Letters to the Editor – Brief Case Reports
Association of minimal-change disease and polycythaemia in a very elderly patient
Asociación de nefropatía por cambios mínimos y policitemia en un paciente muy anciano
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His medical history included hypertension, atrial fibrillation, hiatal hernia and benign prostatic hypertrophy. He had undergone surgery for colorectal adenocarcinoma in 2006. No history of smoking or lung disease. He is receiving regular treatment with amlodipine 5<span class="elsevierStyleHsp" style=""></span>mg/day, enalapril 5<span class="elsevierStyleHsp" style=""></span>mg/day, dabigatran 110<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h (for last 10 days), tamsulosin 0.4<span class="elsevierStyleHsp" style=""></span>mg/day, dutasteride 0.5<span class="elsevierStyleHsp" style=""></span>mg/day omeprazole 40<span class="elsevierStyleHsp" style=""></span>mg/day. In the 5 days prior to admission, the patient had come to the emergency room on 2 occasions with edema in hands and legs, and treatment with furosemide 80<span class="elsevierStyleHsp" style=""></span>mg orally was prescribed. Without achieving clinical improvement, he went to the emergency room for a third time, and the Department of Nephrology was then consulted for edema and urinalysis with protein +++. On physical examination, the patient had an acceptable general condition, was conscious and responsive. On admission, blood pressure was 126/78<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate 73<span class="elsevierStyleHsp" style=""></span>bpm, and temperature 37<span class="elsevierStyleHsp" style=""></span>°C. Cardiac auscultation was arrhythmic with no murmurs, and respiratory auscultation presented bibasilar crackles. He had pitting edema (+++/+++) at both limbs. The remainder of the physical examination was anodyne. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows test results before the nephrotic syndrome was detected during a visit to the ER, at the day of admission, during hospitalization and at the first visit after his discharge from the hospital.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">All other blood analytical determinations showed: glucose 100<span class="elsevierStyleHsp" style=""></span>mg/dl, urea 72<span class="elsevierStyleHsp" style=""></span>mg/dl, uric acid 7.9<span class="elsevierStyleHsp" style=""></span>mg/dl, cholesterol 439<span class="elsevierStyleHsp" style=""></span>mg/dl, LDL-cholesterol 342<span class="elsevierStyleHsp" style=""></span>mg/dl, HDL cholesterol 75<span class="elsevierStyleHsp" style=""></span>m/dl, triglycerides 112<span class="elsevierStyleHsp" style=""></span>mg/dl, total protein 4.9<span class="elsevierStyleHsp" style=""></span>mg/dl, calcium 7.6<span class="elsevierStyleHsp" style=""></span>mg dl, phosphorus 3.6<span class="elsevierStyleHsp" style=""></span>mg/dl, sodium 127<span class="elsevierStyleHsp" style=""></span>mmol/l, potassium 4.5<span class="elsevierStyleHsp" style=""></span>mmol/l. Blood electrophoresis showed an increase in α2 and β globulins levels, with a percent decrease in albumin without monoclonal peaks. Tumor markers (CEA, CA 19.9, PSA) were within normal limits. Serology for hepatitis B, C and HIV was negative. Immunological study (C-reactive protein, rheumatoid factor, ANA, complement and immunoglobulins A and M) was normal. There was a slight decrease in immunoglobulin G of 730<span class="elsevierStyleHsp" style=""></span>mg/dl (normal: 751–1560). Vitamin B<span class="elsevierStyleInf">12</span> and folic acid levels were normal. In urine, the electrophoretic study showed non-selective proteinuria and negative Bence-Jones.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Abdominal ultrasound was difficult to assess due to poor acoustic window: the left kidney had a very difficult viewing while the right had a normal morphology and echogenicity, but there was no dilation of the urinary tract. No findings in the rest of the ultrasound examination. Venous Doppler in lower limb excluded DVT.</p><p id="par0020" class="elsevierStylePara elsevierViewall">We proceeded to perform symptomatic treatment of nephrotic syndrome with intravenous use of 20% albumin and furosemide 120<span class="elsevierStyleHsp" style=""></span>mg, spironolactone 12.5<span class="elsevierStyleHsp" style=""></span>mg, enalapril 5<span class="elsevierStyleHsp" style=""></span>mg/day, atorvastatin 40<span class="elsevierStyleHsp" style=""></span>mg/day along with enoxaparin 60<span class="elsevierStyleHsp" style=""></span>mg/day sc. To determine the cause of nephrotic syndrome, a first renal biopsy was performed on the left kidney without getting sufficient material to establish an etiologic diagnosis (2 sclerotic glomeruli). After the first renal biopsy, empirical treatment was initiated with prednisone 60<span class="elsevierStyleHsp" style=""></span>mg/day. The patient was clinically better, and weight and edema loss started. However, in the new proteinuria control performed seven days after starting prednisone, proteinuria remained above 25<span class="elsevierStyleHsp" style=""></span>g. Given the histological lack of available information, it was decided to repeat a second renal biopsy of the right kidney, finding “6 glomeruli per slice plane without significant alterations, and tubule-interstitium component and vessels without findings”, that is why the patient was diagnosed with minimal change glomerulonephritis. Given these histological findings, the established treatment with prednisone was maintained, and 5 days after the second biopsy, proteinuria was reduced to less than 2<span class="elsevierStyleHsp" style=""></span>g. With clinical and analytical improvement, the patient was discharged.</p><p id="par0025" class="elsevierStylePara elsevierViewall">From the first visit to the ER, polycythemia was detected, with the rest of the series in the normal range. The polycythemia has been present during hospitalization and even on the first visit after discharge. Hematology were consulted, and a blood morphology study was requested (red blood cells: normocytic–normochromic with ovalocytes presence and some poikilocytes, white blood cells series: neutrophils with decreased cytoplasmic granulation; Platelet series: without significant morphological alterations); JAK-2 mutations not detected and exon 12 was negative. By these findings, together with the absence of splenomegaly, the polycythemia was considered spurious. Despite clinical improvement, with remission of proteinuria, polycythemia persisted, that is why it was decided to perform a phlebotomy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The association of nephrotic syndrome and polycythemia is rare. Less common is minimal change glomerulonephritis, the cause of nephrotic syndrome in patients with polycythemia. Well, we are describing a case of this association in a very elderly patient.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Most cases of nephrotic syndrome and polycythemia documented in the literature correspond to focal segmental glomerulosclerosis, mainly related with polycythemia vera,<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1–3</span></a> and, in some isolated cases, with secondary polycythemia,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">4</span></a> Some cases of idiopathic membranous nephropathy and secondary polycythemia,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">5,6</span></a> are also collected. Regarding the association of minimal-change disease and polycythemia, as in our case, in reviewing the literature we have only found a few casos.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">7,8</span></a> Although nephrotic syndrome occurs in childhood, and both entities are treated with glucocorticoids, it is in the second decade of life, coinciding with a nephrotic relapse when polycythemia is discovered. In our case, the beginning of both the nephrotic syndrome and polycythemia occur simultaneously and in the eighth decade of life.</p><p id="par0040" class="elsevierStylePara elsevierViewall">In the cases of minimal-change disease and/or membranous nephropathy associated with polycythemia reported in the literature, it is established the hypothesis that as a result of renal hypoxia and increased secretion of interleukin-8 by the kidney, an overproduction of erythropoietin would take place, although in some of these cases the levels were normal and in others they were not available. In our case, although we do not have the levels of erythropoietin, having ruled out the presence of primary polycythemia and other secondary causes, perhaps this can be explained by the existence of renal ischemia associated with severe nephrotic syndrome.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Glucocorticoid therapy in known cases of minimal-change disease and polycythemia allows the disappearance of proteinuria and the levels of hemoglobin and hematocrit were maintained within normal range. In our patient, treatment with corticosteroids allowed a complete remission of proteinuria and a normalization of the levels of transferrin, while polycythemia persisted until the first outpatient visit, requiring the completion of a phlebotomy as a treatment for this.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, we are describing a rare case of minimal-change disease and secondary polycythemia, with a simultaneous onset of both clinical entities in a very elderly patient. Steroid treatment allowed proteinuria remission and transferrin normalization, but without changes in blood parameters. A phlebotomy was necessary to correct the problem.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Heras M, Saiz A, Rosado B, Fernández-Reyes MJ, Queizán JA, Callejas R, et al. Asociación de nefropatía por cambios mínimos y policitemia en un paciente muy anciano. Nefrología. 2016;36:67–69.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CCr, creatinine clearance.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Date \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">2014 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">20/3/2015 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">22/3/2015 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">24/3/2015 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">25/3/2015 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">30/3/2015 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">06/4/2015 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">13/4/2015 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">27/4/2015 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Creatinine (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Albumin (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">2.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">3.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Erythrocytes (×10<span class="elsevierStyleSup">6</span>/μl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.97 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.47 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.56 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6.66 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.94 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.16 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.81 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.05 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hemoglobin (g/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">16.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">19.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">18.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hematocrit (%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">47.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">54.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">56.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">56.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">55.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Leukocytes (×10<span class="elsevierStyleSup">3</span>/μl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5.49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.07 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.35 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.70 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">7.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10.11 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9.85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">8.98 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Platelets (×10<span class="elsevierStyleSup">3</span>/μl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">133 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">159 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">174 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">174 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">202 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">144 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">208 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">182 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">108 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Iron (μ/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">132 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">86 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">179 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ferritin (ng/ml) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">30 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">362 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">185 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Transferrin (mg/dl) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">279 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">165 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Systematic urine (proteinuria) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(−) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">+++ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">(−) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Proteinuria<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> (g/24<span class="elsevierStyleHsp" style=""></span>h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">26.96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.17 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CCr (m/min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">90 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">73.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1381842.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Collected urine in 24<span class="elsevierStyleHsp" style=""></span>h.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Basal laboratory values during the diagnosis of nephrotic syndrome and in the first outpatient visit after discharge.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Focal segmental glomerulosclerosis associated with polycythemia vera: report of a case and review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 9 | 25 |
| 2024 October | 88 | 46 | 134 |
| 2024 September | 81 | 23 | 104 |
| 2024 August | 81 | 69 | 150 |
| 2024 July | 74 | 31 | 105 |
| 2024 June | 60 | 38 | 98 |
| 2024 May | 65 | 37 | 102 |
| 2024 April | 59 | 29 | 88 |
| 2024 March | 53 | 24 | 77 |
| 2024 February | 38 | 35 | 73 |
| 2024 January | 36 | 27 | 63 |
| 2023 December | 44 | 27 | 71 |
| 2023 November | 46 | 35 | 81 |
| 2023 October | 52 | 26 | 78 |
| 2023 September | 36 | 28 | 64 |
| 2023 August | 56 | 30 | 86 |
| 2023 July | 69 | 29 | 98 |
| 2023 June | 64 | 29 | 93 |
| 2023 May | 77 | 31 | 108 |
| 2023 April | 36 | 17 | 53 |
| 2023 March | 64 | 25 | 89 |
| 2023 February | 35 | 18 | 53 |
| 2023 January | 48 | 25 | 73 |
| 2022 December | 59 | 26 | 85 |
| 2022 November | 61 | 34 | 95 |
| 2022 October | 58 | 47 | 105 |
| 2022 September | 59 | 29 | 88 |
| 2022 August | 59 | 49 | 108 |
| 2022 July | 56 | 50 | 106 |
| 2022 June | 52 | 44 | 96 |
| 2022 May | 61 | 34 | 95 |
| 2022 April | 78 | 48 | 126 |
| 2022 March | 66 | 47 | 113 |
| 2022 February | 73 | 54 | 127 |
| 2022 January | 71 | 37 | 108 |
| 2021 December | 60 | 43 | 103 |
| 2021 November | 91 | 42 | 133 |
| 2021 October | 87 | 48 | 135 |
| 2021 September | 131 | 49 | 180 |
| 2021 August | 60 | 54 | 114 |
| 2021 July | 54 | 32 | 86 |
| 2021 June | 39 | 26 | 65 |
| 2021 May | 62 | 42 | 104 |
| 2021 April | 116 | 71 | 187 |
| 2021 March | 105 | 40 | 145 |
| 2021 February | 91 | 46 | 137 |
| 2021 January | 68 | 14 | 82 |
| 2020 December | 64 | 26 | 90 |
| 2020 November | 73 | 26 | 99 |
| 2020 October | 65 | 27 | 92 |
| 2020 September | 85 | 16 | 101 |
| 2020 August | 67 | 17 | 84 |
| 2020 July | 69 | 18 | 87 |
| 2020 June | 71 | 13 | 84 |
| 2020 May | 91 | 17 | 108 |
| 2020 April | 56 | 23 | 79 |
| 2020 March | 54 | 16 | 70 |
| 2020 February | 70 | 22 | 92 |
| 2020 January | 86 | 29 | 115 |
| 2019 December | 77 | 40 | 117 |
| 2019 November | 52 | 21 | 73 |
| 2019 October | 68 | 18 | 86 |
| 2019 September | 87 | 21 | 108 |
| 2019 August | 50 | 18 | 68 |
| 2019 July | 53 | 25 | 78 |
| 2019 June | 48 | 20 | 68 |
| 2019 May | 66 | 20 | 86 |
| 2019 April | 122 | 35 | 157 |
| 2019 March | 53 | 22 | 75 |
| 2019 February | 27 | 11 | 38 |
| 2019 January | 36 | 21 | 57 |
| 2018 December | 126 | 36 | 162 |
| 2018 November | 190 | 31 | 221 |
| 2018 October | 140 | 38 | 178 |
| 2018 September | 69 | 22 | 91 |
| 2018 August | 50 | 21 | 71 |
| 2018 July | 36 | 12 | 48 |
| 2018 June | 30 | 16 | 46 |
| 2018 May | 49 | 13 | 62 |
| 2018 April | 60 | 8 | 68 |
| 2018 March | 47 | 10 | 57 |
| 2018 February | 55 | 7 | 62 |
| 2018 January | 57 | 7 | 64 |
| 2017 December | 59 | 6 | 65 |
| 2017 November | 54 | 15 | 69 |
| 2017 October | 50 | 10 | 60 |
| 2017 September | 28 | 9 | 37 |
| 2017 August | 26 | 14 | 40 |
| 2017 July | 47 | 14 | 61 |
| 2017 June | 39 | 17 | 56 |
| 2017 May | 44 | 13 | 57 |
| 2017 April | 47 | 12 | 59 |
| 2017 March | 28 | 20 | 48 |
| 2017 February | 24 | 17 | 41 |
| 2017 January | 16 | 8 | 24 |
| 2016 December | 35 | 8 | 43 |
| 2016 November | 49 | 11 | 60 |
| 2016 October | 59 | 9 | 68 |
| 2016 September | 101 | 2 | 103 |
| 2016 August | 95 | 2 | 97 |
| 2016 July | 136 | 3 | 139 |
| 2016 June | 104 | 0 | 104 |
| 2016 May | 156 | 0 | 156 |
| 2016 April | 99 | 0 | 99 |
| 2016 March | 61 | 0 | 61 |
| 2016 February | 8 | 0 | 8 |
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