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Clone-directed therapy for proliferative glomerulonephritis with monoclonal immunoglobulin depositions: is it always necessary? : Two case reports and literature review. J Nephrol 2020; 33:611-617. [PMID: 32221859 PMCID: PMC7220881 DOI: 10.1007/s40620-020-00723-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/12/2020] [Indexed: 11/21/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) encompasses a group of disorders in which a monoclonal immunoglobulin (M-protein) secreted by a B-cell or plasma cell clone causes renal disease. Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a form of MGRS where M-protein is deposited in the glomerulus. Although evidence is limited, the current consensus is that therapy for PGNMID should be directed against the underlying clone. However, it is conceivable that there is heterogeneity in the renal prognosis of PGNMID and that not all patients have need for clone-directed therapy. Here, we report two cases of PGNMID with IgM-kappa gammopathy. In one case of a 53-year-old woman the glomerulonephritis resolved without clone-directed therapy. In the other case of a 34-year-old woman clone-directed therapy was discontinued due to adverse effects. Although no hematological response was achieved, the PGNMID resolved. In both cases there are no signs of a recurrent glomerulonephritis in over 3 years of follow-up. Here, we review the literature and suggest that some PGNMID patients have a favorable renal prognosis in whom clone-directed therapy can be withheld or postponed. Further research is warranted to yield predictors to identify these patients and to better understand the disease course of PGNMID.
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Batko K, Malyszko J, Jurczyszyn A, Vesole DH, Gertz MA, Leleu X, Suska A, Krzanowski M, Sułowicz W, Malyszko JS, Krzanowska K. The clinical implication of monoclonal gammopathies: monoclonal gammopathy of undetermined significance and of renal significance. Nephrol Dial Transplant 2020; 34:1440-1452. [PMID: 30169860 DOI: 10.1093/ndt/gfy259] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Indexed: 12/23/2022] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) has introduced a new perspective to several well-known disease entities impacting nephrology, haematology and pathology. Given the constantly changing disease spectrum of these entities, it is clinically imperative to establish diagnostic and treatment pathways supported by evidence-based medicine. MGRS is a disease of the kidney, secondary to plasma cell clonal proliferation or immune dysfunction, requiring therapeutic intervention to eradicate the offending clone. To fully understand the disease(s), it is prerequisite to determine the significance of the findings. The diagnostic work up should be extensive due to the wide heterogeneity of clinical presentation, ultimately necessitating kidney biopsy. Particular patient profiles such as AL amyloidosis, which may be diagnosed through biopsies of other tissues/organs, may be an exception. Treatment decisions should be formulated by multi-disciplinary consensus: nephrologists, haematologists and pathologists. The ultimate goal in managing MGRS is eradication of the offending plasma cell clone which requires targeted chemotherapy and, in eligible cases, haematopoietic stem cell transplantation. We present a review of diagnostic procedures, treatment options and advances in the last few years in the management of MGRS in an effort to acquaint specialists with this new face of several older diseases.
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Affiliation(s)
- Krzysztof Batko
- Departament of Nephrology, Jagiellonian University Medical College, Kraków, Poland
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warszawa, Poland
| | - Artur Jurczyszyn
- Departament of Hematology, Jagiellonian University Medical College, Kraków, Poland
| | - David H Vesole
- Myeloma DIvision, John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Xavier Leleu
- Service d`Hematologie CHU, Hopital de la Miletrie, Poitiers, France
| | - Anna Suska
- Departament of Hematology, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Krzanowski
- Departament of Nephrology, Jagiellonian University Medical College, Kraków, Poland
| | - Władysław Sułowicz
- Departament of Nephrology, Jagiellonian University Medical College, Kraków, Poland
| | - Jacek S Malyszko
- 1st Department of Nephrology, Medical University, Bialystok, Poland
| | - Katarzyna Krzanowska
- Departament of Nephrology, Jagiellonian University Medical College, Kraków, Poland
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103
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Zuo C, Zhu Y, Xu G. An update to the pathogenesis for monoclonal gammopathy of renal significance. Crit Rev Oncol Hematol 2020; 149:102926. [PMID: 32199132 DOI: 10.1016/j.critrevonc.2020.102926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 12/20/2019] [Accepted: 03/02/2020] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is characterized by the nephrotoxic monoclonal immunoglobulin (MIg) secreted by an otherwise asymptomatic or indolent B-cell or plasma cell clone, without hematologic criteria for treatment. The spectrum of MGRS-associated disorders is wide, including non-organized deposits or inclusions such as C3 glomerulopathy with monoclonal glomerulopathy (MIg-C3G), monoclonal immunoglobulin deposition disease, proliferative glomerulonephritis with monoclonal immunoglobulin deposits and organized deposits like immunoglobulin related amyloidosis, type I and type II cryoglobulinaemic glomerulonephritis, light chain proximal tubulopathy, and so on. Kidney biopsy should be conducted to identify the exact disease associated with MGRS. These MGRS-associated diseases can involve one or more renal compartments, including glomeruli, tubules and vessels. Hydrophobic residues replacement, N-glycosylated, increase in isoelectric point in MIg causes it to transform from soluble form to tissue deposition, causing glomerular damage. Complement deposition is found in MIg-C3G, which is caused by an abnormality of the alternative pathway and may involve multiple factors including complement component 3 nephritic factor, anti-complement factor auto-antibodies or MIg which directly cleaves C3. The effect of transforming growth factor beta and platelet-derived growth factor-β on mesangial extracellular matrix is associated with glomerular and tubular basement membrane thickening, nodular glomerulosclerosis, and interstitial fibrosis. Furthermore, inflammatory factors, growth factors and virus infection may play an important role in the development of the diseases. In this review, for the first time, we discussed current highlights in the mechanism of MGRS-related lesions.
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Affiliation(s)
- Chao Zuo
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China; Grade 2016, the Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Yuge Zhu
- Grade 2016, the First Clinical Medical College of Nanchang University, Nanchang, China
| | - Gaosi Xu
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China.
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104
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Zhao JT, Ye WL, Zhuang JL. [Advances in diagnosis and treatment of monoclonal immunoglobulin deposit disease]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:84-86. [PMID: 32023762 PMCID: PMC7357915 DOI: 10.3760/cma.j.issn.0253-2727.2020.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- J T Zhao
- Department of Hematology, Peking Union Medical College Hospital, Beijing 100730, China
| | - W L Ye
- Department of Nephrology, Peking Union Medical College Hospital, Beijing 100730, China
| | - J L Zhuang
- Department of Hematology, Peking Union Medical College Hospital, Beijing 100730, China
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105
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Higashihara T, Okada A, Nakamura Y, Saigusa H, Homma S, Matsumura M, Kusano T, Shimizu A, Takano H. Proliferative Glomerulonephritis with Monoclonal Immunoglobulin Deposits without Conspicuous Mesangial Proliferation, Complicated with Squamous Cell Lung Carcinoma. Intern Med 2020; 59:557-562. [PMID: 31611527 PMCID: PMC7056369 DOI: 10.2169/internalmedicine.2993-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We performed a renal biopsy for nephrotic syndrome in a patient with squamous cell lung carcinoma, which can worsen the prognosis. Chemoradiation therapy was effective for the cancer and proteinuria; we thus inferred that the nephrotic syndrome had been closely associated with the carcinoma. A pathological analysis of the kidney showed monoclonality for λ chain, satisfying the diagnostic criteria of proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID); however, conspicuous mesangial proliferation was not observed. This is the first case of PGNMID complicated with lung carcinoma; furthermore, our findings underscore the importance of examining renal lesions and assessing monoclonality in cancer patients.
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MESH Headings
- Aged
- Antibodies, Monoclonal/blood
- Carcinoma, Non-Small-Cell Lung/complications
- Carcinoma, Non-Small-Cell Lung/diagnosis
- Carcinoma, Non-Small-Cell Lung/physiopathology
- Carcinoma, Non-Small-Cell Lung/radiotherapy
- Carcinoma, Squamous Cell/complications
- Carcinoma, Squamous Cell/diagnosis
- Carcinoma, Squamous Cell/physiopathology
- Carcinoma, Squamous Cell/radiotherapy
- Cell Proliferation/drug effects
- Epithelial Cells/drug effects
- Glomerulonephritis, Membranoproliferative/diagnosis
- Glomerulonephritis, Membranoproliferative/etiology
- Glomerulonephritis, Membranoproliferative/physiopathology
- Humans
- Immunoglobulin G/blood
- Male
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Affiliation(s)
- Takaaki Higashihara
- Department of Nephrology, Tokyo Teishin Hospital, Japan
- Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Japan
| | - Akira Okada
- Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Japan
| | - Yasuna Nakamura
- Department of Nephrology, Tokyo Teishin Hospital, Japan
- Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Japan
| | - Hanako Saigusa
- Department of Nephrology, Tokyo Teishin Hospital, Japan
- Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Japan
| | - Shiko Homma
- Department of Nephrology, Tokyo Teishin Hospital, Japan
| | | | - Taiko Kusano
- Department of Nephrology, Tokyo Teishin Hospital, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Graduate School of Medicine, Nippon Medical School, Japan
| | - Hideki Takano
- Department of Nephrology, Tokyo Teishin Hospital, Japan
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106
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Soliman KM, Fülöp T, Ploth DW, Herberth J. Diffuse membranoproliferative glomerulonephritis with focal sclerosis and renal amyloidosis in an adult male with autosomal dominant dystrophic epidermolysis bullosa: a case report. Ren Fail 2020; 41:850-854. [PMID: 31498016 PMCID: PMC6746271 DOI: 10.1080/0886022x.2019.1614056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Previous reports of glomerular disease in adult patients with autosomal dominant dystrophic epidermolysis bullosa (EB) are limited and include post-infectious glomerulonephritis, IgA nephropathy, amyloidosis, and leukocytoclastic vasculitis. To our knowledge, membranoproliferative glomerulonephritis (MPGN) has not been described before. We report a case of a 39-year-old male with autosomal dominant dystrophic EB, presenting with bilateral leg swelling of one-week duration. There was no other significant past medical history. The physical examination was remarkable for scars and erosions over all body areas, with all extremities with blisters and ulcers covered, absent finger and toenails and bilateral lower extremity edema. Serum creatinine was 0.9 mg/dL, albumin 1.3 g/dL and urine protein excretion 3.7 g/24 h. Viral markers (hepatitis-B, C, and HIV), complement c3 and c4 levels and auto-immune antibody profile all remained negative or within normal limits. Renal ultrasound and echocardiogram were normal. Renal biopsy recovered 14 glomeruli, all with proliferation of mesangial and endothelial cells as well as an expansion of the mesangial matrix, focal segmental sclerosis and amorphous homogeneous deposits demonstrating apple-green birefringence under polarized light with Congo red stain. Our observation emphasizes the importance of recognizing MPGN and secondary amyloidosis in patients with EB, especially with the availability of newer treatment modalities.
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Affiliation(s)
- Karim M Soliman
- Department of Medicine, Division of Nephrology, Medical University of South Carolina , Charleston , SC , USA.,Department of Medicine, Division of Nephrology, Cairo University , Cairo , Egypt
| | - Tibor Fülöp
- Department of Medicine, Division of Nephrology, Medical University of South Carolina , Charleston , SC , USA.,Medical Services, Ralph H. Jonson VA Medical Center , Charleston , SC , USA
| | - David W Ploth
- Department of Medicine, Division of Nephrology, Medical University of South Carolina , Charleston , SC , USA
| | - Johann Herberth
- Medical Services, Ralph H. Jonson VA Medical Center , Charleston , SC , USA
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107
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Rovin BH, Caster DJ, Cattran DC, Gibson KL, Hogan JJ, Moeller MJ, Roccatello D, Cheung M, Wheeler DC, Winkelmayer WC, Floege J, Alpers CE, Ayoub I, Bagga A, Barbour SJ, Barratt J, Chan DT, Chang A, Choo JCJ, Cook HT, Coppo R, Fervenza FC, Fogo AB, Fox JG, Glassock RJ, Harris D, Hodson EM, Hogan JJ, Hoxha E, Iseki K, Jennette JC, Jha V, Johnson DW, Kaname S, Katafuchi R, Kitching AR, Lafayette RA, Li PK, Liew A, Lv J, Malvar A, Maruyama S, Mejía-Vilet JM, Mok CC, Nachman PH, Nester CM, Noiri E, O'Shaughnessy MM, Özen S, Parikh SM, Park HC, Peh CA, Pendergraft WF, Pickering MC, Pillebout E, Radhakrishnan J, Rathi M, Ronco P, Smoyer WE, Tang SC, Tesař V, Thurman JM, Trimarchi H, Vivarelli M, Walters GD, Wang AYM, Wenderfer SE, Wetzels JF. Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:281-295. [PMID: 30665569 DOI: 10.1016/j.kint.2018.11.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
| | - Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcus J Moeller
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany
| | - Dario Roccatello
- CMID (Center of Research of Immunopathology and Rare Diseases), and Division of Nephrology and Dialysis (ERK-Net member), University of Turin, Italy
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany.
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108
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Peña C, Schutz NP, Riva E, Valjalo R, Majlis A, López‐Vidal H, Lois V, Zamora D, Ochoa P, Shanley C, Gonzalez JT, Fantl D, Correa G, Ramirez J, Mur P, Silva G, Verri V, Rojas C, Escobar K, Glavic G, Méndez GP. Epidemiological and clinical characteristics and outcome of monoclonal gammopathy of renal significance‐related lesions in Latin America. Nephrology (Carlton) 2019; 25:442-449. [DOI: 10.1111/nep.13685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 11/20/2019] [Accepted: 12/01/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Camila Peña
- Department of HematologyHospital del Salvador Santiago de Chile
| | - Natalia P. Schutz
- Department of HematologyHospital Italiano de Buenos Aires Buenos Aires Argentina
| | - Eloísa Riva
- Department of HematologyCátedra de Hematología, Hospital de Clínicas, Facultad de Medicina Montevideo Uruguay
- Department of HematologyHospital Británico Montevideo Uruguay
| | - Ricardo Valjalo
- Department of NephrologyHospital del Salvador Santiago de Chile
| | - Alejandro Majlis
- Department of Hematology, Hemato‐Oncology DepartmentClínica Las Condes Santiago de Chile
| | | | - Vivianne Lois
- Department of HematologyHospital Barros Luco Trudeau Santiago de Chile
| | - Daniela Zamora
- Department of NephrologyHospital Barros Luco Trudeau Santiago de Chile
| | - Paola Ochoa
- Department of HematologyInstituto Alexander Fleming Buenos Aires Argentina
| | - Claudia Shanley
- Department of HematologyHospital Británico Buenos Aires Argentina
| | | | - Dorotea Fantl
- Department of HematologyHospital Italiano de Buenos Aires Buenos Aires Argentina
| | - Gonzalo Correa
- Department of NephrologyHospital del Salvador Santiago de Chile
| | | | - Paola Mur
- Department of NephrologyHospital San Juan de Dios Santiago de Chile
| | | | - Verónica Verri
- Department of HematologyInstituto de Investigaciones Médicas Alfredo Lanari – UBA Buenos Aires Argentina
| | - Christine Rojas
- Department of HematologyHospital Gustavo Fricke Viña del Mar Chile
| | - Karen Escobar
- Department of HematologyHospital Gustavo Fricke Viña del Mar Chile
| | - Gustavo Glavic
- Department of NephrologyHospital Sótero del Río Santiago de Chile
| | - Gonzalo P. Méndez
- Department of Pathology, Facultad de MedicinaPontificia Universidad Católica de Chile Santiago de Chile
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109
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Jebakumar D, Jones KA. Educational Case: Dysproteinemic Nephropathies: Renal Amyloidosis as an Example. Acad Pathol 2019; 6:2374289519888731. [PMID: 31828220 PMCID: PMC6886272 DOI: 10.1177/2374289519888731] [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: 07/02/2019] [Revised: 09/09/2019] [Accepted: 10/19/2019] [Indexed: 12/01/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, see http://journals.sagepub.com/doi/10.1177/2374289517715040.1
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Affiliation(s)
- Deborah Jebakumar
- Department of Pathology and Laboratory Medicine, Baylor Scott & White Medical Center, Temple, TX, USA.,Texas A&M College of Medicine, Temple, TX, USA
| | - Kathleen A Jones
- Department of Pathology and Laboratory Medicine, Baylor Scott & White Medical Center, Temple, TX, USA.,Texas A&M College of Medicine, Temple, TX, USA
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110
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Saeki T, Kuroha T, Sato Y, Tamura M, Iguchi A, Ito T, Yamazaki H, Ito Y, Yoshita K, Imai N, Narita I, Usuda H. Tubulointerstitial nephritis with monotypic lympho-plasmacytic infiltrates in a patient with primary Sjögren's syndrome accompanied by IgA-type monoclonal gammopathy. BMC Nephrol 2019; 20:464. [PMID: 31842799 PMCID: PMC6915943 DOI: 10.1186/s12882-019-1646-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 11/28/2019] [Indexed: 11/23/2022] Open
Abstract
Background Although most cases of tubulointerstitial nephritis in paraproteinemia are monoclonal light chain deposition-mediated, interstitial nephritis as neoplastic interstitial cell infiltration has rarely been described. On the other hand, lympho-plasma-cell-rich tubulointerstitial nephritis, in which the infiltrative cells are usually polytypic, is often evident in primary Sjögren’s syndrome (pSS). Herein we present a rare case of pSS in a patient who had been diagnosed as having IgA kappa-type monoclonal gammopathy of undetermined significance (MGUS) and developed tubulointerstitial nephritis with monotypic (IgA kappa) lympho-plasmacytic infiltrates. Case presentation A 74-year-old Japanese woman with pSS who had been diagnosed as having IgA kappa-type MGUS developed progressive renal dysfunction. Renal biopsy revealed tubulointerstitial nephritis with abundant plasma cell-rich mononuclear cell infiltrates without atypia. Immunohistochemical staining for immunoglobulins and light chains showed that most infiltrates were positive for IgA and kappa. Most of the infiltrative cells were positive for CD38 and CD138, and cells positive for CD 19 and CD 45 were also widely evident. Electron microscopy and immunofluorescence studies revealed no apparent immunological deposits in the glomeruli and tubules. Bone marrow and whole-body radiological examinations revealed no findings suggestive of multiple myeloma or lymphoma. Renal function improved rapidly with prednisolone 40 mg daily and has been maintained at the same level on low-dose prednisolone and azathioprine for 18 months. Conclusion Tubulointerstitial nephritis with monotypic cell infiltrates, without immunological deposits, is a quite rare histological picture in MGUS, and might be a unique renal manifestation in patients with pSS.
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Affiliation(s)
- Takako Saeki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, 2-297-1 Senshu, Nagaoka, Niigata, 940-2085, Japan.
| | - Takashi Kuroha
- Department of Internal Medicine, Nagaoka Red Cross Hospital, 2-297-1 Senshu, Nagaoka, Niigata, 940-2085, Japan
| | - Yuya Sato
- Department of Internal Medicine, Nagaoka Red Cross Hospital, 2-297-1 Senshu, Nagaoka, Niigata, 940-2085, Japan
| | - Maasa Tamura
- Department of Internal Medicine, Nagaoka Red Cross Hospital, 2-297-1 Senshu, Nagaoka, Niigata, 940-2085, Japan
| | - Akira Iguchi
- Department of Internal Medicine, Nagaoka Red Cross Hospital, 2-297-1 Senshu, Nagaoka, Niigata, 940-2085, Japan
| | - Tomoyuki Ito
- Department of Internal Medicine, Nagaoka Red Cross Hospital, 2-297-1 Senshu, Nagaoka, Niigata, 940-2085, Japan
| | - Hajime Yamazaki
- Department of Internal Medicine, Nagaoka Red Cross Hospital, 2-297-1 Senshu, Nagaoka, Niigata, 940-2085, Japan
| | - Yumi Ito
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
| | - Kazuhiro Yoshita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
| | - Naofumi Imai
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, 1-757 Asahimachi-dori, Niigata, 951-8510, Japan
| | - Hiroyuki Usuda
- Department of Pathology, Nagaoka Red Cross Hospital, 2-297-1 Senshu, Nagaoka, Niigata, 940-2085, Japan
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111
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Monoclonal immunoglobulin mediates complement activation in monoclonal gammopathy associated-C3 glomerulonephritis. BMC Nephrol 2019; 20:459. [PMID: 31823738 PMCID: PMC6902416 DOI: 10.1186/s12882-019-1640-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 11/22/2019] [Indexed: 12/28/2022] Open
Abstract
Background C3 glomerulonephritis (C3GN) is a rare disease caused by inherited or acquired complement alternative pathway (CAP) dysregulation, which could also be secondary to monoclonal gammopathy of undetermined significance (MGUS). Herein, we described a patient presenting with C3GN and monoclonal gammopathy, and the pathogenic association between the two diseases was further explored in vitro. Case presentation A 76-year-old Chinese man presented with low serum C3 level, haematuria and nephrotic syndrome, and experienced rapid worsening of renal function over a period of 10 months. His serum and urine immunofixation electrophoresis both revealed a monoclonal IgGλ. A bone marrow puncture showed plasma cell dyscrasias with the highest plasma cell count of 5.25%. Kidney biopsy showed the presence of C3 glomerulonephritis, with exclusive deposits of C3 visible on immunofluorescence, a membranoproliferative pattern on light microscopy and electron dense deposits in sub-epithelial, intramembranous, sub-endothelial and mesangial regions by electron microscopy. The patient was positive for C3 nephritic factor (C3NeF) activity and anti-CFH autoantibodies, and all became negative during disease remission. The anti-CFH autoantibodies purified from the patient’s plasma exchange fluids were proven to be a monoclonal IgGλ, and could inhibit CFH binding to C3b and accelerate the formation of C3 convertase indirectly by interfering with the formation-impeding activity of CFH. No deficiency of candidate genes, especially variants in CFH, was detected in our patient. Based on the pathological and laboratory findings, the diagnosis of monoclonal gammopathy of renal significance (MGRS)-associated C3GN was finally made. Conclusions This is the first demonstration that intact monoclonal immunoglobulin (IgGλ) could act as an anti-CFH antibody and lead to MGRS-associated C3GN by activating the CAP.
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Leung N, Bridoux F, Batuman V, Chaidos A, Cockwell P, D'Agati VD, Dispenzieri A, Fervenza FC, Fermand JP, Gibbs S, Gillmore JD, Herrera GA, Jaccard A, Jevremovic D, Kastritis E, Kukreti V, Kyle RA, Lachmann HJ, Larsen CP, Ludwig H, Markowitz GS, Merlini G, Mollee P, Picken MM, Rajkumar VS, Royal V, Sanders PW, Sethi S, Venner CP, Voorhees PM, Wechalekar AD, Weiss BM, Nasr SH. The evaluation of monoclonal gammopathy of renal significance: a consensus report of the International Kidney and Monoclonal Gammopathy Research Group. Nat Rev Nephrol 2019; 15:45-59. [PMID: 30510265 PMCID: PMC7136169 DOI: 10.1038/s41581-018-0077-4] [Citation(s) in RCA: 283] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The term monoclonal gammopathy of renal significance (MGRS) was introduced by the International Kidney and Monoclonal Gammopathy Research Group (IKMG) in 2012. The IKMG met in April 2017 to refine the definition of MGRS and to update the diagnostic criteria for MGRS-related diseases. Accordingly, in this Expert Consensus Document, the IKMG redefines MGRS as a clonal proliferative disorder that produces a nephrotoxic monoclonal immunoglobulin and does not meet previously defined haematological criteria for treatment of a specific malignancy. The diagnosis of MGRS-related disease is established by kidney biopsy and immunofluorescence studies to identify the monotypic immunoglobulin deposits (although these deposits are minimal in patients with either C3 glomerulopathy or thrombotic microangiopathy). Accordingly, the IKMG recommends a kidney biopsy in patients suspected of having MGRS to maximize the chance of correct diagnosis. Serum and urine protein electrophoresis and immunofixation, as well as analyses of serum free light chains, should also be performed to identify the monoclonal immunoglobulin, which helps to establish the diagnosis of MGRS and might also be useful for assessing responses to treatment. Finally, bone marrow aspiration and biopsy should be conducted to identify the lymphoproliferative clone. Flow cytometry can be helpful in identifying small clones. Additional genetic tests and fluorescent in situ hybridization studies are helpful for clonal identification and for generating treatment recommendations. Treatment of MGRS was not addressed at the 2017 IKMG meeting; consequently, this Expert Consensus Document does not include any recommendations for the treatment of patients with MGRS. This Expert Consensus Document from the International Kidney and Monoclonal Gammopathy Research Group includes an updated definition of monoclonal gammopathy of renal significance (MGRS) and recommendations for the use of kidney biopsy and other modalities for evaluating suspected MGRS
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Affiliation(s)
- Nelson Leung
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Frank Bridoux
- Department of Nephrology, Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France; CNRS UMR7276, Limoges, France; and Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Poitiers, France
| | - Vecihi Batuman
- Veterans Administration Medical Center, New Orleans, LA, USA and Tulane University Medical School, Tulane, LA, USA
| | - Aristeidis Chaidos
- Centre for Haematology, Department of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Paul Cockwell
- Department of Nephrology, Renal Medicine - University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Vivette D D'Agati
- Department of Pathology, Renal Pathology Laboratory, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Angela Dispenzieri
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fernando C Fervenza
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jean-Paul Fermand
- Department of Haematology and Immunology, University Hospital St Louis, Paris, France
| | - Simon Gibbs
- The Victorian and Tasmanian Amyloidosis Service, Department of Haematology, Monash Univerity Easter Health Clinical School, Melbourne, Victoria, Australia
| | - Julian D Gillmore
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Guillermo A Herrera
- Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Arnaud Jaccard
- Service d'Hématologie et de Thérapie Cellulaire, Centre de Référence des Amyloses Primitives et des Autres Maladies par Dépôts d'Immunoglobuline, CHU Limoges, Limoges, France
| | - Dragan Jevremovic
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | - Vishal Kukreti
- University Health Network, Princess Margaret Cancer Centre, Toronto, Canada
| | - Robert A Kyle
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Helen J Lachmann
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | | | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - Glen S Markowitz
- Department of Pathology, Renal Pathology Laboratory, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Peter Mollee
- Haematology Department, Princess Alexandra Hospital and School of Medicine, University of Queensland, Brisbane, Australia
| | - Maria M Picken
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
| | - Vincent S Rajkumar
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Virginie Royal
- Department of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montreal, Montreal, Quebec, Canada
| | - Paul W Sanders
- Department of Medicine, University of Alabama at Birmingham and Department of Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Sanjeev Sethi
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Peter M Voorhees
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium System, Charlotte, NC, USA
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Brendan M Weiss
- Abramson Cancer Center, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Samih H Nasr
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Abstract
Glomerulonephritis (GN) refers to a group of renal diseases affecting the glomeruli due to the damage mediated by immunological mechanisms. A large proportion of the disease manifestations are caused by disturbances in the complement system. They can be due to genetic errors, autoimmunity, microbes or abnormal immunoglobulins, like modified IgA or paraproteins. The common denominator in most of the problems is an overactive or misdirected alternative pathway complement activation. An assessment of kidney function, amount of proteinuria and hematuria are crucial elements to evaluate, when glomerulonephritis is suspected. However, the cornerstones of the diagnoses are renal biopsy and careful examination of the complement abnormality. Differential diagnostics between the various forms of GN is not possible based on clinical features, as they may vary greatly. This review describes the known mechanisms of complement dysfunction leading to different forms of primary GN (like IgA glomerulonephritis, dense deposit disease, C3 glomerulonephritis, post-infectious GN, membranous GN) and differences to atypical hemolytic uremic syndrome. It also covers the basic elements of etiology-directed therapy and prognosis of the most common forms of GN. Common principles in the management of GN include treatment of hypertension and reduction of proteinuria, some require immunomodulating treatment. Complement inhibition is an emerging treatment option. A thorough understanding of the basic disease mechanism and a careful follow-up are needed for optimal therapy.
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Affiliation(s)
- Kati Kaartinen
- Department of Nephrology, Abdominal Center, Helsinki University Central Hospital, Helsinki, Finland
| | - Adrian Safa
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Bacteriology and Immunology, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | - Soumya Kotha
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Bacteriology and Immunology, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | - Giorgio Ratti
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Bacteriology and Immunology, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland
| | - Seppo Meri
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Department of Bacteriology and Immunology, Translational Immunology Research Program, University of Helsinki, Helsinki, Finland; HUSLAB, Helsinki University Central Hospital, Helsinki, Finland.
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114
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Nasr SH, Larsen CP, Sirac C, Theis JD, Domenger C, Chauvet S, Javaugue V, Hogan JJ, Said SM, Dasari S, Vrana JA, McPhail ED, Cornell LD, Vilaine E, Massy ZA, Boffa JJ, Buob D, Toussaint S, Guincestre T, Touchard G, D'Agati VD, Leung N, Bridoux F. Light chain only variant of proliferative glomerulonephritis with monoclonal immunoglobulin deposits is associated with a high detection rate of the pathogenic plasma cell clone. Kidney Int 2019; 97:589-601. [PMID: 32001067 DOI: 10.1016/j.kint.2019.10.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/25/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
Abstract
IgG (mainly IgG3) is the most commonly involved isotype in proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID). Here we describe the first series of PGNMID with deposition of monoclonal immunoglobulin light chain only (PGNMID-light chain). This multicenter cohort of 17 patients presented with nephritic or nephrotic syndrome with underlying hematologic conditions of monoclonal gammopathy of renal significance (71%) or multiple myeloma (29%). Monoclonal immunoglobulin was identified by serum and urine immunofixation in 65% and 73%, respectively, with abnormal serum free light chain in 83%, and a detectable bone marrow plasma cell clone in 88% of patients. Renal biopsy showed a membranoproliferative pattern in most patients. By immunofluorescence, deposits were restricted to glomeruli and composed of restricted light chain (kappa in 71%) and C3, with granular appearance and subendothelial, mesangial and subepithelial distribution by electron microscopy. Proteomic analysis in four cases of kappa PGNMID-light chain revealed spectra for kappa constant and variable domains, without evidence of Ig heavy chains; spectra for proteins of the alternative pathway of complement and terminal complex were detected in three. The classical pathway was not detected in three cases. After median follow up of 70 months, the renal response was dependent on a hematologic response and occurred in six of ten patients treated with plasma cell-directed chemotherapy but none of five patients receiving other therapies. Thus, PGNMID-light chain differs from PGNMID-IgG by higher frequency of a detectable pathogenic plasma cell clone. Hence, proper recognition is crucial as anti-myeloma agents may improve renal prognosis. Activation of an alternative pathway of complement by monoclonal immunoglobulin light chain likely plays a role in its pathogenesis.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | | | - Christophe Sirac
- Department of Immunology, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, French Reference Center for AL Amyloidosis, University Hospital Dupuytren, Limoges, France
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Camille Domenger
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
| | - Sophie Chauvet
- Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Department of Nephrology, Paris, France; INSERM UMRS1138, Research Center Cordeliers, Paris Descartes Sorbonne Paris-Cité University, Paris, France
| | - Vincent Javaugue
- Department of Immunology, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, French Reference Center for AL Amyloidosis, University Hospital Dupuytren, Limoges, France; Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
| | - Jonathan J Hogan
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samar M Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eve Vilaine
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology, Ambroise Paré Hospital, Boulogne-Billancourt, France; Inserm U1018 Team5 UVSQ, University Paris Saclay, Villejuif, France
| | - Ziad A Massy
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology, Ambroise Paré Hospital, Boulogne-Billancourt, France; Inserm U1018 Team5 UVSQ, University Paris Saclay, Villejuif, France
| | - Jean-Jacques Boffa
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology, Hôpital Tenon, Paris Sorbonne University, Paris, France
| | - David Buob
- Assistance Publique-Hôpitaux de Paris, Department of Pathology, Hôpital Tenon, Paris Sorbonne University, Paris, France
| | - Stéphanie Toussaint
- Department of Nephrology, Bourg-en-Bresse General Hospital, Bourg-en-Bresse, France
| | | | - Guy Touchard
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank Bridoux
- Department of Immunology, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, French Reference Center for AL Amyloidosis, University Hospital Dupuytren, Limoges, France; Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
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115
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Fung AWS, Sugumar V, Ren AH, Kulasingam V. Emerging role of clinical mass spectrometry in pathology. J Clin Pathol 2019; 73:61-69. [PMID: 31690564 DOI: 10.1136/jclinpath-2019-206269] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/14/2019] [Indexed: 12/20/2022]
Abstract
Mass spectrometry-based assays have been increasingly implemented in various disciplines in clinical diagnostic laboratories for their combined advantages in multiplexing capacity and high analytical specificity and sensitivity. It is now routinely used in areas including reference methods development, therapeutic drug monitoring, toxicology, endocrinology, paediatrics, immunology and microbiology to identify and quantify biomolecules in a variety of biological specimens. As new ionisation methods, instrumentation and techniques are continuously being improved and developed, novel mass spectrometry-based clinical applications will emerge for areas such as proteomics, metabolomics, haematology and anatomical pathology. This review will summarise the general principles of mass spectrometry and specifically highlight current and future clinical applications in anatomical pathology.
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Affiliation(s)
- Angela W S Fung
- Department of Pathology and Laboratory Medicine, St Paul's Hospital, Vancouver, British Columbia, Canada.,Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Vijithan Sugumar
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Annie He Ren
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Vathany Kulasingam
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada .,Clinical Biochemistry, University Health Network, Toronto, Ontario, Canada
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116
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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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117
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Pande M, Srivastava R. Molecular and clinical insights into protein misfolding and associated amyloidosis. Eur J Med Chem 2019; 184:111753. [PMID: 31622853 DOI: 10.1016/j.ejmech.2019.111753] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 09/24/2019] [Accepted: 10/01/2019] [Indexed: 12/13/2022]
Abstract
The misfolding of normally soluble proteins causes their aggregation and deposition in the tissues which disrupts the normal structure and function of the corresponding organs. The proteins with high β-sheet contents are more prone to form amyloids as they exhibit high propensity of self-aggregation. The self aggregated misfolded proteins act as template for further aggregation that leads to formation of protofilaments and eventually amyloid fibrils. More than 30 different types of proteins are known to be associated with amyloidosis related diseases. Several aspects of the amyloidogenic behavior of proteins remain elusive. The exact reason that causes misfolding of the protein and its association into amyloid fibrils is not known. These misfolded intermediates surpass the over engaged quality control system of the cell which clears the misfolded intermediates. This promotes the self-aggregation, accumulation and deposition of these misfolded species in the form of amyloids in the different parts of the body. The amyloid deposition can be localized as in Alzheimer disease or systemic as reported in most of the amyloidosis. The amyloidosis can be of acquired type or familial. The current review aims at bringing together recent updates and comprehensive information about protein amyloidosis and associated diseases at one place.
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Affiliation(s)
- Monu Pande
- Department of Biochemistry, Institute of Medical Science, Banaras Hindu University, Varanasi, 221005, India
| | - Ragini Srivastava
- Department of Biochemistry, Institute of Medical Science, Banaras Hindu University, Varanasi, 221005, India.
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118
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Kumar P, Borz-Baba C, Raissi S. "D" is for Dilemma. Cureus 2019; 11:e5669. [PMID: 31720145 PMCID: PMC6823037 DOI: 10.7759/cureus.5669] [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: 11/05/2022] Open
Abstract
Immunoglobulin D (IgD) monoclonal gammopathy is a rare subtype of multiple myeloma (MM) associated with a worse prognosis compared with other variants of MM. A 61-year-old man with no known past medical history presented with complaints of abdominal pain, nausea, and vomiting for three weeks. Physical examination revealed mild epigastric tenderness. Laboratory data demonstrated a significantly elevated creatinine with minimal proteinuria and small abnormality in the gamma fraction. Ultrasound of the kidneys described normal-sized kidneys. Serum-free light chains and immunofixation were consistent with IgD kappa monoclonal gammopathy. Kidney biopsy revealed cast nephropathy. Bone marrow biopsy was remarkable for sheets of CD 38+ plasma cells comprising approximately 80% of the marrow cells. Recognizing the atypical presentation of IgD MM is crucial to facilitate early diagnosis and management and improve the prognosis of this subtype of MM.
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Affiliation(s)
- Pirkash Kumar
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | | | - Sina Raissi
- Medicine, Saint Mary's Hospital, Waterbury, USA
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119
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Bridoux F, Javaugue V, Nasr SH, Leung N. Proliferative glomerulonephritis with monoclonal immunoglobulin deposits: a nephrologist perspective. Nephrol Dial Transplant 2019; 36:208-215. [DOI: 10.1093/ndt/gfz176] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/26/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Proliferative glomerulonephritis (GN) with monoclonal immunoglobulin deposits (PGNMIDs) is a recently described entity among the spectrum of monoclonal gammopathy of renal significance (MGRS). The disease is renal limited and manifests with chronic glomerular disease, altered renal function and albuminuria, sometimes in the nephrotic range. Acute nephritic syndrome is rare. PGNMID occurs mostly in the sixth decade, but it may affect young adults. Histologically, PGNMID is characterized predominantly by membranoproliferative GN and less frequently by diffuse endocapillary GN, mesangioproliferative GN or atypical membranous GN. Immunofluorescence and electron microscopic studies are the cornerstone of diagnosis, showing granular deposits involving glomeruli only, and composed of monotypic immunoglobulin G (IgG), with a single heavy chain subclass (most commonly IgG3) and light chain (LC) restriction (usually κ), admixed with complement deposits. PGNMID variants with monotypic LC-only, IgA or IgM deposits are uncommon. Ultrastructurally, deposits are amorphous with predominant subendothelial and mesangial distribution. PGNMID should be distinguished from type 1 cryoglobulinemic GN and immunotactoid GN, which share some common pathological features. Contrary to other MGRS lesions, the rate of detection of the nephrotoxic monoclonal Ig in the serum or urine, and of an abnormal bone marrow B-cell clone, is only ∼30%. Renal prognosis is poor, with progression to end-stage renal disease in 25% of patients within 30 months and frequent early recurrence on the renal allograft. The pathophysiology of PGNMID is unclear and its treatment remains challenging. However, recent studies indicate that clone-targeted chemotherapy may significantly improve renal outcomes, opening future perspectives for the management of this rare disease.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, Centre de Référence Maladies Rares « Amylose AL et autres maladies par dépôts d’immunoglobulines monoclonales », Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, and CNRS UMR 7276-INSERM 1262, Limoges, France
| | - Vincent Javaugue
- Department of Nephrology, Centre de Référence Maladies Rares « Amylose AL et autres maladies par dépôts d’immunoglobulines monoclonales », Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, and CNRS UMR 7276-INSERM 1262, Limoges, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension and Division of Hematology, Mayo Clinic, Rochester, MN, USA
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120
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Chapman J, Dogan A. Fibrinogen alpha amyloidosis: insights from proteomics. Expert Rev Proteomics 2019; 16:783-793. [PMID: 31443619 PMCID: PMC6788741 DOI: 10.1080/14789450.2019.1659137] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 08/20/2019] [Indexed: 12/17/2022]
Abstract
Introduction: Systemic amyloidosis is a diverse group of diseases that, although rare, pose a serious health issue and can lead to organ failure and death. Amyloid typing is essential in determining the causative protein and initiating proper treatment. Mass spectrometry-based proteomics is currently the most sensitive and accurate means of typing amyloid. Areas covered: Amyloidosis can be systemic or localized, acquired or hereditary, and can affect any organ or tissue. Diagnosis requires biopsy, histological analysis, and typing of the causative protein to determine treatment. The kidneys are the most commonly affected organ in systemic disease. Fibrinogen alpha chain amyloidosis (AFib) is the most prevalent form of hereditary renal amyloidosis. Select mutations in the fibrinogen Aα (FGA) gene lead to AFib. Expert commentary: Mass spectrometry is currently the most specific and sensitive method for amyloid typing. Identification of the mutated fibrinogen alpha chain can be difficult in the case of 'private' frameshift mutations, which dramatically change the sequences of the expressed fibrinogen alpha chain. A combination of expert pathologist review, mass spectrometry, and gene sequencing can allow for confident diagnosis and determination of the fibrinogen alpha chain mutated sequence.
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Affiliation(s)
- Jessica Chapman
- Hematopathology Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Ahmet Dogan
- Hematopathology Service, Memorial Sloan Kettering Cancer Center , New York , NY , USA
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121
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Bianchi G, Richardson PG. Towards a better understanding of monoclonal gammopathy of renal significance. Br J Haematol 2019; 186:653-654. [DOI: 10.1111/bjh.15989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Giada Bianchi
- Department of Medical Oncology LeBow Institute for Myeloma Therapeutics and Jerome Lipper Multiple Myeloma Center Harvard Medical School Dana Farber Cancer Institute Boston MA USA
| | - Paul G. Richardson
- Department of Medical Oncology LeBow Institute for Myeloma Therapeutics and Jerome Lipper Multiple Myeloma Center Harvard Medical School Dana Farber Cancer Institute Boston MA USA
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122
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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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Lim WH, Shingde M, Wong G. Recurrent and de novo Glomerulonephritis After Kidney Transplantation. Front Immunol 2019; 10:1944. [PMID: 31475005 PMCID: PMC6702954 DOI: 10.3389/fimmu.2019.01944] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/01/2019] [Indexed: 12/13/2022] Open
Abstract
The prevalence, pathogenesis, predictors, and natural course of patients with recurrent glomerulonephritis (GN) occurring after kidney transplantation remains incompletely understood, including whether there are differences in the outcomes and advances in the treatment options of specific GN subtypes, including those with de novo GN. Consequently, the treatment options and approaches to recurrent disease are largely extrapolated from the general population, with responses to these treatments in those with recurrent or de novo GN post-transplantation poorly described. Given a greater understanding of the pathogenesis of GN and the development of novel treatment options, it is conceivable that these advances will result in an improved structure in the future management of patients with recurrent or de novo GN. This review focuses on the incidence, genetics, characteristics, clinical course, and risk of allograft failure of patients with recurrent or de novo GN after kidney transplantation, ascertaining potential disparities between “high risk” disease subtypes of IgA nephropathy, idiopathic membranous glomerulonephritis, focal segmental glomerulosclerosis, and membranoproliferative glomerulonephritis. We will examine in detail the management of patients with high risk GN, including the pre-transplant assessment, post-transplant monitoring, and the available treatment options for disease recurrence. Given the relative paucity of data of patients with recurrent and de novo GN after kidney transplantation, a global effort in collecting comprehensive in-depth data of patients with recurrent and de novo GN as well as novel trial design to test the efficacy of specific treatment strategy in large scale multicenter randomized controlled trials are essential to address the knowledge deficiency in this disease.
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Affiliation(s)
- Wai H Lim
- Department of Renal Medicine, Sir Charles Gairdner Hospital, Perth, WA, Australia.,School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Meena Shingde
- NSW Health Pathology, Institute of Clinical Pathology and Medical Research, Westmead Hospital, Westmead, NSW, Australia
| | - Germaine Wong
- Sydney School of Public Health, University of Sydney, Sydney, NSW, Australia.,Centre for Transplant and Renal Research, Westmead Hospital, Sydney, NSW, Australia.,Centre for Kidney Research, The Children's Hospital at Westmead, Sydney, NSW, Australia
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124
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Proliferative Glomerulonephritis With Monoclonal IgG3λ Deposits: A Case Report of a Rare Cause of Monoclonal Gammopathy of Renal Significance. Kidney Med 2019; 1:221-225. [PMID: 32734203 PMCID: PMC7380409 DOI: 10.1016/j.xkme.2019.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Proliferative glomerulonephritis with monoclonal immunoglobulin G (IgG) deposits is a rare monoclonal gammopathy of renal significance with dense deposits on electron microscopy similar to polyclonal immune complex-mediated glomerulonephritis. 70% of patients with proliferative glomerulonephritis with monoclonal IgG are negative for a monoclonal (M) spike, and patients with this condition rarely develop an M spike during follow-up. We report a Chinese man in his 50s who presented with nephrotic syndrome and normal glomerular filtration rate. His first kidney biopsy showed masked IgG3 deposition, such that IgG3 staining was apparent only after digestion by enzyme on paraffin tissue, with a membranoproliferative pattern. During follow-up, his glomerular filtration rate worsened and proteinuria increased. 18 months after the first biopsy, the patient developed an M spike; a second kidney biopsy showed proliferative glomerulonephritis with monoclonal IgG deposits with unmasked IgG3λ deposition. The patient was successfully treated with bortezomib and dexamethasone, followed by lenalidomide and dexamethasone maintenance therapy.
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125
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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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126
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Huang J, Sun C, Su H, Zhang C, Xiong J. Bortezomib-Based Chemotherapy with Autologous Stem Cell Transplantation for Monoclonal Gammopathy of Renal Significance: A Case Report and Literature Review. Kidney Blood Press Res 2019; 44:858-869. [PMID: 31352451 DOI: 10.1159/000501314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/02/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The term monoclonal gammopathy of renal significance (MGRS) was introduced in 2012 to emphasize kidney lesions in monoclonal gammopathy patients. Bortezomib-based chemotherapy has become the first-line treatment for MGRS. OBJECTIVES The objective of this study was to investigate whether the strategy of combining chemotherapy with autologous stem cell transplantation (ASCT) could improve prognosis and decrease functional kidney impairment in patients with MGRS. METHODS We reported the case of a 44-year-old Asian patient who was diagnosed with MGRS and received 5 cycles of Velcade® (a trade name for bortezomib), thalidomide, and dexamethasone therapy (VTD therapy), and subsequently underwent ASCT. In addition, we performed a literature review and summarized the latest advances in the characterization, treatment, and prognosis of MGRS. RESULTS The patient was diagnosed with light chain deposition disease by renal biopsy. After 5 cycles of VTD therapy, the patient had a very good partial response characterized by the resolution of M-protein (20.2% before treatment vs. 2.5% after treatment), remission of the level of serum free lambda (FLAM; over 80% decline), and normalization of the serum free light chain (sFLC) ratio (κ to λ). He also had a renal response characterized by a decreased serum creatinine level (1.61 vs.1.34 mg/dL) and less severe proteinuria (6.77 g/24 h vs.1.264 g/24 h) after chemotherapy. Importantly, after ASCT, the patient achieved a complete response (CR) characterized by a negative serum immunofixation electrophoresis (IFE) result and a dramatic decrement in FLAM (over 90%). Furthermore, 6 months after ASCT, the patient still remained in stable condition with a negative IFE result, normal sFLC ratio, and low level of serum creatinine (1.31 mg/dL) and proteinuria (0.339 g/24 h). In our retrospective literature analysis, we found that MGRS patient survival time and renal outcome had been markedly improved by current therapies due to the popularization of bortezomib-based chemotherapy and ASCT. CONCLUSIONS The patient successfully achieved CR after VTD therapy followed by ASCT. However, this treatment is controversial, and a standard therapy recommendation for MGRS has not been established. Bortezomib-based chemotherapy combined with ASCT may have prospects for the treatment of MGRS, but the exact effects of ASCT remain unclear and should be thoroughly investigated.
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Affiliation(s)
- Jing Huang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunyan Sun
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Xiong
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,
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Yu XJ, Hu N, Wang SX, Zhou FD, Zhao MH. Membranoproliferative glomerulonephritis with deposition of monoclonal IgG evolved from polyclonal IgG: a case report with two consecutive renal biopsies. BMC Nephrol 2019; 20:275. [PMID: 31331283 PMCID: PMC6647130 DOI: 10.1186/s12882-019-1453-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2019] [Accepted: 07/03/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proliferative glomerulonephritis with monoclonal Immunoglobulin (G) deposits (PGNMID) is a rare kind of MGRS with intact monoclonal IgG deposition. Seventy percent of PGNMID patients were negative for M-spike. CASE PRESENTATION A 51-year-old Chinese woman presented with 16-month history of chronic nephritic syndrome. Her first biopsy showed a MPGN pattern, and the IF showed polyclonal IgG deposition but with IgG3λ dominance, MGRS was highly suspected. But the serum/urine IFE and bone marrow examination was negative for monoclonal gammopathy. She was treated with RAS inhibitors, and monitored carefully in the outpatient clinic. When the proteinuria was not controlled by RAS inhibitors, immunosuppressive agents were initiated. The second biopsy was done due to her acute kidney injury 9 months later, showing a MPGN pattern with acute tubulointerstitial disease, but the IF showed monoclonal IgG3λ deposition. The κ light chain, IgG1, IgG2 and IgG4 were absent. Electron microscopic examination revealed electron-dense deposits in the mesangial, subendothelial and subepithelial area which is the same as the first renal biopsy. The final diagnose of this patient was PGNMID (IgG3λ) with non-organized deposits. Repeated serum/urine IFE and free light chain still failed to identify monoclonal gammopathy. The patient was treated with steroid and cyclophosphamide, and her serum creatinine decreased. CONCLUSIONS Some of the PGNMID patients may be derived from polyclonal immune complex mediated glomerulonephritis.
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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.,Renal Pathology Center, 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
| | - Nan Hu
- 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.,Renal Pathology Center, 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. .,Renal Pathology Center, 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.,Renal Pathology Center, 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.,Renal Pathology Center, 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, People's Republic of China
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128
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Zhao H, Huang WH, Huang JY, Lu SY, Yang YH, Ma ZG. Henoch-Schönlein purpura nephritis associated with monoclonal gammopathy of renal significance: a case report. ACTA ACUST UNITED AC 2019; 52:e8222. [PMID: 31291381 PMCID: PMC6694773 DOI: 10.1590/1414-431x20198222] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 05/07/2019] [Indexed: 02/06/2023]
Abstract
Monoclonal gammopathy of renal significance (MGRS) can present with different morphologic features and lead to kidney failure. The Henoch-Schönlein purpura nephritis (HSPN) that cannot be relieved by treatment with glucocorticoid and immunosuppressive agents suggests the presence of monoclonal gammopathy in adult patients. The present study reports on a single case of HSPN associated with IgA-κMGRS. The patient who suffered from recurrent skin purpura for 6 months and nephrotic syndrome for 2 months was admitted to our hospital. Bone marrow biopsy showed monoclonal gammopathy of undetermined significance. Kidney biopsy indicated a Henoch-Schönlein purpura nephritis (HSPN, ISKDC classified as type III) with positive staining with κ-light chain in the glomeruli and renal tubular epithelial cells. Furthermore, skin biopsy showed leukocytoclastic vasculitis and negative staining for Congo red and light chain. Given both the renal and cutaneous involvement, the patient was considered to have HSPN associated with IgA-κMGRS. The patient experienced an exacerbation in his purpura-like lesions and clinical status after treatment with glucocorticoid and immunosuppressive agents. Consequently, the patient was put on a regimen that included dexamethasone (20 mg on the 1st, 4th, 8th, and 11th days of each month, iv) and bortezomib (2.4 mg on the 1st, 4th, 8th, and 11th days of each month, iv). Eight weeks after treatment, he had complete resolution of his cutaneous purpura and his biochemical parameters improved. The latent presence of MGRS in cases of HSPN should be considered in adult patients. Increased cognizance and correct treatment options could improve patient outcomes.
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Affiliation(s)
- Hui Zhao
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Wen-Hui Huang
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Jun-Yue Huang
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Shou-Yan Lu
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Ya-Hong Yang
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, Gansu, China
| | - Zhi-Gang Ma
- Department of Nephrology, Gansu Provincial Hospital, Lanzhou, Gansu, China
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129
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Rezk T, Gilbertson JA, Mangione PP, Rowczenio D, Rendell NB, Canetti D, Lachmann HJ, Wechalekar AD, Bass P, Hawkins PN, Bellotti V, Taylor GW, Gillmore JD. The complementary role of histology and proteomics for diagnosis and typing of systemic amyloidosis. J Pathol Clin Res 2019; 5:145-153. [PMID: 30740936 PMCID: PMC6648380 DOI: 10.1002/cjp2.126] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/28/2019] [Accepted: 02/04/2019] [Indexed: 12/30/2022]
Abstract
The tissue diagnosis of amyloidosis and confirmation of fibril protein type, which are crucial for clinical management, have traditionally relied on Congo red (CR) staining followed by immunohistochemistry (IHC) using fibril protein specific antibodies. However, amyloid IHC is qualitative, non-standardised, requires operator expertise, and not infrequently fails to produce definitive results. More recently, laser dissection mass spectrometry (LDMS) has been developed as an alternative method to characterise amyloid in tissue sections. We sought to compare these techniques in a real world setting. During 2017, we performed LDMS on 640 formalin-fixed biopsies containing amyloid (CR+ve) comprising all 320 cases that could not be typed by IHC (IHC-ve) and 320 randomly selected CR+ve samples that had been typed (IHC+ve). In addition, we studied 60 biopsies from patients in whom there was a strong suspicion of amyloidosis, but in whom histology was non-diagnostic (CR-ve). Comprehensive clinical assessments were conducted in 532 (76%) of cases. Among the 640 CR+ve samples, 602 (94%) contained ≥2 of 3 amyloid signature proteins (ASPs) on LDMS (ASP+ve) supporting the presence of amyloid. A total of 49 of the 60 CR-ve samples were ASP-ve; 7 of 11 that were ASP+ve were glomerular. The amyloid fibril protein was identified by LDMS in 255 of 320 (80%) of the IHC-ve samples and in a total of 545 of 640 (85%) cases overall. The LDMS and IHC techniques yielded discordant results in only 7 of 320 (2%) cases. CR histology and LDMS are corroborative for diagnosis of amyloid, but LDMS is superior to IHC for confirming amyloid type.
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Affiliation(s)
- Tamer Rezk
- National Amyloidosis Centre, University College London, London, UK.,Department of Renal Medicine, University College London, London, UK
| | | | - P Patrizia Mangione
- Wolfson Drug Discovery Unit, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK.,Department of Molecular Medicine, Institute of Biochemistry, University of Pavia, Pavia, Italy
| | - Dorota Rowczenio
- National Amyloidosis Centre, University College London, London, UK
| | - Nigel B Rendell
- Wolfson Drug Discovery Unit, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Diana Canetti
- Wolfson Drug Discovery Unit, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, University College London, London, UK
| | | | - Paul Bass
- Department of Renal Medicine, University College London, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, UK
| | - Vittorio Bellotti
- Wolfson Drug Discovery Unit, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK.,Department of Molecular Medicine, Institute of Biochemistry, University of Pavia, Pavia, Italy
| | - Graham W Taylor
- Wolfson Drug Discovery Unit, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
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130
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Abstract
AIM Analysis of etiology, clinical and morphological manifestations, approaches to therapy and prognosis of membranoproliferative glomerulonephritis (MPGN). MATERIALS AND METHODS Cases of MPGN were retrospectively identified in the period 2000-2017 with subsequent analysis of etiology, clinical data and morphology (including deposits of immunoglobulins (Ig) and C3 complement fractions). The achievement of complete and partial remissions (PR, CR), overall survival, progression (by composite endpoint: decrease in the estimated GFR (eGFR) ≥50% from the baseline or eGFR <15 ml/min/1.73 m2 or the onset of dialysis). RESULTS 214 cases of MPGN entered the study with the average age of 44±16 years. Most patients had nephrotic syndrome and significant hematuria. In 58.4% of cases, eGFR was <60 mL/min/1.73 m2, and every fifth patient had CKD 4 or 5 stages. The prevalence of MPGN among all biopsy-confirmed glomerulopathies was 9.3%. Idiopathic MPGN (iMPGN) was detected in 30.4% of cases, secondary MSGN (sMPGN) - in 69.6% (autoimmune diseases - 34.1%, infectious diseases - 16.4%, monoclonal gammopathies - 9.3%, complement-mediated damage - 9.8%). Ig+C3+MPGN was mainly associated with autoimmune diseases and infections; C3-glomerulopathy or thrombotic microangiopathy were most often causes of Ig-C3+MPGN; Ig-C3-/Ig+C3-MPGN had heterogeneous etiology. The median follow-up period was 28 [7; 37] months. The 10-year total cumulative patient and renal survival rates were 71 and 50%, respectively (without differences between sMPGN and iMPGN). The frequency of the PR/CR was 50% (iMPGN - 46.2%, sMPGN - 51.3%) depending on the etiology of the MPGN (p=0.049). The cumulative 10-year progression-free renal survival was nearly 100% in cases with PR/CR and 0% in non-responders. CONCLUSION MPGN is a severe variant of glomerular damage with a heterogeneous etiological structure and an unfavorable prognosis. Targeted clinical and morphological diagnostics of MPGN allows to identify the cause of the disease in most cases. This approach is reliable for the adequate treatment choice and improvement of outcomes in MPGN.
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Affiliation(s)
- V A Dobronravov
- Research Institute of Nephrology, I.P. Pavlov First Saint Petersburg State Medical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| | - A V Smirnov
- Research Institute of Nephrology, I.P. Pavlov First Saint Petersburg State Medical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
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131
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Kozlovskaya(Lysenko) LV, Chebotareva NV, Mrykhin NN, Rameev VV, Androsova TV, Roshchupkina SV, Maryina SA, Kogarko IN, Kogarko BS. Modern approaches to the detection of monoclonal gammopathy of undetermined significance (MGUS) in patients with kidney diseases. TERAPEVT ARKH 2019; 91:67-72. [DOI: 10.26442/00403660.2019.06.000281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Indexed: 11/22/2022]
Abstract
Monoclonal gammopathy (MG) is not only the state preceding of hematological neoplasms, but also associated with non - hematological diseases, in particular kidney damage. Aim. To assess the diagnostic value of “Freelite” methods in addition to electrophoresis (EF) and immunofixation (IF) of serum and urine proteins for detecting MG in patients with kidney diseases. Materials and methods. 87 patients with kidney damage, in which MG was established using the method of electrophoresis of serum proteins (EF), immunofixation (IF) and the method of free light chains determination - FLC “Freelite” were selected. The diagnostic value of three - component serum panel was compared with EF and IF. Results and discussion. AL-amyloidosis with kidney involvement was diagnosed in 41% patients, cryoglobulinemic glomerulonephritis (cryo GN) - in 18%, chronic glomerulonephritis (CGN) - in 35%, also there was small number of patients with light chain disease and cast - nephropathy. Determination of MG using EP was possible only in 38 (44%). Adding to the serum electrophoretic methods instead of the “Freelite” method, the urine EF and IF reduced the number of missed patients with monoclonal gammopathy from 24 (27%) to 11 (13%), including in the subgroup of patients with AL-amyloidosis but did not reach the sensitivity of the three - component serum screening panel. In 10 (11.5%) MG was represented only by intact mIg with one type of light chain, either κ or λ. Most often - in 25% of patients, intact monoclonal gammopathy was observed in HCV (+) cryo GN. A combination of intact mIgM, mIgG or mIgA with mFLC, was detected in 37 (42.5%). In almost half (46%) of the patients, only mFLC was detected - an abnormal κ/λ ratio. Conclusion: The serum screening panel EF + IF + “Freelite” spreads the low - grade monoclonal gammopathy recognition (MGUS) and should be included in the algorithm of examining patients with kidney disease.
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132
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Chow KL, Kanellis J, Dayan S, Ryan J. Recurrent membranoproliferative glomerulonephritis in a renal transplant secondary to monoclonal gammopathy of renal significance successfully treated with bortezomib. Intern Med J 2019; 49:801-802. [PMID: 31185533 DOI: 10.1111/imj.14313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 07/23/2018] [Accepted: 09/05/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Ke Li Chow
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - John Kanellis
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Sukhpal Dayan
- Department of Pathology, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Jessica Ryan
- Department of Nephrology, Monash Medical Centre, Melbourne, Victoria, Australia.,Department of Medicine, Monash University, Melbourne, Victoria, Australia
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133
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Singh L, Subbiah AK, Singh G, Bagchi S, Dinda AK, Agarwal SK. Monoclonal gammopathy of renal significance with heavy-chain deposition disease in renal allograft: challenges in the diagnosis and management. Transpl Int 2019; 32:769-770. [PMID: 31081947 DOI: 10.1111/tri.13461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lavleen Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Kumar Subbiah
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Geetika Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Soumita Bagchi
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Kumar Dinda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Kumar Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
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134
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Cheng M, Gu X, Turbat-Herrera EA, Herrera GA. Tubular Injury and Dendritic Cell Activation Are Integral Components of Light Chain-Associated Acute Tubulointerstitial Nephritis. Arch Pathol Lab Med 2019; 143:1212-1224. [PMID: 31063013 DOI: 10.5858/arpa.2018-0032-oa] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Light chain-associated acute tubulointerstitial nephritis (LC-ATIN) is a variant of light chain proximal tubulopathy (LCPT). It is characterized by interstitial inflammation with tubulitis and deposition of monoclonal light chains in the tubulointerstitium. LC-ATIN is a rather poorly recognized pattern of LCPT and not much is known about this entity. OBJECTIVE.— To determine the clinicopathologic features of patients with LC-ATIN and investigate the proximal tubular injury and mechanism of interstitial inflammation in LC-ATIN. DESIGN.— A total of 38 cases of LC-ATIN were identified from the archives of 5043 renal biopsy specimens. In all cases, routine light microscopic examination, immunofluorescence, and electron microscopic examination were performed. In selected cases, immunofluorescent staining of dendritic cells and immunohistochemical staining for 4 tubular injury markers-KIM-1, p53, bcl-2, and Ki-67-were performed. RESULTS.— A characteristic finding in LC-ATIN cases was immunofluorescence staining of monoclonal light chains along tubular basement membranes in linear fashion and inside proximal tubular cells with a granular pattern. No monoclonal light chains were present in glomerular or vascular compartments confirmed with immunofluorescence, electron microscopy, and ultrastructural gold labeling. Ten of 15 LC-ATIN cases (67%) were concurrently positive for the 4 tubular injury markers. Dendritic cells were identified within the tubulointerstitium in the renal biopsy specimens, interacting with surrounding tubules with light-chain deposits and inflammatory cells. CONCLUSIONS.— Significant proximal tubular injury occurs associated with LC-ATIN, and the monoclonal light chains accumulated in proximal tubular cells contribute to the injury. Dendritic cells are involved in the pathogenesis of interstitial inflammation in LC-ATIN.
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Affiliation(s)
- Mingyu Cheng
- From the Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento (Dr Cheng); and the Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport (Drs Gu, Turbat-Herrera, and Herrera)
| | - Xin Gu
- From the Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento (Dr Cheng); and the Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport (Drs Gu, Turbat-Herrera, and Herrera)
| | - Elba A Turbat-Herrera
- From the Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento (Dr Cheng); and the Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport (Drs Gu, Turbat-Herrera, and Herrera)
| | - Guillermo A Herrera
- From the Department of Pathology and Laboratory Medicine, University of California Davis School of Medicine, Sacramento (Dr Cheng); and the Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport (Drs Gu, Turbat-Herrera, and Herrera)
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135
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Martellosio JP, Leleu X, Roblot P, Martin M, Puyade M. Dosage des chaînes légères libres : indications et méthodes. Rev Med Interne 2019; 40:297-305. [DOI: 10.1016/j.revmed.2019.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/04/2019] [Accepted: 01/20/2019] [Indexed: 12/18/2022]
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136
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Nasr SH, Fogo AB. New developments in the diagnosis of fibrillary glomerulonephritis. Kidney Int 2019; 96:581-592. [PMID: 31227146 DOI: 10.1016/j.kint.2019.03.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/28/2019] [Accepted: 03/08/2019] [Indexed: 11/25/2022]
Abstract
Fibrillary glomerulonephritis is a glomerular disease historically defined by glomerular deposition of Congo red-negative, randomly oriented straight fibrils that lack a hollow center and stain with antisera to immunoglobulins. It was initially considered to be an idiopathic disease, but recent studies highlighted association in some cases with autoimmune disease, malignant neoplasm, or hepatitis C viral infection. Prognosis is poor with nearly half of patients progressing to end-stage renal disease within 4 years. There is currently no effective therapy, aside from kidney transplantation, which is associated with disease recurrence in a third of cases. The diagnosis has been hampered by the lack of biomarkers for the disease and the necessity of electron microscopy for diagnosis, which is not widely available. Recently, through the use of laser microdissection-assisted liquid chromatography-tandem mass spectrometry, a novel biomarker of fibrillary glomerulonephritis, DnaJ homolog subfamily B member 9, has been identified. Immunohistochemical studies confirmed the high sensitivity and specificity of DnaJ homolog subfamily B member 9 for this disease; dual immunofluorescence showed its colocalization with IgG in glomeruli; and immunoelectron microscopy revealed its localization to individual fibrils of fibrillary glomerulonephritis. The identification of this tissue biomarker has already entered clinical practice and undoubtingly will improve the diagnosis of this rare disease, particularly in developing countries where electron microscopy is less available. Future research is needed to determine whether DnaJ homolog subfamily B member 9 is an autoantigen or just an associated protein in fibrillary glomerulonephritis, whether it can serve as a noninvasive biomarker, and whether therapies that target this protein are effective in improving prognosis.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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137
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Horino T, Ichii O, Terada Y. IgA-Proliferative Glomerulonephritis with Monoclonal Immunoglobulin Deposits. Am J Med 2019; 132:e542-e545. [PMID: 30611830 DOI: 10.1016/j.amjmed.2018.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 12/14/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Taro Horino
- Department of Endocrinology, Metabolism, and Nephrology, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan.
| | - Osamu Ichii
- Laboratory of Anatomy, Department of Basic Veterinary Sciences, Faculty of Veterinary Medicine, Hokkaido University, Sapporo, Hokkaido, Japan
| | - Yoshio Terada
- Department of Endocrinology, Metabolism, and Nephrology, Kochi Medical School, Kochi University, Nankoku, Kochi, Japan
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Javaugue V, Debiais-Delpech C, Nouvier M, Gand E, Chauvet S, Ecotiere L, Desport E, Goujon JM, Delwail V, Guidez S, Tomowiak C, Leleu X, Jaccard A, Rioux-Leclerc N, Vigneau C, Fermand JP, Touchard G, Thierry A, Bridoux F. Clinicopathological spectrum of renal parenchymal involvement in B-cell lymphoproliferative disorders. Kidney Int 2019; 96:94-103. [PMID: 30987838 DOI: 10.1016/j.kint.2019.01.027] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/20/2018] [Accepted: 01/04/2019] [Indexed: 01/25/2023]
Abstract
The clinicopathological characteristics of kidney infiltration in B-cell lymphoproliferative disorders remain poorly described. We retrospectively studied 52 adults with biopsy-proven malignant B-cell kidney infiltration, including Waldenström's macroglobulinemia (n=21), chronic lymphocytic leukemia (n=11), diffuse large B-cell lymphoma (DLBCL) (n=8), other lymphoma (n=11), and multiple myeloma (n=1). Kidney disease varied according to the underlying lymphoproliferative disorder. In DLBCL, malignant kidney infiltration was prominent, resulting in acute kidney injury (AKI, 75%) and kidney enlargement (88%). In the other types, associated immunoglobulin-related nephropathy (most commonly AL amyloidosis) was more common (45%), and chronic kidney disease with proteinuria was the primary presentation. All patients received chemotherapy. Over a median follow-up of 31 months, 20 patients died and 21 reached end-stage kidney disease. Renal response, achieved in 25 patients (48%), was associated with higher overall survival (97 vs. 37 months in non-renal responders). In univariate analysis, percentage of sclerotic glomeruli, kidney enlargement, and complete hematological response at 6 months were predictive of renal response. In multivariate analysis, concomitant immunoglobulin-related nephropathy was the sole independent predictor of poor renal outcome. In conclusion, clinical presentation of renal lymphomatous infiltration depends on the nature of the underlying lymphoproliferative disorder. In DLBCL, massive renal infiltration manifests with enlarged kidneys and AKI, and the diagnosis primarily relies on lymph node biopsy. In other B-cell lymphoproliferative disorders, the clinicopathological spectrum is more heterogeneous, with a high frequency of immunoglobulin-related nephropathy that may affect renal outcome; thus kidney biopsy is required for early diagnosis and prognostic assessment.
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Affiliation(s)
- Vincent Javaugue
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France; INSERM CIC 1402, Centre Hospitalier Universitaire, Poitiers, France.
| | - Céline Debiais-Delpech
- Department of Pathology and Ultrastructural Pathology, Centre Hospitalier Universitaire, Poitiers, France
| | - Mathilde Nouvier
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Elise Gand
- INSERM CIC 1402, Centre Hospitalier Universitaire, Poitiers, France
| | - Sophie Chauvet
- INSERM UMR 1138, Centre de Recherche des Cordeliers, Complement and Diseases Team, Paris, France; Assistance Publique Hôpitaux de Paris, Department of Nephrology, Hôpital Européen Georges Pompidou, Paris, France
| | - Laure Ecotiere
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Estelle Desport
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Jean-Michel Goujon
- Department of Pathology and Ultrastructural Pathology, Centre Hospitalier Universitaire, Poitiers, France
| | - Vincent Delwail
- Department of Hematology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Stéphanie Guidez
- Department of Hematology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Cécile Tomowiak
- Department of Hematology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Xavier Leleu
- Department of Hematology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Arnaud Jaccard
- Department of Hematology, Centre Hospitalier Universitaire, Université de Limoges, Limoges, France
| | | | - Cécile Vigneau
- Department of Nephrology, Centre Hospitalier Universitaire, Rennes, France; CNRS UMR 6290, Université Rennes 1, France
| | | | - Guy Touchard
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; Department of Pathology and Ultrastructural Pathology, Centre Hospitalier Universitaire, Poitiers, France
| | - Antoine Thierry
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; INSERM UMR 1082, Centre Hospitalier Universitaire, Poitiers, France
| | - Frank Bridoux
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France; INSERM CIC 1402, Centre Hospitalier Universitaire, Poitiers, France
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139
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Cao Q, Qi H, Yao L, Liu Q. Monoclonal gammopathy of renal significance: clinical manifestation, pathogenic characteristic and treatment. Panminerva Med 2019; 62:38-53. [PMID: 30848114 DOI: 10.23736/s0031-0808.19.03609-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a group of renal disorders caused by a monoclonal immunoglobulin (MIg) secreted by a dangerous plasmatic/B-cell clone hyperplasia through MIg deposition or dysfunction of complement pathway, with increasing risk of progress to end stage renal disease (ESRD) and the underlying hematologic malignancy. The combination of renal biopsy, complete laboratory examination and bone marrow biopsy is an indispensable diagnostic tool for MGRS to identify accurately and unequivocally the pathogenic monoclonal MIg and provide guidance to treatment. Treatment of MGRS is composed of conventional therapy, chemotherapy, and stem cell transplantation to target the underlying clone and eliminate the noxious MIg on the basis of clinical data of some retrospective studies and a small amount of prospective trial. In addition, it is worthwhile point out assessment of therapeutic effect is significantly relevant for renal and overall prognosis. Thus, by comprehensively analyzing the clinical manifestations and pathogenic characteristic of MGRS, early recognition and prompt treatment can improve the prognosis and prevent post-translation recurrence with multidisciplinary cooperation.
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Affiliation(s)
- Qin Cao
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, China
| | - Huimeng Qi
- Department of General Practice, The First Hospital of China Medical University, Shenyang, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Qiang Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China -
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140
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Sidana S, Tandon N, Gertz MA, Dispenzieri A, Ramirez‐Alvarado M, Murray DL, Kourelis TV, Buadi FK, Kapoor P, Gonsalves W, Warsame R, Lacy MQ, Kyle RA, Rajkumar SV, Kumar SK, Leung N. Clinical features, laboratory characteristics and outcomes of patients with renal
versus
cardiac light chain amyloidosis. Br J Haematol 2019; 185:701-707. [DOI: 10.1111/bjh.15832] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 01/02/2019] [Indexed: 12/25/2022]
Affiliation(s)
- Surbhi Sidana
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Nidhi Tandon
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Morie A. Gertz
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Angela Dispenzieri
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Marina Ramirez‐Alvarado
- Department of Biochemistry and Molecular Biology Mayo Clinic Rochester MNUSA
- Department of Immunology Mayo Clinic Rochester MNUSA
| | - David L. Murray
- Department of Laboratory and Pathology Medicine Mayo Clinic Rochester MNUSA
| | | | - Francis K. Buadi
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Prashant Kapoor
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Wilson Gonsalves
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Rahma Warsame
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Martha Q. Lacy
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Robert A. Kyle
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - S. Vincent Rajkumar
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Shaji K. Kumar
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
| | - Nelson Leung
- Division of Hematology Department of Internal Medicine Mayo Clinic Rochester MNUSA
- Division of Nephrology Department of Internal Medicine Mayo Clinic Rochester MN USA
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Navaratnarajah A, Sambasivan K, Cook TH, Pusey C, Roufosse C, Willicombe M. Predicting long-term renal and patient survival by clinicopathological features in elderly patients undergoing a renal biopsy in a UK cohort. Clin Kidney J 2019; 12:512-520. [PMID: 31384442 PMCID: PMC6672059 DOI: 10.1093/ckj/sfz006] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Indexed: 12/13/2022] Open
Abstract
Background Several publications have demonstrated the use of renal biopsy in elderly patients in establishing a diagnosis and enabling directed therapy. However, evidence on the long-term outcomes following biopsies is lacking. The aim of this study is to describe the renal and patient outcomes in elderly patients according to indication for biopsy, clinical parameters and the histological diagnosis. Methods We performed a retrospective cohort study of 463 patients >70 years old who underwent a renal biopsy at our centre between 2006 and 2015. Results The median age of the patients was 74.8 (range 70.0-89.6) years. The most frequent primary diagnoses were pauci-immune crescentic glomerulonephritis (GN; 12%), acute interstitial nephritis (10.8%) and membranous GN (7.1%). Death-censored renal survival at 1 and 5 years following the index biopsy was 85.2 and 75.9%, respectively, and patient survival at 1 and 5 years was 92.2 and 71.6%, respectively. Patients who progressed to end-stage renal disease (ESRD) were at higher risk of dying compared with patients who did not require dialysis [hazard ratio 2.41 (95% confidence interval 1.58-3.68; P < 0.001]. On multivariate analysis, factors associated with the risk of progression to ESRD were creatinine (P < 0.001), heavy proteinuria (P = 0.002) and a non-chronic kidney disease (CKD) biopsy indication (P = 0.006). A histological diagnosis of primary GN (P = 0.001) or tubulointerstitial nephritis (P = 0.008) was associated with a favourable renal outcome, while patients with vasculitis and paraprotein-related renal disease (PPRD) had the highest risk of requiring dialysis (P = 0.0002 and P = 0.003, respectively). PPRD was also an independent risk factor for death. Conclusions This study demonstrates that renal biopsies in the elderly not only enable directed therapy, but also provide prognostic information on renal and patient survival.
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Affiliation(s)
- Arunraj Navaratnarajah
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Khrishanthne Sambasivan
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Terry H Cook
- Department of Medicine, Division of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College Hammersmith Campus, London, UK.,Department of Cellular Pathology, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Pusey
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK.,Department of Medicine, Division of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College Hammersmith Campus, London, UK
| | - Candice Roufosse
- Department of Medicine, Division of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College Hammersmith Campus, London, UK.,Department of Cellular Pathology, Imperial College Healthcare NHS Trust, London, UK
| | - Michelle Willicombe
- Imperial College Renal and Transplant Centre, Imperial College Healthcare NHS Trust, London, UK.,Department of Medicine, Division of Immunology and Inflammation, Centre for Inflammatory Disease, Imperial College Hammersmith Campus, London, UK
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142
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Chronological change of renal pathological findings in the proliferative glomerulonephritis with monoclonal IgG deposits considered to have recurred early after kidney transplantation. CEN Case Rep 2019; 8:151-158. [PMID: 30805792 DOI: 10.1007/s13730-019-00384-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 01/23/2019] [Indexed: 10/27/2022] Open
Abstract
Proliferative glomerulonephritis with monoclonal immunoglobulin G (IgG) deposits (PGNMID) is a rare disease that recently became recognized. Its pathological findings are characterized by the deposition of a single heavy chain subclass and a single light chain isotype. PGNMID has been proven to recur in renal allografts. Herein, the authors describe the case of a 46-year-old man who presented with nephrotic syndrome and progressive kidney injury following kidney transplantation. One month after transplantation, his clinical condition stabilized; however, the protocol biopsy showed depositions of IgG and complement on the glomeruli by immunofluorescence staining. Electron microscopy (EM) revealed granular electron-dense deposits (EDD) in the mesangium. Thereafter, renal biopsy was repeated because his proteinuria level increased. Proliferative glomerulonephritis, mainly in the mesangium, with IgG and complement deposits and mesangial and subendothelial EDD were observed; however, the pathological diagnosis was difficult. Renal dysfunction then became apparent, and renal biopsy was performed again 4 years and 10 months after kidney transplantation. Glomerular deposits on a single IgG subclass and a single light chain isotype (IgG3 kappa) with membranoproliferative features were observed. Abundant subendothelial EDD were detected on EM. Finally, the patient was diagnosed with PGNMID. Since it seemed that PGNMID had already developed at 1 month after transplantation, we considered recurrent PGNMID case in the allograft. The treatment for PGNMID has not been established yet, and even in this case, the graft function was eventually lost. For improving renal prognosis, early diagnosis and further investigation on the treatment are necessary.
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143
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Von Visger J, Cassol C, Nori U, Franco-Ahumada G, Nadasdy T, Satoskar AA. Complete biopsy-proven resolution of deposits in recurrent proliferative glomerulonephritis with monoclonal IgG deposits (PGNMIGD) following rituximab treatment in renal allograft. BMC Nephrol 2019; 20:53. [PMID: 30764798 PMCID: PMC6376770 DOI: 10.1186/s12882-019-1239-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Accepted: 01/30/2019] [Indexed: 12/18/2022] Open
Abstract
Background Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMIGD) is a disease entity classified under the group of “Monoclonal gammopathy-related kidney diseases”, and can recur after transplant. Clinical remission of proteinuria in patients with PGNMIGD has been previously shown following anti-B cell and/or anti-plasma cell therapies. Our case is the first to show complete histologic resolution of the glomerular monoclonal IgG kappa deposits in a case of recurrent PGNMIGD in renal allograft after rituximab and steroid treatment. This is a novel finding and it shows that the deposits are amenable to therapy. This case also highlights the importance of IgG subclass staining in the recognition of the monoclonal nature of the deposits. It is particularly important in PGNMIGD because only 20 to 30% of patients with this disease are reported to have detectable monoclonal gammopathy, and the deposits do not have any organized substructure on electron microscopic examination. Morphologically, they resemble polyclonal immune-type deposits seen in other immune complex glomerulonephritides such as lupus nephritis, infection-associated glomerulonephritis, and membranoproliferative glomerulonephritis (MPGN type I). Case presentation The patient is a 44 year old Caucasian male who received a living unrelated donor kidney transplant for end-stage renal disease diagnosed 7 years before transplant. The reported native kidney biopsy diagnosis was membranoproliferative glomerulonephritis (MPGN) with IgG, C3 and kappa restricted deposits. Fourteen months post-transplant, he presented with abrupt worsening of graft function, proteinuria and serum IgG kappa monoclonal spike. Allograft biopsy was consistent with recurrent PGNMIGD, considering the native kidney diagnosis and interval post-transplant. He underwent plasmapheresis, IV pooled immune globulin, steroid pulse and taper, and anti-CD-20 Rituximab therapy. Patient had gradual decline in proteinuria and complete resolution of the immune deposits on repeat biopsy 3 months later. Unfortunately he subsequently developed chronic antibody-mediated rejection and transplant glomerulopathy and graft failure 34 months post-transplant. Conclusions In a transplant setting, repeat allograft biopsies are frequently performed for graft dysfunction. This provides a good opportunity to study the evolution of the immune deposits following treatment. Our case shows complete histologic resolution of the deposits in allograft PGNMIGD.
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Affiliation(s)
- Jon Von Visger
- Department of Internal Medicine, Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, USA
| | - Clarissa Cassol
- Department of Pathology, Division of Renal and Transplant Pathology, Ohio State University Wexner Medical Center, M018 Starling-Loving Hall, 320 W 10th Ave, Columbus, OH, 43210, USA
| | - Uday Nori
- Department of Internal Medicine, Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, USA
| | - Gerardo Franco-Ahumada
- Department of Internal Medicine, Division of Nephrology, Ohio State University Wexner Medical Center, Columbus, USA
| | - Tibor Nadasdy
- Department of Pathology, Division of Renal and Transplant Pathology, Ohio State University Wexner Medical Center, M018 Starling-Loving Hall, 320 W 10th Ave, Columbus, OH, 43210, USA
| | - Anjali A Satoskar
- Department of Pathology, Division of Renal and Transplant Pathology, Ohio State University Wexner Medical Center, M018 Starling-Loving Hall, 320 W 10th Ave, Columbus, OH, 43210, USA.
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Randall-type monoclonal immunoglobulin deposition disease: novel insights from a nationwide cohort study. Blood 2019; 133:576-587. [DOI: 10.1182/blood-2018-09-872028] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/15/2018] [Indexed: 12/27/2022] Open
Abstract
Abstract
Monoclonal immunoglobulin deposition disease (MIDD) is a rare complication of B-cell clonal disorders, defined by Congo red negative–deposits of monoclonal light chain (LCDD), heavy chain (HCDD), or both (LHCDD). MIDD is a systemic disorder with prominent renal involvement, but little attention has been paid to the description of extrarenal manifestations. Moreover, mechanisms of pathogenic immunoglobulin deposition and factors associated with renal and patient survival are ill defined. We retrospectively studied a nationwide cohort of 255 patients, with biopsy-proven LCDD (n = 212) (including pure LCDD [n = 154], LCDD with cast nephropathy (CN) [n = 58]), HCDD (n = 23), or LHCDD (n = 20). Hematological diagnosis was monoclonal gammopathy of renal significance in 64% and symptomatic myeloma in 34%. Renal presentation was acute kidney injury in patients with LCCD and CN, and chronic glomerular disease in the other types, 35% of whom had symptomatic extrarenal (mostly hepatic and cardiac) involvement. Sequencing of 18 pathogenic LC showed high isoelectric point values of variable domain complementarity determining regions, possibly accounting for tissue deposition. Among 169 patients who received chemotherapy (bortezomib-based in 58%), 67% achieved serum free light chain (FLC) response, including very good partial response (VGPR) or above in 52%. Renal response occurred in 62 patients (36%), all of whom had achieved hematological response. FLC response ≥ VGPR and absence of severe interstitial fibrosis were independent predictors of renal response. This study highlights an unexpected frequency of extrarenal manifestations in MIDD. Rapid diagnosis and achievement of deep FLC response are key factors of prognosis.
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Ito K, Hara S, Yamada K, Zoshima T, Mizushima I, Fujii H, Miyazaki R, Kawai Y, Yachie A, Nagata M, Izui S, Yamagishi M, Kawano M. A case report of crystalline light chain inclusion-associated kidney disease affecting podocytes but without Fanconi syndrome: A clonal analysis of pathological monoclonal light chain. Medicine (Baltimore) 2019; 98:e13915. [PMID: 30702553 PMCID: PMC6380839 DOI: 10.1097/md.0000000000013915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Crystalline light chain inclusion-associated kidney disease affects mainly tubular epithelial cells and is often clinically manifested as Fanconi syndrome. However, only very few case reports about the crystalline deposits within the podocytes are available, and the nature of the pathogenic monoclonal light chain implicated in these cases is still unknown. We report a case of crystalline inclusion-associated kidney disease manifested as crystalline podocytopathy in which we identified the complete structure of the pathogenic monoclonal light chain as belonging to the germ-line gene of Vκ1-39. PATIENT CONCERNS We describe a 65-year-old woman with crystalline light chain inclusion-associated kidney disease showing mild proteinuria and renal insufficiency with monoclonal gammopathy of undetermined significance without Fanconi syndrome. She had crystalline inclusions mainly within podocytes, tubular epithelial cells and histiocytes in the kidney. Light microscopy showed vacuolation of podocytes and tubular epithelial cells, while eosin negative pale needle-like crystals were present within these cells. Electron microscopy showed accumulation of club-like crystals with high electron density in podocytes, proximal tubular epithelial cells and interstitial histiocytes. Clonal analysis revealed that a pathogenic monoclonal light chain was derived from germline gene, Vκ1-39. DIAGNOSES The diagnosis of crystalline light chain inclusion-associated kidney disease was made. INTERVENTIONS AND OUTCOMES Bortezomib and dexamethasone were started and her renal function improved to eGFR 36 mL/min/1.73 m after 9 courses of therapy. LESSONS Patients with light chain crystalline podocytopathy may have a similar pathogenic monoclonal light chain derived from the same germline gene, Vκ1-39, to that of patients with light chain proximal tubulopathy.
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Affiliation(s)
- Kiyoaki Ito
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Satoshi Hara
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Kazunori Yamada
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Takeshi Zoshima
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Ichiro Mizushima
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Hiroshi Fujii
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | | | - Yasukazu Kawai
- Department of Hematology and Oncology, Fukui Prefectural Hospital, Fukui
| | - Akihiro Yachie
- Department of Pediatrics, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Michio Nagata
- Department of Kidney and Vascular Pathology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shozo Izui
- Department of Pathology and Immunology, University Medical Center, University of Geneva, Switzerland
| | - Masakazu Yamagishi
- Division of Cardiology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
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146
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Kanzaki G, Okabayashi Y, Nagahama K, Ohashi R, Tsuboi N, Yokoo T, Shimizu A. Monoclonal Immunoglobulin Deposition Disease and Related Diseases. J NIPPON MED SCH 2019; 86:2-9. [DOI: 10.1272/jnms.jnms.2019_86-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Go Kanzaki
- Department of Analytic Human Pathology, Nippon Medical School
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine
| | - Yusuke Okabayashi
- Department of Analytic Human Pathology, Nippon Medical School
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine
| | | | - Ryuji Ohashi
- Department of Diagnostic Pathology, Nippon Medical School Hospital
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School
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147
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α1-Heavy Chain Deposition Disease With Negative Immunofluorescence Staining on Renal Biopsy. Kidney Int Rep 2019; 4:178-183. [PMID: 30596184 PMCID: PMC6308384 DOI: 10.1016/j.ekir.2018.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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148
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Khrabrova MS, Dobronravov VA, Smirnov AV. KIDNEY DISEASE ASSOCIATED WITH MONOCLONAL GAMMOPATHIES: SINGLE-CENTER STUDY. ACTA ACUST UNITED AC 2018. [DOI: 10.24884/1561-6274-2018-22-6-38-46] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
INTRODUCTION:Renal injury associated with monoclonal gammopathies (MG) is an area of interest of practical onconephrology. Prevalence, spectrum and renal outcome as far as approaches to treatment in this pathological entity, particularly in Russian population, still remain unclear and need refinement. AIM: Analysis of the prevalence, spectrum, treatment approaches and renal outcome in kidney injury associated with monoclonal gammopathies (MG).PATIENTS AND METHODS:Patients with MG and renal injury proven by kidney biopsies from 01.01.2011 till 01.05.2018 were enrolled into this one-center prospective study (n=119). Cases of MG of undetermined significance and non-amyloid kidney lesions were estimated as MG of renal significance (MGRS). Treatment approaches, haematological and renal responses were analysed. Worsening of kidney function was estimated as eGFR decrease >25 % from initial value or initiation of renal replacement treatment (RRT), improving – as eGFR increase >25 % from the initial value or the discontinuation of RRT. Other cases were determined as stable kidney function. Kidney outcome was determined in RRT initiation or eGFR<15 ml/min/1,73m2 at the end of follow-up. Long-term kidney outcome was estimated by Kaplan-Meier survival analysis. The median follow-up period was 12 (2; 27) months.RESULTS.Prevalence of kidney injury associated with MG among all performed kidney biopsies was 7,5 %, MGRS – 0,94 %. Multiple myeloma (MM), AL-amyloidosis and lymphoproliferative disorder (LPD) were diagnosed in 39, 55 and 10 patients, respectively. Prevalence of kidney injury types was the following: Al-amyloidosis (53 %); cast nephropathy (12 %); light chain deposition disease (12 %); C3-glomerulopathy (3 %); proliferative glomerulonephritis (GN) with monoclonal immunoglobulin deposits (3 %); cryoglobulinemic GN (2 %); thrombotic microangiopathy (2 %); podocytopathy (2 %); acute tubular necrosis – 2 %; immunotactoid GN (1 %); fibrillary GN (1 %); proximal tubulopathy (1 %), combination of different types (6 %). Patients mostly were treated with bortezomib and dexamethasone. Autologous stem cell transplantation was performed in 13 patients. Haematological response was achieved in 48,8 %, 45,4 % and 46,7 % of patients with MM, AL-amyloidosis and MGRS, respectively. Worsening of kidney function was registered in 11,1 % of MM and in 37,2 % of AL-amyloidosis; improving or stable kidney function was in 88,9 % and 62,7 % MM and AL-amyloidosis patients, respectively. In MGRS improving (20 %) and stable kidney function (80 %) were detected. Four-years cumulative renal survival in MM, AL-amyloidosis, MGRS and LPD groups was 63 %, 54 %, 80 % and 39 %, respectively, and does not differ between 4 groups.CONCLUSION:MG-associated kidney disease represented by diverse clinical and morphological patterns is standard problem in routine clinical practice. It is associated with inferior renal outcome and requires a practical implementation of highly-specialized interdisciplinary approach to diagnostics and treatment.
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Affiliation(s)
- M. S. Khrabrova
- Department of Propedeutics of Internal Diseases, First Pavlov Saint-Petersburg State Medical University
| | - V. A. Dobronravov
- Research Institute of Nephrology, First Pavlov Saint-Petersburg State Medical University
| | - A. V. Smirnov
- Research Institute of Nephrology, First Pavlov Saint-Petersburg State Medical University
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149
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Küchlin S, Duffner J, Scheubeck S, Schoeller K, Maruschke L, Seidl M, Engelhardt M, Walz G, Prager EP, Waldschmidt JM. Kidney embolization induces prompt organ response in a 86‐year‐old patient with MGRS‐related AL‐amyloidosis. Hemodial Int 2018; 23:E59-E64. [DOI: 10.1111/hdi.12707] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Sebastian Küchlin
- Department of Medicine IVUniversity Medical Center, Faculty of Medicine, University of Freiburg Freiburg Germany
| | - Johannes Duffner
- Department of Medicine IVUniversity Medical Center, Faculty of Medicine, University of Freiburg Freiburg Germany
| | - Sophia Scheubeck
- Department of Hematology, Oncology and Stem Cell TransplantationFaculty of Medicine, University of Freiburg Freiburg Germany
| | - Katja Schoeller
- Department of Hematology, Oncology and Stem Cell TransplantationFaculty of Medicine, University of Freiburg Freiburg Germany
| | - Lars Maruschke
- Department of RadiologyUniversity Medical Center Freiburg Freiburg Germany
| | - Maximilian Seidl
- Institute for Surgical PathologyUniversity Medical Center Freiburg, Faculty of Medicine, University of Freiburg Freiburg Germany
| | - Monika Engelhardt
- Department of Hematology, Oncology and Stem Cell TransplantationFaculty of Medicine, University of Freiburg Freiburg Germany
| | - Gerd Walz
- Department of Medicine IVUniversity Medical Center, Faculty of Medicine, University of Freiburg Freiburg Germany
| | - Eric Peter Prager
- Department of Medicine IVUniversity Medical Center, Faculty of Medicine, University of Freiburg Freiburg Germany
| | - Johannes Moritz Waldschmidt
- Department of Hematology, Oncology and Stem Cell TransplantationFaculty of Medicine, University of Freiburg Freiburg Germany
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150
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González-Calle V, Mateos MV. Monoclonal gammopathies of unknown significance and smoldering myeloma: Assessment and management of the elderly patients. Eur J Intern Med 2018; 58:57-63. [PMID: 29907380 DOI: 10.1016/j.ejim.2018.05.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 05/09/2018] [Accepted: 05/23/2018] [Indexed: 11/16/2022]
Abstract
Monoclonal gammopathy of unknown significance (MGUS) is the most frequent plasma cell disorder that commonly affects elderly patients. Although it is an asymptomatic condition, as well as smoldering myeloma (SMM), the risk of progression to multiple myeloma requiring therapy or other B-cell disorders varies greatly for individual patients, remaining low for MGUS (1% per year), while higher and not uniform for SMM patients (10% per year). This scenario implies some special considerations regarding assessment and follow-up, especially in the elderly. In this review, we provide the updated diagnostic criteria of monoclonal gammopathies proposed by the International Myeloma Working Group (IMGW); the current recommendations for the assessment of asymptomatic plasma cell disorders, with some concerns about the need of geriatric evaluation in the elderly population, the importance of distinguishing myeloma-related symptomatology from signs or symptoms caused by multiple chronic conditions typically found in the elderly. Finally, the identification of predictor markers of progression has enabled a proposal of risk-adapted follow-up strategies in MGUS and SMM that should be implemented in clinical practice. Although the standard of care is observation for MGUS and SMM patients as well, a recent randomized trial targeting high-risk SMM showed the clinical benefit of early intervention. The change of the treatment paradigm is also very promising and feasible for elderly patients, as long as a comprehensive geriatric assessment is conducted to optimize early treatment and reach maximum benefit with minimum toxicity, in other words, to ensure a better quality of life for these patients.
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Affiliation(s)
- Verónica González-Calle
- Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.
| | - María Victoria Mateos
- Complejo Asistencial Universitario de Salamanca, Instituto de Investigación Biomédica de Salamanca (IBSAL), Salamanca, Spain.
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