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"tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "368" "paginaFinal" => "369" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Carolina Fonseca de Jesus Silva, Alberto Martin Arribas, Pilar Fraile Gómez" "autores" => array:3 [ 0 => array:4 [ "nombre" => "Carolina" "apellidos" => "Fonseca de Jesus Silva" "email" => array:1 [ 0 => "carolina.fjs@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "Alberto" "apellidos" => "Martin Arribas" ] 2 => array:2 [ "nombre" => "Pilar" "apellidos" => "Fraile Gómez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Nefrología, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Nefropatía membranosa primaria y enfermedad de Crohn: ¿causalidad o coincidencia?" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 942 "Ancho" => 1400 "Tamanyo" => 154400 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Colonoscopy with diagnosis of type-A3L2B1 Colonic Crohn's disease, showing friable mucosa with deep, linear punched-out ulcers (arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Inflammatory bowel disease is associated with a wide range of kidney diseases, particularly tubulointerstitial and glomerular.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–5</span></a> IgA nephropathy is the most common, but it is important to consider other entities and even the overlapping with different systemic diseases.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report a case of anti-PLA2R-positive membranous nephropathy and antiphospholipid syndrome associated with Crohn's disease.</p><p id="par0015" class="elsevierStylePara elsevierViewall">41-year-old man diagnosed with anti-PLA2R-positive membranous nephropathy and antiphospholipid syndrome, which began as nephrotic syndrome during admission for multiple pulmonary thromboembolism and renal vein thrombosis. It started with generalised oedema, normal renal function, preserved diuresis, nephrotic proteinuria (15<span class="elsevierStyleHsp" style=""></span>g/24<span class="elsevierStyleHsp" style=""></span>h), hypoalbuminaemia, normal protein test, serum immunoglobulins and complement study, negative autoimmunity study except for positive anti-PLA2R antibodies and lupus anticoagulant. Given the positive anti-PLA2R antibodies and the patient's high bleeding risk at that time, a renal biopsy was ruled out. It was decided to postpone immunosuppression due to a tendency towards spontaneous remission with normal renal function and progressive decrease in proteinuria (5.6<span class="elsevierStyleHsp" style=""></span>g/day) with symptomatic treatment (ACE inhibitors). One month later, proteinuria (10<span class="elsevierStyleHsp" style=""></span>g/day), albuminuria (8.36<span class="elsevierStyleHsp" style=""></span>g/day), microscopic haematuria (99<span class="elsevierStyleHsp" style=""></span>RBC/uL) worsened, along with weight gain and limb oedema, for which corticosteroid therapy and tacrolimus 0.5<span class="elsevierStyleHsp" style=""></span>mg/kg/day were started, with a partial response to treatment and stable proteinuria. Given the patient's age and reproductive desires, treatment with cyclophosphamide was ruled out and treatment with rituximab was avoided due to persistent hypogammaglobulinemia <500<span class="elsevierStyleHsp" style=""></span>mg/dl. Two years later, the patient presented with weight loss, fever, chronic abdominal pain with diarrhoea and rectal bleeding, stable renal function and increased proteinuria (4<span class="elsevierStyleHsp" style=""></span>g/day), having previously been asymptomatic and stable with antiproteinuric treatment, prednisone and tacrolimus. Laboratory tests showed normal renal function, increased acute phase reactants and faecal calprotectin (>8000<span class="elsevierStyleHsp" style=""></span>μg/g), microscopic haematuria, proteinuria (protein/creatinine ratio 7.71<span class="elsevierStyleHsp" style=""></span>mg/mg), positive anti-PLA2R antibodies without fulfilling the criteria for antiphospholipid syndrome. Imaging tests (abdominal X-ray and CT scan) showed intestinal obstruction in the probable context of an inflammatory intestinal process, subsequently confirmed by colonoscopy and intestinal biopsy, compatible with Crohn's disease (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). In view of this diagnosis associated with anti-PLA2R-positive membranous nephropathy, treatment was started with vedolizumab and intravenous tacrolimus, as at that time serum tacrolimus levels were low despite correct oral administration due to probable intestinal malabsorption as a result of the inflammatory bowel process. After starting treatment, he maintained a partial renal response with normal renal function, negative autoimmunity and proteinuria (1.4−2<span class="elsevierStyleHsp" style=""></span>g/day), and a single intestinal flare of Crohn's disease with abdominal pain, diarrhoea of 5–6 stools per day without rectal bleeding, increased faecal calprotectin (981<span class="elsevierStyleHsp" style=""></span>μg/g) and stable proteinuria 2.3<span class="elsevierStyleHsp" style=""></span>g/day without oedema. We observed a causal relationship between worsening proteinuria and inflammatory bowel activity as it tends to increase during Crohn's disease flares.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">This case highlights the atypical coexistence between primary anti-PLA2R-positive membranous nephropathy and Crohn's disease, due to the uncommon sequence of diagnoses, including the chronological order and the association with antiphospholipid syndrome when the diagnosis of membranous nephropathy is made.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> Cases described in the medical literature usually start with a primary diagnosis of Crohn's disease and subsequent development of membranous nephropathy.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,4,5</span></a> As for the association of membranous nephropathy with antiphospholipid syndrome, it has been described in the context of renal vein thrombosis, coinciding with the case described. There are several peculiarities to this case, starting with the chronological order of the diagnoses and their association, the onset of anti-PLA2R membranous nephropathy associated with an antiphospholipid syndrome and finally the inconsistent course with partial response to immunosuppressive treatment. It is important to recognise the variability in the presentation and progression of these diseases and to approach complex cases such as this in a multidisciplinary way.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Ethical considerations</span><p id="par0025" class="elsevierStylePara elsevierViewall">This paper complies with established ethical considerations and did not involve animal experimentation. Informed consent was obtained from the patient.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Funding</span><p id="par0030" class="elsevierStylePara elsevierViewall">This work did not receive any funding.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">There is no conflict of interest in this work.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Ethical considerations" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Funding" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflict of interest" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 942 "Ancho" => 1400 "Tamanyo" => 154400 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Colonoscopy with diagnosis of type-A3L2B1 Colonic Crohn's disease, showing friable mucosa with deep, linear punched-out ulcers (arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Asociación de glomerulonefritis membranosa y enfermedad de Crohn" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R.C. Díaz" 1 => "E. Granja" 2 => "M.E. Vázquez" 3 => "F. Sacristán" 4 => "F.A. Moreno" 5 => "R.C. González" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Nefrología" "fecha" => "2004" "volumen" => "XXIV" "numero" => "4" "paginaInicial" => "368" "paginaFinal" => "371" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Membranous Glomerulonephritis in a patient with Chron’s Disease of the small bowel" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "E.V. O’Loughlin" 1 => "L. Robson" 2 => "B. Scott" 3 => "F. Alexander" 4 => "D.G. 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Self" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Kidney Disease" "fecha" => "2003" "volumen" => "41" "numero" => "5" "paginaInicial" => "1097" "paginaFinal" => "1109" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000016300000007/v1_202410101439/S238702062400411X/v1_202410101439/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000016300000007/v1_202410101439/S238702062400411X/v1_202410101439/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S238702062400411X?idApp=UINPBA00004N" ]
Journal Information
Vol. 163. Issue 7.
Pages 368-369 (October 2024)
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Vol. 163. Issue 7.
Pages 368-369 (October 2024)
Letter to the Editor
Membranous nephropathy and Crohn’s disease: Is it a cause and effect or just a coincidence?
Nefropatía membranosa primaria y enfermedad de Crohn: ¿causalidad o coincidencia?
Carolina Fonseca de Jesus Silva
, Alberto Martin Arribas, Pilar Fraile Gómez
Corresponding author
Servicio de Nefrología, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
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