array:21 [
  "pii" => "X2013251408033045"
  "issn" => "20132514"
  "doi" => " "
  "estado" => "S300"
  "fechaPublicacion" => "2008-04-01"
  "documento" => "article"
  "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
  "subdocumento" => "fla"
  "cita" => "Nefrologia (English Version). 2008;28:212-5"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 4307
    "formatos" => array:3 [
      "EPUB" => 287
      "HTML" => 3469
      "PDF" => 551
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:17 [
      "pii" => "X0211699508033048"
      "issn" => "02116995"
      "doi" => " "
      "estado" => "S300"
      "fechaPublicacion" => "2008-04-01"
      "documento" => "article"
      "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
      "subdocumento" => "fla"
      "cita" => "Nefrologia. 2008;28:212-5"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 17187
        "formatos" => array:3 [
          "EPUB" => 300
          "HTML" => 14930
          "PDF" => 1957
        ]
      ]
      "es" => array:10 [
        "idiomaDefecto" => true
        "titulo" => "Insuficiencia renal por enfermedad de depósito de cadenas ligeras"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "212"
            "paginaFinal" => "215"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Renal failure due to light chain deposition disease"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig1"
            "etiqueta" => "Fig. 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "copyright" => "Elsevier España"
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "507127_figura1.jpg"
                "Alto" => 384
                "Ancho" => 512
                "Tamanyo" => 32239
              ]
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "A. García Pérez, A. M. Ramos, V. Petkov, Marta Albalate, C. Caramelo, J. L. López Lorenzo, J. Aneiros, M. T. Miguel, A. Barat"
            "autores" => array:9 [
              0 => array:2 [
                "Iniciales" => "A."
                "apellidos" => "García Pérez"
              ]
              1 => array:2 [
                "Iniciales" => "A. M."
                "apellidos" => "Ramos"
              ]
              2 => array:2 [
                "Iniciales" => "V."
                "apellidos" => "Petkov"
              ]
              3 => array:2 [
                "nombre" => "Marta"
                "apellidos" => "Albalate"
              ]
              4 => array:2 [
                "Iniciales" => "C."
                "apellidos" => "Caramelo"
              ]
              5 => array:2 [
                "Iniciales" => "J. L."
                "apellidos" => "López Lorenzo"
              ]
              6 => array:2 [
                "Iniciales" => "J."
                "apellidos" => "Aneiros"
              ]
              7 => array:2 [
                "Iniciales" => "M. T."
                "apellidos" => "Miguel"
              ]
              8 => array:2 [
                "Iniciales" => "A."
                "apellidos" => "Barat"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "X2013251408033045"
          "doi" => " "
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033045?idApp=UINPBA000064"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508033048?idApp=UINPBA000064"
      "url" => "/02116995/0000002800000002/v0_201502091346/X0211699508033048/v0_201502091346/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:17 [
    "pii" => "X2013251408033037"
    "issn" => "20132514"
    "doi" => " "
    "estado" => "S300"
    "fechaPublicacion" => "2008-04-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia (English Version). 2008;28:216-7"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 4668
      "formatos" => array:3 [
        "EPUB" => 307
        "HTML" => 3824
        "PDF" => 537
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "High blood pressure due to aortic coarctation and renal artery stenosis in a teenager with type 1 neurofibromatosis"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "216"
          "paginaFinal" => "217"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Hipertensión secundaria a coartación de aorta y estenosis de arteria renal en adolescente con neurofibromatosis tipo 1"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "R. Pardo, L. Somalo, Serafín Málaga Guerrero, F. Santos"
          "autores" => array:4 [
            0 => array:2 [
              "Iniciales" => "R."
              "apellidos" => "Pardo"
            ]
            1 => array:2 [
              "Iniciales" => "L."
              "apellidos" => "Somalo"
            ]
            2 => array:2 [
              "nombre" => "Serafín"
              "apellidos" => "Málaga Guerrero"
            ]
            3 => array:2 [
              "Iniciales" => "F."
              "apellidos" => "Santos"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X021169950803303X"
        "doi" => " "
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X021169950803303X?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033037?idApp=UINPBA000064"
    "url" => "/20132514/0000002800000002/v0_201502091614/X2013251408033037/v0_201502091615/en/main.assets"
  ]
  "itemAnterior" => array:17 [
    "pii" => "X2013251408033119"
    "issn" => "20132514"
    "doi" => " "
    "estado" => "S300"
    "fechaPublicacion" => "2008-04-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia (English Version). 2008;28:203-11"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 7067
      "formatos" => array:3 [
        "EPUB" => 273
        "HTML" => 4242
        "PDF" => 2552
      ]
    ]
    "en" => array:9 [
      "idiomaDefecto" => true
      "titulo" => "Polyoma virus in transplant recipients"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "203"
          "paginaFinal" => "211"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Virus polioma en trasplante renal"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Mara Medeiros, J. Alberú, G. R. García, Y. Fuentes, L. Velasquez"
          "autores" => array:5 [
            0 => array:2 [
              "nombre" => "Mara"
              "apellidos" => "Medeiros"
            ]
            1 => array:2 [
              "Iniciales" => "J."
              "apellidos" => "Alberú"
            ]
            2 => array:2 [
              "Iniciales" => "G. R."
              "apellidos" => "García"
            ]
            3 => array:2 [
              "Iniciales" => "Y."
              "apellidos" => "Fuentes"
            ]
            4 => array:2 [
              "Iniciales" => "L."
              "apellidos" => "Velasquez"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X0211699508033111"
        "doi" => " "
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508033111?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033119?idApp=UINPBA000064"
    "url" => "/20132514/0000002800000002/v0_201502091614/X2013251408033119/v0_201502091615/en/main.assets"
  ]
  "en" => array:10 [
    "idiomaDefecto" => true
    "titulo" => "Renal failure due to light chain deposition disease"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "212"
        "paginaFinal" => "215"
      ]
    ]
    "autores" => array:1 [
      0 => array:3 [
        "autoresLista" => "A. García Pérez, A. M. Ramos, V. Petkov, Marta Albalate, C. Caramelo, J. L. López Lorenzo, J. Aneiros, M. T. Miguel, A. Barat"
        "autores" => array:9 [
          0 => array:3 [
            "Iniciales" => "A."
            "apellidos" => "García Pérez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          1 => array:3 [
            "Iniciales" => "A. M."
            "apellidos" => "Ramos"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          2 => array:3 [
            "Iniciales" => "V."
            "apellidos" => "Petkov"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          3 => array:4 [
            "nombre" => "Marta"
            "apellidos" => "Albalate"
            "email" => array:1 [
              0 => "malbalate&#64;senefro&#46;org"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          4 => array:3 [
            "Iniciales" => "C."
            "apellidos" => "Caramelo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          5 => array:3 [
            "Iniciales" => "J. L."
            "apellidos" => "L&#243;pez Lorenzo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "affb"
              ]
            ]
          ]
          6 => array:3 [
            "Iniciales" => "J."
            "apellidos" => "Aneiros"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "affc"
              ]
            ]
          ]
          7 => array:3 [
            "Iniciales" => "M. T."
            "apellidos" => "Miguel"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "affc"
              ]
            ]
          ]
          8 => array:3 [
            "Iniciales" => "A."
            "apellidos" => "Barat"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "affc"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "Servicio de Nefrología, Fundación Jiménez Díaz-Capio, Madrid, Madrid, España, "
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "affa"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Hematología, Fundación Jiménez Díaz-Capio, Madrid, Madrid, España, "
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "affb"
          ]
          2 => array:3 [
            "entidad" => "Servicio de Anatomía Patológica, Fundación Jiménez Díaz-Capio, Madrid, Madrid, España, "
            "etiqueta" => "<span class="elsevierStyleSup">c</span>"
            "identificador" => "affc"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Insuficiencia renal por enfermedad de dep&#243;sito de cadenas ligeras"
      ]
    ]
    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">A 64 year-old woman with a history of multinodular goiter&#44; osteoporosis and duodenal ulcer referred asthenia and dyspnea for several months&#46; The initial laboratory investigations disclosed Hb value of 9 g&#47;dL&#46; The patient was referred to the Hematology Department&#44; where a normocytic anemia with low blood production&#44; as well as total protein levels of 8&#46;2 g&#47;dL and albumin levels of 4&#46;2 g&#47;dL were detected&#46; An IgG Kappa peak was seen by serum immunofixation&#46; The bone marrow aspirate revealed diffuse plasmacytosis and an immunophenotype with a mainly monoclonal component&#44; with aberrant characteristics similar to myeloma cells&#46; According to percentage of plasmocytes the condition was classified as monoclonal gammopathy of undetermined significance&#46; The creatinine value was 1&#46;6 mg&#47;dL and creatinine clearance was 23 mL&#47;min&#44; and the patient was referred to Nephrology&#46; Antinuclear&#44; anti-mitochondrial and anti-cytoplasmic antibodies were negative&#46; A proteinuria of 352 mg&#47;24 h was found with no monoclonal peaks on urine immunofixation&#46; On renal ultrasound the kidneys measured 9&#46;5 and 10&#46;5 cm and the corticomedullary area was spared&#46; Treatment was initiated with oral iron and erythropoietin&#46;</p><p class="elsevierStylePara">In the following months high blood pressure developed with progressive worsening of renal function&#44; creatinine levels reaching 4&#46;7 mg&#47;dL&#46; A subcutaneous cellular tissue biopsy was negative for Congo red stain&#46; The echocardiography showed diastolic dysfunction without left ventricular hypertrophy&#46; Proteinuria reached 800 mg&#47;24 h and immunofixation disclosed monoclonal IgG kappa type and albumin traces&#46;</p><p class="elsevierStylePara">Apercutaneous renal biopsy was performed and the sample was analyzed by means of conventional light microscopy&#44; immunohistochemistry and direct immunofluorescence on 3 &#956;m slices obtained with the cryostatic microtome&#46; Light microscopy showed a globally distorted structure because of severe glomerular involvement and chronic tubulo-interstitial nephropathy&#44; moderate inflammatory infiltrate with lymphoid predominance and atrophic tubular groups with sclerosed glomeruli&#46; A total of ten glomeruli could be identified&#44; three of them were sclerosed&#44; while the rest showed lobule-like clews&#44; marked diffuse mesangial enlargement&#44; with a nodular tendency &#40;figs&#46; 1 and 2&#41;&#44; a cellular component&#44; PAS&#43; material and reticulate appearance&#46; PAS&#43; material could also be observed within the Bowman&#191;s capsule&#44; as well as in the tubular basement membrane&#44; in an evident zone&#44; that with the Masson&#191;s trichromic stain appeared to be fuchsinophilic&#46; There was no material that stained with Congo red technique&#46; In the medulla a vast interstitial deposition of PAS positive material could be seen&#46;</p><p class="elsevierStylePara">The following anti-sera were applied for the direct immunofluorescence technique &#40;FITC&#41;&#58; anti-IgG&#44; anti-IgA&#44; anti-IgM&#44; anti-C3&#44; anti-C1q&#44; anti-kappa chains and anti-lambda chains&#46; Two glomeruli could be seen in each slice&#46; Of note was the fixation of the anti-kappa chains serum in glomerular and tubular basement membrane and Bowman&#191;s capsule&#44; including the interstitial material seen in the medulla &#40;fig&#46; 3&#41;&#46; The immunohistochemistry for kappa and lambda chains yielded similar results as those seen with immunofluorescence &#40;fig&#46; 4&#41;&#46;</p><p class="elsevierStylePara">The pathological diagnosis was kappa chains deposition-induced nephropathy and chronic tubulo interstitial nephropathy&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">EVOLUTION</span></p><p class="elsevierStylePara">After the biopsy&#44; renal function went on worsening until the patient required renal replacement therapy&#46; The patient is currently on chronic hemodialysis&#46; Treatment with melphalan and prednisone was initiated and the monoclonal IgG peak could be reduced&#46; She always needed frequent transfusion therapy&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Dysproteinemic disorders are characterized by immunoglobulin synthesis by clones of B lymphocytes&#46; They are associated to different forms of renal disease&#44; like nephropathy due to Ig deposition or precipitation&#46; In patients with light chains deposition disease&#44; the typically Kappa Ig fragments accumulate in a disorganized granular manner&#44; different from the crystalline deposition observed in &#171;myeloma kidney&#187;&#44; the fibrillary deposition of amyloidosis and the microtubular deposition of immunotactoid glomerulopathy&#46; The different structural characteristics are responsible for the different clinical pictures&#46; For example&#44; the myeloma kidney progresses rapidly to renal failure&#44; even with acute flares&#44; while the conditions with predominantly mesangial depositions lead to clinical pictures like nephrotic syndrome&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">The factors determining the formation of granular or fibrillary tissue deposition are not clearly understood&#46; If light chains from affected patients are infused into mice a similar renal lesion is produced&#44; like that in patients&#46; That suggests that the biochemical characteristics of the protein are relevant&#46;<span class="elsevierStyleSup">2</span> Likewise&#44; some in vitro studies indicate that the amino acid composition or the net protein charge could determine the deposition formation&#46;<span class="elsevierStyleSup">3</span> For example&#44; it was initially observed that in the majority of the patients the chains were longer or shorter as usual and that was associated to a greater tendency to precipitate&#46; In recent studies&#44; the investigation of chains which were not initially detected showed that they were N-glycosilated&#44; which increases their ability to precipitate and makes them difficult to detect in serum&#46;<span class="elsevierStyleSup">4</span> Moreover&#44; the sequencing studies reveal that most of the abnormalities are localized within the molecular area involved in antigenbinding and so it is possible that the first step in deposition formation could be the interaction with a foreign component acting as an antigen&#46;<span class="elsevierStyleSup">5</span> The present case is an especially illustrative example of the importance of the protein type&#44; as the apparently low grade of abnormal protein synthesis and urine elimination is associated to severe&#44; rapid and characteristic renal disease&#46; Renal involvement in cases of light chains deposition disease is constant&#44; and most patients develop renal failure and proteinuria&#46;<span class="elsevierStyleSup">6</span> Up to a 55&#37; of cases present nephrotic syndrome and in those patients with proteinuria lower than 1 g&#47;d the main clinical picture is a tubulointerstitial syndrome&#46;<span class="elsevierStyleSup">7</span> Hematuria can be detected in up to a 40&#37; of the cases&#46; The evolution to end-stage is usually rapid and frequently similar between patients with varying degrees of proteinuria&#46; Other organs are less frequently affected than with amyloidosis&#44; hepatomegaly and hepatic dysfunction being possible and seldom heart involvement is seldom encountered&#46; The disease can be associated to other conditions like lymphoma&#44; leukemia&#44; Waldenstr&#246;m&#191;s macroglobulinemia or multiple myeloma&#44; which are diagnosed in up to 50&#37; of the cases&#46; In 10&#37;-15&#37; of patients monoclonal immunoglobulin is not detected either in blood or in urine&#46; That is probably not due to a lack of secretion&#44; but to rapid post-synthesis tissue deposition or protein degradation&#46;</p><p class="elsevierStylePara">The analysis of the renal biopsy samples by means of light microscopy always shows the deposition of eosinophilic PAS positive material in the outer part of the basement membrane&#46; Glomerular lesions are more heterogeneous&#44; being most characteristic the nodular glomerulosclerosis&#46; Mesangial nodules consist of PAS-positive Congo red-negative material&#44; which is accompanied with hypercellularity in most cases&#46; In the early stages or in case of mild involvement&#44; it is possible to find only an increase in mesangial matrix and mild hypercellularity&#44; with mild enlargement of the basement membranes&#46; In advanced disease a marked interstitial fibrosis can also be seen including depositions&#44; independent of the tubular lesions&#46;<span class="elsevierStyleSup">8</span> Besides depositions related to the basement membrane of arteries&#44; arterioles and peritubular capillaries can be observed&#46; The differential diagnosis must be made with diabetic nodular glomerulosclerosis&#46; In this condition Kimmelstiel-Wilson&#191;s nodules are more frequently localized in the periphery of the glomerulus&#44; and exudative lesions and hyalinosis can also be observed within the efferent arteries&#46; The differential diagnosis with amyloidotic nephropathy is made by means of Congo red stain&#44; which is negative in light chains depositions&#46;</p><p class="elsevierStylePara">The immunofluorescence technique shows the fixation of the anti-light chains anti-serum&#44; mainly of the kappa type&#44; along the tubular basement membranes&#46; Glomerular depositions are extensively observed in basement membranes and less markedly in the nodules themselves and the fixation is typically weaker than that on the tubules&#46; In patients without nodular lesions mesangial involvement can be appreciated&#46;</p><p class="elsevierStylePara">Lineal depositions of light chains within the basement membrane of Bowman&#191;s capsule can also be observed and they are always present in vascular walls&#46; Immunofluorescence is strongly positive comparing to that of amyloidosis&#44; as the Ig fraction that forms the depositions is typically the constant region&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">On electronic microscopy granular depositions of electron dense material along the outer side of the basement membranes and in mesangial nodules are observed&#46; Basement membranes are preserved&#46;</p><p class="elsevierStylePara">Disease evolution is variable since extrarenal deposition may vary from completely asymptomatic to severe organic dysfunction&#46; In published series&#44; survival from the time of diagnosis can vary from 1 month to 10 years&#46; The prognosis is worse in patients with associated myeloma and greater extrarenal involvement&#46;</p><p class="elsevierStylePara">The treatment is directed to diminishing immunoglobulin production with chemotherapy to eliminate the plasma cells clone that produces the monoclonal protein&#46; In young patients bone marrow transplantation is concomitantly performed&#46; In some cases&#44; it was not only observed a disappearance of immunoglobulin in blood an urine&#44; but also the regression of the mesangial nodular lesions and of the light chains depositions&#46; That supports an aggressive approach in patients with severe visceral involvement&#46;<span class="elsevierStyleSup">9</span> Some cases are reported in which renal function notably improved&#44; even after initiating renal replacement therapy&#46; After transplantation the disease always recurs&#46; For this reason the transplantation is not indicated unless complete hematologic remission is achieved&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">QUESTIONS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Dr&#46; Rivera &#40;General Hospital of Ciudad Real&#41;&#46;</span> Patients diagnosed with monoclonal gammopathy of undetermined significance and renal involvement with diminution of glomerular filtration rate and mild proteinuria are frequently encountered&#46; Most patients are of advanced age and have concomitant conditions like type 2 diabetes mellitus or arteriosclerosis&#44; which are also associated to renal involvement&#46; The clinical picture is then diagnosed as nephroangiosclerosis or diabetic nephropathy&#46; In this setting&#44; are the results from blood and urine immunofixation indicative of the presence of a light chain nephropathy&#63; What kind of immunoglobulin or light chain is most nephrotoxic&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">R&#58;</span> The presence of light chains&#44; mainly kappa type in immunofixation &#40;keeping in mind that they are not detected in 10-15&#37; of the cases&#41; points out the presence of this nephropathy&#44; especially if nephroangiosclerosis is accompanied by unexplained proteinuria&#44; or if there is a rapid progression of diabetic nephropathy&#46;</p><p class="elsevierStylePara">The kappa isotype is mostly identified&#44; although the nephrotoxicity seems to be determined by the deposition conformation&#46; Nevertheless different mutations in Ig chains can be involved in the type of deposition&#46; It was also observed that in the case of amyloidosis different variable regions of lambda chain could determine the affinity to the different tissues&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Dr&#46; Poveda &#40;Hospital of Bellvitge&#46; Barcelona&#41;&#46;</span> Your case clearly illustrates the poor prognosis of light chains nephropathy&#46; On the other hand some authors point out that good results may be achieved with chemotherapy if early applied&#46; That speaks for an early diagnosis&#46; To your opinion&#44; which are the indications of a renal biopsy in patients with monoclonal gammopathy and renal involvement&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">R&#58;</span> The prevalence of the gammopathy of undetermined significance in patients older than 70 years is 3&#37;&#44; and this percentage increases with age&#46; Concomitant morbidity&#44; which can explain the renal disease&#44; is also very frequent&#44; as we have already commented&#46; So&#44; we think that it is not efficacious to schedule a biopsy in all cases&#46; We think the indication should be limited to those patients in whom no other causes of renal failure can be found or if an unexplained worsening of renal function develops&#46; It would be interesting if in the future the conformational characteristics of the proteins responsible for the pathogenesis could be detected&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Dr&#46; Julia Blanco &#40;San Carlos Clinic University Hospital&#46; Madrid&#41;&#46;</span> The glomeruli with silver methenamine stain are strongly positive&#46; Have you seen something similar in other cases of light chain disease&#63; In patients seen at the Clinic University Hospital of Madrid&#44; the mesangial nodules&#44; as well as the enlarged tubular basement membranes are strongly argentophilic&#46; However in some books of Nephropathology&#44; such as Tisher&#191;Brenner&#191;s textbook of Renal Pathology the negativity of glomerular depositions with silver technique is established as a dogma&#46; What do you think about&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">R&#58; </span>In fact&#44; the positivity has also been described in similar cases&#46; I think that the silver technique is useful&#44; but the results must be interpreted with caution&#44; probably taking into account the time course and the different compositions of the chains with different affinity for the silver stains&#46; <br></br></p>"
    "pdfFichero" => "P-E-S-A507-EN.pdf"
    "tienePdf" => true
    "bibliografia" => array:2 [
      "titulo" => "Bibliography"
      "seccion" => array:1 [
        0 => array:1 [
          "bibliografiaReferencia" => array:11 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Ronco PM, Aucouturier P, Mougenot B. Kidney involvement in plasma cell dyscrasias. Oxford Textbook of Clinical Nephrology. Oxford University Press, 2005"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Solomon, A, Weiss, DT, Kattine, AA. Nephrotoxic potential of Bence Jones proteins. N Engl J Med 1991; 324: 1845."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Kaplan, B, Livneh, A, Gallo, G. Charge differences between in vivo deposits in immunoglobulin light chain amyloidosis and non-amyloid light chain deposition disease. Br J Haematol 2007; 136: 723. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17223908" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Ganeval D, Noël LH, Preud¿homme JL, Droz D y cols. Light-chain deposition disease: its relation with AL-type amyloidosis. Kidney International 1984; 26: 1."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Rocca A, Khamlichi AA, Aucouturier P. Primary structure of a variable region of the V!I subgroup (ISE) in light chain deposition disease. Clinical and Experimental Immunology 1993; 91: 506. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7680298" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Pozzi C, D¿Amico M, Fogazzi GB. Light Chain Deposition Disease- With Renal involvement: clinical Characteristics and Prognostic Factors. Am J Kidney Dis 2003; 42: 1154. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14655186" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Lin, J, Markowitz, GS, Valeri, AM y cols. Renal monoclonal immunoglobulin deposition disease: the disease spectrum. J Am Soc Nephrol 2001; 12: 1482. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11423577" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Salant D, Sanchorawala V,¿ and Vivette D. D¿Agati V. A Case of Atypical Light Chain Deposition Disease ¿Diagnosis and Treatment. Clin J Am Soc Nephrol 2007; 2: 858-867."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Leung N, Lager DJ, Gertz MA y cols. High dose chemotherapy in light chain or light and heavy chain deposition disease. Kidney Int 2004; 65: 642-648. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14717936" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Leung N, Lager DJ, Gertz MA, Wilson K, Kanakiriya S, Fervenza FC. Long-term outcome of renal transplantation in light-chain deposition disease. Am J Kidney Dis 2005; 43; 147-153. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14712438" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Abraham, RS, Geyer, SM, Price-Troska, TL y cols. Immunoglobulin light chain variable (V) region genes influence clinical presentation and outcome in light chain-associated amyloidosis (AL). Blood 2003; 101: 3801.  <a href="http://www.ncbi.nlm.nih.gov/pubmed/12515719" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/20132514/0000002800000002/v0_201502091614/X2013251408033045/v0_201502091615/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "35423"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Case Reports from Nephropathology Club "
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002800000002/v0_201502091614/X2013251408033045/v0_201502091615/en/P-E-S-A507-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033045?idApp=UINPBA000064"
]
Share
Journal Information

Statistics

Follow this link to access the full text of the article

Renal failure due to light chain deposition disease
Insuficiencia renal por enfermedad de depósito de cadenas ligeras
A.. García Péreza, A. M.. Ramosa, V.. Petkova, Marta Albalatea, C.. Carameloa, J. L.. López Lorenzob, J.. Aneirosc, M. T.. Miguelc, A.. Baratc
a Servicio de Nefrología, Fundación Jiménez Díaz-Capio, Madrid, Madrid, España,
b Servicio de Hematología, Fundación Jiménez Díaz-Capio, Madrid, Madrid, España,
c Servicio de Anatomía Patológica, Fundación Jiménez Díaz-Capio, Madrid, Madrid, España,
Read
9335
Times
was read the article
2199
Total PDF
7136
Total HTML
Share statistics
 array:21 [
  "pii" => "X2013251408033045"
  "issn" => "20132514"
  "doi" => " "
  "estado" => "S300"
  "fechaPublicacion" => "2008-04-01"
  "documento" => "article"
  "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
  "subdocumento" => "fla"
  "cita" => "Nefrologia &#40;English Version&#41;. 2008;28:212-5"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 4307
    "formatos" => array:3 [
      "EPUB" => 287
      "HTML" => 3469
      "PDF" => 551
    ]
  ]
  "Traduccion" => array:1 [
    "es" => array:17 [
      "pii" => "X0211699508033048"
      "issn" => "02116995"
      "doi" => " "
      "estado" => "S300"
      "fechaPublicacion" => "2008-04-01"
      "documento" => "article"
      "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
      "subdocumento" => "fla"
      "cita" => "Nefrologia. 2008;28:212-5"
      "abierto" => array:3 [
        "ES" => true
        "ES2" => true
        "LATM" => true
      ]
      "gratuito" => true
      "lecturas" => array:2 [
        "total" => 17187
        "formatos" => array:3 [
          "EPUB" => 300
          "HTML" => 14930
          "PDF" => 1957
        ]
      ]
      "es" => array:10 [
        "idiomaDefecto" => true
        "titulo" => "Insuficiencia renal por enfermedad de dep&#243;sito de cadenas ligeras"
        "tienePdf" => "es"
        "tieneTextoCompleto" => "es"
        "paginas" => array:1 [
          0 => array:2 [
            "paginaInicial" => "212"
            "paginaFinal" => "215"
          ]
        ]
        "titulosAlternativos" => array:1 [
          "en" => array:1 [
            "titulo" => "Renal failure due to light chain deposition disease"
          ]
        ]
        "contieneTextoCompleto" => array:1 [
          "es" => true
        ]
        "contienePdf" => array:1 [
          "es" => true
        ]
        "resumenGrafico" => array:2 [
          "original" => 0
          "multimedia" => array:7 [
            "identificador" => "fig1"
            "etiqueta" => "Fig. 1"
            "tipo" => "MULTIMEDIAFIGURA"
            "mostrarFloat" => true
            "mostrarDisplay" => false
            "copyright" => "Elsevier Espa&#241;a"
            "figura" => array:1 [
              0 => array:4 [
                "imagen" => "507127_figura1.jpg"
                "Alto" => 384
                "Ancho" => 512
                "Tamanyo" => 32239
              ]
            ]
          ]
        ]
        "autores" => array:1 [
          0 => array:2 [
            "autoresLista" => "A. Garc&#237;a P&#233;rez, A. M. Ramos, V. Petkov, Marta Albalate, C. Caramelo, J. L. L&#243;pez Lorenzo, J. Aneiros, M. T. Miguel, A. Barat"
            "autores" => array:9 [
              0 => array:2 [
                "Iniciales" => "A."
                "apellidos" => "Garc&#237;a P&#233;rez"
              ]
              1 => array:2 [
                "Iniciales" => "A. M."
                "apellidos" => "Ramos"
              ]
              2 => array:2 [
                "Iniciales" => "V."
                "apellidos" => "Petkov"
              ]
              3 => array:2 [
                "nombre" => "Marta"
                "apellidos" => "Albalate"
              ]
              4 => array:2 [
                "Iniciales" => "C."
                "apellidos" => "Caramelo"
              ]
              5 => array:2 [
                "Iniciales" => "J. L."
                "apellidos" => "L&#243;pez Lorenzo"
              ]
              6 => array:2 [
                "Iniciales" => "J."
                "apellidos" => "Aneiros"
              ]
              7 => array:2 [
                "Iniciales" => "M. T."
                "apellidos" => "Miguel"
              ]
              8 => array:2 [
                "Iniciales" => "A."
                "apellidos" => "Barat"
              ]
            ]
          ]
        ]
      ]
      "idiomaDefecto" => "es"
      "Traduccion" => array:1 [
        "en" => array:9 [
          "pii" => "X2013251408033045"
          "doi" => " "
          "estado" => "S300"
          "subdocumento" => ""
          "abierto" => array:3 [
            "ES" => true
            "ES2" => true
            "LATM" => true
          ]
          "gratuito" => true
          "lecturas" => array:1 [
            "total" => 0
          ]
          "idiomaDefecto" => "en"
          "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033045?idApp=UINPBA000064"
        ]
      ]
      "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508033048?idApp=UINPBA000064"
      "url" => "/02116995/0000002800000002/v0_201502091346/X0211699508033048/v0_201502091346/es/main.assets"
    ]
  ]
  "itemSiguiente" => array:17 [
    "pii" => "X2013251408033037"
    "issn" => "20132514"
    "doi" => " "
    "estado" => "S300"
    "fechaPublicacion" => "2008-04-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia &#40;English Version&#41;. 2008;28:216-7"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 4668
      "formatos" => array:3 [
        "EPUB" => 307
        "HTML" => 3824
        "PDF" => 537
      ]
    ]
    "en" => array:11 [
      "idiomaDefecto" => true
      "titulo" => "High blood pressure due to aortic coarctation and renal artery stenosis in a teenager with type 1 neurofibromatosis"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => array:2 [
        0 => "es"
        1 => "en"
      ]
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "216"
          "paginaFinal" => "217"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Hipertensi&#243;n secundaria a coartaci&#243;n de aorta y estenosis de arteria renal en adolescente con neurofibromatosis tipo 1"
        ]
      ]
      "contieneResumen" => array:2 [
        "es" => true
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "R. Pardo, L. Somalo, Seraf&#237;n M&#225;laga Guerrero, F. Santos"
          "autores" => array:4 [
            0 => array:2 [
              "Iniciales" => "R."
              "apellidos" => "Pardo"
            ]
            1 => array:2 [
              "Iniciales" => "L."
              "apellidos" => "Somalo"
            ]
            2 => array:2 [
              "nombre" => "Seraf&#237;n"
              "apellidos" => "M&#225;laga Guerrero"
            ]
            3 => array:2 [
              "Iniciales" => "F."
              "apellidos" => "Santos"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X021169950803303X"
        "doi" => " "
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X021169950803303X?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033037?idApp=UINPBA000064"
    "url" => "/20132514/0000002800000002/v0_201502091614/X2013251408033037/v0_201502091615/en/main.assets"
  ]
  "itemAnterior" => array:17 [
    "pii" => "X2013251408033119"
    "issn" => "20132514"
    "doi" => " "
    "estado" => "S300"
    "fechaPublicacion" => "2008-04-01"
    "documento" => "article"
    "licencia" => "http://www.elsevier.com/open-access/userlicense/1.0/"
    "subdocumento" => "fla"
    "cita" => "Nefrologia &#40;English Version&#41;. 2008;28:203-11"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 7067
      "formatos" => array:3 [
        "EPUB" => 273
        "HTML" => 4242
        "PDF" => 2552
      ]
    ]
    "en" => array:9 [
      "idiomaDefecto" => true
      "titulo" => "Polyoma virus in transplant recipients"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "203"
          "paginaFinal" => "211"
        ]
      ]
      "titulosAlternativos" => array:1 [
        "es" => array:1 [
          "titulo" => "Virus polioma en trasplante renal"
        ]
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Mara Medeiros, J. Alber&#250;, G. R. Garc&#237;a, Y. Fuentes, L. Velasquez"
          "autores" => array:5 [
            0 => array:2 [
              "nombre" => "Mara"
              "apellidos" => "Medeiros"
            ]
            1 => array:2 [
              "Iniciales" => "J."
              "apellidos" => "Alber&#250;"
            ]
            2 => array:2 [
              "Iniciales" => "G. R."
              "apellidos" => "Garc&#237;a"
            ]
            3 => array:2 [
              "Iniciales" => "Y."
              "apellidos" => "Fuentes"
            ]
            4 => array:2 [
              "Iniciales" => "L."
              "apellidos" => "Velasquez"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "Traduccion" => array:1 [
      "es" => array:9 [
        "pii" => "X0211699508033111"
        "doi" => " "
        "estado" => "S300"
        "subdocumento" => ""
        "abierto" => array:3 [
          "ES" => true
          "ES2" => true
          "LATM" => true
        ]
        "gratuito" => true
        "lecturas" => array:1 [
          "total" => 0
        ]
        "idiomaDefecto" => "es"
        "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X0211699508033111?idApp=UINPBA000064"
      ]
    ]
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033119?idApp=UINPBA000064"
    "url" => "/20132514/0000002800000002/v0_201502091614/X2013251408033119/v0_201502091615/en/main.assets"
  ]
  "en" => array:10 [
    "idiomaDefecto" => true
    "titulo" => "Renal failure due to light chain deposition disease"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "212"
        "paginaFinal" => "215"
      ]
    ]
    "autores" => array:1 [
      0 => array:3 [
        "autoresLista" => "A. Garc&#237;a P&#233;rez, A. M. Ramos, V. Petkov, Marta Albalate, C. Caramelo, J. L. L&#243;pez Lorenzo, J. Aneiros, M. T. Miguel, A. Barat"
        "autores" => array:9 [
          0 => array:3 [
            "Iniciales" => "A."
            "apellidos" => "Garc&#237;a P&#233;rez"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          1 => array:3 [
            "Iniciales" => "A. M."
            "apellidos" => "Ramos"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          2 => array:3 [
            "Iniciales" => "V."
            "apellidos" => "Petkov"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          3 => array:4 [
            "nombre" => "Marta"
            "apellidos" => "Albalate"
            "email" => array:1 [
              0 => "malbalate&#64;senefro&#46;org"
            ]
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          4 => array:3 [
            "Iniciales" => "C."
            "apellidos" => "Caramelo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">a</span>"
                "identificador" => "affa"
              ]
            ]
          ]
          5 => array:3 [
            "Iniciales" => "J. L."
            "apellidos" => "L&#243;pez Lorenzo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">b</span>"
                "identificador" => "affb"
              ]
            ]
          ]
          6 => array:3 [
            "Iniciales" => "J."
            "apellidos" => "Aneiros"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "affc"
              ]
            ]
          ]
          7 => array:3 [
            "Iniciales" => "M. T."
            "apellidos" => "Miguel"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "affc"
              ]
            ]
          ]
          8 => array:3 [
            "Iniciales" => "A."
            "apellidos" => "Barat"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">c</span>"
                "identificador" => "affc"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:3 [
          0 => array:3 [
            "entidad" => "Servicio de Nefrología, Fundación Jiménez Díaz-Capio, Madrid, Madrid, España, "
            "etiqueta" => "<span class="elsevierStyleSup">a</span>"
            "identificador" => "affa"
          ]
          1 => array:3 [
            "entidad" => "Servicio de Hematología, Fundación Jiménez Díaz-Capio, Madrid, Madrid, España, "
            "etiqueta" => "<span class="elsevierStyleSup">b</span>"
            "identificador" => "affb"
          ]
          2 => array:3 [
            "entidad" => "Servicio de Anatomía Patológica, Fundación Jiménez Díaz-Capio, Madrid, Madrid, España, "
            "etiqueta" => "<span class="elsevierStyleSup">c</span>"
            "identificador" => "affc"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Insuficiencia renal por enfermedad de dep&#243;sito de cadenas ligeras"
      ]
    ]
    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">A 64 year-old woman with a history of multinodular goiter&#44; osteoporosis and duodenal ulcer referred asthenia and dyspnea for several months&#46; The initial laboratory investigations disclosed Hb value of 9 g&#47;dL&#46; The patient was referred to the Hematology Department&#44; where a normocytic anemia with low blood production&#44; as well as total protein levels of 8&#46;2 g&#47;dL and albumin levels of 4&#46;2 g&#47;dL were detected&#46; An IgG Kappa peak was seen by serum immunofixation&#46; The bone marrow aspirate revealed diffuse plasmacytosis and an immunophenotype with a mainly monoclonal component&#44; with aberrant characteristics similar to myeloma cells&#46; According to percentage of plasmocytes the condition was classified as monoclonal gammopathy of undetermined significance&#46; The creatinine value was 1&#46;6 mg&#47;dL and creatinine clearance was 23 mL&#47;min&#44; and the patient was referred to Nephrology&#46; Antinuclear&#44; anti-mitochondrial and anti-cytoplasmic antibodies were negative&#46; A proteinuria of 352 mg&#47;24 h was found with no monoclonal peaks on urine immunofixation&#46; On renal ultrasound the kidneys measured 9&#46;5 and 10&#46;5 cm and the corticomedullary area was spared&#46; Treatment was initiated with oral iron and erythropoietin&#46;</p><p class="elsevierStylePara">In the following months high blood pressure developed with progressive worsening of renal function&#44; creatinine levels reaching 4&#46;7 mg&#47;dL&#46; A subcutaneous cellular tissue biopsy was negative for Congo red stain&#46; The echocardiography showed diastolic dysfunction without left ventricular hypertrophy&#46; Proteinuria reached 800 mg&#47;24 h and immunofixation disclosed monoclonal IgG kappa type and albumin traces&#46;</p><p class="elsevierStylePara">Apercutaneous renal biopsy was performed and the sample was analyzed by means of conventional light microscopy&#44; immunohistochemistry and direct immunofluorescence on 3 &#956;m slices obtained with the cryostatic microtome&#46; Light microscopy showed a globally distorted structure because of severe glomerular involvement and chronic tubulo-interstitial nephropathy&#44; moderate inflammatory infiltrate with lymphoid predominance and atrophic tubular groups with sclerosed glomeruli&#46; A total of ten glomeruli could be identified&#44; three of them were sclerosed&#44; while the rest showed lobule-like clews&#44; marked diffuse mesangial enlargement&#44; with a nodular tendency &#40;figs&#46; 1 and 2&#41;&#44; a cellular component&#44; PAS&#43; material and reticulate appearance&#46; PAS&#43; material could also be observed within the Bowman&#191;s capsule&#44; as well as in the tubular basement membrane&#44; in an evident zone&#44; that with the Masson&#191;s trichromic stain appeared to be fuchsinophilic&#46; There was no material that stained with Congo red technique&#46; In the medulla a vast interstitial deposition of PAS positive material could be seen&#46;</p><p class="elsevierStylePara">The following anti-sera were applied for the direct immunofluorescence technique &#40;FITC&#41;&#58; anti-IgG&#44; anti-IgA&#44; anti-IgM&#44; anti-C3&#44; anti-C1q&#44; anti-kappa chains and anti-lambda chains&#46; Two glomeruli could be seen in each slice&#46; Of note was the fixation of the anti-kappa chains serum in glomerular and tubular basement membrane and Bowman&#191;s capsule&#44; including the interstitial material seen in the medulla &#40;fig&#46; 3&#41;&#46; The immunohistochemistry for kappa and lambda chains yielded similar results as those seen with immunofluorescence &#40;fig&#46; 4&#41;&#46;</p><p class="elsevierStylePara">The pathological diagnosis was kappa chains deposition-induced nephropathy and chronic tubulo interstitial nephropathy&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">EVOLUTION</span></p><p class="elsevierStylePara">After the biopsy&#44; renal function went on worsening until the patient required renal replacement therapy&#46; The patient is currently on chronic hemodialysis&#46; Treatment with melphalan and prednisone was initiated and the monoclonal IgG peak could be reduced&#46; She always needed frequent transfusion therapy&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Dysproteinemic disorders are characterized by immunoglobulin synthesis by clones of B lymphocytes&#46; They are associated to different forms of renal disease&#44; like nephropathy due to Ig deposition or precipitation&#46; In patients with light chains deposition disease&#44; the typically Kappa Ig fragments accumulate in a disorganized granular manner&#44; different from the crystalline deposition observed in &#171;myeloma kidney&#187;&#44; the fibrillary deposition of amyloidosis and the microtubular deposition of immunotactoid glomerulopathy&#46; The different structural characteristics are responsible for the different clinical pictures&#46; For example&#44; the myeloma kidney progresses rapidly to renal failure&#44; even with acute flares&#44; while the conditions with predominantly mesangial depositions lead to clinical pictures like nephrotic syndrome&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">The factors determining the formation of granular or fibrillary tissue deposition are not clearly understood&#46; If light chains from affected patients are infused into mice a similar renal lesion is produced&#44; like that in patients&#46; That suggests that the biochemical characteristics of the protein are relevant&#46;<span class="elsevierStyleSup">2</span> Likewise&#44; some in vitro studies indicate that the amino acid composition or the net protein charge could determine the deposition formation&#46;<span class="elsevierStyleSup">3</span> For example&#44; it was initially observed that in the majority of the patients the chains were longer or shorter as usual and that was associated to a greater tendency to precipitate&#46; In recent studies&#44; the investigation of chains which were not initially detected showed that they were N-glycosilated&#44; which increases their ability to precipitate and makes them difficult to detect in serum&#46;<span class="elsevierStyleSup">4</span> Moreover&#44; the sequencing studies reveal that most of the abnormalities are localized within the molecular area involved in antigenbinding and so it is possible that the first step in deposition formation could be the interaction with a foreign component acting as an antigen&#46;<span class="elsevierStyleSup">5</span> The present case is an especially illustrative example of the importance of the protein type&#44; as the apparently low grade of abnormal protein synthesis and urine elimination is associated to severe&#44; rapid and characteristic renal disease&#46; Renal involvement in cases of light chains deposition disease is constant&#44; and most patients develop renal failure and proteinuria&#46;<span class="elsevierStyleSup">6</span> Up to a 55&#37; of cases present nephrotic syndrome and in those patients with proteinuria lower than 1 g&#47;d the main clinical picture is a tubulointerstitial syndrome&#46;<span class="elsevierStyleSup">7</span> Hematuria can be detected in up to a 40&#37; of the cases&#46; The evolution to end-stage is usually rapid and frequently similar between patients with varying degrees of proteinuria&#46; Other organs are less frequently affected than with amyloidosis&#44; hepatomegaly and hepatic dysfunction being possible and seldom heart involvement is seldom encountered&#46; The disease can be associated to other conditions like lymphoma&#44; leukemia&#44; Waldenstr&#246;m&#191;s macroglobulinemia or multiple myeloma&#44; which are diagnosed in up to 50&#37; of the cases&#46; In 10&#37;-15&#37; of patients monoclonal immunoglobulin is not detected either in blood or in urine&#46; That is probably not due to a lack of secretion&#44; but to rapid post-synthesis tissue deposition or protein degradation&#46;</p><p class="elsevierStylePara">The analysis of the renal biopsy samples by means of light microscopy always shows the deposition of eosinophilic PAS positive material in the outer part of the basement membrane&#46; Glomerular lesions are more heterogeneous&#44; being most characteristic the nodular glomerulosclerosis&#46; Mesangial nodules consist of PAS-positive Congo red-negative material&#44; which is accompanied with hypercellularity in most cases&#46; In the early stages or in case of mild involvement&#44; it is possible to find only an increase in mesangial matrix and mild hypercellularity&#44; with mild enlargement of the basement membranes&#46; In advanced disease a marked interstitial fibrosis can also be seen including depositions&#44; independent of the tubular lesions&#46;<span class="elsevierStyleSup">8</span> Besides depositions related to the basement membrane of arteries&#44; arterioles and peritubular capillaries can be observed&#46; The differential diagnosis must be made with diabetic nodular glomerulosclerosis&#46; In this condition Kimmelstiel-Wilson&#191;s nodules are more frequently localized in the periphery of the glomerulus&#44; and exudative lesions and hyalinosis can also be observed within the efferent arteries&#46; The differential diagnosis with amyloidotic nephropathy is made by means of Congo red stain&#44; which is negative in light chains depositions&#46;</p><p class="elsevierStylePara">The immunofluorescence technique shows the fixation of the anti-light chains anti-serum&#44; mainly of the kappa type&#44; along the tubular basement membranes&#46; Glomerular depositions are extensively observed in basement membranes and less markedly in the nodules themselves and the fixation is typically weaker than that on the tubules&#46; In patients without nodular lesions mesangial involvement can be appreciated&#46;</p><p class="elsevierStylePara">Lineal depositions of light chains within the basement membrane of Bowman&#191;s capsule can also be observed and they are always present in vascular walls&#46; Immunofluorescence is strongly positive comparing to that of amyloidosis&#44; as the Ig fraction that forms the depositions is typically the constant region&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">On electronic microscopy granular depositions of electron dense material along the outer side of the basement membranes and in mesangial nodules are observed&#46; Basement membranes are preserved&#46;</p><p class="elsevierStylePara">Disease evolution is variable since extrarenal deposition may vary from completely asymptomatic to severe organic dysfunction&#46; In published series&#44; survival from the time of diagnosis can vary from 1 month to 10 years&#46; The prognosis is worse in patients with associated myeloma and greater extrarenal involvement&#46;</p><p class="elsevierStylePara">The treatment is directed to diminishing immunoglobulin production with chemotherapy to eliminate the plasma cells clone that produces the monoclonal protein&#46; In young patients bone marrow transplantation is concomitantly performed&#46; In some cases&#44; it was not only observed a disappearance of immunoglobulin in blood an urine&#44; but also the regression of the mesangial nodular lesions and of the light chains depositions&#46; That supports an aggressive approach in patients with severe visceral involvement&#46;<span class="elsevierStyleSup">9</span> Some cases are reported in which renal function notably improved&#44; even after initiating renal replacement therapy&#46; After transplantation the disease always recurs&#46; For this reason the transplantation is not indicated unless complete hematologic remission is achieved&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">QUESTIONS</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Dr&#46; Rivera &#40;General Hospital of Ciudad Real&#41;&#46;</span> Patients diagnosed with monoclonal gammopathy of undetermined significance and renal involvement with diminution of glomerular filtration rate and mild proteinuria are frequently encountered&#46; Most patients are of advanced age and have concomitant conditions like type 2 diabetes mellitus or arteriosclerosis&#44; which are also associated to renal involvement&#46; The clinical picture is then diagnosed as nephroangiosclerosis or diabetic nephropathy&#46; In this setting&#44; are the results from blood and urine immunofixation indicative of the presence of a light chain nephropathy&#63; What kind of immunoglobulin or light chain is most nephrotoxic&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">R&#58;</span> The presence of light chains&#44; mainly kappa type in immunofixation &#40;keeping in mind that they are not detected in 10-15&#37; of the cases&#41; points out the presence of this nephropathy&#44; especially if nephroangiosclerosis is accompanied by unexplained proteinuria&#44; or if there is a rapid progression of diabetic nephropathy&#46;</p><p class="elsevierStylePara">The kappa isotype is mostly identified&#44; although the nephrotoxicity seems to be determined by the deposition conformation&#46; Nevertheless different mutations in Ig chains can be involved in the type of deposition&#46; It was also observed that in the case of amyloidosis different variable regions of lambda chain could determine the affinity to the different tissues&#46;<span class="elsevierStyleSup">11</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Dr&#46; Poveda &#40;Hospital of Bellvitge&#46; Barcelona&#41;&#46;</span> Your case clearly illustrates the poor prognosis of light chains nephropathy&#46; On the other hand some authors point out that good results may be achieved with chemotherapy if early applied&#46; That speaks for an early diagnosis&#46; To your opinion&#44; which are the indications of a renal biopsy in patients with monoclonal gammopathy and renal involvement&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">R&#58;</span> The prevalence of the gammopathy of undetermined significance in patients older than 70 years is 3&#37;&#44; and this percentage increases with age&#46; Concomitant morbidity&#44; which can explain the renal disease&#44; is also very frequent&#44; as we have already commented&#46; So&#44; we think that it is not efficacious to schedule a biopsy in all cases&#46; We think the indication should be limited to those patients in whom no other causes of renal failure can be found or if an unexplained worsening of renal function develops&#46; It would be interesting if in the future the conformational characteristics of the proteins responsible for the pathogenesis could be detected&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Dr&#46; Julia Blanco &#40;San Carlos Clinic University Hospital&#46; Madrid&#41;&#46;</span> The glomeruli with silver methenamine stain are strongly positive&#46; Have you seen something similar in other cases of light chain disease&#63; In patients seen at the Clinic University Hospital of Madrid&#44; the mesangial nodules&#44; as well as the enlarged tubular basement membranes are strongly argentophilic&#46; However in some books of Nephropathology&#44; such as Tisher&#191;Brenner&#191;s textbook of Renal Pathology the negativity of glomerular depositions with silver technique is established as a dogma&#46; What do you think about&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">R&#58; </span>In fact&#44; the positivity has also been described in similar cases&#46; I think that the silver technique is useful&#44; but the results must be interpreted with caution&#44; probably taking into account the time course and the different compositions of the chains with different affinity for the silver stains&#46; <br></br></p>"
    "pdfFichero" => "P-E-S-A507-EN.pdf"
    "tienePdf" => true
    "bibliografia" => array:2 [
      "titulo" => "Bibliography"
      "seccion" => array:1 [
        0 => array:1 [
          "bibliografiaReferencia" => array:11 [
            0 => array:3 [
              "identificador" => "bib1"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Ronco PM, Aucouturier P, Mougenot B. Kidney involvement in plasma cell dyscrasias. Oxford Textbook of Clinical Nephrology. Oxford University Press, 2005"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib2"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Solomon, A, Weiss, DT, Kattine, AA. Nephrotoxic potential of Bence Jones proteins. N Engl J Med 1991; 324: 1845."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib3"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Kaplan, B, Livneh, A, Gallo, G. Charge differences between in vivo deposits in immunoglobulin light chain amyloidosis and non-amyloid light chain deposition disease. Br J Haematol 2007; 136: 723. <a href="http://www.ncbi.nlm.nih.gov/pubmed/17223908" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib4"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Ganeval D, Noël LH, Preud¿homme JL, Droz D y cols. Light-chain deposition disease: its relation with AL-type amyloidosis. Kidney International 1984; 26: 1."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib5"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Rocca A, Khamlichi AA, Aucouturier P. Primary structure of a variable region of the V!I subgroup (ISE) in light chain deposition disease. Clinical and Experimental Immunology 1993; 91: 506. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7680298" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib6"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Pozzi C, D¿Amico M, Fogazzi GB. Light Chain Deposition Disease- With Renal involvement: clinical Characteristics and Prognostic Factors. Am J Kidney Dis 2003; 42: 1154. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14655186" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib7"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Lin, J, Markowitz, GS, Valeri, AM y cols. Renal monoclonal immunoglobulin deposition disease: the disease spectrum. J Am Soc Nephrol 2001; 12: 1482. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11423577" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib8"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Salant D, Sanchorawala V,¿ and Vivette D. D¿Agati V. A Case of Atypical Light Chain Deposition Disease ¿Diagnosis and Treatment. Clin J Am Soc Nephrol 2007; 2: 858-867."
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib9"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Leung N, Lager DJ, Gertz MA y cols. High dose chemotherapy in light chain or light and heavy chain deposition disease. Kidney Int 2004; 65: 642-648. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14717936" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib10"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Leung N, Lager DJ, Gertz MA, Wilson K, Kanakiriya S, Fervenza FC. Long-term outcome of renal transplantation in light-chain deposition disease. Am J Kidney Dis 2005; 43; 147-153. <a href="http://www.ncbi.nlm.nih.gov/pubmed/14712438" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib11"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:3 [
                  "referenciaCompleta" => "Abraham, RS, Geyer, SM, Price-Troska, TL y cols. Immunoglobulin light chain variable (V) region genes influence clinical presentation and outcome in light chain-associated amyloidosis (AL). Blood 2003; 101: 3801.  <a href="http://www.ncbi.nlm.nih.gov/pubmed/12515719" target="_blank">[Pubmed]</a>"
                  "contribucion" => array:1 [
                    0 => null
                  ]
                  "host" => array:1 [
                    0 => null
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/20132514/0000002800000002/v0_201502091614/X2013251408033045/v0_201502091615/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "35423"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Case Reports from Nephropathology Club "
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/20132514/0000002800000002/v0_201502091614/X2013251408033045/v0_201502091615/en/P-E-S-A507-EN.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251408033045?idApp=UINPBA000064"
]
Article information
ISSN: 20132514
Original language: English
DOI:
The statistics are updated each day
Year/Month Html Pdf Total
2024 November 22 6 28
2024 October 77 40 117
2024 September 70 25 95
2024 August 87 76 163
2024 July 72 33 105
2024 June 80 56 136
2024 May 89 30 119
2024 April 70 35 105
2024 March 65 21 86
2024 February 55 43 98
2024 January 67 25 92
2023 December 54 22 76
2023 November 58 29 87
2023 October 73 35 108
2023 September 75 30 105
2023 August 71 21 92
2023 July 109 29 138
2023 June 63 26 89
2023 May 94 36 130
2023 April 34 20 54
2023 March 42 19 61
2023 February 62 19 81
2023 January 58 25 83
2022 December 70 30 100
2022 November 65 25 90
2022 October 89 42 131
2022 September 60 25 85
2022 August 63 43 106
2022 July 40 37 77
2022 June 38 23 61
2022 May 62 37 99
2022 April 73 47 120
2022 March 58 52 110
2022 February 79 33 112
2022 January 91 38 129
2021 December 80 38 118
2021 November 56 31 87
2021 October 50 40 90
2021 September 51 32 83
2021 August 67 36 103
2021 July 64 43 107
2021 June 64 27 91
2021 May 64 33 97
2021 April 165 37 202
2021 March 103 34 137
2021 February 85 17 102
2021 January 46 24 70
2020 December 43 10 53
2020 November 32 13 45
2020 October 35 13 48
2020 September 31 7 38
2020 August 40 11 51
2020 July 38 6 44
2020 June 57 12 69
2020 May 46 18 64
2020 April 44 17 61
2020 March 53 8 61
2020 February 38 15 53
2020 January 53 23 76
2019 December 48 27 75
2019 November 51 25 76
2019 October 41 7 48
2019 September 53 21 74
2019 August 38 14 52
2019 July 32 19 51
2019 June 26 8 34
2019 May 35 16 51
2019 April 75 24 99
2019 March 35 19 54
2019 February 15 16 31
2019 January 20 10 30
2018 December 61 30 91
2018 November 102 10 112
2018 October 70 12 82
2018 September 81 19 100
2018 August 67 13 80
2018 July 45 11 56
2018 June 42 12 54
2018 May 52 18 70
2018 April 46 10 56
2018 March 39 10 49
2018 February 45 7 52
2018 January 58 9 67
2017 December 74 9 83
2017 November 41 8 49
2017 October 30 8 38
2017 September 31 10 41
2017 August 28 12 40
2017 July 31 10 41
2017 June 28 14 42
2017 May 47 10 57
2017 April 30 11 41
2017 March 26 7 33
2017 February 25 9 34
2017 January 21 9 30
2016 December 58 5 63
2016 November 55 5 60
2016 October 100 10 110
2016 September 125 4 129
2016 August 193 6 199
2016 July 200 7 207
2016 June 102 0 102
2016 May 119 0 119
2016 April 87 0 87
2016 March 74 0 74
2016 February 99 0 99
2016 January 78 0 78
2015 December 110 0 110
2015 November 56 0 56
2015 October 72 0 72
2015 September 58 0 58
2015 August 72 0 72
2015 July 53 0 53
2015 June 43 0 43
2015 May 47 0 47
2015 April 6 0 6
Show all

Follow this link to access the full text of the article

Idiomas
Nefrología (English Edition)
es en

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?