CHAPTER 1 Overview Of Renal Biopsy In Malaysia Lee Ming Lee Lily Mushahar Lee Day Guat

Table 1.2.1: Total number of renal biopsies by centres, 2005 – 2012 5th MRRB report 2011 & 2012, Malaysia

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5th MRRB report 2011 & 2012, Malaysia Table 1.2.2: Distribution of reported native and graft renal biopsies by centre, 2005-2012 5th MRRB report 2011 & 2012, Malaysia

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5th MRRB report 2011 & 2012, Malaysia Table 1.2.3(a): Distribution of native renal biopsy in patients by number of episodes, 2005-2012 Native 2005 - 2010 2011 2012 Total n % 1st episode 4711 86.8 1214 84.5 1219 85.0 7144 2nd episode 577 10.6 174 12.1 162 11.3 913 3rd episode 119 2.2 37 2.6 41 2.9 197 ≥4th episode 21 0.4 11 0.8 12 44 Total Patient 5428 100 1436 1434 8298 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.3(b): Distribution of renal allograft biopsy in patients by number of episodes, 2005-2012 Graft 2005 - 2010 2011 2012 Total n % 1st episode 344 58.6 71 46.7 96 49.7 511 2nd episode 148 25.2 46 30.3 53 27.5 247 3rd episode 55 9.4 10 6.6 20 10.4 85 ≥4th episode 40 6.8 25 16.4 24 12.4 89 Total Patient 587 100 152 193 932 5th MRRB report 2011 & 2012, Malaysia

Table 1.2.4.1(a): Age distribution of native renal biopsy, 2005-2012 Age group (years) 2005 - 2010 2011 2012 Total n % <15 879 184 158 1221 14.1 15-<25 1589 404 391 2384 27.5 25-<35 1266 373 341 1980 22.9 35-<45 892 205 234 1331 15.4 45-<55 627 180 192 999 11.5 55-<65 292 100 109 501 5.8 ≥65 147 48 46 241 2.8 5692 1494 1471 8657 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.4.1(b): Age distribution of renal allograft biopsy, 2005-2012 Age group (years) 2005 - 2010 2011 2012 Total n % <15 37 9 8 54 4.2 15-<24 122 34 21 177 13.7 25-<35 133 36 78 247 19.1 35-<45 218 86 76 380 29.3 45-<55 176 44 69 289 22.3 55-<65 65 29 33 127 9.8 65 15 1 5 1.6 766 239 290 1295 100 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.4.1(c): Age group distribution of reported renal biopsies by state, 2005-2012 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.4.2(a): Gender distribution of native renal biopsy, 2005-2012 Gender 2005 – 2010 2011 2012 Total n % Male 2176 589 599 3364 40.5 Female 3252 847 835 4934 59.5 5428 1436 1434 8298 100 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.4.2(b): Gender distribution of renal allograft biopsy, 2005-2012 Gender 2005 - 2010 2011 2012 Total n % Male 370 101 121 592 63.5 Female 217 51 72 340 36.5 587 152 193 932 100 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.4.3(a): Racial distribution of native renal biopsy, 2005-2012 Race 2005 - 2010 2011 2012 Total n % Malay 3110 862 851 4823 58.1 Chinese 1390 320 346 2056 24.8 Indian 359 109 98 566 6.8 Others 569 145 139 853 10.3 5428 1436 1434 8298 100 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.4.3(b): Racial distribution of renal allograft biopsy, 2005-2012 Race 2005 - 2010 2011 2012 Total n % Malay 186 49 59 294 31.5 Chinese 314 80 97 491 52.7 Indian 56 12 24 92 9.9 Others 31 11 13 55 5.9 587 152 193 932 100 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.5: Number of glomeruli obtained at each biopsy by centres, 2005-2012 5th MRRB report 2011 & 2012, Malaysia

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Table 1.2.6: Distribution of biopsy specimens to histopathology laboratories by participating centres, 2005-2012 Centre Local histopathology laboratories 2005 - 2010 2011 2012 Total n % 180 669 73.4 136 14.9 107 11.7 912 100 480 368 71.5 78 15.1 69 13.4 515 481 73 62.4 22 18.8 117 580 168 49.6 89 26.3 82 24.2 339 880 54 50.9 13 12.3 39 36.8 106 881 44 78.6 8 14.3 4 7.1 56 980 137 72.1 33 17.4 20 10.5 190 1080 456 75.1 88 14.5 63 10.4 607 1180 12 1280 60 47.2 30.7 28 127 1380 77 51.7 51 34.2 21 14.1 149 2081 248 75.2 41 12.4 330 4380 21.5 159 38.5 165 40 413 4381 29.6 24 33.8 26 36.6 71 20080 75 50.3 74 49.7 20180 394 49.9 21.3 227 28.8 789 20280 57.1 37.1 2 5.7 35 61280 18 72 7 25 62380 172 89.1 10.9 193 3080 1065 20.7 990 19.3 5135 5th MRRB report 2011 & 2012, Malaysia

Continue; Centre Outside histopathology laboratories 2005 - 2010 2011 2012 Total  All n % 180 103 98.1 1 105 100 1017 10.2 380 319 60.6 96 18.3 111 21.1 526 5.3 480 99 614 6.2 481 34 151 1.5 580 9 90 10 349 3.5 780 302 67.6 80 17.9 65 14.5 447 4.5 880 98 60.1 36 22.1 29 17.8 163 269 2.7 881 5 61 0.6 980 191 1.9 1080 608 6.1 1180 130 58.6 44 19.8 48 21.6 222 234 2.4 1181 0.1 1280 50 2 129 1.3 1380 78 83.9 15 16.1 93 242 1480 142 96.6 3 1.4 147 1780 516 73.5 81 11.5 702 7.1 2081 96.7 3.3 30 360 3.6 2380 28 22.8 40 32.5 55 44.7 123 1.2 4380 699 1112 11.2 4381 169 1.7 7781 192 12.2 24 9.8 246 2.5 5th MRRB report 2011 & 2012, Malaysia

Continue; Centre Outside histopathology laboratories 2005 - 2010 2011 2012 Total  All n % 20080 1 100 150 1.5 20180 4 9.1 15 34.1 25 56.8 44 833 8.4 20280 2 37 0.4 25280 14 70 3 20 0.2 60680 5 0.1 60980 18 51.4 7 10 28.6 35 61080 39 59.1 21.2 13 19.7 66 0.7 61280 8 33.3 16.7 12 50 24 49 0.5 61880 62380 6 199 62480 31 40 69 58 0.6 62580 85.7 14.3 65780 65880 36 69.2 13.5 9 17.3 52 68580 71 12.9 16.1 62 106881 69.6 56 108180 162 52.6 76 24.7 22.7 308 3.1 121580 77.8 22.2 126080 63 82 32.5 107 42.5 252 2.5 127780 60 23.3 30 0.3 3378 70.1 668 13.9 771 16 4817 9952 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Figure 1.2.6(b) i: Distribution of biopsy specimens to Local histopathology laboratories by participating centres, 2005-2012 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Figure 1.2.6(b) ii: Distribution of biopsy specimens to Outside histopathology laboratories by participating centres, 2005-2012 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.6(c): Summary of biopsies received by local and outside laboratories, 2007-2010 2007 (1st report) 2008 (2nd report) 2009 (3rd report) 2010 (4th report) 2012 (5th report) n % In house Lab 1085 44.9 1799 47.6 2360 48.5 2984 47.8 5135 51.6 Outside Lab 1334 55.1 1978 52.4 2506 51.5 3265 52.2 4817 48.40 All Lab 2419 100  3777  100 4866 6249 9952 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.2.6(d): Histopathology laboratories receiving renal biopsy specimens, 2005-2012 5th MRRB report 2011 & 2012, Malaysia

Table 1.3.1(a): Indications for native renal biopsies, 2005-2012 Clinical Presentations 2005 - 2010 2011 2012 Total n % Asymptomatic urine abnormality 1624 28.5 409 27.4 443 30.1 2476 28.6 Nephritic syndrome 480 8.4 124 8.3 96 6.5 700 8.1 Nephrotic syndrome 2492 43.8 558 37.3 490 33.3 3540 40.9 Nephrotic-Nephritic syndrome 505 8.9 187 12.5 136 9.2 828 9.6 Not available/Missing 591 10.4 216 14.5 306 20.8 1113 12.9 5692 100 1494 1471 8657 5th MRRB report 2011 & 2012, Malaysia

Table 1.3.1(b): Renal function at time of biopsy, 2005-2012 Clinical Presentations 2005 – 2010 2011 2012 Total n % Normal 2936 51.6 729 48.8 670 45.5 4335 50.1 Impaired 2106 37.0 551 36.9 541 36.8 3198 Not available/Missing 650 11.4 214 14.3 260 17.7 1124 13.0 5692 100 1494 1471 8657 5th MRRB report 2011 & 2012, Malaysia

Table 1.3.2: Histopathology of all native renal biopsies, 2005-2012 5th MRRB report 2011 & 2012, Malaysia

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5th MRRB report 2011 & 2012, Malaysia Table 1.3.3.1: HPE diagnosis in patients presenting with Nephrotic Syndrome, 2005-2012 Type Histopathological Diagnosis n % Primary GN Minimal Change 969 26.9 FSGS 751 20.9 lg A nephropathy 182 5.1 Membranous nephropathy 207 5.8 Membrano-proliferative 33 0.9 Mesangial Proliferative GN-non IgA 51 1.4 Crescentic 0.0 Idiopathic crescentic 8 0.2 Not available/Missing 7 Sub total 2208 61.3 Secondary GN Other infection 9 0.3 Lupus Nephritis 815 22.6 Henoch Schonlein Purpura 4 0.1 HUS/TTP 1 Amyloidosis 12 Systemic vasculitis Post infection GN 29 0.8 Polyarteritis nodosa Malignancy Light/ heavy chain disease Diabetic nephropathy 181 5.0 Anti GBM Immunotactoid / fibrillary GN Multiple myeloma 10 1065 29.6 Others 327 9.1 Total 3600 100.0 *Patients may have either one or more histopathology or not have any histopathology Others = Tubulo. Disease + Vascular + Advance GN + Others + Hereditary (no observation) 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.3.3.2: HPE diagnosis in Patients presenting with Asymptomatic Urine Abnormalities, 2005-2012 Type Histopathological Diagnosis n % Primary GN Minimal Change 151 6.2 FSGS 232 9.6 lg A nephropathy 376 15.5 Membranous nephropathy 66 2.7 Membrano-proliferative 8 0.3 Mesangial Proliferative GN-non IgA 42 1.7 Crescentic Idiopathic crescentic 13 0.5 Not available/Missing 6 0.2 Sub total 902 37.3 Secondary GN Other infection 3 0.1 Lupus Nephritis 1031 42.6 Henoch Schonlein Purpura 22 0.9 HUS/TTP 0.0 Amyloidosis Systemic vasculitis 5 Post infection GN 24 1.0 Polyarteritis nodosa Malignancy Light/ heavy chain disease 1 Diabetic nephropathy 90 3.7 Anti GBM Immunotactoid / fibrillary GN Multiple myeloma 7 Missing 1196 49.4 Others 321 13.3 Total 2419 100.0 * Patients may have either one or more histopathology or not have any histopathology Others = Tubulo. Disease + Vascular + Advance GN + Others + Hereditary 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.3.3.3: HPE diagnosis in patients presenting with Nephritic-Nephrotic, 2005-2012 Type Histopathological Diagnosis n % Primary GN Minimal Change 49 5.7 FSGS 62 7.2 lg A nephropathy 78 9.0 Membranous nephropathy 13 1.5 Membrano-proliferative 11 1.3 Mesangial Proliferative GN-non IgA 15 1.7 Crescentic 2 0.2 Idiopathic cresentic 8 0.9 Not available/Missing 1 0.1 Sub total 239 27.7 Secondary GN Other infection 5 0.6 Lupus Nephritis 427 49.5 Henoch Schonlein Purpura HUS/TTP Amyloidosis 0.0 Systemic vasculitis Post infection GN 44 5.1 Polyarteritis nodosa Malignancy Light/ heavy chain disease Diabetic nephropathy 24 2.8 Anti GBM Immunotactoid / fibrillary GN Multiple myeloma 516 59.8 Others 108 12.5 Total 863 100.0 * Patients may have either one or more histopathology or not have any histopathology Others = Tubulo. Disease + Vascular + Advance GN + Others + Hereditary (no observation) 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Table 1.3.3.4: HPE diagnosis in Patients presenting with Nephritic syndrome, 2005-2012 Type Histopathological Diagnosis n % Primary GN Minimal Change 43 6.2 FSGS 55 7.9 lg A nephropathy 64 9.2 Membranous nephropathy 4 0.6 Membrano-proliferative 12 1.7 Mesangial Proliferative GN-non IgA 14 2.0 Crescentic 7 1.0 Idiopathic cresentic 13 1.9 Not available/Missing 5 0.7 Sub total 217 31.0 Secondary GN Other infection 0.0 Lupus Nephritis 288 41.2 Henoch Schonlein Purpura HUS/TTP Amyloidosis 1 0.1 Systemic vasculitis Post infectious GN 53 7.6 Polyarteritis nodosa Malignancy Light/ heavy chain disease Diabetic nephropathy 22 3.1 Anti GBM Immunotactoid / fibrillary GN Multiple myeloma 380 54.4 Others 102 14.6 Total 699 100 * Patients may have either one or more histopathology or not have any histopathology Others = Tubulo. Disease + Vascular + Advance GN + Others + Hereditary 5th MRRB report 2011 & 2012, Malaysia

Table 1.3.3.5: Table for Primary Glomerulonephritis, 2005-2012 5th MRRB report 2011 & 2012, Malaysia

5th MRRB report 2011 & 2012, Malaysia Figure 1.3.3.5: Primary gromerulonephritis according to the various age group, 2005-2012 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% <15 15-<25 25-<35 35-<45 45-<55 55-<65 >65 Age Percentage (%) Minimal change disease FSGS Ig A Nephropathy Membranous nephropathy Membrano proliferative Mesangial proliferative Non-Ig A Crescentic ANCA Idiopathic crescentic Not available/Missing 5th MRRB report 2011 & 2012, Malaysia