Idiopathic glomerulonephritis in the elderly

The renal histopathology spectrum of elderly patients with kidney diseases: a study of 430 patients in a single Chinese center

The elderly population has significantly increased in China. However, data regarding renal histopathology in this population is lacking. The present study retrospectively analyzed renal disease spectrum of 430 elderly patients who had received renal biopsy at Peking University First Hospital between January 2003 and December 2012. Among 6049 patients receiving renal biopsies during the same period, 430 (7.10%) were elderly (≥65 years). The ratio of male (263 patients) to female (167 patients) was 1.57:1, with an age of 70.29±3.99 (range 65-82) years at the time of biopsy. The most common indication for renal biopsy was nephrotic syndrome (59.53%), followed by acute kidney injury (AKI, 19.53%) and chronic glomerulonephritis (CGN, 16.05%). The most common renal histopathology in primary glomerular disease was idiopathic membranous nephropathy (iMN, 61.02%), followed by IgA nephropathy (18.22%), minimal change disease (MCD, 9.32%) and focal segmental glomerulosclerosis (6.78%). ANCA-associated vasculitis (AAV, 43.95%) was the leading secondary glomerular disease, followed by HBV-related glomerulonephritis (HBV-GN, 24.2%), and amyloidosis (14.01%). In patients with nephrotic syndrome, iMN (50%) was the leading cause, followed by HBV-GN (16.02%), MCD (7.81%), and amyloidosis (7.81%). In patients with iMN, 89.5% presented as nephrotic syndrome, 8.39% as CGN. In patients with AKI, the leading cause was AAV (48.12%), followed by acute interstitial nephritis (20.48%) and acute tubular necrosis (8.43%). In conclusion, in elderly Chinese patients, the most common renal histopathology pattern was iMN in patients with nephrotic syndrome, and AAV in patients with AKI.

Renal disease in the elderly and the very elderly Japanese: analysis of the Japan Renal Biopsy Registry (J-RBR)

BACKGROUND AND OBJECTIVES

Data regarding renal disease in the elderly (age ≥65 years old) and very elderly (age ≥80 years old) Japanese are extremely limited. The aim of this study was to examine the causes of renal disease and their clinical presentations in elderly patients who underwent renal biopsy.

DESIGN, SETTING, PARTICIPANTS, AND MEASUREMENTS

From July 2007 to November 2011, all of the elderly native renal biopsy patients who had been registered in the Japan Renal Biopsy Registry (J-RBR; 2802 including 1596 males and 1206 females) were identified. Their data were compared with a control group of 7416 patients who ranged in age from 20 to 64 years old and were registered on the J-RBR over the same period. In addition, the clinical and pathological classifications of 276 very elderly patients were also analyzed.

RESULTS

The indications for biopsy were nephrotic syndrome (NS) in 36.2 and 50.7 % of the elderly and the very elderly patients, chronic nephritic syndrome in 31.8 and 17.4 %, and acute kidney injury including rapidly progressive glomerulonephritis in 18.6 and 22.5 %, respectively. Primary glomerular disease was the most frequent diagnosis, followed by MPO-ANCA-positive nephritis, IgA nephropathy (IgAN), and diabetic nephropathy. In primary GN including IgAN, membranous nephropathy (MN) was the most frequent histological type, followed by IgAN and minor glomerular abnormalities. A comparison with the control group showed that MN, MPO-ANCA-positive nephritis, and amyloid nephropathy were more common in the elderly (P < 0.001), and IgAN was less common (P < 0.001). As for nephrotic syndrome in the elderly, MN was the most common histological type, followed by minimal change NS, diabetic nephropathy, amyloid nephropathy, and focal segmental glomerulosclerosis. There was a significant discrepancy between the urinary protein/creatinine ratio and daily proteinuria after the 7th decade of life.

CONCLUSIONS

Renal biopsy is a valuable diagnostic tool, even in elderly and very elderly Japanese patients. In the future, modified clinical guidelines for elderly renal disease should be developed.

Renal biopsy in the very elderly

BACKGROUND AND OBJECTIVES

Data regarding renal biopsy in the very elderly (>or=age 80 yr) are extremely limited. The aim of this study was to examine the causes of renal disease and their clinical presentations in very elderly patients who underwent native renal biopsy.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

All native renal biopsies (n = 235 including 106 men, 129 women) performed in patients aged >or=80 yr over a 3.67-yr period were retrospectively identified. Results were compared with a control group of 264 patients aged 60 to 61 who were biopsied over the same period.

RESULTS

The indications for biopsy were acute kidney injury (AKI) in 46.4%, chronic-progressive kidney injury in 23.8%, nephrotic syndrome (NS) in 13.2%, NS with AKI in 9.4%, and isolated proteinuria in 5.5%. Pauci-immune GN was the most frequent diagnosis (19%), followed by focal segmental glomerulosclerosis secondary to hypertension (7.6%), hypertensive nephrosclerosis (7.1%), IgA nephropathy (7.1%) and membranous nephropathy (7.1%). Comparison with the control group showed pauci-immune GN to be more frequent (P < 0.001) and diabetic glomerulosclerosis (P < 0.001) and membranous nephropathy (P < 0.05) less frequent in the very elderly. Diagnostic information had the potential to modify treatment in 67% of biopsies from the very elderly, particularly in those with AKI or NS.

CONCLUSIONS

Renal biopsy in very elderly patients is a valuable diagnostic tool that should be offered in clinical settings with maximal potential benefit. Advanced age per se should no longer be considered a contraindication to renal biopsy.

Glomerular diseases in the elderly in India

Three hundred fifteen (315) elderly (> or = 60 years) patients with clinical renal diseases were evaluated for the evidence of glomerular diseases between November 1998 to June 2002. Glomerular diseases (GN) were observed in 20.6% (65/315) of the elderly patients. The age of the patients (male 56; female 9) ranged between 60-90 (mean 64.17 +/- 3.83) years. The clinical presentation of GN included: nephrotic syndrome 40 (61.5%), acute nephritic syndrome 19 (29.2%), rapidly progressive GN 4 (6.15%) and asymptomatic urinary abnormality 2 (3.0%). Overall, primary and secondary glomerular disease were seen in 47 (72.3%) and 18 (27.6%) elderly patients respectively. Idiopathic membranous nephropathy was the most common GN responsible for nephrotic syndrome in 11 (27.5%) of elderly patients. Diabetic Nephropathy related to type 2 diabetes mellitus was the second common cause 9 (22.5%) of nephrotic syndrome. Amyloidosis was noted in 6 (15%) patients. Nephrotic syndrome was related to leprosy in one patient. Amyloidosis occurred in association with multiple myeloma in 5 and carcinoma colon in 1 patient. Thus, primary and secondary GN were responsible for nephrotic syndrome in 60% and 40% of cases respectively. Endocapillary proliferative GN of post infectious etiology was the most prevalent (82.6%) form of acute GN in our elderly patients. Hypertension occurred in 78.2% of cases and edema in 69.5%. Pulmonary congestion (52.2%) and ARF (73.9%) were the dominant presenting feature of acute GN and 39% of patients required dialytic support. Glomerular crescents were seen in 4 (17.4%) patients with acute glomerulonephritis. Pauci-immune crescentic GN which is the commonest type of acute GN in the elderly in western countries was not observed in this study. Renal biopsy revealed mesangiocapillary GN (1) and mesangioproliferative GN (1) in two patients with asymptomatic urinary abnormalities. Thus, overall spectrum of glomerular disease in the Indian elderly population is similar to that of developed countries except in two ways: (1) post infectious endocapillary proliferative-GN was the commonest type of acute GN (2) rarity or absence of pauci-immune crescentic glomerulonephritis.

Etiologies and outcome of acute renal insufficiency in older adults: a renal biopsy study of 259 cases

Acute renal insufficiency is a common problem, yet one that is frequently reversible with proper diagnosis and treatment. Although it has been argued that a renal biopsy is not needed for diagnosis in most cases of acute renal failure in the elderly, other studies have shown frequent disagreements between clinical and renal biopsy diagnoses in such cases. To investigate the causes of acute renal insufficiency in patients aged at least 60 years who underwent a renal biopsy and possible correlations between biopsy findings and renal survival, we first identified all native renal biopsy specimens from patients aged 60 years or older processed at The University of Chicago Medical Center (Chicago, IL) from 1991 through 1998 and reviewed the clinical records to determine the indication for the biopsy. We then reviewed again the records of those patients who underwent biopsy because of acute renal insufficiency, recorded the primary renal biopsy diagnosis in each of these cases, and obtained follow-up information for patients who underwent biopsy before July 1996. During the study period, 1,065 of 4,264 biopsy specimens (25.0%) received were obtained from patients aged 60 years or older, and acute renal insufficiency was the indication for biopsy in 259 of these patients (24.3%). The most frequent primary diagnoses on these latter biopsy specimens were pauci-immune crescentic glomerulonephritis (GN) with or without arteritis, 31.2% of biopsy specimens; acute interstitial nephritis, 18.6%; acute tubular necrosis (ATN) with nephrotic syndrome, 7.5%; atheroemboli, 7.1%; ATN alone, 6.7%; light chain cast nephropathy (LCCN), 5.9%; postinfectious GN, 5.5%; anti-glomerular basement membrane antibody nephritis, 4.0%; and immunoglobulin A (IgA) nephropathy and/or Henoch-Schönlein nephritis, 3.6%. Eight biopsy specimens (3.2%) showed only benign nephrosclerosis without an apparent cause of acute renal insufficiency, and another six specimens were inadequate. The renal biopsy diagnosis was in agreement with the prebiopsy clinical diagnosis (or differential diagnosis) in 107 of the 161 cases (67%) in which such information was provided. The distribution of diagnoses was similar in patients in the age groups of 60 to 69, 70 to 79, and 80 years or older, although younger age correlated significantly with improved renal and patient survival. The relative risk for progression to end-stage renal disease (ESRD) also increased according to diagnostic categories: LCCN (greatest risk) > GN other than pauci-immune > atheroemboli congruent with pauci-immune crescentic GN > tubulointerstitial diseases other than LCCN (the latter category including ATN with nephrotic syndrome). Development of ESRD correlated significantly with decreased patient survival. In summary, renal biopsy in patients aged 60 years or older with acute renal insufficiency uncovered the cause in greater than 90% of the cases and provided clinically useful information with respect to expectation for renal survival and potential treatment options.

The epidemiology and prognosis of glomerulonephritis in Denmark 1985-1997

BACKGROUND

The existence of a national renal biopsy register and a national terminal uraemia status register in Denmark provides an opportunity to study the prognosis of glomerulonephritis (GN), and factors influencing prognosis.

METHODS

Multivariate analysis of 2380 renal biopsies with GN performed between 1985 and 1997 was done to determine the influence of clinical and histological factors on prognosis.

RESULTS

The incidence of GN (39/mo/year) and individual diagnoses did not change during the period. After 10 years, 32%, were dead, 13% terminally uraemic, 5%, uraemic and 50% well. Older age increased mortality, but not the incidence of renal failure after the first year. Male sex increased both mortality and incidence of renal failure (34 vs 24% at 10 years, P < 0.001). The diagnoses could be divided into three prognostic groups compared with the general population: a good prognostic group (minimal change GN and membranous GN ), with a relative mortality of three and a combined renal and patient mortality of four; a poor prognostic group [crescentic GN, HUS/TTP, chronic GN] with relative mortalities of 8-19 and 13-33, respectively; and the remainder with mortalities of 4-7 and 6-12. The presence of multiple glomerular pathology, chronic GN, nephrosclerosis and chronic interstitial nephropathy worsened the prognosis, while the presence of immune deposits only worsened the prognosis of focal segmental glomerulopathy. Mortality was related to uraemia and co-morbidity at biopsy, and to the incidence of renal failure. Renal failure was correlated to uraemia and hypertension at biopsy but not to nephrotic syndrome or atherosclerosis. All vascular complications were increased and were positively related to hypertension and negatively correlated to the incidence of uraemia. Crescentric glomerulonephritis combined with anti-GBM disease had a worse prognosis than Wegener's granulomatosis, with microscopic polyangiitis and pauci-immune disease occupying an intermediate position. The prognosis of mesangioproliferative GN was unaffected by the presence of IgA nephropathy and systemic lupus erythematosus.

Incidence of biopsy-proven primary glomerulonephritis in an Italian province

Between January 1, 1970, and December 31, 1994, 1,926 cases of biopsy-proven primary glomerulonephritis (PGN) were diagnosed in an adult population (> 15 years of age) in a northwestern region of Italy with approximately 3.5 million inhabitants. The principal long-term changes were an increase in the absolute number of biopsies per year, an increase in the mean age of patients undergoing biopsy (from 29.3 +/- 12.2 years to 47.0 +/- 17.8 years), an increase in the percentage of patients older than 65 years (from 1.7% to 20.4%), and an increase in the percentage of isolated urinary abnormalities as an indication for biopsy (from 3.5% to 29.6%). In the total biopsy material, immunoglobulin A glomerulonephritis (IgA-GN) is the most frequent type (26%), followed by membranous glomerulonephritis (MGN; 20%). An incidence study was begun in 1990; this survey was restricted to the population of the province of Torino (approximately 2 million inhabitants) as only this area completely refers to the nephrologic centers that entered patients into this study. The overall incidence of PGN is 4.68 new cases/yr/10(5) population with a predominance of males (> 2:1); IgA-GN is the most common type (1.47/yr/10(5) population [34.5%]) in the overall population. In the elderly, cases of PGN are twice as high as in adults (8.19/yr/10(5) population v 4.02/yr/10(5) population in the 65 to 74 year and 45 to 54 year age groups, respectively); MGN mainly accounts for this high incidence (3.4/yr/10(5) population), while the nephrotic syndrome is the most common indication for biopsy (53.8%). A comparison with the incidence in the same area in the early 1970s is evaluable only for PGN, which was mainly registered in the age groups for which an unrestricted biopsy policy was already in place (15 to 35 years). In contrast with a misleading increase of all types of PGN, which is in reality due to the extension of the biopsy policy to older and asymptomatic patients, membranoproliferative glomerulonephritis type I shows a countercurrent decrease from 0.43 to 0.13/yr/10(5) population. Evidence of a simultaneous decrease in severe cardiac valvulopathy, due to rheumatic fever, is also provided. We feel that before epidemiologic conclusions can be reached, a clear understanding of one's own biopsy policy is essential. An apparent change in the PGN rate in our region over the last 25 years mainly depends on modifications in our biopsy policy, most probably coupled with a change in the threshold of detection of symptoms in the general population. At present, according to our experience, IgA-GN is the most common type of PGN in the total bioptic material, as demonstrated in other European countries, while the elderly show a peculiar pattern with a higher PGN incidence, mainly represented by MGN and heralded by the nephrotic syndrome. We also confirm that membranoproliferative glomerulonephritis type I is indeed decreasing in parallel with changes in the microbiologic environment.