Chronic diseases are one of the most important non-communicable diseases in the world. Approximately 10% of the world’s population suffers from chronic renal failure, ref. [1]. In most developing countries, glomerulonephritis is the most common cause of the end-stage renal disease (ESRD), and the most common kidney disease in hospitalized patients undergoing a renal biopsy, ref. [2] [3].

The indications for performing this practice continue to increase because of the need for reliable diagnosis for efficient treatment of renal disease in both native and transplant kidneys, ref. [4]. The common indications for renal biopsy are varied. Renal biopsy is recommended for nephrotic syndrome, prolonged acute renal failure, unexplained chronic renal failure, systemic renal disease, non-nephrotic proteinuria, isolated microscopic hematuria, familial renal disease, and renal transplantation failure, ref. [5].

The spectrum of renal biopsy findings differs according to geographic area, ethnicity, and environmental and socioeconomic factors. IgA nephropathy (IgAN) is the main pathological outcome of rare biopsies in many European countries, ref. [6] [7] in Australia, ref. [8] and in most Asian countries, ref. [9] [10] [11]. In contrast, Focal segmental glomerulosclerosis (FSGS) is the predominant pathologic outcome in the United States, ref. [12] [13] and Brazil, ref. [14]. While membranoproliferative glomerulonephritis (MPGN) is the most common pathology in South Africa, ref. [15] and membranous nephropathy (MN) are the most common pathology in biopsies in Spain, ref. [16].

In Ivory Coast, the practice of performing renal biopsies is rare and low. Therefore, we conducted this study to investigate the epidemiology and prevalence of diseases detected by biopsies in our context.

Diseases of aging are one of the most common non-communicable diseases in the world today. These diseases increase over the years with human social development and environmental diseases such as diabetes, HTA, obesity and infections [11]. In sub-Saharan Africa, few studies on rare diseases are mentioned in the literature [2] [15]. The present study was conducted in a resource-limited country, Côte d’Ivoire, in sub-Saharan Africa.

Our data showed a low prevalence of renal and graft disease in the department’s activity. Biopsies examined during the study period were generally from women. Our results differ from those of Das et al. ref. [19] in India, who found a male preponderance. In our study, female obesity may be related to the prevalence of HIV-associated nephropathy, non-HIV FSGS, and membranous glomerulonephritis. These three conditions are frequently observed in a young female population coming from underprivileged backgrounds where impoverishment, promiscuity, and unscrupulousness coexist.

HIV is the main risk and severity factor for one in four patients in our study. The biopsies examined in our study came from a variety of sources. Most biopsies were from the university hospitals of Abidjan in Ivory Coast, and only a few were from Togo. Other countries such as Burkina Faso, Guinea, Mali, and Niger are also interested in the practice of renal biopsy to increase our expertise in renal pathology. This underscores the importance of pathologic examination in the therapeutic management and prognostic assessment of nephrologic disease. In our series, nephrotic syndrome (49%) was the most common symptom or the main indication for renal biopsy, as described by several authors worldwide, ref. [19] [20], while some studies have found a high incidence of tubulo-interstitial nephritis, ref. [21] [22]. These variations could be related to environmental and familial factors. Occupationally, the least favored members of our study population, high school and college students, were affected by renal pathology. The causes could be related to infectious diseases, including HIV, alcohol, tobacco, hypertension, and unknown genetic diseases. Histologically, several diseases such as HIV-associated nephropathy, focal segmental glomerulosclerosis, nephroangiosclerosis, and other pathologies have been diagnosed. HIV-associated nephropathy is a common complication of HIV, accounting for 3.5% to 48.5% of cases, ref. [23]. In our study, it was the most common cause of renal biopsy, accounting for 24.2% of cases and resulting in high proteinuria. The majority of people with HIV-associated nephropathy were young women working in the informal sector. In our current study, classic HIVAN was predominant. It is characterized by a drop in the floculus to the vascular pole, microcystic dilatation of the tubules, and interstitial inflammation, ref. [24]. Classic HIVAN is also found in 3.5% - 10% of HIV-infected African Americans, ref. [24]. However, our result shows a high proportion of classical HIVAN with 78% of cases. Our result differs from that of Cisse et al. ref. [25] from Senegal, who reported a low incidence of 16% in 20 histologically confirmed patients. The high proteinuria reflects the severity of renal involvement in HIV patients in our country. The incidence of immune complex nephropathies due to HIV infection is low. These immune complex forms are prevalent in European and Asian countries, while they are rare in patients from Africa, ref. [26] [27] [28], as also observed in our study.

Other conditions, such as tubulo-interstitial nephropathy, vascular nephropathy, and toxic nephropathy (Tenofovir toxicity), have been reported. The causes of renal toxicity could not be determined in some cases. In fact, patients exposed to the side effects of medicinal plants were identified in our study. The occurrence of chronic renal failure during HIV infection is mediated by viral, genetic, and environmental factors. Direct infection of renal cells leads to clinical disorders (proteinuria and disease progression) and histological lesions (collapsing glomerulopathy and tubular lesion). The recent discovery of the APOL1 gene on chromosome 22 and its variants has shown that it is involved in the occurrence of HIVAN, ref. [26]. FSGS, which is not related to HIV, was common in our study and mainly affected young patients with nephrotic syndrome. FSGS was common in Africans and South Americans due to the high rate of APOL1 gene in this population and infectious diseases. Microscopically, FSGS showed segmental and focal hyaline deposits associated with floculo-capsular fibrosis, synechiae, and podocytosis. The common FSGS subtype was most prevalent in our study. Recent studies have highlighted the role of glomerular basement membrane podocyte proteins and signaling receptors in the development of the disease, ref. [29]. The high proportion of children and adolescents in our study could be investigated by genetic studies for efficient clinical management. Moreover, glomerular lesions associated with podocyte pathology were less frequent in our series than in Asian countries (Japan, India, and Korea), where they are the main cause of nephropathy, ref. [19]. The frequency of benign and malignant nephroangiosclerosis is due to the high prevalence of hypertension and its concomitants in our country. It affected young people who consumed alcohol and tobacco. This disease was found in the large vascular trunks, arterioles, and glomeruli. However, it is rare in Asian and European studies, ref. [19]. With a frequency of 11.6% of cases, post-infectious glomerulonephritis occupies an important place in renal pathology. Post-infectious glomerulonephritis occurs frequently in young patients with bacterial, parasitic, viral, and mycotic diseases in most sub-Saharan African countries. In Europe and North America, post-infectious glomerulonephritis has virtually disappeared due to the use of effective targeted antibiotic therapy, ref. [19]. Common membranous glomerulonephritis is nephropathy related to an infectious and dysimmune context. This disease was diagnosed in all age groups of our study population. The main risk factors are viral infections (hepatitis B virus or HIV), liver cirrhosis, chronic inflammatory diseases (rheumatoid arthritis), and tumors, ref. [29]. Further studies with a large cohort would help clarify the causes of these regular and homogeneous membranous IgG deposits. The absence of subclasses in the antibody panel did not allow us to make such an observation. It is the third most common renal disease after focal segmental glomerulosclerosis and minimal glomerular lesion in Brazil, ref. [21]. IgA-dependent nephropathy is not very common in our context. All our cases were diagnosed by an immunofluorescence study. The lesions observed in IgA depot nephropathy were very characteristic. They appeared in the form of IgA deposits in the mesangial axes and occasionally in the walls of some vessels. It frequently affects adolescents, as reported in larger series from European and American countries, where it is the main cause of glomerular nephropathy. IgA-dependent nephropathy frequently affects adolescents, as reported in larger series from European and American countries, where it is the main cause of glomerular nephropathies, ref. [24] [26]. The other causes of renal failure were rare in our study. Sickle-shaped glomerulonephritis was primarily related to lupus nephropathy, ANCA vasculitis, and rheumatoid purpura. Crescentic glomerulonephritis was common in young women in our study population. Membranoproliferative glomerulonephritis was seen in two patients, in one lupus patient, and in one patient with viral hepatitis C associated with cryoglobulinemia. One case of renal amyloidosis was observed in a patient with chronic inflammatory rheumatism and tuberculosis. Tubulo-interstitial nephritis was essentially caused by drugs and cancer. Deposits of Ig light chains were observed in tubule cells or in the lumen of tubules without any association with amyloidosis or other glomerulopathies with monoclonal Ig deposits. Regarding the graft unit, graft biopsies are less frequent. Transplant biopsies are less frequent in the transplant unit because patients are often referred to well-equipped hospitals in Europe and North Africa. Two graft biopsies were performed: one in a patient with acute tubular necrosis and the other in a patient with cytomegalovirus nephritis.

The biases and limitations were related to demographics, geographic characteristics, and biopsy indications in our country. Informed consent is required from patients for biologic and immunologic tests, radiologic examinations, and the cost of performing renal biopsies. In addition, the cost of the needle, ultrasound, and various biological and pathological tests were borne by the patient. However, these difficulties can be ameliorated by appropriate disease prevention and screening programs in our country and in the East African region.

Renal biopsy is an important procedure for better treatment strategies in patients with renal and transplant diseases. Glomerular nephropathies are the most common kidney diseases on Ivory Coast. Glomerular nephropathies mainly affect young people and are dominated by HIV-associated nephropathy and focal segmental glomerulosclerosis. Difficulties in the management of renal disease hinder the performance and sustainability of biopsies in our country. Complete management of the performance and interpretation of renal biopsies would be an undeniable advantage for the efficient care of renal or transplant pathologies in our country.

The authors declare that they have no competing interests.

N’Dah, K.J., Tia, W.M., Abouna, A.D., Toure, I., Lagou, A.D., Guei, M.C., Cherif, I., Traore, M., Amekoudi, E., Kobenan, A.A.R., Diopo, S.P.O., Yao, K.H., Ackoundou, N.C., Adonis, K.L., Gnionsahié, D.A. and Diomande, M.I.J.M. (2022) Epidemiological and Clinical Characteristics of Renal Diseases Diagnosed by Biopsies in Ivory Coast. Open Journal of Pathology, 12, 100-113. https://doi.org/10.4236/ojpathology.2022.123012