| Abstract|| |
To evaluate the patterns of glomerular diseases in the Madinah region in Saudi Arabia we reviewed 85 biopsies from native kidneys of adult patients presenting with clinical and or biological features suggestive of glomerular disease. Only light microscopy was used to evaluate these biopsies. There were 62 males and 23 females with age ranging from 12 to 80 years (mean 28 + 13.4 years). The main clinical presenting features were nephrotic syndrome in 68 patients (80%), renal insufficiency in 31 (36.5%), hypertension in 25 (24%) and/or hematuria in 19 (22.4%). Histopathology revealed minimal change disease in 25 patients (29%), mesangioproliferative glomerulonephritis (GN) in 13 (15.3%), focal segmental glomerulosclerosis in 13 (15.3%), membranoproliferative GN in seven (8.2%), membranous GN in three (3.5%), diffuse proliferative GN in five (5.9%), crescentic GN in four (4.7%), lupus nephritis in 13 (15.3%), and amyloidosis in two (2.4%). In conclusion, Minimal change disease was the most common type of primary GN in our patients. The mean age for this group was 27.2 (range 13-43 years). Lupus nephritis was the commonest secondary GN in the Madinah region.
|How to cite this article:|
Bernieh B, Sirwal IA, Abbadi MA, Ashfaquddin M, Mohammad AO. The Spectrum of Glomerulonephritis in Adults in Madinah Munawarah Region. Saudi J Kidney Dis Transpl 2000;11:455-60
|How to cite this URL:|
Bernieh B, Sirwal IA, Abbadi MA, Ashfaquddin M, Mohammad AO. The Spectrum of Glomerulonephritis in Adults in Madinah Munawarah Region. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2021 Apr 13];11:455-60. Available from: https://www.sjkdt.org/text.asp?2000/11/3/455/36669
| Introduction|| |
Glomerulonephritis (GN) is a common cause of end-stage renal disease.  The prognosis and response to treatment varies with different types of glomerulonephritis.  The pattern of GN varies widely from country to country and also in different regions of the same country, reflecting possible effects of genetic and environmental factors. This study was undertaken to determine the pattern of GN in adults of Madinah Al Munawarah region and to evaluate the response to treatment and the subsequent prognosis.
| Material and Methods|| |
From 1990 to 1999, eighty five biopsies of native kidneys with adequate tissue were reviewed along with clinical and biochemical parameters. Biopsies with inadequate tissue, non-specific changes, changes indicating only interstitial disease, acute tubular necrosis and from transplanted kidneys were not included in the study. More than one-biopsy specimens for the same patient, even when done at different times, were counted as one. All biopsy specimens were studied by light microscopy alone. All patients were adults (12-80 years age). Males outnumbered females (62 vs 23). Meticulous screening for possible etiology of glomerulonephritis was done in all patients.
| Results|| |
Eighty-five biopsies were classified either as primary glomerular disease or a glomerular disease occurring as a part of systemic disease. The main clinical features are shown in [Table - 1]. The pattern of glomerulonephritis observed at histopathology is depicted in [Table - 2].
Minimal Change Disease (MCD)
This entity comprised the major portion of primary glomerular disease. Of the 85 patients 25 (29.4%) showed MCD. All the patients (16M, 9F) presented with typical clinical and biochemical features of nephrotic syndrome. The age range of the patients was (13-43) years. Follow-up period varied from one month to nine years (23 + 29.7 months). Steroids were the mainstays of treatment in 24 patients. In six patients, there was no follow-up data. Of the remaining 19 patients, 12 had complete remission with steroids alone (63%) and four (21%) had partial remission. In three (16%) other patients cyclophosphamide was used for frequent relapses or steroid resistant nephrotic syndrome and one of these three also received cyclosporin with complete remission.
One patient had concomitant Hashimotos thyroiditis and another was diagnosed to have carcinoma of breast while on treatment.
The encountered complications in this group included renal vein thrombosis (RVT) with recurrent pulmonary embolism in one patient who died at the initial hospitalization with septicemia and gastrointestinal bleeding. Another patient had steroid induced psychosis, which responded well to the decrease in steroid dose. Renal failure due to tubular necrosis was encountered in one patient who subsequently recovered completely.
One patient relapsed after each upper respiratory tract infection and each time responded to moderate increase in steroid dose for 10 days to two weeks.
Complications and associations are shown in [Table - 3].
Focal segmental glomerulosclerosis (FSGS)
These were the second common glomerulopathies encountered in this region. Of the 13 patients (15.3%) with FSGS (11M, 2F), eight were Saudis and five non-Saudis. The majority (12/13) of them presented with renal insufficiency and hypertension with proteinuria. There was progressive renal failure in all the patients except one who had normal renal function at the time of diagnosis. Five of 13 patients were treated with pulse cyclophosphamide in addition to steroids. There was observable improvement in only one of these patients.
Mesangial proliferative GN
In 13 (15.3%) patients (8M, 5F) biopsy revealed mesangial proliferative GN on light microscopy. The main presentation included edema in four patients who also had renal insufficiency. Seven patients were followed for less than four months. Of five patients followed from nine months to 12 ½ years, four (80%) had complete remission with steroids alone whereas the fifth one attained remission after cyclophosphamide. One female patient died five months after diagnosis with severe heart failure due to peripartum cardiomyopathy.
All the seven patients with membranoproliferative GN presented with nephrotic proteinuria, six also had renal insufficiency and two also had hypertension. In one patient, renal function was stable at one year after pulse cyclophosphamide although proteinuria did not remit. Of the six patients with impaired renal function at presentation, two were started on hemodialysis (HD), two had stable chronic renal failure (not needing dialysis at one year) and two were lost to follow-up. One of the patients had hepatitis B viral (HBV) infection and also tuberculous pericardial and pleural effusions, which responded to anti-tuberculous therapy. One patient had expressive dysphasia secondary to stroke.
Four patients (3M, 1F) had crescentic GN. Three of the four had advanced renal failure at presentation and needed maintenance HD. One patient was HBV positive, and one patient had remission following steroid and cyclophosphamide treatment. This last patient had moderate renal insufficiency (creatinine 201) at the end of four years of follow-up.
Post infectious-diffuse proliferative GN (DPGN)
Five patients (3M, 2F) showed DPGN on biopsy. Three of these had azotemia at presentation; two had edema, hematuria, and hypertension. Two patients were lost to follow-up. Complete resolution was noted in the remaining three.
Membranous Nephropathy (MGN)
All the three patients with MGN presented with the nephrotic syndrome. One patient was lost to follow-up. The other two patients received steroid therapy. One patient developed tuberculous pleural effusion and acute myocardial infarction during his course of steroid therapy and he is now on regular hemodialysis. The other patient has left for his country of origin after five months of treatment without any improvement of his nephrotic syndrome.
Secondary Glomerular Diseases
The common entity encountered in this group was lupus nephritis. Of 13 patients (11F & 2M), five patients showed WHO (class IV), three (class III), two (class II), two (class IV-V), and one (class V) lesion. Four patients were lost to follow-up. Patients were treated with steroids, cyclophosphamide pulse and/or cyclosporin. Four patients underwent several sessions of plasmapheresis mainly for extra renal complications. Three patients attained complete clinical remission and one had partial remission. Four had progressive renal failure and one was lost to follow-up.
Renal amyloidosis was diagnosed in two patients, one with rheumatoid arthritis (RA) and another with familial Mediterranean fever More Details (FMF). The patient with RA needed dialysis at the initial admission but did not turn up for follow-up subsequently. The patient with FMF was treated with colchicine but proteinuria persisted.
| Discussion|| |
Primary glomerular disease comprised 82.3% and secondary GN 17.7% of all the cases of glomerulonephritis in the present study. Similar distribution of primary and secondary GN has been reported elsewhere from the Kingdom.  Schena  has reported primary and secondary GN in 59.9% and 25.4% cases, respectively.
The most common clinical presentation in our study was that of a full blown nephrotic syndrome followed by renal insufficiency, hypertension, hematuria, and oliguria.
We compared our results with the other studies published from the Arabian Gulf and other parts of the world. [Table - 4] shows data from these studies that have been recalculated to indicate the relative frequency of various glomerulopathies in a comparable manner. The most frequently diagnosed lesion in our study was minimal change disease, which represented 29% of all cases of GN.
Such a high percentage has not been reported from Saudi Arabia ,, but similar figures have been reported from Singapore  and India.  The trend towards increased occurrence of minimal change disease in adults has also been observed by others. ,, Although MCD in adults is less regularly and more slowly responsive to corticosteroids, it is, however, less likely to relapse once remission is achieved.  The majority (84%) of our MCD patients showed a favorable response to steroid therapy [63% had complete and 21% partial remission].
FSGS and mesangioproliferative GN were the second common diagnoses in our series and each represented 15.3% of all the cases of GN. In most countries the frequency of FSGS is around 15% [Table - 4]. However, a higher prevalence (34.9%) and (40.8%) of FSGS has been reported from elsewhere in the Kingdom of Saudi Arabia , and other countries. , The outcome in this subgroup of our study patients was generally poor with regards to preservation of renal function. However, therapeutic protocols using intravenous methyl prednisolone pulses followed by alternate day prednisolone combined with an alkylating agent have produced high percentages of sustained remission with normal renal functions. 
Mesangial proliferative glomerulonephritis was reported in 15.3%, 29.1%, and 8.5% cases of nephrotic syndrome from other centers in the Kingdom. ,, In our series it accounted for 15.3% of all the cases. Some of these patients could have IgA nephropathy, but immunofluorescence (IF) was not done in our study in order to ascertain from this diagnosis.
Contrary to reports from the UK,  USA  and other countries and also centers in Saudi Arabia, ,, which all reported higher frequency of membranous glomerulonephritis, we encountered MGN in only 3.5% of the study cases.
Among the secondary causes of glomerulonephritis, lupus nephritis accounted for the majority of cases (13/15). Other authors have reported similar observations. ,,, The increased frequency is probably due to the increased awareness of the disease and the facilities available for its diagnosis. Amyloidosis was noted in two cases, which represents 2.4% of all the biopsy specimens. This is in agreement with the observation of the other authors from Saudi Arabia who found amyloidosis in 2.7%, 3.9%, and 1.1% of the biopsies. ,, These figures are different from those of the other Arab and Mediterranean countries, where frequency of amyloidosis varies from 11 to 32.4% of all the renal biopsies and is probably related to the prevalence of familial Mediterranean fever in these countries. 
In conclusion, the pattern of glomerular disease in Madinah is different from the western world and also from the other regions in the kingdom of Saudi Arabia. There is high prevalence of MCD among adults and also lupus nephritis is the commonest secondary GN in this region, whereas membranous GN is uncommon. The different spectrum of GN in the different regions of this country necessitates the establishment of a national registry for glomerulonephritis for better understanding, planning, and conduction of therapeutic trials for GN in a coordinated fashion.
| References|| |
|1.||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(3):205-13. |
|2.||Heaf J, Lokkegaard H, Larsen S. The epidemiology and prognosis of glomerulonephritis in Denmark 1985-1997. Nephrol Dial Transplant 1999;14(8):1889-97. |
|3.||Akhtar M, Qunibi W, Taher S, et al. Spectrum of renal disease in Saudi Arabia. Ann Saudi Med 1990;10(1):37-44. |
|4.||Schena FP. Survey of the Italian registry of renal biopsies frequency of the renal diseases for 7 consecutive years. The Italian Group of Renal Immunopathology. Nephrol Dial Transplant 1997;12(3):418-26. |
|5.||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. |
|6.||Mitwalli AH, Al-Wakeel JS, Al-Mohaya SS, et al. Pattern of glomerular disease in Saudi Arabia. Am J Kidney Dis 1996; 27(6):797-802. |
|7.||Sinniah R. Renal disease in Singapore with particular reference to glomerulo-nephritis in adults. Singapore Med J 1980;21:583-91. [PUBMED] |
|8.||Sud A, Bhuyan UN, Tandon HD. Spectrum of morphological lesions in renal biopsies associated with primary nephrotic syndrome. Indian J Med Res 1978;68:811-23. [PUBMED] |
|9.||Haas M, Meehan SM, Karrison TG, Spargo BH. Changing etiologies of unexplained adult nephrotic syndrome: a comparison of renal biopsy findings from 1976-1979 and 1995-1997. Am J Kid Dis 1997;30(5):621-31. |
|10.||Borok MZ, Nathoo KJ, Gabriel R, Porter KA. Clinicopathological features of Zimbabwean patients with sustained proteinuria. Cent Afr J Med 1997;43(6):152-8. |
|11.||Yahya TM, Pingle A, Boobes Y, Pingle S. Analysis of 490 kidney biopsies: data from United Arab Emirates Renal Disease Registry. J Nephrol 1998;11(3):148-50. |
|12.||Tune BM, Mendoza SA. Treatment of the idiopathic nephrotic syndrome: regimens and outcomes in children and adults. J Am Soc Nephrol 1997;8(5):824-32. |
|13.||Lai M, Lai KN, Chan KW, et al. Pattern of glomerulonephritis in Hong Kong. Pathology 1987;19:247-52. |
|14.||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. |
|15.||Wass VJ, Jarrett RJ, Chilvers C, Cameron JS. Does the nephrotic syndrome increase the risk of cardiovascular disease. Lancet 1979;2:664-7. [PUBMED] |
|16.||Bolton WK, Atuk NO, Sturgill BC, Westervelt FB Jr. Therapy of the idiopathic nephrotic syndrome with alternate day steroids. Am J Med 1977;62:60-70. [PUBMED] |
|17.||Seedat YK, Nathoo BC, Parag KB, Naiker IP, Ramsaroop R. IgA nephropathy in blacks and Indians of Natal. Nephron 1988;50:137-41. [PUBMED] |
|18.||Verroust P, Ben-Maiz H, Morel-Maroger L, et al. A clinical and immunopathological study of 304 cases of glomerulonephritis in Tunisia. Eur J Clin Invest 1979;9:75-9. [PUBMED] |
|19.||Sohar E, Gafni J, Pras M, Heller. Familial Mediterranean fever. A survey of 470 cases and review of the literature. Am J Med 1967;43:227-53. |
Department of Nephrology, P.O. Box 1088, Madinah Al Munawarah
[Table - 1], [Table - 2], [Table - 3], [Table - 4]