A five-year analysis of the incidence of glomerulonephritis at Cairo University Hospital-Egypt

Salwa Ibrahim; Ahmed Fayed; Sawsan Fadda; Dawlet Belal

doi:10.4103/1319-2442.98191

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Year : 2012 | Volume : 23 | Issue : 4 | Page : 866-870

A five-year analysis of the incidence of glomerulonephritis at Cairo University Hospital-Egypt

Salwa Ibrahim, Ahmed Fayed, Sawsan Fadda, Dawlet Belal
Department of Internal Medicine and Pathology, Cairo University, Egypt

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Date of Web Publication

9-Jul-2012

Abstract

Our study aimed to obtain a comprehensive review of the incidence of biopsy-proven glomerulonephritis (GN) at the Cairo University Hospitals, Egypt, over the last five years. We analyzed the clinical and pathological data of all renal biopsy samples that were performed during the period from July 2003 to July 2008. Renal biopsy samples of 924 patients were referred for pathological assessment during the period of the study [437 male and 487 female patients; their mean age was 26.5 ± 14.6 years (range: 2.5-71 years)]. Focal segmental glomerulo-nephritis was the most frequent cause of primary GN (21.21%), followed by mesangial proliferative GN (18.93%), diffuse proliferative GN (13.96%), focal proliferative GN (12.77%) and membranous GN (10.93%). The results could be explained by the high incidence of lupus nephritis among the study subjects as well as the relatively young age of the study group.

How to cite this article:
Ibrahim S, Fayed A, Fadda S, Belal D. A five-year analysis of the incidence of glomerulonephritis at Cairo University Hospital-Egypt. Saudi J Kidney Dis Transpl 2012;23:866-70

How to cite this URL:
Ibrahim S, Fayed A, Fadda S, Belal D. A five-year analysis of the incidence of glomerulonephritis at Cairo University Hospital-Egypt. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Dec 3];23:866-70. Available from: https://www.sjkdt.org/text.asp?2012/23/4/866/98191

Introduction

Glomerulonephritis (GN) varies in incidence among the different geographical areas due to socioeconomic conditions, ethnicity, genetic variability and environmental factors. Recent studies suggested a changing pattern of incidence of GN in the different parts of the world. ^[1],[2] For instance, the incidence of end-stage renal disease (ESRD) as a result of focal segmental glomerulosclerosis (FSGS) has increased 11fold in the past two decades in a recent US study. ^[2] A previous Egyptian study of 1234 renal biopsies revealed a high prevalence of proliferative GNs and FSGS. ^[3] Our study aimed to determine the incidence of biopsy-proven GN at the Cairo University Hospitals over the last five years.

Material and Methods

In a retrospective study, we analyzed the clinical and pathological data of all renal biopsy samples that were performed during the period from July 2003 to July 2008 at the Cairo University Hospitals, Egypt. Cairo University Hospitals are the largest tertiary referral hospitals in Egypt, playing a major role in the health care management. The Nephrology unit of the Cairo University Hospitals (King Fahd Unit) is considered to be one of the largest nephrology centers in Egypt.

Age, gender, indication for renal biopsy and pathological findings were recorded for analysis.

The renal biopsies were processed for light microscopy ± immunoflurescence examination. We do not have an electron microscopy service in our hospital and immunoflurescence examination was not performed routinely in all cases for financial reasons. The main indications for renal biopsy include the nephrotic syndrome (urinary protein excretion >3.5 g/day), nephritic syndrome (active urinary sediments with/without azotemia), sub-nephrotic proteinuria (<3.5 g/day), combined proteinuria and hematuria, renal failure (acute and chronic) and isolated hematuria. Renal biopsies with sole tubulointerstitial affection were excluded from the analysis.

Results

Renal biopsy samples of 924 patients were referred for pathological assessment during the period of the study; they were 437 male and 487 female patients, and their mean age was 26.5 ± 14.6 years.

[Table 1] showed the main indications for renal biopsy. The main indications for renal biopsy included persistent subnephrotic proteinuria (43.07%), the nephrotic syndrome (25.32%) and combined proteinuria and hematuria (12.9%). The monthly incidence of biopsy-proven GN was 15.4 (range 13-19). Proliferative GN was reported in 497 (53.78%) cases and non-proliferative GN was reported in 427 (46.22%) cases.

Table 1: Main indications for renal biopsy (924 cases).

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[Table 2] shows the pathological pattern of GN encountered in our study. Lupus nephritis (LN) was reported in 264 (28.57%) cases. The female/male ratio was 221/41 (84.2% of class II, 90% of class III, 79.5% of class IV and 82.9% of class V were females); 70% of lupus patients aged 18-45 years (55.3% class II, 76.3% class III, 71.2% class IV and 82.9% class V) and 85% had renal impairment (mean serum creatinine was 3.21 ± 4.09 mg/dL). The common glomerular pathologies in patients with LN were the proliferative classes II-III- IV (28.78%, 30.30% and 27.65%, respectively). Class V was reported in 13.25% of the cases [Figure 1].

Figure 1: The incidence of histopathological classes of lupus nephritis in the study group.

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Table 2: Incidence of biopsy-proven GNs in the study group.

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[Table 2] also shows that FSGS was the most frequent cause of primary GN (21.21%), followed by mesangial proliferative GN (18.93%), diffuse proliferative GN (13.96%), focal proliferative GN (12.77%) and membranous GN (10.93%). In females, LN, mesangial proliferative, FSGS and diffuse proliferative GN were the predominant pathological findings. However, in males, FSGS, diffuse proliferative GN and mesangial proliferative GN were the predominant findings. In those aged less than 18 years, mesangial proliferative GN, minimal change disease and FSGS were more prevalent compared with that in adults. [Figure 2] shows the frequency of the different types of GN in patients with renal insufficiency; FSGS, mesangial and diffuse proliferative lesions were the predominant lesions in this group. Family history of FSGS was reported in 19 out of 196 cases (9.69%) of the FSGS cases, while 12.75% of the FSGS cases were secondary to heroin addiction.

Figure 2: Incidence of different GNs in patients with renal insufficiency (352 cases, 38.09%).

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Diffuse proliferative GN with crescents (extra-capillary proliferative GN) was reported in 54 (5.8%) cases. Diabetic nephropathy (DN) was reported in two adult females (0.22%). The nephrotic syndrome was the main presentation in cases of DN (100%), amyloidosis (81.1%), minimal change disease (56%), LN (47.7%), focal proliferative GN (45.8%), membrano-proliferative GN (45.3%), FSGS (41.3%), diffuse proliferative GN (41.1%) and membranous nephropathy (38.6%).

The nephrotic syndrome was the main presentation in 34.9% of the cases of mesangioproliferative GN, while 30% of them had acute nephritis, 21.7% had combined hematuria and proteinuria and 5% had isolated hematuria.

IgA deposits were detected in 9.8% of mesangioproliferative cases, accounting for 15% of cases presented with isolated hematuria.

Discussion

The current study showed that FSGS and proliferative GN [systemic lupus erythematosus (SLE) and others] were the predominant forms of GN in the population of the study. LN was the most commonly encountered disease in the whole group, whereas FSGS was the most frequent disease in adults and middle-aged male groups. In addition, FSGS was the most common pathology in patients with renal insufficiency.

LN constituted the most common condition among female patients in adults and in the middle age groups. Increased prevalence of LN as a cause of secondary GN has been observed in several studies from Egypt, ^[3] Sudan, ^[5] Iran, ^[6] Bahrain, ^[7] Jordan ^[8] and Australia. ^[9]

Increased awareness of the disease and the adoption of the National Institute of Health (NIH) protocol for treatment of lupus nephritis, which requires renal biopsy to determine the WHO class of LN as well as activity and chronicity indices before starting therapy, has encouraged most centers to perform renal biopsies more readily than before in SLE cases. ^[9] Besides, our unit is a large tertiary referral center that receives many referred cases from other general and private hospitals located in the Cairo, Giza and Upper Egypt governates. This may explain the increased prevalence of LN in the reports released from the nephrology departments in the university hospitals in Egypt. The renal histopathological findings in LN were similar to those reported before in other series. ^[3] It should be noted that the pathology service in our hospital has started to adopt the ISN/RPS 2033 classification of LN ^[4] in 2005; therefore, we could not use this classification in the current analysis as it was not applied for all the cohort cases.

FSGS was the main primary GN among the study group. Compared with other Arab countries, FSGS was the predominant GN in two studies published from Saudi Arabia, ^[10] Kuwait ^[11] and Jordan. ^[8] It was the second most common lesion in a study from Bahrain. ^[7] FSGS is increasingly reported to be common in the USA in all ethnic groups. ^[12],[13]

Mesangial proliferative GN was the second common primary GN reported in the study group. IgA deposits were detected in 9.8% of the mesangioproliferative cases, accounting for 15% of cases presented with isolated hematuria. The low incidence of IgA nephropathy matches the lower frequencies of IgA nephropathy in the neighboring countries in the region as Saudi Arabia, ^[14],[15] Bahrain ^[9] and Iran. ^[16] This contrasts the high incidence of IgA in Europe, ^[16],[17] North America ^[12] and Far East. ^[18],[19]

Memranous glomerulonephritis (MGN was reported in 10.93% of the study group. MGN was the predominant GN in two reports from United Arab Emirates and Iran. ^[20],[6]

The main limitations of our study were the lack of electron microscopy assessment as this service is not available yet in our hospital. Immunoflurescence staining was not routinely performed in every case for financial reasons. We analyzed the histopathological data obtained from the pathology department; unfortunately, some clinical and laboratory data were missing and that included body mass index, hepatitis and other serological tests as ANCA and anti-glomerular basement membrane. The lack of these data precludes detailed clinico-pathological correlation analysis that would be of benefit if they are available.

We do not have a national registry for renal biopsy. But, being a large tertiary referral center, our results might reflect to a large extent the current histopathologiacal pattern of GNs. However, multicenter studies with larger sample size from different parts of the country would give more accurate information on the incidence and frequency of GNs in Egypt.

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