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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sneddon&#39;s syndrome &#40;SS&#41; is a rare and slowly progressive vascular disease that affects small and medium-sized arteries&#44; characterised by the association of <span class="elsevierStyleItalic">livedo reticularis</span> and recurrent cerebrovascular accidents &#40;CVA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Approximately 80&#37; of SS patients are women with a median age of 40 years&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The aetiopathogenesis is unknown&#44; with two proposed primary mechanisms &#40;autoimmune&#47;inflammatory versus thrombophilia&#41;&#44; and it is classified mainly as positive or negative antiphospholipid&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The main symptoms are cutaneous&#44; which usually precede neurological symptoms by more than 10 years&#46; The vast majority of patients present with labile systolic hypertension and it can also affect the heart valves or the kidneys&#44; inter alia&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> After reviewing the literature&#44; histopathological renal involvement in this syndrome is extremely rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Below we describe a case of SS with biopsy-proven chronic kidney disease associated with features of membranous nephropathy&#58;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 53-year-old woman diagnosed with SS&#44; arterial hypertension&#44; arterial toe ischaemia and an active smoker&#44; receiving treatment with acetylsalicylic acid &#40;ASA&#41;&#44; atorvastatin and valsartan&#46; She is referred to nephrology due to the onset of albuminuria&#46; Asymptomatic&#44; with good blood pressure control&#46; Normal physical examination except for <span class="elsevierStyleItalic">livedo reticularis</span> in the facial area&#44; back of the hands&#44; upper and lower limbs&#46; An investigation was started&#44; which revealed plasma levels of creatinine of 1&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; urea 48<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; sodium 141<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; potassium 3&#46;8<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; total cholesterol 155<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; triglycerides 153<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; total protein 6&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; albumin 3&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; normal immunoglobulins &#40;Igs&#41;&#44; C3 77&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; C4 18<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; positive antinuclear antibodies 1&#47;1280 &#40;1&#47;320 centrometric&#41;&#44; anti-Jo-1 1&#47;18 and anticardiolipin antibodies &#62;160&#46; The remaining autoimmunity&#44; including anti-phospholipase A2 antibodies&#44; protein electrophoresis and serologies were negative&#46; Normal blood count and coagulation&#46; Urinalysis revealed an albumin&#47;creatinine ratio &#40;ACR&#41; of 1478&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;g&#46; Sonography revealed kidneys of decreased size and a diffuse increase in bilateral cortical echogenicity&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Due to renal involvement&#44; a renal biopsy was performed that revealed chronic arteriolar&#47;arterial vascular lesions with extensive interstitial and glomerular kidney damage associated with incipient membranous glomerulopathy&#46; Glomerular damage was associated with ischaemia and deposition of immune complexes in capillary membranes without complement deposition&#46; Immunofluorescence showed negativity for C1q&#44; C3&#44; C4&#44; fibrinogen and albumin&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To complete the study of this systemic entity&#44; a cranial CT scan was performed&#44; which found vascular-degenerative leukoencephalopathy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding the treatment of SS&#44; antiplatelets and anticoagulants are indicated as secondary CVA prophylaxis&#44; in addition to improving the prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In patients with antiphospholipid syndrome&#44; anticoagulants give rise to a better outcome than antiplatelets&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The use of anti-inflammatory or immunosuppressive therapies is controversial&#46; In some cases&#44; treatment has been started with intravenous immunoglobulins in patients with <span class="elsevierStyleItalic">livedoid</span> vasculopathy&#44; with adequate outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our case&#44; anticoagulant and antiproteinuric treatment was administered&#44; with stability of renal function and a decrease in the ACR to 175<span class="elsevierStyleHsp" style=""></span>mg&#47;g&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; it is a rare clinical syndrome that is probably underdiagnosed and in which kidney involvement is rare&#44; so its detection adds complexity to the case&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The case described is interesting since&#44; in addition to presenting with vascular lesions associated with SS in the kidneys&#44; there was associated membranous nephropathy&#44; which has not been previously reported in conjunction with SS in the literature&#44; and may be related to the existence of an associated antiphospholipid syndrome&#46;</p></span>"
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Letter to the Editor
Renal involvement in Sneddon's syndrome
Afectación renal en el síndrome de Sneddon
Elena Hernández Garcíaa,
Corresponding author
elena_46hg@hotmail.com

Corresponding author.
, María José Sánchez Torresb
a Servicio de Nefrología, Hospital Universitario San Cecilio, Granada, Spain
b Servicio de Nefrología, Hospital Universitario Virgen de las Nieves, Granada, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Sneddon&#39;s syndrome &#40;SS&#41; is a rare and slowly progressive vascular disease that affects small and medium-sized arteries&#44; characterised by the association of <span class="elsevierStyleItalic">livedo reticularis</span> and recurrent cerebrovascular accidents &#40;CVA&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Approximately 80&#37; of SS patients are women with a median age of 40 years&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The aetiopathogenesis is unknown&#44; with two proposed primary mechanisms &#40;autoimmune&#47;inflammatory versus thrombophilia&#41;&#44; and it is classified mainly as positive or negative antiphospholipid&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The main symptoms are cutaneous&#44; which usually precede neurological symptoms by more than 10 years&#46; The vast majority of patients present with labile systolic hypertension and it can also affect the heart valves or the kidneys&#44; inter alia&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> After reviewing the literature&#44; histopathological renal involvement in this syndrome is extremely rare&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Below we describe a case of SS with biopsy-proven chronic kidney disease associated with features of membranous nephropathy&#58;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A 53-year-old woman diagnosed with SS&#44; arterial hypertension&#44; arterial toe ischaemia and an active smoker&#44; receiving treatment with acetylsalicylic acid &#40;ASA&#41;&#44; atorvastatin and valsartan&#46; She is referred to nephrology due to the onset of albuminuria&#46; Asymptomatic&#44; with good blood pressure control&#46; Normal physical examination except for <span class="elsevierStyleItalic">livedo reticularis</span> in the facial area&#44; back of the hands&#44; upper and lower limbs&#46; An investigation was started&#44; which revealed plasma levels of creatinine of 1&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; urea 48<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; sodium 141<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; potassium 3&#46;8<span class="elsevierStyleHsp" style=""></span>mEq&#47;l&#44; total cholesterol 155<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; triglycerides 153<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; total protein 6&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; albumin 3&#46;9<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; normal immunoglobulins &#40;Igs&#41;&#44; C3 77&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; C4 18<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; positive antinuclear antibodies 1&#47;1280 &#40;1&#47;320 centrometric&#41;&#44; anti-Jo-1 1&#47;18 and anticardiolipin antibodies &#62;160&#46; The remaining autoimmunity&#44; including anti-phospholipase A2 antibodies&#44; protein electrophoresis and serologies were negative&#46; Normal blood count and coagulation&#46; Urinalysis revealed an albumin&#47;creatinine ratio &#40;ACR&#41; of 1478&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;g&#46; Sonography revealed kidneys of decreased size and a diffuse increase in bilateral cortical echogenicity&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Due to renal involvement&#44; a renal biopsy was performed that revealed chronic arteriolar&#47;arterial vascular lesions with extensive interstitial and glomerular kidney damage associated with incipient membranous glomerulopathy&#46; Glomerular damage was associated with ischaemia and deposition of immune complexes in capillary membranes without complement deposition&#46; Immunofluorescence showed negativity for C1q&#44; C3&#44; C4&#44; fibrinogen and albumin&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">To complete the study of this systemic entity&#44; a cranial CT scan was performed&#44; which found vascular-degenerative leukoencephalopathy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Regarding the treatment of SS&#44; antiplatelets and anticoagulants are indicated as secondary CVA prophylaxis&#44; in addition to improving the prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> In patients with antiphospholipid syndrome&#44; anticoagulants give rise to a better outcome than antiplatelets&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The use of anti-inflammatory or immunosuppressive therapies is controversial&#46; In some cases&#44; treatment has been started with intravenous immunoglobulins in patients with <span class="elsevierStyleItalic">livedoid</span> vasculopathy&#44; with adequate outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In our case&#44; anticoagulant and antiproteinuric treatment was administered&#44; with stability of renal function and a decrease in the ACR to 175<span class="elsevierStyleHsp" style=""></span>mg&#47;g&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; it is a rare clinical syndrome that is probably underdiagnosed and in which kidney involvement is rare&#44; so its detection adds complexity to the case&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The case described is interesting since&#44; in addition to presenting with vascular lesions associated with SS in the kidneys&#44; there was associated membranous nephropathy&#44; which has not been previously reported in conjunction with SS in the literature&#44; and may be related to the existence of an associated antiphospholipid syndrome&#46;</p></span>"
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Article information
ISSN: 20132514
Original language: English
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