Letter to the Editor
Sjogren syndrome and mixed nephropathy. Significance of early kidney biopsy
Síndrome de Sjogren y nefropatía mixta. La importancia de la precocidad en la biopsia renal
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La importancia de la precocidad en la biopsia renal" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "451" "paginaFinal" => "453" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Sjogren syndrom and mixed nephropathy. Significance of early kidney biopsy" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2149 "Ancho" => 2926 "Tamanyo" => 1007214 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Biopsia renal. Glomérulos con proliferación mesangial y endocapilar en los que se observan ocasionales pseudotrombos hialinos de distinto tamaño (flechas). A) PAS 60x. B) Hematoxilina eosina 40x. C) Presencia de numerosos macrófagos intraglomerulares. Inmunohistoquímica para CD 68 40x.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Adoración Martín-Gómez, Mercedes Caba Molina, Gracia Cruz Caparros, Javier Muñoz Vico, Mercedes Gómez Morales" "autores" => array:5 [ 0 => array:2 [ "nombre" => "M. 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Significance of early kidney biopsy" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "451" "paginaFinal" => "453" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "M. Adoración Martín-Gómez, Mercedes Caba Molina, Gracia Cruz Caparros, Javier Muñoz Vico, Mercedes Gómez Morales" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M. Adoración" "apellidos" => "Martín-Gómez" "email" => array:1 [ 0 => "doritamg@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Mercedes" "apellidos" => "Caba Molina" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Gracia" "apellidos" => "Cruz Caparros" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Javier" "apellidos" => "Muñoz Vico" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "Mercedes" "apellidos" => "Gómez Morales" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad de Nefrología, Hospital de Poniente, El Ejido, Almería, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital San Cecilio, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Medicina Interna, Hospital de Poniente, El Ejido, Almería, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Inmunología Hospital Torrecárdenas, Almería, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Síndrome de Sjogren y nefropatía mixta. La importancia de la precocidad en la biopsia renal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1106 "Ancho" => 1508 "Tamanyo" => 428094 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Renal biopsy. Glomeruli with mesangial and endocapillary proliferation in which some hyaline pseudothrombi of different sizes are observed (arrows). (A) Periodic acid–Schiff (PAS) 60×. (B) Haematoxylin and eosin 40×. (C) Presence of numerous intraglomerular macrophages. Immunohistochemistry for CD68 40×.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">We present the case of a 76-year-old patient with primary Sjogren's syndrome (pSS) and mild acute renal failure with active sediment. Prior medical history included hypertension well controlled with 2 drugs and pSS with glandular (biopsy) and extraglandular involvement (pulmonary fibrosis, skin purpura and Raynaud's disease that required treatment with steroids), being treated with azathioprine, prednisone 5<span class="elsevierStyleHsp" style=""></span>mg/day, biphosphonate, calcium/vitamin D, pentoxifylline, acetylcysteine, perindopril 4<span class="elsevierStyleHsp" style=""></span>mg and amlodipine 5<span class="elsevierStyleHsp" style=""></span>mg.</p><p id="par0010" class="elsevierStylePara elsevierViewall">She was admitted in July 2013 because of recurrence of purpura in the lower limbs, weakness, fever of 37.8<span class="elsevierStyleHsp" style=""></span>°C, dry cough, nausea and bilious vomiting, together with weight loss of up to 10<span class="elsevierStyleHsp" style=""></span>kg in 2 months. Findings on physical examination included skin purpura and bilateral basal hypoventilation, attributed to her pulmonary fibrosis. She was stable as confirmed by CT scan (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), with no palpable lymphadenopathies. Findings on laboratory testing included acute normochromic normocytic anaemia that was neither haemolytic nor iron-deficient, with normal protein electrophoresis, creatinine 1.07<span class="elsevierStyleHsp" style=""></span>mg/dl (reatinine clearance of 68<span class="elsevierStyleHsp" style=""></span>ml/min), proteinuria 200<span class="elsevierStyleHsp" style=""></span>mg/dl (0.38<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h) and sediment 20 RBCs/field (56% dysmorphic). Positive routine autoimmunity (ANA+, Ro+, La+, C4 hypocomplementaemia 1<span class="elsevierStyleHsp" style=""></span>mg/dl and very high IgM and rheumatoid factor [RF]). In addition to current C3 hypocomplementaemia 66<span class="elsevierStyleHsp" style=""></span>mg/dl, drop in IgG 600<span class="elsevierStyleHsp" style=""></span>mg/dl (previously normal) and positive for cryoglobulins. Negative hepatitis C and B and HIV serology. Negative ANCAs. A skin biopsy was performed and reported small-vessel leukocytoclastic vasculitis. A renal biopsy of 28 glomeruli reported the following: glomerulomegaly; in 3 glomeruli, widespread sclerosis and, in the rest of glomeruli, lesions of ischaemia–basement membrane folding, mesangial and endocapillary hypercellularity, and some small PAS<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>hyaline thrombi with inflammatory cells CD68+ in their interior; mononuclear interstitial infiltrate; mild fibrosis and atrophy; focal tubular inflammation and ischaemia; arterioles with focal deposition of PAS<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>hyaline substance and thickening of the intima on immunofluorescence (9 glomeruli/1 sclerotic); IgM+ in interstitial inflammatory cell foci and around tubules; C3± heterogeneous mesangial C3 and in vascular walls; and negative Epstein–Barr virus <span class="elsevierStyleItalic">in situ</span> hybridisation (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Given such findings, she was diagnosed with mixed cryoglobulinaemia associated with pSS, and it was decided to start treatment with rituximab 375<span class="elsevierStyleHsp" style=""></span>mg/m<span class="elsevierStyleSup">2</span>/week (4 doses) and to maintain azathioprine and prednisone at routine doses. The result was satisfactory: CD20 lymphocytes dropped to 0.3%, the anaemia and renal profile (sediment and clearance) returned to normal and she was negative for cryoglobulins. At her last follow-up (25 months post-biopsy), the stability of renal function and percentage of CD20 B lymphocytes persisted, but she was again positive for cryoglobulins at her last 2 follow-ups. Now, we are expectant, with close monitoring.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Notable in this case was the low clinical expressivity of the patient's cryoglobulinaemic glomerulonephritis, which we attributed to early clinical diagnosis. The indication for a renal biopsy was relative, given the mild nature of the clinical and laboratory findings, but baseline disease and the large variety of potential associated nephropathies<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> led us to perform the renal biopsy. Had it been delayed, she probably would have had greater parenchymal damage.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The most commonly reported finding in kidney biopsy of pSS is tubulointerstitial disease; glomerular disease is rare and coexistence of the two as in the patient described is uncertain. The presence of the glomerular and cryoglobulinaemic component seems to worsen the prognosis of survival.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Induction with Rituximab in cryoglobulinaemic glomerulonephritis produces positive results in terms of the balance efficacy/safety.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> The baseline level of CD27+ memory lymphocytes seems to predict a better response to this drug.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> With respect to maintenance treatment, nothing has been established yet. A relapse rate of up to 40% has been reported, but this was in series with a majority of patients with HCV+ and without consideration of predictive factors.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> Reactivating the complement, cryoglobulins or CD20 cells does not in itself is not an indication of a new cycle of immunosuppressant therapy, but it suggest a closer follow-up as a precaution in anticipation of a clinical recurrence. This is the attitude adopted in this case.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Martín-Gómez MA, Caba Molina M, Cruz Caparros G, Muñoz Vico J, Gómez Morales M. Síndrome de Sjogren y nefropatía mixta. La importancia de la precocidad en la biopsia renal. Nefrologia. 2016;36:451–453.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1050 "Ancho" => 753 "Tamanyo" => 133982 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Chest X-ray and CT scan. Distortion of the pulmonary interstitium on the subpleural level of both bases, with thickening of the intralobular interstitium and interlobular septa, consistent with pulmonary fibrosis predominately on the posterior–basal subpleural level. Also bilateral basal cylindrical bronchiectasis.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1106 "Ancho" => 1508 "Tamanyo" => 428094 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Renal biopsy. Glomeruli with mesangial and endocapillary proliferation in which some hyaline pseudothrombi of different sizes are observed (arrows). (A) Periodic acid–Schiff (PAS) 60×. (B) Haematoxylin and eosin 40×. (C) Presence of numerous intraglomerular macrophages. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 3 | 7 |
| 2024 October | 69 | 42 | 111 |
| 2024 September | 67 | 26 | 93 |
| 2024 August | 83 | 74 | 157 |
| 2024 July | 66 | 26 | 92 |
| 2024 June | 53 | 36 | 89 |
| 2024 May | 70 | 50 | 120 |
| 2024 April | 63 | 33 | 96 |
| 2024 March | 78 | 29 | 107 |
| 2024 February | 54 | 40 | 94 |
| 2024 January | 52 | 28 | 80 |
| 2023 December | 65 | 20 | 85 |
| 2023 November | 68 | 28 | 96 |
| 2023 October | 58 | 34 | 92 |
| 2023 September | 70 | 25 | 95 |
| 2023 August | 38 | 18 | 56 |
| 2023 July | 71 | 30 | 101 |
| 2023 June | 66 | 17 | 83 |
| 2023 May | 72 | 24 | 96 |
| 2023 April | 44 | 15 | 59 |
| 2023 March | 66 | 21 | 87 |
| 2023 February | 46 | 18 | 64 |
| 2023 January | 71 | 23 | 94 |
| 2022 December | 91 | 24 | 115 |
| 2022 November | 76 | 24 | 100 |
| 2022 October | 102 | 33 | 135 |
| 2022 September | 50 | 27 | 77 |
| 2022 August | 68 | 41 | 109 |
| 2022 July | 80 | 48 | 128 |
| 2022 June | 67 | 32 | 99 |
| 2022 May | 97 | 40 | 137 |
| 2022 April | 109 | 41 | 150 |
| 2022 March | 120 | 44 | 164 |
| 2022 February | 121 | 42 | 163 |
| 2022 January | 97 | 42 | 139 |
| 2021 December | 114 | 42 | 156 |
| 2021 November | 74 | 36 | 110 |
| 2021 October | 101 | 55 | 156 |
| 2021 September | 98 | 37 | 135 |
| 2021 August | 67 | 40 | 107 |
| 2021 July | 84 | 43 | 127 |
| 2021 June | 66 | 26 | 92 |
| 2021 May | 75 | 50 | 125 |
| 2021 April | 112 | 62 | 174 |
| 2021 March | 77 | 39 | 116 |
| 2021 February | 100 | 30 | 130 |
| 2021 January | 51 | 19 | 70 |
| 2020 December | 51 | 20 | 71 |
| 2020 November | 41 | 27 | 68 |
| 2020 October | 35 | 20 | 55 |
| 2020 September | 42 | 19 | 61 |
| 2020 August | 38 | 12 | 50 |
| 2020 July | 39 | 15 | 54 |
| 2020 June | 42 | 16 | 58 |
| 2020 May | 60 | 20 | 80 |
| 2020 April | 40 | 14 | 54 |
| 2020 March | 36 | 14 | 50 |
| 2020 February | 49 | 18 | 67 |
| 2020 January | 54 | 21 | 75 |
| 2019 December | 61 | 19 | 80 |
| 2019 November | 40 | 18 | 58 |
| 2019 October | 28 | 11 | 39 |
| 2019 September | 35 | 15 | 50 |
| 2019 August | 31 | 20 | 51 |
| 2019 July | 31 | 22 | 53 |
| 2019 June | 25 | 19 | 44 |
| 2019 May | 27 | 26 | 53 |
| 2019 April | 496 | 35 | 531 |
| 2019 March | 480 | 17 | 497 |
| 2019 February | 36 | 20 | 56 |
| 2019 January | 46 | 22 | 68 |
| 2018 December | 113 | 42 | 155 |
| 2018 November | 188 | 24 | 212 |
| 2018 October | 194 | 20 | 214 |
| 2018 September | 95 | 31 | 126 |
| 2018 August | 57 | 18 | 75 |
| 2018 July | 72 | 10 | 82 |
| 2018 June | 72 | 14 | 86 |
| 2018 May | 100 | 12 | 112 |
| 2018 April | 130 | 7 | 137 |
| 2018 March | 122 | 9 | 131 |
| 2018 February | 108 | 4 | 112 |
| 2018 January | 87 | 5 | 92 |
| 2017 December | 119 | 9 | 128 |
| 2017 November | 78 | 10 | 88 |
| 2017 October | 39 | 6 | 45 |
| 2017 September | 41 | 13 | 54 |
| 2017 August | 36 | 12 | 48 |
| 2017 July | 47 | 9 | 56 |
| 2017 June | 49 | 32 | 81 |
| 2017 May | 161 | 14 | 175 |
| 2017 April | 56 | 9 | 65 |
| 2017 March | 43 | 25 | 68 |
| 2017 February | 45 | 13 | 58 |
| 2017 January | 25 | 9 | 34 |
| 2016 December | 51 | 13 | 64 |
| 2016 November | 66 | 15 | 81 |
| 2016 October | 87 | 13 | 100 |
| 2016 September | 94 | 6 | 100 |
| 2016 August | 102 | 1 | 103 |
| 2016 July | 8 | 0 | 8 |
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