Letter to the Editor
Acute renal colic: Beyond kidney stones
Cólico renal agudo: más allá de los cálculos renales
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After a negative diagnostic work-up, sickling vaso-occlusive crisis in the setting of sickle cell trait (SCT) was diagnosed. This report aims to raise awareness that SCT should be included in the differential diagnosis of unexplained hematuria and/or renal colic.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Renal abnormalities are frequently described in patients with sickle hemoglobinopathies, but SCT patients (heterozygous carriers, with one sickle cell gene and one normal gene) are mostly asymptomatic.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> However sickle cell crisis can occur if the patient is exposed to hypoxic conditions, high altitude and intense physical exercise.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Acute events include vaso-occlusive crises such as papillary necrosis of the kidney, ischemic stroke and infections.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A 59-year-old Caucasian woman presented with dark-red urine and colicky pain in the left flank. She had no fever, dysuria, urinary urgency and no history of trauma, nephrolithiasis or additional episodes of hematuria. She was of Asian ascendancy and had non-consanguineous parents. Her medical history was unremarkable, except for hypertension. Her chronic medication consisted of candesartan/hydrochlorothiazide and she denied non-steroidal anti-inflammatory drugs use.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Physical examination revealed modest overweight, blood pressure of 110/60<span class="elsevierStyleHsp" style=""></span>mmHg, no evidence of hepatosplenomegaly, although left costovertebral tenderness was noted.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Laboratory tests showed normal blood cell counts, coagulation parameters, electrolytes, and renal and hepatic tests. No rhabdomyolysis nor hemolysis were present. Urine dipstick revealed a specific gravity of 1.010, 3+ hemoglobin and no protein; the microscopic exam showed 168 red blood cells per high power field, but no casts or white blood cells. Urine cultures, including for mycobacteria, were negative. She had no anomalous cells in cytology and a normal cystoscopy. A computed tomography scan (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A–C) suggested renal papillary necrosis and excluded other abnormalities. There were no criteria for diabetes mellitus. Hemoglobin's electrophoresis showed the presence of an abnormal hemoglobin (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) which was subsequently documented to be HbS. A molecular study revealed an heterozygosity for the hemoglobin sickle mutation of the β-globin gene (HBB:c.20A>T) establishing a diagnosis of SCT.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0030" class="elsevierStylePara elsevierViewall">Clinical findings resolved after conservative therapy with rest, hydration and analgesia. The patient was recommended to avoid circumstances that may precipitate vaso-occlusive crises. Her daughter was referred for genetic testing.</p><p id="par0035" class="elsevierStylePara elsevierViewall">SCT is generally asymptomatic, although occasionally associated with significant morbidity, including papillary necrosis.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It is a highly prevalent recessive illness, mainly found in African but also in Asian populations.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> In SCT patients, HbS is abnormally found with plasma concentrations typically between 35% and 45% of total hemoglobin.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Hematuria is the most common complication<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> of SCT, but the usual etiologies, such as stones, urinary tract infections or neoplasms should be considered first. Hence, initial testing must include urine analysis, culture, cytology and imaging studies. In SCT patients, occlusion of small vessels by sickled blood cells, causes microthrombi and ischaemia.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> In the kidneys, this obstruction is predominantly apparent in the renal papilla due to their marginal blood supply. Papillary necrosis can be difficult to diagnose. The presence of sloughed papillae in the urine examination is diagnostic, but has low sensitivity.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> In our patient an ultrasound and a tomography scan allowed the diagnosis. Treatment is usually conservative, but adjuvant therapies (desmopressin or epsilon-amino caproic acid) can be of benefit.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> Most severe cases may require arterial embolization or surgical exploration. The outcome is generally good but the patient must be informed about avoidable precipitating conditions and genetic counseling.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Hemoglobin's electrophoresis should be part of the diagnostic work-up of renal colic and/or hematuria, namely in patients whose etiology has never been established.</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflict of interest</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest related to the contents of this article.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 3651 "Ancho" => 1667 "Tamanyo" => 499274 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">A, B, C: Sagital, coronal and axial sections of abdominal computed tomography revealing structural heterogeneity of the left renal parenquima with diminished enhancement at the tip of the medullary pyramid and the presence of small cavities filled by contrast on the borders of the small calices – aspects highly suggestive of papillary necrosis ischemia.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1417 "Ancho" => 1667 "Tamanyo" => 69796 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hemoglobin electrophoresis (cellulose acetate): amino acids substitution in hemoglobin variants alter charge and subsequently hemoglobin's mobility pattern. Presence of an abnormal hemoglobin variant in Z5 region, compatible with HbS (<span class="elsevierStyleBold">*</span>).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0030" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sickle cell trait and gross hematuria" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "K. Kiryluk" 1 => "A. Jadoon" 2 => "M. Gupta" 3 => "J. Radhakrishnan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1038/sj.ki.5002060" "Revista" => array:6 [ "tituloSerie" => "Kidney Int" "fecha" => "2007" "volumen" => "71" "paginaInicial" => "706" "paginaFinal" => "710" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17191080" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Renal abnormalities in sickle cell disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "T.P. Phuong-Thu" 1 => "T.P. Phuong-Chi" 2 => "H.W. Alan" 3 => "Q.L. Susie" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1046/j.1523-1755.2000.07501.x" "Revista" => array:6 [ "tituloSerie" => "Kidney Int" "fecha" => "2000" "volumen" => "57" "paginaInicial" => "1" "paginaFinal" => "8" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/10828753" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0040" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sickle cell anaemia. Agenda item 11.4, in 59th World Health Assembly, 27 May 2006" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "World Health Organisation" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Libro" => array:3 [ "fecha" => "2006" "editorial" => "World Health Organisation" "editorialLocalizacion" => "Geneva, Switzerland" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sickle-cell anemia: a look at global haplotype distribution" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A. Gabriel" 1 => "J. Przybylski" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Nat Educ" "fecha" => "2010" "volumen" => "3" "numero" => "3" "paginaInicial" => "2" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Renal papillary necrosis: review and comparison of findings at multi-detector row CT and intravenous urography" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Dae Chul Jung" 1 => "Seung Hyup Kim" 2 => "Jung Sung II" 3 => "Hwang Sung II" 4 => "Sun Ho Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1148/rg.266065039" "Revista" => array:6 [ "tituloSerie" => "Radiographics" "fecha" => "2006" "volumen" => "26" "paginaInicial" => "1827" "paginaFinal" => "1836" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17102053" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/02116995/0000003600000002/v3_201704120115/S0211699515001393/v3_201704120115/en/main.assets" "Apartado" => array:4 [ "identificador" => "43981" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Cartas al Director: Comentarios breves sobre casos clínicos" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/02116995/0000003600000002/v3_201704120115/S0211699515001393/v3_201704120115/en/main.pdf?idApp=UINPBA000064&text.app=https://revistanefrologia.com/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0211699515001393?idApp=UINPBA000064" ]
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| 2020 Junio | 41 | 23 | 64 |
| 2020 Mayo | 43 | 17 | 60 |
| 2020 Abril | 50 | 25 | 75 |
| 2020 Marzo | 52 | 28 | 80 |
| 2020 Febrero | 64 | 18 | 82 |
| 2020 Enero | 78 | 33 | 111 |
| 2019 Diciembre | 87 | 34 | 121 |
| 2019 Noviembre | 77 | 24 | 101 |
| 2019 Octubre | 47 | 19 | 66 |
| 2019 Septiembre | 45 | 33 | 78 |
| 2019 Agosto | 41 | 30 | 71 |
| 2019 Julio | 69 | 29 | 98 |
| 2019 Junio | 79 | 27 | 106 |
| 2019 Mayo | 134 | 25 | 159 |
| 2019 Abril | 197 | 50 | 247 |
| 2019 Marzo | 150 | 29 | 179 |
| 2019 Febrero | 82 | 29 | 111 |
| 2019 Enero | 56 | 27 | 83 |
| 2018 Diciembre | 167 | 42 | 209 |
| 2018 Noviembre | 281 | 20 | 301 |
| 2018 Octubre | 320 | 24 | 344 |
| 2018 Septiembre | 140 | 28 | 168 |
| 2018 Agosto | 113 | 76 | 189 |
| 2018 Julio | 120 | 15 | 135 |
| 2018 Junio | 119 | 14 | 133 |
| 2018 Mayo | 157 | 15 | 172 |
| 2018 Abril | 150 | 17 | 167 |
| 2018 Marzo | 140 | 14 | 154 |
| 2018 Febrero | 70 | 12 | 82 |
| 2018 Enero | 59 | 6 | 65 |
| 2017 Diciembre | 76 | 12 | 88 |
| 2017 Noviembre | 61 | 14 | 75 |
| 2017 Octubre | 62 | 8 | 70 |
| 2017 Septiembre | 59 | 16 | 75 |
| 2017 Agosto | 46 | 7 | 53 |
| 2017 Julio | 79 | 15 | 94 |
| 2017 Junio | 62 | 15 | 77 |
| 2017 Mayo | 77 | 8 | 85 |
| 2017 Abril | 84 | 22 | 106 |
| 2017 Marzo | 86 | 12 | 98 |
| 2017 Febrero | 38 | 12 | 50 |
| 2017 Enero | 48 | 15 | 63 |
| 2016 Diciembre | 62 | 14 | 76 |
| 2016 Noviembre | 85 | 13 | 98 |
| 2016 Octubre | 98 | 14 | 112 |
| 2016 Septiembre | 113 | 5 | 118 |
| 2016 Agosto | 127 | 5 | 132 |
| 2016 Julio | 176 | 10 | 186 |
| 2016 Junio | 128 | 0 | 128 |
| 2016 Mayo | 202 | 0 | 202 |
| 2016 Abril | 201 | 0 | 201 |
| 2016 Marzo | 123 | 0 | 123 |
| 2016 Febrero | 49 | 0 | 49 |
| 2016 Enero | 36 | 0 | 36 |
| 2015 Diciembre | 33 | 0 | 33 |
| 2015 Noviembre | 43 | 0 | 43 |
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