Hypomagnesemia due to renal disease of unknown etiology

Hypomagnesemia

Due to Renal Disease of

Unknown Etiology

LAW RUNEBERG,M.D. YRJG COLLAN, M.D. EERO J. JOKINEN, M.D. JUHANI LAHDEVIRTA, M.D. ANTTI ARO, M.D. Helsinki, Finland

A young man, investigated because of tetanic convulsions and arthritic pains, was shown to have hypomagnesemla, hypermagnesuria, hypokalemia, hypercalciuria, progresslve nephrocalclnosis and chondrocalcinosis. In this syndrome, renal function was normal except for the abnormal excretion of electrolytes. Renal sodium conservation was normal. Light and electron microscopic studies of renal biopsy specimens showed the presence of several abnormal tubules. lmmunofluorescent staining showed deposits of immunoglobulins in the glomeruli and tubules. Magnesium therapy was started under balance study conditions and resulted in decreased cakiuria and complete remission of subjective symptoms. the progression of nephrocalcinosls was halted, and there was some decrease in the intra-articular cakiurn deposits after two years of continuous oral magnesium therapy. The administration of spironolactone decreased urinary magnesium but did not normalize it, whereas triamterene administration was without effect in this respect. The results of the morphologic and electrolyte balance studies are discussed. The patient was found to exhibit several features which have not been described before In connectlon wtth hypomagnesemia of unknown origin. Persistent excessive renal loss of magnesium is an uncommon syndrome of often unknown etiology [l-4]. In this report we describe our investigations in a young man with severe loss of mag-

nesium into the urine, together with hypercalciuria, nephrocalcinosis, chondrocalcinosis and secondary hyperaldosteronism. When he was given magnesium, the tetanic and arthritic symptoms disappeared and his chemical abnormalities were alleviated. CASE REPORT

From the Third Department of Medicine, Universky Central Hospital: and Second Department of Pathology, and Department of Serology and Bacteriology, University of Helsinki, Helsinki, Finland. Requests for reprints should be addressed to Dr. Lars Runeberg, Maria Hospital, Lapinlahdenkatu 16, 00180 Helsinki 18, Finland. Manuscript accepted April 2, 1975.

In 1961, at the age of six, the patient was brought to the hospital for the first time complaining of tetanic convulsions. Hypocalcemia and hypokalemic alkalosis were found. Eighteen months later he had arthritic pains in his ankles and knees. The hypocalcemia and hypokalemia persisted although extra calcium and potassium were given. A renal biopsy was performed. On light microscopy the glomeruli appeared normal. An occasional homogeneous cast was seen in a cortical tubule, but there was heavy medullary nephrocalcinosis with calcified granular intratubular material and microliths. These stained blue with hematoxylin and eosin, and von Kossa’s reaction was positive. The areas with the most prominent calcification showed fibrosis, but no other signs of inflammation were seen.

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TABLE I

ET AL.

Laboratory Investigations Before and During Magnesium Therapy Determination

Reference Value

May 72t

April 73t

April 74t

Serum potassium (mmol/liter)

3.7-5.3

2.9

3.3

3.0

3.8

Serum magnesium (mmol/liter) Serum calcium (mmol/liter) Serum protein (g/liter)

0.7-1.0

0.19

0.45

0.46

0.56

2.25-2.75

2.20

2.42

2.52

2.72

60-85

Urinary magnesium (mmol/24 hours) Urinary calcium (mmol/24 hours) *Pretreatment values. t Values during continuous

treatment

81

0.5-12.5

4.80

1.25-5.5

14.65

started

in January

The boy had developed normallywhen he was reexamined at the age of 13 in the Department of Pediatrics, University Central Hospital, Helsinki. A second biopsy specimen showed a few hyalinized glomeruli, slight patchy interstitial fibrosis and thickening of the distal tubular basement membrane in a few tubules. Potassium and ammonium chloride supplements were given, but the patient continued to have tetanic symptoms and intermittent arthritic pains. At the age of 14 his serum magnesium level was estimated for the first time and found to be low, 0.24 mmol/liter (reference value 0.70 to 1.0 mmol/liier). X-ray examination showed bilateral nephrocalcinosis. Two years later he had a swollen left knee after a minor injury. The synovial fluid contained numerous white cells, mainly lymphocytes. Cultures for bacteria were negative. The patient was then transferred to the Third Department of Medicine for further investigation. He was in a good general condition when examined in December 1971. He was 168 cm tall and weighed 51.5 kg. His blood pressure was 120180 mm Hg. There was an effusion in the left knee and Chvostek’s sign was strongly positive. An electrocardiogram showed sinus tachycardia, prominent U waves and occasional premature ventricular beats.

77

82

81

13.2

14.2

10.1

9.90

nephrocalcinosis in Jan&y

December

1975

7.85

Hemoglobin, fractioned serum proteins, serum alkaline phosphatases, creatinine and uric acid levels were normal, and tests for rheumatoid factor and antinuclear antibodies were negative. The erythrocyte sedimentation rate was 47 mm/hour. Serum sodium was 142, chloride 101 and phosphate 1.61 mmol/liter. Biood pH was 7.39 and carbon dioxide tension PC02 41 mm Hg. The values for potassium, magnesium, calcium and serum protein are given in Table I. The urinalysis was normal. Roentgenograms (Figure 1) showed that, compared with earlier pictures, the nephrocalcinosis had markedly increased. Roentgenograms of the skeleton showed no abnormalities except for those of the knees, which showed chondrocalcinosis (Figure 2). Calcium pyrophosphate crystals were demonstrated by microscopy in the synovial fluid of the left knee. For the arthritis, the patient was treated with immobilization and indomethacine for one month. After treatment with magnesium was begun, the effusion vanished and the joints have since given no symptoms. The erythrocyte sedimentation rate became normal. Both the mother and the siblings of the patient had normal serum potassium and magnesium values. The father had died in a traffic accident in 1961. The families of the parents originate from different parts of Finland and consanguinity is unlikely. BALANCE

STUDY

The patient was given an isocaloric diet (2,400 kcal/ day) containing 95 mmol of sodium, 102 mmol of potassium, 11.5 mmol of magnesium and 22.8 mmol of calcium per 24 hours; 140 mmol of potassium chloride and 48 mmol of ammonium chloride, which had been his daily medication during the preceding year, were added. Using CraOa as an internal nonabsorbable marker to allow correction for fecal flow as described previously [5], his urine and stools were collected and analyzed. The results of the balance study are summarized in Figures 3 and 4. Serum potassium (2.9 to 3.3 mmol/liter) and magnesium (0.22 to 0.29 mmol/liter) as well as red cell potassium (80 mmol/

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HYPOMAGNESEMIADUE To RENAL DISEASE---RUNEBERG ET AL.

Roentgenogram of the left knee. The picture on the left shows the chondrocalcinosis before treatment in January 1972. The picture on the right shows a slight decrease in the calcified deposits after two years of treatment.

Figure 2.

liter) and magnesium (1.5 to 1.6 mmol/liter) values were low at the beginning of the study. The red cell potassium content increased to 98 mmol/liter during the control period, while the red cell magnesium level remained unchanged. Serum sodium, chloride, calcium, phosphate, creatinine, protein and Astrup analyses were normal. The urinary excretion of magnesium (6.0 to 7.2 mmol/day), potassium (196 to 229 mmol/day) and calcium ( 10.7 to 12.7 mmol/day) was ’ inappropriately high. The magnesium balance was neutral (Figure 4), and the fecal magnesium level was normal or low indicating normal intestinal absorption. The calcium balance was negative mainly because of high urinary excretion. Intravenous infusions of 40 to 60 mmol of magnesium chloride were then given on eight subsequent days. The urinary magnesium increased and a positive balance was achieved as the patient’s fecal magnesium remained unchanged. A total of 247 mmol of magnesium appeared to have been retained during this period. His serum magnesium, potassium, sodium and calcium levels increased and his urinary calcium and phosphate levels decreased. The infusions were stopped and then magnesium was given orally as a mixture of magnesium hydroxide and chloride in variable daily amounts as noted in Figure 4. The volume of feces increased and the fecal magnesium increased five to sixfold indicating poor absorption of excess magnesium. His urinary magnesium level was higher than during the control period. The balance remained positive, red cell magnesium increased to 1.90 to 2.14 mmol/liter, and a total of 320 mmol appeared to have been retained during

December

the 32 days of oral magnesium therapy. The administration of 400 mg spironolactone per day decreased, but did not abolish, renal wasting of magnesium and it also decreased urinary potassium while urinary sodium increased. The administration of 200 mg triamterene decreased urinary potassium but did not affect urinary magnesium. When dietary sodium was restricted, urinary sodium decreased appropriately and urinary magnesium also decreased but remained inappropriately high. The patient was polyuric during the entire study, but his urine volume decreased somewhat during magnesium therapy. Urinary aldosterone increased during the control period but decreased to normal during magnesium therapy. Sodium depletion caused an expected increase in urinary aldosterone. The initial hyperaldosteronism was thus probably due to magnesium depletion [6,7]. Urinary 17-keto and -ketogenic steroids were normal and a primary disturbance of adrenal function was thus excluded. RENAL BIOPSY STUDIES A percutaneous renal biopsy specimen was taken with a Silverman needle. The specimen was divided in chilled Ringer solution for light microscopic, electron microscopic and immunofluorescence studies. The technical details for light microscopy and electron microscopy have been described previously [8]. For immunofluorescence examination cryostat sections, 6 pm thick, were prepared from kidney tissue, and stained by the direct technic with FITC-conjugated antibody to immunoglobulins A (IgA), G (IgG), M (IgM), C3 and fibrinogen. Monospecific antiserums to

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I

control

S-Na

oral administration of Mg(OH12 and MgC12

MgC12infusion

115

mmoles/l

1LO 1.0

S-K mmoles/l S-Ca mmoles /L S-Mg mmoles/l

2.5 3.0 2.0 0.8 0.2

dU-Na mmoles/2C

h

100 0 200

dU-K mmoles/2l

h

dU-Ca mmoles/2C

h

100

0 30

I

II I

dU-Mg mmoles/2l

L

20 h

0 300 dU-CI mmoles/21.

h 200 100

dU-Pi mmoles/21

h

dU-Volume 1/2L h

0 30 20 10 0 8 -y LO800 -

dU-Aldosterone nmoles/21 h J,,~,,;,, 10

20

,,, 30

(((

,,,

,,I--

LO

days

Changes in blood chemistry and renal excretion of electrolytes, water and atiosterone during magnesium therapy and low sodium intake. Sodium and potassium intakes are indicated in the figure. The intake of magnesium and calcium is given in Figure 4. Spironolactone, 400 mg/day, was given on days 3 1 to 34 and friamterene, 200 mg/day, on days 39 to 42.

Figure 3.

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unnary excretion fecal ercretlon 10

Figure 4. magnesium

20

The intake and excretion

30

of magnesium

LO

days

and calcium during different

loads.

alpha, gamma and mu chains and fibrinogen were obtained commercially (Behringwerke AG). Otherwise the technic was unchanged from that described previously [8]. The sections for light microscopy study contained cortical tissue with 10 glomeruli. Of these, 6 appeared normal, around 3 there was fibrosis, and 1 was hyalinized with slight surrounding chronic interstitial inflammation. The juxtaglomerular apparatus at a few glomeruli appeared prominent. The proximal tubules with their basement membranes and surrounding interstitial tissue appeared normal. Sections across the loops of Henle were not seen. Adjacent to 2 glomeruli, sections of a winding abnormal tubule were seen. The basement membrane was greatly thickened and the tubule cells were low with large nuclei (Figure 5A). In a serial section study [9] on an Epon embedded biopsy piece (144 individual 1 pm sections, 10 pm between sections), no direct contact between these abnormal tubules and the glomeruli could be found. Adjacent to 3 glomeruli surrounded by fibrosis, distal tubules with homogeneous intraluminal casts were seen close to the juxtaglomerular apparatus. The light microscopy findings were similar to those observed in earlier biopsy specimens and, considering the patchy distribution of the lesions, no definite progression could be postulated. Under electron microscopy the glomeruli appeared normal except for dark globular masses which could be seen in the basement membranes of the glomerular arterioles in the glomerular hilus, and occasional small dark deposits in the mesangial basement membrane (Figure 6). The juxtaglomerular apparatus appeared hypertrophic and contained cells with specific granules. The abnormal tubules described under light microscopy had greatly thickened homogeneous

December

basement membranes (Figures 5B and 5C) and were surrounded by fibrotic interstitium. The cells were low and had small luminal fingerlike projections. They were attached to each other by junctional complexes at their luminal borders. The nuclei and the nucleoli were large (Figures 58 and 5C). Basal infoldings typical of normal tubular cells [lo] were almost absent, and the distal tubular profiles close to the macula densa also showed defective basal infoldings. Occasionally the tubule cells also had a layer of apical microvilli (Figure 5C). The sections for immunofluorescence contained 4 glomeruli with focal deposits typical of immune complex disease. Along the capillary basement membrane a fine granular deposit could be seen (Figure 7). The pattern of fluorescence was quite similar with IgG, IgA, IgM, C3 and fibrinogen. In some tubules, especially in the neighborhood of glomeruli, a coarse deposit consisting of IgG, C3 and fibrinogen was seen along the basement membrane (Figure 7). In addition, the cells in these tubules contained granules of IgG and C3. In the interstitial tissue, a focal accumulation of fibrinogen and some IgG-containing plasma cells were noted. THERAPY In the 23 months following the studies described, the patient received the following daily medication orally: 30 mmol of magnesium chloride, 20 mmol of magnesium hydroxide and 45 mmol of potassium chloride. During this period he has been free from tetanic convulsions and arthritis, and his general condition has been good. He has been admitted three times for control investigations, the results of which are summarized in Table I. The serum magnesium level appears to rise slowly during the treatment, but it does

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Flgure 5. A, low power view of the kidney biopsy specimen obtained when the patient was 16 years old. Note the norma! appearing glomerulus and in its neighborhood the abnormal tubules with greatly thickened basement membrane. kðylene blue stained Epon@ section; original magnification X 250, reduced by 34 per cent. B, electron micrograph of an abnormal tubular epithelial cell. The nucleus is huge and shows two round nonchromatin areas (arrows) and a large nucleolus. There is a junctional complex binding adjacent epithelial cells tightly together. Cell cytoplasm does not show the signs of differentiation typical of normal tubular cells and basal infoldings are deficient. The basement membrane is thick and homogeneous with no deposits. Original magnification X 15,000, reduced by 47 per cent. C, another tubule with abnormally thickened basement membrane containing a few granular deposits (arrow). In this case there are apical microvilli (arrow) in the epithelial cells. Original magnification X 6,700, reduced by 48 per cent.

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Figure 6. Mesangial glomerular basement membrane with dark granular intramembranous deposit (arrow). Original magnification X 24.000, reduced by 25 per cent.

Figure 7. lmmunofluorescent studies on the renal biopsy specimen. The picture on the left shows fine granular deposits of IgA along the glomerular basement membrane. The section is stained with fluorescent antihuman IgA antibody. The picture on the r/ghf shows granular deposits of C3 along the tubular basement membrane and in the tubular ceils. The section is stained with fluorescent antihuman C3 antibody. Original magnification X 320 (left) and X 675 (right), reduced by 72 per cent.

not reach normal levels. The renal leak of magnesium appears to increase with increasing serum concentration and/or body stores of magnesium (Figure 3) and the renal lesion may thus prevent complete correction of the magnesium deficiency. The calcification in the kidneys and knees has definitely not increased: they seem to have actually decreased, particularly in the knees (Figure 2) although the nephrocalcinosis was steadily progressing until magnesium therapy was started.

COMMENTS The results of the balance study imply defective renal tubular handling of magnesium. A general disturbance of tubular function is excluded since glucose, amino acids, uric acid and sodium were conserved efficiently. The renal loss of potassium may have been due to severe magnesium depletion [ 111, because magnesium therapy reduced the excretion of aldosterone to normal while the serum potassium concentration increased. But the patient still needed

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regular potassium supplements and we cannot say whether this was due to inadequate magnesium supplements or whether it was an independent phenomenon. The renal tubular handling of magnesium resembles that of potassium [ 12,131, and loss of both these intracellular cations may well be due to the same etiologic cause. Magnesium deficiency causes hypercalciuria and nephrocalcinosis in experimental animals [ 13- 151. In our patient, magnesium therapy normalized urinary calcium and stopped progression of nephro- and chondrocalcinosis. So the disturbed calcium metabolism was at least partly caused by magnesium deficiency. Urinary calcium reached its minimal value after about two weeks of magnesium therapy. At that time the patient was receiving oral magnesium substitution, and both serum and urinary magnesium levels were lower than during the initial period of parenteral substitution. We conclude that the effect of magnesium on urinary calcium was probably due to resaturation of intracellular magnesium rather than to changes in the extracellular fluid. Since there was no decrease in filtered calcium, tubular reabsorption was apparently increased. This is particularly interesting in view of the fact that extra magnesium usually increases calcium loss because there is competition between calcium and magnesium for reabsorption by the tubular cells. The results of magnesium therapy also suggest that the chondrocalcinosis was due to magnesium deficiency. A low magnesium concentration is known to inhibit pyrophosphatase and also to favor the precipitation of calcium pyrophosphate in vitro [ 161. Both these facts may be important for the development of chondrocalcinosis [ 16,171. Chondrocalcinosis has, however, not been described as a typical feature of experimental or clinical magnesium deficiency, and additional factors may have been operating in our patient. We know of only one patient in whom chondrocalcinosis was associated with hypomagnesemia of unknown cause

[181. In additon to nephrocalcinosis, the morphologic study of the renal biopsy specimens showed several abnormal tubules with thickened basement membranes whereas most tubules appeared normal. The abnormal tubules do not resemble those observed in nephrocalcinosis due to magnesium deficiency or other causes [l&19,20], and we believe that they may reflect the primary lesion responsible for the electrolyte disturbance. Spironolactone decreased urinary magnesium and potassium, but especially the renal excretion of magnesium remained high with respect to the prevailing hypomagnesemia. It may be that spironolactone acted on the normal tubules but did not affect the abnormal ones, which may have

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continued to excrete magnesium at an abnormal rate. We could not definitely localize the lesion. The general appearance of the affected tubules suggested that they were distal tubules, but the brush border observed in a few tubular cells suggested that they might have been proximal tubules. No contact with the glomeruli was demonstrated by serial sectioning, so the cells could not have belonged to the neck region of the proximal tubules. Increasing urinary magnesium and potassium could result from impaired absorption as well as from excessive leakage of intracellular ions into the tubular lumen in any part of the nephron. So the balance study did not help to localize the lesion. The immunofluorescent staining revealed a granular deposit of immunoglobulins and complement along the glomerular capillary and tubular basement membranes. These findings are in concordance with those obtained by electron microscopy, and they suggest an acquired renal lesion. The deposits in the glomeruli are typical of circulating immunocomplexes with antigens of either renal or nonrenal origin [21] whereas the deposits in the tubules suggest the involvement of tubular antigens. These deposits could have resulted from autoantigens leading out from tubular cells and combining with autoantibodies diffusing from peritubular capillaries [22]. Similar deposits have been observed in patients with membranous glomerulonephritis [23], lupus nephritis [24] and in renal allografts [25]. It could be that the same agent which is responsible for the leaking out of intracellular cations from the tubular cells may also allow intracellular antigens to escape from the leaky cells. The relatively late onset of symptoms and the patchy distribution of the lesion in the kidney suggest an acquired primary lesion, whereas the uncommon and specific disturbance of the excretion of intracellular cations might fit better with an inborn error of metabolism. So we have no final conclusions as to the etiology in this case. Longstanding renal magnesium loss as severe as in our patient is uncommon, but has been reported in three patients who were extensively studied by Gitelman et al. [3], who suggested a hereditary etiology. In contrast to their patients, our patient had severe neuromuscular symptoms, nephrocalcinosis, hypercalciuria, chondrocalcinosis, no dermal changes and he responded to spironolactone. There may, therefore, be several variants in the syndrome of persistent and severe renal magnesium loss of unknown cause. In our patient, the long and successful treatment with maximal magnesium supplements illustrates the importance of carrying out magnesium determinations in the presence of unusual electrolyte disturbances.

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REFERENCES Yendt ET: Disorders of calcium, phosphorus and magnesium metabolism. Clinical Disorders of Fluid and Electrolyte Metabolism (Maxwell MH, Kleeman CR eds). New York, McGraw-Hill Book Co, 1972, p 401. 2. Freeman RM. Pearson E: Hypomagnesemfa of unknown etiology. Am J Med 41: 645. 1966. 3. Gitelman HJ, Graham J, Welt A: A familial disorder characterised by hypokalemia and hypomagnesemia. Ann NY Acad Sci 162: 856. 1969. Booth BE, Johanson A: Hypomagnesemfa due to renal tubular defect in reabsorption of magnesium. J Pediatr 84: 350, 1974. Runeberg L. Miettinen TA, Nikkil;i EA: Effect of cholestyramine on mineral excretion in man. Acta Med Stand 192: 71. 1972. Ginn HE, Cade R, McCallum T, Fregley M: Aldosterone secretion in magnesium deficient rats. Endocrinology 80: 969. 1967. 7. Cantin M: Relationship of juxtaglomerular apparatus and adrenal cortex to biochemical and extracellular fluid volume changes in magnesium deficiency. Lab Invest 22: 558, 1970. a. Runeberg L, Uhdevirta J, Collan Y, Jokiien EJ: Renal tubular dysfunction and hypergammaglobulinemia. Acta Med Stand 189: 341, 1971. 9. Collan Y, Collan l-l: interpretation of serial sections. 2 Wiss Mikrosk 70: 156, 1970. 10. Trump BF, Bulger RE: Morphology of the kidney. Structural Basis of Renal Disease (Lovell Becker E, ed), New York, Hoeber Medical Division, 1968, p 1. 11. Shils ME: Experimental human magnesium depletion. Medicine (Baltimore) 48: 6 1, 1969. 12. Wen SF, Evanson RL, Dirks JH: Micropuncture study of magnesium transport in proximal and distal tubule of the dog. Am J Physiol219: 570, 1970. 13. Gftelman HJ, Welt LG: Magnesium deficiency. Ann Rev Med 20: 233. 1969.

14. 15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

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Clark I: Effect of magnesium ions on calcium and phosphorus metabolism. Am J Physiol 214: 348, 1968. Weft LG: Physiological data on magnesium and the kidney. 1st international Symposium on Magnesium Deficit in Human Pathology (Durlach J, ed). Vittei, 1971. p 347. McCarty DJ. Sheldon DS, Warnock ML. et al.: Inorganic pyrophosphate concentrations in the synoviai fluid of arthritic patients. J Lab Clin invest 78: 216, 1971. Yaron M. Zurkowski P, Weiser HI. et al.: Pseudogout with low values of alkaline phosphatase in the synoviai fluid. Ann Intern Med 73: 751. 1970. McCarty DJ, Silcox DC, Coe F, et al.: Diseases associated with calcium pyrophosphate dihydrate crystal deposition. A controlled study. Am J Med 56: 704, 1974. Collan Y. Luoma H. Ylinen A, Teir H: Histological and ultrastructural features of nephrocaicinosis caused by a caries-reducing diet. Calc Tissue Res 8: 247, 1972. Oliver J, MacDowell M, Whang R, Welt LG: The renal lesions of electrolyte imbalance. IV. The intranephronic calculosis of experimental magnesium depletion. J Exp Med 124: 263, 1966. Edgington TS. Glassock RJ, Dixon FJ: Autoiogous immunecomplex pathogenesis of experimental allergic glomerulonephritis. Science (Washington) 155: 1432, 1967. Klassen J, McCluskey RT, Milgrom F: Nonglomerular renal disease produced in rabbits by immunization with homologous kidney. Am J Pathoi 63: 333, 197 1. Berger J, Galle P: Depots denses au sein des membranes basales du rein. Etude en microscpmicroscopies optique et eiectronique. Presse Med 7 1: 235 1, 1963. McCluskey RT: The value of immunofluorescence in the study of human renal disease. J Exp Med 134: 242s 1971. Andres GA, Accini L, Hsu KC, et al.: Human renal transplants. ill. lmmunopathoiogical studies. Lab Invest 22: 588, 1970.

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