Acute renal failure with low complement levels: check for tubulointerstitial nephritis
Fracaso renal agudo con complemento bajo: no olvidar la nefritis túbulo-intersticial
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class="elsevierStyleSup">b</span>" "identificador" => "affb" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Clínico Universitario de Salamanca, " "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "affc" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fracaso renal agudo con complemento bajo: no olvidar la nefritis túbulo-intersticial" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12575_16025_64424_en_f212575.jpg" "Alto" => 490 "Ancho" => 654 "Tamanyo" => 370196 ] ] "descripcion" => array:1 [ "en" => "Interstitial infiltrate with healthy glomeruli" ] ] ] "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor,</span></p><p class="elsevierStylePara">A 75 year-old male came to the emergency department due to epigastralgia of five days of evolution. Two weeks before, he had received non-steroidal anti-inflammatory drugs (NSAIDs), due to a trauma of his right wrist, which he had to suspend due to the digestive symptoms described above.</p><p class="elsevierStylePara">As personal history of significance, he had undergone a radical prostatectomy for a tumour and suffered sphenoid sinus aspergillosis in October 2011.</p><p class="elsevierStylePara">- Physical examination: blood pressure 195/77mmHg; no other relevant findings.</p><p class="elsevierStylePara">- Laboratory tests showed: creatinine: 5.38mg/dL, urea: 116mg/dL, amylase: 113IU/L, sodium: 136mEq/L, potassium: 4.7mEq/L, normal blood count.</p><p class="elsevierStylePara">- Urine analysis: leukocyturia.</p><p class="elsevierStylePara">- Complement:<span class="elsevierStyleBold"> C3: 39 </span>(85-180),<span class="elsevierStyleBold"> C4: <1.4 </span>(10-40).</p><p class="elsevierStylePara">- Immunoglobulins: IgG: 2460 (680-1530), IgG4: 72 (9-104), IgM: 36 (40-240), IgA: 127 (70-400).</p><p class="elsevierStylePara">- Antinuclear antibodies, anti-DNA antibodies, ANCA, anti-RO antibodies, anti-La antibodies: negative.</p><p class="elsevierStylePara">- Cryoglobulins: negative.</p><p class="elsevierStylePara">- Angiotensin-converting enzyme: 30 (8-50).</p><p class="elsevierStylePara">- Hepatitis B, Hepatitis C, and human immunodeficiency virus serology: negative.</p><p class="elsevierStylePara">- Protein in 24-hour urine: 0.5 grams.</p><p class="elsevierStylePara">- Blood immunoelectrophoresis: normal.</p><p class="elsevierStylePara">- Urine immunoelectrophoresis: light precipitation band in kappa light-chain.</p><p class="elsevierStylePara">- Bone marrow: normal.</p><p class="elsevierStylePara">- Upper digestive endoscopy and colonoscopy were normal.</p><p class="elsevierStylePara">- Abdominal ultrasound, chest and abdomen X-ray: nothing of note.</p><p class="elsevierStylePara">Initially, it was interpreted as tubulointerstitial nephritis (TIN) related to NSAIDs. Finding low complement values expanded our differential diagnosis and included suspected lupus nephritis, mixed cryoglobulinaemia, post-infectious and membranoproliferative glomerulonephritis. So we performed a renal biopsy (Figures 1 and 2): renal cylinder with six glomeruli without significant alterations. Inflammatory interstitial lymphocyte infiltrate with few plasma cells. On direct immunofluorescence, a granular deposit of immunoglobulin G and C3 is seen in the tubular baseline membrane and in Bowman's capsule of some glomeruli.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">This finding led us to consider a differential diagnosis with systemic lupus erythematosus (SLE), Sjogren, TIN related to Ig4 and idiopathic TIN.</p><p class="elsevierStylePara">This last term covers three separate entities: TINU (tubulointerstitial nephritis and uveitis), nephritis due to baseline membrane antibodies and low complement TIN. SLE is ruled out due to the absence of antibodies and negative symptoms, Sjogren's syndrome is also ruled out since there is no xerostomia or xerophthalmia, and antibodies are negative.</p><p class="elsevierStylePara">IgG4-related TIN, name proposed by Saeki et al, is included in a recently described syndrome known as IgG4-related autoimmune disease of unknown origin. It is characterised by elevated plasma IgG4 associated with lymphocyte and plasma cell infiltrates of any organ with a predominance of IgG4-positive plasma cells. In the kidney, TIN is the most characteristic finding with low complement in a high percentage of cases.</p><p class="elsevierStylePara">We ruled out this entity as IgG4 levels were not high and no other organ was involved.</p><p class="elsevierStylePara">The patient was diagnosed with low complement TIN. It is a rare entity of unknown pathogenesis. There are several hypotheses regarding the formation of in situ or preformed circulating immune-complex deposits. This disorder usually affects males with a mean age at presentation of 66 years. The most common clinical presentation is renal failure with low complement.</p><p class="elsevierStylePara">Treatment experience is limited and consists mainly of steroids associated or not with other immunosuppressive drugs.</p><p class="elsevierStylePara">Mean duration of treatment is 3-12 months. In some cases of recurrence or treatment failure other drugs used are: cyclophosphamide, mycophenolate mofetil and tacrolimus.</p><p class="elsevierStylePara">In the case of our patient, we used prednisone at a dose of 1mg/kg/day, gradually tapered off, with excellent tolerance and partial response in renal function. In the last review, after four months of treatment, the patient had creatinine values of 2.7mg/dL and normal C3 and C4 values: 6.</p><p class="elsevierStylePara">We conclude that low-complement TIN should be included in the differential diagnosis of any renal failure with low complement without failing to consider IgG4-related disease.</p><p class="elsevierStylePara"> </p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara"> </p><p class="elsevierStylePara">The authors declare that they have no conflicts of interest related to the contents of this article.</p><p class="elsevierStylePara"><a href="grande/12575_16025_64424_en_f212575.jpg" class="elsevierStyleCrossRefs"><img src="12575_16025_64424_en_f212575.jpg" alt="Interstitial infiltrate with healthy glomeruli"></img></a></p><p class="elsevierStylePara">Figure 2. Interstitial infiltrate with healthy glomeruli</p><p class="elsevierStylePara"><a href="grande/12575_16025_64426_en_f112575.jpg" class="elsevierStyleCrossRefs"><img src="12575_16025_64426_en_f112575.jpg" alt="Deposits of IgG and C3 in the baseline membranes of the tubules and in Bowman's capsule with intact glomeruli"></img></a></p><p class="elsevierStylePara">Figure 1. Deposits of IgG and C3 in the baseline membranes of the tubules and in Bowman's capsule with intact glomeruli</p>" "pdfFichero" => "P1-E577-S4807-A12575-EN.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig1" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12575_16025_64424_en_f212575.jpg" "Alto" => 490 "Ancho" => 654 "Tamanyo" => 370196 ] ] "descripcion" => array:1 [ "en" => "Interstitial infiltrate with healthy glomeruli" ] ] 1 => array:8 [ "identificador" => "fig2" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "copyright" => "Elsevier España" "figura" => array:1 [ 0 => array:4 [ "imagen" => "12575_16025_64426_en_f112575.jpg" "Alto" => 490 "Ancho" => 655 "Tamanyo" => 331097 ] ] "descripcion" => array:1 [ "en" => "Deposits of IgG and C3 in the baseline membranes of the tubules and in Bowman's capsule with intact glomeruli" ] ] ] "bibliografia" => array:2 [ "titulo" => "Bibliography" "seccion" => array:1 [ 0 => array:1 [ "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib1" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Gupta A, Jothy S, Somerville P. Hypocomplementemic inmune complex tubulointerstitial nephritis. NDT plus 2010;3:78." "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => null ] ] ] ] 1 => array:3 [ "identificador" => "bib2" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Kambham N, Markowitz GS, Tanji N, Mansukhani MM, Orazi A, D'Agati VD. Idiopathic hypocomplementemic interstitial nephritis with extensive tubulointerstitial deposits. Am J Kidney Dis 2001;37(2):388-99. <a href="http://www.ncbi.nlm.nih.gov/pubmed/11157382" target="_blank">[Pubmed]</a>" "contribucion" => array:1 [ 0 => null ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:1 [ "itemHostRev" => array:3 [ "pii" => "S0300893211005549" "estado" => "S300" "issn" => "03008932" ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib3" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:3 [ "referenciaCompleta" => "Vaseemuddin M, Schwartz MM, Dunea G, Kraus MA. 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| 2020 July | 87 | 25 | 112 |
| 2020 June | 66 | 21 | 87 |
| 2020 May | 77 | 19 | 96 |
| 2020 April | 72 | 20 | 92 |
| 2020 March | 70 | 16 | 86 |
| 2020 February | 80 | 22 | 102 |
| 2020 January | 68 | 28 | 96 |
| 2019 December | 71 | 18 | 89 |
| 2019 November | 83 | 21 | 104 |
| 2019 October | 76 | 13 | 89 |
| 2019 September | 91 | 13 | 104 |
| 2019 August | 47 | 22 | 69 |
| 2019 July | 56 | 20 | 76 |
| 2019 June | 80 | 42 | 122 |
| 2019 May | 69 | 25 | 94 |
| 2019 April | 118 | 65 | 183 |
| 2019 March | 71 | 25 | 96 |
| 2019 February | 63 | 21 | 84 |
| 2019 January | 70 | 35 | 105 |
| 2018 December | 153 | 44 | 197 |
| 2018 November | 128 | 12 | 140 |
| 2018 October | 145 | 16 | 161 |
| 2018 September | 108 | 17 | 125 |
| 2018 August | 102 | 19 | 121 |
| 2018 July | 77 | 12 | 89 |
| 2018 June | 79 | 21 | 100 |
| 2018 May | 88 | 13 | 101 |
| 2018 April | 93 | 16 | 109 |
| 2018 March | 88 | 7 | 95 |
| 2018 February | 67 | 7 | 74 |
| 2018 January | 81 | 6 | 87 |
| 2017 December | 82 | 8 | 90 |
| 2017 November | 74 | 12 | 86 |
| 2017 October | 91 | 16 | 107 |
| 2017 September | 68 | 9 | 77 |
| 2017 August | 60 | 12 | 72 |
| 2017 July | 81 | 8 | 89 |
| 2017 June | 64 | 18 | 82 |
| 2017 May | 77 | 9 | 86 |
| 2017 April | 50 | 13 | 63 |
| 2017 March | 47 | 8 | 55 |
| 2017 February | 71 | 16 | 87 |
| 2017 January | 26 | 11 | 37 |
| 2016 December | 67 | 15 | 82 |
| 2016 November | 81 | 15 | 96 |
| 2016 October | 127 | 16 | 143 |
| 2016 September | 139 | 6 | 145 |
| 2016 August | 211 | 7 | 218 |
| 2016 July | 234 | 11 | 245 |
| 2016 June | 150 | 0 | 150 |
| 2016 May | 162 | 0 | 162 |
| 2016 April | 136 | 0 | 136 |
| 2016 March | 111 | 0 | 111 |
| 2016 February | 132 | 0 | 132 |
| 2016 January | 126 | 0 | 126 |
| 2015 December | 142 | 0 | 142 |
| 2015 November | 116 | 0 | 116 |
| 2015 October | 128 | 0 | 128 |
| 2015 September | 95 | 0 | 95 |
| 2015 August | 106 | 0 | 106 |
| 2015 July | 128 | 0 | 128 |
| 2015 June | 60 | 0 | 60 |
| 2015 May | 68 | 0 | 68 |
| 2015 April | 6 | 0 | 6 |
Show all
