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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
REVIEW ARTICLE  
Year : 2018  |  Volume : 29  |  Issue : 6  |  Page : 1256-1266
Spectrum of glomerular diseases in Arab countries: A systematic review


Department of Allied Health Sciences, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman

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Date of Submission24-May-2018
Date of Acceptance11-Jul-2018
Date of Web Publication27-Dec-2018
 

   Abstract 

According to the best of our knowledge, there is no review compiling incidence of glomerular disease in all Arab countries. Most of the Arab countries do not have a national renal biopsy registry. In addition, there is scanty data available on the epidemiology of glomerular diseases in Arab countries. In this review, we performed a systematic review analyzing the incidence of glomerular disease in all Arab countries. Relevant manuscripts in all 22 Arab countries found through searches of Medline, Science Direct, Embase, and Google Scholar were evaluated. The time was from January 1990 to March 2018. A total of 36 manuscripts containing 10,727 biopsies from 11 countries were analyzed. The male-to-female ratio was 1.2:1. Saudi Arabia had the largest number of published studies with 14 papers followed equally by Iraq, Jordan, and Sudan with three papers each. The average period of study was 8.17 years. Retrospective studies represented 86.11%. Focal and segmental glomerulosclerosis (FSGS) (27%), minimal change disease (14%), membranoproliferative glomerulonephritis (13%), mesangioproliferative glomerulonephritis (13%), and membranous glomerulopathy (11%) were the main types of primary glomerular diseases. The most common types of secondary glomerular diseases were lupus nephritis (LN) (58%), amyloidosis (10.19%), diabetic nephropathy (9.89%), hypertension (4.84%) and poststreptococcal glomerulonephritis (2.72%). In conclusion, FSGS and LN are the most common types of primary and secondary glomerular diseases, respectively, in all evaluated Arab countries. The trend of all types of glomerular diseases has not changed in the last three decades. We strongly recommend that each Arab country should have its own renal biopsy registry.

How to cite this article:
Alwahaibi NY, Al Issaei HK, Al Dhahli BS. Spectrum of glomerular diseases in Arab countries: A systematic review. Saudi J Kidney Dis Transpl 2018;29:1256-66

How to cite this URL:
Alwahaibi NY, Al Issaei HK, Al Dhahli BS. Spectrum of glomerular diseases in Arab countries: A systematic review. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 May 23];29:1256-66. Available from: http://www.sjkdt.org/text.asp?2018/29/6/1256/248285

   Introduction Top


Worldwide, glomerular diseases are a major health public concern, Arab countries included. Most of the Arab countries do not have a national renal biopsy registry. In addition, there is scanty data available on the epidemiology of glomerular diseases in Arab countries. Glomerular diseases are the most common cause of end-stage renal disease and subsequently may lead to death.[1] Renal biopsy is still the gold standard in the diagnosis and treatment of glomerular diseases.[2]

Knowledge of the incidence of glomerular diseases should improve the treatment and may enhance many preventive ways. In addition, gathering of geographic, socioeconomic, environmental, and genetic factors, which contribute to the pathogenesis of glomerular diseases, might help to specify the most common cause of each pattern of glomerular disease. To the best of our knowledge, there is no review of the combined incidence of glomerular disease in Arab countries. In this review, we performed a systematic review analyzing the incidence of glomerular disease in Arab countries.


   Materials and Methods Top


Medline, Science Direct, Embase, and Google Scholar websites were used to search for glomerular diseases, glomerulonephritis, glomerulosclerosis, kidney (renal) biopsy and with each of the following Arab countries: Algeria, Bahrain, Comoros, Djibouti, Egypt, Iraq, Jordan, Kuwait, Lebanon, Libya, Mauritania, Morocco, Oman, Palestine, Qatar, Saudi Arabia, Somalia, Sudan, Syria, Tunisia, United Arab Emirates and Yemen. The time period was from January 1990 to March 2018. The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).[3]

Inclusion criteria included original report, published manuscripts written in English, diagnosed with light microscope (LM) with or without immunofluorescence (IF) or electron microscope (EM). Exclusion criteria included thesis, review articles, studies written in languages other than English, not using LM for diagnosis, reports on only pediatric or adolescent population, and glomerular diseases reported in transplant or autopsy specimens. The following information was collected from each included manuscript: Arabic country region, publication year, name of journal, time period, study design, number of biopsies, age range or average, gender, type of histopathological diagnosis, and frequency of primary and secondary glomerular diseases, the most common types of primary glomerular diseases including minimal change disease (MCD), IgA nephropathy (IgAN), mesangioproliferative glomerulonephritis (MesGN), membranoproliferative glomerulonephritis (MPGN), focal and segmental glomerulosclerosis (FSGS) and membranous glomerulopathy (MG), and the most common types of secondary glomerular diseases including lupus nephritis (LN), amyloidosis (Amyl), diabetic nephropathy (DN), hereditary (H), hypertension (HTN), Henoch-Schönlein purpura (HSP) and post-streptococcal glomerulonephritis (PSGN).

The data were analyzed using the Statistical Package for the Social Sciences (SPSS) software version 23.0 (SPSS Inc., Chicago, IL, USA) and Microsoft Excel version 2013. Results are presented as numbers, percentages, and means. ANOVA test was used to compare the mean proportion of primary and secondary glomerular diseases at the different period time. P <0.05 was considered statistically significant.


   Results Top


General information

We identified 112 papers, after applying the PRISMA criteria; we excluded 76 papers and included 36 with a total of 10,727 biopsies. Only 50% of Arab countries showed relevant renal data. We could not find relevant manuscripts for Algeria, Comoros, Djibouti, Libya, Mauritania, Palestine, Somalia, Syria, Qatar, Tunisia, and Yemen. Saudi Arabia had the largest number of published studies with 14 papers (38.88%) followed equally by Iraq, Jordan, and Sudan with three papers each. The minimum and maximum age were few days and 90 years, respectively. There was an overall male predominance in almost all studies. Only six studies showed female predominance. Males represented 54.54% and females, 45.45% of the study population. The male-to-female ratio was 1.2:1. Only 13.89% were prospective studies while the remaining were retrospective (86.11%). The average period of study was 8.17 years. The shortest period was one year in Saudi Arabia, and the longest was 23 years also in Saudi Arabia. The year 2000 showed the most published studies with six manuscripts followed by 2013, with five studies. Regarding histopathological diagnosis, 52.94% of the reviewed studies used LM, IF, selected EM or EM for reporting glomerular diseases. Only three cases (8.82%) used LM alone for histopathological diagnosis while 38.23% of the evaluated studies used both LM and IF for glomerular diseases [Table 1].[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39] Twenty-two (61.11%) papers were published in the Saudi Journal of Kidney Diseases and Transplantation.
Table 1: Characteristics of 36 evaluated studies in Arab countries.

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Primary glomerular diseases

Based on the 36 studies, there were a total of 6470 cases of primary glomerular diseases in all evaluated Arab countries. FSGS (1736), MCD (923), MesGN (868), MPGN (818), and MG (708) were the common types of primary glomerular diseases [Figure 1].
Figure 1: Pattern of primary glomerular diseases in Arab countries.
FSGS: focal and segmental glomerulosclerosis, MCD: minimal change disease, MG: membranous glomerulopathy, IgAN: IgA nephropathy, MPGN: membranoproliferative glomerulonephritis, MesGN: mesangioproliferative glomerulonephritis.


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When we separated Arab countries into those from Asia (8) and Africa (3), we did not observe considerable differences in almost all the pattern of primary glomerular diseases. However, IgAN showed 468 cases (9%) in Asia compared with only 31 cases (2%) in Africa [Figure 2].
Figure 2: Pattern of primary glomerular diseases in Asian and African Arab countries.
FSGS: Focal and segmental glomerulosclerosis, MCD: Minimal change disease, MG: Membranous glomerulopathy, IgAN: IgA nephropathy, MPGN: Membranoproliferative glomerulonephritis, MesGN: Mesangioproliferative glomerulonephritis.


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Secondary glomerular diseases

Based on reports from 33 studies, there were a total of 2315 cases of secondary glomerular diseases in all evaluated Arab countries. The most common types of secondary glomerular diseases were LN (1343), Amyl (236), DN (229), HTN (112), and PSGN (63) [Figure 3].
Figure 3: Pattern of secondary glomerular diseases in Arab countries.
LN: Lupus nephritis, Amyl: Amyloidosis, DN: Diabetic nephropathy, H: Hereditary, HTN: Hypertension, HSP: Henoch–Schönlein purpura, PSGN: Poststreptococcal glomerulonephritis.


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When we separated Arab countries into those from Asia and Africa, we noticed that DN was the second most common type of secondary glomerular diseases in Asia with 12% and HTN and H were not reported in African countries [Figure 4].
Figure 4: Pattern of secondary glomerular diseases in Asian and African Arab countries.
LN: Lupus nephritis, Amyl: Amyloidosis, DN: Diabetic nephropathy, H: Hereditary, HTN: Hypertension, HSP: Henoch–Schönlein purpura, PSGN: Poststreptococcal glomerulonephritis.


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Trends of glomerular diseases

We divided the 28 years evaluated period into three periods: period one from 1990 to 1999, period two from 2000 to 2009, and period three from 2010 to 2018. Based on the evaluation of 36 studies, the trend in all types of primary glomerular diseases was almost consistent as no significant changes were observed during the three periods [Figure 5].
Figure 5: Trend of primary glomerular diseases in Arab countries.
FSGS: Focal and segmental glomerulosclerosis, MCD: Minimal change disease, IgAN: IgA nephropathy, MesGN: Mesangioproliferative glomerulonephritis, MPGN: Membranoproliferative glomerulonephritis, MG: Membranous glomerulopathy.


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Based on the evaluation of 33 studies, we did not observe significant changes during the last three decades with all types of secondary glomerular diseases. There was a rise in LN during period three (66.77%) as compared with 47.81% and 47.87% in the periods one and two, respectively; however, this increase is not significant [Figure 6].
Figure 6: Trend of secondary glomerular diseases in Arab countries.
LN: Lupus nephritis, Amyl: Amyloidosis, DN: Diabetic nephropathy, H: Hereditary, HTN: Hypertension, HSP: Henoch–Schönlein purpura, PSGN: Poststreptococcal glomerulonephritis.


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   Discussion Top


The primary glomerular disease represents the most common type of all renal biopsies with 60.32%. FSGS was the most common pattern of primary glomerular disease in Arab countries studied. The lowest incidence was 10% in Morocco[28] whereas the highest reported incidence was 55% in Sudan.[18] In fact, FSGS was a predominant pattern worldwide as it accounts for 20%–25% of kidney disease in adults.[40] Similarly, some Asian countries have revealed that FSGS was the most common primary glomerular disease in India and Pakistan.[41],[42]

A recent systematic review of histologically proven glomerular disease in Africa showed that FSGS (15.9%) was the second most frequently reported pattern of glomerular disease after MCD (16.5%).[43]

Another recent large study which compared different glomerular diseases, in which diagnosis was determined based on light, electron and IF microscopic findings across continents, showed that FSGS (19.1%), DN (19.1%), and IgAN (11.8%) predominated in North America (USA and Canada). IgAN (22.1%), FSGS (14.9%), and MG (12.5%) predominated in Europe. LN (38.1%), FSGS (15.8%), and MG (11.1%) predominated in Latin America (Brazil, Colombia, and Mexico). IgAN (39.5%), LN (16.8%), and DN (10.7%) predominated in Japan and Thailand.[44]

In addition, a very recent systematic review study in China on histologically proven glo-merular disease revealed that IgAN (24.3%), MG (12.6%), MesPGN (10.5%), MCD (9.8%), and FSGS (4.6%) were the top five types of primary glomerular diseases.[45] The same study showed that the top four types of secondary glomerular disease were LN (8.6%), HSP (4.1%), hepatitis B virus associated glomerulonephritis (2.6%), and DN (1.6%).

In Australia, where they performed the largest study of biopsy-proven glomerular disease from 2002 to 2011 and analyzed 3697 adult native kidney biopsies, IgAN (30.60%) was the most common primary glomerular disease followed by FSGS (22%).[46] In Mexico, FSGS was the most frequent type of primary glomerular disease seen in 47% of all cases, followed by MG in 15%.[47] In Lithuania, FSGS was the second most common entity among primary glomerular diseases with 13.2%, after IgAN (34%).[48] In Turkey, FSGS was the most second most common primary glomerular disease with 19.3% after MG (28.8%).[49]

Among a racially and ethnically diverse population in the USA, FSGS (38.9%) was the most common primary glomerular disease, followed by MGN (12.7%), MCD (11%), and IgAN (10.2%).[50] In Columbia, whereas researchers reviewed 12,613 kidney cases from 2013 to 2015, it was found that FSGS (22%) was the most prevalent glomerular disease followed by IgAN (21%), LN (17%), and MG (13%).[51] In Taiwan, where the first report of the National Renal Biopsy Registry revealed that among primary glomerular diseases, IgAN (26%), FSGS (21.6%), and MG (20.6%) were the most frequently diagnosed pattern.[52] Obviously, FSGS is high in the Arab countries and in many other countries. The main cause is not clear but genetic, viral, racial, socioeconomic and immune factors have been linked with this disease.[11]

In the current review, LN was the most common secondary GN seen in 58% of the patients. This finding is similar to other studies.[45],[53],[54],[55] Amyl was the second most common pattern of secondary GN, seen in 10.19%. This finding is also similar to other studies.[55] However, an Australian study showed that DN is the most common secondary pattern of glomerular disease seen in 10.95%, followed by LN and Amyl with 33.81% and 9.05%, respectively.[46]

The current study showed that DN represents 9.89%. Many studies refer to the change in lifestyle as obesity might play a role. In the current study, we did not have information on the body mass index to correlate with the incidence of DN. In addition, usually, patients with diabetes are not biopsied. However, a recent study showed that in the past two decades, obesity has led to an increase in the incidence of type-2 diabetes mellitus among the Arab population.[56] The findings of this review did not observe any significant changes in the trend of all types of glomerular diseases in Arab countries over the last 28 years. However, another study reported an increase in the incidence of DN from 6.2% in the period before 2000 to 18.8% in the period after 2010.[45]

This systematic review also showed that most of the histopathological interpretation is performed by the three most accurate tests, LM, IF, and EM (52.94%). Only 8.82% used LM alone or, a combination of LM and IF (38.23%) for the diagnosis. Therefore, misdiagnosis is unlikely to occur. It is interesting to note that 61.11% of the reviewed manuscripts are published in the Saudi Journal of kidney diseases and transplantation, an open free access journal with a distinctive section for studies from the Arab world.

Our study is not without limitations. First, relatively small number of cases (10,727) as compared with the Arab population (422 million), was studied.[57] Second, most of the studies were retrospective (86.11%). Third, many Arab countries did not report relevant glomerular studies (50%). Fourth, many non-Arab nationalities work in the Arab countries and most of those evaluated papers did not distinguish Arabs from non-Arabs. Fifth, inconsistency in reporting types of glomerular diseases among Arab countries. Finally, most of the evaluated papers did not correlate the age groups (pediatrics, adults, and elderly) with the types of glomerular diseases.


   Conclusion Top


FSGS and LN were the most common types of primary and secondary glomerular diseases in all evaluated Arab countries, respectively. The trend of all types of glomerular diseases has not changed in the last three decades. We strongly recommend that each Arab country should have its own renal biopsy registry.

Conflict of interest: None declared.

 
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Correspondence Address:
Dr. Nasar Yousuf Alwahaibi
Department of Allied Health Sciences, College of Medicine and Health Sciences, Sultan Qaboos University, P. O. Box 35, Postal Code 123, Muscat
Sultanate of Oman
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DOI: 10.4103/1319-2442.248285

PMID: 30588955

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    Abstract
   Introduction
    Materials and Me...
   Results
   Discussion
   Conclusion
    References
    Article Figures
    Article Tables
 

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