chapter 4 paediatric renal biopsies
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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. 4 th MRRB report 2010, Malaysia. - PowerPoint PPT PresentationTRANSCRIPT
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)
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
Total number of Patient 1106 100.0
4th MRRB report 2010, Malaysia
Table 4.3.1: Conclusive report
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
4th MRRB report 2010, Malaysia
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
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
Total 1106 100.0
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
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
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
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
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
4th MRRB report 2010, Malaysia
* 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
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
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
4th MRRB report 2010, Malaysia
Figure 4.10.3: Renal survival by focal segmental glomerulosclerosis and minimal change
4th MRRB report 2010, Malaysia
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0.75
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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
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
Total Patient 270 100.0
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
Total 270 100.0
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
Figure 4.11.6: Patient survival in lupus nephritis
4th MRRB report 2010, Malaysia
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0 50 100 150Duration (months)
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
4th MRRB report 2010, Malaysia
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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 104 100.04th MRRB report 2010, Malaysia
Table 4.13.1: Frequency of complication
4th MRRB report 2010, Malaysia
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