Year : 2000 | Volume
: 11 | Issue : 3 | Page : 434--441
The Spectrum of Glomerulonephritis in Saudi Arabia: The Results of the Saudi Registry
S Huraib1, A Al Khader2, F.A.M Shaheen3, H Abu Aisha4, MZ Souqiyyeh5, F Al Mohana6, M Soliman2, J Al Wakeel4, A Mitwalli4, S Al Mohaya6, R Said1, Abdulhaleem2, L Al Menawy3, M Sohaibani4, N Chan1,
1 King Fahad National Guard Hospital, Saudi Arabia
2 Riyadh Kharj Military Hospital, Saudi Arabia
3 Jeddah Kidney Center, Saudi Arabia
4 King Khalid University Hospital, Saudi Arabia
5 Riyadh Medical Complex, Saudi Arabia
6 King Faisal University Hospital, Saudi Arabia
Coordinator for Saudi GN Registry, King Fahad National Guard Hospital, P.O. Box 22490, Riyadh 11426
Only few studies regarding glomerulonephritis, with relatively small numbers of patients, have so far been published from different centers in Saudi Arabia, and have reported conflicting results regarding the patterns, even in the same city. The possible reasons for these differences include the small number of patients in the different studies, differences in the indications for renal biopsies, referral bias, geographical differences, and, sometimes, the nonavailability of the necessary diagnostic facilities in the reporting centers. In order to overcome these problems, a registry for glomerulonephropathy was attempted in Saudi Arabia. Six large referral hospitals from different regions of Saudi Arabia participated in this registry. Biopsy reports and clinical information of 1294 renal biopsies were obtained. There were 782 renal biopsies due to glomerulonephritis (GN) accounting for 77.2% of the total biopsies. Five hundred eighty seven (72.6%) were primary glomerulonephritidis. Focal and segmental glomerulosclerosis (FSGS) (21.3%) and membrano-proliferative glomerulonephritis (MPGN) (20.7%) were the most common types found in the primary glomerulonephritidis. Membranous glomerulonephritis (MGN) was present in only 10.6% of the cases. IgA nephropathy was found in 6.5% of the cases. Of the secondary glomerulo-nephritides, systemic lupus erythematosus (SLE) was the most common indication for biopsy (57.0%) and amyloidosis was found in only 3.2% of the biopsies. In conclusion, FSGS and MPGN were the most common forms of primary glomerulonephritis in adult patients in Saudi Arabia. MGN was not as common as in the western world. SLE was the commonest cause of secondary GN. Amyloidosis was not as common as in other Arab countries. There is a need for more centers from Saudi Arabia to join this national GN registry. Similar registries can be established in different Arab countries, which all would, hopefully, lead to a PanArab GN registry.
|How to cite this article:|
Huraib S, Al Khader A, Shaheen F, Abu Aisha H, Souqiyyeh M Z, Al Mohana F, Soliman M, Al Wakeel J, Mitwalli A, Al Mohaya S, Said R, Abdulhaleem, Al Menawy L, Sohaibani M, Chan N. The Spectrum of Glomerulonephritis in Saudi Arabia: The Results of the Saudi Registry.Saudi J Kidney Dis Transpl 2000;11:434-441
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Huraib S, Al Khader A, Shaheen F, Abu Aisha H, Souqiyyeh M Z, Al Mohana F, Soliman M, Al Wakeel J, Mitwalli A, Al Mohaya S, Said R, Abdulhaleem, Al Menawy L, Sohaibani M, Chan N. The Spectrum of Glomerulonephritis in Saudi Arabia: The Results of the Saudi Registry. Saudi J Kidney Dis Transpl [serial online] 2000 [cited 2021 Dec 8 ];11:434-441
Available from: https://www.sjkdt.org/text.asp?2000/11/3/434/36666
The exact pattern of glomerulonephritis (GN) in Saudi Arabia and the Arab world is not well known. Unfortunately, there are only few published studies on this topic with small numbers of patients. ,,,,, The majority of these studies are from the Riyadh area and they have reported conflicting results. Some reported that focal and segmental glome-rulosclerosis (FSGS) was the most common pattern of primary GN, , with a prevalence as high as 40.8%,  while others reported membranoproliferative glomerulonephritis (MPGN) as the predominant lesion. , A report from the western region of Saudi Arabia showed that membranous glomerulonephritis (MGN) was the most common form seen there,  while another report from the southern region of Saudi Arabia showed that mesangioproliferative glomerulonephritis (MsPGN) was the commonest lesion in that region. 
There are several possible reasons for these differences in the pattern of glomerulonephritis seen in different studies. These include: the small numbers of patients in the different studies, differences in the indications for renal biopsies, referral bias, geographical differences and the nonavailability of the necessary facilities for accurate classification (e.g. electron microscopy) in some of the reporting centers.
In order to overcome these problems, a registry for GN was attempted in Saudi Arabia with the following objectives:
to determine the pattern of GN in Saudi Arabiato better understand the natural history of GN in this countryConducting multicenter trials for the treatment of GN in a coordinated fashion.
Here, we report a preliminary result of this GN registry regarding the pattern of GN in Saudi Arabia.
Materials and Methods
Six major referral hospitals from different regions of Saudi Arabia participated in this registry. Four hospitals were from the Riyadh area (King Khalid University Hospital, Riyadh Kharj Military Hospital, King Fahed National Guard Hospital and Riyadh Medical Complex). One large center from the western province (Jeddah Kidney Center) and the University Hospital from the eastern province (King Faisal University Hospital) covered these two main regions of the Kingdom. The clinical and laboratory data on pre-made questionnaire included age, sex, nationality, blood pressure, urinalysis, 24-hour urine protein excretion and creatinine clearance, serum creatinine, urea and electrolytes. The indications for renal biopsy included nephrotic syndrome, proteinuria more than one gram/day with active urine sediment, systemic disease with evidence of renal involvement, and un-explained renal insufficiency. All biopsies were performed under ultrasound guidance using Tru-cut® needles. At least two cores of tissue were submitted for pathological examination. All biopsies were studied using light microscopy, immunofluorescence and electron microscopy. Biopsy specimens containing five or more glomeruli were considered adequate. Renal histopathologist interpreted the findings according to the World Health Organization (WHO) classification. All the biopsy results and the answered questionnaire were sent to the coordinator of the registry. The data were entered into a computer for analysis.
Of the 1294 renal biopsies obtained, 1013 were from adults and 281 were from children. The types of renal diseases found in renal biopsies are shown in [Table 1]. There were 782 (77.2%) renal biopsies which showed one form or another of GN. Of these, 587 (72.6%) were primary GN and 221 (27.4%) were secondary GN.
The demographic data of the primary and secondary GN are shown in [Table 2]. The age distribution was almost equal in both the primary and secondary GN. There were more males (62.9%) in the primary GN group, while more females (60.4%) were seen in the secondary GN group. The majority of patients were Saudis in both the primary and secondary GN (67.5% and (74.7%% respectively).
The histological findings of the primary glomerular diseases are shown in [Table 3]. FSGS (21.3%) and MPGN (20.7%) were the most commonly found types. MPGN type I accounted for 90.9% of the cases in this category followed by type III (7.5%), while type II was very rare (1.6%).
[Table 4] shows the pattern of secondary GN. Systemic lupus nephritis (SLE) was the most common systemic disease associated with nephropathy, accounting for 57.0% of the secondary cases. Post-infectious GN was the second most common disease, being present in 11% of the cases.
[Table 5] shows the clinical presentations of the different histological lesions of primary GN. The nephrotic syndrome was present more with minimal change disease (MCD), FSGS and MGN. Hypertension was present more frequently in patients with FSGS, MPGN and diffuse proliferative glomerulonephritis [Table 5]. Renal insufficiency was more with diffuse proliferative glomerulonephritis (DPGN) and MPGN. Microscopic hematuria presented more with proliferative glomerulonephritis while gross hematuria was seen mainly with IgA nephropathy.
This is, as yet, the largest report of the spectrum of GN as seen in Saudi Arabia. The few previously published reports were from different parts of the Kingdom and did not use a unified protocol. ,,,,,, In the King Faisal Specialist Hospital, Riyadh, Qunibi et al found FSGS to be the most common form of primary GN (30.7%) followed by MsPGN (25%) and MPGN (17.3%). A similar result but in a larger number of patients was reported by Akhtar et al from the same institute.  The possible reason for the high prevalence of FSGS in both studies was thought to be due to referral bias of more steroid resistant MCD to this tertiary care center.
Huraib et al reported the results of GN from King Khalid University Hospital, Riyadh, in which they found MPGN was the most common (26.4%), while FSGS was seen in only 11.5% of the cases. Similarly, Al Khader et al, from Riyadh Kharj Military Hospital,  found in their series of patients with the nephrotic syndrome that MPGN was the most common (25%), while FSGS was present in 15.5%. Mitwalli et al,  again from Riyadh, reported the highest prevalence of FSGS (40.8%) and the lowest prevalence of MCD (1.1%) in their adult population with nephropathies. This also indicates a referral bias of biopsying only steroid-resistant MCD. On the other hand, Jorgenson et al  from the southern part of Saudi Arabia reported the lowest prevalence of FSGS (4%). The frequency of FSGS in most non-Western countries is less than 19%, ,,,,,,, as shown in [Table 6]. However, a higher prevalence of FSGS has been reported form Ghana  and Hong Kong  (36% and 23.6% respectively).
Our registry results showed a relatively higher prevalence of FSGS than most of the reports from different parts of the world, but much less than what has been reported from some centers in Saudi Arabia ,, as well as from Ghana.  The cause of this relatively high prevalence of FSGS in Saudi Arabia is not clear. Racial factors have been reported , the disease being more in blacks. However, other possible precipitating factors such as genetic, viral infection (hepatitis C and B), socio-economic status or immune system abnormalities need further evaluation.
The prevalence of MPGN in our registry was almost equal to that of FSGS. This high prevalence of MPGN has also been found in some reports from other Arab countries ,, as well as from other developing countries  [Table 7]. This high prevalence of MPGN in developing countries is probably related to infection, particularly hepatitis B and C. In contrast, the prevalence of MPGN is very low in the western countries ,,, and has decreased with time in some countries such as Italy,  where it decreased from 21% during the period between 1972-1976 to 6% between 1979-1983.
This evolution of GN lesion has been also reported in some of the developing countries. In a study from Tunisia,  reviewing 1090 primary renal biopsies over three periods of time, there was predominance of proliferative GN (65.8%) during the period of 1975-1980. The proliferative GN and nonproliferative GN became equal during the period 1981-1985. Then, there was regression of proliferative GN (41.7%) over the period of 1986-1990. The authors attributed this regression to better diagnosis and treatment of infection. MPGN type II was a rare finding in our study (1.6%), which is similar to reports from Singapore,  but is different from what has been reported from the western world, where it was reported to be as high as 24% of MPGN.  This could be due to geographical differences or selection of only adult patients as this lesion is more common in children.
Membranous GN, in our report was much less than what has been reported in the western world; 21% in England  and 50% in USA.  A similar low prevalence of MGN was seen in Malaysia  and Tunisia.  There is no good explanation for this low prevalence of MGN despite the high incidence of HBsAg infections in Saudi Arabia. 
IgA nephropathy also was not common in our study because its main presentation is asymptomatic microscopic or gross hematuria. According to the registry indications for biopsy, many patients were not included and diagnosed only clinically.
Amyloidosis was not a common finding (3.2%) in our study. This is in agreement with the previous reports ,,, that showed amyloidosis as an uncommon finding in the Saudi population, despite the high prevalence of tuberculosis and other chronic infections. By contrast, amyloidosis was a fairly frequent finding in reports from other Arab and Mediterranean countries, where the incidence was 11% in Jordan,  14.4% in Tunisia,  13% in Lebanon  and 32.4% in Turkey.  This is mainly related to the high prevalence of Familial Mediterranean Fever in these countries.
Among the secondary causes of GN in our study, SLE accounted for 57% of the cases. This is probably, in part, due to the increased awareness of the disease. Moreover, the adoption of the National Institute of Health (NIH) protocol  for treatment of lupus nephritis (which requires renal biopsy to determine the WHO class of lupus nephritis as well as the activity and chronicity index before starting therapy) has made most centers perform renal biopsies more readily than before in SLE cases.
Finally, We feel that the "Saudi Registry of Glomerular Diseases" will contribute to the compilation of an accurate record of the glomerulonephritides in Saudi Arabia. However, to achieve its goals, the registry needs continuous updating and evaluation, since there is always change of the pattern with time. Moreover, the registry will help to study the natural history of the common glomerular diseases in the country, their possible causes and the best modalities of treatment. We suggest the structure of the registry as shown in [Figure 1] which is similar to what is present in some Western countries.  In addition, we recommend the formation of similar registries in the different Arab countries. Reports from these registries could be combined for future establishment of a Pan-Arab registry of glomerular diseases.
|1||Qunibi W, al Saibai M, Taher S, Akhtar M. Renal disease in Saudi Arabia: a study of 147 renal biopsies. The King Faisal Specialist Hospital Medical Journal 1984; 4(4):317-23.|
|2||Jorgenson HE, Malik GH, Paul TT, Wohra PC. Renal disease in Saudi Arabia. Ann Saudi Med 1990;10:37-44.|
|3||Huraib SO, Abu-Aisha H, Mitwalli A, Mahmoud K, Memon NA, Sulimani F. The spectrum of renal disease found by kidney biopsies at King Khalid University Hospital. Saudi Kidney Dis Transplant Bull 1990;1:15-9.|
|4||Al-Khader A, Al Sulaiman M, Dhar JM. Renal histology in Saudi population with overt nephrotic syndrome. Ann Saudi Med 1990;5:581.|
|5||Akhtar M, Qunibi W, Taher S, et al. Spectrum of renal disease in Saudi Arabia. Ann Saudi Med 1990;10:37-44.|
|6||Mitwalli A, Al Wakeel J, Al Mohaya S, et al. Pattern of glomerular disease in Saudi Arabia. Am J Kidney Dis 1996;27(6):797-802.|
|7||Al Shohaib S, Nassif O, Jalal S. The patterns of renal disease in the western part of Saudi Arabia. Saudi Kidney Dis Transplant Bull 1990;4:563.|
|8||Yahya TM, Pingle A, Boobes Y, Pugle S. Analysis of 490 kidney biopsies: data from the United Arab Emirates renal disease registry. J Nephrol 1998;11(3):148-50.|
|9||Verroust P, Ben-Maiz H, Morel-Maroger L, et al. A clinical and immunopathological study of 304 cases of glomerulonephritis in Tunisia. Eur J Clin Invest 1979;9(1):75-9.|
|10||Musa AR, Veress B, Kordofani AM, et al. Pattern of the nephrotic syndrome in Sudan. Ann Trop Med Parasitol 1980;74:37-44.|
|11||Cameron JS. The natural history of glomerulonephritis. In: Kincaid-Smith P, d'Apices AJ, Atkins RC, Eds. Progress in glomerulonephritis. New York: Wiley 1978:1-25.|
|12||Sinniah R. Renal disease in Singapore with particular reference to glomerulo-nephritis in adults. Singapore Med J 1980;21:583-91.|
|13||Prathap K, Looi LM. Morphological pattern of glomerular disease in renal biopsies from 1000 Malaysian patients. Ann Acad Med Singapore 1982;11:52-6.|
|14||Seedat YK, Nathoo BC, Parag KB, Naiker IP, Ramsaroop R. IgA nephropathy in blacks and Indians of Natal. Nephron 1988;50:137-41.|
|15||Abu Romeh SH, van der Meulen J, Cozma MC, et al. Renal diseases in Kuwait. Experience with 244 renal biopsies. Int Urol Nephrol 1989;21:25-9.|
|16||Adu D, Anim-Addo Y, Foli AK. The nephrotic syndrome in Ghana: clinical and pathological aspects. Q J Med 1981;50:297-306.|
|17||Lai FM, Lai KN, Chan KW, et al. Pattern of glomerulonephritis in Hong Kong. Pathology 1987;19:247-52.|
|18||Pontier PJ, Patel TG. Racial differences in the prevalence and presentation of glomerular disease in adults. Clin Nephrol 1994;42:79-84.|
|19||Bakir AA, Bazilinski NG, Rhee HL, Ainis H, Dunea G. Focal segmental glomerulosclerosis: A common entity in nephrotic black adults. Arch Intern Med 1989;149:1802-4.|
|20||Ramzy MF, El Ghoneimy H, El Khashab O, et al. Pathological patterns of adult primary chronic glomerular disease in Egypt, retrospective light microscopy study. Second Congress of the Arab Society of Nephrol and Renal Transplant Abstract book, N39, 1991.|
|21||Bolton WK, Atuk NO, Sturgill BC, Westervelt-FB JR. Therapy of the idiopathic nephrotic syndrome with alternate day steroids. Am J Med 1977;62:60-70.|
|22||Wass VJ, Jarrett RJ, Chilvers C, Cameron JS. Does the nephrotic syndrome increase the risk of cardiovascular disease. Lancet 1979;2:664-7.|
|23||Barbiano-di-Belgiojoso G, Baroni M, Pagliari B, et al. Is membranoproliferative glomerulonephritis really decreasing. A multicenter study of 1548 cases of primary glomerulonephritis. Nephron 1985;40:380-1.|
|24||Ben Maiz H, Ben Moussa F, Ben Hamida F, Goucha R, Ben Ayed H. Primary glomerulonephritis in adults: Evolution of lesions during a period of 15 years. (Abstract) 2nd Congress of the ASNRT Congress 1991, N12.|
|25||Habib R, Gubler MC, Loirat C, Maiz HB, Levy M. Dense deposit disease: a variant of membranoproliferative glomerulo-nephritis. Kidney Int 1975;7:204-15.|
|26||Glassock R, Cohen A, Adler S. Primary glomerular disease. In: Brenner BM, Rector FC, (eds). The Kidney 1996, pp. 1392-94.|
|27||Alfaleh FZ. Hepatitis B infection in Saudi Arabia. Ann Saudi Med 1988;8(6).|
|28||Amor SS, Hamjeh YS. Renal amyloidosis in Jordan. Presented at the 8 th Saudi Medical Conference, Riyadh, Saudi Arabia 1983.|
|29||Moukheibir N. Computer analysis of renal disease in Lebanon. J Med Leban 1970; 23(1):219-22.|
|30||Sokmen C, Ozdemir AI. The spectrum of renal diseases found by kidney biopsy in Turkey. Ann Intern Med 1967;67:603-5.|
|31||Austin HA 3d, Klippel JH, Balow JF, et al. Therapy of lupus nephritis. Controlled trial of prednisone and cytotoxic drugs. N Engl J Med 1986;314:614-9.|
|32||Central Committee of the Toronto glomerulonephritis registry. Regional program for the study of glomerulonephritis. CMA Journal 1981;124:158-61.|