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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In adult age group&#44; the cause of membranous glomerulonephritis &#40;MG&#41; cannot be detected in about 75&#37; of the patients&#46; These cases are defined as idiopathic &#40;primary&#41; MG&#46; MG associated with drugs and other diseases are defined as secondary MG&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Penicillamine and gold salts&#44; formerly used in the treatment of rheumatoid arthritis &#40;RA&#41;&#44; are responsible for the development of MG&#46; Amyloidosis&#44; analgesic nephropathy&#44; glomerulonephritis and rheumatoid vasculitis can be observed in RA&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the literature sulfasalazine was reported to cause interstitial nephritis&#44; nephrotic syndrome&#44; acute renal failure&#44; non-nephrotic proteinuria&#44; hematuria&#44; and leucocyturia&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;4</span></a> Sulfasalazine 2000<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; hydroxychloroquine&#44; prednisolone 5<span class="elsevierStyleHsp" style=""></span>mg&#47;day was started for a 55 year old non-diabetic man who was diagnosed as rheumatoid arthritis a year ago&#46; He did not have a history of nonsteroidal antiinflamatory drug use&#46; Proteinuria was detected a month later&#46; Daily protein excretion was 14&#44;725<span class="elsevierStyleHsp" style=""></span>mg&#47;day and serum albumin was 2&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; On physical examination&#44; the patient was normotensive and had pitting oedema in his legs&#46; The patient&#39;s blood urea nitrogen and creatinine level and C3&#44; C4 was in normal range and HBsAg&#44; AntiHCV&#44; p-ANCA and c-ANCA was found to be negative&#46; ANA was positive&#44; but anti-ds DNA was found to be negative&#46; Duodenal biopsy was negative for amyloid and percutaneous kidney biopsy was performed&#46; In light microscopic examination&#44; mild thickening of the glomerular basement membrane&#44; mild interstitial inflammatory cell infiltration and hyaline material accumulation in some tubular spaces was observed&#46; By immunofluorescence microscopy strong linear&#47;granular IgG and complement deposition and mild granular&#44; C3&#44; C1q and kappa deposition in glomerular basal membranes was detected&#46; These pathological findings suggested the diagnosis of membranous glomerulonephritis anti-phospholipase A2 receptor antibodies were negative&#46; Considering this condition to be related to sulfasalazine&#44; treatment was dropped out and prednisolone dosage was increased as 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46; In follow-up&#44; two months later&#44; 24-h urine protein excretion was found to be 389<span class="elsevierStyleHsp" style=""></span>mg&#47;day and steroid dosage was tapered gradually&#46; He is now being followed without proteinuria&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although rare&#44; case reports blaming sulfasalazine in the pathogenesis of parenchymal kidney injury&#44; exist&#46; Nevertheless&#44; the US FDA placed a warning within the prescribing information for mesalazine products that stated &#8220;It is recommended that all patients have an evaluation of renal function prior to initiation of therapy and periodically while on treatment&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">5-Aminosalicylate &#40;5-ASA&#41; is blamed for the nephrotoxicity of these drugs&#46; Nephrotoxicity is thought to be idiosyncratic rather than dose-related&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Cases reported in the literature were mainly in the form of progressive interstitial nephritis&#46; Following cessation of treatment&#44; improvement of renal function can be observed in some cases&#44; while steroid treatment can be indicated if improvement is not observed&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In a cohort of ulcerative colitis 6 patients were reported to develop nephrotic syndrome&#46; 3 of these patients were using mesalasine while 2 were using sulfasalazine and one patient was using both&#46; In histological evaluation of the patients&#44; 5 had minimal change disease and one patient had focal segmental glomerulosclerosis&#46; All of the patients improved with steroid treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The pathogenesis of nephrotic syndrome associated with the use of sulfasalazine is not understood yet&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was also using hydroxychloroquine&#46; This drug continued and remission of proteinuria existed&#44; so the cause is not probably this drug&#46; Also rheumatologic diseases can cause MN but proteinuria remission after discontinuation of the drug excluded this possibility&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In our case&#44; the histopathologic diagnosis was membranous glomerulonephritis and this varies from case reports in the literature&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Drugs are one of the important causes of secondary membranous glomerulonephritis&#46; By presenting this case we want to remind that sulfasalazine may be a cause of secondary membranous glomerulonephritis&#46;</p></span>"
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Letter to the Editor
A membranous nephropathy case: Is it related to sulfasalazine?
Un nefropatía membranosa Caso: ¿Está relacionado con sulfasalazina?
Oktay Bagdatoglua, Yuksel Marasb, Ozlem Yayara,
Corresponding author
ozlemderen@hotmail.com

Corresponding author.
, Baris Eserc
a Nephrology Department, Ankara Ataturk Research and Training Hospital , Turkey
b Rheumatology Department, Ankara Ataturk Research and Training Hospital, Turkey
c Nephrology Department, Corum Hitit University, Turkey
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        "titulo" => "Un nefropat&#237;a membranosa Caso&#58; &#191;Est&#225; relacionado con sulfasalazina&#63;"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In adult age group&#44; the cause of membranous glomerulonephritis &#40;MG&#41; cannot be detected in about 75&#37; of the patients&#46; These cases are defined as idiopathic &#40;primary&#41; MG&#46; MG associated with drugs and other diseases are defined as secondary MG&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Penicillamine and gold salts&#44; formerly used in the treatment of rheumatoid arthritis &#40;RA&#41;&#44; are responsible for the development of MG&#46; Amyloidosis&#44; analgesic nephropathy&#44; glomerulonephritis and rheumatoid vasculitis can be observed in RA&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the literature sulfasalazine was reported to cause interstitial nephritis&#44; nephrotic syndrome&#44; acute renal failure&#44; non-nephrotic proteinuria&#44; hematuria&#44; and leucocyturia&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#8211;4</span></a> Sulfasalazine 2000<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#44; hydroxychloroquine&#44; prednisolone 5<span class="elsevierStyleHsp" style=""></span>mg&#47;day was started for a 55 year old non-diabetic man who was diagnosed as rheumatoid arthritis a year ago&#46; He did not have a history of nonsteroidal antiinflamatory drug use&#46; Proteinuria was detected a month later&#46; Daily protein excretion was 14&#44;725<span class="elsevierStyleHsp" style=""></span>mg&#47;day and serum albumin was 2&#46;8<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#46; On physical examination&#44; the patient was normotensive and had pitting oedema in his legs&#46; The patient&#39;s blood urea nitrogen and creatinine level and C3&#44; C4 was in normal range and HBsAg&#44; AntiHCV&#44; p-ANCA and c-ANCA was found to be negative&#46; ANA was positive&#44; but anti-ds DNA was found to be negative&#46; Duodenal biopsy was negative for amyloid and percutaneous kidney biopsy was performed&#46; In light microscopic examination&#44; mild thickening of the glomerular basement membrane&#44; mild interstitial inflammatory cell infiltration and hyaline material accumulation in some tubular spaces was observed&#46; By immunofluorescence microscopy strong linear&#47;granular IgG and complement deposition and mild granular&#44; C3&#44; C1q and kappa deposition in glomerular basal membranes was detected&#46; These pathological findings suggested the diagnosis of membranous glomerulonephritis anti-phospholipase A2 receptor antibodies were negative&#46; Considering this condition to be related to sulfasalazine&#44; treatment was dropped out and prednisolone dosage was increased as 20<span class="elsevierStyleHsp" style=""></span>mg&#47;day&#46; In follow-up&#44; two months later&#44; 24-h urine protein excretion was found to be 389<span class="elsevierStyleHsp" style=""></span>mg&#47;day and steroid dosage was tapered gradually&#46; He is now being followed without proteinuria&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Although rare&#44; case reports blaming sulfasalazine in the pathogenesis of parenchymal kidney injury&#44; exist&#46; Nevertheless&#44; the US FDA placed a warning within the prescribing information for mesalazine products that stated &#8220;It is recommended that all patients have an evaluation of renal function prior to initiation of therapy and periodically while on treatment&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">5-Aminosalicylate &#40;5-ASA&#41; is blamed for the nephrotoxicity of these drugs&#46; Nephrotoxicity is thought to be idiosyncratic rather than dose-related&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Cases reported in the literature were mainly in the form of progressive interstitial nephritis&#46; Following cessation of treatment&#44; improvement of renal function can be observed in some cases&#44; while steroid treatment can be indicated if improvement is not observed&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In a cohort of ulcerative colitis 6 patients were reported to develop nephrotic syndrome&#46; 3 of these patients were using mesalasine while 2 were using sulfasalazine and one patient was using both&#46; In histological evaluation of the patients&#44; 5 had minimal change disease and one patient had focal segmental glomerulosclerosis&#46; All of the patients improved with steroid treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a> The pathogenesis of nephrotic syndrome associated with the use of sulfasalazine is not understood yet&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">The patient was also using hydroxychloroquine&#46; This drug continued and remission of proteinuria existed&#44; so the cause is not probably this drug&#46; Also rheumatologic diseases can cause MN but proteinuria remission after discontinuation of the drug excluded this possibility&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">In our case&#44; the histopathologic diagnosis was membranous glomerulonephritis and this varies from case reports in the literature&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Drugs are one of the important causes of secondary membranous glomerulonephritis&#46; By presenting this case we want to remind that sulfasalazine may be a cause of secondary membranous glomerulonephritis&#46;</p></span>"
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