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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2019  |  Volume : 30  |  Issue : 5  |  Page : 1144-1150
Pattern of biopsy-proven kidney diseases: experience of a teaching hospital in Bahawalpur, Pakistan

1 Department of Nephrology, Quaid-e-Azam Medical College, Bahawal Victoria Hospital, Bahawalpur, Pakistan
2 Department of Radiology, Quaid-e-Azam Medical College, Bahawal Victoria Hospital, Bahawalpur, Pakistan
3 Department of Medicine, Quaid-e-Azam Medical College, Bahawal Victoria Hospital, Bahawalpur, Pakistan

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Date of Submission22-Dec-2018
Date of Acceptance22-Jan-2019
Date of Web Publication4-Nov-2019


This descriptive observational study was conducted at the Department of Nephrology, Bahawal Victoria Hospital, Bahawalpur, Pakistan, from January 2012 to April 2018, to study the pattern of biopsy-proven kidney diseases in that region as a part to establish a national renal biopsy registry. All adult patients who underwent renal biopsy at the Bahawal Victoria Hospital, Bahawalpur, Pakistan, from January 2012 to April 2018, were included in the study. All the biopsies were evaluated by light microscopy and immunofluorescence. All the patients underwent urine dipstick, microscopic examination, and quantification of proteinuria. Hepatitis B surface antigen, anti-hepatitis C virus, human immunodeficiency virus, and serology (antinuclear antibody, anti-ds DNA, and C3 and C4) were checked in all the patients. There were a total of 195 patients, with a mean age of 30.5 ± 12.8 years. Females were comparatively younger than males (P = 0.0154). Primary glomerulonephritis (GN) accounted for 77% (155) of all the patients, whereas secondary GN contributed 15.8%. Focal and segmental glomerulosclerosis (FSGS) was the most common diagnosis (28.2%) followed by membranous nephropathy (MN) (18.9%). Lupus nephritis was the third-most common pathology, and it predominated among females (P= 0.0026). Out of the eight diabetic patients, one each had FSGS and crescentic GN. In conclusion, primary glomerular diseases were the predominant biopsy-proven kidney diseases, and FSGS and MN were the most common glomerular diseases. This pattern in South Punjab closely resembles that in southern and northern parts of the country.

How to cite this article:
Malik SI, Idrees MK, Naseem K, Sadiq S, Raza SH, Ahmad Fu. Pattern of biopsy-proven kidney diseases: experience of a teaching hospital in Bahawalpur, Pakistan. Saudi J Kidney Dis Transpl 2019;30:1144-50

How to cite this URL:
Malik SI, Idrees MK, Naseem K, Sadiq S, Raza SH, Ahmad Fu. Pattern of biopsy-proven kidney diseases: experience of a teaching hospital in Bahawalpur, Pakistan. Saudi J Kidney Dis Transpl [serial online] 2019 [cited 2021 Oct 18];30:1144-50. Available from: https://www.sjkdt.org/text.asp?2019/30/5/1144/270271

   Introduction Top

The pattern and prevalence of kidney diseases in general and glomerular diseases in particular widely vary across the globe depending on environmental, genetic, and socioeconomic factors. Kidney diseases are common in Pakistan, and patients usually present late when disease is already advanced. The use of herbal, homeopathic, and traditional remedies and use of potentially nephrotoxic drugs prescribed by quacks and semi-trained medical professionals add more insult to the kidneys and the overall health of patients. By the time patients present to nephrologist, the disease is already advanced.[1] Renal biopsy remains the gold standard for the diagnosis of primary glomerulonephritis (GN) with immunofluorescence (IF) and electron microscopic examination.[2] The most common indication for renal biopsy is unexplained elevation of renal parameters and proteinuria. Initially, it was quite difficult to convince the patients for kidney biopsy in most parts of Pakistan, but with continued efforts, this diagnostic tool has become more acceptable to the public as compared to few decades ago.

The epidemiology of nephrotic syndrome has shown dramatic fluctuations in etiology, and there is a racial and age preference for some types of nephropathies which could represent a change in the disease pattern or better understanding of glomerular disorders.[3] Apart from genetic profile, environmental factors and prevalence of infectious diseases may attribute to socioeconomic and demographic differences seen in the patterns of glomerulopathy.

Due to the absence of national renal data registry, the exact prevalence and pattern of glomerular diseases in Pakistan are not known. It is only recently that the Pakistan Society of Nephrology has announced to start Pakistan Renal Data System.[4] Till now, most of the data were confined to institution-/hospital-based studies. In 1988, Jamal et al[5] reported that out of 1508 percutaneous renal biopsies, 75% had primary glomerular diseases, and minimal change disease (MCD) accounted for 29% followed by membranous nephropathy (MN) (25%), while focal and segmental glomerulosclerosis (FSGS) was the least common primary glomerular disease. Over the last few years, a changing pattern of glomerular diseases has been noted.[6] MN was the most common cause of adult nephrotic syndrome in the Western world till few years ago, but now, FSGS has become the most common glomerular disease in African-Americans and Hispanic populations.[7] A few studies from Pakistan and India have noted an increasing incidence of FSGS emerging as the leading cause of primary GN over the last decade.[8],[9],[10]

Most of the studies based on kidney biopsies are reported from big cities of Pakistan (Islamabad, Lahore, Karachi, and Peshawar), and there is no study from South Punjab and adjoining areas of Sindh. This study was designed to determine the clinical presentation and laboratory and pathological features of patients who underwent renal biopsy and were followed up at our center. As planning and rationing of the resources require specific knowledge of the renal diseases in a given population, our study may also help in defining the pattern of kidney disease and allocation of funds in this part of the country.

   Patients and Methods Top

All patients on regular follow-up at the nephrology outpatient department (OPD) (Kidney Center OPD) of Bahawal Victoria Hospital, Bahawalpur, Pakistan, from January 2012 to April 2018, and who had undergone renal biopsy at our institution, were included in the study. This teaching hospital caters to most of the referrals from South Punjab and has the biggest dialysis and nephrology unit in the region. Written informed consent was obtained from the participants, and the study was approved by the institutional ethical review board of the Quaid-e-Azam Medical College, Bahawalpur, Pakistan. Detailed history and physical exami-nation were carried out and recorded on initial visit and updated at each follow-up visit. All patients (if not anuric) underwent quantification of 24-h urinary protein excretion. The baseline tests performed in all patients included serum urea, creatinine, electrolytes, total proteins, serum albumin, hemoglobin, and coagulation profile. Serology including complement levels (C3 and C4), hepatitis B surface antigen and anti-hepatitis C virus antibody, human immunodeficiency virus antibodies, anti-nuclear antibody, anti-dsDNA, rheumatoid arthritis factor, and anti-streptolysin O titer were also tested. Antineutrophilic cytoplasmic antibodies (cANCa and pANCA) and anti-GBM antibodies were checked, when indicated.

Two cores of native kidney tissue were routinely obtained under ultrasonographic guidance using Bard® Monopty disposable core biopsy instrument (biopsy gun) for histopathologic evaluation: one core was fixed in 10% neutral buffered formalin for light microscopy and the other core was put into an optimal cutting temperature containing capsule and snap frozen in liquid nitrogen for IF study. All the biopsies were evaluated and reported by the same histopathologist.

All the data were entered and analyzed using Microsoft Excel 2010. Descriptive statistics including mean ± standard deviation or median/range for continuous variables such as age, serum creatinine, and proteinuria and numbers (percentages) were used to describe the proportion of categorical variables such as sex. Chi-square test was used to compare the frequency of different parameters among the various groups, P <0.05 was considered statistically significant.

   Results Top

There were 195 patients in the study, with a mean age of 30.5 ± 12.8 years and males outnumbered females [Table 1]. The age of the study patients ranged from 14 to 68 years, with females being comparatively younger than males (sP = 0.0154). Twenty-four percent of the patients had hypertension (persistently high blood pressure, detected at presentation and con-firmed later). Edema was the most common presentation (66%), whereas 24.6% of the patients had hematuria (including both gross and microscopic). Nearly 20% of the patients were found to have proteinuria/renal dysfunction/microscopic hematuria during routine laboratory investigation for other reasons (medical examination for job or annual checkup). Serum albumin was statistically significantly lower among female than male patients (P = 0.0160).
Table 1: Demographics of the study patients.

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All these patients underwent ultrasound-guided renal biopsy. Biopsy was performed in patients with no evidence of coagulopathy as determined by prothrombin time, partial thromboplastin time, and stable blood pressure (up to 140/80 mm Hg), and one unit of cross-matched blood was arranged. After the procedure, the patients remained in bed, flat on their back for 6 h, and remained in the hospital for 24 h. Overall, it was a safe procedure with few complications. None required exploration/ nephrectomy, whereas hematuria was noticed in 14 patients who required bladder irrigation to prevent clot retention. Five patients required blood (packed cell) transfusion because of drop in hemoglobin. These patients had renal dysfunction and developed gross hematuria after biopsy. Minor complaints such as local pain or discomfort resolved with analgesics, and patients with persistent pain had repeat ultrasound to rule out perinephric hematoma.

Primary glomerulopathies accounted for the highest number of patients (150 of 195, 77%), with FSGS and MN being the most frequent pathologies [Table 2]. Among secon-dary glomerular diseases, lupus nephritis (LN) was the most common accounting for 8.7% of all the patients followed by secondary amyloidosis and diabetic nephropathy (DNP). LN was found more frequently in females, and this difference was statistically significant (P = 0.0026). Eight patients with diabetes mellitus (DM) underwent renal biopsies because of unusual features such as hematuria, rapid decline in kidney function, and nephrotic range proteinuria, not concordant with the duration of DM. Of these diabetic patients, six had histopathologic features of DNP, whereas one each had FSGS and crescentic GN.
Table 2: Presentation and histopathologic diagnoses.

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   Discussion Top

To the best of our knowledge, this is the first report of biopsy proven renal diseases (BPRDs) from the southern part of Punjab (Pakistan). Although the number of biopsies was small during the initial three years, since 2017, it has increased with the expansion of nephrology services in our hospital. Males outnumbered females as in other studies from the country, mainly due to social deprivation of females. The mean age of females was significantly less than that of males. There are conflicting reports of the effect of age and gender on the prevalence of biopsy-proven kidney diseases. A study from Canada[11] found that females comprised one-third of all the patients with GN and were on average two years younger than males.

Primary glomerular diseases comprised 77% of our study population. It is close to the 73% primary GN reported by Mubarak et al.[8] It is not surprising that nephrotic syndrome was the most common indication of renal biopsy in our study. FSGS was the most common primary GN and constituted 28% of the study population followed by MN (18.9%). This concurs with the reports of the rising prevalence of FSGS in the Pakistani population.[8],[12] There is a distinct shift in the pattern of glomerular diseases over time because earlier reports showed higher prevalence of membranous and membranoproliferative GN (MPGN), and FSGS accounted for a small number of patients.[13],[14]

Chronic sclerosing GN was found in about 8% of patients. Half of these patients had renal dysfunction with normal-sized kidneys at presentation, representing delayed presentation to nephrology services which is a common phenomenon in this part of world.[1] Mesangio-proliferative GN, having mesangial proliferation with negative IF and serology, accounted for 6.1% of cases. Its prevalence is highly variable across the globe.[8] Eight patients (4.1%) had crescentic GN. The majority of these patients had renal dysfunction ([acute kidney injury (AKI)] at presentation and required hemodialysis. Five of them had pauci-immune GN, whereas three had immune complex GN. Our results closely match that of Absar et al.[15] Immunoglobulin A (IgA) nephropathy constituted only 3% of the study population. This small proportion of IgA nephropathy is probably due to the trend of not performing renal biopsies in patients with asymptomatic urinary abnormalities and thus, most cases go undetected.[8] Only six patients had a diagnosis of MCD. This concurs with other studies from the country.[8],[15] IgM nephropathy accounted for 2.5% of patients. It is an increasingly described pathology with heterogenous prevalence.[16] Our results closely resemble that of Mubarak et al.[8] Five patients (2.5%) had MPGN as their diagnosis. This proportion is slightly higher than that described by Mubarak et al,[8] but much lower than that of earlier studies from the country.[14]

NL was the most common secondary GN and accounted for 8.7% of the patients with statistically significant female predominance (P = 0.0026). The prevalence of LN in our study is higher than 4.9% reported by Mubarak et al,[8] but less than 14% reported by Hashmi et al.[9] Secondary amyloidosis was the second-most common secondary GN. It affected 3.6% of patients and is close to 4.6% reported by Mubarak et al.[8] Successful eradication of chronic infections such as tuberculosis in the West has been followed by a sharp decline in the development of secondary amyloidosis,[17] but there is still a huge burden of chronic infections in our part of the world and could account for a considerable number of patients with secondary amyloidosis. Diabetic nephropathy had its share of 3% of all patients, which is much higher than 0.9% reported by Mubarak et al,[8] but less than 5% reported by Hashmi et al.[9] Two diabetic patients had nondiabetic kidney disease (FSGS, crescentic GN) on biopsy. Nondiabetic kidney diseases account for >50% of histological diagnosis among diabetic patients who undergo kidney biopsy, [8] and a recent study from Karachi[19] found that DM is the most common cause of chronic kidney disease (37.5%).

Eleven patients (5.6%) had tubulointerstitial diseases (TIDs) on kidney biopsies. AKI was the most common indication for kidney biopsy among these patients. The workup of patients suspected to have TID is usually guided by the clinical and occupational histories, epidemiology of known diseases, as well as clues offered by the initial workup, and renal biopsy is infrequently performed to exclude glomerular diseases. This restrictive biopsy policy could be the reason for the lower prevalence of TID in our study, and it concurs with the findings of Mubarak et al.[8]

Among vascular lesions on biopsies, two patients had hypertensive nephrosclerosis. Only one patient had acute cortical necrosis (ACN) in our study, while it has been reported to account for 2.9% (48 out of 1670 biopsies) from the northern part of Pakistan.[20] A study from Karachi[21] has reported that over a period of 25 years, 6% of obstetric AKI patients (87 out of 1441) had biopsy-proven ACN.

The limitations of the study include lack of electron microscopy and being a single-center study.

   Conclusion Top

Primary glomerular diseases predominated the biopsy-proven kidney diseases, and FSGS and MN were the most common glomerular diseases. The pattern of BPRDs in South Punjab closely resembles that in southern and northern parts of the country. Renal biopsy registry in the country will be helpful to establish a database of BPRD in Pakistan.

Conflict of interest: None declared.

   References Top

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Braden GL, Mulhern JG, O’Shea MH, Nash sSV, Ucci AA Jr., Germain MJ. Changing incidence of glomerular diseases in adults. Am J Kidney Dis 2000:35:878-83.  Back to cited text no. 3
PKRDS; 2018. Available from: https://pkrds.com/about.html. [Last accessed on 2018 Nov 07].  Back to cited text no. 4
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Haas M, Meehan SM, Karrison TG, Spargo BH. Changing etiologies of unexplained adult nephrotic syndrome: A comparison of renal biopsy findings from 1976-1979 and 1995-1997. Am J Kidney Dis 1997:30:621-31.  Back to cited text no. 6
Dragovic D, Rosenstock JL, Wahl SJ, Panagopoulos G, DeVita MV, Michelis MF. Increasing incidence of focal segmental glomerulosclerosis and an examination of demographic patterns. Clin Nephrol 2005:63:1-7.  Back to cited text no. 7
Mubarak M, Kazi JI, Naqvi R, et al. Pattern of renal diseases observed in native renal biopsies in adults in a single centre in Pakistan. Nephrology (Carlton) 2011;16:87-92.  Back to cited text no. 8
Hashmi AA, Hussain Z, Edhi MM, Mumtaz s, Faridi N, Khan M. Insight to changing morphologic patterns of glomerulopathy in adult Pakistani patients: An institutional perspective. BMC Res Notes 2016:9:73.  Back to cited text no. 9
Rathi M, Bhagat RL, Mukhopadhyay P, et al. Changing histologic spectrum of adult nephrotic syndrome over five decades in North India: A single center experience. Indian J Nephrol 2014:24:86-91.  Back to cited text no. 10
Cattran DC, Reich HN, Beanlands HJ, et al. The impact of sex in primary glomerulonephritis. Nephrol Dial Transplant 2008:23: 2247-53.  Back to cited text no. 11
Kazi JI, Mubarak M, Ahmed E, Akhter F, Naqvi SA, Rizvi SA. Spectrum of glomerulonephritis in adults with nephrotic syndrome in Pakistan. Clin Exp Nephrol 2009:13:38-43.  Back to cited text no. 12
Huq N, Khatun H, Jinnah SA. Morphological pattern of glomerular diseases in adult nephrotic syndrome. Mymensingh Med J 2011:20:652-7.  Back to cited text no. 13
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Absar A, Asif N, Khan Q, Kashif W. Experience of percutaneous kidney biopsy from a tertiary care center of Pakistan. Open J Nephrol 2015:5:61-6.  Back to cited text no. 15
Mubarak M, Kazi JI. IgM nephropathy revisited. Nephrourol Mon 2012:4:603-8.  Back to cited text no. 16
Hazenberg BP, van Rijswijk MH. Where has secondary amyloid gone? Ann Rheum Dis 2000:59:577-9.  Back to cited text no. 17
Yaqub S, Kashif W, Hussain SA. Non-diabetic renal disease in patients with type-2 diabetes mellitus. Saudi J Kidney Dis Transpl 2012:23:1000-7.  Back to cited text no. 18
Salman B, Imtiaz S, Qureshi R, Dhrolia MF, Ahmad A. The causes of chronic kidney disease in adults in a developing country. J Nephrol Ren Dis 2017:1:1.  Back to cited text no. 19
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Naqvi R, Ahmed E, Sheikh R, Rizvi A. Obstetrical acute kidney injury: 25 years’ experience from nephrology care unit in Pakistan. Open Access Libr J 2015;2:el778.  Back to cited text no. 21

Correspondence Address:
Muhammad Khalid Idrees
Department of Nephrology (Kidney Centre), Quaid-e-Azam Medical College, Bahawal Victoria Hospital, Bahawalpur
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DOI: 10.4103/1319-2442.270271

PMID: 31696854

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