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      Infection-related glomerulonephritis is the most common finding in renal biopsies in the very elderly in India

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          Abstract

          Renal disease in the very elderly (≥80 years of age) is often considered the result of ageing and comorbid conditions, including hypertension and diabetes mellitus. There is reluctance to perform renal biopsies in very elderly patients. However, a significant proportion of patients in this age group have potentially reversible renal disease. A number of previous studies analysed findings from renal biopsies in elderly patients (≥60 years of age) [1–4]. However, only a few studies have focused on very elderly patients [5, 6]. To our knowledge, this is the first Indian study analysing the spectrum of renal biopsy findings in this demographic subset. We also compared our findings with those obtained in a western population. We retrospectively examined our records from August 2013 to October 2018 to retrieve data on native kidney biopsies performed in very elderly patients. Of a total of 16 641 patients, there were 48 (0.29%) very elderly patients who underwent native kidney biopsies during this time period. The mean age was 82.17 years (range 80–89) and the male:female ratio was 2.7:1. The most common indication for renal biopsy in this age group was acute nephritic syndrome, followed by acute kidney injury (AKI) and rapidly progressive renal failure (RPRF). The most common diagnosis obtained from the renal biopsies was infection-related glomerulonephritis (IRGN), which was diagnosed in 13 patients (27.1%). The diagnoses in the remaining 35 patients (expressed as a percentage of the total of 48 patients) included minimal change disease (14.6%), membranous nephropathy (8.4%), amyloidosis (6.3%), pauci-immune crescentic glomerulonephritis (2.1%), immunoglobulin A (IgA) nephropathy (2.1%), membranoproliferative pattern of glomerular injury (2.1%), acute tubular injury (18.8%), acute interstitial nephritis (4.2%), light chain cast nephropathy (4.2%), light chain proximal tubulopathy (2.1%), light chain cast nephropathy with light chain proximal tubulopathy (2.1%), hypertensive nephrosclerosis (2.1%), diabetic glomerulosclerosis (2.1%) and acute pyelonephritis (2.1%). Five patients diagnosed with IRGN presented with nephritic syndrome, five patients with RPRF, two patients with nephrotic syndrome and one patient with AKI (Table 1). Of these 13 patients with IRGN, crescents were identified in 7 patients. Two of three patients diagnosed with amyloid light chain (AL) amyloidosis presented with nephrotic syndrome and one with chronic kidney disease. In all three patients, underlying plasma cell dyscrasia was not clinically suspected. One patient was diagnosed with IgA nephropathy who presented with massive proteinuria. Table 1. Renal biopsy findings in a very elderly Indian population compared with a corresponding Western population Clinical presentation Diagnosis Our study (N = 48), n (%) Nair et al. [6] (N = 100), n (%) Nephrotic syndrome 16 (33.3) 33 (33) Minimal change disease 7 (43.8) 6 (18.2) Focal segmental glomerulosclerosis 0 5 (15.2) Membranous nephropathy 4 (25) 2 (6.1) IRGN 2 (12.5) 0 Amyloidosis 2 (12.5) 3 (9.1) Benign nephrosclerosis 0 14 (42.4) Diabetic nephropathy 0 1 (3) IgA nephropathy 1 (6.2) 1 (3) Other 0 1 (3) RPRF 9 (18.8) 6 (6) IRGN 5 (55.6) 0 Acute tubular injury 2 (22.2) 0 Pauci-immune crescentic GN 1 (11.1) 2 (33.2) Crescentic GN, anti-GBM disease 0 1 (16.7) Light chain cast nephropathy 1 (11.1) 1 (16.7) Focal segmental glomerulosclerosis 0 1 (16.7) Crescentic GN, amyloidosis 0 1 (16.7) Acute nephritic syndrome 6 (12.5) 20 (20) IRGN 5 (83.3) 0 Membranoproliferative pattern of glomerular injury 1 (16.7) 1 (5) Crescentic GN, anti-GBM disease 0 1 (5) Crescentic GN, pauci-immune 0 12 (60) Granulomatous vasculitis 0 1 (5) IgA nephropathy 0 2 (10) Cryoglobulinaemia, type I 0 1 (5) Cholesterol emboli 0 1 (5) Non-specific changes/other 0 1 (5) AKI 14 (29.2) 23 (23) Acute tubular injury 7 (50) 2 (8.7) Acute tubulointerstitial nephritis 2 (14.3) 0 Acute interstitial nephritis 0 5 (21.7) IRGN 1 (7.1) 0 Acute pyelonephritis 1 (7.1) 0 Light chain cast nephropathy 1 (7.1) 3 (13) Light chain proximal tubulopathy 1 (7.1) 0 Light chain cast nephropathy with light chain proximal tubulopathy 1 (7.1) 0 Light chain deposition disease 0 1 (4.4) Benign nephrosclerosis 0 5 (21.7) Diabetic nephropathy 0 2 (8.7) Crescentic GN, pauci-immune 0 2 (8.7) Cholesterol emboli 0 1 (4.4) IgA nephropathy 0 2 (8.7) Chronic kidney disease 2 (4.2) 17 (17) Diabetic nephropathy 1 (50) 1 (6) Amyloidosis 1 (50) 0 Benign nephrosclerosis 0 15 (88) Focal segmental glomerulosclerosis 0 1 (6) Asymptomatic urinary abnormalities 1 (2.1) 1 (1) Hypertensive arterionephrosclerosis 1 (100) 1 (100) Figures in bold indicate the total number of cases under each clinical presentation. GBM, glomerular basement membrane; GN, glomerulonephritis. One of the 48 patients developed perirenal haematoma that was managed medically. No major complications occurred in the remaining 47 patients. Further, 77.1% of our patients had a histopathological diagnosis that could potentially alter their treatment (Table 1). Even in the remaining 22.9% of patients, renal biopsy helped in prognostication and also in avoiding the use of potentially harmful empirical treatment. The distribution of renal diseases in the very elderly Indian population is markedly different from that in Western populations (Table 1). In our study, minimal change disease was the most common cause of nephrotic syndrome, compared with benign nephrosclerosis as reported by Nair et al. [6] (Table 1). Our study also showed IRGN was the most common cause of acute nephritic syndrome, whereas only one patient had IRGN in the study by Nair et al. [6]. There has been a recent shift in age predominance in patients with IRGN [7]. In Nair et al.’s study, 34% of adults with IRGN were elderly [8], compared with <6% reported about four decades ago [9]. The spectrum of renal diseases in the very elderly Indian population is distinct, and IRGN was the most common diagnosis found here. Our study confirms that histopathological analyses help in the choice of appropriate treatment, as well as in estimating prognosis in very elderly patients. There were no major biopsy related complications in our series. CONFLICT OF INTEREST STATEMENT None declared.

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          Most cited references 9

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

           E Wit,  B H Spargo,  C Haas (2000)
          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.
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            Renal biopsy in the very elderly.

            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.
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              Renal biopsy in patients aged 80 years and older.

              Renal abnormalities discovered in the elderly have often been considered the result of aging, hypertensive changes, and so on. Recently, we noted an increase in renal biopsies among patients 80 years and older. This is a demographic subset with little or no previously reported clinicopathologic correlation between renal biopsy findings and clinical syndromes.
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                Author and article information

                Journal
                Clin Kidney J
                Clin Kidney J
                ckj
                Clinical Kidney Journal
                Oxford University Press
                2048-8505
                2048-8513
                January 2021
                04 December 2019
                04 December 2019
                : 14
                : 1
                : 454-456
                Affiliations
                [1 ] Renopath, Center for Renal and Urological Pathology , Chennai, India
                [2 ] Department of Nephrology, Madras Medical College , Chennai, India
                Author notes
                Correspondence to: Anila A. Kurien; E-mail: anila_abraham08@ 123456yahoo.com
                Article
                sfz162
                10.1093/ckj/sfz162
                7857827
                © The Author(s) 2019. Published by Oxford University Press on behalf of ERA-EDTA.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com

                Page count
                Pages: 3
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                Categories
                Letters to the Editor
                AcademicSubjects/MED00340

                Nephrology

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