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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2004  |  Volume : 15  |  Issue : 2  |  Page : 176-179
Pattern of Glomerulonephritis in Sudan: Histopathological and Immunofluorescence Study

1 Faculty of Medical Laboratory Sciences, University of Khartoum, Khartoum, Sudan
2 Nephrology Unit, Military Hospital Omdurman, Sudan
3 Renal Dialysis and Transplant Center, University of Khartoum, Khartoum, Sudan
4 Institute of Endemic Diseases, University of Khartoum, Sudan

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The final diagnosis of renal disease can only be established with the study of renal biopsy using light microscopy, immunohistochemistry and electron microscopy. This study reports on the pattern of glomerulonephritis, diagnosed with light microscopy and immunofluorescence, in two major nephrology referral centers in Sudan. Renal biopsies from 86 consecutive patients were studied by light and immunofluorescence microscopy. The latter was introduced for the first time in the country. Focal and segmental glomerulosclerosis, membranoproliferative glomerulonephritis, minimal change disease and rapidly progressive glomerulonephritis accounted for 26.6%, 22.1%, 10.5% and 3.5% of cases respectively. Lupus nephritis was the commonest cause of secondary glomerulonephritis, accounting for 11.6% of cases. In contrast to the frequency seen in developed countries, IgA nephropathy was uncommon in our series and was seen in only 4.7% of cases. Primary renal amyloidosis was diagnosed in 3.5% of the patients. The pattern of glomerulonephritis in our series is similar to the reports from other developing countries with focal and segmental glomerulosclerosis being the commonest primary glomerulopathy and lupus nephritis, the commonest secondary glomerulopathy.

Keywords: Glomerulonephritis, Lupus nephritis, IgA nephropathy, Immunohistochemistry, Focal and segmental glomerulosclerosis.

How to cite this article:
Khalifa EH, Kaballo BG, Suleiman SM, Khalil EA, El-Hassan AM. Pattern of Glomerulonephritis in Sudan: Histopathological and Immunofluorescence Study. Saudi J Kidney Dis Transpl 2004;15:176-9

How to cite this URL:
Khalifa EH, Kaballo BG, Suleiman SM, Khalil EA, El-Hassan AM. Pattern of Glomerulonephritis in Sudan: Histopathological and Immunofluorescence Study. Saudi J Kidney Dis Transpl [serial online] 2004 [cited 2022 Jul 6];15:176-9. Available from: https://www.sjkdt.org/text.asp?2004/15/2/176/32903

   Introduction Top

Glomerulonephritides constitute an important cause of morbidity and mortality and impose a considerable burden on the already strained health services in developing countries. The final diagnosis of renal disease, associated with acute renal failure, nephritic syndrome or the nephrotic syndrome, is made possible with the study of renal biopsy using light microscopy (LM), immunofluorescence (IF) and electron microscopy (EM). Findings in biopsies from patients with chronic renal failure are generally non-specific and renal biopsy is rarely indicated. Ideally, the three techniques of LM, EM and IF should be used for every renal biopsy. However, EM is ex­pensive and is often not available in developing countries. The combination of LM and IF can diagnose most of the common glomerular diseases encountered in clinical practice and is cost effective. We used these two methods to determine the pattern of glomerulonephritis in two major nephrology units in Sudan.

   Material & Methods Top

Patients & samples

Following informed consent, one hundred and seventy two biopsies were obtained from eighty six consecutive patients who reported to the Renal Dialysis and Transplant Center, University of Khartoum and the Renal Dialysis Unit, Military Hospital, Omdurman. One sample was fixed in neutral formalin and the other was embedded in Optimum Cooling Temperature solution (OCT) in aluminum foil and snap frozen in liquid nitrogen.

Laboratory procedures

Paraffin sections of formalin-fixed biopsies were stained with Hematoxylin and Eosin (H&E), Masson's trichrome stain, methenamine silver and PAS. Where indicated, sections were stained with crystal violet to demonstrate amyloid. From a block of each specimen, six µm thick frozen sections were cut and processed for direct IF staining as described by the manufacturer (DAKO Company, Kulstrop, Denmark). Briefly, air-dried frozen sections were fixed with cold acetone at 4o Celcius for ten minutes and washed in phosphate buffered saline (PBS, pH 7.2) for 10 minutes. The sections were then incubated with diluted anti-human rabbit mono­clonal immunoglobulins (IgA, IgG, IgM and complement fragments C3c , C1q ). The sections were then washed in three changes of PBS at 4o C. The slides were mounted in buffered glycerol and examined under a Zeiss fluore­scent microscope. Control slides without the addition of the monoclonal antibodies were included to test the specificity of the antibodies.

   Results Top

Combined results from both routine tests and IF showed that focal and segmental glomerulosclerosis (FSGS) was the commonest type, accounting for about a quarter of the cases (26.6%) (Table1). The commonest type of FSGS was the collapsing type followed by perihilar sclerosis and the least common was the tip lesion [Table - 2]. The patients with FSGS presented with proteinuria (n = 16), the nephrotic syndrome (n = 4) or combined hematuria and proteinuria (n = 3). In three cases, trapped IgM was seen in the glomeruli.

Of them, two presented with proteinuria and one with proteinuria and hypertension. Membranoproliferative glomerulonephritis (MPGN) was almost as common as FSGS with a frequency of 22.1%, while minimal change disease was seen in 10.5% of biopsies. IgA nephropathy accounted for 4.7% of cases and none of them reported positive family history of this lesion. Biopsies in these patients showed an increase in mesangial matrix and cellularity with diffuse mesangial deposits of IgA. Lupus nephritis was the commonest cause of secondary glomerulonephritis with a frequency of 11.6% followed by amyloidosis that was seen in 3.5% of cases. Lupus nephritis types II and III of the WHO classification were the most frequent types. Membranous nephropathy and Alport's syndrome were seen in a small number of cases with frequencies of 2.3% and 1.2% respectively. Membranous nephropathy showed uniform thickening of the glomerular basement membrane with normal cellularity and subepithelial deposits of IgG, IgM and C3c .

   Discussion Top

In the present study, we used H&E staining, selected special stains and IF to determine the pattern of glomerular disease in two major nephrology referral centers in Sudan. Immuno­fluorescence, which has been made available only recently in Sudan, is regarded essential for the diagnosis of renal disease. It was therefore possible to diagnose for the first time, such entities as IgA nephropathy and to distinguish the two types of MPGN.

FSGS was the commonest type of glome­rulonephritis in our series which is similar to reports from Saudi Arabia, [1] Zaire, [2] North America [3] and Iraq. [4] The most frequent sub-type of FSGS was the collapsing type which is reported to be most common in black Americans. [5] In a study from Sudan in 1980, the prevalence of FSGS was reported to be 12% [6] which is significantly different from our figure of 26.6%. The report of Musa et al, in 1980 was based on LM alone whereas we used both LM and IF. This is unlikely to explain the difference in frequency of FSGS in the two series since light microscopy alone is generally capable of diagnosing this con­dition. It is therefore possible that there is a genuine increase in the incidence of FSGS in the last 20 years, an observation that has been reported by other groups as well. [2],[7] The frequency of FSGS in a given population varies with the racial composition of the population; the disease is more common in blacks than whites in the United States. [3] The collapsing type of FSGS may be primary or secondary. The secondary form is asso­ciated with intravenous drug abuse and HIV infection. [5] None of our patients had HIV infection or a history of drug abuse.

Type I MPGN is a common form of glome­rulonephritis in countries where there is a high incidence of hepatitis B and C infection. [8],[9] In our series, we could associate only one case with HBV infection; hepatitis C was not tested for. Minimal change disease was seen with a lower frequency than that reported from neigh­bouring countries. Most clinicians would treat children with minimal change glomeruloneph­ritis on clinical criteria and biopsy is performed only in those patients who do not respond to steroid therapy. In our experience, most of the steroid resistant cases proved to be FSGS. The five patients in our series who had minimal change glomerulonephritis were all adults who had concomitant acute renal failure.

This association is most frequently seen in blacks and has a good prognosis. [10]

The cases of IgA nephropathy in our series are the first to be reported from Sudan, and this was made possible only by the use of IF. The use of IF was also helpful in distingui­shing types I and II lupus nephritis as well as types I and II MPGN. An apparent increase in the prevalence of membranous nephritis (MN) was seen when its frequency in this study was compared to that of Musa et al. [2] We believe that the difference is most likely due to difference in the diagnostic approaches, but a genuine increase of MN over the years cannot be ignored as has been reported by Morgan et al. [11]

IgM nephropathy was uncommon in the present study. It was diagnosed in 136 out of 1413 patients with glomerular disease in Hong Kong. [12] IgM nephropathy may evolve into FSGS [13] although, our patients with IgM nephropathy were not followed-up to see if such progression occurred.

In conclusion, the pattern of glomerular disease in Sudan is not markedly different from that of other developing countries. Immunofluorescence helped to diagnose IgA nephropathy, differentiate types I and II MPGN and specifically categorize types I and II lupus nephritis.

   Acknowledgment Top

This work is dedicated to the memory of some of the members of the Kidney Dialysis and Transplant Centre team including Dr. Selma M. Suleiman, a co-author of this study, who lost their lives tragically in a boat mishap on the river Nile in 2002.

   References Top

1.Mitwalli AH, Al-Wakeel JS, Al Mohaya SS, et al. Pattern of glomerular disease in Saudi Arabia. Am J Kidney Dis 1996;27:797-802.  Back to cited text no. 1    
2.Pakasa M, Mangani N, Dikassa L. Focal and segmental glomerulosclerosis in nephrotic syndrome: a new profile of adult nephrotic syndrome in Zaire. Mod Pathol 1993;6:125-8.  Back to cited text no. 2    
3.Bakir AA, Share DS, Levy PS, Arruda JA, Dunea G. Focal segmental glomerulo­sclerosis in adult African Americans. Clin Nephrol 1996;46:306-11.  Back to cited text no. 3    
4.Shaker IK, Al-Saedi AJ, Al-Salam S, Saleem MS, Al-Shamma IA. Spectrum of glomerular disease in Iraqi patients from a single center. Saudi J Kidney Dis Transplant 2002;13:515-9.  Back to cited text no. 4    
5.Detwiler RK, Falk RJ, Hogan SL, Jennette JC. Collapsing glomerulopathy: a clinically and pathologically distinct variant of focal segmental glomerulosclerosis. Kidney Int 1994;45:1416-24.  Back to cited text no. 5    
6.Musa AR, Veress B, Kordofani AM, Asha HA, Satir A, El- Hassan AM. Pattern of the nephrotic syndrome in the Sudan. Ann Trop Med Parasitol 1980; 74:37-44.  Back to cited text no. 6    
7.Braden GL, Mulhern JG, O'Shea MH, Nash SV, Ucci AA Jr, Germain MJ. Changing incidence of glomerular diseases in adults. Am J Kidney Dis 2000; 35: 878-83.  Back to cited text no. 7    
8.Jorgensen HE, Malik SH, Paul TT, Whorra PC. Renal disease in Saudi Arabia. Pediatr Nephrol 1985;5:195.  Back to cited text no. 8    
9.Al-Homrany MA. Pattern of renal diseases among adults in Saudi Arabia: a clinico­pathologic study. Ethn & Dis 1999;9:463-7.  Back to cited text no. 9    
10.Jennette JC, Falk RJ.Adult minimal change glomerulopathy with acute renal failure. Am J Kidney Dis 1990;16:432-7.  Back to cited text no. 10    
11.Morgan AG, Shah DJ, Williams W, Forrester TE. Proteinuria and glomerular disease in Jamaica. Clin Nephrol 1984; 21:205-9.  Back to cited text no. 11    
12.Chan KW, Chan TM, Cheng IK. Clinical and pathological characteristics of patients with glomerular disease at a university teaching hospital: 5-year prospective review. Hong Kong Med J 1999; 5: 240-4.  Back to cited text no. 12    
13.Zeis PM, Kavazarakis E, Nakopoulou L, et al. Glomerulopathy with mesangial IgM deposits: long-term follow up of 64 children. Pediatr Int 2001; 43:287-92.  Back to cited text no. 13    

Correspondence Address:
Ahmed M El-Hassan
Institute of Endemic Diseases, P.O.Box 3516; Khartoum
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Source of Support: None, Conflict of Interest: None

PMID: 17642773

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  [Table - 1], [Table - 2]


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