Multiple metabolic renal manifestations of a systemic disease

Mohamad Hanouneh; Jose M. Monroy Trujillo

doi:10.3949/ccjm.91a.23021

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TABLE 1

Laboratory results

Tests	Results^a	Reference range
Sodium	148 mmol/L	136–145

Potassium	3.1 mmol/L	3.5–5.1

Chloride	115 mmol/L	98–107

Bicarbonate	20 mmol/L	21–32

Blood urea nitrogen	24 mg/dL	7–18

Creatinine	1.0 mg/dL	0.6–1.3

Glucose	74 mg/dL	60–99

Calcium	9.2 mg/dL	8.4–10.5

Hemoglobin	10.2 g/dL	13.9–16.3

White blood cell count	5.99 × 10⁹/L	4.5–11.0
Neutrophils	67.6%	46.2%–80%
Lymphocytes	18.5%	10.3%–40.5%
Monocytes	12.7%	3.0%–14%
Eosinophils	1.0%	0.0%–-5.0%
Basophils	0.2%	0.0%–1.0%

Platelet count	311 × 10⁹/L	150–350

Alanine aminotransferase	50 U/L	6–65

Aspartate aminotransferase	26 U/L	3–37

Alkaline phosphatase	87 U/L	45–117

Bilirubin, total	< 0.2 mg/dL	0.2–1.2

Albumin	3.7 g/dL	3.5–5.0

Magnesium	2.3 mg/dL	1.8–2.4

Serum osmolality	303 mOsm/kg	275–295

Phosphorus	2.1 mg/dL	2.5–4.9

Thyrotropin	1.59 mIU/L	0.5–4.5

Arterial blood gasses
pH	7.34	7.35–7.45
Partial pressure of carbon dioxide	40 mm Hg	35–45
Partial pressure of oxygen	95 mm Hg	75–100

Urine
Random sodium	67 mmol/L	20–214
Random potassium	8 mmol/L	17–95
Random chloride	53 mmol/L	24–255
Random urea	207 mg/dL	132–1,629
Osmolality	165 mOsm/kg	50–1,200

↵a Abnormal results are in boldface.

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TABLE 2

Causes of primary and secondary distal renal tubular acidosis

Primary distal renal tubular acidosis
Sporadic (idiopathic)
Inherited (due to a congenital mutation)

Secondary distal renal tubular acidosis
Hypergammaglobulinemia
Autoimmune disorders (eg, lupus erythmatosus, Sjögren syndrome, rheumatoid arthritis)
Chronic renal allograft rejection
Obstructive uropathy
Medullary sponge kidney
Autoimmune hepatitis
Primary biliary cholangitis
Lithium, amphotericin B, ifosfamide
Sickle cell anemia

Based on information in reference 2.

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TABLE 3

Serology workup

Tests	Results	Normal range
Antinuclear antibody	1:80	< 40 = Negative
dsDNA antibody	Negative	Titers < 10 = Negative
Anti-Ro52 (SS-A) IgG	366	< 20
Anti-La (SS-B) antibody	< 3	< 20
Anti-Ro60 IgG	< 5	< 20
Cryoglobulin	Negative	Negative

ds = double strand; Ig = immunoglobulin; SS = Sjögren syndrome

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TABLE 4

2016 American College of Rheumatology (ACR) and European Alliance of Associations for Rheumatology (EULAR) classification for primary Sjögren syndrome

Inclusion criteria	Exclusion criteria
At least 1 symptom of ocular or oral dryness, defined as a positive response to at least 1 of the following questions: Have you had daily, persistent, troublesome dry eyes for more than 3 months? Do you have a recurrent sensation of sand or gravel in the eyes? Do you use tear substitutes more than 3 times a day? Have you had a daily feeling of dry mouth for more than 3 months? Do you frequently drink liquids to aid in swallowing dry food? Or suspicion of Sjögren syndrome based on glandular enlargement or the presence of characteristic extraglandular involvement	Prior diagnosis of any of the following conditions: History of head and neck radiation treatment Active hepatitis C infection (with positive polymerase chain reaction) Acquired immunodeficiency syndrome Sarcoidosis Amyloidosis Graft-vs-host disease Immunoglobulin G4-related disease
ACR/EULAR classification criteria for primary Sjögren syndrome^a
Criteria	Score
ACR/EULAR classification criteria for primary Sjögren syndrome	3
Anti-Ro/SS-A positive	3
Ocular staining score ≥ 5 (or van Bijsterveld score ≥ 4) in at least 1 eye	1
Schirmer test ≤ 5 mm at 5 minutes in at least 1 eye	1
Unstimulated whole saliva flow rate ≤ 0.1 mL/minute	1

↵a The classification of primary Sjögren syndrome applies to any patient who meets the inclusion criteria, does not have any of the conditions listed as exclusion criteria, and has a score ≥ 4.
Adapted from reference 7.