Twenty-eight-year review of childhood renal diseases from renal biopsy data: A single centre in China

Demographic distribution analysis of different glomerular diseases in Southwest China from 2008 to 2022

BACKGROUND

Environmental and lifestyle factors play an etiological role in the pathogenesis of different glomerular diseases. Thus, exploring the epidemic characteristics of renal disease in different nationalities and regions is important.

MATERIALS AND METHODS

Patients who underwent renal biopsy from October 2008 to October 2022 were included. The proportion and change tendency of glomerular diseases and the differences between the sexes and different ages and races were analyzed.

RESULTS

There were 15,146 cases of glomerular diseases (98.5%), involving 7538 males (49.8%) and 7608 females (50.2%). The mean age was 37.0 years (range 0-80 years). The proportion of membranous nephropathy (MN) and diabetic nephropathy (DN) showed an increased trend. The most common primary glomerulonephritis (PGN) was IgA nephropathy (IgAN, 44.6%), followed by minimal-change disease (MCD, 24.3%) and MN (15.4%). Lupus nephritis (LN, 30%) accounted for the largest proportion of SGNs, followed by Henoch-Schonlein purpura nephritis (HSPN, 20.9%) and DN (19.8%). Compared with adults aged 18-60 years old, MCD and HSPN were more common in children and MN and DN in elderly individuals, statistically significant differences. Additionally, the sex and age distribution of PGN and SGN between the Tibetan and Han populations differed significantly, whereby LN was higher in the Han population and HSPN in the Tibetan population.

CONCLUSION

The distribution of glomerular diseases showed age, sex and race differences. This research will be beneficial for providing epidemiological evidence for clinical diagnosis, disease prevention and public health decision-making.

Clinical characteristics of pediatric hypertension: a multicenter study in China

OBJECTIVES

Hypertension in children has attracted increasing attention. However, clinical-based studies investigating characteristics and secular trends of pediatric hypertension remain limited. This study aimed to investigate the clinical characteristics and secular trends of different types of hypertension among hospitalized children in China.

METHODS

This retrospective analysis was based on medical records from nine tertiary children's hospitals in China during 2010∼2020. A total of 5847 pediatric inpatients (aged <18 years) with the diagnosis of hypertension were enrolled. Information on the clinical characteristics of each patient was obtained from their first admission records.

RESULTS

During the past decade, secondary hypertension sustained to be the dominant type of hypertension in children, with the proportion increased from 51.2% during 2010∼2015 to 59.8% during 2016∼2020. The main causes of secondary hypertension were neurologic disorders in children aged 0∼2 years, which changed to renal diseases after 3 years of age. Compared with primary hypertension, secondary hypertension was common in girls (43.1 vs. 23.3%) and children under 5 years of age (32.2 vs. 2.1%). Moreover, over four-fifths of primary hypertensive individuals had obesity and obesity-related comorbidities, and the proportion of clusters of one or more comorbidities increased in the past decade (79.7 → 85.2%).

CONCLUSION

Secondary hypertension sustained to be the dominant type of hypertension among children, especially in girls. Renal diseases were the most common causes of secondary hypertension in children, followed by rheumatic immune diseases. For primary hypertension, over four-fifths of inpatients had obesity and obesity-related diseases, and the proportion kept rising.

The spectrum and changes of biopsy-proven kidney diseases in Chinese children

AIM

The study aimed to investigate the spectrum of biopsy-proven kidney disease in Chinese children.

METHODS

Records of children 0-17 years old who underwent native kidney biopsy from June 1st, 2013 to December 31st, 2018 in the national inpatients' database of China were analyzed. Biopsy-proven kidney diseases of different sex, age groups, and diagnosis, and the changing patterns of kidney disease compared with the previous study were analyzed.

RESULTS

A total of 21,311 patients from 232 hospitals with a median age of 11.34 years were included. Immunoglobulin A vasculitis with nephritis (IgAVN) was the most common pathological finding [29.17%, 95% confidence interval (confidence interval, CI) = 28.56-29.78], followed by IgA nephropathy (IgAN) (22.70%, 95% CI = 22.14-23.27). IgAN was the most common finding in patients with hematuria (60.75%, 95% CI = 58.83-62.65], proteinuria (33.43%, 95% CI = 30.54-36.42), and hematuria plus proteinuria (62.77%, 95% CI = 56.19-69.02). Minimal change disease was the most common finding (40.69%, 95% CI = 39.41-41.98) in nephrotic syndrome. The proportion of IgAVN in patients with biopsy-proven glomerular disease increased year by year during 2013-2018 (p for trend < 0.001) and was higher than that of 2004-2014 [29.41% (95% CI = 29.10-29.72) in 2013-2018 vs. 13.35% (95% CI = 12.97-13.73) 2004-2014, p < 0.001]. The proportion of hepatitis B virus associated nephritis during 2013-2018 was lower than that of  2004-2014 [0.44% (95% CI = 0.36-0.54) in 2013-2018 vs. 0.87% (95% CI = 0.67-1.10) in 2004-2014, p < 0.001].

CONCLUSIONS

IgAVN and IgAN were the most common types of pathological findings in children who underwent kidney biopsies from 2013 to 2018. The pathological spectrum of kidney biopsy changed over time.

Epidemiology of biopsy-proven glomerular diseases in Chinese children: A scoping review

Background

Glomerular disease is the leading cause of chronic kidney disease globally. No scoping review reports have focused on China's spectrum of glomerular diseases in children. This study aimed to systematically identify and describe retrospective studies on pediatric glomerular disease based on available data on sex, age, study period, and region.

Methods

Six databases were systematically searched for relevant studies from initiation to December 2021 in PubMed, Embase, Web of Science, Global Health Library, Wangfang Database, and CNKI.

Results

Thirty-four studies were identified in the scoping review, including 40,430 patients with biopsy-proven diagnoses. The proportion of boys was significantly higher than that of girls. In this study, 28,280 (70%) cases were primary glomerular disease, 10,547 (26.1%) cases were diagnosed as secondary glomerular disease, and 1146 (2.8%) cases were hereditary glomerular disease. Minimal change disease is the most common glomerular disease among children in China, followed by mesangial proliferative glomerulonephritis, IgA nephropathy, and purpura nephritis. We observed increments in glomerular diseases in periods 2 (2001-2010) and 3 (2011-2021). The proportion of major glomerular diseases varies significantly in the different regions of China.

Conclusion

The spectrum of pediatric glomerular diseases varied across sex, age groups, study periods, and regions, and has changed considerably over the past 30 years.

Focal Segmental Glomerulosclerosis in Paediatric Population of South Punjab Pakistan: A Tertiary Care Hospital Experience

Objectives:

To find out frequency, clinicopathological features, response of treatment and outcome among children with primary focal segmental glomerulosclerosis (FSGS).

Methods:

This retrospective, non-interventional medical charts review study was conducted from a period of January 2011 to January 2020 at Pediatric Department of Nishtar Medical University Hospital, Multan, Pakistan. During the nine years study period, children of both genders, aged less than 16 years, with renal biopsies proven FSGS were included. Patient’s demographic along with clinical and laboratory data, urine dipstick for proteinuria, renal functions, 24 hours urinary protein and ultrasonography findings of kidneys, ureters and bladder (KUB) were noted from case records. Response rates of various treatment options and their outcome like remission, partial remission, no remission with stable kidney disease & no remission with progression of kidney disease were noted.

Results:

During the study duration, out of 307 renal biopsies performed in glomerulonephritis cases, 124 (40.4%) had primary FSGS. In 124 primary FSGS cases, mean age was 8.83±3.05 years while most of the children, 70 (56.5%) were above 10 years of age. Majority of the cases, 64 (51.6%) were male. Mean follow up duration was noted to be 28.35+18.47 months. Most of the cases, 68 (54.8%) were found to have complete remission, 22 (17.7%) partial remission while 11 (8.9%) progressed to ESKD.

Conclusions:

Among children, frequency of primary FSGS was high at our setting. Most of the cases achieved sustained remission rates with the help of immunosuppressive drugs. Cyclosporine and tacrolimus were found to be the most effective drugs.

Clinical correlation and prognostic significance of immunofluorescence in renal biopsies of patients having Glomerulonephritis

Objective

To correlate the immunofluorescence (IF) findings on renal biopsies of patients of glomerulonephritis (GN) with the clinical course of the disease.

Methods

This retrospective descriptive study was done at the Department of Pediatrics Medicine Unit-I, Nishtar Hospital Multan, from January 2008 to January 2019. A total of 387 cases of both gender, aged up to 16 years, diagnosed having GN on the basis of renal biopsies by light microscopy (LM) and IF findings, were included. Outcome as remission, partial remission, no remission with stable kidney disease, no remission with progressive kidney disease and end-stage kidney disease (ESKD) were computed. Chi square test was applied to see the correlation of IF findings and outcome by taking p value less than 0.05 as statistically significant.

Results

Focal segmental glomerulosclerosis (FSGS) was found to be the commonest histopathology finding noted in 158 (40.8%) followed by mesangioproliferative GN 74 (19.1%) and membranous nephropathy 42 (10.9%). Complete remission was observed in 145 (37.5%) cases whereas ESKD was seen in 26 (6.7%). Distinct pattern of IF findings were shown when distribution of IF findings were seen with respect to all study variables (p value < 0.001). For outcome, 134 (51.3%) IF negative cases had complete remission while 93 (35.6%) negative IF findings also had partial remission. ESKD was seen among 14 (25.9%) IgM positive and three (33.3%) IgA positive cases.

Conclusion

Immunofluorescence proved an important diagnostic tool in reaching the exact diagnosis in various types of GN. Distinct correlation between IF findings and clinical course of various types of GN was observed. IF negative cases had better outcome and was not having progressive course of disease so prognosis remained better than IF positive cases in this study.

[Efficacy and safety of steroid combined with immunosuppressants in the treatment of primary IgA nephropathy in children: a Meta analysis]

OBJECTIVE

To systematically evaluate the efficacy and safety of steroid combined with immunosuppressants in the treatment of primary IgA nephropathy in children.

METHODS

English and Chinese electronic databases were searched to include the studies on the efficacy and safety of steroid combined with immunosuppressants versus steroid alone in the treatment of primary IgA nephropathy in children. Outcome measures included proteinuria remission rate, urinary protein quantification, incidence of adverse events, estimated glomerular filtration rate, and incidence of renal dysfunction. Review Manager 5.3 software was used for data analysis.

RESULTS

A total of 7 studies with 381 children were included. The children had moderate to severe proteinuria. The Meta analysis showed that compared with the steroid alone group, the steroid combined with immunosuppressants group achieved a significantly higher rate of proteinuria remission (RR=1.36, 95%CI: 1.19-1.55, P<0.001) and significantly lower urinary protein quantification (SMD=-0.82, 95%CI: -1.23 to -0.41, P<0.001). There was no significant difference in the incidence rate of adverse events between the two groups (RR=1.28, 95%CI: 0.92-1.77, P=0.14).

CONCLUSIONS

The current evidence shows that for children with primary IgA nephropathy who have moderate to severe proteinuria, steroid combined with immunosuppressants has a better effect than steroid alone and does not increase the incidence rate of adverse events.

KLF6 Acetylation Promotes Sublytic C5b-9-Induced Production of MCP-1 and RANTES in Experimental Mesangial Proliferative Glomerulonephritis

Rat Thy-1 nephritis (Thy-1N) is an experimental mesangial proliferative glomerulonephritis (MsPGN) for studying human MsPGN. Although sublytic C5b-9 complex formation on glomerular mesangial cells (GMCs) and renal MCP-1 and RANTES production in rats with Thy-1N have been proved, the role and mechanism of MCP-1 or RANTES synthesis in GMCs induced by sublytic C5b-9 are poorly elucidated. In this study, we first found the expression of transcription factor (KLF6), co-activator (KAT7) and chemokines (MCP-1 and RANTES) was all up-regulated both in renal tissue of Thy-1N rats (in vivo) and in sublytic C5b-9-induced GMCs (in vitro). Further in vitro experiments revealed that KLF6 bound to MCP-1 promoter (-297 to -123 nt) and RANTES promoter (-343 to -191 nt), leading to MCP-1 and RANTES gene transcription. Meanwhile, KAT7 also bound to the same region of MCP-1 and RANTES promoter in a KLF6-dependent manner, and KLF6 was acetylated by KAT7 at lysine residue 100, which finally promoted MCP-1 and RANTES expression. Moreover, our in vivo experiments discovered that knockdown of renal KAT7 or KLF6 gene obviously reduced MCP-1 and RANTES production, GMCs proliferation, ECM accumulation, and proteinuria secretion in Thy-1N rats. Collectively, our study indicates that sublytic C5b-9-induced MCP-1 and RANTES synthesis is associated with KAT7-mediated KLF6 acetylation and elevated KLF6 transcriptional activity, which might provide a new insight into the pathogenesis of rat Thy-1N and human MsPGN.

Epidemiology of 10-year paediatric renal biopsies in the region of southern Croatia

Background

Information about renal diseases in children is available from national registries of renal biopsies. Aim of the study was to compare the clinical presentation of glomerular diseases and tubulointerstitial space diseases with pathohistological diagnosis of indicated renal biopsies from pediatric population in the Croatian region of Dalmatia.

Methods

Out of 231 pediatric patients with suspected glomerular and tubulointerstitial diseases, 54 underwent ultrasound-guided renal biopsy at University Hospital of Split. Kidney allograft biopsy, and re-biopsy were excluded. The biopsy sections were examined under light microscopy, immunofluorescence and electron microscopy. The data was reviewed to determine the pathohistological spectrum and clinicopathologic correlations. We retrospectively analyzed kidney biopsy data from 2008 to 2017 and compared them to that between 1995 and 2005.

Results

The mean age of patients was 9.84 ± 5.4 years. Male:female ratio was 1.2:1. The main indications for biopsy were pure nephrotic syndrome without hematuria (25.9%), non-nephrotic proteinuria with haematuria (22.2%), nephritic syndrome with nephrotic proteinuria (18.5%), and isolated hematuria (16.7%). The most common pathohistological findings were IgA nephropathy (IgAN, 24.1%), minimal change disease (MCD, 16.7%), Henoch-Schönlein purpura glomerulonephritis (HSPN, 14.8%), Alport syndrome and focal segmental glomerulosclerosis (AS and FSGS, 11.1% each), tubulointerstitial nephritis and membranous glomerulopathy (TIN and MGN, 3.7% each), while other cases were diagnosed rarely.

Conclusions

Changes in epidemiology of renal diseases in children between the analyzed periods showed an increasing trend of IgAN, MCD, HSPN, AS and FSGS, while mesangioproliferative glomerulonephritis (MesPGN) and endoproliferative glomerulonephritis (EDGN) showed a decreasing trend that can be explained with the new pathohistological classification.

Nephrotic Syndrome

Nephrotic syndrome is characterized by edema, proteinuria, hypoalbuminemia, and hyperlipidemia. Minimal change disease, the most common cause in childhood, generally responds to corticosteroids, although most patients experience disease relapses. Focal segmental glomerulosclerosis is usually resistant to corticosteroids and carries a significant risk of kidney failure, necessitating renal transplantation. Nephrotic syndrome may also be secondary to gene mutations and systemic diseases such as lupus. Clinical evaluation involves distinguishing primary and secondary causes and monitoring for disease complications, including blood clots and serious infections such as spontaneous bacterial peritonitis. Immunosuppressive medications are used to prevent relapses and treat corticosteroid-resistant disease.

The Spectrum of Biopsy-Proven Glomerular Diseases among Children in China: A National, Cross-Sectional Survey

BACKGROUND AND OBJECTIVES

High-quality epidemiologic data on the spectrum of biopsy-proven glomerular diseases among children are limited. This study aimed to determine the profile of and temporal change in biopsy-proven pediatric glomerular diseases in China.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

We previously conducted a nationwide kidney biopsy survey including 71,151 patients over an 11-year period from January 2004 to December 2014. A total of 7962 children younger than 18 years old from 115 hospitals across China with biopsy-proven glomerular diseases were included in this study. The demographic and clinical variables were extracted from referral records and pathology reports. The composition of pediatric glomerular diseases and clinicopathologic correlations in different sexes, age groups, and regions were assessed. The changing patterns of common glomerulopathies over the study period were examined.

RESULTS

Nephrotic syndrome (50%) was the most frequent indication for kidney biopsy in children. Minimal change disease was the most common primary glomerular disease (29%) followed by IgA nephropathy (17%). Henoch-Schonlein purpura nephritis (13%) and lupus nephritis (9%) were the most common secondary glomerular diseases. The proportion of minimal change disease was significant higher in boys (38%) than in girls (13%), whereas lupus nephritis was more prevalent in girls (20%) than in boys (3%). Purpura nephritis (23%) was the major pathologic pattern in younger children (0-12 years old), whereas minimal change disease (33%) was the most common glomerulopathy in adolescents (13-18 years old). The clinicopathologic correlations were slightly different between sexes and age groups. We observed increases in the proportions of minimal change disease, purpura nephritis, and membranous nephropathy over the study period that were contemporaneous with a fall in the proportion of FSGS.

CONCLUSIONS

The spectrum of glomerular diseases among children varied across sexes, age groups, and regions and changed substantially from 2004 to 2014 in China.

Characterization and Etiopathogenic Approach of Pediatric Renal Biopsy Patients in a Colombian Medical Center from 2007-2017

Introduction

Renal biopsy is the principal instrument to evaluate the diagnosis and prognosis of children with kidney disease. There are relatively few studies establishing epidemiology of its findings in the pediatric population.

Methods

A descriptive study was conducted to describe characteristics of pediatric patients who had undergone a renal biopsy over the last 10 years in a national reference center, trying to accomplish an etiopathogenic approach of biopsy findings.

Results

241 patients were included. Most frequent indications were nephrotic syndrome (34.1%) and systemic disease with renal involvement (30.2%). The most prevalent biopsy diagnosis was glomerulonephritis (44%) and among these patients, glomerulonephritis mediated by immune complexes was the most frequent pathogenic type (90.5%). When the biopsy was indicated for proteinuria plus hematuria and systemic disease with renal involvement, the most frequent biopsy diagnosis was glomerulonephritis (60 and 85%, respectively). For isolated hematuria, the predominant biopsy diagnosis was inherited diseases of the glomerular basement membrane (70%) and for nephrotic syndrome, podocytopathy (82%). Glomerulonephritis was more frequent in patients older than 10 yrs (65%) and the rate of postbiopsy major complications was low (1.2%).

Conclusion

Immune complex glomerulonephritis was the most frequent histological finding, differing from previous reports. To our knowledge this is the first description that classifies biopsy findings according to the probable pathogenic mechanism.

Renal Tubular Complement 3 Deposition in Children with Primary Nephrotic Syndrome

Background

This study aimed to investigate the clinical significance of complement 3 (C3) deposition in renal tubules of children with primary nephrotic syndrome (PNS).

Methods

The clinical and pathological characteristics of PNS were retrospectively reviewed in 99 PNS pediatric patients, who were divided into the C3 deposition and the non-C3 deposition groups.

Results

A total of 39 patients (39.39%) had renal tubule C3 deposition. In the C3 deposition group, the ratios of urine N-acetylglucosaminidase/creatinine (UNAG/Cr), urine β2 microglobulin/creatinine (Uβ2MG/Cr), and urine transferrin/creatinine (UTRF/Cr) were significantly higher than those of the non-C3 deposition group. The patients of the C3 deposition group had lower serum total protein and albumin, higher cholesterol and D-dimer (DD), lower proportion of CD3+CD8+ cells, and higher proportion of CD19+CD23+ cells. The number of the patients with interstitial fibrosis, renal cell vacuolar degeneration, renal tubular immunoglobulin deposition, and severe tubulointerstitial injury in the C3 deposition group was higher than that of the non-C3 deposition group. The C3 deposition intensity was positively correlated with the number of recurrences.

Conclusion

PNS pediatric patients with C3 deposition in renal tubules have more severe disease condition, tubulointerstitial injury, and recurrence suggesting a worse long-term prognosis.