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The patient presented toxic syndrome and had been vomiting and suffering from diarrhoea for two months&#46; The only notable findings during the physical examination were a painful&#44; enlarged spleen and high blood pressure &#40;162&#47;90mm Hg&#41;&#46; The following analytical findings were of note&#58; haemoglobin&#58; 11&#46;7mg&#47;dl&#44; calcium&#58; 12&#46;0mg&#47;dl&#44; phosphorus&#58; 3&#46;0mg&#47;dl&#44; iPTH&#58; 0&#46;3pg&#47;ml &#40;normal values 10-65pg&#47;ml&#41;&#44; alanine aminotransferase &#40;ALT&#41;&#58; 22U&#47;l&#44; aspartate aminotransferase &#40;AST&#41;&#58; 69U&#47;l&#44; gamma glutamyl transpeptidase &#40;GGT&#41;&#58; 69U&#47;l&#44; ferritin&#58; 495ng&#47;ml&#44; uric acid&#58; 7&#46;0mg&#47;dl&#44; urea&#58; 56mg&#47;dl&#44; creatinine&#58; 2&#46;13mg&#47;dl&#44; estimated glomerular filtration rate &#40;eGFR&#41;&#58; 33ml&#47;min&#44; proteinuria&#58; 0&#46;334g&#47;24 hours and in the sediment there were only 10-20 erythrocytes per field&#46; Calciuria was 896mg&#47;24h&#46; Angiotensin converting enzyme &#40;ACE&#41; levels&#58; 167U&#47;l &#40;normal range 8-55&#41;&#44; 25-&#40;OH&#41;-vitamin D3&#58; 69pg&#47;ml &#40;normal range 9-52&#41;&#44; 1&#44;25-&#40;OH&#41;2-vitamin D3&#58; 89pg&#47;ml &#40;normal range 15-60pg&#47;ml&#41;&#46; The other biochemical parameters&#44; and the immunological and tumour marker results were normal&#46; The chest X-ray revealed an interstitial pattern at the base of the right lung&#46; In the thoraco-abdominal computed tomography &#40;CT&#41; scan&#44; the lung parenchyma analysis showed diffuse&#44; non-specific interstitial reinforcement in both lungs&#46; The abdominal exploration revealed small inflammatory&#47;reactive retroperitoneal adenopathies&#44; homogenous spleen enlargement and bilateral renal microlithiasis&#46; A renal ultrasound scan confirmed the morphology&#44; position and size of the kidneys to be normal&#46; Gammagraphy with gallium revealed moderately severe inflammation of the parotid glands and the base of the right lung&#46; The renal histology tests detected 13 diagnostically useful glomeruli&#46; Three of them were completely sclerotic&#44; and the rest had preserved their structure and morphology&#46; Focal ischaemic ondulations and minimal mesangial segmental increases were identified&#46; Glomerular cell proliferation was not observed&#46; No granulomas were observed&#44; and patches of interstitial fibrosis and tubular atrophy&#44; which together accounted for 10&#37; of the cylinder&#44; were identified&#46; Two interlobular arteries without morphological changes were identified&#46; Immunofluorescence assays using anti-IgG&#44; IgA&#44; IgM and C1q&#44; C3&#44; kappa and lambda sera were negative&#46; Pulmonary histology samples obtained by fibrobronchoscopy and transbronchial biopsy showed the presence of a non-caseating granuloma&#46;</p><p class="elsevierStylePara">Sarcoidosis was diagnosed and prednisone was administered&#44; starting with a dose of 1mg&#47;kg body weight and progressively reducing the dose from the first month onwards&#46; After three months&#44; the constitutional syndrome disappeared&#44; progressive weight gain was achieved and renal function improved significantly &#40;creatinine 1&#46;3mg&#47;dl and eGFR 58&#46;8ml&#47;m&#41;&#46; The patient&#8217;s calcaemia &#40;calcium 8&#46;9mg&#47;dl&#41; and anaemia &#40;Hb 13&#46;0mg&#47;dl&#41; were corrected and his iPTH &#40;32pg&#47;ml&#41; and ACE &#40;13U&#47;l&#41; levels were normal&#46;</p><p class="elsevierStylePara">Sarcoidosis is a multi-systemic disease of unknown aetiology and the pulmonary and lymphatic systems are the most commonly affected &#40;30&#37;-60&#37; of cases&#41;&#46; Hypercalcaemia &#40;2&#37;-10&#37;&#41; and hypercalciuria &#40;6&#37;-30&#37;&#41; can cause nephrocalcinosis&#44; lithiasis and renal insufficiency&#46; The prevalence of tubulo-interstitial nephritis ranges from 7&#37; to 27&#37;&#44; although chronic renal failure develops in less than 1&#37; of cases&#44; according to a number of retrospective studies&#46;<span class="elsevierStyleSup">2</span> Sarcoidosis patients often have high levels of vitamin D and ACE&#44; which are synthesised by the epithelioid cells of the granuloma&#46;<span class="elsevierStyleSup">3&#44;4 </span>In the case that we present the clinico-radiological involvement was minimal and the diagnosis was confirmed by transbronchial biopsy&#46; The analytical profile was indicative of sarcoidosis &#40;hypercalcaemia&#44; hypercalciuria&#44; high levels of vitamin D and ACE and substantial iPTH suppression&#41;&#46;</p><p class="elsevierStylePara">Renal function impairment in sarcoidosis is generally due to hypercalcaemia&#44; hypercalciuria and nephrocalcinosis&#44; although nephrolithiasis&#44; glomerulopathies and interstitial nephritis &#40;with or without sarcoid granuloma&#41; form part of the spectrum of renal pathologies in sarcoidosis&#46;<span class="elsevierStyleSup">1 </span></p><p class="elsevierStylePara">Corticosteroids<span class="elsevierStyleSup">5</span> are the treatment of choice and in the case presented here a good response was obtained&#46; Renal involvement without the lungs being affected is very rare<span class="elsevierStyleSup">2</span> and in this case it was not possible to establish that this was the case until the lung biopsy was performed&#46; 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Sarcoidosis: diagnosis from the renal function and hypercalcaemia study
Sarcoidosis: diagnóstico a partir del estudio de insuficiencia renal e hipercalcemia
O.. Ibrika, R.. Samona, A.. Rodaa, R.. Rocaa, J.C.. Gonzáleza, J.. Viladomsa, J.. Vilasecab, M.. Serranob
a Servicio de Nefrología, Hospital de Mollet, Mollet del Vallès, Barcelona,
b Servicio de Neumología, Hospital de Mollet, Mollet del Vallès, Barcelona,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">Sarcoidosis is a multi-systemic granulomatous disease of unknown aetiology&#44; which is characterised by the presence of non-caseating epithelioid granulomas&#46; Renal involvement is uncommon in sarcoidosis and&#44; in cases where it does occur&#44; it is associated with hypercalcaemia&#44; hypercalciuria&#44; increased levels of calcitriol and parathyroid hormone &#40;iPTH&#41; suppression&#46;<span class="elsevierStyleSup">1 </span></p><p class="elsevierStylePara">We present the case of a 64-year-old male patient with a family history &#40;patient&#39;s father&#41; of emphysema&#46; Incidents of note in his medical history include various episodes of macrohaematuria when the patient was 15&#44; pleuritis at the age of 30&#44; rhinitis at the age of 60 and glaucoma&#46; He was admitted to the nephrology department with suspected renal failure&#46; The patient presented toxic syndrome and had been vomiting and suffering from diarrhoea for two months&#46; The only notable findings during the physical examination were a painful&#44; enlarged spleen and high blood pressure &#40;162&#47;90mm Hg&#41;&#46; The following analytical findings were of note&#58; haemoglobin&#58; 11&#46;7mg&#47;dl&#44; calcium&#58; 12&#46;0mg&#47;dl&#44; phosphorus&#58; 3&#46;0mg&#47;dl&#44; iPTH&#58; 0&#46;3pg&#47;ml &#40;normal values 10-65pg&#47;ml&#41;&#44; alanine aminotransferase &#40;ALT&#41;&#58; 22U&#47;l&#44; aspartate aminotransferase &#40;AST&#41;&#58; 69U&#47;l&#44; gamma glutamyl transpeptidase &#40;GGT&#41;&#58; 69U&#47;l&#44; ferritin&#58; 495ng&#47;ml&#44; uric acid&#58; 7&#46;0mg&#47;dl&#44; urea&#58; 56mg&#47;dl&#44; creatinine&#58; 2&#46;13mg&#47;dl&#44; estimated glomerular filtration rate &#40;eGFR&#41;&#58; 33ml&#47;min&#44; proteinuria&#58; 0&#46;334g&#47;24 hours and in the sediment there were only 10-20 erythrocytes per field&#46; Calciuria was 896mg&#47;24h&#46; Angiotensin converting enzyme &#40;ACE&#41; levels&#58; 167U&#47;l &#40;normal range 8-55&#41;&#44; 25-&#40;OH&#41;-vitamin D3&#58; 69pg&#47;ml &#40;normal range 9-52&#41;&#44; 1&#44;25-&#40;OH&#41;2-vitamin D3&#58; 89pg&#47;ml &#40;normal range 15-60pg&#47;ml&#41;&#46; The other biochemical parameters&#44; and the immunological and tumour marker results were normal&#46; The chest X-ray revealed an interstitial pattern at the base of the right lung&#46; In the thoraco-abdominal computed tomography &#40;CT&#41; scan&#44; the lung parenchyma analysis showed diffuse&#44; non-specific interstitial reinforcement in both lungs&#46; The abdominal exploration revealed small inflammatory&#47;reactive retroperitoneal adenopathies&#44; homogenous spleen enlargement and bilateral renal microlithiasis&#46; A renal ultrasound scan confirmed the morphology&#44; position and size of the kidneys to be normal&#46; Gammagraphy with gallium revealed moderately severe inflammation of the parotid glands and the base of the right lung&#46; The renal histology tests detected 13 diagnostically useful glomeruli&#46; Three of them were completely sclerotic&#44; and the rest had preserved their structure and morphology&#46; Focal ischaemic ondulations and minimal mesangial segmental increases were identified&#46; Glomerular cell proliferation was not observed&#46; No granulomas were observed&#44; and patches of interstitial fibrosis and tubular atrophy&#44; which together accounted for 10&#37; of the cylinder&#44; were identified&#46; Two interlobular arteries without morphological changes were identified&#46; Immunofluorescence assays using anti-IgG&#44; IgA&#44; IgM and C1q&#44; C3&#44; kappa and lambda sera were negative&#46; Pulmonary histology samples obtained by fibrobronchoscopy and transbronchial biopsy showed the presence of a non-caseating granuloma&#46;</p><p class="elsevierStylePara">Sarcoidosis was diagnosed and prednisone was administered&#44; starting with a dose of 1mg&#47;kg body weight and progressively reducing the dose from the first month onwards&#46; After three months&#44; the constitutional syndrome disappeared&#44; progressive weight gain was achieved and renal function improved significantly &#40;creatinine 1&#46;3mg&#47;dl and eGFR 58&#46;8ml&#47;m&#41;&#46; The patient&#8217;s calcaemia &#40;calcium 8&#46;9mg&#47;dl&#41; and anaemia &#40;Hb 13&#46;0mg&#47;dl&#41; were corrected and his iPTH &#40;32pg&#47;ml&#41; and ACE &#40;13U&#47;l&#41; levels were normal&#46;</p><p class="elsevierStylePara">Sarcoidosis is a multi-systemic disease of unknown aetiology and the pulmonary and lymphatic systems are the most commonly affected &#40;30&#37;-60&#37; of cases&#41;&#46; Hypercalcaemia &#40;2&#37;-10&#37;&#41; and hypercalciuria &#40;6&#37;-30&#37;&#41; can cause nephrocalcinosis&#44; lithiasis and renal insufficiency&#46; The prevalence of tubulo-interstitial nephritis ranges from 7&#37; to 27&#37;&#44; although chronic renal failure develops in less than 1&#37; of cases&#44; according to a number of retrospective studies&#46;<span class="elsevierStyleSup">2</span> Sarcoidosis patients often have high levels of vitamin D and ACE&#44; which are synthesised by the epithelioid cells of the granuloma&#46;<span class="elsevierStyleSup">3&#44;4 </span>In the case that we present the clinico-radiological involvement was minimal and the diagnosis was confirmed by transbronchial biopsy&#46; The analytical profile was indicative of sarcoidosis &#40;hypercalcaemia&#44; hypercalciuria&#44; high levels of vitamin D and ACE and substantial iPTH suppression&#41;&#46;</p><p class="elsevierStylePara">Renal function impairment in sarcoidosis is generally due to hypercalcaemia&#44; hypercalciuria and nephrocalcinosis&#44; although nephrolithiasis&#44; glomerulopathies and interstitial nephritis &#40;with or without sarcoid granuloma&#41; form part of the spectrum of renal pathologies in sarcoidosis&#46;<span class="elsevierStyleSup">1 </span></p><p class="elsevierStylePara">Corticosteroids<span class="elsevierStyleSup">5</span> are the treatment of choice and in the case presented here a good response was obtained&#46; Renal involvement without the lungs being affected is very rare<span class="elsevierStyleSup">2</span> and in this case it was not possible to establish that this was the case until the lung biopsy was performed&#46; When we are faced with a case of renal failure associated with hypercalcaemia&#44; sarcoidosis should be suspected&#44; even though there is no clinical manifestation of lung pathology&#46;</p>"
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