|Year : 2018 | Volume
| Issue : 4 | Page : 126-129
Spectrum of biopsy-proven kidney diseases at a tertiary care hospital in South India
Sanjeev S Manjunath, Chettypunyam S Chetan, Chaandrashekar Manoj, Satish Suchitha, Krishnamurthy K Kiran, Gangadhar Chirag
Department of Nephrology, JSS Medical College & Hospital, Mysore, Karnataka State, India
|Date of Submission||08-May-2018|
|Date of Acceptance||05-Oct-2018|
|Date of Web Publication||17-Dec-2018|
Dr. Chettypunyam S Chetan
Department of Nephrology, JSS Medical College & Hospital, Mysore, Karnataka State, 570004
Source of Support: None, Conflict of Interest: None
Introduction The prevalence of kidney diseases, glomerular and tubulointerstitial, varies with the geographical area, socioeconomic conditions of the people, population demographics, race and ethnicity, access to health care, and also the threshold for doing a renal biopsy.
Objective The primary objective was to study the prevalence of biopsy-proven kidney diseases presenting to a tertiary care hospital in Mysore, South India.
Patients and methods We have retrospectively analyzed the renal biopsy data from 2005 to 2013. The clinical and laboratory data of patients were collected from biopsy request forms, and histopathology data were recorded. Biopsy specimens were examined by light and immunofluorescence microscopy. As a hospital policy, all biopsies were based on definite indications. A total of 1113 biopsies were considered. Transplant biopsies and those with inadequate specimen were excluded.
Results A total of 914 patients had some kind of glomerulopathy. Minimal change disease (n=182/1113) was the commonest histological type among glomerular diseases, followed in order by postinfectious glomerulonephritis, focal segmental glomerular sclerosis, membranous glomerulopathy, and immunoglobulin A nephropathy. Among the secondary glomerular diseases, the commonest was diabetic nephropathy (n=72) followed by lupus nephritis (n= 58) and crescentic glomerulonephritis. Most common indication for renal biopsy was nephrotic syndrome (n=274/1113), chronic kidney disease (n=141), acute glomerulonephritis (n=107), acute kidney injury with unclear etiology or delayed recovery, and rapidly progressive glomerulonephritis.
Conclusion Nephrotic syndrome was the commonest indication for renal biopsy, and minimal change nephrotic syndrome (MCNS) was the most common glomerular disease followed by focal segmental glomerular sclerosis. Membranoproliferative glomerulonephritis, the incidence of which has decreased in the developed world, still accounts for a significant number in our population. There is a need for electronic data monitoring in India with nationwide integration for a proper analysis of the changing trends of diseases occurring over an extended time frame.
Keywords: kidney biopsy, biopsy proven kidney disease, minimal change disease, focal segmental glomerular scclerosis, chronic kidney disease
|How to cite this article:|
Manjunath SS, Chetan CS, Manoj C, Suchitha S, Kiran KK, Chirag G. Spectrum of biopsy-proven kidney diseases at a tertiary care hospital in South India. J Egypt Soc Nephrol Transplant 2018;18:126-9
|How to cite this URL:|
Manjunath SS, Chetan CS, Manoj C, Suchitha S, Kiran KK, Chirag G. Spectrum of biopsy-proven kidney diseases at a tertiary care hospital in South India. J Egypt Soc Nephrol Transplant [serial online] 2018 [cited 2019 Mar 20];18:126-9. Available from: http://www.jesnt.eg.net/text.asp?2018/18/4/126/247755
| Introduction|| |
Kidney diseases form the major reason for referral to tertiary care hospitals. Renal biopsy is an important diagnostic tool for the nephrologist. It is useful for diagnosis, planning treatment, and prognostication. Indications for biopsy can be varied like nephrotic syndrome, nephritic, rapidly progressive renal disease, chronic kidney disease (CKD), and acute kidney injury (AKI) with unclear etiology or delayed recovery. To know the epidemiology of glomerular or tubulointerstitial diseases, a proper maintenance of patient biophysical data, laboratory, and histopathology records is very much essential. This is a challenging task in a country like India where electronic medical records are not available in most hospitals, and more than 80% population reside in rural areas. In this study, we have presented the common biopsy-proven renal diseases seen in JSS Hospital, Mysore, between 2005 and 2013, with emphasis on the glomerular disease. Hospital receives patients from Mysore and surrounding villages. Most of patients belong to lower socioeconomic strata to middle class. The sample is representative of this region.
| Patients and methods|| |
This is a retrospective analytical study of our renal biopsy data at JSS hospital Mysore between 2005 and 2013. Patient details such as age, sex, and the available clinical data were collected from the histopathology requests. All renal biopsies were performed based on definite indications, and prior informed consent was taken from patients. Patients underwent biopsy only if coagulation was normal and blood pressure was under control. An informed consent before renal biopsy was taken from all patients. Renal biopsy was performed under local anesthesia using 2% lignocaine and an automated gun (Bard Company) with disposable needles. Two cores were taken. The tissue was placed in 10% formalin for light microscopic examination and in saline for immunofluorescence studies. For light microscope, multiple-step serials (32) from renal core were stained and studied using hematoxylin and eosin, periodic acid-Schiff, Masson trichrome, and Jones’ silver methenamine stains. For immunofluorescence, the biopsy specimens were washed in PBS thrice followed by embedding the tissue for frozen section in optimum cutting temperature medium. Once the tissue was freezed, 2–3-µ-thin sections were cut. Two to three sections were layered on each slide and were labeled as immunoglobulin (Ig)G, IgA, IgM, C3, C1q, κ, and λ. The slides were then stained with fluorescein isothiocynate-labeled antihuman antibodies of IgG, IgA, IgM, C3, C1q, κ, and λ light chains, respectively. The slides were then incubated for an hour at 37°C. After incubation, the slides were again washed thrice with PBS, mounted with glycerin, and viewed under immunofluorescent microscope Olympus BX 41, Olympus, USA. Electron microscope was not done in any of them owing to nonavailability. Indications for renal biopsy were nephrotic syndrome, nephritic syndrome, rapidly progressive glomerulonephritis, asymptomatic urine abnormalities like proteinuria and hematuria, unexplained AKI, CKD, and rapid worsening of CKD. Histologically reports were classified as primary and secondary glomerular diseases, tubule-interstitial diseases, and those due to hypertension. Primary glomerular diseases included minimal change disease (minimal change nephrotic syndrome (MCNS)/MCD), focal segmental glomerular sclerosis (FSGS), membranous nephropathy, membranoproliferative glomerulonephritis (MPGN), IgA nephropathy (IgAN), and postinfectious glomerulonephritis (PIGN). Most patients who underwent renal biopsies were older than 16 years. Children especially less than 10 years of age accounted for a very small percentage, and among them with nephrotic presentation underwent renal biopsy for steroid-resistant nephrotic syndrome.
| Results|| |
A total of 1113 biopsies performed at JSS hospital between 2005 and 2013 were analyzed. Males outnumbered females; there were 707 males and 406 females ([Table 1]). Glomerular diseases accounted for 82.1% (n=914). In males, glomerular diseases accounted for 61.5% (n=562/707) and in females 38.5% (n=352/406).
Patient’s age ranged from 5 years to over 80 years, with most patients biopsied coming under 20–40 years of age category ([Table 2]).
Indication for renal biopsy was nephrotic syndrome in 38.8% (N=432) followed by CKD in 16.7% (n=186) and acute glomerulonephritis in 16.1% (n=179). Few patients underwent renal biopsy for asymptomatic proteinuria and hematuria ([Table 3]) and ([Table 4]).
The most common primary glomerular disease is MCNS 16.47% (n=182) followed by PIGN 10.8% (n=120) and FSGS 10.5% (n=117). The most common among the secondary glomerular disease is diabetic nephropathy (4.6%, n=51) and class 4 lupus nephritis (4.4%, n=49). There were ten biopsies that showed PIGN on underlying diabetic nephropathy.
Acute interstitial nephritis (5.41%, n=60), acute tubular necrosis (5.32%, n=59), and chronic tubulointerstitial disease (3.33%, n=37) were the common tubulointerstitial pathologies ([Table 5]).
| Discussion|| |
The present study shows the common indications for renal biopsy and the types of renal histopathology we see in this part of India. As observed in many studies, even in the present series, males outnumber females in terms of biopsy numbers. The majority of the study population was in the 20–60 years of age group.
The main indication for renal biopsy in our study was nephrotic syndrome. This is observed in several other studies ,,,,.
Minimal change disease (MCNS) was the most common primary glomerular disease in our series (33.7%) followed by FSGS, membranous nephropathy, IgAN, and MPGN. This is commonest among young adults. MCNS as the commonest primary glomerular disease has been observed by Benitez Llanes et al.  and Ramesh Chandra et al. .
Studies from Asia and Europe have reported increased prevalence of IgAN ,,, IgAN comprises 8.2% among the glomerular disease in the present study. However, the prevalence of IgAN is increasing and is seen in all age groups compared with the earlier series; the reason probably is the reduced threshold for renal biopsies for asymptomatic proteinuria and hematuria.
FSGS is reported as the leading cause of adult nephrotic syndrome and in those undergoing biopsy for proteinuria in the USA, Mexico, and Saudi Arabia ,,,. In our study, FSGS accounts for 21.7% among primary glomerular disease. The prevalence of FSGS in this part of the world has remained the same over the years. Some of the biopsy series from South India puts the prevalence of FSGS at 15.3 and 17% ,.
MPGN has a varied prevalence in different regions of the world. The developed world has seen a decline in the incidence of MPGN probably owing to better control of infectious diseases and improvement in the socioeconomic standards. Studies from South India have shown a prevalence of 3.7% ,. A study from North India shows a prevalence of 18% . Our study shows MPGN pattern on renal biopsy in 9.8%, and most of these were primary MPGN and seen in younger age groups.
PIGN has a prevalence of 10.8% among glomerular diseases in this study. Other studies from India show a prevalence of 5.6 and 12.3% ,. MPGN parallels PIGN as some of them share the etiopathogenic pathways. PIGN superimposed on underlying diabetic nephropathy causing acute worsening of renal failure. PIGN in this setting carried poor outcome, although analysis of this data was not done in our study.
Acute interstitial nephritis and acute tubular necrosis account for 5.41% and 5.32% of biopsies in our study. Biopsy in these cases was based on standard indications. Chronic interstitial nephritis was seen in 3.33%. Frequency of tubulointerstitial disease is almost similar to one other study from the region .
Among the secondary glomerular disease, diabetic nephropathy (4.6%) and lupus nephritis (5.2% of biopsy-proven renal disease) were common in this study.
This study shows the distribution of biopsy-proven kidney disease at a tertiary center in Mysore, South India. There is a need for electronic data recording with integration into a national registry so that the prevalence of a disease and its evolving trends can be better understood.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Balakrishnan N, John G, Korula A, Visalakshi J, Talaulikar G, Thomas P et al.
Spectrum of biopsy proven renal disease and changing trends at a tropical tertiary care centre 1990-2001. Indian J Nephrol 2003; 13:29–29. [Full text]
Das U, Dakshinamurty KV, Prayaga A. Pattern of biopsy-proven renal disease in a single center of south India: 19 years experience. Indian J Nephrol 2011; 21:250–257.
] [Full text]
Mendiola-Fernández R, Gómez-Vázquez A, Cardona-Pérez M, Noyola-Villalobos H, Martínez-Calva IE. Biopsia renal percutánea, experiencia en el Hospital Central Militar. Revista de Sanidad Militar 2006; 60:379–382.
Mubarak M, Kazi JI, Naqvi R, Ahmed E, Akhter F, Naqvi SAA et al.
Pattern of renal diseases observed in native renal biopsies in adults in a single centre in Pakistan. Nephrology (Carlton) 2011; 16:87–92.
Rychlík I, Jancová E, Tesar V, Kolsky A, Lácha J, Stejskal J et al.
The Czech registry of renal biopsies. Occurrence of renal diseases in the years 1994-2000. Nephrol Dial Transplant 2004; 19:3040–3049.
Benítez Llanes O, Fuentes Abreu J, Pérez Bomboust I, Cuervo Cura R, Valdés Salazarte A. La biopsia renal en el diagnóstico de las glomerulopatías. Revista Cubana de Medicina 2002; 41:87–92.
Ramesh Chandra V, Ravi Kumar M, Prasad Gullipulli . Spectrum of biopsy proven renal disease − referral hospital experience in a developing nations: analysis based on 624 renal biopsies. Int J Sci Res 2015; 4:704–708.
Chang JH, Kim DK, Kim HW, Park SY, Yoo T-H., Kim BS et al.
Changing prevalence of glomerular diseases in Korean adults: a review of 20 years of experience. Nephrol Dial Transplant 2009; 24:2406–2410.
Hanko JB, Mullan RN, O’Rourke DM, McNamee PT, Maxwell AP, Courtney AE. The changing pattern of adult primary glomerular disease. Nephrol Dial Transplant 2009; 24:3050–3054.
Pesce F, Schena FP. Worldwide distribution of glomerular diseases: the role of renal biopsy registries. Nephrol Dial Transplant 2010; 25:334–336.
Swaminathan S, Leung N, Lager DJ, Melton LJ, Bergstralh EJ, Rohlinger A et al.
Changing incidence of glomerular disease in Olmsted County, Minnesota: a 30-year renal biopsy study. Clin J Am Soc Nephrol 2006; 1:483–487.
Chávez Valencia V, Orizaga de La Cruz C, Becerra Fuentes JG, Fuentes Ramírez F, Parra Michel R, Aragaki Y et al.
Epidemiology of glomerular disease in adults: a database review. Gac Med Mex 2014; 150:403–408.
Nair R, Walker PD. Is IgA nephropathy the commonest primary glomerulopathy among young adults in the USA? Kidney Int 2006; 69:1455–1458.
Nawaz Z, Mushtaq F, Mousa D, Rehman E, Sulaiman M, Aslam N et al.
Pattern of glomerular disease in the Saudi population: a single-center, five-year retrospective study. Saudi J Kidney Dis Transpl 2013; 24:1265–1270.
] [Full text]
Polito MG, de Moura LAR, Kirsztajn GM. An overview on frequency of renal biopsy diagnosis in Brazil: clinical and pathological patterns based on 9,617 native kidney biopsies. Nephrol Dial Transplant 2010; 25:490–496.
Narasimhan B, Chacko B, John GT, Korula A, Kirubakaran MG, Jacob CK. Characterization of kidney lesions in Indian adults: towards a renal biopsy registry. J Nephrol 2006; 19:205–210.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]