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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA - AFRICA  
Year : 2018  |  Volume : 29  |  Issue : 1  |  Page : 140-144
Importance of renal biopsy in patients aged 60 years and older: Experience from a tertiary care hospital


1 Department of Pathology, Sir Ganga Ram Hospital, New Delhi, India
2 Department of Nephrology, Sir Ganga Ram Hospital, New Delhi, India

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Date of Web Publication15-Feb-2018
 

   Abstract 

As the life expectancy is increasing, there is a rise in elderly population and consequent increase in the patients with renal disease. There is an inconsistency between clinical and histopathological diagnosis in elderly, and so renal biopsy is important in these patients to decide appropriate clinical management and prognosis. This study outlines the importance of renal biopsy in elderly and describes the clinical and pathologic spectrum of renal diseases in patient ≥60 years. All patients (age ≥60 years) undergoing renal biopsies from January 2011 to December 2014 were included in this retrospective study. The clinical presentation and biochemical findings were recorded, and the patients were grouped based on their clinical presentation. Renal biopsies were also evaluated. The mean age of patients was 67.7 ± 6.4 years with a male:female ratio of 3:1. The most common clinical manifestation was nephrotic syndrome (37.4%) followed by rapidly progressive renal failure (RPRF) (20.6%). Amyloidosis and membranous nephropathy were two most common diagnoses in patients with nephrotic presentation whereas pauci-immune crescentic glomerulonephritis and cast nephropathy were common in patients presenting with RPRF. Clinical diagnosis differed from the histopathological diagnosis in 32% cases of nephrotic syndrome. There was good agreement between clinical diagnosis and histology in cases with RPRF. In 73% cases of elderly with (Type II) diabetes suspected of having nondiabetic renal disease clinically, renal biopsy showed evidence of diabetic nephropathy. Renal biopsy is essential in the diagnosis of renal diseases even in elderly. Amyloidosis and membranous nephropathy are common causes of nephrotic syndrome in elderly. Renal biopsy is very useful in diagnosing cast nephropathy and amyloidosis as they are not suspected clinically. It is also helpful in elderly diabetics without retinopathy to differentiate between diabetic and nondiabetic kidney diseases.

How to cite this article:
Gupta P, Rana DS. Importance of renal biopsy in patients aged 60 years and older: Experience from a tertiary care hospital. Saudi J Kidney Dis Transpl 2018;29:140-4

How to cite this URL:
Gupta P, Rana DS. Importance of renal biopsy in patients aged 60 years and older: Experience from a tertiary care hospital. Saudi J Kidney Dis Transpl [serial online] 2018 [cited 2021 Apr 16];29:140-4. Available from: https://www.sjkdt.org/text.asp?2018/29/1/140/225195

   Introduction Top


There is a progressive loss of renal mass and renal function in human beings as the age advances.[1] World over, elderly population is increasing at a rapid pace. In India, individuals ≥60 years accounted for 9.7% of total population in the year 2015 as compared to 7.6% in the year 2000.[2] In elderly, spectrum of renal disease differs as compared to younger population, secondary renal diseases being more common as compared to primary renal disorders.[3] It is observed that glomerulopathies account for up to 25% cases of renal diseases in elderly.[4] Kidney biopsy is considered to be a safe procedure even in elderly and yields valuable information which can help decide the patient management and prognosis.[5] Limited literature is available with respect to renal diseases in elderly. The present study highlights the importance of performing renal biopsy in elderly and describes pathological spectrum and clinical manifestation of renal diseases in elderly patients.


   Subjects and Methods Top


All patients (age ≥60 years) undergoing renal biopsies from January 2011 to December 2014 were included in this retrospective study. Patients with inadequate renal biopsy (<10 glomeruli) were excluded from the study. The clinical presentation, biochemical findings, and urine examination findings of these patients were obtained from electronic records and case files. The patients were grouped based on their clinical presentation and laboratory results into (1) nephrotic syndrome which is characterized by edema, and proteinuria (>3.5 g/day) along with hypoalbuminemia, hypercholesterolemia, and/or coagulopathy; (2) rapidly progressive renal failure (RPRF) which is rapid deterioration in renal function, defined as doubling of serum creatinine or a 50% decrease in glomerular filtration rate (GFR) over a period of three months or less; (3) acute renal failure (ARF) which is abrupt decrease in renal function, resulting in retention of nitrogenous waste in the body; (4) chronic renal failure (CRF) is a kidney damage for three months or longer in the form of structural or functional abnormalities of kidney, with or without decreased GFR manifested by pathological abnormalities, abnormalities in composition of blood or urine, or in imaging tests; (5) nephritic syndrome is clinically patients have hypertension and edema along with hematuria, proteinuria, and dysmorphic red blood cells and/ or red blood cell casts; and (6) asympto-matic proteinuria wherein patients with subnephrotic range proteinuria with or without renal failure.

Renal biopsies stained with routine histochemical stains (hematoxylin and eosin, periodic acid Schiff, and periodic acid silver methenamine) were retrospectively evaluated by renal pathologist, and findings were recorded with respect to glomerular morphology, tubular, interstitial, and vascular changes. The tubular atrophy and interstitial fibrosis were semi-quantitatively graded [mild (<25%), moderate (25%–50%), and severe (>50%)]. The results of direct immunofluorescence performed on cryostat sections [immunoglobulins (IgG, IgM, and IgA), complements (C3 and C1q), and kappa and lambda light chains] were available in all cases.

The data were expressed in terms of mean ± standard deviation wherever required. The data were analyzed on Statistical Package for Social Sciences (SPSS) version 20.0 (SPSS Inc., Chicago, IL, USA).


   Results Top


A total of 1260 patients underwent indication renal biopsies at our center between January 2011 and December 2014. One hundred nine patients were ≥60 years of age, accounting for 8.7% of total biopsies. Only three of the patients suffered from postbiopsy complications (2.7%) in the form of gross hematuria. Two patients with inadequate renal biopsy were excluded from the study. The mean age of patients was 67.7 ± 6.4 years (range: 60–85 years). The male to female ratio was 3:1.

The most common clinical manifestation was nephrotic syndrome (37.4%) followed by RPRF (20.6%) and nephritic syndrome (15%). The distribution of patients in various clinical syndromes is given in [Table 1].
Table 1: Clinical manifestation of elderly patients undergoing renal biopsy (n =107).

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Among the patients with nephrotic presentation [Table 2], the mean 24 h urine protein level was 5.3 ± 3.19 g. Amyloidosis (10 amyloid A [AA], 6 amyloid light-chain amyloidosis) was the most common histological diagnosis accounting for 40% cases followed by membranous nephropathy (27.5%). Diabetic nephropathy, minimal change nephropathy, and focal segmental glomerulosclerosis were other causes of nephrotic range proteinuria. All the patients with diabetic nephropathy had nodular (Kimmelstiel-Wilson nodule) glomerulosclerosis with mild to moderate tubular atrophy and interstitial fibrosis.
Table 2: Histological diagnosis in cases with nephrotic presentation (n =40).

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Among the patients presenting with RPRF, the mean serum creatinine level was 3.58 ± 1.48 mg/dL. Pauci-immune crescentic glome- rulonephritis was the most common histo- logical diagnosis followed by cast nephro- pathy. The distribution of these cases is highlighted in [Table 3]. Majority of the cases were c-ANCA positive (83%) and only 17% were pANCA positive. All these cases had crescents in >50% of total glomeruli with no immune complex deposits on immunofluorescence and normal serum compliments. There was a single case of antiglomerular basement membrane disease with linear IgG positivity along glomerular capillary basement membrane on immunofluorescence and raised serum anti-GBM antibody levels.
Table 3: Histological diagnosis in cases with rapidly progressive renal failure (n = 22).

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Among the patients with ARF, renal biopsy showed evidence of acute tubular injury and acute interstitial nephritis (AIN) in three cases each. All three patients with AIN had a history of nonsteroidal anti-inflammatory drug intake.

Majority of patients with nephritic presentation (10/16) had membranoproliferative glomerulonephritis (MPGN Type I) followed by IgA nephropathy (5/16) and lupus nephritis (1/16). Patients with MPGN had reduplication of glomerular capillary basement membrane with endocapillary and mesangial proliferation along with granular IgG and C3 capillary wall and mesangial deposits on immunofluorescence and low serum C3 and C4 levels. In patients with IgA nephropathy, serum C3 and C4 levels were normal along with IgA and C3 mesangial deposits. Single case of lupus nephritis had diffuse proliferative glomerulonephritis with low serum C3 and C4 levels and full house pattern on immunofluorescence.

In the group with CRF, three patients were diagnosed to have chronic interstitial nephritis (3/13). Remaining patients had diffuse global glomerulosclerosis on biopsy without any specific deposits on immunofluorescence (10/13).

Thirteen patients had subnephrotic range proteinuria with or without renal failure. Eleven of these patients had evidence of diabetic nephropathy (8 with nodular pattern and 3 with diffuse pattern) and two patients had features of benign nephrosclerosis on renal biopsy. The mean 24 h urine protein levels were 1.45 ± 0.49 g and mean serum creatinine levels were 1.56 ± 0.8 mg/dL.

In 32% cases of nephrotic syndrome, clinical diagnosis differed from the histopathological diagnosis. These patients were diagnosed as amyloidosis or diabetic nephropathy on renal biopsy and were not suspected clinically. In 73% cases of (Type II) diabetes with asymptomatic proteinuria, nondiabetic kidney disease was suspected clinically based on the absence of diabetic retinopathy. However, renal biopsy in all these patients showed evidence of diabetic nephropathy. There was a good agreement between clinical diagnosis and histology in cases with RPRF (91%), ARF (100%), CRF (80%), and nephritic presentation (81%).


   Discussion Top


In elderly patients, many cases of primary glomerular diseases can be missed clinically as similar symptoms can be attributed to systemic disorders such as diabetes and hypertension.[5] Many cases of plasma cell proliferative disorders such as amyloidosis and myeloma are first picked up based on renal biopsy examination. It is also known that clinical presentation in elderly patients with renal disease does not frequently correlate with the histopathology findings.[6] It is, therefore, essential to perform a kidney biopsy for arriving at a correct diagnosis and planning appropriate clinical management for these patients. According to a study by Uezono et al, nephrotic syndrome is most common clinical presentation in elderly followed by ARF/rapidly progressive renal failure as compared to younger adults in whom nephritic syndrome is the most common presentation.[7] In our study also, nephrotic syndrome and RPRF were first and second most common clinical presentation in elderly patients with renal diseases. In another Indian study on individual ≥60 years, CRF was the most common clinical presentation followed by ARF and nephrotic syndrome.[4]

In elderly patients, membranous nephropathy and diabetic nephropathy are considered to be the most common causes of nephrotic syndrome.[4] However, few recent studies have shown different observations. Harmankaya et al in their study on elderly population have shown AA amyloidosis and membranous nephropathy to be the most common causes of nephrotic syndrome.[8] In the present study also, AA amyloidosis was the most common cause of nephrotic syndrome followed by membranous nephropathy. To the best of our knowledge, no other study from Asian subcontinent has described amyloidosis to be the most common cause of nephrotic syndrome in elderly.

Crescentic glomerulonephritis is responsible for about 50% cases of RPRF in elderly patients.[9],[10] In a study by Kohli et al, discordance was seen between clinical diagnosis and histopathology in 42% of RPRF.[5] In our study, pauci-immune crescentic glomerulonephritis accounted for 54% cases of RPRF with a concordance of 91% between clinical and histopathological diagnosis. Renal biopsy showed cast nephropathy in 27.3% cases of RPRF and provided the first clue for diagnosing myeloma in these clinically unsuspected patients.

In our study, MPGN was the most common cause of nephritic syndrome in elderly population followed by IgA nephropathy as compared to study by Harmankaya et al, in which crescentic glomerulonephritis was the most common cause.[8]

Studies have shown that type II diabetics without retinopathy can have nondiabetic kidney disease in up to 30% cases.[11],[12] Renal biopsy is also helpful in such patients to differentiate between diabetic and nondiabetic kidney diseases. In our study, eight of 11 elderly patients with type II diabetes and asymptomatic proteinuria were suspected to have nondiabetic kidney disease. However, histopathology confirmed a diagnosis of diabetic nephropathy instead of primary glomerular disease, thereby preventing unnecessary immunosuppression.


   Conclusion Top


Renal biopsy can be considered as a useful modality in diagnosis of renal diseases and planning appropriate management in elderly population without any significant complications. In our experience, renal biopsy is useful in elderly patients to diagnose amyloidosis and cast nephropathy in clinically unsuspected cases, thereby preventing unwanted immunosuppression. Amyloidosis and membranous nephropathy are the major causes of nephrotic syndrome whereas pauci-immune crescentic glomerulonephritis and cast nephropathy are the most common histological diagnosis in elderly patients presenting with RPRF. Renal biopsy is also useful in elderly diabetics to differentiate between diabetic and nondiabetic kidney diseases.

Conflict of interest: None declared.

 
   References Top

1.
Tauchi H, Tsuboi K, Okutomi J. Age changes in the human kidney of the different races. Gerontologia 1971;17:87-97.  Back to cited text no. 1
    
2.
United Nations. ESA/P/WP.241. Department of Economics and Social Affairs, Population Division 2015. World Population Prospects: The 2015 Revision, Key Findings and Advance Tables. United Nations; 2015.  Back to cited text no. 2
    
3.
Samiy AH. Renal disease in the elderly. Med Clin North Am 1983;67:463-80.  Back to cited text no. 3
    
4.
Prakash J, Saxena RK, Sharma OP, Usha. Spectrum of renal diseases in the elderly: Single center experience from a developing country. Int Urol Nephrol 2001;33:227-33.  Back to cited text no. 4
    
5.
Kohli HS, Jairam A, Bhat A, et al. Safety of kidney biopsy in elderly: A prospective study. Int Urol Nephrol 2006;38:815-20.  Back to cited text no. 5
    
6.
Nair R, Bell JM, Walker PD. Renal biopsy in patients aged 80 years and older. Am J Kidney Dis 2004;44:618-26.  Back to cited text no. 6
    
7.
Uezono S, Hara S, Sato Y, et al. Renal biopsy in elderly patients: A clinicopathological analysis. Ren Fail 2006;28:549-55.  Back to cited text no. 7
    
8.
Harmankaya O, Okuturlar Y, Kocoglu H, et al. Renal biopsy in the elderly: A single-center experience. Int Urol Nephrol 2015;47:1397- 401.  Back to cited text no. 8
    
9.
Haas M, Spargo BH, Wit EJ, Meehan SM. Etiologies and outcome of acute renal insufficiency in older adults: A renal biopsy study of 259 cases. Am J Kidney Dis 2000;35:433-47.  Back to cited text no. 9
    
10.
Schena FP. Survey of the Italian registry of renal biopsies. Frequency of the renal diseases for 7 consecutive years. The Italian group of renal immunopathology. Nephrol Dial Transplant 1997;12:418-26.  Back to cited text no. 10
    
11.
Christensen PK, Larsen S, Horn T, Olsen S, Parving HH. Causes of albuminuria in patients with type 2 diabetes without diabetic retinopathy. Kidney Int 2000;58:1719-31.  Back to cited text no. 11
    
12.
Brocco E, Fioretto P, Mauer M, et al. Renal structure and function in non-insulin dependent diabetic patients with microalbuminuria. Kidney Int Suppl 1997;63:S40-4.  Back to cited text no. 12
    

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Correspondence Address:
Dr. Pallav Gupta
Department of Pathology, Sir Ganga Ram Hospital, New Delhi - 110 060
India
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DOI: 10.4103/1319-2442.225195

PMID: 29456220

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