Renal biopsy in patients with diabetes: a pooled meta-analysis of 48 studies

Abstract

Background. The utility of renal biopsy in patients with diabetes is highly debated. Diabetics with rapidly worsening renal disease are often 'clinically' labelled as having diabetic nephropathy (DN), whereas, in many cases, they are rather developing a nondiabetic renal disease (NDRD) or mixed forms (DN þ NDRD). Methods. We performed a systematic search for studies on patients with diabetes with data on the frequency of DN, NDRD and mixed forms, and assessed the positive predictive values (PPVs) and odds ratios (ORs) for such diagnoses by metaanalysing single-study prevalence. Possible factors explaining heterogeneity among the different diagnoses were explored by meta-regression. Results. In the 48 included studies (n ¼ 4876), the prevalence of DN, NDRD and mixed forms ranged from 6.5 to 94%, 3 to 82.9% and 4 to 45.5% of the overall diagnoses, respectively. IgA nephropathy was the most common NDRD (3-59%). PPVs for DN, NDRD and mixed forms were 50.1% [95% confidence interval (CI): 44.7-55.2], 36.9% (95% CI: 32.3-41.8) and 19.7% (95% CI: 16.3-23.6), respectively. The PPV when combining NDRD and mixed forms was 49.2% (95% CI: 43.8-54.5). Metaregression identified systolic pressure, HbA1c, diabetes duration and retinopathy as factors explaining heterogeneity for NDRD, creatinine and glomerular filtration rate for mixed forms and only serum creatinine for DN. ORs of DN versus NDRD and mixed forms were 1.71 (95% CI: 1.54-1.91) and 4.1 (95% CI: 3.43-4.80), respectively. Conclusions. NDRD are highly prevalent in patients with diabetes. Clinical judgment alone can lead to wrong diagnoses and delay the establishment of adequate therapies. Risk stratification according to individual factors is needed for selecting patients who might benefit from biopsy.

Design and validation of a scoring model for differential diagnosis of diabetic nephropathy and nondiabetic renal diseases in type 2 diabetic patients

“…The results showed that a duration of diabetes ≤6 years was an independent predictor of NDRD, with a PPV of 77.7%. These findings are similar to some of previous studies, whereas there are also some studies that fail to find out a significant association between short duration of diabetes and NDRD …”

“…This may be explained by the very low proportion of MIX groups in their cohort (2/113). However, we and other researchers have revealed a certain proportion of patients with MIX lesions, varying from 4% to 45.5% . Therefore, we further validated the practicability of the NDRD score in the overall population involving the MIX group.…”

“…As one of the most severe complications of diabetes, diabetic nephropathy (DN) is the leading cause of end‐stage renal disease (ESRD) . However, it is noteworthy that besides DN, nondiabetic renal disease (NDRD) alone or superimposed on DN is also a common finding in patients with diabetes subjected to renal biopsy, especially in type 2 diabetic patients . Because type 2 diabetes mellitus (T2DM) is more prevalent in the population, it may coexist with other common glomerular diseases merely by coincidence.…”

“…In fact, DN is diagnosed according to clinical features in most cases, and kidney biopsy is recommended only when NDRD is highly suspected in clinical practice . Previous studies have recognized some clinical features useful for predicting NDRD in type 2 diabetes, such as short duration of diabetes, absence of diabetic retinopathy (DR), hematuria, or unexplained acute kidney injury . However, the predictive value of these factors is inconsistent in different studies, and no single clinical parameter performs satisfying prediction.…”

Non-Diabetic Kidney Disease in Type 2 Diabetic Patients: Prevalence, Clinical Predictors and Outcomes

“…The most frequently seen NDKD types were, IgA nephropathy in 16 studies, MN in 9 studies, FSGS in 6 studies and TIN in 4 studies. Compared to studies from Europe and the United States, in the studies from Asia, IgA nephropathy was the most frequently seen condition, while in the European studies the most frequently seen NDKD was FSGS [23]. In a retrospective study including 620 patients performed in the United States, Sharma et al reported DKD, NDKD and DKD+NDKD prevalence as 37%, 36% and 27%, respectively.…”