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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">Sarcoidosis is a multisystemic disease which affects the kidneys in between 4&#37; and 20&#37; of cases&#46; Disorders of calcium metabolism such as hypercalcaemia and&#47;or hypercalciuria&#44; nephrolithiasis&#44; and tubular dysfunctions are the most common kidney disorders&#46;<span class="elsevierStyleSup">1</span>&#160;Glomerular disorders associated with sarcoidosis have also been reported&#44; among which membrane glomerulonephritis is the most common&#46;<span class="elsevierStyleSup">2</span>&#160;Interstitial granulomatous infiltration is usually silent and rarely manifests as acute kidney failure&#44; and if this does happens&#44; damage to other organs is usually evident&#46; Kidney failure caused by granulomatous interstitial nephritis &#40;GIN&#41; in the absence of extrarenal sarcoidosis is an extremely rare clinical condition&#46;</p><p class="elsevierStylePara">We present the case of a patient with acute renal failure caused by sarcoidosis affecting only the kidneys&#46;</p><p class="elsevierStylePara">The patient was a 56-year-old woman with no allergies or substance abuse and with no medical history of interest or regular medical treatment&#46; She was referred to emergency services by her family doctor after an abnormal blood test &#40;creatinine 8mg&#47;dl&#41;&#44; carried out to study a toxic syndrome of 6 to 7 months evolution with a weight loss of 10 kg&#46; She had an analysis carried out 5 months earlier in a check-up at work which highlighted a Hb level of 11 g&#47;dl and creatinine level of 1&#46;7 mg&#47;dl&#46; The patient had normal blood pressure in the physical examination&#44; and pale mucous membranes&#59; everything else was normal&#46; Analyses showed results of Hct&#47;Hb 28 &#37;&#47;9&#46;6 g&#47;dl&#44; urea&#47;creatinine 192&#47;9&#46;4 mg&#47;dl &#40;estimated GFR 4ml&#47;min&#41;&#44; calcium 10 mg&#47;dl&#44; FENa 10&#46; Proteinuria 0&#46;6 g&#47;24 h&#44; and sediment was normal&#46; PTHi and vitamin D levels were normal&#46; Patient was negative for HbsAg&#44; HCV and HIV&#46; Immunological study&#58; ANA&#44; anti-DNA&#44; ANCA&#44; serum complement and immunoelectrophoresis were normal or negative&#46; The Rose Bengal test for anti-Brucella antibodies was negative&#46; Urine culture in L&#246;wenstein-Jensen medium was negative&#46; The PPD skin test was negative&#46; ACE levels were 189 U&#47;l &#40;8-52 U&#47;l&#41;&#46; The chest x-ray&#44; abdominal ultrasound and CT scan of chest&#44; abdomen and pelvis were normal&#46; No significant changes were found in the eye and ENT examinations&#46; A jugular catheter was inserted and haemodialysis was begun&#46; A percutaneous kidney biopsy was performed showing 10 glomeruli&#44; 2 of them sclerotic&#44; the rest with normal appearance&#46; Large amount of granulomas comprised of epithelioid cells and Langhans multinucleated giant cells without necrosis &#40;Figure 1&#41; were observed in the interstitium&#46; The histochemical techniques to detect fungi and acid-alcohol resistant bacilli were negative&#46; Treatment began with prednisone at 1 mg&#47;kg&#47;day&#46; The patient had conserved diuresis and haemodialysis was well tolerated&#46; After four weeks of corticosteroid treatment&#44; a progressive improvement in kidney function was observed&#44; enabling her to stop the replacement treatment&#46; At present&#44; 4 months after starting treatment and with a dose of 0&#46;3 mg&#47;kg&#47;day&#44; she has a plasma creatinine level of 2&#46;8 mg&#47;dl &#40;GF 19 ml&#47;min&#41; and a normal level of ACE&#46;</p><p class="elsevierStylePara">GIN is a very rare histological diagnosis&#44; found in between 0&#46;5&#37; and 0&#46;9&#37; of native kidney biopsies&#46;<span class="elsevierStyleSup">3&#44;4</span>&#160;It has been associated with drugs &#40;mainly NSAID&#44; allopurinol and antibiotics&#41;&#44; infections &#40;tuberculosis&#44; brucellosis and fungal infections&#44; among others&#41;&#44; Wegener&#8217;s granulomatosis&#44; crystal-induced nephropathy&#44; paraproteinemia&#44; TINU syndrome&#44; idiopathic infections&#44; and sarcoidosis&#46; Joss et al&#46; reviewed the cases of kidney biopsies performed in Glasgow over a 15-year period and identified a total of 18 GIN &#40;in less than 1&#37; of the total biopsies&#41;&#46; Of these&#44; 5 were due to sarcoidosis&#44; 2 were associated with TINU syndrome&#44; 2 were secondary to medication&#44; and 9 were classified as idiopathic&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Acute renal failure in sarcoidosis is mainly associated with hypercalcaemia&#44; and in its chronic form with nephrocalcinosis&#46;<span class="elsevierStyleSup">6</span>&#160;GIN is another cause of kidney disease in sarcoidosis&#44; present in a third of patients with sarcoidosis and evidence of kidney disease&#46; In 1987&#44; Ford described the first association of GIN in a patient with sarcoidosis who developed acute renal failure&#46;<span class="elsevierStyleSup">7</span>&#160;GIN in the absence of extrarenal sarcoidosis is very rare&#46; Robson et al&#46; presented 7 cases of GIN in the absence of extrarenal sarcoidosis&#46;<span class="elsevierStyleSup">8</span>&#160;Of note is the predominance of men &#40;71&#37;&#41;&#44; the mean age of 69&#44; the severe renal failure at the time of presentation &#40;calculated creatinine clearance of 14 ml&#47;min&#41;&#44; the need for temporaryy haemodialysis at onset in one case&#44; minimal proteinuria &#40;mean 0&#46;4 g&#47;day&#41;&#44; high ACE levels in 3 patients&#44; and good response to corticosteroid treatment in 5 cases &#40;prednisolone at between 20 and 60 mg&#47;day&#41;&#46; Two patients needed to begin periodic haemodialysis at 3 and 15 months after diagnosis&#46; The common histological characteristics were normal glomerular levels and the presence in the interstitial fluid of in the interstitial fluid composed of epithelioid cells and multinuclear giant cells&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">It is worth highlighting the importance of kidney biopsies in cases of non-justified kidney failure&#44; and in cases of suspected sarcoidosis in particular&#44; given the variety of lesions it can cause&#46; Performing a biopsy can optimize the choice of clinical treatment&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10504&#95;108&#95;11430&#95;en&#95;10504&#95;18107&#95;6168&#95;es&#95;10504&#95;15136&#95;6168&#95;es&#95;sarcoidosi&#95;31&#46;jpg" class="elsevierStyleCrossRefs"><img src="10504_108_11430_en_10504_18107_6168_es_10504_15136_6168_es_sarcoidosi_31.jpg" alt="Kidney cortical "></img></a></p><p class="elsevierStylePara">Figure 1&#46; 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Granulomatous interstitial nephritis in the absence of extrarenal sarcoid
Nefritis intersticial granulomatosa sin afectación sarcoidea extrarrenal
M.. Cuxarta, M.. Picazoa, R.. Sans Lormana, M.J.. Muntanéb
a Servicio de Nefrología, Hospital de Figueres, Figueres, Girona,
b Servicio de Anatomía Patológica, Hospital de Figueres, Figueres, Girona,
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She was referred to emergency services by her family doctor after an abnormal blood test &#40;creatinine 8mg&#47;dl&#41;&#44; carried out to study a toxic syndrome of 6 to 7 months evolution with a weight loss of 10 kg&#46; She had an analysis carried out 5 months earlier in a check-up at work which highlighted a Hb level of 11 g&#47;dl and creatinine level of 1&#46;7 mg&#47;dl&#46; The patient had normal blood pressure in the physical examination&#44; and pale mucous membranes&#59; everything else was normal&#46; Analyses showed results of Hct&#47;Hb 28 &#37;&#47;9&#46;6 g&#47;dl&#44; urea&#47;creatinine 192&#47;9&#46;4 mg&#47;dl &#40;estimated GFR 4ml&#47;min&#41;&#44; calcium 10 mg&#47;dl&#44; FENa 10&#46; Proteinuria 0&#46;6 g&#47;24 h&#44; and sediment was normal&#46; PTHi and vitamin D levels were normal&#46; Patient was negative for HbsAg&#44; HCV and HIV&#46; Immunological study&#58; ANA&#44; anti-DNA&#44; ANCA&#44; serum complement and immunoelectrophoresis were normal or negative&#46; The Rose Bengal test for anti-Brucella antibodies was negative&#46; Urine culture in L&#246;wenstein-Jensen medium was negative&#46; The PPD skin test was negative&#46; ACE levels were 189 U&#47;l &#40;8-52 U&#47;l&#41;&#46; The chest x-ray&#44; abdominal ultrasound and CT scan of chest&#44; abdomen and pelvis were normal&#46; No significant changes were found in the eye and ENT examinations&#46; A jugular catheter was inserted and haemodialysis was begun&#46; A percutaneous kidney biopsy was performed showing 10 glomeruli&#44; 2 of them sclerotic&#44; the rest with normal appearance&#46; Large amount of granulomas comprised of epithelioid cells and Langhans multinucleated giant cells without necrosis &#40;Figure 1&#41; were observed in the interstitium&#46; The histochemical techniques to detect fungi and acid-alcohol resistant bacilli were negative&#46; Treatment began with prednisone at 1 mg&#47;kg&#47;day&#46; The patient had conserved diuresis and haemodialysis was well tolerated&#46; After four weeks of corticosteroid treatment&#44; a progressive improvement in kidney function was observed&#44; enabling her to stop the replacement treatment&#46; At present&#44; 4 months after starting treatment and with a dose of 0&#46;3 mg&#47;kg&#47;day&#44; she has a plasma creatinine level of 2&#46;8 mg&#47;dl &#40;GF 19 ml&#47;min&#41; and a normal level of ACE&#46;</p><p class="elsevierStylePara">GIN is a very rare histological diagnosis&#44; found in between 0&#46;5&#37; and 0&#46;9&#37; of native kidney biopsies&#46;<span class="elsevierStyleSup">3&#44;4</span>&#160;It has been associated with drugs &#40;mainly NSAID&#44; allopurinol and antibiotics&#41;&#44; infections &#40;tuberculosis&#44; brucellosis and fungal infections&#44; among others&#41;&#44; Wegener&#8217;s granulomatosis&#44; crystal-induced nephropathy&#44; paraproteinemia&#44; TINU syndrome&#44; idiopathic infections&#44; and sarcoidosis&#46; Joss et al&#46; reviewed the cases of kidney biopsies performed in Glasgow over a 15-year period and identified a total of 18 GIN &#40;in less than 1&#37; of the total biopsies&#41;&#46; Of these&#44; 5 were due to sarcoidosis&#44; 2 were associated with TINU syndrome&#44; 2 were secondary to medication&#44; and 9 were classified as idiopathic&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">Acute renal failure in sarcoidosis is mainly associated with hypercalcaemia&#44; and in its chronic form with nephrocalcinosis&#46;<span class="elsevierStyleSup">6</span>&#160;GIN is another cause of kidney disease in sarcoidosis&#44; present in a third of patients with sarcoidosis and evidence of kidney disease&#46; In 1987&#44; Ford described the first association of GIN in a patient with sarcoidosis who developed acute renal failure&#46;<span class="elsevierStyleSup">7</span>&#160;GIN in the absence of extrarenal sarcoidosis is very rare&#46; Robson et al&#46; presented 7 cases of GIN in the absence of extrarenal sarcoidosis&#46;<span class="elsevierStyleSup">8</span>&#160;Of note is the predominance of men &#40;71&#37;&#41;&#44; the mean age of 69&#44; the severe renal failure at the time of presentation &#40;calculated creatinine clearance of 14 ml&#47;min&#41;&#44; the need for temporaryy haemodialysis at onset in one case&#44; minimal proteinuria &#40;mean 0&#46;4 g&#47;day&#41;&#44; high ACE levels in 3 patients&#44; and good response to corticosteroid treatment in 5 cases &#40;prednisolone at between 20 and 60 mg&#47;day&#41;&#46; Two patients needed to begin periodic haemodialysis at 3 and 15 months after diagnosis&#46; The common histological characteristics were normal glomerular levels and the presence in the interstitial fluid of in the interstitial fluid composed of epithelioid cells and multinuclear giant cells&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">It is worth highlighting the importance of kidney biopsies in cases of non-justified kidney failure&#44; and in cases of suspected sarcoidosis in particular&#44; given the variety of lesions it can cause&#46; Performing a biopsy can optimize the choice of clinical treatment&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10504&#95;108&#95;11430&#95;en&#95;10504&#95;18107&#95;6168&#95;es&#95;10504&#95;15136&#95;6168&#95;es&#95;sarcoidosi&#95;31&#46;jpg" class="elsevierStyleCrossRefs"><img src="10504_108_11430_en_10504_18107_6168_es_10504_15136_6168_es_sarcoidosi_31.jpg" alt="Kidney cortical "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Kidney cortical </p>"
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Nefrología (English Edition)