CHAPTER 4 Paediatric Renal Biopsies Lee Ming Lee
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 5 th MRRB report 2011 & 2012, Malays
Table 4. 2. 2: Number of patients from various hospitals 20052010 n % Hospitals Hospital Kuala 191 24. 2 Lumpur Other MOH 573 73. 0 Hospitals University 7 0. 9 Hospital Army Hospital 1 0. 1 Private Hospital 14 Total 1. 8 786 100 2011 2012 All n % n % 32 18. 5 34 22. 0 257 23. 0 123 71. 5 118 76. 0 814 73. 3 13 7. 6 3 2. 0 23 2. 0 0 0 1 0. 1 4 2. 4 0 0 18 1. 6 172 100 155 100 1113 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 2. 3: Number of renal biopsies Year n % 2005 -2010 882 72. 1 2011 184 15. 0 2012 158 12. 9 Total 1224 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 2. 4: Distribution of native renal biopsy in patients by number of attempts. Total number of biopsy/patient 2005 -2010 1 st episode 768 87. 1 157 85. 3 142 89. 9 1067 87. 2 2 nd 90 10. 2 25 13. 6 10 6. 3 125 10. 2 3 rd 21 2. 4 2 1. 1 5 3. 2 28 2. 3 >4 th 3 0 0. 0 1 0. 6 4 0. 3 Total patient n 882 % 2011 n % 2012 n 100 184 100 158 % All n 100 1224 % 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 3. 1: Conclusive report Year 20052010 2011 2012 Total Report Total number conclusive of biopsies n % Report not conclusive n % 882 851 96. 5 31 3. 5 184 158 1224 167 152 1170 90. 8 96. 2 95. 6 17 6 54 9. 2 3. 8 4. 4 5 th MRRB report 2011 & 2012, Malays
Table 4. 3. 2: Number of glomeruli obtained at each biopsy Year 2005 -2010 2011 2012 Total number of biopsies (Data available) 882 (877) 184 (182) 158 (156) 1224 (1215 ) ≥ 10 Glomeruli n % 693 79. 0 133 73. 1 132 84. 6 958 78. 8 < 10 Glomeruli n % 184 21. 0 49 26. 9 24 15. 4 257 21. 2 *9 cases with missing number of glomeruli 5 th MRRB report 2011 & 2012, Malays
Table 4. 4. 1: Gender and racial distribution 2005 -2010 n % 2011 n % 2012 n % 378 48. 1 94 54. 7 76 49. 0 548 Gender Female 408 51. 9 78 45. 4 79 51. 0 565 Male Race All n Total 786 100 172 100 155 100 1113 Malay 480 61. 1 120 69. 8 112 72. 3 712 154 19. 6 26 15. 1 21 13. 6 201 61 7. 8 9 5. 2 7 4. 5 77 91 11. 5 17 9. 9 15 9. 6 123 786 100 172 100 155 100 1113 Chines e Indian Others * Total * inclusive of 11 foreigners % 49. 2 50. 8 100 64. 0 18. 1 6. 9 11. 0 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 4. 2: Age distribution Age (years) n Mean Standard deviation Minimum Maximum 2005 - 2010 882 9. 82 2011 2012 All 184 9. 63 158 9. 66 1224 9. 77 3. 88 4. 32 4. 28 4. 00 0. 25 14. 99 0. 23 14. 98 0. 13 14. 97 0. 13 14. 99 5 th MRRB report 2011 & 2012, Malays
Table 4. 5. 1: Clinical presentation at biopsy Clinical presentation Asymptomatic urine abnormalities Nephritic syndrome Nephrotic syndrome Nephritic nephrotic syndrome Not available Missing 20052010 n % 2011 n % 2012 n % All n % 19. 17. 22 161 18. 3 35 27 18. 2 0 1 3 15. 13. 15 109 12. 4 28 21 12. 9 2 3 8 45. 46. 61 455 51. 6 83 74 50. 0 1 8 2 92 10. 4 28 15. 13. 14 22 11. 6 2 9 2 54 11 3. 3 2. 2 6. 1 1. 3 6 4 7 7 4. 4 67 5. 5 4. 4 22 1. 8 5 th MRRB report 2011 & 2012, Malays
Table 4. 5. 2: Renal function at biopsy Renal function at 2005 -10 biopsy n % Impaired Normal 2011 2012 All n % n % 30. 269 30. 5 59 32. 1 40 25. 3 368 1 63. 563 63. 8 111 60. 3 106 67. 1 780 7 14 7. 6 12 7. 6 76 6. 2 Not available or missing 50 Total 122 882 100 184 100 158 100 4 5. 7 5 th MRRB report 2011 & 2012, Malays
Table 4. 5. 3(a): Hypertension at biopsy Hypertension At biopsy 2005 -10 2011 2012 All n % n % Not available or missing 27 3. 1 14 7. 6 12 7. 6 4. 3 Total 882 100 184 100 158 100 Present Absent n % 37. 306 34. 7 85 46. 2 64 40. 5 455 2 58. 546 62. 2 85 46. 2 82 51. 9 716 5 122 10 4 0 5 th MRRB report 2011 & 2012, Malays
Table 4. 5. 3(b): Type of antihypertension Anti-hypertensives ACEI Alpha Blocker ARB B Blocker Calcium Channel Blocker Others No drug available 2005 -10 n % 33. 103 7 13. 40 1 9 2. 9 18. 55 0 52. 161 6 14. 44 4 27. 84 2011 2012 n % 48. 46. 41 30 2 9 14. 1 1. 2 9 1 4 4. 7 3 4. 7 12. 20. 11 13 9 3 51. 62. 44 40 8 5 47. 64. 40 41 1 1. 2 1 All n % 174 38. 2 50 11. 0 16 3. 5 79 17. 4 245 53. 8 125 27. 5 1. 6 86 201118. 9 5 MRRB report & 2012, Malays th
Table 4. 7. 2: The histopathological profile in different steroid response categories Diagnosis FSGS MCD Lupus nephritis Ig. A nephropathy Mesangial proliferative GN non-Ig. A Post-infectious GN Others* Total Steroid sensitive n % 36 29. 0 55 44. 4 20 16. 1 1 0. 8 5 4. 0 1 0. 8 6 4. 8 124 100 Steroid resistant n % 109 43. 3 86 34. 1 24 9. 5 6 2. 4 4 1. 6 1 0. 4 22 8. 7 252 100 *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 Missing of 8 cases with NA/Missing between steroid responsive and steroid resistant 5 th MRRB report 2011 & 2012, Malays
Table 4. 6. 1: Diagnosis of paediatric renal biopsies *Patients may have more than 1 diagnosis classification 5 th MRRB report 2011 & 2012, Malaysi
Table 4. 7. 1: Renal histopathology diagnosis of children presenting with nephrotic syndrome Diagnosis FSGS MCD Lupus nephritis Ig. A nephropathy Mesangial proliferative GN non-Ig. A Post-infectious GN 20052011 2012 All 2010 n % n % 39. 25. 37. 178 19 28 225 37. 4 6 0 3 32. 52. 32. 145 40 24 209 34. 8 2 6 0 14. 10. 16. 66 8 12 86 14. 3 7 5 0 12 2. 7 2 2. 6 1 1. 3 15 2. 5 8 1. 8 2 2. 6 2 2. 7 12 2. 0 4 0. 9 2 2. 6 1 1. 3 7 1. 2 Others** 37 8. 2 3 *Patients may have more than 1 diagnosis classification 3. 9 7 9. 3 47 7. 8 ** Others – Henoch Schonlein Purpura, HUS/TTP, Total 450 Systemic 100 76 100 75 100 601 100 vasculitis, Malignancy, Membranous nephropathy, Membrano-proliferative, Idiopathic crescentic GN, Acute interstitial nephritis, Acute tubular necrosis, Chronic interstitial nephritis, Heredity (others), Advance GN, Others (nephrotic n=612 but report conclusive for nephrotic n=589) 5 th MRRB report 2011 & 2012, Malays
Table 4. 8: Renal histopathology diagnosis of children presenting with nephritic syndrome 20052010 n % n Post-infectious GN 26 22. 8 8 Lupus nephritis 30 26. 3 3 Ig. A nephropathy 7 Diagnosis 6. 1 Henoch Schonlein Purpura 5 4. 4 FSGS 9 7. 9 MCD 7 6. 1 Messangial proliferative GN 3 2. 6 *Patients may have more than 1 diagnosis classification non lg. A ** Others – HUS/TTP, Anti GBM disease, Advance GN, Acute tubular necrosis 10 8. 8 Systemic vasculitis, Membrano-proliferative, Idiopathic 2011 2012 % 33. 3 12. 5 n 2 8. 3 2 0 0. 0 8. 3 0. 0 1 1 0 % 29. 4 11. 8 5. 9 0. 0 2 8. 3 0 0. 0 5 5 All n % 39 25. 2 38 24. 5 11 7. 1 6 12 7 3. 9 7. 7 4. 5 5 3. 2 1 4. 2 0 0. 0 11 7. 1 25. 17. crescentic GN, Acute interstitial nephritis, Chronic Others** 17 14. 9 6 3 26 16. 8 interstitial nephritis, Alport’s syndrome 0 6 (nephritic n=158 but report conclusive for nephritic Total 114 100 24 100 17 100 155 100 n=151) 5 th MRRB report 2011 & 2012, Malays
Table 4. 9: Histology finding of children who had severe renal failure (needed dialysis therapy) who underwent renal biopsy Post-infectious GN 2005 -2010 n % 1 1. 3 2011 n % 2 15. 4 2012 n % 0 0. 0 Lupus nephritis 22 28. 6 2 15. 4 1 16. 7 25 26. 0 FSGS 21 27. 3 2 15. 4 0 0. 0 23 24. 0 15 19. 5 2 15. 4 3 50. 0 20 20. 8 0 0. 0 Acute tubular necrosis 2 2. 6 0 0. 0 2 2. 1 MCD 1 1. 3 1 7. 7 0 0. 0 2 2. 1 Acute interstitial nephritis 1 1. 3 0 0. 0 1 1. 0 Ig. A nephropathy 5 6. 5 0 0. 0 1 16. 7 6 6. 3 Others* 9 11. 7 4 30. 8 1 16. 7 14 14. 6 Total 77 100 13 100 6 100 96 100 Diagnosis Advanced glomerulosclerosis (advance GN) HUS/TTP All n % 3 3. 1 * Membrano-proliferative, Messangial Proliferative GN-non lg. A, Idiopathic Crescentic GN, Henoch scholein purpura, Systemic vasculitis, Malignancy, Chronic interstitial nephritis, Others * Severe renal failure extracted from chronic impaired renal function 5 th MRRB report 2011 & 2012, Malays
Table 4. 10. 1: Clinical characteristics of children with steroid resistant nephrotic syndrome (2005 -2012) Clinical characteristics Number Age/year (mean (sd)) Age/year(median (IQR)) Race BMI (mean (sd)) Gender Gross haematuria Hypertension Family history e. GFR ml/min/1. 73 m² Dialysis required Malay Chinese Indian Others Total Boy Girl Present Absent Not available/Missing Present Absent Yes No Unknown/ missing GFR <30 GFR 30 -60 GFRl 60 -90 GFR > 90 Missing Yes No Unknown 24 HUP g/day (mean, sd) Urine albumin g/mmol (mean, sd) (urine. PCI) Albumin g/L (mean, sd) Histology Yes No Tubulointerstitial disease Performed Wilcoxon Rank Sum test Performed Chi-square test e, g, i, m Performed Fisher’s exact test FSGS n % 105 42. 5 7. 6 4. 03 7. 3 6. 42 71 67. 6 14 13. 3 6 5. 7 14 13. 3 105 100 19. 16 3. 870 66 62. 9 39 37. 1 4 3. 8 92 87. 6 9 8. 6 48 46. 6 55 53. 4 4 3. 8 100 95. 2 1 1. 0 6 5. 7 11 10. 5 10 9. 5 62 59. 0 16 15. 2 4 3. 8 98 93. 3 3 2. 9 3. 7 3. 15 0. 9 0. 68 22. 3 10. 65 3 2. 9 102 97. 1 MCD n 79 6. 5 5. 14 59 5 12 3 79 18. 50 55 24 1 77 1 26 53 3 73 3 2 2 7 59 9 0 78 1 0. 1 1. 1 21. 1 0 79 p-value % 32. 0 4. 23 7. 51 74. 7 6. 3 15. 2 3. 8 100 4. 478 69. 6 30. 4 1. 3 97. 5 1. 3 32. 9 67. 1 3. 8 92. 4 3. 8 2. 5 8. 9 74. 7 11. 4 0. 0 98. 7 1. 3 0. 09 0. 96 10. 18 0. 0 100. 0 0. 0563 a 0. 012 b 0. 055 c 0. 339 d 0. 381 e 0. 062 f >0. 995 g 0. 084 h 0. 134 i 0. 101 j 0. 715 k 0. 532 l 0. 261 m a, c, j, k, l b, d, f, h 5 th MRRB report 2011 & 2012, Malays
Table 4. 10. 2: Patient survival for focal segmental glomerulosclerosis and minimal change disease 20052012 Minimal Change Disease % SE survival 0 216 100 12 185 99 0. 008 24 136 97 0. 012 36 100 97 0. 012 48 79 97 0. 012 60 54 97 0. 012 72 22 95 0. 025 *Missing of 6 censored cases outcome date < date 84 9 where the 95 0. 025 Interval (months) n of first biopsy **Missing of 3 censored cases where the outcome date < date of 1 st biopsy Event = death; Status as at 31 Dec 2012 or last follow-up Focal Segmental Glomerulosclerosis % n SE survival 239 100 183 98 0. 009 156 96 0. 013 126 96 0. 013 97 96 0. 013 68 95 0. 018 44 95 0. 018 21 95 0. 018 5 th MRRB report 2011 & 2012, Malays
Figure 4. 10. 2: Patient survival by focal segmental glomerulosclerosis and minimal change disease 5 th MRRB report 2011 & 2012, Malays
Table 4. 10. 3: Death-censored renal survival of patient with focal segmental glomerulosclerosis and minimal change disease 2005 -2012 Focal Segmental Glomerulosclerosis % % Interval (months) n SE survival 0 216 100 239 100 12 185 99 0. 005 183 93 0. 017 24 136 98 0. 011 156 91 0. 020 36 100 95 0. 020 126 88 0. 024 48 79 95 0. 020 97 82 0. 030 60 54 92 0. 026 68 80 0. 033 72 22 92 0. 026 44 77 0. 039 84 9 where the 92 0. 026 21 75 0. 044 *Missing of 6 censored cases outcome date < date of 1 st Minimal Change Disease biopsy **Missing of 1 case and 2 censored cases where the outcome date < date of 1 st biopsy Event = ESRF; Status as at 31 Dec 2012 or died or last follow-up 5 th MRRB report 2011 & 2012, Malays
Figure 4. 10. 3: Renal survival by focal segmental glomerulosclerosis and minimal change disease 20052012 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 1: Total number of patients and biopsies (SLE) Year Total no of patients Total no of biopsies 2005 -2010 186 213 2011 30 31 2012 32 33 All 248 277 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 2: Distribution of renal biopsy in patient with lupus by number of episodes 2005 -2012 Total no of biopsy /patient 1 st episode 2 nd 3 rd Total Patient n % 234 84. 5 36 13. 0 7 2. 5 277 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 3. 1: Gender distribution for paediatric lupus nephritis, 2005 -2012 Gender n % Male 40 16. 1 Female 208 83. 9 Total 248 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 3. 2: Racial distribution for paediatric lupus nephritis, 2005 -2012 Ethnic Malay Chinese Indian Others* Total N % 155 63 7 23 248 62. 5 25. 4 2. 8 9. 3 100 ** by patient count, SLE race * inclusive of 2 foreigners 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 3. 3: Age distribution for paediatric lupus nephritis, 2005 -2012 Age (years) 2005 - 2010 2011 2012 All 213 31 33 277 11. 85 12. 08 11. 53 11. 84 2. 733 3. 667 3. 878 2. 993 0. 25 0. 23 0. 27 0. 23 Maximum 15. 00 14. 98 ** by biopsy count, age at biopsy, SLE 14. 97 15. 00 n Mean Standard deviation Minimum 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 3. 4: Dialysis therapy for paediatric lupus nephritis at the time of biopsy, 2005 -2012 Needed dialysis therapy Yes No Missing/Not available Total n % 19 6. 9 215 77. 6 43 15. 5 277 100. 0 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 3. 5: Patient with hypertension (SLE), 20052012 Hypertension n % Yes 114 41. 2 No Missing/Not available Total 150 54. 2 13 4. 7 277 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 3. 6: Clinical presentation at biopsy (SLE), 2005 -2012 Clinical presentation n % Urine abnormalities 89 32. 1 Nephritic syndrome 35 12. 6 Nephrotic syndrome Nephritic nephrotic syndrome Unknown 84 30. 3 42 15. 2 21 7. 6 Missing 6 2. 2 277 100. 0 Total 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 4(a): Clinical presentation of paediatric lupus, 2005 -2012 Clinical presentation Total number of patient Malar rash Discoid rash Photosensitivity Oral ulcers Arthritis Serositis Renal Cerebral Hematological N 277 124 18 64 78 90 42 229 32 163 % 44. 8 6. 5 23. 1 28. 2 32. 5 15. 2 82. 7 11. 6 58. 8 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 4(b): ARA criteria at presentation, 2005 -2012 Number of ARA criteria <4 N % 71 25. 6 ≥ 4 206 74. 4 Total 277 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 5: Classification of paediatric lupus nephritis, 20052012 WHO/ISN /RPS Class III or V+III Class IV or V+IV Class V or V+II Class VI Unknown Total Needed dialysis therapy n % 0 0. 0 2 10. 5 3 15. 8 11 57. 9 1 5. 3 2 10. 5 0 0. 0 19 100 Not needed dialysis therapy n % 2 0. 9 19 8. 8 49 22. 8 135 62. 8 9 4. 2 0 0. 0 1 0. 5 215 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 6: Patients survival in lupus nephritis 20052012 Interval (months) 0 12 24 36 48 60 72 84 n 246 199 160 120 95 64 37 15 Lupus Nephritis patients % survival 100 97 94 91 91 87 86 82 SE 0. 012 0. 016 0. 021 0. 029 0. 032 0. 048 *Missing of 2 censored cases where the outcome date < date of 1 st biopsy Event = death; Status as at 31 Dec 2012 or last followup 5 th MRRB report 2011 & 2012, Malays
Figure 4. 11. 6: Patient survival in lupus nephritis 5 th MRRB report 2011 & 2012, Malays
Table 4. 11. 7: Death-censored Renal survival of patient with lupus nephritis, 2005 -2012 Interval (months) 0 12 24 36 48 60 72 84 n 246 199 160 120 95 64 37 15 Lupus Nephritis patients % survival 100 98 98 96 94 91 91 91 SE 0. 010 0. 014 0. 019 0. 026 *Missing of 1 case and 1 censored case where the outcome date < date of 1 st biopsy Event = ESRF; Status as at 31 Dec 2012 or died or last followup 5 th MRRB report 2011 & 2012, Malays
0. 00 0. 25 Cumulative Survival 0. 50 0. 75 1. 00 Figure 4. 11. 7 : Death-censored renal survival in lupus nephritis, 2005 -2012 0 20 40 60 Duration (months) 80 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 12: Causes of end stage renal disease in children who underwent renal biopsy (2005 -2012) Causes FSGS Advance gloemrulosclerosis (advance GN) Lupus nephritis Ig. A nephropathy MCD Post-infectious GN Chronic interstitial nephritis Idiopathic crescentic GN Mesangial proliferative GN non. Ig. A Membranous nephropathy Henoch Schonlein Purpura Systemic vasculitis Membranoproliferative GN Acute tubular necrosis HUS/TTP Acute interstitial nephritis * by patient count Total n 37 % 31. 9 21 18. 1 13 11 9 4 4 4 11. 2 9. 5 7. 8 3. 4 3 2. 6 3 3 2 1 1 116 2. 6 1. 7 0. 9 100 5 th MRRB report 2011 & 2012, Malays
Table 4. 13. 1: Frequency of complication (2005 -2012) n % 1, 224 - 44 3. 6 Bleeding Gross haematuria Haematoma Perirenal collection Infection Arteriovenous malformation Hypotension 39 88. 6 36 81. 8 2 4. 5 7 15. 9 0 0. 0 2 4. 5 1 2. 3 Others 0 0. 0 Total Number of biopsies Total Number of complication Type of complication 5 th MRRB report 2011 & 2012, Malays
Table 4. 13. 2: Risk factors for complication (2005 -2012) Factors Age (years) n Number of Odds complicati ratio on 95% CI p-value 2 48 6 4. 71 1. 76, 12. 63 0. 002 >2 -≤ 5 152 6 1. 53 0. 60, 3. 91 0. 372 326 698 101 11 21 9 1. 07 1. 00 2. 72 0. 51, 2. 27 1. 24, 5. 97 0. 851 0. 012 959 31 1. 00 - - 164 4 65 9 4. 32 1. 82, 10. 23 0. 001 69 3 1. 28 0. 36, 4. 52 0. 699 125 8 1. 90 0. 80, 4. 51 0. 148 165 554 246 6 18 0 1. 08 1. 00 0. 42, 2. 80 0. 870 >5 -≤ 10 >10 (ref*) needed dialysis Renal failure not needed dialysis * Unknowna <15 15 -<30 Calculated 30 -<60 GFR 60 - <90 ml/min/1. 73 m² > 90 unknown 5 th MRRB report 2011 & 2012, Malays
Table 4. 13. 2: Risk factors for complication (2005 -2012) ~continuation Factors n Number of complication 3 8 32 1 16 28 0 0 41 3 5 39 7 36 1 0 25 19 0 0 ≤ 8 28 Hemoglobin (Hb) level >8 -≤ 10 201 g/dl (ref*) ≥ 11 927 Unknownc 68 Not realtime 356 (ref*) Ultrasound –guidance Realtime 396 d Unknown 472 Yes 6 (ref*) Not 704 Plug biopsy ** Unknowne 514 SLE 288 SLE status (ref*) Non SLE 936 14 G 117 (ref*) 16 G 480 Needle size 18 G 214 Unknownf 413 ≤ 2 480 (ref*) 3 -≤ 4 300 Number of passes ≥ 5** 19 Unknowng 425 (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 Odds ratio 95% CI p-value 3. 49 1. 18 1. 00 0. 61 1. 00 0. 44 1. 00 0. 78 1. 00 0. 06 0. 81 1. 00 0. 97, 12. 58 0. 53, 2. 62 0. 33, 1. 15 0. 17, 1. 13 0. 34, 1. 79 0. 01, 0. 42 0. 44, 1. 51 0. 056 0. 684 0. 128 0. 087 0. 552 0. 005 0. 512 5 th MRRB report 2011 & 2012, Malays
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