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Revista de la Facultad de Medicina Humana

versión impresa ISSN 1814-5469versión On-line ISSN 2308-0531

Rev. Fac. Med. Hum. vol.20 no.4 Lima oct./dic 2020

http://dx.doi.org/10.25176/rfmh.v20i4.3188 

Original Article

Kidney biopsy. Clinicopathological features, complications, and evolution in a general hospital in Peru

VH Meneses-Liendo1  , Surgeons, Specialist in Nephrology, Magister in Medicine

MC Medina-Chávez1  , Surgeons, Specialist in Nephrology,

M Gómez-Lujan1  , Surgeons, Specialist in Nephrology,, Magister in Management in Health Services

1Unidad del Glomérulo, Hospital Nacional Edgardo Rebagliati Martins, Lima-Perú.

ABSTRACT

Introduction:

Renal biopsy is one of the essential tests for the characterization of chronic kidney disease (CKD).

Objective:

To determine the most frequent primary and secondary glomerulonephritis, complications of renal biopsy, and the number of patients on hemodialysis when undergoing renal biopsy.

Methods:

Observational, descriptive, case series, retrospective, and cross-sectional study carried out at the E. Rebagliati Martins-Perú. The medical records of patients older than 15 years of age who underwent kidney biopsy between 2008-2016 were reviewed. The data were processed using Stata 16.1

Results:

2278 medical records were used. They corresponded to 1234 women and 1044 men. The most frequent primary and secondary glomerulonephritis were focal and segmental glomerulosclerosis (FSGS) 683 (29.98%) and systemic lupus erythematosus (SLE) 434 (19.04%) respectively. A total of 1644 biopsied patients were analyzed 36 (2.19%), 241 (14.66%) had major and minor complications respectively. Major complications were more frequent when the procedure was performed by radiology with ultrasound guidance compared to that performed by the nephrologist without ultrasound guidance (p = 0.03694). From a total of 1324 patients, 329 underwent kidney biopsy while on hemodialysis, 43 (13.07%) managed to get out of this therapy, and 144 (51.99%) had major or minor complications.

Conclusion:

FSGS and SLE were the most frequent primary and secondary glomerulonephritis, respectively. In 1644 patients the major and minor complications were 36 (2.19%) and 241 (14.66%) respectively. In 1,324 patients, 329 (24.8%) were biopsied while on hemodialysis, and 144 (51.99%) of them had major or minor complications.

Keywords: Biopsy; Kidney; Complications; Glomerulonephritis (source: MeSH NLM).

INTRODUCTION

Chronic kidney disease (CKD) is a global public health problem with an increased prevalence and incidence, poor outcome, and high associated costs1,2,3.

The characterization of CKD in all its stages constitutes an essential part of its management, and it is essential for the development of therapeutic strategies aimed at slowing its progression or avoiding the need for replacement treatment of renal function. Within this reasoning, renal biopsy occupies an expectant place4,5,6, especially when it comes to glomerulonephritis.

Like any invasive diagnostic test, renal biopsy is indicated taking into account the following criteria: 1. Making a diagnosis and providing information for treatment. 2. Knowing the natural history of the disease that is suspected to be associated with high morbidity and mortality. 3. The natural history of this disease can be improved with therapy (if this natural history cannot be improved, the biopsy should not be performed). 4. The treatments for these diseases differ according to the kidney biopsy diagnosis (there is no single treatment). 5. The adverse events of the treatment and the risk of the procedure are acceptable according to the current state of health of the patient4,5,6.

In patients with CKD, renal biopsy is essential for characterizing the disease according to the stage as well as for the therapeutic management of the patient, who is often on dialysis. Therefore, our objective is to determine the frequency of primary and secondary glomerulonephritis, complications of renal biopsy, and the number of patients on hemodialysis when undergoing a renal biopsy, in children under 15 years of age.

METHODS

Design and study area

An observational, descriptive, case series, retrospective, and cross-sectional study carried out in the Organ Unit of the Nephrology Department of the Hospital Edgardo Rebagliati Martins (HNERM) in the city of Lima, serving 16% of the population attached to the Social Security of Peru (ESSALUD).

Population and sample

The population was made up of all patients older than 15 years of age who underwent renal biopsy between January 1, 2008, to December 31, 2016; The sample was not found since the entire population was included.

Procedures and variables

Regarding the procedures, the medical records of patients older than 15 years of age who underwent renal biopsy were reviewed.

The collected data were entered into the Excel 2019 program. Later, the statistical software Stata 16.1 was used, and the correct coding of the variables was verified.

The documentation technique was used, a data collection sheet was prepared with each of the variables involved in the study.

The variables were: gender, age, glomerulonephritis (primary and secondary), renal indicators, complications of the renal biopsy according to the operator, patients with hemodialysis, and complications of the renal biopsy in patients with hemodialysis and discharge from hemodialysis.

Major complications considered those patients requiring blood transfusion, requiring surgery, nephrectomy, arteriography, selective endovascular embolization of the bleeding vessel or death; and minor complications to the decrease in Hb>1gr / L, macroscopic hematuria, hypotension, pain in the puncture site (all of them without the need for blood transfusion).

Statistical analysis

The frequencies and percentages for the qualitative variables were calculated. Furthermore, an exploration was performed comparing the frequencies of major and minor complications of the renal biopsy when the procedure was performed by the radiologist with ultrasound guidance in relation to that performed by the nephrologist without ultrasound guidance. A significance level of 95% was used.

Ethical considerations

Authorizations were obtained from the heads of the Glomerulus Unit, the Department of Nephrology, the Office of Research and Teaching, and the HNERM Ethics Committee. The dignity, integrity, privacy, and confidentiality of patients have been protected by protecting their data by the Declaration of Helsinki.

RESULTS

2278 medical records of patients undergoing renal biopsy were reviewed, 1234 were women, and 1044 men. The age groups included 431 patients (18.92%) between 15 and 29 years old, 846 (37.14%) between 30 and 44 years old, 389 (17.08%) between 45 and 59 years old, 377 (16, 55%) between 60 and 74 years and 235 (10.32%) over 75 years.

Table 1.  Distribution of glomerulonephritis by renal biopsy. 

Diagnosis Number Percentage
FSGS 683 29.98
Membranous 250 10.97
Membranoproliferative 68 2.99
Mesangial 32 1.40
Minimal changes 11 0.48
SLE 434 19.04
Multiple myeloma 87 3.82
Diabetes mellitus 68 2.99
Rapidly progressive GN 28 1.23
Kidney transplantation 123 5.40
Amyloidosis 86 3.78
HT 102 4.48
Thrombotic microangiopathy 68 2.99
Others 238 10.45
Total 2278 100.00

Focal and segmental glomerulosclerosis (FSGS); Systemic lupus erythematosus (SLE); Glomerulonephritis (GN); Arterial hypertension (HTN).

Table 2.  Distribution of glomerulonephritis by renal biopsy according to age. 

Diagnosis 15 to 29 30 to 44 45 to 59 60 to 74 75 or more
n % n % n % n % n %
FSGS 80 11.71 302 44.22 158 23.13 77 11.27 66 9.66
Membranous 26 10.40 24 9.60 56 22.40 97 38.80 47 18.80
Membranoproliferative 28 41.18 19 27.94 10 14.71 4 5.88 7 10.29
Mesangial 14 43.75 11 34.38 6 18.75 1 3.13 0  
Minimal changes 10 90.91 1 9.09 0 0 0 0 0 0
SLE 129 29.72 269 61.98 32 7.37 4 0.92 0  
Multiple myeloma 0 0 3 3.45 4 4.60 41 47.13 39 44.83
Diabetes mellitus 3 4.41 7 10.29 34 50.00 20 29.41 4 5.88
Rapidly progressive GN 12 42.86 11 39.29 3 10.71 2 7.14 0 0
Renal transplant 22 17.89 71 57.72 24 19.51 6 4.88 0 0
Amyloidosis 5 5.81 12 13.95 26 30.23 28 32.56 15 17.44
HTA 4 3.92 8 7.84 14 13.73 56 54.90 20 19.61
Thrombotic microangiopathy 6 8.82 9 13.24 16 23.53 34 50.00 3 4.41
Others 92 38.66 99 41.60 6 2.52 7 2.94 34 14.29
Total 431   846   389   377   235  

Table 3. Main renal indicators in patients with renal biopsy. 

Diagnosis Number Creatinine Proteinuria Hb HTA
Yes No
% %
FSGS 683 2.6±1.9 3.2±1.2 11.8±0.6 25 75
Membranous 250 1.8±1.2 4.8±1.1 11.7±0.5 19 81
Membranoproliferative 68 2.4±1.1 3.3±1.0 11.6±0.7 31 69
Mesangial 32 1.3±1.0 2.9±0.7 11.1±0.5 23 77
Minimal changes 11 1.0±0.2 2.5±0.7 11.4±0.4 10 90
SLE 434 3.8±2.2 1.8±0.9 11.2±0.3 29 71
Multiple myeloma 87 3.6±1.9 3.6±1.0 11.1±0.4 13 87
Diabetes mellitus 68 1.2±0.4 4.1±1.1 10.8±0.4 68 32
Rapidly progressive GN 28 4.8±2.3 2.8±0.9 10.6±0.3 13 87
Kidney transplant 123 2.3±1.9 1.8±0.7 10.5±0.5 45 55
Amyloidosis 86 1.4±0.5 2.5±,0.7 9.9±0.4 12 88
HT 102 2.4±1.0 2.8±0.6 10.0±0.4 100 0
Thrombotic microangiopathy 68 1.3±0.6 3.0±1.0 11.1±0.3 32 68
Others 238 2.6±0.8 3.9±1.1 11.2±0.3 42 58
Total 2278          

Table 4.  Complications of renal biopsy according to the method of performing the procedure. 

Complications n (%) Radiology Nephrology p
Major complications 36(2,19) 25 11 0,037
Minor complications 241(14,66) 133 108 0,386
Total 277(16,85) 158 119  

Of 1644 patients, 36 (2, 19%) and 241 (14.66%), had major and minor complications respectively. Major complications were more frequent when the procedure was performed by radiology with ultrasound guidance compared to that performed by the nephrologist without ultrasound guidance (p = 0.03694).

Table 5.  Hemodialysis and hemodialysis withdrawal in patients with renal biopsy. 

Glomerulonephritis Hemodialysis (%) Withdrawal (%)
SLE, vasculitis 112 (34.04) 9 (8.04)
Primary glomerulonephritis 113 (34.35) 18 (15.93)
DBM2 49 (14.89) 4 (8.16)
Others 55 (16.72) 12 (21.82)
Total 329 (100) 43 (13.07)

*Hemodialysis before, during, and up to 90 days after renal biopsy. **Hemodialysis discharge up to 90 days after renal biopsy.

Table 6.  Complications of renal biopsy in hemodialysis patients. 

Complications hemodialysis (%) No hemodialysis (%) Total (%)
Major complications 20 (55.56) 16 (44.44) 36 (100)
Minor complications 124 (51.45) 117 (48.55) 241 (100)
Total 144 (51.99) 133 (48.01) 241 (100)

*Hemodialysis and non-hemodialysis, before, during, and up to 90 days after renal biopsy.

DISCUSSION

The FSGS is the most frequent primary glomerulonephritis 683 (29.98%) (Table 1) and 460 biopsies corresponded to patients aged between 30 and 59 years of age (67.35%) (Tabla 2), numbers consistent with published evidence(7-14).

SLE is the most frequent secondary glomerulonephritis 434 (19.04%) of all renal biopsies (Table 1), 398 (91,71%) 398 (91.71%) patients underwent renal biopsy between 15 and 44 years of age (Table 2) and serum creatinine was 3, 8±2.2 (Table 3). A 112 of 434 (25.81%) patients with SLE underwent a renal biopsy with concomitant hemodialysis, finding in this group of patients the lowest percentage of discharge from hemodialysis (8.04%) (Table 5). All these figures make us think that the indications for kidney biopsy will probably have to be reviewed and think about much earlier detection and treatment; with the aim of reducing the progression to chronic kidney disease and the subsequent definitive renal replacement therapy15.

We found 68 (2.99%) cases with glomerulonephritis corresponding to patients with type 2 diabetes mellitus (DBM2) (Table 1). Kidney biopsy with hemodialysis was performed in 49 patients (72.06%) and 4 (8.06%) came off hemodialysis. The same trend is observed in SLE(16).

In the present study, 612 patients were older than 60 years of age (26.87% of all patients evaluated) (Table 2). Membranous glomerulonephritis, with 144 patients (38.8% between 60 and 74 years and 18.8% between 75 and older), is the most frequent primary glomerulonephritis in this age group. The most frequent secondary glomerulonephritis are multiple myeloma in 80 patients (47.13% between 60 and 74 years of age and 44.83% between 75 and over) and HTN in 76 patients (54.9% between 60 and 74 years and 19, 61% from 75 to more years of age). The increase in secondary causes can be seen, with membranous glomerulonephritis being the most frequent in this age group(17).

In the 45 to 59 age group, FSGS (302 patients) and membranous glomerulonephritis (24 patients) were the most common primary diseases and DBM2 (34 patients) and SLE (32 patients) the most seen secondary (Table 2). The results found to correspond to that reported in the previous series10, perhaps the only difference is in the number of patients with DBM2.

Data related to complications of the renal biopsy were found in only 1644 patients. The complications found in the present study have frequencies similar to other series18. Strikingly is that major complications are more frequent when the procedure is performed by radiology with ultrasound guidance (Table 4). The reason could be the nephrologist's greater experience with the procedure. However, there are no figures in other series in this regard.

In the medical records of only 1324 patients, hemodialysis records were found. 329 of them underwent kidney biopsy while on renal replacement therapy: hemodialysis, and 43 of the 329 (13.07%) managed to get off hemodialysis as a consequence of the evolution of the patient and the treatment received. This is an interesting figure, in the sense that it could translate the late diagnosis and treatment and the need to review the indication for renal biopsy, especially in secondary glomerulonephritis, for example, SLE.

Table 6shows that 51.99% of renal biopsies performed in hemodialysis patients at the time of the procedure had major or minor complications due to the intervention. Data that should be taken into consideration when considering a renal biopsy in a patient with little chance of recovery of this function.

It was not possible to complete all the information required in all the patients evaluated, due to inadequate and/or incomplete recording of the information in the clinical history, which is clearly a limitation of the present study.

CONCLUSIONS

The most frequent primary glomerulonephritis was GEFyS with 683 patients (29.88%) and the most evaluated secondary glomerulonephritis was SLE with 434 patients (19.04%). 36 (2.19%) and 241 (14.66%) patients out of 1644 with renal biopsy presented major and minor complications, respectively. In 1,324 patients, 329 (24.8%) underwent kidney biopsy while on hemodialysis, of which 144 (51.99%) had major or minor complications.

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Funding: Self-financed.

Received: July 16, 2020; Accepted: July 28, 2020

Correspondence: Víctor Hugo Meneses Liendo. Address: Jr. Manuel Gómez 270 Lince Lima 14- Perú. Telephone: 999644644 Email:vhmeneses@yahoo.com

Author’s contributions: The authors participated in the genesis of the idea, project design, data collection and interpretation, analysis of results and preparation of the manuscript of this research work.

Conflict of interest: The authors declare that they have no conflict of interest.

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