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Best Rocha A, Larsen CP. Membranous Glomerulopathy With Light Chain-Restricted Deposits: A Clinicopathological Analysis of 28 Cases. Kidney Int Rep 2017; 2:1141-1148. [PMID: 29270522 PMCID: PMC5733688 DOI: 10.1016/j.ekir.2017.07.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/17/2017] [Accepted: 07/24/2017] [Indexed: 02/07/2023] Open
Abstract
Introduction Membranous glomerulopathy (MG) is a common cause of nephrotic syndrome that results from the formation of immune complexes along the subepithelial aspect of the glomerular basement membranes. Although it is most frequently caused by polytypic deposits, cases with light chain isotype-restricted deposits are rarely seen. Methods We conducted a retrospective analysis of 28 cases of MG that showed light chain isotype restriction. Results The mean age at diagnosis was 62.2 years and the male-to-female ratio was 1. All patients presented with proteinuria (73.1% nephrotic range), and the mean serum creatinine was 1.5 mg/dl. Six patients had an underlying lymphoproliferative disorder (LPD), 2 had autoimmune disease, and 1 patient was positive for both hepatitis B and syphilis. Only 1 of the patients with an LPD had a detectable monoclonal Ig. Four patients (14.3%) showed focal proliferation or crescents, 3 of whom had an underlying LPD. Kappa (κ) restriction was seen in 26 of 28 patients (85.7%). Staining for IgG subclasses was performed in 19 cases, 14 of which showed positive staining for a single subclass. PLA2R was positive in 7 of 27 cases. 30% of PLA2R-negative patients and 28.6% of those with positive staining for a single IgG subclass had an associated LPD. Discussion The majority of MG cases with light chain isotype-restricted deposits lack a recognizable secondary etiology. However, the absence of PLA2R positivity, positive staining for a single IgG subclass, and presence of focal proliferation are worrisome histopathologic features that should prompt a thorough clinical workup to exclude the presence of an underlying LPD.
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Soldarini M, Farina L, Genderini A, Bolli N. A rare case of atypical chronic lymphocytic leukaemia presenting as nephrotic syndrome. BMJ Case Rep 2017; 2017:bcr-2016-218850. [PMID: 28710302 DOI: 10.1136/bcr-2016-218850] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Chronic lymphocytic leukaemia (CLL) is characterised by a lymphocytosis of mature-appearing clonal CD5+, CD23+ B lymphocytes. CLL cells arise from the bone marrow and infiltrate lymphoid tissues such as lymph nodes and spleen. Presentation is usually through discovery of lymphocytosis or lymphadenopathy. Unusual presentations, especially paraneoplastic syndromes are rare. Here, we describe a rare case presenting with severe nephrotic syndrome associated with the presence of a monoclonal protein in serum. Workup for suspected plasma cell dyscrasia led instead to the diagnosis of bone marrow infiltration by atypical CLL without lymphocytosis. Renal biopsy showed a glomerulonephritis that turned out to be paraneoplastic as it went into remission after treatment for CLL. Our case shows an unusual presentation of CLL and prompts for increased awareness of lymphoproliferative disorders in the context of seemingly unrelated conditions that may be paraneoplastic in origin.
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Affiliation(s)
- Martina Soldarini
- Dipartimento di Oncologia ed Onco-Ematologia, Universita' degli Studi di Milano, Milano, Italy
| | - Lucia Farina
- Dipartimento di Oncologia medica ed Ematologia, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - Augusto Genderini
- Unità operativa complessa di nefrologia e dialisi, Azienda Ospedaliera-Polo Universitario Luigi Sacco, Milano, Italy
| | - Niccolo Bolli
- Dipartimento di Oncologia ed Onco-Ematologia, Universita' degli Studi di Milano, Milano, Italy
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Strati P, Parikh SA, Chaffee KG, Kay NE, Call TG, Achenbach SJ, Cerhan JR, Slager SL, Shanafelt TD. Relationship between co-morbidities at diagnosis, survival and ultimate cause of death in patients with chronic lymphocytic leukaemia (CLL): a prospective cohort study. Br J Haematol 2017; 178:394-402. [PMID: 28580636 DOI: 10.1111/bjh.14785] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 03/29/2017] [Indexed: 11/27/2022]
Abstract
The ultimate cause of death for most patients with newly diagnosed chronic lymphocytic leukaemia (CLL) and its relationship to co-morbid health conditions is poorly defined. We conducted a prospective cohort study that systematically followed 1143 patients diagnosed with CLL between June 2002 and November 2014. Comorbid health conditions at the time of CLL diagnosis and their relationship to survival and cause of death were evaluated. Collectively, 1061 (93%) patients had at least one co-morbid health condition at the time of CLL diagnosis (median number 3). Despite this, 89% of patients had a low-intermediate Charlson Comorbidity Index score (CCI) at diagnosis. After a median follow-up of 6 years, 225 patients have died. Death was due to CLL progression in 85 (46%) patients, infection in 14 (8%) patients, other cancer in 35 (19%) patients and comorbid health conditions in 50 (27%) patients. Higher CCI score and a greater number of major comorbid health conditions at the time of CLL diagnosis was associated with shorter non-CLL specific survival, but not with shorter CLL-specific survival on multivariate analysis. In conclusion, CLL and CLL-related complications (infections and second cancers) are the overwhelming cause of death in patients with CLL, regardless of CCI score and number of comorbid health conditions at diagnosis.
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Affiliation(s)
- Paolo Strati
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | | | - Neil E Kay
- Mayo Clinic College of Medicine, Rochester, MN, USA
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Visentin A, Imbergamo S, Gurrieri C, Frezzato F, Trimarco V, Martini V, Severin F, Raggi F, Scomazzon E, Facco M, Piazza F, Semenzato G, Trentin L. Major infections, secondary cancers and autoimmune diseases occur in different clinical subsets of chronic lymphocytic leukaemia patients. Eur J Cancer 2016; 72:103-111. [PMID: 28027513 DOI: 10.1016/j.ejca.2016.11.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Revised: 11/03/2016] [Accepted: 11/17/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Major infections (MIs), secondary cancers (SCs) and autoimmune diseases (ADs) are the most common and relevant complications in patients with chronic lymphocytic leukaemia. METHODS We performed a single-centre retrospective study to investigate the prevalence of the above quoted complications, the association with most important prognostic markers and their impact on survival (n = 795). RESULTS Almost one out of three patients experienced at least one complication and only 0.9% of the cohort developed all three complications. One hundred and twenty (20%) subjects developed SC, 98 MI (12%) and 80 AD (10%); these complications seem to occur in a mutually exclusive manner. By Kaplan-Meier analysis we estimated that after 20 years from the diagnosis SC, MI and AD occurred in 48%, 42% and 29% of patients, respectively. Furthermore, we showed that some clinical and biological markers are skewed among patients with different complications and that subjects with MI and SC had a worse prognosis than those with AD and all other patients (p < 0.0001). CONCLUSIONS This study reveals the existence of different clinical subsets of chronic lymphocytic leukaemia patients characterised by an increased and different risk for developing specifically MI, SC and AD.
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Affiliation(s)
- Andrea Visentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy
| | - Silvia Imbergamo
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Carmela Gurrieri
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Federica Frezzato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy
| | - Valentina Trimarco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy
| | - Veronica Martini
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy
| | - Filippo Severin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy
| | - Flavia Raggi
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy
| | - Edoardo Scomazzon
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy
| | - Monica Facco
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy
| | - Francesco Piazza
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy
| | - Gianpietro Semenzato
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy.
| | - Livio Trentin
- Hematology and Clinical Immunology Unit, Department of Medicine, University of Padua, Italy; Venetian Institute of Molecular Medicine, Centro di Eccellenza per la Ricerca Biomedica Avanzata, Italy.
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Strati P, Chaffee KG, Achenbach SJ, Slager SL, Leung N, Call TG, Ding W, Parikh SA, Kay NE, Shanafelt TD. Renal insufficiency is an independent prognostic factor in patients with chronic lymphocytic leukemia. Haematologica 2016; 102:e22-e25. [PMID: 27634202 DOI: 10.3324/haematol.2016.150706] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Paolo Strati
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | | | | | - Nelson Leung
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Wei Ding
- Mayo Clinic College of Medicine, Rochester, MN, USA
| | | | - Neil E Kay
- Mayo Clinic College of Medicine, Rochester, MN, USA
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Vos JM, Gustine J, Rennke HG, Hunter Z, Manning RJ, Dubeau TE, Meid K, Minnema MC, Kersten MJ, Treon SP, Castillo JJ. Renal disease related to Waldenström macroglobulinaemia: incidence, pathology and clinical outcomes. Br J Haematol 2016; 175:623-630. [PMID: 27468978 DOI: 10.1111/bjh.14279] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Accepted: 06/07/2016] [Indexed: 01/08/2023]
Abstract
The incidence and prognostic impact of nephropathy related to Waldenström macroglobulinaemia (WM) is currently unknown. We performed a retrospective study to assess biopsy-confirmed WM-related nephropathy in a cohort of 1391 WM patients seen at a single academic institution. A total of 44 cases were identified, the estimated cumulative incidence was 5·1% at 15 years. There was a wide variation in kidney pathology, some directly related to the WM: amyloidosis (n = 11, 25%), monoclonal-IgM deposition disease/cryoglobulinaemia (n = 10, 23%), lymphoplasmacytic lymphoma infiltration (n = 8, 18%), light-chain deposition disease (n = 4, 9%) and light-chain cast nephropathy (n = 4, 9%), and some probably related to the WM: thrombotic microangiopathy (TMA) (n = 3, 7%), minimal change disease (n = 2, 5%), membranous nephropathy (n = 1, 2%) and crystal-storing tubulopathy (n = 1, 2%). The median overall survival in patients with biopsy-confirmed WM-related nephropathy was 11·5 years, shorter than for the rest of the cohort (16 years, P = 0·03). Survival was better in patients with stable or improved renal function after treatment (P = 0·05). Based on these findings, monitoring for renal disease in WM patients should be considered and a kidney biopsy pursued in those presenting with otherwise unexplained renal failure and/or nephrotic syndrome.
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Affiliation(s)
- Josephine M Vos
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA.,Department of Internal Medicine/Haematology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Joshua Gustine
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Zachary Hunter
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Robert J Manning
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Toni E Dubeau
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Kirsten Meid
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Monique C Minnema
- Department of Haematology, Academic Medical Centre, Amsterdam, the Netherlands
| | - Marie-Jose Kersten
- Department of Haematology, UMC Utrecht Cancer Centre, Utrecht, the Netherlands
| | - Steven P Treon
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Jain P, Kanagal-Shamanna R, Wierda W, Ferrajoli A, Keating M, Jain N. Membranoproliferative glomerulonephritis and acute renal failure in a patient with chronic lymphocytic leukemia: Response to obinutuzumab. Hematol Oncol Stem Cell Ther 2016; 10:151-154. [PMID: 27352257 PMCID: PMC7001725 DOI: 10.1016/j.hemonc.2016.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Revised: 04/18/2016] [Accepted: 05/21/2016] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE/BACKGROUND Membranoproliferative glomerulonephritis (MPGN) is a common extramedullary renal presentation in chronic lymphocytic leukemia (CLL) and can present with either a frank renal failure or proteinuria. One of its etiologies has been attributed to a paraneoplastic, immune complex phenomenon occurring in CLL. Although there is no standard of care in such patients, use of anti-CD20 monoclonal antibodies like rituximab have been used before in such patients with variable responses. Obinutuzumab is a novel, type II, immunoglobulin-G1 monoclonal antibody with a higher efficacy than rituximab and has an established safely profile in patients with comorbidities and poor renal functions. There are no such reported cases of MPGN in CLL being treated with obinutuzumab. METHODS We used the standard doses of obinutuzumab in our elderly patient (78-year-old woman) with high-risk CLL due to an underlying TP53 mutation, along with a MPGN-related acute renal failure. RESULTS The patient achieved complete remission after six cycles of obinutuzumab; however, she remained positive for minimal residual disease on flow cytometry. Her renal function improved completely, suggesting a complete response of her underlying MPGN. CONCLUSION Obinutuzumab has an established safety profile in patients with CLL, but our case is the first reported case of a paraneoplastic, immune complex-mediated MPGN in CLL being treated with obinutuzumab. Obinutuzumab should be explored as a potential option in patients with CLL and MPGN.
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Affiliation(s)
- Punit Jain
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | | | - William Wierda
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | | | - Michael Keating
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA
| | - Nitin Jain
- Department of Leukemia, MD Anderson Cancer Center, Houston, TX, USA.
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Glavey SV, Leung N. Monoclonal gammopathy: The good, the bad and the ugly. Blood Rev 2015; 30:223-31. [PMID: 26732417 DOI: 10.1016/j.blre.2015.12.001] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Revised: 12/04/2015] [Accepted: 12/08/2015] [Indexed: 12/13/2022]
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is a condition characterized by the presence of a monoclonal gammopathy (MG) in which the clonal mass has not reached a predefined state in which the condition is considered malignant. It is a precursor to conditions such as multiple myeloma or lymphoma at a rate of ~1%/year. Thus, from a hematologic standpoint, MGUS is a fairly benign condition. However, it is now recognized that organ damage resulting from just the MG without the need MM or lymphoma can occur. One of the most recognized is nephropathy secondary to monoclonal gammopathy of renal significance (MGRS). Other well-recognized conditions include neuropathies, oculopathies and dermopathies. Some conditions such as autoimmune diseases and coagulopathies are less common and recognized. Finally, systemic involvement of multiple organs is well described in several entities. In all of these conditions, the role of the MG is no longer insignificant. Thus, the term MGUS should be avoided when describing these entities.
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Affiliation(s)
- Siobhan V Glavey
- Department of Hematology, National University of Ireland, Galway, Ireland
| | - Nelson Leung
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA; Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA.
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59
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Strati P, Gharaibeh KA, Leung N, Cosio FG, Call TG, Shanafelt TD. Solid organ transplant in individuals with monoclonal B-cell lymphocytosis and chronic lymphocytic leukaemia. Br J Haematol 2015; 174:162-5. [DOI: 10.1111/bjh.13759] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Paolo Strati
- Mayo Clinic College of Medicine; Rochester MN USA
| | | | - Nelson Leung
- Mayo Clinic College of Medicine; Rochester MN USA
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