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Dumas De La Roque C, Brocheriou I, Mirouse A, Cacoub P, Le Joncour A. [Fibrillary glomerulonephritis]. Rev Med Interne 2024:S0248-8663(24)00567-8. [PMID: 38755072 DOI: 10.1016/j.revmed.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/15/2024] [Accepted: 05/02/2024] [Indexed: 05/18/2024]
Abstract
Fibrillary glomerulonephritis (FGN) is a glomerular disease described since 1977, with a prevalence in renal biopsies of less than 1%. It presents as renal failure, proteinuria, haematuria and hypertension in middle-aged adults. It is defined histologically, using light microscopy, which reveals organised deposits of fibrils measuring around 20nm, which are negative for Congo red staining. Electron microscopy, the first gold standard for diagnosis, has now been superseded by immunohistochemistry using the anti-DNAJB9 antibody. The discovery of this molecule has revolutionised the diagnosis of GNF, thanks to its excellent sensitivity and specificity (98% and 99% respectively). The association of GNF with hepatitis C virus, autoimmune diseases, neoplasia or haemopathy is debated. Renal prognosis is guarded, with 50% of patients progressing to end-stage renal failure within 2 to 4years of diagnosis. In the absence of randomised controlled trials, the recommended treatment is based on nephroprotective measures, corticosteroid therapy and possibly a second-line immunosuppressant such as rituximab. After renal transplantation, recovery or recurrence is possible. The pathophysiology of the disease is still poorly understood, and further studies are needed.
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Affiliation(s)
- C Dumas De La Roque
- Département de médecine interne et immunologie clinique, hôpital de la Pitié-Salpêtrière, 75013 Paris, France; Centre de référence maladies auto-immunes systémiques rares, Paris, France; Sorbonne université, Paris, France
| | - I Brocheriou
- Service d'anatomie pathologique, hôpital de la Pitié-Salpêtrière, 75013 Paris, France; Sorbonne université, Paris, France
| | - A Mirouse
- Département de médecine interne et immunologie clinique, hôpital de la Pitié-Salpêtrière, 75013 Paris, France; Centre de référence maladies auto-immunes systémiques rares, Paris, France; Sorbonne université, Paris, France
| | - P Cacoub
- Département de médecine interne et immunologie clinique, hôpital de la Pitié-Salpêtrière, 75013 Paris, France; Centre de référence maladies auto-immunes systémiques rares, Paris, France; Sorbonne université, Paris, France
| | - A Le Joncour
- Département de médecine interne et immunologie clinique, hôpital de la Pitié-Salpêtrière, 75013 Paris, France; Centre de référence maladies auto-immunes systémiques rares, Paris, France; Sorbonne université, Paris, France.
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Jagadish A, Vedantam V, Vedantam N, Magacha HM. Fibrillary Glomerulonephritis in a Patient With Vulvar Squamous Cell Carcinoma. Cureus 2023; 15:e35068. [PMID: 36942185 PMCID: PMC10024594 DOI: 10.7759/cureus.35068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2023] [Indexed: 02/18/2023] Open
Abstract
Fibrillary glomerulonephritis is a rare condition characterized by glomerular accumulation of non-branching fibrils, leading to hematuria, proteinuria, and hypertension. It is often associated with malignancy but has no known cause. A 66-year-old Caucasian female with a history of vulvar squamous cell carcinoma presented with one month of painless hematuria in the setting of new-onset progressive renal dysfunction and nephrotic range proteinuria. Comprehensive evaluation, including renal biopsy with staining for DnaJ heat shock protein family member B9 (DNAJB9), provided a definitive diagnosis of fibrillary glomerulonephritis. The patient initially received rituximab and prednisone therapy. Unfortunately, her renal function continued to decline over the next month, requiring re-hospitalization with initiation of hemodialysis. To our knowledge, this is the first case describing an association between vulvar squamous cell carcinoma and fibrillary glomerulonephritis.
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Affiliation(s)
- Ashwin Jagadish
- Internal Medicine, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Venkata Vedantam
- Internal Medicine, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Neethu Vedantam
- Infectious Diseases, East Tennessee State University Quillen College of Medicine, Johnson City, USA
| | - Hezborn M Magacha
- General Practice, East Tennessee State University College of Public Health, Johnson City, USA
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Jeyabalan A, Trivedi M. Paraneoplastic Glomerular Diseases. Adv Chronic Kidney Dis 2022; 29:116-126.e1. [PMID: 35817519 DOI: 10.1053/j.ackd.2022.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 02/20/2022] [Accepted: 02/25/2022] [Indexed: 11/11/2022]
Abstract
Paraneoplastic glomerular diseases (GNs) are rare manifestations in patients with underlying hematologic and solid organ malignancies and can occur before or after the detection of cancer. In the absence of established algorithms for investigation and reliable tests, they remain difficult to diagnose. Given the heterogeneity and infrequency of cases, the pathogenesis of most paraneoplastic GNs is poorly understood. Most of our recent understanding of paraneoplastic GNs has emerged from the discovery of target antigens in membranous nephropathy such as thrombospondin type-1 domain-containing protein 7A and neural epidermal growth factor-like 1 protein that appear to be promising in differentiating a primary vs paraneoplastic cause of membranous nephropathy. Treatment of paraneoplastic GNs is usually directed at the underlying malignancy. This review will focus on the epidemiology, pathogenesis, and diagnosis of paraneoplastic glomerular processes.
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Affiliation(s)
- Anushya Jeyabalan
- Vasculitis and Glomerulonephritis Center, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Mayuri Trivedi
- Department of Nephrology, Lokmanya Tilak Municipal General Hospital, Mumbai, India.
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Andeen NK, Avasare RS. DNA J homolog subfamily B member 9 and other advances in fibrillary glomerulonephritis. Curr Opin Nephrol Hypertens 2021; 30:294-302. [PMID: 33767057 DOI: 10.1097/mnh.0000000000000706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Fibrillary glomerulonephritis (FGN) involves ∼1% of native kidney biopsies and is characterized by glomerular deposition of fibrils larger than amyloid (12-24 nm diameter) composed of polyclonal immunoglobulin G (IgG). The recent discovery of DNA J homolog subfamily B member 9 (DNAJB9) in FGN glomerular deposits has contributed a specific and sensitive biomarker, informing morphologic classification and pathogenesis. This review will consider contemporary FGN incidence and genetics, pathogenesis, (lack of) paraprotein association, variants, treatment, and transplantation. RECENT FINDINGS DNAJB9 tissue assays have enabled the identification of morphologic variants and improved classification of fibrillary-like glomerular diseases. Together with paraffin immunofluorescence and IgG subclass studies, these have established that FGN is only rarely monoclonal and these patients usually do not have an monoclonal gammopathy. The discovery of DNAJB9 opens new avenues of investigation into FGN pathogenesis, especially those of the unfolded protein response. Treatment for FGN remains empiric, with some encouraging data on rituximab-based therapy. Transplantation is a good option for patients progressing to end-stage kidney disease. SUMMARY Advances building on the discovery of DNAJB9 in FGN should lead to long-term evolution in targeted treatment and outcome of this glomerular disease.
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Affiliation(s)
| | - Rupali S Avasare
- Department of Medicine, Division of Nephrology and Hypertension, Portland, Oregon, USA
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Rahman SU, Sana MK, Tahir Z, Ali A, Shah PA. Paraneoplastic syndromes in cholangiocarcinoma. World J Hepatol 2020; 12:897-907. [PMID: 33312417 PMCID: PMC7701960 DOI: 10.4254/wjh.v12.i11.897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/13/2020] [Accepted: 09/08/2020] [Indexed: 02/06/2023] Open
Abstract
Paraneoplastic syndromes are the symptoms or signs which result from damage to tissues that are distant from the site of malignancy, due to complex interactions between the body’s immune system and malignant neoplasm. Cholangiocarcinoma (CCA) is an aggressive epithelial malignancy of hepatobiliary tree and it is found to be associated with various paraneoplastic syndromes. These syndromes can present as dermatological, neurological, renal, hematological, or multi-systemic manifestations. Clinical suspicion and timely recognition of these syndromes can lead to early diagnosis of covert malignancies like CCA. The management plan remains the removal of the underlying cause which in this case is CCA.
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Affiliation(s)
- Saad Ur Rahman
- Department of Medicine, King Edward Medical University, Lahore 54000, Punjab, Pakistan
| | - Muhammad Khawar Sana
- Department of Medicine, King Edward Medical University, Lahore 54000, Punjab, Pakistan
| | - Zabreen Tahir
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA 02115, United States
| | - Aamir Ali
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA 02215, United States
| | - Pir Ahmad Shah
- Department of Medicine, University of Texas Health Science Center, San Antonio, TX 78229, United States
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Andeen NK, Troxell ML, Riazy M, Avasare RS, Lapasia J, Jefferson JA, Akilesh S, Najafian B, Nicosia RF, Alpers CE, Smith KD. Fibrillary Glomerulonephritis: Clinicopathologic Features and Atypical Cases from a Multi-Institutional Cohort. Clin J Am Soc Nephrol 2019; 14:1741-1750. [PMID: 31685544 PMCID: PMC6895488 DOI: 10.2215/cjn.03870319] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 08/02/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND OBJECTIVES Fibrillary GN has been defined as an immune complex-mediated GN with amyloid-like fibrils larger than amyloid which are IgG positive and Congo red negative. With discovery of DNAJB9 as a highly sensitive and specific marker for fibrillary GN, the specificity of the morphologic criteria for establishing the diagnosis of fibrillary GN has come into question. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We sought to (1) determine anatomic characteristics that best define fibrillary GN and (2) identify clinical and pathologic features that predict outcomes. RESULTS We retrospectively reviewed kidney biopsies from patients diagnosed with fibrillary GN or suspected fibrillary GN between 1997 and 2017 (n=266, 65% female, median age 61). Approximately 11% of kidney biopsies had one or more unusual feature including monotypic deposits, Congo red positivity, or unusual fibril diameter. Fibrillary GN as a possible monoclonal gammopathy of renal significance represented <1% of cases. Immunostaining for DNAJB9 confirmed fibrillary GN in 100% of cases diagnosed as fibrillary GN and 79% of atypical cases diagnosed as possible fibrillary GN. At a median time of 24 months (interquartile range, 8-46 months) after biopsy (n=100), 53% of patients reached the combined primary outcome of ESKD or death, 18% had CKD, and 18% had partial remission. On multivariable analysis, male sex (adjusted hazard ratio [aHR], 3.82; 95% confidence interval [95% CI], 1.97 to 7.37) and eGFR were the most significant predictors of primary outcome (aHR of 8.02 if eGFR <30 ml/min per 1.73 m2 [95% CI, 1.85 to 34.75]; aHR of 6.44 if eGFR 30 to <45 ml/min per 1.73 m2 [95% CI, 1.38 to 29.99]). Immunosuppressive therapy with rituximab was significantly associated with stabilization of disease progression. CONCLUSIONS Detection of DNAJB9 is a useful diagnostic tool for diagnosing atypical forms of fibrillary GN. The outcomes for fibrillary GN are poor and progression to ESKD is influenced predominantly by the degree of kidney insufficiency at the time of diagnosis and male sex. Rituximab may help preserve kidney function for select patients with fibrillary GN. PODCAST This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2019_11_04_CJN03870319.mp3.
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Affiliation(s)
- Nicole K. Andeen
- Department of Pathology, St. Paul Hospital, University of British Columbia, Vancouver, Canada
| | - Megan L. Troxell
- Division of Nephrology, Department of Medicine, Oregon Health & Science University, Portland Oregon
| | - Maziar Riazy
- Nephrology Service Line, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California
| | | | - Jessica Lapasia
- Nephrology Service Line, The Permanente Medical Group, Kaiser Permanente Northern California, Oakland, California
| | | | | | | | - Roberto F. Nicosia
- Department of Pathology, University of Washington; and
- Seattle Veterans Affairs Medical Center, Seattle, Washington
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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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