1
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Stavart L, Halfon M, Dewarrat N, Rotman S, Golshayan D. Case report: Bruton tyrosine kinase inhibitor as therapy for chronic lymphocytic leukemia infiltrating a kidney allograft. Front Med (Lausanne) 2024; 11:1451264. [PMID: 39267975 PMCID: PMC11390570 DOI: 10.3389/fmed.2024.1451264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Accepted: 08/07/2024] [Indexed: 09/15/2024] Open
Abstract
The burden of chronic lymphocytic leukemia (CLL) in the prognosis of solid organ transplant (SOT) recipients seems non-negligible. Whether transplanting a patient with previous CLL is safe or what is the optimal monitoring and treatment management after transplantation is still unclear and only based on few case series and reports. Therefore, we aimed to contribute to this understanding by reporting the first documented case of a clinically significant CLL with biopsy-proven infiltration of the kidney allograft and its successful management with a Bruton tyrosine kinase inhibitor (BTKi). We then reviewed the related literature, with a focus on CLL and kidney transplantation. Our main message is that BTKi may represent a safe and effective intervention to prevent the hazardous patient and graft outcomes of CLL in SOT patients.
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Affiliation(s)
- Louis Stavart
- Transplantation Center and Transplantation Immunopathology Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Matthieu Halfon
- Transplantation Center and Transplantation Immunopathology Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Natacha Dewarrat
- Service and Central Laboratory of Hematology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Samuel Rotman
- Institute of Pathology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Dela Golshayan
- Transplantation Center and Transplantation Immunopathology Laboratory, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Faculty of Biology and Medicine, University of Lausanne (UNIL), Lausanne, Switzerland
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2
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Udomkarnjananun S, Suttaluang C, Surintrspanont J, Kanjanabuch T. Leukocytoclastic vasculitis as a presenting symptom of immunotactoid glomerulopathy. Nephrology (Carlton) 2024. [PMID: 39092806 DOI: 10.1111/nep.14377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/01/2024] [Accepted: 07/24/2024] [Indexed: 08/04/2024]
Affiliation(s)
- Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence Renal Immunology and Renal Transplantation, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Chalermchon Suttaluang
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Jerasit Surintrspanont
- Department of Pathology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Talerngsak Kanjanabuch
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Center of Excellence in Kidney Metabolic Disorders, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
- CAPD Excellent Center, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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3
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Ali K, Agrawal A, Karan A, Marsalisi C, O'Brien MC, Liu S, Jaikaransingh V. Immunotactoid Glomerulopathy Masquerading as Heart Failure. Cureus 2024; 16:e63687. [PMID: 39092324 PMCID: PMC11293071 DOI: 10.7759/cureus.63687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 07/01/2024] [Indexed: 08/04/2024] Open
Abstract
Immunotactoid glomerulopathy (ITG) is a rare form of glomerular disease. It is characterized by organized, dense immunoglobulin deposits in the glomerulus, impairing glomerular function and filtration. The prognosis tends to be poor, and the majority of patients develop end-stage renal disease (ESRD). Here, we present a case of a young male with no prior medical history who presented with anasarca. His presentation was initially thought to be due to a new diagnosis of heart failure with a decreased ejection fraction. However, significant proteinuria led to a diagnosis of ITG.
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Affiliation(s)
- Kabeer Ali
- Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Avni Agrawal
- Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Abhinav Karan
- Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | | | - Melville C O'Brien
- Internal Medicine, University of Florida College of Medicine, Jacksonville, USA
| | - Shiguang Liu
- Pathology and Laboratory Medicine, University of Florida College of Medicine, Jacksonville, USA
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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.
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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.
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5
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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.
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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.
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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.
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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.
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Nasr SH, Kudose S, Valeri AM, Kashkouli A, Said SM, Santoriello D, Markowitz GS, Bu L, Cornell LD, Samad A, Ahmed J, Sethi S, Leung N, D'Agati VD. Clinicopathologic Characteristics of Crystalglobulin-Induced Nephropathy: A Case Series. Am J Kidney Dis 2024:S0272-6386(24)00837-0. [PMID: 38908425 DOI: 10.1053/j.ajkd.2024.04.019] [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: 02/13/2024] [Revised: 04/17/2024] [Accepted: 04/24/2024] [Indexed: 06/24/2024]
Abstract
RATIONALE & OBJECTIVE Crystalglobulinemia is a rare syndrome characterized by intravascular crystallization of monoclonal immunoglobulins (MIg). Data on kidney involvement are limited to case reports. This series characterizes the clinicopathologic spectrum of crystalglobulin-induced nephropathy (CIN). STUDY DESIGN Case series. SETTING & PARTICIPANTS Nineteen CIN cases identified from the nephropathology archives of Mayo Clinic and Columbia University. CIN was defined by intravascular (extracellular) MIg crystals visible by light microscopy (LM) and electron microscopy (EM). RESULTS Among the cases, 68% were male, and 65% were Caucasian (median age, 56 years). Most patients presented with severe acute kidney injury (AKI) (median creatinine, 3.5mg/dL), hematuria, and mild proteinuria (median, 1.1g/day). Common extrarenal manifestations were constitutional (67%), cutaneous (56%), and rheumatologic (50%). Fifty percent of cases had hypocomplementemia. The hematologic disorders were monoclonal gammopathy of renal significance (MGRS) (72%), lymphoma (17%), or myeloma (11%), with 65% of these disorders discovered concomitantly with CIN. All patients had MIg identified on serum protein electrophoresis/immunofixation (IgGκ in 65%). The serum free light chain ratio was outside the renal range in 40%, and bone marrow biopsy detected the responsible clone in 67%. On LM, crystals involved glomeruli (100%) and vessels (47%), often with an inflammatory reaction (89%) and fibrin (58%). All cases exhibited crystal substructures (mostly paracrystalline) by EM. Immunofluorescence on paraffin-embedded tissue was more sensitive than frozen tissue (92% vs 47%) for demonstrating the crystal composition (IgGκ in 63%). Follow-up observation (median, 20 months) was available in 16 patients. Eighty-one percent received steroids, 44% plasmapheresis, 38% hemodialysis, and 69% chemotherapy. Ninety-percent of patients who received clone-directed therapy achieved kidney recovery versus 20% of those who did not (P=0.02). LIMITATIONS Retrospective design, small sample size. CONCLUSIONS CIN is a rare cause of nephropathy associated with lymphoplasmacytic disorders (mostly MGRS) and typically presents with severe AKI and extrarenal manifestations. Diagnosis often requires immunofluorescence performed on paraffin-embedded kidney tissue. Prompt initiation of clone-directed therapy, coupled with corticosteroids and plasmapheresis, may lead to recovery of kidney function.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Rochester, Minnesota.
| | - Satoru Kudose
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Anthony M Valeri
- Division of Nephrology, Columbia University Medical Center, New York, New York
| | - Ali Kashkouli
- Division of Renal Medicine; Emory University, Atlanta, Georgia
| | - Samar M Said
- Mayo Clinic, and Department of Pathology, Olmsted County Medical Center, Rochester, Minnesota
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Lihong Bu
- Department of Laboratory Medicine and Pathology, Rochester, Minnesota
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Rochester, Minnesota
| | - Adel Samad
- Kidney and Hypertension Associates, Orland Park, Illinois
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Rochester, Minnesota
| | | | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York.
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8
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Yu SMW, Deoliveira M, Chung M, Lafayette R. Membranoproliferative Glomerulonephritis Pattern of Injury. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:216-222. [PMID: 39004461 PMCID: PMC11251708 DOI: 10.1053/j.akdh.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 02/24/2024] [Accepted: 03/13/2024] [Indexed: 07/16/2024]
Abstract
Membranoproliferative glomerulonephritis (MPGN) is no longer a disease but a pattern of injury in various diseases. Characterized by electron-dense deposits, mesangial proliferation, and duplication of the glomerular basement membrane, MPGN was previously classified by findings seen by electron microscopy. However, recognizing complement dysfunction in relation to cases with the MPGN pattern of injury substantially changed our view of its pathogenesis. A new classification, including immune complex-mediated and complement-mediated MPGN, has become preferable and has been adopted by international guidelines. Despite these advancements, accurate diagnosis of MPGN remains a clinical challenge, given the pathological and clinical similarities between immune complex-mediated and complement-mediated MPGN. Additional testing, such as molecular and genetic testing, is often necessary. Here, we will summarize our current understanding of the MPGN pattern of injury from a pathology perspective as an introductory article in the following chapters.
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Affiliation(s)
| | | | - Miriam Chung
- Division of Nephrology, Mount Sinai Hospital, New York, NY
| | - Richard Lafayette
- Division of Nephrology, Stanford University Medical Center, Stanford, CA
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9
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Medeiros LJ, Chadburn A, Natkunam Y, Naresh KN. Fifth Edition of the World Health Classification of Tumors of the Hematopoietic and Lymphoid Tissues: B-cell Neoplasms. Mod Pathol 2024; 37:100441. [PMID: 38309432 DOI: 10.1016/j.modpat.2024.100441] [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: 10/03/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
We review B-cell neoplasms in the 5th edition of the World Health Organization classification of hematolymphoid tumors (WHO-HEM5). The revised classification is based on a multidisciplinary approach including input from pathologists, clinicians, and other experts. The WHO-HEM5 follows a hierarchical structure allowing the use of family (class)-level definitions when defining diagnostic criteria are partially met or a complete investigational workup is not possible. Disease types and subtypes have expanded compared with the WHO revised 4th edition (WHO-HEM4R), mainly because of the expansion in genomic knowledge of these diseases. In this review, we focus on highlighting changes and updates in the classification of B-cell lymphomas, providing a comparison with WHO-HEM4R, and offering guidance on how the new classification can be applied to the diagnosis of B-cell lymphomas in routine practice.
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Affiliation(s)
- L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Amy Chadburn
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Yasodha Natkunam
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Kikkeri N Naresh
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle; Section of Pathology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle
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10
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Leung N, Heybeli C. Kidney Transplantation in Multiple Myeloma and Monoclonal Gammopathy of Renal Significance. Semin Nephrol 2024; 44:151497. [PMID: 38485643 DOI: 10.1016/j.semnephrol.2024.151497] [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] [Indexed: 06/30/2024]
Abstract
Recent advances in the treatment of plasma cell disorders (PCDs) have provided a wealth of therapy alternatives and improved overall survival tremendously. Various types of PCDs are associated with kidney injury and end-stage kidney disease in a considerable number of patients. Kidney transplantation (KTx) is the best option for renal replacement therapy in select patients in terms of both quality of life parameters and overall survival. Even with modern therapies, all PCDs carry the risk of hematologic progression, whereas histologic recurrence and graft loss are other prevailing concerns in these patients. The risk of mortality is also higher in some of these disorders compared with KTx recipients who suffer from other causes of kidney disease. Unlike solid cancers, there is no well-defined "waiting time" after hematologic remission before proceeding to KTx. Thus, clinicians are usually reluctant to recommend KTx to patients who develop end-stage kidney disease due to PCDs. This review aims to provide the current evidence on KTx outcomes in patients with monoclonal gammopathy of renal significance and multiple myeloma. Although immunoglobulin light chain amyloidosis is a monoclonal gammopathy of renal significance subtype, KTx outcomes in this group are mentioned in another chapter of this issue.
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Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Cihan Heybeli
- Division of Nephrology, Dokuz Eylül University Hospital, Balcova, Turkey
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11
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Terashita M, Selamet U, Midha S, Nadeem O, Laubach J, Rennke HG, Murakami N. Clinical Outcomes of Monoclonal Gammopathy of Renal Significance Without Detectable Clones. Kidney Int Rep 2023; 8:2765-2777. [PMID: 38106576 PMCID: PMC10719651 DOI: 10.1016/j.ekir.2023.09.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 09/09/2023] [Accepted: 09/11/2023] [Indexed: 12/19/2023] Open
Abstract
Introduction Monoclonal gammopathy of renal significance (MGRS) is characterized by monoclonal immunoglobulin deposition in kidneys. However, monoclonal immunoglobulin and responsible clone(s) are not always detectable. Treatment response and kidney outcome of MGRS without detectable clones remain unclear. Methods In this single-center, retrospective cohort study, we identified MGRS without detectable clones from our biopsy repository between 2010 and 2022. We investigated the correlations between treatment regimens and kidney outcomes defined by proteinuria and estimated glomerular filtration rate (eGFR), and the impact of repeat kidney biopsy. Results Our study cohort included 29 cases (27 native kidney and 2 transplant allograft biopsies) of MGRS without detectable clones. At diagnosis, median serum creatinine was 1.8 mg/dl (interquartile range [IQR] 1.3-2.7), with proteinuria 4.6 g/gCr (IQR 2.3-7.9). Treatment regimens were variable: 6 (21%) received conservative therapy, 13 (45%) received plasma cell clone-directed therapy, 8 (28%) received lymphocytic clone-directed therapy, and 2 (7%) received nonclone-directed immunosuppressive therapy. Of 24 patients with proteinuria >0.5 g/gCr at diagnosis, 9 (38%) and 6 (25%) achieved complete response (CR) and partial response (PR), respectively. If interstitial fibrosis and tubular atrophy (IFTA) was >50% at the initial biopsy, less proportion of patients achieved CR. Six of 7 repeat biopsies showed progression of chronic changes (e.g., IFTA) but provided limited information on treatment response. Conclusion Treatment regimens and outcomes of MGRS without detectable clones were extremely variable. Repeat biopsy provided limited information to assess disease activity or the need for additional treatment. More sensitive tools are needed to detect clones and to assess treatment response.
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Affiliation(s)
- Maho Terashita
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Nephrology and Hypertension, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Umut Selamet
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Shonali Midha
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Jerome Lipper Multiple Myeloma Center, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Omar Nadeem
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Jerome Lipper Multiple Myeloma Center, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Jacob Laubach
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Medical Oncology, Dana Farber Cancer Institute, Boston, Massachusetts, USA
- Jerome Lipper Multiple Myeloma Center, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Helmut G. Rennke
- Harvard Medical School, Boston, Massachusetts, USA
- Pathology Department, Brigham and Women’s Hospital. Boston, Massachusetts, USA
| | - Naoka Murakami
- Renal Division, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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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
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13
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Dzekova-Vidimliski P, Karanfilovski V, Nikolov IG, Rambabova-Bushljetik I, Ristovska V, Petrushevska G, Selim G. Glomerulopathies with Fibrillary Deposits. Pril (Makedon Akad Nauk Umet Odd Med Nauki) 2023; 44:99-106. [PMID: 37453107 DOI: 10.2478/prilozi-2023-0030] [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] [Indexed: 07/18/2023]
Abstract
The glomerulopathies associated with the deposition of extracellular fibrils in the glomeruli are subdivided into Congo red positive (amyloidosis) and Congo red negative (non-amyloidotic glomerulopathies) based on Congo red staining. The non-amyloidotic glomerulopathies are divided into immunoglobulin-derived and non-immunoglobulin-derived glomerulopathies. The immunoglobulin-derived glomerulopathies: fibrillary glomerulopathy (FGn) and immunotactoid glomerulopathy (ITG) are rare glomerulopathies. The diagnosis of fibrillary-immunotactoid glomerulopathy depends on electron microscopy, which shows the presence of microfibrils in the glomeruli. The microfibrils in FGn are randomly arranged with diameters less than 30 nm. The microfibrils in ITG are larger than 30 nm with a visible lumen (microtubules), focally arranged in parallel bundles. Patients with fibrillary-immunotactoid glomerulopathy present with proteinuria (usually in the nephrotic range), microscopic hematuria, arterial hypertension, and chronic kidney disease that progresses to kidney failure over months to years. Currently, there are no guidelines for the treatment of fibrillary-immunotactoid glomerulopathy, although immunotactoid glomerulopathy could be associated with underlying hematologic disorders with the need for clone-directed therapy.
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Affiliation(s)
- Pavlina Dzekova-Vidimliski
- 1University Hospital of Nephrology, Skopje, RN Macedonia
- 2Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Vlatko Karanfilovski
- 1University Hospital of Nephrology, Skopje, RN Macedonia
- 2Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Igor G Nikolov
- 1University Hospital of Nephrology, Skopje, RN Macedonia
- 2Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Irena Rambabova-Bushljetik
- 1University Hospital of Nephrology, Skopje, RN Macedonia
- 2Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Vesna Ristovska
- 1University Hospital of Nephrology, Skopje, RN Macedonia
- 2Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Gordana Petrushevska
- 3Institute for Pathology, Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
| | - Gjulsen Selim
- 1University Hospital of Nephrology, Skopje, RN Macedonia
- 2Faculty of Medicine, Ss. Cyril and Methodius University in Skopje, Skopje, RN Macedonia
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14
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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.
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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.
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15
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Karanfilovski V, Ristovska V, Gjorgjievski N, Nikolov IG, Dzekova-Vidimliski P, Petrushevska G. Immunotactoid Glomerulopathy: A Rare Glomerular Disease Case Study. Indian J Nephrol 2023; 33:140-143. [PMID: 37234440 PMCID: PMC10208538 DOI: 10.4103/ijn.ijn_107_22] [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: 03/20/2022] [Revised: 04/28/2022] [Accepted: 05/13/2022] [Indexed: 11/07/2022] Open
Abstract
Immunotactoid glomerulopathy (ITG) is a rare glomerular disease with variable responsiveness to the immunosuppressive therapy and with uncertain prognosis. ITG was diagnosed in two patients with type 2 diabetes mellitus with nephrotic syndrome and chronic kidney disease. The absence of diabetic retinopathy in the first case and the recent onset of diabetes in the second case accompanied with sudden increase in the 24-hour proteinuria and rapid decline in kidney function, prompted us to perform kidney biopsy. The electron microscopy set the diagnosis of ITG in both cases. There is no consensus for the treatment of ITG. The first patient was treated with combination of steroids and mycophenolate mofetil with reduction of the 24-hour proteinuria, but with persistence of the chronic kidney disease. The second patient received high doses of steroids with continuous deterioration of kidney function with the need of hemodialysis treatment.
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Affiliation(s)
- Vlatko Karanfilovski
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Vesna Ristovska
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Nikola Gjorgjievski
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Igor G. Nikolov
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Pavlina Dzekova-Vidimliski
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Gordana Petrushevska
- Institute of Pathology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
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16
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Rago A, Pettorini L, Andriani A, Caravita di Toritto T. Immunotactoid glomerulopathy and chronic lymphocytic leukemia: The need for a multidisciplinary approach. EJHAEM 2023; 4:266-268. [PMID: 36819169 PMCID: PMC9928648 DOI: 10.1002/jha2.592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 12/15/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in western countries. The association between CLL and glomerular disease (GD) is rare. The most frequent GD associated with CLL is membranoproliferative membranous glomerulonephritis (GN) (MPGN) (45%) types I and II, followed by membranous glomerulonephritis, with the same reports of immunotactoid glomerulopathy (ITG). We report a case of ITG diagnosed on kidney biopsy in a CLL patient and the response of renal parameters to drug treatment for CLL. The patient was treated with several lines of therapies with a good response.
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Affiliation(s)
- Angela Rago
- Haematology Unit, ASL ROMA 1Santo Spirito Hospital of RomeRomeItaly
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17
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Sugita E, Sonoda H, Ryuzaki M, Hashiguchi A, Tokuyama H, Wakino S, Kanda T, Itoh H. Diagnosis of monoclonal immunotactoid glomerulopathy with positive λ chain by immunoelectron microscopy. CEN Case Rep 2023; 12:7-13. [PMID: 35699924 PMCID: PMC9892404 DOI: 10.1007/s13730-022-00714-1] [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: 12/19/2021] [Accepted: 05/24/2022] [Indexed: 02/05/2023] Open
Abstract
We report the case of a 73-year-old-man who developed immunotactoid glomerulopathy (ITG). ITG is a rare disease characterized by proliferative glomerulonephritis and capillary wall deposits with a 10-60 nm diameter microtubular substructure. In monoclonal ITG, immunofluorescence analysis typically exhibits IgG with light chain restriction. Recent reviews recommend distinguishing monoclonal ITG from polyclonal ITG because monoclonal ITG is associated with a higher incidence of hematological disorders and better responsiveness to clone-directed therapy and renal prognosis. In our case, IgG, IgA, and IgM were negative by routine immunofluorescence; however, immunoelectron microscopy revealed positive λ chain. At 6 months after renal biopsy, the IgG λ chain was detected in the serum and urine, reflecting possible monoclonality. Therefore, it is useful to perform immunoelectron microscopy and follow-up with serum and urine protein electrophoresis and immunofixation to diagnose monoclonal ITG, even when routine immunofluorescence shows negative or nonspecific findings.
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Affiliation(s)
- Erina Sugita
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Homare Sonoda
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masaki Ryuzaki
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Akinori Hashiguchi
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hirobumi Tokuyama
- Department of Internal Medicine, Tokyo Dental University Ichikawa General Hospital, 5-11-13 Sugano, Ishikawa-shi, Chiba, 272-8513, Japan
| | - Shu Wakino
- Division of Nephrology, Department of Internal Medicine, Tokushima University School of Medicine, 2-50-1 Kuramoto-cho, Tokushima-shi, Tokushima, 770-8503, Japan
| | - Takeshi Kanda
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Hiroshi Itoh
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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18
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Zhuo N, Wang G, Song P, Liu Y, Li S, Liu Y. A case of seronegative anti-glomerular basement membrane disease with linear IgG deposition. Ren Fail 2022; 44:2006-2009. [PMID: 36377710 PMCID: PMC9673809 DOI: 10.1080/0886022x.2022.2146314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Ning Zhuo
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Gang Wang
- Department of Rheumatology and Immunology, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Panai Song
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yao Liu
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Shuqing Li
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Yinghong Liu
- Department of Nephrology, The Second Xiangya Hospital of Central South University, Changsha, China
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19
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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.
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20
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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.
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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.
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21
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Wang Y, Yan Y, Dong B, Zou W, Li X, Shao C, Jiang L, Wang M, Zuo L. Clinicopathological manifestations of coexistent monoclonal immunoglobulin deposition disease and immunotactoid glomerulopathy. Front Med (Lausanne) 2022; 9:911998. [PMID: 36091681 PMCID: PMC9452626 DOI: 10.3389/fmed.2022.911998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Combination of monoclonal immunoglobulin deposition disease (MIDD) and immunotactoid glomerulopathy (ITG) is a rare form of monoclonal immunoglobulin (MIg)-associated renal disease. We retrospectively reviewed the native kidney biopsy specimens at Peking University People’s Hospital from 2011 to 2020. Five patients were diagnosed as MIDD + ITG. Their clinical and pathological characteristics were studied. The typical clinical features were nephritic syndrome and renal dysfunction with prominent anemia, but hematuria was mild. Unlike single MIDD and single ITG, on light microscopy, segmentally distributed mesangial nodular sclerosis on the basis of mesangial matrix hyperplasia was the major lesion. Others including membranoproliferative glomerulonephritis (MPGN)-like lesion, glomerular basement membrane thickness, and mild to moderate mesangial and endothelial proliferations might presented at the same time and in the same glomeruli. On immunofluorescence, MIg, usually monoclonal light chains, deposited along glomerular basement membranes and tubular basement membranes, while the intact MIg or monoclonal heavy chain deposited in the mesangial regions. Corresponding to the depositions on immunofluorescence, punctate “powdery” deposits along glomerular basement membranes and tubular basement membranes under electronic microscopy indicated the presence of MIDD. Microtubular substructures (diameters of 20–50 nm) exhibiting hollow cores arranged in parallel arrays in mesangial regions indicated the presence of ITG. Patients treated with bortezomib-based regimen seemed to have better outcomes. In conclusion, MIDD + ITG is a rare combination form of MIg-associated renal disease. Accurate diagnosis requires the comprehensive pathological investigations.
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Affiliation(s)
- Yina Wang
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Yu Yan
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
- *Correspondence: Yu Yan,
| | - Bao Dong
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Wanzhong Zou
- Department of Pathology, Peking University Health Science Center, Beijing, China
| | - Xin Li
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Chunying Shao
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Lei Jiang
- Electron Microscope Laboratory, Peking University People’s Hospital, Beijing, China
| | - Mei Wang
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Li Zuo
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
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22
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Yu XJ, Wang SX. Recognizing the true face of noninfectious cryoglobulinemic glomerulonephritis. Kidney Int 2022; 102:238-241. [PMID: 35870814 DOI: 10.1016/j.kint.2022.05.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 05/18/2022] [Accepted: 05/19/2022] [Indexed: 11/15/2022]
Abstract
Cryoglobulinemia encompasses a group of diseases with circulating aberrant Igs, which can cause systemic cryoglobulinemic vasculitis, including cryoglobulinemic glomerulonephritis. The complexities of different types and changing etiologies of cryoglobulinemias determine its heterogeneous clinical manifestations and diagnostic difficulties. In this issue of Kidney International, Javaugue et al. have emphasized the diagnostic points of cryoglobulinemic glomerulonephritis and hematological disorders as the major culprits of noninfectious cryoglobulinemic glomerulonephritis in a large cohort.
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Affiliation(s)
- Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China; Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Su-Xia Wang
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China.
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23
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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.
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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.
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24
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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.
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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
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25
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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.
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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
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26
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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.
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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
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27
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Andeen NK, Abdulameer S, Charu V, Zuckerman JE, Troxell M, Kambham N, Alpers CE, Najafian B, Nicosia RF, Smith KD, Kung VL, Avasare RS, Vallurupalli A, Jefferson JA, Hecox D, Swetnam L, Yamashita M, Lin M, Bissonnette ML, Akilesh S, Hou J. A Diverse Spectrum of Immune Complex- and Complement-Mediated Kidney Diseases Is Associated With Mantle Cell Lymphoma. Kidney Int Rep 2022; 7:568-579. [PMID: 35257069 PMCID: PMC8897291 DOI: 10.1016/j.ekir.2021.12.020] [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: 12/06/2021] [Accepted: 12/13/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction There are limited reports on kidney biopsy findings in patients with mantle cell lymphoma (MCL). Methods We initiated a multi-institutional, retrospective review of kidney biopsy findings in patients with active and treated MCL. Results A total of 30 patients with MCL and kidney biopsies were identified, with a median age of 67 (range 48-87) years, 73% of whom were men. A total of 20 patients had active MCL at the time of biopsy, of whom 14 (70%) presented with acute kidney injury (AKI), proteinuria and/or hematuria, and biopsy findings potentially attributable to lymphoma. Of the 14, 11 had immune complex (IC) or complement-mediated (C3) disease including proliferative glomerulonephritis (GN) with monotypic Ig deposits (PGNMID [2]), C3GN, (2), secondary membranous nephropathy (MN [3]), tubular basement membrane (TBM) deposits (2), and modest lupus-like GN (2). Lymphomatous infiltration was present in 8 of the 20 patients, 5 with coincident IC or C3 lesions. A total of 6 patients with available follow-up were treated for MCL, all with clinical remission of GN (2 PGNMID, 2 C3GN, and 2 MN). Conclusion MCL is associated with diverse monoclonal and polyclonal glomerular and extra-glomerular IC and C3 disease. For patients with active MCL and kidney dysfunction requiring biopsy, 70% had findings due or potentially due to lymphoma, including 55% with IC or C3 disease and 40% had lymphomatous kidney infiltration. IC and C3GN in the setting of active MCL was responsive to lymphoma-directed therapy.
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Affiliation(s)
- Nicole K. Andeen
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Shahad Abdulameer
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Vivek Charu
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Jonathan E. Zuckerman
- Department of Pathology and Laboratory Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Megan Troxell
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Neeraja Kambham
- Department of Pathology, Stanford University, Stanford, California, USA
| | - Charles E. Alpers
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Behzad Najafian
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Roberto F. Nicosia
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Kelly D. Smith
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Vanderlene L. Kung
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Rupali S. Avasare
- Division of Nephrology, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Anusha Vallurupalli
- Center for Hematologic Malignancies, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - J. Ashley Jefferson
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | | | - Leah Swetnam
- Nephrology, Kaiser Permanente, Portland, Oregon, USA
| | - Michifumi Yamashita
- Department of Pathology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Mercury Lin
- Department of Pathology, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Mei Lin Bissonnette
- Department of Pathology, St Paul’s Hospital, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Shreeram Akilesh
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, Washington, USA
| | - Jean Hou
- Department of Pathology, Cedars Sinai Medical Center, Los Angeles, California, USA
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28
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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.
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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
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29
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Kudose S, Jagannathan G, Santoriello D, Sekulic M, Batal I, Stokes MB, D’Agati VD, Markowitz GS. Validation Study on the Utility of Immunoglobulin Heavy/Light Chain Immunofluorescence in Kidney Biopsies with Potential MGRS Lesions. Kidney Int Rep 2022; 7:1119-1122. [PMID: 35570997 PMCID: PMC9091611 DOI: 10.1016/j.ekir.2022.01.1071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Satoru Kudose
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
- Correspondence: Satoru Kudose, Department of Pathology and Cell Biology, Columbia University Irving Medical Center, Room VC14-238, 630 West 168th Street, New York, New York 10032, USA.
| | - Geetha Jagannathan
- 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
| | - Miroslav Sekulic
- 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
| | - M. Barry Stokes
- 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
| | - Glen S. Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
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30
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Shimizu Y, Wakabayashi K, Iwasaki H, Kishida C, Seki S, Okuma T, Iwakami N, Iwasawa T, Maekawa H, Tomino Y, Wada R, Suzuki Y. Immunotactoid Glomerulopathy with Nontuberculous Mycobacterial Infection: A Novel Association. Case Rep Nephrol Dial 2021; 11:136-146. [PMID: 34250031 PMCID: PMC8255749 DOI: 10.1159/000515583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/01/2021] [Indexed: 12/23/2022] Open
Abstract
A 70-year-old woman underwent a renal biopsy due to nephrotic syndrome. She had suffered from nontuberculous mycobacterial infection (NTM) for 14 years. The patient was diagnosed as having membranoproliferative glomerulonephritis (MPGN) type 3 and immunoglobulin (Ig)-associated MPGN based upon LM/erythromycin and IF findings, respectively. In high-magnification imaging, electron-dense deposits showed immunotactoid glomerulopathy (ITG). There was no evidence of hematological cancer, and the patient improved after receiving treatments for NTM. To the best of our knowledge, this patient is the first to show an association between ITG and NTM. Although ITG is generally considered as related to lymphoproliferative disease, it is suggested that ITG is driven by bacterial infection and is a potential outcome of Ig-associated MPGN.
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Affiliation(s)
- Yoshio Shimizu
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan.,Shizuoka Medical Research Center for Disaster, Juntendo University, Izunokuni, Japan
| | - Keiichi Wakabayashi
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Hiroyuki Iwasaki
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Chiaki Kishida
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Sayaka Seki
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Teruyuki Okuma
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Naoko Iwakami
- Division of Respiratory Medicine, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Takumi Iwasawa
- Shizuoka Medical Research Center for Disaster, Juntendo University, Izunokuni, Japan
| | - Hiroshi Maekawa
- Department of Surgery, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Yasuhiko Tomino
- Asian Pacific Renal Research Promotion Office, Medical Corporation SHOWAKI, Tokyo, Japan
| | - Ryo Wada
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
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31
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Menter T, Hopfer H. Renal Disease in Cryoglobulinemia. GLOMERULAR DISEASES 2021; 1:92-104. [PMID: 36751424 PMCID: PMC9677724 DOI: 10.1159/000516103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/19/2021] [Indexed: 11/19/2022]
Abstract
Background Renal disease in cryoglobulinemia is difficult to grasp and diagnose because it is rare, serological testing is challenging and prone to artifacts, and its morphology is shared by other renal diseases resulting in a spectrum of differential diagnoses. On occasion, a definitive diagnosis cannot even be rendered after immunofluorescence and electron microscopic studies. Summary Based on kidney biopsies seen in our routine diagnostic and referral practice, we discuss and illustrate various morphological patterns of renal injury associated with cryoglobulins. We outline key pathophysiologic and clinical aspects associated with cryoglobulinemia induced renal disease and describe morphologic changes with a focus on electron microscopy. We present our practical, morphology-based approach to diagnostic decision-making with special consideration of differential diagnoses and disease mimickers. Since cryoglobulins are rarely tested for prior to kidney biopsy, pathologists and clinicians alike must have a high level of suspicion when interpreting renal biopsies and managing patients. Key Messages Cryoglobulinemia-associated glomerulonephritis (GN) is a multifactorial disease which is important to recognize for clinical practice. Morphological features suggestive of cryoglobulinemia-associated GN include a pattern of membranoproliferative GN with abundance of monocytes and the presence of (pseudo)thrombi. By electron microscopy, the main diagnostic features are a prominent infiltration of monocytes/macrophages and the presence of mesangial and subendothelial deposits with frequently curved microtubular/cylindrical and annular substructures.
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32
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Aucouturier P, D'Agati VD, Ronco P. A Fresh Perspective on Monoclonal Gammopathies of Renal Significance. Kidney Int Rep 2021; 6:2059-2065. [PMID: 34386655 PMCID: PMC8343799 DOI: 10.1016/j.ekir.2021.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/20/2022] Open
Abstract
Monoclonal gammopathies of renal significance (MGRS) encompass a remarkable variety of kidney diseases that result from intrinsic nephrotoxic properties of certain monoclonal Igs or their subunits. Effective disease-modifying treatments rely on the targeting of a malignant B-cell clone that may be demonstrable but often is quite hypothetical. Hence, convincing arguments for the genuine monoclonal character of the causative mono-isotypic Ig tissue deposits is needed for design of appropriate treatment strategies. The purpose of this article was to critically analyze distinct situations of suspected MGRS that occur in the practice of pathologists, nephrologists, hematologists, and immunologists. A particular focus of interest is the group of conditions known as proliferative glomerulonephritis with mono-isotypic immunoglobulin deposits (PGNMIDs), which illustrates the difficulties and ambiguities surrounding a definitive assignment of MGRS status.
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Affiliation(s)
- Pierre Aucouturier
- Hôpital St-Antoine, Département d'Immunologie Biologique, AP-HP, and Sorbonne Université / Inserm UMRS 938, Paris, France
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | - Pierre Ronco
- Sorbonne Université / Inserm UMRS 1155, Paris, France; Service de Néphrologie Centre Hospitalier du Mans, Le Mans, France
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33
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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.
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34
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Steinberg AG, Fox LC, Bender S, Batrouney A, Juneja S, Sirac C, Touchard G, Blombery P, Finlay MJ, Bridoux F, Barbour TD. Proliferative Glomerulonephritis With Fibrils, Monoclonal κ Light Chain, and C3 Deposits. Am J Kidney Dis 2021; 78:459-463. [PMID: 33774080 DOI: 10.1053/j.ajkd.2021.01.014] [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: 07/06/2020] [Accepted: 01/07/2021] [Indexed: 11/11/2022]
Abstract
There is increasing recognition of monoclonal gammopathy as a cause of proliferative glomerulonephritis (GN), including cases in which glomerular deposition of monoclonal immunoglobulin is demonstrated. Recently, proliferative GN with monoclonal immunoglobulin deposits (PGNMID) has incorporated a light chain variant of the disease (termed PGNMID-LC). Intriguingly, glomerular co-deposition of C3 is found in addition to monotypic light chain, implying complement activation via the alternative pathway (AP). We present a unique case of proliferative GN in a 42-year-old man who presented with nephrotic syndrome and was found to have κ light chain multiple myeloma. Immune staining of the glomerulus was positive only for κ light chain and C3, with the striking appearance of nonamyloid fibrils on electron microscopy. Following clonally targeted therapy for myeloma, the renal clinical abnormalities resolved completely. We present detailed molecular studies for light chain and complement and consider local mechanisms whereby monoclonal κ light chain fibrils may have triggered AP activation within the glomerulus.
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Affiliation(s)
- Adam G Steinberg
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia.
| | - Lucy C Fox
- Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Sebastien Bender
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
| | - Ahida Batrouney
- Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Surender Juneja
- Department of Hematology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Christophe Sirac
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
| | - Guy Touchard
- Service de Néphrologie, Hémodialyse et Transplantation Rénale, CIC INSERM 1402, Centre de référence pour l'amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Piers Blombery
- Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Moira J Finlay
- Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Frank Bridoux
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France; Service de Néphrologie, Hémodialyse et Transplantation Rénale, CIC INSERM 1402, Centre de référence pour l'amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Thomas D Barbour
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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35
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Segmental membranous nephropathy. Clin Exp Nephrol 2021; 25:700-707. [PMID: 33755821 DOI: 10.1007/s10157-021-02056-1] [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: 08/12/2020] [Accepted: 03/17/2021] [Indexed: 10/21/2022]
Abstract
Most cases of membranous nephropathy (MGN) present with global and diffuse distribution of subepithelial deposits. However, segmental MGN, in which there is focal or diffuse segmental subepithelial deposits, are occasionally encountered. The clinical and pathologic significance of segmental MGN is not well understood and thought to be more likely due to either early or resolving phase of the global form of MGN. Several case reports and literature available suggest that it may be a manifestation of secondary causes based on pathologic features such as presence of C1q and mesangial deposits, extra-glomerular deposits involving tubular basement membranes, absence of PLA2R and THSD7A, IgG1 and IgG3 subclass dominance, and the presence of other co-existing renal disease. Other reports, however, suggest that some of these cases may be a variant of the primary form of MGN. In this review, we integrate what is known about segmental MGN in order to better direct interpretation of renal biopsies in which it is identified.
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36
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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.
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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
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