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Usual treatment&#58; nifedipine&#44; deflazacort&#44; lithium and olanzapine&#46;</p><p class="elsevierStylePara">In January 2008&#44; the patient was referred for renal failure &#40;RF&#41; study&#44; due to recent presentation of plasma creatinine at about 2mg&#47;dl&#44; proteinuria 300mg&#47;dl and hypoalbuminaemia 2&#46;36g&#47;dl&#46;</p><p class="elsevierStylePara">Physical examination showed limited flexion of the fingers&#59; the rest was normal&#46; BP&#58; 123&#47;76mmHg&#46;</p><p class="elsevierStylePara">Analytical tests showed&#58; haemoglobin&#44; 11&#46;5g&#47;dl&#59; urea&#44; 138&#59; creatinine&#44; 4&#46;2&#59; cholesterol 157mg&#47;dl&#46; Total proteins&#44; 5&#46;4&#59; albumin 2&#46;6g&#47;dl&#46; PTH&#44; 119pg&#47;mml&#46; Widespectrum immunology screen negative except for ANCA-anti-MPO&#43;&#46; Proteinuria&#44; 4&#46;2g&#47;d&#237;a&#59; sediment&#44; 1&#44;042 red blood cells per high-power field&#46; Creatinine clearance 25ml&#47;min&#46; In studies prior to 2000&#44; anti-scl 70 and ANA&#43; were prominent&#46; The ultrasound showed kidneys measuring 11&#46;5cm with an increase in cortical echogenicity&#46;</p><p class="elsevierStylePara">Given the presence of RF and proteinuria in the nephrotic range&#44; we started treatment with ramipril and recommended discontinuing the lithium&#46;</p><p class="elsevierStylePara">15 days later&#44; the patient came to the Emergency Room with nausea&#44; vomiting&#44; and abdominal pain that had been evolving over several days&#46;He presented a lithaemia of 4&#46;4 mEq&#47;l&#44;&#59; crp 5&#46;8&#59; urea 178mg&#47;dl&#46; Hydration treatment was started&#44; despite the fact that it increased lithaemia&#59; for this reason&#44; the patient underwent emergency haemodialysis&#46; In subsequent checks&#44; the lithaemia was below 1&#46;5meq&#47;l&#44; so it was not necessary for him to undergo additional haemodialysis sessions&#46;</p><p class="elsevierStylePara">As glomerular disease was suspected&#44; we performed a kidney biopsy&#46; The anatomical pathology showed 10 glomerules&#44; of which two were sclerotic and six had focal and circumferential epithelial crescents and diffuse mesangial proliferation and capillary lumens obliteration with a mixed interstitial inflammatory infiltrate&#46; Negative immunofluorescence test &#40;figures 1 and 2&#41;&#46;</p><p class="elsevierStylePara">We started immunosuppression with three methylprednisolone tablets&#44; followed by 1mg prednisone&#47;kg&#47;day and 900mg of cyclophosphamide in a monthly bolus&#44; and followed up on the patient&#46;</p><p class="elsevierStylePara">We arrived at the clinical opinion that it was probably overlap syndrome scleroderma&#47;vasculitis with ANCA-anti-MPO&#43; with stage IV CKD secondary to proliferative mesangial glomerulonephritis with extracapillary proliferation&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">Hybrid forms of scleroderma&#47;ANCAvasculitis&#44; sometimes associated with glomerulonephritis&#44; are described in up to 10&#37; of all cases&#46; This overlap syndrome may occur after a period of treatment with D-penicilamine which varies from five months to five years&#46; For some authors&#44; this association represents a new entity that is related with this drug&#46;Although our patient had gone at least a year without taking it&#44; we can establish the hypothesis that the D-penicilamine could have acted latently as an antigenic factor&#44; and then triggered the extracapillary form of vasculitis&#46;<span class="elsevierStyleSup">3-7</span></p><p class="elsevierStylePara"><a href="grande&#47;19218078&#95;f1&#95;p281&#46;jpg" class="elsevierStyleCrossRefs"><img src="19218078_f1_p281.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;19218078&#95;f2&#95;p281&#46;jpg" class="elsevierStyleCrossRefs"><img src="19218078_f2_p281.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p>"
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Lithium poisoning and proteinuria in the nephrotic range
Intoxicación por litio y proteinuria en rango nefrótico
M.. Polaina Rusilloa, M.D.. Sánchez Martosa, G.. Viedma Chamorroa, I.. Ruiz Ávilaa, V.. Pérez Bañascoa
a Servicio de Nefrología. Servicio de Anatomía Patológica, Complejo Hospitalario de Jaén, Jaén, Jaén, España,
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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#58;</p><p class="elsevierStylePara">The incidence of renal affectation in Systemic Sclerosis &#40;SSc&#41; is difficult to establish&#44; because in the early stages and in its milder forms&#44; the manifestations may be subclinical&#44; and they may coincide with other pathologies&#44; given the disease&#8217;s long evolution&#46; We distinguish between three types of nephropathy&#58; acute&#44; chronic and overlap syndrome &#40;associating scleroderma and other rheumatic illnesses&#41;&#46;<span class="elsevierStyleSup">1-2</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical case</span></p><p class="elsevierStylePara">Male patient&#44; aged 36 years with a history of SSc since 2000&#44; bipolar disorder&#44; terminal ileitis&#44; consumer of alcohol and marijuana&#46;</p><p class="elsevierStylePara">Underwent treatment with D-penicilamine for the SSc for several years&#44; which was discontinued a year ago due to gastric distress&#46; Usual treatment&#58; nifedipine&#44; deflazacort&#44; lithium and olanzapine&#46;</p><p class="elsevierStylePara">In January 2008&#44; the patient was referred for renal failure &#40;RF&#41; study&#44; due to recent presentation of plasma creatinine at about 2mg&#47;dl&#44; proteinuria 300mg&#47;dl and hypoalbuminaemia 2&#46;36g&#47;dl&#46;</p><p class="elsevierStylePara">Physical examination showed limited flexion of the fingers&#59; the rest was normal&#46; BP&#58; 123&#47;76mmHg&#46;</p><p class="elsevierStylePara">Analytical tests showed&#58; haemoglobin&#44; 11&#46;5g&#47;dl&#59; urea&#44; 138&#59; creatinine&#44; 4&#46;2&#59; cholesterol 157mg&#47;dl&#46; Total proteins&#44; 5&#46;4&#59; albumin 2&#46;6g&#47;dl&#46; PTH&#44; 119pg&#47;mml&#46; Widespectrum immunology screen negative except for ANCA-anti-MPO&#43;&#46; Proteinuria&#44; 4&#46;2g&#47;d&#237;a&#59; sediment&#44; 1&#44;042 red blood cells per high-power field&#46; Creatinine clearance 25ml&#47;min&#46; In studies prior to 2000&#44; anti-scl 70 and ANA&#43; were prominent&#46; The ultrasound showed kidneys measuring 11&#46;5cm with an increase in cortical echogenicity&#46;</p><p class="elsevierStylePara">Given the presence of RF and proteinuria in the nephrotic range&#44; we started treatment with ramipril and recommended discontinuing the lithium&#46;</p><p class="elsevierStylePara">15 days later&#44; the patient came to the Emergency Room with nausea&#44; vomiting&#44; and abdominal pain that had been evolving over several days&#46;He presented a lithaemia of 4&#46;4 mEq&#47;l&#44;&#59; crp 5&#46;8&#59; urea 178mg&#47;dl&#46; Hydration treatment was started&#44; despite the fact that it increased lithaemia&#59; for this reason&#44; the patient underwent emergency haemodialysis&#46; In subsequent checks&#44; the lithaemia was below 1&#46;5meq&#47;l&#44; so it was not necessary for him to undergo additional haemodialysis sessions&#46;</p><p class="elsevierStylePara">As glomerular disease was suspected&#44; we performed a kidney biopsy&#46; The anatomical pathology showed 10 glomerules&#44; of which two were sclerotic and six had focal and circumferential epithelial crescents and diffuse mesangial proliferation and capillary lumens obliteration with a mixed interstitial inflammatory infiltrate&#46; Negative immunofluorescence test &#40;figures 1 and 2&#41;&#46;</p><p class="elsevierStylePara">We started immunosuppression with three methylprednisolone tablets&#44; followed by 1mg prednisone&#47;kg&#47;day and 900mg of cyclophosphamide in a monthly bolus&#44; and followed up on the patient&#46;</p><p class="elsevierStylePara">We arrived at the clinical opinion that it was probably overlap syndrome scleroderma&#47;vasculitis with ANCA-anti-MPO&#43; with stage IV CKD secondary to proliferative mesangial glomerulonephritis with extracapillary proliferation&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">Hybrid forms of scleroderma&#47;ANCAvasculitis&#44; sometimes associated with glomerulonephritis&#44; are described in up to 10&#37; of all cases&#46; This overlap syndrome may occur after a period of treatment with D-penicilamine which varies from five months to five years&#46; For some authors&#44; this association represents a new entity that is related with this drug&#46;Although our patient had gone at least a year without taking it&#44; we can establish the hypothesis that the D-penicilamine could have acted latently as an antigenic factor&#44; and then triggered the extracapillary form of vasculitis&#46;<span class="elsevierStyleSup">3-7</span></p><p class="elsevierStylePara"><a href="grande&#47;19218078&#95;f1&#95;p281&#46;jpg" class="elsevierStyleCrossRefs"><img src="19218078_f1_p281.jpg"></img></a></p><p class="elsevierStylePara">Figure 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;19218078&#95;f2&#95;p281&#46;jpg" class="elsevierStyleCrossRefs"><img src="19218078_f2_p281.jpg"></img></a></p><p class="elsevierStylePara">Figure 2&#46; </p>"
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