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Jeong JY, Yang HT, Cho SH, Lee YR, Kim J, Kang MK, Hong J, Moon JH, Seo AN. Plasma cell myeloma initially diagnosed as light-chain deposition disease on liver biopsy: A case report and literature review. Medicine (Baltimore) 2023; 102:e33406. [PMID: 37000077 PMCID: PMC10063314 DOI: 10.1097/md.0000000000033406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 04/01/2023] Open
Abstract
RATIONALE Light-chain deposition disease (LCDD) is a rare condition characterized by the abnormal deposition of monoclonal light chains (LCs) in multiple organs, leading to progressive organ dysfunction. Herein, we report a case of plasma cell myeloma initially diagnosed as LCDD on liver biopsy performed for prominent cholestatic hepatitis. PATIENT CONCERNS A 55-year-old Korean man complained of dyspepsia as the main symptom. On abdominal computed tomography performed at another hospital, the liver showed mildly decreased and heterogeneous attenuation with mild periportal edema. Preliminary liver function tests revealed abnormal results. The patient was treated for an unspecified liver disease; however, his jaundice gradually worsened, prompting him to visit our outpatient hepatology clinic for further evaluation. Magnetic resonance cholangiography revealed liver cirrhosis with severe hepatomegaly of unknown cause. A liver biopsy was performed for the diagnosis. Hematoxylin and eosin staining revealed diffuse extracellular amorphous deposits in perisinusoidal spaces with compressed hepatocytes. The deposits, which morphologically resembled amyloids, were not stained by Congo red but stained strongly positive for kappa LCs and weakly positive for lambda LCs. DIAGNOSES Therefore, the patient was diagnosed with LCDD. Further systemic examination revealed a plasma cell myeloma. INTERVENTIONS Fluorescence in situ hybridization, cytogenetics, and next-generation sequencing tested in bone marrow showed no abnormalities. The patient initially received bortezomib/lenalidomide/dexamethasone as the treatment regimen for plasma cell myeloma. OUTCOMES However, he died shortly thereafter because of coronavirus disease 2019 complications. LESSONS This case demonstrates that LCDD may present with sudden cholestatic hepatitis and hepatomegaly, and may be fatal if patients do not receive appropriate and timely treatment because of delayed diagnosis. Liver biopsy is useful for the diagnosis of patients with liver disease of unknown etiology.
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Affiliation(s)
- Ji Yun Jeong
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Hyeon Tae Yang
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Seung Hyun Cho
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Yu Rim Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Jinhee Kim
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Min Kyu Kang
- Department of Radiation Oncology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Jihoon Hong
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - Joon Ho Moon
- Department of Hematology/Oncology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
| | - An Na Seo
- Department of Pathology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, South Korea
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Zhang S, Ni H, Xu Q, Cai X, Li H, Wei Z, Cao J. A case of light chain deposition disease involving the kidney with a normal serum free kappa/lambda light chain ratio. Ren Fail 2022; 44:103-105. [PMID: 35156899 PMCID: PMC8856072 DOI: 10.1080/0886022x.2021.2021943] [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)
- Suojian Zhang
- Department of Nephrology, Taixing People’s Hospital, Taizhou, China
| | - Haifeng Ni
- Department of Nephrology, Zhongda Hospital Southeast University, Nanjing, China
| | - Qin Xu
- Department of Nephrology, Taixing People’s Hospital, Taizhou, China
| | - Xiaoqin Cai
- Department of Nephrology, Taixing People’s Hospital, Taizhou, China
| | - Haitao Li
- Department of Nephrology, Taixing People’s Hospital, Taizhou, China
| | - Zhiqiang Wei
- Department of Nephrology, Taixing People’s Hospital, Taizhou, China
| | - Juan Cao
- Department of Nephrology, Taixing People’s Hospital, Taizhou, China
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Xu ZG, Li WL, Wang X, Zhang SY, Zhang YW, Wei X, Li CD, Zeng P, Luan SD. Proliferative glomerulonephritis with monoclonal immunoglobulin G deposits in a young woman: A case report. World J Clin Cases 2021; 9:2357-2366. [PMID: 33869614 PMCID: PMC8026847 DOI: 10.12998/wjcc.v9.i10.2357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/02/2021] [Accepted: 01/28/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Proliferative glomerulonephritis with monoclonal immunoglobulin G (IgG) deposits (PGNMID) is a newly recognized rare disease. The renal pathology is characterized by prominent manifestations of membranous hyperplasia, which are easy to misdiagnose. The clinical symptoms are severe. Massive proteinuria and hypoproteinemia are conspicuous, and most patients are accompanied by renal insufficiency and microscopic hematuria.
CASE SUMMARY A 27-year-old woman was admitted to a hospital for macroscopic hematuria and proteinuria 4 years prior, and renal biopsy in the hospital suggested moderate-to-severe mesangial proliferating glomerulonephritis (MsPGN). She had taken a glucocorticoid, cyclophosphamide, mycophenolate mofetil, and other treatments and achieved brief partial remission. Recently, the patient visited our hospital due to massive proteinuria. Repeated renal biopsy and re-evaluation of the first biopsy obtained 4 years previously revealed monoclonal immunoglobulin deposition in the glomeruli. A bone marrow examination was performed to exclude hematologic malignancy, and a diagnosis of PGNMID was established. The patient showed remission after four cycles of a bortezomib + cyclophosphamide + dexamethasone scheme.
CONCLUSION PGNMID is usually misdiagnosed as MsPGN or membranoproliferative glomerulonephritis. Although it often occurs in middle-aged and elderly individuals, it cannot be readily excluded in young people, even when serum immunofixation electrophoresis is negative. IgG subtype and light chain staining are necessary when this disease is highly suspected. An accurate diagnosis at the earliest stage may avoid the overuse of glucocorticoids and immunosuppressants.
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Affiliation(s)
- Zi-Gan Xu
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Wei-Long Li
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Xi Wang
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Shu-Yuan Zhang
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Ying-Wei Zhang
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Xing Wei
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Chun-Di Li
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Ping Zeng
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
| | - Shao-Dong Luan
- Department of Nephrology, Shenzhen Longhua District Central Hospital, Shenzhen 518110, Guangdong Province, China
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Masson Trichrome and Sulfated Alcian Blue Stains Distinguish Light Chain Deposition Disease From Amyloidosis in the Lung. Am J Surg Pathol 2021; 45:405-413. [PMID: 33002919 DOI: 10.1097/pas.0000000000001593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Light chain deposition disease, characterized by nonamyloidogenic deposits of immunoglobulin light chains, is rare in the lung and possibly underdiagnosed due to low clinical suspicion and lack of readily accessible tests. We encountered a case of pulmonary light chain deposition disease (PLCDD) in which light chain deposits appeared crimson red with a Masson trichrome (MT) stain and salmon pink with a sulfated Alcian blue (SAB) stain. This prompted us to characterize a series of PLCDD cases and assess the utility of MT and SAB stains to distinguish them from amyloidosis. From the pathology archives of 2 institutions spanning 10 years, we identified 11 cases of PLCDD, including 7 diagnosed as such and 4 determined retrospectively. The deposits in all cases of PLCDD stained crimson red with MT and salmon pink with SAB, while the cases of pulmonary amyloid (n=10) stained blue-gray and blue-green, respectively. The immunoglobulin light chain nature of the deposits was confirmed in 10 of 11 cases by either immunofluorescence microscopy (n=5) or mass spectrometry (n=5). Transmission electron microscopy revealed osmiophilic, electron-dense deposits in all cases analyzed (n=3). An extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue type was diagnosed in 10 cases and 1 represented a plasma cell neoplasm. Our study highlights the importance of considering PLCDD in the differential diagnosis of amyloid-like deposits in the lung and the value of performing MT and SAB stains to distinguish between PLCDD and amyloidosis.
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Cohen C, Joly F, Sibille A, Javaugue V, Desport E, Goujon JM, Touchard G, Fermand JP, Sirac C, Bridoux F. Randall-Type Monoclonal Immunoglobulin Deposition Disease: New Insights into the Pathogenesis, Diagnosis and Management. Diagnostics (Basel) 2021; 11:diagnostics11030420. [PMID: 33801393 PMCID: PMC7999117 DOI: 10.3390/diagnostics11030420] [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: 02/04/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/16/2022] Open
Abstract
Randall-type monoclonal immunoglobulin deposition disease (MIDD) is a rare disease that belongs to the spectrum of monoclonal gammopathy of renal significance (MGRS). Renal involvement is prominent in MIDD, but extra-renal manifestations can be present and may affect global prognosis. Recent data highlighted the central role of molecular characteristics of nephrotoxic monoclonal immunoglobulins in the pathophysiology of MIDD, and the importance of serum free light chain monitoring in the diagnosis and follow-up disease. Clone-targeted therapy is required to improve the overall and renal survival, and the achievement of a rapid and deep hematological response is the goal of therapy. This review will focus on the recent progress in the pathogenesis and management of this rare disease.
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Affiliation(s)
- Camille Cohen
- Department of Nephrology Hôpital Necker, and INSERM U830 “Stress and Cancer” Laboratory, Institut Curie, 75015 Paris, France
- Correspondence:
| | - Florent Joly
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
| | - Audrey Sibille
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
| | - Vincent Javaugue
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
- INSERM CIC 1402, 86000 Poitiers, France
- CNRS UMR 7276-CRIBL, University of Limoges, 87000 Limoges, France;
| | - Estelle Desport
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
| | | | - Guy Touchard
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Department of Pathology, CHU Poitiers, 86000 Poitiers, France;
| | - Jean-Paul Fermand
- Department of Immunology and Hematology, Hôpital Saint Louis, 75010 Paris, France;
| | - Christophe Sirac
- CNRS UMR 7276-CRIBL, University of Limoges, 87000 Limoges, France;
| | - Frank Bridoux
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
- INSERM CIC 1402, 86000 Poitiers, France
- CNRS UMR 7276-CRIBL, University of Limoges, 87000 Limoges, France;
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Gkalea V, Amiot X, Jo Molina T, Frenzel L, Bachmeyer C. Intraperitoneal bleeding as the initial presentation of Randall-type monoclonal immunoglobulin deposition disease with hepatic involvement. Leuk Lymphoma 2020; 62:1263-1266. [PMID: 33300421 DOI: 10.1080/10428194.2020.1856836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
| | - Xavier Amiot
- Department of Hepatology, Tenon Hospital, Paris, France
| | - Thierry Jo Molina
- Departement of Pathology, Necker-Enfants Malades Hospitals, Paris, France
| | - Laurent Frenzel
- Department of Hematology, Necker-Enfants Malades Hospital, Paris, France
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Tuchman SA, Zonder JA. The Spectrum of Monoclonal Immunoglobulin-Associated Diseases. Hematol Oncol Clin North Am 2020; 34:997-1008. [PMID: 33099435 DOI: 10.1016/j.hoc.2020.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The spectrum of immunoglobulin paraprotein-associated diseases requiring therapy extends beyond multiple myeloma and AL amyloidosis. Awareness of these is essential in ensuring timely accurate diagnosis and appropriate treatment. As most paraprotein-associated diseases are fairly uncommon, therapeutic decisions must often be made in the absence of data from randomized controlled trials. Treatment is generally directed at the underlying clonal cell population. This review focuses on the spectrum of the less common paraprotein-associated disorders. In most instances, the monoclonal immunoglobulin plays a direct role in the pathophysiology of the disease course; in a select few, the paraprotein may be a disease marker.
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Affiliation(s)
- Sascha A Tuchman
- Division of Hematology, University of North Carolina - Chapel Hill, Comprehensive Cancer Center, 170 Manning Dr., CB#7305, Chapel Hill, NC 27599, USA
| | - Jeffrey A Zonder
- Barbara Ann Karmanos Cancer Institute/Wayne State University School of Medicine, Myeloma and Amyloidosis Team, Barbara Ann Karmanos Cancer Institute, Detroit, MI, USA.
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8
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Watanabe H, Takeuchi Y, Taniuchi S, Sato H, Nakamura Y, Sasano H, Joh K. Polyclonal immunoglobulin G deposition on the tubular basement membrane in a diabetic nephropathy: A case report. Pathol Int 2020; 70:463-469. [PMID: 32419249 DOI: 10.1111/pin.12940] [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: 08/07/2019] [Revised: 03/31/2020] [Accepted: 04/07/2020] [Indexed: 11/27/2022]
Abstract
A 70-year-old Japanese man with diabetes mellitus was referred to our hospital for treatment of renal dysfunction. Renal biopsy revealed that the tubular basement membrane (TBM) showed extreme thickening histologically, and selective polyclonal immunoglobulin G deposition on the thickened TBM, whereas no immunoglobulin deposition was found in the glomeruli in an immunofluorescence study. In electron microscopy, a powdery type of electron dense material, which was similar to that seen in Randall-type monoclonal immunoglobulin deposition disease (MIDD), was observed on the tubular epithelial side of the TBM. However, the present case was differentiated from MIDD, because polyclonal deposition with both kappa and lambda deposition on the TBM was observed. Moreover, there was no noticeable glomerular deposition, which is usually found in cases of MIDD. Anti-TBM disease was also considered as a differential diagnosis, in which polyclonal immunoglobulin deposits selectively on the TBM. However, in the present case, prominent interstitial nephritis was not observed. A similar case with a history of diabetes mellitus has been reported, which was diagnosed as Polyclonal Immunoglobulin G Deposition Disease. No further reports of this case have emerged thereafter; we present this case as the second report supporting this article.
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Affiliation(s)
| | - Yoichi Takeuchi
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University, Miyagi, Japan
| | - Shinji Taniuchi
- Department of Pathology, Osaki Citizen Hospital, Miyagi, Japan
| | - Hiroshi Sato
- Division of Nephrology, Endocrinology and Vascular Medicine, Tohoku University, Miyagi, Japan
| | - Yasuhiro Nakamura
- Division of Pathology, Faculty of Medicine, Tohoku Medical and Pharmaceutical University, Miyagi, Japan
| | | | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Tokyo, Japan
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Zuo C, Zhu Y, Xu G. An update to the pathogenesis for monoclonal gammopathy of renal significance. Crit Rev Oncol Hematol 2020; 149:102926. [PMID: 32199132 DOI: 10.1016/j.critrevonc.2020.102926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 12/20/2019] [Accepted: 03/02/2020] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is characterized by the nephrotoxic monoclonal immunoglobulin (MIg) secreted by an otherwise asymptomatic or indolent B-cell or plasma cell clone, without hematologic criteria for treatment. The spectrum of MGRS-associated disorders is wide, including non-organized deposits or inclusions such as C3 glomerulopathy with monoclonal glomerulopathy (MIg-C3G), monoclonal immunoglobulin deposition disease, proliferative glomerulonephritis with monoclonal immunoglobulin deposits and organized deposits like immunoglobulin related amyloidosis, type I and type II cryoglobulinaemic glomerulonephritis, light chain proximal tubulopathy, and so on. Kidney biopsy should be conducted to identify the exact disease associated with MGRS. These MGRS-associated diseases can involve one or more renal compartments, including glomeruli, tubules and vessels. Hydrophobic residues replacement, N-glycosylated, increase in isoelectric point in MIg causes it to transform from soluble form to tissue deposition, causing glomerular damage. Complement deposition is found in MIg-C3G, which is caused by an abnormality of the alternative pathway and may involve multiple factors including complement component 3 nephritic factor, anti-complement factor auto-antibodies or MIg which directly cleaves C3. The effect of transforming growth factor beta and platelet-derived growth factor-β on mesangial extracellular matrix is associated with glomerular and tubular basement membrane thickening, nodular glomerulosclerosis, and interstitial fibrosis. Furthermore, inflammatory factors, growth factors and virus infection may play an important role in the development of the diseases. In this review, for the first time, we discussed current highlights in the mechanism of MGRS-related lesions.
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Affiliation(s)
- Chao Zuo
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China; Grade 2016, the Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Yuge Zhu
- Grade 2016, the First Clinical Medical College of Nanchang University, Nanchang, China
| | - Gaosi Xu
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China.
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10
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An update to the pathogenesis for monoclonal gammopathy of renal significance. Ann Hematol 2020; 99:703-714. [PMID: 32103323 DOI: 10.1007/s00277-020-03971-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 02/18/2020] [Indexed: 01/16/2023]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is characterized by the nephrotoxic monoclonal immunoglobulin secreted by an otherwise asymptomatic or indolent B cell or plasma cell clone, without hematologic criteria for treatment. These MGRS-associated diseases can involve one or more renal compartments, including glomeruli, tubules, and vessels. Hydrophobic residue replacement, N-glycosylated, increase in isoelectric point in monoclonal immunoglobulin (MIg) causes it to transform from soluble form to tissue deposition, and consequently resulting in glomerular damage. In addition to MIg deposition, complement deposition is also found in C3 glomerulopathy with monoclonal glomerulopathy, which is caused by an abnormality of the alternative pathway and may involve multiple factors including complement component 3 nephritic factor, anti-complement factor auto-antibodies, or MIg which directly cleaves C3. Furthermore, inflammatory factors, growth factors, and virus infection may also participate in the development of the diseases. In this review, for the first time, we discussed current highlights in the mechanism of MGRS-related lesions.
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Randall-type monoclonal immunoglobulin deposition disease: novel insights from a nationwide cohort study. Blood 2019; 133:576-587. [DOI: 10.1182/blood-2018-09-872028] [Citation(s) in RCA: 53] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/15/2018] [Indexed: 12/27/2022] Open
Abstract
Abstract
Monoclonal immunoglobulin deposition disease (MIDD) is a rare complication of B-cell clonal disorders, defined by Congo red negative–deposits of monoclonal light chain (LCDD), heavy chain (HCDD), or both (LHCDD). MIDD is a systemic disorder with prominent renal involvement, but little attention has been paid to the description of extrarenal manifestations. Moreover, mechanisms of pathogenic immunoglobulin deposition and factors associated with renal and patient survival are ill defined. We retrospectively studied a nationwide cohort of 255 patients, with biopsy-proven LCDD (n = 212) (including pure LCDD [n = 154], LCDD with cast nephropathy (CN) [n = 58]), HCDD (n = 23), or LHCDD (n = 20). Hematological diagnosis was monoclonal gammopathy of renal significance in 64% and symptomatic myeloma in 34%. Renal presentation was acute kidney injury in patients with LCCD and CN, and chronic glomerular disease in the other types, 35% of whom had symptomatic extrarenal (mostly hepatic and cardiac) involvement. Sequencing of 18 pathogenic LC showed high isoelectric point values of variable domain complementarity determining regions, possibly accounting for tissue deposition. Among 169 patients who received chemotherapy (bortezomib-based in 58%), 67% achieved serum free light chain (FLC) response, including very good partial response (VGPR) or above in 52%. Renal response occurred in 62 patients (36%), all of whom had achieved hematological response. FLC response ≥ VGPR and absence of severe interstitial fibrosis were independent predictors of renal response. This study highlights an unexpected frequency of extrarenal manifestations in MIDD. Rapid diagnosis and achievement of deep FLC response are key factors of prognosis.
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Sirac C, Herrera GA, Sanders PW, Batuman V, Bender S, Ayala MV, Javaugue V, Teng J, Turbat-Herrera EA, Cogné M, Touchard G, Leung N, Bridoux F. Animal models of monoclonal immunoglobulin-related renal diseases. Nat Rev Nephrol 2018; 14:246-264. [DOI: 10.1038/nrneph.2018.8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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13
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Bridoux F, Javaugue V, Bender S, Leroy F, Aucouturier P, Debiais-Delpech C, Goujon JM, Quellard N, Bonaud A, Clavel M, Trouillas P, Di Meo F, Gombert JM, Fermand JP, Jaccard A, Cogné M, Touchard G, Sirac C. Unravelling the immunopathological mechanisms of heavy chain deposition disease with implications for clinical management. Kidney Int 2016; 91:423-434. [PMID: 27773425 DOI: 10.1016/j.kint.2016.09.004] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 08/11/2016] [Accepted: 09/01/2016] [Indexed: 10/20/2022]
Abstract
Randall-type heavy chain deposition disease (HCDD) is a rare disorder characterized by tissue deposition of a truncated monoclonal immunoglobulin heavy chain lacking the first constant domain. Pathophysiological mechanisms are unclear and management remains to be defined. Here we retrospectively studied 15 patients with biopsy-proven HCDD of whom 14 presented with stage 3 or higher chronic kidney disease, with nephrotic syndrome in 9. Renal lesions were characterized by nodular glomerulosclerosis, with linear peritubular and glomerular deposits of γ-heavy chain in 12 patients or α-heavy chain in 3 patients, without concurrent light chain staining. Only 2 patients had symptomatic myeloma. By serum protein electrophoresis/immunofixation, 13 patients had detectable monoclonal gammopathy. However, none of these techniques allowed detection of the nephrotoxic truncated heavy chain, which was achieved by immunoblot and/or bone marrow heavy chain sequencing in 14 of 15 patients. Serum-free kappa to lambda light chain ratio was abnormal in 11 of 11 patients so examined. Immunofluorescence studies of bone marrow plasma cells showed coexpression of the pathogenic heavy chain with light chain matching the abnormal serum-free light chain in all 3 tested patients. Heavy chain sequencing showed first constant domain deletion in 11 of 11 patients, with high isoelectric point values of the variable domain in 10 of 11 patients. All patients received chemotherapy, including bortezomib in 10 cases. Renal parameters improved in 11 patients who achieved a hematological response, as assessed by normalization of the free light chain ratio in 8 cases. Tissue deposition in HCDD relates to physicochemical peculiarities of both variable and constant heavy chain domains. Early diagnosis and treatment with bortezomib-based combinations appear important to preserve renal prognosis. Thus, monitoring of serum-free light chain is an indirect but useful method to evaluate the hematological response.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France; Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France.
| | - Vincent Javaugue
- Department of Nephrology, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Sébastien Bender
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France
| | - Fannie Leroy
- Department of Nephrology, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Pierre Aucouturier
- Department of Immunology, Inserm UMRS 938, Saint Antoine Hospital; Université Pierre et Marie Curie - Paris6, Paris, France
| | - Céline Debiais-Delpech
- Department of Pathology and Ultrastructural Pathology, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Jean-Michel Goujon
- Department of Pathology and Ultrastructural Pathology, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Nathalie Quellard
- Department of Pathology and Ultrastructural Pathology, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Amélie Bonaud
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France
| | - Marie Clavel
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France
| | - Patrick Trouillas
- INSERM UMR 850, University of Limoges, School of Pharmacy, Limoges, France; Regional Centre of Advanced Technologies and Materials, Department of Physical Chemistry, Faculty of Science, Palacký University Olomouc, Olomouc, Czech Republic
| | - Florent Di Meo
- INSERM UMR 850, University of Limoges, School of Pharmacy, Limoges, France
| | - Jean-Marc Gombert
- Department of Immunology, University Hospital of Poitiers, Poitiers, France
| | - Jean-Paul Fermand
- Department of Hematology and Clinical Immunology, Saint Louis University Hospital, Paris, France
| | - Arnaud Jaccard
- Department of Hematology, University Hospital of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France
| | - Michel Cogné
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France
| | - Guy Touchard
- Department of Nephrology, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Christophe Sirac
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France
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Cohen C, Javaugue V, Joly F, Arnulf B, Fermand JP, Jaccard A, Sirac C, Knebelmann B, Bridoux F, Touchard G. Maladie de dépôts d’immunoglobulines monoclonales de type Randall : du diagnostic au traitement. Nephrol Ther 2016; 12:131-9. [DOI: 10.1016/j.nephro.2015.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Revised: 12/02/2015] [Accepted: 12/02/2015] [Indexed: 11/17/2022]
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Bortezomib produces high hematological response rates with prolonged renal survival in monoclonal immunoglobulin deposition disease. Kidney Int 2015; 88:1135-43. [PMID: 26176826 DOI: 10.1038/ki.2015.201] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Revised: 04/23/2015] [Accepted: 05/14/2015] [Indexed: 01/17/2023]
Abstract
Monoclonal immunoglobulin deposition disease (MIDD) is a rare complication of plasma cell disorders, defined by linear Congo red-negative deposits of monoclonal light chain, heavy chain, or both along basement membranes. While renal involvement is prominent, treatment strategies, such as the impact of novel anti-myeloma agents, remain poorly defined. Here we retrospectively studied 49 patients with MIDD who received a median of 4.5 cycles of intravenous bortezomib plus dexamethasone. Of these, 25 received no additional treatment, 18 also received cyclophosphamide, while 6 also received thalidomide or lenalidomide. The hematological diagnoses identified 38 patients with monoclonal gammopathy of renal significance, 10 with symptomatic multiple myeloma, and 1 with Waldenstrom macroglobulinemia. The overall hematologic response rate, based on the difference between involved and uninvolved serum-free light chains (dFLCs), was 91%. After median follow-up of 54 months, 5 patients died and 10 had reached end-stage renal disease. Renal response was achieved in 26 patients, with a 35% increase in median eGFR and an 86% decrease in median 24-h proteinuria. Predictive factors were pre-treatment eGFR over 30 ml/min per 1.73 m(2) and post-treatment dFLC under 40 mg/l; the latter was the sole predictive factor of renal response by multivariable analysis. Thus, bortezomib-based therapy is a promising treatment strategy in MIDD, mainly when used early in the disease course. dFLC response is a favorable prognostic factor for renal survival.
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16
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Chauvet S, Bridoux F, Ecotière L, Javaugue V, Sirac C, Arnulf B, Thierry A, Quellard N, Milin S, Bender S, Goujon JM, Jaccard A, Fermand JP, Touchard G. Kidney diseases associated with monoclonal immunoglobulin M-secreting B-cell lymphoproliferative disorders: a case series of 35 patients. Am J Kidney Dis 2015; 66:756-67. [PMID: 25987261 DOI: 10.1053/j.ajkd.2015.03.035] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 03/27/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Kidney diseases associated with immunoglobulin M (IgM) monoclonal gammopathy are poorly described, with few data for patient outcomes and renal response. STUDY DESIGN Case series. SETTING & PARTICIPANTS 35 patients from 8 French departments of nephrology were retrospectively studied. Inclusion criteria were: (1) detectable serum monoclonal IgM, (2) estimated glomerular filtration rate (eGFR) < 60mL/min/1.73m(2) and/or proteinuria with protein excretion > 0.5g/d and/or microscopic hematuria, and (3) kidney biopsy showing monoclonal immunoglobulin deposits and/or lymphomatous B-cell renal infiltration. All patients received chemotherapy, including rituximab-based regimens in 8 cases. PREDICTORS Patients were classified into 3 groups according to renal pathology: glomerular AL amyloidosis (group 1; n=11), nonamyloid glomerulopathies (group 2; n=15, including 9 patients with membranoproliferative glomerulonephritis), and tubulointerstitial nephropathies (group 3; n=9, including cast nephropathy in 5, light-chain Fanconi syndrome in 3, and isolated tumor infiltration in 1). OUTCOMES Posttreatment hematologic response (≥50% reduction in serum monoclonal IgM and/or free light chain level) and renal response (≥50% reduction in 24-hour proteinuria or eGFR≥30mL/min/1.73m(2) in patients with glomerular and tubulointerstitial disorders, respectively). RESULTS Nephrotic syndrome was observed in 11 and 6 patients in groups 1 and 2, respectively. Patients in group 3 presented with acute kidney injury (n=7) and/or proximal tubular dysfunction (n=3). Waldenström macroglobulinemia was present in 26 patients (8, 12, and 6 in groups 1, 2, and 3, respectively). Significant lymphomatous interstitial infiltration was observed in 18 patients (4, 9, and 5 patients, respectively). Only 9 of 29 evaluable patients had systemic signs of symptomatic hematologic disease (2, 5, and 2, respectively). In groups 1, 2, and 3, respectively, hematologic response was achieved after first-line treatment in 3 of 9, 9 of 10, and 5 of 6 evaluable patients, while renal response occurred in 5 of 10, 9 of 15, and 5 of 8 evaluable patients. LIMITATIONS Retrospective study; insufficient population to establish the impact of chemotherapy. CONCLUSIONS IgM monoclonal gammopathy is associated with a wide spectrum of renal manifestations, with an under-recognized frequency of tubulointerstitial disorders.
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Affiliation(s)
- Sophie Chauvet
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Frank Bridoux
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France; CNRS UMR 6101, Université de Limoges, Limoges, France.
| | - Laure Ecotière
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Vincent Javaugue
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Christophe Sirac
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; CNRS UMR 6101, Université de Limoges, Limoges, France
| | - Bertrand Arnulf
- Department of Immunology and Hematology, Hôpital Saint-Louis AP-HP, Paris, France
| | - Antoine Thierry
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Nathalie Quellard
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Pathology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Serge Milin
- Department of Pathology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Sébastien Bender
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; CNRS UMR 6101, Université de Limoges, Limoges, France
| | - Jean-Michel Goujon
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Pathology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Arnaud Jaccard
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; CNRS UMR 6101, Université de Limoges, Limoges, France; Department of Hematology, CHU Limoges, Université de Limoges, Limoges, France
| | - Jean-Paul Fermand
- Department of Immunology and Hematology, Hôpital Saint-Louis AP-HP, Paris, France
| | - Guy Touchard
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
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Cohen C, El-Karoui K, Alyanakian MA, Noel LH, Bridoux F, Knebelmann B. Light and heavy chain deposition disease associated with CH1 deletion. Clin Kidney J 2015; 8:237-9. [PMID: 25815184 PMCID: PMC4370302 DOI: 10.1093/ckj/sfv002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 01/07/2015] [Indexed: 11/29/2022] Open
Abstract
Light and heavy chain deposition disease (LHCDD) is a rare complication of monoclonal gammopathy. In all documented cases, LHCDD is the association of deposits of a monoclonal light chain with a normal heavy chain, especially in the kidneys. We describe here a 78-year-old woman whose renal biopsy showed nodular glomerulosclerosis, initially diagnosed as diabetic nephropathy. Detailed kidney biopsy immunofluorescence study corrected the diagnosis to γ1-κ-LHCDD. Advanced immunoblot analysis showed deletion of CH1 in the both blood and kidney heavy chain. We report here, to our knowledge, the first case of γ1 LHCDD associated with a deletion of CH1.
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Affiliation(s)
- Camille Cohen
- Service de néphrologie, hôpital Necker, Paris, France
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18
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Watanabe H, Osawa Y, Goto S, Habuka M, Imai N, Ito Y, Hirose T, Chou T, Ohashi R, Shimizu A, Ehara T, Shimotori T, Narita I. A case of endocapillary proliferative glomerulonephritis with macrophages phagocytosing monoclonal immunoglobulin lambda light chain. Pathol Int 2014; 65:38-42. [PMID: 25410550 DOI: 10.1111/pin.12229] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 10/07/2014] [Indexed: 11/30/2022]
Abstract
Multiple myeloma (MM) is a plasma-cell neoplasm that can cause renal disorders. Renal lesions in MM can present with a very rare pathological manifestation involving a specific monoclonal immunoglobulin (Ig). We report the case of a 33-year-old woman who had edema, fatigue, elevated serum creatinine levels, hypoalbuminemia, and hypercholesterolemia. She had persistent hematuria and proteinuria lasting 3 years. Serum protein electrophoresis showed an M-spike, and serum immunofixation demonstrated the presence of monoclonal IgG λ. She had proteinuria in the nephrotic range, and a monoclonal λ fragment was present on urine immunofixation. Renal biopsy showed proliferative glomerulonephritis with λ light chain and C3c deposition and inflammatory cell infiltration with CD68. Macrophage lysosomes contained λ light chains, suggesting their partial phagocytosis. She was diagnosed with symptomatic MM and was treated with bortezomib and dexamethasone and an autologous peripheral stem cell transplant conditioned with intravenous melphalan. She achieved a partial response with decreased serum monoclonal protein and improved renal function. This case may be categorized as a monoclonal gammopathy-associated proliferative glomerulonephritis. The biopsy finding of partially phagocytosed Ig λ light chains by macrophages is very rare; this pathological condition is similar to crystal-storing histiocytosis.
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Affiliation(s)
- Hirofumi Watanabe
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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19
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Probable light- and heavy-chain deposition disease in a patient with nodular diabetic glomerulosclerosis. CEN Case Rep 2014; 3:162-166. [PMID: 28509191 DOI: 10.1007/s13730-014-0110-9] [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: 06/21/2013] [Accepted: 01/28/2014] [Indexed: 10/25/2022] Open
Abstract
We report a case of probable light- and heavy-chain deposition disease (LHCDD) in a diabetic patient, a rare and educational case. The patient was a 71-year-old man having a long history of uncontrolled diabetes mellitus with retinopathy. He showed heavy proteinuria and renal insufficiency, and did not have paraproteins. Renal biopsy revealed nodular glomerulosclerosis with severe mesangial widening and microaneurysm. Immunofluorescence (IF) showed weak staining of kappa light chain, IgG and C1q along glomerular basement membrane (GBM). At first, we interpreted these IF findings to be nonspecific, thus we diagnosed as diabetic nodular glomerulosclerosis. Later, we recognized one of a few case reports of monoclonal immunoglobulin deposition disease (MIDD) in diabetic patients, and reconsidered the first diagnosis. The added electron microscopy (EM) showed obvious electron-dense materials in GBM, while tubular basement membrane deposits were not identified. A concurrence of LHCDD and diabetic nodular glomerulosclerosis may be suggested in this case. Like this case, IF staining in MIDD is often weak, so it is difficult to diagnose MIDD accurately without EM. Reports of MIDD in diabetic patients are extremely rare, possibly due to being often overlooked. This case emphasizes that overall pathological examination including IF and EM is important for the accurate differentiation of nodular glomerulosclerosis, even in diabetic patients.
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20
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Pereira VG, Jacinto M, Santos J, de Abreu TT. Periorbital purpura (raccoon's eyes). BMJ Case Rep 2014; 2014:bcr-2013-201407. [PMID: 25139913 DOI: 10.1136/bcr-2013-201407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Vera Gomes Pereira
- Department of Internal Medicine, Hospital Espírito Santo-Évora, E.P.E., Évora, Portugal
| | - Margarida Jacinto
- Department of Internal Medicine, Hospital Espírito Santo-Évora, E.P.E., Évora, Portugal
| | - Jaime Santos
- Department of Oncology, Hospital Espírito Santo-Évora, E.P.E., Évora, Portugal
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21
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Chan JKC. The wonderful colors of the hematoxylin-eosin stain in diagnostic surgical pathology. Int J Surg Pathol 2014; 22:12-32. [PMID: 24406626 DOI: 10.1177/1066896913517939] [Citation(s) in RCA: 181] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The hematoxylin-eosin (H&E) stain has stood the test of time as the standard stain for histologic examination of human tissues. This simple dye combination is capable of highlighting the fine structures of cells and tissues. Most cellular organelles and extracellular matrix are eosinophilic, while the nucleus, rough endoplasmic reticulum, and ribosomes are basophilic. This review discusses the spectrum, intensity, and texture of colors observed in H&E-stained slides to illustrate their value in surgical pathology diagnosis. Changes in color of the nuclei occur in the presence of nuclear pseudoinclusions (such as papillary thyroid carcinoma) or inclusions (such as viral infection, surfactant, immunoglobulin, and biotin). The color of the cytoplasm of spindly cells can provide clues to their nature, such as basophilic (fibroblast), eosinophilic (smooth muscle and others), and amphophilic (myofibroblast). Eosinophilic globules have diagnostic value for sclerosing polycystic adenosis of salivary gland, low-grade B-cell lymphoma, solid pseudopapillary tumor of pancreas, and inclusion body fibromatosis. Eosinophilic granules are characteristic of granular cells (lysosome-rich), oncocytic cells (mitochondria-rich), and cells with secretory products (including neuroendocrine cells). Eosinophilic crystals can be diagnostic of lymphoma/plasmacytoma and crystal-storing histiocytosis. Basophilic granules or inclusions are diagnostic of acinic cell carcinoma and malakoplakia (Michaelis-Gutmann bodies). Yellow or brown inclusions are characteristic of hyalinizing trabecular adenoma of thyroid (yellow bodies), brown bowel syndrome, and malignant melanoma. Extracellular eosinophilic deposits can be produced by many conditions, but amyloid and monoclonal immunoglobulin deposition disease are important considerations. Extracellular basophilic deposits may be seen in small cell carcinoma and systemic lupus erythematosus, but they differ in that the former is blue (nuclear material) while the latter is purple (nuclear material plus immunoglobulin).
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22
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Nakaosa N, Takane K, Fukui A, Manabe M, Tsuboi N, Yokoo T, Miyazaki Y, Utsunomiya Y, Hosoya T. [Case report; a case of monoclonal immunoglobulin deposition disease with membranoproliferative glomerulonephritis-like lesion]. ACTA ACUST UNITED AC 2013; 102:1800-3. [PMID: 23947244 DOI: 10.2169/naika.102.1800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Naoko Nakaosa
- Division of Kidney and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine, Japan
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23
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Talukdar A, Mukherjee K, Khanra D, Saha M. Portal hypertension related to light chain deposition disease of liver: an enlightening experience. BMJ Case Rep 2013; 2013:bcr2013009553. [PMID: 23723105 PMCID: PMC3669975 DOI: 10.1136/bcr-2013-009553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 55-year-old alcoholic man presented with firm hepatomegaly, ascites and markedly elevated alkaline phosphatase. He had a history of pulmonary tuberculosis. Work-up for malignancy was negative. Histological examination of liver showed extracellular deposition of pink amorphous material which is Congo red stain negative. Deteriorating renal function and nephrotic-range proteinuria were noted. Renal histology showed thickening of the glomerular and tubular basement membranes by non-congophilic deposits along with mesangial expansion. Bone marrow examination revealed patchy areas of pink amorphous deposits which are Congo red stain negative. Immunohistochemical staining of amorphous depositions in liver, kidney and bone marrow were positive for κ light chains. Serum-free light chain assay confirmed markedly elevated free κ-light chain. κ-light chain deposition disease is a systemic disease with universal renal involvement but rarely it presents as chronic cholestatic liver disease with portal hypertension and frequently associated with fatal outcome due to diagnostic delay.
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Affiliation(s)
- Arunansu Talukdar
- Department of General Medicine, Medical College, Kolkata, West Bengal, India.
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24
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Komatsuda A, Masai R, Togashi M, Ohtani H, Sawada K, Wakui H. Discrete renal deposition of IgM heavy chain and κ light chain in Waldenström macroglobulinemia (IgM-κ). Clin Kidney J 2012; 5:438-41. [PMID: 26019823 PMCID: PMC4432407 DOI: 10.1093/ckj/sfs088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 06/29/2012] [Indexed: 11/28/2022] Open
Abstract
We report previously undescribed renal lesions associated with monoclonal gammopathy in a 59-year-old man with Waldenström macroglobulinemia (IgM-κ). Light microscopy showed mesangial proliferation and thickening of glomerular basement membranes (GBMs) and tubular basement membranes (TBMs). Neither intraglomerular thrombi nor nodular glomerulosclerosis was observed. Immunofluorescence studies disclosed essentially discrete localization of IgM heavy chain within the mesangial area and κ light chain along GBMs and TBMs. Electron microscopy showed continuous linear deposits of finely granular electron-dense material along the inner aspect of GBMs and TBMs. Repeated rituximab treatment and chemotherapy (melphalan and prednisolone) led to the improvement of proteinuria.
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Affiliation(s)
- Atsushi Komatsuda
- Department of Hematology, Nephrology, and Rheumatology , Akita University Graduate School of Medicine , Akita , Japan
| | - Rie Masai
- Department of Hematology, Nephrology, and Rheumatology , Akita University Graduate School of Medicine , Akita , Japan
| | - Masaru Togashi
- Department of Hematology, Nephrology, and Rheumatology , Akita University Graduate School of Medicine , Akita , Japan
| | - Hiroshi Ohtani
- Department of Nephrology and Dialysis , Akita Kumiai General Hospital , Akita , Japan
| | - Kenichi Sawada
- Department of Hematology, Nephrology, and Rheumatology , Akita University Graduate School of Medicine , Akita , Japan
| | - Hideki Wakui
- Department of Hematology, Nephrology, and Rheumatology , Akita University Graduate School of Medicine , Akita , Japan
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25
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Bridoux F, Fermand JP. Optimizing treatment strategies in myeloma cast nephropathy: rationale for a randomized prospective trial. Adv Chronic Kidney Dis 2012; 19:333-41. [PMID: 22920644 DOI: 10.1053/j.ackd.2012.07.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Revised: 07/10/2012] [Accepted: 07/10/2012] [Indexed: 11/11/2022]
Abstract
Renal failure is a frequent complication of multiple myeloma (MM) that strongly affects patient survival. Although a variety of renal diseases may be observed in MM, myeloma cast nephropathy (MCN), a tubulo-interstitial disorder related to precipitation of a monoclonal light chain (LC) within tubular distal lumens, is the main cause of severe and persistent renal failure. To date, the respective frequency and initial evolution of renal disorders associated with monoclonal LC in MM remain poorly defined. Treatment of MCN relies on urgent symptomatic measures and rapid introduction of chemotherapy to reduce the production of monoclonal LC. The introduction of novel chemotherapy regimens based on the association of bortezomib with dexamethasone is likely to have improved the prognosis of MM patients with renal failure. In addition, the combination of novel agents with efficient removal of circulating LC through high cut-off hemodialysis membrane may further increase renal response rate. However, the impact on patient and renal outcomes of these potential therapeutic advances has not been evaluated in prospective studies. The randomized trials EuLITE in the UK and Germany and MYRE in France should help to answer these issues. MYRE is a randomized controlled phase III trial (NCT01208818) that aims to better define the epidemiology and typology of inaugural renal failure in MM and to optimize therapy of MCN patients with and without dialysis-dependent renal failure.
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26
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Periventricular white matter immunoglobulin lambda light chain deposition disease diagnosed by proteomic analysis. Acta Neuropathol 2012; 124:293-5. [PMID: 22760528 DOI: 10.1007/s00401-012-1008-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Revised: 06/22/2012] [Accepted: 06/22/2012] [Indexed: 10/28/2022]
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Darouich S, Goucha R, Jaafoura MH, Zekri S, Kheder A, Maiz HB. Light-chain deposition disease of the kidney: a case report. Ultrastruct Pathol 2012; 36:134-8. [PMID: 22471437 DOI: 10.3109/01913123.2011.642464] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
A 41-year-old man was admitted for evaluation of nephrotic syndrome associated with microhematuria, hypertension, and moderate renal failure. In serum and urine samples, monoclonal IgG-lambda was detected. Bone marrow examination showed normal representation of all cell lines with normal range of plasma cells. Renal biopsy demonstrated diabetes-like nodular glomerulosclerosis. Immunofluorescence failed to demonstrate the presence of kappa or lambda light chains in the kidney. Electron microcopy showed granular electron-dense deposits along the glomerular basement membranes and in the mesangial nodules. The patient was diagnosed as having light-chain deposition disease (LCDD) without evidence of plasma cell dyscrasia. This report was designed to stress the significant challenges that remain in the diagnosis of LCDD-related glomerulopathy. The salient morphological features that help in making an accurate diagnosis are discussed.
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Affiliation(s)
- Sihem Darouich
- Electron Microscopy Laboratory, Faculty of Medicine of Tunis, Tunis, Tunisia
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28
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Atteintes rénales des dysglobulinémies : avancées diagnostiques et thérapeutiques. Presse Med 2012; 41:276-89. [DOI: 10.1016/j.lpm.2011.11.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2011] [Accepted: 11/14/2011] [Indexed: 11/20/2022] Open
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Komatsuda A, Nara M, Ohtani H, Nimura T, Sawada K, Wakui H. Proliferative glomerulonephritis with monoclonal immunoglobulin light chain deposits: a rare entity mimicking immune-complex glomerulonephritis. Intern Med 2012. [PMID: 23207123 DOI: 10.2169/internalmedicine.51.8513] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 39-year-old man developed proteinuria, hematuria, and renal insufficiency. A renal biopsy revealed the presence of mesangial proliferative glomerulonephritis with monoclonal λ-light chain deposits without evidence of immunoglobulin G (IgG), immunoglobulin A (IgA) or immunoglobulin M (IgM) deposits. Electron microscopy revealed granular electron-dense deposits resembling immune-complex deposits. No monoclonal proteins were detected in the serum or urine. The patient was treated with an angiotensin II receptor antagonist, and his condition was almost stable during the 1-year follow-up. This case shares common pathological characteristics with the newly described entity referred to as "proliferative glomerulonephritis with monoclonal IgG deposits" in which, glomerular deposits are composed entirely of monoclonal IgG. Therefore, we term the unusual form of glomerulonephritis observed in the present case "proliferative glomerulonephritis with monoclonal immunoglobulin light chain deposits."
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Affiliation(s)
- Atsushi Komatsuda
- Department of Hematology, Nephrology, and Rheumatology, Akita University Graduate School of Medicine, Japan.
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Bridoux F, Desport E, Frémeaux-Bacchi V, Chong CF, Gombert JM, Lacombe C, Quellard N, Touchard G. Glomerulonephritis with isolated C3 deposits and monoclonal gammopathy: a fortuitous association? Clin J Am Soc Nephrol 2011; 6:2165-74. [PMID: 21784830 DOI: 10.2215/cjn.06180710] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVES Glomerular deposition of monoclonal Ig has been exceptionally described as the cause of membranoproliferative glomerulonephritis, through activation of the complement alternative pathway (CAP). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We retrospectively studied six adults with monoclonal gammopathy and glomerulonephritis (GN) characterized by isolated C3 deposits. RESULTS All patients presented with hematuria, associated with chronic renal failure and proteinuria in five patients, three of whom had nephrotic syndrome. Five patients had monoclonal gammopathy of undetermined significance and one had smoldering myeloma. The serum monoclonal IgG (κ four of six, λ two of six) was associated with light chain (LC) proteinuria in five patients. Four patients had low serum C3 and/or factor B levels. C4, factor H (CFH), and I protein levels were normal in five of five patients; none had detectable C3NeF. IgG anti-CFH activity was positive in one case. No mutations in CFH, CFI, and MCP genes were identified in four of four patients. Deposits were intramembranous, subepithelial, and mesangial by electron microscopy, and stained positive for C3 (six of six), properdin, and CFH (two of two) but negative for Ig LC and heavy chains, C4, and C1q (6/6) by immunofluorescence. Five patients progressed to end-stage renal disease over a median period of 47 months, despite chemotherapy in four patients. In one patient, monoclonal λLC deposits were observed on a follow-up kidney biopsy after 4 years. CONCLUSIONS GN with isolated glomerular C3 deposits might represent an unusual complication of plasma cell dyscrasia, related to complement activation through an autoantibody activity of the monoclonal Ig against a CAP regulator protein.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology and Renal Transplantation, Hôpital Jean Bernard, 2, rue de la Milétrie, CHU Poitiers, 86021 Poitiers, France.
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Basnayake K, Stringer SJ, Hutchison CA, Cockwell P. The biology of immunoglobulin free light chains and kidney injury. Kidney Int 2011; 79:1289-301. [DOI: 10.1038/ki.2011.94] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Fujita H, Hishizawa M, Sakamoto S, Kondo T, Kadowaki N, Ishikawa T, Itoh J, Fukatsu A, Uchiyama T, Takaori-Kondo A. Durable hematological response and improvement of nephrotic syndrome on thalidomide therapy in a patient with refractory light chain deposition disease. Int J Hematol 2011; 93:673-676. [DOI: 10.1007/s12185-011-0829-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Revised: 03/07/2011] [Accepted: 03/22/2011] [Indexed: 10/18/2022]
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Boumediene A, Oblet C, Oruc Z, Duchez S, Morelle W, Huynh A, Pourrat J, Aldigier JC, Cogné M. Gammopathy with IgA mesangial deposition provides a monoclonal model of IgA nephritogenicity and offers new insights into its molecular mechanisms. Nephrol Dial Transplant 2011; 26:3930-7. [DOI: 10.1093/ndt/gfr131] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Herrera GA, Turbat-Herrera EA. Ultrastructural Immunolabeling in the Diagnosis of Monoclonal Light-and Heavy-chain-related Renal Diseases. Ultrastruct Pathol 2010; 34:161-73. [DOI: 10.3109/01913121003672873] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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36
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Komatsuda A, Wakui H, Ohtani H, Nimura T, Sawada KI. Steroid-responsive nephrotic syndrome in a patient with proliferative glomerulonephritis with monoclonal IgG deposits with pure mesangial proliferative features. NDT Plus 2010; 3:357-9. [PMID: 25949430 PMCID: PMC4421504 DOI: 10.1093/ndtplus/sfq076] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 04/09/2010] [Indexed: 11/13/2022] Open
Abstract
A 78-year-old woman developed acute-onset nephrotic syndrome. A renal biopsy showed mild mesangial proliferative glomerulonephritis. Immunofluorescence studies revealed granular IgG3- λ deposits within the mesangial area and along the glomerular capillary walls. Electron microscopy showed mesangial and subendothelial granular electron-dense deposits. The pattern of deposition was predominantly mesangial. Serum or urine monoclonal proteins were not detected. Middle-dose steroid therapy induced a rapid remission of nephrotic syndrome. We consider that this is the first case of steroid-responsive nephrotic syndrome due to an extremely rare glomerular disease, proliferative glomerulonephritis with monoclonal IgG deposits associated with pure mesangial proliferative features.
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Affiliation(s)
- Atsushi Komatsuda
- Department of Hematology, Nephrology, and Rheumatology , Akita University Graduate School of Medicine , Akita , Japan
| | - Hideki Wakui
- Department of Hematology, Nephrology, and Rheumatology , Akita University Graduate School of Medicine , Akita , Japan
| | - Hiroshi Ohtani
- Department of Nephrology and Dialysis , Akita Kumiai General Hospital , Japan
| | - Takashi Nimura
- Department of Internal Medicine , Senboku Kumiai General Hospital , Daisen , Japan
| | - Ken-Ichi Sawada
- Department of Hematology, Nephrology, and Rheumatology , Akita University Graduate School of Medicine , Akita , Japan
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Petrakis I, Stylianou K, Mavroeidi V, Vardaki E, Stratigis S, Stratakis S, Xylouri I, Perakis C, Petraki C, Nakopoulou L, Daphnis E. Biopsy-proven resolution of renal light-chain deposition disease after autologous stem cell transplantation. Nephrol Dial Transplant 2010; 25:2020-3. [PMID: 20133281 DOI: 10.1093/ndt/gfq023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Light-chain deposition disease (LCDD) is caused by an underlying clonal plasma cell dyscrasia in which monoclonal immunoglobulin light chains (LCs) are deposited in tissues, resulting in varying degrees of organ dysfunction. Autologous stem cell transplantation (ASCT) has been reported to stabilize renal function in patients with LCDD, but currently, no evidence of histopathologic resolution of LC deposition after ASCT exists. We present a patient, with severe renal dysfunction due to LCDD, who was treated with high-dose melphalan and ASCT that resulted in a significant and extended period of improved renal function. Four years after the initial improvement, the patient developed nephrotic range proteinuria, without any evidence of relapse of the plasma cell dyscrasia. At that time, a repeat renal biopsy showed complete resolution of LC depositions and development of extensive glomerulosclerosis, thus explaining proteinuria. To the best of our knowledge, this is the first report of a biopsy-proven resolution of renal LCDD following ASCT. A timely application of ASCT should be considered in LCDD to prevent deterioration of renal function in the long run.
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Affiliation(s)
- Ioannis Petrakis
- Department of Nephrology, Heraklion University Hospital, Crete, Greece
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Toyonaga J, Masutani K, Tsuruya K, Haruyama N, Sugiwaka S, Suehiro T, Maeda H, Taniguchi M, Katafuchi R, Iida M. Severe anasarca due to beriberi heart disease and diabetic nephropathy. Clin Exp Nephrol 2009; 13:518-521. [PMID: 19459028 DOI: 10.1007/s10157-009-0189-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2008] [Accepted: 04/06/2009] [Indexed: 11/28/2022]
Abstract
A 40-year-old man was transferred to our hospital because of severe anasarca. He was a heavy drinker for more than 20 years, and diagnosed with diabetes mellitus 8 years earlier and treated with retinal photocoagulation 8 months earlier. He reported loss of appetite after divorce 10 months prior to admission. On admission, he presented with systemic edema and dyspnea. Chest radiography showed massive pleural effusion and cardiomegaly. Serum total protein was 5.6 g/dl, albumin 2.6 g/dl, and urinary protein excretion was 5.3 g/day. Glucose tolerance test showed normal pattern. Ultrafiltration and continuous hemofiltration resulted in loss of 40 kg body weight in 5 days. Echocardiography revealed high-output heart failure and blood tests showed low serum thiamine level of 12 ng/ml (normal, >28 ng/ml). Accordingly, the diagnosis was established as beriberi heart disease complicated with nephrotic syndrome. Treatment with 50 mg/day thiamine intravenously and 80 mg/day furosemide resulted in increase in urine output, decrease in cardiac output, resolution of pulmonary effusion, and about 70 kg body weight loss. Percutaneous renal biopsy showed nodular glomerulosclerosis, mesangial matrix expansion, and thickening of glomerular basement membrane (GBM). Immunofluorescence study showed no glomerular deposition of immunoglobulin or complement. Electron microscopy showed GBM thickening and mesangial matrix deposition without electron-dense deposits or fibrils. These findings were compatible with diabetic glomerulosclerosis. In this patient, extreme malnutrition altered glucose tolerance but, on the other hand, nephrotic syndrome associated with diabetic nephropathy made the diagnosis of beriberi heart disease difficult.
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Affiliation(s)
- Jiro Toyonaga
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kohsuke Masutani
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Kidney Care Unit, Kyushu University Hospital, Fukuoka, Japan
| | - Kazuhiko Tsuruya
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan. .,Department of Integrated Therapy for Chronic Kidney Disease, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Naoki Haruyama
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shoichi Sugiwaka
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Takaichi Suehiro
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroto Maeda
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masatomo Taniguchi
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ritsuko Katafuchi
- Division of Internal Medicine, National Fukuoka Higashi Hospital, Koga, Japan
| | - Mitsuo Iida
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Herrera GA. Renal lesions associated with plasma cell dyscrasias: practical approach to diagnosis, new concepts, and challenges. Arch Pathol Lab Med 2009; 133:249-67. [PMID: 19195968 DOI: 10.5858/133.2.249] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/11/2008] [Indexed: 11/06/2022]
Abstract
CONTEXT Patients with plasma cell dyscrasias (myeloma) may exhibit a variety of renal manifestations as a result of damage from circulating light- and heavy-chain immunoglobulin components produced by the neoplastic plasma cells. The renal alterations can occur in any of the renal compartments, and in a significant number of the cases more than one compartment is affected. Research in the laboratory has helped considerably in providing a solid conceptual understanding of how renal damage occurs. OBJECTIVES To detail advances that have been made in the diagnosis of these conditions and to provide an account of research accomplishments that have solidified diagnostic criteria. The new knowledge that has been acquired serves to provide a solid platform for the future design of new therapeutic interventions aimed at ameliorating or abolishing the progressive renal damage that typically takes place. DATA SOURCES Translational efforts have substantially contributed to elucidate mechanistically the molecular events responsible for the renal damage. The spectrum of renal manifestations associated with plasma cell dyscrasias has expanded significantly in the last 10 years. Diagnostic criteria have also been refined. This information has been summarized from work done at several institutions. CONCLUSIONS A number of significant challenges remain in the diagnosis of these conditions, some of which will be discussed in this article. Dealing with these challenges will require additional translational efforts and close cooperation between basic researchers, clinicians, and pathologists in order to improve the diagnostic tools available to renal pathologists and to acquire a more complete understanding of clinical and pathologic manifestations associated with these conditions.
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Affiliation(s)
- Guillermo A Herrera
- Pathology Department, Nephrocor Laboratory, 1700 N Desert Drive, Tempe, AZ 85281, USA.
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40
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Foguem C, Kantelip B, Deconinck E, Hafsaoui C, Méaux-Ruault N, Gil H, Magy-Bertrand N, Dupond JL. [Kappa light chain deposition disease, presenting as Sjögren's syndrome, successfully treated by high-dose melphalan and autologous blood stem transplantation]. Rev Med Interne 2008; 30:49-52. [PMID: 18801600 DOI: 10.1016/j.revmed.2008.08.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2008] [Revised: 07/03/2008] [Accepted: 08/02/2008] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Light chain deposition disease is a systemic disorder characterised by tissue deposition of monoclonal immunoglobulin light chains without tinctorial properties. It has been exceptionally reported with salivary involvement mimicking Sjögren's syndrome and peripheral neuropathy. CASE REPORT We report a case of light chain deposition disease associated with plasma cell dyscrasia presenting as sicca syndrome with salivary glands hypertrophy and polyneuropathy successfully treated by high dose melphalan and autologous blood stem transplantation. CONCLUSION Light chain deposition disease should be recognized as an aetiology of sicca syndrome and peripheral neuropathy. Further studies should assess the prevalence of sicca syndrome in light chain deposition disease and better characterise the neurological manifestations.
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Affiliation(s)
- C Foguem
- Service de médecine interne, hôpital Jean-Minjoz, CHU de Besançon, boulevard Fleming, 25030 Besançon cedex, France.
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Komatsuda A, Masai R, Ohtani H, Togashi M, Maki N, Sawada KI, Wakui H. Monoclonal immunoglobulin deposition disease associated with membranous features. Nephrol Dial Transplant 2008; 23:3888-94. [PMID: 18596130 DOI: 10.1093/ndt/gfn363] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Very few cases of non-organized and non-Randall-type monoclonal immunoglobulin deposition disease (MIDD) associated with membranous features have been reported. Information on clinicopathological features and prognosis in this entity is limited. METHODS We reviewed 5443 renal biopsies processed at our department, and identified three patients with MIDD associated with membranous features. We evaluated clinicopathological features and outcomes in these patients. RESULTS All patients had proteinuria, and one patient developed nephrotic syndrome. Renal insufficiency was not observed. Cryoglobulin or monoclonal protein in serum and urine was not detected. A renal biopsy showed thickening of the glomerular capillary walls and spike formation. Tubulointerstitial and vascular alterations were mild or absent. Immunofluorescence studies revealed granular IgG3-kappa deposits in two patients and IgG1-kappa deposits in one patient, along the glomerular capillary walls. Immunofluorescence studies using antibodies specific for gamma-heavy chain Fab containing C(H)1 domain, C(H)2 domain and C(H)3 domain did not show any apparent deletion. On confocal microscopy, glomerular colocalization of light and heavy chains was observed. Electron microscopy showed predominant subepithelial granular deposits without distinct ultrastructural organization. All patients were treated with steroids, and good effects were observed. A follow-up renal biopsy performed in one patient showed histological improvements. No patient developed myeloma or other haematological malignancy during the course of follow-up (mean 44 months). CONCLUSIONS MIDD associated with membranous features is an extremely rare but distinctive entity. Our study suggests glomerular deposition of a nondeleted whole immunoglobulin molecule. Patients with this entity appear to respond well to steroid therapy.
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Affiliation(s)
- Atsushi Komatsuda
- Third Department of Internal Medicine, Akita University School of Medicine, Akita City, Akita 010-8543, Japan.
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Shaheen SP, Talwalkar SS, Medeiros LJ. Multiple myeloma and immunosecretory disorders: an update. Adv Anat Pathol 2008; 15:196-210. [PMID: 18580096 DOI: 10.1097/pap.0b013e31817cfcd6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The immunosecretory disorders are a diverse group of diseases associated with proliferation of an abnormal clone of immunoglobulin (Ig)-synthesizing, terminally differentiated B cells. These disorders include multiple myeloma (MM) and its variants, plasmacytoma, Waldenstrom macroglobulinemia, monoclonal gammopathy of undetermined significance, and monoclonal Ig deposition diseases, the latter including primary amyloidosis and nonamyloidotic types. These disorders are histologically composed of plasma cells, or plasmacytoid cells which produce Ig that is synthesized and usually secreted and can be deposited in some diseases. The Ig can be complete or can be composed of either heavy or light chains and is termed M-(monoclonal) protein. In MM, this proliferation overwhelms the normal cellular counterparts that synthesize and secrete appropriate levels of Ig. Immunosecretory disorders have been classified in multiple schemes, mostly morphologic, to such a degree that the classification of these entities has become a challenge to pathologists. The World Health Organization classification in 2001 was helpful because it provided specific clinicopathologic criteria for diagnosis. However, terms such as "progressive" disease were not well defined. In 2003, the International Myeloma Group defined MM as a disease with related organ and tissue injury, serving to better explain progressive in terms of deterioration of organ (renal, bone, and bone marrow) function over time. Therefore, modern classification of immunosecretory diseases is based on integration of clinical, morphologic, laboratory, radiographic, and biologic (including molecular) parameters, which we review here.
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Abstract
In routine diagnosis on renal biopsy, one of the confusing fields for pathological diagnoses is the glomerulopathies with fibrillary structure. The primary glomerulopathies with a deposit of ultrastructural fibrillary structure, which are negative for Congo-red stain but positive for immunoglobulins, include fibrillary glomerulonephritis and immunotactoid glomerulopathy. Several paraproteinemias including cryoglobulinemia, monoclonal gammopathy, and light chain deposition disease as well as hematopoietic disorders including plasmacytoma, plasma cell dyscrasia, and B cell lymphoproliferative disorders involve glomerulopathy with an ultrastructural fibrillary structure. A rare glomerulopathy with fibrillary structure that stains negative for Congo-red as well as for immunoglobulins has been also reported. The pathological diagnoses of these glomerulopathies can include either glomerular diseases, or paraproteinemic diseases, or hematopoietic diseases. The terminology is still confusing when glomerular diseases can be combined with paraproteinemic diseases and/or hematopoietic diseases. Therefore, the generic term, 'glomerular deposition disease' (GDD), has been proposed by pathologists with a requirement for clinicians to detect autoantibodies, paraproteins as well as to carry out a bone marrow check. An attempt has been made to rearrange the diseases with related disorders of fibrillary deposits, based on detailed clinical and pathological finding and to elucidate the correlation between GDD, paraproteinemia, and hematopoietic disorder.
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Affiliation(s)
- Kensuke Joh
- Division of Immunopathology, Clinical Research Center, Chiba-East National Hospital, Chuo-ku, Chiba, Japan.
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Popović M, Tavćar R, Glavac D, Volavsek M, Pirtosek Z, Vizjak A. Light chain deposition disease restricted to the brain: the first case report. Hum Pathol 2007; 38:179-84. [PMID: 17059841 DOI: 10.1016/j.humpath.2006.07.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Revised: 07/06/2006] [Accepted: 07/20/2006] [Indexed: 11/15/2022]
Abstract
A 35-year-old white male with symptoms of paranoid schizophrenia was treated by psychiatrists for 13 years. During the final year, he developed severe dysphagia, reduced strength of the upper extremity muscles, and cognitive dysfunction. The patient died in his sleep. The only pathology found in coronal brain sections was ill-defined periventricular foci with prominent, firm vessels. Microscopy revealed abundant, hematoxylin and eosin-eosinophilic, periodic acid-Schiff-positive, thioflavin T-positive, and Congo red-negative deposits in the vessel walls, with hypoxic encephalopathy in the affected regions. Immunohistochemistry showed lambda light chains as the main component of the deposits. Ultrastructural analysis showed amorphous electron dense material in the vessel walls. Perivascular B-cell proliferation was present in the vicinity of affected areas. Polymerase chain reaction was applied for the assessment of B-cell clonality, revealing monoclonal rearrangement of the heavy chain Ig gene. Neither in the kidney nor in any other organ were deposits detected. This is the first case report of light chain deposition disease restricted to the brain.
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Affiliation(s)
- Mara Popović
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, SI-1000 Ljubljana, Slovenia.
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Bridoux F, Sirac C, Jaccard A, Ayache RA, Goujon JM, Cogné M, Touchard G. Chapter 12 Renal Disease in Cryoglobulinemic Vasculitis. ACTA ACUST UNITED AC 2007. [DOI: 10.1016/s1571-5078(07)07012-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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Sirohi B, Powles R. Epidemiology and outcomes research for MGUS, myeloma and amyloidosis. Eur J Cancer 2006; 42:1671-83. [PMID: 16870424 DOI: 10.1016/j.ejca.2006.01.065] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2005] [Revised: 01/09/2006] [Accepted: 01/18/2006] [Indexed: 11/19/2022]
Abstract
The epidemiology of plasma cell dyscrasias clearly links to a complicated multi-factorial pathogenic pathway that at the individual patient level gives no clear indication of why the malignant process has occurred but factors in the environment and within the genome give clues and are discussed. MGUS is a pre-malignant disorder characterised by monoclonal plasma cell proliferation in the bone marrow and no end-organ damage; the patients are asymptomatic. Primary amyloidosis is a rare disorder that is characterised by deposition of amyloid fibrils composed of immunoglobulin light chain fragments; symptoms relate to the affected organ. Multiple myeloma is a malignant disease of plasma cells and with improvements in treatment, patients can now expect a doubling of median survival to 5 years, a 20% chance of surviving >10 years and a 50% chance of complete remission (CR), morphological and biochemical. The challenge is now to determine exactly what this means to the individual myeloma patient in terms of benefit, and to society as a whole and this is the basis of 'outcomes research' which is discussed in this review.
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Affiliation(s)
- Bhawna Sirohi
- Royal Marsden NHS Trust and Parkside Cancer Centre, London, UK
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48
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Matsuura K, Ohara K, Munakata H, Hifumi E, Uda T. Pathogenicity of catalytic antibodies: catalytic activity of Bence Jones proteins from myeloma patients with renal impairment can elicit cytotoxic effects. Biol Chem 2006; 387:543-8. [PMID: 16740125 DOI: 10.1515/bc.2006.070] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Some Bence Jones proteins (BJPs) can display catalytic activity. Although the catalytic activity of BJPs might be associated with the pathogenesis of disease, this relationship has not yet been established. We tested the effects of seven BJPs on LLC-PK1 cells to assess their pathogenicity. Two out of the seven BJPs showed cytotoxic activity, as assessed by microscopic analysis, the WST method and TUNEL staining. Moreover, the cytotoxic BJPs were excreted by patients who presented with renal impairment. The cytotoxic BJPs displayed 20- to 40-fold higher catalytic activities (k
cat of 3.5–2.2 min-1) in hydrolyzing a chromogenic substrate compared to the other BJPs. By treating the cytotoxic BJPs with diisopropylfluorophosphate, they lost not only their catalytic activity, but also the cytotoxic effects. These results indicate a direct link between cytotoxicity and the catalytic activity of the BJPs. The catalytic activity of BJPs contributes to the pathogenesis, as well as to development, of symptoms of multiple myeloma. Inhibition of the catalytic activity of BJPs may form the basis of a novel treatment for multiple myeloma patients with renal dysfunction.
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Affiliation(s)
- Kinji Matsuura
- Hanada Clinic and Laboratory, 3-13 Higashiasakayamacho, Sakai, Osaka 591-8008, Japan.
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49
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Omtvedt LA, Royle L, Husby G, Sletten K, Radcliffe CM, Harvey DJ, Dwek RA, Rudd PM. Glycan analysis of monoclonal antibodies secreted in deposition disorders indicates that subsets of plasma cells differentially process IgG glycans. ACTA ACUST UNITED AC 2006; 54:3433-40. [PMID: 17075835 DOI: 10.1002/art.22171] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare the glycosylation of polyclonal serum IgG heavy chains in a patient with rheumatoid arthritis (RA) with that of monoclonal serum IgG heavy chains in the same patient during an episode of heavy-chain deposition disease (HCDD), to establish whether glycosylation processing is specific for subsets of B cells. METHODS Serum IgG was purified using a HiTrap protein G column. Immunoglobulins were run on sodium dodecyl sulfate-polyacrylamide gel electrophoresis gels, and IgG glycans were isolated from gel bands and fluorescently labeled. Glycans were analyzed by normal-phase high-performance liquid chromatography and by liquid chromatography-electrospray ionization-mass spectrometry. RESULTS The glycosylation of serum immunoglobulins from a patient with seronegative RA and HCDD was analyzed. The predominant immunoglobulin was a truncated glycosylated gamma3 heavy chain, and a small amount of polyclonal IgG was also present. The glycan profile showed that the monoclonal gamma3 heavy chain contained fully galactosylated biantennary glycans with significantly less fucose but more sialic acid than in IgG3 from healthy controls. In contrast, the polyclonal IgG showed an RA-like profile, with a predominance of fucosylated biantennary glycans and low levels of galactosylation. The glycan profile of serum IgG obtained from the same patient during disease remission resembled a typical RA profile. CONCLUSION These data indicate that different types of B cells process a particular set of IgG glycoforms.
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Affiliation(s)
- Lone A Omtvedt
- Department of Molecular Biosciences, University of Oslo, Postboks 1041 Blindern, 0316 Oslo, Norway.
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Bladé J, Rosiñol L. Renal, hematologic and infectious complications in multiple myeloma. Best Pract Res Clin Haematol 2005; 18:635-52. [PMID: 16026742 DOI: 10.1016/j.beha.2005.01.013] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Renal failure is a common complication in patients with multiple myeloma. It is generally due to tubular light-chain damage, and it is reversible in about 50% of patients. The reversibility rate depends on the degree of light-chain nephropathy. The initial therapy should consist of dexamethasone- or cyclophosphamide-based regimens. High-dose therapy/autologous transplant may be of benefit in selected patients. Early plasma exchange may be useful in patients who have severe renal failure but do not yet require dialysis. Renal replacement with dialysis is a worthwhile measure in patients with end-stage renal failure. Anemia is the most common hematologic complication. About 70% of anemic patients respond to recombinant human erythropoietin (rHuEPO), resulting not only in an increase in the hemoglobin level but also in an improvement in the quality of life. The hemoglobin level should ideally be maintained at around 12 g/dL. Infection is the main cause of morbidity and mortality in patients with myeloma. The highest risk of infection is within the first 2 months of initiation of therapy as well as in patients with renal failure and in those with relapsed and refractory disease.
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Affiliation(s)
- Joan Bladé
- Hematology Department, Institute of Hematology and Oncology, Postgraduate School of Hematology Farreras-Valentí, IDIBAPS, Hospital Clínic, Barcelona, Spain.
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