Letter to the Editor
When kidneys are no longer a friend: An “out of the box” management for an unexpected evolution of an uncommon disease
Cuando los riñones dejan de ser un amigo: Una gestión “fuera de la caja” de una evolución imprevista de una enfermedad poco común
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Española de Nefrología" "documento" => "simple-article" "crossmark" => 0 "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/" "subdocumento" => "cor" "cita" => "Nefrologia (English Version). 2016;36:560-2" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:2 [ "total" => 3729 "formatos" => array:3 [ "EPUB" => 322 "HTML" => 2744 "PDF" => 663 ] ] "en" => array:11 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Rare brown tumour location in chronic renal failure" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "560" "paginaFinal" => "562" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Rara localización de tumour pardo en paciente pediátrico" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ 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"figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3122 "Ancho" => 1658 "Tamanyo" => 459612 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Description of the patient's brown tumour bone lesion. (A) Marked genu varus with mild left lower limb oedema. (B) AP X-ray of left knee, incomplete fracture zone of left femur distal epiphysis, with infiltrative radiopaque image. (C) CT of same anatomical area, solid osteolytic lesion 40<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>33<span class="elsevierStyleHsp" style=""></span>mm in the distal femoral epiphysis, cartilage growth seems to be unaffected. (D) Processed tissue sample, large quantity of multinucleated cells. (E) MRI of same anatomical area, metaphyseal, irregular, heterogeneous, space-occupying process with compromise of bone and cortical portion centred in the distal femoral metaphyseal portion 35<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>33<span class="elsevierStyleHsp" style=""></span>mm and with the presence of perilesional fluid; not compromising other structures. (F) Whole-body bone scan with <span class="elsevierStyleSup">99m</span>Tc-sestaMIBI shows uptake of radiotracer in distal metaphysis of left femur. (G) 3-Dimensional tomographic view, lateral and posterior view of distal epiphysis of left femur. (H) Precise identification of the multinucleated giant cell, characteristic of brown tumour of bone.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Juan Miguel Alemán-Iñiguez, Franklin Mora-Bravo, Christian Bravo-Aguilar" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Juan Miguel" "apellidos" => "Alemán-Iñiguez" ] 1 => array:2 [ "nombre" => "Franklin" "apellidos" => "Mora-Bravo" ] 2 => array:2 [ "nombre" => "Christian" "apellidos" => "Bravo-Aguilar" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0211699516300200" "doi" => "10.1016/j.nefro.2016.03.017" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => true "ES2" => true "LATM" => true ] "gratuito" => true "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699516300200?idApp=UINPBA000064" ] ] "EPUB" => 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"oliveirasilva.sandra@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" => "Ricardo" "apellidos" => "Pereira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Ivo" "apellidos" => "Cunha" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Carlos" "apellidos" => "Ferreira" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Ana" "apellidos" => "Branco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" 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=> array:3 [ "nombre" => "José" "apellidos" => "Costa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Nephrology, Hospital Pedro Hispano, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Internal Medicine, Hospital Pedro Hispano, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Urology, Hospital Pedro Hispano, Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Pathology, Hospital Pedro Hispano, Porto, Portugal" "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" => "Cuando los riñones dejan de ser un amigo: Una gestión “fuera de la caja” de una evolución imprevista de una enfermedad poco común" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 626 "Ancho" => 1700 "Tamanyo" => 235792 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histological examination of the kidneys. (A) Glomerular nodular deposits of amyloid stained with Congo red. (B) Amyloid showing typical apple-green birefringence under polarized light.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">AA amyloidosis (AAA) is one of most severe complications of chronic inflammatory and infectious diseases and may induce nephrotic syndrome.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Its association with Crohn's disease has been regularly reported, but amyloidosis complicating ulcerative colitis (UC) has been described only exceptionally.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of a 58-year-old woman who was admitted with anasarca and nephrotic syndrome (NS). Relevant medical history included UC, gangrenous pyoderma and a tuberculous empyema. In 2002, a NS was identified and a renal biopsy displayed the diagnosis of AAA. In addition to treatment with 5-aminosalicylic-acid, a trial of colchicine was implemented but had to be stopped due to diarrhea. Renal function (RF) was sustainably preserved and the proteinuria spontaneously remitted. Throughout time she had long-lasting, moderate gastrointestinal symptoms with evidence of mild endoscopic inflammation. In 2015 she developed once more disabling proteinuria with normal RF and a diagnostic workup corroborated the clinical impression of recurrence of her amyloidosis (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). An endoscopic review exhibited mild disease and, in addition to messalazine and prednisone, she was started on azathioprine, which had to be suspended due to pancreatitis. Therapy with an angiotensin-converting enzyme inhibitor was initiated but not tolerated; albumin-plus-furosemide infusion led merely to temporary improvement. A decision to deteriorate RF to decrease proteinuria was attempted: indomethacin led to acute renal dysfunction but didn’t significantly improved proteinuria. Hemodialysis was started but had to be interrupted due to hemodynamic instability. After a multidisciplinary consultation, she underwent a bilateral nephrectomy. Post-operatively, serum albumin and postural symptoms gradually improved with subsequent better hemodialysis tolerance. Histology revealed extensive amyloid deposits (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and immunohistochemical staining was positive for AA amyloid. Nutritional and functional status gradually improved.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">AAA in the setting of UC is a rarity and typically, severe gastrointestinal illness precedes the development of amyloidosis,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> however this was not the case in our patient, who had a long standing, though mild disease. We speculate that the ongoing activity and the prolonged duration may have had a role; nevertheless, an additional contribution from the tuberculosis cannot be ruled out.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Another peculiar aspect is the spontaneous remission of the patient's NS. Improvement of amyloidosis manifestations is extensively documented in the context of remission of the underlying disease, but spontaneous regression is extremely unlikely.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Patients with large proteinuria due to AAA can experience a life-threatening cachexic state with massive edema, respiratory distress and infectious complications, along with a poor functional status and a reduced quality-of-life. Up to the present, AAA has no specific treatment and despite the development of novel therapies (eprodisate)<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> targeting the formation/stability of fibrils, the current available approach is to treat the underlying condition and thereby reduce the amyloid production. Nevertheless, this goal is not always achieved and the management of proteinuria can be challenging, resorting, in intractable cases like ours, to renal ablation. Medical ablation, with non-steroidal anti-inflammatory drugs<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> has been attempted; bilateral renal artery embolization is an alternative, although frequently complicated by a ‘post-infarction syndrome’.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> Recently, bilateral ureteral ligation<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> has been described, but the experience is limited and can induce persistent loin pain and ascending infections. Surgical nephrectomy is another option: although laparoscopic surgery is a less invasive procedure than an open nephrectomy, it precludes the chance for peritoneal dialysis and, consequently, we elected a bilateral nephrectomy by lombotomy.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The histological examination of the kidneys revealed extensive presence of AA amyloid deposits comprising the glomeruli, the blood vessels and the interstitium, an infrequent finding in the review by Hopfer et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> who reported interstitium involvement in only 5.9%.</p><p id="par0035" class="elsevierStylePara elsevierViewall">AAA has a major impact in patient's quality of life: Esteve et al.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> reported that in 1/3 of the patients, dialysis was not performed due to their poor clinical condition and disturbing quality of life. Bilateral nephrectomy in our patient, led to an improvement in hemodynamic stability allowing hemodialysis to be accomplished. Additionally, her functional and nutritional status enhanced gradually.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Radical bilateral nephrectomy may be considered in seriously ill patients with nephrotic syndrome and disabling complications of proteinuria.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflict of interest.</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 "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" => 626 "Ancho" => 1700 "Tamanyo" => 235792 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Histological examination of the kidneys. (A) Glomerular nodular deposits of amyloid stained with Congo red. (B) Amyloid showing typical apple-green birefringence under polarized light.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "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="" valign="top" scope="col" style="border-bottom: 2px solid black"> \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">Result \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">Reference range \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">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">9.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">12–16 \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 (<span class="elsevierStyleSmallCaps">10</span><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">9.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4–11 \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 (<span class="elsevierStyleSmallCaps">10</span><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">183 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">150–400 \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">C-reactive protein (mg/L/sedimentation rate 1st h) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">24/127 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><5/0–30 \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">Total protein/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">4.4/1.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">6.4–8.3/3.5–5.0 \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">AST/ALT/LDH (U/L)<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">11/18/205 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5–34/<55/110–220 \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">Fasting glucose/total bilirubin (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">83/0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">60–110/0.2–1.2 \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">Total/LDL/HDL cholesterol (mg/dL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">270/169/40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><200/<100/≥60 \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">Urea/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">52/0.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">21–43/0.6–1.1 \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">Urinalysis/24 hours protein (mg/day) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">4+ proteinuria/19<span class="elsevierStyleHsp" style=""></span>538 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0+/<300 \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">Serum immunoelectrophoresis/serum kappa-lambda ratio \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Absence of monoclonal gammopathy/normal \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urinary electrophoresis/urinary immunoelectrophoresis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Albumin<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>46% and gamma globulin<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>14%/no band suggestive of monoclonality \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tests for hepatitis B and C, HIV<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a>, and syphilis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Negative \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ANA, anti-dsDNA and ANCA<a class="elsevierStyleCrossRef" href="#tblfn0015"><span class="elsevierStyleSup">c</span></a> antibodies; C3 and C4 complement levels \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Normal \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></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Serum amyloide A (mg/L) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">79.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top"><7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1299527.png" ] ] ] "notaPie" => array:3 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">AST: aspartate transaminase, ALT: alanine transaminase, LDH: lactate dehydrogenase.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">HIV: human immunodeficiency virus.</p>" ] 2 => array:3 [ "identificador" => "tblfn0015" "etiqueta" => "c" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">ANA: antinuclear antibodies, anti-dsDNA: anti-double stranded DNA antibodies, ANCA: antineutrophil cytoplasmic antibodies.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Laboratory tests results.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Amyloid nephropathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 1 | 1 | 2 |
| 2024 October | 32 | 28 | 60 |
| 2024 September | 46 | 27 | 73 |
| 2024 August | 62 | 64 | 126 |
| 2024 July | 31 | 23 | 54 |
| 2024 June | 55 | 36 | 91 |
| 2024 May | 42 | 28 | 70 |
| 2024 April | 51 | 40 | 91 |
| 2024 March | 34 | 23 | 57 |
| 2024 February | 35 | 29 | 64 |
| 2024 January | 38 | 28 | 66 |
| 2023 December | 31 | 19 | 50 |
| 2023 November | 44 | 28 | 72 |
| 2023 October | 64 | 27 | 91 |
| 2023 September | 59 | 25 | 84 |
| 2023 August | 53 | 20 | 73 |
| 2023 July | 70 | 25 | 95 |
| 2023 June | 59 | 20 | 79 |
| 2023 May | 77 | 27 | 104 |
| 2023 April | 54 | 15 | 69 |
| 2023 March | 89 | 16 | 105 |
| 2023 February | 40 | 18 | 58 |
| 2023 January | 25 | 18 | 43 |
| 2022 December | 54 | 26 | 80 |
| 2022 November | 49 | 34 | 83 |
| 2022 October | 50 | 28 | 78 |
| 2022 September | 55 | 40 | 95 |
| 2022 August | 65 | 45 | 110 |
| 2022 July | 30 | 40 | 70 |
| 2022 June | 45 | 29 | 74 |
| 2022 May | 99 | 30 | 129 |
| 2022 April | 48 | 48 | 96 |
| 2022 March | 55 | 41 | 96 |
| 2022 February | 38 | 36 | 74 |
| 2022 January | 27 | 30 | 57 |
| 2021 December | 50 | 38 | 88 |
| 2021 November | 44 | 27 | 71 |
| 2021 October | 57 | 47 | 104 |
| 2021 September | 61 | 33 | 94 |
| 2021 August | 29 | 35 | 64 |
| 2021 July | 47 | 24 | 71 |
| 2021 June | 62 | 30 | 92 |
| 2021 May | 63 | 37 | 100 |
| 2021 April | 104 | 75 | 179 |
| 2021 March | 52 | 44 | 96 |
| 2021 February | 49 | 30 | 79 |
| 2021 January | 71 | 28 | 99 |
| 2020 December | 40 | 22 | 62 |
| 2020 November | 35 | 12 | 47 |
| 2020 October | 32 | 19 | 51 |
| 2020 September | 24 | 12 | 36 |
| 2020 August | 42 | 15 | 57 |
| 2020 July | 37 | 12 | 49 |
| 2020 June | 28 | 8 | 36 |
| 2020 May | 39 | 15 | 54 |
| 2020 April | 27 | 17 | 44 |
| 2020 March | 43 | 10 | 53 |
| 2020 February | 28 | 22 | 50 |
| 2020 January | 35 | 23 | 58 |
| 2019 December | 46 | 17 | 63 |
| 2019 November | 35 | 29 | 64 |
| 2019 October | 30 | 13 | 43 |
| 2019 September | 25 | 15 | 40 |
| 2019 August | 21 | 12 | 33 |
| 2019 July | 13 | 23 | 36 |
| 2019 June | 29 | 11 | 40 |
| 2019 May | 23 | 14 | 37 |
| 2019 April | 44 | 33 | 77 |
| 2019 March | 34 | 16 | 50 |
| 2019 February | 17 | 15 | 32 |
| 2019 January | 19 | 13 | 32 |
| 2018 December | 150 | 39 | 189 |
| 2018 November | 378 | 15 | 393 |
| 2018 October | 369 | 26 | 395 |
| 2018 September | 152 | 30 | 182 |
| 2018 August | 70 | 19 | 89 |
| 2018 July | 67 | 20 | 87 |
| 2018 June | 91 | 7 | 98 |
| 2018 May | 155 | 17 | 172 |
| 2018 April | 163 | 7 | 170 |
| 2018 March | 180 | 8 | 188 |
| 2018 February | 251 | 6 | 257 |
| 2018 January | 295 | 11 | 306 |
| 2017 December | 281 | 7 | 288 |
| 2017 November | 71 | 16 | 87 |
| 2017 October | 28 | 5 | 33 |
| 2017 September | 49 | 17 | 66 |
| 2017 August | 25 | 6 | 31 |
| 2017 July | 20 | 5 | 25 |
| 2017 June | 25 | 16 | 41 |
| 2017 May | 28 | 10 | 38 |
| 2017 April | 31 | 15 | 46 |
| 2017 March | 23 | 18 | 41 |
| 2017 February | 30 | 10 | 40 |
| 2017 January | 48 | 15 | 63 |
| 2016 December | 2 | 0 | 2 |
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