International J.

of Healthcare and Biomedical Research, Volume: 2, Issue: 3 , April 2014 , Pages 53-59

Original article :

Profile of renal biopsies in a tertiary care hospital

Sunita Singh , Nisha Marwah, Rajeev Sen , Monika Sangwan , Renuka Verma , Megha Ralli

Department of Pathology,
Pt. B.D. Sharma PGIMS Rohtak, Haryana , India
Corresponding author : Dr Megha Ralli
Abstract:
Background: Renal biopsy is an invaluable method used in evaluation of patient with renal disease. Light microscopy and
immunofluorescence findings make it possible to establish accurate diagnosis, get information on evaluation and prognosis of
disease process and develop approach in treatment of renal disorders.We in this study tried to evaluate the profile of renal
biopsies received in a year and correlated the findings of routine microscopy to immunofluorescence (IF) staining.
Material and method: We retrospectively studied 75 consecutive kidney biopsies received from January 2012 to December 2012
at Pt. BD Sharma, PGIMS, Rohtak. H&E and special stained sections were examined and findings were correlated with
immunofluorescence staining.
Results: The study included 75 cases. Male : female- 1.3:1 ranging from age group 15- 76 years with maximum number of cases
belonging to second to third decade. The cases were categorized into 5 groups: [1]. Primary Glomerulonephritis- 61.3% (46/75).
[2]. Secondary Glomerulonephritis- 16% (12/75). [3]. Vascular and tubulointerstitial disease- 1.3% (1/75). [4]. End stage renal
disease-4% (3/75). [5]. Inadequate-17.4% (13/75). The largest group comprises of primary glomerulonephritis with membranous
glomerulonephritis being the most common (32.6% - 15/46). This was followed by secondary glomerulonephritis group with
lupus nephritis (58.4% - 7/12) being the most common cause.
Conclusion: Renal biopsy and IF appears to be an important tool for diagnosing glomerular diseases. Immunofluorescence helped
in making diagnosis where light microscopy findings were equivocal and it also helps in understanding immunological
mechanisms involved in various renal lesions. Hence it is less time consuming and effective method in diagnosing glomerular
diseases on renal biopsies.
Key words: kidney biopsy, immunoflorescence, glomerular lesions.

INTRODUCTION: responsible for glomerular injury in most cases of

Renal diseases constitute one of the major causes of
1
morbidity and mortality. Renal biopsy is
invaluable method used in evaluation of patient with
renal disease. It is useful for identifying the specific
diagnosis, assessing the level of disease activity, and
for allowing specific decisions about treatment to be
2
made. A review of renal biopsy data can give some
insight into the spectrum of clinically significant
renal disease and basic epidemiological data on renal
3
disease in the community. Immune mechanisms are
primary glomerulonephritis (GN) and many of the
an secondary GN. Correct diagnosis of glome-
rulonephritis requires renal biopsy and histopa-
thological examination by light, immunofluorescence
and electron microscopic examination. Facilities for
electron microscopic study is not readily available in
many institutions. In most cases light microscopy
(LM) and direct immunofluorescence (DIF) study are
more than enough for definitive diagnosis of
glomerulonephritis.4 Patients with immune complex

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deposits can be treated very easily with steroid or
immunosuppressant. Hence DIF helps in better
treatment of patients. We in this study tried to
evaluate the profile of renal biopsies received in a
year and correlated the findings of
microscopy to immunofluorescence (IF) staining.
MATERIAL AND METHOD:
We retrospectively studied 75 consecutive kidney
biopsies received from January 2012 to December
2012 in department of Pathology at Pt. BD Sharma,
PGIMS, Rohtak. H&E and special stained sections
were examined and findings were correlated with
immunofluorescence staining.
Samples from nephrectomy and mass biopsy were
excluded. Only percutaneous needle biopsies with
two core of renal biopsies obtained for each patient
were considered. Biopsy specimens
examination were fixed in 10% formalin. Sections
were cut at 2- 3 µm thickness from paraffin
embedded material and stained routinely with
haematoxylin and eosin (H&E), periodic acid schiff
(PAS) stain, and silver stain. Specimens for DIF
microscopy were received in normal saline and
immediately frozen and embedded in O. C. T.
routine (Optimal Cutting Temperature) compound. Cryose-
ctioning at 4-5 µm thickness was done and mounted
on glass slides. The slides were air dried and washed
in phosphate buffer saline (PBS, pH 7.2) and again
air dried. The sections were then stained with
fluorescence conjugated anti-sera against human
IgM, IgG, IgA, C3 and fibrinogen, and stored in cool
dark place until review.1
For light microscopy 6-10 glomeruli were considered
adequate for evaluation. For immunofluorescence
(IF) biopsy containing >5 glomeruli was adequate.
RESULTS:
for LM Seventy five cases were included over a year time.
Age group ranges from 15- 76 years with maximum
number of cases belonging to second to third decade.
Male to female ratio was 1.3:1.

Table 1: Distribution of total 75 cases:

GLOMERULAR DISEASES NO. OF BIOPSIES PERCENTAGE
Primary glomerulonephritis 46 61.3
Secondary glomerulonephritis 12 16
Vascular and tubulointerstitial 1 1.3
disease
End stage renal disease 3 4
Inadequate 13 17.4
TOTAL 75 100

Adequacy rate was 82.6% for diagnosis.

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Table 2: Distribution of total cases:

GLOMERULAR DISEASES NO. OF CASES PERCENTAGE(%)

PRIMARY GLOMERULONEPHRITIS
Minimal change disease 5 8.6
FSGS 4 6.8
Membranous GN 15 25.8
Mesangiocapillary GN 10 17.2
Mesangioproliferative GN 4 6.8
IgA Nephropathy 3 5.2
Crescentic GN 5 8.6
SECONDARY GLOMERULONEPHRITIS

Lupus Nephrits 7 12.1

Amyloidosis 4 6.8
Diabetic nephropathy 1 1.7

TOTAL 58

FSGS: Focal segmental glomerulosclerosis, GN: Glomerulonephritis.

Table 3: Distribution according to immunoflorescence deposits in glomerulonephritis.
GLOMERULAR IgA IgG IgM C3 Fibrinogen
DISEASES
Minimal change 1
disease (5)
FSGS (4) 1 3 4
Membranous GN (15) 15 5 11 15
Mesangiocapillary 1 10 9 9 10
GN (10)
Mesangioproliferative 3 4 3
GN (4)
IgA Nephropathy (3) 3 1 2 2
Crescentic GN (5) 2 3 5
Lupus Nephrits (7) 7 7 7 7 7
Diabetes (1) 1

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Membranous glomerulopathy was found to be most with female predominance. The IF findings revealed
common cause of primary glomerular diseases intense irregular granular deposits of C3 and IgG
(25.9%) followed by mesangiocapillary glomer- along capillaries with weak positivity of fibrinogen in
ulonephritis (17.3%). Amongst the secondary some.
glomerular diseases, lupus nephritis was most It has been proved that IF gives invaluable
common (12.1%) followed by amyloidosis (6.9%). information in cases where there are minimal changes
Fifteen cases of membranous glomerulonephritis on light microscopy. Membranous glomer-
were reported in which IF revealed diffuse granular ulonephritis (MGN) stage-1 shows no thickening of
IgG deposits along the capillary walls in membranous the glomerular basement membrane (GBM) and no
fashion. Seventy three percent cases (11/15) also spikes on silver stain and may not be distinguished
showed granular capillary wall deposits of C3. from minimal change disease (MCD).8 In our study
Seven cases of lupus nephritis were included in the minimal change disease was observed in 6.6% cases
study which involved 2 males and 5 females. The IF with male: female ratio of 1.5:1. Immunoflorescence
showed full house pattern in all cases with diffuse staining for immunoglobulin and complement is not
strong IgG positivity in glomerular capillary loops seen in minimal change disease but in our study faint
and mesangium. Also granular deposits of IgM, IgA , positivity of IgM in the mesangium was observed in
C3 and Fibrinogen seen in glomerular capillary walls one of the cases. IgA nephropathy was observed in
and mesangium. 5.2% cases. The IF findings revealed mesangial
DISCUSSION deposits of IgA in all three cases along with IgM and
Since glomerulonephritis are immunologically C3 mesangial deposits in two cases. There is no
mediated, immunofluorescence microscopy is best single histopathological finding characteristic of IgA
alternative for diagnosis of glomerular diseases. Yet, nephropathy and mesangial proliferation may be
combined analysis of light microscopy and DIF observed in variety of glomerular lesions. Similarly,
findings are essential for accurate diagnosis.In our IgA nephropathy may also show diffuse
study of 75 cases, glomerular diseases were found to endocapillary proliferation, segmental sclerosis,
be more common in males than in females with membranoproliferative glomerulonephritis or
maximum number of patients (57.3%) lying in age crescents formation. Hence, confirmation by
group 15-35 years. Membranous glomerulonephritis immunoflorescence is required in such cases. FSGS
was found to be the most common pathology and was was observed in 6.9% cases. The IF findings revealed
almost evenly distributed among patients of age focal deposits of IgM and C3 in most of the cases.
group 15-35 (23.3%) and 36-55 years (20.8%). This Crescentric glomerulonephritis was observed in 8.6%
was consistent with report from Western region of cases. The different diagnostic categories of
Saudi Arabia, Pakistan, Iran.5,6,7 The IF findings crescentric GN include pauci- immune GN, anti-
revealed granular deposits of IgG along glomerular GBM nephritis and immune complex mediated GN,
capillaries in a diffuse pattern along with C3 in many distinguished from one another by immune-
cases. Mesangiocapillary GN was found to be second flourescence and electron microscopic study of the
most common cause of primary glomerular diseases biopsy. The IF findings in our cases revealed linear
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deposits of IgG and C3 in glomerular basement interstitial fibrosis. IF was faintly positive for IgG in
membrane in two cases pointing towards Good sclerotic segment of the biopsy.
Pasteur’s syndrome and granular deposits of IgM and CONCLUSION:
C3 in three cases pointing towards RPGN type II of Renal biopsy and IF appears to be an important tool
most probably post- infectious etiology. Fibrinogen for diagnosing glomerular diseases. Immuno-
positivity in crescents was observed in all cases. fluorescence helped in making diagnosis where light
Hence, IF is important in further categorization of microscopy findings were equivocal and it also helps
RPGN. in understanding immunological mechanisms
Lupus nephritis was commonest of the secondary involved in various renal lesions. Hence it is less time
glomerular diseases (12.1%) and contributing to consuming and effective method in diagnosing
9.3% of the total biopsies. These findings were glomerular diseases on renal biopsies.
9
similar to those observed by Moorani et al. The age
group distribution of lupus nephritis in our study was
from 20- 50 years was in accordance with age
observed by Shawarby et al.10 The IF study in these
cases helped to place the biopsies in different classes
according to WHO classification.Amyloidosis
contributed to 5.3% of total renal biopsies. On light
Figure 1a: Section showing diffuse thickening of
microscopy, the biopsies show homogenous
glomerular capillary wall consistent with
eosinophilic mesangial and capillary loop deposits
membranous glomerulonephritis (H&E, 40X)
which was congo red positive revealing apple green
Figure 1b: Section showing glomeruli with mesangial
birefringence on polarizing microscopy. IF for
cellular proliferation and increase in mesangial
immunoglobulins and complement was inconclusive
matrix consistent with mesangiocapillary/
but in institutions with kappa and lambda light chain
membranoproliferative glomerulonephritis (MPGN)
markers IF plays a definite role even if congo red is
(H&E, 20X)
non contributory. Anti-Ig light chains (k or λ) are
useful for amyloid AL diagnosis and differentiating
from AA type.
Diabetic glomerulosclerosis accounted for 1.7% of
the glomerular diseases. On light microscopy, the
characteristic nodular lesions Kimmelstiel- Wilson
lesions were observed. The IF studies revealed linear
staining for IgG along GBM. End stage renal disease Figure 2a: Section showing sclerosis of few lobules

contributed to 4% of the spectrum of renal biopsies in in the tuft consistent with focal segmental

our institute. Light microscopy revealed global glomerulosclerosis (FSGS) (PAS, 40X)

glomerular sclerosis with tubular atrophy and Figure 2b: Section showing focal and segmental
proliferation of mesangial cells and endothelial cells
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consistent with mesangioproliferative glomeru-

lonephritis (PAS, 40X)

Figure 4a: Kidney biopsy section showing athero-

sclerosis in renal vessel along with cholesterol clefts
Figure 3a: Kidney biopsy showing crescent formation
(PAS, 40X).
on inside of bowman’s capsule consistent with
Figure 4b: Kidney biopsy section showing tubule
rapidly progressive glomerulonephritis (PAS, 20X).
necrosis (H&E, 10X).
Figure 3b: Section showing ‘wire loop’ lesions due to
diffuse thickening of glomerular capillary wall
consistent with lupus nephritis (PAS, 20X).

Figure 5a: C3, IgG and IgM deposits, being those of

C3 more frequent and constant. Deposits are granular
in the capillary walls consistent with MPGN Type1.
Figure 5b: Deposits of C3 along capillary walls
consistent with MPGN type 2.
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Date of submission: 02 January 2014, Date of provisional acceptance:07 Feb 2013

Date of Final acceptance: 22 March 2014 Date of Publication: 07 April 2014
Source of support: Nil; Conflict of interest: Nil

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