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RENAL DATA FROM THE ARAB WORLD |
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| Year : 2009 | Volume
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| Issue : 5 | Page : 858-861 |
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| Pathology of nondiabetic glomerular disease among adult Iraqi patients from a single center |
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Ali J Hashim Al-Saedi
Al-Kindi College of Medicine, Faculty of Medicine, Baghdad, Iraq
Click here for correspondence address and email
| Date of Web Publication | 2-Sep-2009 |
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 Abstract | | |
Almost all forms of glomerular diseases have been reported in diabetics. In a recent series, 12% of those with type I and 27% of those with type II diabetes were found to have non diabetic renal disease. We studied 80 adult diabetic Iraqi patients who were diagnosed with glomerular disease on native kidney biopsies from January 2000 to April 2008. Membranoproliferative GN was seen in 32 patients (40%), Focal and Segmental glomerulosclerosis in 16 patients (20%), Membranous nephropathy in 20 patients (25%), Minimal change disease in 8 patients (10%), Renal amyloidosis in 4 patients (5%). In conclusion Membranoproliferative GN was the most common histological diagnosis in our diabetic patients undergoing renal biopsy.
How to cite this article:
Hashim Al-Saedi AJ. Pathology of nondiabetic glomerular disease among adult Iraqi patients from a single center. Saudi J Kidney Dis Transpl 2009;20:858-61 |
How to cite this URL:
Hashim Al-Saedi AJ. Pathology of nondiabetic glomerular disease among adult Iraqi patients from a single center. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Oct 20];20:858-61. Available from: https://www.sjkdt.org/text.asp?2009/20/5/858/55380 |
| Introduction | |  |
Almost every form of glomerular disease has been reported in diabetics. [1] In a recent series, 12% of those with type I and 27% of those with type II diabetes mellitus were found to have non diabetic renal disease. [2] It is not clear whether most of these reports represent the coincidence of two conditions rather than a specific association. [3]
Inevitably the perceived incidence of nondiabetic glomerular disease will depend on the frequency with which renal biopsy is performed and the clinical criteria used to select patients for renal biopsy. [4] Nondiabetic renal disease superimposed on diabetic nephropathy (DN) occurs more frequently in type II rather than type I diabetics. [5]
In type I diabetes, proteinuria develops in only 4% of patients within 10 years of diagnosis so early onset proteinuria should raise the suspicion of other renal disease. [6] Approximately 8% of type II diabetics have proteinuria at diagnosis, making the duration of unknown diabetes of less value in elucidating the cause of renal pathology. [7]
Overall, the threshold for renal biopsy and further investigations should be lower in type II than in type I diabetics. [8]
When proteinuria develops in a diabetic, the clinical evaluation is directed at establishing a presumptive diagnosis of diabetic nephropathy (DN), thus obviating the need for renal biopsy. [9] Alternatively, atypical clinical and laboratory features may be identified that point to nondiabetic glomerular disease requiring identification by renal biopsy. [10]
The third possibility, in the presence of low grade proteinuria is renovascular disease or papillary necrosis. [11] The majority of diabetic patients with proteinuria and retinopathy will develop diabetic nephropathy. [12] With prolonged disease duration, most type I diabetics develop the typical histological lesion of diabetic glomerulosclerosis, [13] although one third develop clinically apparent nephropathy. [14]
About one third of type II diabetics with proteinuria will demonstrate the classical diabetic glomerular changes, and they usually have coexisting retinopathy. [15] Slightly under a third will have nondiabetic renal disease while the rest will have a mixed picture of diabetic and non diabetic renal changes. [16]
| Material and Methods | | |
From January 2000 to April 2008, a total of 80 patients were studied. These patients were seen in Al-Rasheed Military hospital (from January 2000 until February 2003) and thereafter in Al Kindy Teaching Hospital, Department of Nephrology, Baghdad. All biopsies were adequate (10-15) glomeruli within the specimen and were processed for light microscopy (LM). (No electron Microscopy (EM), or immunofluorescence (IF) was performed).
The age range of the study patients was (1762) years. 56 were males and 24 patients were females. All patients had no signs of diabetic retinopathy.
Indications for biopsy included: Nephrotic range proteinuria without progression through microalbuminuria in (48 patients). Type I Diabetes Mellitus for less than 10 years duration (16 patients).
16 patients had macroscopic hematuria and red cell casts.
| Results | | |
Membranoproliferative GN was seen in 32 patients accounting for 40% of the biopsies. Almost half of them had haematuria with red cell casts on urine l examination.
FSGS was seen in 16 (20%) patients. Membranous nephropathy was seen in 20 (25%) patients.
Minimal change disease was seen in 8 patients (10%), all patients showed nephritic proteinuria without active sediment.
Renal amyloidosis was seen in 4 patients (5%), one of them gave history of pulmonary TB for which he received 4 drugs.
| Discussion | | |
Almost every form of glomerular disease has been reported in diabetics. Despite the reluctance to perform kidney biopsy in patients with diabetes mellitus due to obvious diagnosis in general, the selection criteria in our patients for kidney biopsy were justified.
Lack of IF and EM is a weakness of our study however LM pictures were convincing for the diagnosis of GN along the clinical scenario.
Membranous nephropathy is commonly described glomerular disease in association with diabetes. [17] Patients frequently present at age 4060 years after 10 or more years of diabetes and in one series, only 25% of those with MN had retinopathy along with subnephrotic proteinuria. [18] 25% of our patients had Membranous GN, however due to retrospective nature of the study we were unable to find clearly an association with retinopathy. While the association of membranous nephropathy and diabetes may also be a coincidence, [19] it has been proposed that structural alteration of glomerular basement membrane and its interactions with the podocyte may predispose to expression of a neoantigen initiating an autoimmune process at that site. [20] In membranous nephropathy the thickening of the capillary loops and the degree of glomerular involvement are even whereas this is rare in diabetes. [21]
Membranoproliferative Gn was the commonest lesion and may be associated with infection such as HCV; no data was available in this regard due to the retrospective nature of our study.
In conclusion, presence of glomerular disease in diabetics other than diabetic nephropathy is of vital importance in making plan of management in such patients. The more kidney biopsies done according to strict criteria in diabetics will have a positive impact on management of renal disease.[Figure 1]
| References | | |
| 1. | Rudberg S, Osterby R. Decreasing GFR an indicator of more advanced diabetic glomerulopathy in the early course of microalbuminuria in IDDM adolescents. Nephrol Dial Transplant 1997;12: 1149-54.  [PUBMED] [FULLTEXT] |
| 2. | Vora JP, Dolben J, Dean JD, et al. Renal haemodynamics in NIDDM. Kidney Int 1992;41:829-35. [PUBMED] |
| 3. | Osterby R. Microalbuminuria in diabetes mellitus. Nephrol Dialysis Transplant 1995;10:12-4. |
| 4. | Vora JP, Chattington PD, Ibrahim H. Clinical manifestations & natural history of diabetic nephropathy. Comprehensive Clin Nephrol p. 348-9. |
| 5. | Pathology of the Kidney 14 th . Edn. Robert H. Heptinstall. Predictors of Nephropathy P 1741. |
| 6. | A Companion to Brenner & Rector's The Kidney Own. Pereria. Sayegh. P306. |
| 7. | Balal M, Paydas S, Seyrek N, Karayaylali I, Gonlusen G. Other glomerular pathologies in three patients with diabetes mellitus. Ren Fail 2004;26(2):185-8. |
| 8. | Heine GH, Sester U, Girndt M, Kohler H. Acanthocytes in the urine: useful tool to differentiate diabetic nephropathy from glomerulonephritis? Diabetes Care 2004;27(1):190-4. |
| 9. | Stokes MB. The diagnosis of minimal change disease in diabetic nephropathy. Scientific World Journal 2005;5:828-33. [PUBMED] [FULLTEXT] |
| 10. | Appel GB, Cook HT, Hageman G, et al: Membranoproliferative glomerulonephritis type II dense deposit disease: An update. J Am Soc Nephrol 2005;16:1392-403. |
| 11. | Couser WG, Ngaku M. Cellular and molecular biology of membranous nephropathy. J Nephrol 2006;19:699-705. [PUBMED] |
| 12. | D'Agati VD, Fogo A, Bruijn JA, Jennette JC. Pathologic classification of focal segmental glomeruloslcerosis. Am J Kidney Dis 2004;43: 368-82. |
| 13. | The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulindependent diabetes mellitus. N Engl J Med 1993;329(14):977-86. |
| 14. | Finne P, Reunanen A, Stenman S, Groop PH, Gronhagen-Riska C. Incidence of end-stage renal disease in patients with type 1 diabetes. JAMA 2005;294(14):1782-7. |
| 15. | Remuzzi G, Schieppati A, Ruggenenti P. Clinical practice. Nephropathy in patients with type 2 diabetes. N Engl J Med 2002;346(15):1145-51. |
| 16. | Ruggenenti P, Fassi A, Ilieva AP, et al. Bergamo Nephrologic Diabetes Complications Trial (BENEDICT) Investigators. Preventing microalbuminuria in type 2 diabetes. N Engl J Med 2004;351(19):1941-51. |
| 17. | Strippoli GF, Craig M, Deeks JJ, Schena FP, Craig JC. Effects of angiotensin converting enzyme inhibitors and angiotensin II receptor antagonists on mortality and renal outcomes in diabetic nephropathy: systematic review. Br Med J 2004;329(7470):828. |
| 18. | Cattran DC. Idiopathic membranous glomerulonephritis. Kidney Int 2001;59(5):1983-94. |
| 19. | Gross JL, de Azevedo MJ, Silveiro SP, Canani LH, Caramori ML, Zelmanovitz T. Diabetic nephropathy: Diagnosis, prevention, and treatment. Diabetes Care 2005;28:164. [PUBMED] [FULLTEXT] |
| 20. | Hurtado A, Johnson RJ. Hygiene hypothesis and the prevalence of glomerulonephritis. Kidney Int 2005;68:S62. |
| 21. | Stumvoll M, Goldstein BJ, van Haeften TW. Type 2 diabetes: Principles of pathogenesis and therapy. Lancet 2005;365(9467):1333-46. |
Correspondence Address:
Ali J Hashim Al-Saedi
Al-Kindi College of Medicine, Faculty of Medicine, Baghdad
Iraq
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PMID: 19736492 
[Figure 1] |
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