1
|
Abramson M, Shaikh A. Immunotactoid Glomerulopathy. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:326-333. [PMID: 39084758 DOI: 10.1053/j.akdh.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 03/04/2024] [Accepted: 03/05/2024] [Indexed: 08/02/2024]
Abstract
Immunotactoid glomerulopathy (ITG) is a rare glomerular disease that typically presents with proteinuria, hematuria, and kidney dysfunction. A kidney biopsy is essential to establish the diagnosis of ITG. ITG is characterized by glomerular electron-dense immunoglobulin deposits with hollow-cored microtubules. ITG is classified as either monoclonal or polyclonal based on immunofluorescence staining of the immunoglobulin deposits. Monoclonal ITG is associated with an underlying hematologic disorder in two-thirds of the cases, lymphoma and plasma cell dyscrasias being the most common. Polyclonal ITG is associated with autoimmune diseases but can be seen with hematologic disorders and chronic infections. Due to the preponderance of hematologic disorders in both monoclonal and polyclonal ITG, a thorough hematologic workup must be performed in all cases of ITG. In monoclonal ITG with a detectable clone, clone-directed therapy is administered to achieve hematologic remission, as the renal response is highly dependent on the hematologic response. In clone-negative monoclonal ITG, anti-B cell therapy is often used as a first-line therapy. Management of polyclonal ITG without an underlying hematologic disorder is poorly defined. Compared to monoclonal ITG, patients with polyclonal ITG have a higher risk of progression to end-stage kidney disease. Recurrence of ITG following kidney transplantation is common and is often associated with hematologic relapse.
Collapse
Affiliation(s)
- Matthew Abramson
- Division of Nephrology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Aisha Shaikh
- Memorial Sloan Kettering Cancer Center, Renal Service, New York, NY; Department of Medicine, Weill Cornell Medical College, New York, NY.
| |
Collapse
|
2
|
Miao J, Herrmann SM, Obaidi Z, Caza T, Bonilla M. Paraprotein-Mediated Glomerular Diseases. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:358-373. [PMID: 39084761 DOI: 10.1053/j.akdh.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 08/02/2024]
Abstract
Paraproteinemias are a group of complex diseases associated with an overproduction of a monoclonal immunoglobulin that can cause a diversity of kidney disorders and end-organ damage. In this review, we focus on paraprotein-mediated glomerular diseases. Kidney biopsy plays a crucial role in diagnosing these disorders, enabling the identification of specific histological patterns. These lesions are categorized into organized (such as amyloidosis, immunotactoid glomerulopathy, fibrillary glomerulonephritis, cryoglobulinemic glomerulonephritis, and monoclonal crystalline glomerulopathies) and nonorganized deposits (such as monoclonal Ig deposition disease and proliferative glomerulonephritis with monoclonal Ig deposits) based on the characteristics of immunofluorescence findings and the ultrastructural appearance of deposits on electron microscopy. This review aims to provide an update, highlight, and discuss clinicopathological aspects such as definition, epidemiology, clinical manifestations, mechanisms of kidney injury, histological features, and diagnostic procedures.
Collapse
Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Zainab Obaidi
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL
| | | | - Marco Bonilla
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL.
| |
Collapse
|
3
|
Lafargue MC, Cohen C. [Latest updates on immunotactoid glomerulopathy and fibrillary glomerulonephritis]. Bull Cancer 2024; 111:741-747. [PMID: 36803980 DOI: 10.1016/j.bulcan.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/10/2022] [Accepted: 12/18/2022] [Indexed: 02/17/2023]
Abstract
Various hematologic malignancies can lead to renal complications. The most common of these hemopathies to affect the kidney is multiple myeloma, however an increasing number of kidney diseases are associated with other monoclonal gammopathies. It is recognized that clones in small abundance can be responsible for severe organ damage, thus the concept of monoclonal gammopathy of renal significance (MGRS) has emerged. Although the hemopathy in these patients is more consistent with monoclonal gammopathy of undetermined significance (MGUS) than with multiple myeloma, the diagnosis of a renal complication changes the therapeutic management. Preservation and restoration of renal function is possible with treatment targeting the responsible clone. In this article, we take as an example immunotactoid and fibrillary glomerulopathies, two distinct entities with different etiologies and consequently different management. Immunotactoid glomerulopathy is most often associated with monoclonal gammopathy or chronic lymphocytic leukemia, the deposits on renal biopsy are monotypic, and treatment is therefore based on clone targeting. Fibrillary glomerulonephritis, on the other hand, is caused by autoimmune diseases or solid cancers. Deposits on renal biopsy are in the vast majority polyclonal. There is a specific immunohistochemical marker, DNAJB9, and treatment is less well established.
Collapse
Affiliation(s)
- Marie-Camille Lafargue
- Université Paris Cité, Assistance Publique-hôpitaux de Paris, hôpital Necker, service de néphrologie, 149, rue de Sèvres, 75015 Paris, France
| | - Camille Cohen
- Inserm U1151 « mechanisms and therapeutic strategies of chronic kidney diseases », hôpital Necker, université Paris Cité, service de néphrologie et transplantation rénale, hôpital Necker, Assistance Publique-hôpitaux de Paris, Paris, France.
| |
Collapse
|
4
|
Xu M, Li G, Li J, Xiong H, He S. Pharmacovigilance for rare diseases: a bibliometrics and knowledge-map analysis based on web of science. Orphanet J Rare Dis 2023; 18:303. [PMID: 37752556 PMCID: PMC10523788 DOI: 10.1186/s13023-023-02915-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/07/2023] [Indexed: 09/28/2023] Open
Abstract
OBJECTIVES The aims of this paper is to search and explore publications in the field of pharmacovigilance for rare diseases and to visualize general information, research hotspots, frontiers and future trends in the field using the bibliometric tool CiteSpace to provide evidence-based evidence for scholars. METHODS We searched the Web of Science Core Collection (WoSCC) for studies related to pharmacovigilance for rare diseases, spanning January 1, 1997-October 25, 2022. CiteSpace software was utilized to discuss countries/regions, institutions, authors, journals, and keywords. RESULTS After screening, a total of 599 valid publications were included in this study, with a significant upward trend in the number of publications. These studies were from 68 countries/regions with the United States and the United Kingdom making the largest contributions to the field. 4,806 research scholars from 493 institutions conducted studies on pharmacovigilance for rare diseases. Harvard University and University of California were the top two productive institutions in the research field. He Dian of the Affiliated Hospital of Guizhou Medical University and Peter G.M. Mol of the University of Groningen, The Netherlands, were the two most prolific researchers. The Cochrane Database of Systematic Reviews and the New England Journal of Medicine were the journals with the highest number of articles and co-citation frequency respectively. Clinical trial, therapy and adverse event were the top three most cited keywords. CONCLUSIONS Based on keywords co-occurrence analysis, four research topics were identified: orphan drug clinical trials, postmarketing ADR surveillance for orphan drugs, rare diseases and orphan drug management, and diagnosis and treatment of rare diseases. Immune-related adverse reactions and benefit-risk assessment of enzyme replacement therapy were at the forefront of research in this field. Treatment outcomes, early diagnosis and natural history studies of rare diseases may become hotspots for future research.
Collapse
Affiliation(s)
- Mengdan Xu
- School of Clinical Pharmacy, Guangdong Pharmaceutical University, Guangzhou, Guangdong, China.
- NMPA Key Laboratory for Technology Research and Evaluation of Pharmacovigilance, Guangzhou, Guangdong, China.
| | - Guozhi Li
- NMPA Key Laboratory for Technology Research and Evaluation of Pharmacovigilance, Guangzhou, Guangdong, China
| | - Jiazhao Li
- School of Clinical Pharmacy, Guangdong Pharmaceutical University, Guangzhou, Guangdong, China
| | - Huiyu Xiong
- Center for ADR Monitoring of Guangdong, Guangzhou, Guangdong, China
| | - Suzhen He
- The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, China
| |
Collapse
|
5
|
Feng Y, Wang W, Li G, Zhang P. A case of membranous immunotactoid glomerulopathy misdiagnosed as membranous nephropathy: significance of electron microscopy in kidney biopsy. Ren Fail 2023; 45:2249102. [PMID: 38532725 DOI: 10.1080/0886022x.2023.2249102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/13/2023] [Indexed: 03/28/2024] Open
Affiliation(s)
- Yunlin Feng
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, 610072 China
- Renal Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Wei Wang
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, 610072 China
| | - Guisen Li
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, 610072 China
| | - Ping Zhang
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, 610072 China
| |
Collapse
|
6
|
Karam S, Haidous M, Dalle IA, Dendooven A, Moukalled N, Van Craenenbroeck A, Bazarbachi A, Sprangers B. Monoclonal gammopathy of renal significance: Multidisciplinary approach to diagnosis and treatment. Crit Rev Oncol Hematol 2023; 183:103926. [PMID: 36736510 DOI: 10.1016/j.critrevonc.2023.103926] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a hemato-nephrological term referring to a heterogeneous group of kidney disorders characterized by direct or indirect kidney injury caused by a monoclonal immunoglobulin (MIg) produced by a B cell or plasma cell clone that does not meet current hematologic criteria for therapy. MGRS-associated kidney diseases are diverse and can result in the development of end stage kidney disease (ESKD). The diagnosis is typically made by nephrologists through a kidney biopsy. Many distinct pathologies have been identified and they are classified based on the site or composition of the deposited Mig, or according to histological and ultrastructural findings. Therapy is directed towards the identified underlying clonal population and treatment decisions should be coordinated between hematologists and nephrologists in a multidisciplinary fashion, depend on the type of MGRS, the degree of kidney function impairment and the risk of progression to ESKD.
Collapse
Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, United States
| | - Mohammad Haidous
- Department of Medicine, Saint Vincent Charity Medical Center, Cleveland, OH, United States
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amélie Dendooven
- Department of Pathology, University Hospital Ghent, Ghent, Belgium
| | - Nour Moukalled
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amaryllis Van Craenenbroeck
- Department of Microbiology, Immunology and Transplantation, Laboratory of Nephrology, KU Leuven, Leuven, Belgium; Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ben Sprangers
- Biomedical Research Institute, Department of Immunology and Infection, University Hasselt, Diepenbeek, Belgium; Department of Nephrology, Ziekenhuis Oost-Limburg, Genk, Belgium.
| |
Collapse
|
7
|
Kidney Transplantation in Patients With Monoclonal Gammopathy of Renal Significance. Transplantation 2022; 107:1056-1068. [PMID: 36584374 DOI: 10.1097/tp.0000000000004443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Monoclonal gammopathy of renal significance (MGRS) defines disorders characterized by direct or indirect kidney injury caused by a monoclonal immunoglobulin produced by a B-cell or plasma-cell clone that does not meet current hematologic criteria for therapy. MGRS-associated kidney diseases are diverse and can result in the development of end-stage kidney disease. The current paradigm states that the underlying hematologic condition should be treated and in deep remission before kidney transplantation can be performed because recurrence has been reported for all MGRS-associated kidney diseases. However, we suggest that decisions regarding kidney transplantation in MGRS patients should be individualized considering many factors such as the subtype of MGRS-associated kidney disease, patient age and comorbidity, presence and risk of extrarenal complications, estimated waiting time, the availability of a living kidney donor, and previous hematological treatment and response. Thus, kidney transplantation should be considered even in treatment-naive patients, with hematological treatment initiated after successful kidney transplantation.
Collapse
|
8
|
Bu L, Javaugue V, Chauvet S, Napier J, Dasari S, Theis JD, Vrana JA, McPhail ED, Nasr SH. Light Chain-Only Immunotactoid Glomerulopathy: A Case Report. Am J Kidney Dis 2022; 81:611-615. [PMID: 36328099 DOI: 10.1053/j.ajkd.2022.08.025] [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: 05/25/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022]
Abstract
The monotypic variant of immunotactoid glomerulopathy (ITG), strongly associated with low-grade lymphoproliferative disorders, is characterized histologically by glomerulonephritis and microtubular deposits of monoclonal immunoglobulin G (IgG). We report a patient with high-risk κ light chain multiple myeloma who presented with acute kidney injury, hematuria, proteinuria, and hypocomplementemia. Kidney biopsy revealed immunotactoid glomerulopathy concomitant with κ light chain myeloma cast nephropathy. The glomerular microtubular deposits stained for κ light chain and C3 only. Proteomic analysis of glomeruli and atypical casts detected κ light chain constant domain and a single VL variability subgroup (IGKV3) in both glomeruli and casts (without γ, α, or μ heavy chain or λ light chain). C3, C5, C6, C7, and C9 were detected in glomeruli. No autoantibodies against alternative pathway of complement proteins were detected. Despite clone-directed chemotherapy, the patient remained on dialysis treatment. For this light chain-only variant of immunotactoid glomerulopathy, pathogenesis potentially involves activation of the alternative pathway of complement by a nephrotoxic κ light chain.
Collapse
Affiliation(s)
- Lihong Bu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
| | - Vincent Javaugue
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, 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
| | - Jerold Napier
- Up Health System Medical Specialists, Marquette, Michigan
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
| |
Collapse
|
9
|
Javaugue V, Valeri AM, Sathick IJ, Said SM, Damgard SE, Murray DL, Klobucher T, Andeen NK, Sethi S, Fervenza FC, Leung N, Nasr SH. The characteristics of seronegative and seropositive non-hepatitis-associated cryoglobulinemic glomerulonephritis. Kidney Int 2022; 102:382-394. [PMID: 35513122 DOI: 10.1016/j.kint.2022.03.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/15/2022] [Accepted: 03/30/2022] [Indexed: 12/14/2022]
Abstract
cryoglobulinemic glomerulonephritis (CryoGN) are not well-defined and cases with undetectable serum cryoglobulin (seronegative CryoGN) have not been investigated. Corresponding author: To resolve this, we retrospectively identified 81 patients with biopsy-proven non-hepatitis CryoGN, including 22 with seronegative CryoGN. The median age was 61 years and 76% presented with nephritic syndrome. A hematologic condition was found in 89% of patients, including monoclonal gammopathy of renal significance (65%) and symptomatic lymphoproliferative disorder (35%). In the seropositive group, 56% had type II, 29% type I, 8% type III cryoglobulin. Extrarenal manifestations, mostly of skin, were present in 64% and were significantly less common in seronegative CryoGN. Glomerular deposits by immunofluorescence were IgM dominant (84%) and polytypic (70%) in the seropositive group, whereas 52% of seronegative cases had monotypic deposits (i.e., type I cryoglobulin). Ultrastructurally, the deposits were organized in 77% of cases. Substructure appearance significantly differed according to the type of CryoGN, forming most commonly short cylindrical structures in type II and other organized substructures in type I CryoGN. Most patients were treated with clone-directed therapy. On follow up (median 33 months), 77% had partial or complete remission, 10% reached kidney failure and 14% died. Predictors of kidney failure on univariate analysis were AKIN stage 3, positive rheumatoid factor and biclonal gammopathy at diagnosis. We conclude that most CryoGN cases (types I and II) are due to hematologic condition and are associated with favorable outcome after clone-directed therapy. Seronegative CryoGN accounts for about a quarter of cases and is mostly a kidney-limited disease. Thus, further investigations are needed to unravel the pathophysiology of seronegative CryoGN.
Collapse
Affiliation(s)
- Vincent Javaugue
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France.
| | - Anthony M Valeri
- Division of Nephrology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Insara Jaffer Sathick
- Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samar M Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tyler Klobucher
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicole K Andeen
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernando C Fervenza
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| |
Collapse
|
10
|
Santoriello D, Nasr SH. Novel approaches beyond standard immunofluorescence for kidney biopsies. Curr Opin Nephrol Hypertens 2022; 31:221-227. [PMID: 35256574 DOI: 10.1097/mnh.0000000000000783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Immunofluorescence on frozen tissue (IF-F) utilizing antibodies against immunoglobulin (Ig) heavy and light chains (IgA, IgG and IgM, kappa and lambda) and components of classical and alternative complement pathways (C1q, C3c and C4) is the standard of renal pathology. However, conventional IF-F has limitations, particularly in nephropathies associated with organized and/or monoclonal Ig deposits. This review will discuss new applications of established methods beyond conventional IF-F and recent novel immunohistochemical methods. RECENT FINDINGS The combined application of paraffin immunofluorescence (IF-P) and IgG subtype staining excluded monotypic deposits in 62-66% of DNA J homolog subfamily B member 9-associated fibrillary glomerulonephritis (FGN) with apparent monotypic deposits by IF-F, whereas IF-P unmasks IgG deposits in a subset of cases of immunotactoid glomerulopathy. A novel IF technique targeting epitopes at the junction of the Ig heavy and light chains was introduced and unmasked polytypic deposits in a subset of glomerulonephritis with apparent monotypic deposits on IF-F. A recent study described the successful application of co-detection by indexing (CODEX) multiplexed IF to visualize more than a dozen target antigens within a single kidney tissue section. Finally, immunohistochemical protocols for detection of the novel antigens in membranous nephropathy have already entered the clinical practice of renal pathology. SUMMARY Novel ancillary techniques in renal pathology have the potential to significantly enhance our ability to evaluate renal biopsies.
Collapse
Affiliation(s)
- Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
11
|
Sethi S, De Vriese AS, Fervenza FC. Acute glomerulonephritis. Lancet 2022; 399:1646-1663. [PMID: 35461559 DOI: 10.1016/s0140-6736(22)00461-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
Glomerulonephritis is a heterogeneous group of disorders that present with a combination of haematuria, proteinuria, hypertension, and reduction in kidney function to a variable degree. Acute presentation with full blown nephritic syndrome or rapidly progressive glomerulonephritis is uncommon and is mainly restricted to patients with post-infectious glomerulonephritis, anti-neutrophil cytoplasmic antibodies-associated vasculitis, and anti-glomerular basement membrane disease. Most frequently, patients present with asymptomatic haematuria and proteinuria with or without reduced kidney function. All glomerulonephritis disorders can show periods of exacerbation, but disease flairs characteristically occur in patients with IgA nephropathy or C3 glomerulopathy. The gold standard for the diagnosis of a glomerulonephritis is a kidney biopsy, with a hallmark glomerular inflammation that translates into various histopathological patterns depending on the location and severity of the glomerular injury. Traditionally, glomerulonephritis was classified on the basis of the different histopathological patterns of injury. In the last few years, substantial progress has been made in unravelling the underlying causes and pathogenetic mechanisms of glomerulonephritis and a causal approach to the classification of glomerulonephritis is now favoured over a pattern-based approach. As such, glomerulonephritis can be broadly classified as immune-complex glomerulonephritis (including infection-related glomerulonephritis, IgA nephropathy, lupus nephritis, and cryoglobulinaemic glomerulonephritis), anti-neutrophil cytoplasmic antibodies-associated (pauci-immune) glomerulonephritis, anti-glomerular basement membrane glomerulonephritis, C3 glomerulopathy, and monoclonal immunoglobulin-associated glomerulonephritis. We provide an overview of the clinical presentation, pathology, and the current therapeutic approach of the main representative disorders in the spectrum of glomerulonephritis.
Collapse
Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
| | | |
Collapse
|
12
|
Mohamed MW, Al-Hammadi M, Hussein AM, Alarab D, Albreak HA, Tungekar MF, Dandi B. Immunotactoid glomerulopathy - an enigmatic case in the setting of nodal marginal zone lymphoma and systemic sclerosis sine scleroderma. BMC Nephrol 2022; 23:103. [PMID: 35291980 PMCID: PMC8922905 DOI: 10.1186/s12882-022-02730-w] [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: 12/14/2021] [Accepted: 03/09/2022] [Indexed: 12/01/2022] Open
Abstract
Background Immunotactoid Glomerulopathy (ITG) is an exceedingly rare type of glomerulopathy characterised by distinctive electron microscopic features. ITG has been linked to lymphoproliferative or autoimmune disorders. The clinical manifestations are diverse including nephrotic syndrome (NS), haematuria, acute kidney injury and end stage renal failure (ESRD). We present a case with a stage 3 Nodal Marginal Zone Lymphoma (NMZL) and systemic sclerosis sine scleroderma (SSSS), where the evolution of ITG was documented in 2 renal biopsies 19 months apart. To the best of our knowledge, no cases have been reported linking ITG to NMZL. Furthermore, there is only one non-peer reviewed report linking ITG to scleroderma. We discuss the implications of our findings and highlight the satisfactory management of the case. Case presentation A 79-year-old female with history of systemic sclerosis sine scleroderma and stage 3 NMZL presented with acute kidney injury and NS on a background of chronic kidney disease. Her first kidney biopsy showed a diffuse proliferative glomerulonephritis and her serum protein electrophoresis showed no abnormalities. She was managed satisfactorily with conservative measures. She returned 19 months later with features of fluid overload, increasing proteinuria and rising serum creatinine. A repeat serum protein electrophoresis showed excess free kappa light chains and ITG was detected in the repeat kidney biopsy. Her kidney function and proteinuria showed a good and sustained response to rituximab administered after the second biopsy. Conclusion ITG is a rare type of glomerulopathy, associated with underlying haematological malignancies and autoimmune disorders that may result in ESRD. Rituximab is one of the effective agents used in the management of ITG with haematological malignancies.
Collapse
Affiliation(s)
- Mohamed Wael Mohamed
- Internal Medicine Department, King Hamad University Hospital, Muharraq, Kingdom of Bahrain.
| | - Mariam Al-Hammadi
- Internal Medicine Department, King Hamad University Hospital, Muharraq, Kingdom of Bahrain
| | - Ali Mohammad Hussein
- Internal Medicine Department, King Hamad University Hospital, Muharraq, Kingdom of Bahrain
| | - Daher Alarab
- Internal Medicine Department, King Hamad University Hospital, Muharraq, Kingdom of Bahrain
| | - Hisham Ahmad Albreak
- Internal Medicine Department, King Hamad University Hospital, Muharraq, Kingdom of Bahrain.,Nephrology Unit, King Hamad University Hospital, Muharraq, Kingdom of Bahrain
| | - Mohammad Fahim Tungekar
- Uranologics Ltd, London, United Kingdom & Expressmed Laboratories, Manama, Kingdom of Bahrain
| | - Balaji Dandi
- Internal Medicine Department, King Hamad University Hospital, Muharraq, Kingdom of Bahrain.,Nephrology Unit, King Hamad University Hospital, Muharraq, Kingdom of Bahrain
| |
Collapse
|
13
|
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.
Collapse
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.
| |
Collapse
|
14
|
Sy-Go JPT, Herrmann SM, Seshan SV. Monoclonal Gammopathy-Related Kidney Diseases. Adv Chronic Kidney Dis 2022; 29:86-102.e1. [PMID: 35817530 DOI: 10.1053/j.ackd.2022.01.004] [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: 07/14/2021] [Revised: 12/09/2021] [Accepted: 01/18/2022] [Indexed: 11/11/2022]
Abstract
Monoclonal gammopathies occur secondary to a broad range of clonal B lymphocyte or plasma cell disorders, producing either whole or truncated monoclonal immunoglobulins. The kidneys are often affected by these monoclonal proteins, and, although not mutually exclusive, can involve the glomeruli, tubules, interstitium, and vasculature. The nephrotoxic potential of these monoclonal proteins is dependent on a variety of physicochemical characteristics that are responsible for the diverse clinicopathologic manifestations, including glomerular diseases with organized deposits, glomerular diseases with granular deposits, and other lesions, such as C3 glomerulopathy and thrombotic microangiopathy with unique pathophysiologic features. The diseases that involve primarily the tubulointerstitial and vascular compartments are light chain cast nephropathy, light chain proximal tubulopathy, crystal-storing histiocytosis, and crystalglobulin-induced nephropathy with distinct acute and chronic clinicopathologic features. The diagnosis of a monoclonal gammopathy-related kidney disease is established by identification of an underlying active or more commonly, low-grade hematologic malignancy, serologic evidence of a monoclonal gammopathy when detectable, and most importantly, monoclonal protein-induced pathologic lesions seen in a kidney biopsy, confirming the association with the monoclonal protein. Establishing a diagnosis may be challenging at times, particularly in the absence of an overt hematologic malignancy, with or without monoclonal gammopathy, such as proliferative glomerulonephritis with monoclonal immunoglobulin deposits. Overall, the treatment is directed against the underlying hematologic disorder and the potential source of the monoclonal protein.
Collapse
Affiliation(s)
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| | - Surya V Seshan
- Department of Anatomic Pathology and Clinical Pathology, Weil Cornell Medical College, New York, NY
| |
Collapse
|
15
|
Javaugue V, Pascal V, Bender S, Nasraddine S, Dargelos M, Alizadeh M, Saintamand A, Filloux M, Derouault P, Bouyer S, Desport E, Jaccard A, Bridoux F, Cogné M, Sirac C. RNA-based immunoglobulin repertoire sequencing is a new tool for the management of monoclonal gammopathy of renal (kidney) significance. Kidney Int 2021; 101:331-337. [PMID: 34767830 DOI: 10.1016/j.kint.2021.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 09/07/2021] [Accepted: 10/01/2021] [Indexed: 11/16/2022]
Abstract
The diagnostic approach of monoclonal gammopathy of renal significance is based on the detection of a monoclonal immunoglobulin in the blood and urine, and the identification of the underlying clone through bone marrow and/or peripheral blood cytologic and flow cytometry analysis. However, the monoclonal component and its corresponding clone may be undetectable using these routine techniques. Since clone identification is the cornerstone for guiding therapy and assessing disease response, more sensitive methods are required. We recently developed a high-throughput sequencing assay from bone marrow mRNA encoding immunoglobulins (RACE-RepSeq). This technique provides both full-length V(D)J region (variable, diversity and joining genes that generate unique receptors as antigen receptors) of the monoclonal immunoglobulin and the dominant immunoglobulin repertoire. This allows analysis of mutational patterns, immunoglobulin variable gene frequencies and diversity due to somatic hypermutation. Here, we evaluated the diagnostic performance of RACE-RepSeq in 16 patients with monoclonal-associated kidney lesions, and low serum monoclonal immunoglobulin and free light chain levels at diagnosis. Bone marrow immunohistochemical analysis was negative in all 11 patients so tested and 7 of 12 patients had no detectable clone matching the kidney deposits using flow cytometry analysis. By contrast, RACE-RepSeq detected a dominant clonal light chain sequence of matched isotype with respect to kidney deposits in all patients. Thus, high throughput mRNA sequencing appears highly sensitive to detect subtle clonal disorders in monoclonal gammopathy of renal significance and suggest this novel approach could help improve the management of this kidney disease.
Collapse
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; Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales
| | - Virginie Pascal
- CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France; Laboratory of Immunology and Immunogenetics, Centre Hospitalier Universitaire de Limoges, Limoges, France; Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales
| | - Sébastien Bender
- CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France; Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales
| | - Sarah Nasraddine
- Laboratory of Immunology and Immunogenetics, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Mathilde Dargelos
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales
| | - Mehdi Alizadeh
- Etablissement Français du Sang Bretagne, Plateforme de Biotechnologies Innovantes, Rennes, France
| | | | - Matthieu Filloux
- Laboratory of Immunology and Immunogenetics, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Paco Derouault
- Centre Hospitalier Universitaire de Limoges, Bioinformatic Functional Unit, Limoges France
| | - Sabrina Bouyer
- Laboratory of Hematology, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
| | - Estelle Desport
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales
| | - Arnaud Jaccard
- CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France; Department of Hematology, Centre Hospitalier Universitaire, Université de Limoges, Limoges, France; Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales
| | - 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; Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales
| | - Michel Cogné
- CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France; INSERM U1236, Université Rennes 1, Rennes, France; Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales.
| | - Christophe Sirac
- CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France; Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales.
| |
Collapse
|
16
|
The Clone Wars: Diagnosing and Treating Dysproteinemic Kidney Disease in the Modern Era. J Clin Med 2021; 10:jcm10081633. [PMID: 33921394 PMCID: PMC8069250 DOI: 10.3390/jcm10081633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 11/17/2022] Open
Abstract
Dysproteinemic kidney diseases are disorders that occur as the result of lymphoproliferative (B cell or plasma cell) disorders that cause kidney damage via production of nephrotoxic monoclonal immunoglobulins or their components. These monoclonal immunoglobulins have individual physiochemical characteristics that confer specific nephrotoxic properties. There has been increased recognition and revised characterization of these disorders in the last decade, and in some cases, there have been substantial advances in disease understanding and treatments, which has translated to improved patient outcomes. These disorders still present challenges to nephrologists and patients, since they are rare, and the field of hematology is rapidly changing with the introduction of novel testing and treatment strategies. In this review, we will discuss the clinical presentation, kidney biopsy features, hematologic characteristics and treatment of dysproteinemic kidney diseases.
Collapse
|
17
|
Hogan JJ, Vogl DT. Untangling immunotactoid glomerulopathy in the MGRS era. Kidney Int 2021; 99:303-305. [PMID: 33509349 DOI: 10.1016/j.kint.2020.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/31/2022]
Abstract
Immunotactoid glomerulopathy (ITG) is a rare disease diagnosed by kidney biopsy showing characteristic microtubules, often in parallel arrays, in glomeruli on electron microscopy. Most cases are caused by lymphoproliferative disorders that produce monoclonal immunoglobulins that cause kidney damage, but these disorders do not meet criteria for overt malignancy. The published literature on ITG is limited. In this issue of Kidney International, 2 manuscripts provide significant insight into the clinical presentation, pathology, and treatment of ITG.
Collapse
Affiliation(s)
- Jonathan J Hogan
- Division of Nephrology Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Dan T Vogl
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| |
Collapse
|
18
|
Kudose S, Canetta P, Andeen NK, Stokes MB, Batal I, Markowitz GS, D’Agati VD, Santoriello D. Diagnostic Approach to Glomerulonephritis With Fibrillar IgG Deposits and Light Chain Restriction. Kidney Int Rep 2021; 6:936-945. [PMID: 33912743 PMCID: PMC8071626 DOI: 10.1016/j.ekir.2021.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/03/2020] [Accepted: 01/04/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction The pathologic approach to glomerulonephritis (GN) with fibrillar IgG deposits and light chain restriction remains a diagnostic challenge. Method All GN with fibrillar deposits of IgG and apparent light chain restriction on standard immunofluorescence on frozen tissue (IF-F) accessioned at the Columbia Renal Pathology Laboratory from 2012 to 2019 were identified. Additional studies including staining for Congo red, DNAJB9, IgG subtypes, and immunofluorescence on pronase-digested paraffin sections (IF-P) were performed. Result Based on the results, biopsy samples were reclassified as polytypic DNAJB9-positive fibrillary glomerulonephritis (pFGN, n = 14), monotypic DNAJB9-positive FGN (mFGN, n = 7), GN with polytypic DNAJB9-negative fibrillar IgG deposits (n = 2), and GN with monotypic DNAJB9-negative fibrillar IgG deposits (n = 6). Among DNAJB9-positive FGN samples, IgG subtype staining was able to exclude monotypic deposits by demonstrating reactivity for ≥2 IgG subtypes (usually IgG1 and IgG4) in 67% (14 of 21), including 9 that would have been misclassified as monotypic by IF-F and IF-P alone. Monotypic DNAJB9-positive fibrillary glomerulonephritis (FGN) was not associated with monoclonal gammopathy in 5 of 6 patients. GN with monotypic DNAJB9-negative fibrillar IgG deposits exhibited focal parallel fibril alignment and frequent association with chronic lymphocytic leukemia, but lacked the diagnostic microtubules of immunotactoid GN. Conclusion A systematic diagnostic approach with ancillary techniques is essential for proper classification and assignment of monoclonal gammopathy of renal significance status in cases of GN with fibrillary IgG deposits and light chain restriction by IF-F.
Collapse
Affiliation(s)
- Satoru Kudose
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Pietro Canetta
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Nicole K. Andeen
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - M. Barry Stokes
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Glen S. Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vivette D. D’Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
- Correspondence: Dominick Santoriello, Department of Pathology, Columbia University Irving Medical Center, 630 West 168th Street, Room VC14-224, New York, New York 10032, USA.
| |
Collapse
|