40% of all biopsies, for 20% in Europe and for 10% in North America.  The incidence of IgAN in our country is much lower (4.67-7%) in comparison with other Asian countries (Singapore, China, Taiwan, up to 50%), which may be explained by varying approaches to the use of renal biopsy in patient with mild urinary abnormalities such as asymptomatic microscopic hematuria.  Among the secondary causes of GN, lupus nephritis in six (6.32%) accounted for the majority of cases. Histologically, four (66.66%) cases were diagnosed as lupus nephritis class IV, one (16.67%) as lupus nephritis class V and one (16.67%) as lupus nephritis class VI, which was similar to another Bangladeshi study.  Amyloidosis was noted in one case, which represents 1.05% of all the biopsy specimens, closer to the study of Balakrishnan et al. 
Our present data showed that the pattern of glomerular disease in Rajshahi is similar to that of other studies done in Bangladesh, but differs from the western world. This difference may be possibly due to the difference in socio-economic status and genetic and environmental factors. Although the result is quite significant in comparison with other studies, further large-scale multi-center studies should be carried out for a longer period and a national registry for GN should be established to determine current status, better planning, and management of glolomerular diseases. In tropical areas, many of the diseases are rampant and kidney diseases, particularly glomerular disease, share a good number of cases causing considerable morbidity and mortality. This is an endeavor to highlight, at least in part, the details of the glomerular diseases occurring in the Northern Region of Bangladesh for better clarity and understanding of the prevailing problem.
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M A Habib
Assistant Professor, Department of Pathology, Rangpur Medical College, Rangpur
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]