Jackie Hicks

Fifty-three patients who by clinical and/or histological criteria were judged to have vasculitis affecting the kidney were reviewed. Patients with systemic lupus or Schönlein-Henoch purpura were excluded. Segmental necrotising glomerulitis was taken as a manifestation of vasculitis ('microscopic polyarteritis'). Those patients in whom vasculitis was confined to glomerular capillaries were compared with those who in addition had vascular lesions outside the glomeruli. The two groups were found to have identical clinical features. Clinical presentation was predominantly extrarenal, and exclusively renal in only two. Three patients were classified histologically as Wegener's granulomatosis, four had malignant tumours and two relapsing polychondritis. Hepatitis B surface antigen was absent in all of 37 patients tested. Renal disease presented with microscopic haematuria and minor proteinuria in the majority (32) but 16 patients presented with rapid deterioration of renal function, including seven with anuria. Histologically 42 patients showed segmental necrotising glomerulitis ('microscopic polyarteritis'), six diffuse proliferative glomerulonephritis,and in five only minor or ischaemic glomerular changes were present. Crescents were found in 41/42 of those with segmental necrotising glomerulitis, nd involved more than 50 per cent of glomeruli in 15 patients. Immunohistochemical studies were generally negative except the fibrin. Electron microscopy showed no evidence of immune deposits in necrotising glomerulitis, but these were present in 2/6 patients with diffuse proliferative glomerulonephritis. Overall prognosis was poor, 35 patients having died, 20 early in the course of the disease and 15 later. Oligoanuria and extensive crescent formation were adverse signs. Survivals were 54, 38 and 34 per cent at one, five and 10 years respectively. Of those who survived the initial illness, 12 were stable with apparently inactive disease, whilst 16 continued to show clinical signs of activity and required treatment. A variety of treatments was employed including oral and intravenous corticosteroids, immunosuppressive agents, anticoagulants; only one patient was treated by plasmapheresis. It is difficult to draw any firm conclusions as to the efficacy of treatment and survival rates remain unsatisfactory.

'Biopsy' (Besnier 1895) became useful towards the end of the 19th century with the development of good histology and microbiology. Needle biopsy of the liver, although first performed in 1895, did not become current until 50 years later. Surgical biopsy of the kidney at incidental operations, particularly the then fashionable renal decapsulation, was performed from 1900 to 1930. Percutaneous needle renal biopsy was introduced after first, the successful liver biopsy and second, demonstration of the value of aspiration needle biopsy in tumours of the kidney. In addition, a number of physicians obtained renal tissue by accident and without problems during intended biopsies of the liver. Nils Alwall of Sweden performed the first systematic aspiration needle biopsies of the kidney in 1944, but did not publish his results because of an early death which led him to abandon the technique. However, when Iversen and Brun in Copenhagen described their results in 1951, a number of physicians around the world immediately began to attempt renal biopsy, using cutting as well as aspiration techniques. Success was inconsistent and operator dependent: the refinements of technique and needles introduced by the group in Chicago led by Robert Kark, plus their advocacy of the technique and their training of many physicians in its performance rapidly led to widespread acceptance. New techniques of immunofluorescence and electron microscopy arrived at the same time so that the technique could be fully exploited. The performance and interpretation of renal biopsies became, along with classical whole-organ and nephron physiology and the introduction of dialysis and transplantation, powerful agents determining the emergence of Nephrology as a specialty around 1960.