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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">Dear Editor&#44;</span></p><p class="elsevierStylePara">C1q nephropathy &#40;C1qN&#41; is an idiopathic glomerular disease characterized by extensive mesangial deposition of C1q with associated mesangial immune complexes&#44; in the absence of evidence of systemic lupus erythematosus&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">The prevalence of C1qN has been estimated from 0&#46;2&#37; to 16&#37;&#46;<span class="elsevierStyleSup">1-9</span> Light microscopy &#40;LM&#41; findings range from no glomerular abnormalities to mesangial proliferation<span class="elsevierStyleSup">1&#44;6-9&#44;11&#44;12</span> or focal segmental glomerulosclerosis &#40;FSG&#41;&#46;<span class="elsevierStyleSup">2-4&#44;6-8&#44;13</span> Clinical presentations vary from asymptomatic urinary anomalies&#44;<span class="elsevierStyleSup">5&#44;7&#44;8&#44;11&#44;13</span> and macroscopic hematuria&#44;<span class="elsevierStyleSup">14</span> to nephritic syndrome<span class="elsevierStyleSup">3&#44;15</span> and corticorresistent nephrotic syndrome &#40;NS&#41;&#46;<span class="elsevierStyleSup">1&#44;2-4&#44;6-8</span> Earlier reports found a poor response to steroids and a high risk of progression to end-stage renal disease &#40;ESRD&#41;&#44;<span class="elsevierStyleSup">1&#44;3&#44;6&#44;12&#44;15</span> particularly those with FSG&#46; Patients presenting asymptomatic urinary anomalies have been found to have a good prognosis&#46;<span class="elsevierStyleSup">2-5&#44;7&#44;8</span>&#160;The variability in the prevalence&#44; clinical presentation and prognosis of C1qN has been attributed to different ages and ethnicities of the patients included in the series&#44; and to different thresholds to perform a renal biopsy&#46;</p><p class="elsevierStylePara">The association between NS and malignancy has been reported in various glomerulopathies&#44; but not with C1qN&#46; Recognition of malignancy-associated glomerulopathies is important to prevent ineffective and potentially harmful treatment&#46;</p><p class="elsevierStylePara">A 56-year-old male was admitted to our Department with NS&#46; He reported persistent peripheral edema lasting for two months&#46; He was a smoker of 80 packs&#47;year&#46; He had exuberant edema of lower extremities and abdominal wall&#46; Laboratory findings revealed hypoalbuminemia &#40;1&#46;1g&#47;dL&#41;&#44; proteinuria &#40;10g&#47;day&#41; and microscopic hematuria&#59; serum creatinine was 1&#46;1mg&#47;dL and urea&#58; 48mg&#47;dL&#46; Hyperlipidemia &#40;total-cholesterol&#58; 326mg&#47;dL&#41; was also noted&#46; HBs-antigen&#44; HCV-antibody and HIV-antibody were all negative&#46; Serum protein electrophoresis was unremarkable&#59; complement levels&#44; ANCA&#44; ANA&#44; cryoglobulins and anti-phospholipid antibodies were normal&#46; Ultrassonography of the kidneys was unremarkable&#46; Abdominal ultrassonography showed small volume ascites&#44; and chest X-ray revealed small pleural effusions&#44; without any other abnormal findings&#46;</p><p class="elsevierStylePara">A renal biopsy was performed&#44; whose histological findings are shown in Figure 1&#46; Fifteen glomeruli were observed&#44; showing segmental thickening of glomerular basement membranes &#40;GBM&#41; and mesangium by an eosinophilic Congo-red negative amorphous material&#46; Spike formation or stippling of the GBM was absent in periodic-acid methenamine-silver staining&#46; Immunofluorescence &#40;IF&#41; revealed predominant presence of comma-shaped C1q mesangial deposits&#46;</p><p class="elsevierStylePara">We started prednisolone &#40;1mg&#47;Kg&#47;day&#41;&#44; cyclosporine &#40;3mg&#47;Kg&#47;day&#41; and acenocumarol&#46; One month later&#44; he had an acute pyelonephritis&#44; with worsening renal function &#40;creatinine&#58; 1&#46;6mg&#47;dL&#41;&#46; Prednisolone dose was reduced to 0&#46;5mg&#47;Kg&#47;day&#46;</p><p class="elsevierStylePara">Two months later&#44; his clinical condition deteriorated&#44; with asthenia&#44; anorexia and anasarca&#46; Laboratory findings revealed a serum creatinine of 3&#46;9mg&#47;d&#44; with proteinuria &#40;39g&#47;day&#41; and hypoalbuminemia &#40;1&#46;1g&#47;dL&#41;&#59; trough levels of cyclosporine were 176ng&#47;mL&#46; In an attempt to reduce proteinuria&#44; non-steroidal anti-inflammatory drugs were tried&#44; without response&#46; Cyclosporine was stopped and a right nephrectomy was performed&#46; FSG was noted in all of the 15 glomeruli&#44; with persistence of mesangial C1q deposits&#46; It&#160;is plausible that the first biopsy was not representative&#44; or maybe this findings represented the rapid course of the disease&#46;</p><p class="elsevierStylePara">In the post-operative period&#44; the patient developed signs of hyperhydration and started haemodialysis&#46; Hypoalbuminemia and signs of hyperhidration gradually improved&#44; but he maintained severe proteinuria&#46; When clinical euvolemia was achieved&#44; a right pleural effusion persisted&#46; A CT scan was performed&#44; revealing a disseminated neoplasm &#40;Figure 2&#41;&#46; A pleural exudate without malignant cells was drained&#46; Tumor markers Ca 19&#46;9 &#40;95&#46;2U&#47;L&#44; normal &#60;27U&#47;L&#41; and neuron specific enolase &#40;NSE&#41; &#40;96&#46;6U&#47;L&#44; normal &#60;15&#46;2U&#47;L&#41; were elevated&#46;</p><p class="elsevierStylePara">The patient&#8217;s general condition rapidly deteriorated with marked cachexy and&#44; later on&#44; respiratory failure&#46; Invasive investigation was not possible&#44; as the patient was not fit&#46; A week later&#44; he died with a nosocomial respiratory infection&#46; Histological characterization of the neoplasm was not possible&#44; as the patient&#8217;s family refused an autopsy&#46;</p><p class="elsevierStylePara">C1qN can present with NS&#44; typically with histological phenotype of either MCD or FSG&#46; In a report of 15 pediatric patients with C1qN&#44; 9 children had corticorresistent NS&#46; FSG was diagnosed in four cases with poor outcome&#46;<span class="elsevierStyleSup">3</span> Markowitz et al&#46;<span class="elsevierStyleSup">2</span> reported 19 patients with C1qN&#44; 79&#37; of which with nephrotic proteinuria&#46; Renal biopsy disclosed FSG in 17 patients and MCD in two&#46; Four patients with FSG had progressive renal insufficiency and two developed ESRD within 27 months&#46; In a report of 20 pediatric patients&#44; 70&#37; presented nephrotic range proteinuria&#46;<span class="elsevierStyleSup">4</span> The most common histological phenotypes were FSG &#40;40&#37;&#41; and MCD &#40;30&#37;&#41;&#46; Patients with FSG had poor prognosis&#44; with half progressing to ESRD in 3 years&#46; In the report of Vizjak et al&#46;<span class="elsevierStyleSup">7</span> comprising 72 kidney biopsies with C1qN&#44; FSG was found in 11 patients with NS&#44; 33&#37; which progressed to ESRD within 2&#46;9 years&#46; Hisano et al&#46;<span class="elsevierStyleSup">8</span> reported a lower prevalence of NS &#40;41&#37;&#41; among 61 Japanese patients with C1qN&#46; The prevalence of MCD in the nephrotic group was 92&#37;&#44; while FSG corresponded only to 8&#37; of the cases&#46; The majority of the patients in nephrotic group were frequent relapsers&#44; but only 4&#37; progressed to ESRD&#46;</p><p class="elsevierStylePara">A paraneoplastic syndrome is usually inferred when glomerular proteinuria develops in the six months before or after the diagnosis of malignancy&#46; In our patient&#44; initial evaluation didn&#8217;t provide any clue to an underlying diagnosis of malignancy&#46; His systemic manifestations were attributed to severe protein loss&#44; as well as to prolonged periods of hospitalization&#46; Five months after the diagnosis of NS&#44; a right pleural effusion persisted after achievement of euvolemia&#44; and a CT was performed showing a disseminated neoplasm&#46; The patient&#8217;s clinical condition had markedly deteriorated and he died of sepsis and respiratory failure within a week&#46;</p><p class="elsevierStylePara">Previous immunossupressive therapy may have triggered tumor cells&#44; and promote the rapid and inexorable outcome&#46; The patient was a heavy smoker&#44; a known risk factor for several types of neoplasm&#44; including lung and gastrointestinal tract carcinomas&#44; the most frequently associated with paraneoplastic glomerulopathies&#46; He also had high levels of NSE and Ca 19&#46;9&#44; which can be found in gastrointestinal and lung cancers&#46;</p><p class="elsevierStylePara">Failure to recognize paraneoplastic glomerulonephritis can subject patients to ineffective and potentially harmful therapy&#46; It is important to highlight the possible association between C1qN and malignancy&#46; Before refractory NS associated with C1qN&#44; an underlying malignancy should be suspected&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflict of interest</span></p><p class="elsevierStylePara">The authors declare that there is no conflict of interest associated with this manuscript&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11246&#95;16025&#95;23512&#95;en&#95;f1&#95;11246&#46;jpg" class="elsevierStyleCrossRefs"><img src="11246_16025_23512_en_f1_11246.jpg" alt="Kidney biopsy specimen&#46;"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Kidney biopsy specimen&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11246&#95;16025&#95;23513&#95;en&#95;f2&#95;11246&#46;jpg" class="elsevierStyleCrossRefs"><img src="11246_16025_23513_en_f2_11246.jpg" alt="CT scan"></img></a></p><p class="elsevierStylePara">Figure 2&#46; CT scan</p>"
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                  "referenciaCompleta" => "Jennette JC, Hipp CG. C1q nephropathy: a distinct clinical pathologic entity usually causing nephrotic syndrome. Am J Kidney Dis 1985;6(2):103-10. <a href="http://www.ncbi.nlm.nih.gov/pubmed/3875286" target="_blank">[Pubmed]</a>"
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                  "referenciaCompleta" => "2.\u{A0}Markowitz G, Schwimmer J, Stokes M, Nasr S, Seigle RL, Valeri AM, et al.\u{A0} C1q nephropathy: A variant of focal segmental glomerulosclerosis. Kidney Int 2003;64:1232-40. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12969141" target="_blank">[Pubmed]</a>"
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