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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">The phenomenon of immigration has experienced significant growth during the last decade&#44; with the foreign population reaching 10&#37; of the population living in Spain&#46; Immigration has also brought us diseases that are uncommon in our country&#44; which are sometimes only seen in old studies of medical pathology studied at degree level&#46; This is one such case&#46; We wanted to publish it due to its infrequency and academic value&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical case</span></p><p class="elsevierStylePara">A 40 year old male patient from Bulgaria&#44; with no family antecedents of any relevance&#46; Patient history&#58; AHTN&#44; known for 12 years&#44; heavy smoker for seven years&#44; moderate drinker&#44; and vesical tumour removed nine years ago in native country&#46; Current illness&#58; admitted to our hospital in 2006 for haematuria&#59; advanced Chronic Renal Failure was confirmed&#46;</p><p class="elsevierStylePara">Ultrasound showed small kidneys&#44; poor corticomedullary differentiation&#44; cortical hyperechogenicity and in the bladder&#44; multiple solid nipple shaped lesions and therefore partial transurethral resection had been performed&#46; An anatomopathological study showed low-grade urothelial carcinoma infiltrating the lamina tropria of the mucosa &#40;papillary urothelial carcinoma&#44; grade II&#44; stage A&#46;&#41; Following this&#44; the patient was treated with endovesical Bacillus Calmette-Gu&#233;rin &#40;BCG&#46;&#41; Examinations in the pre-dialysis centre began in November 2006&#46; The patient presented with polydipsia&#44; polyuria and nycturia&#46; The patient was working&#46; Clinical examination found that the weight was 77&#46;2kg and height 168cm&#59; blood pressure 145-150&#47;95mmHg&#59; the patient had a median infraumbilical surgical scar&#59; the rest &#40;head&#44; neck&#44; lungs&#44; heart&#44; abdomen and extremities&#41; were normal&#46;</p><p class="elsevierStylePara">Blood tests from the laboratory showed&#58; red cell count 3&#44;570&#44;000&#59; HCT 32&#46;7&#37;&#59; Hb 11&#46;1g&#47;dl&#59; MCV 91&#46;7fl&#59; MCH 31&#46;2pg&#59; MCHC 34&#46;1g&#47;dl&#59; reticulocytes 1&#37;&#59; IS 11&#46;85&#37;&#59; ferritin 19&#46;2ng&#47;ml&#59; vitamin B12 515pg&#47;ml&#59; folic acid 5&#46;34ng&#47;ml&#59; leukocytes 6400 &#40;S 65&#37;&#44; L 21&#37;&#44; M 7&#37;&#44; E 6&#37;&#44; B 1&#37;&#41;&#44; platelets 319&#44;000&#44; TPP 10&#46;4 sec&#46; &#40;activity 121&#37;&#44; ratio 0&#46;92&#41;&#59; TTPA 30&#46;5 sec&#46; &#40;ratio 1&#46;02&#41;&#44; fibrinogen 435mg&#47;dl&#44; urea 174mg&#47;dl&#44; creatinine 4&#46;74mg&#47;dl&#44; Ccr 21&#46;06ml&#47;min&#44; FRR 15&#46;9ml&#47;min&#59; GF &#40;MDRD-4&#41; 14&#46;8ml&#47;min&#59; Cl 108mEq&#47;l&#59; Na 139mEq&#47;l&#59; K 5&#46;4mEq&#47;l&#59; HCO3 18&#46;4mmol&#47;l&#59; Ca 8&#46;48mg&#47;dl&#59; P 6&#46;47mg&#47;dl&#59; PTHi 1&#44;086pg&#47;ml&#59; alkaline phosphatase 111 IU&#47;L&#59; albumin 4&#46;18g&#47;dl&#59; CRP 15&#46;2mg&#47;l&#59; glucose 90mg&#47;dl&#59; cholesterol 277mg&#47;dl&#59; triglycerides 183mg&#47;dl&#59; uric acid 8&#46;4mg&#47;dl&#59; GOT 13 IU&#47;L&#59; GPT 14 IU&#47;L&#59; GGT 18IU&#47;L&#59; total bilirubin 0&#46;46mg&#47;dl&#59; HBsAg negative&#59; HBsAc &#62; 1000 U&#47;L&#59; HBcAc positive&#59; anti-HCV negative&#59; anti-HIV negative&#46;</p><p class="elsevierStylePara">Urine&#58; diuresis 4840ml&#47;24 hours&#44; pH 5&#44; negative nitrites&#44; proteins 2&#46;7g&#47;24 hours&#44; sediment 8-15 leukocytes and erythrocytes per field&#59; Cl 71mEq&#47;l&#59; Na 75mEq&#47;l&#59; K 19&#46;8mEq&#47;l&#59; urea 5&#46;57g&#47;l&#59; creatinine 29&#46;7mg&#47;dl&#46; The patient was diagnosed with Balkan endemic nephropathy and conservative symptomatic therapy was begun&#46; The patient was examined on several occasions&#44; both in pre-dialysis clinic and in urology&#46; Where vesical tumours were removed on two occasions&#46; On 8 June 2007&#44; an abdominal catheter was inserted and on 2 July 2007&#44; continuous ambulatory peritoneal dialysis was started&#46; Two months later&#44; the patient suffered his first episode of peritonitis due to Staphylococcus aureus which progressed slowly and suffered a relapse one month after the first episode&#46; The progress was eventually satisfactory&#46; In his last examination in the PD clinic the patient reported that he was feeling fine and had returned to work&#46; The urological examination showed no abnormal results&#46; The presence of an active tumour disease prevents the patient&#8217;s inclusion on the waiting list for a kidney transplant at the moment&#46; The patient does not attend follow-ups when advised&#46; The most significant analytical data on the patient&#8217;s evolution are included in table 1&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">Balkan endemic nephropathy&#44; which was first described in 1956&#44; is a chronic tubulointerstitial disease of unknown aetiology&#46;</p><p class="elsevierStylePara">It is very often associated with urothelial atypia which can culminate in tumours of the urinary tract&#46; Patients are from South-East Europe&#58; Serbia&#44; Bosnia Herzegovina&#44; Croatia&#44; Romania and Bulgaria&#44; generally in the valleys of the River Danube and its surroundings&#46; The prevalence of the disease in these areas is 0&#46;5 to 4&#46;4&#37;&#46; However&#44; it can reach 20&#37; if investigated more thoroughly&#59; many of the patients are farmers&#46;</p><p class="elsevierStylePara">The aetiology of the disease includes environmental and genetic factors&#46; Among the first&#44; the following have been studied&#58; trace elements &#40;lead&#44; cadmium&#44; selenium&#44; silicon&#44; etc&#46;&#41;&#44; viruses&#44; plant toxins &#40;aristolochic acid&#41;&#44; fungi &#40;ochratoxin A&#41;&#44; aromatic hydrocarbons&#44; heavy metals&#44; etc&#46;</p><p class="elsevierStylePara">Ochratoxin A is a mycotoxin that causes oxidative damage in the DNA and produces nephrotoxicity in experimental models&#46;</p><p class="elsevierStylePara">Higher levels of this product have been found in the blood and urine of nephropathy patients from the Balkans and patients living in this zone&#46; This product may be derived from food products&#46; Aristolochic acid is a mutagenic and nephrotoxic alkaloid found in the Aristolochia clematitis plant&#46; It has been linked to nephropathy endemic to the Balkans<span class="elsevierStyleSup">2</span> and nephropathy linked to Chinese herb nephropathy &#40;which caused a disaster in Belgium at the start of the nineties&#44; to such an extent that nowadays we talk of aristolochic acid nephropathy&#46;&#41;<span class="elsevierStyleSup">3&#44;4</span> The theory of genetic factors is based on family cases&#44; considering a type of polygenic inheritance&#46; Candidate genes have been located in the 3q24 and 3q26 region&#59; given the link with bladder carcinoma&#44; mutations of the tumour suppressor gene p53 have been explored&#46;</p><p class="elsevierStylePara">Many authors accept that the disease is familial but not hereditary&#46; The etiopathogenic theory would be that of individuals who are genetically prone to and chronically exposed to a causal agent &#40;aristolochic acid&#41; found within these endemic areas&#46; In terms of the anatomical pathology of the disease&#44; as well as tubulointerstitial changes&#44; focal and segmental glomerular changes and global sclerosis may occur&#46;</p><p class="elsevierStylePara">Patients are generally aged between 30 and 50&#46; One of the first signs is tubular dysfunction&#44; characterised by increased elimination of low molecular weight proteins &#40;beta 2-microglobulin and neopterin etc&#46;&#41;</p><p class="elsevierStylePara">Glycosuria&#44; aminoaciduria and difficulties managing acid load may also appear&#46; However it has been calculated that a reduction in concentration capacity&#44; arterial hypertension and reduced glomerular filtration will only appear after 20 years&#46;</p><p class="elsevierStylePara">Anaemia&#44; which is initially seen&#44; increases as the disease progresses&#46; There is not normally any infection of the urinary tract&#46; Kidney size is initially normal&#44; but decreases symmetrically in time&#44; with smooth edges and without calcifications&#46;There is a high incidence &#40;2 to 10 times greater than in non-epidemic areas&#41; of urinary tract transitional cell carcinoma&#44; in which aristolochic acid is also involved&#46;<span class="elsevierStyleSup">5</span> If there is no diagnosis of urinary tract tumour&#44; it is advisable to carry out a urinary cell biology once or twice a year&#46; Diagnosis is easy if you take into account&#44; given the slow evolution of the disease&#44; the fact that the patient lives in a certain area and there are tumours in the urinary tract&#46; For differential diagnosis&#44; two entities must be taken into account&#58; Analgesic nephropathy and Chinese herb nephropathy&#44; as shown in table 2&#44; while&#44; as previously mentioned&#44; they can normally be explained by the causal factor itself&#58; aristolochic acid&#46;</p><p class="elsevierStylePara">When does not exist the diagnosis of tumor of urinary tract&#44; urinary cytology has to be performed one or two times a year&#46; The diagnosis is easy if it is thought about this disease&#44; given the slow evolution &#44; to live in a concrete zone and the presence of tumors in urinary tract&#46; In the differential diagnosis it is necessary to remember two entities&#58; analgesic nephropathy and nephropathy caused by chinese herbs&#44; as shown in table 2&#44; though&#44; as it has been said&#44; nowadays they tend to be explained by the same causal factor&#58; the acid aristolochic&#44; Balkan nephropathy and nephropathy caused by Chinese herbs&#46;</p><p class="elsevierStylePara"><a href="grande&#47;23818078&#95;t1&#95;p87&#46;jpg" class="elsevierStyleCrossRefs"><img src="23818078_t1_p87.jpg"></img></a></p><p class="elsevierStylePara">Table 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;23818078&#95;t2&#95;p88&#46;jpg" class="elsevierStyleCrossRefs"><img src="23818078_t2_p88.jpg"></img></a></p><p class="elsevierStylePara">Table 2&#46; </p>"
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A probable case of Balkan endemic nephropathy
Antonio Molina Miguela, Mª Concepción Ruiz Erroa
a Hospital Universitario Río Hortega, Valladolid, Valladolid, España,
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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">The phenomenon of immigration has experienced significant growth during the last decade&#44; with the foreign population reaching 10&#37; of the population living in Spain&#46; Immigration has also brought us diseases that are uncommon in our country&#44; which are sometimes only seen in old studies of medical pathology studied at degree level&#46; This is one such case&#46; We wanted to publish it due to its infrequency and academic value&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Clinical case</span></p><p class="elsevierStylePara">A 40 year old male patient from Bulgaria&#44; with no family antecedents of any relevance&#46; Patient history&#58; AHTN&#44; known for 12 years&#44; heavy smoker for seven years&#44; moderate drinker&#44; and vesical tumour removed nine years ago in native country&#46; Current illness&#58; admitted to our hospital in 2006 for haematuria&#59; advanced Chronic Renal Failure was confirmed&#46;</p><p class="elsevierStylePara">Ultrasound showed small kidneys&#44; poor corticomedullary differentiation&#44; cortical hyperechogenicity and in the bladder&#44; multiple solid nipple shaped lesions and therefore partial transurethral resection had been performed&#46; An anatomopathological study showed low-grade urothelial carcinoma infiltrating the lamina tropria of the mucosa &#40;papillary urothelial carcinoma&#44; grade II&#44; stage A&#46;&#41; Following this&#44; the patient was treated with endovesical Bacillus Calmette-Gu&#233;rin &#40;BCG&#46;&#41; Examinations in the pre-dialysis centre began in November 2006&#46; The patient presented with polydipsia&#44; polyuria and nycturia&#46; The patient was working&#46; Clinical examination found that the weight was 77&#46;2kg and height 168cm&#59; blood pressure 145-150&#47;95mmHg&#59; the patient had a median infraumbilical surgical scar&#59; the rest &#40;head&#44; neck&#44; lungs&#44; heart&#44; abdomen and extremities&#41; were normal&#46;</p><p class="elsevierStylePara">Blood tests from the laboratory showed&#58; red cell count 3&#44;570&#44;000&#59; HCT 32&#46;7&#37;&#59; Hb 11&#46;1g&#47;dl&#59; MCV 91&#46;7fl&#59; MCH 31&#46;2pg&#59; MCHC 34&#46;1g&#47;dl&#59; reticulocytes 1&#37;&#59; IS 11&#46;85&#37;&#59; ferritin 19&#46;2ng&#47;ml&#59; vitamin B12 515pg&#47;ml&#59; folic acid 5&#46;34ng&#47;ml&#59; leukocytes 6400 &#40;S 65&#37;&#44; L 21&#37;&#44; M 7&#37;&#44; E 6&#37;&#44; B 1&#37;&#41;&#44; platelets 319&#44;000&#44; TPP 10&#46;4 sec&#46; &#40;activity 121&#37;&#44; ratio 0&#46;92&#41;&#59; TTPA 30&#46;5 sec&#46; &#40;ratio 1&#46;02&#41;&#44; fibrinogen 435mg&#47;dl&#44; urea 174mg&#47;dl&#44; creatinine 4&#46;74mg&#47;dl&#44; Ccr 21&#46;06ml&#47;min&#44; FRR 15&#46;9ml&#47;min&#59; GF &#40;MDRD-4&#41; 14&#46;8ml&#47;min&#59; Cl 108mEq&#47;l&#59; Na 139mEq&#47;l&#59; K 5&#46;4mEq&#47;l&#59; HCO3 18&#46;4mmol&#47;l&#59; Ca 8&#46;48mg&#47;dl&#59; P 6&#46;47mg&#47;dl&#59; PTHi 1&#44;086pg&#47;ml&#59; alkaline phosphatase 111 IU&#47;L&#59; albumin 4&#46;18g&#47;dl&#59; CRP 15&#46;2mg&#47;l&#59; glucose 90mg&#47;dl&#59; cholesterol 277mg&#47;dl&#59; triglycerides 183mg&#47;dl&#59; uric acid 8&#46;4mg&#47;dl&#59; GOT 13 IU&#47;L&#59; GPT 14 IU&#47;L&#59; GGT 18IU&#47;L&#59; total bilirubin 0&#46;46mg&#47;dl&#59; HBsAg negative&#59; HBsAc &#62; 1000 U&#47;L&#59; HBcAc positive&#59; anti-HCV negative&#59; anti-HIV negative&#46;</p><p class="elsevierStylePara">Urine&#58; diuresis 4840ml&#47;24 hours&#44; pH 5&#44; negative nitrites&#44; proteins 2&#46;7g&#47;24 hours&#44; sediment 8-15 leukocytes and erythrocytes per field&#59; Cl 71mEq&#47;l&#59; Na 75mEq&#47;l&#59; K 19&#46;8mEq&#47;l&#59; urea 5&#46;57g&#47;l&#59; creatinine 29&#46;7mg&#47;dl&#46; The patient was diagnosed with Balkan endemic nephropathy and conservative symptomatic therapy was begun&#46; The patient was examined on several occasions&#44; both in pre-dialysis clinic and in urology&#46; Where vesical tumours were removed on two occasions&#46; On 8 June 2007&#44; an abdominal catheter was inserted and on 2 July 2007&#44; continuous ambulatory peritoneal dialysis was started&#46; Two months later&#44; the patient suffered his first episode of peritonitis due to Staphylococcus aureus which progressed slowly and suffered a relapse one month after the first episode&#46; The progress was eventually satisfactory&#46; In his last examination in the PD clinic the patient reported that he was feeling fine and had returned to work&#46; The urological examination showed no abnormal results&#46; The presence of an active tumour disease prevents the patient&#8217;s inclusion on the waiting list for a kidney transplant at the moment&#46; The patient does not attend follow-ups when advised&#46; The most significant analytical data on the patient&#8217;s evolution are included in table 1&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Discussion</span></p><p class="elsevierStylePara">Balkan endemic nephropathy&#44; which was first described in 1956&#44; is a chronic tubulointerstitial disease of unknown aetiology&#46;</p><p class="elsevierStylePara">It is very often associated with urothelial atypia which can culminate in tumours of the urinary tract&#46; Patients are from South-East Europe&#58; Serbia&#44; Bosnia Herzegovina&#44; Croatia&#44; Romania and Bulgaria&#44; generally in the valleys of the River Danube and its surroundings&#46; The prevalence of the disease in these areas is 0&#46;5 to 4&#46;4&#37;&#46; However&#44; it can reach 20&#37; if investigated more thoroughly&#59; many of the patients are farmers&#46;</p><p class="elsevierStylePara">The aetiology of the disease includes environmental and genetic factors&#46; Among the first&#44; the following have been studied&#58; trace elements &#40;lead&#44; cadmium&#44; selenium&#44; silicon&#44; etc&#46;&#41;&#44; viruses&#44; plant toxins &#40;aristolochic acid&#41;&#44; fungi &#40;ochratoxin A&#41;&#44; aromatic hydrocarbons&#44; heavy metals&#44; etc&#46;</p><p class="elsevierStylePara">Ochratoxin A is a mycotoxin that causes oxidative damage in the DNA and produces nephrotoxicity in experimental models&#46;</p><p class="elsevierStylePara">Higher levels of this product have been found in the blood and urine of nephropathy patients from the Balkans and patients living in this zone&#46; This product may be derived from food products&#46; Aristolochic acid is a mutagenic and nephrotoxic alkaloid found in the Aristolochia clematitis plant&#46; It has been linked to nephropathy endemic to the Balkans<span class="elsevierStyleSup">2</span> and nephropathy linked to Chinese herb nephropathy &#40;which caused a disaster in Belgium at the start of the nineties&#44; to such an extent that nowadays we talk of aristolochic acid nephropathy&#46;&#41;<span class="elsevierStyleSup">3&#44;4</span> The theory of genetic factors is based on family cases&#44; considering a type of polygenic inheritance&#46; Candidate genes have been located in the 3q24 and 3q26 region&#59; given the link with bladder carcinoma&#44; mutations of the tumour suppressor gene p53 have been explored&#46;</p><p class="elsevierStylePara">Many authors accept that the disease is familial but not hereditary&#46; The etiopathogenic theory would be that of individuals who are genetically prone to and chronically exposed to a causal agent &#40;aristolochic acid&#41; found within these endemic areas&#46; In terms of the anatomical pathology of the disease&#44; as well as tubulointerstitial changes&#44; focal and segmental glomerular changes and global sclerosis may occur&#46;</p><p class="elsevierStylePara">Patients are generally aged between 30 and 50&#46; One of the first signs is tubular dysfunction&#44; characterised by increased elimination of low molecular weight proteins &#40;beta 2-microglobulin and neopterin etc&#46;&#41;</p><p class="elsevierStylePara">Glycosuria&#44; aminoaciduria and difficulties managing acid load may also appear&#46; However it has been calculated that a reduction in concentration capacity&#44; arterial hypertension and reduced glomerular filtration will only appear after 20 years&#46;</p><p class="elsevierStylePara">Anaemia&#44; which is initially seen&#44; increases as the disease progresses&#46; There is not normally any infection of the urinary tract&#46; Kidney size is initially normal&#44; but decreases symmetrically in time&#44; with smooth edges and without calcifications&#46;There is a high incidence &#40;2 to 10 times greater than in non-epidemic areas&#41; of urinary tract transitional cell carcinoma&#44; in which aristolochic acid is also involved&#46;<span class="elsevierStyleSup">5</span> If there is no diagnosis of urinary tract tumour&#44; it is advisable to carry out a urinary cell biology once or twice a year&#46; Diagnosis is easy if you take into account&#44; given the slow evolution of the disease&#44; the fact that the patient lives in a certain area and there are tumours in the urinary tract&#46; For differential diagnosis&#44; two entities must be taken into account&#58; Analgesic nephropathy and Chinese herb nephropathy&#44; as shown in table 2&#44; while&#44; as previously mentioned&#44; they can normally be explained by the causal factor itself&#58; aristolochic acid&#46;</p><p class="elsevierStylePara">When does not exist the diagnosis of tumor of urinary tract&#44; urinary cytology has to be performed one or two times a year&#46; The diagnosis is easy if it is thought about this disease&#44; given the slow evolution &#44; to live in a concrete zone and the presence of tumors in urinary tract&#46; In the differential diagnosis it is necessary to remember two entities&#58; analgesic nephropathy and nephropathy caused by chinese herbs&#44; as shown in table 2&#44; though&#44; as it has been said&#44; nowadays they tend to be explained by the same causal factor&#58; the acid aristolochic&#44; Balkan nephropathy and nephropathy caused by Chinese herbs&#46;</p><p class="elsevierStylePara"><a href="grande&#47;23818078&#95;t1&#95;p87&#46;jpg" class="elsevierStyleCrossRefs"><img src="23818078_t1_p87.jpg"></img></a></p><p class="elsevierStylePara">Table 1&#46; </p><p class="elsevierStylePara"><a href="grande&#47;23818078&#95;t2&#95;p88&#46;jpg" class="elsevierStyleCrossRefs"><img src="23818078_t2_p88.jpg"></img></a></p><p class="elsevierStylePara">Table 2&#46; </p>"
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