Acute renal failure in a case of nephrotic syndrome secondary to focal and segmental glomerulosclerosis
Fracaso renal agudo en síndrome nefrótico secundario a glomeruloesclerosis focal y segmentaria
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J. Borrego Utiel, I. Ruiz Ávila, V. Pérez Bañasco" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Manuel" "apellidos" => "Polaina Rusillo" "email" => array:1 [ 0 => "nefropolaina@yahoo.es" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "F. J." "apellidos" => "Borrego Utiel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "I." "apellidos" => "Ruiz Ávila" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "V." "apellidos" => "Pérez Bañasco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:3 [ "entidad" => " Complejo Hospitalario de Jaén, Jaén, Jaén, España, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fracaso renal agudo en síndrome nefrótico secundario a glomeruloesclerosis focal y segmentaria" ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">The development of acute renal failure (ARF) in patients with nephrotic syndrome is rare and usually associated to minimal changes nephropathy.<span class="elsevierStyleSup">1</span> The pathogenesis is not clear and several mechanisms have been implicated.<span class="elsevierStyleSup">2, 3</span> The increase in the pressure within the tubules and the Bowman¿s space can play a role. This is due both to interstitial edema and to intratubular obstruction because of accumulation of proteins<span class="elsevierStyleSup">4</span> and cellular detritus.<span class="elsevierStyleSup">5</span> Hypovolemia is another mechanism implicated and is related to hypoalbuminemia and to the excessive use of diuretics.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">A 36 year-old male is presented with a history of nephrotic syndrome in complete remission since 2000.</p><p class="elsevierStylePara">In 2004 he was evaluated in the Emergency Room because of edemas. The laboratory findings revealed mild renal function impairment and mild proteinuria. Diuretics were prescribed and the patient was referred to the outpatient clinic. Eight days later he was again evaluated because of increasing edemas and he was admitted to the hospital. The following laboratory findings were obtained: urea 71, Cr 1.15, cholesterol 423, triglycerides 254 mg/dL; total proteins 4.32, albumin 2.22g/dL; proteinuria 3.1 g/12-hours. A new renal biopsy was performed and the patient was discharged.</p><p class="elsevierStylePara">A week later the patients was again admitted with anasarca and oligo-anuria. Serum level of urea was 287 and creatinine was 4.1 mg/dL. Severe hypoalbuminemia was detected that prompted the administration of albumin. The urine analysis revealed Na < 10 mEq/L and Cr > 130 mg/dL, which supported the diagnosis of prerrenal renal failure. Diuretics were withdrawn. The patient developed anuria and a central catheter was placed to initiate hemodialysis. Renal biopsy (fig. 1) showed 8 glomeruli with mild sclerosis and capillary collapse within the vascular pole and others with capsular adhesions or capillary lumen collapse. The interstitium and the tubules were normal. The immunofluorescence pattern was granular mesangial IgM+ and C3 ++. Adiagnosis of focal and segmentary glomerulosclerosis (FSGS) was made and three boluses of steroids were administrated followed by oral prednisone and cyclophosphamide. When the patient was discharged he was in anuria and required periodic hemodialysis.</p><p class="elsevierStylePara">Two days later the patient was again admitted to the hospital to evaluate renal function because he referred increasing diuresis that reached 7 L/day. On day 9 of hospital stay the laboratory parameters were as follows: urea 32, Cr 0.8 mg/dL; proteinuria 2.5 g/24h; CrCl 156 mL/min.</p><p class="elsevierStylePara">After 10 months of periodic follow up, the proteinuria was negative and therefore treatment with steroids and cyclophosphamide could be discontinued. The patient remained asymptomatic, with no signs of nephropathy relapse.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">Some cases of ARF remission without steroidal administration have been reported.<span class="elsevierStyleSup">7</span> However the treatment with high doses of prednisone (1 mg/kg/day) is considered necessary in case of nephrotic syndrome associated to FSGS and can induce complete remission in 35-45% of the patients.<span class="elsevierStyleSup">8</span> The effect of steroids on glomerular filtrate in ARF associated to nephrotic syndrome is unknown, but they may prevent the tubular reabsorption of sodium and allow the complete recovery of filtration fraction<span class="elsevierStyleSup">9, 10</span> as proteinuria decreases. The judicious use of diuretics should maintain the diuresis, avoiding a misbalance of pressures within the glomeruli and the potential progression to anuria. Ultrafiltration hemodialysis is indicated in case of nephrotic syndrome due to FSGS with ARF, which presents with oligo-anuria and accumulation of nitrogen products. At the same time, steroidal treatment should be initiated or their dose increased. The resolution of ARF is in this way to be expected, which may occur in a few weeks or months<span class="elsevierStyleSup">5, 11</span> or dramatically, as it happened in the reported case.<br></br></p>" "pdfFichero" => "P-E-S-A10009-EN.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "es" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438753" "palabras" => array:1 [ 0 => "Síndome nefrótico" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438755" "palabras" => array:1 [ 0 => "Fracaso renal agudo" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec438757" "palabras" => array:1 [ 0 => "Glomeruloesclerosis focal y segmentaria" ] ] ] "en" => array:3 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438754" "palabras" => array:1 [ 0 => "Nephrotic syndrome" ] ] 1 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438756" "palabras" => array:1 [ 0 => "Acute renal failure" ] ] 2 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec438758" "palabras" => array:1 [ 0 => "Focal and segmental glomeruloesclerosis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "es" => array:1 [ "resumen" => "El fracaso renal agudo en el síndrome nefrótico es poco frecuente y suele asociarse con una nefropatía de cambios mínimos. Su etiopatogenia es oscura y se relaciona con una reducción de la permeabilidad glomerular, con necrosis tubular aguda o con un incremento de la presión intrarrenal debido al edema intersticial. Presentamos un varón de 36 años con un síndrome nefrótico por glomeruloesclerosis focal y segmentaria que desarrolló un fracaso renal agudo anúrico. A pesar de reducir el edema con hemodiálisis fue tras iniciar tratamiento con esteroides e inmunosupresores cuando la diuresis se restableció y mejoró rápidamente la función renal. En la biopsia renal no se observaron datos de necrosis u obstrucción tubular ni de edema intersticial, por lo que atribuimos el fracaso renal agudo a una severa reducción del coeficiente de ultrafiltración glomerular." ] "en" => array:1 [ "resumen" => "Nephrotic syndrome is infrequently complicated with appearance of acute renal failure and minimal change disease is the glomerulopathy more usually involved. Pathogenesis is unclear and three possible mechanisms it has been proposed to explain the decrease of glomerular filtration rate: a severe reduction of glomerular permeability, the presence of acute tubular necrosis or an increased intrarrenal pressure related with interstitial oedema. Here we present a 36 years-old-male with a nephrotic syndrome caused by focal and segmental glomerulosclerosis who developed an anuric acute renal failure. Renal function did not change despite oedema removal with haemodialysis and only after corticosteroid and cyclophosphamide therapy introduction we observed a rapid recovery of urinary output and resolution of acute renal failure. Renal biopsy did not show signs of tubular damage or obstruction with proteins nor significant interstitial oedema. Therefore, in this case we think acute renal failure was caused by a severe reduction in glomerular ultrafiltration rate and steroids were the effective treatment that allowed recovery of renal function." ] ] "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" => "Sakarcan A, Timmons C, Seikaly MG. Reversible idiopathic acute renal failure in children with primary nephrotic syndrome. J Pediatr 125 (5 Pt 1): 723-7, 1994. <a href="http://www.ncbi.nlm.nih.gov/pubmed/7965423" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Cameron MA, Peri U, Rogers TE, Moe OW. 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| 2022 September | 66 | 23 | 89 |
| 2022 August | 91 | 42 | 133 |
| 2022 July | 50 | 37 | 87 |
| 2022 June | 70 | 23 | 93 |
| 2022 May | 82 | 37 | 119 |
| 2022 April | 81 | 46 | 127 |
| 2022 March | 101 | 41 | 142 |
| 2022 February | 126 | 36 | 162 |
| 2022 January | 104 | 29 | 133 |
| 2021 December | 122 | 41 | 163 |
| 2021 November | 113 | 31 | 144 |
| 2021 October | 79 | 48 | 127 |
| 2021 September | 89 | 44 | 133 |
| 2021 August | 105 | 37 | 142 |
| 2021 July | 99 | 50 | 149 |
| 2021 June | 73 | 38 | 111 |
| 2021 May | 52 | 34 | 86 |
| 2021 April | 123 | 40 | 163 |
| 2021 March | 107 | 34 | 141 |
| 2021 February | 139 | 21 | 160 |
| 2021 January | 66 | 17 | 83 |
| 2020 December | 51 | 19 | 70 |
| 2020 November | 58 | 16 | 74 |
| 2020 October | 36 | 17 | 53 |
| 2020 September | 42 | 10 | 52 |
| 2020 August | 55 | 13 | 68 |
| 2020 July | 53 | 14 | 67 |
| 2020 June | 50 | 14 | 64 |
| 2020 May | 72 | 21 | 93 |
| 2020 April | 68 | 19 | 87 |
| 2020 March | 67 | 11 | 78 |
| 2020 February | 75 | 20 | 95 |
| 2020 January | 97 | 22 | 119 |
| 2019 December | 88 | 26 | 114 |
| 2019 November | 85 | 19 | 104 |
| 2019 October | 76 | 15 | 91 |
| 2019 September | 103 | 16 | 119 |
| 2019 August | 80 | 13 | 93 |
| 2019 July | 80 | 26 | 106 |
| 2019 June | 88 | 17 | 105 |
| 2019 May | 80 | 12 | 92 |
| 2019 April | 140 | 29 | 169 |
| 2019 March | 54 | 21 | 75 |
| 2019 February | 66 | 13 | 79 |
| 2019 January | 56 | 26 | 82 |
| 2018 December | 122 | 47 | 169 |
| 2018 November | 160 | 16 | 176 |
| 2018 October | 179 | 12 | 191 |
| 2018 September | 159 | 19 | 178 |
| 2018 August | 120 | 16 | 136 |
| 2018 July | 119 | 12 | 131 |
| 2018 June | 78 | 16 | 94 |
| 2018 May | 72 | 9 | 81 |
| 2018 April | 51 | 17 | 68 |
| 2018 March | 57 | 11 | 68 |
| 2018 February | 50 | 3 | 53 |
| 2018 January | 54 | 8 | 62 |
| 2017 December | 58 | 9 | 67 |
| 2017 November | 35 | 12 | 47 |
| 2017 October | 38 | 13 | 51 |
| 2017 September | 47 | 14 | 61 |
| 2017 August | 28 | 6 | 34 |
| 2017 July | 39 | 8 | 47 |
| 2017 June | 34 | 5 | 39 |
| 2017 May | 51 | 25 | 76 |
| 2017 April | 42 | 16 | 58 |
| 2017 March | 27 | 9 | 36 |
| 2017 February | 19 | 13 | 32 |
| 2017 January | 18 | 10 | 28 |
| 2016 December | 77 | 10 | 87 |
| 2016 November | 68 | 11 | 79 |
| 2016 October | 94 | 9 | 103 |
| 2016 September | 153 | 16 | 169 |
| 2016 August | 220 | 5 | 225 |
| 2016 July | 182 | 13 | 195 |
| 2016 June | 140 | 0 | 140 |
| 2016 May | 148 | 0 | 148 |
| 2016 April | 91 | 0 | 91 |
| 2016 March | 73 | 0 | 73 |
| 2016 February | 109 | 0 | 109 |
| 2016 January | 106 | 0 | 106 |
| 2015 December | 105 | 0 | 105 |
| 2015 November | 106 | 0 | 106 |
| 2015 October | 93 | 0 | 93 |
| 2015 September | 73 | 0 | 73 |
| 2015 August | 68 | 0 | 68 |
| 2015 July | 60 | 0 | 60 |
| 2015 June | 35 | 0 | 35 |
| 2015 May | 51 | 0 | 51 |
| 2015 April | 5 | 0 | 5 |
Show all
