Year : 1997 | Volume
: 8 | Issue : 3 | Page : 289--293
Percutaneous Renal Biopsy and its Findings in Children and Adolescents in Saudi Arabia: A Single Center Experience
Lubna Al Menawy1, John Amuosi1, KS Ramprasad2, Faissal A.M Shaheen3,
1 Department of Pathology, King Fahad Hospital, Jeddah, Saudi Arabia
2 Saudi Center for Organ Transplantation, Riyadh, Saudi Arabia
3 Department of Nephrology, King Fahad Hospital, Jeddah, Saudi Arabia
Lubna Al Menawy
Department of Pathology, King Fahd Hospital, Jeddah Kidney Center, Jeddah
A retrospective study of 108 consecutive renal biopsies in children and adolescents below 18 years of age performed at the King Fahd Hospital, Jeddah, during an eight-year period ending 1996, was made. All the biopsies were performed by a single consultant nephrologist and under ultrasound guidance. Tru-cut needles were employed in all cases and in the last two years, the bioptic gum was used. The age of the patients ranged between 3 months and 18 years with a mean of 10.6 years. There were 58 males and 50 females. All patients tolerated the biopsy well and there were no failures. The common side effects noted included gross hematuria in three (2.8%) and severe pain at the biopsy site in 11 (10.2%). None of the patients needed blood transfusions or prolonged hospitalization. Nephrotic syndrome was the commonest indication for performing the biopsy (83.3%) and among them, minimal change was the commonest lesion found (25%) followed by focal and segmental glomerulosclerosis (14.8%) and mesangial proliferative glomerulonephritis (15.7%). Our study further shows that renal biopsy is a safe procedure in children and the commonest indication is nephrotic syndrome.
|How to cite this article:|
Al Menawy L, Amuosi J, Ramprasad K S, Shaheen FA. Percutaneous Renal Biopsy and its Findings in Children and Adolescents in Saudi Arabia: A Single Center Experience.Saudi J Kidney Dis Transpl 1997;8:289-293
|How to cite this URL:|
Al Menawy L, Amuosi J, Ramprasad K S, Shaheen FA. Percutaneous Renal Biopsy and its Findings in Children and Adolescents in Saudi Arabia: A Single Center Experience. Saudi J Kidney Dis Transpl [serial online] 1997 [cited 2020 Nov 29 ];8:289-293
Available from: https://www.sjkdt.org/text.asp?1997/8/3/289/39357
It is estimated that children and adolescents below 18 years of age constitute about 55% of the total population of Saudi Arabia.
Thus, it is important to have a good knowledge of the prevalence of various renal disorders in this age-group, in order to take appropriate preventive and therapeutic measures. Literature on the prevalence and pattern of renal diseases in Saudi Arabia is scanty and the available data are all from the Central Province ,,, .
The gold standard for renal diagnosis remains histological examination of biopsied tissue. Numerous studies have reported on the ease and safety of percutaneous renal biopsy, even in pediatric patients ,,, . Also, it is a common observation that various racial, genetic and environmental factors can influence the pattern of renal disease. This retrospective study was performed to assess the safety of percutaneous renal biopsy and to study the pattern of renal disease in children below 18 years of age in the Western Province of Saudi Arabia. The results are compared with those from the Central Province as well as international literature.
Materials and Methods
A retrospective study of children and adolescents who underwent percutaneous renal biopsy at the Jeddah Kidney Center, Jeddah, Saudi Arabia over an eight-year period ending 1996 was performed. All the biopsies were performed by a single consultant nephrologist and all were under ultrasound guidance. Tru-cut needles were used in all cases and in the last two years of the study, the bioptic gun was employed. All biopsy samples were processed for light microscopy and immunofluorescence while 17 of them were subjected to electron microscopic study in addition.
The sample for light microscopic study was fixed in 10% formaldehyde solution and the sections were stained by hematoxylin and eosin, periodic acid schiff, silver methenamine and in some cases with elastic vangison and masson trichrome. The sample for immunofluorescence study was submitted in saline as transport medium and the sections were stained for IgG, IgM, IgA, C3 and fibrinogen using Dako reagent. The samples for electron microscopic examination were fixed in glutaraldehyde media immediately after obtaining the tissue.
The indications for performing the renal biopsy included patients with steroid dependent or steroid resistant nephrotic syndrome, in whom cytotoxic therapy was contemplated, renal failure of uncertain etiology, mixed nephritic-nephrotic presentation, rapidly progressive renal disease and persistent or recurrent asymptomatic hematuria and/or proteinuria. For the purpose of the study, a biopsy was considered adequate if it contained five or more glomeruli.
The investigations carried out on each patient prior to renal biopsy included the following: hemoglobin, platelet count, prothrombin time, partial thromboplastin time and renal ultrasound examination. Premedication was in the form of mild sedation using chloral hydrate, promethazine or chlorpromazine. Most of the patients were discharged the same day following the biopsy and none of them had any complications.
During the eight-year period of study, a total of 108 consecutive renal biopsies performed in children and adolescents at our center were studied. Their age ranged between 3 months and 18 years with a mean of 10.6 years. There were 58 males and 50 females. There were 90 Saudis, five Yemenis, three each from Bangladesh, Egypt and Jordan, two Pakistanis and one each from India and Sudan. Overall, there were 41 patients below the age of 10 years and five below one year of age.
All patients tolerated the biopsy well and there were no failures. The most common complication seen was severe pain at the biopsy site (n=ll, 10.2%) followed by gross hematuria in two patients (2.8%). None of our patients developed serious complications requiring prolonged hospitalization, blood transfusions or nephrectomy. There were no instances of perirenal hematoma, arteriovenous fistula or hypotension.
Nephrotic syndrome was the commonest indication for performing the biopsy. It was seen in 90 patients (83.3%). Among them, minimal change glomerulonephritis (GN) was the commonest lesion seen in 27 patients (25%) followed by mesangial proliferative GN in 17 patients (15.7%) and focal and segmental glomerulosclerosis in 16 (14.8%). There was one patient with IgA nephropathy in this group, six patients had systemic lupus erythematosus (SLE) and two each had Alport's syndrome and congenital nephrotic syndrome [Table 1].
Acute renal failure of uncertain etiology constituted the indication for biopsy in nine patients (8.3%). Renal histology revealed crescentic GN in five, hemolytic uremic syndrome in two and mesangial proliferative GN and acute tubular necrosis in one patient each.
A total of six patients (5.5%) presented with, chronic renal insufficiency of uncertain cause. In this group, two patients each had diffuse global sclerosis, chronic tubulointerstitial nephritis and chronic pyelonephritis.
Three patients (2.8%) presented with persistent asymptomatic hematuria of whom two had IgA nephropathy and one had idiopathic mesangial proliferative GN.
Our study further shows that percutaneous renal biopsy is a safe procedure in children and adolescents with complications seen in only 10.2% of cases with none of them causing significant morbidity. There was no mortality in our series. The overall incidence of complications related to renal biopsy is reported to be about 10% with most of them being procedure-related bleeding ,, .
Nephrotic syndrome constituted the commonest indication for biopsy in our study. This is similar to other studies  . The reported annual incidence of the nephrotic syndrome in children aged 16 years or below ranges between two to seven cases per 100,000 total population , . However, such data are not available from our region.
The prevalence of minimal change GN in 25% of our cases compares well with the 23.3% reported by Al-Rasheed, et al from Riyadh, Saudi Arabia  . However, this is considerably lower than what is reported in relatively older studies [Table 2]. These studies were on non-selective nephrotics whereas the more recent ones are on a selected group in whom the indication for biopsy was either steroid nonresponsiveness or an atypical presentation. Thus, it is logical to expect a lower prevalence of minimal change GN in children who are biopsied for nephrotic syndrome in future years. A total of 20.4% of our study patients had mesangial proliferative GN of whom three had IgA nephropathy. This is similar to other reports from Saudi Arabia ,, as well as from other developing countries , . This high prevalence could be related to factors such as infections or infestations as well as genetic and racial factors.
Focal and segmental glomerulosclerosis was seen in 14.8% of our cases as against 24% in the KKUH study  . This high prevalence is a cause for worry since most of these patients continue to have massive proteinuria and also carry a high recurrence rate following renal transplantation.
IgA nephropathy was seen in 2.8% of our cases and 3.0% cases in the KKUH study  . The low prevalence in Saudi Arabia in contrast to the findings of about 40% prevalence in Japan  and Australia  is quite striking. This difference may be due to early screening of school children in Japan apart from racial, genetic and environmental factors.
Two of the most striking features of our study were: a) A 100% success rate in procuring adequate biopsies and b) absence of major complications. Different studies have reported variable success rates of biopsy in children ranging between 76% to 89%  . We attribute the 100% success rate in our series to the fact that all biopsies were performed by a senior consultant and under ultrasound guidance. Also, majority of our patients were discharged from the hospital the same day of the biopsy and none had any complications. Similar experience has been reported by Ogborn, et al also  .
Our experience further confirms that renal biopsy is a safe procedure in children and adolescents provided it is performed by an experienced person. It may be performed even as a day-care procedure without compromising on safety. Nephrotic syndrome remains the commonest indication with minimal change, mesangial proliferative GN and focal segmental glomerulosclerosis being the most prevalent lesions.
|1||Abdurrahman MB, Elidrissy ATH. Childhood renal disorders in Saudi Arabia. Pediatr Ncphrol 1988;2:36S|
|2||Akhtar M, Qunibi W, Taher S, et al. Spectrum of renal disease in Saudi Arabia. Ann Saudi Med 1990;10:37.|
|3||Mattoo TK, Mahmood MA, Al-Harbi M. Nephrotic syndrome in Saudi children. Clinicopathological study of 150 \cases. Pediatr Ncphrol 1990;4:517.|
|4||Abdurrahman MB, Elidrissy ATH, Shipkey FH, Al-Rasheed S, Al-Mugeiren M. Clinicopathological features of childhood nephrotic syndrome in Saudi Arabia. Ann Trop Paediatr 1990;10:125.|
|5||Bohlin AB, Edstrom S, Almgren B, Jaremko G, Jorulf H. Renal biopsy in children: indications, technique and efficacy in 119 consecutive cases. Pediatr Nephrol 1995;9(2):201-3.|
|6||Webb NJ, Pereira JK, Chait PG, Geary DF. Renal biopsy in children: comparison of two techniques. Pediatr Nephrol 1994;8(4):486-8.|
|7||Sahney S, Mohan GC. Renal biopsy in infants and children. Am J Kidney Dis 1994;23(l):31-2.|
|8||Towbin RB, Amundson GM, Fleischmann LE, Becker CJ, Chang CH. Real-time US guidance during renal biopsy in children: a different approach. Technical note. J Vase Interv Radiol 1991;2(4):561-2.|
|9||Altebarmakian VK, Guthinger WP, Yakub YN, et al. Percutaneous kidney biopsies: Complications and their management. Urology 1981;18:118.|
|10||Abdurrahman MB. Percutaneous renal biopsy in a developing country: Experience with 300 cases. Ann Trop Paeditr 1984;4:25.|
|11||Sweet M, Brouhard BH, Ramirez-Seijas F, et al. Percutaneous renal biopsy in infants and young children. Clin Nephrol 1986;26:192.|
|12||Al-Rasheed SA, Al-Mugeiren MM, AlSalloum AA, Al-Sohaibani MO. Childhood renal diseases in Saudi Arabia. A clinicopathological study of 167 cases. Int Urol Nephrol 1996;28(5):607-13,|
|13||Schlesinger ER, Sultz HA, Mosher WE, Feldman JC. The nephrotic syndrome: its incidence and implications for the community. Am J Dis Child 1968;116:623-32.|
|14||Rothenberg MB, Heymann W. The incidence of the nephrotic syndrome in children. Pediatr 1957;19:446-52.|
|15||Seggie J, Davies PG, Ninin D, Henry J. Pattern of glomerulonephritis in Zimbabwe: Survey of disease characterized by nephrotic proteinuria. Q J Med 1984;209:109.|
|16||Musa AM, Abu-Aisha H, Veress B. Nephrotic syndrome in Sudanese patients with Schistosomiasis mansoni infection. Ann Trop Med Parasitol 1980;74:615.|
|17||Kitajima T, Murakami M, Sakai O. Clinicopathological features in Japanese patients with IgA nephropathy. Jpn J Med 1983;22:219-22.|
|18||Clarkson AR, Seymour AE, Thompson AJ, Haynes WDG, Chan YL, Jackson B. IgA nephropathy: a syndrome of uniform morphology, diverse clinical features and uncertain prognosis. Clin Nephrol 1977;8:459-71.|
|19||Edelmann CM Jr, Greifer I. A modified technique for percutaneous needle biopsy of the kidney. J Pediatr 1976;70:81-6.|
|20||Ogborn MR, Grimm PC. Pediatric renal biopsy in the ambulatory care environment. Pediatr Nephrol 1992;6(3):311-2.|
|21||White RHR, Glasgow EF, Mills RJ. Clinicopathologic study of nephrotic syndrome in children. Lancet 1970;l:353.|
|22||Habib R, Kleinknecht C. The primary nephrotic syndrome of children: Classification and clinicopathologic study of 406 children, in Sommers SC (ed): Pathology Annual. New York, Appleton Century Crofts 1971;17.|
|23||International study of kidney disease in children. Nephrotic syndrome in children: Prediction of histopathology from clinical and laboratory characteristics at time of diagnosis. Kidney Int 1978;13:159.|