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1.
Vnitr Lek ; 66(4): 249-252, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32972189

RESUMO

Microscopic polyangiitis is a rare, systemic, necrotizing, pauci-immune, ANCA associated small vessel vasculitis, with no evidence of granulomatous inflammation. Diagnosing microscopic polyangiitis is often difficult because of it´s presentation by a number of non-specific symptoms. We treated a 35-year old patient, who was admitted for migrating arthritis and fever with papulous rash. In this case, we want to point out the importance of considering the diagnosis of MPA and similar rare diseases in the process of differential diagnosis, mainly in patients presenting with non-specific symptoms, because the mortality of this disease without adequate treatment is alarmingly high.


Assuntos
Glomerulonefrite , Poliangiite Microscópica , Adulto , Anticorpos Anticitoplasma de Neutrófilos , Diagnóstico Diferencial , Glomerulonefrite/diagnóstico , Humanos , Poliangiite Microscópica/diagnóstico
3.
Medicine (Baltimore) ; 99(28): e21101, 2020 Jul 10.
Artigo em Inglês | MEDLINE | ID: mdl-32664131

RESUMO

INTRODUCTION: Amyloidosis and fibrillary glomerulonephritis (FGN) share similar electron microscopic signatures including random arrangement of fibrils. However, distinction between the 2 can often be made using Congo Red staining. PATIENT CONCERNS: Here we describe a unique case of FGN, which stained positive for Congo Red, as well as DnaJ heat shock protein family (Hsp40) member B9 which is more specific for FGN. The patient presented with acute kidney injury and severe proteinuria. DIAGNOSIS: Congophilic FGN. INTERVENTIONS: Six-month course of mycophenolate mofetil and prednisone. OUTCOMES: complete resolution of acute kidney injury and proteinuria TAKE HOME LESSONS:: To our knowledge, this is the first reported case of successful treatment of this rare condition using mycophenolate mofetil and prednisone.


Assuntos
Glomerulonefrite/terapia , Glomérulos Renais/ultraestrutura , Biópsia , Diagnóstico Diferencial , Inibidores Enzimáticos/uso terapêutico , Glomerulonefrite/diagnóstico , Glomerulonefrite/tratamento farmacológico , Glucocorticoides/uso terapêutico , Humanos , Masculino , Microscopia Eletrônica , Pessoa de Meia-Idade , Ácido Micofenólico/uso terapêutico , Prednisona/uso terapêutico
4.
PLoS One ; 15(7): e0236051, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32716952

RESUMO

INTRODUCTION: Crescentic glomerulonephritis (CrGN) is a histologic feature of severe glomerular injury, clinically characterized by a rapid decline of renal function when not treated in a timely fashion. Factors associated with CrGN prognosis have not been thoroughly investigated. This study investigated the prognostic predictors of renal outcomes associated with CrGN, such as the histopathologic classification of anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis, arteriosclerosis, and tertiary lymphoid organ (TLO) formation. METHODS: A total of 114 patients diagnosed with CrGN between 2010 and 2018 at two university-based hospitals has been retrospectively analyzed. Relationships between potential predictors and renal outcomes were analyzed using Cox proportional hazards model and linear regression analysis. RESULTS: The mean age was 61.0 ± 15.3 years, and 49.1% were male. Among them, 92 (80.7%) and 11 (9.6%) patients were positive for ANCA and for anti-glomerular basement membrane antibody, respectively. During the median follow-up of 458.0 days, 55 patients (48.2%) had advanced to end-stage renal disease (ESRD). Cox proportional hazards analysis revealed that patients under the mixed and sclerotic classes had worse renal survival compared to those in the focal class (mixed: hazard ratio [HR], 3.74; 95% confidence interval [CI], 1.18 to 11.82; P = 0.025; sclerotic: HR, 4.84; 95% CI, 1.44 to 16.32; P = 0.011). Severe arteriosclerosis was also associated with poor renal survival (HR, 2.44; 95% CI, 1.04 to 5.77; P = 0.042). TLOs were observed in 41 patients (36.0%). Moreover, TLO formation was also a prognostic factor for ESRD (HR, 1.82; 95% CI, 1.03 to 3.21; P = 0.040). In the multivariate linear regression analysis, age and sclerotic class were independent predictors for the change in estimated glomerular filtration rate during 1 year after biopsy. CONCLUSIONS: Specific histopathologic findings, histopathologic classification, severity of arteriosclerosis, and TLO formation provide helpful information in predicting renal outcomes associated with CrGN.


Assuntos
Glomerulonefrite/diagnóstico , Glomerulonefrite/patologia , Rim/patologia , Feminino , Glomerulonefrite/fisiopatologia , Humanos , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Análise de Sobrevida
5.
Iran J Kidney Dis ; 14(3): 239-242, 2020 05.
Artigo em Inglês | MEDLINE | ID: covidwho-170320

RESUMO

During the COVID-19 pandemic, we had a 25 years old male case without any underlying disease or history of autoimmune disease in COVID-19 Clinic, Isfahan, Iran. He presented with arthralgia and weakness so we started COVID-19 therapeutic regimen. In his hospitalization, creatinine increases and abnormalities in random urine sediment was seen. Methylprednisolone and cyclophosphamide were prescribed due to suspected glomerulonephritis. After renal biopsy the diagnose was confirmed as crescentic proliferative glomerulonephritis. The patient also, underwent plasmapheresis and intravenous immunoglobulin injection. He was discharged healthy without development of new pulmonary symptoms despite immunosuppressive treatment.


Assuntos
Infecções por Coronavirus/complicações , Glomerulonefrite/complicações , Glomerulonefrite/diagnóstico , Pneumonia Viral/complicações , Administração Intravenosa , Adulto , Biópsia , Infecções por Coronavirus/diagnóstico , Ciclofosfamida/uso terapêutico , Glomerulonefrite/tratamento farmacológico , Glomerulonefrite/cirurgia , Humanos , Imunoglobulinas/administração & dosagem , Masculino , Metilprednisolona/uso terapêutico , Pandemias , Pneumonia Viral/diagnóstico , Resultado do Tratamento
6.
Am J Kidney Dis ; 76(2): 295-297, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32362418
7.
Iran J Kidney Dis ; 14(3): 239-242, 2020 05.
Artigo em Inglês | MEDLINE | ID: mdl-32361703

RESUMO

During the COVID-19 pandemic, we had a 25 years old male case without any underlying disease or history of autoimmune disease in COVID-19 Clinic, Isfahan, Iran. He presented with arthralgia and weakness so we started COVID-19 therapeutic regimen. In his hospitalization, creatinine increases and abnormalities in random urine sediment was seen. Methylprednisolone and cyclophosphamide were prescribed due to suspected glomerulonephritis. After renal biopsy the diagnose was confirmed as crescentic proliferative glomerulonephritis. The patient also, underwent plasmapheresis and intravenous immunoglobulin injection. He was discharged healthy without development of new pulmonary symptoms despite immunosuppressive treatment.


Assuntos
Infecções por Coronavirus/complicações , Glomerulonefrite/complicações , Glomerulonefrite/diagnóstico , Pneumonia Viral/complicações , Administração Intravenosa , Adulto , Biópsia , Infecções por Coronavirus/diagnóstico , Ciclofosfamida/uso terapêutico , Glomerulonefrite/tratamento farmacológico , Glomerulonefrite/cirurgia , Humanos , Imunoglobulinas/administração & dosagem , Masculino , Metilprednisolona/uso terapêutico , Pandemias , Pneumonia Viral/diagnóstico , Resultado do Tratamento
8.
Int J Mol Sci ; 21(7)2020 Apr 08.
Artigo em Inglês | MEDLINE | ID: mdl-32276523

RESUMO

It is widely known that glomerulonephritis (GN) often develops after the curing of an infection, a typical example of which is GN in children following streptococcal infections (poststreptococcal acute glomerulonephritis; PSAGN). On the other hand, the term "infection-related glomerulonephritis (IRGN)" has recently been proposed, because infections are usually ongoing at the time of GN onset in adult patients, particularly in older patients with comorbidities. However, there has been no specific diagnostic biomarker for IRGN, and diagnosis is based on the collection of several clinical and pathological findings and the exclusion of differential diagnoses. Nephritis-associated plasmin receptor (NAPlr) was originally isolated from the cytoplasmic fraction of group A streptococcus as a candidate nephritogenic protein for PSAGN and was found to be the same molecule as streptococcal glyceraldehyde-3-phosphate dehydrogenase and plasmin receptor. NAPlr deposition and related plasmin activity were observed with a similar distribution pattern in the glomeruli of patients with PSAGN. However, glomerular NAPlr deposition and plasmin activity could be observed not only in patients with PSAGN but also in patients with other glomerular diseases, in whom a preceding streptococcal infection was suggested. Furthermore, such glomerular staining patterns have been demonstrated in patients with IRGN induced by bacteria other than streptococci. This review discusses the recent advances in our understanding of the pathogenesis of bacterial IRGN, which is characterized by NAPlr and plasmin as key biomarkers.


Assuntos
Fibrinolisina/análise , Glomerulonefrite/diagnóstico , Receptores de Peptídeos/análise , Infecções Estreptocócicas/complicações , Infecções Bacterianas/complicações , Biomarcadores/análise , Glomerulonefrite/etiologia , Humanos , Glomérulos Renais/metabolismo
11.
Internist (Berl) ; 61(4): 416-423, 2020 Apr.
Artigo em Alemão | MEDLINE | ID: mdl-32179970

RESUMO

This article presents a case of recurrent anti-GBM disease (with antibodies against the glomerular basement membrane [GBM]) in a 17-year-old patient successfully treated with rituximab. Kidney biopsy with detection of linear deposition of immunoglobulin G (IgG) along the basement membrane is the diagnostic gold standard, which should be accompanied by serological testing. However, standard assays for the detection of anti-GBM antibodies have a high rate of false-negative results. In this particular case, an increase in proteinuria despite standard therapy (plasmapheresis, steroids, cyclophosphamide) was the clinical correlate of relapsing disease. The use of rituximab completely resolved the recurrent anti-GBM disease.


Assuntos
Doença Antimembrana Basal Glomerular/tratamento farmacológico , Glomerulonefrite/tratamento farmacológico , Fatores Imunológicos/uso terapêutico , Rituximab/uso terapêutico , Adolescente , Doença Antimembrana Basal Glomerular/imunologia , Doença Antimembrana Basal Glomerular/patologia , Anticorpos Monoclonais , Autoanticorpos , Biópsia , Membrana Basal Glomerular/patologia , Glomerulonefrite/diagnóstico , Humanos , Imunoglobulina G/imunologia , Rim/patologia , Troca Plasmática , Proteinúria , Recidiva , Resultado do Tratamento
12.
Medicine (Baltimore) ; 99(7): e19179, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32049851

RESUMO

RATIONALE: Polyglandular autoimmune syndromes (PAS) are a heterogeneous group of rare diseases characterized by the association of at least 2 organ-specific autoimmune disorders, concerning both the endocrine and nonendocrine organs. Type III is defined as the combination of autoimmune thyroid disease and other autoimmune conditions (other than Addison disease), and is divided into 4 subtypes. We describe a patient with Hashimoto thyroiditis, adult-onset Still disease, alopecia, vasculitis, antineutrophil cytoplasmic antibody (ANCA)-mediated crescentic glomerulonephritis, and hyperparathyroidism. Co-occurrence of these 5 diseases allowed us to diagnose PAS type IIIc. The rare combination of these different diseases has not been reported before. PATIENT CONCERNS: A 51-year-old woman was admitted in April, 2019 after the complaint of an enlarged thyroid. She was diagnosed with Hashimoto thyroiditis at the age of 36. At age 40, she was diagnosed with an adult-onset Still disease. Three months before admission, she experienced renal insufficiency. After admission, she was diagnosed with hyperparathyroidism. DIAGNOSIS: Renal biopsy revealed renal vasculitis and crescentic nephritis. Antineutrophil cytoplasmic autoantibody showed that human perinuclear ANCA and myeloperoxidase ANCA were positive. Therefore, the patient was diagnosed with vasculitis and ANCA-mediated crescentic glomerulonephritis. After admission, parathyroid single-photon emission computed tomography/computed tomography fusion image demonstrated the presence of hyperparathyroidism. INTERVENTIONS: The patient was treated with high-dose methylprednisolone pulse therapy (0.1 g/d) for vasculitis and ANCA-mediated crescentic glomerulonephritis, calcium and vitamin D3 (600 mg/d elemental calcium [calcium carbonate] and 2.5 µg/d active vitamin D3) for hyperparathyroidism, and levothyroxine sodium (50 ug/d) for Hashimoto thyroiditis. OUTCOMES: Up to now, serum thyroid-stimulating hormone, total triiodothyronine, total thyroxine, free triiodothyronine, and free thyroxine were within the normal ranges. Patient's renal function did not deteriorate. LESSONS: We report a patient with Hashimoto thyroiditis, adult-onset Still disease, alopecia, vasculitis, ANCA-mediated crescentic glomerulonephritis, and hyperparathyroidism, which is a very rare combination. We present this case as evidence for the coexistence of several different immune-mediated diseases in the clinical context of a PAS IIIc.


Assuntos
Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/diagnóstico , Glomerulonefrite/diagnóstico , Doença de Hashimoto/diagnóstico por imagem , Poliendocrinopatias Autoimunes/diagnóstico , Feminino , Glomerulonefrite/imunologia , Doença de Hashimoto/complicações , Humanos , Pessoa de Meia-Idade , Poliendocrinopatias Autoimunes/complicações
13.
Medicine (Baltimore) ; 99(5): e18857, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32000387

RESUMO

RATIONALE: IgG4-related disease (IgG4-RD) is a slowly progressing inflammatory disease that can involve multiple organ systems. There is considerable overlap between IgG4-RDs and anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Herein, we present an unusual case of IgG4-associated tubulointerstitial nephritis (IgG4-TIN) and ANCA-associated glomerulonephritis (ANCA-GN) co-occurring with C3 glomerulonephritis (C3GN). PATIENT CONCERNS: A 72-year-old male was admitted to hospital because of fever and fatigue. He was diagnosed with elevated serum creatinine and IgG4 levels, and was positive for ANCA. DIAGNOSIS: Initially, the pathology supported a diagnosis of IgG4-TIN and ANCA-GN; however, further examination revealed he also had C3GN. INTERVENTIONS: The patient was treated with methylprednisolone and cyclophosphamide and received regular follow-up care. OUTCOMES: After treatment, the patient no longer exhibited fever or fatigue and had no complications. The seven-month follow-up showed downward trends in IgG4 and MPO-ANCA levels and stable 24-hour urine protein, serum creatinine levels. LESSONS: Anti-neutrophil cytoplasmic antibody-associated glomerulonephritis and IgG4-associated tubulointerstitial nephritis with C3glomerulonephritis rarely occur simultaneously. Laboratory analysis and pathology are both needed to ensure diagnostic accuracy. However, in this case, the three diseases overlapped to such a large extent that achieving a definitive diagnosis was particularly challenging. Timely and accurate diagnosis is crucial for selecting the best treatment course and optimizing patient outcome.


Assuntos
Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/diagnóstico , Glomerulonefrite/diagnóstico , Nefrite Intersticial/diagnóstico , Idoso , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/tratamento farmacológico , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/imunologia , Anticorpos Anticitoplasma de Neutrófilos/imunologia , Complemento C3/imunologia , Ciclofosfamida/uso terapêutico , Glomerulonefrite/tratamento farmacológico , Glomerulonefrite/imunologia , Glucocorticoides/uso terapêutico , Humanos , Imunoglobulina G/imunologia , Imunossupressores/uso terapêutico , Masculino , Metilprednisolona/uso terapêutico , Nefrite Intersticial/tratamento farmacológico , Nefrite Intersticial/imunologia
15.
J Am Soc Nephrol ; 31(4): 829-840, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32034108

RESUMO

BACKGROUND: The pathophysiology of the leading cause of pediatric acute nephritis, acute postinfectious GN, including mechanisms of the pathognomonic transient complement activation, remains uncertain. It shares clinicopathologic features with C3 glomerulopathy, a complement-mediated glomerulopathy that, unlike acute postinfectious GN, has a poor prognosis. METHODS: This retrospective study investigated mechanisms of complement activation in 34 children with acute postinfectious GN and low C3 level at onset. We screened a panel of anticomplement protein autoantibodies, carried out related functional characterization, and compared results with those of 60 children from the National French Registry who had C3 glomerulopathy and persistent hypocomplementemia. RESULTS: All children with acute postinfectious GN had activation of the alternative pathway of the complement system. At onset, autoantibodies targeting factor B (a component of the alternative pathway C3 convertase) were found in a significantly higher proportion of children with the disorder versus children with hypocomplementemic C3 glomerulopathy (31 of 34 [91%] versus 4 of 28 [14%], respectively). In acute postinfectious GN, anti-factor B autoantibodies were transient and correlated with plasma C3 and soluble C5b-9 levels. We demonstrated that anti-factor B antibodies enhance alternative pathway convertase activity in vitro, confirming their pathogenic effect. We also identified crucial antibody binding sites on factor B, including one correlated to disease severity. CONCLUSIONS: These findings elucidate the pathophysiologic mechanisms underlying acute postinfectious GN by identifying anti-factor B autoantibodies as contributing factors in alternative complement pathway activation. At onset of a nephritic syndrome with low C3 level, screening for anti-factor B antibodies might help guide indications for kidney biopsy to avoid misdiagnosed chronic glomerulopathy, such as C3 glomerulopathy, and to help determine therapy.


Assuntos
Autoanticorpos/sangue , Ativação do Complemento/fisiologia , Complemento C3/metabolismo , Fator B do Complemento/imunologia , Glomerulonefrite/sangue , Glomerulonefrite/diagnóstico , Criança , Pré-Escolar , Fator Nefrítico do Complemento 3/metabolismo , Feminino , França , Humanos , Masculino , Estudos Retrospectivos
17.
Dtsch Med Wochenschr ; 145(4): 223-231, 2020 02.
Artigo em Alemão | MEDLINE | ID: mdl-32069489

RESUMO

Chronic kidney disease (CKD) is an increasing health problem in all societies. The role of diabetes mellitus and hypertension in CKD is well established in the medical community. This is not necessarily the case for the various forms of glomerulonephitis (GN). The single entities of GN are rare diseases. In total, glomerulonephritis, however, is accountable for about 20 % of all patients which reach end stage renal disease (ESRD). GN therefore plays an important clinical role. Since many forms of GN have only sparse clinical symptoms at the beginning of the disease and the treatment is only effective in early stages, it is important for patients' outcome to make an early diagnosis. In case of any - even small - changes in the urine of patients the diagnoses of GN should be considered. It is the purpose of this article to describe the clinical significance and the road to the diagnosis of the most frequent forms of GN to allow an early start of therapy in order to prevent the development of ESRD.


Assuntos
Glomerulonefrite , Glomerulonefrite/classificação , Glomerulonefrite/diagnóstico , Glomerulonefrite/fisiopatologia , Glomerulonefrite/terapia , Humanos , Rim/fisiopatologia , Falência Renal Crônica/prevenção & controle
19.
Mymensingh Med J ; 29(1): 5-15, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31915329

RESUMO

Acute post-streptococcal glomerulonephritis (APSGN) is the commonest cause of acute glomerulonephritis (AGN), which usually present with gross hematuria, mild edema, oliguria, hypertension and varying degree of renal insufficiency. It is more common among the population of school going age where poverty, overcrowding and poor hygienic conditions are prevailing. This cross sectional observational study was aimed to know the socio-demographic variables, clinical profile and immediate outcome of AGN in hospitalized children and was conducted in the Pediatric department of Mymensingh Medical College Hospital (MMCH), Mymensingh, Bangladesh from November 2014 to April 2015. A detailed history was taken from the parents in each case with a written questionnaire. A written consent was also taken from the guardian of the including patients and also permission was taken from the ethical committee of MMCH. Thorough clinical examination and available relevant investigations were done in all patients. Progresses of the patient were monitored by daily clinical examinations and also by investigations. Data were analyzed by statistical package for social science (SPSS) windows version 18. Results were verified by doing standard test for significance. Among total 60 cases male was 58.3% & female was 41.7%. The common age group of presentation was between 7-12 years (73%), peak age of incidence was 7-9 years. Most of them came from low socioeconomic status (83.3%), 63.3% from rural area with average 5-6 member's family size. Most of the parents were illiterate. History of (H/O) skin infection was present in 35(58.3%) patients, 15(25%) had H/O sore throat, 15% did not give any H/O infection before presentation. Average duration of gap between infection and appearance of clinical feature was 7-14 days in 73.40%and 15-21 days was in 45.7% in case of sore throat & skin infection respectively. Almost all (95%) patients presented with puffiness of face, others presented with scanty micturition, gross hematuria, respiratory distress, fever, convulsion and altered sensorium. Edema (75%), hypertension (88.3%), pallor (38%), tachypnea (25%), tachycardia (26.7%) were the important clinical findings. Microscopic hematuria was present among 96.66% patients; low complement level was found in 85% cases. There is significant association between low socioeconomic statuses with more hospital stay. Only one patient died due to heart failure and 98.3% patient had complete recovery. Results of this study conclude that most of the patients came from rural illiterate family with low socioeconomic background. Skin infection is the commonest cause of acute glomerulonephritis. Edema, scanty micturation, hematuria and hypertension are the common mode of presentation. Heart failure and hypertensive encephalopathy are the common complication of AGN. Immediate prognosis of AGN was excellent.


Assuntos
Glomerulonefrite/diagnóstico , Tempo de Internação/estatística & dados numéricos , Doença Aguda , Bangladesh/epidemiologia , Criança , Estudos Transversais , Feminino , Glomerulonefrite/epidemiologia , Humanos , Incidência , Masculino , Pediatria , População Rural , Fatores Socioeconômicos
20.
Expert Rev Gastroenterol Hepatol ; 14(2): 113-125, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31951758

RESUMO

Introduction: Multiple studies have revealed a strong relationship between the development of nephropathy and hepatitis B virus (HBV) infection. The underlying pathogenesis of hepatitis B-related glomerulonephritis (HBV-GN) involves immune complexes, which can be isolated from kidney tissues. Clearance of HBV antigenemia improves renal impairment and proteinuria in HBV-GN patients.Areas covered: In this review, we present our current understanding of the epidemiology, pathogenesis, pathology, diagnosis, and treatment of HBV-GN. We discuss the advantages and disadvantages of oral nucleoside/nucleotide analogs (NAs), and the main pharmaceutical treatment for hepatis B.Expert opinion: Currently, antiviral agents are the main HBV-GN therapeutic agents. Although no randomized controlled clinical trials have compared the efficacy of interferon (IFN) and NA, we suggest IFN treatment for pediatric patients (IFN-α in patients ≥1 year; pegIFN-α in patients ≥3 years) considering treatment duration and absence of resistance. Novel NAs have brought about promising treatment options involving high efficacy viral suppression and low resistance rates. NAs with a high barrier to resistance (e.g. entecavir) are recommended as first-line therapy of HBV-GN. Immunosuppression monotherapy, such as corticosteroids, is of little benefit and potentially harmful to HBV-GN patients due to the possibility of viral reactivation.


Assuntos
Glomerulonefrite/diagnóstico , Glomerulonefrite/tratamento farmacológico , Hepatite B Crônica/imunologia , Complexo Antígeno-Anticorpo/imunologia , Antivirais/uso terapêutico , Glomerulonefrite/epidemiologia , Glomerulonefrite/etiologia , Hepatite B Crônica/complicações , Hepatite B Crônica/tratamento farmacológico , Humanos , Doenças do Complexo Imune/imunologia , Doenças do Complexo Imune/patologia , Doenças do Complexo Imune/virologia , Imunossupressores/uso terapêutico , Interferon-alfa/uso terapêutico , Rim/imunologia , Rim/patologia , Nucleosídeos/efeitos adversos , Nucleosídeos/uso terapêutico , Nucleotídeos/uso terapêutico
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