Acute renal failure in patient treated with anti-tumour necrosis factor alpha
Fracaso renal agudo en paciente tratado con antifactor de necrosis tumoral-alfa
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Justo Ávila, C. Gracia Iguacel, A. Ortiz Arduán, C. Martín-Cleary, M. Acuña Ramos, V. Sainz Prestel, L. Rodríguez-Osorio, A. Barat Cascante, C. Santonja, J. Egido" "autores" => array:10 [ 0 => array:4 [ "Iniciales" => "P." "apellidos" => "Justo Ávila" "email" => array:1 [ 0 => "pjusto83@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 1 => array:3 [ "Iniciales" => "C." "apellidos" => "Gracia Iguacel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 2 => array:3 [ "Iniciales" => "A." "apellidos" => "Ortiz Arduán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] 3 => array:3 [ "Iniciales" => "C." 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"apellidos" => "Egido" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Nefrología, ISS-Fundación Jiménez Díaz, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "affa" ] 1 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, ISS-Fundación Jiménez Díaz, Madrid, " "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "affb" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fracaso renal agudo en paciente tratado con antifactor de necrosis tumoral-alfa" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10978_108_19082_en_t1.jpg" "Alto" => 114 "Ancho" => 600 "Tamanyo" => 70223 ] ] "descripcion" => array:1 [ "en" => "Evolution of renal function prior to hospital admission" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">CASE REPORT</span></p><p class="elsevierStylePara">Woman aged 58 years, with history of depressive syndrome and lumbar canal stenosis. Diagnosed with B27 positive ankylosing spondylitis in 2005 and treated with adalimumab since 2008. Before treatment was started, a positive Mantoux test made it necessary to perform prophylaxis with isoniazid for nine months. Her regular medication included nonsteroidal anti-inflammatory drugs, tramadol, antidepressants and proton pump inhibitors.</p><p class="elsevierStylePara">During a routine rheumatology review, a significant deterioration in renal function was discovered and she was referred to a nephrologist for assessment. The patient was asymptomatic. The initial physical examination did not reveal oedema, no lateral cervical or retroauricular adenopathy were palpable and cardiopulmonary auscultation was normal.</p><p class="elsevierStylePara">Given the laboratory findings (Table 1), a renal ultrasound was performed in which the kidneys were observed to be 10cm and 12cm, respectively, with good corticomedullary differentiation. There were no data on ureterolithiasis or pyelocaliceal dilation. Hypodense lesions in the spleen suggested possible lymphomatous involvement and the patient was admitted for further studies.</p><p class="elsevierStylePara">Thoracic-abdominopelvic computed tomography (CT) highlighted the presence of multiple pulmonary nodules (predominantly in the upper lobes in a peribronchovascular pattern) and mediastinal adenopathies. There were no splenic lesions.</p><p class="elsevierStylePara">A cervical adenopathy biopsy was performed in which epithelioid granulomatous inflammation was observed with extensive caseous necrosis (Figure 1). A few bacilli were observed in the Ziehl-Nielsen stain (Figure 2).</p><p class="elsevierStylePara">Given these findings, a fibrobronchoscopy was performed, which did not reveal any macroscopic lesions in the airway. Bronchoalveolar lavage showed a moderate amount of lymphocytes. Bronchial lavage was negative and a transbronchial fine needle aspiration of a mediastinal adenopathy identified granulomas. Ziehl stain was initially reported as negative, but a second observation noted a single acid-alcohol resistant bacillus. After fibrobronchoscopy, a gamma interferon release assay for tuberculosis (QuantiFERON®) was performed, which was positive. Based on these tests, a decision was made to start treatment for tuberculosis.</p><p class="elsevierStylePara">As part of the nephrology study, antinuclear antibodies (ANA), anticytoplasmic neutrophil antibodies (ANCA), anti-ADN antibodies and anti-glomerular basement membrane antibodies were negative. Viral serology was negative for the human immunodeficiency and hepatitis B and C viruses. The complement was normal. Urine tests initially showed a microalbuminuria/creatininuria index of 261.9mg/g and proteinuria/creatininuria of 1.1 with no nephrotic syndrome. The only information of note in the proteinogram was the monoclonal IgM peak, with a serum level of 305mg/dl, and negative urinary light chains.</p><p class="elsevierStylePara">During her evolution in hospital, the patient presented sustained hypertension without evidence of fluid overload or other noteworthy symptoms.</p><p class="elsevierStylePara">Given the clinical (severe renal failure), radiological (kidneys of normal size and echostructure) and laboratory findings (anaemia, proteinuria and microscopic haematuria), a renal biopsy was performed in which interstitial inflammation at the expense of lymphocytes was detected, accompanied by histiocytes, which formed granulomas at several points (Figure 2 and 3). One of these contained multinucleated Langhans giant cells. Glomeruli were normal. Granular material occupied the tubules and the epithelium was flattened. There were no microorganisms in the PAS or Ziehl-Nielsen stain.</p><p class="elsevierStylePara">After performing the renal biopsy, the patient was discharged with treatment of prednisone at a dosage of 40mg/day, erythropoietin and complete tuberculosis treatment (rifampicin, isoniazid, ethambutol and pyrazinamide).</p><p class="elsevierStylePara">The patient progressed slowly but showed continuous improvement in renal function (Table 2). Her anaemia persisted along with the high erythropoietin requirements, hypertension treated with two drugs, and hyperuricaemia, which resolved with allopurinol.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">We were faced with grade III nonoliguric renal failure as per the AKIN classification (Acute Kidney Injury Network) and loss of RIFLE classification (Risk, Injury, Failure, Loss and End stage renal disease).</p><p class="elsevierStylePara">1. Based on the clinical picture, initial differential diagnosis was established between the most common renopulmonary syndromes: <span class="elsevierStyleItalic">ANCA-associated systemic vasculitis </span>(Wegener's granulomatosis, Churg-Strauss syndrome and microscopic polyangiitis), <span class="elsevierStyleItalic">Goodpasture's syndrome</span>, <span class="elsevierStyleItalic">systemic lupus erythematosus</span>, <span class="elsevierStyleItalic">sarcoidosis</span> and <span class="elsevierStyleItalic">systemic infections.</span></p><p class="elsevierStylePara">2. The following differential diagnosis was established based on the renal biopsy:</p><p class="elsevierStylePara">a) Acute tubulointerstitial nephritis secondary to drugs related to the dense lymphocytic infiltrate. The patient took NSAIDs from the start, but did not have cutaneous exanthema, fever, eosinophilia or eosinophiluria.</p><p class="elsevierStylePara">b) Renal sarcoidosis and sarcoidosis-like syndrome, due to the presence of non-caseous granulomas in the biopsy. Although it has been reported in patients treated with adalimumab, it cannot be definitively ruled out since, in our case, a PCR of the<span class="elsevierStyleItalic"> Koch’s bacillus </span>DNA was not performed in the renal biopsy, nor were there any acid-alcohol resistant bacilli. In addition, there were no clinical data for other organs that justified a diagnosis of sarcoidosis with parotid, ocular or bilateral parahilar mediastinal adenopathy involvement.<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">c) Tuberculosis with granulomatous interstitial involvement (our primary hypothesis). Included in the histological data of the biopsy supporting this hypothesis is the presence of Langhans cell granulomas, although caseous necrosis was not observed. The absence of acid-alcohol resistant bacilli in the renal biopsy and the lack of PCR of the sample prevents us from concluding that granulomatous interstitial nephritis due to tuberculosis was the definite diagnosis.<span class="elsevierStyleSup">2</span> However, the clinical picture of pulmonary tuberculosis and caseous necrosis in the cervical adenopathy biopsy almost certainly confirm the diagnosis. </p><p class="elsevierStylePara">Clinically, patients with this condition have problems characteristic of urinary tract infection, sterile pyuria and renal failure. The presence of tubulointerstitial nephritis is common in renal biopsies.<span class="elsevierStyleSup">3</span> The existence of mycobacteria in the kidney can be seen by auramine stain (mycobacteria stains), although its sensitivity is low (32%-43%). PCR for detecting <span class="elsevierStyleItalic">Koch’s bacillus </span>in urine has high sensitivity (from 84% to 95%) and specificity (from 85% to 98%). In contrast, renal biopsy PCR, due to inclusion in paraffin, has low sensitivity and specificity. These tests do not preclude culture in Lowenstein-Jensen medium for evaluating antibiotic sensitivity.<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Tuberculous interstitial nephritis has a poor prognosis. In a review of a follow-up study of 25 patients over 10 years, 17 had an estimated glomerular filtration rate (eGFR) of less than 15ml/min at the time of presentation, and 11 of the patients required renal replacement therapy for the first 12 months of follow-up. In the eight patients with eGFR greater than 15ml/min, renal function stabilisation was observed in the first two years of follow-up after initiating tuberculosis treatment. At two years, they had progressive deterioration related to tubular and glomerular atrophy. Despite these data, there was no significant relationship between the degree of improvement and renal function and the initial proteinuria of each patient.<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara"><span class="elsevierStyleBold">CONCLUSIONS</span></p><p class="elsevierStylePara">Systemic infections, in particular those caused by mycobacteria and fungi, should be considered in the differential diagnosis of pulmonary and renal involvement in immunocompromised patients. The second most frequent extrapulmonary location for tuberculosis is the genitourinary system. Tuberculosis may involve the kidney as the localised organ or as a component of the haematogenous spread of mycobacteria. We believe that anti-tumour necrosis factor alpha (anti-TNF-α) immunosuppression favoured the reactivation of tuberculosis. An increase in lethal infection rates and the possibility of developing lymphomas and extrapulmonary tuberculosis have been reported among the side effects of adalimumab.<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">Granulomatous interstitial nephritis is an infrequent cause of renal failure. It has a non-specific presentation and clinical diagnosis is not easy.<span class="elsevierStyleSup">7</span> Nephritis is attributable to the involvement of tubercle bacillus, although sarcoidosis-like syndrome secondary to the use of anti-TNF-α antibodies cannot be ruled out.</p><p class="elsevierStylePara">Combination therapy using antituberculosis drugs and steroids with a decreasing dosing regimen has shown clinical improvement in patient outcomes.</p><p class="elsevierStylePara">Despite this positive outcome and given the history in the literature,<span class="elsevierStyleSup">8</span> it is not possible to predict the prognosis for patient renal survival in the medium to long term before requiring renal replacement therapy.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">QUESTIONS</span></p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Dr. Julia Blanco (Madrid</span>). The observation of a single Ziehl positive bacillus in the lymph node biopsy and the appearance of caseous necrosis are sufficiently conclusive with the tuberculous etiology. However, did you consider PCR analysis for tuberculosis bacilli in paraffin material to confirm it beyond doubt?</p><p class="elsevierStylePara">Answer. PCR analyses of <span class="elsevierStyleItalic">Koch’s bacillus</span> were established as a confirmatory test for the presence of bacillus in the renal biopsy. Despite this, the PCR of samples included in paraffin significantly reduces its sensitivity and specificity. Therefore, in the end, we decided against performing the test.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Dr. Xavier Fulladosa (Barcelona).</span> In this type of tuberculous interstitial nephritis after reactivation in an immunocompromised patient, why did you not consider treating the tuberculosis with only antituberculosis agents without steroids?</p><p class="elsevierStylePara">Answer. It was not considered due to the significant interstitial inflammatory component and the severe deterioration in renal function. With renal inflammatory involvement, the use of antituberculosis agents as the only treatment seemed to us insufficient at the start. Therefore, we started steroid therapy at 1mg/kg of body weight, which resulted in significant initial improvement, so we maintained a decreasing dose regimen.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Dr. Adoración Martín-Gómez (Almería).</span> About the isoniazid prophylaxis, why was it maintained for only two months instead of the minimum six? My second observation is that the finding of a second negative Mantoux is of little use regarding the intention to treat.</p><p class="elsevierStylePara">Answer. Looking back on the medical history and confirming it with rheumatology, the patient received a total of nine months of prophylactic treatment. The prophylaxis commonly used in immunosuppressed patients is six to nine months of isoniazid or four months of rifampicin. The Mantoux variation in this clinical case has no importance given the radiological, pathological and clinical findings. Nevertheless, we only wanted to highlight this as a potential confounding factor. </p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Dr. Ana Alexandra (Madrid).</span> In terms of the sarcoidosis-like management in the differential diagnosis, what were the difficulties in choosing between tuberculosis and sarcoidosis?</p><p class="elsevierStylePara">Answer. Actually the patient's symptoms were very indicative of tuberculosis; however the non-caseous granulomas in the biopsy and the mediastinal adenopathies may have resulted in a possible diagnostic error. The patient's extrarenal symptoms (she did not present uveitis or parotid involvement) partially provided us with the final diagnosis with microbiological confirmation.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Dr. Manuel Praga (Madrid).</span> It seems that the importance of early treatment in tubulointerstitial nephritis has been established to achieve good results in renal function recovery. Why the almost two month delay in this patient?</p><p class="elsevierStylePara">Answer. The initial renal function impairment that was observed in January 2010 (Table 1) was attributed to possible functional factors in the context of community-acquired pneumonia, which was treated with broad-spectrum antibiotics. This datum was the main reason for the delay in diagnosis, which favoured significant renal function impairment.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Dr. Miguel Ángel Frutos (Malaga). </span>Was the poor expression of urinary sediment at the time of diagnosis of urinary tuberculosis not surprising in this patient?</p><p class="elsevierStylePara">Answer. Yes, this patient's sediment was fairly unremarkable. We found it interesting that the patient did not present eosinophiluria, which was justified upon treatment of chronic interstitial nephritis. The absence of leukocyte cylinders also surprised us. Similarly, the quantity of erythrocytes and leukocytes in urine, which are expected with such a significant renal involvement, would be much greater (Table 1).</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Dr. Mario Espinosa (Cordoba</span>). What role did paraproteinaemia play in this patient?</p><p class="elsevierStylePara">Answer. Paraproteinaemia was exclusively serendipitous in this clinical case. She was diagnosed with monoclonal gammopathy of undetermined significance without any renal expression.</p><p class="elsevierStylePara"><span class="elsevierStyleItalic">Dr. Francisco Rivera (Ciudad Real</span>). When was treatment with adalimumab suspended? How much time elapsed between the suspension of adalimumab and the renal biopsy?</p><p class="elsevierStylePara">Answer. Treatment with adalimumab was suspended once renal function impairment was observed. The time elapsed between the last dose of adalimumab (Humira 40mg) received and the renal biopsy was 24 days.</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Acknowledgements</span></p><p class="elsevierStylePara">This case was selected in the <span class="elsevierStyleItalic">IV Reunión del Grupo de Enfermedades Glomerulares</span> (IV Meeting of the Glomerular Diseases Group) of the <span class="elsevierStyleItalic">Sociedad Española de Nefrología</span> (Spanish Society of Nephrology, S.E.N.) (GLOSEN) for publication in <span class="elsevierStyleItalic">Nefrología</span> (Nephrology) (Madrid, March 31 to April 2, 2011), thanks to the special sponsorship of Novartis.</p><p class="elsevierStylePara"><a href="grande/10978_108_19082_en_t1.jpg" class="elsevierStyleCrossRefs"><img src="10978_108_19082_en_t1.jpg" alt="Evolution of renal function prior to hospital admission"></img></a></p><p class="elsevierStylePara">Table 1. Evolution of renal function prior to hospital admission</p><p class="elsevierStylePara"><a href="grande/10978_108_19083_en_t2.jpg" class="elsevierStyleCrossRefs"><img src="10978_108_19083_en_t2.jpg" alt="Evolution of renal function during hospitalisation and at consultation"></img></a></p><p class="elsevierStylePara">Table 2. Evolution of renal function during hospitalisation and at consultation</p><p class="elsevierStylePara"><a href="grande/10978_108_19084_en_f1.jpg" class="elsevierStyleCrossRefs"><img src="10978_108_19084_en_f1.jpg" alt="Extensive caseous necrosis foci in the right supraclavicular lymph node biopsy"></img></a></p><p class="elsevierStylePara">Figure 1. Extensive caseous necrosis foci in the right supraclavicular lymph node biopsy</p><p class="elsevierStylePara"><a href="grande/10978_108_19085_en_f2.jpg" class="elsevierStyleCrossRefs"><img src="10978_108_19085_en_f2.jpg" alt="Detection of a bacillus in the Ziehl-Nielsen stain of the lymph node biopsy"></img></a></p><p class="elsevierStylePara">Figure 2. Detection of a bacillus in the Ziehl-Nielsen stain of the lymph node biopsy</p><p class="elsevierStylePara"><a href="grande/10978_108_19086_en_f3.jpg" class="elsevierStyleCrossRefs"><img src="10978_108_19086_en_f3.jpg" alt="Interstitial lymphocytic infiltrate and epithelioid granuloma in the renal biopsy"></img></a></p><p class="elsevierStylePara">Figure 3. Interstitial lymphocytic infiltrate and epithelioid granuloma in the renal biopsy</p><p class="elsevierStylePara"><a href="grande/10978_108_19087_en_f4.jpg" class="elsevierStyleCrossRefs"><img src="10978_108_19087_en_f4.jpg" alt="Detail of the interstitial infiltrate"></img></a></p><p class="elsevierStylePara">Figure 4. Detail of the interstitial infiltrate</p>" "tienePdf" => false "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Tab. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10978_108_19082_en_t1.jpg" "Alto" => 114 "Ancho" => 600 "Tamanyo" => 70223 ] ] "descripcion" => array:1 [ "en" => "Evolution of renal function prior to hospital admission" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Tab. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10978_108_19083_en_t2.jpg" "Alto" => 166 "Ancho" => 600 "Tamanyo" => 94282 ] ] "descripcion" => array:1 [ "en" => "Evolution of renal function during hospitalisation and at consultation" ] ] 2 => array:8 [ "identificador" => "fig3" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10978_108_19084_en_f1.jpg" "Alto" => 439 "Ancho" => 600 "Tamanyo" => 202135 ] ] "descripcion" => array:1 [ "en" => "Extensive caseous necrosis foci in the right supraclavicular lymph node biopsy" ] ] 3 => array:8 [ "identificador" => "fig4" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10978_108_19085_en_f2.jpg" "Alto" => 443 "Ancho" => 600 "Tamanyo" => 169280 ] ] "descripcion" => array:1 [ "en" => "Detection of a bacillus in the Ziehl-Nielsen stain of the lymph node biopsy" ] ] 4 => array:8 [ "identificador" => "fig5" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10978_108_19086_en_f3.jpg" "Alto" => 434 "Ancho" => 600 "Tamanyo" => 335842 ] ] "descripcion" => array:1 [ "en" => "Interstitial lymphocytic infiltrate and epithelioid granuloma in the renal biopsy" ] ] 5 => array:8 [ "identificador" => "fig6" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "10978_108_19087_en_f4.jpg" "Alto" => 449 "Ancho" => 600 "Tamanyo" => 331059 ] ] "descripcion" => array:1 [ "en" => "Detail of the interstitial infiltrate" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Korsten P, Sweiss NJ, Nagorsnik U. Drug-induced granulomatous interstitial nephritis in a patient with ankylosing spondylitis during therapy with adalimumab. Am J Kidney Dis 2010;56:17-21." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Nasr SH,\u{A0}Koscica J. Granulomatous interstitial nephritis. Am J Kidney Dis 2003;41:714-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12612999" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Eastwood JB, Corbishley CM, Grange JM. Tuberculosis and the kidney. J Am Soc Nephrol 2001;12:1307-14. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11373356" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 3 => array:3 [ "identificador" => "bib4" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "4.\u{A0}Larsen CP. Kidney biopsy findings in a patient with fever, bilateral pulmonary infiltrates and acute renal failure. Am J Kidney Dis 2008;51:524-9. <a href="http://www.ncbi.nlm.nih.gov/pubmed/18295069" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 4 => array:3 [ "identificador" => "bib5" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Chapagain A, Dobbie H, Sheaff M, Yaqoob MM. Presentation, diagnosis, and treatment outcome of tuberculous-mediated tubulointerstitial nephritis. Kidney Int 2011;79:671-7. <a href="http://www.ncbi.nlm.nih.gov/pubmed/21160461" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 5 => array:3 [ "identificador" => "bib6" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Van der Heijde D, Kivitz A, Schiff MH, ATLAS Study Group. Efficacy and safety of adalimumab in patients with ankylosing spondylitis: results of a multicenter, randomized, double-blind, placebo-controlled trial. Arthritis Rheum 2006;54:2136-46. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16802350" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 6 => array:3 [ "identificador" => "bib7" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Javaud N, Belenfant X, Stirnemann J. Renal granulomatoses: a retrospective study of 40 cases and review of the literature. Medicine (Baltimore) 2007;86:170-80." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 7 => array:3 [ "identificador" => "bib8" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Bijol V, Mendez GP, Nosé V, Rennke HG. Granulomatous interstitial nephritis: a clinicopathologic study of 46 cases from a single institution. Int J Surg Pathol 2006;14:57-63. <a href="http://www.ncbi.nlm.nih.gov/pubmed/16501836" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/20132514/0000003100000004/v0_201502091636/X2013251411052185/v0_201502091637/en/main.assets" "Apartado" => array:4 [ "identificador" => "35423" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case Reports from Nephropathology Club " "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/X2013251411052185?idApp=UINPBA000064" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 9 | 0 | 9 |
| 2024 October | 92 | 0 | 92 |
| 2024 September | 90 | 0 | 90 |
| 2024 August | 99 | 0 | 99 |
| 2024 July | 67 | 0 | 67 |
| 2024 June | 101 | 0 | 101 |
| 2024 May | 121 | 0 | 121 |
| 2024 April | 85 | 0 | 85 |
| 2024 March | 64 | 2 | 66 |
| 2024 February | 69 | 13 | 82 |
| 2024 January | 71 | 12 | 83 |
| 2023 December | 55 | 8 | 63 |
| 2023 November | 91 | 11 | 102 |
| 2023 October | 64 | 11 | 75 |
| 2023 September | 90 | 17 | 107 |
| 2023 August | 89 | 11 | 100 |
| 2023 July | 138 | 11 | 149 |
| 2023 June | 77 | 10 | 87 |
| 2023 May | 90 | 11 | 101 |
| 2023 April | 56 | 5 | 61 |
| 2023 March | 94 | 12 | 106 |
| 2023 February | 83 | 13 | 96 |
| 2023 January | 103 | 15 | 118 |
| 2022 December | 83 | 22 | 105 |
| 2022 November | 146 | 20 | 166 |
| 2022 October | 104 | 249 | 353 |
| 2022 September | 98 | 14 | 112 |
| 2022 August | 103 | 25 | 128 |
| 2022 July | 86 | 10 | 96 |
| 2022 June | 116 | 16 | 132 |
| 2022 May | 88 | 12 | 100 |
| 2022 April | 110 | 18 | 128 |
| 2022 March | 86 | 18 | 104 |
| 2022 February | 116 | 20 | 136 |
| 2022 January | 96 | 29 | 125 |
| 2021 December | 86 | 45 | 131 |
| 2021 November | 111 | 12 | 123 |
| 2021 October | 155 | 16 | 171 |
| 2021 September | 102 | 18 | 120 |
| 2021 August | 107 | 12 | 119 |
| 2021 July | 101 | 20 | 121 |
| 2021 June | 108 | 12 | 120 |
| 2021 May | 109 | 17 | 126 |
| 2021 April | 213 | 18 | 231 |
| 2021 March | 181 | 36 | 217 |
| 2021 February | 174 | 23 | 197 |
| 2021 January | 111 | 20 | 131 |
| 2020 December | 106 | 11 | 117 |
| 2020 November | 91 | 11 | 102 |
| 2020 October | 80 | 11 | 91 |
| 2020 September | 109 | 5 | 114 |
| 2020 August | 97 | 10 | 107 |
| 2020 July | 92 | 11 | 103 |
| 2020 June | 121 | 21 | 142 |
| 2020 May | 101 | 11 | 112 |
| 2020 April | 93 | 16 | 109 |
| 2020 March | 93 | 16 | 109 |
| 2020 February | 132 | 14 | 146 |
| 2020 January | 136 | 16 | 152 |
| 2019 December | 121 | 18 | 139 |
| 2019 November | 107 | 11 | 118 |
| 2019 October | 82 | 4 | 86 |
| 2019 September | 106 | 13 | 119 |
| 2019 August | 88 | 12 | 100 |
| 2019 July | 139 | 15 | 154 |
| 2019 June | 103 | 10 | 113 |
| 2019 May | 121 | 1 | 122 |
| 2019 April | 170 | 15 | 185 |
| 2019 March | 77 | 16 | 93 |
| 2019 February | 82 | 9 | 91 |
| 2019 January | 81 | 14 | 95 |
| 2018 December | 166 | 28 | 194 |
| 2018 November | 157 | 16 | 173 |
| 2018 October | 162 | 30 | 192 |
| 2018 September | 140 | 19 | 159 |
| 2018 August | 105 | 13 | 118 |
| 2018 July | 85 | 9 | 94 |
| 2018 June | 81 | 12 | 93 |
| 2018 May | 92 | 9 | 101 |
| 2018 April | 71 | 11 | 82 |
| 2018 March | 56 | 7 | 63 |
| 2018 February | 81 | 9 | 90 |
| 2018 January | 65 | 5 | 70 |
| 2017 December | 77 | 11 | 88 |
| 2017 November | 72 | 10 | 82 |
| 2017 October | 56 | 11 | 67 |
| 2017 September | 60 | 8 | 68 |
| 2017 August | 45 | 5 | 50 |
| 2017 July | 57 | 10 | 67 |
| 2017 June | 60 | 8 | 68 |
| 2017 May | 90 | 4 | 94 |
| 2017 April | 57 | 2 | 59 |
| 2017 March | 58 | 2 | 60 |
| 2017 February | 205 | 9 | 214 |
| 2017 January | 55 | 5 | 60 |
| 2016 December | 82 | 4 | 86 |
| 2016 November | 140 | 5 | 145 |
| 2016 October | 228 | 11 | 239 |
| 2016 September | 295 | 7 | 302 |
| 2016 August | 230 | 0 | 230 |
| 2016 July | 223 | 0 | 223 |
| 2016 June | 130 | 0 | 130 |
| 2016 May | 129 | 0 | 129 |
| 2016 April | 119 | 0 | 119 |
| 2016 March | 95 | 0 | 95 |
| 2016 February | 124 | 0 | 124 |
| 2016 January | 114 | 0 | 114 |
| 2015 December | 128 | 0 | 128 |
| 2015 November | 99 | 0 | 99 |
| 2015 October | 99 | 0 | 99 |
| 2015 September | 88 | 0 | 88 |
| 2015 August | 86 | 0 | 86 |
| 2015 July | 100 | 0 | 100 |
| 2015 June | 42 | 0 | 42 |
| 2015 May | 62 | 0 | 62 |
| 2015 April | 10 | 0 | 10 |
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