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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Muscle weakness is a symptom that can be explained by the impaired function of&#58; muscle&#44; peripheral nerves&#44; central nervous system or neuromuscular junction&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> When first examining it&#44; it is essential to document a reduction of muscle strength and to define the location of the lesion and its cause&#44; which may be inflammatory&#44; infectious&#44; genetic&#44; metabolic&#44; autoimmune&#44; neoplastic or toxic&#46; Myasthenia gravis &#40;MG&#41; is part of the spectrum of diseases affecting the neuromuscular junction and occurs very rarely during the kidney post-transplantation period&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 29-year-old woman&#44; diagnosed with idiopathic terminal chronic kidney disease&#44; requiring renal replacement therapy for 6 years&#46; Transplantation with a kidney from a deceased haploidentical donor was performed on 11 January 2010&#46; The patient received induction therapy with alemtuzumab and maintenance therapy with cyclosporine&#44; azathioprine and prednisone&#46; One year later the patient came to hospital complaining of persistent muscle weakness in the legs&#44; with frequent falls and occasional reduction of upper arm strength&#46; Subsequently&#44; in the course of a urinary infection treated with ciprofloxacin&#44; she presented with vertical diplopia&#44; respiratory distress and dysphagia for solids&#46; She was hospitalised in the Intensive Care Unit due to the risk of respiratory failure&#46; Neurological examination revealed facial diplegia&#44; 1&#47;5 neck flexor strength&#44; 4&#47;5 strength in the 4 proximal extremities and 5&#47;5 distal extremity strength&#46; For the suspected diagnosis of myasthenic syndrome&#44; tests were performed confirming the diagnosis of MG &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; MG was treated with 5 sessions of plasmapheresis and with pyridostigmine&#44; with favourable progression&#46; At the 5-year follow-up&#44; the patient&#39;s renal function is adequate and her performance status is normal with the use of pyridostigmine&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">MG is a B-lymphocyte-mediated autoimmune disease that produces antibodies against the acetylcholine receptor &#40;AChR&#41;&#46; It is characterised by muscle weakness that is triggered by repetitive activity and which improves with rest and cold&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a> It frequently starts with paresis of the extraocular muscles&#44; which may be isolated or accompanied by bulbar symptoms with dysphagia and dysarthria&#44; respiratory distress due to paresis of muscles of the rib cage and escalation to limb muscles&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">1&#44;2</span></a> For the diagnosis&#44; it is very important to determine AChR antibodies&#44; which are found in up to 85&#37; of cases&#44; and to perform a neurophysiological study with a repetitive stimulation test and a single-fibre test&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Multiple triggers are responsible for the onset or escalation of the disease<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a>&#59; however&#44; myopathic change &#40;MC&#41; is the first manifestation of the disease in up to 8&#37; of patients&#44; with no apparent cause&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In the case reported&#44; the clinical symptoms began acutely as a proximal strength loss&#44; which progressed to respiratory failure&#46; However&#44; it is striking that this occurred while the patient was receiving immunosuppressive therapy&#44; without other clear triggers&#44; except for a urinary infection that was controlled early on&#46; MC is a scenario that requires aggressive management because it represents severe clinical forms with acute bulbar involvement and a high risk of respiratory failure without response to conventional treatments&#46; Intravenous immunoglobulin and plasmapheresis are the therapies of choice in these cases&#44; and both are adequately effective in restoring strength&#46; Therefore&#44; choosing between them depends on the profile of adverse effects&#44; comorbidities&#44; availability and hospital setting&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;3&#44;5</span></a> The preferred drug for symptomatic management is pyridostigmine&#59; its response is a useful diagnostic tool in patients with negative antibodies&#46; Our patient presented with MC that responded very well to plasmapheresis and maintenance therapy with pyridostigmine&#46; In addition&#44; the immunosuppression she received for her transplant likely helped to control the disease&#44; since anti-calcineurin drugs&#44; azathioprine and steroids are reported in the literature as useful treatments for this disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;6&#8211;9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The literature includes 2 reports on MG after kidney transplantation&#58; Hwang<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> describes MC 3 days after kidney transplantation attributed to perioperative stress&#44; while O&#8217;Reilly<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> reports an early MC after kidney transplantation attributed to cyclosporine&#44; which is controversial since this drug is useful for treating MG&#44; and there were many other peri-transplantation factors that could explain it&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">In our case&#44; we did not find any correlation between MG and alemtuzumab&#44; which the patient received a year before presenting with MG as an induction therapy in renal transplantation&#44; or between MG and immunosuppressive maintenance therapy&#46; An association between MG and kidney transplantation is therefore unlikely&#44; and so we conclude that our cases was an epiphenomenon&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The relationship of MG after a solid organ transplantation is not clear&#44; but many perioperative and postoperative factors may be associated with the onset of the disease&#46; There are conditions that are preventable and only clinical judgement and strict monitoring can allow for early suspicion for a timely diagnosis and treatment of a condition that can be fatal&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Nieto-R&#237;os JF&#44; Zuluaga Quintero M&#44; Moreno G&#243;mez L&#44; Aristiz&#225;bal-Alzate A&#44; Ocampo-Kohn C&#44; Serna-Higuita LM&#44; et al&#46; Miastenia gravis posterior a trasplante renal&#46; Nefrologia&#46; 2016&#59;36&#58;716&#8211;718&#46;</p>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">LVEF&#58; left ventricular ejection fraction&#59; CT&#58; computerised axial tomography&#46;</p>"
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                  \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">Electrophysiological studies and images&nbsp;\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&nbsp;\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">Electromyography and Lambert&#8211;Eaton myasthenic syndrome test&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Non-inflammatory myopathic changes in the proximal musculature of the lower and upper limbs&#46; No evidence of peripheral neuropathy or the neuromuscular junction &#40;repetitive stimulation test&#41;&nbsp;\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">Single-fibre electromyography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Pattern of neuromuscular disease&nbsp;\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">Brain MRI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\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">Simple and contrast-enhanced chest CT scan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Without presence of the thymus&#44; without masses&nbsp;\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">Echocardiogram&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal LVEF 65&#37;&nbsp;\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">Fibrobronchoscopy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Normal&nbsp;\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">Muscle biopsy of the lower right limb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Denervation changes&#46; Without atrophy or dystrophy&nbsp;\t\t\t\t\t\t\n
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