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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
RENAL DATA FROM ASIA–AFRICA  
Year : 2018  |  Volume : 29  |  Issue : 5  |  Page : 1192-1198
Pattern of glomerulonephritis in the Kashmir valley


1 Department of Nephrology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India
2 Department of Internal Medicine, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir, India

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Date of Submission28-Dec-2016
Date of Decision21-Feb-2017
Date of Acceptance03-Mar-2017
Date of Web Publication26-Oct-2018
 

   Abstract 

Glomerulonephritis (GN) is a common cause of end-stage kidney disease (ESKD) that can affect patients at any age. With respect to ESKD, there are significant global variations in the percentage of the incident and prevalent patients secondary to GN. The present study was therefore conducted to know the pattern of GN in the Kashmir valley. Retrospective study was conducted in the tertiary center Sher-I-Kashmir Institute of Medical Sciences of Kashmir valley which included cases of different types of GN diagnosed on histopathology over a period of three years. Basic demographic profile including age, sex, clinical presentation, relevant investigations, and the histopathological type of GN was noted for each patient. Histopathological examination due to various nonneoplastic renal diseases was done in 336 cases and out of these, glomerular diseases were diagnosed in 298 cases. Proteinuria and edema was the most common presentation. Primary GN was observed in 81% of cases and secondary GN in 16% of cases. IgA nephropathy was the most common primary GN 42% and nephropathy due to lupus was the most common secondary GN. The study concluded that primary GN is the most common primary renal disease with IgA as the most common primary GN and most presented as renal failure, highest until date recorded in India and lupus nephritis as the most common secondary GN which is similar to other studies from India and other regions of the world. This study may be useful to pathologists, nephrologists, and health care providers to formulate a basic platform for effective diagnostic, therapeutic, and research base for glomerular diseases so as to prevent its complications.

How to cite this article:
Chowdry AM, Bhat MA, Najar MS, Sharma A, Azad H, Mir I. Pattern of glomerulonephritis in the Kashmir valley. Saudi J Kidney Dis Transpl 2018;29:1192-8

How to cite this URL:
Chowdry AM, Bhat MA, Najar MS, Sharma A, Azad H, Mir I. Pattern of glomerulonephritis in the Kashmir valley. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2018 Dec 15];29:1192-8. Available from: http://www.sjkdt.org/text.asp?2018/29/5/1192/243967

   Introduction Top


Glomerular disease is an important cause of end-stage kidney disease (ESKD). The societal burden of glomerulonephritis (GN) to the individual and the healthcare system is grossly underappreciated and the costs underestimated due to the lack of national or international registries of GN at the level of renal pathologic processes. The full disease impact is also substantially discounted if assessed solely from figures derived from ESKD registries, as GN is not only a common cause of ESKD that can affect patients at any age but also treatment strategies for the disease are chronic and not without significant morbidity and mortality even in patients who never reach ESKD.

The prevalence of glomerular diseases differ according to geographical area, race, age, and different histopathological patterns exist in different regions of the world.[1],[2] These differences have been attributed to various factors, including genetic backgrounds as well as environmental and infectious exposures but additional factors such as differences in health care policies and disparities in access to ESKD programs may also exist.[3]

Glomerular diseases may be categorized into those that primarily involve the kidney (primary glomerular diseases), and those in which kidney involvement is part of a systemic disorder (secondary glomerular diseases), such as diabetes mellitus, hypertension, connective tissue disorder, vasculitis, amyloidosis, plasma cell dyscrasias, infections, drugs, etc. Clinical evaluation of glomerular syndromes should include the assessment of proteinuria, hematuria, the presence or absence of renal insufficiency, and the presence or absence of hypertension. The glomerular disease may have an indolent course or begin abruptly, leading to acute or rapidly progressive GN. Although some glomerular disorders consistently cause a specific syndrome (e. g., minimal change glomerulopathy results in nephrotic syndrome), most disorders are capable of causing features of both nephrosis and nephritis. This sharing and variability of clinical manifestations among different glomerular diseases confounds determination of an accurate diagnosis based on clinical features alone. Therefore, renal biopsy has an important role to play in the evaluation of glomerular disease in many patients and remains the gold standard.

We believe that it is relevant to know the evidence that supports the benefits of disease control recognizing our current inability to cure most of the progressive GN variants. It is very important to understand shifts in the incidence and distribution of GN in a geographic area, as the prevalence of glomerular diseases differs according to the geographic area, race, age, and histologic variants. The present study was therefore conducted in the Department of Nephrology, Sher-I-Kashmir Institute of Medical Sciences (SKIMS), Soura, Srinagar, India to study the incidence and pattern of GN in the Kashmir valley. The present study may, therefore, be useful to nephrologists and healthcare providers to formulate a basic platform for effective diagnostic, therapeutic, and research base for glomerular disease to prevent renal failure.


   Materials and Methods Top


Retrospective study was conducted in the tertiary care center of Kashmir valley of India, in which all the cases of different types of GN were reviewed which were diagnosed on histopathology over a period of three years (January 2013 to December 2015). Basic demographic profile of all patients including age, sex, clinical presentation, relevant investigations, and the histopathological type of GN were noted. All biopsies were reported by a single renal pathologist. The histopathological sections were stained for hematoxylin and eosin, periodic acid–Schiff (PAS), silver methamine, and if required Congo red. Particular note was made of glomerular architecture, mesangial hypercellularity. Focal segmental and global glomerular sclerosis was paid attention to, which indicates that disease has been going on for some time. Tubulointerstitial inflammation, interstitial fibrosis, and tubular atrophy were noted to look for long-standing disease. Immunofluorescence has been done in all cases included in the study. The histopathological typing of GN was based on the WHO classification and was divided into primary and secondary GN accordingly.

The exclusion criteria were neoplastic renal diseases.


   Results Top


Histopathological examination due to various nonneoplastic renal diseases was done in 336 cases during the period of study and out of these glomerular diseases were diagnosed in 298 cases. Majority were males with a male: female ratio 1.7:1. Mean age of all patients was 40 years. [Table 1] summarizes the clinical and biochemical characteristics of all patients. Presenting features [Table 2] were edema (72%) and proteinuria (67%), hematuria (29%), acute renal failure (35%), asymptomatic urinary abnormalities (23.4%), and accelerated hypertension (4%).
Table 1: Baseline characteristics of cases of glomerulonephritis (n=298).

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Table 2: Clinical presentation in cases of glomerulonephritis (n=298).

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Primary GN was observed in 81% and secondary GN in 16% of all cases [Figure 1]. IgA nephropathy was the most common primary GN (42%) [Figure 2] and nephropathy due to lupus was the most common secondary GN [Figure 3]. In our study, majority (47%) of the patients of IgA nephropathy [Figure 4] presented with renal failure (47%) followed by asymptomatic urinary abnormalities (21%) and macroscopic hematuria (17%).
Figure 1: Distribution of histological diagnosis.
PRY GN: Primary glomerulonephritis, SEC. GN: Secondary glomerulonephritis.


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Figure 2: Incidence of various forms of primary glomerulonephritis.
IgA: immunoglobulin A, FSGS: Focal segmental glomerulosclerosis, MPGN: Membranoproliferative glomerulonephritis, MN: Membranous nephropathy, MCD: Minimal change disease.


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Figure 3: Incidence of various forms of secondary glomerulonephritis.

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Figure 4: Distribution of clinical syndromes in IgA nephropathy in the study.
mac hem: Macroscopic hematuria, AUA: Asymptomatic urinary abnormalities.


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   Discussion Top


Identifying incidence and distribution of GN in a geographic area should be straight forward. Unfortunately, the lack of any coherent national or international registry of GN, even at the level of renal pathology, limits our ability to answer these questions. There is generally held belief that the overall frequency of GN as a cause of ESRD has declined.[4] A plausible alternative[5] is that there has been no change in the absolute numbers but only a relative percentage reduction in proportion because of the increased number of ESRD cases attributable to other causes, particularly diabetes mellitus. In addition, although the incidence rate may be decreasing, a significant proportion of prevalent patients in many ESRD registries are still secondary to progressive GN.[6],[7]

The clinicopathological pattern of renal and glomerular diseases vary geographically, and therefore, various renal registries have been documented in the literature for different region.[5],[8],[9] A study from Korea by Chang et al observed that GN comprised of 85.9% of the total renal biopsies.[1] The experience of Czech registry of renal disease showed the mean annual incidence of primary GN to be 32.4% and that of secondary GN to be 13.8.[8] A review of glomerular diseases in Morocco showed that the number of renal biopsies during each two years increased from 12 cases in 2000–2001 to 71 cases during 2006–2007.[10] The present study also showed a significant percentage of 85.6% of cases of GN out of the total 336 nonneoplastic renal diseases. This data itself show the importance of clinicopathological study of GN in this part of the world. Primary GN was more common (81%) than secondary GN (16.2%) in the present study with male preponderance. The previous study from Morocco has also shown primary GN (52%) to be more common than the secondary (33%) but with a lesser difference of percentage between the two glomerulopathies.[10] Another study from India accounted primary glomerular diseases in 71% of all renal biopsies.[11]

Clinically, the nephrotic syndrome was more common with edema (72%) and proteinuria (67%) as the common presentation in our study which is consistent with a study from Morocco.[10] However, another study from Czech republic observed micro- and macrohematuria as the most common clinical presentation (75.1% cases) while nephrotic proteinuria was observed in only 39.3% of cases in patients of renal diseases.[8]

Another finding observed in the present study was that lupus nephritis as the most common secondary nephritis which is similar to other studies from India and other regions of world.[1],[8],[10],[11]

The worldwide frequency of IgA nephropathy varies widely from 2% to 52% of all renal biopsies.[12] The striking geographic variation has been associated with the presence of particular gene alleles that protect from IgA nephropathy.[13] The available evidence suggests an increasing incidence of IgA nephropathy in India. IgA nephropathy was the most common (42.9%) of all cases of primary GN in our study, the highest until date reported in India. Similar results were found in a large retrospective review of 600 biopsies from China,[4] IgA nephropathy accounted for 40% of all diagnoses and was almost twice as common as the second leading type of biopsy proven GN, which was vasculitis and Koyama et al[14] in Japan noted 47.2% IgA nephropathy prevalence, which is much higher compared to other parts of India and our neighboring countries Nepal and Pakistan. A single center in Nepal experienced IgA in 9.8% cases only[15] and among the recent studies in Pakistan, the highest IgA nephropathy prevalence noted was 12.65%[13] and 20.83%.[16]

IgA nephropathy is the most common form of the primary glomerular disease in Asia, accounting for up to 30% to 40% of all biopsies performed for glomerular disease, and it accounts for 20% of all biopsies in Europe and 10% of all biopsies in North America.[17] This wide variation in incidence is partly attributable to the differing indications for renal biopsy in Asia compared with those in North America. In Asia, urinalyses are performed routinely in school-aged children. Those with asymptomatic hematuria generally undergo biopsy, which may lead to an increased number of diagnoses of IgA nephropathy. Genetic issues may also be important in the geographic differences.

The typical patterns of clinical presentation of IgA nephropathy described in the natural history are hematuria, proteinuria, and hypertension, and rarely a renal failure. In our study, majority (47%) of the patients of IgA nephropathy presented with renal failure (47%) followed by asymptomatic urinary abnormalities (21%) and macroscopic hematuria (17%). The higher occurrence of renal failure has been traced long back in the history of IgA nephropathy in Asian countries. In 1992, Bhuyan et al[18] in north India described IgA nephropathy presenting with renal failure in 34% of patients, and in Pakistan 24% of patients presented with renal failure in one study.[16] This high occurrence of renal failure in Asians has been attributed to the undue genetic susceptibility of Asians to IgA nephropathy and its complications.[19],[20] Renal failure is uncommon (<5% of all cases) in the presentation of IgA nephropathy in regions other than Asia, except one study in Spain reports that AKI may be the presentation in up to 27% of patients older than 65 years.[21]

Biopsy practice pattern is another important factor affecting the frequency of IgA nephropathy as has been pointed out in a study from the UK in which the frequency varied from 7.1% (1972–78) to 21.1% (1979–86).[22] The high prevalence of IgA nephropathy in our population is partly explained by low threshold for the biopsy practice patterns. In our center, isolated hematuria found during routine screening obliges the patient to submit to a renal biopsy, but in North America, significant clinical indicators of underlying renal disease such as proteinuria over 1 g/day or systemic feature of disease are the dominant indicators of renal biopsy.

We acknowledge important limitation in the present study, that it was a hospital-based study and it does not give an exact burden and pattern of glomerular diseases in whole Kashmir valley as only those cases were included in the study which were biopsied in our tertiary care center.


   Conclusion Top


The study concludes that primary GN is the most common renal disease with edema, proteinuria, and asymptomatic urinary abnormalities as the common clinical presentation. The histopathological pattern, in this study, observed IgA nephropathy as the most common primary GN while lupus nephritis as the most common secondary nephritis which is similar to other studies from India and other regions of world. Although the study does not give the exact burden and pattern of the glomerular disease in Kashmir valley, but it can be used as the basis for the formulation of the adequate renal registry. In addition, the study may also be useful to pathologists, nephrologists and health care providers to formulate a basic platform for effective diagnostic, therapeutic, and research base for glomerular diseases to prevent complications.

Conflict of interest: None declared.

 
   References Top

1.
Chang JH, Kim DK, Kim HW, et al. Changing prevalence of glomerular diseases in Korean adults: A review of 20 years of experience. Nephrol Dial Transplant 2009;24:2406-10.  Back to cited text no. 1
    
2.
Carvalho E, do Sameiro Faria M, Nunes JP, Sampaio S, Valbuena C. Renal diseases: A 27-year renal biopsy study. J Nephrol 2006;19: 500-7.  Back to cited text no. 2
    
3.
Prakash S, Kanjanabuch T, Austin PC, et al. Continental variations in IgA nephropathy among Asians. Clin Nephrol 2008;70:377-84.  Back to cited text no. 3
    
4.
Li LS, Liu ZH. Epidemiologic data of renal diseases from a single unit in China: Analysis based on 13,519 renal biopsies. Kidney Int 2004;66:920-3.  Back to cited text no. 4
    
5.
Wirta O, Mustonen J, Helin H, Pasternack A. Incidence of biopsy-proven glomerulonephritis. Nephrol Dial Transplant 2008;23:193-200.  Back to cited text no. 5
    
6.
Yang WC, Hwang SJ, Taiwan Society of Nephrology. Incidence, prevalence and mortality trends of dialysis end-stage renal disease in Taiwan from 1990 to 2001: The impact of national health insurance. Nephrol Dial Transplant 2008;23:3977-82.  Back to cited text no. 6
    
7.
United States Renal Data System. United States Renal Data System 2009 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes, Digestive and Kidney Diseases; 2009.  Back to cited text no. 7
    
8.
Rychlík I, Jancová E, Tesar V, et al. The Czech registry of renal biopsies. Occurrence of renal diseases in the years 1994-2000. Nephrol Dial Transplant 2004;19:3040-9.  Back to cited text no. 8
    
9.
Gesualdo L, Di Palma AM, Morrone LF, Strippoli GF, Schena FP; Italian Immunopathology Group, Italian Society of Nephrology, et al. The Italian experience of the national registry of renal biopsies. Kidney Int 2004;66:890-4.  Back to cited text no. 9
    
10.
Aatif T, Maoujoud O, Montasser DI, Benyahia M, Oualim Z. Glomerular diseases in the military hospital of Morocco: Review of a single centre renal biopsy database on adults. Indian J Nephrol 2012;22:257-63.  Back to cited text no. 10
[PUBMED]  [Full text]  
11.
Narasimhan B, Chacko B, John GT, Korula A, Kirubakaran MG, Jacob CK. Characterization of kidney lesions in Indian adults: Towards a renal biopsy registry. J Nephrol 2006;19:205-10.  Back to cited text no. 11
    
12.
Muzaffar S, Azad NS, Kayani N, Pervaz S, Ahmed A, Hasan SH ,et al. The frequency of IgA at a single centre in Pakistan. J Pak Med Assoc 2003;53:301-5.  Back to cited text no. 12
    
13.
Kiryluk K, Li Y, Sanna-Cherchi et al. Geographic differences in genetic susceptibility to IgA nephropathy: GWAS replication study and geospatial risk analysis. PLoS Genet 2012;8:e1002765.  Back to cited text no. 13
    
14.
Koyama A, Igarashi M, Kobayashi M. Natural history and risk factors for immunoglobulin A nephropathy in Japan. Research group on progressive renal diseases. Am J Kidney Dis 1997;29:526-32.  Back to cited text no. 14
    
15.
Khakurel S, Agrawal RK, Hada R. Pattern of glomerular disease in Nepal: A single-center experience. Saudi J Kidney Dis Transpl 2015; 26:833-8.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Noor M, Mahmmod S, Jamal, Mohammad W, Shah D. IgA nephropathy in North West Frontier province of Pakistan. Gomal J Med Sci 2007:5:62-4.  Back to cited text no. 16
    
17.
D’Amico G. The commonest glomerulonephritis in the world: IgA nephropathy. Q J Med 1987;64:709-27.  Back to cited text no. 17
    
18.
Bhuyan UN, Dash SC, Srivastava RN, Tiwari SC, Malhotra KK. IgA associated glomerulonephritis. J Assoc Physicians India 1992;40: 310-3.  Back to cited text no. 18
    
19.
Deenitchina SS, Shinozaki M, Hirano T, et al. Association of a T-cell receptor constant alpha chain gene polymorphism with progression of IgA nephropathy in Japanese patients. Am J Kidney Dis 1999;34:279-88.  Back to cited text no. 19
    
20.
Xia Y, Li Y, Du Y, et al. Association of MEGSIN 2093C-2180T haplotype at the 3’ untranslated region with disease severity and progression of IgA nephropathy. Nephrol Dial Transplant 2006;21:1570-4.  Back to cited text no. 20
    
21.
Rivera F, López-Gómez JM, Pérez-García R, Spanish Registry of Glomerulonephritis. Clinicopathologic correlations of renal pathology in Spain. Kidney Int 2004;66:898-904.  Back to cited text no. 21
    
22.
Ballardie FW, O’Donoghue DJ, Feehally J. Increasing frequency of adult IgA nephropathy in the UK? Lancet 1987;2:1205.  Back to cited text no. 22
    

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Correspondence Address:
Dr. Abdul Majeed Chowdry
Department of Nephrology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir
India
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DOI: 10.4103/1319-2442.243967

PMID: 30381518

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