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Zeng Y, Liu R, Li S, Wei J, Luo F, Chen Y, Zhou D. Analysis of risk factors and development of a nomogram prediction model for renal tubular acidosis in primary Sjogren syndrome patients. Arthritis Res Ther 2024; 26:151. [PMID: 39175019 PMCID: PMC11340110 DOI: 10.1186/s13075-024-03383-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 08/05/2024] [Indexed: 08/24/2024] Open
Abstract
OBJECTIVE To investigate the risk factors of renal tubular acidosis (RTA) in patients with primary Sjögren's syndrome (pSS) and create a personalized nomogram for predicting pSS-RTA patients. METHOD Data from 99 pSS patients who underwent inpatient treatment at our hospital from January 2012 to January 2024 were retrospectively collected and analyzed. Bootstrap resampling technique, single-factor, and multi-factor logistic regression analyses were used to explore the risk factors for pSS-RTA. A nomogram was developed based on the results of the multivariate logistic model. The model was evaluated through receiver operating characteristic curve, C-index, calibration curve, and decision curve analysis. In addition, we graded the severity of pSS-RTA patients and used univariate analysis to assess the relationship between pSS-RTA severity and risk factors. RESULTS A multivariate logistic regression analysis revealed that concurrent thyroid disease, long symptom duration, subjective dry mouth, and positive RF were independent risk factors for pSS-RTA patients. Based on them, a personalized nomogram predictive model was established. With a p-value of 0.657 from the Hosmer-Lemeshow test, the model demonstrated a good fit. The AUC values in the training and validation groups were 0.912 and 0.896, indicating a strong discriminative power of the nomogram. The calibration curves for the training and validation groups closely followed the diagonal line with a slope of 1, confirming the model's reliable predictive ability. Furthermore, the decision curve analysis showed that the nomogram model had a net benefit in predicting pSS-RTA, emphasizing its clinical value.This study did not find an association between the severity of pSS-RTA and risk factors. DISCUSSION We developed a nomogram to predict RTA occurrence in pSS patients, and it is believed to provide a foundation for early identification and intervention for high-risk pSS patients.
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Affiliation(s)
- Yanzhen Zeng
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Runzhi Liu
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Shuyi Li
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Jingwen Wei
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Fei Luo
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Yongkang Chen
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Dongmei Zhou
- Rheumatology And Immunology Department, The Affiliated Hospital Of Xuzhou Medical University, Jiangsu Province, China.
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Wagner CA, Unwin R, Lopez-Garcia SC, Kleta R, Bockenhauer D, Walsh S. The pathophysiology of distal renal tubular acidosis. Nat Rev Nephrol 2023; 19:384-400. [PMID: 37016093 DOI: 10.1038/s41581-023-00699-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2023] [Indexed: 04/06/2023]
Abstract
The kidneys have a central role in the control of acid-base homeostasis owing to bicarbonate reabsorption and production of ammonia and ammonium in the proximal tubule and active acid secretion along the collecting duct. Impaired acid excretion by the collecting duct system causes distal renal tubular acidosis (dRTA), which is characterized by the failure to acidify urine below pH 5.5. This defect originates from reduced function of acid-secretory type A intercalated cells. Inherited forms of dRTA are caused by variants in SLC4A1, ATP6V1B1, ATP6V0A4, FOXI1, WDR72 and probably in other genes that are yet to be discovered. Inheritance of dRTA follows autosomal-dominant and -recessive patterns. Acquired forms of dRTA are caused by various types of autoimmune diseases or adverse effects of some drugs. Incomplete dRTA is frequently found in patients with and without kidney stone disease. These patients fail to appropriately acidify their urine when challenged, suggesting that incomplete dRTA may represent an intermediate state in the spectrum of the ability to excrete acids. Unrecognized or insufficiently treated dRTA can cause rickets and failure to thrive in children, osteomalacia in adults, nephrolithiasis and nephrocalcinosis. Electrolyte disorders are also often present and poorly controlled dRTA can increase the risk of developing chronic kidney disease.
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Affiliation(s)
- Carsten A Wagner
- Institute of Physiology, University of Zurich, Zurich, Switzerland.
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK.
| | - Robert Unwin
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Sergio C Lopez-Garcia
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Robert Kleta
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
| | - Detlef Bockenhauer
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
- Department of Paediatric Nephrology, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Stephen Walsh
- Department of Renal Medicine, Royal Free Hospital, University College London, London, UK
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Jin YB, Dai YJ, Chen JL, Li J, Zhang X, Sun XL, He J. Anti-carbonic anhydrase II antibody reflects urinary acidification defect especially in proximal renal tubules in patients with primary Sjögren syndrome. Medicine (Baltimore) 2023; 102:e32673. [PMID: 36637955 PMCID: PMC9839274 DOI: 10.1097/md.0000000000032673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Primary Sjögren syndrome (pSS) is a systemic autoimmue disease featured by excessive autoantibody production. It has been demonstrated that anti-carbonic anhydrase II (anti-CA II) antibody is correlated with renal tubular acidosis in pSS; however, no further details about urinary acidification defect have been reported, and the antibody's relationship with other organ impairments remains unknown. This case-control study aimed to examine anti-CA II antibody levels in relation to various systemic complications in pSS, and evaluate its potential role as a organ-specific biomarker in a Chinese cohort. Serum anti-CA II antibody levels were determined using ELISA in 123 patients with pSS and 72 healthy controls. The medical records of the patients were collected, and the correlation between serum anti-CA II antibody and clinical/immunological parameters was investigated. Serum anti-CA II antibody level and its positive rate were significantly increased in pSS patients compared with controls, and ANA-positive patients presented even higher titers of the antibody. In anti-CA II positive group, remarkably higher urine pH and bicarbonate, as well as lower urine titratable acid and serum potassium were observed, which indicated renal tubular acidification dysfunction both involving bicarbonate reabsorption and acid secretion. In addition, platelet count and complement 3, complement 4 levels decreased, whereas serum IgG, IgA and γ-globulin levels increased notably in accord with a higher EULAR SS disease activity index score in these patients. Further analysis showed that anti-CA II antibody was most elevated in patients with defect in bicarbonate reabsorption, reflecting proximal renal tubular injury, rather than in patients with distal renal tubular acidosis as previously reported. In conclusion, anti-CA II antibody reflects renal (especially proximal renal tubular) and hematologic impairment as well as increased disease activity in pSS. It may act as a serum biomarker of systemic damage of pSS.
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Affiliation(s)
- Yue-Bo Jin
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis, Peking University People’s Hospital, Beijing, China
| | - Yi-Jun Dai
- Rheumatology and Immunology Department, Fujian Provincial Hospital, Shengli Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jia-Li Chen
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis, Peking University People’s Hospital, Beijing, China
| | - Jing Li
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis, Peking University People’s Hospital, Beijing, China
| | - Xia Zhang
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis, Peking University People’s Hospital, Beijing, China
| | - Xiao-Lin Sun
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis, Peking University People’s Hospital, Beijing, China
| | - Jing He
- Department of Rheumatology and Immunology, Beijing Key Laboratory for Rheumatism and Immune Diagnosis, Peking University People’s Hospital, Beijing, China
- * Correspondence: Jing He, Department of Rheumatology and Immunology, Peking University People’s Hospital, No. 11. Xizhimen South Street, Beijing 100044, China (e-mail: )
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Agrawal N, Mahata R, Chakraborty PP, Basu K. Secondary distal renal tubular acidosis and sclerotic metabolic bone disease in seronegative spondyloarthropathy. BMJ Case Rep 2022; 15:e248712. [PMID: 35292549 PMCID: PMC8928265 DOI: 10.1136/bcr-2021-248712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/03/2022] Open
Abstract
Adults with distal renal tubular acidosis (dRTA) commonly present with hypokalaemia (with/without paralysis), nephrolithiasis/nephrocalcinosis and vague musculoskeletal symptoms. All adults with dRTA should be thoroughly evaluated for systemic diseases, certain medications and toxins. The leading cause of acquired or secondary dRTA in adults is primary Sjögren syndrome (SS); however, other collagen vascular diseases (CVDs) including seronegative spondyloarthropathy (SSpA) may at times give rise to secondary dRTA. Metabolic bone disease is often encountered in adults with dRTA, and the list includes osteomalacia and secondary osteoporosis; sclerotic metabolic bone disease is an extremely rare manifestation of dRTA. Coexistence of dRTA and sclerotic bone disease is seen in primary dRTA due to mutation in CA2 gene and acquired dRTA secondary to systemic fluorosis. Primary SS and SSpA, rarely if ever, may also lead to both secondary dRTA and osteosclerosis. Circulating autoantibodies against carbonic anhydrase II and possibly calcium sensing receptor may explain both these features in patients with CVD.
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Affiliation(s)
- Neeti Agrawal
- Endocrinology & Metabolism, Medical College and Hospital Kolkata, Kolkata, West Bengal, India
| | - Rahin Mahata
- Endocrinology & Metabolism, Medical College and Hospital Kolkata, Kolkata, West Bengal, India
| | | | - Kaushik Basu
- General Medicine & Rheumatology, Medical College and Hospital Kolkata, Kolkata, West Bengal, India
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Adomako EA, Bilal S, Liu YL, Malik A, Van Buren PN, Shastri S, Sambandam KK. Idiopathic Hypokalemia in Lupus Nephritis: A Newly Recognized Entity. KIDNEY360 2021; 2:1553-1559. [PMID: 35372968 PMCID: PMC8785789 DOI: 10.34067/kid.0004352021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 08/04/2021] [Indexed: 02/04/2023]
Abstract
Background Various causes of hypokalemia (HK) from renal potassium wasting, including distal renal tubular acidosis (RTA), have been described in lupus nephritis (LN). We report a phenomenon of otherwise unexplained HK among a population with LN. Methods From our population of 403 patients with LN, we identified a cohort of 20 patients with idiopathic HK, defined by serum potassium <3.5 mmol/L without any apparent explanation. This cohort is compared with 90 LN controls (CON) and ten patients with LN with distal RTA from the same population. Results The patients with HK had lower median serum potassium compared with CON and RTA subjects (3.26 versus 4.00 versus 3.75 mmol/L, respectively; P<0.001). The median serum bicarbonate was normal in HK and CON, but low in RTA (26.0 versus 25.0 versus 19.4 mmol/L; P<0.001). The median urine pH was abnormally high only in the RTA group (6.00 versus 6.25 versus 6.67; P=0.012). The median serum magnesium was modestly lower in HK compared with the CON and RTA groups (1.73 versus 2.00 versus 1.85 mg/dl; P=0.002). Although both HK and RTA showed a higher rate of seropositivity than CON for anti-Ro/SSA (79% and 80% versus 37%, respectively; P<0.001), only HK revealed a higher rate of seropositivity than CON for anti-RNP (84% versus 42%; P=0.003) and only RTA showed a higher rate of seropositivity than CON for anti-La/SSB (40% versus 12%; P=0.05). Conclusions A syndrome of idiopathic HK was revealed in 20 out of 403 (5%) of patients within our LN population, and proved to be distinct from the RTA that occurs in LN. Furthermore, it was associated with a distinct pattern of autoantibodies. We speculate that idiopathic HK is the result of a novel target of autoimmunity in LN, affecting renal tubular potassium transport.
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Affiliation(s)
- Emmanuel A. Adomako
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Saira Bilal
- Division of Rheumatology, George Washington University, Washington, D.C
| | - Yu-lun Liu
- Department of Population and Data Science, University of Texas Southwestern, Dallas, Texas
| | - Ayesha Malik
- Medical College, Aga Khan University, Karachi, Pakistan
| | - Peter N. Van Buren
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shani Shastri
- Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, Texas
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Xing E, Billi AC, Gudjonsson JE. Sex Bias and Autoimmune Diseases. J Invest Dermatol 2021; 142:857-866. [PMID: 34362556 DOI: 10.1016/j.jid.2021.06.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 06/03/2021] [Accepted: 06/15/2021] [Indexed: 02/08/2023]
Abstract
Sex bias in immune function has been well-described, and women have been shown to counter immunologically stimulating phenomena such as infection, malignancy, and trauma with more protective responses than men. Heightened immunity in women may also result in a predisposition for loss of self-tolerance and development of autoimmunity, reflected by the overwhelming female sex bias of patients with autoimmune diseases. In this review, we discuss the postulated evolutionary etiologies for sexual dimorphism in immunity. We also review the molecular mechanisms underlying divergent immune responses in men and women, including sex hormone effects, X chromosome dosage, and autosomal sex-biased genes. With increasing evidence that autoimmune disease susceptibility is influenced by numerous hormonal and genetic factors, a comprehensive understanding of these topics may facilitate the development of much-needed targeted therapeutics.
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Affiliation(s)
- Enze Xing
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Allison C Billi
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Johann E Gudjonsson
- Department of Dermatology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA; A. Alfred Taubman Medical Research Institute, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.
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7
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Thatayatikom A, Jun I, Bhattacharyya I, Berg K, Lee YJ, Kim Y, Adewumi A, Zhang W, Thatayatikom S, Shah A, Beal C, Modica R, Elder ME, Cha S. The Diagnostic Performance of Early Sjögren's Syndrome Autoantibodies in Juvenile Sjögren's Syndrome: The University of Florida Pediatric Cohort Study. Front Immunol 2021; 12:704193. [PMID: 34249010 PMCID: PMC8267463 DOI: 10.3389/fimmu.2021.704193] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 06/02/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives The aim of this study was to evaluate the clinical validity of early Sjögren's syndrome (SS) autoantibodies (eSjA), which were originally marketed for early diagnosis of SS, for juvenile SS (JSS) in a recently identified pediatric cohort. Methods A total of 105 symptomatic subjects with eSjA results available were evaluated at the Center for Orphaned Autoimmune Disorders at the University of Florida and enrolled for this study. JSS diagnosis was based on the 2016 ACR/EULAR SS criteria. Demographic/clinical/laboratory parameters were compared between JSS (n = 27) and non-JSS (n = 78) for % positivity, sensitivity, and specificity of eSjA (SP1, anti-salivary protein; CA6, anti-carbonic anhydrase VI; PSP, anti-parotid secretory protein) and classic SS-autoantibodies (cSjA; ANA, SSA/SSB, RF, and others) either alone or in combination. Associations between eSjA and diagnostic/glandular parameters were also determined by Fisher's exact test. Results Compared to non-JSS, JSS patients exhibited sicca symptoms demonstrating reduced unstimulated salivary flow rate (USFR) and abnormal glandular features revealed by salivary gland ultrasound (SGUS). Among cSjA, ANA demonstrated the highest sensitivity of 69.2%, while SSA, SSB, and RF showed around 95% specificities for JSS diagnosis. The % positive-SSA was notably higher in JSS than non-JSS (56% vs. 5%). Of eSjA, anti-CA6 IgG was the most prevalent without differentiating JSS (37%) from non-JSS (32%). Sensitivity and specificity of eSjA were 55.6 and 26.9%, respectively. Autoantibodies with potentially applicable specificity/sensitivity for JSS were seen only in cSjA without a single eSjA included. There were no associations detected between eSjA and focus score (FS), USFR, SSA, SGUS, and parotitis/glandular swelling analyzed in the entire cohort, JSS, and non-JSS. However, a negative association between anti-PSP and parotitis/glandular swelling was found in a small group of positive-SSA (n = 19, p = 0.02) whereas no such association was found between anti-PSP-positive compared to anti-PSP-negative. JSS and non-JSS groups differed in FS, USFR, and EULAR SS Patient Reported Index Dryness/Mean in CA6/PSP/ANA, SP1, and SSA-positive groups, respectively. Additionally, a higher FS was found in RF-positive than RF-negative individuals. Conclusions eSjA underperformed cSjS in differentiating JSS from non-JSS. The discovery of clinical impact of eSjA on early diagnosis of JSS necessitates a longitudinal study.
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Affiliation(s)
- Akaluck Thatayatikom
- Department of Pediatrics, Division of Allergy, Immunology, Rheumatology, College of Medicine, University of Florida, Gainesville, FL, United States.,Center for Orphaned Autoimmune Disorders (COAD), College of Dentistry, University of Florida, Gainesville, FL, United States
| | - Inyoung Jun
- Department of Epidemiology, College of Public Health and Health Professions & College of Medicine, University of Florida, Gainesville, FL, United States
| | - Indraneel Bhattacharyya
- Center for Orphaned Autoimmune Disorders (COAD), College of Dentistry, University of Florida, Gainesville, FL, United States.,Division of Oral Pathology, Department of Oral and Maxillofacial Diagnostic Sciences, College of Dentistry, University of Florida, Gainesville, FL, United States
| | - Kathleen Berg
- Center for Orphaned Autoimmune Disorders (COAD), College of Dentistry, University of Florida, Gainesville, FL, United States.,Division of Oral Medicine, Department of Oral and Maxillofacial Diagnostic Sciences, College of Dentistry, University of Florida, Gainesville, FL, United States
| | - Yun Jong Lee
- Division of Rheumatology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yoosik Kim
- Department of Chemical and Biomolecular Engineering, Korea Advanced Institute of Science and Technology (KAIST), Daejeon, South Korea
| | - Abi Adewumi
- Department of Pediatric Dentistry, College of Dentistry, University of Florida, Gainesville, FL, United States
| | - Weizhou Zhang
- Department of Pathology, Immunology and Laboratory Medicine, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Sthorn Thatayatikom
- Department of Pediatrics, Division of Allergy, Immunology, Rheumatology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Ankit Shah
- Department of Ophthalmology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Casey Beal
- Department of Ophthalmology, College of Medicine, University of Florida, Gainesville, FL, United States
| | - Renee Modica
- Department of Pediatrics, Division of Allergy, Immunology, Rheumatology, College of Medicine, University of Florida, Gainesville, FL, United States.,Center for Orphaned Autoimmune Disorders (COAD), College of Dentistry, University of Florida, Gainesville, FL, United States
| | - Melissa E Elder
- Department of Pediatrics, Division of Allergy, Immunology, Rheumatology, College of Medicine, University of Florida, Gainesville, FL, United States.,Center for Orphaned Autoimmune Disorders (COAD), College of Dentistry, University of Florida, Gainesville, FL, United States
| | - Seunghee Cha
- Center for Orphaned Autoimmune Disorders (COAD), College of Dentistry, University of Florida, Gainesville, FL, United States.,Division of Oral Medicine, Department of Oral and Maxillofacial Diagnostic Sciences, College of Dentistry, University of Florida, Gainesville, FL, United States
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Mbengue M, Ouanekpone C, Diagne S, Niang A. From Hypokalemic Crisis to Sjogren's Syndrome: A Case Report and Literature Review. Case Rep Nephrol Dial 2021; 11:147-151. [PMID: 34250032 PMCID: PMC8255739 DOI: 10.1159/000515588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 02/28/2021] [Indexed: 12/27/2022] Open
Abstract
Renal involvement occurs in approximately 5% of patients with Sjögren's syndrome (SS). We reported the case of a 20-year-old African woman who was received for paralysis of 4 limbs secondary to hypokalemia. The diagnosis of renal tubular acidosis type 1 complicated by hypokalemia was retained. In the etiologic research of renal tubular acidosis type 1, primary SS was retained. The patient received symptomatic treatment based on potassium chloride, sodium bicarbonate, hydration, and a low protein diet. In terms of etiological treatment, she was put on corticosteroid and hydroxychloroquine. The outcome was favorable with correction of acidosis and hypokalemia.
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Affiliation(s)
- Mansour Mbengue
- Department of Nephrology, Dalal Jamm University Hospital, Dakar, Senegal
| | - Cedric Ouanekpone
- Department of Nephrology, Aristide Le Dantec University Hospital, Dakar, Senegal
| | | | - Abdou Niang
- Department of Nephrology, Dalal Jamm University Hospital, Dakar, Senegal
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9
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Vitali C, Minniti A, Pignataro F, Maglione W, Del Papa N. Management of Sjögren's Syndrome: Present Issues and Future Perspectives. Front Med (Lausanne) 2021; 8:676885. [PMID: 34164418 PMCID: PMC8215198 DOI: 10.3389/fmed.2021.676885] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Accepted: 04/06/2021] [Indexed: 12/15/2022] Open
Abstract
In view of the new possibilities for the treatment of primary Sjögren's syndrome (pSS) given by the availability of new biotechnological agents targeting the various molecular and cellular actors of the pathological process of the disease, classification criteria aimed at selecting patients to be enrolled in therapeutic trials, and validated outcome measures to be used as response criteria to these new therapies, have been developed and validated in the last decades. Unfortunately, the therapeutic trials so far completed with these new treatments have yielded unsatisfactory or only partially positive results. The main issues that have been evoked to justify the poor results of the new therapeutic attempts are: (i) the extreme variability of the disease phenotypes of the patients enrolled in the trials, which are dependent on different underlying patterns of biological mechanisms, (ii) the fact that the disease has a long indolent course, and that most of the enrolled patients might already have irreversible clinical features. The advances in the research of new disease biomarkers that can better distinguish the different clinical phenotypes of patients and diagnose the disease in an earlier phase are also discussed.
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Affiliation(s)
- Claudio Vitali
- Rheumatology Outpatient Clinics, "Mater Domini" Humanitas Hospital, Castellanza, Italy
| | | | | | - Wanda Maglione
- Department of Rheumatology, ASST G. Pini-CTO, Milan, Italy
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10
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Chatzis L, Vlachoyiannopoulos PG, Tzioufas AG, Goules AV. New frontiers in precision medicine for Sjogren's syndrome. Expert Rev Clin Immunol 2021; 17:127-141. [PMID: 33478279 DOI: 10.1080/1744666x.2021.1879641] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Introduction: Sjögren's syndrome is a unique systemic autoimmune disease, placed in the center of systemic autoimmunity and at the crossroads of autoimmunity and lymphoproliferation. The diverse clinical picture of the disease, the inefficacy of current biologic treatments, and the co-existence with lymphoma conferring to the patients' morbidity and mortality force the scientific community to review disease pathogenesis and reveal the major implicated cellular and molecular elements.Areas covered: Biomarkers for early diagnosis, prediction, stratification, monitoring, and targeted treatments can serve as a tool to interlink and switch from the clinical phenotyping of the disease into a more sophisticated classification based on the underlying critical molecular pathways and endotypes. Such a transition may define the establishment of the so-called precision medicine era in which patients' management will be based on grouping according to pathogenetically related biomarkers. In the current work, literature on Sjogren's syndrome covering several research fields including clinical, translational, and basic research has been reviewed.Expert opinion: The perspectives of clinical and translational research are anticipated to define phenotypic clustering of high-risk pSS patients and link the clinical picture of the disease with fundamental molecular mechanisms and molecules implicated in pathogenesis.
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Affiliation(s)
- Loukas Chatzis
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Athanasios G Tzioufas
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas V Goules
- Department of Pathophysiology, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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11
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Abstract
Primary Sjögren syndrome is an autoimmune disorder characterized by lymphoplasmacytic infiltration of the exocrine (salivary and lachrymal) glands resulting in sicca symptoms (dryness). Systemic complications can occur in primary Sjögren syndrome, but renal involvement is rare, affecting<10% patients. The most frequent form of nephropathy in primary Sjögren syndrome is tubulointerstitial nephritis, where infiltration of the kidney by plasma cells is a key feature and shows similarity to the lymphoplasmacytic infiltration of the salivary glands. Electrolyte disturbances may occur in primary Sjögren syndrome, such as renal distal tubular acidosis, diabetes insipidus, Gitelman syndrome, or Fanconi syndrome. Glomerular involvement is less frequently detected in patients with primary Sjögren syndrome, but can take the form of membranoproliferative glomerulonephritis secondary to cryoglobulinaemia. The renal prognosis in patients with primary Sjögren syndrome and TIN or glomerular disease is usually good, but the risk of chronic kidney disease remains significant for some patients. Appropriate screening must be performed at least once a year in patients with systemic primary Sjögren syndrome in order to facilitate the early detection of renal complications. In this Review, we discuss the epidemiology, pathophysiology, differential diagnosis, and treatment of renal disease in primary Sjögren syndrome.
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Affiliation(s)
- Hélène François
- Département d'Urgences Néphrologiques et Transplantation Rénale, INSERM UMR_S 1155, Hôpital Tenon, Sorbonne université, AP-HP, Paris, France.
| | - Xavier Mariette
- Inserm, CEA, rheumatology department, centre de recherche en immunologie des infections virales et des maladies auto-immunes, université Paris-Saclay, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France
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12
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Parisis D, Chivasso C, Perret J, Soyfoo MS, Delporte C. Current State of Knowledge on Primary Sjögren's Syndrome, an Autoimmune Exocrinopathy. J Clin Med 2020; 9:E2299. [PMID: 32698400 PMCID: PMC7408693 DOI: 10.3390/jcm9072299] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 07/15/2020] [Accepted: 07/16/2020] [Indexed: 12/13/2022] Open
Abstract
Primary Sjögren's syndrome (pSS) is a chronic systemic autoimmune rheumatic disease characterized by lymphoplasmacytic infiltration of the salivary and lacrimal glands, whereby sicca syndrome and/or systemic manifestations are the clinical hallmarks, associated with a particular autoantibody profile. pSS is the most frequent connective tissue disease after rheumatoid arthritis, affecting 0.3-3% of the population. Women are more prone to develop pSS than men, with a sex ratio of 9:1. Considered in the past as innocent collateral passive victims of autoimmunity, the epithelial cells of the salivary glands are now known to play an active role in the pathogenesis of the disease. The aetiology of the "autoimmune epithelitis" still remains unknown, but certainly involves genetic, environmental and hormonal factors. Later during the disease evolution, the subsequent chronic activation of B cells can lead to the development of systemic manifestations or non-Hodgkin's lymphoma. The aim of the present comprehensive review is to provide the current state of knowledge on pSS. The review addresses the clinical manifestations and complications of the disease, the diagnostic workup, the pathogenic mechanisms and the therapeutic approaches.
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Affiliation(s)
- Dorian Parisis
- Laboratory of Pathophysiological and Nutritional Biochemistry, Université Libre de Bruxelles, 1070 Brussels, Belgium; (D.P.); (C.C.); (J.P.)
- Department of Rheumatology, Erasme Hospital, Université Libre de Bruxelles, 1070 Brussels, Belgium;
| | - Clara Chivasso
- Laboratory of Pathophysiological and Nutritional Biochemistry, Université Libre de Bruxelles, 1070 Brussels, Belgium; (D.P.); (C.C.); (J.P.)
| | - Jason Perret
- Laboratory of Pathophysiological and Nutritional Biochemistry, Université Libre de Bruxelles, 1070 Brussels, Belgium; (D.P.); (C.C.); (J.P.)
| | | | - Christine Delporte
- Laboratory of Pathophysiological and Nutritional Biochemistry, Université Libre de Bruxelles, 1070 Brussels, Belgium; (D.P.); (C.C.); (J.P.)
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Xia W, Gao B, Duan L, Li Y, Wen Y, Chen L, Li X, Zheng F, Li M. Clinical significance of C4d deposition in renal tissues from patients with primary Sjögren's syndrome-a preliminary study. BMC Nephrol 2019; 20:189. [PMID: 31138153 PMCID: PMC6540533 DOI: 10.1186/s12882-019-1341-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 04/17/2019] [Indexed: 01/06/2023] Open
Abstract
Background To evaluate renal expression of C4d, a complement component in the classical/mannose binding lectin (MBL) pathway, in patients with primary Sjögren’s syndrome (pSS)-associated renal impairments. Methods We retrospectively reviewed the clinical and pathological data from 39 patients with pSS presenting with renal impairments. C4d was examined in paraffin-embedded biopsy tissues using immunohistochemistry. Glomerular C4d positive was defined when > 75% glomeruli were globally stained. Tubulointerstitial C4d (TI-C4d) were scored semi-quantitatively as 0 (absent), 1 (spotty or weak), 2 (patchy) and 3 (diffuse). A TI-C4d score ≥ 2 was considered TI-C4d positive and included in the TI-C4d+ group and vice versa. Peritubular capillary (PTC) C4d was scored as 0 (absent), 1 (0~10%, minimal), 2 (10%~ 50%, focal), and 3 (> 50%, diffuse). Results Glomerular C4d deposition was observed in all 8 patients with pSS-related membranous nephropathy (MN) without obvious C1q deposition. Two of 5 patients with mesangial proliferative glomerulonephritis and 1 of 2 patients with IgA nephropathy had mild mesangial C4d deposition. Sixteen patients (6 glomerular dominant and 10 tubulointerstitial dominant) presented TI-C4d score ≥ 2. Patients in the TI-C4d+ group exhibited a higher serum creatinine level at the time of renal biopsy (TI-C4d+ 132.5 [89.7, 165.5] vs. TI-C4d− 83.0 [70.7, 102.0] μmol/L, P = 0.008). PTC C4d was observed in 12 patients, with each of minimal, focal and diffuse staining being noted in 4 patients. Conclusions The MBL pathway of complement activation was potentially involved in pSS-related MN. Tubulointerstitial C4d might be a pathological marker of severe renal injury in patients with pSS-related renal impairments. Electronic supplementary material The online version of this article (10.1186/s12882-019-1341-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wenli Xia
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China.,Department of Nephrology, Beijing Jishuitan Hospital, Fourth Clinical College, Peking University, Beijing, 100035, China
| | - Bixia Gao
- Renal Division, Department of Medicine, Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Peking University First Hospital, Peking University, Beijing, 100034, China
| | - Lin Duan
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Yan Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Yubing Wen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Limeng Chen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Falei Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Mingxi Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China.
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Jain A, Srinivas BH, Emmanuel D, Jain VK, Parameshwaran S, Negi VS. Renal involvement in primary Sjogren’s syndrome: a prospective cohort study. Rheumatol Int 2018; 38:2251-2262. [DOI: 10.1007/s00296-018-4118-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/02/2018] [Indexed: 12/19/2022]
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Fritzler MJ, Choi MY. Editorial: Are Autoantibodies Involved in the Pathogenesis of Systemic Sclerosis? Arthritis Rheumatol 2018; 68:2067-70. [PMID: 27111351 DOI: 10.1002/art.39727] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Accepted: 04/19/2016] [Indexed: 11/09/2022]
Affiliation(s)
- Marvin J Fritzler
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - May Y Choi
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
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16
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Abstract
Distal renal tubular acidosis (DRTA) is defined as hyperchloremic, non-anion gap metabolic acidosis with impaired urinary acid excretion in the presence of a normal or moderately reduced glomerular filtration rate. Failure in urinary acid excretion results from reduced H+ secretion by intercalated cells in the distal nephron. This results in decreased excretion of NH4+ and other acids collectively referred as titratable acids while urine pH is typically above 5.5 in the face of systemic acidosis. The clinical phenotype in patients with DRTA is characterized by stunted growth with bone abnormalities in children as well as nephrocalcinosis and nephrolithiasis that develop as the consequence of hypercalciuria, hypocitraturia, and relatively alkaline urine. Hypokalemia is a striking finding that accounts for muscle weakness and requires continued treatment together with alkali-based therapies. This review will focus on the mechanisms responsible for impaired acid excretion and urinary potassium wastage, the clinical features, and diagnostic approaches of hypokalemic DRTA, both inherited and acquired.
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Jakubowski M, Szahidewicz-Krupska E, Doroszko A. The Human Carbonic Anhydrase II in Platelets: An Underestimated Field of Its Activity. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4548353. [PMID: 30050931 PMCID: PMC6046183 DOI: 10.1155/2018/4548353] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Accepted: 05/24/2018] [Indexed: 12/15/2022]
Abstract
Carbonic anhydrases constitute a group of enzymes that catalyse reversible hydration of carbon dioxide leading to the formation of bicarbonate and proton. The platelet carbonic anhydrase II (CAII) was described for the first time in the '80s of the last century. Nevertheless, its direct role in platelet physiology and pathology still remains poorly understood. The modulation of platelet CAII action as a therapeutic approach holds promise as a novel strategy to reduce the impact of cardiovascular diseases. This short review paper summarises the current knowledge regarding the role of human CAII in regulating platelet function. The potential future directions considering this enzyme as a potential drug target and important pathophysiological chain in platelet-related disorders are described.
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Affiliation(s)
- Maciej Jakubowski
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Ewa Szahidewicz-Krupska
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
| | - Adrian Doroszko
- Department of Internal Medicine, Occupational Diseases and Hypertension, Wroclaw Medical University, Borowska 213, 50-556 Wroclaw, Poland
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Sandhya P, Kurien BT, Danda D, Scofield RH. Update on Pathogenesis of Sjogren's Syndrome. Curr Rheumatol Rev 2018; 13:5-22. [PMID: 27412602 DOI: 10.2174/1573397112666160714164149] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Revised: 11/15/2015] [Accepted: 01/01/2016] [Indexed: 01/06/2023]
Abstract
Sjogren's syndrome is a common autoimmune disease that presents with sicca symptoms and extraglandular features. Sjogren's syndrome is presumably as common as RA; yet it is poorly understood, underdiagnosed and undertreated. From the usual identity as an autoimmune exocrinopathy to its most recent designate as an autoimmune epithelitis - the journey of SS is complex. We herein review some of the most important milestones that have shed light on different aspects of pathogenesis of this enigmatic disease. This includes role of salivary gland epithelial cells, and their interaction with cells of the innate and adaptive immune system. Non-immune factors acting in concert or in parallel with immune factors may also be important. The risk genes identified so far have only weak association, nevertheless advances in genetics have enhanced understanding of disease mechanisms. Role of epigenetic and environmental role factors is also being explored. SS has also some unique features such as congenital heart block and high incidence of lymphoma; disease mechanisms accounting for these manifestations are also reviewed.
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An J, Braam B. Complete Hypokalemic Quadriparesis as a First Presentation of Sjögren Syndrome. Can J Kidney Health Dis 2018; 5:2054358118774536. [PMID: 29774167 PMCID: PMC5952274 DOI: 10.1177/2054358118774536] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2017] [Accepted: 03/18/2018] [Indexed: 11/29/2022] Open
Abstract
RATIONALE We hope to increase awareness that hypokalemic paralysis may be the first presentation of Sjögren syndrome, for which potassium-sparing diuretics can be an effective adjunct to potassium replenishment. PRESENTING CONCERNS A 73-year-old female presented to a peripheral hospital with quadriparesis and a critically low serum potassium of 1.6 mmol/L with U waves on the electrocardiogram (ECG). The initial arterial blood gas showed a pH of 7.19, bicarbonate of 13 mEq/L, and a CO2 of 35 mm Hg. Over the next 6 days, she was administered a total of 450 mEq of potassium supplements. Despite this, her potassium never increased above 2.9 mmol/L and was thus transferred to the University Hospital for further management. On arrival, her vital signs were within normal limits. Her only other symptoms were fatigue and ocular dryness. Physical exam showed slightly weakened quadriceps muscles bilaterally, graded 4/5. Examination was otherwise unremarkable. Admission investigations included a potassium of 2.8 mmol/L, chloride 118 mmol/L, sodium 136 mmol/L, and eGFR 48 mL/min/1.73 m2. Renin aldosterone ratio was normal. DIAGNOSES Distal renal tubular acidosis (RTA) was diagnosed based on a normal anion gap metabolic acidosis, positive urine anion gap, and elevated urine potassium to creatinine ratio. Investigation of underlying causes revealed a positive Antinuclear antibody (ANA), elevated rheumatoid factor, and high anti-Ro/SSA titre which directed us toward a unifying diagnosis of Sjögren syndrome. A renal biopsy was undertaken as an outpatient and demonstrated severe interstitial nephritis with acute and chronic components, parenchymal scarring, atrophy, and small vessel arteriosclerosis. INTERVENTIONS In the acute setting, the patient was treated with bicarbonate and amiloride in addition to potassium supplementation. OUTCOMES The patient's hypokalemic paralysis and metabolic acidosis were corrected. LESSONS LEARNED Severe hypokalemic paralysis in distal RTA associated with Sjögren syndrome can be successfully treated with amiloride in addition to potassium supplementation. We also review the literature on the aberrancies seen in H+ATPase, Band 3, Pendrin, and carbonic anhydrase that may underlie the pathogenesis of distal RTA in Sjögren syndrome.
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Affiliation(s)
- Jason An
- Division of Internal Medicine, Department Medicine, University of Alberta, Edmonton, Canada
| | - Branko Braam
- Division of Nephrology and Immunology, Department Medicine, University of Alberta, Edmonton, Canada
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Abstract
Sjögren's syndrome (pSS) is a complex and heterogeneous disorder characterized by different clinical subsets. Recently, great efforts have been made searching for reliable biomarkers able to ameliorate the diagnostic algorithm and the prognostic stratification of pSS patients and ultimately allowing the scientific community to address some of the unmet needs for the disease. In this review, we have summarized the state of the art of 'traditional' widely acknowledged clinical, serological and histologic biomarkers for pSS with the aim of highlighting their relevance and limitations in clinical practice. We have also explored some of the novel potential biomarkers that have been proposed more recently, potentially able to open new ways in the assessment of the disease.
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Affiliation(s)
- Chiara Baldini
- Rheumatology Unit, Department of Clinical & Experimental Medicine, University of Pisa, 56126, Italy
| | - Francesco Ferro
- Rheumatology Unit, Department of Clinical & Experimental Medicine, University of Pisa, 56126, Italy
| | - Elena Elefante
- Rheumatology Unit, Department of Clinical & Experimental Medicine, University of Pisa, 56126, Italy
| | - Stefano Bombardieri
- Rheumatology Unit, Department of Clinical & Experimental Medicine, University of Pisa, 56126, Italy
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21
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Nishita T, Miyazaki R, Miyazaki T, Ochiai H, Orito K. Antibodies reacting to carbonic anhydrase isozymes (I and II) and albumin in sera from dogs. Res Vet Sci 2016; 106:180-2. [PMID: 27234558 DOI: 10.1016/j.rvsc.2016.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 04/26/2016] [Accepted: 04/29/2016] [Indexed: 11/19/2022]
Abstract
IgGs to carbonic anhydrase isozymes (CA-I and CA-II) and albumin were identified in dog serum. IgG titers were determined in the sera of asymptomatic dogs, and in dogs with atopic dermatitis, diarrhea and/or vomiting, diabetes and/or pancreatitis, kidney disease, hepatic disease, and thyroid gland disease, using ELISA. Low titres of IgG-reactive CA-I, CA-II, BSA, and CSA were found in the sera of healthy beagles. Compared with healthy beagles, there was a significant difference in the titers of antibodies against CA-I in asymptomatic dogs, dogs with diabetes and/or pancreatitis, or thyroid gland disease, or hepatic disease. Compared with healthy beagles, there was a significant difference in the antibody titer of anti-CA-II IgG in asymptomatic dogs and in those with hepatic disease. There was a significant difference in the antibody titer of anti-BSA IgG between healthy beagles and dogs with hepatic disease.
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Affiliation(s)
- Toshiho Nishita
- Laboratory of Physiology I, School of Veterinary Medicine, Azabu University, 1-17-71 Fuchinobe, Sagamihara, Kanagawa 252-5201, Japan.
| | - Rui Miyazaki
- Laboratory of Physiology I, School of Veterinary Medicine, Azabu University, 1-17-71 Fuchinobe, Sagamihara, Kanagawa 252-5201, Japan
| | - Takae Miyazaki
- Laboratory of Physiology I, School of Veterinary Medicine, Azabu University, 1-17-71 Fuchinobe, Sagamihara, Kanagawa 252-5201, Japan
| | - Hideharu Ochiai
- Research Institute of Biosciences, School of Veterinary Medicine, Azabu University, 1-17-71 Fuchinobe, Sagamihara, Kanagawa 252-5201, Japan
| | - Kensuke Orito
- Laboratory of Physiology II, School of Veterinary Medicine, Azabu University, 1-17-71 Fuchinobe, Sagamihara, Kanagawa 252-5201, Japan
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22
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Abstract
Primary Sjögren syndrome (pSS) is an autoimmune disorder characterized by lymphoplasmacytic infiltration of the exocrine (salivary and lachrymal) glands that results in sicca symptoms (dryness of the eyes and mouth). Systemic complications can occur in pSS, but renal involvement is rare, affecting <10% patients. The most frequent form of nephropathy in pSS is tubulointerstitial nephritis (TIN), in which infiltration of the kidney by plasma cells is a key feature and shows similarity to the lymphoplasmacytic infiltration of the salivary glands. Electrolyte disturbances may occur in pSS, such as renal distal tubular acidosis, diabetes insipidus, Gitelman syndrome or Fanconi syndrome. Glomerular involvement is less frequently detected in patients with pSS, but usually takes the form of membranoproliferative glomerulonephritis secondary to cryoglobulinaemia. The renal prognosis in patients with pSS and TIN or glomerular disease is usually favourable, but the risk of chronic kidney disease remains high in patients with TIN. Appropriate screening must be performed at least once a year in patients with systemic pSS in order to facilitate the early detection of renal complications. In this Review we discuss the epidemiology, pathophysiology, differential diagnosis and treatment of renal disease in pSS.
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Affiliation(s)
- Hélène François
- Department of Nephrology, Dialysis, and Transplantation, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Saclay, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Paris, France
| | - Xavier Mariette
- Department of Rheumatology, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Saclay, IMVA Centre of Immunology of Viral Infections and Autoimmune Diseases, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Paris, France
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Evans R, Zdebik A, Ciurtin C, Walsh SB. Renal involvement in primary Sjögren's syndrome. Rheumatology (Oxford) 2015; 54:1541-8. [PMID: 26070939 DOI: 10.1093/rheumatology/kev223] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Indexed: 01/09/2023] Open
Abstract
SS is a prevalent and underdiagnosed systemic disease that primarily affects epithelial tissue. It may affect renal function either as epithelial disease causing tubulointerstitial nephritis or as an immune complex-mediated glomerulopathy. These lesions may cause a variety of clinical features, both overt and occult. The epithelial disease is mediated by B and T cells, notably the Th17 subtype. We review the prevalence of renal SS, its presentation, likely pathogenesis and treatment.
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Affiliation(s)
- Rhys Evans
- UCL Centre for Nephrology, UCL Medical School, Rowland Hill Street and
| | - Anselm Zdebik
- UCL Centre for Nephrology, UCL Medical School, Rowland Hill Street and
| | - Coziana Ciurtin
- Department of Rheumatology, University College London Hospital, London, UK
| | - Stephen B Walsh
- UCL Centre for Nephrology, UCL Medical School, Rowland Hill Street and
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Rosner MH, Perazella MA, Choi MJ. American Society of Nephrology quiz and questionnaire 2014: acid-base and electrolyte disorders. Clin J Am Soc Nephrol 2015; 10:530-9. [PMID: 25617429 DOI: 10.2215/cjn.10911114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The Nephrology Quiz and Questionnaire remains an extremely popular session for attendees of the Annual Kidney Week Meeting of the American Society of Nephrology. Once again, in 2014 the conference hall was overflowing with audience members and eager quiz participants. Topics covered by the expert discussants included electrolyte and acid-base disorders, glomerular disease, ESRD/dialysis, and transplantation. Complex cases from each of these categories along with single-best-answer questions were prepared and submitted by the panel of experts. Before the meeting, program directors of United States nephrology training programs and nephrology fellows answered the questions using an Internet-based questionnaire. During the live session, members of the audience tested their knowledge and judgment on a series of case-oriented questions prepared and discussed by the experts. They compared their answers in real time using audience response devices with the answers of the nephrology fellows and training program directors. The correct and incorrect answers were then discussed after the audience responses and the results of the questionnaire were displayed. As always, the audience, lecturers, and moderators enjoyed this educational session. This article recapitulates the acid-base and electrolyte disorders portion of the session and reproduces its educational value for the readers of the Clinical Journal of the American Society of Nephrology. Enjoy the clinical cases and expert discussions.
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Affiliation(s)
- Mitchell H Rosner
- Chairman, Department of Medicine, Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia;
| | - Mark A Perazella
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut; and
| | - Michael J Choi
- Division of Nephrology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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Abstract
Renal tubular acidosis (RTA) is a disorder of renal acidification characterized by inability to acidify urine to pH < 5.5 despite the presence of severe systemic metabolic acidosis and hypokalemia. Hypokalemia leads to acute-onset paralysis and may be a presenting manifestation of RTA. Its association with various autoimmune disease has been reported previously in published reports, but has not been much emphasized. We, hereby, report a case of RTA that presented during the flare of rheumatoid arthritis (RA). A 42-year-old female, a known case of RA for 5 years, presented with persistent joint pain for 1 week and acute-onset quadriparesis for 3 days. Primary investigations revealed hypokalemia with metabolic acidosis. She was managed conservatively with potassium supplements and bicarbonate supplements along with steroids and disease-modifying anti-rheumatic drugs. Such a presentation of renal tubular acidosis in a patient during the flare of rheumatoid arthritis is distinctly rare and previously unreported in published studies.
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Affiliation(s)
- Ankur Nandan Varshney
- Ankur Nandan Varshney, Department of General Medicine,, Institute of Medical Sciences,, Banaras Hindu University,, Varanasi, Uttar Pradesh,, India 221005, T: 9411491192,
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Corsiero E, Sutcliffe N, Pitzalis C, Bombardieri M. Accumulation of self-reactive naïve and memory B cell reveals sequential defects in B cell tolerance checkpoints in Sjögren's syndrome. PLoS One 2014; 9:e114575. [PMID: 25535746 PMCID: PMC4275206 DOI: 10.1371/journal.pone.0114575] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 11/11/2014] [Indexed: 11/18/2022] Open
Abstract
Sjögren's syndrome (SS) is an autoimmune disease characterised by breach of self-tolerance towards nuclear antigens resulting in high affinity circulating autoantibodies. Although peripheral B cell disturbances have been described in SS, with predominance of naïve and reduction of memory B cells, the stage at which errors in B cell tolerance checkpoints accumulate in SS is unknown. Here we determined the frequency of self- and poly-reactive B cells in the circulating naïve and memory compartment of SS patients. Single CD27-IgD+ naïve, CD27+IgD+ memory unswitched and CD27+IgD- memory switched B cells were sorted by FACS from the peripheral blood of 7 SS patients. To detect the frequency of polyreactive and autoreactive clones, paired Ig VH and VL genes were amplified, cloned and expressed as recombinant monoclonal antibodies (rmAbs) displaying identical specificity of the original B cells. IgVH and VL gene usage and immunoreactivity of SS rmAbs were compared with those obtained from healthy donors (HD). From a total of 353 VH and 293 VL individual sequences, we obtained 114 rmAbs from circulating naïve (n = 66) and memory (n = 48) B cells of SS patients. Analysis of the Ig V gene repertoire did not show significant differences in SS vs. HD B cells. In SS patients, circulating naïve B cells (with germline VH and VL genes) displayed a significant accumulation of clones autoreactive against Hep-2 cells compared to HD (43.1% vs. 25%). Moreover, we demonstrated a progressive increase in the frequency of circulating anti-nuclear naïve (9.3%), memory unswitched (22.2%) and memory switched (27.3%) B cells in SS patients. Overall, these data provide novel evidence supporting the existence of both early and late defects in B cell tolerance checkpoints in patients with SS resulting in the accumulation of autoreactive naïve and memory B cells.
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Affiliation(s)
- Elisa Corsiero
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, John Vane Science Centre, Charterhouse Square, London EC1M 6BQ, United Kingdom
- * E-mail: (EC); (MB)
| | - Nurhan Sutcliffe
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, John Vane Science Centre, Charterhouse Square, London EC1M 6BQ, United Kingdom
| | - Costantino Pitzalis
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, John Vane Science Centre, Charterhouse Square, London EC1M 6BQ, United Kingdom
| | - Michele Bombardieri
- Centre for Experimental Medicine & Rheumatology, William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, John Vane Science Centre, Charterhouse Square, London EC1M 6BQ, United Kingdom
- * E-mail: (EC); (MB)
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27
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Both T, Hoorn EJ, Zietse R, van Laar JAM, Dalm VASH, Brkic Z, Versnel MA, van Hagen PM, van Daele PLA. Prevalence of distal renal tubular acidosis in primary Sjögren's syndrome. Rheumatology (Oxford) 2014; 54:933-9. [PMID: 25354755 DOI: 10.1093/rheumatology/keu401] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2014] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Our objectives were to analyse the prevalence of distal renal tubular acidosis (dRTA) in primary SS (pSS) and to compare a novel urinary acidification test with furosemide and fludrocortisone (FF) with the gold standard ammonium chloride (NH4Cl) to detect dRTA. METHODS Urinary acidification was assessed in 57 pSS patients using NH4Cl and FF. A urinary acidification defect was defined as an inability to reach a urinary pH of <5.3 after NH4Cl. RESULTS The prevalence of complete dRTA (urinary acidification defect with acidosis) was 5% (3/57). All three patients had positive SSA/Ro and SSB/La autoantibodies and impaired kidney function. The prevalence of incomplete dRTA (urinary acidification defect without acidosis) was 25% (14/57). Compared with patients without dRTA, patients with incomplete dRTA had significantly lower venous pH and serum bicarbonate and higher urinary pH. SSB/La antibodies were more prevalent in the dRTA groups (P < 0.05). Compared with NH4Cl, the positive and negative predictive values of FF were 46% and 82%, respectively. Vomiting occurred more often during the urinary acidification test with NH4Cl than with FF (9 vs 0, P < 0.05). CONCLUSION Incomplete dRTA is common in pSS and causes mild acidaemia and higher urinary pH, which may contribute to bone demineralization and kidney stone formation. FF cannot replace NH4Cl in testing urinary acidification in pSS, but may be considered as a screening tool, given its reasonable negative predictive value and better tolerability.
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Affiliation(s)
- Tim Both
- Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ewout J Hoorn
- Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Robert Zietse
- Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan A M van Laar
- Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Virgil A S H Dalm
- Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Zana Brkic
- Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marjan A Versnel
- Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - P Martin van Hagen
- Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Paul L A van Daele
- Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands Division of Clinical Immunology and Division of Nephrology and Transplantation, Department of Internal Medicine and Department of Immunology, Erasmus Medical Center, Rotterdam, The Netherlands
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Everything you need to know about distal renal tubular acidosis in autoimmune disease. Rheumatol Int 2014; 34:1037-45. [PMID: 24682397 PMCID: PMC4107275 DOI: 10.1007/s00296-014-2993-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 03/14/2014] [Indexed: 11/24/2022]
Abstract
Renal acid–base homeostasis is a complex process, effectuated by bicarbonate reabsorption and acid secretion. Impairment of urinary acidification is called renal tubular acidosis (RTA). Distal renal tubular acidosis (dRTA) is the most common form of the RTA syndromes. Multiple pathophysiologic mechanisms, each associated with various etiologies, can lead to dRTA. The most important consequence of dRTA is (recurrent) nephrolithiasis. The diagnosis is based on a urinary acidification test. Potassium citrate is the treatment of choice.
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29
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Yamamoto S, Okada Y, Mori H, Hirata S, Saito K, Inokuchi N, Tanaka Y. Successful treatment of osteomalacia caused by renal tubular acidosis associated with Sjögren’s syndrome. Mod Rheumatol 2014. [DOI: 10.3109/s10165-012-0667-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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30
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Bournia VK, Vlachoyiannopoulos PG. Subgroups of Sjögren syndrome patients according to serological profiles. J Autoimmun 2012; 39:15-26. [PMID: 22575069 DOI: 10.1016/j.jaut.2012.03.001] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Sjögren Syndrome (SS) is a systemic, autoimmune disorder characterized by lymphocytic infiltration of the exocrine glands. Different clinical associations have been described for each of the diverse autoantibodies found in SS patients. Antibodies directed against the Ro/La ribonucleoprotein complexes have been correlated with younger age, more severe dysfunction of the exocrine glands and a higher prevalence of extraglandular manifestations. Anti-nuclear antibodies and rheumatoid factors have been associated to extraglandular manifestations and an active immunological profile, while cryoglobulins are markers of more severe disease and correlate to lymphoma development and death. Antibodies to cyclic citrullinated peptides are scarce in SS and have been linked in some cases to the development of non-erosive arthritis. Furthermore, the presence of anti-mitochondrial antibodies and anti-smooth muscle antibodies in the sera of primary SS patients is considered indicative of primary biliary cirrhosis and autoimmune hepatitis, respectively. In addition, anti-centromere antibodies have been associated with a clinical phenotype intermediate between primary SS and systemic sclerosis, while antibodies against carbonic anhydrase have been related to renal tubular acidosis. Finally, an association of anti-muscarinic antibodies with cytopenias and a higher disease activity has also been described in primary SS. In conclusion, although not all of the above mentioned antibodies are useful for predicting distinct patient subgroups in SS, knowledge of the clinical associations of the different autoantibody specificities encountered in SS can advance our understanding of the disease and improve patient management.
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Affiliation(s)
- Vasiliki-Kalliopi Bournia
- Department of Pathophysiology, Medical School, University of Athens, Mikras Asias 75, 115 27 Athens, Greece
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31
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Tzioufas AG, Tatouli IP, Moutsopoulos HM. Autoantibodies in Sjögren's syndrome: clinical presentation and regulatory mechanisms. Presse Med 2012; 41:e451-60. [PMID: 22840991 DOI: 10.1016/j.lpm.2012.05.022] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2012] [Accepted: 05/02/2012] [Indexed: 12/24/2022] Open
Abstract
Primary Sjögren's syndrome (pSS) is a systemic autoimmune disease mostly affecting the exocrine glands. A large number of autoantibodies have been detected in the serum of patients with pSS. Among them, anti-Ro/SSA and anti-La/SSB autoantibodies are the most common; they serve as disease markers and are involved in the pathogenesis of neonatal lupus syndrome (NLS). Other autoantibodies are associated with significant clinical phenotypes, such as cryoglobulins with development of non-Hodgkin's lymphoma, anti-centromere antibodies with Raynaud's phenomenon and anti-mitochondrial antibodies with liver pathology. As a result, pSS patients can be schematically categorized in subgroups according to their serological profile. Although the clinical utility of these autoantibodies is appreciated, little is known about the mechanisms related to their production and the regulation of the autoimmune response. In the present review, the clinical subsets of patients with pSS related to different autoantibodies as well as the regulating mechanisms of their production with special emphasis on idiotypic/anti-idiotypic network are discussed.
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Affiliation(s)
- Athanasios G Tzioufas
- Medical School, University of Athens, Department of Pathophysiology, 11527 Athens, Greece.
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32
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Successful treatment of osteomalacia caused by renal tubular acidosis associated with Sjögren's syndrome. Mod Rheumatol 2012; 23:401-5. [PMID: 22740247 DOI: 10.1007/s10165-012-0667-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 05/08/2012] [Indexed: 10/28/2022]
Abstract
A 62-year-old woman was diagnosed with severe osteomalacia caused by renal tubular acidosis associated with Sjögren's syndrome. She was treated with sodium bicarbonate, risedronate, alfacalcidol, and prednisolone (1 mg/kg). By 24 months, renal tubular acidosis was improved and the bone density had normalized. Here we report the successful amelioration of bone lesions through a multidisciplinary approach that improved renal tubular acidosis, with a special focus on treatment of the underlying inflammatory disorder with glucocorticoids.
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33
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Rastegar A. Attending Rounds: Patient with Hypokalemia and Metabolic Acidosis. Clin J Am Soc Nephrol 2011; 6:2516-21. [DOI: 10.2215/cjn.04150511] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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34
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Ng JL, Morgan DJR, Loh NKM, Gan SK, Coleman PL, Ong GSY, Prentice D. Life‐threatening hypokalaemia associated with ibuprofen‐induced renal tubular acidosis. Med J Aust 2011; 194:313-6. [DOI: 10.5694/j.1326-5377.2011.tb02982.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Accepted: 11/21/2010] [Indexed: 11/17/2022]
Affiliation(s)
| | | | | | - Seng K Gan
- Royal Perth Hospital, Perth, WA
- University of Western Australia, Perth, WA
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35
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Youinou P, Devauchelle-Pensec V, Pers JO. Significance of B cells and B cell clonality in Sjögren's syndrome. ACTA ACUST UNITED AC 2010; 62:2605-10. [PMID: 20496425 DOI: 10.1002/art.27564] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Pierre Youinou
- EA2216 Immunology and Pathology, IFR 148 ScInBioS, European University of Brittany, and Brest University Medical School Hospital, Brest, France.
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36
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Monnier S, Lebas C, Meckenstock R, Khau D, Therby A, GrederBelan A. [Hypokalemia induced quadriparesis as the presenting manifestation of Gougerot-Sjögren's syndrome]. Rev Med Interne 2010; 32:e108-10. [PMID: 21035924 DOI: 10.1016/j.revmed.2010.09.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 05/19/2010] [Accepted: 09/22/2010] [Indexed: 10/18/2022]
Abstract
We report a 30-year-old woman who presented with a hypokaliemia-related subacute quadriparesis. The various causes of hypokalemia induced paresis were discussed but the association of hypokalemia with metabolic acidosis and normal anion gap was diagnostic of distal renal tubular acidosis. The renal tubulopathy was the presenting manifestation of a primary Sjogren's syndrome. Distal renal tubular acidosis concerns a third of the patients affected by this auto-immune disease.
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Affiliation(s)
- S Monnier
- Service de médecine interne, maladies infectieuses et tropicales, centre hospitalier de Versailles, 177, avenue de Versailles, 78153 Le-Chesnay cedex, France.
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37
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DuBose TD. A 42-year-old woman with flaccid paralysis. Am J Kidney Dis 2009; 54:965-9. [PMID: 19781834 DOI: 10.1053/j.ajkd.2009.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2009] [Accepted: 07/07/2009] [Indexed: 11/11/2022]
Affiliation(s)
- Thomas D DuBose
- Wake Forest University School of Medicine, Winston-Salem, NC 27157-1052, USA.
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38
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Apparently persistent weakness after recurrent hypokalemic paralysis: a tale of two disorders. South Med J 2008; 101:940-2. [PMID: 18708979 DOI: 10.1097/smj.0b013e3181809186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A 19-year-old woman presented with recurrent hypokalemic paralysis, followed by apparently persistent symptoms due to coexisting osteomalacia. Distal renal tubular acidosis type 1 (dRTA1) linked the metabolic abnormalities and occurred as an extraglandular feature of Sjögren syndrome (SS). This case highlights the fact that in the setting of recurrent hypokalemia, apparently progressive weakness should be distinguished from primary hypokalemic paralysis and evaluated for dRTA1, as the metabolic alterations are potentially treatable. Further dRTA1 may precede the occurrence of sicca syndrome in SS.
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