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Saudi Journal of Kidney Diseases and Transplantation
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RENAL DATA FROM ASIA–AFRICA  
Year : 2021  |  Volume : 32  |  Issue : 2  |  Page : 522-529
‘Snapshot’ of an annual data from a large South Indian Renal Biopsy Registry


1 Department of Nephrology, SRM Medical College and Research Centre, Tamil Nadu, India
2 Institute of Nephrology, Madras Medical College, Chennai, India
3 Renopath, Center for Renal and Urological Pathology, Chennai, India

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Date of Web Publication11-Jan-2022
 

   Abstract 


Results from biopsy registries are important to know about the prevalence of renal diseases. In large studies done over several years, significant interobserver variability could have existed. Single-year biopsy registry data are analyzed in this study. The study included 481 renal biopsy specimens including 65 from allografts. Primary glomerulonephritis constituted 37.74% and secondary glomerular diseases constituted 32.21% of native kidney biopsies. Minimal change disease was the most common primary glomerular disease, followed by membranous nephropathy (MN). Lupus nephritis was the most common secondary glomerular disease. This study included specimens from 34 geriatric patients and MN was the most common lesion in that age group. Acute cellular rejection was the most common diagnosis in renal allograft biopsies.

How to cite this article:
Jayaprakash V, Kumar T D, Gopalakrishnan N, Kurien AA. ‘Snapshot’ of an annual data from a large South Indian Renal Biopsy Registry. Saudi J Kidney Dis Transpl 2021;32:522-9

How to cite this URL:
Jayaprakash V, Kumar T D, Gopalakrishnan N, Kurien AA. ‘Snapshot’ of an annual data from a large South Indian Renal Biopsy Registry. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 Jan 28];32:522-9. Available from: https://www.sjkdt.org/text.asp?2021/32/2/522/335465



   Introduction Top


Findings from renal biopsy registries help clinicians to know about the pattern of histological lesions in a particular geographical region and compare them with studies from other regions. Biopsy studies enrich our knowledge regarding the prevalence of biopsy proven renal diseases and evolution of newer lesions at different timelines.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10] Most of the studies in the literature are descriptive studies done retrospectively for considerably longer study periods.[1],[2],[3],[4],[5],[6],[11],[12],[13] Nephrology practice patterns and histopathology reporting evolve with time as new scientific developments continue to accumulate.[14],[15] For example, the current histopathology reporting of diseases such as membranoproliferative glomerulonephritis (MPGN), C3 glomerulonephritis, “nodular”glomerulosclerosis, light and heavy chain deposit diseases (HCDDs) and renal allograft pathologies are completely different from how they were reported several years back.

In findings from large registries spanning over decades, there is scope for considerable interobserver variability in the diagnosis of the renal illness/syndromes and in deciding the indications for biopsy. Furthermore, considerable interobserver variability could have existed in histopathological reporting. Some registries have excluded significant number of specimens quoting sample inadequacy and/or poor reporting. In some older registries, immunofluorescence (IF) studies had not been done, and diagnosis made from light microscopy (LM) findings alone might not always be reliable.

Hence, it would be helpful to the clinicians if biopsy data from this decade are reported from across the world. This annual biopsy data review intends to provide a “snapshot” of native renal and allograft pathologies from one of the largest nephrology units in South India.


   Materials and Methods Top


The study was done at the Institute of Nephrology, Madras Medical College, Chennai. The center is a government-funded teaching hospital and is the largest referral unit for nephrology services in that region. Indications for biopsy were acute nephritic syndrome, nephritic syndrome, rapidly progressive renal failure, unexplained renal failure, nonrecovery of acute kidney injury, renal manifestations in systemic illness, etc. Renal allograft biopsy was done for graft dysfunction. Routine “protocol” biopsy in renal transplant recipients was not done. After thorough clinical assessment and laboratory workup including coagulation profile, renal biopsy was done under ultrasound guidance/assistance by nephrologists/residents.

Two cores of renal tissue were taken from all patients. One specimen was preserved in formalin for LM reporting and the other was preserved in Michael’s fixative for IF studies. The specimens were stained with hematoxylineosin, Masson’s trichome, periodic acid–Schiff, and Jones silver methanamine for LM, whereas antisera against human immunoglobulin (Ig) G, IgA, IgM, C3, C1q, and kappa and lambda light chains were used for IF. Electron microscopy was done only when the clinician felt that it was mandatory for diagnosis. All the histopathological interpretations were done by a single pathologist. The study period was one year (January 2014 to December 2014). Since the patient’s identity is confidential in this data analysis, consent was not required. Institute Review Board permission was obtained for the study.


   Results Top


The study included 481 renal specimens. Of them, 416 specimens were from native kidneys and 65 were from renal allografts.

Native kidney biopsies (n=416)

Glomerular diseases

In native kidney biopsy specimens, 209 (50.24%) were from male patients and 207 (50.76%) from female patients.

There was wide age distribution in our study (13–83 years). Adolescents (13–19 years) constituted 10.57% (n = 44) of patients and adults 80.05% (n = 333) of patients. 34 (8.17%) specimens were from geriatric age group (>60 years of age). Five (1.2%) specimens were from very elderly age group (>80 years)

Renal disorders were classified into glome-rular, tubulointerstitial, and vascular etiology. Glomerular disorders were further classified into primary and secondary glomerular disorders [Table 1]. In the primary glomerular diseases category, minimal change disease (MCD) (n = 37; 8.89%) was the most common histological lesion, followed by membranous nephropathy (MN) (n = 35; 8.41%). IgA nephropathy (IgAN) constituted 7.69% (n = 32) of cases and focal segmental glomerulosclerosis (FSGS) 6.49% (n = 27) of cases. Relevant histological classification and age distribution for primary glomerular diseases are described [Table 2],[Table 3],[Table 4].
Table 1: Native kidney biopsies (n = 416).

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Table 2: Immunoglobulin A nephropathy (n = 32).

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Table 3: Focal segmental glomerulosclerosis (n = 27).

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Table 4: Membranous nephropathy (n= 35) Male: Female = 22:13.

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MPGN was present in nine (2.16%) cases and mesangial proliferation and diffuse proliferative glomerulonephritis were present in three cases each.

Anti-glomerular basement membrane (anti-GBM) disease was present in five cases and anti-neutrophil cytoplasmic antibody (ANCA) disease was present in six cases.

In the secondary glomerular diseases category, lupus nephritis (LN) was the most common histological lesion which was present in 63 (15.14%) specimens. The disease was common in females (92%) and was more prevalent in the third decade of life. Class IV A LN was the most common histological lesion according to the International Society of Nephrology/Renal Pathology Society (ISN/RPS) classification system [Table 5].
Table 5: Lupus nephritis (n= 63).

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Infection-related glomerulonephritis (IRGN) was diagnosed in 41 (9.86%) cases. Male-to-female ratio was 16:25. Three were diabetic patients and three belonged to the geriatric age group.

Diabetic nephropathy (DN) constituted 6% (n = 25) of cases. Most of the samples had class III changes (n= 11), followed by class IV (n = 9), class II B (n = 4) and class IIA (n = 1), according to RPS classification for DN.

Amyloidosis was present in five(1.2%) samples. AL amyloidosis was present in three cases and AA amyloidosis secondary to rheumatoid arthritis was found in one case. Crescentic GN was present in 24 cases (5.77%). The etiology was immune complex mediated in 13 (3.12%) cases, pauci-immune, ANCA vasculitis in six (1.44%) cases, anti-GBM disease in five cases, and IRGN in four cases.

Some rare glomerular diseases/histopathology patterns were found in this biopsy series. [Table 1]. Cortical necrosis and malignant nephrosclerosis were found in two specimens each, diagnostic features of collapsing glomerulopathy, Henoch-Schonlein purpura and HCDD were found in one case each.

Tubulointerstitial disease

Acute tubular injury (ATI) was the most common tubular pathology present in 43 (10.33%) samples, followed by acute interstitial nephritis (AIN) (n = 19; 4.5%). The etiology for ATI is described [Table 6]. Chronic interstitial nephritis (CIN) was seen in seven (1.6%) specimens. Granulomatous interstitial nephritis was present in three cases. Myeloma cast nephropathy was present in three specimens. Histological features suggestive of acute pyelonephritis were found in two specimens and obstructive nephropathy/ATI in one specimen.
Table 6: Etiology of acute tubular injury (n = 43).

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Vascular pathology

Thrombotic microangiopathy (TMA) was present in six (1.44%) specimens.

Histologic diagnosis suggestive of chronic kidney disease (CKD) with significant glomerulosclerosis, interstitial fibrosis, and tubular atrophy (IFTA) were seen in 33 (7.9%) samples.

Three patients suffering from retroviral disease had undergone biopsy. AIN and IRGN were present in one sample each and one sample showed advanced CKD. Thirty-four patients in the geriatric age group had undergone biopsy. The spectrum of histopathological diagnoses are described [Table 7].
Table 7: Geriatric biopsy profile (n = 34).

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Electron microscopy was done only when it was mandatory for etiologic diagnosis. Dense deposit disease was found in three cases, HCDD was present in two samples, and three specimens showed immune deposits.

Renal allograft biopsies (n=65)

Renal allograft biopsies were done in 65 recipients. Of them, 53 (81.54%) were males and 12 (18.46%) were females. The age distribution was from 14 to 59 years. The histopathologic diagnoses in renal allograft biopsies were reviewed.

Acute cell mediated rejection (ACR) was the commonest finding present in 27 (41.54%) cases. According to Banff classification, borderline changes were present in 11 cases, 1A changes were seen in nine cases, 1B changes were seen in two changes, and 2A changes were found in five cases. ATI was the next common diagnosis (n = 21; 32.31%). Other diagnoses in the decreasing order of frequency were acute antibody-mediated rejection (AMR) (n = 3), TMA (n = 3), and graft pyelonephritis (n = 3). Both ACR and AMR were present in two specimen and significant IFTA in two specimens. Findings suggestive of collapsing glomerulopathy, FSGS, cortical necrosis, and renal candidiasis were present in one specimen each.

Biopsy was done in one cadaveric donor kidney before transplant in view of renal dysfunction and sub-nephrotic proteinuria. The findings were suggestive of DN with mild ATI.


   Discussion Top


In this annual data, primary GN constituted 37.74% and secondary glomerular diseases constituted 32.21% of native kidney biopsies. The higher proportion of secondary glomerular diseases is striking in this study. Similar studies from the region have reported incidence of secondary glomerular diseases in the range of 10.9% to 18.2%[1],[2],[4],[6] [Table 8]. A study by Jamil et al on glomerular disorders reported higher incidence of secondary glomerular diseases.[7] The proportion of interstitial and vascular disorders in this study is comparable with other biopsy registries.[1],[2],[4],[6]
Table 8: Comparison with other biopsy registries from South Asia.

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Among primary glomerular diseases, MCD (8.89%) was the most common histological lesion closely followed by MN (8.41%) in this study. MCD was the most common lesion in studies by Varun et al and Das et al, whereas FSGS was the commonest histology in studies done by Balakrishnan et al and Mubarak et al.[1],[2],[4],[6] In a registry study from the Far-east, Chang et al reported that the most common primary GN was IgAN (28.3%), which was followed by MCD (15.5%).[5] In a study from Brazil, FSGS (24.6%) was the most frequent primary glomerular disease, followed closely by MN (20.7%) and IgAN (20.1%).[12]

LN was the most common secondary glome-rular disease in this study. Similar finding is reported in many several studies.[2],[6],[7],[8],[11],[12],[13] LN was followed by IRGN and diabetic nephropathy. ATI was the most common tubular pathology present in 10.33%, followed by AIN (4.5%). Varun et al reported tubulointerstitial nephritis in 17.5% of cases and Mubarak et al in 11.6% of cases.[1],[6]

This study included significant proportion of biopsy specimens (n = 34; 8.17%) from geriatric age group. The most common glomerular lesion was MN, followed by DN and IRGN. In a study by Chen et al, 17.1% (n = 74) of biopsy specimens were from geriatric age group.[16] In another study by Rollino et al, patients aged more than 75 years represented 11.1% (n = 131) of the biopsies.[17] MN was the most common glomerular disease in both these studies.

To our knowledge, only few centers have published biopsy registry data of this decade. The model utilized in the study, where analysis is done for a single year is practical and is the first of its kind. The study included data from both native kidney and renal allograft biopsies. IF studies were done in all the specimens. Relevant histological classification, age, and gender distribution have been analyzed for important glomerular diseases. The reporting of all specimens was done by an experienced pathologist. Several rare histopathologic lesions are present in this study.

Since the study center is a major referral unit for renal disorders, the results include a variety of histopathological lesions and could be considered representative of the region. Other units can adopt this kind of single year analysis since data acquisition and results interpretation would be easy. Moreover, comparison with other center data will become much easier.

The major limitation of this study is that clinicopathologic correlation was not done for glomerular diseases. Electron microscopy was done only when it was mandatory for diagnosis.


   Conclusion Top


MCD was the most common primary glome-rular disease, followed by MN. LN was the most common secondary glomerular disease and Class IV A was the most common histological lesion. MN was the common diagnosis in geriatric age group. ACR was the most common finding in renal allograft biopsies.

Conflict of interest: None declared.



 
   References Top

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Chang JH, Kim DK, Kim HW, et al. Changing prevalence of glomerular diseases in Korean adults: A review of 20 years of experience. Nephrol Dial Transplant 2009;24:2406-10.  Back to cited text no. 5
    
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Mubarak M, KaziJ I, Naqvi R, 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.  Back to cited text no. 6
    
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Jamil M, Bhattacharya PK, Raphael V, Khonglah Y, Lyngdoh M, Roy A. Spectrum of glomerular diseases in adults: A study from north eastern India. J Assoc Physicians India 2018;66:36-9.  Back to cited text no. 7
    
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Gesualdo L, DiPalma AM, Morrone LF, Strippoli GF, Schena FP; Italian Immunopathology Group; Italian Society of Nephrology. The Italian experience of the national registry of renal biopsies. Kidney Int 2004;66:890-4.  Back to cited text no. 9
    
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Simon P, Ramee MP, Boulahrouz R, et al. Epidemiologic data of primary glomerular diseases in western France. Kidney Int 2004; 66:905-8.  Back to cited text no. 10
    
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Naumovic R, Pavlovic S, Stojkovic D, Basta-Jovanovic G, Nesic V. Renal biopsy registry from a single centre in Serbia: 20 years of experience. Nephrol Dial Transplant 2009;24: 877-85.  Back to cited text no. 11
    
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Polito MG, deMoura LA, 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;25:490-6.  Back to cited text no. 12
    
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Okpechi I, Swanepoel C, Duffield M, et al. Patterns of renal disease in Cape town South Africa: A 10-year review of a single-centre renal biopsy database. Nephrol Dial Transplant 2011;26:1853-61.  Back to cited text no. 13
    
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Sethi S, Haas M, Markowitz GS, et al. Mayo clinic/renal pathology society consensus report on pathologic classification, diagnosis, and reporting of GN. J Am Soc Nephrol 2016;27: 1278-87.  Back to cited text no. 14
    
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Haas M, Loupy A, Lefaucheur C, et al. The Banff 2017 kidney meeting report: Revised diagnostic criteria for chronic active T cell-mediated rejection, antibody-mediated rejection, and prospects for integrative endpoints for next-generation clinical trials. Am J Transplant 2018;18:293-307.  Back to cited text no. 15
    
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Chen Y, LiP, Cui C, Yuan A, Zhang K, Yu C. Biopsy-proven kidney diseases in the elderly: Clinical characteristics, renal histopathological spectrum and prognostic factors. J Int Med Res 2016;44:1092-102.  Back to cited text no. 16
    
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Rollino C, Ferro M, Beltrame G, et al. Renal biopsy in patients over 75: 131 cases. Clin Nephrol 2014;82:225-30.  Back to cited text no. 17
    

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Correspondence Address:
V Jayaprakash
Department of Nephrology, SRM Medical College and Research Centre, SRM Institute of Science and Technology, Kattankulathur, Tamil Nadu
India
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DOI: 10.4103/1319-2442.335465

PMID: 35017347

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