Paraneoplastic glomerular diseases and malignancies

Association between proteinuria changes and colorectal cancer incidence: evidence from a nationwide cohort study

BACKGROUND

The presence of excess proteins in the urine, known as proteinuria, has been linked to various health conditions, including chronic kidney disease and cancer. Emerging evidence suggests an association between proteinuria and colorectal cancer, a leading global cause of cancer-related morbidity and mortality. However, the impact of changes in proteinuria status on colorectal cancer risk remains unclear. Understanding this relationship may identify proteinuria as a modifiable risk factor for colorectal cancer prevention.

METHODS

This retrospective cohort study analyzed data from 3,043,138 adults aged over 19 years who participated in biennial health screenings by the South Korean National Health Insurance Service in 2010 and 2012. Participants were classified into four groups based on changes in proteinuria status: no proteinuria, newly developed proteinuria, recovered proteinuria, and persistent proteinuria. Proteinuria was measured using dipstick urinalysis, and colorectal cancer diagnoses were identified using medical records. Cox proportional hazards models adjusted for age, sex, body mass index, lifestyle behaviors, and other confounders were used to estimate cancer risk.

RESULTS

Over a median follow-up period of 9.19 years, 36,846 participants (1.2%) developed colorectal cancer. After adjusting for multiple confounding factors, including age, sex, lifestyle behaviors, medication use, diabetes, hypertension, dyslipidemia, and chronic kidney disease, the persistent proteinuria group demonstrated a significantly higher risk of colorectal cancer compared with the proteinuria-free group (adjusted hazard ratio [aHR], 1.27; 95% CI, 1.13-1.42). Additionally, greater severity of proteinuria was associated with progressively increased colorectal cancer risk (aHR for overt proteinuria [+ 2 to + 4], 1.17; 95% CI, 1.05-1.29).

CONCLUSIONS

Changes in proteinuria status are significantly associated with colorectal cancer risk. Persistent proteinuria poses the highest risk, while transient proteinuria also elevates risk compared to individuals without proteinuria. Regular monitoring and management of proteinuria could potentially be beneficial in identifying individuals at higher colorectal cancer risk, suggesting its possible role as an indicator for targeted prevention strategies. However, further research, including randomized controlled trials, is necessary to confirm any causal relationship.

Pembrolizumab-Mediated Complete Remission of a PLA2R-Positive Paraneoplastic Membranous Nephropathy: A Case Report

Management of paraneoplastic membranous nephropathy (MN) is directed toward the underlying malignancy, and prescriptions of immune checkpoint inhibitors (ICIs) are skyrocketing in the field of oncology. However, this drug category is usually discouraged for patients with autoimmune disorders (AIDs) because it might trigger immune-related adverse events (irAEs) in the form of flare-ups or even genesis of AID. Yet, nothing is known about the efficacy and safety of ICIs for cancers associated with paraneoplastic MN. Here, we report a rare case of PLA2R-positive MN related to a PDL1-positive locally advanced lung adenocarcinoma. Antineoplastic treatment with the anti-PD1 pembrolizumab as a first-line, single-drug therapy allowed for both cancer and nephropathy remissions. To date, to our knowledge, this is the first description of a (PLA2R-positive) paraneoplastic MN that was put into remission via an ICI monotherapy successfully targeting the associated neoplasia only, without additional immunosuppressive agents.

Association Between Lupus Nephritis and Renal Clear-Cell Carcinoma: A Case Report and Review of the Literature

Systemic lupus erythematosus (SLE) is an autoimmune disease affecting several organs, including the kidneys, potentially leading to lupus nephritis (LN). SLE has also been associated with several neoplasias, but its relation to renal cell carcinoma (RCC) has been little explored. We report a young women diagnosed concomitantly with LN and RCC. The latter was discovered incidentally during an investigation of nephrotic syndrome and confirmed on histology and renal microscopy. The patient was submitted to partial nephrectomy and immunosuppression, with good outcome, as shown by the improvement in proteinuria and other symptoms. Our case highlights the complexity of diagnosing SLE in combination with RCC and the importance of permanent surveillance and multidisciplinary approach to optimize treatment.

Minimal change glomerular disease associated with solid neoplasms: a systematic review

BACKGROUND

Paraneoplastic minimal change disease (MCD) has been associated with hematological malignancies, whereas solid malignancies are commonly associated with membranous glomerulonephritis. In this systematic review of the literature, we describe the clinical features, treatment and outcome of MCD associated with solid neoplasms.

METHODS

We performed a systematic review of the MEDLINE, COCHRANE, EMBASE and SCOPUS databases, including case reports of adult patients with biopsy-proven MCD and solid malignancy, without language or time restrictions.

RESULTS

Sixty-seven papers were included, presenting 86 cases with a mean age of 57.8 ± 14.7 years; 41.0% were women. Nephrotic syndrome was the initial presentation in 96.2% of patients; 67.2% had kidney function impairment, and 21.2% required kidney replacement therapy. The most frequent malignancies were malignant thymoma (34.9%), kidney (14.0%), lung (12.8%), and gastrointestinal tumors (12.8%). In 40.7% of cases, the neoplasm diagnosis preceded MCD by 33.8 ± 46.1 months, while in 31.4%, it followed diagnosis of MCD by 12.4 ± 22.6 months. In 27.9%, the neoplasm and kidney disease were diagnosed simultaneously. Immunosuppressive therapy was started in 79.1% of cases and tumor-specific treatment in 83.7%. Remission of MCD was achieved in 80.2% of patients: 38.2% responded to immunosuppressive treatment alone and 29.6% to oncological treatment alone.

CONCLUSIONS

The association between MCD and solid neoplasms is well-documented. Immunosuppressive therapy alone induced nephrotic syndrome remission in over one-third of cases; most others responded to tumor-specific treatment. Solid tumor screening should be considered in MCD independently of the steroid response, though more data on solid tumor-associated MCD prevalence are needed for a definitive statement.

PROSPERO TRIAL REGISTRATION NUMBER

CRD42024521854.

Carcinoma of the ampulla of Vater with membranous nephropathy: a case report

Nephrotic syndrome can occur secondary to malignancy, and its resolution is sometimes observed following tumor resection. We herein report the case of a 67-year-old Asian man who presented with membranous nephropathy associated with carcinoma of the ampulla of Vater. The patient initially presented with edema, hypoalbuminemia, and significant proteinuria with positive PLA2R antibody. Following surgical removal of the tumor, his urinary protein levels normalized, his serum albumin returned to normal, and the nephrotic syndrome achieved complete remission. This case underscores the importance of screening for secondary causes, such as malignancies, in patients with nephrotic syndrome. For those with malignancy-associated nephrotic syndrome, prompt and targeted treatment of the underlying tumor is critical to avoid missing the window for surgical intervention. This report aims to provide insights into the diagnosis and management of tumor-associated nephrotic syndrome, contributing to a better understanding of this rare clinical entity.

Potentially paraneoplastic glomerulopathies in a Brazilian cohort: a retrospective analysis

INTRODUCTION

Glomerular diseases can be associated with solid or hematopoietic malignancies. The prevalence of these associations varies according to the studied glomerular disease. This study aimed to evaluate the frequency and type of neoplasms in patients with glomerular diseases as well as their clinical, laboratory, and histopathological features and the relationship with immunosuppressive therapy.

METHODS

This was a retrospective, descriptive, observational, longitudinal study that reviewed 4,820 medical records and included 95 patients with glomerular disease and neoplasms. Demographic, clinical, laboratory, and histologic data were collected.

RESULTS

The prevalence of neoplasms was 1.97% (95 patients; 81 [85.3%] malignant, 14 [14.7%] benign). Hematologic malignancies (35.8%) showed the highest prevalence, followed by colon, rectal, and gynecologic tumors. The glomerulopathy with the highest frequency was membranous glomerulopathy (MGN, 25 patients, 35.7%). The dose of the immunosuppressive agents among patients with neoplasms before or after immunosuppression was not statistically different. Neoplasm was diagnosed before glomerulopathy in 53% of patients. Among cases in which neoplasms were diagnosed after glomerulopathy, 43% were diagnosed in the first year of follow-up of the renal disease. The predominant syndrome at presentation was nephrotic syndrome. Progression to chronic kidney disease stage 5 at the end of follow-up occurred in 8.4% of the cases.

CONCLUSIONS

Neoplasms manifested before or, less frequently, after the diagnosis of glomerular diseases. As neoplasms diagnosed after presentation of glomerulopathy often appeared early after this diagnosis, it is necessary to be aware of neoplasms during the first year of follow-up of glomerulopathies, especially in patients with nephrotic syndrome, and MGN.

Recurrent paraneoplastic nephrotic syndrome; insights from a Lynch syndrome patient with multiple malignancies

Nephrotic syndrome is a common clinical presentation of glomerulopathy. A glomerulopathy as a paraneoplastic manifestation caused by underlying malignancy is rare. In patients with a solid tumor, membranous nephropathy is the most frequent paraneoplastic glomerulopathy. We present a case of recurrent paraneoplastic nephrotic syndrome caused by minimal change disease in a patient with Lynch syndrome. Over the years, a decrease in creatinine clearance and nephrotic-range proteinuria repeatedly functioned as a warning signal for underlying malignancies; consecutively, a colon adenocarcinoma, renal cell carcinoma and gastric adenocarcinoma were diagnosed. After treatment of the malignancies the nephrotic syndrome resolved without immunosuppressive therapy. Our patient also developed a primary lung carcinoma thrice, which did not cause an exacerbation of the minimal change disease. To further elucidate the mechanism behind the development of this phenomenon, we performed immunohistochemical analysis for vascular endothelial growth factor (VEGF) on the different tumor specimens. We found a high VEGF expression in the gastro-intestinal tumors, whereas the VEGF expression in the lung tumors was low, suggesting an association between VEGF expression and the development of paraneoplastic minimal change disease. This case report not only underlines the importance of considering a malignancy as a cause for (recurrent) nephrotic syndrome, especially in patients with an increased risk of developing malignancies like Lynch syndrome patients, but also suggests a role for VEGF in the pathogenesis of paraneoplastic minimal change disease.

Rapidly Progressive Glomerulonephritis Due to IgA Nephropathy in a Patient With a Large Renal Mass

IgA nephropathy (IgAN) is a common primary glomerulonephritis characterized by the deposition of IgA immune complexes within the glomerular mesangium. IgAN can present with a wide range of clinical manifestations, ranging from asymptomatic hematuria to severe renal disease. This case describes a 67-year-old woman with a history of diabetes mellitus, hypertension, and obesity who presented with acute kidney injury and clinical manifestations of nephrotic syndrome. A renal biopsy confirmed the diagnosis of IgAN. Additionally, imaging studies revealed a large, complex renal mass, raising concerns for renal cell carcinoma. The IgAN was treated with high-dose corticosteroids; however, the patient opted for active surveillance of the renal mass rather than surgical intervention. This case highlights the complex clinical presentation of IgAN and the challenges associated with managing patients with both IgAN and renal mass.

Nephrotic syndrome as a possible indicator of colonic cancer: A case report

The concept of paraneoplastic syndromes encompasses a spectrum of indirect clinical manifestations caused by secretion of bioactive products by malignant cells. Paraneoplastic glomerulopathy represent a distinct clinical entity where nephrotic syndrome can arise as a manifestation of underlying malignancies, particularly solid tumors. Membranous nephropathy is notably associated with such malignancies, highlighting the intricate relationship between nephrotic syndrome and cancer. The present study reports the case of a 44-year-old Caucasian male, smoker (22 pack-years) and chronic ethanol consumer who presented in the Emergency County Hospital of Craiova in March 2018 with abdominal distension, genital and leg edema and no prior medical history. Laboratory tests revealed inflammatory syndrome (erythrocyte sedimentation rate=110 mm/h, fibrinogen, 150 mg/dl, high levels of C reactive protein=6.87 mg/dl), as well as hypoproteinemia (total protein levels=3.90 g/l), hypertriglyceridemia=213 mg/dl, hypercholesterolemia=475 mg/dl, total urinary protein excretion of 12,500 mg/24 h and normal levels of urea (38 mg/dl) and creatinine (0.90 mg/dl). After meeting the diagnostic criteria for nephrotic syndrome (edema, proteinuria, hypoalbuminemia, and hyperlipidemia, it was investigated whether the syndrome was primary or secondary in origin. Notably, an unexplained inflammatory syndrome in conjunction with elevated tumor marker levels (carbohydrate antigen 19-9, 82.47 U/ml; Carcinoembryonic antigen-CEA=9.46 ng/ml) prompted a thorough imagistic investigation, using computer tomography. A polyp was discovered during colonoscopy, prompting a biopsy. The presence of adenocarcinoma was confirmed by histopathological analysis. The only clinical manifestation of the colonic malignancy was the symptomatic presentation of nephrotic syndrome, which led to early detection of the underlying cancer. Paraneoplastic nephropathy connects kidney disease with systemic cancer, showing that renal symptoms may aid in diagnosing hidden malignancies. Nephrotic syndrome, especially membranous nephropathy, is associated with various solid tumors. The present case demonstrated that paraneoplastic syndrome, though rare, may lead to early cancer detection. Ongoing research is essential for improving understanding, targeted therapy and patient management.

Renal involvement in solid cancers: epidemiological, clinical and histological characteristics study of 154 onconephrology patients

BACKGROUND

Onconephrology is a growing discipline that aims to improve the management of patients with cancer and kidney disease. If kidney histology is an essential key, the anatomopathological data remain weak although essential to this complex management.

METHODS

Patients with active cancer who had a kidney biopsy (KB) between 2014 and 2020 were included, and their clinicobiological and histological data were analyzed retrospectively.

RESULTS

Our cohort consisted of 154 patients (83 women) with a mean age of 58 years. One hundred twelve patients presented with proteinuria, 95 with acute kidney injury, and 59 with arterial hypertension. Histologically, interstitial fibrosis was found in 74% of KBs, tubular atrophy in 55.1%, arteriolar hyalinosis in 58.4%, and fibrous endarteritis in 54.4%. Regarding the main acute lesions, thrombotic microangiopathy (TMA) was found in 29.9% of biopsies, acute tubular necrosis (ATN) in 51.3%, and acute interstitial nephritis in 24.8%. The etiological diagnosis most often made was the nephrotoxicity of anticancer drugs (87 patients), followed by a pre-renal (15 patients) and kidney disease unrelated to cancer (13 patients). Sixty-seven patients presented with at least 2 associated diagnoses reflecting the complexity of kidney damage in cancer. Different clusters were found, highlighting that immunotherapy and anti-VEGF were the most commonly involved drugs.

CONCLUSIONS

During onconephrology practice, kidney toxicity of treatments is the most common etiology. Several mechanisms can be involved, underscoring the importance of kidney biopsy and the complexity of its management. Chronic histological lesions were very common.

Paraneoplastic Syndrome After Kidney Transplantation: Frequency, Risk Factors, Differences to Paraneoplastic Occurrence of Glomerulonephritis in the Native Kidney, and Implications on Long-Term Kidney Graft Function

Posttransplant malignancies are an important complication of solid organ transplantation. Kidney transplant recipients are at particularly high risk of cancer development. The most relevant risk factors of carcinogenesis are the use of immunosuppressive agents and oncogenic viral infections. Additionally, immune dysregulation caused by these factors may predispose to various types of organ damage. Paraneoplastic glomerular diseases are one of the most interesting and understudied cancer manifestations. The appropriate diagnosis of paraneoplastic glomerular damage can be challenging in kidney transplant recipients, due to factors inherent to concomitant medication and common comorbidities. Recent advances in the field of molecular and clinical nephrology led to a significant improvement in our understanding of glomerular diseases and their more targeted treatment. On the other hand, introduction of novel anticancer drugs tremendously increased patients' survival, at the cost of kidney-related side effects. Our review aims to provide insights into diagnosis and treatment of paraneoplastic glomerular diseases, with a special attention to kidney transplant recipients.

Nephrotic syndrome associated with solid malignancies: a systematic review

BACKGROUND

Nephrotic syndrome (NS) can occur as a paraneoplastic disorder in association with various types of carcinoma. However, paraneoplastic nephrotic syndrome (PNS) is often misdiagnosed as idiopathic nephrotic syndrome or as an adverse effect of oncology treatment, leading to delayed diagnosis and suboptimal treatment. The characteristics of NS associated with solid malignancies are not yet elucidated. We systematically summarized the clinical data for 128 cases of NS combined with solid malignancies with the aim of informing the clinical management of PNS.

METHODS

We searched the PubMed database for articles published from the date of inception through to October 2023 using the following keywords: "cancer" or "malignant neoplasms" or "neoplasia" or "tumors" and "nephrotic syndrome", "nephrotic" or "syndrome, nephrotic". All data were extracted from case reports and case series, and the extraction included a method for identifying individual-level patient data.

RESULTS

A literature search yielded 105 cases of PNS and 23 of NS induced by cancer therapy. The median age at diagnosis was 60 years, with a male to female ratio of 1.8:1. In patients with PNS, manifestations of NS occurred before, concomitantly with, or after diagnosis of the tumor (in 36%, 30%, and 34% of cases, respectively). Membranous nephropathy (49%) was the most prevalent renal pathology and found particularly in patients with lung, colorectal, or breast carcinoma. Regardless of whether treatment was for cancer alone or in combination with NS, the likelihood of remission was high.

CONCLUSION

The pathological type of NS may be associated with specific malignancies in patients with PNS. Prompt identification of PNS coupled with suitable therapeutic intervention has a significant impact on the outcome for patients.

Paraneoplastic Glomerular Diseases

Paraneoplastic glomerular disease (PGD) develops from tumor cell products, leading to renal dysfunction. Unlike direct tumor effects, PGD illustrates the complex association between cancer and diverse clinical presentations and outcomes. Initially detected in a Hodgkin's disease patient, current research has defined diagnostic criteria based on PGD symptoms and cancer progression. PGDs, although rare (found in <1% of adult cancer patients with overt renal manifestations), are crucial, as they can signal cancer onset and frequently resist standard glomerulonephritis treatments. The emerging field of onconephrology studies this relationship between kidney disorders and cancers. The exact cause of many PGD cases remains unknown. This review examines PGDs, their clinicopathological features, related cancers, and mechanisms, emphasizing the need for early diagnosis and tailored treatment for kidney disease and linked cancer.

Genetic association between membranous nephropathy and malignancies: a two-sample Mendelian randomisation study

BACKGROUND

Various studies have reported that individuals with membranous nephropathy (MN) exhibit an elevated susceptibility to cancers. However, a causal relationship has not been clearly established.

METHODS

We constructed a genetic score that predicts MN by utilizing genetic variants linked to this condition as instrumental variables. These genetic scores were then compared with lung, colon, breast, and prostate cancer risks by a two-sample Mendelian randomisation analysis involving the following methods: MR-Egger, weighted median, inverse variance weighted, simple mode, and weighted mode.

RESULTS

This study demonstrated a lack of empirical substantiation for a causal association between genetic variants in MN and the susceptibility to lung, colon, prostate, or breast cancer.

CONCLUSION

Overall, we did not detect a causal link between MN and lung, colon, breast, or prostate cancer. Hence, additional research is imperative to elucidate the underlying factors contributing to the heightened occurrence of tumour in patients with MN.

A Child With Concomitant Neuroblastoma and IgA Nephropathy: A Case Report and Literature Review

Concurrent malignancy and IgA nephropathy are rare. Despite the lack of solid experimental evidence, there are theoretical hypotheses of pathophysiology for the development of glomerular damage in cancer patients, like aberrant immune activities. Here, we describe a nine-year-old child who was admitted due to nephrotic syndrome. Abdominal imaging examination accidentally revealed a retroperitoneal tumor, and surgical resection was performed with a pathological diagnosis of neuroblastoma. However, complete removal of the tumor had no impact on the clinical manifestation of nephrotic syndrome, like proteinuria. The use of corticosteroids alone only led to a partial resolution of proteinuria, and resistance developed after one month of treatment. A further kidney biopsy was performed, which suggested IgA nephropathy. Clinical remission of IgA nephropathy was achieved after standard combination treatment of corticosteroids and mycophenolate mofetil for 10 months. This study represented the first case report of neuroblastoma associated with IgA nephropathy. We postulated that IgA nephropathy pathogenesis might be associated with neuroblastoma, though a coincidence of these two conditions cannot be fully excluded. Standard treatment for IgA nephropathy is applicable for patients with concomitant cancer.

Cancer detection in dogs using rapid Raman molecular urinalysis

Introduction

The presence of cancer in dogs was detected by Raman spectroscopy of urine samples and chemometric analysis of spectroscopic data. The procedure created a multimolecular spectral fingerprint with hundreds of features related directly to the chemical composition of the urine specimen. These were then used to detect the broad presence of cancer in dog urine as well as the specific presence of lymphoma, urothelial carcinoma, osteosarcoma, and mast cell tumor.

Methods

Urine samples were collected via voiding, cystocentesis, or catheterization from 89 dogs with no history or evidence of neoplastic disease, 100 dogs diagnosed with cancer, and 16 dogs diagnosed with non-neoplastic urinary tract or renal disease. Raman spectra were obtained of the unprocessed bulk liquid urine samples and were analyzed by ISREA, principal component analysis (PCA), and discriminant analysis of principal components (DAPC) were applied using the Rametrix®Toolbox software.

Results and discussion

The procedure identified a spectral fingerprint for cancer in canine urine, resulting in a urine screening test with 92.7% overall accuracy for a cancer vs. cancer-free designation. The urine screen performed with 94.0% sensitivity, 90.5% specificity, 94.5% positive predictive value (PPV), 89.6% negative predictive value (NPV), 9.9 positive likelihood ratio (LR+), and 0.067 negative likelihood ratio (LR-). Raman bands responsible for discerning cancer were extracted from the analysis and biomolecular associations were obtained. The urine screen was more effective in distinguishing urothelial carcinoma from the other cancers mentioned above. Detection and classification of cancer in dogs using a simple, non-invasive, rapid urine screen (as compared to liquid biopsies using peripheral blood samples) is a critical advancement in case management and treatment, especially in breeds predisposed to specific types of cancer.

Successful Treatment of a Case of Crescentic Glomerulonephritis in a Patient with Primary Peritoneal Carcinoma: A case report

Crescentic glomerulonephritis has been associated with several solid tumour malignancies. Only a few cases of nephropathy have been reported in association with tubo-ovarian/peritoneal malignancies. We report a 55-year-old female patient who presented to a tertiary care centre, Muscat, Oman, in 2022. She developed combined immune complex-mediated glomerulonephritis and pauci-immune necrotising crescentic vasculitis simultaneously with the diagnosis of tubo-ovarian/peritoneal cancer. The baseline estimated glomerular filtration rate (eGFR) was 13 mL/min. The patient received two doses of rituximab and three doses of pulse corticosteroids, leading to significant improvement in renal function and the disappearance of her proteinuria. The eGFR improved to >60mL/min; her proteinuria gradually resolved after 10 weeks of treatment. She was then given a combination chemotherapy treatment for tubo-ovarian/peritoneal cancer leading to a normalisation of her CA-125 after three months of therapy.

Metastatic Non-Small-Cell Lung Cancer Presenting as Renal Failure From IgA Nephropathy

Studies have highlighted a potential link between malignancies and immunoglobulin A nephropathy (IgAN). In such studies, the treatment of malignancy improved the symptoms of IgAN. Here, we report a patient case involving a history of hypertension, tobacco use disorder, and chronic kidney disease (CKD) presenting with hematuria with acute renal failure secondary to IgAN per renal biopsy. Prompted by this association, a malignancy workup was performed including computed tomography (CT) body imaging and biopsies of mediastinal and cervical lymph nodes which revealed a metastatic adenocarcinoma. Current knowledge includes a general mechanism behind the development of IgAN that points toward glomerular deposition of tumor-specific immunoglobulin A (IgA) immunoglobulins. However, the association of IgAN and malignancy has no definitive management guidelines. This clinical case serves as an important contribution in the hopes of future development of guidelines regarding the surveillance and management of IgAN in the setting of malignancy.

Spontaneous Remission of Minimal Change Disease in a Colon Cancer Patient: A Case Report

Introduction

Minimal change disease (MCD) is most often primary but may occur secondary to other systemic diseases such as malignancy. In secondary MCD, spontaneous remission of nephrotic syndrome after the treatment of related diseases without steroid therapy is rare.

Case Presentation

A 78-year-old man visited the outpatient clinic with foamy urine and generalized edema that had persisted for 2 months. The patient had nephrotic syndrome. Before a kidney biopsy, he underwent several tests to determine the secondary cause of the nephrotic syndrome. The serum CEA was slightly elevated, and colon cancer was detected in the sigmoid colon. MCD was diagnosed from a kidney biopsy. He immediately underwent surgery for colon cancer. Complete remission of the MCD was achieved within 2 weeks after surgery.

Conclusion

Here, we report a rare case of a patient with secondary MCD who successfully achieved spontaneous remission after colon cancer surgery.

Causal associations between thyroid cancer and IgA nephropathy: a Mendelian randomization study

BACKGROUND

The incidence of kidney disease caused by thyroid cancer is rising worldwide. Observational studies cannot recognize whether thyroid cancer is independently associated with kidney disease. We performed the Mendelian randomization (MR) approach to genetically investigate the causality of thyroid cancer on immunoglobulin A nephropathy (IgAN).

METHODS AND RESULTS

We explored the causal effect of thyroid cancer on IgAN by MR analysis. Fifty-two genetic loci and single nucleotide polymorphisms were related to thyroid cancer. The primary approach in this MR analysis was the inverse variance weighted (IVW) method, and MR‒Egger was the secondary method. Weighted mode and penalized weighted median were used to analyze the sensitivity. In this study, the random-effect IVW models showed the causal impact of genetically predicted thyroid cancer across the IgAN risk (OR, 1.191; 95% CI, 1.131-1.253, P < 0.001). Similar results were also obtained in the weighted mode method (OR, 1.048; 95% CI, 0.980-1.120, P = 0.179) and penalized weighted median (OR, 1.185; 95% CI, 1.110-1.264, P < 0.001). However, the MR‒Egger method revealed that thyroid cancer decreased the risk of IgAN, but this difference was not significant (OR, 0.948; 95% CI, 0.855-1.051, P = 0.316). The leave-one-out sensitivity analysis did not reveal the driving influence of any individual SNP on the association between thyroid cancer and IgAN.

CONCLUSION

The IVW model indicated a significant causality of thyroid cancer with IgAN. However, MR‒Egger had a point estimation in the opposite direction. According to the MR principle, the evidence of this study did not support a stable significant causal association between thyroid cancer and IgAN. The results still need to be confirmed by future studies.

Minimal change disease associated with thyroid cancer: a case report

A patient complaining of edema of the face and lower extremities was admitted to the nephrology department for nephrotic syndrome. Renal biopsy revealed findings of minimal change disease (MCD). Thyroid ultrasound showed a hypoechoic 16 × 13 mm nodule in the right lobe, suspicious of malignancy. Later, total thyroidectomy confirmed the diagnosis of papillary thyroid carcinoma (PTC). After surgery, MCD remitted rapidly and completely, strongly suggesting the diagnosis of MCD secondary to PTC. We report here the first adult case of the paraneoplastic finding of MCD secondary to PTC. Additionally, we discuss the possible role of the BRAF gene in the pathophysiology of PTC-associated MCD in this case and highlight the importance of tumor screening.

The Onco-Nephrology Field: The Role of Personalized Chemotherapy to Prevent Kidney Damage

In recent years, the onco-nephrology field has acquired a relevant role in internal medicine due to the growing number of cases of renal dysfunction that have been observed in cancer patients. This clinical complication can be induced by the tumor itself (for example, due to obstructive phenomena affecting the excretory tract or by neoplastic dissemination) or by chemotherapy, as it is potentially nephrotoxic. Kidney damage can manifest as acute kidney injury or represent a worsening of pre-existing chronic kidney disease. In cancer patients, physicians should try to set preventive strategies to safeguard the renal function, avoiding the concomitant use of nephrotoxic drugs, personalizing the dose of chemotherapy according to the glomerular filtration rate (GFR) and using an appropriate hydration therapy in combination with nephroprotective compounds. To prevent renal dysfunction, a new possible tool useful in the field of onco-nephrology would be the development of a personalized algorithm for the patient based on body composition parameters, gender, nutritional status, GFR and genetic polymorphisms.

Secondary IgA Nephropathy and IgA-Associated Nephropathy: A Systematic Review of Case Reports

Primary (pIgAN), secondary IgA nephropathy (sIgAN), and IgA-associated nephropathy can be distinguished. While pIgAN has been thoroughly studied, information about the etiology of sIgAN remains scarce. As concerns sIgAN, several studies suggest that different etiologic factors play a role and ultimately lead to a pathophysiologic process similar to that of pIgAN. In this article, we review a vast number of cases in order to determine the novel putative underlying diseases of sIgAN. Moreover, updates on the common pathophysiology of primary disorders and sIgAN are presented. We identified liver, gastrointestinal, oncological, dermatological, autoimmune, and respiratory diseases, as well as infectious, iatrogenic, and environmental factors, as triggers of sIgAN. As novel biological therapies for listed underlying diseases emerge, we suggest implementing drug-induced sIgAN as a new significant category. Clinicians should acknowledge the possibility of sIgAN progression in patients treated with TNF-α inhibitors, IL-12/IL-23-inhibitors, immune checkpoint inhibitors, CTLA-4, oral anticoagulants, thioureylene derivatives, and anti-vascular endothelial growth factor drugs.

Paraneoplastic Glomerulonephropathy Associated With Renal Cell Carcinoma: A Descriptive Analysis of Published Reports

Paraneoplastic glomerulonephropathy (PGN) is a rare paraneoplastic syndrome that is associated with a variety of malignancies. Patients with renal cell carcinomas (RCCs) often develop paraneoplastic syndromes including PGN. To date, objective diagnostic criteria of PGN are not defined. As a result, the true occurrences are unknown. Many RCC patients develop renal insufficiency in the course of their disease, and diagnosis of PGN in this population is challenging and often delayed, which may lead to significant morbidity and mortality. Here, we provide a descriptive analysis of the clinical presentation, treatment, and outcomes of 35 published patient cases of PGN associated with RCCs over the past four decades in PubMed-indexed journals. Most patients with PGN were male (77%), over 60 years of age (60%), and diagnosed with PGN prior to or concurrent with their diagnosis of RCC (20% prior, 71% concurrent). Membranous nephropathy (34%) was the most common pathologic subtype. Among the patients with localized RCCs, 16 (67%) of 24 patients had improvement in PGN compared to 4 (36%) of 11 patients with metastatic RCCs. All 24 patients with localized RCCs underwent nephrectomy, but patients who were treated with nephrectomy with immunosuppression (7/9, 78%) had a better outcome than patients who were treated with nephrectomy alone (9/15, 60%). Among the patients with metastatic RCCs, patients who were treated with systemic therapy along with immunosuppression (4/5, 80%) had a better outcome than those who were treated with systemic therapy, nephrectomy, or immunosuppression alone (1/6, 17%). Our analysis demonstrates the importance of cancer-specific therapy; nephrectomy in localized disease and systemic therapy in metastatic disease, along with immunosuppression, was the effective management of PGN. Immunosuppression alone is not adequate in most patients. This is distinct from other glomerulonephropathy and warrants further study.

Cause-specific mortality among patients with renal cell carcinoma in the United States from 2000 to 2018

OBJECTIVES

There has been little focus on the non-cancer causes of death in patients with renal cell carcinoma (RCC). Therefore, we aimed to assess the frequency and risk of different causes of death, stratified by tumor stage, and demographics, after a diagnosis of RCC in the United States.

MATERIALS AND METHODS

Data on eligible patients with RCC from January 1, 2000, to December 31, 2018, in the United States were retrieved from the Surveillance, Epidemiology, and End Results (SEER) database. Standardized mortality ratios for causes of death were calculated using the SEER*Stat software 8.3.9.2 for the overall population and stratified subgroups.

RESULTS

A total of 165,969 patients with RCC were included and 60,290 (36.3%) died during follow-up. The majority of deaths were due to kidney cancer (51.3%) but a significant proportion was non-cancer causes (37.6%). The proportion of deaths attributed to RCC decreased with increasing follow-up with non-cancer causes becoming dominant after the fifth year following RCC diagnosis. Overall, cardiovascular diseases and cerebrovascular diseases were the most common non-RCC-related causes of death. AJCC stage I and localized RCC had the most deaths attributed to non-cancerous causes (66.2% and 61.2%, respectively) while AJCC stage IV and distant RCC had the most deaths due to RCC (86.2% and 86.5%, respectively).

CONCLUSION

A large proportion of RCC patients die of non-cancerous causes especially early-stage patients and advanced-stage patients who survive >5 years. Coordination of multidisciplinary care with relevant specialists depending on the stage of the disease is needed to better prevent death overtime from non-cancer causes.

Case of metastatic epithelioid haemangioendothelioma from an unknown primary site associated with membranous nephropathy and hypercoagulable state

We report a rare case of metastatic epithelioid haemangioendothelioma from an unknown primary site presenting with axillary lymph node metastases. The patient also had a new-onset membranous glomerulonephritis and thromboembolism, which we postulate were paraneoplastic. The pathogenesis of this rare cancer, the risk of misdiagnosis and membranous glomerulonephritis as a paraneoplastic syndrome are discussed.

Chronic Kidney Disease and Cancer: Inter-Relationships and Mechanisms

Chronic kidney disease (CKD) has been recognized as an increasingly serious public health problem globally over the decades. Accumulating evidence has shown that the incidence rate of cancer was relatively higher in CKD patients than that in general population, which, mechanistically, may be related to chronic inflammation, accumulation of carcinogenic compounds, oxidative stress, impairment of DNA repair, excessive parathyroid hormone and changes in intestinal microbiota, etc. And in patients with cancer, regardless of tumor types or anticancer treatment, it has been indicated that the morbidity and incidence rate of concomitant CKD was also increased, suggesting a complex inter-relationship between CKD and cancer and arousing increasing attention from both nephrologists and oncologists. This narrative review focused on the correlation between CKD and cancer, and underlying molecular mechanisms, which might provide an overview of novel interdisciplinary research interests and the potential challenges related to the screening and treatment of CKD and cancer. A better understanding of this field might be of help for both nephrologists and oncologists in the clinical practice.

Critical evaluation of cancer risks in glomerular disease

The increased cancer incidence in patients with glomerular disease can be secondary to an intrinsic immune dysfunction associated with the disease or/and extrinsic factors, especially immunosuppressants. The treatment for paraneoplastic glomerulopathy is different from primary glomerular disease. Immunosuppressive therapy often used for primary glomerulopathy may aggravate concomitant cancers in patients with paraneoplastic glomerulopathy. In membranous nephropathy (MN), measurement of serum circulating autoantibodies against podocyte transmembrane glycoprotein M-type phospholipase A2 receptor (PLA2R) and thrombospondin type 1 domain-containing 7A (THSD7A), immunohistochemical staining of kidney tissue for glomerular PLA2R, THSD7A, neural epidermal growth factor-like 1 protein (NELL-1) and specific types of immunoglobulin G (IgG) may be useful adjuncts when screening for underlying malignancies. This review addresses overall cancer risks in individuals with glomerular diseases and employment of biomarkers available for MN. We propose a scheme of screening of cancers frequently reported in the setting of glomerular disease.

Minimal change disease associated with gastrointestinal stromal tumor accompanied by significantly elevated serum IgE level: a case report

BACKGROUND

Minimal change disease (MCD) is a common cause of the nephrotic syndrome. Several studies have shown an increased incidence of cancer in patients with MCD. However, there are no reports on the association between MCD and gastrointestinal stromal tumor (GIST).

CASE PRESENTATION

We report a case of a 66-year-old female with severe nephrotic syndrome and concomitant duodenal GIST. Immunoglobulin test showed a significant increase of IgE levels. The diagnosis of renal histopathology was MCD with subacute tubulointerstitial injury. The combination of preoperative Imatinib mesylate chemotherapy and tumor excision was accompanied by significant remission of proteinuria, and IgE level decreasing, without immunosuppressivetherapy.

CONCLUSIONS

It is the first case report that MCD was associated with GIST and elevated IgE level. Clinically, in patients with elevated IgE level associated with nephrotic syndrome, the possibility of tumor must be taken into account when allergic factors are excluded.

Nephrotic syndrome associated with metastatic melanoma: a case report

Nephrotic syndrome (NS) may occur after or concomitantly with malignancy. The use of immunosuppressive approaches in patients with cancer and NS is controversial, especially when the association between the pathologies is unclear. The aim of this study was to report the case of a patient with metastatic melanoma who developed NS and to examine the association between NS and neoplasia. A 56-year-old woman diagnosed with right hallux melanoma, removed by marginal resection with no sign of metastasis, developed NS after 6 months without the detection of another associated disease. The histological diagnosis was focal and segmental glomerulosclerosis (FSGS). The patient was older than most patients with FSGS and was treated with immunosuppressive agents (prednisone and cyclosporine) concomitantly with melanoma treatment. Nephrotic syndrome was the first manifestation of metastatic melanoma recurrence in this patient. Proteinuria was controlled adequately after immunosuppression and melanoma treatment. Although NS has been associated with cancer, laboratory and histological markers correlating it with melanoma are needed.

Paraneoplastic Glomerular Diseases

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.

Pauci-immune crescentic glomerulonephritis associated with metastatic rectal carcinoma

Paraneoplastic glomerular disease is well recognised, although it most frequently presents with clinical features of the nephrotic syndrome. This case describes a 74-year-old male with metastatic rectal adenocarcinoma treated surgically with anterior resection followed by adjuvant capecitabine chemotherapy. Having previously had normal renal function, he developed an acute kidney injury with active urinary sediment following the discovery of liver metastases. A renal biopsy was performed, which revealed an active crescentic pauci-immune glomerulonephritis. The patient was treated with high dose oral corticosteroids which led to some improvement in renal function, although he was still left with significant kidney impairment, which limited further safe oncological treatment. This case highlights a rare presentation of glomerular disease in the setting of malignancy and also demonstrates the adverse impact that kidney impairment can have on outcomes in patients with cancer.

Complete Resolution of Paraneoplastic Membranous Nephropathy Following Curative Therapy of Triple-Negative Breast Cancer

A paraneoplastic syndrome, which includes glomerulopathy, is a manifestation of malignancy unexplained by direct tumor burden. Membranous nephropathy (MN) may be associated with malignancies that are primarily solid tumors of the lung, prostate and gastrointestinal tract. It is rarely associated with breast cancer. To our knowledge, we herein report the first case of MN associated with triple-negative carcinoma of the breast. The patient initially presented with MN as a paraneoplastic nephrotic syndrome. Treatment resulting in a complete pathological response of the breast cancer also resolved the MN. Neither has recurred after a 48-month follow-up. The patient exhibited autoantibodies against phospholipase A2 receptor and was also antinuclear antibody (ANA) and anti-Smith (anti-Sm) antibody positive. These results suggest that the neoplasm evoked an autoimmune response, which resolved with treatment. ANA and anti-SM positivity closely correlated with the neoplasm activity supporting this hypothesis.

Muscle invasive urinary bladder urothelial carcinoma presenting with secondary nephrotic symptoms

INTRODUCTION

Nephrotic syndrome secondary to malignant disease accounts for approximately 10% of cases of nephrotic syndrome in adults. However, urothelial carcinoma of the bladder is a rare cancer, with only four cases reported to date.

CASE PRESENTATION

A 76-year-old man presented with chief complaints of edema and anorexia. Laboratory examinations revealed hypoalbuminemia and marked proteinuria, and computed tomography demonstrated multiple bladder tumors. Transurethral resection of the bladder tumors was performed. The pathological diagnosis was urothelial carcinoma with muscular invasion. The patient underwent simple cystectomy and ileal conduit formation, and proteinuria disappeared after 4 weeks. However, urethral recurrence was noted, and he died 35 months after cystectomy.

CONCLUSION

Five cases including ours were clinically reviewed. Nephrotic symptoms improved relatively rapidly after surgery in all cases. In contrast to the poor preoperative general condition, postoperative improvement can be expected, and surgical treatment should, therefore, be considered.

Pediatric onco-nephrology: time to spread the word : Part I: early kidney involvement in children with malignancy

Onco-nephrology has been a growing field within the adult nephrology scope of practice. Even though pediatric nephrologists have been increasingly involved in the care of children with different forms of malignancy, there has not been an emphasis on developing special expertise in this area. The fast pace of discovery in this field, including the development of new therapy protocols with their own kidney side effects and the introduction of the CD19-targeted chimeric antigen receptor T cell (CAR-T) therapy, has introduced new challenges for general pediatric nephrologists because of the unique effects of these treatments on the kidney. Moreover, with the improved outcomes in children receiving cancer therapy come an increased number of survivors at risk for chronic kidney disease related to both their cancer diagnosis and therapy. Therefore, it is time for pediatric onco-nephrology to take its spot on the expanding subspecialties map in pediatric nephrology.

Collapsing focal segmental glomerulosclerosis in a patient with oral cavity cancer: A case report

RATIONALE

Focal segmental glomerulosclerosis (FSGS) is one of the most common glomerular diseases, leading to end-stage renal disease. Among the 5 variants of FSGS, the collapsing variant is rare and has the worst prognosis. Solid and hematologic malignancies are associated with glomerular diseases, such as membranous nephropathy, minimal change disease, and FSGS. However, squamous cell carcinoma of the oral cavity is rarely associated with nephrotic syndrome, especially FSGS.

PATIENT CONCERNS

A 55-year-old woman diagnosed with oral cavity cancer presented with generalized edema with heavy proteinuria and renal dysfunction after neoadjuvant chemotherapy and wide surgical excision.

DIAGNOSIS

Renal biopsy shows segmental or global collapse of glomerular capillaries with marked hyperplasia and swelling of overlying epithelial cells, suggesting a collapsing variant of FSGS.

INTERVENTIONS

After the renal biopsy, we prescribed oral prednisolone at a dose of 1 mg/kg/day. Despite immunosuppressive treatment, renal function deteriorated, and hemodialysis was started.

OUTCOMES

After 23 sessions of hemodialysis and high-dose oral glucocorticoid treatment, renal function gradually improved, and oral glucocorticoid therapy was discontinued after 8 months. Currently, this patient is in a cancer-free state and has normal renal function without proteinuria.

LESSONS

Unusual collapsing FSGS might be associated with neoadjuvant chemotherapy and wide surgical excision in patients with oral cavity cancer. Proper diagnostic workup, such as renal biopsy and high-dose glucocorticoid therapy, might have helped recover from nephrotic syndrome and acute renal injury in cancer patients.

Anti-Neutrophil Cytoplasmic Antibody-Associated Glomerulonephritis and Malignancy: A Case of a Patient Diagnosed with Renal Failure and Pulmonary Carcinoma Concurrently

A 70-year-old man presented with proteinuria, microscopic hematuria, and an increased level of serum creatinine. A systemic workup revealed that the patient had bronchogenic carcinoma and anti-neutrophil cytoplasmic antibody (ANCA)-associated glomerulonephritis concurrently. Despite the increase in the cumulative number of publications on paraneoplastic glomerulopathies, an awareness of the link between cancer and ANCA-associated glomerulonephritis is lacking. We strongly recommend the accumulation of more cases similar to our own, thereby allowing us to clarify the management strategies as well as the nature of this disease condition more precisely.

Spectrum of cancer patients receiving renal biopsy

BACKGROUND

The frontier of onco-nephrology, particularly renal complications of cancer and treatment, remains unexplored. We revisit the fundamental tool of diagnosing kidney disease, renal biopsy, in cancer patients with renal manifestation.

METHODS

Patients who received renal biopsy from July 2015 to July 2019 were analyzed. Primary outcomes included end-stage renal disease (ESRD), mortality, and catastrophic outcome defined as either ESRD or mortality. A Cox proportional hazards model and Kaplan-Meier technique were used to assess the association with outcome measurements and survival analyses. Immunosuppression after renal biopsy and response to the treatment were evaluated.

RESULTS

Among the 77 patients, the median age was 66 years (interquartile range [IQR] 59-73 years) and 46 (59.7%) were male. At the time of renal biopsy, 57 patients (74%) had various degrees of renal insufficiency. Tubulointerstitial damage score, quantified by renal pathology, were associated with higher hazards of ESRD (hazard ratio [HR], 1.77; 95% confidence interval [95% CI], 1.20 to 2.61; P = 0.004) and catastrophic outcome (HR, 1.30; 95% CI, 0.99 to 1.70; P = 0.058). The response rate to immunosuppression was lower in those diagnosed with tubulointerstitial nephritis (1 of 4 patients, 25%) than those with glomerulopathy (10 of 20 patients, 50%).

CONCLUSION

Renal biopsy may improve diagnostic accuracy and assist in treatment guidance of cancer patients with renal manifestation. Renal biopsy should be encouraged with clinical indication. Collaboration between oncologists and nephrologists is of paramount importance to provide more comprehensive care for caner patients.

An elderly-onset neuroblastoma concomitant with minimal change nephrotic syndrome: the first autopsy case report

BACKGROUND

Neuroblastoma is a well-known embryonal cancer; however, adult-onset neuroblastomas are rare. The systemic symptoms are related to catecholamine excretion or intraabdominal mass effects. Only two cases of neuroblastoma with nephrotic syndrome have previously been reported. We herein present the first autopsy case of neuroblastoma in an older individual associated with minimal change nephrotic syndrome.

CASE PRESENTATION

A 63-year-old man was admitted to our hospital for investigation of general fatigue. His renal function was normal and his urine was negative for protein. A computed tomography scan showed a renal tumor and intraabdominal lymph node swelling. Approximately 4 months after admission, he suddenly developed acute renal failure and severe proteinuria, and hemodialysis was instituted. A computed tomography scan revealed an increase in the size of the renal tumor and lymph nodes. He died 1 month later and an autopsy was performed. The tumor exhibited diffuse proliferation of tumor cells with scant cytoplasm, namely small blue cell tumor with rosette formation. As a result of immunohistochemical study, a neuroblastoma was diagnosed. Despite the patient's severe renal failure, most glomeruli showed no remarkable changes. The tubular epithelium exhibited detachment and vacuolation. Electron microscopic study of the glomeruli showed diffuse effacement of the foot processes. These features indicate a diagnosis of minimal change nephrotic syndrome with acute tubular injury.

CONCLUSIONS

Minimal change nephrotic syndrome is the most common renal manifestation associated with lymphoproliferative malignancies. We here present an extremely rare case of adult-onset neuroblastoma with minimal change nephrotic syndrome.

Onconephrology

Current advances in cancer chemotherapeutics have remarkably helped in rapid and definitive treatment options. However, these potent chemotherapeutics have been associated with severe renal toxicities that later impact treatment options. Acute kidney injury is common in patients with cancer. In hospitalized patients with cancer, acute kidney injury is associated with increased morbidity, mortality, length of stay, and costs. This article provides an overview of acute kidney injury caused by cancer or its treatment, including prerenal, tubular, glomerular diseases, infiltrative disease, tumor lysis syndrome, anticancer drug nephrotoxicity, hematopoietic stem cell transplantation-related acute kidney injury, and cancer-associated thrombotic microangiopathy.

Malignancy-associated membranous nephropathy with PLA2R double-positive for glomeruli and carcinoma

Phospholipase A2 receptor (PLA2R) is the most common primary target antigen of idiopathic membranous nephropathy (MN) although PLA2R antibodies are also reported to be present in malignancy-associated MN. However, a case of PLA2R-positive MN secondary to PLA2R-positive carcinoma has not been reported. A 26-year-old Japanese woman presented with general fatigue, fever, and nonproductive cough. Computed tomography demonstrated a left kidney mass with pathologic diagnosis of Xp11.2 translocation renal cell carcinoma (RCC). After the second time of administration with Sunitinib, the patients exhibited significant proteinuria and hypoalbuminemia. Renal biopsy revealed a diagnosis of diffuse MN secondary to RCC. Immunofluorescence staining showed granular patterns positive for immunoglobulin (Ig) G, IgA, and C3c. PLA2R and IgG1-3 were positive, while IgG4 was negative. For the treatment of severe nephrotic syndrome, we attempted steroid therapy without any clinical improvement. Open nephrectomy was performed and surprisingly, RCC was stained for PLA2R with polarity for the basal side. At outpatient follow-up, 4 months after the operation, urinary protein had still persisted, although serum albumin was slightly increased. We report a case of PLA2R-positive MN secondary to PLA2R-positive RCC.

Onconephrology: The intersections between the kidney and cancer

Onconephrology is a new subspecialty of nephrology that recognizes the important intersections of kidney disease with cancer. This intersection takes many forms and includes drug-induced nephrotoxicity, electrolyte disorders, paraneoplastic glomerulonephritis, and the interactions of chronic kidney disease with cancer. Data clearly demonstrate that, when patients with cancer develop acute or chronic kidney disease, outcomes are inferior, and the promise of curative therapeutic regimens is lessened. This highlights the imperative for collaborative care between oncologists and nephrologists in recognizing and treating kidney disease in patients with cancer. In response to this need, specific training programs in onconephrology as well as dedicated onconephrology clinics have appeared. This comprehensive review covers many of the critical topics in onconephrology, with a focus on acute kidney injury, chronic kidney disease, drug-induced nephrotoxicity, kidney disease in stem cell transplantation, and electrolyte disorders in patients with cancer.

Secondary Membranous Nephropathy. A Narrative Review

Membranous nephropathy (MN) is a common cause of proteinuria and nephrotic syndrome all over the world. It can be subdivided into primary and secondary forms. Primary form is an autoimmune disease clinically characterized by nephrotic syndrome and slow progression. It accounts for ~70% cases of MN. In the remaining cases MN may be secondary to well-defined causes, including infections, drugs, cancer, or autoimmune diseases, such as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), urticarial vasculitis, sarcoidosis, thyroiditis, Sjogren syndrome, systemic sclerosis, or ankylosing spondylitis. The clinical presentation is similar in primary and secondary MN. However, the outcome may be different, being often related to that of the original disease in secondary MN. Also, the treatment may be different, being targeted to the etiologic cause in secondary MN. Thus, the differential diagnosis between primary and secondary MN is critical and should be based not only on history and clinical features of the patient but also on immunofluorescence and electron microscopy analysis of renal biopsy as well as on the research of circulating antibodies. The identification of the pathologic events underlying a secondary MN is of paramount importance, since the eradication of the etiologic factors may be followed by remission or definitive cure of MN. In this review we report the main diseases and drugs responsible of secondary MN, the outcome and the pathogenesis of renal disease in different settings and the possible treatments.

Autoimmune disorders and paraneoplastic syndromes in thymoma

Thymomas are counted among the rare tumour entities which are associated with autoimmune disorders (AIDs) and paraneoplastic syndromes (PNS) far more often than other malignancies. Through its complex immunological function in the context of the selection and maturation of T cells, the thymus is at the same time highly susceptible to disruptive factors caused by the development and growth of thymic tumours. These T cells, which are thought to develop to competent immune cells in the thymus, can instead adopt autoreactive behaviour due to the uncontrolled interplay of thymomas and become the trigger for AID or PNS affecting numerous organs and tissues within the human body. While myasthenia gravis is the most prevalent PNS in thymoma, numerous others have been described, be they related to neurological, cardiovascular, gastrointestinal, haematological, dermatological, endocrine or systemic disorders. This review article sheds light on the pathophysiology, epidemiology, specific clinical features and therapeutic options of the various forms as well as courses and outcomes of AID/PNS in association with thymomas. Whenever suitable and backed by the limited available evidence, the perspectives from both the thymoma and the affected organ/tissue will be highlighted. Specific issues addressed are the prognostic significance of thymectomy on myasthenia gravis and other thymoma-associated AID/PND and further the impact and safety of immunotherapies on AID and PND relating to thymomas.

Lung Cancer Cell-Derived Secretome Mediates Paraneoplastic Inflammation and Fibrosis in Kidney in Mice

Simple Summary

Paraneoplastic nephrotic syndrome is a complication arising in lung cancer patients. In the present study, we established an LLC1 cell orthotopic xenograft C57BL/6 mice model to translation paraneoplastic nephrotic syndrome (PNS). The pathological aspects of PNS were characterized in TGF-β signaling-engaged renal fibrosis, and renal inflammation with IL-6 expression in kidney. To reveal how the lung cancer cells remotely drive pathogenic progression, secretome derived from LLC1 cells and A549 cells were proteomically profiled. Additionally, the secretome profiling was subjected to diseases and biofunctions assessment by Ingenuity Pathway analysis (IPA). As matter of secretome profiling and IPA prediction, the Fibronectin, C1r, and C1s are potential of nephrotoxicity linked to paraneoplastic effects on glomerular pathogenesis in these lung cancer mice.

Abstract

Kidney failure is a possible but rare complication in lung cancer patients that may be caused by massive tumor lysis or a paraneoplastic effect. Clinical case reports have documented pathological characteristics of paraneoplastic syndrome in glomeruli, but are short of molecular details. When Lewis lung carcinoma 1 (LLC1) cells were implanted in mice lungs to establish lung cancer, renal failure was frequently observed two weeks post orthotopic xenograft. The high urinary albumin-to-creatinine ratio (ACR) was diagnosed as paraneoplastic nephrotic syndrome in those lung cancer mice. Profiling the secretome of the lung cancer cells revealed that the secretory proteins were potentially nephrotoxic. The nephrotoxicity of lung cancer-derived secretory proteins was tested by examining the pathogenic effects of 1 × 10⁶, 2 × 10⁶, and 5 × 10⁶ LLC1 cell xenografts on the pathogenic progression in kidneys. Severe albuminuria was present in the mice that received 5 × 10⁶ LLC1 cells implantation, whereas 10⁶ cell and 2 × 10⁶ cell-implanted mice have slightly increased albuminuria. Pathological examinations revealed that the glomeruli had capillary loop collapse, tumor antigen deposition in glomeruli, and renal intratubular casts. Since IL-6 and MCP-1 are pathologic markers of glomerulopathy, their distributions were examined in the kidneys of the lung cancer mice. Moderate to severe inflammation in the kidneys was correlated with increases in the number of cells implanted in the mice, which was reflected by renal IL-6 and MCP-1 levels, and urine ACR. TGF-β signaling-engaged renal fibrosis was validated in the lung cancer mice. These results indicated that lung cancer cells could provoke inflammation and activate renal fibrosis.