Changing histologic spectrum of adult nephrotic syndrome over five decades in north India: A single center experience

To interpret and analyze the changing patterns of histology and direct immunofluorescence findings in membranoproliferative glomerulonephritis

Background

Membranoproliferative glomerulonephritis has in the recent past been regrouped into immune complex-mediated (ICM MPGN) disease (driven by the classical complement pathway) and complement-mediated (C3GN) disease (driven by the alternative complement pathway) based on pathogenetic role of alternative complement pathway and immunofluorescence deposits. The proposed regrouping lent therapeutic and prognostic support in managing the disease of MPGN.

Aims and Objectives

The present study is undertaken to study the patterns of MPGN based on histopathological and DIF examination and sub-categorize the cases into mainly complement dominant and immune complex-mediated diseases for better prognostic and therapeutic utility.

Materials and Methods

This is a prospective observational study carried out in a tertiary care center over a period of 2 yrs. The clinically suspected cases of MPGN were subjected to histopathologic and direct immunofluorescence examination (DIF), and the findings were interpreted in light of complement-mediated and immune complex-mediated MPGN.

Results

Out of 620 renal biopsies, diagnosis of MPGN was confirmed both on histopathology and DIF in 36 cases accounting for 5.8% of all biopsies. Based on DIF findings, the various groups comprised 20 cases (55.6%) of immune complex deposits, 11 (30.5%) of C3 dominant picture, and 5 (13.9%) of Nil immune deposits. On analysis of the patterns on DIF, 16 cases (80%) of C3 + Ig group and 6 (54.5%) of C3GN group showed predominantly MPGN pattern. Crescentic glomerulonephritis, global glomerulosclerosis, and interstitial fibrosis were markedly observed in C3GN group.

Conclusion

DIF is of immense prognostic and therapeutic value in managing cases of MPGN.

Glomerulosclerosis is a prognostic risk factor in patients with membranous nephropathy and non-nephrotic proteinuria

OBJECTIVE

To explore the predictive value of the proportion of glomerulosclerosis (GS) incidences on the progression of membranous nephropathy with non-nephrotic proteinuria (NNP).

METHODS

This study was a single-center, retrospective, cohort study. Patients with biopsy-proven idiopathic membranous nephropathy were divided into three groups based on the proportion of glomerular sclerosis, and their demographic, clinical, and pathological data were compared. The proportions of primary and secondary endpoints were recorded, and the relationship between GS and primary outcomes (progression to nephrotic syndrome, complete remission, and persistent NNP) and the renal composite endpoint was analyzed.

RESULTS

A total of 112 patients were divided into three groups according to the proportions of glomerulosclerosis. The median follow-up time was 26.5 (13-51) months. There were significant differences in blood pressure (p < 0.01), renal interstitial lesions (p < 0.0001), and primary endpoints (p = 0.005). The survival analysis showed that prognosis was significantly worse in patients with a high proportion of GS than in those patients with a middle and low proportion of GS (p < 0.001). The Cox multivariate analysis showed that after adjusting for age, sex, BP, 24-h urinary protein, serum creatinine, treatment scheme, and pathological factors, the risk of renal composite outcome in the low proportion group was 0.076 times higher than that in the high proportion group (p = 0.009, HR = 0.076, 95% CI: 0.011-0.532).

CONCLUSION

A high level of glomerulosclerosis was an independent risk factor for the prognosis of patients with membranous nephropathy with non-nephrotic proteinuria.

Clinicopathological spectrum of biopsy-proven renal diseases of patients at a single center in Sri Lanka: a cross sectional retrospective review

BACKGROUND

The clinical presentation of renal diseases can vary widely. The lack of a comprehensive national registry for Sri Lanka makes it difficult to provide a detailed record of the various clinical presentations and histopathology of renal disorders in the nation. Therefore, this study aims to provide a record of the spectrum of renal diseases in Sri Lanka.

METHODS

Renal biopsies performed at the nephrology unit in Colombo South Teaching Hospital (CSTH), Sri Lanka from March 2018 to October 2019 was retrospectively studied. Indications for renal biopsy were nephrotic range proteinuria, sub nephrotic range proteinuria, acute kidney injury without obvious etiology, chronic renal disease without obvious etiology and haematuria.

RESULTS

A total of 140 native kidney biopsies were analyzed in which majority were females (55.7%). The mean age of the population was 46 ± 15.3 years. The most common indications for renal biopsy were nephrotic range proteinuria (54.3%), followed by sub-nephrotic range proteinuria (14.3%), nephrotic range proteinuria with haematuria (14.3%), sub-nephrotic range proteinuria with haematuria (9.3%), AKI without known cause (4.3%), and CKD without known cause (3.6%). The leading histopathological diagnoses were FSGS (22.1%), lupus nephritis (20%), PSGN (17.1%), DN (12.1%), HTN (9.3%), MCD (6.4%), IgA nephropathy (5.7%), IN (4.3%), vasculitis (2.1%), and MGN (0.7%).

CONCLUSIONS

The most common indication for renal biopsy was nephrotic range proteinuria in our population. FSGS was the most prevalent histopathological diagnosis and the least frequent diagnosis reported was MGN. The spectrum of renal diseases could differ according to the study location and it changes over time. Therefore, a renal biopsy registry is needed for documenting the changing disease pattern in Sri Lanka.

Long-Term Follow-Up of Cyclical Cyclophosphamide and Steroids Versus Tacrolimus and Steroids in Primary Membranous Nephropathy

Introduction

Kidney Disease: Improving Global Outcomes (KDIGO) 2012 recommends cyclical cyclophosphamide plus glucocorticoids (GC) (modified Ponticelli regimen) or calcineurin inhibitors (CNIs) such as tacrolimus (TAC) or cyclosporine as the first-line agents for the management of primary membranous nephropathy (PMN) that is resistant to antiproteinuric therapy with renin-angiotensin system blockers. However, the long-term outcome of patients treated with CNIs is not known.

Methods

We report the outcomes of 70 patients randomized 1:1 to receive modified Ponticelli regimen or TAC/GC for renin-angiotensin system–resistant PMN who were prospectively followed for 6 years. Patients were followed monthly for 12 months, then quarterly for 12 months, and then every 6 months through the end of 6 years.

Results

At the end of 6 years, 21 (61.76%) and 9 (28.12%) patients maintained relapse-free remission in modified Ponticelli regimen and TAC/GC groups, respectively (relative risk [RR]: 2.19, 95% confidence interval [CI]: 1.23 to 4.15), and 30 (88.23%) and 17 (53.12%) patients were in remission (including relapses) in modified Ponticelli regimen and TAC/GC groups (RR: 1.66; 95% CI: 1.21 to 2.45), respectively. There was no significant difference in the proportion of patients who had a 40% decline in the estimated glomerular filtration rate (eGFR), death, or end-stage kidney disease between the groups. None of the patients treated with modified Ponticelli regimen reported a solid organ or hematological malignancy.

Conclusions

To conclude, in the long-term, modified Ponticelli regimen is superior to TAC/GC as first-line therapy for the management of antiproteinuric-resistant PMN.

Calcineurin inhibitors in the treatment of primary focal segmental glomerulosclerosis: A protocol of systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Evidence suggesting a role for including calcineurin inhibitors(CNIs) in early therapy remains limited for low quality and mainly based on small observation cohort study. We will conduct a systematic reviews to explore the effect and adverse effect of calcineurin inhibitors compared with other interventions in the treatment of primary focal segmental glomerulosclerosis (FSGS).

METHODS

A comprehensive literature search of MEDLINE (through PubMed), EMBASE, The Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL) will be conducted. Two investigators will independently select studies, extract data and assess the quality of the included study. Extracted information will include study characteristics, the contents of included randomized controlled trials, outcomes, the quality of randomized controlled trials and etc. A risk of bias tool will be used to assess the methodological quality. Any disagreement will be resolved by the third investigator. There is no requirement of ethical approval and informed consent.

RESULTS

This study will provide high-quality evidence for treatment of FSGS in terms of effectiveness and safety.

CONCLUSION

This systematic review aims to provide evidence for treatment of FSGS in different CNIs.

REGISTRATION

The systematic review and meta-analysis is registered in the OSF REGISTERS (10.17605/OSF.IO/3B7DE) international prospective register of systematic review.

Spectrum of biopsy-proven renal disease in northern India: A single-centre study

AIM

Pattern of kidney diseases varies across geographies due to multiple factors. There is a paucity of information from South Asia due to the absence of nationwide/regional biopsy registries. This study aimed to delineate the spectrum of renal parenchymal diseases in our region.

METHODS

Records of kidney biopsies done in our nephrology department between 2006 and 2016 were analysed. Clinico-pathological correlation was done from the available records.

RESULTS

Of the 3275 biopsy evaluated, 61.9% were males, and mean age was 33.2 ± 14.2 years. 6.2% patients were elderly (age ≥ 60 years). Nephrotic syndrome (60.3%) was the commonest indication for biopsy. On histology, 73.0% patients had primary glomerulonephritis (GN), 15.5% secondary GN, 5.3% tubulo-interstitial and 3.7% vascular disease. Focal segmental glomerulosclerosis (FSGS) was the commonest primary GN accounting for 18.2% of all GNs, followed by minimal change disease (16.8%), membranous nephropathy (MN) (16.0%) and IgA nephropathy (10.4%). Lupus nephritis (10.6%) and amyloidosis (3.7%) were the commonest secondary GN. The commonest cause of nephrotic syndrome was minimal change disease (22.9%), acute nephritic syndrome was lupus nephritis (30.6%), rapidly progressive renal failure was pauci-immune crescentic GN (24.5%). IgA nephropathy was the commonest etiology of asymptomatic urinary abnormalities (26.3%) and gross haematuria (50%). About 60.9% patients of undetermined chronic kidney disease had glomerular diseases, and 13.6% had chronic tubulointerstitial nephritis. Lupus nephritis and acute cortical necrosis were significantly more common in females compared with males.

CONCLUSION

This is one of the largest cohorts of kidney biopsies from India, and it delineates the unique features and differences in the pattern of kidney disease in our population.

Persistent CD-19 depletion by rituximab is cost-effective in maintaining remission in calcineurin-inhibitor dependent podocytopathy

AIM

A significant proportion of patients with minimal change disease (MCD) and focal segmental glomerulosclerosis (FSGS) are either steroid dependent or steroid resistant, requiring long-term calcineurin inhibitors (CNI) use. Rituximab has more favourable safety profile. The present study was undertaken to evaluate the efficacy and safety of rituximab in CNI-dependent patients.

METHODS

This was a prospective observational study conducted from July 2014 to February 2018. Steroid-dependent nephrotic syndrome or steroid-resistant nephrotic syndrome (biopsy proven MCD/FSGS), who were CNI dependent were enrolled. Mean age at enrolment was 22.77 ± 7.45 years. All patients received rituximab at a dose of 375 mg/m² at entry in the study. CD-19 levels were monitored monthly and patients having CD-19 levels >5/μL and/or > 1% received additional low-dose (100 mg) of rituximab.

RESULTS

A total of 24 patients were followed up for 12 months. At the end of 6 and 12 months, 87.5% and 79.16% of the patients achieved remission, respectively. Eight (33.33%) patients developed relapse. The mean dose of rituximab in the first year was 791 mg. The average cost of rituximab in the first year was 487.17$. Rituximab was well-tolerated, with mild infusion reactions, respiratory tract infection and oral candidiasis in 5 (20.83%), 5 (20.83%) and 1 (4.17%) patient, respectively.

CONCLUSIONS

CD-19 targeted rituximab is a safe and cost-effective agent in remission maintenance in adults with CNI dependent. Over three-fourths of the patients with CNI-dependent podocytopathy maintain clinical remission with CD-19 targeted rituximab therapy.

Glucocorticoids in the treatment of patients with primary focal segmental glomerulosclerosis and moderate proteinuria

BACKGROUND

To compare the efficacy of glucocorticoids in primary focal segmental glomerulosclerosis (pFSGS) patients with moderate proteinuria. Registered at http://www.chictr.org.cn/ , study No. ChiCTR-OPN-17012789.

METHODS

pFSGS patients with urine protein between 1.0 and 3.5 g/24 h were recruited from 2006 to 2016. No decline in urine protein > 50% was observed after 2 months of run-in angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACEI/ARB) treatment. Patients were assigned to study group (glucocorticoids with ACEI/ARB) or control group (ACEI/ARB without glucocorticoids). Variables including 24-h urinary protein, serum albumin and serum creatinine during the trial were recorded. Remission was defined as proteinuria < 0.3 g/24 h or declined > 50%, and our composite end point as > 30% decrease of eGFR or eGFR < 30 ml/min.

RESULTS

A total of 102 patients were enrolled (study group N = 52, control group N = 50), and the median follow-up time was 36 (12-117) months without significant difference between groups. During the 12-month follow-up, the remission rate was significantly higher in study group [73.1 vs 50.0% (P = 0.01)], and the initial median response time was 3 months in the study group while 6 in the control group. The end point was reached by 22.2% cases in study group, and 42.0% in control. The medium survival times were study group 72 months and control 57 (P = 0.03). Minor adverse reactions were observed in 10 patients (study group N = 8, control group N = 2).

CONCLUSIONS

Additional glucocorticoids therapy is more efficacious compared to ACEI/ARB alone in the treatment of patients with pFSGS and moderate proteinuria.

Role of Immunofluorescence in Adult Onset Nephrotic Syndrome-A Study in a Tertiary Care Centre of Western India

INTRODUCTION

Study of renal Immunofluorescence (IF) is an ancillary but essential technique in evaluation of renal biopsies in glomerulopathies and also it enlightens on the pathogenesis of nephrotic syndrome.

AIM

To determine the role of IF in evaluating definite subtyping and diagnosis of adult onset nephrotic syndrome and attempting clinicopathological correlation.

MATERIALS AND METHODS

A total of 52 patients of adult onset nephrotic syndrome were evaluated clinically and with pertinent investigations; and subjected to USG guided percutaneous renal biopsy which was processed and stained for light microscopy and for immunofluorescence by direct method (DIF) using antibodies against IgG, IgM, IgA and C3.

RESULTS

The predominant age group affected was 18-47 years (78.85%). Male:female ratio was 1:0.63. The most frequent glomerular lesion encountered was Focal Segmental Glomerulosclerosis (FSGS, 36.54%) followed by lupus nephritis (26.92%) and IgA nephropathy (9.62%). The most common glomerular lesion in males was FSGS and that in females was lupus nephritis. DIF was mainly coarsely granular whenever present. One case of lupus nephritis and diabetic nephropathy, showed non specific IF. It was negative in all cases of FSGS, Minimal Change Disease (MCD) and renal amyloidosis. The IF helped in differentiating eight cases that were normal on light microscopy as IgA nephropathy (n=5) and authentic MCD (n=3). It helped in endorsing 19 cases of FSGS to be a progression of MCD. It was also of help in sub-typing all cases of Membranoproliferative Glomerulonephritis (MPGN) (n=3) as MPGN-Type I.

CONCLUSION

IF was of great help in diagnosing exact type of glomerulopathy in adult onset nephrotic syndrome and provided insight in its pathogenesis.

Serum anti-PLA2R antibody and glomerular PLA2R deposition in Chinese patients with membranous nephropathy: A cross-sectional study

M-type phospholipase A2 receptor (PLA2R) is the major target antigen in primary membranous nephropathy (PMN). Previous studies have evaluated the diagnostic value of serum anti-PLA2R antibody. However, the correlation of serum anti-PLA2R antibody and glomerular PLA2R deposition, and their association with clinical characteristics need to be further evaluated.A total of 136 patients were involved as inception group because serum anti-PLA2R antibody and glomerular PLA2R antigen were simultaneously measured. We examined serum anti-PLA2R antibody by ELISA and glomerular PLA2R deposition by immunofluorescence assay.Positive serum anti-PLA2R antibody and glomerular PLA2R deposition were seen in 58.8% (80/136) and 95.6% (130/136) patients, respectively (P < .001). Proteinuria, serum total protein, serum albumin, serum creatinine, and estimated glomerular filtration rate (eGFR) had significant differences between patients with serum anti-PLA2R antibody and those without. Serum anti-PLA2R antibody levels were correlated with serum albumin, serum creatinine, eGFR, and proteinuria. Glomerular PLA2R deposition intensities were weakly correlated with proteinuria. Unexpectedly, there was a positive correlation rather than a negative correlation between glomerular PLA2R deposition intensity and eGFR.In conclusion, serum anti-PLA2R antibody is more closely correlated with disease activity and renal function than glomerular PLA2R deposition.

Clinicopathological Analysis of Glomerular Disease of Adult Onset Nephrotic Syndrome in an Indian Cohort- A Retrospective Study

INTRODUCTION

Primary glomerular disease presenting with adult onset nephrotic syndrome are a major cause of chronic renal failure worldwide. The spectrum of renal disease presenting with nephrotic syndrome has undergone a gradual change globally over the course of time. However, there still exist regional differences in the incidence of primary glomerular diseases causing adult onset nephrotic syndrome.

AIM

To observe the spectrum of renal diseases presenting with adult onset nephrotic syndrome with comparative analysis of changing trends over the last five decades with regards to Western and Indian literature.

MATERIALS AND METHODS

Subjects included patients with age of 18-80 years presenting with nephrotic syndrome. Renal biopsies with immunofluoroscence studies were performed in all patients. Baseline clinical parameters of serum urea, creatinine, albumin, globulin, cholesterol, 24 hour urine protein and urine microscopy were recorded. Descriptive statistics was used and results were expressed as frequencies, percentages, and mean±standard deviation.

RESULTS

A total of 227 patients (72% males) were included for the study. Primary glomerular diseases formed 74.01% of total cases and majority of patients included males in the 4^th decade. Minimal Change Disease (MCD) (15.8%) including its variants was the most common primary glomerular disease for adult onset of nephrotic syndrome followed by Mesangial proliferative Glomerulonephritis (MSGN) (13.2%). Membranous nephropathy and Type I Membranoproliferative Glomerulonephritis (MPGN) individually accounted for 12.3% of patients. Focal and Segmental Glomerulosclerosis (FSGS) accounted for only 11% of patients. Although, increased incidence of FSGS has been observed worldwide, there exist important regional differences in primary glomerular diseases in Indian population. MCD remains a major glomerular disease for adult onset nephrotic syndrome in different parts of India.

CONCLUSION

Our study over three years represents important data of regional variations of primary glomerular diseases presenting with adult onset nephrotic syndrome.

Evaluation of cases of membranoproliferative glomerulonephritis according to newer classification: A retrospective record-based study

Background

Membranoproliferative glomerulonephritis (MPGN) has traditionally been classified on electron microscopy (EM) into different types based on the location of the immune complexes. Sethi et al. subsequently suggested a more relevant etiology-based and clinically useful classification based on immunofluorescence.

Methods

In this retrospective study, 18 diagnosed cases of MPGN over a one-year period for which direct immunofluorescence (DIF) study results were available, were selected. Cases without archived records of immunofluorescence photographs/reports were excluded. Histological diagnosis of MPGN was confirmed and DIF results were analyzed with reference to antibodies to IgG, IgA, IgM, C3, C1q, kappa, and lambda light chains.

Results

Evaluation of cases revealed 8 males and 10 females with age range from 11 to 66 years. Fifteen cases presented with nephrotic syndrome. On evaluation, 88.89% cases (16/18) were immune complex mediated while two (11.11%) were of complement mediated type of MPGN. Among immune complex-mediated cases, a single case of monoclonal gammopathy associated or light chain mediated MPGN was present.

Conclusion

The classification described by Sethi et al. is easy to use since it relies on DIF instead of EM which is not readily available. Most of the cases were immune complex mediated whereas incidence of complement mediated MPGN, that is, C3 glomerulopathy was low (11.11%). Application of the new classification allows more relevant categorization of cases based on etiology and without the requirement of EM.

Insight to changing morphologic patterns of glomerulopathy in adult Pakistani patients: an institutional perspective

Background

Idiopathic nephrotic syndrome encompasses diverse histogenetic patterns and depicts socioeconomic and demographic differences attributable to genetic profile, environmental factors and prevalence of infectious diseases. A lack of renal registry in our country necessitates a need to document changing histologic patterns of nephrotic syndrome as noted in different parts of the world.

Methods

We retrospectively analyzed 140 patients who underwent renal biopsy at Liaquat National Hospital from January 2009 to December 2013 over a period of 3 years. On the basis of clinical profile cases were segregated into nephritic and nephrotic syndrome and histologic and immunoflourescence findings were analyzed.

Results

Among 140 cases of glomerulonephritis diagnosed in the study period, 98 cases (70 %) were those of primary glomerulonephritis and 42 were of secondary glomerulopathy (30 %). Membranous glomerulonephritis was the most common primary glomerulonephritis (33.6 %) followed by focal segmental glomerulosclerosis FSGS (20.4 %), whereas lupus nephritis is the most common secondary glomerulopathy (47.6 %) followed by amyloidosis and diabetic glomerulosclerosis (16.6 % each).

Conclusion

We found a considerable high incidence of membranous glomerulonephritis and FSGS in our population that entails a need to investigate prevalence of associated factors like Hepatitis B and HIV infections in population at risk. Moreover, renal biopsy registry would be instrumental in this regard to record changing disease pattern in this part of the world.