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infection is the identified trigger&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a case of a 42-year-old woman with long standing Systemic lupus erythematosus &#40;SLE&#41; and stage 4 chronic kidney disease &#40;CKD&#41;&#44; that following a cholecystitis complicated with cholangitis plus pancreatitis&#44; presented with persistent fever accompanied by refractory anemia&#44; despite laparoscopic cholecystectomy and combined large spectrum antibiotics having been performed&#46; Concomitantly&#44; her renal function declined&#44; requiring hemodialysis initiation&#46; During this period&#44; she was under erythropoietin 30&#44;000<span class="elsevierStyleHsp" style=""></span>U per week and she received a total of 6 red cell units&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Laboratory investigation showed thrombocytopenia&#44; anemia&#44; with low reticulocyte production index&#44; high lactate dehydrogenase&#44; but normal haptoglobin&#46; Folate and vitamin B12 were normal&#46; Iron kinetics revealed low serum iron&#44; normal transferrin saturation and an extremely high ferritin&#46; Other inflammatory markers as leucocytes&#44; C-reactive protein and procalcitonin were markedly elevated&#46; She evolved with hepatic cytolysis and cholestasis&#44; with normal bilirubin levels&#44; normal lipase and slightly high amylase &#40;104<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&#46; Lipid profile showed hypertriglyceridemia&#46; Imaging studies exhibited hepatosplenomegaly and excluded biliary obstruction&#46; No coagulopathy was found&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the presence of bicytopenia&#44; extremely high ferritin&#44; increased liver enzymes&#44; hypertriglyceridemia and hepatosplenomegaly&#44; MAS was suspected&#46; Bone marrow biopsy was not contributive for the diagnosis&#44; and it was found an increase of serum soluble IL-2 receptor &#945; &#40;sIL-2R&#945;&#41;&#46; After almost two weeks the diagnosis of MAS was made&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As there was strong data indicating a bacterial infectious process ongoing&#44; it was assumed that was the trigger&#46; Immunosuppression was withdrawn and antibiotics were maintained&#44; although no agent was identified&#46; Intravenous human immunoglobulin &#40;IVIg&#41; of 20<span class="elsevierStyleHsp" style=""></span>g &#40;500<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; was administered for three days&#46; She became apyretic and almost all analytical parameters improved &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; However&#44; she remained dependent on dialysis at discharge&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">During hemodialysis&#44; no significant medical episodes were registered&#44; and patient&#39;s hemoglobin levels were within the target&#44; between 10 and 12<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; with an average of 100<span class="elsevierStyleHsp" style=""></span>U&#47;kg&#47;week of erythropoietin&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Sixteen months after dialysis start&#44; a living-donor kidney transplant from her brother was performed&#44; and five days after&#44; in the setting of a respiratory infection&#44; she developed <span class="elsevierStyleItalic">de novo</span> persistent fever&#44; bicytopenia&#44; high ferritin&#44; elevated DHL&#44; hepatic cytolysis&#44; cholestasis&#44; hepatosplenomegaly and hypertriglyceridemia&#46; This time sIL-2R&#945; was not above the cut-off&#44; but still there were enough criteria for the diagnosis of recurrent MAS&#46; Besides antibiotics and IVIg&#44; corticosteroids dose was increased&#44; tacrolimus maintained&#44; and mycophenolate was withdrawn&#46; Again&#44; no microbiologic agent was identified&#44; after an extended investigation&#44; including bacterial cultures&#44; large panel of virus and mycobacterium tuberculosis&#46; Clinical and analytical improvement was rapidly registered &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">MAS has been associated to SLE since 1991&#44; when it was first described by Wong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The reason why this association occurs is yet to be explained&#46; The challenge is that signs and symptoms as fever&#44; cytopenia and splenomegaly&#44; present in MAS&#44; can easily be part of a SLE flare-up&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to HLH diagnostic complexity&#44; different classifications have been proposed&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes its characteristics&#46; In each episode&#44; our patient met the criteria in all classifications&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Infections and immunosuppression are frequent reported triggers&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Both conditions can be present in the context of a solid organ transplantation&#44; as the kidney&#46; To date&#44; HLH has been reported in less than a hundred kidney transplant patients&#44; representing a rare complication&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Most cases reported were triggered by all-kind infections&#44; viral in its majority&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> More rarely&#44; it can occur in the setting of neoplasms&#44; and there are also some reports associated to allograft rejection&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Although the best protocol is yet to be established&#44; treatment of HLH should be oriented to the underlying disease and associated trigger&#46; In order to diminish the hyperinflammatory process&#44; high dose of steroids are usually indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In the setting of kidney transplant&#44; besides steroids&#44; and given the role of cyclosporine described in HLH-2004&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> calcineurin inhibitors should be maintained&#44; and the antimetabolite suspended&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;5</span></a> The use of IVIg can be also beneficial and should be considered&#44; especially if rejection is suspected&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; HLH is a rare condition and kidney transplants are at risk due to the immunosuppression regimens and susceptibility to infections&#46; A high level of suspicion leads to early recognition and prompt treatment&#44; which can be decisive for patient&#39;s prognosis&#46; Due to its rarity&#44; no strong evidence is available to guide therapy and for that reason we should consider each case individually&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Anti-dsDNA &#40;UI&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#95;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab2744941.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Evolution of analytical parameters&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">AST &#8211; aspartate aminotransferase&#59; Hb &#8211; hemoglobin&#59; HIV &#8211; human immunodeficiency virus&#59; HLH &#8211; hemophagocytic lymphohistiocytosis&#59; NK &#8211; natural killer&#46;</p>"
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                  <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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HLH2004<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HScore2014<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">EULAR&#47;ACR&#47;PRINTO 2016<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Study population</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Primary HLH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Secondary HLH in adults&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">MAS in the setting of sJIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Diagnostic criteria</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Fever &#40;&#176;C&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; &#60;38&#46;4&#59;33&#58; 38&#46;4&#8211;39&#46;4&#59;49&#58; &#62;39&#46;4&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hepatosplenomegaly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;if splenomegaly&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; None23&#58; One present38&#58; Both&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Immunosuppression drugs and&#47;or HIV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; No18&#58; Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ferritin &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; &#60;2000&#59;35&#58; 2000&#8211;6000&#59;50&#58; &#62;6000&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;684&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cytopenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41; if 2 out of 3&#58;Hb &#60;90<span class="elsevierStyleHsp" style=""></span>g&#47;L&#59;Platelets &#60;100<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSup">9</span>&#47;LNeutrophils &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; 1 lineage&#59;24&#58; 2 lineages&#59;34&#58; 3 lineages&#46;Hb &#8804;9&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59;Platelets &#8804;110&#44;000&#47;&#956;LNeutrophils &#8804;5000&#47;&#956;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;if Platelets &#60;181<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypertriglyceridaemia &#40;mg&#47;dL&#41; and&#47;or Hypofibrinogenemia &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;either ifTriglycerides &#8805; 265Fibrinogen &#8804; 150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Triglycerides0&#58; &#60;132&#59;44&#58; 132&#8211;353&#59;64&#58; &#62;353&#46;Fibrinogen0&#58; &#62;250&#59;30&#58; &#8804;250&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;for eachTriglycerides &#62;156Fibrinogen &#8804; 360&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AST &#40;U&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; &#60;30&#59;19&#58; &#8805;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;if &#62;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Soluble CD25 &#40;U&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;if &#8805;2400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low or absent NK cell activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemophaocytosis in bone marrow&#44; spleen or lymph nodes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; No&#59;35&#58; If present in bone marrow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Fulfillment of criteria</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;5 of the 8 clinical and laboratory diagnostic criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Score gives the probability of having HLH&#40;best cut-off value&#58; score 169&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever &#43; Ferritin &#62;684<span class="elsevierStyleHsp" style=""></span>ng&#47;mL plus two other diagnostic criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patient scores</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Before kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;6&#41; out of &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Score of 246&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&#40;5&#41; out of &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Score of 206&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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Letter to the Editor
Diagnostic challenge of recurrent macrophage activation syndrome before and after kidney transplant
Desafío diagnóstico en un síndrome de Activación Macrofágica recurrente, antes y después del transplante renal
Joana Tavares
Corresponding author
joanatavares91@gmail.com

Corresponding author.
, Filipa Silva, Ana Castro, Josefina Santos, Guilherme Rocha, Manuela Almeida, La Salete Martins, Leonídio Dias, António Castro Henriques, António Cabrita
Serviço de Nefrologia do Centro Hospitalar Universitário do Porto, Porto, Portugal
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    "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>"
    "titulo" => "Diagnostic challenge of recurrent macrophage activation syndrome before and after kidney transplant"
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        "autoresLista" => "Joana Tavares, Filipa Silva, Ana Castro, Josefina Santos, Guilherme Rocha, Manuela Almeida, La Salete Martins, Leon&#237;dio Dias, Ant&#243;nio Castro Henriques, Ant&#243;nio Cabrita"
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            "apellidos" => "Almeida"
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            "apellidos" => "Martins"
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            "entidad" => "Servi&#231;o de Nefrologia do Centro Hospitalar Universit&#225;rio do Porto&#44; Porto&#44; Portugal"
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        "titulo" => "Desaf&#237;o diagn&#243;stico en un s&#237;ndrome de Activaci&#243;n Macrof&#225;gica recurrente&#44; antes y despu&#233;s del transplante renal"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hemophagocytic lymphohistiocytosis &#40;HLH&#41; is a rare&#44; life-threatening condition&#44; secondary to an overwhelming inflammatory process&#46; When associated to rheumatic disorders&#44; it can be called as macrophage activation syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The main manifestations are unremitting fever&#44; cytopenias&#44; hepatosplenomegaly and multisystem organ failure&#46; Unfortunately&#44; there is no pathognomonic test&#44; making the diagnosis hard to reach&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> It can be triggered by infection&#44; malignancy&#44; auto-inflammatory disease and immunosuppression associated with solid organ transplantation&#46; Kidney transplant recipients are&#44; particularly&#44; at risk&#44; and in most cases&#44; infection is the identified trigger&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present a case of a 42-year-old woman with long standing Systemic lupus erythematosus &#40;SLE&#41; and stage 4 chronic kidney disease &#40;CKD&#41;&#44; that following a cholecystitis complicated with cholangitis plus pancreatitis&#44; presented with persistent fever accompanied by refractory anemia&#44; despite laparoscopic cholecystectomy and combined large spectrum antibiotics having been performed&#46; Concomitantly&#44; her renal function declined&#44; requiring hemodialysis initiation&#46; During this period&#44; she was under erythropoietin 30&#44;000<span class="elsevierStyleHsp" style=""></span>U per week and she received a total of 6 red cell units&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Laboratory investigation showed thrombocytopenia&#44; anemia&#44; with low reticulocyte production index&#44; high lactate dehydrogenase&#44; but normal haptoglobin&#46; Folate and vitamin B12 were normal&#46; Iron kinetics revealed low serum iron&#44; normal transferrin saturation and an extremely high ferritin&#46; Other inflammatory markers as leucocytes&#44; C-reactive protein and procalcitonin were markedly elevated&#46; She evolved with hepatic cytolysis and cholestasis&#44; with normal bilirubin levels&#44; normal lipase and slightly high amylase &#40;104<span class="elsevierStyleHsp" style=""></span>U&#47;L&#41;&#46; Lipid profile showed hypertriglyceridemia&#46; Imaging studies exhibited hepatosplenomegaly and excluded biliary obstruction&#46; No coagulopathy was found&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">In the presence of bicytopenia&#44; extremely high ferritin&#44; increased liver enzymes&#44; hypertriglyceridemia and hepatosplenomegaly&#44; MAS was suspected&#46; Bone marrow biopsy was not contributive for the diagnosis&#44; and it was found an increase of serum soluble IL-2 receptor &#945; &#40;sIL-2R&#945;&#41;&#46; After almost two weeks the diagnosis of MAS was made&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">As there was strong data indicating a bacterial infectious process ongoing&#44; it was assumed that was the trigger&#46; Immunosuppression was withdrawn and antibiotics were maintained&#44; although no agent was identified&#46; Intravenous human immunoglobulin &#40;IVIg&#41; of 20<span class="elsevierStyleHsp" style=""></span>g &#40;500<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#41; was administered for three days&#46; She became apyretic and almost all analytical parameters improved &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; However&#44; she remained dependent on dialysis at discharge&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">During hemodialysis&#44; no significant medical episodes were registered&#44; and patient&#39;s hemoglobin levels were within the target&#44; between 10 and 12<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#44; with an average of 100<span class="elsevierStyleHsp" style=""></span>U&#47;kg&#47;week of erythropoietin&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Sixteen months after dialysis start&#44; a living-donor kidney transplant from her brother was performed&#44; and five days after&#44; in the setting of a respiratory infection&#44; she developed <span class="elsevierStyleItalic">de novo</span> persistent fever&#44; bicytopenia&#44; high ferritin&#44; elevated DHL&#44; hepatic cytolysis&#44; cholestasis&#44; hepatosplenomegaly and hypertriglyceridemia&#46; This time sIL-2R&#945; was not above the cut-off&#44; but still there were enough criteria for the diagnosis of recurrent MAS&#46; Besides antibiotics and IVIg&#44; corticosteroids dose was increased&#44; tacrolimus maintained&#44; and mycophenolate was withdrawn&#46; Again&#44; no microbiologic agent was identified&#44; after an extended investigation&#44; including bacterial cultures&#44; large panel of virus and mycobacterium tuberculosis&#46; Clinical and analytical improvement was rapidly registered &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">MAS has been associated to SLE since 1991&#44; when it was first described by Wong et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The reason why this association occurs is yet to be explained&#46; The challenge is that signs and symptoms as fever&#44; cytopenia and splenomegaly&#44; present in MAS&#44; can easily be part of a SLE flare-up&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Due to HLH diagnostic complexity&#44; different classifications have been proposed&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> summarizes its characteristics&#46; In each episode&#44; our patient met the criteria in all classifications&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Infections and immunosuppression are frequent reported triggers&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Both conditions can be present in the context of a solid organ transplantation&#44; as the kidney&#46; To date&#44; HLH has been reported in less than a hundred kidney transplant patients&#44; representing a rare complication&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Most cases reported were triggered by all-kind infections&#44; viral in its majority&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> More rarely&#44; it can occur in the setting of neoplasms&#44; and there are also some reports associated to allograft rejection&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Although the best protocol is yet to be established&#44; treatment of HLH should be oriented to the underlying disease and associated trigger&#46; In order to diminish the hyperinflammatory process&#44; high dose of steroids are usually indicated&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> In the setting of kidney transplant&#44; besides steroids&#44; and given the role of cyclosporine described in HLH-2004&#44;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> calcineurin inhibitors should be maintained&#44; and the antimetabolite suspended&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;5</span></a> The use of IVIg can be also beneficial and should be considered&#44; especially if rejection is suspected&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;8</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In conclusion&#44; HLH is a rare condition and kidney transplants are at risk due to the immunosuppression regimens and susceptibility to infections&#46; A high level of suspicion leads to early recognition and prompt treatment&#44; which can be decisive for patient&#39;s prognosis&#46; Due to its rarity&#44; no strong evidence is available to guide therapy and for that reason we should consider each case individually&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
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          "identificador" => "sec0005"
          "titulo" => "Conflicts of interest"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Leuc &#8211; leucocytes&#59; Neut &#8211; neutrophils&#59; Hb &#8211; hemoglobin&#59; HD &#8211; hemodialysis&#59; LDH &#8211; lactate dehydrogenase&#59; Sat &#8211; transferrin saturation&#59; RPC &#8211; reactive protein C&#59; PC &#8211; prolcalcitonine&#59; AST &#8211; aspartate aminotransferase&#59; ALT &#8211; alanine aminotransferase&#59; AP &#8211; alkaline phosphatase&#59; GGT &#8211; gamma-glutamyl transpeptidase&#59; CT &#8211; cholesterol&#59; TG &#8211; triglycerides&#46;</p>"
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                  <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="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Analytical parameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="center" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Ambulatory&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">2nd MAS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Discharge&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Leuc&#47;Neut &#40;&#47;&#956;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3560&#47;2240&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">12&#44;690&#47;10&#44;360&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Under HD</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Sat &#40;&#37;&#41;&#47;ferritin &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Anti-dsDNA &#40;UI&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
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          "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">AST &#8211; aspartate aminotransferase&#59; Hb &#8211; hemoglobin&#59; HIV &#8211; human immunodeficiency virus&#59; HLH &#8211; hemophagocytic lymphohistiocytosis&#59; NK &#8211; natural killer&#46;</p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">HLH2004<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">EULAR&#47;ACR&#47;PRINTO 2016<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#58; None23&#58; One present38&#58; Both&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Immunosuppression drugs and&#47;or HIV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; No18&#58; Yes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Ferritin &#40;ng&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; &#60;2000&#59;35&#58; 2000&#8211;6000&#59;50&#58; &#62;6000&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#62;684&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cytopenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41; if 2 out of 3&#58;Hb &#60;90<span class="elsevierStyleHsp" style=""></span>g&#47;L&#59;Platelets &#60;100<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSup">9</span>&#47;LNeutrophils &#60;1<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; 1 lineage&#59;24&#58; 2 lineages&#59;34&#58; 3 lineages&#46;Hb &#8804;9&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59;Platelets &#8804;110&#44;000&#47;&#956;LNeutrophils &#8804;5000&#47;&#956;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;if Platelets &#60;181<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleSup">9</span>&#47;L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypertriglyceridaemia &#40;mg&#47;dL&#41; and&#47;or Hypofibrinogenemia &#40;mg&#47;dL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;either ifTriglycerides &#8805; 265Fibrinogen &#8804; 150&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Triglycerides0&#58; &#60;132&#59;44&#58; 132&#8211;353&#59;64&#58; &#62;353&#46;Fibrinogen0&#58; &#62;250&#59;30&#58; &#8804;250&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;for eachTriglycerides &#62;156Fibrinogen &#8804; 360&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>AST &#40;U&#47;L&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; &#60;30&#59;19&#58; &#8805;30&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;if &#62;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Soluble CD25 &#40;U&#47;mL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;if &#8805;2400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Low or absent NK cell activity&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hemophaocytosis in bone marrow&#44; spleen or lymph nodes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;&#43;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#58; No&#59;35&#58; If present in bone marrow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">N&#46;A&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Fulfillment of criteria</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#8805;5 of the 8 clinical and laboratory diagnostic criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Score gives the probability of having HLH&#40;best cut-off value&#58; score 169&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever &#43; Ferritin &#62;684<span class="elsevierStyleHsp" style=""></span>ng&#47;mL plus two other diagnostic criteria&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Patient scores</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Before kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;6&#41; out of &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Score of 246&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever &#43; Hyperferritin &#43; &#40;3&#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="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>After kidney transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#40;5&#41; out of &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Score of 206&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever &#43; Hyperferritin &#43; &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Different types of HLH classification criteria&#46;</p>"
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      "titulo" => "References"
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        0 => array:2 [
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          "bibliografiaReferencia" => array:10 [
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            1 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Hemophagocytic lymphohistiocytosis&#58; an update for nephrologists"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                            1 => "L&#46; Galicier"
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                  "host" => array:1 [
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                      "doi" => "10.1016/j.amjmed.2014.04.034"
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              "identificador" => "bib0070"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "K&#46;F&#46; Wong"
                            1 => "P&#46;K&#46; Hui"
                            2 => "J&#46;K&#46; Chan"
                            3 => "Y&#46;W&#46; Chan"
                            4 => "S&#46;Y&#46; Ha"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Ann Intern Med"
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                        "volumen" => "114"
                        "paginaInicial" => "387"
                        "paginaFinal" => "390"
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              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
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Article information
ISSN: 20132514
Original language: English
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