Histopathological types in adult nephrotic syndrome

Md. Ghulam Yusuf; Bidhu Bhushan Das; Amaresh Chandra Shaha; Md. Zakir Hossain

doi:10.4103/1319-2442.182403

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Year : 2016 | Volume : 27 | Issue : 3 | Page : 576-580

Histopathological types in adult nephrotic syndrome

Md. Ghulam Yusuf¹, Bidhu Bhushan Das², Amaresh Chandra Shaha², Md. Zakir Hossain²
¹ Department of Internal Medicine, Prime Medical College and Hospital, Rangpur, Bangladesh
² Department of Medicine, Rangpur Medical College, Rangpur, Bangladesh

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Date of Web Publication

13-May-2016

Abstract

In Bangladesh, there are very few studies about biopsy proven adult Nephrotic syndrome (NS) with histological types and their clinical findings. To determine the histological types of glomerulonephritis (GN) in adult NS and correlate them with the clinical presentations and biochemical parameters, we studied 100 biopsies in 87 patients who underwent ultrasonography- guided renal biopsy in Rangpur Medical College and Hospital from July 2010 to June 2012. The mean age of the patients was 32.8 ± 13.2 years; male was preponderance (72.4%) and most of the patients (67.8%) came from rural areas. Membranoproliferative GN (MPGN) was the most common underlying cause that was found in 32 (36.8%) patients followed by mesangial prolife- rative GN in 27 (31%) patients, membranous GN in 16 (18.4%) cases, minimal change disease in four (4.6%) patients, diffuse proliferative GN in four (4.6%) patients, focal segmental GN, and focal proliferative GN in two (2.4%) patients each. High proteinuria level was found in minimal change disease, which was 7.59 ± 0.24 g/24 h (mean ± standard deviation). The most common symptoms were oliguria (92%) and edema (86.2%) followed by hematuria (dark urine) (72.4%) and hypertension (35.6%). MPGN was the most common histological type of adult NS in Rangpur.

How to cite this article:
Yusuf M, Das BB, Shaha AC, Hossain M. Histopathological types in adult nephrotic syndrome. Saudi J Kidney Dis Transpl 2016;27:576-80

How to cite this URL:
Yusuf M, Das BB, Shaha AC, Hossain M. Histopathological types in adult nephrotic syndrome. Saudi J Kidney Dis Transpl [serial online] 2016 [cited 2022 May 24];27:576-80. Available from: https://www.sjkdt.org/text.asp?2016/27/3/576/182403

Introduction

Nephrotic syndrome (NS) is not a disease; rather it is the manifestation of a wide variety of underlying disease processes.^[1]Though the disease is more common in children, it is one of the most common presentations of adult kidney disease.^[2]Glomerulonephritis (GN) is a common cause of chronic kidney disease (CKD) and end-stage renal disease (ESRD) as well. Patterns of GN are vary in different countries and environments.^[3]Different studies show that among primary GN, membranous GN (MGN) is the most common histological type (28%) in adult NS.^[4],[5],[6]In the USA, focal segmental glo- merulosclerosis (FSGS) occurs more in elderly and it is associated with high prevalence of ESRD (26.5%), hypertension (71.4%), and hematuria (81.6%).^[2]However, largely enough epidemiological population-based studies of biopsy-proved GN with detailed clinicopatho- logical correlation do not exist.^[4]

Ever since Richard Bright's (1827) discover that precipitation in urine heated on a spoon over a candle was diagnostic of kidney disease, various tests have been used for assessment or diagnosis of kidney disease.^[7]However, the introduction of renal biopsy in clinical practice by Inverson and Bruun in 1951 has repre- sented one of the most important advances in the field of nephrology.^[8]It is essential in the management of renal parenchymal disease and remains the only definite method of esta- blishing the underlying lesion causing the idiopathic Nephritic syndrome.^[5]

We aimed in this study to determine the histological types of GN in adult NS in a single center in Bangladesh and correlate them with the clinical presentations and biochemical parameters.

Subjects and Methods

We studied adult patients with NS in the Department of Medicine, at Rangpur Medical College and Hospital, Rangpur, Bangladesh from July 2010 to June 2012.

The sample size was calculated by using the following formula: n = Z²× pq/d².

n = sample size, Z = the value of standard normal variant at a given confidence interval and it is 1.96 for a 95% confidence level, p = prevalence of NS in pediatric population. As the true prevalence of NS in adult population was not known in Bangladesh, prevalence of pediatric NS was considered; it was 5%. Hence, p = 5% = 0.05, Q + 1−P = 1−0.05 = 0.95, and

d = accepting error, (0.05). There-fore, n = Z²

× pq/d², (1.96)²× 0.05 × 0.95/(0.05)²= 3.84 ×

475/25 = 73. Hence, the required sample size is 73. One hundred patients were studied for the convenience of the study.

One hundred consecutive patients were enrolled according to exclusion and inclusion criteria. The inclusion criteria were: age 18 years and above, both genders, and adult NS patients. The exclusion criteria were: age <18 years, pregnancy, patients with diabetes mel- litus, patients with infection (hepatitis-B infec- tion, hepatitis-C infection, and malaria), patients with renal artery aneurysm, solitary kidney, horseshoe shaped kidney or renal artery ste- nosis, patients with uncontrolled hypertension, patients with bleeding or clotting disorders, and kidney size <60% on ultrasound.

Prior permission was taken for this study from the Ethical Committee of Rangpur Medical College and Hospital, Rangpur, Bangladesh. Keeping compliance with Helsinki Declaration for Medical Research Involving Human Subjects 1964, all patients were informed verbally about the study design, the purpose of the study and right of the participant to withdraw themselves from the project at any time, for any reason, what so ever. Written consent was obtained from each patient. All precautions were taken to protect anonymity of the parti- cipating patients.

The demographic characteristics included age, sex, residence, and occupation. Hematuria (dark/smoky urine), hypertension, edema, and oliguria were used as variables of clinical fea- tures. Laboratory investigations included pro- teinuria, serum creatinine, serum albumin, and serum cholesterol. The frequencies of different histological types were determined by kidney biopsies in all the patients. The biopsies were examined by light microscopy.

Statistical analysis

Data were processed and analyzed using Statistical Package for Social Science (SPSS) version-16 software. The test statistics used to analyze the data were descriptive statistics, Chi-square (c² test, and one-way ANOVA test. P < 0.05 was considered significant.

Results

We studied 100 patients who underwent kid- ney biopsies of which 87 had specific biopsy results and the rest 13 were deemed unsuitable for histological opinion and were discarded.

Among the 87 evaluable patients, the mean age (years) ± standard deviation was 32.8 ±

13.2. Most of the patients were in-between 18 and 27 years. Males were more (72.4%) than females (27.6%). More patients from rural areas (67.8%) were in our study than those from urban areas (32.2%). Primary or idio- pathic NS was observed in 82 (94.3%) patients and secondary cause seen in five (5.7%) patients. Membranoproliferative GN (MPGN) was the most common underlying cause of GN which was found in 32 (36.8%) cases. Mesangial proliferative (MesPGN) was the second most common cause found in 28 (32.1%) cases fol- lowed by MGN in 16 (18.3%) cases, minimal change disease (MCD) in four (4.6%), FSGS in three (3.4%) cases, diffuse proliferative GN (DPGN), and focal proliferative GN (FPGN) in two (2.4%) cases each.

[Table 1] shows the frequencies of the different histological types in particular age group. In 18-27 years of age group MPGN was the common histological type, (P = 0.002).

Table 1. Frequency distribution of histological types of nephritic syndrome according to age groups (n=87)

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[Table 2] shows the distribution of the histo- logical types according to residence of pa- tients. MPGN was the most common histolo- gical type in the patients from the rural areas. In urban people, MPGN and MesPGN were the most common histological types.

Table 2. Distribution of residence in different histological types of the study population (n=87)

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Edema was the predominant clinical feature (67%), but significant number of study popu- lation (NS) also present with oliguria (91%), hematuria as dark urine (72%) and hypertension (35%). Association of the important clinical features of the NS and the different histo- logical types of GN is shown in [Table 3]. Among MesPGN, 13 (48.1%) patients present

Table 3. Distribution of clinical features according to histological types of the study population (n=87)

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with HTN (P = 0.003) and 32 (100%) patients of MPGN present with hematuria or dark urine (P = 0.000).

In our study, the mean serum creatinine, proteinuria, serum albumin, and serum choles- terol levels among all NS patients were - 1.63 mg/dL, 5.34 g/24 h, 2.1 g/dL, and 355 mg/dL, respectively.

Comparison of the investigation result at the time of presentation with most common GN is shown in [Table 4]. P value was significant in proteinuria levels and serum cholesterol levels (P = 0.000 and P = 0.035).

Table 4. Distribution of biochemical parameters of the study population (n=87)

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Discussion

In our study, males were more than females; this finding is consistent with other studies^[1],[4],[5]and in contrast with others.^[9]In addition, the mean age in our study was higher than some studies^[1]and lower than others.^[10],[11]

Our study showed that MesPGN was the most common underlying pathology in 18-27 years of age group followed by MGN. Tarik et al^[1]in his study mentioned that incidence of MGN was increased as age increased but this result in contrast with our results. Changing pattern of GN within the same country probably due to infection control, changing environmental pollution, increase awareness of the disease, and change in the life expectancy as men- tioned by Reshi et al.^[12]Furthermore, Naini et al^[13]denoted that epidemiological data of renal disease are population based and have great variability according to geographical area, socioeconomic condition, and race. In another study, Simon et al^[14]also supported the changing pattern of GN. Accordingly, we ana- lyzed the results of our study in terms of the residence patients and found that those who lived in rural areas had different predominant patterns of GN than those who lived in urban areas. In rural area, MPGN was the most com- mon type of GN, while both MPGN and MesPGN were equally the most common histological types.

In our study, the prevalence of hypertension and hematuria (dark urine) was more than that in Cohen study.^[2]In the present study, edema was the predominant feature of the NS and was also noted by other investigators.^[2],[6],[12]Wahbeh et al^[15]and Quirσs et al^[16]found an average of 6.12 ± 4.59 g/24 h proteinuria in their cohorts; in our study, the mean protei- nuria was slightly lower than those studies. Abnormal serology was seen in 75% of patient in the form of low C3 and C4 in other studies,^[17],[18]but in our study we investigated complements in only 25 patients and all results were normal.

In the present study, most common presen- tation of adult NS was MPGN followed by MesPGN and MGN.

Acknowledgment

The author would like to thank the following individuals: Associate Prof. Dr. Shah Md Sarwar, Assistant Prof. Ashraful Hoque, Dr. Helal Mia, Dr. Shukumar Roy, and Dr. Moklesur Rahman Sarker.

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