| Abstract|| |
Epidemiological studies on renal biopsies are necessary to establish the pattern and trends of renal diseases in a particular geographic area. In this retrospective study, we reviewed the medical records, histopathology findings and complications of renal biopsy in a region of Morocco. We studied a total of 130 native kidney biopsies taken between January 2008 and January 2012. All biopsies were examined by light microscopy and immunofluorescence microscopy. There were 86 males (66.2%) and 44 females (33.8%), with a mean patient age of 44.82 ± 17.86 (range 8-86) years. The most common indications of renal biopsy was nephritic syndrome (61.5%), followed by renal failure of unknown etiology (30.8%) and asymptomatic urinary abnormalities (5.4%). Primary glomerulonephritis (PGN) was found in 60 (46.2%) of the patients. Among the PGN cases, the most common one was membranous nephropathy (MN) (12.3%). Secondary glomerular disease (SGN) accounted for 48 (36.9%) of the cases. The most common SGN was lupus nephritis (LN) (10%). Tubulointerstitial disease [13 (10%)] and vascular disease [9 (6.9%)] were less common. The most common complications of the procedure were pain at the biopsy site in 12.3%, gross hematuria in 12.3%, perirenal hematoma in 7.7% and hematuria requiring nephrectomy in 0.8% of the patients. The most common indication for renal biopsy was nephrotic syndrome, MN was the most frequent PGN and LN was the most frequent SGN in our report.
|How to cite this article:|
Zajjari Y, Aatif T, Bahadi A, Hassani K, El Kabbaj D, Benyahia M. Kidney biopsy in the military hospital of morocco: Complications and histopathological findings. Saudi J Kidney Dis Transpl 2015;26:1044-9
|How to cite this URL:|
Zajjari Y, Aatif T, Bahadi A, Hassani K, El Kabbaj D, Benyahia M. Kidney biopsy in the military hospital of morocco: Complications and histopathological findings. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2020 May 31];26:1044-9. Available from: http://www.sjkdt.org/text.asp?2015/26/5/1044/164604
| Introduction|| |
Histological examination of the biopsied kidneys remains the gold standard for renal diagnosis. In 1951, Inverson and Brun reported the first large series of needle biopsies of the kidney.  Subsequently, hundreds of papers have been published reporting on the technique, ease and safety of precautious renal biopsies in different age groups. The technological advances have enabled precise localization of the renal poles, minimized the number of passes necessary to obtain adequate tissue and minimized the dwell time of the needle in the kidney. ,,,, However, bleeding remains a serious complication of percutaneous renal biopsy. ,
Renal biopsy data analysis is essential to study the prevalence of biopsy-proven renal disease and its variation and distribution as per geographic areas, socioeconomic conditions, race, age and indication for renal biopsy, to understand the regional epidemiology of kidney diseases in a particular geographical region.  Unfortunately, there are no data on the pattern of renal diseases in Morocco as there is no national renal biopsy registry. Thus, the aim of this study was to analyze the pattern of various nephropathy diseases at the Military Hospital Mohammed V, Rabat, Morocco between January 2008 and January 2012.
| Subjects and Methods|| |
This was a retrospective study of all native kidney biopsies performed at the Military Hospital Mohammed V in Rabat, Morocco, between January 2008 and January 2012. An informed consent was mandatory in all patients. We recorded the following data for each patient: Name, age, sex, indication for renal biopsy, histopathological diagnosis, laboratory investigations (serum creatinine, 24-h urinary protein, urine microscopy) and complications after renal biopsy (pain at biopsy site, gross hematuria, symptomatic hematoma, nephrectomy).
Patients were excluded if they had bleeding problems, uncontrolled hypertension, single kidney and morbid obesity or were uncooperative. Before the biopsy procedure, clotting profile including platelet count, bleeding time, clotting time and prothrombin and partial thromboplastin times were performed. Only a small numbers of patients needed correction for one or more abnormalities of these parameters before performing the biopsies.
The indications for performing the biopsies were nephrotic syndrome, nephritic syndrome, renal failure of unknown etiology, asymptomatic urinary abnormalities [low-grade proteinuria (<3.5 g/24 h with or without microhematuria)]. More than one of these four conditions overlapped in some patients.
Each biopsy was performed with an automated biopsy gun with a 16-gauge needle (C Rose Bard Inc ® , Murray Hill, NJ, USA). An ATL HDI 5000 ultrasound machine (Philips Medical Systems ® , Eindhoven, The Netherlands) was used for localization of the lower pole of the kidney.
All the biopsies were evaluated by light microscopy and immunofluorescence (IF) microscopy; electron microscopy was not available for use in this study. Biopsy samples were considered satisfactory for diagnosis if they contained five or more glomeruli. We examined the stained sections using light microscopy; one section was stained with hematoxylin and eosin, one with Periodic Acid- Schiff, one with Masson's trichrome and one with Jones silver. The IF microscopy panel included IgA, IgM, IgG, C3, C1q, fibrinogen and, if necessary, kappa and lambda light chains.
Immediately after the biopsy the patient remained lying flat on their back for 24 h. During this time, pain, blood pressure, pulse rate, urine flow and color of the urine were monitored frequently and the patient was encouraged to drink large volumes of fluid. Histological categories were classified as follows:
- Primary glomerulonephritis (PGN), which included minimal change disease (MCD), focal segmental glomerulosclerosis (FSGS), membranous nephropathy (MN), IgA nephropathy (IgAN), IgM nephropathy (IgMN), mesangioproliferative glomerulonephritis (MesPGN), membranoproliferative glomerulonephritis (MPGN), crescentic glomerulonephritis (CresGN), diffuse proliferative glomerulonephritis (DPGN), post-infectious glomerulonephritis (PIGN);
- Secondary glomerulonephritis (SGN) included lupus nephritis (LN), diabetic nephropathy (DN), amyloidosis (AM), Henoch- Schönlein purpura (HSP), light chain deposit disease (LCDD), systemic vasculitis (VAS);
- Tubulointerstitial nephritis (TIN);
- Vascular nephropathy (VN).
Simple descriptive statistics were used and the quantitative variables were expressed as mean and standard deviation. Numbers and percentages were used for qualitative variables.
| Results|| |
A total of 130 adequate native renal biopsies were performed in our centers during the specified period. Among them, 86 cases (66.2%) were male and 44 cases (33.8%) were fe-male. The mean age of the patients was 44.82 ± 17.86 (range 8-86) years.
The most common indication for renal biopsy was nephrotic syndrome: 80 cases (61.5%), followed by renal failure of unknown etiology: 40 cases (30.8%), asymptomatic urinary abnormalities: seven cases (5.4%) and nephritic syndrome: three cases (2.3%) [Table 1].
The over-all frequencies of different renal diseases in native renal biopsies, together with some basic data for each disease, are shown in [Table 2].
|Table 2: distribution and basic data of renal diseases observed in the native kidney biopsies.|
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PGN comprised 60 (46.2%) of the total patients. Among the PGN cases, MN, comprising 16 cases (12.3%), was the leading category, followed by MCD 14 cases (10.8%), FSGS 12 cases (9.2%), IgAN nine cases (4.6%), PIGN six cases (4.6%), CresGN three cases (2.3%) and MPGN three cases (2.3%) [Table 3].
SGN accounted for 48 (36.9%) of the cases. The most common SGN was LN 13 cases (10%), followed by AM 12 cases (9.2%), DN 11 cases (6.5%), VAS nine cases (6.9%), HSP two cases (1.5%) and LCDD one case (0.8%) [Table 4]. TIN and VN were less-common diagnostic categories. There were no hereditary glomerular diseases in this analysis.
The most common complications of the procedure were pain at the biopsy site in 16 cases (12.3%), gross hematuria in 16 cases (12.3%), perirenal hematoma in 10 cases (7.7%) and hematuria requiring nephrectomy in one case (0.8%). [Table 5] shows the distribution of all renal complication biopsies.
| Discussion|| |
This study provides much needed information about the demographics, clinical syndromes and pattern of kidney diseases diagnosed by renal biopsy during a period of four years and one month in a single center in Morocco. There are several biases regarding demographical, geographical and racial characteristics, differences in indications for renal biopsy, the analyzed clinical syndromes and variations in pathological classifications. Hence, comparison with different data and drawing accurate conclusions was difficult.
We observed a male predominance in our cases. All recently published studies worldwide showed a similar pattern. ,,,, Our data show that nephrotic syndrome was the most frequent clinical presentation at all age groups, accounting for 61.5% of all cases. This is similar to that reported in many studies around the world. ,, Conversely, studies from Japan and Italy reported a higher frequency of asymptomatic urinary abnormalities, which is quite different from ours, perhaps because of a tendency to biopsy asymptomatic hematuria or proteinuria in those countries. ,
PGN was the most predominant renal disease in our study as well as in all recent studies, followed by SGN and TIN. ,, We did not observe any hereditary nephropathies, which may be due to the unavailability of electron microscopy or because they are being diagnosed by other non-invasive methods. The most frequently diagnosed lesion in our patients with PGN was MN (12.3%), followed by MCD (10.8%), FSGS (9.2%), IgAN (4.6%), PIGN (4.6%), CresGN (2.3%) and MPGN (2.3%). MN is the most common cause of idiopathic nephrotic syndrome (INS) in adults, and is still cited as the most common cause of INS in adults in widely used renal pathology textbooks. , MCD was a rare disease in others studies in the world, ,,,, while IgAN is the most common glomerular disease worldwide, but its detection rate varies widely mostly depending on biopsy indications and mass urinary screening for asymptomatic hematuria or proteinuria.  The low prevalence of IgAN in our series (4.6% of all renal biopsies) is most probably due to the very low rate of renal biopsies in patients with asymptomatic hematuria or proteinuria.
The most common SGN in our study was LN (10%), which was more common in females than in males (92.3% vs 7.7%). This finding is comparable with that reported in many studies across the world. ,,,, AM (9.2%) and DN (8.5%) were the next frequent causes. The data of our hospital are in line with the data from China, Czech Republic and Serbia. ,, Similarly, a study from Pakistan and a few previously published studies from our country had reported a high incidence of amyloidosis due to the high prevalence of tuberculosis and other infectious diseases. , We had performed renal biopsy only on unsuspected cases of amyloidosis. In suspected cases of amyloidosis with an underlying etiology of tuberculosis, rheumatoid arthritis or other chronic inflammatory conditions, amyloidosis was confirmed by biopsies from other sites such as rectum, gum or abdominal fat. We usually do not biopsy diabetic patients unless there are doubts about the role of diabetes in the causation of renal disease. This restrictive biopsy approach accounts for the apparent low prevalence of this disease in our study.
With regard to post-biopsy complications, the overall frequency of important complications varies from 5-13% in previous reports. , We recorded high rates of clinical complications compared with the experience of other authors  who reported pain at the biopsy site in 12.3%, gross hematuria in 12.3% and severe perirenal hemorrhage in 7.7%. In our study, one patient needed open surgical intervention for nephrectomy. However, there were no cases of death.
We conclude that the most common indication for renal biopsy was nephrotic syndrome, MN was the most frequent PGN and LN was the most frequent SGN in our report. This information is an important contribution to understanding the prevalence of renal diseases in Morocco.
Conflict of interest: None declared.
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Department of Nephrology-Dialysis, Military Hospital Mohammed V, Hay Ryad BP 10100, Rabat
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]