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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2015  |  Volume : 26  |  Issue : 4  |  Page : 810-815
Indications and results of renal biopsy in children: A single-center experience from Morocco

1 Department of Pediatrics, Hassan II University Hospital; Faculty of Medicine and Pharmacy, Sidi Mohamed Ben Abdellah University, Fez, Morocco
2 Department of Nephrology, Hassan II University Hospital, Fez, Morocco
3 Department of Pathology, Hassan II University Hospital, Fez, Morocco
4 Department of Pediatrics, Hassan II University Hospital, Fez, Morocco

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Date of Web Publication8-Jul-2015


The contribution of renal biopsy (RB) is of major importance in the management of many renal diseases in children. Specific indications for performing biopsy in children include steroid-resistant nephrotic syndrome (NS) and secondary nephropathies. The aim of our study was to report the common histological varieties of kidney diseases in children in Morocco. In this retrospective and descriptive study, we included all renal biopsies performed in patients under 16 years in the Department of Pediatrics of Hassan II University Hospital, Fez, Morocco from July 2009 to December 2013. Biopsy samples without glomeruli and those with less than five glomeruli or repeat biopsies on the same patient were excluded from our study. We performed 112 RBs during this period; the average age at the time of RB was 10.05 ± 4 years and the sex-ratio was 1.07. The indications for RB were NS with hematuria and/or renal failure (RF) in 32.1%, active urinary sediment in 21.4%, isolated NS in 15.2%, RF in 13.4% and steroid-resistant NS in 10.7% of cases. Primary nephropathies represented 59.8% of cases, with a predominance of minimal change disease (MCD) seen in 40.2% of the cases. Secondary nephropathies accounted for 27.7% of the cases, with a predominance of lupus nephritis (11.6%), followed by Henoch-Schonlein purpura nephritis (6.2% of cases) and post-streptococcal glomerulonephritis (3.6%). There was one case of hepatitis B virus-associated membranous glomerulonephritis. Chronic glomerulonephritis accounted for 12.5% of the cases. Vascular and tubulo-interstitial nephritis were rare. Our study confirmed that primary glomerular nephropathy was the most common renal disease in children. The most common lesion was MCD. Secondary nephropathies were less frequent, with a predominance of lupus nephritis.

How to cite this article:
Souilmi FZ, Houssaini TS, Alaoui H, Harmouch T, Atmani S, Hida M. Indications and results of renal biopsy in children: A single-center experience from Morocco. Saudi J Kidney Dis Transpl 2015;26:810-5

How to cite this URL:
Souilmi FZ, Houssaini TS, Alaoui H, Harmouch T, Atmani S, Hida M. Indications and results of renal biopsy in children: A single-center experience from Morocco. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2023 Feb 6];26:810-5. Available from: https://www.sjkdt.org/text.asp?2015/26/4/810/160225

   Introduction Top

Renal biopsy (RB) plays a major role in the management of pediatric kidney diseases. It especially helps to identify glomerular diseases that are a major cause of chronic kidney disease in developing countries. [1],[2] In pediatric practice, there are very precise indications for performing kidney biopsy: They include steroid-resistant nephrotic syndrome (NS) and secondary nephropathies. In this study, we aimed to evaluate the indications for performing renal biopsy and the spectrum of renal histopathological findings in a tertiary care pediatric nephrology center in Morocco.

   Subjects and Methods Top

Our study was descriptive and retrospective. We included all renal biopsies performed in the Pediatric Department of the Hassan II University Hospital, Fez, Morocco, from July 2009 to December 2013, in children under 16 years.

All biopsies were performed using a percutaneous automated spring-loaded biopsy instrument (Bard Magnum, 16 or 18 Gauge) under ultrasound guidance. The procedure was performed after obtaining informed consent from the families of the patients. The samples were studied under light and immunofluorescent microscopy in the pathology laboratory of the Hassan II University Hospital, Fez. Immunofluorescence staining using polyclonal anti-sera against human IgG, IgM, IgA, C3, C4, C1q and, if indicated, kappa and lambda light chains were employed. Electron microscopy was not performed on any of the samples. Biopsy samples with absence of, or presence of less than five glomeruli, or repeat biopsies on the same patient were excluded from our study. We defined steroid-resistant and steroid-dependent NS according to the French recommendations. [3] Abnormalities of urinary sediment included the presence of casts and/or microscopic hematuria and/or leukocyturia. Lupus nephritis (LN) was classified according to the recommendations of the International Society of Nephrology (ISN/RPS 2003). [4] Clinical data were collected from the medical records of patients at the Department of Pediatrics. Data were processed for descriptive analysis using the statistical software (SPSS 17.0 statistics) under license from the Faculty of Medicine and Pharmacy of Fez.

   Results Top

During the study period of 54 months, a total of 127 kidney biopsies were performed, of which 112 were selected for the study. The success rate of procuring adequate renal biopsy samples was 88.2%. Biopsy was performed under sedation in 86% of the cases and under local anesthesia in the remaining cases. The mean age of the study cases was 10.05 ± 4 years (range 2 months to 16 years). Children aged 13 years and older accounted for 41.9% of the cases and those aged six to 12 years represented 35.7% of the cases [Figure 1]. The sex-ratio was 1.07 (58 M/54 F). The main indications for renal biopsy were the following: NS with hematuria and/or renal failure (RF) in 32.1% of the cases, isolated NS in 15.2% of the cases, steroid-resistant NS in 10.7% of the cases, congenital or infantile NS in 5.4% of the cases, abnormal urinary sediment in 21.4% of the cases and RF in 13.4% of the cases [Figure 2]. Among cases with isolated NS, RB was performed for age above 12 years in 14 cases, high-dose steroid-dependent NS in two cases and associated extra-renal signs in one case. RB was performed for abnormal urinary sediment in 20 cases (17.9%), of whom 13 cases (11.6%) had systemic lupus erythematous (SLE) and seven cases (6.3%) had Henoch- Schönlein purpura (HSP). Isolated hematuria was the indication in 3.6% of the renal biopsies performed.
Figure 1: Distribution of patients according to age and gender.

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Figure 2: Indications for renal biopsy by gender.

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Primary glomerulonephritis (GN) was diagnosed in 59.8% of the cases and was most common in males (53.7%), whereas secondary GN was diagnosed in 27.7% of the cases and was more common in females (70.9%). Chronic GN was diagnosed in 12.5% of the patients.

The most frequently encountered GN on histopathology was MCD (40.2%), followed by chronic GN in 12.5% of the cases, LN in 11.6% of the cases and focal and segmental glomerulosclerosis (FSGS) and IgA nephropathy in 8% of the cases each [Table 1].
Table 1: Pathological results in our series.

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Among cases with primary GN, apart from the MCD and FSGS, there was mesangial hyperplasia in four cases and IgA nephropathy in two cases. LN was the most common secondary GN, with predominance of female gender (77%) and in children older than 10 years (77%). LN was proliferative (class 3 or 4) in 54% of the cases. HSP nephritis was seen in 6.2% and acute post-streptococcal GN in 3.6% of cases. Membranoproliferative GN (MPGN) was diagnosed in five cases (4.5%), and two of them were secondary to sickle cell disease and infection. There were four cases (3.6%) of membranous glomerulonephritis (MGN). One of them was associated with hepatitis B virus. Vascular and tubulo-interstitial nephritis were distributed as follows: Hemolytic uremic syndrome (HUS) in 1.8% and glomerulosclerosis, tubular necrosis and diffuse interstitial fibrosis in 0.9% of cases each.

   Discussion Top

RB is an essential diagnostic tool for histological diagnosis of glomerular and tubulo-interstitial diseases. It allows to classify nephropathies to tailor a therapeutic approach to histopathological lesions and to assess the prognosis of the disease. [5],[6] Knowledge of the epidemiology of renal disease in children and clinicopathological correlations provides important information in pediatric nephrology. [7] One of the difficulties in determining the epidemiological situation of GN in Morocco is the lack of national registries for both adult and pediatric populations. [8]

In our study, the success rate of RBs in obtaining an adequate sample (88.2%) was comparable to reports from other authors. [9],[10],[11] The mean age of our patients was in accordance with the range reported in the literature (9-11.5 years). [7],[9],[10],[12],[13],[14] Patients aged between 13 and 16 years accounted for the majority of the cases (41.9%), followed by those aged between 6 and 12 years (35.7%). These data were comparable to other reports, with 31% aged between six and 10 years and 48% aged between 11 and 14 years. [9],[15]

In our series, as in most other surveys, there was a slight male predominance, with a sex-ratio of 1.07. This is partly due to the general masculine predominance in kidney diseases, especially in children. [14] In most published studies in children, NS was the main indication for RB, ranging from 28.5% to 62.9% of cases, and represented 63.4% in our series. [10],[13],[14] In other studies from Italy and England, proteinuria was the most common indication for renal biopsy, while in a recent study from Hong Kong, systemic diseases were the most common indications. [10],[15]

Our findings of the frequency of other indications for RB, such as abnormal urinary sediment in association with systemic diseases (16%) and RF (17.5%), were comparable to that reported by Printza et al. [9] Isolated hematuria was uncommon in our series (3.6%), but was an important cause (32% of cases) or the main indication (75% of cases) for RB in other studies, especially in Europe and Asia. [9],[16] This could be related to the lack of systematic dipstick screening in children in Morocco. Primary kidney disease in children was more frequent (two-thirds of cases) than secondary nephropathy (nearly one-third of cases) in our series. These results were similar to those reported by most other authors (59.8% and 25.4% in the Czech Republic, 69% and 31% in Greece, 64% and 17.3% in Serbia and 66% and 34% in Hong Kong). [9],[10],[15],[16] Primary GN was predominant among boys while secondary GN was predominant among girls. [15],[16]

As in our study, MCD was the predominant pathologic lesion among primary GN in other studies from Iran, Jordan and Hong Kong. [12],[14],[15] European studies have found more lesions of FSGS as the main pathological form of idiopathic NS, followed by MCD and mesangial cell hyperplasia. [9],[7],[17] The prevalence of FSGS in idiopathic NS in children is increasing according to various studies. This increase appears to be related to socio-economic changes, increased obesity and improved histological analysis. African-American and Chinese ethnic origins and intrauterine growth restriction are also predisposing factors. [10],[15],[18]

IgA nephropathy was the most common primary renal disease in the world, whether in Europe (Spain, Italy, England) or Asia. [15],[19],[20] Its frequency varied widely depending on the race and ethnic composition of the study populations. [9] It was rare in our series (two cases), as in Saudi Arabia. [21]

In secondary nephropathies, LN and HSP nephropathy were the two main reported causes with variable frequency and distribution across studies. [7],[9],[10],[12],[13],[14],[19] The incidence and severity of lupus in children was variable depending on ethnicity, which makes the comparison of specific studies in each population inconclusive. It seems likely that Asians, Blacks and Hispanics were more frequently affected than Caucasians. [22] In our study, LN was the most common secondary GN among girls over 10 years, followed by HSP nephropathy in boys, which corresponded to the results of Serbian, Chinese and Pakistani studies. [10],[15],[23] LN was more common in children than in adults. It was present in two-thirds of cases early in the disease or at diagnosis of SLE. [24] Diffuse proliferative LN (class IV) was found in approximately 20% of children biopsied for SLE regardless of disease activity. [9],[22] In our series, four patients (30.7%) had class IV LN.

HSP was the most common vasculitis in children. It accounted for 6.3% of RBs in our series and for 11.6-18.8% of all biopsies in children in Italy and 19.2% in the Czech Republic. [7] In the United States, it was responsible for 49% of vasculitis in children. HSP nephropathy occurred in 60% of cases in the form of hematuria and/or proteinuria, NS or even RF. [25]

The frequency of occurrence of acute poststreptococcal GN in our series was consistent with that of studies conducted in Jordan (5.5% of cases) or Greece (6% of cases) and was higher in Pakistan (10.6%), while this entity has become very uncommon in developed countries. [7],[10],[12],[17] In patients with chronic kidney disease, renal biopsies diagnosed lesions of chronic GN in 92.9% of cases in our series and in 62.5% of cases in the series of Coppo et al. [19] The large percentage of chronic GN in our study compared with the European data (1.9%) [10],[19] could be due to a delay in diagnosis and management of renal disease in children. Vascular and interstitial nephritis were rarely found in most series. [9],[10],[23]

   Conclusion Top

This study provided epidemiological data on the pathological profile of nephropathy in Moroccan children at a tertiary care center. We conclude that NS was the major indication for RBs and that primary GN was most common in children. MCD was the major pathological pattern. Early diagnosis of kidney disease in children is necessary given the number of cases of chronic kidney disease diagnosed at very late stages.

   Acknowledgments Top

The authors would like to thank the Department of Radiology and the Department of Anesthesiology and Reanimation, Hassan II University Hospital of Fez, Morocco.

   References Top

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Correspondence Address:
Fatima Zohra Souilmi
Department of Pediatrics, Hassan II University Hospital, Fez
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.160225

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