Frequency of Crescentic Glomerulonephritis in Adults Presenting with Acute Kidney Injury

By Bushra Sikandar¹, Mubarak Mohammad², Aiyesha Humaira¹

Affiliations

1. Department of Pathology, Dow Dental College, Dow University of Health Sciences, Karachi, Pakistan
2. Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan.

doi: 10.29271/jcpsp.2026.08.1018

ABSTRACT
Objective: To determine the frequency of crescentic glomerulonephritis (CRGN) in adults presenting with acute kidney injury (AKI), defined according to the latest Kidney Disease: Improving Global Outcomes (KDIGO) guidelines.
Study Design: A cross-sectional observational design.
Place and Duration of the Study: Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan, from April to October 2023.
Methodology: A total of 152 renal biopsies were obtained through a non-probability consecutive sampling technique, including all patients aged ≥18 years, of both genders, who presented with AKI and underwent renal biopsy. Demographics, clinical signs, and symptoms of CRGN were recorded. Data were stratified based on age, gender, and laboratory findings (serum creatinine (sCr) and serum urea). A post-stratification chi-square test was applied.
Results: Most participants were females (n = 97, 63.8%) with a mean age of 37 ± 18 years. Only 12 (8%) patients had CRGN. However, the majority of patients with AKI had acute tubular injury (n = 56, 36.8%), followed by cortical infarction (n = 27, 17.8%). No Significant difference was found between age (p = 0.814), gender (p = 0.143), serum urea (p = 0.117), and sCr levels (p = 0.229).
Conclusion: The study identified a significant but low prevalence of CRGN (8%) among AKI patients. This finding provides a crucial insight into the burden of CRGN in a developing country such as Pakistan, highlighting the need for heightened clinical awareness and diagnostic vigilance.

Key Words: Acute kidney injury, Adults, Crescentic glomerulonephritis, Frequency, serum creatinine.

INTRODUCTION

Crescentic glomerulonephritis (CRGN) remains a significant but under-researched cause of acute kidney injury (AKI), parti- cularly in Asian countries such as Pakistan. CRGN is a clinic- pathological syndrome with rapid loss of renal function in a short period.¹ CRGN may be underreported due to a lack of awareness among healthcare providers and patients. Addi- tionally, limited access to renal biopsy facilities and diag- nostic tools can contribute to underdiagnosis.² Addressing the paucity of data through comprehensive research, improved diagnostic capabilities, and targeted healthcare policies can enhance the understanding and management of this critical condition. By doing so, healthcare providers can better identify at-risk populations, implement effective treatments, and ultimately improve renal health outcomes in these regions.³

The natural course of CRGN renders it a medical emergency. In this disease, renal function declines rapidly, leading to end- stage renal failure if not treated promptly.⁴ CRGN is a critical condition that necessitates prompt diagnosis and treatment to prevent severe renal damage. While substantial data are available from Western countries, information from Asian populations, including Pakistan, remains limited.⁵ Addressing this gap through robust research and improved healthcare infrastructure is essential for better management of CRGN in these regions.

Comprehensive epidemiological studies and renal biopsy registries are essential to accurately determine the incidence and prevalence of CRGN in these populations.⁶ Local studies are crucial for understanding the epidemiological patterns of CRGN within specific populations. They can help identify unique risk factors and disease characteristics pertinent to the local context.⁷

It should be noted that most studies included the spectrum of glomerulonephritis (GN), and no recent data are available on the frequency of CRGN among patients presenting with AKI according to the latest Kidney Disease: Improving Global Outcomes (KDIGO) guidelines (2020 consensus meeting).⁸ Therefore, there is a gap in the literature regarding the true frequency of CRGN among patients who present with AKI.

Hence, this study aimed to assess the frequency of CRGN among patients with AKI, according to the latest KDIGO 2020 criteria.

METHODOLOGY

This descriptive, cross-sectional study was conducted at the Department of Histopathology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan, from April to October 2023. All adult AKI patients who had undergone renal biopsies to determine the cause of AKI were included in this study. This study was approved by the Institute Ethical Review Committee (Approval # SIUT-ERC-2022/A-389; dated: 30 July 2022).

A non-probability, convenience sampling technique was used to recruit the study participants. A total of 152 samples were collected. The sample size was calculated using the Raosoft formula with a response distribution rate of 26.1%, 6 representing the frequency of CRGN in patients with AKI, a margin of error of 7%, and a confidence interval of 95%.

All patients aged ≥18 years, including both males and females, who presented with AKI (defined as an absolute increase in serum creatinine [sCr] of at least 0.3 mg/dL [26.5 μmol/L] within 48 hours, a >50% increase in sCr from baseline within 7 days, or a urine output of <0.5 mL/kg/h for at least 6 hours) and who underwent percutaneous renal biopsy were included. Patients with a history of chronic kidney disease, AKI combined with another syndrome, such as nephrotic syndrome, and any renal syndrome other than AKI were excluded. In addition, graft biopsies from kidney transplant recipients, inadequate biopsy samples, and patients aged <18 years were also excluded.

The renal biopsy request forms were collected from the Department of Histopathology for patients with AKI. Patient confidentiality was maintained throughout the study. Patient identity and identifying information were not used. Demographics, clinical signs and symptoms such as oliguria, anuria, and haematuria, laboratory results, and final diagnosis were recorded in the structured pro forma.

The data were entered and analysed in the Statistical Package for Social Sciences (SPSS) version 22.0. Descriptive statistics were applied to summarise the data. The mean and standard deviation (SD) were calculated for continuous variables, such as age, serum urea, and sCr. Frequencies and percentages were calculated for categorical variables such as gender, crescent type, and laboratory findings. Data were stratified based on age, gender, and laboratory findings (sCr, urea, and antinuclear antibody positivity). Post-stratification chi-square test was used. A p-value of <0.05 was considered significant.

RESULTS

A total of 152 patients with AKI who underwent renal biopsies were investigated in this study. The mean age of all patients was 37 ± 18 years (range: 18-70 years). Furthermore, 97 (63.8%) were females, and 55 (36.2%) were males. A total of 23 (15%) patients reported a history of hypertension, while 17 (11.2%) reported a history of oedema. sCr levels were 6.48 ± 2.70 mg/dL. Serum urea levels were 115.03 ± 56.535 mg/dL. On ultrasound, almost all patients had normal-sized kidneys (Table I).

Out of 152 patients with AKI, only 12 (8%) patients had CRGN. The majority of patients with AKI had acute tubular injury (n = 56, 36.8%), followed by cortical infarction (n = 27, 17.8%), while other diagnostic findings included 11 (7.2%) cases of chronic sclerosing GN, 10 (6.6%) cases of tubulo-interstitial nephritis, and 6 (3.9%) cases each of pyelonephritis and focal segmental GN.

No significant association was found between age and CRGN (p = 0.814). However, the majority of the patients with AKI fell in the age category of 26-50 years. No significant association was found between the patients’ gender and CRGN (p = 0.143). CRGN was more common in female AKI patients compared to males. No significant difference was found between serum urea levels (p = 0.117), sCr levels (p = 0.229), and other variables and CRGN. However, all patients with CRGN had higher mean sCr levels than the other patients (Table II).
 

Table I: Demographics, clinical, and laboratory findings of patients with AKI (n = 152).

Demographic characteristics	Results
Age in years (mean ± SD)	37.53 ± 18.08 (range: 18-70 years)
Males n (%)	55 (36.2)
Females n (%)	97 (63.8)
Clinical parameters
Hypertension n (%)	23 (15)
Oedema n (%)	17 (11.2)
Laboratory parameters
sCr (mg/dL; mean ± SD/range)	6.48 ± 2.70 (range: 0.90-11.28 years)
Serum urea (mg/dL; mean ± SD/range)	115.03 ± 56.535 (range: 16-276 years)

Table II: Distribution of age, gender, and renal function tests among patients with CRGN and other causes of AKI (n = 152).

Variables		Diagnosis		p-values*
		CRGN n (%)	Other cause n (%)
Age	<25 years	2 (9)	20 (91)	0.814
	26-50 years	9 (8.4)	99 (91.6)
	>50 years	1 (4.5)	21 (95.5)
	Total	12 (7.9)	140 (92.1)
Gender	Male	2 (1.3)	53 (34.9)	0.143
	Female	10 (6.6)	87 (57.2)
	Total	12 (7.9)	140 (92.1)
Serum urea levels		152.6 ± 60.29	112.9 ± 57.73	0.117
sCr levels		6.79±1.36	6.38 ± 2.73	0.229
*Chi-square test.

DISCUSSION

The present study showed a low but significant prevalence of CRGN  (12, 8%) among AKI patients undergoing renal biopsy. In a subsequent study conducted on the biopsy cases, the frequency of CRGN in acute renal failure in the Pakistani population was reported to be 26.1%.⁹

In another study, which included only glomerular pathologies, the frequency of CRGN in the local population was 50%.⁷ However, the latter study included GN cases; hence, a very high prevalence of CRGN was reported in that study. Very few studies have been conducted specifically on the frequency of CRGN in AKI patients undergoing renal biopsies.^10-12 A lower frequency of CRGN was also found in their cohorts. On the other hand, no study has been conducted, according to the KDIGO 2020 criteria, on the frequency of CRGN in patients with AKI.⁸

This study included only the cases of AKI that underwent renal biopsies. The most common causes of AKI in this study, related to ischaemic injury, included ATI and cortical infarction. Glomerular diseases, overall, constitute a minority of cases of AKI. This is not truly reflective of the causes of AKI in the general population. Moreover, the number of cases in this study was not very high. Nevertheless, it represented an important cross-section of the AKI patient population at the study centre.

The mean age of all patients was 37 ± 18 years (range: 18–70 years). Similarly, a study conducted in sub-Saharan countries also reported a relatively young mean age of 29.7 ± 12 years.¹³ An even lower mean age of 18.06 ± 13.49 years was reported in a study conducted at a single centre in Saudi Arabia involving 17 cases of CRGN.¹⁴ In contrast, several studies from Western countries reported higher mean ages.^15,16

This reflected the different aetiological factors of AKI in those studies. In the current study, no significant association was found between age and CRGN. This was most probably due to a small number of cases. However, it was found that the majority of patients aged 26-50 years had CRGN. This finding is consistent with a recent study, which reported that anti-GBM antibody disease was more common in younger age groups, whereas pauci-immune CRGN was more common in adults, with a peak prevalence in the fourth to sixth decades of life.¹⁷

Furthermore, the current study showed that the majority of patients with AKI had CRGN (n = 12, 8%), followed by chronic sclerosing GN (n = 11, 7.2%), focal segmental GN (n = 6, 3.9%), mesangiocapillary GN (n = 3, 2%), and membranous GN (n = 2, 1.3%). However, contrasting results were found in different studies conducted previously locally and internationally.^13-17

Regarding gender distribution, the majority of patients in the overall AKI cohort were female. A similar trend was noted in many other studies.^18-20 This reflected the different aetiolo- gical factors in those studies. Moreover, no significant association was found between gender and CRGN. However, it was found that the female gender had a higher prevalence of CRGN than males. This might be due to an overall predominance of female patients (63.8%) in the current study sample compared to males.

Some previous studies showed a higher prevalence of males than females.^21-23 The findings from these previous studies highlighted that glomerular diseases were significantly preva-lent among males. The variations in findings between genders could be attributed to pathological processes, environmental variation, and social and other factors. However, further studies are required to evaluate these variations and thereby tailor the gender-specific treatments.

Furthermore, no significant difference was found in serum urea and sCr levels with CRGN. This might be due to the small number of patients in the CRGN group. However, it was found that the majority of patients with higher serum urea and creatinine levels had CRGN. Several studies have reported similar results showing that pauci-immune CRGN patients had higher sCr levels.^12,24,25

The current study not only describes the frequency of CRGN but also examines its clinicopathological parameters, offering a detailed understanding of its presentation and characteristics. This comprehensive approach is essential for identifying specific patterns and informing targeted interventions. While the initial study provided valuable insights into CRGN, its limitations highlighted the need for more extensive, multicentre, prospective research with larger sample sizes and comprehensive analyses, specifically compre-hensive immunofluorescence-based classification and fur-ther elaboration of histopathological and immunofluorescence characteristics. Future studies that address these recommendations will be better positioned to confirm the findings, establish causal relationships, and improve the management and outcomes of patients with CRGN.

CONCLUSION

The study identified a significant but low prevalence of CRGN (8%) among AKI patients. This finding provided a crucial insight into the burden of CRGN in a developing country such as Pakistan, highlighting the need for heightened clinical awareness and diagnostic vigilance.

ETHICAL APPROVAL:
This study was approved by the Institute Ethical Review Committee of Sindh Institute of Urology and Transplantation, Karachi, Pakistan (Approval # SIUT-ERC-2022/A-389; dated: 30 July 2022).
 

PATIENTS’ CONSENT:
Informed consent was obtained from all the participants.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTIONS:
BS, MM, AH: Conception, design of the study, acquisition, analysis, interpretation of data, and drafting of the manuscript.
All authors approved the final version of the manuscript to be published.

REFERENCES

1. Antonelou M, Evans RD, Henderson SR, Salama AD. Neutrophils are key mediators in crescentic glomerulonephritis and targets for new therapeutic approaches. Nephrol Dial Transplant 2022; 37(2):230-8. doi: 10.1093/ ndt/gfaa206.
2. O'Shaughnessy MM. Studying glomerular disease epidemiology: Tackling challenges and paving a path forward. MD Thesis, University College Cork; 2020. Available from: httpss:// cora.ucc.ie/items/66adfcae-f31c-4ecc-977b-962100 a369d3.
3. Sethi S, Fervenza FC. Standardised classification and repor-ting of glomerulonephritis. Nephrol Dial Transplant 2019; 34(2):193-9. doi: 10.1093/ndt/gfy220.
4. Rout P, Leslie SW. Rapidly Progressive Glomerulonephritis. 2024 Jun 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan–. Available from: httpss://pub med.ncbi.nlm.nih.gov/32491362/.
5. Alexander S, Yusuf S, Rajan G, John EE, Roy S, Annamalai VC, et al. Crescentic glomerulonephritis: What’s different in South Asia? A single-centre observational cohort study. Wellcome Open Res 2020; 5:164. doi: 10.12688/wellcomeo penres. 16071.1.
6. Naqvi R, Mubarak M, Ahmed E, Akhtar F, Bhatti S, Naqvi A, et al. Spectrum of glomerular diseases causing acute kidney injury; 25 years' experience from a single centre. J Renal Inj Prev 2015; 4(4):113-6. doi: 10.12861/jrip.2015.24.
7. Naqvi R, Ahmed E, Sheikh R, Rizvi A. Obstetrical acute kidney injury: 25 years’ experience from the nephrology care unit in Pakistan. Open Acc Lib J 2015; 2(8):1-7. doi: 10.4236/oalib. 1101778.
8. Levey AS, Eckardt KU, Dorman NM, Christiansen SL, Hoorn EJ, Ingelfinger JR, et al. Nomenclature for kidney function and disease—executive summary and glossary from a KDIGO consensus conference. Kidney Int 2020; 97(6): 1117-29. doi: 10.1016/j.kint.2020.02.010.
9. Mubarak M, Kazi JI, Naqvi R, Ahmed E, Akhter F, Naqvi SA, et al. Pattern of renal diseases observed in native renal biopsies in adults in a single centre in Pakistan. Nephrology (Carlton) 2011; 16(1):87-92. doi: 10.1111/j.1440-1797. 2010.01410.x.
10. Chen S, Tang Z, Xiang H, Li X, Chen H, Zhang H, et al. Aetiology and outcome of crescentic glomerulonephritis from a single centre in China: A 10-year review. Am J Kidney Dis 2016; 67(3):376-83. doi: 10.1053/j.ajkd.2015.07.034.
         
11. Pesce F, Stea ED, Rossini M, Fiorentino M, Piancone F, Infante B, et al. Glomerulonephritis in AKI: From pathogenesis to therapeutic intervention. Front Med (Lausanne) 2021; 7:582272. doi: 10.3389/fmed.2020.582272.
12. Chen Z, Xu J, Wu J, Xue C, Ruan M, Mei C, et al. Prognostic ana- lysis of crescentic glomerulonephritis with acute kidney injury: A single-centre cohort with 5-year follow-up. Int Urol Nephrol 2022; 54(9):2375-83. doi: 10.1007/ s11255-022-03111-w.
13. Faye M, Lemrabott AT, Cisse MM, Nzambaza JDD, Dia CM, Seck SM, et al. Idiopathic adult nephrotic syndrome: A clinicopathological study and response to steroids in a sub-Saharan African country. Open J Nephrol 2016; 6(2):61-5. doi: 10. 4236/ojneph.2016.62008.
14. Alsuheili AZ, Alhozali H, Bukhari AA, Khan MA, Alzahrani AS, Abualnaja SK, et al. Clinico-pathological outcomes of patients with crescentic glomerulonephritis: A single- centre study. Cureus 2023; 15(5):e38647. doi: 10.7759/ cureus.38777.
15. Susantitaphong P, Cruz DN, Cerda J, Abulfaraj M, Alqahtani F, Koulouridis I, et al. World incidence of AKI: A meta-analysis. Clin J Am Soc Nephrol 2013; 8(9):1482-93. doi: 10.2215/ CJN.00710113.
16. Selmi Y, Ariba YB, Labidi J. Epidemiology, diagnosis, and aetiology of acute kidney injury in the elderly: A retrospective analysis. Saudi J Kidney Dis Transpl 2019; 30(3): 678-85. doi: 10.4103/1319-2442.261344.
17. Parmar MS, Bashir K. Crescentic Glomerulonephritis (Archived). In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2025. Available from: httpss://pubmed. ncbi.nlm.nih.gov/28613478/.
18. Guzel C, Yesiltas S, Daskaya H, Uysal H, Sumer I, Turkay M. The effect of gender on acute kidney injury in the intensive care unit. Hosp Pract 2019; 47(3):126-31. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC7307507/.
19. Frydman S, Freund O, Banai A, Zornitzki L, Banai S, Shacham Y. Relation of gender to the occurrence of AKI in STEMI patients. J Clin Med 2022; 11(21):6565. doi: 10. 3390/jcm11216565.
20. Neugarten J, Golestaneh L. Sex differences in acute kidney injury. Semin Nephrol 2022; 42(2):208-18. doi: 10.1016/j. semnephrol.2022.04.010.
21. Sadaf A, Khemchand MN, Fouzia L, Asia Z. Clinicopathological profile of pediatric renal biopsies at a tertiary care hospital, Pakistan. Saudi J Kidney Dis Transpl 2018; 29(6):1403-9. doi: 10.4103/1319-2442.248290.
22. Krishin J, Shah M, Ghazi SS, Hussain M, Farzeen M. Frequency of histopathological subtypes of steroid-resistant nephrotic syndrome among children below 12 years in a tertiary care hospital of Islamabad, Pakistan. Rawal Med J 2020; 45(1):245-8. Available from: httpss://www.rmj.org.pk/index. php?mno=55521.
23. Shafique M, Bukhari U, Kumar S, George A, Bukhari A, Mehmood MS. Morphological audit of glomerular diseases in a tertiary care Hospital. Int J Endor Health Sci Res 2022; 10(1):95-101. doi: 10.29052/IJEHSR.v10.i1.2022.95-101.
     
24. Gupta R, Singh L, Sharma A, Bagga A, Agarwal SK, Dinda AK. Crescentic glomerulonephritis: A clinical and histomorphological analysis of 46 cases. Indian J Pathol Microbiol 2011; 54(3):497-500. doi: 10.4103/0377-4929.85081.
25. Oudah N, Al Duhailib Z, Alsaad K, Qurashi S, Ghamdi G, Flaiw A, et al. Glomerulonephritis with crescents among adult Saudi patients: outcome and its predictors. Clin Exp Med 2012; 12(2):121-5. doi: 10.1007/s10238-011-0147-4.