Images in Clinical Rheumatology
Nephrocalcinosis in a Patient With Rheumatoid Arthritis and Secondary Sjögren's Syndrome
Nefrocalcinosis en una paciente con artritis reumatoide y síndrome de Sjögren secundario
Luis María Jiménez Liñán
, Sergio Antonio Rodríguez Montero, José Luis Marenco de la Fuente
Corresponding author
Unidad de Gestión Clínica de Reumatología, Hospital Universitario Nuestra Señora de Valme, Sevilla, Spain
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Radiopaques of calcium density were observed in the X-ray images which covered both renal silhouettes (white arrows). (B) Lateral radiograph where these calcifications are apparent, from vertebrae L2 to L4 (white arrow).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Presentation of the Case</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 48-year-old female was diagnosed in 2008 with rheumatoid arthritis with a presence of the rheumatoid factor (RF) and an absence of antibodies against cyclic citrullinated peptides (anti-CCPs). She met with the 1987 ACR classification criteria (morning stiffness for over 1<span class="elsevierStyleHsp" style=""></span>h, symmetric arthritis of both carpal joints and of the 2nd to 4th bilateral proximal interphalangeal joints, a positive RF result and radiography showing erosions in carpal joints). She also met with four out of six criteria of the 2002 American/European Consensus Classification (AECC) for Sjögren's syndrome (xerostomia, xerophthalmia, Schirmer 4<span class="elsevierStyleHsp" style=""></span>mm test and positive results for anti-Ro/SSA 52 and 60 and anti-La/SSB antibodies), together with hypergammaglobulinaemia and infiltration of parotid glands viewed in the CT scan. In her clinical history, renal colic is notable, repeated over 10 years ago. It was assessed by the urology department which determined a wait-and-see approach. She is currently undergoing treatment with prednisone, sulfasalazine, methotrexate and ophthalmic cyclosporine, having already completed two cycles of 1<span class="elsevierStyleHsp" style=""></span>g rituximab due to persistent polyarthritis.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We observed an incidental finding of bilateral renal calcifications on an X-ray of the abdomen (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Analytically, the levels of creatinine and urea were normal (CKD-EPI 100.7<span class="elsevierStyleHsp" style=""></span>ml/min), there were no basic–acid and hydroelectrolitical equilibrium alterations, she did not present with proteinuria and calcium levels were normal in urine at 24<span class="elsevierStyleHsp" style=""></span>h (90<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h), as was phosphaturia. The pH balance was slightly alkaline (6.5) and there was insufficient vitamin D (36.8<span class="elsevierStyleHsp" style=""></span>nmol/l) although parathyroid hormone levels were normal.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Diagnosis and Evolution</span><p id="par0015" class="elsevierStylePara elsevierViewall">As a result of the radiologic findings, the patient was diagnosed with nephrocalcinosis within the context of SS, despite not presenting with clinical or analytical alterations of nephropathy or alterations in the phosphocalcic metabolism. Close monitoring of renal function with periodical analytical controls was determined as treatment.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">Nephrocalcinosis is characterised by calcification of the renal parenchyma. There are many causes including hyperparathyroidism, hypercalcemic nephropathy from excess vitamin D, Cacchi–Ricci disease (medullary sponge kidney) or distal renal tubular acidosis (dRTA) or type I acidosis.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In SS, specifically, kidney function may be compromised in around 5% of cases. One of the possible causes of kidney compromise is dRTA. This leads to urinary alkalosis (pH<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>5.5), hyposthenuria, hypercalciuria, hyperphosphatemia and hypocitraturia, with or without metabolic acidosis and in several cases to hypokalaemia.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">2,3</span></a> Those patients with suspected dRTA who do not meet with analytical criteria may be given the ammonium chloride acid loading test to demonstrate the kidney's inability to acidify urine (pH<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>5.5).<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">When there is development of basic–acid and hydroelectrolytic equilibrium alterations, treatment consists of administering bicarbonate and potassium citrate supplements to alkalinise the medium and recover losses, as well as a baseline treatment with glucocorticoids and immunosuppressants.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1,5,6</span></a> It should be highlighted that the course of nephrolithiasis is distinct from that of nephrocalcinosis and that an incorrect treatment of metabolic acidosis may lead to the progression of nephrocalcinosis.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">We would therefore recommend an initial screening in patients with SS to detect possible nephropathy. An analysis of ions in the blood and of the phosphocalcic metabolism should be requested, as should a urine test at 24<span class="elsevierStyleHsp" style=""></span>h, to evaluate the pH level, the proteinuria and excretion of ions, an immunological and serological test and also imaging tests.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Ethical Liabilities</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Protection of people and animals</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no experiments using human beings or animals have been carried out for this research study.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Data confidentiality</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare they have followed the protocols of their centre of work on patient data publication.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of Interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Presentation of the Case" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Diagnosis and Evolution" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 3 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical Liabilities" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of people and animals" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Data confidentiality" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of Interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-12-13" "fechaAceptado" => "2017-02-11" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Jiménez Liñán LM, Rodríguez Montero SA, Marenco de la Fuente JL. Nefrocalcinosis en una paciente con artritis reumatoide y síndrome de Sjögren secundario. Reumatol Clin. 2019;15:58–59.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 985 "Ancho" => 1750 "Tamanyo" => 162509 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(A) Anteroposterior X-ray of the abdomen. Radiopaques of calcium density were observed in the X-ray images which covered both renal silhouettes (white arrows). (B) Lateral radiograph where these calcifications are apparent, from vertebrae L2 to L4 (white arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nephrocalcinosis: initial manifestation of primary Sjögren's syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "E. Lazaro" 1 => "G. Étienne" 2 => "P. Mercié" 3 => "M. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 16 | 13 | 29 |
| 2024 October | 67 | 26 | 93 |
| 2024 September | 68 | 39 | 107 |
| 2024 August | 69 | 55 | 124 |
| 2024 July | 90 | 38 | 128 |
| 2024 June | 75 | 54 | 129 |
| 2024 May | 76 | 45 | 121 |
| 2024 April | 78 | 33 | 111 |
| 2024 March | 62 | 55 | 117 |
| 2024 February | 23 | 45 | 68 |
| 2024 January | 56 | 26 | 82 |
| 2023 December | 37 | 37 | 74 |
| 2023 November | 35 | 25 | 60 |
| 2023 October | 55 | 38 | 93 |
| 2023 September | 63 | 45 | 108 |
| 2023 August | 85 | 19 | 104 |
| 2023 July | 53 | 24 | 77 |
| 2023 June | 57 | 27 | 84 |
| 2023 May | 70 | 30 | 100 |
| 2023 April | 44 | 10 | 54 |
| 2023 March | 65 | 25 | 90 |
| 2023 February | 60 | 30 | 90 |
| 2023 January | 84 | 25 | 109 |
| 2022 December | 52 | 29 | 81 |
| 2022 November | 68 | 32 | 100 |
| 2022 October | 71 | 30 | 101 |
| 2022 September | 57 | 36 | 93 |
| 2022 August | 70 | 41 | 111 |
| 2022 July | 70 | 30 | 100 |
| 2022 June | 63 | 30 | 93 |
| 2022 May | 81 | 38 | 119 |
| 2022 April | 113 | 54 | 167 |
| 2022 March | 99 | 39 | 138 |
| 2022 February | 102 | 44 | 146 |
| 2022 January | 85 | 33 | 118 |
| 2021 December | 56 | 39 | 95 |
| 2021 November | 53 | 42 | 95 |
| 2021 October | 77 | 50 | 127 |
| 2021 September | 60 | 36 | 96 |
| 2021 August | 46 | 37 | 83 |
| 2021 July | 46 | 31 | 77 |
| 2021 June | 35 | 23 | 58 |
| 2021 May | 49 | 37 | 86 |
| 2021 April | 108 | 72 | 180 |
| 2021 March | 70 | 28 | 98 |
| 2021 February | 68 | 22 | 90 |
| 2021 January | 35 | 26 | 61 |
| 2020 December | 38 | 16 | 54 |
| 2020 November | 57 | 22 | 79 |
| 2020 October | 26 | 20 | 46 |
| 2020 September | 40 | 23 | 63 |
| 2020 August | 32 | 18 | 50 |
| 2020 July | 27 | 9 | 36 |
| 2020 June | 45 | 14 | 59 |
| 2020 May | 23 | 14 | 37 |
| 2020 April | 22 | 13 | 35 |
| 2020 March | 24 | 10 | 34 |
| 2019 June | 0 | 2 | 2 |
| 2019 February | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
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