of all renal biopsies done in the pediatric population , 5% to 15% are due to crescentic glomerulonephritis [ 1 , 2 ] . the criteria for the number of affected glomeruli required for the diagnosis of crescentic glomerulonephritis vary from 20 to 75% in various pediatric studies . the reports on crescentic glomerulonephritis in children are very few and most of these reports are over a decade old [ 2 , 46 ] . most of these reports suggest that the comments cause for crescentic glomerulonephritis in children is postinfectious glomerulonephritis and that the prognosis is generally poor . we undertook this study to assess the etiology , presentation , and outcome in saudi children with biopsy - proven crescentic glomerulonephritis . all the renal biopsies in children below the age of 18 years done over a 9-year period ( 20012009 ) which showed crescents in > 20% of the glomeruli were included . all biopsies were reviewed by light microscopy , immunofluorescence , and electron microscopy and reviewed by a north american trained nephropathologist blinded to the patient outcome . the etiology was ascertained by clinical assessment , serological tests ( including anti - dna , aso titer , anti - gbm , anca , c3 , and c4 ) and histological criteria . the diagnosis of sle in the patients with this entity was made based on the american rheumatologic association criteria of sle . the histological findings recorded included the number of glomeruli with crescents present , global and segmental glomerular sclerosis , acute tubular necrosis ( atn ) and interstitial infiltrate . the activity and chronicity , in cases of lupus nephritis , were scored based on previously described methods . the serum creatinine levels and 24-hour proteinuria and serological tests were recorded at the time of biopsy and at the end of followup period . the baseline and end of followup means was compared using two - tailed paired t test and non - paired continuous data was compared using independent t test and one way anova for comparing multiple continuous data significance of changes for categorical data ( e.g. , gender , etiology ) was assessed using chi - square test or kruskal wallis . the risk and prognostic factors for different variables were analyzed by linear multivariate regression when the dependent factor is continuous and by logistic multivariate regression when it is categorical . the mean followup period from the time of biopsy was 30.9 ( 22 ) months . the causes of crescentic glomerulonephritis was lupus nephritis in 20 ( 54.1% ) , postinfectious glomerulonephritis in 6 ( 16.2% ) , immune complex glomerulonephritis in 5 ( 13.5% ) , pauci immune glomerulonephritis in 3 ( 8.1% ) , and others in 3 ( 8.1% ) . the mean age in the whole group , was 13.2 (  5.6 ) years , 15.8 (  3.0 ) in the lupus nephritis group and 9.4 (  4.7 ) years in the nonlupus group ( p = 0.000 ) . the females comprised 75.7% of the whole group and 80% of the lupus nephritis group ( p = ns ) . ( table 1 ) at the time of biopsy , 68.20% had acute renal failure , 12.5% required dialysis , 95.6% had proteinuria and 52.2% had nephrotic range proteinuria , ( table 2 ) . there were no significant differences between the lupus nephritis and nonlupus nephritis groups in the prevalences of acute renal failure or proteinuria . however , there were over three times as many patients in the non - lupus nephritis group who required dialysis at biopsy ( table 2 ) . in the group as a whole , the serum creatinine and 24-hour urine excretion , at the time of biopsy , were 218.2 ( 174.3 ) umol / l and 5.1 ( 6.4 )  gms , respectively . by the end of the follow - up period , these values dropped 81.0 ( 67.7 )  umol / l ( p = 0.001 ) and 2.7 ( 6.9 )  gms ( p = 0.008 ) , respectively . at the end of the followup period , the lupus nephritis group fared better than the nonlupus nephritis group in that less patients required dialysis ( p = 0.017 ) and more patients showed improved renal function ( p = 0.01 ) . however , there was no significant difference in end of follow - up proteinuria ( p = 0.5 ) ( table 3 )   among the lupus nephritis group , the mean activity score was 11.4 ( 4.3 ) and the mean chronicity score was 3 ( 1.2 ) . table 4 shows that there were no significant differences in the histological findings between the lupus and nonlupus groups except that there were more globally sclerorsed glomeruli in the non - lupus group ( p = 0.05 ) . although the non - lupus group had higher percentage of glomeruli with crescents , higher interstitial fibrosis / atrophy , acute tubular necrosis , and vasculopathy than the lupus nephritis group , none of these reached significant levels ( table 4 ) .   in the group as a whole , the factors associated with worsening renal function were younger age ( p = 0.002 ) , being non - lupus nephritis ( p = 0.01 ) , higher percent of glomeruli with crescents ( p = 0.019 ) , presence of more atn on biopsy ( p = 0.05 ) , and more vasculopathy ( p = 0.02 ) ( table 5 ) . , the only independent factors found to predict need for dialysis were percent of globally sclerorsed glomeruli ( p = 0.034 ) . baseline proteinuria or scr , gender , number of glomeruli with crescents , on the other hand , did not impact prognosis . using linear regression multivariate analysis , scr , protein excretion , and activity score at biopsy did not influence change in scr or final scr during the followup period . no correlation as found between the changes in serum creatinine over the observation period and any of the following parameters : baseline scr or proteinuria but there was a significant correlation with % of glomeruli with crescents ( r = 0.98 , p = 0.03 ) ( table 6 ) . one of the most striking differences we noted from other reports is in the etiology of crescentic glomerulonephritis . in our group , lupus nephritis and postinfectious gn contributed 54.1% and 16.2% of the cases , respectively . in a recent report on indian children , lupus nephritis contributed only 9.1% with the main etiology being post infectious gn ( 36.8% ) . table 7 compares our findings to reports from iusa , india , france , and uk   on crescentic glomerulonephritis in the pediatric group . the most striking differences can be seen in the etiology and frequency of renal loss . in our group , the etiology of the glomerulonephritis was lupus nephritis in over 50% of the cases , whereas in the other groups less than 10% of the cases were due to lupus nephritis . we also observed a better renal outcome in our patients . this may simply be related to the less severe baseline renal impairment ( table 7 ) . in our study , the lupus nephritis group had a better prognosis despite higher baseline serum creatinine . more patients in this group were dialysis - free by the end of the observation period ( p = 0.017 ) and showed improvement in renal function by the end of the observation period ( 0.01 ) . this might reflect the less percent of glomeruli with crescents and those with global sclerosis in the ln group . similar good renal outcome was reported by others [ 1012 ] ( table 8) . in one study ,   none of the children with lupus nephritis required dialysis which is similar to our finding ( table 8) . however , unlike us , they found that that the presence of nephrotic syndrome was associated with worse renal prognosis .   in a recent study on adults with crescentic lupus nephritis , the renal prognosis was also found to be good with only 4.3% developing end - stage renal failure at the end of a mean follow up period of 56 months . frequency and type of renal involvement in sle is different in different ethnic groups being , for example , higher in afro - americans and hispanics that caucasians in usa . moreover , in afro - americans and hispanics , the prognosis of ln seems to be worse than in caucasians . scanty reports for ksa would suggest that there is a high prevalence of ln among saudi patients with sle . in saudi children , the commonest cause of crescentic glomerulonephritis by far is lupus nephritis . the factors associated with worsening renal function were younger age ( p = 0.002 ) , higher percent of glomeruli with crescents ( p = 0.019 ) , and the etiology being due to non - lupus nephritis ( p = 0.01 ) . the other factors constitute more evidence of atn and vasculopathy ( p = 0.02 ) on histology ( p = 0.05 ) . others have also found that pathologic features associated with a poor prognosis included predominance of large crescents ( p = 0.004 ) , global glomerular sclerosis , interstitial fibrosis and tubular atrophy .
objective . to investigate the clinicopathological features and outcome of glomerulonephritis with crescents among saudi children 
 . method . 
 this is a retrospective study of cases of crescentic glomerulonephritis ( crgn ) seen over a 9-year period . 
 histological features and renal function were recorded . 
 results . 
 thirty - seven cases were enrolled . 
 the mean percent of glomeruli with crescents was 39% ( 19 ) . 
 lupus nephritis ( ln ) was the commonest etiology ( 54.1% ) . at presentation , the serum creatinine ( scr ) was 218.2 ( 174.3 ) umol / l , and 57.1% of the cases had nephrotic range proteinuria . by the end of the observation period , 
 scr dropped to 81.0 ( 67.7 ) umol / l ( p = 0.001 ) . worsening renal function was associated with younger age ( p = 0.002 ) , non - ln etiology ( p = 0.01 ) , more crescents ( p = 0.019 ) , and atn ( p = 0.05 ) . at the end of the followup , more patients in the ln group were dialysis - free ( p = 0.017 ) and had improved renal function ( 0.01 ) than in the non - ln group . using multivariate analysis , 
 the only independent factor found to predict need for dialysis or change in scr level was percent of globally sclerosed glomeruli ( p = 0.034 ) . 
 conclusion . 
 ln is the main cause of crgn in our cohort of children . 
 the ln group had less globally sclerorsed glomeruli and better renal prognosis than the non - ln group .