CHAPTER 4 Paediatric Renal Biopsies

CHAPTER 4Paediatric Renal Biopsies

Lee Ming LeeLim Yam NgoLynster Liaw

Mirunalini a/p Appadurai Selva Kumar a/l Sivapuniam

Susan PeeWan Jazilah Wan Ismail

Yap Yok Chin

Table 4.2.2: Number of patients from various hospitals

Hospitals N %

Hospital Kuala Lumpur 404 39.1

Other MOH Hospitals 606 58.7

University Hospital 7 0.7

Army Hospital 1 0.1

Private Hospital 14 1.4

Total number of patients 1032 100.0

4th MRRB report 2010, Malaysia

Table 4.2.3: Number of renal biopsies

Year n (%)

1999 44 (4.0)

2000 34 (3.1)

2001 31 (2.8)

2002 31(2.8)

2003 57 (5.2)

2004 40 (3.6)

2005 128 (11.6)

2006 137 (12.4)

2007 145 (13.1)

2008 165 (14.9)

2009 137 (12.4)

2010 157 (14.2)

Total 1106 (100.0)


Table 4.2.4: Number of biopsies done on each patients at different times

Total no of biopsy/patient n %

1st episode 980 88.6

2nd 102 9.2

3rd 22 2.0

>4th 2 0.2

Total number of Patient 1106 100.0


Table 4.3.1: Conclusive report


YearTotal

number of biopsies

Report conclusive Report not conclusive

n % n %

1999 -2010 1106 1056 95.5 50 4.5

Table 4.3.2: Number of glomeruli obtained at each biopsy

*7 cases with missing number of glomeruli


YearTotal number of

biopsies

≥ 10 Glomeruli < 10 Glomeruli

n % n %

1999 -2010 1106 858 78.1 241 21.9

Table 4.4.1: Gender and racial distribution

n %

Gender

Male 494 47.9

Female 538 52.1

Total 1032 100.0

Race

Malay 640 62.0

Chinese 203 19.7

Indian 73 7.1

Others* 116 11.2

Total 1032 100.0


Table 4.4.2: Age distribution

Age (years) 1999-2010

n 1106

Mean 9.5

Standard deviation 4.0

Minimum 0.02

Maximum 15.0


Table 4.5.1: Clinical presentation at biopsy

Clinical presentation n %

Asymptomatic urine abnormalities 172 15.6

Nephritic syndrome 163 14.7

Nephrotic syndrome 578 52.3

Nephritic nephrotic syndrome 108

9.8

Not available 76 6.9

Missing 9 0.8

Total 1106 100.0


Table 4.5.2: Renal function at biopsy

Renal function at biopsy n %

Impaired 348 31.5

Normal 695 62.8

Not available or missing data 63 5.7

Total 944 100.0


Table 4.5.3: Hypertension at biopsy

Hypertension At biopsy n %

Present 371 33.5

Absent 708 64.0

Not available or missing data 27 2.4

Total 1106 100.0

Drug a

ACEI 107 28.8

Alpha Blocker 41 11.1

ARB 9 2.4

Beta Blocker 54 14.6

Calcium Channel Blocker 158 42.6

Others 28 7.5

No drug available 146 39.4


Table 4.6.1: Diagnosis of paediatric renal biopsies

*Patients may have more than 1 diagnosis classification 4th MRRB report 2010, Malaysia

Table 4.6.2 Annual frequency of the main renal biopsy findings 1999-2010

HSP: Henoch Schonlein Purpura*Patients may have more than 1 diagnosis classification


Table 4.7.1: Renal histopathology diagnosis of children presenting with nephrotic syndrome

Diagnosis n %

FSGS 229 39.9

MCD 167 29.1

Lupus nephritis 87 15.2

IgA nephropathy 13 2.3

Mesangial proliferative GN non-IgA 14 2.4

Post-infectious GN 7 1.2

Others** 49 8.5

Unknown/Missing 8 1.4

Total 574 100.0*Patients may have more than 1 diagnosis classification ** Others – Henoch Schonlein Purpura, HUS/TTP, Systemic vasculitis, Malignancy, Membranous nephropathy, Membrano-proliferative, Idiopathic crescentic GN, Acute interstitial nephritis, Acute tubular necrosis, Chronic interstitial nephritis, Hereditary (others), Advance GN, Others


Table 4.7.2: The histopathological profile in different steroid response categories

Diagnosis Steroid responsive Steroid resistant

n % n %

FSGS 26 29.2 121 51.1

MCD 40 44.9 58 24.5

Lupus nephritis 10 11.2 23 9.7

IgA nephropathy 1 1.1 3 1.3

Mesangial proliferative GN non-IgA 3 3.4 7 3.0

Post-infectious GN - - 1 0.4

Others* 6 6.7 20 8.4

Unknown 3 3.4 4 1.7

Total 89 100.0 237 100.0

*Patients may have more than 1 diagnosis classification ** Others – Henoch Schonlein Purpura, Membranous nephropathy, Membrano-proliferative, Idiopathic crescentic GN, Acute interstitial nephritis, Acute tubular necrosis, Chronic interstitial nephritis, Advance GN, Others


Table 4.8: Renal histopathology diagnosis of children presenting with nephritic syndrome

Diagnosis n %



Acute tubular necrosis 10 6.0

Henoch Schonlein Purpura 9 5.4

FSGS 9 5.4


MCD 8 4.8

Messangial proliferative GN-non lgA 4 2.4

Others** 19 11.4

Total 166 100.0

*Patients may have more than 1 diagnosis classification ** Others – HUS/TTP, Anti GBM disease, Advance GN, Systemic vasculitis, Membrano-proliferative, Idiopathic crescentic GN, Acute interstitial nephritis, Chronic interstitial nephritis, Alport’s syndrome


Table 4.9: Histology finding of children who had severe renal failure (needed dialysis therapy) who underwent renal biopsy

Diagnosis n %




FSGS 5 7.4

Advanced glomerulosclerosis (advance GN) 5 7.4

Acute interstitial nephritis 3 4.4

HUS/TTP 1 1.5


Others* 9 13.2

Total 68 100.0


* Membrano-proliferative, Messangial Proliferative GN-non lgA, Idiopathic Crescentic GN, Henoch scholein purpura, Systemic vasculitis, Malignancy, Chronic interstitial nephritis, Others

Table 4.10.1: Clinical characteristics of children with steroid resistant nephrotic syndrome

a, c, j, k, l Performed Wilcoxon Rank Sum testb, d, f, h Performed Chi-square test

e, g, i, m Performed Fisher’s exact test4th MRRB report 2010, Malaysia

Continue;

a, c, j, k, l Performed Wilcoxon Rank Sum testb, d, f, h Performed Chi-square test

e, g, i, m Performed Fisher’s exact test 4th MRRB report 2010, Malaysia

Table 4.10.2: Patient survival for focal segmental glomerulosclerosis and minimal change disease

Clinical characteristics

Minimal change disease FSGS

Interval (months) n % survival SE n % survival SE

0 170 100.0 - 229 100.0 -

12 136 98.2 0.011 204 98.7 0.008

24 109 96.6 0.015 177 98.1 0.010

36 86 96.6 0.015 148 98.1 0.010

48 52 96.6 0.015 121 98.1 0.010

60 36 96.6 0.015 89 97.2 0.013

72 23 96.6 0.015 54 97.2 0.013

84 18 96.6 0.015 42 94.9 0.026

96 13 96.6 0.015 34 94.9 0.026

108 13 96.6 0.015 22 94.9 0.026

120 7 96.6 0.015 16 94.9 0.026

132 5 96.6 0.015 6 88.5 0.066


Figure 4.10.2: Patient survival by focal segmental glomerulosclerosis and minimal change disease


Table 4.10.3: Renal survival of patient with focal segmental glomerulosclerosis and minimal change disease

Clinical characteristics

Minimal change disease FSGS*

Interval (days) n % survival SE n % survival SE

0 170 100.0 - 228 100.0 -

12 136 98.2 0.011 193 94.1 0.016

24 108 95.7 0.017 166 91.9 0.019

36 84 94.8 0.020 135 90.0 0.021

48 50 94.8 0.020 110 90.0 0.021

60 34 94.8 0.020 77 85.3 0.029

72 23 94.8 0.020 46 84.0 0.031

84 18 94.8 0.020 35 78.0 0.045

96 13 94.8 0.020 26 75.0 0.052

108 13 94.8 0.020 17 75.0 0.052

120 7 94.8 0.020 14 75.0 0.052

132 5 92.8 0.020 5 69.2 0.073


Figure 4.10.3: Renal survival by focal segmental glomerulosclerosis and minimal change


0.00

0.25

0.50

0.75

1.00

Cu

mu

lati

ve S

urv

ival

0 50 100 150Duration (months)

FSGS MCD

…

Table 4.11.1: Total number of patient and biopsies (SLE)

Year Total number of Patient Total number of biopsies

1999 -2010 230 270


Table 4.11.2: Distribution of renal biopsy in patients with lupus by numbers of biopsy

Total number of biopsy /patient n %

1st episode 232 85.9

2nd episode 34 12.6

3rd episode 4 1.5

Total Patient 270 100.0


Table 4.11.3.1: Gender distribution for paediatric lupus nephritis

Gender n %

Male 31 13.5

Female 199 86.5

Total 230 100.0


Table 4.11.3.2: Racial distribution for paediatric lupus nephritis

Ethnic n %

Malay 144 62.6

Chinese 59 25.7

Indian 7 3.0

Others* 20 8.7

Total 230 100.0


Table 4.11.3.3 Age for paediatric lupus nephritis

Age (years) 1999-2010

n 270

Mean 11.4

Standard deviation 3.1

Minimum 0.1

Maximum 15.0


Table 4.11.3.4 Dialysis therapy for paediatric lupus nephritis at the time of biopsy

Needed dialysis therapy n %

Yes 16 5.9

No 206 76.3

Missing/Not available 48 17.8

Total 270 100.0


Table 4.11.3.5: Patient with hypertension (SLE)

Hypertension n %

Yes 112 41.5

No 148 54.8

Missing/Not available 10 3.7

Total 270 100.0


Table 4.11.3.6: Clinical presentation at biopsy (SLE)

Clinical presentation n %

Asymptomatic urine abnormalities 70 25.9

Nephritic syndrome 44 16.3

Nephrotic syndrome 84 31.1

Nephritic nephrotic syndrome 46 17.0

Unknown 23 8.5

Missing 3 1.1

Total 270 100.0


Table 4.11.4(a): Clinical presentation of paediatric lupus

Clinical presentation N=270 %

Malar rash 141 52.2

Photosensitivity 85 31.5

Oral ulcers 71 26.3

Discoid rash 10 3.7

Hematological 148 54.8

Arthritis 74 27.4

Serositis 36 13.3

Cerebral 34 12.6

Renal 231 85.6


Table 4.11.4(b): ARA criteria at presentation

Number of ARA criteria n %

<4 61 22.6

≥ 4 209 77.4

Total 270 100.0


Table 4.11.5: Classification of paediatric lupus nephritis

WHO/ISN /RPS Class Needed dialysis therapy

Not needed dialysis therapy

n % n %

Class I 0 0.0 1 0.5

Class II 1 6.3 15 7.3

Class III or V+III 0 0.0 43 20.9

Class IV or V+IV 11 68.8 136 66.0

Class V or V+II 2 12.5 10 4.9

Class VI 2 12.5 0 0.0

Unknown 0 0.0 1 0.5

Total 16 100.0 206 100.0


Table 4.11.6: Patients survival in lupus nephritis

Lupus Nephritis patients

Interval (months) n % survival SE

0 246 100.0 -

12 197 95.6 0.014

24 165 93.0 0.018

36 130 91.8 0.019

48 100 91.8 0.019

60 72 88.4 0.027

72 48 88.4 0.027

84 39 88.4 0.027

96 30 88.4 0.027

108 23 84.7 0.044

120 19 84.7 0.044

132 12 78.7 0.071


Figure 4.11.6: Patient survival in lupus nephritis


0.00

0.25

0.50

0.75

1.00

Cu

mu

lati

ve S

urv

ival


Table 4.11.7: Renal survival of patients with lupus nephritis (ESRF&ESRF+died)

Lupus Nephritis patients

Interval (months) n % survival SE

0 246 100.0 -

12 191 97.3 0.011

24 160 96.7 0.012

36 124 95.5 0.015

48 95 95.5 0.015

60 67 93.3 0.021

72 45 93.3 0.021

84 37 93.3 0.021

96 26 86.9 0.048

108 19 86.9 0.048

120 15 81.4 0.069

132 9 81.4 0.0694th MRRB report 2010, Malaysia

Figure 4.11.7: Renal survival of patient with lupus nephritis


0.00

0.25

0.50

0.75

1.00

Cu

mu

lati

ve S

urv

ival


...

Table 4.12: Causes of end stage renal disease in children who underwent renal biopsy

Causes n %

FSGS 33 31.7


Advance glomerulosclerosis (advance GN) 16 15.4



Chronic interstitial nephritis 4 3.8

Acute interstitial nephritis 3 2.9

Systemic vasculitis 3 2.9

Membranoproliferative GN 3 2.9

MCD 3 2.9

Mesangial proliferative GN non-IgA 2 1.9

Henoch Schonlein Purpura 2 1.9

HUS/TTP 2 1.9


Idiopathic crescentic GN 1 1.0

Membranous nephropathy 1 1.0

Total 104 100.04th MRRB report 2010, Malaysia

Table 4.13.1: Frequency of complication


n %

Total Number of biopsies 1106 -

Total Number of complication 55 5

Type of complication

Bleeding

• Gross haematuria 38 69.1

• Haematoma 2 3.6

Perirenal collection 10 18.2

Infection 0 0

Arteriovenous malformation 1 1.8

Hypotension 1 1.8

Others 3 5.5

Table 4.13.2: Risk factors for complication

(ref*) Reference categoryCI-confidence interval

** Not able to do compute due to the small sample sizea No information on renal failure needed dialysis for biopsy procedure data

b No information on calculated gfr for biopsy procedure datac No information on haemoglobin (Hgb) level for biopsy procedure data

d No information ultrasound biopsy for biopsy procedure datae No information on plug biopsy for biopsy procedure dataf No information on needle size for biopsy procedure data

g No information on number of passes for biopsy procedure data 4th MRRB report 2010, Malaysia

Continue;

(ref*) Reference categoryCI-confidence interval

** Not able to do compute due to the small sample sizea No information on renal failure needed dialysis for biopsy procedure data

b No information on calculated gfr for biopsy procedure datac No information on haemoglobin (Hgb) level for biopsy procedure data

d No information ultrasound biopsy for biopsy procedure datae No information on plug biopsy for biopsy procedure dataf No information on needle size for biopsy procedure data

g No information on number of passes for biopsy procedure data 4th MRRB report 2010, Malaysia

CHAPTER 4 Paediatric Renal Biopsies

Documents

Transcript of CHAPTER 4 Paediatric Renal Biopsies