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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2000  |  Volume : 11  |  Issue : 3  |  Page : 291-294
Glomerulonephritis: Lessons Learnt from Epidemiological Studies


Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia

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How to cite this article:
Ramprasad K S. Glomerulonephritis: Lessons Learnt from Epidemiological Studies. Saudi J Kidney Dis Transpl 2000;11:291-4

How to cite this URL:
Ramprasad K S. Glomerulonephritis: Lessons Learnt from Epidemiological Studies. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2021 Apr 10];11:291-4. Available from: https://www.sjkdt.org/text.asp?2000/11/3/291/36650
Saudi Center for Organ Transplantation, Riyadh, Kingdom of Saudi Arabia Glomerulonephritis (GN) constitutes a major cause of morbidity and mortality from renal disease. It accounts for 16-18% of patients on dialysis in the United States, [1] 9-15% in Europe [2] and 23.2-58.4% in the tropics. [3],[4],[5] The prevalence of various forms of GN varies in different geographical areas. Also, various factors including genetic, racial and environmental have been incriminated in the pathogenesis of GN. It is important to know the epidemiology of various forms of GN if one has to successfully chalk out therapeutic and/or preventive measures to control them. The special issue on GN has been brought out to highlight some of the recent thoughts on the diagnosis and management of some common forms of GN. This is covered in the first half of the journal while the second half examines the prevalence patterns of different forms of GN in different institutions in Saudi Arabia as also some other countries in the region.

The latter half of the issue of the journal covers the prevalence of various forms of GN with four reports from within Saudi Arabia and one each from Egypt and Jordan [Table - 1]. The indications for renal biopsy in these reports included the nephrotic syndrome in 66.3%, hematuria/proteinuria in 30.8%, renal functional impairment in 25.4% and isolated hematuria in 14% of the cases. There were no significant discrepancies in this regard amongst the previous papers. Thus, the selection criteria for renal biopsy was more or less uniform.

The paper of Huraib et al is probably the most comprehensive report from Saudi Arabia to date on GN. This preliminary report of the GN registry involves four major hospitals from Riyadh in the central province of the Kingdom, and one each from Jeddah in the West and Al-Khobar in the East. This paper has three major strengths: a) the report comprises a large number of patients b) the methodology was uniform and standardized and c) patients are from three different regions of Saudi Arabia thereby eliminating any regional bias. Of the 1294 renal biopsies studied, 782 patients had GN of whom 587 had primary GN. Focal and segmental glomerulosclerosis (FSGS) and mesangio­capillary GN (MCGN) were the two most common lesions found constituting 21.3% and 20.7% respectively. Although the study included 281 children, the prevalence of minimal change disease (MCD) was only 11.6%. This probably reflects the biopsy policies of the participating institutions. The results of this report are similar to what has been published by Quinibi et al [6] and Akhtar et al [7] from the King Faisal Specialist Hospital (KFSH) in Riyadh, which is a tertiary referral center. Interestingly, the report is different from what was published by Huraib et al [8] from the King Khalid University Hospital (KKUH) in Riyadh in 1990. They had reported a prevalence of MCGN of 26.4% followed by membranous nephropathy (21.8%). In that report, they had contended that this difference between KFSH and KKUH may be due to different biopsy policies and/or secondary causes like hepatitis. Ten-years later, considering that KKUH is one of the participating hospitals in the study, FSGS was the commonest lesion found. Whether this reflects a "uniformity" in biopsy policies or better control for some secondary causes remains to the seen.

The relatively low prevalence of IgAN in the registries study is unexpected. However, the authors believe that it is related to the biopsy policy of the registry wherein many patients with asymptomatic microscopic hematuria were not biopsied. This obviously would have resulted in underestimation of the prevalence of IgAN as well as some other forms of GN.

Mitwalli et al in their report from the KKUH review the biopsy findings of 200 consecutive patients. Again FSGS was the commonest lesion found, seen in 22% of the cases. The surprising observation is the low prevalence of MCGN, seen in 10% of the cases as against a 26.4% prevalence reported from the same institution in 1990. Considering that the biopsy policies as well as metho­dology of processing the samples remained the same, this most likely represents an evolving pattern as reported from other countries. Thus, proliferative lesions like MCGN seen to be getting replaced by FSGS.

Mousa et al in a prospective study over one year, have analyzed 49 biopsies. They have found a very high prevalence of FSGS of 36.6% and a prevalence of MCGN of only 2.4%. No plausible explanation can be offered for the latter finding. The striking findings in this study is a 14.5% prevalence of IgAN. Since patients with asymptomatic urinary abnormalities were biopsied in this study, this probably represents the true prevalence of IgAN in the community.

Bernieh et al have reported on 85 patients. The major weaknesses of this study are: a) lack of IF and EM on any biopsy material and b) inclusion of patients between 12 and 18 years of age. Consequently, the results obtained are not very surprising; MCD, was the commonest lesion seen (29%) and FSGS occurred in 15.3% of cases. Needless to say, no cases of IgAN were reported. One can only draw broad conclusions from this report and this should serve as a reminder that renal histopathology is incomplete without at least IF in all and EM in selected cases.

The meta analysis of Barsoum et al gives a broad picture of various renal disorders seen in Egypt. A total of 1234 biopsy samples were studied. The major drawback is that IF was not done as a routine, but only when specifically requested. Despite this disadvantage, FSGS constituted 23.9%, and IgAN was diagnosed in 9.8% of the cases. Considering the selection bias, it is possible that the prevalence of IgAN is higher than the quoted figure.

Said et al reporting on 350 biopsies found that MCGN was the commonest lesion (35%) followed by FSGS (27.1%). This is comparable to a previous report from Jordan [9] . They found a prevalence of IgAN of 9.5% which is significant considering that all patients had IF. A striking feature in this report is a prevalence of 40.7% of amyloidosis among patients with secondary nephrotic syndrome. This is perhaps related to the high prevalence of Familial  Mediterranean fever More Details in Jordan.

Analysis of data from the four centers wherein all biopsy samples were processed for IF in addition to LM, revealed FSGS to be the commonest lesion (23%) followed closely by MCGN (20.7%) [Table - 2].

Secondary glomerular diseases were encountered in 491 of the 2,500 total study patients (19.6%). Although it is difficult to draw any firm conclusions, lupus nephritis was the commonest lesion, seen in about 48.9% of cases with secondary glomerular diseases. Amyloidosis was seen in about 13.6% with a noticeably high prevalence in Egypt and Jordan. It is a matter of surprise that amyloid is relatively uncommon in Saudi Arabia despite the high prevalence of tuberculosis and other chronic inflam­matory disorders [Table - 3].

The salient messages from this data compilation are: a) FSGS seem to be the commonest lesion encountered amongst adults with primary nephrotic syndrome, b) the prevalence of IgAN is not as low as was believed in the past and, c) the prevalence of MCGN is coming down for various reasons.

This report further strengthens the thought that it is very essential to have a GN registry not only in different countries of the region but also involving the entire region. This will help in identifying the problem of GN better including its etiopathogenesis, and with this knowledge, therapeutic and preventive strategies can be outlined so that progression to ESRD can be stopped, or at least slowed down.

 
   References Top

1.United States Renal Data System. Annual report 1998. Website: http://www.usrds. org/research_guide.htm  Back to cited text no. 1    
2.Valderrabano F, Berthoux FC, Jones EH, Mehls O. Report on management of renal failure in Europe, XXV, 1994 end stage renal disease and dialysis report. The EDTA-ERA Registry. European dialysis and Transplant Association-European Renal Association. Nephrol Dial Transplant 1996;11(Suppl 1):2-21.  Back to cited text no. 2    
3.Chan MK. Dialysis: a global perspective. Dial Transplant 1991;20:463-7.  Back to cited text no. 3    
4.Rahman M, Rashid HU, Ahmed S, et al. Morbidity and mortality of patients on maintenance hemodialysis in Bangladesh [Abstract]. The 1 st Int Congr Dial Develop Countries, Singapore 1994;83.  Back to cited text no. 4    
5.Habte B. Nephrology in Ethiopia. Proc ISN. African Kid. Electrolyte Conf Cairo. Cairo Univ Press 1987;15-629.  Back to cited text no. 5    
6.Qunibi WY, Al-Sibai B, Taher S, Akhtar M. Renal disease in Saudi Arabia: a study of 147 renal biopsies. King Faisal Specialist Hospital J 1984;4:317-23.  Back to cited text no. 6    
7.Akhtar M, Qunibi W, Taher S, et al. Spectrum of renal disease in Saudi Arabia. Ann Saudi Med 1990;10(1):37-44.  Back to cited text no. 7    
8.Huraib SO, Abu-Aisha H, Mitwalli A, Mahmoud K, Memon NA, Sulimani F. The spectrum of renal disease found by kidney biopsies at King Khalid University Hospital. Saudi Kid Dis Transplant Bull 1990;1(1):15-9.  Back to cited text no. 8    
9.Ghnaimat M, Akash N, El-Lozi M. Kidney biopsy in Jordan. Saudi J Kidney Dis Transplant 1999;10(2):152-6.  Back to cited text no. 9    

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Correspondence Address:
K S Ramprasad
Consultant Nephrologist, Saudi Center for Organ Transplantation, P.O. Box 27049, Riyadh 11417
Saudi Arabia
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PMID: 18209320

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