| Abstract|| |
This is a retrospective study of all native kidney biopsies performed at our center between October 1, 2012 and March 31, 2015. Relevant clinical and laboratory variables were recorded. Biopsy samples were processed for light microscopy and immunofluorescence in all cases. Histological classification was adapted from the World Health Organization recommendations. The indications for kidney biopsy were nephrotic syndrome in adults in 190 cases, rapidly progressive renal failure in 43, unexplained renal failure in 25, and steroid-resistant nephrotic syndrome in children in 12. The mean age of the patients was 31.48 ± 13.46 years. Male-to-female ratio was 1.87:1. Mean serum creatinine (SCr) of the patients was 2.36 ± 2.07 mg/dL. Primary glomerulonephritis accounted for 88.89% of cases (240) while secondary glomerulonephritis accounted for 7.40% of total cases (20). Interstitial disease accounted for 1.5% and vascular disease for 2.2%. The most common lesion among primary glomerulonephritis was focal segmental glomerulosclerosis (FSGS) (31.11%) followed by diffuse proliferative glomerulonephritis (DPGN) (13.33%) and membranous glomerulonephritis (MGN) (12.59%). Among secondary glomerulonephritis, lupus nephritis was the most common (5.56%). In patients with SCr 1.4 mg/dL or less (n = 131), FSGS was the most common histology (17.26%) followed by MGN (23.66%) and minimal change disease (7.63%). Whereas, in patients with SCr more than 1.4 mg/dL (n = 139), DPGN was the most common diagnosis (23.74%) followed by FSGS (17.26%) and IgAN (12.23%). Fourteen patients (5.2%) had one or more episode of gross hematuria, three of whom required blood transfusion. The overall FSGS was the most common lesion seen. When we consider only patients with deranged renal function, DPGN was the most common histopathological lesion. The reason for disproportionate high incidence for DPGN is not clear and requires further research.
|How to cite this article:|
Krishna A, Vardhan H, Singh PP, Kumar O. Analysis of native kidney biopsy: Data from a single center from Bihar, India. Saudi J Kidney Dis Transpl 2018;29:1174-80
|How to cite this URL:|
Krishna A, Vardhan H, Singh PP, Kumar O. Analysis of native kidney biopsy: Data from a single center from Bihar, India. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 May 19];29:1174-80. Available from: http://www.sjkdt.org/text.asp?2018/29/5/1174/243975
| Introduction|| |
Kidney biopsy is the “gold standard” diagnostic tool in patients with renal parenchymal disease. It not only provides an accurate diagnosis but also provides information about prognosis and guides the choice of therapeutic options., The incidence of biopsy-proven types of renal disease depends not only on age, gender, ethnicity, and geographical area but also on nutritional, environmental, and socioeconomic conditions.,,,,, There is no central registry for kidney biopsies in India, and there is a paucity of data from the Eastern part of the country. Our institute is a tertiary care center in the state of Bihar, and presently, we are the only center in the state where kidney biopsies are performed regularly. Here, we are presenting the data of biopsy-proven kidney disease of our Institute.
| Subject and Methods|| |
This is a retrospective study of all native kidney biopsies performed at our center between October 1, 2012, and March 31, 2015. For each patient, we recorded following variables: name, age, gender, duration of illness, indication for biopsy, blood pressure, laboratory parameters in the form of hemoglobin, serum creatinine (SCr), serum albumin, serum total protein, serum cholesterol, serum triglyceride, 24-h urinary protein, screening for hepatitis B virus, hepatitis C virus, human immunodeficiency virus and where indicated C3, C4, ANA, ANCA, anti-ds-DNA, anti-GBM antibody, and serum protein electrophoresis.
All kidney biopsies were done using automated biopsy gun under ultrasound guidance. Any complications of the biopsy, such as excessive pain, gross hematuria, drop in hemoglobin, or requirement of blood transfusions, were also recorded.
Biopsy samples were processed for light microscopy and immunofluorescence in all cases. All samples were processed and reported by the same renal histopathologist at a private center at New Delhi, India. Inadequate/ incomplete reports were not included in our study.
Histological classification was adapted from the World Health Organization recommendations.
The Statistical Package for the Social Sciences (SPSS) software version 20.0 for Windows (SPSS, Inc., Chicago, IL, USA) was used to store and analyze the data. The quantitative variables were expressed as mean with standard deviation while qualitative variables were expressed as numbers and percentage.
| Results|| |
A total of 284 kidney biopsies were performed. Fourteen cases were excluded as the tissue obtained were inadequate. The mean age was 31.48 ± 13.46 years, and the male-to-female ratio was 1.87:1. The mean duration of illness was 5.98 ± 6.66 months. At presentation, the mean hemoglobin was 11.02 ± 2.27 mg/dL, mean SCr was 2.36 ± 2.07 mg/dL, and mean 24-h urinary protein excretion was 5004 ± 2460 mg.
The most common indication for biopsy was adult-onset nephrotic syndrome in 190 (70.37%) patients, followed by rapidly progressive renal failure in 43 (15.93%), unexplained renal failure with normal size kidneys in 25 (9.26%), and steroid-resistant and steroid-dependent nephrotic syndrome in 12 (4.44%).
Out of 270 patients, five were found to be positive for HBs Ag during the evaluation, and none were positive for HIV or anti-HCV antigen. The distribution of renal disease on biopsy is shown in [Table 1].
The primary glomerular disease was the most common diagnosis [240 (88.89%)]. The most common lesion in primary glomerulonephritis was focal segmental glomerulosclerosis (FSGS) which accounts for 31.11% of all cases and 35% of cases of primary glomerulonephritis, followed by diffuse proliferative glomerulonephritis (DPGN) (13.33% of total cases) and membranous glomerulonephritis (MGN) (12.59% of total cases). Lupus nephritis (LN) accounted for 75% of all cases of secondary glomerulonephritis, but only 5.56% of total cases. Vascular and interstitial diseases accounted for 2.2 % and 1.5% of total cases, respectively.
LN was more common in females, and membranoproliferative GN (MPGN) and mesangio-proliferative GN were also slightly more common in female. By contrast, minimal change disease (MCD), FSGS, MN IgAN, DPGN, DN, and crescentic GN were more common in males.
All primary glomerular diseases were more common in the age group of 19–39 years [Table 2]. FSGS was the most common lesion across the age groups. In the age group of 18 years or less, it accounted for 35.71% of cases while in the age group of 19–39 years, it accounted for 30.57% of cases and in the age group of 40 years and more it accounted for 29.58% of cases.
In age group, 18 years and less MGN (11.90%) and MPGN (9.5%) were second and third most common diagnosis, respectively. In the age group of 19–39 years, DPGN was the second most common histology accounting for 13.38% of all cases in this age group, while MGN was the third most common diagnosis, accounting for 10.2% of biopsy in the age group. IgA nephropathy and MPGN were also a common diagnosis in the group, accounting each for 9.5% of diagnosis.
In age group, 40 years or more MGN was the second most common diagnosis accounting for 18.4% of cases followed by DPGN (16.90%) In secondary glomerulonephritis, LN was more common in the age group of 19–39 years; however, DN and amyloidosis were seen only in the age group of 40 years and above.
Out of a total of 270 cases, 131 (48.5 %) had SCr ≤1.4 mg/dL while the rest (139 (51.5%) had SCr ≥1.4 mg/dL.
FSGS was the most common histology (37.3%) in patients with SCr ≤ 1.4 mg/dL followed by MGN (23.7%) and MCD (7.6%) while DPGN was the most common diagnosis in patients with SCr ≥1.4 mg/dL accounting for 23.74% of cases in this group followed by FSGS (17.3%) and IgAN (12.2%). All cases of crescentic GN, CSGN, DN, ATN, CIN, and vasculitis presented with renal failure.
Following the biopsy, 32 (11.8%) patients complained of excessive pain at biopsy site, 14 (5.2%) complained of one or more episodes of gross hematuria, and three (1.1%) required blood transfusion. None of the patient required any endovascular or surgical intervention.
| Discussion|| |
Our study provides information about renal disease diagnosed on kidney biopsy in a single center from Bihar, located in Eastern part of India. There is a paucity of data on kidney biopsy from our state and comparison of this data to data from other part of the country is difficult because of difference in geographical and demographical characteristics, difference in indication for kidney biopsy at different centers.
[Table 3] shows the comparison of data from different previous Indian studies and Asian studies with our study. In our study, there was male predominance in overall subjects for biopsy. This observation is similar to various Indian and international studies.,,,,,, In our subjects, FSGS was the most common histopathological diagnosis. MGN is believed to be the most common cause of glomerulonephritis globally. There is now an increase in the incidence of FSGS worldwide. This is independent of racial variation. Our results are consistent with similar studies for India. Rathi et al have reported the incidence of FSGS as 30.6% and Golay as 24.63%. In both these studies, FSGS was the most common histological diagnosis. Study from Pakistan, Iran, and Oman also have reported FSGS as the most common diagnosis in evaluation of kidney biopsy. The prevalences of FSGS in these studies were 21.2%, 25.4%, and 19.5%, respectively. Reports from Brazil and Zaire revealed that FSGS were present in 34.8% and 41% of renal biopsies, respectively.,
|Table 3: Comparison of data from different previous Indian and Asian studies with our study.|
Click here to view
In our study, DPGN was the second most common, (13.3%). Similar prevalence was reported by Balkrishnan et al However, Das et al, Rathi et al, and Golay et al have reported a much lower prevalence of 4.7%, 2.8%, and 2.8%, respectively. This may be explained on the basis of difference in mean SCr level in different studies. In our study, the mean SCr was 2.4 ± 2.1 mg/dL which is similar to a study by Balkrishnan et al but much higher than the other studies. In our study, 91.7% (33/36) of cases of DPGN were seen in patients presenting with a SCr of 1.4 mg/dL or more.
In our series, MN was less common than FSGS (12.6% vs. 31.11%). In fact, it was the third most common diagnosis. Other Indian studies have made similar observations., Study by Arias et al from Brazil also shows that MGN was present in only 10.6% of biopsies and was the third most common diagnosis on histopathology of native renal biopsies after FSGS and IgA nephropathy. A study from Saudi Arabia also indicates that the incidence of MGN is 13.6% and is the third most common diagnosis in their study after FSGS and MPGN.
The incidence of MPGN is decreasing worldwide, and it is now considered as a rare disease affecting mainly adolescent.,, However, our findings contradict these observations. In our study, the incidence of MPGN was 8.5%, and it was most common in young adults of the age group of 19–39 years. Similar observation had been made in a study from the neighboring state of West Bengal where the reported incidence of MPGNs as 8.10%. A study from Iran has also observed that MPGN is not uncommon (11.5%). One study from Romania has concluded MPGN as the most common histological finding on kidney biopsy. These differences in the incidence of MPGN may be explained, besides racial differences, by difference in socioeconomic condition, dietary habits, and access to medical services and immunization.
IgA nephropathy is a common cause of glomerulonephritis in Europe and some Asian countries., The incidence of IgAN in Indian studies varies from 1.8% to 8.4%.,,, In our study, the incidence of IgAN was 8.5%. Similar incidence has been reported by Balkrishnan and Golay et al. However, other studies, have reported a much lower incidence.
The incidence of MCD in our study was lower than that reported by other Indian study. The incidence of MCD in various studies is 10.8%–23.90%.,,, The incidence of MCD as reported by our study in 5.56%. The reason for this difference is not clear, however, none of the Indian studies have included data from this region. Similar incidence of MCD (5.8%) has been reported by a Pakistani study from Karachi. Another study from Oman could not report a single case of MCD in 133 kidney biopsy over eight years.
Among secondary glomerulonephritis, LN was the most common entity in our study and was comparable to other Indian and international studies.,,,,,,,,,, Diabetic nephropathy and amyloidosis were next most frequent causes for secondary glomerulonephritis. These too are in concurrence with other Indian studies which have reported the incidence of diabetic nephropathy between 0.29% and 2.8% and that of amyloidosis between 1% and 3.43%.,,, The incidence of vasculitis in our study was higher than those reported else were. The reason for this difference is not clear, however, it may be related to our policy of aggressive performance of renal biopsy in patients with rapidly progressive renal failure.
In our study, adult-onset nephritic syndrome was the most common indication for renal biopsy. Overall, FSGS was the most common lesion. However, the incidence of DPGN in our study was higher than previous studies. When we considered patients with deranged renal function, then DPGN was the most common histopathological lesion. The reason for disproportionate high incidence for DPGN is not clear and requires further research.
Conflict of interest: None declared.
| References|| |
Bosan IB. Recommendations for early diag-nosis of chronic kidney disease. Ann Afr Med 2007; 6:130-6.
] [Full text]
Madaio MP. Renal biopsy. Kidney Int 1990; 38:529-43.
Nationwide and long-term survey of primary glomerulonephritis in Japan as observed in 1,850 biopsied cases. Research group on progressive chronic renal disease. Nephron 1999;82:205-13.
Naumovic R, Pavlovic S, Stojkovic D, Basta-Jovanovic G, Nesic V. Renal biopsy registry from a single centre in Serbia: 20 years of experience. Nephrol Dial Transplant 2009;24: 877-85.
Al Arrayed A, George SM, Malik AK, et al. The spectrum of glomerular diseases in the Kingdom of Bahrain: An epidemiological study based on renal biopsy interpretation. Transplant Proc 2004; 36:1792-5.
Chugh KS, Sakhuja V. Glomerular diseases in the tropics. Am J Nephrol 1990;10:437-50.
Balakrishnan N, John GT, Korula A. Spectrum of biopsy proven renal disease and changing trends at a tropical tertiary care centre 1990-2001. Indian J Nephrol 2003;13:29-35. [Full text]
Aggarwal HK, Yashodara BM, Nand N, Sonia, Chakrabarti D, Bharti K. Spectrum of renal disorders in a Tertiary Care Hospital in Haryana. J Assoc Physicians India 2007;55:198-202.
Churg J, Sobin LH. Renal Disease: Classification and Atlas of Glomerular Diseases. Tokyo: Igaku Shoin; 1982.
Das U, Dakshinamurty KV, Prayaga A. Pattern of biopsy-proven renal disease in a single center of South India: 19 years experience. Indian J Nephrol 2011;21:250-7.
] [Full text]
Rathi M, Bhagat RL, Mukhopadhyay P, et al. Changing histologic spectrum of adult nephritic syndrome over five decades in North India: A single center experience. Indian J Nephrol 2014; 24:86-91.
] [Full text]
Golay V, Trivedi M, Kurien AA, Sarkar D, Roychowdhary A, Pandey R. Spectrum of nephrotic syndrome in adults: Clinicopathological study from a single center in India. Ren Fail 2013;35:487-91.
Monfared A, Khosravi M, Lebadi M, et al. Distribution of renal histopathology in Guilan: A single-center report. Iran J Kidney Dis 2012; 6:173-7.
Al Riyamı D, Al Shaaili K, Al Bulushi Y, Al Dhahli A, Date A. The spectrum of glomerular diseases on renal biopsy: Data from a single tertiary center in Oman. Oman Med J 2013;28: 213-5.
Wang YT, Zhou CY, Zhu TC, et al. Analysis of kidney biopsy data from a single center in the midland rural area of China, 1996-2010. Curr Ther Res Clin Exp 2013;74:22-5.
Mubarak M, Kazi JI, Naqvi R, et al. Pattern of renal diseases observed in native renal biopsies in adults in a single centre in Pakistan. Nephrology (Carlton) 2011;16:87-92.
Haas M, Spargo BH, Coventry S. Increasing incidence of focal-segmental glomerulosclerosis among adult nephropathies: A 20-year renal biopsy study. Am J Kidney Dis 1995;26:740-50.
Arias LF, Henao J, Giraldo RD, Carvajal N, Rodelo J, Arbeláez M. Glomerular diseases in a Hispanic population: Review of a regional renal biopsy database. Sao Paulo Med J 2009;127: 140-4.
Pakasa M, Mangani N, Dikassa L. Focal proliferative glomerulosclerosis in nephritic syndrome: a new profile of adult onset nephrotic syndrome in Zaire. Mod Pathol 1996;6:125-8.
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.
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.
] [Full text]
Covic A, Schiller A, Volovat C, Gluhovschi G, et al. Epidemiology of renal disease in Romania: A 10 year review of two regional renal biopsy databases. Nephrol Dial Transplant 2006;21:419-24.
Dr. Prit Pal Singh
Department of Nephrology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar
[Table 1], [Table 2], [Table 3]