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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD  
Year : 2015  |  Volume : 26  |  Issue : 6  |  Page : 1223-1231
Analysis of histopathological pattern of kidney biopsy specimens in Kuwait: A single-center, five-year prospective study


1 Department of Nephrology, Theodor Bilharz Research Institute, Cairo, Egypt; Al-Khezam Dialysis Center, Yiaco, Al-Adan Hospital, Hadiya, Kuwait
2 Al-Khezam Dialysis Center, Yiaco, Al-Adan Hospital, Hadiya, Kuwait
3 Radiology Center, Yiaco, Al-Adan Hospital, Hadiya, Kuwait

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Date of Web Publication30-Oct-2015
 

   Abstract 

Glomerulonephritis (GN) varies in incidence in different geographical areas due to different socioeconomic conditions and ethnicity, genetic variability and environmental factors. Our study is aimed to determine the histopathological pattern of kidney biopsies in Kuwait over the preceding five years. In a prospective study, we analyzed the clinical and pathological data of 214 kidney biopsies that were performed during the period from November 2009 to November 2014 at the Al-Khezam Dialysis Center, Al-Adan Hospital, Kuwait. Kidney biopsies were performed percutaneously using an automated gun guided by ultrasound. The biopsy samples were processed for light microscopy and immunofluorescence. Electron microscopy was performed only in selected cases. Age, gender, serum creatinine, 24-h urinary protein, virology, immunology profiles, indication for renal biopsy and histopathological findings were recorded for analysis. Primary GN was reported in 46.7%, secondary GN was reported in 42.9% and tubulointerstitial disease was reported in 10.3% of the 214 kidney biopsies studied. Among primary GN, membranous GN (MGN) was the most common lesion (12.1%), followed by immunoglobulin A nephropathy (IgAN, 11.7%), minimal change disease (9.8%), focal and segmental glomerulosclerosis (9.3%), membranoproliferative GN (1.9%), Alport's syndrome (1.4%) and fibrillary GN (0.46%). Among biopsies that showed secondary GN, lupus nephritis was the most common (11.7%), followed by hypertensive glomerulosclerosis (10.3%), crescentic GN (7.1%), diabetic nephropathy (3.3%), thrombotic microangiopathy (2.3%), amyloidosis (2.3%), post-infectious GN (1.4%) and myeloma kidney (0.9%). Among biopsies that showed tubulointerstitial disease, acute interstitial nephritis was the most common lesion (6.1%), followed by chronic interstitial nephritis (2.8%) and acute tubular necrosis (1.4%). Our study indicates that MGN was the most common primary GN, followed by IgAN, while lupus nephritis was the most common secondary GN, followed by hypertensive glomerulosclerosis.

How to cite this article:
Abdallah E, Al-Helal B, Asad R, Kannan S, Draz W, Abdelgawad Z. Analysis of histopathological pattern of kidney biopsy specimens in Kuwait: A single-center, five-year prospective study. Saudi J Kidney Dis Transpl 2015;26:1223-31

How to cite this URL:
Abdallah E, Al-Helal B, Asad R, Kannan S, Draz W, Abdelgawad Z. Analysis of histopathological pattern of kidney biopsy specimens in Kuwait: A single-center, five-year prospective study. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2019 Jun 16];26:1223-31. Available from: http://www.sjkdt.org/text.asp?2015/26/6/1223/168646

   Introduction Top


Glomerulonephritis (GN) is characterized by inflammation within the glomerulus and other compartments of the kidney and is caused by a range of immune-mediated disorders. [1] The GN is considered to be primary when there is no associated disease elsewhere or secondary when glomerular involvement is part of a systemic disease, e.g. systemic lupus erythematosus (SLE) or polyarteritis nodosa. Primary GN can also be classified according to the clinical syndrome produced, the histopathological appearance or the underlying etiology. [2]

GN varies in incidence among the different geographical areas due to socioeconomic conditions, ethnicity, genetic variability and environmental factors. Recent studies have suggested a changing pattern of incidence of GN in different parts of the world. [3] For instance, the incidence of end-stage renal disease (ESRD) due to focal and segmental glomerulosclerosis (FSGS) has increased 11-fold in the past two decades in a recent US study. [4] A previous Egyptian study of 1234 renal biopsies revealed a high prevalence of proliferative GN and FSGS. [5] Our study was conducted to determine the histopathological pattern of kidney biopsies performed over the last five years, at the Al-Khezam Dialysis Center, Al-Adan Hospital, Kuwait.


   Patients and Methods Top


In a prospective study, we analyzed the clinical and pathological data of all kidney biopsy samples (214 kidney biopsies) that were performed during the period from November 2009 to November 2014 at the Al-Khezam Dialysis Center, Al-Adan Hospital, Kuwait. The Al-Adan Hospital, Kuwait, is the largest tertiary referral hospital in Kuwait and plays a major role in health-care management.

The main indications for renal biopsy were nephrotic syndrome (urinary protein excretion >3 g/day), nephritic syndrome (active urinary sediment with/without azotemia), sub-nephrotic proteinuria (<3 g/day), combined proteinuria and hematuria, renal failure (acute and chronic) and isolated hematuria.

Kidney biopsies were performed percutaneously using an automated gun guided by ultrasound. The biopsy samples were processed for light microscopy and immunofluorescence examination. Electron microscopy examination was performed only in selected cases.

Age, gender, blood pressure, serum creatinine, blood urea, serum glucose, 24-h urinary protein, fundus examination for diabetic patients, virology, immunology profiles, indications for renal biopsy and histopathological findings were recorded for analysis. Kidney biopsies with sole tubulo-interstitial involvement were also included in the analysis.


   Statistical Analysis Top


Data were analyzed as means ± standard deviation (SD) using the MedCalc Statistical Software or number (%) using an online percentage calculator. Statistical analysis was performed with the aid of the SPSS computer program (version 12 windows).


   Results Top


The kidney biopsy samples of 214 patients were referred for pathological assessment during the period of the study; they included 118 male and 96 female patients and 116 Kuwaiti patients and 98 non-Kuwaiti patients, and their mean age was 37.13 ± 12.9 years (range: 12-76 years).

Primary GN was reported in 100 cases (46.7%), secondary GN was reported in 92 cases (42.9%) and tubulo-interstitial disease was reported in 22 (10.3%) of the 214 kidney biopsies performed [Table 1].
Table 1: Frequency of renal diseases in the 214 kidney biopsies studied.

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Among biopsies that showed primary GN, membranous GN (MGN) was the most common lesion seen in 12.1% of the biopsies, followed by immunoglobulin A nephropathy (IgAN) seen in 11.7% [Table 2] and [Figure 1].
Figure 1: Frequency of primary glomerulonephritis in the kidney biopsies studied (n = 92/214).

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Table 2: Frequency of primary glomerulonephritis in the kidney biopsies studied (n = 100/214).

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Among biopsies that showed secondary GN, lupus nephritis (LN) was the most common lesion, seen in 11.7% of the biopsies as illustrated in [Table 3] and [Figure 2] and [Figure 3].
Figure 2: Frequency of secondary glomerulonephritis in the kidney biopsies studied (n = 92/214).

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Figure 3: Frequency of classes of lupus nephritis.

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Table 3: Frequency of secondary glomerulonephritis in the kidney biopsies studied (n = 92/214).

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Among biopsies that showed tubulo-interstitial disease, acute interstitial nephritis (AIN) was the most common lesion, seen in 6.1% of the biopsies [Table 4].
Table 4: Frequency of tubulo-interstitial diseases in the kidney biopsies studied (n = 22/214).

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The frequency of kidney diseases, male/female ratio, Kuwaiti/non-Kuwaiti patient ratio, mean age, serum creatinine, blood urea and 24-h urinary protein of primary GN, secondary GN and tubulo-interstitial disease are illustrated in [Table 1], [Table 2], [Table 3] and [Table 4] and [Figure 1], [Figure 2] and [Figure 3].

Post-biopsy complications included gross hematuria, which was seen in three cases (1.4% of kidney biopsies performed); none of them required any blood transfusions or other interventions, and the hematuria subsided spontaneously.

Hypertension (HTN) was present in 19.2% of cases with MGN, 28% with IgAN, 4.76% with minimal change disease (MCD), 25% with FSGS, 50% with membrano-proliferative GN (MPGN), 100% with fibrillary GN, 28% with LN, 100% with hypertensive glomerulosclerosis, 26.6% with crescentic GN, 57.1% with diabetic nephropathy (DN), 100% with thrombotic microangiopathy (TMA), 20% with amyloidosis (AMD), 33.3% with post-infectious GN (PIGN), 33.3% with Alport's syndrome, 50% with secondary MPGN, 100% with secondary FSGS and 66.6% of with acute tubular necrosis (ATN).

Diabetes mellitus was present in 3.8% of cases with MGN, 4% with IgAN, 13.6% with hypertensive glomerulosclerosis, 13.3% with crescentic GN, 100% with DN, 20% with AMD and 16.6% of cases with chronic interstitial nephritis (CIN).

Hematuria/dysmorphic red blood cells were present in 36.76%/3.8% of cases with MGN, 72%/4% with IgAN, 10%/10% with FSGS, 50%/25% with MPGN, 52%/32% with LN, 4.5%/4.5% with HTN GS, 53.3%/33.3% with crescentic GN, 28.57%/14.3 with DN, 50%/0% with secondary MGN, 100%/33.3% with PIGN, 66.6%/0% with Alport's syndrome, 100%/0% with secondary MPGN, 100%/0% with secondary FSGS, 100%/0% with chyluria, 7.7%/7.7% with AIN, 16.6%/0% with CIN and 100%/66.6% of cases with ATN.

Complement C3/C4 levels were both low in 32% of the cases with LN. Anti-hepatitis C virus and antibody/hepatitis B surface antigen were positive in 25%/25% of cases with secondary MGN and positive in 100%/0% of cases with secondary MPGN.


   Discussion Top


The present study showed that MGN and LN were the predominant forms of GN in the study population. MGN was the most commonly encountered disease in the whole group, followed by LN and IgAN.

MGN was the most common primary GN among the study group (12.15%). This finding was similar to two earlier reports from the United Arab Emirates and Iran. [6],[7] Jalalah [8] has reported the highest frequency of MGN in Saudi Arabia, of 25.7% in the Western region (range 3.5-25.7%). In contrast, MGN was the fourth most common cause of primary MGN in a report from Egypt (7.03%). [9] MGN represented 9.9% of primary GN in a study from Saudi Arabia. [10]

IgAN was the second most common primary GN reported in our study group (11.7%). Lower frequencies of IgAN have been reported in the neighboring countries in regions such as Saudi Arabia, [11],[12] Bahrain [13] and Iran. [7] This is in contrast to the high incidence of IgAN in Europe, [14],[15] North America [16] and Far East. [17],[18]

MCD was the third most common primary GN among the study group (9.8%); it was the second most common cause of primary GN (17.7%) in Saudi Arabia [10] and the third most common primary GN in Egypt (8.5%), [9] while other studies have reported a wide range from 5.4% to 29%. [8],[11],[12],[19],[20],[21],[22]

FSGS was the fourth most common primary GN among the study group (9.3%). FSGS was the predominant GN in studies published from Saudi Arabia, [10],[23] Kuwait, [24] Jordan [25] and Egypt. [9] It was the second most common lesion in a study from Bahrain. [13] FSGS is increasingly reported to be common in the USA in all ethnic groups. [16],[26]

Literature from the Western countries state that MGN has a male predominance, with a M:F ratio of 2:1, while we found a female predominance with a M:F ratio of 12/14. [16],[17],[27],[28],[29]

In the Western population, IgAN demonstrated a male preponderance by 17/8, while MPGN and MCD were equally distributed; we found a male predominance in both lesions by a ratio of 3/1 and 12/9, respectively. We also found a male predominance (M:F 13/7) of FSGS, as reported in Western countries, Egypt [9] and Saudi Arabia. [10]

In the present study, LN was the most common cause of secondary GN (11.7%) and constituted the most common lesion among female adults and in the middle-age groups. Increased prevalence of LN as a cause of secondary GN has been observed in several studies from Egypt, [5],[9] Sudan, [30] Iran, [7] Bahrain, [13] Jordan, [25] Australia, [29] Kuwait [24] and Saudi Arabia. [10]

Hypertensive glomerulosclerosis was the second most common cause of secondary GN (10.3%) in our study. Similarly, hypertensive nephropathy was the second most common cause of secondary nephropathies in Saudi Arabia. [10] Surprisingly, the prevalence of DN in our study was only 3.3%, similar to reports from Egypt [9] and Saudi Arabia. [10] The most likely reason for this could be that diabetic patients are not biopsied unless the diagnosis is doubtful and there was no diabetic retinopathy.

In our study, crescentic GN was seen in 7.1% of the biopsies compared with 4.5% in Saudi Arabia, [10] TMA was seen in 2.3% and AMD was seen in 2.3%, similar to data (2.5%) reported from Egypt. [31] Secondary MGN was seen in 1.9% and PIGN was seen in 1.4% compared with 7.5% in Saudi Arabia [10] ; myeloma was seen in 0.9% of biopsies, secondary MPGN was seen in 0.9%, secondary FSGS seen in 0.46% and chyluria was seen in 0.46% of the biopsies studied.

Among tubulo-interstitial diseases, AIN was the most common, seen in 6.1%, CIN was seen in 2.8% and ATN was seen in 1.4%. Primary tubulo-interstitial diseases constitute 10-15% of all kidney diseases both in the United States and around the world. In certain regions, such as the Balkans (i.e., Yugoslavia, Bosnia, Croatia, Romania, Bulgaria), interstitial diseases are more prevalent than elsewhere. [32],[33]

In conclusion, MGN was the most common primary GN, followed by IgAN, while LN was the most common secondary GN, followed by hypertensive glomerulosclerosis in our study from Kuwait.


   Acknowledgments Top


The authors would like to acknowledge the help rendered by the nephrologists at the AlKhezam Dialysis Center, Al-Adan Hospital, Kuwait; the pathologists at the Mubarak Hospital, Kuwait; and the dialysis nursing staff at the Al-Khezam Dialysis Center, Al-Adan Hospital, Kuwait in collecting and tabulating the data.

Conflict of Interest

The authors declare that they have no conflict of interest.

 
   References Top

1.
Chadban SJ, Atkins RC. Glomerulonephritis. Lancet 2005;365:1797-806.  Back to cited text no. 1
    
2.
Mason PD, Pusey CD. Glomerulonephritis: Diagnosis and treatment. BMJ 1994;309:1557-63.  Back to cited text no. 2
    
3.
Swaminathan S, Leung N, Lager DJ, et al. Changing incidence of glomerular disease in Olmsted County, Minnesota: A 30-year renal biopsy study. Clin J Am Soc Nephrol 2006; 1:483-7.  Back to cited text no. 3
    
4.
Kitiyakara C, Eggers P, Kopp JB. Twenty-oneyear trend in ESRD due to focal segmental glomerulosclerosis in the United States. Am J Kidney Dis 2004;44:815-25.  Back to cited text no. 4
    
5.
Barsoum RS, Francis MR. Spectrum of glomerulonephritis in Egypt. Saudi J Kidney Dis Transpl 2000;11:421-9.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Yahya TM, Pingle A, Boobes Y, Pingle S. Analysis of 490 kidney biopsies: Data from the United Arab Emirates Renal Diseases Registry. J Nephrol 1998;11:148-50.  Back to cited text no. 6
    
7.
Naini AE, Harandi AA, Ossareh S, Ghods A, Bastani B. Prevalence and clinical findings of biopsy-proven glomerulonephritidis in Iran. Saudi J Kidney Dis Transpl 2007;18:556-64.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Jalalah SM. Patterns of primary glomerular diseases among adults in the western region of Saudi Arabia. Saudi J Kidney Dis Transpl 2009;20:295-9.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.
Ibrahim S, Fayed A, Fadda S, Belal D. A fiveyear analysis of the incidence of glomerulo-nephritis at Cairo University Hospital-Egypt. Saudi J Kidney Dis Transpl 2012;23:866-70.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Nawaz Z, Mushtaq F, Mousa D, et al. Pattern of glomerular disease in the Saudi population: A single-center, five-year retrospective study. Saudi J Kidney Dis Transpl 2013;24:1265-70.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Mitwalli AH, Al Wakeel J, Abu-Aisha H, et al. Prevalence of glomerular diseases: King Khalid University Hospital, Saudi Arabia. Saudi J Kidney Dis Transpl 2000;11:442-8.  Back to cited text no. 11
[PUBMED]  Medknow Journal  
12.
Alkhunaizi AM. Pattern of renal pathology among renal biopsy specimens in Eastern Saudi Arabia. Saudi Med J 2007;28:1676-81.  Back to cited text no. 12
    
13.
Al Arrayed A, George SM, Malik AK, et al. Renal biopsy findings in the Kingdom of Bahrain: A 13-year retrospective study. Saudi J Kidney Dis Transpl 2004;15:503-7.  Back to cited text no. 13
    
14.
Simon P, Ramée MP, Autuly V, et al. Epidemiology of primary glomerulopathies in a French region. Variations as a function of age in patients. Nephrologie 1995;16:191-201.  Back to cited text no. 14
    
15.
Simon P, Ramee MP, Boulahrouz R, et al. Epidemiologic data of primary glomerular diseases in western France. Kidney Int 2004; 66:905-8.  Back to cited text no. 15
    
16.
Dragovic D, Rosenstock JL, Wahl SJ, Panagopoulos G, DeVita MV, Michelis MF. Increasing incidence of focal segmental glomerulosclerosis and an examination of demographic patterns. Clin Nephrol 2005;63: 1-7.  Back to cited text no. 16
    
17.
Kanjanabuch T, Kittikovit W, Lewsuwan S, et al. Etiologies of glomerular diseases in Thailand: A renal biopsy study of 506 cases. J Med Assoc Thai 2005;88 Suppl 4:S305-11.  Back to cited text no. 17
    
18.
Chen H, Tang Z, Zeng C, et al. Pathological demography of native patients in a nephrology center in China. Chin Med J (Engl) 2003;116: 1377-81.  Back to cited text no. 18
    
19.
Huraib S, Al Khader A, Shaheen FA, et al. The spectrum of glomerulonephritis in Saudi Arabia: The results of the Saudi registry. Saudi J Kidney Dis Transpl 2000;11:434-41.  Back to cited text no. 19
[PUBMED]  Medknow Journal  
20.
Bernieh B, Sirwal IA, Abbadi MA, Ashfaquddin M, Mohammad AO. The spectrum of glomerulonephritis in adults in Madinah Munawarah region. Saudi J Kidney Dis Transpl 2000;11:455-60.  Back to cited text no. 20
[PUBMED]  Medknow Journal  
21.
Mousa DH, Al-Hawas FA, Al-Sulaiman MH, Al-Khader AA. A prospective study of renal biopsies performed over one-year at the Riyadh Armed Forces Hospital. Saudi J Kidney Dis Transpl 2000;11:449-54.  Back to cited text no. 21
[PUBMED]  Medknow Journal  
22.
Al-Homrany MA. Pattern of renal diseases among adults in Saudi Arabia: A clinicopathologic study. Ethn Dis 1999;9:463-7.  Back to cited text no. 22
    
23.
Mitwalli AH, Al Wakeel JS, Al Mohaya SS, et al. Pattern of glomerular disease in Saudi Arabia. Am J Kidney Dis 1996;27:797-802.  Back to cited text no. 23
    
24.
El-Reshaid W, El-Reshaid K, Kapoor MM, Madda JP. Glomerulopathy in Kuwait: The spectrum over the past 7 years. Ren Fail 2003;25:619-30.  Back to cited text no. 24
    
25.
Wahbeh AM, Ewais MH, Elsharif ME. Spectrum of glomerulonephritis in adult Jordanians at Jordan university hospital. Saudi J Kidney Dis Transpl 2008;19:997-1000.  Back to cited text no. 25
[PUBMED]  Medknow Journal  
26.
Churg J, Bernstein J, Glassock RJ. Renal Disease: Classification and Atlas of Glomerular Diseases. 2nd ed. New York: Igaky-Shoin; 1995.  Back to cited text no. 26
    
27.
Floege J, Feehally J. Introduction to glomerular disease: Clinical presentations. In: Floege J, Johnson RJ, Feehally J, editors. Comprehensive Clinical Nephrology. 4th ed. St. Louis, Missouri: Saunders; 2010. pp. 193-207.  Back to cited text no. 27
    
28.
Bahiense-Oliveira M, Saldanha LB, Mota EL, Penna DO, Barros RT, Romão-Junior JE. Primary glomerular diseases in Brazil (1979-1999): Is the frequency of focal and segmental glomerulosclerosis increasing? Clin Nephrol 2004;61:90-7.  Back to cited text no. 28
    
29.
Briganti EM, Dowling J, Finlay M, et al. The incidence of biopsy-proven glomerulonephritis in Australia. Nephrol Dial Transplant 2001; 16:1364-7.  Back to cited text no. 29
    
30.
Khalifa EH, Kaballo BG, Suleiman SM, Khalil EA, El-Hassan AM. Pattern of glomerulonephritis in Sudan: Histopathological and immunofluorescence study. Saudi J Kidney Dis Transpl 2004;15:176-9.  Back to cited text no. 30
[PUBMED]  Medknow Journal  
31.
Abdallah E, Waked E. Incidence and clinical outcome of renal amyloidosis: A retrospective study. Saudi J Kidney Dis Transpl 2013;24: 950-8.  Back to cited text no. 31
[PUBMED]  Medknow Journal  
32.
Slade N, Moll UM, Brdar B, Zoric A, Jelakovic B. p53 mutations as fingerprints for aristolochic acid: An environmental carcinogen in endemic (Balkan) nephropathy. Mutat Res 2009;663:1-6.  Back to cited text no. 32
    
33.
Karmaus W, Dimitrov P, Simeonov V, Tsolova S, Batuman V. Offspring of parents with Balkan endemic nephropathy have higher C-reactive protein levels suggestive of inflammatory pro-cesses: a longitudinal study. BMC Nephrol 2009; 10:10.  Back to cited text no. 33
    

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Correspondence Address:
Emad Abdallah
Al-Khezam Dialysis Center, Al-Adan Hospital, P. O. Box Hadiya 47005, Kuwait

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DOI: 10.4103/1319-2442.168646

PMID: 26586063

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