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requiring dialysis and with a strong response to immunosuppressor treatment&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PRESENTATION OF THE CASE</span></p><p class="elsevierStylePara">56 year-old female diagnosed with pSS 13 years before&#46; Presented with dry syndrome&#44; asthenia&#44; and frequent episodes of polyarthritis&#46; During this time&#44; she received a prolonged treatment with non-steroid anti-inflammatory drugs &#40;NSAI&#41; and steroids&#46; Additionally&#44; methotrexate had been applied in recent months with slight improvement of the symptoms&#46;</p><p class="elsevierStylePara">Three months after starting odontological treatment with dental implants&#44; the patient was admitted with facial oedema&#44; fever&#44; and reduced urine output&#46;</p><p class="elsevierStylePara">The physical examination revealed a general deterioration in physical state&#44; blood pressure &#40;BP&#41; at 160&#47;90 mmHg&#44; fever&#44; and submandibular oedema with evidence of an active infection in the lower dental arch&#46; She did not present any distal oedema or skin lesions&#46;</p><p class="elsevierStylePara">The chemical analysis detected Hb 9&#46;2 g&#47;dl&#44; creatinine 2&#46;9 mg&#47;dl&#44; urea 110 mg&#47;dl&#44; and normal liver profile&#44; lipid profile&#44; ANCA and immunoglobulins&#46; ANA positive&#44; anti-DNA negative&#46; Low C3 and C4 levels&#44; 46 and 1&#46;6 mg&#47;dl&#44; respectively&#46; Serology for HBV&#44; HCV&#44; and HIV negative&#46; Haemocultures negative&#46; ANA&#44; anti-LA&#44; anti-Ro antibodies&#44; and rheumatoid factor &#40;RF&#41; were positive from the moment the patient was diagnosed with pSS&#46; Hypocomplementemia was also occasionally presented&#46; The urine sample showed proteinuria &#40;2 g&#47;l&#41; and microhaematuria&#46; The kidney ultrasound came back normal&#46; The patient evolved into a low grade fever that evening&#44; in spite of antibiotic therapy&#44; and oliguria&#44; requiring dialysis treatment&#46;</p><p class="elsevierStylePara">Suspecting acute glomerulonephritis &#40;GN&#41;&#44; probably post-infectious given the mandibular infection and hypocomplementemia&#44; a kidney biopsy was performed with the following results&#58;</p><p class="elsevierStylePara">The cylinder for light microscopy contained 8 glomeruli that presented diffuse capillary occlusion due to thrombi of a PAS-positive proteinaceous material &#40;figure 1&#41;&#46; In some glomeruli&#44; these were accompanied by segmented infiltration of inflammatory cells&#46; Isolated centres of interstitial lymphoplasmacytic inflammation were present&#44; with no alterations in the arteries&#46;</p><p class="elsevierStylePara">In the direct immunofluorescence study &#40;dIF&#41;&#44; we observed intense positivity in the thrombi of IgG&#44; IgM&#44; kappa&#44; and lambda&#44; and to a lesser degree&#44; C3 and IgA &#40;figure 2&#41;&#46; C1q and fibrinogen were negative&#46; The ultrastructural study was performed afterwards&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anatomopathological diagnosis</span></p><p class="elsevierStylePara">Glomeruli with massive intracapillary immunoglobulin thrombi indicating cryoglobulinemic glomerulopathy associated with SS&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Evolution</span></p><p class="elsevierStylePara">The analysis confirmed the existence of cryoglobulinemia &#40;cryocrit 50&#37;&#41; and an IgM kappa monoclonal band&#44; requiring 3 pulses of methylprednisolone and one pulse of 750 mg of i&#46;v&#46; cyclophosphamide&#46; Given the severity of the situation&#44; we decided to continue treatment with three sessions of plasmapheresis and four weekly doses of 375mg&#47;m<span class="elsevierStyleSup">2</span> of rituximab&#46;</p><p class="elsevierStylePara">The patient also presented complications in the form of a <span class="elsevierStyleItalic">Candida </span>infection from the dialysis catheter&#44; which was resolved with antifungals and removal of the catheter&#46; An infection by cytomegalovirus &#40;CMV&#41; was also detected and proceeded without symptoms&#44; and it was controlled following a cycle of treatment with valganciclovir&#46;</p><p class="elsevierStylePara">The patient showed a slow improvement in kidney function&#46; After 9 weeks&#44; the dialysis treatment was suspended&#46; At 5 months&#44; creatinine was at 1 mg&#47;dl&#44; GFR 42 ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#44; the complement and RF were normal&#44; and cryoglobulins negative&#46; Proteinuria and sediments also normalized&#46; The CD19 lymphocyte count in peripheral blood went from 21&#37; pre-treatment to 0&#37; post-treatment&#46; The steroid dose was progressively reduced until stabilizing with 5 mg&#47;48 h of prednisone&#46;</p><p class="elsevierStylePara">Eight months after the episode&#44; the patient was re-admitted with asthenia&#44; polyarthritis&#44; and epigastralgia&#46; Purpura was observed in the lower limbs&#46; The analytical study detected elevated RF and hypocomplementemia&#44; with stable renal function and negative cryoglobulins&#46; After a brief improvement&#44; the patient was stricken with severe gastroenteritis with fever&#44; severe vomiting and diarrhoea&#44; followed by a reduction in diuresis&#46; She continued to present oliguria&#44; in spite of adequate hydration&#44; such that the chemical analysis and renal biopsy were repeated&#46; A cryocrit of 50&#37; was observed as well as a recuperation of the CD19 lymphocytes in peripheral blood &#40;23&#37;&#41;&#46;</p><p class="elsevierStylePara">The renal biopsy showed a recurrence of the cryoglobulinemic glomerulopathy&#44; containing 22 glomeruli&#44; one of which was sclerosed&#59; the rest also presented abundant hyaline thrombi &#40;PAS&#43;&#41; with capillary occlusion and varying levels of monocytic infiltration &#40;at times severe&#41; in the capillary spaces &#40;figure 3 and figure 4&#41;&#46; Few areas of interstitial fibrosis were present&#46; In dIF&#44; the stain was preferentially intraluminal for the same antisera of the previous biopsy&#46; The electron microscope analysis showed that the deposits had microtubular organization &#40;figure 5&#41;&#46;</p><p class="elsevierStylePara">With these findings&#44; and taking into account the favourable evolution observed in the first episode&#44; we applied the same therapeutic regimen&#46; After applying haemodialysis for 3 weeks&#44; the patient started to recover kidney function&#46; At 3 weeks her creatinine levels reached 0&#46;9 mg&#47;dl&#44; GRF 52 ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#44; with normalized complements and negative cryoglobulins&#46; We also observed in this episode an asymptomatic reactivation of the CMV infection with a good response to valganciclovir and an episode of a urinary infection that was resolved with outpatient treatment&#46; No new complications have arisen in the 5 months since the last episode&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">Although SS normally presents as xerostomia and dry keratoconjunctivitis&#44; extraglandular manifestations are very common&#44; and are responsible for the wide variability in the symptoms of this disease&#44; as it can affect practically any organ&#46; The most severe complication is the development of B cell lymphomas&#44; observed in 5 &#8211; 7&#37; of cases&#46;</p><p class="elsevierStylePara">An estimated 25&#37; of patients with pSS present with renal alterations&#46; These tend to be cases of tubulointerstitial nephritis &#40;TIN&#41;&#44; which is primarily manifested by proteinuria and tubular dysfunction with evidence of lymphoplasmacytic infiltrates&#46;<span class="elsevierStyleSup">1</span> It is rarely associated with renal failure&#44; and when it is&#44; this condition tends to be mild&#46; The association of SS with glomerulopathies has been rarely described&#46;</p><p class="elsevierStylePara">In a study of 60 patients with pSS and evidence of tubular and&#47;or glomerular dysfunction&#44; nine were biopsied&#44; six presented TIN&#44; and three glomerular disease&#44; one of which was a cryoglobulinemic membranoproliferative glomerulonephritis &#40;MPGN&#41;&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">In the recently published study by Maripuri et al&#46;&#44; only 24 patients with pSS &#40;0&#46;3&#37; of the 7&#44;276 patients&#41; were evaluated with renal biopsies&#44; 17 had TIN&#44; and seven presented glomerular lesions that included MPGN with cryoglobulinemia&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Mixed cryoglobulinemia is associated with lymphoproliferative&#44; autoimmune&#44; and infectious diseases&#46; In our field&#44; the principal causal agent is HCV&#44; while SS is the most frequent cause of mixed cryoglobulinemia in the absence of HCV infection&#46;<span class="elsevierStyleSup">3</span> In the study by Ramos-Casals et al&#46;&#44; cryoglobulins were detected in as much as 16&#37; of pSS patients&#46; However&#44; only half of these were infected with HCV&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">The polyclonal activation of lymphocyte B &#40;LB&#41; characterized by pSS can in some cases evolve into an oligoclonal or monoclonal LB expansion with production of IgM kappa&#44; which constitutes the principal monoclonal component of cryoglobulinemia&#46; Finally&#44; this monoclonal activation can arise in malignant lymphoproliferative diseases&#46; In this sense&#44; the detection of cryoglobulins indicates an increased risk of lymphoma progression&#46;</p><p class="elsevierStylePara">It still remains to be verified if the intercurrent infectious processes precipitate the stimulation of LB and cryoglobulin synthesis in patients with SS&#46; In the case we have presented&#44; the initial breakout and recurrence of cryoglobulinemic glomerulonephritis were preceded by a submandibular infection and acute gastroenteritis&#44; respectively&#46;</p><p class="elsevierStylePara">The renal disease associated with cryoglobulinemia is heterogeneous&#44; with type I MPGN being the most frequent histological pattern &#40;80&#37;&#41;&#46; Other renal lesion patterns include proliferative diffuse or focal GN&#44; and more rarely&#44; membranous glomerulopathy&#46; Monocyte infiltration is common&#44; although some areas of glomerular segments can also include polymorphonuclears&#46; Intracapillary thrombi are identified in approximately half of these cases and tend to be focal&#46; Massive cryoglobulinic intracapillary thrombi&#44; such as those found in our patient&#44; are infrequent and usually present with a rapid deterioration of renal function&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Three distinctive patterns have been described in dIF&#44; one of which consists of a strong stain of intraluminal thrombi and peripheral mottling&#44; the most characteristic pattern&#44; and must indicate a diagnosis of cryoglobulinemia&#59; however&#44; only a small portion of patients with cryoglobulinemia exhibit this type of appearance&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">Regarding treatment&#44; steroids and various immunosuppressors&#44; cyclophosphamide or azathioprine&#44; as well as plasmapheresis in the most severe cases&#44; are traditionally used with poor results&#46; Only 14&#37; of patients remain in remission for long periods of time&#44; with an elevated incidence of severe complications&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">Rituximab is a monoclonal antibody with anti-CD20 activity capable of producing a strong depletion in B-lymphocytes&#46; Although it was initially indicated in the treatment of B lymphomas&#44; its use in recent years has been extended given the positive results obtained&#46;</p><p class="elsevierStylePara">It has been used in mixed essential cryoglobulinemia and cryoglobulinemia associated with HVC resistant to conventional immunosuppressor treatment&#44; producing a clinical improvement in arthralgia and skin lesions&#44; as well as decreased cryocrit and increase in complement&#46; From the renal point of view&#44; improved kidney function and a decrease in proteinuria have been observed&#46; Cacoub et al&#46; have reviewed 57 cases published on mixed cryoglobulinemia treated with rituximab&#46; They observed a favourable clinical response in 15 out of 18 patients &#40;83&#37;&#41; with compromised renal function&#46; The response was complete in 75&#37; of these cases&#44; although 39&#37; experienced recurrence&#44; which tends to respond to new treatment cycles&#46; In general&#44; the treatment was well tolerated with few side effects&#46;<span class="elsevierStyleSup">8</span> The use of rituximab creates a new expectation for the clinical management of these cases&#46; Even so&#44; very little data is available and new studies are needed to evaluate the costs&#47;benefits of this treatment on a long-term basis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Questions</span></p><p class="elsevierStylePara">Dr&#46; Julia Blanco &#40;Madrid&#41;&#46; How do you explain the presence of kappa and lambda immunoglobulins in the biopsy&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anwer</span>&#46; In cryoglobulinemia&#44; the glomerular deposits detected by direct immunofluorescence in the renal biopsy reflect the composition of the serum precipitate&#46; In type II mixed cryoglobulinemia&#44; which would be the type corresponding to our case&#44; monoclonal &#40;usually IgM kappa&#41; and polyclonal &#40;IgG&#41; immunoglobulins are present&#46; The intracapillary thrombi in these cases usually stain with antisera for both immunoglobulins IgG and IgM&#44; as well as for both kappa and lambda light chains&#46; The monoclonal kappa component of the IgM would be hidden and overlapped by the positivity of both kappa and lambda light chains corresponding to the polyclonal IgG&#46;</p><p class="elsevierStylePara">Dr&#46; Antonio Barat &#40;Madrid&#41;&#46; Do you think that an acute tubular necrosis in the second biopsy could have contributed to the rapid deterioration in renal function&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; In the second biopsy&#44; focal alterations in the tubular epithelium are effectively evidenced&#44; indicating an acute lesion that could simulate ischemic renal failure&#46; In our opinion&#44; as has occurred in other cases of severe glomerulonephritis&#44; we interpret these changes to be secondary to the florid glomerular process that is presented by the patient rather than an acute tubular necrosis&#46;</p><p class="elsevierStylePara">Dr&#46; Miguel &#193;ngel Frutos &#40;M&#225;laga&#41;&#46; The objective after these two episodes of rapid deterioration in renal function is to avoid similar recurrences&#46; What strategy will you use with this patient&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; In our case&#44; the patient presented two episodes of rapidly establishing and severe acute renal failure&#46; In both the initial breakout and the recurrence&#44; the patient was oliguric in a few hours and required prolonged haemodialysis treatment&#46; On the other hand&#44; just 2 weeks before the second episode&#44; renal function was stable&#44; cryoglobulins were negative&#44; and CD19 LB were low &#40;3&#37;&#41;&#46; Given the severity and magnitude of the episodes of renal failure and the absence of serum markers that could allow us to anticipate recurrence with a certain margin&#44; we consider it necessary to apply immunosuppressive treatment as a preventative measure&#46; Some cases from the bibliography have used various levels of rituximab treatments with success&#44;<span class="elsevierStyleSup">9</span> although the proper dosage and duration of treatment remain to be determined&#46; In our patient&#44; the use of rituximab for maintenance could be useful in preventing new outbreaks&#46;</p><p class="elsevierStylePara">Dr&#46; Miguel Perdiguero &#40;Alicante<span class="elsevierStyleItalic">&#41;&#46;</span> In this case&#44; could serial measurements of C3 and C4 aid in predicting outbreaks&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; In our patient&#44; each episode of renal failure was accompanied by hypocomplentemia&#46; However&#44; only 14 days passed between the onset of hypocomplementemia and the development of oliguria&#46; This constitutes a short period of time that does not allow for proper planning of the treatment to be administered before the outbreak&#46;</p><p class="elsevierStylePara">Dr&#46; Simona Alexandrini &#40;Madrid&#41;&#46; Has any effort been put into finding some clone responsible for the production of cryoglobulins&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; The chemical analysis showed the presence of a monoclonal IgM kappa spike&#44; which reflects a monoclonal expansion of LB&#46; Until now we have not been able to directly identify the presence of a cryoglobulin-producing LB clone in peripheral blood&#44; since we do not have the necessary material for such an analysis at our centre&#46;</p><p class="elsevierStylePara">Dr&#46; Jes&#250;s Egido &#40;Madrid&#41;&#46; I was wondering if maintaining such a low dose of prednisone in the treatment following recuperation from the first episode might have facilitated the abrupt outbreak of the second&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; The protocol for dosage and duration of maintenance treatment with steroids in cases of cryoglobulinemic glomerulonephritis is as yet unestablished&#46; The majority of published cases tend not to describe the dose used&#44; and as such&#44; it is difficult to evaluate the influence of the use of low dosage or even the absence of steroids in the appearance of recurrences&#46;</p><p class="elsevierStylePara">Dr&#46; Manuel Praga &#40;Madrid&#41;&#46; Do you have any opinion on the use of bortezomib in similar cases&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; Bortezomib is a selective proteasome inhibitor that has been demonstrated to be effective in the treatment of malignant gammapathies &#40;multiple myeloma&#44; plasmacytoma&#44; leukaemia&#41;&#46; Recently&#44; 3 cases have been communicated on patients with type I cryoglobulinemia and skin vasculitis that were resistant to intensive steroid immunosuppressor treatment&#44; alkylating agents&#44; and even rituximab&#46; Additionally&#44; a significant decrease in cryocrit was observed&#44; as well as a complete resolution of the skin vasculitis&#46;</p><p class="elsevierStylePara">None of the patients presented data on renal damage&#44; which is quite infrequent in cases of type I cryoglobulinemia&#46;<span class="elsevierStyleSup">10&#44;11</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">We would like to thank Novartis Pharma for the facilities for the presentation and discussion of this case at the meeting of the Nephropathology Club and GLOSEN&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7203&#95;en&#95;10390&#95;figura&#95;1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7203_en_10390_figura_1.jpg" alt="PAS&#46; Massive glomerular intracapillary thrombi"></img></a></p><p class="elsevierStylePara">Figure 1&#46; PAS&#46; Massive glomerular intracapillary thrombi</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7204&#95;en&#95;10390&#95;figura&#95;2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7204_en_10390_figura_2.jpg" alt="Intense positivity in intracapillary thrombi for anti IgC&#44; IgM&#44; Kappa and Lambda &#40;In the direct IF image for IgG&#41;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Intense positivity in intracapillary thrombi for anti IgC&#44; IgM&#44; Kappa and Lambda &#40;In the direct IF image for IgG&#41;</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7205&#95;en&#95;10390&#95;figura&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7205_en_10390_figura_3.jpg" alt="Recurrence of cryoglobulinaemic GN&#46; PAS positive intracapillary thrombi and glomerular hypercellularity"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Recurrence of cryoglobulinaemic GN&#46; PAS positive intracapillary thrombi and glomerular hypercellularity</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7206&#95;en&#95;10390&#95;figura&#95;4&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7206_en_10390_figura_4.jpg" alt="Monocyte&#47;macrophage cell line cells with CD68 immunostaining"></img></a></p><p class="elsevierStylePara">Figure 4&#46; Monocyte&#47;macrophage cell line cells with CD68 immunostaining</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7207&#95;en&#95;10390&#95;figura&#95;5&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7207_en_10390_figura_5.jpg" alt="Cryoglobulinaemic glomerulonephritis&#46; Electron microscope&#46; Intraluminal and subendothelial deposits with microtubular sub-structure&#46;"></img></a></p><p class="elsevierStylePara">Figure 5&#46; Cryoglobulinaemic glomerulonephritis&#46; Electron microscope&#46; Intraluminal and subendothelial deposits with microtubular sub-structure&#46;</p>"
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Sjögren's syndrome and acute renal failure after oral surgery
Síndrome de Sjögren y fracaso renal agudo tras cirugía oral
R.. Toledo Rojasa, I.. Garcíab, A.. Torresa, M.A.. Frutosa, G.. Martín-Reyesa, C.. Jirondaa, R.. Franqueloc, M.. Leónb, D.. Hernándeza
a Servicio de Nefrología, Hospital Regional Universitario Carlos Haya, Málaga,
b Servicio de Anatomía Patológica, Hospital Regional Universitario Carlos Haya, Málaga,
c Servicio de Nefrología, Hospital Xanit, Málaga,
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        "titulo" => "S&#237;ndrome de Sj&#246;gren y fracaso renal agudo tras cirug&#237;a oral"
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">INTRODUCTION</span></p><p class="elsevierStylePara">Sj&#246;gren&#8217;s syndrome &#40;SS&#41; is a chronic autoimmune disease characterized by lymphoplasmacytic infiltration of the exocrine glands&#46; It primarily affects lachrymal and salivary glands&#44; giving it the name of dry eye syndrome&#46; In the absence of other associated autoimmune diseases&#44; it is known as primary Sj&#246;gren&#8217;s syndrome &#40;pSS&#41;&#46;</p><p class="elsevierStylePara">Half of pSS patients present extraglandular manifestations&#44; most commonly arthritis and pulmonary disease&#46; Renal damage by interstitial tubular nephritis is also a known complication of pSS&#46; However&#44; glomerulopathies and episodes of acute renal failure are only seen in exceptional cases&#46;</p><p class="elsevierStylePara">Here&#44; we describe the case of a patient affected with SS who develops cryoglobulinemic glomerulopathy with severe acute renal failure&#44; requiring dialysis and with a strong response to immunosuppressor treatment&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">PRESENTATION OF THE CASE</span></p><p class="elsevierStylePara">56 year-old female diagnosed with pSS 13 years before&#46; Presented with dry syndrome&#44; asthenia&#44; and frequent episodes of polyarthritis&#46; During this time&#44; she received a prolonged treatment with non-steroid anti-inflammatory drugs &#40;NSAI&#41; and steroids&#46; Additionally&#44; methotrexate had been applied in recent months with slight improvement of the symptoms&#46;</p><p class="elsevierStylePara">Three months after starting odontological treatment with dental implants&#44; the patient was admitted with facial oedema&#44; fever&#44; and reduced urine output&#46;</p><p class="elsevierStylePara">The physical examination revealed a general deterioration in physical state&#44; blood pressure &#40;BP&#41; at 160&#47;90 mmHg&#44; fever&#44; and submandibular oedema with evidence of an active infection in the lower dental arch&#46; She did not present any distal oedema or skin lesions&#46;</p><p class="elsevierStylePara">The chemical analysis detected Hb 9&#46;2 g&#47;dl&#44; creatinine 2&#46;9 mg&#47;dl&#44; urea 110 mg&#47;dl&#44; and normal liver profile&#44; lipid profile&#44; ANCA and immunoglobulins&#46; ANA positive&#44; anti-DNA negative&#46; Low C3 and C4 levels&#44; 46 and 1&#46;6 mg&#47;dl&#44; respectively&#46; Serology for HBV&#44; HCV&#44; and HIV negative&#46; Haemocultures negative&#46; ANA&#44; anti-LA&#44; anti-Ro antibodies&#44; and rheumatoid factor &#40;RF&#41; were positive from the moment the patient was diagnosed with pSS&#46; Hypocomplementemia was also occasionally presented&#46; The urine sample showed proteinuria &#40;2 g&#47;l&#41; and microhaematuria&#46; The kidney ultrasound came back normal&#46; The patient evolved into a low grade fever that evening&#44; in spite of antibiotic therapy&#44; and oliguria&#44; requiring dialysis treatment&#46;</p><p class="elsevierStylePara">Suspecting acute glomerulonephritis &#40;GN&#41;&#44; probably post-infectious given the mandibular infection and hypocomplementemia&#44; a kidney biopsy was performed with the following results&#58;</p><p class="elsevierStylePara">The cylinder for light microscopy contained 8 glomeruli that presented diffuse capillary occlusion due to thrombi of a PAS-positive proteinaceous material &#40;figure 1&#41;&#46; In some glomeruli&#44; these were accompanied by segmented infiltration of inflammatory cells&#46; Isolated centres of interstitial lymphoplasmacytic inflammation were present&#44; with no alterations in the arteries&#46;</p><p class="elsevierStylePara">In the direct immunofluorescence study &#40;dIF&#41;&#44; we observed intense positivity in the thrombi of IgG&#44; IgM&#44; kappa&#44; and lambda&#44; and to a lesser degree&#44; C3 and IgA &#40;figure 2&#41;&#46; C1q and fibrinogen were negative&#46; The ultrastructural study was performed afterwards&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anatomopathological diagnosis</span></p><p class="elsevierStylePara">Glomeruli with massive intracapillary immunoglobulin thrombi indicating cryoglobulinemic glomerulopathy associated with SS&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Evolution</span></p><p class="elsevierStylePara">The analysis confirmed the existence of cryoglobulinemia &#40;cryocrit 50&#37;&#41; and an IgM kappa monoclonal band&#44; requiring 3 pulses of methylprednisolone and one pulse of 750 mg of i&#46;v&#46; cyclophosphamide&#46; Given the severity of the situation&#44; we decided to continue treatment with three sessions of plasmapheresis and four weekly doses of 375mg&#47;m<span class="elsevierStyleSup">2</span> of rituximab&#46;</p><p class="elsevierStylePara">The patient also presented complications in the form of a <span class="elsevierStyleItalic">Candida </span>infection from the dialysis catheter&#44; which was resolved with antifungals and removal of the catheter&#46; An infection by cytomegalovirus &#40;CMV&#41; was also detected and proceeded without symptoms&#44; and it was controlled following a cycle of treatment with valganciclovir&#46;</p><p class="elsevierStylePara">The patient showed a slow improvement in kidney function&#46; After 9 weeks&#44; the dialysis treatment was suspended&#46; At 5 months&#44; creatinine was at 1 mg&#47;dl&#44; GFR 42 ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#44; the complement and RF were normal&#44; and cryoglobulins negative&#46; Proteinuria and sediments also normalized&#46; The CD19 lymphocyte count in peripheral blood went from 21&#37; pre-treatment to 0&#37; post-treatment&#46; The steroid dose was progressively reduced until stabilizing with 5 mg&#47;48 h of prednisone&#46;</p><p class="elsevierStylePara">Eight months after the episode&#44; the patient was re-admitted with asthenia&#44; polyarthritis&#44; and epigastralgia&#46; Purpura was observed in the lower limbs&#46; The analytical study detected elevated RF and hypocomplementemia&#44; with stable renal function and negative cryoglobulins&#46; After a brief improvement&#44; the patient was stricken with severe gastroenteritis with fever&#44; severe vomiting and diarrhoea&#44; followed by a reduction in diuresis&#46; She continued to present oliguria&#44; in spite of adequate hydration&#44; such that the chemical analysis and renal biopsy were repeated&#46; A cryocrit of 50&#37; was observed as well as a recuperation of the CD19 lymphocytes in peripheral blood &#40;23&#37;&#41;&#46;</p><p class="elsevierStylePara">The renal biopsy showed a recurrence of the cryoglobulinemic glomerulopathy&#44; containing 22 glomeruli&#44; one of which was sclerosed&#59; the rest also presented abundant hyaline thrombi &#40;PAS&#43;&#41; with capillary occlusion and varying levels of monocytic infiltration &#40;at times severe&#41; in the capillary spaces &#40;figure 3 and figure 4&#41;&#46; Few areas of interstitial fibrosis were present&#46; In dIF&#44; the stain was preferentially intraluminal for the same antisera of the previous biopsy&#46; The electron microscope analysis showed that the deposits had microtubular organization &#40;figure 5&#41;&#46;</p><p class="elsevierStylePara">With these findings&#44; and taking into account the favourable evolution observed in the first episode&#44; we applied the same therapeutic regimen&#46; After applying haemodialysis for 3 weeks&#44; the patient started to recover kidney function&#46; At 3 weeks her creatinine levels reached 0&#46;9 mg&#47;dl&#44; GRF 52 ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#44; with normalized complements and negative cryoglobulins&#46; We also observed in this episode an asymptomatic reactivation of the CMV infection with a good response to valganciclovir and an episode of a urinary infection that was resolved with outpatient treatment&#46; No new complications have arisen in the 5 months since the last episode&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION </span></p><p class="elsevierStylePara">Although SS normally presents as xerostomia and dry keratoconjunctivitis&#44; extraglandular manifestations are very common&#44; and are responsible for the wide variability in the symptoms of this disease&#44; as it can affect practically any organ&#46; The most severe complication is the development of B cell lymphomas&#44; observed in 5 &#8211; 7&#37; of cases&#46;</p><p class="elsevierStylePara">An estimated 25&#37; of patients with pSS present with renal alterations&#46; These tend to be cases of tubulointerstitial nephritis &#40;TIN&#41;&#44; which is primarily manifested by proteinuria and tubular dysfunction with evidence of lymphoplasmacytic infiltrates&#46;<span class="elsevierStyleSup">1</span> It is rarely associated with renal failure&#44; and when it is&#44; this condition tends to be mild&#46; The association of SS with glomerulopathies has been rarely described&#46;</p><p class="elsevierStylePara">In a study of 60 patients with pSS and evidence of tubular and&#47;or glomerular dysfunction&#44; nine were biopsied&#44; six presented TIN&#44; and three glomerular disease&#44; one of which was a cryoglobulinemic membranoproliferative glomerulonephritis &#40;MPGN&#41;&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">In the recently published study by Maripuri et al&#46;&#44; only 24 patients with pSS &#40;0&#46;3&#37; of the 7&#44;276 patients&#41; were evaluated with renal biopsies&#44; 17 had TIN&#44; and seven presented glomerular lesions that included MPGN with cryoglobulinemia&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">Mixed cryoglobulinemia is associated with lymphoproliferative&#44; autoimmune&#44; and infectious diseases&#46; In our field&#44; the principal causal agent is HCV&#44; while SS is the most frequent cause of mixed cryoglobulinemia in the absence of HCV infection&#46;<span class="elsevierStyleSup">3</span> In the study by Ramos-Casals et al&#46;&#44; cryoglobulins were detected in as much as 16&#37; of pSS patients&#46; However&#44; only half of these were infected with HCV&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">The polyclonal activation of lymphocyte B &#40;LB&#41; characterized by pSS can in some cases evolve into an oligoclonal or monoclonal LB expansion with production of IgM kappa&#44; which constitutes the principal monoclonal component of cryoglobulinemia&#46; Finally&#44; this monoclonal activation can arise in malignant lymphoproliferative diseases&#46; In this sense&#44; the detection of cryoglobulins indicates an increased risk of lymphoma progression&#46;</p><p class="elsevierStylePara">It still remains to be verified if the intercurrent infectious processes precipitate the stimulation of LB and cryoglobulin synthesis in patients with SS&#46; In the case we have presented&#44; the initial breakout and recurrence of cryoglobulinemic glomerulonephritis were preceded by a submandibular infection and acute gastroenteritis&#44; respectively&#46;</p><p class="elsevierStylePara">The renal disease associated with cryoglobulinemia is heterogeneous&#44; with type I MPGN being the most frequent histological pattern &#40;80&#37;&#41;&#46; Other renal lesion patterns include proliferative diffuse or focal GN&#44; and more rarely&#44; membranous glomerulopathy&#46; Monocyte infiltration is common&#44; although some areas of glomerular segments can also include polymorphonuclears&#46; Intracapillary thrombi are identified in approximately half of these cases and tend to be focal&#46; Massive cryoglobulinic intracapillary thrombi&#44; such as those found in our patient&#44; are infrequent and usually present with a rapid deterioration of renal function&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Three distinctive patterns have been described in dIF&#44; one of which consists of a strong stain of intraluminal thrombi and peripheral mottling&#44; the most characteristic pattern&#44; and must indicate a diagnosis of cryoglobulinemia&#59; however&#44; only a small portion of patients with cryoglobulinemia exhibit this type of appearance&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">Regarding treatment&#44; steroids and various immunosuppressors&#44; cyclophosphamide or azathioprine&#44; as well as plasmapheresis in the most severe cases&#44; are traditionally used with poor results&#46; Only 14&#37; of patients remain in remission for long periods of time&#44; with an elevated incidence of severe complications&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">Rituximab is a monoclonal antibody with anti-CD20 activity capable of producing a strong depletion in B-lymphocytes&#46; Although it was initially indicated in the treatment of B lymphomas&#44; its use in recent years has been extended given the positive results obtained&#46;</p><p class="elsevierStylePara">It has been used in mixed essential cryoglobulinemia and cryoglobulinemia associated with HVC resistant to conventional immunosuppressor treatment&#44; producing a clinical improvement in arthralgia and skin lesions&#44; as well as decreased cryocrit and increase in complement&#46; From the renal point of view&#44; improved kidney function and a decrease in proteinuria have been observed&#46; Cacoub et al&#46; have reviewed 57 cases published on mixed cryoglobulinemia treated with rituximab&#46; They observed a favourable clinical response in 15 out of 18 patients &#40;83&#37;&#41; with compromised renal function&#46; The response was complete in 75&#37; of these cases&#44; although 39&#37; experienced recurrence&#44; which tends to respond to new treatment cycles&#46; In general&#44; the treatment was well tolerated with few side effects&#46;<span class="elsevierStyleSup">8</span> The use of rituximab creates a new expectation for the clinical management of these cases&#46; Even so&#44; very little data is available and new studies are needed to evaluate the costs&#47;benefits of this treatment on a long-term basis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Questions</span></p><p class="elsevierStylePara">Dr&#46; Julia Blanco &#40;Madrid&#41;&#46; How do you explain the presence of kappa and lambda immunoglobulins in the biopsy&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Anwer</span>&#46; In cryoglobulinemia&#44; the glomerular deposits detected by direct immunofluorescence in the renal biopsy reflect the composition of the serum precipitate&#46; In type II mixed cryoglobulinemia&#44; which would be the type corresponding to our case&#44; monoclonal &#40;usually IgM kappa&#41; and polyclonal &#40;IgG&#41; immunoglobulins are present&#46; The intracapillary thrombi in these cases usually stain with antisera for both immunoglobulins IgG and IgM&#44; as well as for both kappa and lambda light chains&#46; The monoclonal kappa component of the IgM would be hidden and overlapped by the positivity of both kappa and lambda light chains corresponding to the polyclonal IgG&#46;</p><p class="elsevierStylePara">Dr&#46; Antonio Barat &#40;Madrid&#41;&#46; Do you think that an acute tubular necrosis in the second biopsy could have contributed to the rapid deterioration in renal function&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; In the second biopsy&#44; focal alterations in the tubular epithelium are effectively evidenced&#44; indicating an acute lesion that could simulate ischemic renal failure&#46; In our opinion&#44; as has occurred in other cases of severe glomerulonephritis&#44; we interpret these changes to be secondary to the florid glomerular process that is presented by the patient rather than an acute tubular necrosis&#46;</p><p class="elsevierStylePara">Dr&#46; Miguel &#193;ngel Frutos &#40;M&#225;laga&#41;&#46; The objective after these two episodes of rapid deterioration in renal function is to avoid similar recurrences&#46; What strategy will you use with this patient&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; In our case&#44; the patient presented two episodes of rapidly establishing and severe acute renal failure&#46; In both the initial breakout and the recurrence&#44; the patient was oliguric in a few hours and required prolonged haemodialysis treatment&#46; On the other hand&#44; just 2 weeks before the second episode&#44; renal function was stable&#44; cryoglobulins were negative&#44; and CD19 LB were low &#40;3&#37;&#41;&#46; Given the severity and magnitude of the episodes of renal failure and the absence of serum markers that could allow us to anticipate recurrence with a certain margin&#44; we consider it necessary to apply immunosuppressive treatment as a preventative measure&#46; Some cases from the bibliography have used various levels of rituximab treatments with success&#44;<span class="elsevierStyleSup">9</span> although the proper dosage and duration of treatment remain to be determined&#46; In our patient&#44; the use of rituximab for maintenance could be useful in preventing new outbreaks&#46;</p><p class="elsevierStylePara">Dr&#46; Miguel Perdiguero &#40;Alicante<span class="elsevierStyleItalic">&#41;&#46;</span> In this case&#44; could serial measurements of C3 and C4 aid in predicting outbreaks&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; In our patient&#44; each episode of renal failure was accompanied by hypocomplentemia&#46; However&#44; only 14 days passed between the onset of hypocomplementemia and the development of oliguria&#46; This constitutes a short period of time that does not allow for proper planning of the treatment to be administered before the outbreak&#46;</p><p class="elsevierStylePara">Dr&#46; Simona Alexandrini &#40;Madrid&#41;&#46; Has any effort been put into finding some clone responsible for the production of cryoglobulins&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; The chemical analysis showed the presence of a monoclonal IgM kappa spike&#44; which reflects a monoclonal expansion of LB&#46; Until now we have not been able to directly identify the presence of a cryoglobulin-producing LB clone in peripheral blood&#44; since we do not have the necessary material for such an analysis at our centre&#46;</p><p class="elsevierStylePara">Dr&#46; Jes&#250;s Egido &#40;Madrid&#41;&#46; I was wondering if maintaining such a low dose of prednisone in the treatment following recuperation from the first episode might have facilitated the abrupt outbreak of the second&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; The protocol for dosage and duration of maintenance treatment with steroids in cases of cryoglobulinemic glomerulonephritis is as yet unestablished&#46; The majority of published cases tend not to describe the dose used&#44; and as such&#44; it is difficult to evaluate the influence of the use of low dosage or even the absence of steroids in the appearance of recurrences&#46;</p><p class="elsevierStylePara">Dr&#46; Manuel Praga &#40;Madrid&#41;&#46; Do you have any opinion on the use of bortezomib in similar cases&#63;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">A</span>&#58; Bortezomib is a selective proteasome inhibitor that has been demonstrated to be effective in the treatment of malignant gammapathies &#40;multiple myeloma&#44; plasmacytoma&#44; leukaemia&#41;&#46; Recently&#44; 3 cases have been communicated on patients with type I cryoglobulinemia and skin vasculitis that were resistant to intensive steroid immunosuppressor treatment&#44; alkylating agents&#44; and even rituximab&#46; Additionally&#44; a significant decrease in cryocrit was observed&#44; as well as a complete resolution of the skin vasculitis&#46;</p><p class="elsevierStylePara">None of the patients presented data on renal damage&#44; which is quite infrequent in cases of type I cryoglobulinemia&#46;<span class="elsevierStyleSup">10&#44;11</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">We would like to thank Novartis Pharma for the facilities for the presentation and discussion of this case at the meeting of the Nephropathology Club and GLOSEN&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7203&#95;en&#95;10390&#95;figura&#95;1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7203_en_10390_figura_1.jpg" alt="PAS&#46; Massive glomerular intracapillary thrombi"></img></a></p><p class="elsevierStylePara">Figure 1&#46; PAS&#46; Massive glomerular intracapillary thrombi</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7204&#95;en&#95;10390&#95;figura&#95;2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7204_en_10390_figura_2.jpg" alt="Intense positivity in intracapillary thrombi for anti IgC&#44; IgM&#44; Kappa and Lambda &#40;In the direct IF image for IgG&#41;"></img></a></p><p class="elsevierStylePara">Figure 2&#46; Intense positivity in intracapillary thrombi for anti IgC&#44; IgM&#44; Kappa and Lambda &#40;In the direct IF image for IgG&#41;</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7205&#95;en&#95;10390&#95;figura&#95;3&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7205_en_10390_figura_3.jpg" alt="Recurrence of cryoglobulinaemic GN&#46; PAS positive intracapillary thrombi and glomerular hypercellularity"></img></a></p><p class="elsevierStylePara">Figure 3&#46; Recurrence of cryoglobulinaemic GN&#46; PAS positive intracapillary thrombi and glomerular hypercellularity</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7206&#95;en&#95;10390&#95;figura&#95;4&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7206_en_10390_figura_4.jpg" alt="Monocyte&#47;macrophage cell line cells with CD68 immunostaining"></img></a></p><p class="elsevierStylePara">Figure 4&#46; Monocyte&#47;macrophage cell line cells with CD68 immunostaining</p><p class="elsevierStylePara"><a href="grande&#47;10390&#95;108&#95;7207&#95;en&#95;10390&#95;figura&#95;5&#46;jpg" class="elsevierStyleCrossRefs"><img src="10390_108_7207_en_10390_figura_5.jpg" alt="Cryoglobulinaemic glomerulonephritis&#46; Electron microscope&#46; Intraluminal and subendothelial deposits with microtubular sub-structure&#46;"></img></a></p><p class="elsevierStylePara">Figure 5&#46; Cryoglobulinaemic glomerulonephritis&#46; Electron microscope&#46; Intraluminal and subendothelial deposits with microtubular sub-structure&#46;</p>"
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                  "referenciaCompleta" => "Maripuri S, Grande JP, Osbor TG, Fervenza FC, Eric L, et al. Renal involvement in primary Sjögrens syndrome: a clinicopathologic study. Clin Am J Soc Nephrol 2009;4:1423-31."
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                  "referenciaCompleta" => "Bossini N, Savoldi S, Franceschini F, Mombelloni S, Baronio M, et al. Clinically morphological features of kidney involvement in primary Sjögren´s syndrome. Nephrol Dial Transplant 2001;16:2328-36.\u{A0} <a href="http://www.ncbi.nlm.nih.gov/pubmed/11733624" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "Matignon M, Cacoub P, Colombat M, Saadoun D, Brocheriou I, et al. Clinical and morphologic spectrum of renal involvement in patients with mixed cryoglobulinemia without evidence of hepatitis C virus infection. Medicine (Baltimore) 2009;88:341-8.\u{A0}"
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                  "referenciaCompleta" => "Ramos-Casals M, Cervera R, Yagüe J, García Carrasco M, Trejo O, et al. Cryoglobulinemia in primary Sjögren´s syndrome: prevalence and clinical characteristics in a series of 115 patients. Sem Arthritis Rheum 1998;28:200-5."
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                  "referenciaCompleta" => "Annear N, Cook HT, Atkins M, Pusey C, Salama A. Non-hepatitis virus associated mixed essential cryoglobulinemia. Kidney Int 2009;77:161-4.\u{A0} <a href="http://www.ncbi.nlm.nih.gov/pubmed/19890273" target="_blank">[Pubmed]</a>"
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ISSN: 20132514
Original language: English
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