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Nasr SH, Sirac C, Leung N, Bridoux F. Monoclonal immunoglobulin crystalline nephropathies. Kidney Int 2024; 106:201-213. [PMID: 38723749 DOI: 10.1016/j.kint.2024.02.027] [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: 12/17/2023] [Revised: 02/18/2024] [Accepted: 02/27/2024] [Indexed: 05/22/2024]
Abstract
Monoclonal Ig crystalline nephropathies are rare lesions resulting from precipitation of monoclonal Igs in the kidney as crystalline inclusions. They can be categorized into lesions with predominant intracellular crystals (light chain [LC] proximal tubulopathy, LC crystal-storing histiocytosis, and LC crystalline podocytopathy) and lesions with predominant extracellular crystals (crystalglobulin-induced nephropathy and crystalline variant of LC cast nephropathy). The majority of these lesions are associated with low tumor burden lymphoproliferative disorders, with the exception of crystalline variant of LC cast nephropathy. Extrarenal involvement (e.g., skin and cornea) is frequent. Kidney biopsy is the cornerstone for diagnosis, which often requires electron microscopy and antigen retrieval. A thorough hematologic workup and evaluation of extrarenal involvement is mandatory for management. Treatment of these lesions is with clone-directed therapy, with the goal of achieving hematologic very good partial response or complete response, which preserves or improves kidney function. In vitro and in vivo studies, animal models, and novel sequencing techniques have been invaluable tools to understand the pathogenesis of LC proximal tubulopathy and can be used to increase our limited knowledge of the pathogenesis of the other monoclonal Ig crystalline nephropathies. This review provides an update on the pathology, renal and hematologic characteristics, extrarenal manifestations, prognosis, treatment, and pathogenesis of monoclonal Ig crystalline nephropathies.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Christophe Sirac
- Control of the Immune Response B and Lymphoproliferation, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, Limoges, France; Centre de Référence de l'Amylose AL et des autres Maladies par Dépôts d'Imunoglobuline Monoclonale, University Hospital Dupuytren, Limoges, France
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank Bridoux
- Control of the Immune Response B and Lymphoproliferation, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, Limoges, France; Centre de Référence de l'Amylose AL et des autres Maladies par Dépôts d'Imunoglobuline Monoclonale, University Hospital Dupuytren, Limoges, France; Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
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2
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Zhang H, Zhang C, Su H. Concurrent Crystalline Light-Chain Proximal Tubulopathy and Membranous Nephropathy: A Case Report and Literature Review. Kidney Med 2024; 6:100816. [PMID: 38720788 PMCID: PMC11077163 DOI: 10.1016/j.xkme.2024.100816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
Abstract
Light-chain proximal tubulopathy (LCPT) is typically characterized by the intracytoplasmic deposition of light chains within the proximal tubular epithelial cells, which is usually classified into crystalline and noncrystalline subgroups. Membranous nephropathy (MN) is a common glomerular disease characterized by diffused subepithelial electron-dense deposits along the capillary loop accompanied by the effacement and microvillus transformation of the foot process. Here, we report a biopsy-confirmed case of a concurrence of LCPT with crystals (κ light chains restricted) and antigen-undetermined MN in a male patient. The patient presented with low-molecular-weight proteinuria, increased serum creatinine levels, and incomplete Fanconi syndrome. To our knowledge, this is the first report of a concurrence of LCPT and independent MN of unknown target antigens, which may enrich our recognition of monoclonal gammopathy of renal significance with synchronous MN.
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Affiliation(s)
- Huizi Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Chunyun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
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3
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Tang X, Wan F, Ye T, Hou X, Li Q. Lessons for the clinical nephrologist: a case of noncrystalline light chain proximal tubulopathy. J Nephrol 2023; 36:323-327. [PMID: 36242736 DOI: 10.1007/s40620-022-01443-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 08/10/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Xuanli Tang
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Feng Wan
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Tian Ye
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Xiaotao Hou
- Department of Renal Pathology, King Medical Diagnostics Center, Guangzhou, China
| | - Qiufen Li
- Department of Nephrology (Key Laboratory of Kidney Disease Prevention and Control Technology), Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China.
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4
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Pathological characteristics of light chain crystalline podocytopathy. Kidney Int 2023; 103:616-626. [PMID: 36581019 DOI: 10.1016/j.kint.2022.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 12/28/2022]
Abstract
Monoclonal immunoglobulin light chain (LC) crystalline inclusions within podocytes are rare, poorly characterized entities. To provide more insight, we now present the first clinicopathologic series of LC crystalline podocytopathy (LCCP) encompassing 25 patients (68% male, median age 56 years). Most (80%) patients presented with proteinuria and chronic kidney disease, with nephrotic syndrome in 28%. Crystalline keratopathy and Fanconi syndrome were present in 22% and 10%, respectively. The hematologic condition was monoclonal gammopathy of renal significance (MGRS) in 55% and multiple myeloma in 45%. The serum monoclonal immunoglobulin was IgG κappa in 86%. Histologically, 60% exhibited focal segmental glomerulosclerosis (FSGS), often collapsing. Ultrastructurally, podocyte LC crystals were numerous with variable effacement of foot processes. Crystals were also present in proximal tubular cells as light chain proximal tubulopathy (LCPT) in 80% and in interstitial histiocytes in 36%. Significantly, frozen-section immunofluorescence failed to reveal the LC composition of crystals in 88%, requiring paraffin-immunofluorescence or immunohistochemistry, with identification of kappa LC in 87%. The LC variable region gene segment, determined by mass spectrometry of glomeruli or bone marrow plasma cell sequencing, was IGKV1-33 in four and IGKV3-20 in one. Among 21 patients who received anti-plasma cell-directed chemotherapy, 50% achieved a kidney response, which depended on a deep hematologic response. After a median follow-up of 36 months, 26% progressed to kidney failure and 17% died. The mean kidney failure-free survival was 57.6 months and was worse in those with FSGS. In sum, LCCP is rare, mostly associates with IgG κappa MGRS, and frequently has concurrent LCPT, although Fanconi syndrome is uncommon. Paraffin-immunofluorescence and electron microscopy are essential to prevent misdiagnosis as primary FSGS since kidney survival depends on early diagnosis and subsequent clone-directed therapy.
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5
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Gueye S, Gauthier M, Benyahia R, Trape L, Dahri S, Kounde C, Perier T, Meklati L, Guelib I, Faye M, Rostaing L. [Nephropathy associated with monoclonal immunoglobulins: From clonal expansion B to renal toxicity of pathological immunoglobulins]. Nephrol Ther 2022; 18:591-603. [PMID: 36428151 DOI: 10.1016/j.nephro.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 10/06/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022]
Abstract
Germinal center regulation pathways are often involved in lymphomagenesis and myelomagenesis. Most of the lymphomas (and multiple myeloma) derive from post-germinal center B-cells that have undergone somatic hypermutation and class switch recombination. Hence, B-cell clonal expansion can be responsible for the presence of a monoclonal component (immunoglobulin) of variable titer which, owing to physicochemical properties, can provoke pathologically defined entities of diseases. These diseases can affect any functional part of the kidney, by multiple mechanisms, either well known or not. The presence of renal deposition is influenced by germinal gene involved, immunoglobulin primary structure, post-translational modifications and microenvironmental interactions. The two ways immunoglobulin can cause kidney toxicity are (i) an excess of production (overcoming catabolism power by proximal tubule epithelial cells) with an excess of free light chains within the distal tubules and a subsequent risk of precipitation due to local physicochemical properties; (ii) by structural characteristics that predispose immunoglobulin to a renal disease (whatever their titer). The purpose of this manuscript is to review literature concerning the pathophysiology of renal toxicities of clonal immunoglobulin, from molecular B-cell expansion mechanisms to immunoglobulin renal toxicity.
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Affiliation(s)
- Serigne Gueye
- Service de néphrologie-dialyse, CH de Cahors, France.
| | | | | | - Lucas Trape
- Service de néphrologie-dialyse, CH de Cahors, France
| | - Souad Dahri
- Service de néphrologie-dialyse, CH de Cahors, France
| | | | - Thomas Perier
- Service de néphrologie-dialyse, CH de Cahors, France
| | | | | | - Maria Faye
- Université Cheikh Anta Diop, Dakar, Sénégal
| | - Lionel Rostaing
- Service de néphrologie-dialyse, CH de Cahors, France; Service de néphrologie, hémodialyse, aphérèses et greffe rénale, France; Inserm U563, IFR-BMT, CHU de Purpan, Toulouse, France; Université Grenoble-Alpes, France
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6
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Büttner-Herold M, Krieglstein N, Chuva T, Minuth K, Pfister F, Daniel C, Klewer M, Büttner A, Ferrazzi F, Bertz S, Amann K. Light Chain Restriction in Proximal Tubules-Implications for Light Chain Proximal Tubulopathy. Front Med (Lausanne) 2022; 9:723758. [PMID: 35419374 PMCID: PMC8995435 DOI: 10.3389/fmed.2022.723758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Monoclonal gammopathy (MG) causes various nephropathies, which may suffice for cytoreductive therapy even in the absence of diagnostic criteria for multiple myeloma or B-cell non-Hodgkin lymphoma. The aim of this study was to better understand the significance of light chain (LC) restriction or crystals (LC-R/C) in proximal tubules in the spectrum of LC-induced nephropathies. A consecutive cohort of 320 renal specimens with a history of B-cell dyscrasia was characterized. Special attention was paid to immunohistochemical LC restriction in proximal tubules, tubular crystals or constipation, and ultrastructural findings. Complementary cell culture experiments were performed to assess the role of LC concentrations in generating LC restriction. Light chain restriction or crystals in proximal tubules was found in a quarter of analyzed cases (81/316) and was associated with another LC-induced disease in 70.4% (57/81), especially LC cast-nephropathy (cast-NP) and interstitial myeloma infiltration. LC restriction without significant signs of acute tubular injury was observed in 11.1% (9/81). LC-R/C was not associated with inferior renal function compared to the remainder of cases, when cases with accompanying cast-NP were excluded. Besides crystals, cloudy lysosomes were significantly associated with LC-R/C on an ultrastructural level. In summary, LC-R/C is frequent and strongly associated with cast-NP, possibly indicating that a high load of clonal LC is responsible for this phenomenon, supported by the observation that LC restriction can artificially be generated in cell culture. This and the lack of significant tubular injury in a subgroup imply that in part LC-R/C is a tubular trafficking phenomenon rather than an independent disease process.
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Affiliation(s)
- Maike Büttner-Herold
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Nathalie Krieglstein
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Teresa Chuva
- Department of Nephrology, Portuguese Institute of Oncology, Porto, Portugal
| | - Kaija Minuth
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Frederick Pfister
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Christoph Daniel
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Monika Klewer
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Anke Büttner
- School of Psychology, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Fulvia Ferrazzi
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.,Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Simone Bertz
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Kerstin Amann
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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7
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Perazella MA, Herlitz LC. The Crystalline Nephropathies. Kidney Int Rep 2021; 6:2942-2957. [PMID: 34901567 PMCID: PMC8640557 DOI: 10.1016/j.ekir.2021.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/12/2021] [Accepted: 09/07/2021] [Indexed: 12/14/2022] Open
Abstract
Crystalline nephropathies are a unique form of kidney disease characterized by the histologic finding of intrarenal crystal deposition. The intrinsic nature of some molecules and ions combined with a favorable tubular fluid physiology leads to crystal precipitation and deposition within the tubular lumens. Crystal deposition promotes kidney injury through tubular obstruction and both direct and indirect cytotoxicities. Further kidney injury develops from inflammation triggered by these crystals. From a clinical standpoint, the crystalline nephropathies are associated with abnormal urinalysis and urinary sediment findings, tubulopathies, acute kidney injury (AKI), and/or chronic kidney disease (CKD). Urine sediment examination is often helpful in alerting clinicians to the possibility of crystal-related kidney injury. The identification of crystals within the kidneys on biopsy by pathologists prompts clinicians to evaluate patients for medication-related kidney injury, dysproteinemia-related malignancies, and certain inherited disorders. This review will focus on the clinical and pathologic aspects of these 3 categories of crystalline nephropathies.
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Affiliation(s)
- Mark A Perazella
- Section of Nephrology, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA.,Section of Nephrology, Department of Medicine, VA Medical Center, West Haven, Connecticut, USA
| | - Leal C Herlitz
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, Ohio, USA
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8
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Minato M, Murakami T, Takahashi N, Ono H, Nishimura K, Tamaki M, Nagai K, Abe H, Iwano M, Joh K, Doi T. Glucocorticoid-dependent Tubulointerstitial Nephritis with IgM-positive Plasma Cells Presenting with Intracellular Crystalline Inclusions within the Rough Endoplasmic Reticulum. Intern Med 2021; 60:3129-3136. [PMID: 33840699 PMCID: PMC8545643 DOI: 10.2169/internalmedicine.7118-21] [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: 11/10/2022] Open
Abstract
Tubulointerstitial nephritis (TIN) with IgM-positive plasma cells (IgMPC-TIN) is an autoimmune kidney disease characterized by IgM/CD138-double-positive plasma cell infiltration in the tubulointerstitium. A 50-year-old man developed IgMPC-TIN and presented with crystalline inclusions in the rough endoplasmic reticulum. Intracellular crystal formation is a rare finding in paraprotein-related kidney diseases, but this case showed no pathogenic monoclonal immunoglobulin. Prednisolone (PSL, 30 mg) improved the TIN, but PSL tapering resulted in the recurrence of TIN. Combination therapy with 15 mg PSL and 150 mg mizoribine ultimately stabilized TIN. This case offers original evidence concerning the pathophysiology and treatment strategy of IgMPC-TIN.
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Affiliation(s)
- Masanori Minato
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Taichi Murakami
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
- Department of Nephrology, Ehime Prefectural Central Hospital, Japan
| | - Naoki Takahashi
- Department of Nephrology, Faculty of Medical Science, University of Fukui, Japan
| | - Hiroyuki Ono
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Kenji Nishimura
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Masanori Tamaki
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Kojiro Nagai
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Hideharu Abe
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Masayuki Iwano
- Department of Nephrology, Faculty of Medical Science, University of Fukui, Japan
| | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Japan
| | - Toshio Doi
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
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9
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Ungari M, Ghiringhelli P, Marchi G, Fisogni S, Lavazza A, Molteni A, Malberti F, Bertoni R, Trombatore M, Ferrero G, Gusolfino MD, Varotti E, Tanzi G, Manotti L. Combined renal proximal tubulopathy and crystal storing histiocytosis in a patient with κ light chain multiple myeloma. Pathologica 2021; 113:285-293. [PMID: 34463673 DOI: 10.32074/1591-951x-154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 07/13/2020] [Indexed: 11/30/2022] Open
Abstract
Multiple myeloma accounts for 10-15% of all hematologic malignancies, and 20% of deaths related to cancers of the blood and bone marrow. Diagnosis is defined by the presence of a serum monoclonal spike (M-spike) of more than 3 g/dL or more than 10% clonal plasma cells in the bone marrow and at least one myeloma-defining event, such as hypercalcemia, anemia, bone lesions, or renal impairment. The kidney is a major target organ, and renal impairment is frequently the first manifestation of the disease. Renal damage occurs in up to 40% of patients and 10-20% will require dialysis. Monoclonal immunoglobulin light chains are the major causes of renal complications in multiple myeloma. Glomerular disease, with the deposition of monoclonal immunoglobulins or their components, includes monoclonal immunoglobulin deposition disease, AL or AH amyloidosis, type I cryoglobulinemia, proliferative glomerulonephritis with monoclonal IgG deposits, immunotactoid glomerulopathy, and fibrillary glomerulonephritis. In addition, tubulointerstitial diseases with the deposition of monoclonal immunoglobulins or their components, are constituted by light chain cast nephropathy, light chain proximal tubulopathy, and crystal-storing histiocytosis. We report the case of a 66-year-old woman who presented with albumin-predominant moderate proteinuria and renal failure. Serum and urine immunofixation electrophoresis showed monoclonal κ light chain in both. Renal biopsy confirmed κ-restricted crystal-storing renal disease involving proximal tubular epithelial cells and crystal storing histiocytosis. Multiple myeloma with crystal storing histiocytosis was discovered in bone marrow biopsy. Thus, we present an unusual case of a myeloma patient presenting light chain proximal tubulopathy and crystal-storing histiocytosis both in the kidney and in the bone marrow.
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Affiliation(s)
| | | | | | | | - Antonio Lavazza
- Virology Unit of IZSLER, Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia- Romagna, Brescia, Italy
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10
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Menè P, Moioli A, Stoppacciaro A, Lai S, Festuccia F. Acute Kidney Injury in Monoclonal Gammopathies. J Clin Med 2021; 10:jcm10173871. [PMID: 34501317 PMCID: PMC8432219 DOI: 10.3390/jcm10173871] [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: 06/30/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 01/07/2023] Open
Abstract
Monoclonal gammopathies (MG) encompass a variety of disorders related to clonal expansion and/or malignant transformation of B lymphocytes. Deposition of free immunoglobulin (Ig) components (light or heavy chains, LC/HC) within the kidney during MG may result over time in multiple types and degrees of injury, including acute kidney injury (AKI). AKI is generally a consequence of tubular obstruction by luminal aggregates of LC, a pattern known as “cast nephropathy”. Monoclonal Ig LC can also be found as intracellular crystals in glomerular podocytes or proximal tubular cells. Proliferative glomerulonephritis with monoclonal Ig deposits is another, less frequent form of kidney injury with a sizable impact on renal function. Hypercalcemia (in turn related to bone reabsorption triggered by proliferating plasmacytoid B cells) may lead to AKI via functional mechanisms. Pharmacologic treatment of MG may also result in additional renal injury due to local toxicity or the tumor lysis syndrome. The present review focuses on AKI complicating MG, evaluating predictors, risk factors, mechanisms of damage, prognosis, and options for treatment.
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Affiliation(s)
- Paolo Menè
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy; (A.M.); (F.F.)
- Correspondence: ; Tel.: +39-(06)-3377-5949
| | - Alessandra Moioli
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy; (A.M.); (F.F.)
| | - Antonella Stoppacciaro
- Division of Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy;
| | - Silvia Lai
- Division of Nephrology, Department of Translational and Precision Medicine, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Francescaromana Festuccia
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy; (A.M.); (F.F.)
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11
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Matthai SM, Alexander S, Jacob S, Duhli N, David VG, Varughese S. Crystals, crystals everywhere but not a clue till late… Light chain crystalline proximal tubulopathy with concomitant myeloma cast nephropathy. INDIAN J PATHOL MICR 2021; 63:463-466. [PMID: 32769341 DOI: 10.4103/ijpm.ijpm_756_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The renal diseases commonly associated with myeloma include primary amyloidosis, cast nephropathy, and light chain deposition disease. Less frequent forms of renal involvement encountered in the course of myeloma are crystalline and non-crystalline proximal tubulopathies, neoplastic plasma cell infiltration, and immunoglobulin crystallization in interstitial histiocytes and glomerular cells including podocytes. Light chain proximal tubulopathy (LCPT) caused by aggregation of non-crystalline and rarely crystalline deposits of monoclonal light chains in the cytoplasm of proximal tubular epithelial cells, accounts for less than 5% of monoclonal gammopathy-associated kidney diseases. We report the case of a 48-year-old Indian woman with multiple myeloma, who presented with acute kidney injury and nephrotic syndrome, in whom the renal biopsy revealed widespread crystalline inclusions in extraglomerular and glomerular compartments. We present illustrative light microscopic (LM) and diagnostic electron microscopic (EM) findings of this case which enabled a diagnosis of crystalline LCPT, crystal storing histiocytosis, and crystalline podocytopathy occurring synchronously with myeloma cast nephropathy. While documenting this unique juxtapositioning of multicompartmental paraproteinemic renal injury in multiple myeloma, diagnosed after EM analysis of the patient's renal biopsy, we discuss the pathogenetic pathways of this condition along with the clinical implications. Due to intrinsic structural properties of the crystals, they frequently escape detection by routine LM, necessitating EM analysis for their diagnosis. Given the prognostic implications of tubulopathies complicating myeloma, LCPT is a critically important diagnosis, highlighting the need for a comprehensive renal biopsy evaluation inclusive of EM for the practice of precision medicine in such scenarios.
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Affiliation(s)
- Smita Mary Matthai
- Department of Pathology, Central Electron Microscopy Facility, Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - Suceena Alexander
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shibu Jacob
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Neelaveni Duhli
- Department of General Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vinoi George David
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
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12
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Sirac C, Batuman V, Sanders PW. The Proximal Tubule Toxicity of Immunoglobulin Light Chains. Kidney Int Rep 2021; 6:1225-1231. [PMID: 34013100 PMCID: PMC8116766 DOI: 10.1016/j.ekir.2021.02.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 01/25/2023] Open
Abstract
Plasma and B cells dyscrasias that overproduce monoclonal immunoglobulin free light chains (FLCs) affect the kidney frequently in various ways. The hematologic dyscrasia responsible for the production of FLCs may or may not meet the criteria for cancer, such as multiple myeloma (MM) or lymphoma, or may remain subclinical. If there is overt malignancy, the accompanying kidney disorder is called myeloma- or lymphoma-associated. If the dyscrasia is subclinical, the associated kidney disorders are grouped as monoclonal gammopathy of renal significance. Glomeruli and tubules may both be involved. The proximal tubule disorders comprise a spectrum of interesting syndromes, which range in severity. This review focuses on the recent insights gained into the patterns and the mechanisms of proximal tubule toxicity of FLCs, including subtle transport disorders, such as proximal tubule acidosis, partial or complete Fanconi syndrome, or severe acute or chronic renal failure. Histologically, there may be crystal deposition in the proximal tubule cells, acute tubule injury, interstitial inflammation, fibrosis, and tubule atrophy. Specific structural alterations in the V domain of FLCs caused by somatic hypermutations are responsible for crystal formation as well as partial or complete Fanconi syndrome. Besides crystal formation, tubulointerstitial inflammation and proximal tubulopathy can be mediated by direct activation of inflammatory pathways through cytokines and Toll-like receptors due to cell stress responses induced by excessive FLC endocytosis into the proximal tubule cells. Therapy directed against the clonal source of the toxic light chain can prevent progression to more severe lesions and may help preserve kidney function.
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Affiliation(s)
- Christophe Sirac
- Unité Mixte de Recherche (UMR) 7276/Institut National de la Santé et de la Recherche Médicale (INSERM) U1262, Centre National de la Recherche Scientifique (CNRS), Université de Limoges, Limoges, France
- Centre National de l’Amylose AL et Autres Maladies par Dépôts d’Immunoglobulines Monoclonales, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Vecihi Batuman
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Veterans Affairs, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
| | - Paul W. Sanders
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Veterans Affairs, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
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13
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The Clone Wars: Diagnosing and Treating Dysproteinemic Kidney Disease in the Modern Era. J Clin Med 2021; 10:jcm10081633. [PMID: 33921394 PMCID: PMC8069250 DOI: 10.3390/jcm10081633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 11/17/2022] Open
Abstract
Dysproteinemic kidney diseases are disorders that occur as the result of lymphoproliferative (B cell or plasma cell) disorders that cause kidney damage via production of nephrotoxic monoclonal immunoglobulins or their components. These monoclonal immunoglobulins have individual physiochemical characteristics that confer specific nephrotoxic properties. There has been increased recognition and revised characterization of these disorders in the last decade, and in some cases, there have been substantial advances in disease understanding and treatments, which has translated to improved patient outcomes. These disorders still present challenges to nephrologists and patients, since they are rare, and the field of hematology is rapidly changing with the introduction of novel testing and treatment strategies. In this review, we will discuss the clinical presentation, kidney biopsy features, hematologic characteristics and treatment of dysproteinemic kidney diseases.
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14
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Combined light chain crystalline tubulopathy, podocytopathy, and histiocytosis associated with Bence-Jones κ protein diagnosed via immuno-electron microscopy. CEN Case Rep 2021; 10:453-458. [PMID: 33675012 DOI: 10.1007/s13730-021-00588-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 02/19/2021] [Indexed: 10/22/2022] Open
Abstract
We herein report a case of a combined crystalline light chain tubulopathy, podocytopathy, histiocytosis, and cast nephropathy in a patient with monoclonal gammopathy of renal significance (MGRS). A 66-year-old female with impaired renal function was referred to our department. Despite intravenous fluid resuscitation, the kidney function worsened progressively; thus, a kidney biopsy was performed. The kidney biopsy revealed light chain proximal tubulopathy (LCPT) with crystals, light chain crystal podocytopathy (LCCP), crystal-storing histiocytosis (CSH), and light chain cast nephropathy (LCCN). Of note, LCCP and CSH were diagnosed via electron microscopy. Serum and urine immunoelectrophoresis (IEP) revealed the presence of monoclonal Bence-Jones protein and free κ light chains. Bone marrow aspiration showed < 10% plasma cell proliferation. Thus, we had encountered a rare case in which a variety of kidney lesions were combined with MGRS. Most of the LCPT, LCCP, and CSH cases show monoclonal IgG κ, while our case showed Bence-Jones protein κ.
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15
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Sy-Go JPT, Dingli D, Gertz MA, Kapoor P, Buadi FK, Dispenzieri A, Lacy MQ, Fidler ME, Leung N. Acute Acquired Fanconi Syndrome in Multiple Myeloma After Hematopoietic Stem Cell Transplantation. Kidney Int Rep 2020; 6:857-864. [PMID: 33733003 PMCID: PMC7938074 DOI: 10.1016/j.ekir.2020.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Janina Paula T. Sy-Go
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Correspondence: Janina Paula T. Sy-Go, Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, 200 First St SW, Rochester, MN 55905.
| | - David Dingli
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Morie A. Gertz
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prashant Kapoor
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Francis K. Buadi
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Angela Dispenzieri
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Martha Q. Lacy
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mary E. Fidler
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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16
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Menè P, De Alexandris L, Moioli A, Raffa S, Stoppacciaro A. Monoclonal Gammopathies of Renal Significance: Renal Biopsy and Beyond. Cancers (Basel) 2020; 12:cancers12071741. [PMID: 32629844 PMCID: PMC7407125 DOI: 10.3390/cancers12071741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/22/2020] [Accepted: 06/28/2020] [Indexed: 12/27/2022] Open
Abstract
Monoclonal Gammopathies of Renal Significance (MGRS) are a rather heterogeneous group of renal disorders caused by a circulating monoclonal (MC) immunoglobulin (Ig) component, often in the absence of multiple myeloma (MM) or another clinically relevant lymphoproliferative disorder. Nevertheless, substantial kidney damage could occur, despite the "benign" features of the bone-marrow biopsy. One example is renal amyloidosis, often linked to a small clone of plasma cells, without the invasive features of MM. However, patients with amyloidosis may present with a nephrotic syndrome and renal failure, eventually leading to end-stage kidney disease. At the same time, other organs, such as the heart and the liver, may be severely damaged by Ig light chains or amyloid deposits, occasionally resulting in fatal arrhythmias and/or organ failure. Acute kidney injury (AKI) may as well result from massive excretion of MC proteins, with deposition disease in glomeruli or renal tubules, not rarely obstructed by luminal aggregates, or "casts". Proliferative glomerulonephritis with monoclonal Ig deposits is another, less frequent clinical presentation of an MGRS. The present review deals with the implications of MGRS for renal function and prognosis, and the potential of tools, such as the renal biopsy, for assessing clinical risk and guiding therapy of the underlying condition.
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Affiliation(s)
- Paolo Menè
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035–1039, 00189 Rome, Italy
- Correspondence: ; Tel.: +39-(06)-3377-5949
| | - Lorenzo De Alexandris
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
| | - Alessandra Moioli
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
| | - Salvatore Raffa
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
| | - Antonella Stoppacciaro
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
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17
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Chopra R, Santana de Roberts R, Batal I, Batra S, Jim B. Light chain proximal tubulopathy with cast nephropathy in monoclonal gammopathy of renal significance. BMJ Case Rep 2020; 13:13/6/e234361. [PMID: 32595131 DOI: 10.1136/bcr-2020-234361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Kidney tubular disorders due to monoclonal immunoglobulin light chains are common manifestations of B-cell neoplasm. Cast nephropathy (CN) is the most frequent type of these disorders and may present with acute kidney injury (AKI) due to the presence of excess light chains in the distal tubules. Light chain proximal tubulopathy (LCPT) is an uncommon form of renal disease and may present as Fanconi syndrome due to proximal tubular cell damage by intracellular deposition of light chains. The concomitant disorder of both CN and LCPT is rare given the inherent differences in the biochemical properties of the immunoglobulin light chains of each disorder. We report a 64-year-old man who presented with AKI and Fanconi syndrome who was discovered to have both CN and LCPT due to the underlying disorder of monoclonal gammopathy of renal significance and who has responded favourably with conventional chemotherapy. We also review the existing literature on this interesting subject.
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Affiliation(s)
- Rebaika Chopra
- Medicine, James J Peters VA Medical Center, Bronx, New York, USA
| | | | - Ibrahim Batal
- Pathology, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Sachin Batra
- Medicine, James J Peters VA Medical Center, Bronx, New York, USA
| | - Belinda Jim
- Medicine, Jacobi Medical Center, Bronx, New York, USA
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18
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Light Chain Crystal Podocytopathy in a Patient With Systemic Indolent B-Cell Lymphoma. Kidney Int Rep 2020; 5:373-376. [PMID: 32154460 PMCID: PMC7056844 DOI: 10.1016/j.ekir.2019.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 11/23/2022] Open
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19
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Patel AB, Choi JY, Mutter WP, Weins A, Riella LV. Crystalline light chain proximal tubulopathy and podocytopathy: a case report. ACTA ACUST UNITED AC 2019; 42:99-105. [PMID: 31799982 PMCID: PMC7213934 DOI: 10.1590/2175-8239-jbn-2019-0086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 08/23/2019] [Indexed: 12/04/2022]
Affiliation(s)
- Ankit B Patel
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, EUA
| | - John Y Choi
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, EUA
| | - Walter P Mutter
- Renal Division, Newton Wellesley Hospital, Harvard Medical School, Boston, MA, EUA
| | - Astrid Weins
- Department of Pathology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, EUA
| | - Leonardo V Riella
- Renal Division, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, EUA
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20
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Bouchet A, Teuma C, Nouvier M, Rousset P, Javaugue V, Lazareth A, Lombard C, Isaac S, Fouque D. Acute Renal Colic Due to Immunoglobulin Free Light Chain Kidney Stones: A Case Report of an Unusual Complication of Multiple Myeloma. Am J Kidney Dis 2019; 74:700-702. [DOI: 10.1053/j.ajkd.2019.03.426] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 03/26/2019] [Indexed: 11/11/2022]
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21
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Proximal Tubulopathy With Fibrillary Inclusions: A Rare Manifestation of Lymphoma-Associated Monoclonal Gammopathy of Renal Significance (MGRS). Kidney Med 2019; 1:397-401. [PMID: 32734220 PMCID: PMC7380423 DOI: 10.1016/j.xkme.2019.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Light chain proximal tubulopathy is a rare M-proteinemia-related nephropathy. The inclusions, composed of light chains in light chain proximal tubulopathy, are generally crystalline, and most exhibit a rhombic shape. Noncrystalline structures, such as rods or needle shapes, may also be present. In our patient, one of the noncrystalline structures, fibrillary inclusions in the cytoplasm, were observed, as previously reported in only 4 patients whose primary disease was either multiple myeloma or monoclonal gammopathy of renal significance. This is the first report involving lymphoma. Early diagnosis of light chain proximal tubulopathy is important because those who undergo chemotherapy have an improved kidney prognosis. However, in cases of kidney involvement with blood disorders, thrombocytopenia is often present. Therefore, in our case, open kidney biopsy was selected. Noncrystalline light chain proximal tubulopathy is believed to be less likely to cause Fanconi syndrome. However, Fanconi syndrome was observed in 3 of the 4 patients with fibrillary inclusions. In our case, hypouricemia was improved by chemotherapy, suggesting that the patient presented with Fanconi syndrome. Noncrystalline light chain proximal tubulopathy with fibrillary inclusions may cause Fanconi syndrome, similar to crystalline light chain proximal tubulopathy. We report a case of light chain proximal tubulopathy with fibrillary inclusions complicated by low-grade B-cell lymphoma in which early treatment was successful.
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22
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Gupta RK, Rosenberg AZ, Bagnasco SM, Arend LJ. Renal crystal-storing histiocytosis involving glomeruli - A comprehensive clinicopathologic analysis. Ann Diagn Pathol 2019; 43:151403. [PMID: 31494491 DOI: 10.1016/j.anndiagpath.2019.151403] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Accepted: 08/28/2019] [Indexed: 11/28/2022]
Abstract
Crystal-storing histiocytosis (CSH) is a rare manifestation of monoclonal gammopathy in which histiocytes containing monoclonal proteins in their cytoplasm are found in various organs of the body including the kidney. Within the kidney, these monoclonal crystal-laden histiocytes have been described to occur in the interstitium (most commonly) or in the glomerular mesangium. CSH within glomerular capillary loops has rarely been reported. We describe three cases of CSH primarily affecting the glomerular capillaries and review the literature of CSH in general. Twenty cases of CSH involving the kidney are present in the literature; three describe CSH in glomeruli, only one of which showed histiocytes predominantly in glomerular capillary loops, while 15 had predominantly or solely interstitial CSH. Most cases involve IgG kappa crystals with only one case involving lambda light chain. Patients with CSH predominantly involving the glomerular capillaries showed a trend toward lower serum creatinine and proteinuria at presentation, and several patients with CSH lacked a definitive diagnosis of a monoclonal gammopathy at the time of diagnosis, emphasizing the role that kidney biopsy and particularly electron microscopy play in diagnosis of this entity.
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Affiliation(s)
- Rajib K Gupta
- Renal Pathology, Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Avi Z Rosenberg
- Renal Pathology, Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Serena M Bagnasco
- Renal Pathology, Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Lois J Arend
- Renal Pathology, Department of Pathology, Johns Hopkins University and Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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23
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Yu XJ, Zhang X, Li DY, Wang SX, Zhou FD, Zhao MH. Renal pathologic spectrum and clinical outcome of monoclonal gammopathy of renal significance: A large retrospective case series study from a single institute in China. Nephrology (Carlton) 2019; 25:202-211. [PMID: 31301197 DOI: 10.1111/nep.13633] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To analysis the pathological spectrum and prognosis of monoclonal gammopathy of renal significance (MGRS) patients. METHODS Patients with renal biopsy-proven MGRS from 1999 to 2017 in Peking University First Hospital were included, clinical data, renal pathology type, treatment and prognosis were collected. RESULTS One hundred and eighty-seven patients were enrolled, accounting for 0.7% of renal biopsies. Seventy-seven per cent of the MGRS patients were amyloidosis. Eighteen patients (9.6%) were monoclonal immunoglobulin deposition disease. Others included 10 patients (5.3%) with proliferative glomerulonephritis with monoclonal immunoglobulin (G) deposits, seven patients (3.7%) with cryoglobulinaemic glomerulonephritis, five patients (2.6%) with light chain proximal tubulopathy, two patients (1.1%) with fibrillary disease and one patient (0.5%) with C3 glomerulonephritis. Sixty-three per cent were treated with chemotherapy and/or stem cell transplantation. The mean follow-up time was 27 ± 32 months. One patient developed multiple myeloma at 17-month during follow-up. At the end of follow-up, 61 patients (33%) died, and 47 patients (25%) reached end-stage renal disease (ESRD). For the 144 amyloid patients, low estimated glomerular filtration rate (eGFR), decreased blood pressure, presence of cardiac involvement and absence of chemotherapy or high-dose melphalan/autologous peripheral blood stem cell transplantation were identified as independent risk factors for death. Low eGFR, decreased blood pressure, and presence of cardiac involvement were identified as independent risk factors for ESRD. For the 43 non-amyloid patients, no factor was identified for the risk of death. Low eGFR was identified as independent risk factor for ESRD. CONCLUSION MGRS was an uncommon form of hematologic disorder related renal injury with a wide spectrum of pathologic lesions, and amyloidosis was the most common type. Treatment with chemotherapy and/or high-dose melphalan/autologous peripheral blood stem cell transplantation improved amyloid patients' survival.
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Affiliation(s)
- Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Xin Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Dan-Yang Li
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Fu-De Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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24
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Manohar S, Nasr SH, Leung N. Light Chain Cast Nephropathy: Practical Considerations in the Management of Myeloma Kidney-What We Know and What the Future May Hold. Curr Hematol Malig Rep 2018; 13:220-226. [PMID: 29725932 DOI: 10.1007/s11899-018-0451-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To update and evaluate the current knowledge on pathogenesis and management of light chain cast nephropathy. Light chain cast nephropathy (LCCN) is the leading cause of acute renal failure in patients with multiple myeloma and is currently recognized as a myeloma defining event. RECENT FINDINGS The immunoglobulin free light chain plays an integral role in the pathogenesis of LCCN. The level of free light chain (FLC) in the blood and urine is directly associated with the risk of developing LCCN. Recovery of renal function is related to the speed and degree of the serum FLC reduction. Recently, two randomized trials using high cutoff dialyzer for the removal of serum FLC produced different results in terms of renal recovery. FLC plays a key role in the development and resolution of LCCN. Future therapies will aim to rapidly reduce its concentration or interrupt its interaction with Tamm-Horsfall protein.
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Affiliation(s)
- Sandhya Manohar
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Division of Anatomic Pathology and Pathology Mayo Clinic, Rochester, MN, USA
| | - Nelson Leung
- Department of Internal Medicine, Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55901, USA.
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25
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Yu XJ, Zhou XJ, Wang SX, Zhou FD, Zhao MH. Monoclonal light chain crystalline podocytopathy and tubulopathy associated with monoclonal gammopathy of renal significance: a case report and literature review. BMC Nephrol 2018; 19:322. [PMID: 30419839 PMCID: PMC6233383 DOI: 10.1186/s12882-018-1108-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 10/19/2018] [Indexed: 12/30/2022] Open
Abstract
Background Monoclonal gammopathy of renal significance (MGRS) is a recently defined group of renal diseases caused by monoclonal immunoglobulin secreted by nonmalignant proliferative B cell or plasma cell. Monoclonal immunoglobulin can form different types of structures deposited in renal tissue, including fibrils, granules, microtubules, crystals and casts, and has mostly been reported in multiple myeloma patients. Here we report a rare case with κ light chain crystals in both podocytes and tubular epithelial cells associated with MGRS, which adds more information to the spectrum of MGRS-related renal diseases. Case presentation A 53-year old woman presented with albumin–predominant moderate proteinuria and renal failure. She had monoclonal IgGκ in the serum and monoclonal IgGκ plus free κ in the urine. Multiple myeloma and lymphoproliferative disorders were excluded. Renal biopsy confirmed κ-restricted crystal-storing renal disease involving the podocytes and proximal tubular epithelial cells. The patient was treated with bortezomib followed by lenalidomide-based chemotherapy, and renal function was stable after 1 year of follow-up. Conclusions This is a rare case of combined crystalline podocytopathy and tubulopathy associated with MGRS, in which diagnosis was dependent on electron and immuno-electron microscopy.
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Affiliation(s)
- Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Xu-Jie Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China. .,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China. .,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China. .,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China. .,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, 100034, People's Republic of China.
| | - Fu-de Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100871, People's Republic of China
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26
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Sirac C, Herrera GA, Sanders PW, Batuman V, Bender S, Ayala MV, Javaugue V, Teng J, Turbat-Herrera EA, Cogné M, Touchard G, Leung N, Bridoux F. Animal models of monoclonal immunoglobulin-related renal diseases. Nat Rev Nephrol 2018; 14:246-264. [DOI: 10.1038/nrneph.2018.8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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27
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Heavy-Chain Diseases and Myeloma-Associated Fanconi Syndrome: an Update. Mediterr J Hematol Infect Dis 2018; 10:e2018011. [PMID: 29326807 PMCID: PMC5760076 DOI: 10.4084/mjhid.2018.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Accepted: 12/23/2017] [Indexed: 12/13/2022] Open
Abstract
The heavy chain diseases (HCDs) are rare B-cell malignancies characterized by the production of a monoclonal immunoglobulin heavy chain without an associated light chain. There are three types of HCD, defined by the class of immunoglobulin heavy chain produced: IgA (α-HCD), IgG (γ-HCD), and IgM (μ-HCD). Alpha-HCD is the most common and usually occurs as intestinal malabsorption in a young adult from a country of the Mediterranean area. Gamma- and μ-HCDs are rarer and associated with a B-cell non-Hodgkin lymphoma that produces an abnormal Ig heavy chain. These patients may occasionally be diagnosed with a monoclonal gammopathy of undetermined significance (MGUS). Fanconi syndrome, on the other hand, can be primary (inherited) or secondary (acquired). The only exception to this rule is the idiopathic form. Adult acquired Fanconi syndrome can be a rare complication of a monoclonal gammopathy. At diagnosis, most patients have an MGUS or smoldering multiple myeloma, with renal failure and evidence of osteomalacia. During follow-up, patients can develop an end-stage renal disease. Chemotherapy provides little benefit on renal function.
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Blancas-Mejía LM, Martin EB, Williams A, Wall JS, Ramirez-Alvarado M. Kinetic stability and sequence/structure studies of urine-derived Bence-Jones proteins from multiple myeloma and light chain amyloidosis patients. Biophys Chem 2017; 230:89-98. [PMID: 28916410 DOI: 10.1016/j.bpc.2017.08.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 08/24/2017] [Accepted: 08/24/2017] [Indexed: 01/05/2023]
Abstract
It is now accepted that the ability of a protein to form amyloid fibrils could be associated both kinetic and thermodynamic protein folding parameters. A recent study from our laboratory using recombinant full-length (encompassing the variable and constant domain) immunoglobulin light chains found a strong kinetic control of the protein unfolding for these proteins. In this study, we are extending our analysis by using urine-derived Bence Jones proteins (BJPs) from five patients with light chain (AL) amyloidosis and four patients with multiple myeloma (MM). We observed lower stability in κ proteins compared to λ proteins (for both MM and AL proteins) in agreement with previous studies. The kinetic component of protein stability is not a universal feature of BJPs and the hysteresis observed during refolding reactions could be attributed to the inability of the protein to refold all domains. The most stable proteins exhibited 3-state unfolding transitions. While these proteins do not refold reversibly, partial refolding shows 2-state partial refolding transitions, suggesting that one of the domains (possibly the variable domain) does not refold completely. Sequences were aligned with their respective germlines and the location and nature of the mutations were analyzed. The location of the mutations were analyzed and compared with the stability and amyloidogenic properties for the proteins in this study, increasing our understanding of light chain unfolding and amyloidogenic potential.
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Affiliation(s)
- Luis M Blancas-Mejía
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA
| | - Emily B Martin
- Department of Medicine, The University of Tennessee Medical Center, Knoxville, TN, USA
| | - Angela Williams
- Department of Medicine, The University of Tennessee Medical Center, Knoxville, TN, USA
| | - Jonathan S Wall
- Department of Medicine, The University of Tennessee Medical Center, Knoxville, TN, USA; Department of Radiology, The University of Tennessee Medical Center, Knoxville, TN, USA
| | - Marina Ramirez-Alvarado
- Department of Biochemistry and Molecular Biology, Mayo Clinic, Rochester, MN, USA; Department of Immunology, Mayo Clinic, Rochester, MN, USA.
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Wu CK, Yang AH, Lai HC, Lin BS. Combined proximal tubulopathy, crystal-storing histiocytosis, and cast nephropathy in a patient with light chain multiple myeloma. BMC Nephrol 2017; 18:170. [PMID: 28545410 PMCID: PMC5445476 DOI: 10.1186/s12882-017-0584-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 05/15/2017] [Indexed: 11/30/2022] Open
Abstract
Background The diagnosis of myeloma, a plasma dyscrasia, often results from the workup of unexplained renal disease. Persistent renal failure in myeloma is commonly caused by tubular nephropathy due to circulating immunoglobulins and free light chains. Myeloma cast nephropathy is characterized by crystalline precipitates of monoclonal light chains within distal tubules. Immunoglobulin crystallization rarely occurs intracellularly, within proximal tubular cells (light chain proximal tubulopathy) and interstitial histiocytes (crystal-storing histiocytosis). We present a case report of a rare simultaneous occurrence of light chain proximal tubulopathy, crystal-storing histiocytosis, and myeloma cast nephropathy in a patient with κ light chain multiple myeloma. Case presentation A 48-years-old man presented with uremia and anemia. Laboratory examination revealed low levels of serum IgG, IgA, and IgM. Serum and urine immunofixation electrophoresis showed a free κ monoclonal band. Bone marrow aspiration and biopsy revealed hypercellularity with marked plasmacytosis. Light microscopy revealed eosinophilic cuboid- and rhomboid-shaped crystals in the cytoplasm of proximal tubular epithelial cells, diffuse large mononuclear and multinuclear cells in the interstitium, and obstructed distal tubules with cast and giant cell reaction. Immunohistochemical examination indicated intense staining for κ light chains within casts, histiocytes, and tubular epithelial cells. Electron microscopy revealed electro-dense cuboid-, rhomboid-, or needle-shaped crystalline inclusions in proximal tubular epithelial cells and interstitial histiocytes. According to these results, we confirmed that this patient with myeloma exhibited simultaneous light chain proximal tubulopathy, crystal-storing histiocytosis, and myeloma cast nephropathy, which were attributed to monoclonal κ light chains. In addition to dialysis, the patient received induction chemotherapy with a combination of bortezomib, cyclophosphamide, and dexamethasone, followed by maintenance therapy with thalidomide. However, the patient did not regain renal function even when less than 5% plasma cells were detected in the bone marrow. Conclusion To the best of our knowledge, this is the first report of simultaneous light chain proximal tubulopathy, crystal-storing histiocytosis, and myeloma cast nephropathy in κ light chain multiple myeloma.
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Affiliation(s)
- Chung-Kuan Wu
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95,Wen Chang Rd., Shih Lin District, Taipei, 11101, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - An-Hang Yang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hung-Chih Lai
- Division of Hematology and Oncology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Bing-Shi Lin
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95,Wen Chang Rd., Shih Lin District, Taipei, 11101, Taiwan. .,School of Medicine, National Yang-Ming University, Taipei, Taiwan.
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Motwani SS, Herlitz L, Monga D, Jhaveri KD, Lam AQ. Paraprotein-Related Kidney Disease: Glomerular Diseases Associated with Paraproteinemias. Clin J Am Soc Nephrol 2016; 11:2260-2272. [PMID: 27526706 PMCID: PMC5142064 DOI: 10.2215/cjn.02980316] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Paraproteins are monoclonal Igs that accumulate in blood as a result of abnormal excess production. These circulating proteins cause a diversity of kidney disorders that are increasingly being comanaged by nephrologists. In this review, we discuss paraprotein-related diseases that affect the glomerulus. We provide a broad overview of diseases characterized by nonorganized deposits, such as monoclonal Ig deposition disease (MIDD), proliferative GN with monoclonal Ig deposits (PGNMID), and C3 glomerulopathy, as well as those characterized by organized deposits, such as amyloidosis, immunotactoid glomerulopathy, fibrillary GN, and cryoglobulinemic GN, and rarer disorders, such as monoclonal crystalline glomerulopathies, paraprotein-related thrombotic microangiopathies, and membranous-like glomerulopathy with masked IgGκ deposits. This review will provide the nephrologist with an up to date understanding of these entities and highlight the areas of deficit in evidence and future lines of research.
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Affiliation(s)
- Shveta S. Motwani
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Adult Survivorship Program, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Leal Herlitz
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Divya Monga
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi; and
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York
| | - Albert Q. Lam
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Adult Survivorship Program, Dana Farber Cancer Institute, Boston, Massachusetts
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Gallan AJ, Khalighi MA. Lambda Light Chain Crystalline Cast Nephropathy and Proximal Tubulopathy. Kidney Int Rep 2016; 1:316-320. [PMID: 29142933 PMCID: PMC5678630 DOI: 10.1016/j.ekir.2016.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Current anti-myeloma therapies in renal manifestations of monoclonal light chain-associated Fanconi syndrome: a retrospective series of 49 patients. Leukemia 2016; 31:123-129. [PMID: 27435002 DOI: 10.1038/leu.2016.195] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 06/08/2016] [Accepted: 06/16/2016] [Indexed: 11/09/2022]
Abstract
We retrospectively reviewed 49 patients with light chain (LC) Fanconi syndrome (FS). Patients presented with chronic kidney disease (median estimated glomerular filtration rate (eGFR) of 33 ml/min/1.73 m2) and tubular proteinuria. All patients tested had elevated fractional excretion of phosphate, uric acid, generalized aminoaciduria and/or normoglycemic glycosuria. Thirty-eight patients had monoclonal gammopathy of renal significance and eleven patients had an overt hematological malignancy. The monoclonal LC isotype was kappa in 46/49 cases. Kidney biopsy in 39 patients showed various proximal tubular lesions and characteristic LC intracytoplasmic crystalline inclusions in 24 patients. Forty-two patients received chemotherapy. Patients with plasma cell proliferation (n=38) received bortezomib-based regimens (n=11), immunomodulatory agents (n=7) or alkylating agents (n=6). High-dose melphalan (HDM) followed by autologous stem cell transplantation was performed in 14 patients. Hematological response was obtained in 90% of evaluable patients, assessed on serum free light chains (FLC). GFR remained stable as long as hematological response was maintained and declined when serum FLC level rebounded. Improvement in proximal tubule function occurred in 13 patients. In patients with LC-associated FS, chemotherapy using HDM and/or new generation anti-myeloma agents can stabilize renal function and improve proximal tubule function. Serum FLC should be used to assess the hematological response, related to renal outcome.
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Angioi A, Amer H, Fervenza FC, Sethi S. Recurrent Light Chain Proximal Tubulopathy in a Kidney Allograft. Am J Kidney Dis 2016; 68:483-7. [PMID: 27321964 DOI: 10.1053/j.ajkd.2016.04.021] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 04/26/2016] [Indexed: 11/11/2022]
Abstract
We describe a rare case of light chain proximal tubulopathy developing in a kidney transplant 12 months following transplantation. The patient was known to have a monoclonal gammopathy of undetermined significance (MGUS) for more than 15 years. A kidney biopsy done to determine the cause of decline in kidney transplant function showed light chain proximal tubulopathy characterized by numerous eosinophilic and fuchsinophilic granules in proximal tubular epithelial cells, which stained for κ light chains on pronase-based immunofluorescence studies. Electron microscopy confirmed the diagnosis and showed numerous amorphous and geometrically shaped inclusions in proximal tubular epithelial cells. Evaluation of free light chains revealed markedly elevated κ light chains and bone marrow biopsy showed 5% to 10% κ light chain-restricted plasma cells. Retrospective evaluation of the native kidney biopsy performed 15 years earlier also showed numerous fuchsinophilic granules in proximal tubules that stained brightly for κ light chains on pronase-based immunofluorescence studies. The patient was treated with a regimen of bortezomib and dexamethasone with good partial hematologic response and improvement of kidney function. To summarize, we describe a case of recurrent light chain proximal tubulopathy in the transplant, which is an unusual but important cause of decreased kidney function in the setting of a monoclonal gammopathy.
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Affiliation(s)
- Andrea Angioi
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN
| | - Hatem Amer
- The William J von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, MN
| | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
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Hoelbeek J, Duivenvoorden R, de Boer OJ, Claessen N, Van den Bergh Weerman MA, Roelofs JJ, Kers J, Ten Berge IJ, Florquin S. Unique Renal Manifestation of Type I Cryoglobulinemia, With Massive Crystalloid Deposits in Glomerular Histiocytes, Podocytes, and Endothelial Cells. Am J Clin Pathol 2016; 145:282-5. [PMID: 26796493 DOI: 10.1093/ajcp/aqv027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES We describe a 62-year-old woman with a 15-year history of a plasma cell dyscrasia (monoclonal IgGκ), manifested by type I cryoglobulinemia and dermal vasculitis. METHODS In addition to the clinical examinations, light microscopy with immunohistochemistry, sequential multicolor immunohistochemistry, and electron microscopy were used to characterize the crystalline deposits. RESULTS At initial presentation and for a later flare, she was treated with cyclophosphamide and prednisolone with good clinical response. She had renal function decline, microscopic hematuria, and proteinuria. A renal biopsy specimen revealed the presence of glomerular macrophages and duplication of the capillary walls with cellular interposition. Glomerular cells contained abundant needle-shaped eosinophilic crystalline inclusions positive for κ light chain. Electron microscopy confirmed the presence of intracytoplasmatic crystalline structures in endothelial cells, podocytes, and macrophages but not in the tubular epithelium. Rituximab treatment was started. At follow-up (now up to 6 months), renal function remained stable. CONCLUSIONS This patient displays a unique renal manifestation of type I cryoglobulinemia related to a plasma cell dyscrasia.
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Wang YD, Dong ZY, Zhang XG, Zhang W, Yin Z, Qiu Q, Chen XM. Renal Light Chain Deposition Associated with the Formation of Intracellular Crystalline Inclusion Bodies in Podocytes: A Rare Case Report. Intern Med 2016; 55:369-73. [PMID: 26875962 DOI: 10.2169/internalmedicine.55.4443] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein report the case of an elderly woman with bone pain and proteinuria as the main clinical manifestations. The patient was diagnosed with the IgG κ type of multiple myeloma. Her renal pathology consisted of widespread κ light chain protein deposition associated with the formation of large quantities of rod-like crystals in podocytes. This phenomenon is very rare. We explored the significance of this crystal formation via a detailed and descriptive analysis and also performed a literature review, thus providing data to increase the available information about this type of disease.
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Affiliation(s)
- Yuan-da Wang
- Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center of Kidney Diseases, China
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Jeon YL, Lee WI, Choi Y, Kang SY, Kim MH, Lim SJ, Lee SH. Crystalloid podocytopathy with focal segmental glomerulosclerosis in PCM: a case report. Diagn Pathol 2015; 10:213. [PMID: 26670310 PMCID: PMC4681144 DOI: 10.1186/s13000-015-0448-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 11/28/2015] [Indexed: 12/16/2022] Open
Abstract
Background Crystalloid podocytopathy with focal segmental glomerulosclerosis in plasma cell myeloma (PCM) is rare. Case Presentation We present a case of crystalline deposition in the bone marrow (BM) and various renal cells with only proteinuria as a symptom. As workup for proteinuria, a renal biopsy sample was obtained. EM showed multiple crystalline depositions in renal tubular cells and podocytes. Focal segmental glomerulosclerosis with crystalloid podocytopathy was diagnosed. Because monoclonal gammopathy was detected in the serum and urine, a BM study was also performed. Plasma cells with needle-shaped inclusion bodies were observed. The crystalline deposits in the plasma cells and podocytes were positive for Masson’s trichrome and kappa light-chain staining. These findings indicated that the crystalline deposits originated from paraprotein. The case showed a rare process of focal segmental glomerulosclerosis via crystalline deposition in podocytes in plasma cell myeloma. Conclusions Crystalloid podocytopathy is a likely cause of renal damage such as FSGS in PCM, although it is an uncommon mechanism for myeloma kidney.
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Affiliation(s)
- You La Jeon
- Department of Laboratory Medicine, School of Medicine, Kyung Hee University and Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, 134-727, Republic of Korea.
| | - Woo In Lee
- Department of Laboratory Medicine, School of Medicine, Kyung Hee University and Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, 134-727, Republic of Korea.
| | - Yujin Choi
- Department of Laboratory Medicine, School of Medicine, Kyung Hee University and Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, 134-727, Republic of Korea.
| | - So Young Kang
- Department of Laboratory Medicine, School of Medicine, Kyung Hee University and Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, 134-727, Republic of Korea.
| | - Myeong Hee Kim
- Department of Laboratory Medicine, School of Medicine, Kyung Hee University and Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, 134-727, Republic of Korea.
| | - Sung-Jig Lim
- Department of Pathology, School of Medicine, Kyung Hee University and Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea.
| | - Sang Ho Lee
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Kyung Hee University and Kyung Hee University Hospital at Gangdong, Seoul, Republic of Korea.
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Luciani A, Sirac C, Terryn S, Javaugue V, Prange JA, Bender S, Bonaud A, Cogné M, Aucouturier P, Ronco P, Bridoux F, Devuyst O. Impaired Lysosomal Function Underlies Monoclonal Light Chain-Associated Renal Fanconi Syndrome. J Am Soc Nephrol 2015; 27:2049-61. [PMID: 26614382 DOI: 10.1681/asn.2015050581] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 10/05/2015] [Indexed: 12/14/2022] Open
Abstract
Monoclonal gammopathies are frequently complicated by kidney lesions that increase the disease morbidity and mortality. In particular, abnormal Ig free light chains (LCs) may accumulate within epithelial cells, causing proximal tubule (PT) dysfunction and renal Fanconi syndrome (RFS). To investigate the mechanisms linking LC accumulation and PT dysfunction, we used transgenic mice overexpressing human control or RFS-associated κLCs (RFS-κLCs) and primary cultures of mouse PT cells exposed to low doses of corresponding human κLCs (25 μg/ml). Before the onset of renal failure, mice overexpressing RFS-κLCs showed PT dysfunction related to loss of apical transporters and receptors and increased PT cell proliferation rates associated with lysosomal accumulation of κLCs. Exposure of PT cells to RFS-κLCs resulted in κLC accumulation within enlarged and dysfunctional lysosomes, alteration of cellular dynamics, defective proteolysis and hydrolase maturation, and impaired lysosomal acidification. These changes were specific to the RFS-κLC variable (V) sequence, because they did not occur with control LCs or the same RFS-κLC carrying a single substitution (Ala30→Ser) in the V domain. The lysosomal alterations induced by RFS-κLCs were reflected in increased cell proliferation, decreased apical expression of endocytic receptors, and defective endocytosis. These results reveal that specific κLCs accumulate within lysosomes, altering lysosome dynamics and proteolytic function through defective acidification, thereby causing dedifferentiation and loss of reabsorptive capacity of PT cells. The characterization of these early events, which are similar to those encountered in congenital lysosomal disorders, provides a basis for the reported differential LC toxicity and new perspectives on LC-induced RFS.
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Affiliation(s)
- Alessandro Luciani
- Institute of Physiology, Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Christophe Sirac
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Limoges, France; National Reference Center for Amyloidosis and other Monoclonal Immunoglobulin Deposition Diseases, University Hospital of Limoges, Poitiers, France
| | - Sara Terryn
- Division of Nephrology, UCL Medical School, Brussels, Belgium
| | - Vincent Javaugue
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Limoges, France; Department of Nephrology, University Hospital, Poitiers University, Poitiers, France
| | - Jenny Ann Prange
- Institute of Physiology, Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland
| | - Sébastien Bender
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Limoges, France; Department of Nephrology, University Hospital, Poitiers University, Poitiers, France
| | - Amélie Bonaud
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Limoges, France
| | - Michel Cogné
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Limoges, France
| | - Pierre Aucouturier
- Department of Immunology, National Institute of Health and Medical Research Unit 938, Saint Antoine Hospital, Pierre et Marie Curie University, Paris, France
| | - Pierre Ronco
- Department of Nephrology and Dialysis, Tenon Hospital, Paris, France; Department of Immunology, National Institute of Health and Medical Research Unit 938, Saint Antoine Hospital, Pierre et Marie Curie University, Department of Nephrology and Dialysis, Tenon Hospital, Paris, France; Sorbonne Universités, UPMC University of Paris, Paris, France
| | - Frank Bridoux
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Limoges, France; Department of Nephrology, University Hospital, Poitiers University, Poitiers, France;
| | - Olivier Devuyst
- Institute of Physiology, Zurich Center for Integrative Human Physiology, University of Zurich, Zurich, Switzerland; Division of Nephrology, UCL Medical School, Brussels, Belgium;
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Huang H, Luo Y, Liang Y, Long XD, Peng Y, Liu Z, Wen X, Jia M, Tian R, Bai C, Li C, Dong X. CD4+CD25+ cells in multiple myeloma related renal impairment. Sci Rep 2015; 5:16565. [PMID: 26564056 PMCID: PMC4643310 DOI: 10.1038/srep16565] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Accepted: 10/15/2015] [Indexed: 11/19/2022] Open
Abstract
CD4+CD25+ cells are critical regulators in almost all of the animal models of human organ-specific autoimmune diseases, transplant rejection and allergic diseases. We aimed to explore the role of CD4+CD25+ cells in the pathogenesis of multiple myeloma (MM) related renal impairment (RI). Thirty patients with MM related RI and 30 healthy volunteers were studied. The number of CD4+CD25+ cells was examined by flow cytometry. Clinical and laboratory data were collected from each subject. Glomerular injury was assessed by histopathology. Serum IL-2, IL-4 and IL-6 were analyzed by ELISA. CD4+CD25+ cells significantly decreased in MM related RI patients compared to the controls (P<0.05). CD4+CD25+ cell number was negatively associated with blood urea nitrogen (BUN), supernatant IL-4, serum IL-6, monoclonal immunoglobulin and β2-microglobulin, as well as bone marrow plasma cell percentage and proteinuria; whereas positively associated with estimated glomerular filtration rate (eGFR) (all P < 0.05). CD4+CD25+ cells gradually decreased as the Clinic Stage increased. The number of CD4+CD25+ cells reduced in MM related RI patients, and was correlated with disease severity. CD4+CD25+ cells may play an important role in the pathogenesis of MM related RI.
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Affiliation(s)
- Hongdong Huang
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China.,Division of Nephrology, Hunan Normal University, Hunan Provincial People's Hospital of China, Changsha, P.R. China
| | - Yang Luo
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Yumei Liang
- Division of Nephrology, Hunan Normal University, Hunan Provincial People's Hospital of China, Changsha, P.R. China
| | - Xi-Dai Long
- Department of Liver Surgery, the Affiliated Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, P.R. China
| | - Youming Peng
- Hunan Key Laboratory of Nephrology and Hemoperfusion, Division of Nephrology, Second Xiangya Hospital of Central South University, Changsha, Hunan Province, P.R. China
| | - Zhihua Liu
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Xiaojun Wen
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Meng Jia
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Ru Tian
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Chengli Bai
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Cui Li
- Division of Nephrology, Beijing Shijitan Hospital, Capital Medical University, P.R. China
| | - Xiaoqun Dong
- Section of Hematology/Oncology, Section of Gastroenterology, Stephenson Cancer Center, Department of Internal Medicine, College of Medicine, The University of Oklahoma Health Sciences Center, USA
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Rousseau-Gagnon M, Agharazii M, De Serres SA, Desmeules S. Effectiveness of Haemodiafiltration with Heat Sterilized High-Flux Polyphenylene HF Dialyzer in Reducing Free Light Chains in Patients with Myeloma Cast Nephropathy. PLoS One 2015; 10:e0140463. [PMID: 26466100 PMCID: PMC4605760 DOI: 10.1371/journal.pone.0140463] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Accepted: 09/25/2015] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION In cases of myeloma cast nephropathy in need of haemodialysis (HD), reduction of free light chains using HD with High-Cut-Off filters (HCO-HD), in combination with chemotherapy, may be associated with better renal recovery. The aim of the present study is to evaluate the effectiveness of haemodiafiltration (HDF) in reducing free light chain levels using a less expensive heat sterilized high-flux polyphenylene HF dialyzer (HF-HDF). METHODS In a single-centre prospective cohort study, 327 dialysis sessions were performed using a 2.2 m2 heat sterilized high-flux polyphenylene HF dialyzer (Phylther HF22SD), a small (1.1m2) or large (2.1 m2) high-cut-off (HCO) dialyzer (HCOS and HCOL) in a cohort of 16 patients presenting with dialysis-dependent acute cast nephropathy and elevated free light chains (10 kappa, 6 lambda). The outcomes of the study were the mean reduction ratio (RR) of kappa and lambda, the proportion of treatments with an RR of at least 0.65, albumin loss and the description of patient outcomes. Statistical analysis was performed using linear and logistic regression through generalized estimating equation analysis so as to take into account repeated observation within subjects and adjust for session duration. RESULTS There were no significant differences in the estimated marginal mean of kappa RR, which were respectively 0.67, 0.69 and 0.70 with HCOL-HD, HCOS-HDF and HF-HDF (P = 0.950). The estimated marginal mean of the proportions of treatments with a kappa RR ≥0.65 were 68%, 63% and 71% with HCOL-HD, HCOS-HDF and HF-HDF, respectively (P = 0.913). The estimated marginal mean of lambda RR were higher with HCOL-HDF (0.78), compared to HCOL-HD and HF-HDF (0.62, and 0.61 respectively). The estimated marginal mean proportion of treatments with a lambda RR ≥0.65 were higher with HCOL-HDF (81%), compared to 57% in HF-HDF (P = 0.042). The median albumin loss were 7, 21 and 63 g/session with HF-HDF, HCOL-HD and HCOL-HDF respectively (P = 0.044). Among survivors, 9 out of 10 episodes of acute kidney injuries became dialysis-independent following a median time of renal replacement therapy of 40 days (range 7-181). CONCLUSION Therefore, in patients with acute dialysis-dependent myeloma cast nephropathy, in addition to chemotherapy, HDF with a heat sterilized high-flux polyphenylene HF dialyzer could offer an alternative to HCO dialysis for extracorporeal kappa reduction with lower albumin loss.
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Affiliation(s)
- Mathieu Rousseau-Gagnon
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
| | - Mohsen Agharazii
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
- * E-mail: (SD); (MA)
| | - Sacha A. De Serres
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
| | - Simon Desmeules
- Division of Nephrology, Department of Medicine, CHU de Quebec-Hôtel-Dieu de Québec, Quebec, Canada
- Department of Medicine, Faculty of Medicine, Université Laval, Québec, Québec, Canada
- * E-mail: (SD); (MA)
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40
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Stokes MB, Valeri AM, Herlitz L, Khan AM, Siegel DS, Markowitz GS, D'Agati VD. Light Chain Proximal Tubulopathy: Clinical and Pathologic Characteristics in the Modern Treatment Era. J Am Soc Nephrol 2015; 27:1555-65. [PMID: 26374607 DOI: 10.1681/asn.2015020185] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 08/02/2015] [Indexed: 01/25/2023] Open
Abstract
Light chain proximal tubulopathy (LCPT) is characterized by cytoplasmic inclusions of monoclonal LC within proximal tubular cells. The significance of crystalline versus noncrystalline LCPT and the effect of modern therapies are unknown. We reported the clinical-pathologic features of 40 crystalline and six noncrystalline LCPT patients diagnosed between 2000 and 2014. All crystalline LCPTs were κ-restricted and displayed acute tubular injury. One-third of noncrystalline LCPT patients displayed λ-restriction or acute tubular injury. Only crystalline LCPT frequently required antigen retrieval to demonstrate monoclonal LC by immunofluorescence. In five of 38 patients, crystals were not detectable by light microscopy, but they were visible by electron microscopy. Hematolymphoid neoplasms, known before biopsy in only 15% of patients, included 21 monoclonal gammopathies of renal significance; 15 multiple myelomas; seven smoldering multiple myelomas; and three other neoplasms. Biopsy indications included Fanconi syndrome (38%; all with crystalline LCPT), renal insufficiency (83%), and proteinuria (98%). Follow-up was available for 30 (75%) patients with crystalline LCPT and all six patients with noncrystalline LCPT, of whom 11 underwent stem cell transplant, 16 received chemotherapy only, and nine were untreated. Complete or very good partial hematologic remissions occurred in six of 22 treated crystalline LCPT patients. By multivariable analysis, the only independent predictor of final eGFR was initial eGFR, highlighting the importance of early detection. All patients with crystalline LCPT treated with stem cell transplant had stable or improved kidney function, indicating the effectiveness of aggressive therapy in selected patients.
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Affiliation(s)
| | - Anthony M Valeri
- Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York
| | - Leal Herlitz
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio; and
| | - Abdullah M Khan
- Department of Medicine, Hackensack University Medical Center, Hackensack, New Jersey
| | - David S Siegel
- Department of Medicine, Hackensack University Medical Center, Hackensack, New Jersey
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41
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Tojo A, Asaba K, Kinugasa S, Ikeda Y, Shintani Y, Fukayama M, Nangaku M. The reduced expression of proximal tubular transporters in acquired Fanconi syndrome with κ light chain deposition. Med Mol Morphol 2015; 49:48-52. [PMID: 26141649 DOI: 10.1007/s00795-015-0114-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 06/23/2015] [Indexed: 11/26/2022]
Abstract
In a case of acquired Fanconi syndrome associated with smoldering myeloma, we confirmed the deposition of protease-resistant κ light chain proteins in a proximal tubular injury and found the decreased expression of apical tubular transporters including sodium glucose co-transporter, sodium phosphate co-transporter, uric acid transporter 1, and a decrease of Na(+)/K(+)-ATPase in the basolateral membrane. The protease-resistant kappa light chain has a pathological role in the expression of tubular transporters in the proximal tubule and causes Fanconi syndrome associated with smoldering myeloma.
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Affiliation(s)
- Akihiro Tojo
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
| | - Kensuke Asaba
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Satoshi Kinugasa
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yoichiro Ikeda
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Yukako Shintani
- Department of Pathology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masashi Fukayama
- Department of Pathology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Masaomi Nangaku
- Division of Nephrology and Endocrinology, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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42
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Corbett RW, Cook HT, Duncan N, Moss J. Fibrillary inclusions in light chain proximal tubulopathy associated with myeloma. Clin Kidney J 2015; 5:75-6. [PMID: 26069757 PMCID: PMC4400460 DOI: 10.1093/ndtplus/sfr161] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Accepted: 11/08/2011] [Indexed: 11/26/2022] Open
Affiliation(s)
- Richard W Corbett
- Imperial Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - H Terence Cook
- Imperial Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Neill Duncan
- Imperial Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Jill Moss
- Imperial Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
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43
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Gowda KK, Joshi K, Nada R, Ramachandran R, Sachdeva M. Light chain proximal tubulopathy with cast nephropathy in a case of multiple myeloma. Indian J Nephrol 2015; 25:119-22. [PMID: 25838654 PMCID: PMC4379621 DOI: 10.4103/0971-4065.138700] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
The renal diseases most frequently associated with myeloma include cast nephropathy (CN), amyloidosis and monoclonal immunoglobulin deposition disease. Light chain proximal tubulopathy (LCPT) is reported less frequently. Majority of the cases with κ-restriction present with Fanconi syndrome (FS) and show crystals in proximal tubular epithelial cytoplasm. In contrast, those with λ-restriction are infrequently associated with FS and show cytoplasmic vacuolations in proximal tubular epithelial cytoplasm. Combination of morphologies in kidney affected by plasma cell dyscrasias is rare and co-existence of LCPT and CN is one of the rarest. We report a case of multiple myeloma having this rare combination of morphologies.
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Affiliation(s)
- K K Gowda
- Department of Histopathology, PGIMER, Chandigarh, India
| | - K Joshi
- Department of Histopathology, PGIMER, Chandigarh, India
| | - R Nada
- Department of Histopathology, PGIMER, Chandigarh, India
| | | | - M Sachdeva
- Department of Hematopathology, PGIMER, Chandigarh, India
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44
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Abstract
Monoclonal gammopathy is produced by neoplastic or non-neoplastic expansion of a clone of plasma cells or B lymphocytes. Monoclonal gammopathy of unknown significance is characterized by low levels of the monoclonal protein and a relatively small population of clonal lymphocytes or plasma cells in the bone marrow. In these cases, the patient is asymptomatic with no evidence of overt myeloma or lymphoma. The abnormal serum protein may be present as a complete immunoglobulin molecule or may consist of ≥1 of its components such as light chains or heavy chains. These proteins may cause a variety of diseases in various tissues and organs, of which the kidney appears to be the most vulnerable. Renal involvement in monoclonal gammopathy may occur as part of a generalized disease such as amyloidosis, immunoglobulin deposition disease, and cryoglobulinemia. In addition, there may be evidence of kidney damage by processes which are renal specific. These include light chain proximal tubulopathy, light chain cast nephropathy, and a variety of glomerulopathies encompassing a wide spectrum of disease patterns.
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45
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Herrera GA. Proximal tubulopathies associated with monoclonal light chains: the spectrum of clinicopathologic manifestations and molecular pathogenesis. Arch Pathol Lab Med 2014; 138:1365-80. [PMID: 25268200 DOI: 10.5858/arpa.2013-0493-oa] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT Lesions associated with monoclonal light and heavy chains display a variety of glomerular, tubular interstitial, and vascular manifestations. While some of the entities are well recognized, including light and heavy chain deposition diseases, AL (light chain) and AH (heavy chain) amyloidosis, and light chain ("myeloma") cast nephropathy, other lesions centered on proximal tubules are much less accurately identified, properly diagnosed, and adequately understood in terms of pathogenesis and molecular mechanisms involved. These proximal tubule-centered lesions are typically associated with monoclonal light chains and have not been reported in patients with circulating monoclonal heavy chains. OBJECTIVE To determine the incidence of proximal tubulopathies in a series of patients with monoclonal light chain-related renal lesions and characterize them with an emphasis on clinical correlations and elucidation of molecular mechanisms involved in their pathogenesis. DESIGN A study of 5410 renal biopsies with careful evaluation of light microscopic, immunofluorescence, and electron microscopic findings was conducted to identify these monoclonal light/heavy chain-related lesions. In selected cases, ultrastructural immunolabeling was performed to better illustrate and understand molecular mechanisms involved or to resolve specific diagnostic difficulties. RESULTS In all, 2.5% of the biopsies were diagnosed as demonstrating renal pathology associated with monoclonal light or heavy chains. Of these, approximately 46% were classified as proximal tubule-centered lesions, also referred to as monoclonal light chain-associated proximal tubulopathies. These proximal tubulopathies were divided into 4 groups defined by characteristic immunomorphologic manifestations associated with specific clinical settings. CONCLUSIONS These are important lesions whose recognition in the different clinical settings is extremely important for patients' clinical management, therapeutic purposes, and prognosis. These entities have been segregated into 4 distinct variants, conceptualized morphologically and clinically. Specific mechanisms involved in their pathogenesis are proposed.
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46
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A case of Fanconi syndrome accompanied by crystal depositions in tubular cells in a patient with multiple myeloma. Kidney Res Clin Pract 2014; 33:112-5. [PMID: 26877961 PMCID: PMC4714179 DOI: 10.1016/j.krcp.2014.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/25/2014] [Accepted: 04/18/2014] [Indexed: 11/27/2022] Open
Abstract
Fanconi syndrome (FS) is a rare condition that is characterized by defects in the proximal tubular function. A 48-year-old woman was admitted for evaluation of proteinuria. The patient showed normal anion gap acidosis, normoglycemic glycosuria, hypophosphatemia, and hypouricemia. Thus, her condition was compatible with FS. The M peak was found behind the beta globulin region in urine protein electrophoresis. Upon bone marrow examination, we found that 24% of cells were CD138+ plasma cells with kappa restriction. From a kidney biopsy, we found crystalline inclusions within proximal tubular epithelial cells. Thereafter, she was diagnosed with FS accompanied by multiple myeloma. The patient received chemotherapy and autologous stem cell transplantation, and obtained very good partial hematologic response. However, proximal tubular dysfunction was persistent until 1 year after autologous stem cell transplantation. In short, we report a case of FS accompanied by multiple myeloma, demonstrating crystalline inclusion in proximal tubular cells on kidney biopsy.
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47
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Vankalakunti M, Bonu R, Shetty S, Siddini V, Babu K, Ballal SH. Crystalloid glomerulopathy in monoclonal gammopathy of renal significance (MGRS). Clin Kidney J 2014; 7:296-8. [PMID: 25852893 PMCID: PMC4377747 DOI: 10.1093/ckj/sfu025] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 02/24/2014] [Indexed: 11/14/2022] Open
Abstract
We report a case of monoclonal gammopathy of renal significance in a 63-year-old man who presented with nephrotic-range proteinuria and renal insufficiency. The kidney biopsy showed a membranoproliferative glomerulonephritis pattern with extensive crystalloid deposits in the glomerular capillary endothelial cells and very few in the tubular epithelial cells. The immunoperoxidase staining showed kappa light chain restriction. Subsequently, the bone marrow showed 6% plasma cells which confirmed the diagnosis of monoclonal gammopathy of renal significance. He responded well to bortezomib treatment with resolution of the nephrotic syndrome and normalization of renal function after 7 months.
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Affiliation(s)
| | | | - Shilpa Shetty
- Department of Nephrology , Manipal Hospital , Bangalore , India
| | | | - Kishore Babu
- Department of Nephrology , Manipal Hospital , Bangalore , India
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48
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Stompór T, Perkowska-Ptasińska A, Wojciechowska M, Zając K, Chmielewska-Badziąg A, Pawłowska A. Unusual manifestation of crystalline light chain tubulopathy in patient with multiple myeloma: case report and review of the literature. Ren Fail 2014; 36:795-9. [DOI: 10.3109/0886022x.2014.884446] [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] Open
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49
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Yao Y, Wang SX, Zhang YK, Wang Y, Liu L, Liu G. Acquired Fanconi syndrome with proximal tubular cytoplasmic fibrillary inclusions of λ light chain restriction. Intern Med 2014; 53:121-4. [PMID: 24429451 DOI: 10.2169/internalmedicine.53.0836] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Light chain proximal tubulopathy is a rarely reported entity associated with plasma cell dyscrasia that classically manifests as acquired Fanconi syndrome and is characterized by the presence of κ-restricted crystals in the proximal tubular cytoplasm. We herein present a case of multiple myeloma with Fanconi syndrome and acute kidney injury due to light chain proximal tubulopathy with light chain cast nephropathy. Prominent phagolysosomes and numerous irregularly shaped inclusions with a fibrillary matrix in the cytoplasm of the proximal tubules were identified on electron microscopy. A monotypic light chain of the λ type was detected in the distal tubular casts, proximal tubular cytoplasmic lysosomes and fibrillary inclusions on immunofluorescence and immune electron microscopy. This case underscores the importance of conducting careful ultrastructural investigations and immunocytologic examinations of light chains for detecting and diagnosing light chain proximal tubulopathy.
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Affiliation(s)
- Ying Yao
- Renal Division, Department of Medicine, Peking University First Hospital; Institute of Nephrology, Peking University; Key Laboratory of Renal Diseases, Ministry of Health of China, China
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50
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Seidowsky A, Moulonguet-Doleris L, Hanslik T, Yattara H, Ayari H, Rouveix E, Massy ZA, Prinseau J. [Tubular renal acidosis]. Rev Med Interne 2013; 35:45-55. [PMID: 24070792 DOI: 10.1016/j.revmed.2013.08.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2012] [Revised: 07/25/2013] [Accepted: 08/17/2013] [Indexed: 11/30/2022]
Abstract
Renal tubular acidosis (RTAs) are a group of metabolic disorders characterized by metabolic acidosis with normal plasma anion gap. There are three main forms of RTA: a proximal RTA called type II and a distal RTA (type I and IV). The RTA type II is a consequence of the inability of the proximal tubule to reabsorb bicarbonate. The distal RTA is associated with the inability to excrete the daily acid load and may be associated with hyperkalaemia (type IV) or hypokalemia (type I). The most common etiology of RTA type IV is the hypoaldosteronism. The RTAs can be complicated by nephrocalcinosis and obstructive nephrolithiasis. Alkalinization is the cornerstone of treatment.
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Affiliation(s)
- A Seidowsky
- Université Versailles Saint-Quentin-en-Yvelines, 78000 Versailles, France; Service de médecine interne, hôpital Ambroise-Paré, AP-HP, 92104 Boulogne-Billancourt cedex, France; Service de néphrologie, hôpital Ambroise-Paré, AP-HP, 92104 Boulogne-Billancourt cedex, France.
| | - L Moulonguet-Doleris
- Service de néphrologie, hôpital Ambroise-Paré, AP-HP, 92104 Boulogne-Billancourt cedex, France
| | - T Hanslik
- Université Versailles Saint-Quentin-en-Yvelines, 78000 Versailles, France; Service de médecine interne, hôpital Ambroise-Paré, AP-HP, 92104 Boulogne-Billancourt cedex, France
| | - H Yattara
- Service de néphrologie, hôpital Ambroise-Paré, AP-HP, 92104 Boulogne-Billancourt cedex, France
| | - H Ayari
- Service de néphrologie, hôpital Ambroise-Paré, AP-HP, 92104 Boulogne-Billancourt cedex, France
| | - E Rouveix
- Université Versailles Saint-Quentin-en-Yvelines, 78000 Versailles, France; Service de médecine interne, hôpital Ambroise-Paré, AP-HP, 92104 Boulogne-Billancourt cedex, France
| | - Z A Massy
- Université Versailles Saint-Quentin-en-Yvelines, 78000 Versailles, France; Service de néphrologie, hôpital Ambroise-Paré, AP-HP, 92104 Boulogne-Billancourt cedex, France
| | - J Prinseau
- Université Versailles Saint-Quentin-en-Yvelines, 78000 Versailles, France; Service de néphrologie, hôpital Ambroise-Paré, AP-HP, 92104 Boulogne-Billancourt cedex, France
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