| Abstract|| |
This study was conducted to retrospectively investigate the indications for renal biopsy in the native kidneys of children and to analyze the pathological findings in a single tertiary care hospital in North-East India for the past 12 years. All children (≤18 years) who underwent renal biopsy at our hospital from March 2007 to April 2018 were included. Renal tissue specimens were studied under light and immunofluorescence microscopy. The study group included 254 patients (female 57%). The median age was 15 years (range 6–18 years). The most frequent indications for renal biopsy were nephrotic syndrome (NS) (53.9%), urinary abnormality in systemic disease (22.1%), nephritic syndrome (15.4%), asymptomatic hematuria (4.7%), significant proteinuria (3.1%), and unexplained renal failure (0.8%). On histopathological examination, primary glomerular diseases were the most frequent (68.9%) followed by secondary glomerular diseases (30.3%) and tubulointerstitial diseases (0.8%). The most common primary glomerular diseases were minimal change disease (26.8%), focal segmental glomerular sclerosis (12.2%), diffuse proliferative glomerulonephritis (9.1%), membranous nephropathy (8.7%), IgA nephropathy (8.3%), membranoproliferative glomerulonephritis (2%), and mesangioproliferative glomerulonephritis (2%). Lupus nephritis (LN) (29.5%) was the most common secondary glomerular disease. NS was the most common indication of renal biopsy, and LN was the most common histopathological diagnosis in children ≤18 years.
|How to cite this article:|
Sharma M, Mazumder MA, Mahanta PJ, Doley PK, Pegu G, Alam S, Parry MA, Jeelani H. Histological patterns of renal diseases in children: A 12-year experience from a single Tertiary Care Center in North-East India. Saudi J Kidney Dis Transpl 2021;32:364-70
|How to cite this URL:|
Sharma M, Mazumder MA, Mahanta PJ, Doley PK, Pegu G, Alam S, Parry MA, Jeelani H. Histological patterns of renal diseases in children: A 12-year experience from a single Tertiary Care Center in North-East India. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Jan 26];32:364-70. Available from: https://www.sjkdt.org/text.asp?2021/32/2/364/335448
| Introduction|| |
Glomerular diseases are a leading cause of chronic kidney disease in children after congenital abnormalities of the kidney and urinary tract. Early recognition and timely institution of optimum therapy can forestall progression to end-stage renal disease. Percutaneous renal biopsy remains a key tool in establishing correct diagnosis, optimization and individualization of treatment, determining the prognosis of glomerular disease.
Because of the complexities associated with performing an invasive procedure in an anxious child, renal biopsies are done more selectively in pediatric population compared to its adult counterpart. Reports from various renal biopsy registries have established that the epidemiology and spectrum of renal diseases in the pediatric age group varies in different geographical regions.,,
Although renal biopsies in children have been reported from our country, there is no national renal biopsy registry available to address the regional difference in the spectrum of renal disease. Our study reports the experience of pediatric renal biopsy in a single tertiary care hospital in North-East India.
| Subjects and Methods|| |
We retrospectively analyzed the clinical and histopathological data for all children (≤18 years) who underwent native renal biopsy at our tertiary nephrology center from March 2007 to April 2018. In all cases, the procedure was performed after providing information to parents and obtaining informed consent. A sample was considered adequate if ≥10 glomeruli were obtained or the pathologist was able to make a diagnosis based on the available number of glomeruli.
All renal biopsies were examined by two experienced renal pathologists. The specimens were studied under light and immunofluorescent microscopy. Immunofluorescence staining using polyclonal antisera against human IgG, IgM, IgA, C3, C4, fibrinogen, C1q and, if indicated, kappa and lambda light chains, was employed. Electron microscopy was not done because it is not available at our center. Data regarding age, sex, indication for renal biopsy, and histopathological diagnosis were collected from the clinical records.
The indications for renal biopsy comprised asymptomatic glomerular hematuria, significant proteinuria, nephrotic syndrome (NS), acute nephritic syndrome (ANS), urinary abnormalities in systemic disease, and unexplained renal failure.
Indications for biopsy in idiopathic NS were (1) atypical age at presentation (age <12 months or >12 years); (2) steroid-resistant NS (SRNS); (3) steroid-dependent NS (SDNS), or (4) frequently relapsing NS (FRNS) before using cytotoxic therapy.
| Statistical Analysis|| |
Data were described as frequencies and percentages for the categorical variables. The continuous variables were reported as medians and ranges or as means and standard deviations.
| Results|| |
We studied the records of 254 patients (male = 109, 43%; female = 145, 53%) who underwent percutaneous renal biopsy. None of the patients required a repeat renal biopsy. The median age was 15 years (range 6–18 years).
[Figure 1] shows the indications for renal biopsy. The most frequent indication for renal biopsy was NS in 137 patients (53.9%) followed by urinary abnormalities in systemic disease in 56 patients (22.1%), ANS in 39 patients (15.4%), asymptomatic hematuria in 12 patients (4.7%), significant proteinuria in eight patients (3.1%) and unexplained renal failure in two patients (0.8%).
[Figure 2] shows the indications for biopsy in NS. Of the 137 patients with NS, 86 (63%) patients had atypical age at presentation, 25 (18%) SDNS, 16 (12%) FRNS and 10 (7%) SRNS. Among those who presented at an atypical age (n = 86), primary glomerular diseases (73 cases, 84.9%) accounted for majority of the cases and secondary glomerular disease accounted for 13 cases (15.1%).
|Figure 2: Indications for renal biopsy in nephrotic syndrome (n = 137).|
SDNS: Steroid-dependent nephrotic syndrome, FRNS: Frequently relapsing nephrotic syndrome, SRNS: Steroid-resistant nephrotic syndrome.
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[Table 1] shows the frequency of histopathological diagnosis in patients of NS. The most common primary glomerular disease leading to NS at an atypical age (n = 86) was minimal change disease (MCD) (39 cases, 45.3%) followed by membranous nephropathy (MN) (19 cases, 22.1%), focal segmental glomerulo-sclerosis (FSGS) (10 cases, 11.6%), IgA nephropathy (IgAN) (3 cases, 3.5%) and membranoproliferative (MPGN) (2 cases, 2.3%). Lupus nephritis (LN) (13 cases, 15.1%) accounted for all cases of secondary glomerular disease leading to NS at an atypical age. MCD (14 cases, 56%) was the most common histopathological diagnosis of SDNS (n = 25) followed by FSGS (7 cases, 28%), IgAN (2 cases, 8%) and MN (2 cases, 8%). MCD (12 cases, 75%) was the leading histopathological diagnosis of FRNS (n = 16) was followed by FSGS (4 cases, 25%). The most frequent histopathological diagnosis of SRNS (n = 10) was FSGS (6 cases, 60%) followed by MCD (3 cases, 30%) and MN (1 case, 10%).
|Table 1: Frequency of histopathological diagnosis in patients biopsied for nephrotic syndrome.|
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On histopathological evaluation [Figure 3], primary glomerular diseases accounted for 175 cases (68.9%) and they were found more frequently than secondary glomerular diseases (n = 77, 30.3%). Tubulointerstitial disease was found in two cases (0.8%).
|Figure 3: Distribution of groups of renal disease in the entire cohort (n = 254).|
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The most common primary glomerular disease (n = 175) [Figure 4] was MCD which accounted for 68 cases (38.8%). The next common primary glomerular disease was FSGS which accounted for 31 cases (17.7%) followed by diffuse proliferative glomerulonephritis (DPGN) (23 cases, 13.1%), MN (22 cases, 12.6%), IgAN (21 cases, 12%), MPGN (5 cases, 2.8%) and mesangioproliferative GN (MesPGN) (5 cases, 2.8%).
|Figure 4: Frequency of primary glomerular diseases (n = 175).|
MCD: Minimal change disease, FSGS: Focal segmental glomerulosclerosis, DPGN: Diffuse proliferative glomerulonephritis, MN: Membranous nephropathy, MPGN: Membranoproliferative glomerulonephritis, MsPGN: Mesangioproliferative glomerulonephritis.
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Among secondary glomerular diseases [Figure 5], majority of the cases were of LN (75 cases, 97.4%). There were 1 case each of Henoch-Schonlein purpura (1.3%) and Pauci-immune glomerulonephritis (Pauci-immune GN) (1.3%). Out of 75 cases of LN [Table 2], 64 cases were female. According to ISN/RPS (International Society of Nephrology/ Renal Pathology Society) histopathological classification of LN, class IV was the most common (26 cases, 34.7%) followed by class V (21 cases, 28.0%), class III (15 cases, 20%) and class II (13 cases, 17.3%).
|Figure 5: Frequency of secondary glomerular disease (n = 77).|
LN: Lupus nephritis, HSP: Henonch-Schonlein purpura, PIGN: Pauci-immune glomerulonephritis.
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| Discussion|| |
With the advent of newer therapies for the management of glomerular diseases in children, the importance of knowing underlying histopathology cannot be over-emphasized. This study provides the data on clinical indications for renal biopsies and underlying histopathological findings in a tertiary North-East Indian hospital during a period between 2007 and 2018. Although most of our findings match with other studies reported earlier, there are some differences worth acknowledging.
The median age of our cohort was 15 years and the upper age limit was 18 years which was the cutoff age in many other studies of renal biopsy in children., Some studies implemented an upper age limit of 20 years,, and few others till 24 years of age., Although most of the studies from across the world have reported male predominance.,, Our findings are in concordance with few other studies which reported female predisposition.,
In this study, the most common indication for renal biopsy was NS accounting for more than half of total cases. Our findings are in conformity with majority of published reports of renal biopsy in children.,,, Among those with NS who underwent renal biopsy, majority had an atypical age at presentation. Among SDNS and FRNS, MCD was the most frequently reported diagnosis as also reported in many other studies.,, Among SRNS, the most commonly diagnosed entity was FSGS, which is consistent with other studies reported previously.,
In the present study, systemic diseases urinary abnormalities were the second most common indication for renal biopsy. Another study from India has also reported the similar findings. Systemic diseases as the predominant cause for renal biopsy have also been reported in a study conducted in Hong Kong. In this study, LN (29.5%) was found to be most frequent histopathological diagnosis, followed by MCD (26.8%), which is similar to the findings of a study from Hong Kong that has reported LN (23%) as the most common histopathological diagnosis followed by MCD (14%). The explanation for this finding could be the fact that the median age (15 years) of the children in our study was high. Furthermore, most of the children with NS do not present any criteria for undergoing renal biopsy. Systemic lupus erythematosus (SLE) is common in the Asian population and at least 75% of children with the disease develop clinically evident LN. LN has been reported as the most common secondary glomerular disease in various other studies.,,, Childhood-onset SLE affects females more often than males (8 to 9:1), even in the prepubescent age group (4 to 5:1).,, In our cohort, 64 out of 75 cases of LN were females. This could explain the higher female preponderance in our study.
| Study Limitations|| |
The important limitations of our study are its retrospective design, relatively small sample from a single center. Electron microscopy was not available at our center.
| Conclusion|| |
This study may represent a significant data in the understanding of glomerular disease in our pediatric population. NS was the most common indication of renal biopsy. Although primary glomerular diseases were more common, LN was the most common glome-rular disease overall in children of North-East India.
Conflict of interest: None declared.
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Mastakim Ahmed Mazumder
Department of Nephrology, Gauhati Medical College and Hospital, Guwahati - 781 032, Assam
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]