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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 3  |  Page : 680-683
Spectrum of biopsy-proven kidney disease in children at a Jordanian Hospital

1 Pediatric Nephrology, Prince Hamzah Hospital, Amman, Jordan
2 Family Medicine, MOH, Amman, Jordan
3 Albasher Hospital, Amman, Jordan

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Date of Web Publication9-May-2014


To determine the patterns of renal disease among Jordanian children based on kidney biopsy results as well as correlating clinical presentation with histopathological diagnosis, we studied the medical records of 55 children who had kidney-biopsy kidney disease at the Prince Hamza Hospital from August 2006 to April 2012. The most common indication for biopsies was steroid-resistant nephrotic syndrome (25%), followed by steroid-dependent nephrotic syndrome (20%). The most common diagnosis of primary glomerular disease was minimal change disease (27%), followed by focal segmental glomerulosclerosis (21%), mesangioproliferative glomerulonephritis (12.7%) and IgA nephropathy (7.3%). The most common secondary renal disease was Henoch-Schonlein purpura (HSP) in 10.9% of the patients, followed by systemic lupus erythematosus in 9.1%. The kidney biopsy was normal in 3.6%. Cyclosporine protocol biopsy was performed in four (7.3%) patients. Gross hematuria after kidney biopsy occurred in 5.5% of cases; however, none of these patients required blood transfusion. Kidney biopsy is a safe procedure that needs to be performed once indicated and our results are comparable with those carried out elsewhere in Jordan. The study also shows the importance of establishing a national registry for pediatric renal disease.

How to cite this article:
Hadidi R, Hadidi M, alDabbas M. Spectrum of biopsy-proven kidney disease in children at a Jordanian Hospital. Saudi J Kidney Dis Transpl 2014;25:680-3

How to cite this URL:
Hadidi R, Hadidi M, alDabbas M. Spectrum of biopsy-proven kidney disease in children at a Jordanian Hospital. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2023 Feb 5];25:680-3. Available from: https://www.sjkdt.org/text.asp?2014/25/3/680/132238

   Introduction Top

Kidney biopsy is a relatively uncommon procedure in children when compared with adults. [3] Pediatric kidney biopsy does not exceed 10% of the total biopsies. [4] This difference is due to the fact that nephrotic syndrome in children is assumed to be minimal change disease (MCD), and steroid therapy is started and kidney biopsies are performed only in case of steroid-resistant or steroid-dependent nephrotic syndrome. [3] With the current availability of the automated, gun biopsy needles, a kidney biopsy is considered as a safe procedure. [12]

The main indications of renal biopsy in children include persistent microscopic hematuria with or without proteinuria, recurrent gross hematuria, steroid-dependent and steroid-resistant nephrotic syndrome, persistent low C3 in acute post-streptococcal glomerulonephritis, acute renal failure (ARF) of unknown etiology, nephritic-nephrotic presentation, cyclosporine protocol biopsy, renal involvement in systemic lupus erythematosus (SLE) and staging of Henoch-Schoenlein purpura (HSP) nephritis.

This study aimed at defining renal disease among Jordanian children based on kidney biopsy results as well as correlating clinical presentation with histopathological diagnosis.

   Materials and Methods Top

This is a retrospective analysis of all kidney biopsies performed at the Prince Hamza Hospital between the period 2006 and 2012. A total of 55 patients were included in the study. The medical records of all the patients were reviewed and the data were collected using a specially formulated form. Demographic data including age and gender of the patients, duration of renal disease since presentation, indication for kidney biopsy and histopathological findings as well as electron microscope and immunofluorescence were all recorded.

The patients were admitted to the pediatric ward one day before the procedure. Complete blood count, bleeding time, prothrombin and partial thromboplastin time were performed for all the patients. Conscious sedation and analgesia was used in our patients according to our local policy with Medazolam (0.1 mg/kg body weight) and intramuscular injection of Pethidine (1 mg/kg body weight) in addition to local infiltration with lidocaine 1% before the procedure. More recently, we started performing the biopsy under general anesthesia in all the children.

The procedure was carried out under complete aseptic techniques with the patients placed in the prone position, and after the radiologist confirmed the presence of both kidneys. Spring-loaded biopsy needles (gauge 16-18) were used for all the patients. Three samples were obtained from each patient: One for light microscopy collected in formalin, one for immunofluorescence (normal saline) and one for electron microscopy (glutaraldehyde). After the procedure, the children were observed for vital signs and any change in urine color for at least 6 h. Follow-up hemoglobin was also performed after 6 h for all the patients. The patients were discharged the next day with strict instructions to avoid heavy exercise for one week.

   Results Top

The total number of patient was 55; 31 male and 24 female (1.3:1). The age ranged from 1-13 years, and the most common indication for renal biopsy in our hospital was steroid-resistant nephrotic syndrome (25%), followed by steroid-dependent nephrotic syndrome (20%) [Table 1].
Table 1: Indication for kidney biopsy.

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The most common primary glomerular disease diagnosed by the renal biopsy was minimal MCD (27%), followed by focal segmental glomerulosclerosis (FSGS) (21%), membranoproliferative GN (MPGN) (12.7%), whereas IgA nephropathy comprised 7.3% [Table 2]. We noticed that MCD was more common in males, diagnosed in 12 of 15 (80%) patients, while focal segmental glomerulosclerosis (FSGS) was more common in females, diagnosed in eight of 12 (75%) patients. IgA nephropathy occurred only in males, while membranous glomerulonephritis was diagnosed only in two patients, both more than ten years of age.
Table 2: The renal biopsy results.

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The most common secondary renal disease was HSP, representing 10.9%, followed by SLE in 9.1%. The kidney biopsy was normal in 3.6% of the patients. Cyclosporine protocol biopsy was performed in four patients, and accounted for 7.3% of the patients; cyclosporine toxicity was observed in two of four patients (50%) [Table 2].

Gross hematuria as a complication of kidney biopsy was observed in three (5.5%) patients.

Blood transfusion was not needed in any patient, and all improved by encouraging adequate fluid intake orally and intravenously to ensure good diuresis. No major other complications were documented in our survey.

   Discussion Top

This report provides some insight to the frequency of biopsy-proven renal disease in the pediatric age group in our tertiary level hospital. There was a male predominance in kidney biopsy mostly due to the general male predominance in kidney disease, as it is elsewhere. [4],[10] The most common indication for kidney biopsy was nephrotic syndrome, both steroid dependent and steroid resistant, which is similar to other reports from our country. However, it was different from the developed countries, where isolated microscopic hematuria is the most common indication; this may be due to the difference in the selection criteria for kidney biopsy rather than the real difference in the distribution of renal disease. [4],[2],[10]

The most common primary glomerular disease in nephrotic children is MCD, which accounts for 90% of the nephrotic syndrome in children worldwide as reported by Foggo et al. [1] The three most common histopathologies in the nephrotic syndrome are MCD, FSGS, and MPGN, not necessarily in the same order. [3],[8],[9],[11],[12] Probably, the lower the threshold for performing kidney biopsy, the greater the chance of picking up cases of MCD, and this explains the difference in the results from our countries (Hazza et al, Saca et Al-Sabban). [2],[3],[4],[5]

There is an ongoing debate regarding the practice patterns of performing pediatric kidney biopsy. [3] Filler et reviewed 17 years' data of pediatric renal biopsy. They concluded that in spite of reports of increasing incidence of FSGS, there is no reason to change the initial therapy and current indications to perform renal biopsy in children. [6] Others recommended modifying the current practice of pediatric kidney biopsy to minimize the likelihood of kidney biopsy with MCD. Webb et al reviewed the childhood steroid-sensitive nephrotic syndrome. They concluded that pre-biopsy clinical courses do not predict the histological diagnosis. [7],[13]

From our study, we recommend to perform kidney biopsy when strongly indicated and of value in the further management and follow-up of the patients.

We conclude that nephrotic syndrome is the most common indication of biopsy in our children, and MCD is the most common pathology encountered in this disease entity. The spectrum of renal disease in Jordan is similar to the other countries in the region, and the threshold for renal biopsies should be raised as we have a large number of MCD in order to avoid unnecessary procedures in children.

   References Top

1.AB Fogo 2001 minimal change disease and focal segmental glomerulosclerosis. NDT 2001.  Back to cited text no. 1
2.Hazza I. Pediatric Renal Disease at King Hussein Medical Center: Experience with 69 Renal Biopsies. J Res Med Sci 2010;17(Supp 2):36-40.  Back to cited text no. 2
3.Absar A, Diamond M, Sonia Y, et al. Ten year experience of pediatric kidney biopsies from a single center in Pakistan. Indian J Nephrol 2010;20:190-2.  Back to cited text no. 3
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4.Saca E, Hazza I. Spectrum of pediatric glomerular disease (King Husssein Medical Center). Jordanian Royal Medical Services 2007;14:34-7.  Back to cited text no. 4
5.Al-Sabban E. Spectrum of Glomerular Disease Among Children in Saudi Arabia. Saudi J Kidney Dis Transpl 1997;8:285-8.  Back to cited text no. 5
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6.Filler G, Young E, Geier P, Carpenter B, Drukker A, Feber J. Is there really an increase in non-minimal change nephrotic syndrome in children? Am J Kidney Dis 2003;42:1107-13.  Back to cited text no. 6
7.Webb NJ, Lewis M, Iqbal J, Smart PJ, London M, Postlethwaite RJ. Childhood steroid sensitive nephrotic syndrome. Does the histology matters? Am J Kidney Dis 1996;27:484-8.  Back to cited text no. 7
8.Pio D, Figueiredo S, Silva P, et al. Conceicao Mota Renal biopsies in children. A twelve-year review. Port J Nephrol Hypert 2010;24:215-21.  Back to cited text no. 8
9.Rees L, Webb NJ, Brogan PA. Paediatric Nephrology, Oxford: Oxford Specialist Handbooks in Pediatrics; 2007. p. 194-7.  Back to cited text no. 9
10.Hamed R. The spectrum and outcome of primary glomerular disorders in 146 Jordanian children. Int Pediatr 2002;17(4):239-42.  Back to cited text no. 10
11.Batiniæ D, Sæukanec-Spoljar M, Miloseviæ D, et al. Clinical and histopathological characteristics of biopsy-proven renal diseases in Croatia. Acta Med Croatica 2007;61:361-4.  Back to cited text no. 11
12.Rahbar M. Kidney biopsy in west of Iran: Complications and histopathological findings. Indian J Nephrol 2009;19:68-70.  Back to cited text no. 12
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13.Kyrieleis HA, Löwik MM, Pronk I, et al. Long-term outcome of biopsy-proven, frequently relapsing minimal-change nephrotic syndrome in children. Clin J Am Soc Nephrol 2009;4: 1593-600.  Back to cited text no. 13

Correspondence Address:
Dr. Reem Hadidi
Pediatric Nephrology, Prince Hamzah Hospital, Amman
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.132238

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