CHAPTER 4 Paediatric Renal Biopsies

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CHAPTER 4Paediatric Renal Biopsies

• Lee Ming LeeLim Yam NgoLynster LiawMirunalini
  a/p Appadurai Selva Kumar a/l Sivapuniam Susan
  PeeWan Jazilah Wan IsmailYap Yok Chin

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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
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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)
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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
gt4th 2 0.2
Total number of Patient 1106 100.0
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Table 4.3.1 Conclusive report
Year Total number of biopsies Report conclusive Report conclusive Report not conclusive Report not conclusive
Year Total number of biopsies n n
1999 -2010 1106 1056 95.5 50 4.5
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Table 4.3.2 Number of glomeruli obtained at each
biopsy
Year Total number of biopsies 10 Glomeruli 10 Glomeruli lt 10 Glomeruli lt 10 Glomeruli
Year Total number of biopsies n n
1999 -2010 1106 858 78.1 241 21.9
7 cases with missing number of glomeruli
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Table 4.4.1 Gender and racial distribution
n
Gender Male 494 47.9
Gender Female 538 52.1
Gender Total 1032 100.0
Race Malay 640 62.0
Race Chinese 203 19.7
Race Indian 73 7.1
Race Others 116 11.2
Race Total 1032 100.0
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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
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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
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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
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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
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Table 4.6.1 Diagnosis of paediatric renal
biopsies
Patients may have more than 1 diagnosis
classification
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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
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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
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Table 4.7.2 The histopathological profile in
different steroid response categories
Diagnosis Steroid responsive Steroid responsive Steroid resistant Steroid resistant
Diagnosis 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
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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, Alports syndrome
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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
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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 Fishers exact test
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a, c, j, k, l Performed Wilcoxon Rank Sum test b,
d, f, h Performed Chi-square test e, g, i, m
Performed Fishers exact test
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Table 4.10.2 Patient survival for focal
segmental glomerulosclerosis and minimal change
disease
Clinical characteristics Minimal change disease Minimal change disease Minimal change disease FSGS FSGS 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
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Figure 4.10.2 Patient survival by focal
segmental glomerulosclerosis and minimal change
disease
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Table 4.10.3 Renal survival of patient with
focal segmental glomerulosclerosis and minimal
change disease
Clinical characteristics Minimal change disease Minimal change disease Minimal change disease FSGS FSGS 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
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Figure 4.10.3 Renal survival by focal segmental
glomerulosclerosis and minimal change
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Table 4.11.1 Total number of patient and
biopsies (SLE)
Year Total number of Patient Total number of biopsies
1999 -2010 230 270
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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
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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
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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
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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
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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
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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
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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
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Table 4.11.4(a) Clinical presentation of
paediatric lupus
Clinical presentation N270
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
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Table 4.11.4(b) ARA criteria at presentation
Number of ARA criteria n
lt4 61 22.6
4 209 77.4
Total 270 100.0
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Table 4.11.5 Classification of paediatric lupus
nephritis
WHO/ISN /RPS Class Needed dialysis therapy Needed dialysis therapy Not needed dialysis therapy Not needed dialysis therapy
WHO/ISN /RPS Class n n
Class I 0 0.0 1 0.5
Class II 1 6.3 15 7.3
Class III or VIII 0 0.0 43 20.9
Class IV or VIV 11 68.8 136 66.0
Class V or VII 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
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Table 4.11.6 Patients survival in lupus nephritis
Lupus Nephritis patients Lupus Nephritis patients 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
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Figure 4.11.6 Patient survival in lupus nephritis
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Table 4.11.7 Renal survival of patients with
lupus nephritis (ESRFESRFdied)
Lupus Nephritis patients Lupus Nephritis patients 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
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Figure 4.11.7 Renal survival of patient with
lupus nephritis
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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 104 100.0
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Table 4.13.1 Frequency of complication
  n
Total Number of biopsies 1106 -
Total Number of complication 55 5
Type of complication Type of complication 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
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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
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(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
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