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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 : 6  |  Page : 1410-1416
Pattern of glomerular disease and clinicopathological correlation: A single-center study from Eastern Nepal


1 Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
2 Department of Radiology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal
3 Department of Pathology, B.P. Koirala Institute of Health Sciences, Dharan, Nepal

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Date of Submission03-Nov-2017
Date of Acceptance12-Dec-2017
Date of Web Publication27-Dec-2018
 

   Abstract 

The pattern of glomerular disease varies worldwide. In the absence of kidney disease/kidney biopsy registry in Nepal, the exact etiology of different forms of glomerular disease is primarily unknown in our country. We analyzed 175 cases of renal biopsies performed from September 2014 to August 2016 in Internal Medicine Ward at B.P. Koirala Institute of Health Sciences. The most common indication for renal biopsy was nephrotic syndrome (34.9%), followed by systemic lupus erythematosus (SLE) with suspected renal involvement (22.3%). Majority of patients were in the 30–60 years’ bracket (57.2%), with the mean age of the patients being 35.37 years. The average number of glomeruli per core was 13, with inadequate sampling in 5.1%. Immunoglobulin A (IgA) nephropathy (17%) was found to be the most common primary glomerular disease, followed by membranous nephropathy (14.6%) and focal segmental glomerulosclerosis (14.6%). The most common secondary glomerular disease was lupus nephritis (LN). Complications associated with renal biopsy were pain at biopsy site in 18% of cases, hematuria in 6%, and perinephric hematoma in 4% cases. Although the most common primary glomerular disease was IgA nephropathy, significantly higher population of SLE with LN among Nepalese in comparison with other developing countries warrants further evaluation. As an initial attempt toward documentation of glomerular diseases in the national context, this study should serve as a stepping stone toward the eventual establishment of a full-fledged national registry of glomerular diseases in Nepal.

How to cite this article:
Subedi M, Bartaula B, Pant AR, Adhikari P, Sharma SK. Pattern of glomerular disease and clinicopathological correlation: A single-center study from Eastern Nepal. Saudi J Kidney Dis Transpl 2018;29:1410-6

How to cite this URL:
Subedi M, Bartaula B, Pant AR, Adhikari P, Sharma SK. Pattern of glomerular disease and clinicopathological correlation: A single-center study from Eastern Nepal. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2019 Jan 17];29:1410-6. Available from: http://www.sjkdt.org/text.asp?2018/29/6/1410/248302

   Introduction Top


The pattern of glomerular diseases varies throughout the world, with immunoglobulin A (IgA) nephropathy being a leading cause globally. The same holds true for Asians and Caucasians as well. Increasing incidence of focal and segmental glomerulosclerosis (FSGS)[1] and declining incidence of membranoproli-ferative glomerulonephritis (MPGN), from 0.7/100,000/year in 1970 to 0.2/100,000/year in 1990, have been noted in the literature.[1] Although glomerular disease is reported as the most common cause of end-stage renal disease (ESRD) in Nepal,[2] the exact incidence and prevalence are unknown. The pattern of glomerular disease has been analyzed in a previous study, the findings based mainly on light microscopy.[3] In that study, it was reported that membranous glomerulonephritis (MGN) and MPGN were reported as the most common causes of glomerulonephritis.

Different studies done in Nepal to understand the pattern of glomerular disease have presented variable results. Minimal change disease (MCD) as the most common glomerular disease was indicated by Tuladhar et al[4] while mesangial proliferative glomerulonephritis (MesPGN) was the most common in the study conducted by Ghimire et al.[5] However, literature review suggests that IgA nephropathy is the most common glomerular disease in Asian population. Since most of the studies conducted in Nepal were based only on histological findings and not on immunofluorescence (IF) studies, this study was conducted to identify the pattern of glomerular diseases based on histological and IF findings on kidney biopsy.


   Materials and Methods Top


This retrospective study was approved by the Institutional Ethical Board, B.P. Koirala Institute of Health Sciences, Dharan, Nepal. Data collection for the study was done by first preparing a list of patients undergoing renal biopsies dated September 2014 to August 2016 from the inpatient registry maintained at wards. Record files of those patients were retrieved from medical record section and were included in this study. A total of 175 renal biopsies which were available during the period of two years were analyzed. Two samples of biopsy specimen were taken; one was used for light microscope (LM) and the other for IF study. For LM, biopsy sample was fixed in 10% formalin, and for IF, it was kept in normal saline. MCD was diagnosed on the basis of LM and IF only as electron microscopy was not available.


   Results Top


A total of 175 cases who underwent renal biopsy were identified of which 104 (59.4%) were female with a female:male ratio of 1.5:1. The mean age of study population was 35.37 (standard deviation: 13.52) years. The mean age of patients with lupus nephritis (LN) was 30.88 years, FSGS was 36.89 years, membranous nephropathy (MN) was 38.22 years, IgA nephropathy was 27.86 years, MPGN was 32.67 years, and DPGN was 44.82 years. [Table 1] summarizes the indications of renal biopsy with gender distribution. The most common indication for performing renal biopsy was nephrotic syndrome (NS) in 34.9% cases followed by systemic lupus erythematosus (SLE) in 22.3% of cases. Among patients of SLE with suspected renal involvement, 38 (97.4%) were female whereas there was male preponderance (57.3%) among cases of NS.
Table 1: Indication of renal biopsy (n =175).

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[Figure 1] summarizes the age category and gender distribution of patients. Most of the cases (91/175, 57.2%) belonged to 30–60 years. There were 14 cases (8%) who were more than 60 years of age. Distinct pathological patterns were observed within each age group [Figure 2]. In patients <30 years, LN was the most common lesion (18/68, 26.5%), and IgA nephropathy was the most common primary glomerular disease (14/68, 20.6%). In adults (30–60 years), MN was the most common primary glomerular disease (10/85, 11.8%).
Figure 1: Age category and gender distribution among patients who underwent renal biopsy.

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Figure 2: Distribution of individual pathological diagnosis according to age group in the study patients (n = 175).
*Others: Include cases of primary DPGN, primary MPGN, nonproliferative glomerulopathy, tubulointerstitial nephritis, chronic sclerosing glomerulopathy, and crescentic glomerulonephritis.


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LN was found in 23.4% of cases, followed by IgA nephropathy in 12% and FSGS and MN in 10.3% of cases. In 16.6% of cases, neither there was any proliferative change in glome-rulus on light microscopy nor any immune deposits on IF study, which was labeled as nonproliferative glomerulopathy.

On histopathological findings, the median number of glomeruli per core was 13 (inter-quartile range: 10–18). In 9 cases (5.1%), sample revealed no glomeruli; hence, histo-pathological diagnosis could not be made. [Table 2] highlights the patterns of renal biopsy findings in different forms of kidney disease.
Table 2: Pattern of renal biopsy findings in different forms of kidney diseases (n =175)

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Among 75 cases with nephrotic range protei-nuria, 16 cases (21.3%) each were due to FSGS and MN, 10 cases (13.3%) had LN, seven cases (9.3%) had IgA nephropathy, and five (6.6%) had DPGN. The most common etiology of NS was FSGS (26.2%) followed by MN (24.5%).

[Table 3] summarizes the distribution of IF pattern in different renal diseases. The dominant deposit on IF in LN was C3 (97.1%), IgA (94.2%), and kappa/lambda light chains (94.2%). A high deposit of IgG and kappa/ lambda (100%) was seen in cases of MGN. IgA (100%), kappa/lambda (100%), and C3 (90.4%) were dominant in IgAN. In three cases, there were only C3 deposits (1 case each of crescentic glomerulonephritis, MPGN, and diffuse LN). In eight cases, there was only IgM deposits, all of which had FSGS.
Table 3: Distribution of immunofluorescence pattern in different renal diseases

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Most of the patients with LN had class 4 lupus nephritic changes [Figure 3].
Figure 3: Classification of lupus nephritis identified in biopsy findings (n = 41).

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   Discussion Top


Renal diseases often present with very few symptoms but can cause high morbidity and mortality.[6],[7] Renal biopsy is mostly necessary to identify various patterns of renal diseases with similar presentation. The presentation, pattern, and prevalence of renal diseases in different geographical regions of the world vary and are also changing within the countries.[8]

The mean age of patients who underwent renal biopsy was 35.37 years which is similar to study which was conducted in Nepal among 137 cases from 2001 to 2007.[3] There was slight female preponderance among patients with a ratio of 1.5:1. The most common clinical syndrome for performing renal biopsy was NS (34.9%) followed by SLE with suspected renal involvement (22.3%). This is similar to a study conducted in India where 30.7% of cases had initial presentation of NS.[9] NS as the most common indication for renal biopsies has also been noted from various parts of world such as Taiwan,[10] Spain,[11] Romania,[12] and Serbia.[13] Similar to our study, in a review of Ten-Year Registry of Native Kidney Biopsy from a Single Center in China from 2000 to 2010, the most common clinica lpresentation as an indication for renal biopsy was NS (52%).[14]

The majority of patients who underwent renal biopsy were young adults of 30–60 years. In each age group, a distinct pathological pattern was observed. Primary glomerular disease was more common than secondary glomerular disease in our study. This may be attributable to the infrequency with which renal biopsy is performed on patients with secondary causes. Among the secondary glomerular diseases, LN was the most common among all age groups.

LN was the most common pathological pattern and secondary glomerular disease observed in <30 years, similar to results in other studies.[3],[10] IgA nephropathy was the most common primary glomerular disease. Similarly, in 30–60 years, MN was the most common primary glomerular disease. Prior studies conducted in Nepal showed that MN was the most common glomerular disease (42.3%).[3] However, in our study, we found that the most common pathological entity was LN (23.4%) followed by IgA nephropathy (12%) and MN (10.3%). The difference could possibly be because of large number of cases of NS (81.6%) being studied.[3]

Our results match with the large study conducted in China (3722 cases) between 2008 to 2013, in which the most common form of primary glomerulonephritis was due to IgA nephropathy (37.72%), followed by MGN (27.57%), MCD (16.42%), FSGS (8.79%), and MesPGN (non-IgA) (5.05%).[15] Similar results are observed from other Asian countries as well where the most common GN was IgA nephropathy, accounting for 58.2% in China,[16] 47.4% in Japan,[17] and 45% in Singapore.[18]

The most common cause of NS in our study was FSGS followed by MN. FSGS has been reported as the most common cause of NS in two different studies conducted in India and Iran.[19],[20] However, another study conducted in India among patients with NS indicated that the most common cause is MCD followed by MN, FSGS, and DPGN.[20] Surprisingly, cases of MCD were not observed in the present study which could possibly be attributable to age distribution of patients undergoing renal biopsy. IF pattern in cases of MN revealed IgG deposits in 100% cases, C3 in 77.8% cases, and IgM in 16.6% cases, which is similar to the study conducted in South India where IgG was seen in 100% cases, C3 in 84% cases, and IgM in 25% cases.[21]

Nonproliferative glomerulopathy (16.6%) was the most common biopsy finding in primary GN. The exact cause and underlying etiology of which could not be established. It might include cases of MCD, probably the reason we did not see MCD in this series. Nonproliferative forms of glomerulonephritis usually include FSGS, LN Class V, and MCD.

A previous study suggests that the mean number of glomeruli retrieved with a 16-gauge needle is 10.63 ± 6.64.[22] The average glome-ruli retrieved in our study were slightly higher (n = 13), which was probably because renal biopsy in all cases was done under real-time ultrasonographic guidance.

The overall frequency of complications associated with renal biopsy ranges from 5% to 13%.[23],[24] The main complications noted are pain at biopsy site, hematuria (microscopic and gross), and hematoma. In our study, 18% of patients noted pain at biopsy site which was relieved with analgesics. Six percent had hematuria and 4% had perinephric hematoma.


   Limitation of the Study Top


The present study was a retrospective analysis of the renal biopsies performed over two years in a tertiary care center in Eastern Nepal. Since it was a retrospective analysis of the findings from the patient record stored in the medical record section, we could not determine the specific laboratory and clinical parameters that would identify or predict specific histopathological diagnosis.

Conflict of interest: None declared.

 
   References Top

1.
Dragovic D, Rosenstock JL, Wahl SJ, et al. Increasing incidence of focal segmental glomerulosclerosis and an examination of demographic patterns. Clin Nephrol 2005; 63:1-7.  Back to cited text no. 1
    
2.
Khakurel S, Agrawal RK, Hada R. Pattern of end stage renal disease in a tertiary care center. JNMA J Nepal Med Assoc 2009;48:126-30.  Back to cited text no. 2
    
3.
Garyal, Kafle RK. Hisopathological spectrum of glomerular disease in Nepal: A seven-year retrospective study. Nepal Med Coll J 2008; 10:126-8.  Back to cited text no. 3
    
4.
Tuladhar AS, Shrestha A, Pradhan S, et al. USG assisted and USG guided percutaneous renal biopsy at Nepal medical college teaching hospital: A three and half years study. Nepal Med Coll J 2014;16:26-9.  Back to cited text no. 4
    
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Ghimire M, Pahari B, Paudel N, et al. Kidney biopsy: An experience from tertiary hospital. JNMA J Nepal Med Assoc 2014;52:707-12.  Back to cited text no. 5
    
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Agarwal SK, Dash SC. Spectrum of renal diseases in Indian adults. J Assoc Physicians India 2000;48:594-600.  Back to cited text no. 6
    
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Ordonez NG, Rosai J. Urinary tract. In: Rosai J, editor. Rosai and Ackerman’s Surgical Pathology. 9th ed. St. Louis: Mosby; 2004. p. 1163-316.  Back to cited text no. 7
    
8.
Reshi AR, Bhat MA, Najar MS, et al. Etiological profile of nephrotic syndrome in Kashmir. Indian J Nephrol 2008;18:9-12.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Jeganathan J, Kumar S, Khalid M, Maroli C. Pattern of glomerular diseases in a tertiary care center in South India: A prospective study. Saudi J Kidney Dis Transpl 2013;24:168-71.  Back to cited text no. 9
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10.
Chen YA, Yang CS. Renal biopsy in aged patients – 12 years of experience in Taiwan Cathay general hospital. Acta Nephrol 2007; 21:97-103.  Back to cited text no. 10
    
11.
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. 11
    
12.
Covic A, Schiller A, Volovat C, 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.  Back to cited text no. 12
    
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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.  Back to cited text no. 13
    
14.
Lini CK, Lian JD, Wu SW, et al. Ten-year registry of native kidney biopsy from a single center in Taichung. Acta Nephrol 2012;26:68-73.  Back to cited text no. 14
    
15.
Hu YC, Feng YX, Lv XA, Wang R. A clinical and pathological analysis of 3722 renal biopsy specimens from adults with primary glome-rular disease in Shandong province, China. WIMJ Open 2014;1:57.  Back to cited text no. 15
    
16.
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. 16
    
17.
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.  Back to cited text no. 17
    
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Woo KT, Chiang GS, Pall A, et al. The changing pattern of glomerulonephritis in Singapore over the past two decades. Clin Nephrol 1999;52:96-102.  Back to cited text no. 18
    
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Srivastava RN. 50 years of nephrotic syndrome in children, and hereafter. Indian Pediatr 2013;50:107-10.  Back to cited text no. 19
    
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Jennette JC, Olson JL, Schwartz MM, Silva FG (eds): Heptinstall’s Pathology of the kidney, Volumes 1 and 2, 6th edition,: Lippincott Williams and Wilkins, Philadelphia; 2007. p. 126-54.  Back to cited text no. 20
    
21.
Clement WD, Mysorekar VV, Mahesh E, Krishnappa R, Kummavil R. Pattern of glomerular diseases in patients with nephrotic syndrome – A single center South Indian study. Ann Int Med Dent Res 2015;1(3)281-85.  Back to cited text no. 21
    
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Mostbeck GH, Wittich GR, Derfler K, et al. Optimal needle size for renal biopsy: In vitro and in vivo evaluation. Radiology 1989;173: 819-22.  Back to cited text no. 22
    
23.
Mendelssohn DC, Cole EH. Outcomes of percutaneous kidney biopsy, including those of solitary native kidneys. Am J Kidney Dis 1995;26:580-5.  Back to cited text no. 23
    
24.
Whittier WL, Korbet SM. Timing of complications in percutaneous renal biopsy. J Am Soc Nephrol 2004;15:142-7.  Back to cited text no. 24
    

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Correspondence Address:
Dr. Manish Subedi
Department of Internal Medicine, B.P. Koirala Institute of Health Sciences, Dharan
Nepal
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DOI: 10.4103/1319-2442.248302

PMID: 30588974

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