Complications and Risks of Percutaneous Renal Biopsy.

BACKGROUND: Renal biopsy performed in native and transplant kidneys is generally considered a safe procedure. AIM: In this study, we evaluated renal biopsy complications and risk factors in one nephrology facility. MATERIAL AND METHODS: We conducted a three-year retrospective study on patients who underwent renal biopsy between January 2014 and December 2016. Strict written biopsy protocol was followed. Clinical and laboratory data were obtained from medical charts. Complications were categorised as minor and major, according to the need for intervention. Minor complications included macrohematuria and/or hematoma that did not require intervention. Major complications included hematuria or hematoma with fall of hematocrit that required a blood transfusion, surgery or caused death. A binary logistic regression model was used to analyse the possible factors associated with complications after the biopsy. RESULTS: We analysed 345 biopsies; samples were taken from patients aged from 15-81 years, of whom 61% were men. A total of 21 (6%) patients developed a complication, 4.4% minor and 1.7% major complications. There were no nephrectomy or death due to biopsy intervention. Overweight patients, as well as those with higher creatinine, lower hemoglobin, higher blood pressure and biopsy due to AKI had higher chances to develop complications (p = 0.037, p = 0.023, p = 0.032, p = 0.002, p = 0.002, respectively). The patients' age, gender, kidney dimension, number of passes and uninterrupted aspirin therapy were not found as significant predictors of complications. In the multivariate logistic model, body weight (OR = 1.031, 95%CI = 1.002-1.062), lower hemoglobin (OR = 0.973, 95%CI = 0.951-0.996) and hypertension (OR = 1.025, 95%CI = 1.007-1.044) increased the risk of complications in biopsied patients. CONCLUSION: Renal biopsy is a safe procedure with a low risk of complications when strict biopsy protocol is observed. Correction of anaemia and blood pressure is to be considered before the biopsy.

The Spectrum of Histopathological Changes in the Renal Allograft - a 12 Months Protocol Biopsy Study.

INTRODUCTION: Renal transplantation became a routine and successful medical treatment for Chronic Kidney Disease in the last 30 years all over the world. Introduction of Luminex based Single Antigen Beads (SAB) and recent BANFF consensus of histopathological phenotypes of different forms of rejection enables more precise diagnosis and changes the therapeutic approach. The graft biopsies, protocol or cause, indicated, remain a golden diagnostic tool for clinical follow up of kidney transplant recipients (KTR). AIM: The study aimed to analyse the histopathological changes in renal grafts 12 months after the surgery in KTR with satisfactory kidney function. MATERIAL AND METHODS: A 12-month protocol biopsy study was performed in a cohort of 50 Kidney transplant recipients (42 from living and 8 from deceased donors). Usual work-up for suitable donors and recipients, standard surgical procedure, basic principles of peri and postoperative care and follow up were done in all KTR. Sequential quadruple immunosuppression including induction with Anti-thymocyte globulin (ATG) or Interleukin-2R antagonist (IL-2R), and triple drug maintenance therapy with Calcineurin Inhibitors (CNI), Mycophenolate Mofetil (MMF) and Steroids were prescribed to all pts. Different forms of Glomerulonephritis (16), Hypertension (10), End Stage Renal Disease (13), Hereditary Nephropathies (6), Diabetes (3) and Vesicoureteral Reflux (2) were the underlying diseases. All biopsies were performed under ultrasound guidance. The 16 gauge needles with automated "gun" were used to take 2 cores of tissue. The samples were stained with HE, PAS, Trichrome Masson and Silver and reviewed by the same pathologist. A revised and uploaded BANFF 2013 classification in 6 categories (Cat) was used. RESULTS: Out of 48 biopsies, 15 (31%) were considered as normal, 4 (8%), Borderline (BL-Cat 3), 5 (10%) as Interstitial Fibrosis/Tubular Atrophy (IF/TA-Cat 5), 5 (10%) were classified as non-immunological (Cat 6), 2 as a pure antibody-mediated rejection (ABMR-Cat 2) and T-cell Mediated Rejection (TCMR-Cat 4). The remaining 17 samples were classified as a "mixed" rejection: 7 (41%) ABMR + IF/TA, 5 (29%) ABMR + BL + IF/TA, 2 (11%) BL + IF/TA, 1 (5%) ABMR + BL, 1 (5%) ABMR + TCMR and 1 (5%) TCMR + IF/TA. The mean serum creatinine at the time of the biopsy was 126.7 ± 23.4 µmol/L, while GFR-MDRD 63.4 ± 20.7 ml/min, which means that the majority of the findings were subclinical. Among the non-immunological histological findings (Cat 6), 3 cases belonged to CNI toxicity, 1 to BK nephropathy and 1 to recurrence of the primary disease. CONCLUSION: Our 12-month protocol biopsy study revealed the presence of different forms of mixed subclinical rejection. Use of recent BANFF classification and scoring system enables more precise diagnosis and subsequently different approach to the further treatment of the KTR. More correlative long-term studies including Anti HLA antibodies and Endothelial Cell Activation- Associated Transcripts (ENDAT) are needed.

Protocol for performing nephrological activity in the Republic of Macedonia.

The fast development of nephrology in the world, especially in the second half of the 20 th century demanded protocol (guidelines) for nephrological activity for all levels of medical care, of doctors and specialists. The International Society of Nephrology, the European Renal Association and other national associations created their own protocol (guidelines) for nephrological activity. The Macedonian Society of Nephrology, Dialysis, Transplantation and Artificial Organs (MSNDTAO) proclaimed the First Protocol for Performing Nephrological Activity in the Republic of Macedonia at the First Congress of the MSNDTAO, held in Ohrid 1993, and it was published in the Macedonian Medical Review, 1994; Supplement 14: 397-406 [1]. The update of the Protocol for Performing Nephrological Activity in the Republic of Macedonia was proclaimed at the Fourth Congress of MSNDTAO, held in Ohrid 2012 and it presented in this text.

Evaluation of circulating immune complexes and antiphospholipid antibodies (anti beta 2 glycoprotein 1) in heroin addicts and their clinical significance.

INTRODUCTION: Earlier studies have reported that heroin might cause the structural and antigen changes on numerous tissues, organs and subsequent development of autoimmune reactions (production of antibodies and creation of immune complexes) as a result the immunotoxic effect of heroin. The aims of our study were to: a) Evaluate CIC and antibeta2GP1 in heroin addicts; b) Correlate between the values of the obtained CIC and antibeta2GP1 (stratified by the duration and route of heroin application); c) Compare the CIC and antibeta2GP1 in heroin addicts and the control group and d) Assess the clinical importance of CIC and antibeta2GP1 in heroin addicts. PATIENTS AND METHODS: This was a cross-sectional study performed at the University Clinic of Toxicology and the Institute of Transfusiology, Skopje, Republic of Macedonia. Patients referred to the Clinic for clinical examinations who met the inclusion criteria were analyzed. Protocol for work was the following: 1.) detailed anamnestic data, 2.) a whole set of laboratory biochemical blood and urine analyses, 3.) examination with the Schiller's twelve-channel ECG; 4.) toxicological analyses for opioids in a urine sample; circulating immune complexes and 5.) antiphospholipid antibodies (antibeta2GP1, fractions: IgA, IgG, IgM). The obtained results were statistically analyzed. RESULTS: We included 37 heroin addicts and a control group of 27 healthy subjects. Male abusers predominated over female in--28 (76%) subjects; mean age being 26 +/- 5.06. The results which refer to the increased values of circulating immune complexes have shown a high statistically significant dominance of heroin addicts, in comparison with the control group (p < 0.01) and increased values above the reference ones of IgG antibeta2GP1, alone in the group of intravenous heroin abusers (p < 0.025). The mean duration of the heroin use in intravenous abusers was 6.21 +/- 3.25 years, whereas in those snorting heroin was 5.15 +/- 2.26 years. Duration of heroin application was in a positive correlation with IgG antibeta2GP1 (p = 0.35). CONCLUSIONS: Our data showed that heroin-dependent patients in our study had increased values of circulating immune complexes and changes in IgG and IgM antibeta2GP1 with significantly increased values of IgG antibeta2GP1 in the intravenous heroin abusers. The duration of heroin application is in direct proportional relationship with IgG antibeta2GP1. Heroin addicts had significantly higher values of circulating immune complexes and statistically significant difference in IgG antibeta2GP1, in comparison with the control group. Changes in the fractions of antibeta2GP1 and CIC suggest a possible relation with the somatic changes found in heroin addicts (i.e. thrombocytopenia, reduced renal clearance, etc).

The Oxford classification of IgA nephropathy: single centre experience.

The Oxford classification for the pathological classification of a glomerular disease in IgA nephropathy was established and published in 2009. Four of the pathological variables: 1) mesangial hypercellularity score, 2) segmental glomerulosclerosis, 3) endocapillary hypercellularity and 4) tubular atrophy/interstital fibrosis were presented as having value in predicting renal outcome in this glomerular disease. These features were recommended to be taken into account for predicting the outcome. In our study, we correlated these four variables with the outcome of the disease in 40 adult patients with IgA nephropathy. Standard histopathologic procedure was used to determine four variables as 0/1. The results were compared with renal outcome, clinical data were obtained from the out-patient files of the patients. The whole follow-up period was 3-27 years. The average survival of the whole group was 10.8±7.47 years (M±SD). Mesangial hypercellularity was confirmed to be associated with the renal outcome (p=0.047), as well as glomerular sclerosis (p=0.009), endocapillary hypercellularity (p=0.001) and tubular atrophy/interstitial fibrosis (p=0.045). When we analysed only patients with a severe form of the disease (nephrotic syndrome; patients treated with immunosuppression), the survival of the patients was associated only with the degree of tubulointerstitial changes (p=0.018). Analysing separately patients with mild clinical form, we found only a predictive value of segmental glomerulosclerosis on renal survival.

[The possible pathogenesis of AA type amyloidosis in a patient with ulcerative colitis and renal cell carcinoma]. / Sistemna amiloidoza tipa AA u bolesnika s ulceroznim kolitisom i bubreznim karcinomom.

A 43-year-old male with a two-month history of ulcerative colitis and nephrectomy due to a renal cell carcinoma performed a month before was admitted to University Department of Nephrology for nephrotic syndrome and chronic renal failure. Biopsy of the remnant kidney revealed secondary AA amyloidosis with deposits in the glomeruli and walls of intrarenal blood vessels. Re-evaluation of the nephrectomized kidney also showed amyloid deposits both in the renal tissue free from malignant cells and in tumor tissue. In this case the amyloid deposition may have been the result of two coexisting disorders, ulcerative colitis and renal cell carcinoma, both known to be stimulators of amyloid deposition. The remnant kidney function worsened during the follow up and the patients started chronic dialysis after 6 months.

The incidence of biopsy-proven primary glomerulonephritis in the Republic of Macedonia-long-term follow-up.

In order to define the type of renal disease, renal biopsy was performed in 1304 patients, aged 14-72 years. Their biopsies were processed for light and immunofluorescence microscopy, and electron microscopy in some cases. The diagnosis of primary glomerular disease was confirmed in 716 patients with the following incidence: minimal change nephrotic syndrome in 52 (7.2%), focal segmental glomerulosclerosis in 72 (9.9%), membranous nephropathy in 97 (13.5%), IgA nephropathy in 85 (11.8%), diffuse mesangial glomerulonephritis (GN) without IgA in 32 (4.4%), focal mesangial GN in 97 (13.5%), membranoproliferative GN in 59 (8.4%), acute GN in 88 (12.3%), crescentic GN in 53 (7.4%) and sclerosing GN in 46 patients (6.4%).