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Clinical Syndrome. AKI; acute kidney injury, ANS; acute nephritic syndrome, AUA; abnormal urinary analysis, CRF; chronic renal failure, NS; nephrotic syndrome, RPRF; rapidly progressive renal failure
Source publication
Nondiabetic renal disease (NDRD) is seen as a cause of proteinuria and renal failure in type 2 diabetes mellitus (DM). The clinical differences between NDRD and diabetic glomerulosclerosis (DGS) are not clear. This study was done to find the spectrum of NDRD in type 2 DM patients and differences in clinical profile between NDRD and DGS patients. Da...
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Citations
... Similar findings were reported in few other studies too. [13][14][15][16] The common NDKD in patients with DM were acute tubulointerstitial disease (ATIN) followed by MN, FSGS and IgAN, which is of not much different from few other studies. 17 The most common glomerular disease found in this study was lupus nephritis (20%) followed by IgA Nephropathy (18%). ...
Background: Kidney biopsy has been regarded as an important tool for the diagnosis, management and monitoring the prognosis of renal diseases. We conducted this study to find out the clinico-pathological spectrum by native kidney biopsy in a relatively large scale. Methods: This was a hospital based, prospective, observational study carried out in a tertiary hospital of Kathmandu from January 2022 to December 2023. The biopsy specimens were reported by nephropathologists on the basis of light microscopy, direct immunofluorescence for all samples and electron microscopic examination whenever indicated. The patient`s demographic profile, indication and histological findings of kidney biopsy were studied and analyzed using appropriate statistical tools. Results: A total of 610 kidney biopsies were performed during the study period, of which 24 samples did not meet the inclusion criteria and 586 patients were included in the final analysis. The mean age of the patients was 42.08 ±9.09 years and 59.03% of the patients were younger than 40 years. Females outnumbered the males with female to male ratio of 1.09. The most common presentation was limb swelling (81.22%) and nephrotic syndrome was the most common indication for the biopsy and the most common histological finding was lupus nephritis, followed by IgA nephropathy and FSGS. Non-diabetic kidney disease was found in 54.28% of diabetic patients who underwent biopsy. Conclusions: Nephrotic syndrome was the most common indication for kidney biopsy with lupus nephritis being the most common histological finding. Non diabetic kidney disease (NDKD) was found in more than half of the patients with diabetes mellitus.
... acute kidney injury 6(9.1%) and acute nephritic syndrome 3(4.5%). Similarly, other studies also reported the heterogeneous presentation of kidney disease in diabetes [16,17]. DN predominantly presents with either nephrotic syndrome or chronic kidney disease; while NDKD tends to present predominantly with acute kidney injury or acute nephritic syndrome [18]. ...
... It is important to identify the clinical indicators helpful in the clinical diagnosis of DN vs. NDKD, in performing the kidney biopsy to make a correct diagnosis. Multiple clinical factors like the duration of diabetes, features of DR, and level of proteinuria are used to differentiate DN from NDKD [13][14][15][16][17][18][19][20]. Classically long duration of diabetes (>10 years), presence of DR, and severe proteinuria strongly suggest DKD [25][26][27]. ...
Unlabelled:
The heterogeneous spectrum of kidney disease in diabetes ranges from albuminuric or non-albuminuric diabetic kidney disease to non-diabetic kidney diseases. Presumptive clinical diagnosis of diabetic kidney disease may lead to an erroneous diagnosis.
Material and method:
We analyzed the clinical profile and kidney biopsy of a total of 66 type 2 diabetes patients. Based on kidney histology, they were divided into-Class I (Diabetic Nephropathy), Class II (Non-diabetic kidney disease), and Class III (Mixed lesion). Demographic data, clinical presentation, and laboratory values were collected and analyzed. This study tried to examine the heterogeneity in kidney disease, its clinical indicator, and the role of kidney biopsy in the diagnosis of kidney disease in diabetes.
Results:
Class I consisted of 36(54.5%), class II 17(25.8%), and class III 13(19.7%) patients. The commonest clinical presentation was nephrotic syndrome 33(50%) followed by chronic kidney disease 16(24.4%) and asymptomatic urinary abnormality 8(12.1%). Diabetic retinopathy (DR) was present in 27(41%) cases. DR was significantly higher in the class I patients (p < 0.05). Specificity and positive predictive values of DR for DN were 0.83 and 0.81, respectively (sensitivity 0.61; negative predictive values 0.64). The Association of the duration of diabetes and the level of proteinuria with DN was statistically not significant (p > 0.05). Idiopathic MN (6) and Amyloidosis (2) were the most common isolated NDKD; whereas diffuse proliferative glomerulonephritis (DPGN) (7) was the commonest NDKD in mixed disease. Another common form of NDKD in mixed disease was Thrombotic Microangiopathy (2) and IgA nephropathy (2). NDKD was observed in 5(18.5%) cases in presence of DR. We noted biopsy-proven DN even in 14(35.9%) cases without DR, in 4(50%) cases with microalbuminuria and 14(38.9%) cases with a short duration of diabetes.
Conclusion:
Almost half (45%) of cases with atypical presentation have non-diabetic kidney disease (NDKD), though even among these cases with atypical presentation diabetic nephropathy (either alone or in mixed form) is commonly seen in 74.2% of cases. DN has been seen in a subset of cases without DR, with microalbuminuria, and with a short duration of diabetes. Clinical indicators were insensitive in distinguishing DN Vs NDKD. Hence, a kidney biopsy may be a potential tool for the accurate diagnosis of kidney disease.
... In most of the previous studies, the investigators have found difference in certain parameters between DKD and NDKD, but they have mostly not tested the same in the logistic regression model. [19][20][21] In few studies (retrospective studies of targeted renal biopsies), regression analysis was performed, 22 23 and some even came up with equations 24 25 to predict probability of either DKD or NDKD. However, it is important to appreciate that these equations were of little use for decision making at individual patient level in day-to-day clinical practice. ...
Introduction
Renal involvement in type 2 diabetes mellitus (T2DM) may be due to diabetes (diabetic kidney disease (DKD)), causes other than diabetes (non-diabetic kidney disease (NDKD)) or overlap of DKD and NDKD (mixed kidney disease group). Prevalence of NDKD and predictive value of clinical or biochemical indicators have been explored in retrospective cohorts with preselection biases warranting the need for prospectively conducted unbiased renal biopsy study.
Research design and methods
Consecutive subjects aged >18 years with T2DM and renal involvement with estimated glomerular filtration rate of 30–60 mL/min/m ² and/or albumin:creatinine ratio of >300 mg/g were offered renal biopsy. Prevalence of DKD, NDKD and mixed kidney disease was documented. Clinical/laboratory parameters of subjects were recorded and compared between groups and were tested for ability to predict histopathological diagnosis.
Results
We screened 6247 subjects with T2DM of which 869 fulfilled inclusion criteria for biopsy. Of the 869 subjects, biopsy was feasible in 818 subjects. Out of 818, we recruited first 110 subjects who agreed to undergo renal biopsy. Among those 110 subjects, 73 (66.4%) had DKD; 20 (18.2 %) had NDKD; and 17 (15.4 %) had mixed kidney disease. Subjects with NDKD as compared with DKD had shorter duration of diabetes (p<0.001), absence of retinopathy (p<0.001) and absence of neuropathy (p<0.001). Logistic regression revealed that only presence of retinopathy and duration of diabetes were statistically significant to predict histopathological diagnosis of DKD. 30% of DKD did not have retinopathy, thereby limiting the utility of the same as a discriminator. Use of traditional indicators of biopsy would have indicated a need for renal biopsy in 87.2% of subjects, though 64.5% of the subjects had DKD, who would not have benefitted from biopsy.
Conclusion
NDKD and mixed kidney disease in T2DM with renal involvement are very common and traditionally used parameters to select biopsies are of limited value in clinical decision making.
... Diabetic kidney disease (DKD) occurs in 30-40% of diabetic patients of more than 10 years duration [1]. However, 45-80% of diabetics with kidney involvement undergoing kidney biopsy are diagnosed to have non-diabetic kidney disease (NDKD) [2][3][4][5][6][7][8][9][10][11]. There are certain proven clinical predictors of NDKD, which, when present in appropriate clinical settings, would warrant a kidney biopsy. ...
... (3) Absence of hypertension [3,7] Proteinuria (>1 g) or renal dysfunction without hypertension (4) Nephrotic range proteinuria [5] Sudden onset of NRP NRP with marked hypoalbuminemia NRP with elevated serum anti PLA2R antibody titers (5) Renal dysfunction [4] Decline in eGFR by >10ml/min/1.73 m²/year Renal dysfunction without proteinuria (suspicion of renal artery stenosis) (6) Glycemic control [2] Progression of proteinuria or rapid decline in eGFR despite aggressive glycemic control (7) Nephritic syndrome [5,[8][9][10] Glomerular hematuria, acanthocytes, and/or red blood cell casts ...
The diagnosis of non-diabetic kidney disease (NDKD) in a diabetic patient has significant therapeutic and prognostic implications. There are certain proven clinical predictors of NDKD, which, when present in an appropriate clinical setting, would warrant a kidney biopsy. Herein, we describe four cases of NDKD diagnosed in rather unusual clinical settings, which add to the list of clinical predictors of NDKD. The first case was a "parainfectious glomerulonephritis" diagnosed in a 50-year-old diabetic woman who presented with persistent renal dysfunction despite successful treatment of urinary tract infection. The second case was "membranous nephropathy" diagnosed in a 43-year-old man with long-standing type 1 diabetes, which was associated with other microvascular complications. In this case, the only predictor was disproportionately low serum albumin. The third case was "amyloid light chain (AL) amyloidosis" diagnosed in an elderly diabetic who presented with progressive anasarca over six months. In this case, the only clinical predictor was a disassociation observed between urine dipstick and 24-hour protein estimation. In the fourth case, an elderly diabetic woman without underlying diabetic retinopathy presented with sudden onset nephrotic syndrome. A kidney biopsy was suggestive of diffuse nodular glomerulosclerosis. Immunofluorescence and electron microscopic evaluation were diagnostic of "gamma heavy chain deposition disease." In all four cases, diagnosis of NDKD led to major therapeutic changes and attainment of renal remission. We have extensively reviewed all major biopsy cohorts of NDKD and have formulated an approach to the diagnosis of NDKD.
... Categories of NDKD in the mixed lesion were DPGN (6), followed by thrombotic microangiopathy (TMA) (2), pauci-immune glomerulonephritis (GN), and vasculitis in one case each (Table 2). Of 11 diabetes patients with CKD; six (54.4%) had isolated DN, isolated in patients with T2DM is variable and ranges from 11.9 24 to 30%. 25 However, in other studies IgA nephropathy, 18,26 focal segmental glomerulosclerosis, 7,8 and minimal change disease 20 were the common NDKD. Hence, variation in prevalence and type of NDKD in diabetes is considerably high. ...
... 6 However, in other studies also most frequent clinical presentations of diabetic patients with NDKD were NS, rapidly progressive renal failure, and AKI. 20 Our observation with regards to clinical presentation is corresponding with the majority of the published studies. 1,9 The decision for renal biopsy in proteinuric T2DM patients has not been defined and a decision is usually individualized. ...
Background:
Diabetic nephropathy (DN) is an important and catastrophic complication of diabetes mellitus (DM). Kidney disease has heterogeneity in histology in diabetes patients and includes both diabetic kidney disease (DKD) (albuminuric or nonalbuminuric) and nondiabetic kidney disease (NDKD) either in isolation or in coexistence with DN. Diabetic nephropathy is hard to overturn. While NDKD is treatable and reversible.
Materials and methods:
We enrolled a total of 50 type 2 diabetes mellitus (T2DM) patients with clinical kidney disease, of both genders and age >18 years, who underwent kidney biopsy from October 2016 to October 2018. Patients with proteinuria <30 mg per day were excluded from the study. The indications of the renal biopsy were nephrotic syndrome (NS), active urinary sediment, rapid decline in renal function, asymptomatic proteinuria, and hematuria.
Result:
A total of 50 (males: 42 and females: eight) patients with T2DM who underwent kidney biopsy were enrolled. The clinical presentation was: NS 26 (52%), chronic kidney disease (CKD) 11 (22%), asymptomatic proteinuria and hematuria six (12%), acute kidney injury (AKI) four (8%), and acute nephritic syndrome (ANS) three (6%). Diabetic retinopathy (DR) was noted in 19 (38%) cases. Kidney biopsy revealed isolated DN, isolated NDKD, and NDKD superimposed on DN in 26 (52%), 14 (28%), and 10 (20%) cases, respectively. Idiopathic membranous nephropathy (MN) (4) and amyloidosis (2) were the most common forms of NDKD, whereas diffuse proliferative glomerulonephritis (DPGN) was the main form of NDKD superimposed on DN. Diabetic nephropathy was observed in 15 (79%) cases in presence of DR and also in 11 (35.5%) cases even in absence of DR. Of eight patients with microalbuminuria four (50%) cases have biopsy-proven DN.
Conclusion:
About 48% of patients had NDKD either in isolation or in coexistence with DN. Diabetic nephropathy was found in absence of DR and in patients with a low level of proteinuria. The level of proteinuria and presence of DR does not help to distinguish DN vs NDKD. Hence, renal biopsy may be useful in selected T2DM patients with clinical kidney disease to diagnose NDKD.
... Around 20%-40% of patients with DM develop DKD [2]. However, there are a substantial number of diabetic patients who are diagnosed with non-diabetic kidney disease (NDKD), reaching as high as 64%-85% in some studies of biopsied patients [3][4][5][6][7][8][9][10][11]. The diagnosis of DKD in a bulk of the patients remains clinical and invasive tests like renal biopsy are usually reserved for atypical cases. ...
Introduction:
Diabetic kidney disease (DKD) is the commonest cause of chronic kidney disease and end-stage kidney disease worldwide, consequently it has become an important productive implication to the healthcare system. This study was conducted to assess the prevalence of non-DKD (NDKD) in diabetic patients from south India.
Objective:
To assess the prevalence of NDKD in type 2 diabetes mellitus patients presenting to a tertiary care hospital from south India and also to analyze clinical clues to establish a diagnosis of NDKD.
Patient and methods:
It is a retrospective observational study of analyzing patient characteristics and renal biopsies. All Diabetic patients with a clinical suspicion of non-diabetic kidney disease who underwent renal biopsy during the study period between January 2012 and June 2017 were included. Based on the biopsy findings, the patients were classified into three groups (isolated diabetic nephropathy, isolated NDKD, and NDKD with underlying diabetic nephropathy) and patients' characteristics were compared between the groups for analysis.
Results:
A total of 236 renal biopsies were analyzed for the study. Of that, 114 had features of DKD, 78 NDKD with diabetic nephropathy (DN) and 44 had isolated NDKD. Acute interstitial nephritis was the most common cause of NDKD.
Conclusion:
From the current study, the long duration of diabetes mellitus beyond five years and hypertension beyond two years reasonably predict DKD.
... Nondiabetic renal disease (NDRD) comprises a heterogeneous group and is known to be present in diabetic patients with variable prevalence reported in different studies. [8][9][10][11][12][13] Multiple studies have suggested that NDRD has a better prognosis than classic DN but this information can only be fruitful if it is timely diagnosed. [14][15][16] Most patients with T2DM are not formally evaluated with a renal biopsy, as it is an invasive procedure. ...
... This result in diagnostic difficulties in the clinical differentiation between DN and NDRD in certain cases. 8,9,21 The correct diagnoses of these diseases have significant influence on the selection of a proper treatment plan. It is difficult to reverse diabetic nephropathy whereas some NDRD's can be readily treated with favourable outcomes. ...
... 20 There is a wide variation of the prevalence of NDRD among type 2 diabetes patients, undergoing renal biopsy, in the published literature. [8][9][10][11][12][13] The reason for this fact is due to the variable renal biopsy policies in different medical setups. We found a total prevalence of NDRD, alone or mixed with diabetic nephropathy, to be 38% in the patients undergoing renal biopsy with a history of type 2 diabetes. ...
Background:
Diabetes mellitus has become a major emerging health concern. Its burden, estimated to be 451 million in 2017, has been projected to rise to 693 million by 2045. This will bring a rise in the prevalence of its associated complications. There is a wide spectrum of non-diabetic renal disease (NDRD) known to be present in diabetic patients with variable prevalence. However, the majority of diabetes mellitus (DM) patients with renal disease are yet not biopsied and the diagnosis of diabetic nephropathy (DN) is presumed on clinical grounds.
Methods:
It is a retrospective cross-sectional study. We selected a total of 126 cases of renal biopsies with a history of type 2 diabetes mellitus. Demographic data was collected from the medical records and pathology reports while all cases were evaluated by reviewing the archived slides.
Results:
Patients were categorized into group 1 with isolated NDRD, group 2 showing NDRD mixed with DN and group 3 with isolated DN. Thirty-four (27%) cases had isolated NDRD (group 1), 14 (11%) had NDRD mixed with DN and 78 (62%) patients had isolated DN. NDRD, either alone or in combination with DN, was found to be present in 48 patients with an overall prevalence of 38%.
Conclusion:
Our study concludes that NDRD is frequent in type 2 diabetes mellitus patients. Renal biopsy remains the key diagnostic tool in such cases, providing crucial information for proper management of the underlying pathology.
... [2] . The prevalence rates of NDRD, DN, and NDRD + DN varied from 24.73% to 82.9%, 6.5% to 66%, and 4% to 44.08%, respectively, in earlier studies [20,21] . The large variations in percentages are due to different indications for doing renal biopsy, geographical and ethnic factors in these patients [8] . ...
... According to published studies, among diabetic patients who had kidney diseases and underwent renal biopsy 34.5-72.7% presented non-DN kidney injuries (7)(8)(9)(10)(11), of which membranous nephropathy (MN) was most frequently seen (24.1-32.2%) followed by minimal change disease (MCD, 6.9-16.7%) ...
Background:
The pathology of diabetic nephropathy (DN) broadly involves the injury of glomeruli, tubulointerstitium and endothelium. Cells from these compartments can release increased numbers of microvesicles (MVs) into urine when stressed or damaged. Currently whether urinary MVs from these three parts can help diagnose DN and reflect pathological features remain unclear.
Methods:
Forty-nine patients with histologically proven DN and 29 proteinuric controls with membranous nephropathy or minimal change disease were enrolled. Urinary podocyte, proximal tubular and endothelial cell-derived MVs were quantified by flow cytometry. Renal glomerular, tubulointerstitial and vascular lesions were semi-quantitatively scored and their relevance to urinary MVs were analyzed.
Results:
DN patients had greater numbers of urinary MVs from podocytes, proximal tubular and endothelial cells compared with proteinuric controls. The combination of podocyte nephrin+ MVs and diabetic retinopathy optimally diagnose DN with 89.7% specificity and 88.9% sensitivity. Moreover, positive correlations were observed between urinary levels of proximal tubular MVs and the severity of tubular injury and between urinary levels of endothelial MVs and the degree of vascular injury. Using urinary proximal tubular MVs as the indicators for tubular injury, the differences between DN patients and proteinuric controls diminished after matching the degree of renal vascular injury or when proteinuria >8 g/24 h.
Conclusions:
Urinary kidney-specific cell-derived MVs might serve as noninvasive biomarkers for the diagnosis of DN in diabetic proteinuric patients. Their elevated levels could reflect corresponding renal pathological lesions, helping physicians look into the heterogeneity of DN.
... disease. 14,15 The average size of the biopsy tissue was 0.9 ± 0.3 cm and the mean number of glomeruli was 23.4 ± 11.0. It is said that the average number of glomeruli needed for the optimal interpretation of kidney biopsy is around ten. 17 More than 200 (95.2%) ...
... Many studies had shown diabetic patients to have non diabetic kidney disease. 15,16 In our study eight (53.4%) of the diabetic patient had non diabetic kidney disease. The most common pattern of non-diabetic kidney disease was MCD two (13.3%), ...
Background Kidney biopsy is an important diagnostic tool in Nephrology. As of now, we don't have a central kidney biopsy registry in our country and there are many studies showing heterogeneous patterns of pathologies observed in the country. We thought of looking on the clinico-pathological profile of kidney biopsy patients prevailing in our centre. Objective This study was carried out with an objective to know the clinico-pathological profile of kidney biopsy patients prevailing in our centre. Method This was a hospital based, prospective, observational study carried out in a tertiary teaching hospital of Chitwan over a period of 3 years from May 2016 to April 2019. All the consecutive kidney biopsy patients were included in the study. The indication of kidney biopsies were the standard indication based on clinical presentation and investigations. The patient`s demographic profile, indication of kidney biopsy and histological patterns were studied and analysed using appropriate statistical tools. Result A total of 210 kidney biopsies were analysed over a period of three years, that makes around 5-6 biopsies per month. The mean age of the patient was 35.7 ± 14.9 years. Male were 106 (50.5) and females were 104 (49.5) with male to female ratio of 1.01. The average number of glomeruli was 23.4 ± 11.0. The commonest indication of kidney biopsy and histological pattern were nephrotic syndrome 56 (26.7) and IgA nephropathy 51 (24.2) respectively. Among nephrotic syndrome group, the commonest histological pattern was minimal change disease 21 (37.5). Non-diabetic kidney diseases in diabetes were seen in eight (53.4) diabetic patients making it a significant problem in diabetes and the commonest histological pattern in them were minimal change disease and idiopathic cresentic glomerulonephritis two (13.3) each. Conclusion The commonest indication and histological pattern of the kidney biopsy were nephrotic syndrome 56 (26.7), and IgA Nephropathy 51 (24.2) respectively. Nondiabetic kidney diseases in diabetes were seen in eight (53.4) of the diabetic patient making it a significant problem in diabetes and the commonest histological pattern in them were minimal change disease and idiopathic cresentic glomerulonephritis two (13.3) each.
