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Massive proteinuria for minimal change nephropathy secondary to treatment with D-penicillamine in a patient with Wilson’s disease. Case report
Proteinuria masiva por nefropatía por cambios mínimos secundaria a tratamiento con D-penicilamina en un paciente con enfermedad de Wilson hepática. A propósito de un caso
Elena Borrego Garcíaa,
Corresponding author
eborregogarcia@gmail.com

Corresponding author.
, Elena Hernández Garcíaa, Mercedes Caba Molinab, Antonio María Navas-Parejo Casadoa
a Servicio de Nefrología, Hospital San Cecilio, Granada, Spain
b Servicio Anatomía Patológica, Hospital San Cecilio, Granada, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Wilson&#39;s disease &#40;WD&#41; has a prevalence of 142 cases per million population&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It presents an autosomal recessive inheritance pattern with more than 500 different mutations in the ATP7B gene &#40;chromosome 13&#41; This encodes a carrier metalloprotease that leads to the protein deficiency involved in the intrahepatocyte transport of copper&#44; preventing copper from being excreted to the bile canaliculi and the incorporation of copper into apoceruloplasmin&#44; reducing the plasma concentration of ceruloplasmin&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> It may be asymptomatic or manifest hepatic&#44; ocular and&#47;or neurological symptoms&#46; Some of the therapeutic options available are&#58; D-penicillamine&#44; trientine and zinc salts&#46; Cases of renal involvement have been reported with D-penicillamine therapy&#46; The most common cause is the development of membranous glomerulonephritis&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a patient with massive proteinuria in the context of nephrotic syndrome due to minimal change nephropathy secondary to treatment with D-penicillamine&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">It is a 50-year-old male patient with a history of type 2 diabetes mellitus and hepatic Wilson&#39;s disease receiving treatment with D-penicillamine 1&#8239;g&#47;24&#8239;h&#44; with stable liver function&#46; Three years after the diagnosis and treatment&#44; he was referred to nephrology with signs of nephrotic syndrome&#44; with generalised oedema&#44; hypoalbuminaemia&#44; dyslipidaemia and proteinuria of 30&#8239;g&#47;24&#8239;h&#46; Renal function was normal at all times&#46; He was admitted to start depletion therapy with intravenous loop diuretics and suspension of D-penicillamine&#46; A kidney biopsy showed lesions typical of minimal change nephropathy &#40;podocyte oedema&#44; glomeruli intact and podocyte fusion observed by electron microscopy&#41;&#44; excluding IgG&#44; C1q and focal and segmental nephropathy from the differential diagnosis&#46; After the diagnosis&#44; the suspension of D-penicillamine continued and zinc acetate was prescribed&#44; one tablet every 8&#8239;h&#44; together with antithrombotic treatment with bemiparin and oral diuretics&#46; The nephrotic syndrome remitted&#44; achieving proteinuria of 243&#8239;mg&#47;24&#8239;h&#44; maintaining normal renal function and observing unaltered analytical parameters after starting the zinc&#44; and no liver function abnormalities before this change &#40;GOT 79 U&#47;l&#44; GPT 191 U&#47;l&#44; GGT 220 U&#47;l&#44; ALP 137 U&#47;l&#44; ceruloplasmin and copper in urine&#44; normal&#41;&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">D-penicillamine is used in diseases such as rheumatoid arthritis&#44; primary biliary cholangitis and Wilson&#39;s disease&#46; Some of its side effects are arthralgia&#44; skin disorders&#44; hypogeusia&#44; leukopenia&#44; thrombocytopenia&#44; haemolytic or aplastic anaemia&#44; lupus<span class="elsevierStyleItalic">-like</span> phenomena and&#44; occasionally&#44; renal disorders&#46;<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3&#44;4</span></a> Membranous nephropathy is the most common renal disorder reported in relation to D-penicillamine&#46; However&#44; cases have also been described with crescentic glomerulonephritis&#44; focal glomerulonephritis&#44; ANCA&#43; and ANA&#43; vasculitis that can course with complete or incomplete nephrotic syndrome&#44; but all without massive proteinuria&#44; and some cases of minimal change nephropathy&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The mechanism of action of D-penicillamine is not well understood&#46; It is hypothesised that it could alter immune response&#44; inhibiting mitogen-induced lymphoblastic transformation and reducing immunoglobulin production by stimulated lymphocytes&#46; The complications caused by the drug could be due to a modification of autoantigens&#44; due to the presence of a highly reactive thiol group in the molecule or to interference with Th17 lymphocyte response&#46; It has been reported that it can inhibit <span class="elsevierStyleItalic">T helper</span> lymphocyte activity and this could explain its efficacy in the treatment of autoimmune diseases such as rheumatoid arthritis&#46; Ultimately&#44; D-penicillamine could interfere with a regulating immune mechanism&#44; predisposing some patients to develop minimal change nephropathy&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Our case was interesting because it involved the onset of minimal change nephropathy instead of membranous nephropathy&#44; which is the most common associated condition&#44; and due to the intense proteinuria&#44; secondary to the treatment with D penicillamine&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; we believe that it is essential to review renal function and proteinuria in patients receiving chronic treatment with D-penicillamine and suspend the drug with the onset of nephrotic syndrome&#44; as there appears to be a possible association between D-penicillamine and minimal change nephropathy &#40;in our case&#41;&#44; given that the nephrotic syndrome and the disease remitted when the drug was suspended&#46;</p></span>"
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es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos