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HISTOLOGICAL PATTERN OF GLOMERULOPATHIES.

Byline: Noor Mohammad, Taj Mohammad Khan, Akhtar Nawaz Orakzai and Mohammad Imran

ABSTRACT

Background: Glomerulopathies result in a variety of signs and symptoms. The aim of this study was to determine the histological pattern of glomerulopathies in patients admitted to Nephrology unit. Methods: This study was conducted at Nephrology Department, Institute of Kidney Diseases, Hayatabad, Peshawar. One hundred nephrotic and nephritic patients were included. All patients were evaluated by history, clinical examination and relevant investigations. All the patients underwent renal biopsy under ultrasound guidance and tissue was examined for histopathological pattern. All the data were entered into a structured proforma and was analyzed on SPSS version 10. Frequency and percentages were calculated for histological pattern. Chi-square test was applied to compare the significance of proportions of histological patterns and P value less than 0.05 level was considered significant. Results: Out of 100 patients 76 were males and 24 were females.

The mean age was 27.63+14.22 years. The common indications for renal biopsy were nephrotic syndrome, proteinuria/hematuria and nephritic syndrome in 73, 15 and 12 patients respectively. Focal segmental glomerulosclerosis was found in 22 cases (22%) followed by membranous nephropathy in17 cases (17%), IgA nephropathy and mesangioproliferative glomerulonephritis in 10 cases (10%) each. The most common lesion noted in paediatric population was FSGS (26.66% n=8) while in adults the most common histopathological diagnosis was membranous nephropathy and FSGS (20% n=14 each). Conclusion: The most common glomerular pathology seen in our study is FSGS followed by MGN, IgA and mesangioproliferative GN.

KEY WORDS: Glomerulonephritis, Renal Biopsy, Histological pattern.

INTRODUCTION

Glomerulopathy results in a variety of signs and symptoms, including proteinuria, hematuria, azotemia, oliguria, edema and hypertension. Evaluation of pathologic features identified in a renal biopsy specimen may be required for definitive diagnosis. In 1934, Ball performed the first closed needle biopsy with an aspiration device.1

Automated spring loaded guns have increased the yield of successful biopsies from 60-90% with associated minimal complications.2 Situations in which renal biopsy serves an important diagnostic function include nephrotic syndrome in adults, steroid resistant nephrotic syndrome in children, glomerulonephritis (GN) in adults other than clear cut acute post streptococcal GN and ARF of unknown origin. The most common histopathological lesion in paediatric population age less than 10 years is minimal change disease (MCD).3 One local study shows MCD the most common entity followed by focal segmental glomerulus sclerosis (FSGS) and membranous GN.4 Another local study shows mesangioproliferative GN the leading entity followed by membrano-proliferative GN and MCD.5 While in adults of 5th to 6th decade of life membranous nephropathy is most common worldwide.6 Similar audit of renal biopsy at JPMC showed FSGS as most frequently occurring GN.7

In nephrological practice renal histology often dictates treatment modalities. As nephrotic / nephritic syndrome are clinical manifestations of a variety of nephritides, which bear common clinical features of peripheral edema, hypertension, hematuria, and proteinurea.

The aim of this study was to determine the histological pattern of glomerulopathies in patients admitted to Nephrology unit.

MATERIAL AND METHODS

This Case series study was conducted at Nephrology Department, Institute of Kidney Diseases, Hayatabad Peshawar from 12th August 2008 to 11th February 2009. It included 100 patients by non-probability convenience sampling technique after their written informed consent and prior approval of the hospital ethical committee.

The inclusion criteria were nephrotic patients with proteinuria of greater than 3gm/24 hours in adults and hypoalbuminaemia of less than 2.5g/dl, non-nephrotic range proteinuria with evidence of hypertension/ hematuria/deranged renal function or active sediments on urine microscopy (Nephritic syndrome in adults and children), steroid resistant nephrotic syndrome in children, steroid dependant nephrotic syndrome in children and relapsing nephrotic Syndrome. We excluded patients under 8 years of age, long standing diabetics with proteinuria ( greater than 7 years of IDDM and greater than 5 years for NIDDM), bilateral small echogenic or scarred kidneys (Kidney size less than 8 cm), adult polycystic kidney disease diagnosed on ultrasound and coagulation abnormality (Patient prothrombin time greater than 3sec than that of control).

All patients were evaluated by history, clinical examination and investigations including urine routine examination, serum albumin, 24 hours urinary protein, serum cholesterol, blood urea and serum creatinine, anti nuclear factor, HBsAg, AntiHCV Ab, and chest X-Ray.

All the patients underwent renal biopsy using 10 cm long, 18 Gauge Spring loaded Trucut biopsy needle (Monopty Gun(r)) under ultrasound guidance. Six microns of sections were done and specimens were stained with eosin and heamotoxylin, Periodic Acid Schiff (PAS), Silver Nitrate and Congo red and the specimens were seen for the following histopathological pattern of glomerulopathies; minimal change disease, focal segmental glomerulosclerosis, mesangioprolifera-tive glomerulonerphritis, membranoproliferative glomerulonephritis, membranous nephropathy, renal amyloidosis, crescentic glomerulonephritis, proliferative glomerulonephritis and tubulo-interstitial nephritis.

All the data were entered into a structured proforma and was analyzed on SPSS version 10. Frequency and percentages were calculated for histological pattern. Chi-square test was applied to compare the significance of proportions of above mentioned qualitative variables and P value less than 0.05 level was considered significant.

RESULTS

A total of 100 biopsies were done. Out of these 76 (76%) were males and 24 (24%) were females with male to female ratio of 3:1. The mean age was 27.63+14.22 years. The age distribution is shown in Table 1.

Table 1: Age distribution.

Age (years)###Number of###Percentage patients

9 - 19###30###30%

20 - 29###31###31%

30 - 39###18###18%

40 - 49###11###11%

50 - 59###6###6%

greater

than 60###4###4%

Table 2: Indications of renal biopsy. Indications###

###Number of###Percent-

###patients###age

Nephrotic Syndrome###73###73

Proteinuria and###15###15

Haematuria

Nephritic Syndrome###12###12

The histopathological pattern having proteinuria more than 3 gm are shown in Table 3.

Keys: FSGS: Focal Segmental Glomerulosclerosis, MGN: Membranous Nephropathy,

GN: Glomerulonephritis, TIN: Tubulo Interstitial Nephritis, MCD: Minimal Change Disease, MPGN: Membrano Proliferative Glomerulonephritis

Histological Pattern of glomerulopathies in different age groups is shown in Table 4.

Focal segmental glomerulosclerosis was found in 22 cases (22%) followed by membranous nephropathy in 17 cases (17%), IgA nephropathy and mesangioproliferative glomerulonephritis in 10 cases (10%) each.

The most common lesion noted in paediatric population was FSGS (26.66% n=8), followed by mesangioproliferative glomerulonephritis (23.33% n=7), and IgA nephropathy (13.33% n=4).

The most common histopathological diagnosis in adults was membranous nephropathy and

Keys: FSGS: Focal Segmental Glomerulosclerosis, MGN: Membranous Nephropathy,

GN: Glomerulonephritis, TIN: Tubulo Interstitial Nephritis, MCD: Minimal Change Disease, MPGN: Membrano Proliferative Glomerulonephritis

Histological Pattern of glomerulopathies in different age groups is shown in Table 4.

Focal segmental glomerulosclerosis was found in 22 cases (22%) followed by membranous nephropathy in 17 cases (17%), IgA nephropathy and mesangioproliferative glomerulonephritis in 10 cases (10%) each.

The most common lesion noted in paediatric population was FSGS (26.66% n=8), followed by mesangioproliferative glomerulonephritis (23.33% n=7), and IgA nephropathy (13.33% n=4).

The most common histopathological diagnosis in adults was membranous nephropathy and

Histological pattern of glomerulopathies

MGN - Membranous Nephropathy, MPGN - Membranoproliferative glomerulonephritis

FSGS - Focal Segmental Glomerulosclerosis, MCD - Minimal Change Disease, TIN - Tubulointerstitial

Nephritis, ATN - Acute Tubular Necrosis

FSGS (20% n=14 each) followed by Tubulointerstitial nephritis (10% n=7), IgA Nephropathy and MPGN (8.57% n=6 each) each.

DISCUSSION

Renal biopsy is a useful procedure to understand the histological pattern of renal disease. It helps in establishing the accurate diagnosis, identifying the exact pathology and devising the appropriate management plan for patients suffering from different types of nephritides. Significant differences in the disease spectrum were found when this study was compared with national and international studies.

In our study, males (76%) outnumbered females (24%) (Male to female Ratio of 3:1) and the mean age was 27 years. This is validated in a study done by Muzaffar et al8 and Anwar N et al.9 A study in Japan showed female preponderance. This could be due to male dominant society and poor access of female to healthcare facilities in our region especially in Khyber Pukhtunkhwa.

The most common indication for renal biopsy was nephritic syndrome as in a study done by Anwar N et al.9 Contradictory to our results, a study in Okinawa Japan10 revealed proteinuria and hematuria to be the most common indications.

CONCLUSION

The most common glomerular pathology seen in our study was focal segmental glomerulosclerosis followed by Membrahous glomerulonephritis, IgA and mesangioproliferative glomerulonephritis.

In paediatric population focal segmental glomerulosclerosis was the most common entity followed by mesangioproliferative glomerulonephritis and IgA nephropathy.

Proteinuria more than 3 grams was most commonly observed in focal segmental glomerulosclerosis and Membrahous glomerulonephritis.

REFERENCES

1. Ball RP. Needle (Aspiration) biopsy. J Tenn Med assoc 1934;27:203.

2. Ori Y, Neuman H, Changnac A, Siegal A, Tobar A, Itkin M, et al. Using automated biopsy gun with real - time ultrasound for native renal biopsy. Isr Med Assoc J 2002;4:698-701.

3. Eddy AA, Symons JM. Nephrotic syndrome in childhood. Lancet 2003;362:629-39.

4. Aziz F, Qureshi AM. Nephrotic syndrome: minimal change disease. J Ayub Med Coll Abbottabad 2001;13:35-40.

5. Hafeez F, Rasool F, Hamid T. Renal biopsy in childhood nephrotic syndrome. J Coll Physicians Surg Pak 2002;12:454-7.

6. Glassock RJ. Diagnosis and natural course of membranous nephropathy. Semin Nephrol2003;23:324-32.

7. Osmani MH, Farooqui S. An audit of renal biopsy. J Surg Pak 2001;6:28-30.

8. Muzaffar M, Mushtaq S, Khadim M, Khadim MT, Din N, Mamoon N. Morphologist pattern of Glomerular Diseases in patients with Nephrotic Syndrome in Northern Pakistan. Pak Armed Forces Med J 1997;47:3-6.

9. Anwar N, Khan AZ, Azhar A, Subhan M. Histological pattern of glomerulopathies at Khyber Teaching Hospital Peshawar. J Med Sci 2005; 13:111-6.
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Author:Mohammad, Noor; Khan, Taj Mohammad; Orakzai, Akhtar Nawaz; Imran, Mohammad
Publication:Gomal Journal of Medical Sciences
Article Type:Report
Geographic Code:9PAKI
Date:Jun 30, 2012
Words:1622
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