- Email: [email protected]
Coexistence of membranous nephropathy and IgA nephropathy in a patient with auto-immune thyroiditis
Abstracts
RO
OF
antinuclear and double-stranded DNA antibodies were negative. Serum immunoglobulin measurement and complement levels were in the normal range. HIV, HBV and HCV serology were negative. Thyroid function test was abnormal, with free T4 of 0.76 ng/dL and TSH 2.12 UI/ mL. Antithyroglobulin and antiperoxidase antibodies were positive: 31.8 UI/mL (N b 4.11) and 130.4 UI/mL (N b 5.61), respectively. Chest X-ray and renal ultrasound were normal. Thyroid ultrasound showed a diffusely enlarged thyroid gland with a heterogeneous echotexture and hypoechoic micronodules. Renal biopsy showed 13 glomeruli with mesangial proliferation and basement membrane thickening. Immunohistology showed positive staining for IgA and C3c in mesangial areas and granular IgG deposits along the outer surface of capillary walls. C1q was negative. On ultramicroscopy, there were mesangial and subepithelial immunodeposits and effacement of podocyte foot processes. No endothelial tubuloreticular inclusions were observed. Both membranous and IgA nephropathy were diagnosed. Patient was put on lisinopril and diuretics. She needed no thyroid hormone substitutive treatment. Six months later, patient is on partial remission on dual blockade of the renin–angiotensin system, with proteinuria of 1.46 g/day. Thyroid function remains abnormal though. Conclusion: The association of membranous and IgA nephropathy has been rarely reported. Although both conditions have been independently reported in patients with thyroid disease, to our knowledge this is the first time that the coexistence of both diseases is described. We cannot determine whether this is a single disease or two distinct disorders in the context of autoimmune thyroiditis. In the short follow-up the patient is on partial remission with no need for immunosuppressive treatment.
DP
Introduction: Hyperhydration (HH) has been associated to higher morbidity and mortality in the critically ill patients. Objectives: Assess the impact of HH in the prognosis of critically ill patients. Methods: Prospective observational study in an Intensive Care Unit (ICU), including patients over 18-years-old admitted during 2012. Data on demographic elements, fluid balance, SOFA score, furosemide intake, and survival status at ICU and hospital exit was collected. Statistical significance was considered when p b 0.05, and CI N 95%. Results: 81 patients were included, 60,5% (49) males, mean age was 66,4 ± 17,28 years, mean weight 73,0 ± 19,80 kg, mean length of stay in the ICU of 10,7 ± 5,93 days and 16% (13) mortality. HH was considered whenever the daily fluid balance was ≥10 ml/kg. In the first 24 h in the ICU, 48,1% (39) of the patients were HH, by the third day 39,5% (32) and by the fifth day 26,5% (18), with an overall progressively lower fluid balance along the days (meaning less patients meeting the HH criteria). HH status on the first day and during the first 3 and 5 days didn't correlate with higher ICU or in-hospital mortality. Nevertheless, we verified that deceased patients tended to have higher fluid balances in the first 3 days in the ICU, even though it didn't reach statistical significance. Also, patients with less HH by the third day were those with higher furosemide intakes, although also without statistical significance (63,3 mg vs 44,1 mg). Conclusions: This study seems to confirm the results obtained in other series where HH was associated with worst mortality in the ICU setting. Also, the use of diuretics seems to be appropriate as a way to control the fluid balance in the critically ill patient.
e69
doi:10.1016/j.ejim.2013.08.167
doi:10.1016/j.ejim.2013.08.168
a
ID: 555 Reduction of estimated glomerular filtration rate associated with drugs M. SanJulian-Romeroa, V. Escudero-Villaplanab, E. Duran-Garciab, M. Gomez-Antuneza, O. Lopez-Berasteguia, C. Lavilla-Ollerosa, A. Muiño-Migueza
TE
ID: 541 Coexistence of membranous nephropathy and IgA nephropathy in a patient with auto-immune thyroiditis F. Barrosa, M. Fonsecab, R. Vaza, R. Netoa, M. Pestanaa
Nephrology Department, Centro Hospitalar de São João, Porto, Portugal Internal Medicine Department, Hospital de Braga, Braga, Portugal
EC
b
a
UN
CO
RR
Background: Chronic auto-immune thyroiditis is the most common cause of thyroiditis and is diagnosed by the presence of antithyroglobulin and antiperoxidase antibodies. Although this disease has occasionally been reported in patients with glomerulonephritis, no causal relationship between the two disorders has been proved. The most commonly association is with membranous nephropathy followed by IgA nephropathy. The combination of these two disorders is rare and has been exclusively reported in patients without thyroid disease. Methods: An 18 year-old female patient presented to our clinic with nephrotic syndrome and thyroid dysfunction. She had been asymptomatic until 2 months before, when she noted maleolar edema and increase of weight. During the following weeks anasarca developed. She denied malaise, fever, anorexia, rashes, joint pain, hair loss or photophobia. She had no gross haematuria or foamy urine. No other symptoms were present. No previous infections were documented. She denied alcohol or drug abuse and had no active sexual life. Family history was unremarkable. Clinically, she was normotensive, and afebrile with generalized edema. Her physical examination was otherwise normal. Results: Haematological evaluation showed hemoglobin of 16.5 g/dL, normal white blood cell and platelet count. Biochemistry showed serum creatinine of 0.44 mg/dL, BUN of 7.9 mg/dL, normal electrolytes, total cholesterol of 276 mg/dL, total proteins of 57.8 g/L, and albumin of 23.2 g/L. Liver function tests were normal. Erythrocyte sedimentation rate was 62 mm on 1st hr and C-reactive protein was 1.2 mg/L (N b 3.0). Urinalysis revealed haematuria and 24 hour protein measurement was of 4.34 g. Antineutrophil cytoplasmic antibodies,
Medicina Interna B, Hospital Gregorio Marañon, Madrid, Spain Farmacia, Hospital Gregorio Marañon, Madrid, Spain
b
Objective: The objective of the study was to identify the reduction of estimated glomerular filtration rate (GFR) associated with drugs in patients admitted to internal medicine. Methods: Prospective observational study conducted in patients hospitalized in an internal medicine unit. All patients had been hospitalized for at least 24 h in the unit. Biochemical parameters were reviewed daily as well as patient prescriptions. Variables recorded were age, sex, length of hospital stay, and drugs with an estimated GFR. We performed two independent analyses of the data. We studied the possible association between estimated GFR out of range and the use of medication. On the other hand, we studied the association between the use of high-risk drugs (angiotensin convertase enzyme inhibitors (ACE), angiotensin receptor blockers (ARBs), oral antidiabetics) and the emergency of a reduction of estimated GFR. Results: 52 patients, 65% male, and median age was 72 years (62–83). Median hospital stay was 7 days (5–13). Percentage of patients prescribed with the drug were: ACE inhibitors 21,2%, ARBs 5,8%, and oral antidiabetics 3,8%. Percentage of patients with reduction of estimated glomerular filtration rate associated with drugs is 27% The percentage of patients with the drug as an associated reduction of GFR were: ACE inhibitors 34,8%, ARBs 33,3% and oral antidiabetics 50%. All adverse drug reactions (ADRs)identified in our study were mild, which could be due to their rapid detection. Conclusions:
RO
OF
antinuclear and double-stranded DNA antibodies were negative. Serum immunoglobulin measurement and complement levels were in the normal range. HIV, HBV and HCV serology were negative. Thyroid function test was abnormal, with free T4 of 0.76 ng/dL and TSH 2.12 UI/ mL. Antithyroglobulin and antiperoxidase antibodies were positive: 31.8 UI/mL (N b 4.11) and 130.4 UI/mL (N b 5.61), respectively. Chest X-ray and renal ultrasound were normal. Thyroid ultrasound showed a diffusely enlarged thyroid gland with a heterogeneous echotexture and hypoechoic micronodules. Renal biopsy showed 13 glomeruli with mesangial proliferation and basement membrane thickening. Immunohistology showed positive staining for IgA and C3c in mesangial areas and granular IgG deposits along the outer surface of capillary walls. C1q was negative. On ultramicroscopy, there were mesangial and subepithelial immunodeposits and effacement of podocyte foot processes. No endothelial tubuloreticular inclusions were observed. Both membranous and IgA nephropathy were diagnosed. Patient was put on lisinopril and diuretics. She needed no thyroid hormone substitutive treatment. Six months later, patient is on partial remission on dual blockade of the renin–angiotensin system, with proteinuria of 1.46 g/day. Thyroid function remains abnormal though. Conclusion: The association of membranous and IgA nephropathy has been rarely reported. Although both conditions have been independently reported in patients with thyroid disease, to our knowledge this is the first time that the coexistence of both diseases is described. We cannot determine whether this is a single disease or two distinct disorders in the context of autoimmune thyroiditis. In the short follow-up the patient is on partial remission with no need for immunosuppressive treatment.
DP
Introduction: Hyperhydration (HH) has been associated to higher morbidity and mortality in the critically ill patients. Objectives: Assess the impact of HH in the prognosis of critically ill patients. Methods: Prospective observational study in an Intensive Care Unit (ICU), including patients over 18-years-old admitted during 2012. Data on demographic elements, fluid balance, SOFA score, furosemide intake, and survival status at ICU and hospital exit was collected. Statistical significance was considered when p b 0.05, and CI N 95%. Results: 81 patients were included, 60,5% (49) males, mean age was 66,4 ± 17,28 years, mean weight 73,0 ± 19,80 kg, mean length of stay in the ICU of 10,7 ± 5,93 days and 16% (13) mortality. HH was considered whenever the daily fluid balance was ≥10 ml/kg. In the first 24 h in the ICU, 48,1% (39) of the patients were HH, by the third day 39,5% (32) and by the fifth day 26,5% (18), with an overall progressively lower fluid balance along the days (meaning less patients meeting the HH criteria). HH status on the first day and during the first 3 and 5 days didn't correlate with higher ICU or in-hospital mortality. Nevertheless, we verified that deceased patients tended to have higher fluid balances in the first 3 days in the ICU, even though it didn't reach statistical significance. Also, patients with less HH by the third day were those with higher furosemide intakes, although also without statistical significance (63,3 mg vs 44,1 mg). Conclusions: This study seems to confirm the results obtained in other series where HH was associated with worst mortality in the ICU setting. Also, the use of diuretics seems to be appropriate as a way to control the fluid balance in the critically ill patient.
e69
doi:10.1016/j.ejim.2013.08.167
doi:10.1016/j.ejim.2013.08.168
a
ID: 555 Reduction of estimated glomerular filtration rate associated with drugs M. SanJulian-Romeroa, V. Escudero-Villaplanab, E. Duran-Garciab, M. Gomez-Antuneza, O. Lopez-Berasteguia, C. Lavilla-Ollerosa, A. Muiño-Migueza
TE
ID: 541 Coexistence of membranous nephropathy and IgA nephropathy in a patient with auto-immune thyroiditis F. Barrosa, M. Fonsecab, R. Vaza, R. Netoa, M. Pestanaa
Nephrology Department, Centro Hospitalar de São João, Porto, Portugal Internal Medicine Department, Hospital de Braga, Braga, Portugal
EC
b
a
UN
CO
RR
Background: Chronic auto-immune thyroiditis is the most common cause of thyroiditis and is diagnosed by the presence of antithyroglobulin and antiperoxidase antibodies. Although this disease has occasionally been reported in patients with glomerulonephritis, no causal relationship between the two disorders has been proved. The most commonly association is with membranous nephropathy followed by IgA nephropathy. The combination of these two disorders is rare and has been exclusively reported in patients without thyroid disease. Methods: An 18 year-old female patient presented to our clinic with nephrotic syndrome and thyroid dysfunction. She had been asymptomatic until 2 months before, when she noted maleolar edema and increase of weight. During the following weeks anasarca developed. She denied malaise, fever, anorexia, rashes, joint pain, hair loss or photophobia. She had no gross haematuria or foamy urine. No other symptoms were present. No previous infections were documented. She denied alcohol or drug abuse and had no active sexual life. Family history was unremarkable. Clinically, she was normotensive, and afebrile with generalized edema. Her physical examination was otherwise normal. Results: Haematological evaluation showed hemoglobin of 16.5 g/dL, normal white blood cell and platelet count. Biochemistry showed serum creatinine of 0.44 mg/dL, BUN of 7.9 mg/dL, normal electrolytes, total cholesterol of 276 mg/dL, total proteins of 57.8 g/L, and albumin of 23.2 g/L. Liver function tests were normal. Erythrocyte sedimentation rate was 62 mm on 1st hr and C-reactive protein was 1.2 mg/L (N b 3.0). Urinalysis revealed haematuria and 24 hour protein measurement was of 4.34 g. Antineutrophil cytoplasmic antibodies,
Medicina Interna B, Hospital Gregorio Marañon, Madrid, Spain Farmacia, Hospital Gregorio Marañon, Madrid, Spain
b
Objective: The objective of the study was to identify the reduction of estimated glomerular filtration rate (GFR) associated with drugs in patients admitted to internal medicine. Methods: Prospective observational study conducted in patients hospitalized in an internal medicine unit. All patients had been hospitalized for at least 24 h in the unit. Biochemical parameters were reviewed daily as well as patient prescriptions. Variables recorded were age, sex, length of hospital stay, and drugs with an estimated GFR. We performed two independent analyses of the data. We studied the possible association between estimated GFR out of range and the use of medication. On the other hand, we studied the association between the use of high-risk drugs (angiotensin convertase enzyme inhibitors (ACE), angiotensin receptor blockers (ARBs), oral antidiabetics) and the emergency of a reduction of estimated GFR. Results: 52 patients, 65% male, and median age was 72 years (62–83). Median hospital stay was 7 days (5–13). Percentage of patients prescribed with the drug were: ACE inhibitors 21,2%, ARBs 5,8%, and oral antidiabetics 3,8%. Percentage of patients with reduction of estimated glomerular filtration rate associated with drugs is 27% The percentage of patients with the drug as an associated reduction of GFR were: ACE inhibitors 34,8%, ARBs 33,3% and oral antidiabetics 50%. All adverse drug reactions (ADRs)identified in our study were mild, which could be due to their rapid detection. Conclusions: