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    "textoCompleto" => "To the editor&#58; Acute renal infarction results&#160; from&#160; renal&#160; artery&#160; occlusion&#160; by embolic&#160; or&#160; thrombotic&#160; events&#46;1 Renal embolism is most commonly caused by thrombi&#160; released&#160; from&#160; the&#160; heart&#160; in&#160; patients with heart disease&#46; Thrombosis is usually due to trauma&#44; or to generalized atherosclerosis&#160; in&#160; elderly&#160; patients&#46;&#160; A less common cause are hypercoagulability&#160; states&#44;&#160; associated&#160; to&#160; an&#160; increased risk&#160; of&#160; venous&#44;&#160; or more rarely&#160; arterial&#44; thrombosis&#46;&#160; Such&#160; association&#160; is&#160; stronger&#160; in&#160; patients&#160; aged&#160; &#60; 55 years&#160; and women&#46;2 <br></br><br></br>The&#160; case&#160; of&#160; a&#160; 48-year-old&#160; male&#160; patient whose father had died from a stroke is reported&#46; The patient had a personal&#160; history&#160; of&#160; HBP&#44;&#160; dyslipidemia&#160; and former&#160; smoking&#46;&#160; In&#160; 1994&#160; he&#160; experienced&#160; an&#160; inferolateral&#160; non-Q&#160; wave AMI&#44; and in 2001 he was admitted to hospital for&#160; an&#160; ischemic&#160; stroke&#46;&#160; He&#160; was&#160; then diagnosed a mutation in&#160; the prothrombin&#160; &#40;FII&#160; 20210&#41;&#160; and&#160; methylenetetrahydrofolate&#160; reductase&#160; &#40;MTHFR&#41;&#160; genes&#44; with&#160; normal&#160; homocysteine&#160; levels&#46;&#160; Patient was again&#160; admitted&#160; to&#160; hospital&#160; in 2002&#160; for&#160; non-Q&#160; wave&#160; AMI&#46;&#160; He&#160; was being treated wit ramipril&#44; acetyl salicylic&#160; acid&#44;&#160; omeprazole&#44;&#160; pravastatin&#44;&#160; and metoprolol&#46; <br></br><br></br>He&#160; attended&#160; the&#160; emergency&#160; room for&#160; a&#160; sudden&#44;&#160; continuous&#160; pain&#160; in&#160; the periumbilical&#160; region&#160; and&#160; right&#160; flank <br></br>for&#160; the&#160; past&#160; 72&#160; hours&#46;&#160; Pain was&#160; irradiated&#160; to&#160; the&#160; right&#160; renal&#160; fossa and associated to nausea&#44; vomiting&#44; and dark urine&#46; <br></br><br></br>Physical examination revealed abdominal&#160; tenderness&#160; in&#160; the&#160; periumbilical region and right flank&#46; <br></br><br></br>Laboratory&#160; tests&#160; showed&#160; elevated GOT&#44; GPT&#44;&#160; and LDH levels&#160; with&#160; normal renal function&#44; electrolytes&#44; and coagulation&#46; Urine analysis found proteinuria &#40;30 mg&#47;dL&#41;&#46; Chest and abdominal X-rays were unremarkable&#46; <br></br><br></br>An urgent abdominal CT scan with contrast&#160; revealed&#160; patchy&#160; hypodense areas&#160; in&#160; the&#160; right&#160; kidney&#160; consistent <br></br>with renal&#160; infarction &#40;fig&#46; 1&#41;&#46; The patient was&#160; admitted&#160; to&#160; the&#160; nephrology department&#44;&#160; where&#160; anticoagulation <br></br>with low molecular weight heparin at therapeutic doses was&#160; started&#46; Subsequent measurements&#160; of&#160; vitamin B12&#44; <br></br>folate&#44; antinuclear and antiphospholipid&#160; antibodies&#44;&#160; tumor&#160; markers&#44;&#160; and lipid&#160; metabolism&#160; were&#160; all&#160; normal&#46; <br></br>Diagnosis&#160; of&#160; mutation&#160; in&#160; the&#160; FII 20210&#160; gene&#160; &#40;heterozygous&#41;&#160; and&#160; the MTHFR&#160; gene&#160; &#40;homozygous&#41;&#160; was <br></br>confirmed&#44; with&#160; homocysteine&#160; levels in&#160; the&#160; upper&#160; normal&#160; range&#46;&#160; The&#160; thrombophilia study was otherwise normal&#46; A 99m-Tc-DTPA perfusion study showed&#160; a&#160; triangular&#160; uptake&#160; defect&#160; in the&#160; upper&#160; pole&#160; of&#160; the&#160; right&#160; kidney consistent with renal infarction&#46; A 99-Tc-DMSA renal scan confirmed diagnosis&#46; <br></br><br></br>Patient&#160; had&#160; a&#160; favorable&#160; course&#44; with&#160; disappearance&#160; of&#160; pain&#160; and&#160; gradual&#160; decrease&#160; in&#160; LDH&#46;&#160; Heparin&#160; was <br></br>replaced by acenocoumarol for an indefinite&#160; time&#44;&#160; and&#160; folic&#160; acid&#160; was added due to the finding of homocysteine&#160; levels&#160; in&#160; the&#160; upper&#160; normal range&#46; <br></br><br></br>Rapid diagnosis of renal infarction is&#160; critical&#160; if&#160; thrombolysis&#160; or&#160; surgery is to be attempted to preserve kidney <br></br>function&#46;&#160; There&#160; are&#160; several&#160; helpful tests&#160; for&#160; diagnosis&#44;&#160; and&#160; the&#160; choice depends on&#160; test availability&#46; CT with <br></br>a&#160; contrast&#160; agent&#160; provides&#160; a&#160; fast&#44;&#160; accurate&#160; diagnosis&#46;&#160; Isotope&#160; flow&#160; imaging&#160; with&#160; DTPA-Tc99m shows&#160; an&#160; absent&#160; or&#160; decreased&#160; perfusion&#160; in&#160; the affected&#160; kidney&#46;&#160; Doppler&#160; ultrasound has a limited value&#44; and renal arteriography&#160; is&#160; the&#160; definitive&#160; diagnostic procedure&#46; <br></br><br></br>Mutation&#160; in&#160; the FII&#160; 20210&#160; gene&#160; is associated to a 30&#37; increase in baseline&#160; prothrombin&#160; levels&#160; that&#160; predisposes to thrombotic events&#46; Hyperhomocysteinemia may be&#160; congenital or acquired&#46; Acquired&#160; forms&#160; are&#160; secondary&#160; to&#160; folate&#160; or&#160; vitamin B12&#160; or B6 deficiency&#46; Congenital&#160; forms are due to&#160; mutations&#160; in&#160; the&#160; cystathionine-b-synthetase gene or the MTHFR gene&#44; more common&#44; and which is associated&#160; to hyperhomocysteinemia&#160; particularly&#160; in&#160; homozygotes&#160; with&#160; folate deficiency&#46;&#160; Hyperhomocysteinemia predisposes&#160; to&#160; thrombotic&#160; events&#160; by endothelial&#160; activation&#44;&#160; muscle&#160; cell proliferation&#44; and changes in NO production&#160; or&#160; sterol&#160; metabolism&#160; in&#160; endothelium&#46;3 <br></br><br></br>Absence&#160; of&#160; hyperhomocysteinemia in&#160; this&#160; patient&#160; with&#160; MTHFR&#160; mutation was possibly due to the fact that he was <br></br>never detected vitamin B12 or B6 or folate deficiency&#46; <br></br><br></br>Thrombophilia should be searched in patients&#160; with&#160; recurrent&#160; venous&#160; thrombotic&#160; events&#46;&#160; However&#44;&#160; such&#160; search <br></br>does&#160; not&#160; appear&#160; to&#160; be&#160; indicated&#160; in&#160; patients with isolated arterial thrombosis&#44; especially&#160; if&#160; they&#160; have&#160; risk&#160; factors&#160; for arterial disease&#46; <br></br><br></br>The risk of venous thrombosis in patients with FII 20210 or MTHFR mutation is low&#46; Its role in arterial thrombosis is unclear&#44; with a slight risk of AMI or stroke occurrence&#46; An increased risk exists&#160; in&#160; patients&#160; aged&#160; &#60;&#160; 55&#160; years&#160; and <br></br>female patients&#44; with a more significant effect if concomitant coagulation disorders and associated cardiovascular risk factors exist&#46;4 <br></br><br></br>As&#160; to&#160; therapeutic&#160; management&#44; prophylaxis&#160; should&#160; be&#160; started&#160; in asymptomatic&#160; patients&#160; or&#160; patients with&#160; thrombosis associated&#160; to&#160; risk&#160; situations&#44;&#160; and&#160; indefinite&#160; anticoagulation&#160; should&#160; be&#160; given&#160; to&#160; patients with <br></br>two or more spontaneous thromboses&#44; life-threatening thrombosis&#44; or thrombosis&#160; linked&#160; to more&#160; than one genetic <br></br>abnormality&#46; <br></br><br></br>In&#160; our&#160; case&#44;&#160; the&#160; patient&#160; was&#160; &#60;55 years&#44; and had FII 20210 and MTHFR mutations and cardiovascular risk factors&#160; &#40;HBP&#44;&#160; former&#160; smoker&#44;&#160; drinker&#41;&#46; Management would have required the previous start of&#160; indefinite anticoagulation&#160; that would&#160; have&#160; prevented&#160; the occurrence&#160; of&#160; a&#160; third&#160; thrombotic event&#46;5 <br></br><br></br>The interest of the reported case lies in the occurrence of renal infarction in a patient with mutation in the FII 20210 <br></br>and MTHFR genes&#44; a previously unreported clinical condition&#46; <br></br>"
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                  "referenciaCompleta" => "1.Cheng KL, Tseng SS, Tarng DC. Acute renal failure caused by unilateral renal artery thromboembolism. Nephrol Dial Transplant 2003; 18(4): 833-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12637659" target="_blank">[Pubmed]</a>"
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A 48-year-old male with renal infarction and thrombophilia
Varón de 48 años con infarto renal y trombofilia
P.. Frailea, P.. García-Cosmesa, J.L.. Lermaa, J.M.. Taberneroa
a Servicio de Nefrología, Hospital Universitario de Salamanca Salamanca Salamanca España,
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    "textoCompleto" => "To the editor&#58; Acute renal infarction results&#160; from&#160; renal&#160; artery&#160; occlusion&#160; by embolic&#160; or&#160; thrombotic&#160; events&#46;1 Renal embolism is most commonly caused by thrombi&#160; released&#160; from&#160; the&#160; heart&#160; in&#160; patients with heart disease&#46; Thrombosis is usually due to trauma&#44; or to generalized atherosclerosis&#160; in&#160; elderly&#160; patients&#46;&#160; A less common cause are hypercoagulability&#160; states&#44;&#160; associated&#160; to&#160; an&#160; increased risk&#160; of&#160; venous&#44;&#160; or more rarely&#160; arterial&#44; thrombosis&#46;&#160; Such&#160; association&#160; is&#160; stronger&#160; in&#160; patients&#160; aged&#160; &#60; 55 years&#160; and women&#46;2 <br></br><br></br>The&#160; case&#160; of&#160; a&#160; 48-year-old&#160; male&#160; patient whose father had died from a stroke is reported&#46; The patient had a personal&#160; history&#160; of&#160; HBP&#44;&#160; dyslipidemia&#160; and former&#160; smoking&#46;&#160; In&#160; 1994&#160; he&#160; experienced&#160; an&#160; inferolateral&#160; non-Q&#160; wave AMI&#44; and in 2001 he was admitted to hospital for&#160; an&#160; ischemic&#160; stroke&#46;&#160; He&#160; was&#160; then diagnosed a mutation in&#160; the prothrombin&#160; &#40;FII&#160; 20210&#41;&#160; and&#160; methylenetetrahydrofolate&#160; reductase&#160; &#40;MTHFR&#41;&#160; genes&#44; with&#160; normal&#160; homocysteine&#160; levels&#46;&#160; Patient was again&#160; admitted&#160; to&#160; hospital&#160; in 2002&#160; for&#160; non-Q&#160; wave&#160; AMI&#46;&#160; He&#160; was being treated wit ramipril&#44; acetyl salicylic&#160; acid&#44;&#160; omeprazole&#44;&#160; pravastatin&#44;&#160; and metoprolol&#46; <br></br><br></br>He&#160; attended&#160; the&#160; emergency&#160; room for&#160; a&#160; sudden&#44;&#160; continuous&#160; pain&#160; in&#160; the periumbilical&#160; region&#160; and&#160; right&#160; flank <br></br>for&#160; the&#160; past&#160; 72&#160; hours&#46;&#160; Pain was&#160; irradiated&#160; to&#160; the&#160; right&#160; renal&#160; fossa and associated to nausea&#44; vomiting&#44; and dark urine&#46; <br></br><br></br>Physical examination revealed abdominal&#160; tenderness&#160; in&#160; the&#160; periumbilical region and right flank&#46; <br></br><br></br>Laboratory&#160; tests&#160; showed&#160; elevated GOT&#44; GPT&#44;&#160; and LDH levels&#160; with&#160; normal renal function&#44; electrolytes&#44; and coagulation&#46; Urine analysis found proteinuria &#40;30 mg&#47;dL&#41;&#46; Chest and abdominal X-rays were unremarkable&#46; <br></br><br></br>An urgent abdominal CT scan with contrast&#160; revealed&#160; patchy&#160; hypodense areas&#160; in&#160; the&#160; right&#160; kidney&#160; consistent <br></br>with renal&#160; infarction &#40;fig&#46; 1&#41;&#46; The patient was&#160; admitted&#160; to&#160; the&#160; nephrology department&#44;&#160; where&#160; anticoagulation <br></br>with low molecular weight heparin at therapeutic doses was&#160; started&#46; Subsequent measurements&#160; of&#160; vitamin B12&#44; <br></br>folate&#44; antinuclear and antiphospholipid&#160; antibodies&#44;&#160; tumor&#160; markers&#44;&#160; and lipid&#160; metabolism&#160; were&#160; all&#160; normal&#46; <br></br>Diagnosis&#160; of&#160; mutation&#160; in&#160; the&#160; FII 20210&#160; gene&#160; &#40;heterozygous&#41;&#160; and&#160; the MTHFR&#160; gene&#160; &#40;homozygous&#41;&#160; was <br></br>confirmed&#44; with&#160; homocysteine&#160; levels in&#160; the&#160; upper&#160; normal&#160; range&#46;&#160; The&#160; thrombophilia study was otherwise normal&#46; A 99m-Tc-DTPA perfusion study showed&#160; a&#160; triangular&#160; uptake&#160; defect&#160; in the&#160; upper&#160; pole&#160; of&#160; the&#160; right&#160; kidney consistent with renal infarction&#46; A 99-Tc-DMSA renal scan confirmed diagnosis&#46; <br></br><br></br>Patient&#160; had&#160; a&#160; favorable&#160; course&#44; with&#160; disappearance&#160; of&#160; pain&#160; and&#160; gradual&#160; decrease&#160; in&#160; LDH&#46;&#160; Heparin&#160; was <br></br>replaced by acenocoumarol for an indefinite&#160; time&#44;&#160; and&#160; folic&#160; acid&#160; was added due to the finding of homocysteine&#160; levels&#160; in&#160; the&#160; upper&#160; normal range&#46; <br></br><br></br>Rapid diagnosis of renal infarction is&#160; critical&#160; if&#160; thrombolysis&#160; or&#160; surgery is to be attempted to preserve kidney <br></br>function&#46;&#160; There&#160; are&#160; several&#160; helpful tests&#160; for&#160; diagnosis&#44;&#160; and&#160; the&#160; choice depends on&#160; test availability&#46; CT with <br></br>a&#160; contrast&#160; agent&#160; provides&#160; a&#160; fast&#44;&#160; accurate&#160; diagnosis&#46;&#160; Isotope&#160; flow&#160; imaging&#160; with&#160; DTPA-Tc99m shows&#160; an&#160; absent&#160; or&#160; decreased&#160; perfusion&#160; in&#160; the affected&#160; kidney&#46;&#160; Doppler&#160; ultrasound has a limited value&#44; and renal arteriography&#160; is&#160; the&#160; definitive&#160; diagnostic procedure&#46; <br></br><br></br>Mutation&#160; in&#160; the FII&#160; 20210&#160; gene&#160; is associated to a 30&#37; increase in baseline&#160; prothrombin&#160; levels&#160; that&#160; predisposes to thrombotic events&#46; Hyperhomocysteinemia may be&#160; congenital or acquired&#46; Acquired&#160; forms&#160; are&#160; secondary&#160; to&#160; folate&#160; or&#160; vitamin B12&#160; or B6 deficiency&#46; Congenital&#160; forms are due to&#160; mutations&#160; in&#160; the&#160; cystathionine-b-synthetase gene or the MTHFR gene&#44; more common&#44; and which is associated&#160; to hyperhomocysteinemia&#160; particularly&#160; in&#160; homozygotes&#160; with&#160; folate deficiency&#46;&#160; Hyperhomocysteinemia predisposes&#160; to&#160; thrombotic&#160; events&#160; by endothelial&#160; activation&#44;&#160; muscle&#160; cell proliferation&#44; and changes in NO production&#160; or&#160; sterol&#160; metabolism&#160; in&#160; endothelium&#46;3 <br></br><br></br>Absence&#160; of&#160; hyperhomocysteinemia in&#160; this&#160; patient&#160; with&#160; MTHFR&#160; mutation was possibly due to the fact that he was <br></br>never detected vitamin B12 or B6 or folate deficiency&#46; <br></br><br></br>Thrombophilia should be searched in patients&#160; with&#160; recurrent&#160; venous&#160; thrombotic&#160; events&#46;&#160; However&#44;&#160; such&#160; search <br></br>does&#160; not&#160; appear&#160; to&#160; be&#160; indicated&#160; in&#160; patients with isolated arterial thrombosis&#44; especially&#160; if&#160; they&#160; have&#160; risk&#160; factors&#160; for arterial disease&#46; <br></br><br></br>The risk of venous thrombosis in patients with FII 20210 or MTHFR mutation is low&#46; Its role in arterial thrombosis is unclear&#44; with a slight risk of AMI or stroke occurrence&#46; An increased risk exists&#160; in&#160; patients&#160; aged&#160; &#60;&#160; 55&#160; years&#160; and <br></br>female patients&#44; with a more significant effect if concomitant coagulation disorders and associated cardiovascular risk factors exist&#46;4 <br></br><br></br>As&#160; to&#160; therapeutic&#160; management&#44; prophylaxis&#160; should&#160; be&#160; started&#160; in asymptomatic&#160; patients&#160; or&#160; patients with&#160; thrombosis associated&#160; to&#160; risk&#160; situations&#44;&#160; and&#160; indefinite&#160; anticoagulation&#160; should&#160; be&#160; given&#160; to&#160; patients with <br></br>two or more spontaneous thromboses&#44; life-threatening thrombosis&#44; or thrombosis&#160; linked&#160; to more&#160; than one genetic <br></br>abnormality&#46; <br></br><br></br>In&#160; our&#160; case&#44;&#160; the&#160; patient&#160; was&#160; &#60;55 years&#44; and had FII 20210 and MTHFR mutations and cardiovascular risk factors&#160; &#40;HBP&#44;&#160; former&#160; smoker&#44;&#160; drinker&#41;&#46; Management would have required the previous start of&#160; indefinite anticoagulation&#160; that would&#160; have&#160; prevented&#160; the occurrence&#160; of&#160; a&#160; third&#160; thrombotic event&#46;5 <br></br><br></br>The interest of the reported case lies in the occurrence of renal infarction in a patient with mutation in the FII 20210 <br></br>and MTHFR genes&#44; a previously unreported clinical condition&#46; <br></br>"
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        "resumen" => "El infarto renal agudo es la consecuencia de la oclusi&#243;n de la arteria renal por eventos emb&#243;licos o tromb&#243;ticos1&#46; El embolismo renal se debe en la mayor&#237;a de las ocasiones a la suelta de trombos procedentes del coraz&#243;n en pacientes con cardiopat&#237;a&#46; La trombosis habitualmente surge por traumatismos o en pacientes a&#241;osos con arterioesclerosis generalizada&#59; una causa menos frecuente son las situaciones de hipercoagulabilidad&#44; asociadas con un incremento del riesgo de trombosis venosas&#44; y m&#225;s raramente arteriales&#44; siendo dicha asociaci&#243;n m&#225;s robusta en los <55 años y mujeres2</55>"
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        "resumen" => "To the editor&#58; Acute renal infarction results from renal artery occlusion by embolic or thrombotic events&#46;1 Renal embolism is most commonly caused by thrombi released from the heart in patients with heart disease&#46; Thrombosis is usually due to trauma&#44; or to generalized atherosclerosis in elderly patients&#46; A less common cause are hypercoagulability states&#44; associated to an increased risk of venous&#44; or more rarely arterial&#44; thrombosis&#46; Such association is stronger in patients aged &#60; 55 years and women&#46;2"
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                  "referenciaCompleta" => "1.Cheng KL, Tseng SS, Tarng DC. Acute renal failure caused by unilateral renal artery thromboembolism. Nephrol Dial Transplant 2003; 18(4): 833-5. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12637659" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "2.Tripodi A, Mannucci P.M. Laboartory investigation of thrombophilia. Clinical chemistry 2001; 47: 1597-1606. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11514392" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "3.Lane DA, Grant PJ. Role of hemostatic gene polimorphisms in venous and arterial thrombotic disease. Blood 2000; 95(5):1517-32. <a href="http://www.ncbi.nlm.nih.gov/pubmed/10688804" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "4.Kim RJ, Becker RC. Association between factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutatios and events of the arterial circulatory system: a meta-analysis of published studies. Am Heart J 2003;146:948-57. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14660985" target="_blank">[Pubmed]</a>"
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Article information
ISSN: 20132514
Original language: English
DOI:
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