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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM THE ARAB WORLD  
Year : 2020  |  Volume : 31  |  Issue : 5  |  Page : 1069-1077
Multicenter Review of Glomerular Diseases in the Emirates of Abu Dhabi: Six Years' Experience


1 Department of Nephrology, Sheikh Khalifa Medical City Health Authority, Abu Dhabi, United Arab Emirates
2 Department of Internal Medicine, Sheikh Khalifa Medical City Health Authority, Abu Dhabi, United Arab Emirates
3 Department of Pathology, Sheikh Khalifa Medical City Health Authority, Abu Dhabi, United Arab Emirates

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Date of Web Publication21-Nov-2020
 

   Abstract 


Glomerulonephritis (GN) is a rising paramount renal disease that varies in etiology from inherited or acquired factors. Its severity can range from asymptomatic depictions to end-stage renal disease. The aim of this study was to study the patterns of biopsy-proven GN based on the data from a multicenter in Abu Dhabi. Included kidney biopsies were from all patients above the age of 18 years, over a six-year period from 2010 to 2015, who had diagnosis of glomerular disease other than diabetes mellitus. The number of reviewed biopsies was 416. The most common type of GN among the study sample was IgA GN (22.8%) followed by focal segmental glomerulosclerosis (20.4%) and systemic lupus erythematosus (SLE) (19.7%). The least common types were pauciimmune (1.7%). There was female preponderance in lupus nephritis and pauciimmune GN. The nationality comparison did not reveal a predominate GN among Emirati nationals. The age relationship to GN types showed that majority (82.9%) of SLE patients, MCD (74.55%), and noncategorized (71.4%) patients are young aged between 18 and 39 years. On the other hand, 57.1%, 25%, and 16.7% of patients with pauciimmune, other GN types, and membranoproliferative GN, respectively, are 60 years and older. This study shows the histopathological variety of glomerular disease in Abu Dhabi. It could be a driving point to help understand GN better in the region.

How to cite this article:
Al Shamsi H, El Tahrawi R, Hindawy B, Khater E, Hassan M. Multicenter Review of Glomerular Diseases in the Emirates of Abu Dhabi: Six Years' Experience. Saudi J Kidney Dis Transpl 2020;31:1069-77

How to cite this URL:
Al Shamsi H, El Tahrawi R, Hindawy B, Khater E, Hassan M. Multicenter Review of Glomerular Diseases in the Emirates of Abu Dhabi: Six Years' Experience. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2020 Dec 1];31:1069-77. Available from: https://www.sjkdt.org/text.asp?2020/31/5/1069/301173



   Introduction Top


Glomerulonephritis (GN) is a group of kidney diseases characterized by inflammation of the glomeruli. If left untreated, this chronic inflammation can lead to scarring, loss of renal kidney function, hypertension, and end-stage renal disease (ESRD). GNs are classified based on the microscopic appearance of the affected kidney tissue. It is important to pursue knowledge about the incidence and prevalence of GN. There are different GN types that can be grouped as focal and segmental glomerulosclerosis (FSGS), minimal change disease (MCD), membranous GN, membranoproliferative GN (MPGN), IgA nephropathy, pauciimmune GN, and crescentic GN.[1]

The aim of this study stands to assess the patterns of biopsy-proven GN based on the data pooled into one health network from multiple hospitals in the region of Abu Dhabi.

Sixteen percent of all causes of ESRD in the USA is a result of GN,[2] while in Egypt, it was found that 3.7% of ESRD had GN.[3] It is important to widen our knowledge about incidence and prevalence of GN to adopt measures to prevent the progression of GN.[3] However, at the same time, the prevalence of glomerular diseases in the general population is hard to evaluate because optimal conditions for performing epidemiologic surveys are difficult to find. Moreover, a glomerular disease registry does not exist in the United Arab Emirates (UAE). A review of renal biopsy data may provide an insight into the spectrum of GN prevalent within a particular community or geographic area. A study published in 2016 USA in Southern Arizona showed that FSGS was the most common GN type followed by membranous nephropathy,[2] while a study done in South Korea published in 2001 showed that the most common type of GN was MCD followed by IgA nephropathy.[4]

Currently, the data in the UAE regarding our local community prevalence of different types of GN are limited. This study aims at looking at the pattern of glomerular disease in Abu Dhabi. It aims to look into association between sociodemographic data and different types of GN.


   Methodology Top


This was a cross-sectional retrospective study that reflected on 2010–2015. Data were retrieved from the hospital electronic records (Cerner) from a backtracked CPT code (ICD9 code: 5523 and CPT code: 50200) that was inclusive of all interventional radiology (IR)- attained kidney biopsies unified across the same health network. The biopsies were a constellation of four nephrology service provider hospitals in the Emirates of Abu Dhabi (Sheikh Khalifa Medical City, Al Mafraq Hospital, Tawam Hospital, and Al Ain Hospital).

Inclusion criteria are GN other than diabetes mellitus, age 18 and above. Biopsies that were none GN or pediatrics were excluded. Where two pathological findings were found, the predominant pathology was included.


   Results Top


The total number of patients identified was 416 patients.

Sociodemographic of patients with glomerulonephritis

[Table 1] shows the sociodemographic characteristics of the study sample. 56.3% were male, 70.6% were nonnational, and 67.1% were in the age of 18–39 years. The mean age was 36 years [±12.5 standard deviation (SD)].
Table 1: Sociodemographic characteristic of the study sample (n=416).

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Weight, height, and body mass index of the patients with glomerulonephritis

The mean (±SD) height, weight, and body mass index (BMI) were 163 (±11.4), 73.5 (±19.2), and 27 (±6.6), respectively. However, 35.3% of the study samples were having normal BMI and 33.8% were overweight [Table 2] and [Table 3].
Table 2: Mean (standard deviation) of weight, height and body mass index of the study sample.

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Table 3: Body mass index of the study sample (n=399).

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Biopsy results of the study sample

The most common type of GN among the study sample were the IgA GN (22.8) followed by FSGS (20.4%) and systemic lupus erythematosus (SLE) (19.7%). The least common types, i.e., pauciimmune, uncategorized GN, and thrombotic microangiopathy (TMA), were found in 1.7%, 1.7%, and 2, respectively. [Table 4] shows the distribution of other types of the biopsy.
Table 4: Distribution of other biopsy types (n=12).

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Relationship between sociodemographic characteristics and the biopsy results

Age and biopsy results

[Figure 1] shows the relationship between age and the biopsy results, majority (82.9%) of SLE patients, 74.55% of MCD patients, and 71.4% of noncategorized patients are young aged between 18 and 39 years. On the other hand, 57.1%, 25%, and 16.7% of patients with pauciimmune, other GN types, and MPGN, respectively, are 60 years and older. These findings are statistically significant.
Figure 1: Relationship between age and the biopsy results (n=416).
IGA GN: Immunoglobulin A glomerulonephritis, FSGS: Focal and segmental glomerulosclerosis, MPGN: Membranoproliferative glomerulonephritis, MN: Membranous nephropathy, MCD: Minimal change disease, SLE: Systemic lupus erythematosus, TMA: Thrombotic microangiopathy.


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Gender and biopsy results

The relationship between gender and biopsy results is shown in [Figure 2].
Figure 2: Relationship between gender and the biopsy results (n=416).
IGA GN: Immunoglobulin A glomerulonephritis, FSGS: Focal and segmental glomerulosclerosis, MPGN: Membranoproliferative glomerulonephritis, MN: Membranous nephropathy, MCD: Minimal change disease, SLE: Systemic lupus erythematosus, TMA: Thrombotic microangiopathy.


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A statistically significant relationship between gender and biopsy results was noted (P <0.001). Majority of patients with SLE (85.4%) and pauciimmune (71.5%) were female. On the other hand, the rest of GN types were common among male with the highest in the TMA and other types (75% for each).

Nationality and biopsy results

No statistical significant (P = 0.319) relationship was found between nationality and biopsy results [Figure 3].
Figure 3: Relationship between nationality and the biopsy results (n=416).
IGA GN: Immunoglobulin A glomerulonephritis, FSGS: Focal and segmental glomerulosclerosis, MPGN: Membranoproliferative glomerulonephritis, MN: Membranous nephropathy, MCD: Minimal change disease, SLE: Systemic lupus erythematosus, TMA: Thrombotic microangiopathy.


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Body mass index category and biopsy results

No statistical significant (P = 0.353) relationship was found between BMI categories and biopsy results [Table 5].
Table 5: Relationship between body mass index categories and biopsy results (n=399).

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Relationship between sociodemographic characteristics and the body mass index

43.8% of young patients were found to have normal BMI compared to 57.1% of elderly who were found to be overweight. The result is statistically significant (P <0.001) [Figure 4].
Figure 4: Relationship between age category and body mass index category (n=399).

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[Figure 5] shows a statistically significant relationship between gender and BMI category where females tend to have higher BMI than males. Thirty-nine percent of males have normal BMI compared to only 30.5% of females. On the other hand, only 13.5% and 4.5% of males are obese Class 1 and 2 compared to 20.7% and 17.2% of females being obese Class 1 and 2.
Figure 5: Relationship between gender and body mass index category (n=397).

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Similar finding was seen in [Figure 6], in which the UAE nationals tend to have higher BMI than non-UAE nationals. 21.7% of UAE nationals have normal BMI compared to 40.7% of non-UAE nationals.
Figure 6: Relationship between nationality and body mass index category (n=398).

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However, 28.7% and 17.4% of the UAE nationals are obese Class 1 and 2 compared to 12% and 7.1% of non-UAE nationals being obese Class 1 and 2 (P = 0.00).


   Discussion Top


This study allowed us to explore the epidemiological spectrum of glomerular diseases in the UAE shedding light on its frequency and distribution across the multiethnic population of the country. The data collected serve as a base of many potential futuristic opportunities which can explore the variants across ethnic, genetic, and environmental factors contributing to the disease spectrum.

The most common type of GN among the study samples were the IgA GN (22.8%) followed by the FSGS (20.4%) and the SLE (19.7%). The least common types were pauciimmune (1.7%) [Figure 7]. IgA glomerulo-nephropathy reigned predominant (22.8%) withit mostly affecting males (69.1%) and in 77% of non-nationals [Figure 1]. Interestingly, this was the least reported glomerulopathy by Yahya et al from the UAE in 1998.[5] The data collection serves as a registry for the types of glomerular diseases present in the UAE from 2010 to 2016. It is interesting to note that a 14-year period between the time of collection reveals a stark difference which could either depict that it is due to under-diagnosing IgA GN as it was only in 1968 when it was initially described by the French pathologist Berthoux et al[6] or that the increased influx of non-nationals caused the shift.
Figure 7: Distribution of the study sample based on the biopsy results (n = 416).
IGA GN: Immunoglobulin A glomerulonephritis, FSGS: Focal and segmental glomerulosclerosis, MPGN: Membranoproliferative glomerulonephritis, MN: Membranous nephropathy, MCD: Minimal change disease, SLE: Systemic lupus erythematosus, TMA: Thrombotic microangiopathy.


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Another study from Dubai showed IgA nephropathy to be the least common type of GN. They attributed it as the patient will present late with ESRD and the biopsy will not add additional benefit in the management of the patients.[7] FSGS was the second most common glomerular disease (20.4%) and ranked first in Al Riyani et al in a study from Oman, Iraq, Jordan, India, and Saudi Arabia,[8],[9],[10],[11],[12],[13] although the Iraqi study attributed that the lack of IgA nephropathy results to the lack of immunofluorescence in the hospital. While a study from Bahrain showed the most common GN to be MCD followed by FSGS.[14],[15] In Kuwait, the most common GN was FSGS followed by MCD.[16]

Comparing our results to countries from East Asia, we found that reports from Thailand showed that the most common type of GN in their study is IgM nephropathy followed by IgA nephropathy.[17] Another study from China showed that IgA nephropathy was the most common biopsied GN in the hospital registry.[18] In a study from South Korea, the report showed MsPGN was the most common GN followed by IgA nephropathy.[19] However, in North America, FSGS was the most common GN in a study from New York,[20] and in South Africa, also FSGS was the most common GN.[21]

The relationship between age and biopsy results was significant (P <0.001); here, the majority (82.9%) of SLE patients, MCD (74.55%), and noncategorized (71.4%) patients are young aged between 18 and 39 years. On the other hand, 57.1%, 25%, and 16.7% of patients with pauciimmune, other GN types, and MPGN, respectively, are 60 years and older [Figure 1]. The spectrum of ages serves as a useful comparative as none of the other regional studies highlighted this.[5],[8]

There was a significant relationship between the gender and the type of GN depicted (P <0.001) where SLE (85.4%) and pauciimmune (71.5%) were highly of female predominance. Our finding reflects similar results of female predominance in SLE.[22] On the other hand, the rest of the GN types were common among males with the highest in the TMA and other types (75% for each) [Figure 2].

We looked into comparison between Emiratis and non-Emiratis. There was no predominant GN among Emiratis. The non-Emirati group included a diverse number of countries. This emphasized a variety of the spectrum of ethnicities here in the UAE as only 29.4% of the data population collected was Emirati locals [Figure 3].

The relationship between BMI and different GN was not significant. It is known that FSGS can be as a result of obesity[23],[24] in our study though it was not reflected in our results. [Table 5] shows no statistical difference between different GN and BMI categories. It could be that the cause of FSGS in the population is not predominantly due to obesity but other factors.

Challenges and Future Recommendations

Challenges in our study include the lack of unification of the reference units in the laboratory details reported which led to its inclusion in interpretation. All biopsy samples collected from smaller hospitals were either rerouted one of the three major hospitals in the Emirates. All collected data were reviewed by histopathological category and reassessed for verification if under query by microscopic examination. There were a few histopathological specimens which were observed differently in interpretation however were re-screened by the pathologist for verification.

Nonnationals consisted of over 15 nationalities however do not depict the ethnic origin and were thus not mentioned in the study. It would have been interesting to have a log of the ethnic identity of the data collected however as only the nationality was documented in the electronic medical records and is not a categorical identity here in the UAE.


   Conclusion Top


This study allowed us to ascertain the most common biopsy-proven GN in Abu Dhabi. Although the study does not give the exact prevalence report of different GN, it helps give an estimate of the GN in Abu Dhabi and compare it with different reports from other regional and international countries. It would serve as a very interesting source for future projects as the UAE is a hub of international citizens. This could be a driving point to help better understanding genetic and geographical dispositions niche.

Conflict of interest: None declared.



 
   References Top

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Al Riyami D, Al Shaaili K, Al Bulushi Y, Al Dhahli A, Date A. The spectrum of glomerular diseases on renal biopsy: Data from a single tertiary center in Oman. Oman Med J 2013;28: 213-5.  Back to cited text no. 8
    
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Al Arrayed A, George SM, Malik AK, et al. The spectrum of glomerular diseases in the kingdom of Bahrain: An epidemiological study based on renal biopsy interpretation. Transplant Proc 2004;36: 1792-5.  Back to cited text no. 14
    
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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. 20
    
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Vermeulen A, Menezes CN, Mashabane M, Butler OK, et al. Patterns of renal disease: A 30- year renal biopsy study at Chris Hani Baragwanath Academic Hospital, Soweto, Johannesburg, South Africa. S Afr Med J 2019;109:486-92.  Back to cited text no. 21
    
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Kambham N, Markowitz GS, Valeri AM, Lin J, D’Agati VD. Obesity-related glomerulopathy: An emerging epidemic. Kidney Int 2001;59: 1498-509.  Back to cited text no. 24
    

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Correspondence Address:
Hefsa Al Shamsi
Department of Nephrology, Sheikh Khalifa Medical City Health Authority, Abu Dhabi
United Arab Emirates
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DOI: 10.4103/1319-2442.301173

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