Transcript CHAPTER 4 Paediatric Renal Biopsies Lee Ming Lee Lim Yam

CHAPTER 4
Paediatric Renal Biopsies
Lee Ming Lee
Lim Yam Ngo
Lynster Liaw
Mirunalini a/p Appadurai
Selva Kumar a/l Sivapuniam
Susan Pee
Wan 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
1032
100.0
Total number of patients
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)
4th MRRB report 2010, Malaysia
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
1106
100.0
Total number of Patient
4th MRRB report 2010, Malaysia
Table 4.3.1: Conclusive report
Year
1999 -2010
Total
number of
biopsies
1106
Report conclusive
Report not conclusive
n
%
n
%
1056
95.5
50
4.5
4th MRRB report 2010, Malaysia
Table 4.3.2: Number of glomeruli obtained at each biopsy
Year
1999 -2010
Total number of
biopsies
1106
≥ 10 Glomeruli
< 10 Glomeruli
n
%
n
%
858
78.1
241
21.9
*7 cases with missing number of glomeruli
4th MRRB report 2010, Malaysia
Table 4.4.1: Gender and racial distribution
Gender
Race
n
%
Male
494
47.9
Female
538
52.1
Total
1032
100.0
Malay
640
62.0
Chinese
203
19.7
Indian
73
7.1
Others*
116
11.2
1032
100.0
Total
4th MRRB report 2010, Malaysia
Table 4.4.2: Age distribution
Age (years)
n
Mean
Standard deviation
Minimum
Maximum
1999-2010
1106
9.5
4.0
0.02
15.0
4th MRRB report 2010, Malaysia
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
1106
100.0
Total
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
1106
100.0
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
Total
Drug a
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
574
100.0
Total
*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
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
Table 4.8: Renal histopathology diagnosis of children presenting
with nephritic syndrome
Diagnosis
n
%
Post-infectious GN
54
32.5
Lupus nephritis
45
27.1
Acute tubular necrosis
10
6.0
Henoch Schonlein Purpura
9
5.4
FSGS
9
5.4
IgA nephropathy
8
4.8
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
4th MRRB report 2010, Malaysia
Table 4.9: Histology finding of children who had severe renal
failure (needed dialysis therapy) who underwent renal biopsy
Diagnosis
n
%
Post-infectious GN
23
33.8
Lupus nephritis
15
22.1
Acute tubular necrosis
6
8.8
FSGS
5
7.4
Advanced glomerulosclerosis (advance GN)
5
7.4
Acute interstitial nephritis
3
4.4
HUS/TTP
1
1.5
IgA nephropathy
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
4th MRRB report 2010, Malaysia
Table 4.10.1: Clinical characteristics of children with steroid
resistant nephrotic syndrome
a, c, j, k, l Performed Wilcoxon Rank Sum test
b, d, f, h Performed Chi-square test
e, g, i, m Performed Fisher’s exact test
4th MRRB report 2010, Malaysia
Continue;
a, c, j, k, l Performed Wilcoxon Rank Sum test
b, 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
Interval (months)
Minimal change disease
FSGS
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
4th MRRB report 2010, Malaysia
Figure 4.10.2: Patient survival by focal segmental
glomerulosclerosis and minimal change disease
4th MRRB report 2010, Malaysia
Table 4.10.3: Renal survival of patient with focal segmental
glomerulosclerosis and minimal change disease
Clinical
characteristics
Interval (days)
Minimal change disease
FSGS*
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
4th MRRB report 2010, Malaysia
Figure 4.10.3: Renal survival by focal segmental
glomerulosclerosis and minimal change
0.00
Cumulative Survival
0.25
0.50
0.75
1.00
…
0
50
100
150
Duration (months)
FSGS
MCD
4th MRRB report 2010, Malaysia
Table 4.11.1: Total number of patient and biopsies (SLE)
Year
1999 -2010
Total number of Patient Total number of biopsies
230
270
4th MRRB report 2010, Malaysia
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
270
100.0
Total Patient
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
270
100.0
Total
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
0.75
0.50
0.25
0.00
Cumulative Survival
1.00
Figure 4.11.6: Patient survival in lupus nephritis
0
50
100
Duration (months)
150
4th MRRB report 2010, Malaysia
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
0.069
4th MRRB report 2010, Malaysia
Figure 4.11.7: Renal survival of patient with lupus nephritis
0.75
0.50
0.25
0.00
Cumulative Survival
1.00
...
0
50
100
Duration (months)
150
4th MRRB report 2010, Malaysia
Table 4.12: Causes of end stage renal disease in children who
underwent renal biopsy
Causes
n
%
FSGS
33
31.7
Lupus nephritis
16
15.4
Advance glomerulosclerosis (advance GN)
16
15.4
Post-infectious GN
7
6.7
IgA nephropathy
7
6.7
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
Acute tubular necrosis
1
1.0
Idiopathic crescentic GN
1
1.0
Membranous nephropathy
1
1.0
Total
104
4th
100.0
MRRB report 2010, Malaysia
Table 4.13.1: Frequency of complication
n
%
1106
-
55
5
• 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
Total Number of biopsies
Total Number of complication
Type of complication
Bleeding
4th MRRB report 2010, Malaysia
Table 4.13.2: Risk factors for complication
(ref*) Reference category
CI-confidence interval
** Not able to do compute due to the small sample size
a No information on renal failure needed dialysis for biopsy procedure data
b No information on calculated gfr for biopsy procedure data
c No information on haemoglobin (Hgb) level for biopsy procedure data
d No information ultrasound biopsy for biopsy procedure data
e No information on plug biopsy for biopsy procedure data
f 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 category
CI-confidence interval
** Not able to do compute due to the small sample size
a No information on renal failure needed dialysis for biopsy procedure data
b No information on calculated gfr for biopsy procedure data
c No information on haemoglobin (Hgb) level for biopsy procedure data
d No information ultrasound biopsy for biopsy procedure data
e No information on plug biopsy for biopsy procedure data
f 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