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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2016  |  Volume : 27  |  Issue : 5  |  Page : 997-1005
A clinicopathologic study of glomerular disease: A single-center, five-year retrospective study from Northwest India


Department of Nephrology, SMS Medical College and Hospital, Jaipur, Rajasthan, India

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Date of Web Publication22-Sep-2016
 

   Abstract 

Studies published from centers across India have reported different and contradicting patterns of glomerular disease. In this retrospective study, we report our experience from a Tertiary Care Center in Northwest India. A total of 702 renal biopsies performed between 2008 and 2013 were reviewed of which 80 were excluded from the study because of having insufficient records or if the biopsies were taken from an allograft. The study included 411 males (66.1 %) and 211 females (33.9%) with an age range of 12-70 years (mean 30.34 ± 7.04 years). Majority of the biopsies (93.9%) showed some form of glomerulonephritis (GN), either primary (79.4%) or secondary glomerular disease (SGD) (14.5%). Minimal change disease (MCD) was the most common type of primary GN (26.5% of primary GN), followed by membranous nephropathy (MN; 18.8%) and focal and segmental glomerulosclerosis (FSGS; 13.2%). Lupus nephritis (LN) was the most frequent SGD (52.2% of secondary GN). Amyloidosis was found in 41.1% and diabetic glomerulosclerosis in 4.4%. LN was also the second most common diagnosis in females after MCD, seen in 19.4% of females. MCD followed by membranoproliferative GN and diffuse proliferative GN were the most common entities in individuals <20 years of age. In the 20-39 years age group, MN was the most common pathology seen. MN was again the most common pathology seen in patients aged above 40 years followed by amyloidosis and FSGS. In this study, MCD was the most common primary GN observed overall from this part of India. MN was the most common GN in individuals above 20 years of age presenting with the nephrotic syndrome. The geographical and regional differences in the pattern of GNs point to the necessity of having a central biopsy registry.

How to cite this article:
Beniwal P, Pursnani L, Sharma S, Garsa R K, Mathur M, Dharmendra P, Malhotra V, Agarwal D. A clinicopathologic study of glomerular disease: A single-center, five-year retrospective study from Northwest India. Saudi J Kidney Dis Transpl 2016;27:997-1005

How to cite this URL:
Beniwal P, Pursnani L, Sharma S, Garsa R K, Mathur M, Dharmendra P, Malhotra V, Agarwal D. A clinicopathologic study of glomerular disease: A single-center, five-year retrospective study from Northwest India. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2019 Jun 24];27:997-1005. Available from: http://www.sjkdt.org/text.asp?2016/27/5/997/190876

   Introduction Top


Glomerular disease is a common cause of endstage renal disease in both developing and developed countries. The prevalence of glomerular disease is different in various regions of the world and varies depending on the race, age, geographical, etiological, cultural, and economic characteristics. [1],[2],[3],[4] Moreover, the pattern of glomerular disease varies in different geographical regions within the same country and has been reported to change with time. [3],[4],[5],[6],[7] A kidney biopsy is needed for the correct characterization of various types of glomerular diseases. National Renal Biopsy Registries are available in the developed countries which depict the pattern of glomerular disease most commonly encountered. Unfortunately, we do not have a National Registry, and there is scattered data on the prevalence of glomerular diseases from different parts of India with none available from Rajasthan, which is the largest state in India and is mostly comprised by arid and inhospitable Thar Desert.

Minimal change disease (MCD) has been reported to be the most common cause of glomerular disease in Northern India, [8],[9] whereas immunoglobulin A nephropathy (IgAN) has been found to be more common in Western India. [10] A recent study from North India compared the profile of glomerular disease at their center across five decades and found a change in the trend of glomerular diseases. They found that focal and segmental glomerulosclerosis (FSGS) followed by membranous nephropathy (MN) were the most common pathologies seen. [7] Non-IgA mesangial proliferative glomerulonephritis (MesPGN) followed by FSGS were the predominant pathologies reported from South India. [6] In another study from South India, the most common primary glomerular disease (PGD) reported was MCD. [11] A tertiary center from Eastern India too reported MCD as the most common PGD encountered. [12]

Since there are differences in the reports of glomerular diseases from different parts of the world and from within the same country, the current study was performed to show the frequency of occurrence of primary and secondary glomerulonephritis (GN) observed in a Tertiary Care Hospital Catering to patients from Rajasthan and adjoining states.


   Materials and Methods Top


The patients referred to the Nephrology Department at the Sawai Man Singh Medical College and Associated Group of Hospitals, Rajasthan, and who were subjected to kidney biopsy, from July 2008 to June 2013, constituted the subjects of this study. A total of 702 renal biopsies were performed in this period out of which 59 (8.40 %) were on transplanted subjects which were not included in the study. Another 21 (2.99 %) were excluded because of either the sample being insufficient or clinical data being unavailable.

The percutaneous technique with ultrasound guidance using Tru-Cut 14-gauge needles and Bard ® disposable core biopsy instrument (Bard Biopsy Systems ® ) was used for all biopsies. In most of the cases, two cores were obtained; one specimen was fixed in formalin to be evaluated under light microscopy and the other sent for immunofluorescence studies. Paraffin sections were prepared and stained with hematoxylin and eosin, periodic acid-Schiff, Masson trichrome, Congo red, and Jones silver methenamine stains. All the renal biopsies were examined by a pathologist and evaluated with light microscopy and immunofluorescence (using IgA, IgG, IgM, IgE, C3, and C4). Electron microscopy facility was not available at our center.

The indications for biopsy included: nephrotic syndrome (NS), proteinuria more than 1 g/day with active urine sediment, systemic disease with renal involvement, and unexplained renal insufficiency.

Glomerular pathologies were classified into the following:

  1. PGD: IgAN, FSGS, MN, MCD, membranoproliferative GN (MPGN), diffuse proliferative GN (DPGN), MesPGN, and crescentic GN (CresGN)
  2. Secondary glomerular diseases (SGD): Lupus nephritis (LN), GN related to hepatitis B or C, systemic vasculitides, HenochSchönlein purpura, diabetic nephropathy (DN), and amyloidosis
  3. Tubulointerstitial nephropathies (TIN), including acute TIN and chronic TIN Vascular nephropathies including benign and malignant nephrosclerosis and thrombotic microangiopathies.


Patients with evidence of chronic glomerulosclerosis were also classified into PGD or SGD depending on the findings on histology.

Significant clinical data were gathered from the patients' medical files, including the following: clinical diagnosis, serum creatinine, 24 h proteinuria, presence of hematuria, and presence of hypertension.

Complications of renal biopsy were also noted. Severe complications were defined as severe renal bleeding requiring blood transfusions, acute kidney injury (AKI) from obstruction with blood clots, urosepsis, and death. [12],[13] Clinical syndromes were categorized into NS, acute nephritic syndrome, rapidly progressive GN, asymptomatic urinary abnormalities, AKI, and chronic kidney disease. Statistical analysis was performed using the SPSS version 16 software program (SPSS Inc., Chicago, IL, USA). Descriptive and nonparametric statistics were adopted.


   Results Top


Of the 622 cases studied, 411 were male (66.1%) and 211 were female (33.9 %). Their age ranged from 12 to 70 years with a mean of 30.34 ± 7.04 years. The frequency of presenting clinical syndromes among the individuals undergoing kidney biopsy is shown in [Figure 1]. NS was the indication for biopsy in two-thirds of the total biopsied sample.
Figure 1: Spectrum of various clinical syndromes in patients who underwent kidney biopsy.

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The types of renal disease found on biopsy are shown in [Figure 2]. Majority (93.9%) of the biopsies showed some form of GN, either PGD (79.4%) or SGD (14.5%). Isolated tubular, interstitial, and vascular pathologies were seen less frequently.
Figure 2: Type of renal diseases found on biopsy among the study patients.

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There were 494 cases (79.4%) of PGD. MCD was the most common type of primary GN observed in 131 cases (26.5% of PGDs), followed by MN (93 cases, 18.8%) and FSGS (65 cases, 13.2%). MPGN was found in 12.1% of cases (60 cases), IgAN in 9.3% (46 cases),

MesPGN in 9.1 % (40 cases), DPGN in 6.7% (33 cases), chronic sclerosing GN (CSGN) in 2.4 % (12 cases), and CresGN in 2.8 % (14 cases).

MCD was also the most prevalent PGD encountered in females, seen in 47 out of 211 cases (22.3%), followed by MN (38, 18 %),

MPGN (19, 9.9 %), FSGS (18, 8.5%), MesPGN (12, 5.7%), DPGN (7, 3.3%), CresGN (5, 2.4%), and finally IgAN (2, 0.9%). IgAN was more common in males (10.7% vs. 0.9%) and MN appeared to be more common in females (18% vs. 13.4%).

Of the SGDs (90 cases, constituting 14.5% of the total biopsies), LN was the most frequently diagnosed disease (47 cases, 52.2% of SGDs). Amyloidosis was found in 37 cases (41.1%) and diabetic glomerulosclerosis was found in four cases (4.4%). LN was also the second most common diagnosis in females after MCD seen in 19.4% of females.

The overall frequencies of different renal diseases in native renal biopsies together with some basic data for each disease are shown in [Table 1]. MCD was the most common pathology seen overall (21.1%) followed by MN (15%) and FSGS (10.5%).
Table 1: Frequency distribution and epidemiologic and clinical data of primary and secondary glomerulonephritides.

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[Table 2] shows the underlying clinical syndrome in each histological category. It is obvious from the table that the most frequent causes of NS were MCD, MN, and FSGS. Of note, 27.6% of patients with lupus and 28.2% of patients with IgAN presented with NS.
Table 2: Frequency of histological diagnosis on the basis of clinical syndromes.

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There was a difference in the prevalence of glomerular diseases according to different age groups [Table 3]. MCD (37.5% of cases) followed by MPGN (13.8%) and DPGN (10.6%) were the most common pathology in individuals below 20 years of age. In the 20-39 years group, MGN (17.9%), MCD (17.5%), and IgAN (12%) were the most common pathologies seen. MGN (21.1%) was again the most common pathology seen in patients aged above 40 years followed by amyloidosis (17.5%) and FSGS (12.3%). LN was the most common secondary GN in patients <40 years and amyloidosis in those >40 years of age.
Table 3: Distribution of primary and secondary glomerular disease in different age groups.

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   Discussion Top


This study is a single-center 5-year retrospective study from Northwest India. As mentioned previously, no previous data are available from Rajasthan state. The Sawai Man Singh Medical College is the Principal Tertiary Referral Center of the state and also caters to nearby states such as Punjab, Uttar Pradesh, and Haryana. Data prior to the period was not analyzed due to poor records and nonstandardization of biopsy reporting. The main shortcoming of our study is that electron microscopy of the biopsy samples was obtained in only in a few cases due to nonavailability in our center.

In the present study, PGDs accounted for 79.4% of all biopsies were performed. Overall, MCD was the most common glomerular pathology encountered. However, MN was the most common histology seen in patients with age above 20 years. Among the secondary GNs, LN was the most common pathology seen. [Table 4] lists the findings from our study as compared with other studies from India and neighboring countries.
Table 4: Comparison of spectrum of glomerular disease seen in our study with other studies in India and neighboring countries.

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PGD was the most predominant renal disease in our study, as well as in other recent studies. [3],[5],[7],[11],[12] Several studies have shown a decline in the relative frequency of MCD. [1],[4],[6],[7],[14],[15] However, in our study, MCD was the most common PGD, which is in concordance with other similar studies. [5],[8],[9],[11],[12] [Table 5] shows the common glomerular diseases encountered in the present study as compared with patterns from countries other than India. [1],[3],[16],[17],[18],[19],[20]
Table 5: Prevalence of primary glomerular diseases compared to that reported in other countries.

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MN was the most commonly seen pathology in patients aged above 20 years, which is a deviation from the trend observed from other studies from India. A recent study from North India also reported MN to be the most common glomerular pathology in individuals older than 40 years. [7] In addition, MN was the most common pathology seen in a study from Nepal [14] and China. [20] In our study, IgAN was seen only in 7.4% of all cases but accounted for 12% of cases in the 20-39 years age group. IgAN is the most common glomerular disease in Europe and most of Asia including China, Korea, and Japan. [21] The same is not true for the Indian subcontinent. Studies from Pakistan and India have reported the prevalence of IgAN to be between 1.5% and 8.6% [6],[7],[11],[12],[15] as was seen in our study.

Among the SGD, LN and amyloidosis were common constituting 52.2% and 44.4%, respectively. LN is the most common SGD worldwide across America, Europe, Asia, and the Middle East. [21] LN is also the most common SGD seen in the Indian subcontinent. [6],[7],[11],[12],[14],[15] Amyloidosis accounted for 5.9% of total biopsies and 44.1% of those with SGD. The majority of renal amyloid cases were diagnosed on renal biopsies from patients with a history of tuberculosis. Only five cases out of 37 were primary or AL amyloidosis. Three out of these five were diagnosed to have multiple myeloma.

Eighty-six percent of cases of amyloidosis were classified as secondary (AA) amyloid. India, with an incidence greater than two million, has the highest number of new cases of TB annually in the world. [22] High rates of secondary amyloidosis in our series are probable since tuberculosis is endemic in this region. DN was found in only 4.4% of SGN cases. This may be because of the practice patterns that diabetics are usually not biopsied unless there is doubt about diabetes being the cause of renal disease. Tubulointerstitial and vascular causes were less prevalent in our series as is seen in other studies with similar indications for biopsy.


   Conclusion Top


The spectrum of glomerular disease differs according to age, race, and geographical regions. The pattern of biopsy-proven renal disease differs between different regions of the same country. We found MCD to be the most common cause of GN overall and MN was the most common GN in individuals above 20 years. The most common SGD in our study, as well as other studies across the globe, has been documented as LN. A high prevalence of amyloidosis was also noted in our study. Because of the heterogeneity among the findings of studies from different nephrology centers across India, it is necessary to maintain a central registry.

Conflict of interest: None declared

 
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Correspondence Address:
Pankaj Beniwal
Department of Nephrology, SMS Medical College and Hospital, Jaipur, Rajasthan
India
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DOI: 10.4103/1319-2442.190876

PMID: 27752010

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