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who initiated urgent haemodialysis in the intensive care unit due to fluid overload&#44; along with a cardiac tamponade that required evacuative pericardiocentesis&#46; The patient&#8217;s medical history included&#58; high blood pressure&#44; asymmetrical renal ultrasound &#40;right kidney&#58; 117mm vs left kidney&#58; 96mm&#41;&#44; atrial fibrillation&#44; chronic degenerative vascular encephalopathy with long-term thalamic haematoma caused by anticoagulation with dicoumarin derivatives&#44; monoclonal gammopathy with mild anaemia and thrombocytopenia&#44; urticaria-angiooedema with sensitivity to anisakis and intolerance to NSAIDs&#44; recurrent respiratory infections with chronic bronchial disease&#44; negative coagulopathy screening study&#44; and unconfirmed findings of a weakly positive lupus anticoagulant&#46; As for his clinical condition&#44; uraemic symptoms upon hospitalisation &#8211; from the first dialysis session and despite meeting the quality standards of the dialysis fluid &#40;ultrapure water&#58; &#60;0&#46;1CFU&#47;ml&#44; &#60;0&#46;03EU&#47;ml endotoxin&#41; &#8211; were accompanied by frequent episodes of hypersensitivity &#40;HPS&#41; type A in the form of hypotension and angioedema with poor response to prophylactic steroid therapy&#44; changes in heparin prescription&#44; dialyser change &#40;polysulfone 1&#46;8m<span class="elsevierStyleSup">2</span> sterilised with in line steam&#44; polyarylethersulfone-polyamide 2&#46;1m<span class="elsevierStyleSup">2</span> sterilised with gamma rays&#44; polyacrylonitrile 2&#46;15m<span class="elsevierStyleSup">2</span> sterilised with gamma rays&#44; heparinised Hephran 1&#46;65m<span class="elsevierStyleSup">2</span> sterilised with gamma rays&#44; etc&#46;&#41; and even transition from on-line haemodiafiltration to high-flow haemodialysis&#46; This simultaneously hindered giving appropriate renal replacement therapy&#44; and constituted an obstacle to the recovery of the patient&#44; which was delayed for several weeks&#46;</p><p class="elsevierStylePara">The additional tests required for the evaluation of the overall process and HPS were&#58;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Pre-dialysis biochemistry&#58;</span> glucose&#58; 70mg&#47;dl&#59; urea&#58; 159mg&#47;dl&#59; creatinine&#58; 7&#46;9mg&#47;dl&#59; calcium&#58; 8mg&#47;dl&#59; rheumatoid factor&#58; 11&#46;9IU&#47;ml&#59; total protein&#58; 6&#46;5g&#47;dl&#59; proteinuria in 24-hour urine sample&#58; 835mg&#47;l&#59; and Bence-Jones proteinuria&#58; negative&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Haemogram&#58;</span> leukocytes&#58; 10030&#47;&#956;l &#40;polymorphonuclear&#58; 84&#46;8&#37;&#59; lymphocytes&#58; 6&#46;6&#37;&#59; monocytes&#58; 5&#46;4&#37;&#59; eosinophils&#58; 2&#37;&#59; basophils&#58; 0&#46;1&#37;&#41;&#59; haemoglobin&#58; 8&#46;6mg&#47;dl &#40;average cell volume&#58; 91&#46;7&#41;&#59; platelets&#58; 261&#44;000&#47;&#956;l&#59; direct Coombs&#58; negative&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Immunity&#58;</span> antinuclear antibodies and antineutrophil cytoplasmic antibody&#58; negative&#59; C3&#47;C4&#58; 123&#47;33&#46;9mg&#47;dl&#44; lupus anticoagulant&#58; &#40;-&#41;&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Serology&#58;</span> HbsAc-HbcAc&#58; &#40;&#43;&#41;&#59; hepatitis C virus&#58; &#40;-&#41;&#59; human immunodeficiency virus&#58; &#40;-&#41;&#59; negative syphilis&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Tumour markers&#58;</span> negative&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Electrophoresis&#58;</span> albumin&#58; 52&#46;1&#37; &#40;&#8595;&#41;&#59; gamma-globulins&#58; 19&#46;7&#37; &#40;&#8593;&#41;&#59; albumin &#47; globulin&#58; 1&#46;09&#37;&#44; with no monoclonal component&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Immunoglobulin&#58; </span>IgG&#58; 1412mg&#47;dl&#59; IgM&#58; 121mg&#47;dl&#59; and IgA&#58; 0mg&#47;dl&#46;</p><p class="elsevierStylePara">As to <span class="elsevierStyleBold">specific allergy tests&#44;</span> there was a very high total IgE &#40;394KU&#47;L&#41;&#44; with negative tests for chloramines&#44; latex of the extracorporeal circuit&#44; and ethylene oxide&#47;formaldehyde used as sterilisers&#46;</p><p class="elsevierStylePara">Finally&#44; and due to the suspected link between the allergic&#47;thrombogenic tendency of the patient&#44; the selective IgA humoral immunodeficiency and HPS manifested during dialysis&#44; it was decided to also request specialised assessment from the haematology department&#44; which excluded any spinal or immunological process different from that observed&#46; However&#44; ambulatory analysis of lymphocyte subpopulations provided new results&#58; total lymphocyte count&#58; 1172&#47;&#956;l &#40;0&#46;9 to 5&#46;2x10<span class="elsevierStyleSup">3</span>&#47;&#181;l&#41;&#59; CD3-T&#58; 889 cells&#47;&#181;l 75&#37; &#40;58&#37;-87&#37;&#41;&#59; CD3-CD4&#43;&#58; 52&#37; &#40;32&#37;-62&#37;&#41;&#59; CD3-CD8&#43;&#58; 19&#37; &#40;12&#37;-45&#37;&#41;&#59; CD4&#47;CD8 ratio&#58; 2&#46;7 &#40;0&#46;8 to 4&#46;5&#41;&#59; CD19-B&#58; 92 cells&#47;ml 7&#37; &#40;7&#37;-23&#37;&#41;&#59; and CD16-NK&#58; 15&#37; &#40;4&#37;-27&#37;&#41;&#46;</p><p class="elsevierStylePara">Thus&#44; having excluded other causes of combined or secondary immunodeficiency&#44; the final diagnosis was established&#58; selective IgA deficiency linked to an allergic substrate with a tendency towards lymphocytopenia&#44; normal CD4&#47;CD8 ratio&#44; and relative decline in B lymphocytes&#46; The clinical expression of the patient&#8217;s condition was not consistent with a reaction to latex&#44; bio-incompatible membranes&#44; or bradykinin release due to ethylene oxide&#46;<span class="elsevierStyleSup">3-5 </span>In contrast&#44; its relationship with the IgE-mediated HPS was obvious&#46; For that reason&#44; the most plausible pathophysiological hypothesis for the manifestation of these symptoms was&#58; 1&#41; IgA deficiency caused initial antigenic overstimulation of CD4 T-cells&#44; responsible for the activation of C3-CD8 and CD19-B lymphocytes&#44; and as a result&#44; the activation of cellular and humoral immunity<span class="elsevierStyleSup">6</span>&#59; 2&#41; there was an abnormal maturation of B clones&#44; responsible for the synthesis of IgA&#44; hence the relative deficit of CD19-B in our patient&#59; however&#44; this was not the case of other immunoglobulins such as IgE&#44; which promote immediate mast cell degranulation when coming into contact with the antigenic factor<span class="elsevierStyleSup">7&#44;8</span>&#59; and 3&#41; there was a tendency to develop infections and autoimmune mechanisms in these patients&#44; where the uncontrolled external antigenaemia by IgA dimers was capable of inducing a direct cytotoxic response or a response mediated by Ag-Ac complexes&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">In this area of immunopathology&#44; the proposed treatment was directed primarily at inhibiting the reaction of the extracorporeal blood-circuit interface&#44; for which clinical experiences in the literature on pH-metric modulation of intradialytic anaphylaxis were reviewed&#46;<span class="elsevierStyleSup">9 </span>This was used to establish a screening protocol for patients with 1&#47;6M-bicarbonate bloodlines &#40;prior to connection during each session&#41; resulting from the onset in an alkalising effect that resolved the episodes of angioedema and haemodynamic instability&#46; Secondly&#44; we also adopted other therapeutic and hygiene measures for the prevention of infectious complications in the patient&#44; such as the creation of an arteriovenous fistula&#44; which was preferable over the central venous catheter that was being used&#44; or even the early administration of antibiotic therapy in the case of respiratory infection&#46; However&#44; we did not consider correcting the IgA deficiency with exogenous immunotherapy&#44; as severe cases of HPS secondary to the formation of anti-IgA antibodies have been described&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare no conflict of interest related to the content of this article&#46;</p>"
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Selective immunoglobulin A deficit in a haemodialysis patient
Déficit selectivo de inmunoglobulina A en paciente en hemodiálisis
María Peña-Ortegaa, Carlos Mañero-Rodrígueza, Elena Borrego-Garcíaa, Antonio Navas-Parejo Casadoa, Sebastián Cerezo-Moralesa
a Servicio de Nefrología, Hospital Universitario San Cecilio, Granada,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">Selective deficit of immunoglobulin A &#40;IgA&#41; is one of the most common primary immunodeficiencies&#44; and complicates the humoral defence system against infections that commonly enter the body via different mucous membranes&#46; Its clinical spectrum is broad and ranges from nondescript symptoms &#40;recurring ear&#44; respiratory or gastrointestinal conditions&#41; to severe invasive complications or even autoimmune disease &#40;20&#37;-30&#37; of all cases&#41;&#46; Another class of common manifestations in these patients are food allergies&#44; asthma or post-transfusion allergies &#40;10&#37;-15&#37; of the total&#41;&#46;<span class="elsevierStyleSup">1&#44;2</span></p><p class="elsevierStylePara">In this singular pathogenic context &#40;which has a variable incidence of 1&#58;100-1&#58;1000 individuals&#41;&#44; we present the case of a 62-year-old patient with a history of advanced chronic kidney disease&#44; who initiated urgent haemodialysis in the intensive care unit due to fluid overload&#44; along with a cardiac tamponade that required evacuative pericardiocentesis&#46; The patient&#8217;s medical history included&#58; high blood pressure&#44; asymmetrical renal ultrasound &#40;right kidney&#58; 117mm vs left kidney&#58; 96mm&#41;&#44; atrial fibrillation&#44; chronic degenerative vascular encephalopathy with long-term thalamic haematoma caused by anticoagulation with dicoumarin derivatives&#44; monoclonal gammopathy with mild anaemia and thrombocytopenia&#44; urticaria-angiooedema with sensitivity to anisakis and intolerance to NSAIDs&#44; recurrent respiratory infections with chronic bronchial disease&#44; negative coagulopathy screening study&#44; and unconfirmed findings of a weakly positive lupus anticoagulant&#46; As for his clinical condition&#44; uraemic symptoms upon hospitalisation &#8211; from the first dialysis session and despite meeting the quality standards of the dialysis fluid &#40;ultrapure water&#58; &#60;0&#46;1CFU&#47;ml&#44; &#60;0&#46;03EU&#47;ml endotoxin&#41; &#8211; were accompanied by frequent episodes of hypersensitivity &#40;HPS&#41; type A in the form of hypotension and angioedema with poor response to prophylactic steroid therapy&#44; changes in heparin prescription&#44; dialyser change &#40;polysulfone 1&#46;8m<span class="elsevierStyleSup">2</span> sterilised with in line steam&#44; polyarylethersulfone-polyamide 2&#46;1m<span class="elsevierStyleSup">2</span> sterilised with gamma rays&#44; polyacrylonitrile 2&#46;15m<span class="elsevierStyleSup">2</span> sterilised with gamma rays&#44; heparinised Hephran 1&#46;65m<span class="elsevierStyleSup">2</span> sterilised with gamma rays&#44; etc&#46;&#41; and even transition from on-line haemodiafiltration to high-flow haemodialysis&#46; This simultaneously hindered giving appropriate renal replacement therapy&#44; and constituted an obstacle to the recovery of the patient&#44; which was delayed for several weeks&#46;</p><p class="elsevierStylePara">The additional tests required for the evaluation of the overall process and HPS were&#58;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Pre-dialysis biochemistry&#58;</span> glucose&#58; 70mg&#47;dl&#59; urea&#58; 159mg&#47;dl&#59; creatinine&#58; 7&#46;9mg&#47;dl&#59; calcium&#58; 8mg&#47;dl&#59; rheumatoid factor&#58; 11&#46;9IU&#47;ml&#59; total protein&#58; 6&#46;5g&#47;dl&#59; proteinuria in 24-hour urine sample&#58; 835mg&#47;l&#59; and Bence-Jones proteinuria&#58; negative&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Haemogram&#58;</span> leukocytes&#58; 10030&#47;&#956;l &#40;polymorphonuclear&#58; 84&#46;8&#37;&#59; lymphocytes&#58; 6&#46;6&#37;&#59; monocytes&#58; 5&#46;4&#37;&#59; eosinophils&#58; 2&#37;&#59; basophils&#58; 0&#46;1&#37;&#41;&#59; haemoglobin&#58; 8&#46;6mg&#47;dl &#40;average cell volume&#58; 91&#46;7&#41;&#59; platelets&#58; 261&#44;000&#47;&#956;l&#59; direct Coombs&#58; negative&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Immunity&#58;</span> antinuclear antibodies and antineutrophil cytoplasmic antibody&#58; negative&#59; C3&#47;C4&#58; 123&#47;33&#46;9mg&#47;dl&#44; lupus anticoagulant&#58; &#40;-&#41;&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Serology&#58;</span> HbsAc-HbcAc&#58; &#40;&#43;&#41;&#59; hepatitis C virus&#58; &#40;-&#41;&#59; human immunodeficiency virus&#58; &#40;-&#41;&#59; negative syphilis&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Tumour markers&#58;</span> negative&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Electrophoresis&#58;</span> albumin&#58; 52&#46;1&#37; &#40;&#8595;&#41;&#59; gamma-globulins&#58; 19&#46;7&#37; &#40;&#8593;&#41;&#59; albumin &#47; globulin&#58; 1&#46;09&#37;&#44; with no monoclonal component&#46;</p><p class="elsevierStylePara">- <span class="elsevierStyleBold">Immunoglobulin&#58; </span>IgG&#58; 1412mg&#47;dl&#59; IgM&#58; 121mg&#47;dl&#59; and IgA&#58; 0mg&#47;dl&#46;</p><p class="elsevierStylePara">As to <span class="elsevierStyleBold">specific allergy tests&#44;</span> there was a very high total IgE &#40;394KU&#47;L&#41;&#44; with negative tests for chloramines&#44; latex of the extracorporeal circuit&#44; and ethylene oxide&#47;formaldehyde used as sterilisers&#46;</p><p class="elsevierStylePara">Finally&#44; and due to the suspected link between the allergic&#47;thrombogenic tendency of the patient&#44; the selective IgA humoral immunodeficiency and HPS manifested during dialysis&#44; it was decided to also request specialised assessment from the haematology department&#44; which excluded any spinal or immunological process different from that observed&#46; However&#44; ambulatory analysis of lymphocyte subpopulations provided new results&#58; total lymphocyte count&#58; 1172&#47;&#956;l &#40;0&#46;9 to 5&#46;2x10<span class="elsevierStyleSup">3</span>&#47;&#181;l&#41;&#59; CD3-T&#58; 889 cells&#47;&#181;l 75&#37; &#40;58&#37;-87&#37;&#41;&#59; CD3-CD4&#43;&#58; 52&#37; &#40;32&#37;-62&#37;&#41;&#59; CD3-CD8&#43;&#58; 19&#37; &#40;12&#37;-45&#37;&#41;&#59; CD4&#47;CD8 ratio&#58; 2&#46;7 &#40;0&#46;8 to 4&#46;5&#41;&#59; CD19-B&#58; 92 cells&#47;ml 7&#37; &#40;7&#37;-23&#37;&#41;&#59; and CD16-NK&#58; 15&#37; &#40;4&#37;-27&#37;&#41;&#46;</p><p class="elsevierStylePara">Thus&#44; having excluded other causes of combined or secondary immunodeficiency&#44; the final diagnosis was established&#58; selective IgA deficiency linked to an allergic substrate with a tendency towards lymphocytopenia&#44; normal CD4&#47;CD8 ratio&#44; and relative decline in B lymphocytes&#46; The clinical expression of the patient&#8217;s condition was not consistent with a reaction to latex&#44; bio-incompatible membranes&#44; or bradykinin release due to ethylene oxide&#46;<span class="elsevierStyleSup">3-5 </span>In contrast&#44; its relationship with the IgE-mediated HPS was obvious&#46; For that reason&#44; the most plausible pathophysiological hypothesis for the manifestation of these symptoms was&#58; 1&#41; IgA deficiency caused initial antigenic overstimulation of CD4 T-cells&#44; responsible for the activation of C3-CD8 and CD19-B lymphocytes&#44; and as a result&#44; the activation of cellular and humoral immunity<span class="elsevierStyleSup">6</span>&#59; 2&#41; there was an abnormal maturation of B clones&#44; responsible for the synthesis of IgA&#44; hence the relative deficit of CD19-B in our patient&#59; however&#44; this was not the case of other immunoglobulins such as IgE&#44; which promote immediate mast cell degranulation when coming into contact with the antigenic factor<span class="elsevierStyleSup">7&#44;8</span>&#59; and 3&#41; there was a tendency to develop infections and autoimmune mechanisms in these patients&#44; where the uncontrolled external antigenaemia by IgA dimers was capable of inducing a direct cytotoxic response or a response mediated by Ag-Ac complexes&#46;<span class="elsevierStyleSup">6</span></p><p class="elsevierStylePara">In this area of immunopathology&#44; the proposed treatment was directed primarily at inhibiting the reaction of the extracorporeal blood-circuit interface&#44; for which clinical experiences in the literature on pH-metric modulation of intradialytic anaphylaxis were reviewed&#46;<span class="elsevierStyleSup">9 </span>This was used to establish a screening protocol for patients with 1&#47;6M-bicarbonate bloodlines &#40;prior to connection during each session&#41; resulting from the onset in an alkalising effect that resolved the episodes of angioedema and haemodynamic instability&#46; Secondly&#44; we also adopted other therapeutic and hygiene measures for the prevention of infectious complications in the patient&#44; such as the creation of an arteriovenous fistula&#44; which was preferable over the central venous catheter that was being used&#44; or even the early administration of antibiotic therapy in the case of respiratory infection&#46; However&#44; we did not consider correcting the IgA deficiency with exogenous immunotherapy&#44; as severe cases of HPS secondary to the formation of anti-IgA antibodies have been described&#46;<span class="elsevierStyleSup">10</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors declare no conflict of interest related to the content of this article&#46;</p>"
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Article information
ISSN: 20132514
Original language: English
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