Biopsy-proven Renal Pathologies: Experience from Multan Institute of Kidney Diseases

Muhammad Nauman Hashmi; Rashid Asghar; Tanzeel Abbasi; Khurram Bashir; Ruqayya Basharat; Sadia Majeed

doi:10.4103/1319-2442.292320

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RENAL DATA FROM ASIA–AFRICA

Year : 2020 | Volume : 31 | Issue : 4 | Page : 850-855

Biopsy-proven Renal Pathologies: Experience from Multan Institute of Kidney Diseases

Muhammad Nauman Hashmi¹, Rashid Asghar¹, Tanzeel Abbasi¹, Khurram Bashir¹, Ruqayya Basharat¹, Sadia Majeed²
¹ Department of Nephrology, Multan Institute of Kidney Diseases, Multan, Pakistan
² Department of Histopathology, Multan Institute of Kidney Diseases, Multan, Pakistan

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Date of Submission	07-Aug-2019
Date of Acceptance	25-Sep-2019
Date of Web Publication	15-Aug-2020

Abstract

In this part of world, nephrology data lack as there is no renal registry, and nephrology is still in its primitive stage. Multan Institute of kidney diseases started tertiary care renal services. We carried out an analysis of our renal biopsies performed here from August 2017 to May 2019. This was carried out to see the spectrum of renal diseases in this area. This is a retrospective analysis of renal biopsies performed at the Multan Institute of Kidney Diseases from August 2017 to May 2019. Renal biopsy was performed using real-time ultrasound. One hundred and seventy-five native renal biopsies were performed during this study period. One hundred and three male (59%) and 72 female (41%) patients underwent renal biopsy. The average age was 36 years, with a range of 16–70 years. Results from our study showed membranous glomerulo- nephritis (36%) as a leading cause of primary glomerular disease in this region. Lupus nephritis (30.3%) was a leading cause in secondary glomerular disease. Reviewing our study and published literature it’s pellucid that lupus nephritis is a leading cause of secondary glomerulonephritis worldwide. In terms of primary glomerular disease, spectrum is different globally. This study sets alight to explore membranous nephropathy, which is the leading primary glomerular disease in our studied population.

How to cite this article:
Hashmi MN, Asghar R, Abbasi T, Bashir K, Basharat R, Majeed S. Biopsy-proven Renal Pathologies: Experience from Multan Institute of Kidney Diseases. Saudi J Kidney Dis Transpl 2020;31:850-5

How to cite this URL:
Hashmi MN, Asghar R, Abbasi T, Bashir K, Basharat R, Majeed S. Biopsy-proven Renal Pathologies: Experience from Multan Institute of Kidney Diseases. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Oct 27];31:850-5. Available from: https://www.sjkdt.org/text.asp?2020/31/4/850/292320

Introduction

Nephrology data are lacking from Pakistan as there is no renal registry. Few articles have been published regarding biopsy results. Multan Institute of Kidney Diseases is a tertiary care center in southern Punjab providing all nephrology and urology services. This institute is functional since 2017. We have performed 175 number of ultrasound-guided percutaneous native kidney biopsies in this institute. We analyzed the data to see the pattern of intrinsic renal pathology in this part of Pakistan.

Materials and Method

This is a retrospective analysis of all native renal biopsies performed at the Multan Institute of Kidney Diseases from August 2017 to May 2019. During this time, 175 adult renal biopsies were performed. The minimum age was 16 and a maximum 70 years old. The indications for renal biopsy included protei- nuria, unexplained microscopic or macroscopic hematuria, and systemic disease with evidence of renal involvement and unexplained renal impairment. All samples were obtained by percutaneous method using a tru- cut needle under ultrasound guidance. Two renal biopsy core samples were taken from each patient, which were processed for light microscopy and immunofluorescence studies.

Both renal cores fixed in 10% neutral buffered formalin. Processing of cores done in automatic tissue processor. For light microscopy, routinely twelve serial sections were cut at 2 pm to perform multiple special stains and Hemotoxylin and Eosin (H&E) stain. Level 6 and 10 stained with H&E, level 7, 8, and 9 stained with Jones’ Methenamine Silver Stain (JMS), level 11 with Periodic acid–Schiff (PAS) and level 12 with trichrome stain. The first five sections were left unstained for performing other stain, if needed. Microscopic examination of all stains was performed by histopathologist.

Immunofluorescence (IMF) was also performed on formalin-fixed, paraffin-embedded renal tissues. EDTA, 8.0 was used as an antigen retrieval solution on renal cores. Further deeper levels (13–17) were cut off 2 μ thickness for IMF. Direct IMF staining method was performed on these slides with FITC conjugated IgA, IgM, IgG, C1q and C3 antibodies. The IMF slides were observed in a dark room under immunofluorescence microscope by histopathologist. The results were recorded in semi-quantitative scoring from +1 to +4, and the pattern of staining was observed (membranous or mesangial in linear or granular distribution). The final diagnosis was made by correlating the immunofluo- rescence and microscopic findings with clinical history and relevant investigations.

Results

Primary glomerular diseases

In our studied population spectrum of primary glomerulonephritis pattern in percentage is shown in [Table 1] and [Figure 1].

Table 1: Histopathological spectrum of primary glomerulonephritis in percentage and gender distribution.

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Figure 1: Renal biopsy-proven cases of primary glomerulonephritis according to gender in our studied population.

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Membranous glomerulonephritis (36%) was the most common biopsy-proven primary glomerular disease. This was followed by focal segmental sclerosis (16.6%). Mesangiocapillary glomerulonephritis (14.5%) and crescentic glomerulonephritis (14.5%) were in the 3^rd place. IgA nephropathy incidence was noted to be 9.3% and minimal change disease at 7.2%.

Secondary glomerular diseases

[Table 2] and [Figure 2] reveal the percentages of secondary glomerular pathologies in our patients.

Table 2: Histopathological spectrum of secondary glomerulonephritis in percentage and gender distribution.

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Figure 2: Renal biopsy-proven cases of secondary glomerulonephritis according to gender in our studied population.

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Lupus nephritis was the mos common secondary glomerular disease in our patients with a female predominance reflecting the tendency of systemic lupus erythematosus to affect females which has been reported repeatedly. This was followed by global glomeruloscle- rosis (24%), acute tubular necrosis (18.9%), amyloidosis (8.8%), hypertensive nephropathy (6.3%) and diabetic nephropathy (5%).

Discussion

Intrinsic renal pathology data from Pakistan are not much reported. There are few institutes providing renal services and perform renal biopsies. Our institute is an emerging hub for renal services in South Punjab, Pakistan. Multan Institute of Kidney Diseases started in 2017, and since the beginning, renal biopsies are being performed with real-time ultrasound. We cover three divisions of South Punjab and serve a population of around 30 million.

Renal biopsy gives definitive diagnosis along with prognostic information, since its establishment as a key diagnostic tool, renal biopsy is considered as the gold standard for classifying renal diseases.^{[1],[2],[3],[4]}

The rate of biopsy-proven renal diseases underestimates the true prevalence of diseases, as not all patients with renal disease are biopsied. Studying histological aspects of renal diseases helps to identify the frequency of renal diseases and determines a platform to raise awareness regarding renal diseases. It lays the foundation to establish research to see the potential regional differences in glomerular diseases. No similar study has been published from this area to date.

A precise diagnosis in nephrotic syndrome can only be reached by combining clinical and laboratory data and light microscopy complimented with IMF, EM, and serology.^[5] Occasional articles published previously in this part of the world are mostly based on light microscopic features.^[6],[7],[8]

We performed a total of 175 renal biopsies during period of August 2017–May 2019. The total number of male patients who were biopsied were 103 and females 72. Such pattern of males being outnumbered to females has been observed in multiple studies.^[9],[10]

In our studied population among primary glomerulonephritis, the highest incidence is of membranous glomerulonephritis (36%) followed by focal segmental sclerosis (16.6%). Among secondary glomerulonephritis highest incidence is of lupus nephritis (30.3%). Our data showed 24% of patients presented with end- stage renal disease. This is a significant concern in this area as patients present late, and the majority of patients (93%) are at CKD-5 stage at the time of presentation.^[11]

Reviewing published literature, spectrum of primary glomerular disease pathology is variable. In the Czech and Polish population, IgA nephropathy was noted to be most common.^[12],[13] One study from china also reported IgA as the most common primary glomerular disease.^[14] Mittal et al, Khalifa et al and Mitwalli et al reported FSGS as the most common primary glomerular pathology.^{[15],[16],[17]} One study from India and one from northeast China reported membranous nephropathy as the leading cause of primary glomerular disease.^[18],[19]

Following [Table 3] is a comparison of a few studies with our study to see the incidence of the most common primary and secondary glomerular diseases.

Table 3: Incidence of most common primary and secondary glomerular diseases in renal biopsies (Comparison of our study with studies published from Czech Republic, India, China, Sudan and Saudi Arabia)

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Our population cohort showed an average age of 36 years who underwent renal biopsies. Membranous nephropathy is reported more common in the middle age population. In secondary glomerular disease, we found lupus nephritis as leading cause and this result is evident in all studies.^{[13],[14],[15],[16],[18],[20]}

We looked into the incidence of membranous nephropathy in published studies from Pakistan and found it to be the most common primary pathology in the majority of cases.^{[9],[20],[21],[22],[23],[24]}

[Table 4] enlists the studies we have reviewed and shows the percentage of membranous nephropathy in respective studies.

Table 4: Incidence of membranous nephropathy in studies published from Pakistan.

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We recommend that a national registry should be formed, and data from all over country should be collected. We also suggest that this data compilation to continue to see pattern of diseases in a larger cohort. Also recommend research studies to explore more prevalent diseases like Membranous nephro- pathy in this geographical area as compared to the rest of the world.

Conflict of interest: None declared.

References

1.	Madaio MP. Renal biopsy. Kidney Int 1990; 38:529-43.
2.	Fuiano G, Mazza G, Comi N, et al. Current indications for renal biopsy: A questionnaire- based survey. Am J Kidney Dis 2000;35:448- 57.
3.	Paone DB, Meyer LE. The effect of biopsy on therapy in renal disease. Arch Intern Med 1981;141:1039-41.
4.	Dhaun N, Bellamy CO, Cattran DC, Kluth DC. Utility of renal biopsy in the clinical management of renal disease. Kidney Int 2014;85:1039-48.
5.	Falk RJ, Jennette JC, Nachman PH. Primary glomerular disease. In: Brenner BM, editor. Brenner and Rector’s the Kidney. 6^th ed. Philadelphia: W. B. Saunders; 2000. p. 1263349.
6.	Muzaffar M, Mushtaq S, Khadim MT, Nabiruddin, Mamoon N. Morphological pattern of glomerular diseases in patients with nephrotic syndrome in northern Pakistan. Pak Armed Forces Med J 1997;47:3-6.
7.	Lakhnana KN, Ahmed I, Amin JS. Pattern of renal glomerular disease. An experience at Pakistan institute of medical sciences, Islamabad. Pak J Pathol 1995;6:19-27.
8.	Jamal Q, Jafarey NA, Naqvi AJ. A review of 1508 percutaneous renal biopsies. J Pak Med Assoc 1988;38:272-5.
9.	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.
10.	Das U, Dakshinamurty KV, Prayaga A. Pattern of biopsy-proven renal disease in a single center of south India: 19 years experience. Indian J Nephrol 2011;21:250-7. [PUBMED] [Full text]
11.	Ullah K, Butt G, Masroor I, Kanwal K, Kifayat F. Epidemiology of chronic kidney disease in a Pakistani population. Saudi J Kidney Dis Transpl 2015;26:1307-10. [PUBMED] [Full text]
12.	Perkowska-Ptasinska A, Bartczak A, Wagrowska-Danilewicz M, et al. Clinico- pathologic correlations of renal pathology in the adult population of Poland. Nephrol Dial Transplant 2017;32:ii209-ii218.
13.	Maixnerova D, Jancova E, Skibova J, et al. Nationwide biopsy survey of renal diseases in the Czech Republic during the years 19942011. J Nephrol 2015;28:39-49.
14.	Yang Y, Zhang Z, Zhu L, Chen DP, Li WG. The spectrum of biopsy-proven glomerular disease in China: A systematic review. Chin Med J (Engl) 2018;131:731-5.
15.	Mittal P, Agarwal SK, Singh G, et al. Spectrum of biopsy-proven renal disease in northern India: A single-centre study. Nephrology (Carlton)2020;25:55-62.
16.	Khalifa EH, Kaballo BG, Suleiman SM, Khalil EA, El-Hassan AM. Pattern of glomerulo- nephritis in Sudan: Histopathological and immunofluorescence study. Saudi J Kidney Dis Transpl 2004;15:176-9. [PUBMED] [Full text]
17.	Mitwalli AH, AlWakeel JS, AlMohaya SS, et al. Pattern of glomerular disease in Saudi Arabia. Am J Kidney Dis 1996;27:797-802.
18.	Bagchi S, Mittal P, Singh G, et al. Pattern of biopsy-proven kidney disease in the elderly in a tertiary care hospital in India: A clinico- pathological study. Int Urol Nephrol 2016;48: 553-60.
19.	Nie P, Chen R, Luo M, et al. Clinical and pathological analysis of 4910 patients who received renal biopsies at a single center in Northeast China. Biomed Res Int 2019;2019: 6869179.
20.	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.
21.	Kazi JI, Mubarak M, Ahmed E, Akhter F, Naqvi SA, Rizvi SA. Spectrum of glomerulo- nephritides in adults with nephrotic syndrome in Pakistan. Clin Exp Nephrol 2009;13:38-43.
22.	Absar A, Asif N, Khan Q, Kashif W. Experience of percutaneus kidney biopsy from a tertiary care center of Pakistan. Open J Nephrol 2015;5:61-6.
23.	Asif N, Ahsan MN, Khanzada WS. Spectrum of renal parenchymal diseases: An eleven year retrospective review of renal biopsy data from a tertiary care hospital in Pakistan. Ann King Edward Med Univ 2017;23:13-17.
24.	Azad NS, Muzaffar S, Pervez S, Ahmed A, Rabbani A, Ali A. Demographic and Clinico- pathologic features of membranous glomerulo- nephritis. J Coll Physicians Surg Pak 2004;14: 35-8.