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A 28-year-old female patient was hospitalized for mild-moderate hypokalaemia which was persistent despite discontinuation of beta-2 agonist bronchodilator treatment. Her past medical history was relevant for two episodes of severe hypokalaemia after active inhaled beta-2 agonist treatment for asthma crisis. Investigations revealed increased potassium in spot urine with a transtubular potassium gradient4. A 24-hour urine analysis showed hypophosphaturia, hypocalciuria, hypomagnesuria and normal urine prostaglandins in favour of Gitelman syndrome. Oral potassium supplementation was started and genetic studies were recommended.An exhaustive aetiological work-up should be performed in young patients with persistent hypokalaemia after withdrawal of bronchodilators.Gitelman syndrome should be suspected in any patient with unexplained hypokalaemia, metabolic alkalosis, and a normal or low blood pressure.

The diagnosis of primary hyperaldosteronism (PHPA) has progressively increased over the last years and some authors consider it as the main cause of secondary hypertension. We studied the prevalence of PHPA in hypertensive patients followed at the Hypertension Unit from July 1999 to July 2017. A total of 2500 patients were included and diagnosis of PHPA was done in 79 of them (3.2%). It was more frequent in women (55.7%) with an increased incidence in the elderly, as compared to previous studies (27.8%). Initial diagnosis was suspected upon the presence of inappropriate kaliuria and metabolic alkalosis, associated to an aldosterone/plasma renin activity ratio30 (ng/dl)/(ng/ml/h). After confirmation of the presence of PA, imaging techniques to determine the etiology were performed. In this way, 29 cases (36.8%) of aldosterone-producing adenoma and 5 cases of bilateral adrenal hyperplasia with nodules were identified. Computed tomography identified the adenomas and hyperplasias with bilateral cortical nodules in all patients. Adrenalectomy and/or antialdosteronics were efficient in controlling blood pressure in 69.9% of cases. Of note in this series was the remission of stage 3 chronic renal failure in two cases, the high prevalence of hypercalciuric urinary lithiasis and a case of breast carcinoma after prolonged treatment with spironolactone.El diagnóstico de hiperaldosteronismo primario (HPAP) aumentó en los últimos años y algunos autores lo consideran la principal causa de hipertensión arterial secundaria. Estudiamos la prevalencia de HPAP en el total de pacientes hipertensos atendidos en la Unidad de Hipertensión Arterial, en el período comprendido entre julio 1999 a julio 2017. Se incluyeron 2500 pacientes y en 79 se diagnosticó HPAP (3.2%). El HPAP fue más frecuente en mujeres (55.7%), observándose un incremento en la edad geriátrica con relación a estudios previos (27.8%). El diagnóstico se sospechó ante la presencia de kaliuria inapropiada y alcalosis metabólica, acompañada de un cociente aldosterona/actividad de renina plasmática superior a 30 (ng/dl)/(ng/ml/h). Tras su confirmación se realizaron estudios de imagen para determinar la etiología. Se detectaron así 29 casos (36.8%) de adenomas productores de aldosterona y 5 de hiperplasia bilateral suprarrenal con nódulos. La tomografía computarizada identificó el 100% de los adenomas y de las hiperplasias con nódulos corticales bilaterales. El tratamiento con suprarrenalectomía y/o antialdosterónicos resultó eficaz en el control de la presión arterial en el 69.9% de los casos. Se comentan aspectos particulares de esta serie, como la remisión de la insuficiencia renal, la elevada presencia de litiasis urinaria hipercalciúrica y la detección de un carcinoma de mama tras dosis prolongadas de espironolactona.

Nutcracker syndrome is a vascular anomaly consisting in the compression of the left renal vein between the superior mesenteric artery and the aorta. Clinical features in nutcracker syndrome include pelvic pain, flank pain, haematuria, gonadal varices or simply asymptomatic. We are presenting two cases, one of them with macroscopic haematuria and flank pain and the other was studied for hypertension but with previous antecedents of left renal vein embolization in the setting of varicocele. We discuss the clinical presentation as well as diagnostic and therapeutic aspects related to this syndrome

We are presenting a case of TTP with undetectable levels of ADAMTS 13 in a 39-year-old woman. Diagnosis of systemic lupus was evoked in the setting of thrombotic microangiopathy. The patient presented normal renal function but important neurological impairment. Treatment with daily plasmapheresis as well as Rituximab, cyclophosphamide as steroids was required to achieve clinical improvement.

ResumenLas infecciones continúan siendo un problema relevante en el paciente trasplantado renal, en especial las infecciones virales.La infección por el parvovirus humano B19 causa anemia refractaria grave, pancitopenia y microangiopatía trombótica. Dicha infección se diagnostica mediante el análisis de la reacción en cadena de la polimerasa (PCR) en sangre y por la presencia de proeritroblastos gigantes típicos en la médula ósea.Presentamos el caso clínico de un varón de 65 años con trasplante renal de donante cadáver en septiembre de 2014. A los 38 días del trasplante comienza con anemia progresiva y resistente a los agentes estimulantes de la eritropoyesis. A los 64 días se produce hipertermia, con deterioro progresivo de su estado general. La serología vírica resultó negativa, al igual que la PCR inicial en sangre del parvovirus humano B19. A los 4 meses y 19 días se realiza una biopsia de médula ósea en la que se observan eritroblastos gigantes con inclusiones víricas nucleares compatibles con parvovirus, por lo que se realiza una PCR en dicho tejido que confirma el diagnóstico. Una segunda PCR en sangre resultó positiva. Tras el tratamiento con inmunoglobulinas intravenosas (IGIV) y la suspensión temporal del micofenolato de mofetilo, se produce una remisión completa de la enfermedad, aunque persistía positiva la PCR para el parvovirus B19 en sangre, lo que hace necesario vigilar probables recidivas.AbstractInfections remain an issue of particular relevance in renal transplant patients, particularly viral infections.Human parvovirus B19 infection causes severe refractory anaemia, pancytopenia and thrombotic microangiopathy. Its presence is recognized by analysing blood polymerase chain reaction (PCR) and by the discovery of typical giant proerythroblasts in the bone marrow.We report the case of a 65 year-old man with a history of deceased donor renal transplant in September 2014. At 38 days after the transplant, the patient presented progressive anaemia that was resistant to erythropoiesis-stimulating agents. At 64 days after transplant, hyperthermia occurred with progressive deterioration of the patient's general condition. The viral serology and the first blood PCR for human parvovirus B19 were both negative. At 4 months and 19 days after, a bone marrow biopsy was conducted, showing giant erythroblasts with nuclear viral inclusions that were compatible with parvovirus; a PCR in the tissue confirmed the diagnosis. A second blood PCR was positive for parvovirus. After treatment with intravenous immunoglobulin and the temporary discontinuation of mycophenolate mofetil, a complete remission of the disease occurred, although the blood PCR for parvovirus B19 remained positive, so monitoring is necessary for future likely recurrence.

We are reporting the case of a 72 year old male patient with no previous relevant medical history presenting with a one week history of non-palpable purpuric rash with normal platelet count. All investigations came back negative except for vitamin C. The resolution of the clinical picture was achieved after vitamin C supplementation was added to prednisone.

We report a case of a 64-year-old man who, 44 days after starting treatment with prasugrel, presented with severe thrombocytopenia, anaemia, renal failure, and severe ADAMTS13 activity deficiency, along with a high titer of autoantibodies to this protease. LEARNING POINTS Drug-induced TTP is a rare condition and difficult to diagnose. Decreased activity of ADAMTS13, unusual in drug-induced TTP, was present in this case.

Infections remain an issue of particular relevance in renal transplant patients, particularly viral infections. Human parvovirus B19 infection causes severe refractory anaemia, pancytopenia and thrombotic microangiopathy. Its presence is recognised by analysing blood polymerase chain reaction (PCR) and by the discovery of typical giant proerythroblasts in the bone marrow. We report the case of a 65 year-old man with a history of deceased donor renal transplant in September 2014. At 38 days after the transplant, the patient presented progressive anaemia that was resistant to erythropoiesis-stimulating agents. At 64 days after transplant, hyperthermia occurred with progressive deterioration of the patient's general condition. The viral serology and the first blood PCR for human parvovirus B19 were both negative. At 4 months and 19 days after, a bone marrow biopsy was conducted, showing giant erythroblasts with nuclear viral inclusions that were compatible with parvovirus; a PCR in the tissue confirmed the diagnosis. A second blood PCR was positive for parvovirus. After treatment with intravenous immunoglobulin and the temporary discontinuation of mycophenolate mofetil, a complete remission of the disease occurred, although the blood PCR for parvovirus B19 remained positive, so monitoring is necessary for future likely recurrence.

Objetivos: Conocer que proporcion de las mujeres canarias posmenopausicas con obesidad de grados II y III (indice de masa corporal [IMC] = 35) se encuentra por debajo del umbral de la pobreza y estudiar en esa misma poblacion la prevalencia de diabetes mellitus, enfermedad tiroidea, obesidad, hipertension arterial, enfermedad reumatica inflamatoria, urolitiasis y fracturas oseas por fragilidad (totales, vertebrales y no vertebrales), la distribucion de una serie de estilos de vida (consumos de tabaco, de alcohol y de cafeina y actividad fisica realizada durante el tiempo libre), y el nivel socioeconomico. Metodo: Estudio observacional transversal. Se entrevisto personalmente a todas las pacientes y se les aplico un cuestionario dirigido a conocer su estilo de vida. Asimismo se reviso su historia clinica para documentar la prevalencia de las enfermedades. Tambien se les efectuo una exploracion fisica detenida y se las tallo y peso con ropa ligera. Asimismo se les extrajo sangre en ayunas para realizar una analitica general. El criterio de pobreza aplicado fue el establecido por el Instituto Nacional de Estadistica. Resultados: Las mujeres con obesidad morbida tenian mayor edad (56,8 ± 11 frente a 53,9 ± 11,6 anos; p = 0,02), menor talla (153,7 ± 6,3 frente a 156,9 ± 36,1 cm; p = 0,001), mayor peso (89,6 ± 9,3 frente a 66,6 ± 10,4 kg; p = 0,001) y mayor superficie corporal que las controles (1,73 ± 0,13 frente a 1,54 ± 0,13 m2; p = 0,001). Estas mujeres consumian menos alcohol y tabaco y mas cafe, y eran mas sedentarias que las mujeres del grupo control. Tambien tenian mayor prevalencia de hipertension arterial (el 36 frente al 17,9%; p = 0,001; odds ratio [OR] = 2,57; intervalo de confianza [IC] del 95%, 1,56-4,24), diabetes mellitus (el 24,4 frente al 11,3%; p = 0,001; OR = 2,52; IC del 95%, 1,47-1,05) e hipotiroidismo (el 14,3 frente al 8%; p = 0,04; OR = 1,91; IC del 95%, 0,99-3,68). Mas de la mitad de las mujeres con obesidad morbida vivian en un habitat rural y se encontraban por debajo del umbral de la pobreza. Conclusiones: Mas de la mitad de las mujeres posmenopausicas con obesidad morbida estan por debajo del umbral de la pobreza y viven en un habitat rural. Consumen menos alcohol y tabaco, son mas sedentarias y presentan una mayor prevalencia de diabetes mellitus, hipertension e hipotiroidismo.

Reverse osmosis membranes at many desalination plants are disinfected by periodic shock treatments with sodium metabisulphite, which have potentially toxic effects to the environment for marine life, although no empirical and experimental evidence for this is yet available. The aim of this study was to characterise for the first time, the physico-chemical modification of the marine environment and its biological effects, caused by hypersaline plumes during these membrane cleaning treatments. The case study was the Maspalomas II desalination plant, located in the south of Gran Canaria (Canary Islands, Spain). Toxicity bioassays were performed on marine species characteristic for the infralittoral soft bottoms influenced by the brine plume (Synodus synodus and Cymodocea nodosa), and revealed a high sensitivity to short-term exposure to low sodium metabisulphite concentrations. The corrective measure of incorporating a diffusion system with Venturi Eductors reduced nearly all the areas of influence, virtually eliminating the impact of the disinfectant., SI

Obesity has become a major public health problem in all western countries, and its prevalence is increasing. This condition is associated with a higher prevalence of diabetes mellitus, hypertension, and coronary heart disease; furthermore, obesity is a risk factor for mortality.To study the association of some prevalent diseases (diabetes mellitus, thyroid disease, obesity, hypertension, inflammatory rheumatic disease, urolithiasis), the distribution of some lifestyle factors (tobacco, alcohol and caffeine consumption and physical activity during leisure time) and the prevalence of poverty in a population of postmenopausal women in the Canary Islands with obesity class II or III (BMI35).A personal interview was performed in all patients. A questionnaire was administered to assess their lifestyles and current medication use. The women's medical records were reviewed to confirm the existence of certain diseases. A complete physical examination was performed in all patients. Weight and height were measured with the patient dressed in light clothing. Blood samples were obtained with the patient in a fasting state for subsequent analysis. Poverty was defined according to the criteria of the Spanish National Institute of Statistics.Women with obesity class II or III were older (56.8+/-11 vs 53.9+/-11.6 years, p=0.02), shorter (153.7+/-6.3 vs 156.9+/-36.1 cm, p=0.001), heavier (89.6+/-9.3 vs 66.6+/-10.4 kg, p=0.001) and had a greater body surface than controls (1.73+/-0.13 vs 1.54+/-0.13 m2, p=0.001). Alcohol and tobacco consumption were lower in obese women than in controls. Obese women drank more coffee and took less physical activity during leisure time than controls. The prevalence of hypertension -36% vs 17.9%, p=0.001, odds ratio [OR] [95% confidence interval (IC)]=2.57 (1.56-4.24)-, diabetes mellitus -24.4% vs 11.3%, p=0.001, OR=2.52 (1.47-1.05)-and hypothyroidism -14.3% vs 8%, p=0.04; OR=1.91 (0.99-3.68)-was higher in obese women than in controls. More than half lived in rural areas and were below the poverty threshold.More than half of postmenopausal women with obesity class II or III were below the poverty threshold and lived in a rural area. In these women there was a lower consumption of alcohol and tobacco, lesser physical activity during leisure time, and a higher prevalence of diabetes mellitus, hypertension and hypothyroidism than in control postmenopausal women.