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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2009  |  Volume : 20  |  Issue : 5  |  Page : 858-861
Pathology of nondiabetic glomerular disease among adult Iraqi patients from a single center


Al-Kindi College of Medicine, Faculty of Medicine, Baghdad, Iraq

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Date of Web Publication2-Sep-2009
 

   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 Nov 25];20:858-61. Available from: https://www.sjkdt.org/text.asp?2009/20/5/858/55380

   Introduction Top


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 Top


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 Top


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 Top


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 Top

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.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Vora JP, Dolben J, Dean JD, et al. Renal haemo­dynamics in NIDDM. Kidney Int 1992;41:829-35.  Back to cited text no. 2  [PUBMED]  
3.Osterby R. Microalbuminuria in diabetes mellitus. Nephrol Dialysis Transplant 1995;10:12-4.  Back to cited text no. 3    
4.Vora JP, Chattington PD, Ibrahim H. Clinical manifestations & natural history of diabetic nephropathy. Comprehensive Clin Nephrol p. 348-9.  Back to cited text no. 4    
5.Pathology of the Kidney 14 th . Edn. Robert H. Heptinstall. Predictors of Nephropathy P 1741.  Back to cited text no. 5    
6.A Companion to Brenner & Rector's The Kidney Own. Pereria. Sayegh. P306.  Back to cited text no. 6    
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.  Back to cited text no. 7    
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.  Back to cited text no. 8    
9.Stokes MB. The diagnosis of minimal change disease in diabetic nephropathy. Scientific World Journal 2005;5:828-33.  Back to cited text no. 9  [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.  Back to cited text no. 10    
11.Couser WG, Ngaku M. Cellular and molecular biology of membranous nephropathy. J Nephrol 2006;19:699-705.  Back to cited text no. 11  [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.  Back to cited text no. 12    
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.  Back to cited text no. 13    
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.  Back to cited text no. 14    
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.  Back to cited text no. 15    
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.  Back to cited text no. 16    
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.  Back to cited text no. 17    
18.Cattran DC. Idiopathic membranous glomerulo­nephritis. Kidney Int 2001;59(5):1983-94.  Back to cited text no. 18    
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.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Hurtado A, Johnson RJ. Hygiene hypothesis and the prevalence of glomerulonephritis. Kidney Int 2005;68:S62.  Back to cited text no. 20    
21.Stumvoll M, Goldstein BJ, van Haeften TW. Type 2 diabetes: Principles of pathogenesis and therapy. Lancet 2005;365(9467):1333-46.  Back to cited text no. 21    

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Correspondence Address:
Ali J Hashim Al-Saedi
Al-Kindi College of Medicine, Faculty of Medicine, Baghdad
Iraq
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PMID: 19736492

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    Abstract
    Introduction
    Material and Methods
    Results
    Discussion
    References
    Article Figures
 

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