|Year : 2021 | Volume
| Issue : 1 | Page : 113-118
Clinicopathologic spectrum of glomerular diseases in a tertiary care hospital
Shalini Bhalla1, Muffazal Ahmad2, Shivanjali Raghuvanshi1, Preeti Agarwal1
1 Department of Pathology, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Nephrology, Sahara Hospital, Lucknow, Uttar Pradesh, India
|Date of Submission||29-Apr-2020|
|Date of Acceptance||14-Sep-2020|
|Date of Web Publication||09-Feb-2021|
Dr. Shalini Bhalla
Department of Pathology, King George's Medical University, Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Biopsy-proven renal diseases give an insight into the prevalence of glomerular diseases. These are uncommon diseases which differ according to geographical area, demography, age, and race of a population.
Aims: This study was aimed to evaluate the histopathological spectrum of glomerular diseases in native kidney biopsies. The secondary aim of the study was to review the literature for pattern of occurrence of glomerular diseases in and around the Indian subcontinent.
Settings and Design: The present study was a retrospective observational study conducted at a tertiary care hospital for a period of 2 years.
Subjects and Methods: One hundred and six consecutive native kidney biopsies performed under ultrasonographic guidance were done, and two renal core tissues, which were obtained in each case, were evaluated for light microscopy and immunofluorescence.
Results: The age at presentation varied from 6 to 70 years, and maximum cases belonged to the third and fourth decades. The male-to-female ratio was 1.6:1. The most common clinical indication for performing the renal biopsy was nephrotic syndrome in 68 cases (64%). The primary glomerular diseases accounted for 86 cases (81.1%), and the remaining were secondary. Minimal change disease (MCD) was the most common histological lesion (29.2%), followed by focal segmental glomerulosclerosis. Among the secondary glomerular diseases, lupus nephritis was the most common, followed by amyloidosis.
Conclusion: In this study of biopsy-proven renal disease, primary glomerulonephritis was found to be more common than secondary causes. Of the primary glomerulonephritis, MCD was the most common renal disease in patients of nephrotic syndrome. The study also highlights the similarities and differences in the spectrum of renal diseases in different regions of the Indian subcontinent.
Keywords: Glomerular diseases, minimal change disease, renal biopsy, spectrum
|How to cite this article:|
Bhalla S, Ahmad M, Raghuvanshi S, Agarwal P. Clinicopathologic spectrum of glomerular diseases in a tertiary care hospital. Indian J Health Sci Biomed Res 2021;14:113-8
|How to cite this URL:|
Bhalla S, Ahmad M, Raghuvanshi S, Agarwal P. Clinicopathologic spectrum of glomerular diseases in a tertiary care hospital. Indian J Health Sci Biomed Res [serial online] 2021 [cited 2021 Apr 16];14:113-8. Available from: https://www.ijournalhs.org/text.asp?2021/14/1/113/308944
| Introduction|| |
Glomerular diseases are a leading cause of end-stage renal disease globally. The prevalence of this disease varies according to geographical, etiological, and socioeconomic differences. Hence, knowledge of its prevalence is important. Biopsy-proven renal diseases provide an accurate tool for clinical practice and investigation. Glomerular diseases can be either primary resulting from environmental causes or systemic in origin. The clinical presentation of this group of diseases can be proteinuria, hematuria, hypertension, or renal insufficiency. The clinical course can vary from indolent to progressive uremia. Chronic renal diseases are a major reason for doing renal biopsy as its incidence in the past few years has increased with patients presenting usually at a late stage. The renal biopsy helps not only in the diagnosis but also in prognosticating the patient and in determining the treatment course. Profiling the glomerular diseases from different areas in and around the country helps understand the spectrum and the trend of disease over a time period. Literature does highlight the occurrence of change in the prevalence of glomerular diseases. The incidence of IgA nephropathy has increased in the Asian and American populations., Previously, Membranous nephropathy (MN) was the most common in the American and Europeans. Improvement in the socioeconomic status and decrease in the prevalence of infectious diseases in different geographical areas has also been contributory. The prevalence of glomerular diseases from different geographical areas in the Indian subcontinent has been done in a few studies as individual centers in the absence of a common renal registry. The present study was undertaken to evaluate the histopathological spectrum of glomerular diseases in native kidney biopsies. The secondary aim of the study was to review the literature for pattern of occurrence of glomerular diseases in and around the Indian subcontinent.
| Subjects and Methods|| |
A retrospective observational study of consecutive native renal biopsies performed on patients referred to the department of nephrology from January 2013 to 2015 was undertaken. The main indication of biopsy was to know the cause of proteinuria and/or renal failure and to plan for the treatment for that particular patient. A percutaneous renal biopsy was performed with a tru-cut needle under ultrasonographic guidance by the nephrologist in assistance with an interventional radiologist. Two renal core tissues were obtained in each case for light microscopy and immunofluorescence (IF). For electron microscopy, tissue was taken from one of the cores and processed wherever available. Renal biopsies were processed for light microscopy and IF in all cases. Sections from formalin-fixed paraffin blocks were stained with hematoxylin and eosin, periodic acid–Schiff, periodic silver methenamine, and Masson's trichrome. For IF, cryostat sections were stained for fluorescein isothiocyanate-conjugated IgG, IgM, IgA, C3, and C1q. Kappa and lambda were put where required. Patient data were obtained from clinical records and clinical diagnosis reconfirmed. The patients were divided into five categories as per standard definition used for the clinical syndromes. The patients were divided into those presenting with nephrotic syndrome, nephritic syndrome, rapidly progressive renal failure, chronic renal failure, and asymptomatic urinary abnormalities. Baseline laboratory parameters were noted such as serum creatinine, blood urea, serum albumin, urine routine and microscopy, 24-hr urinary protein estimation, and hemoglobin. Investigations for secondary etiology were done as part of routine workup wherever indicated. The workup included serology for hepatitis B, C viruses, human immunodeficiency virus, serum complement levels, antinuclear antibodies, serum protein electrophoresis, immunofixation and other related tests. The different glomerular diseases were then classified into primary and secondary glomerulonephritis. Patients with incomplete clinical data and inadequate biopsies were excluded from the study. In case a repeat biopsy was needed for diagnosis, it was done.
| Results|| |
A total of 106 consecutive kidney biopsy cases were included in the study. The male-female ratio was 1.6:1, and the age of presentation varied from 6 to 70 years, with maximum number of cases belonging to the third and fourth decades [Graph 1]. The most common clinical syndrome as an indication for renal biopsy was nephrotic syndrome in 68 (64%). The others were acute nephritic syndrome, rapidly progressive glomerulonephritis, chronic kidney disease, and asymptomatic urinary abnormalities [Graph 2]. The primary glomerular disease was seen in 86 (81.1%) cases, and the rest were as a result of secondary causes. Minimal change disease (MCD) was found to be the most common among the nephrotic syndrome patients [Graph 3]. The other common diseases were focal segmental glomerulosclerosis (FSGS) 22%, MN (19%), and amyloidosis 7% of cases. Among the primary glomerular diseases, the male patients were affected more than females, while in secondary diseases, females were more affected, especially in lupus nephritis. Of the primary glomerulonephritis, the most common was MCD 31 (29%) cases, followed by FSGS 18 (17%) cases and MN 14 (13.3%) cases. The other primary glomerular diseases are shown in [Graph 4]. MCD was found in children and adolescents along with the adult age group, and two patients were of the elderly age group. Among the various subtypes of FSGS, FSGS (not otherwise specified) subtype 15 cases were the most common while hilar variant 2 cases, cellular and tip variants, were one case each. No case of collapsing glomerulonephritis was seen. Lupus nephritis was the most common secondary glomerulonephritis, followed by hypertensive nephropathy and amyloidosis [Graph 5].
Minor complications such as pain at biopsy site, vomiting, abdominal pain, and restlessness were seen in 10%, 22%, 25%, and 4%, respectively. Mild hematuria which resolved spontaneously was seen in 10% of patients. Severe bleeding from biopsy site needing PRBC transfusion occurred in 1 patient. Perirenal hematoma formation occurred in 5 patients. No patient needed nephrectomy or surgical intervention to stop the bleeding. No death occurred related to kidney biopsy.
| Discussion|| |
Glomerular diseases are uncommon, and the individual glomerular disease seen in any individual center is even less. Hence, renal registries at national level help in gathering and maintaining epidemiological data which help understand the influence of age, sex, ethnicity, and geographical variations within the country. The present study was carried out at a nephrology unit in a tertiary care center in northern India. Nephrotic syndrome was the most common presentation accounting for 68 (64%) cases. This is in accordance with other studies both from India and around the world., The occurrence of glomerular diseases has shown a change in prevalence over time.
The spectrum of glomerular diseases in the tropics has been studied by various authors, and it has been found that the common presenting clinical syndrome is nephrotic syndrome and the diseases are predominantly primary in nature except in a few countries like Jamaica where the secondary glomerulonephritis was in 54% of patients of nephrotic syndrome. IgA nephropathy is the most common glomerular disease among Europeans and Americans, while studies have shown that the incidence has increased in East Asia. Initial studies from India are limited from few centers in North and South India.,, In the recent past, gradually, more centers have been established, and standardization of biopsy reporting with IF is being practiced. Fewer reports from eastern and western regions have been published.,,, The prevalence of glomerular diseases in different regions of country and geographical areas gives an insight into the occurrence of this relatively uncommon disease. The pattern of occurrence is influenced by genetic, environmental, and socioeconomic status. India with a population of more than one billion has a chronic renal disease burden of 17.2%. We have attempted to compare the data from India and its immediate neighboring countries [Table 1]. A comparison was also done from different geographical regions of India to see variation in the incidence of various glomerular disorders [Table 2]. Most Indian studies have shown MCD as the most common primary glomerulonephritis while MPGN was found to be more common in Bangladesh while Habib and Badruddoza reported focal segmental and diffuse mesangial proliferative glomerulonephritis as the most frequent.,,, MN is the most common in Nepal in majority of studies and few studies from Pakistan., However, recent studies from India have shown a five-fold increase in frequency of FSGS and a three-fold increase in MN across a five-decade period. Most centers have shown a decrease in mesangioproliferative glomerulonephritis with an increasing trend in FSGS, however, this is not uniform throughout the country. A decrease in the incidence of MPGN has been seen with the advent of regular use of IF and better classification of these cases into IgAN, DN, LN, etc., MCD was the predominant cause of adult-onset nephrotic syndrome in many studies, with an incidence ranging from 15% to 37%. In our study, the incidence of MCD was 29.2%. FSGS and MN were reported as the most common PGN from Chandigarh and Allahabad in northern India and Kolkata in the East.,, The northeast region of India has occasionally published reports with a higher incidence of GD in females. Lupus nephritis was the most common GD, followed by MCD. This difference in incidence of glomerular diseases may be due to the northeastern population having different food and cultural habits along with genetic diversity and similarities to the East Asian population. Although the clinical presentation was similar to other studies from India with nephrotic syndrome (57.8%) being the most common, followed by nephritic syndrome (31.4%). IgA nephropathy is the most common primary GN in Europe and East Asian countries such as Japan, Korea, and China.,, It has been observed that prevalence in India is variable, but increasing trend has been seen. In our study, it represents 10.4% of cases. However, the incidence is lower in Bangladesh and Nepal.
This study shows similarity in the clinical syndrome presentation of glomerular diseases, and the spectrum is similar to many other studies in the country, however, regional variations are noted. Hence, the development of national registry would help in better analysis of the prevalence of glomerular diseases in India. The drawback of the study was the inability to use EM for diagnosis which may have improved the diagnosis.
| Conclusion|| |
In this study, the most common indication for biopsy was nephrotic syndrome which is similar to studies from India with no geographical variation. The primary glomerular disease was more common than secondary glomerular disease. MCD was the most common biopsy-proven glomerular disease with wide age of presentation not only in childhood but also in the elderly age group. Lupus nephritis remains the most common cause of secondary glomerulonephritis both in the different regions of India and surrounding geographical area.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]