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Park K, Kwon SH. Monoclonal gammopathy of renal significance from the perspective of nephrologists. Blood Res 2024; 59:28. [PMID: 39133392 PMCID: PMC11319560 DOI: 10.1007/s44313-024-00027-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 07/04/2024] [Indexed: 08/13/2024] Open
Abstract
Kidney disease is a frequent complication of multiple myeloma and other malignancies associated with monoclonal gammopathies. Additionally, dysproteinemia-related kidney disease can occur independently of overt multiple myeloma or hematologic malignancies. Monoclonal gammopathy of renal significance (MGRS) is a spectrum of disorders in which a monoclonal immunoglobulin produced by a benign or premalignant B-cell or plasma cell clone causes kidney damage. MGRS-associated renal disease manifests in various forms, including immunoglobulin-associated amyloidosis, monoclonal immunoglobulin deposition diseases (light chain, heavy chain, and combined light and heavy chain deposition diseases), proliferative glomerulonephritis with monoclonal immunoglobulin deposits, C3 glomerulopathy with monoclonal gammopathy, and light chain proximal tubulopathy. Although MGRS is a nonmalignant or premalignant hematologic condition, it has significant renal implications that often lead to progressive kidney damage and, eventually, end-stage kidney disease. This review discusses the epidemiology, pathogenesis, and management of MGRS and focuses on the perspective of nephrologists.
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Affiliation(s)
- Kootae Park
- Division of Nephrology, Hyonam Kidney Laboratory, Soonchunhyang University Hospital, 59 Daesagwan-Ro, Yongsan-Gu, Seoul, South Korea
| | - Soon Hyo Kwon
- Division of Nephrology, Hyonam Kidney Laboratory, Soonchunhyang University Hospital, 59 Daesagwan-Ro, Yongsan-Gu, Seoul, South Korea.
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2
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Nishigaito T, Mitsumoto K, Katsunuma R, Hirai Y, Yamashita C, Mizumoto A, Uzu T. Crystalline Light Chain Casts and Hypercalcemia Induced Acute Kidney Injury: A Rare Presentation of Multiple Myeloma. Intern Med 2024; 63:1751-1755. [PMID: 37926541 PMCID: PMC11239252 DOI: 10.2169/internalmedicine.2603-23] [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: 07/12/2023] [Accepted: 09/18/2023] [Indexed: 11/07/2023] Open
Abstract
The most common cause of acute kidney injury (AKI) in multiple myeloma is light-chain cast nephropathy (LCCN), which consists of a light chain and Tamm-Horsfall protein (THP). We herein report a 46-year-old woman with hypercalcemia and AKI. A renal biopsy showed crystalline casts, which were consistent with lambda light chains but not THP. Hydration therapy and treatment to lower her serum calcium concentration were initiated immediately. She subsequently received bortezomib-based anti-myeloma therapy and recovered successfully. This was a rare case of LCCN, suggesting that hypercalcemia may play a role in the development of crystalline LCCN.
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Affiliation(s)
| | | | | | - Yuri Hirai
- Department of Nephrology, Nippon Life Hospital, Japan
| | | | - Aya Mizumoto
- Department of Nephrology, Nippon Life Hospital, Japan
| | - Takashi Uzu
- Department of Nephrology, Nippon Life Hospital, Japan
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3
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Bobot M, Heim X, Max H, Boucraut J, Simeone P, Stein C, Velly L, Bruder N, Forel JM, Hraiech S, Guervilly C, Carvelli J, Gainnier M, Mège JL, Chopinet S, Jourde-Chiche N, Papazian L, Burtey S. Prospective Multicenter Study on Early Proximal Tubular Injury in COVID-19-Related Acute Respiratory Distress Syndrome. Kidney Int Rep 2024; 9:1641-1653. [PMID: 38899195 PMCID: PMC11184390 DOI: 10.1016/j.ekir.2024.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/27/2024] [Accepted: 03/11/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction During COVID-19, renal impairment is associated with poor prognosis in intensive care unit (ICU). We aimed to assess the existence and incidence of early renal dysfunction and its prognostic value in patients with COVID-19-related acute respiratory distress syndrome (ARDS). Methods In this prospective multicenter study, patients aged over 18 years with invasive mechanical ventilation (MV) for ARDS were enrolled in 3 ICUs. Precise evaluation of renal dysfunction markers, including urinary protein electrophoresis (UPE) and quantification, was performed within 24 hours after MV onset. Results From March 2020 to December 2021, 135 patients were enrolled as follows: 100 with COVID-19 ARDS and 35 with non-COVID-19 ARDS. UPE found more tubular dysfunction in patients with COVID-19 (68% vs. 21.4%, P < 0.0001) and more normal profiles in patients without COVID-19 (65.0% vs. 11.2%, P = 0.0003). Patients with COVID-19 significantly displayed early urinary leakage of tubular proteins such as beta-2-microglobulin (ß2m) and free light chains, tended to display acute kidney injury (AKI) more frequently (51.0% vs. 34.3%, P = 0.088), had longer MV (20 vs. 9 days, P < 0.0001) and longer ICU stay (26 vs. 15 days, P < 0.0001). In COVID-19 ARDS, leakage of free lambda light chain was associated with the onset of Kidney Disease: Improving Global Outcomes (KDIGO) ≥2 AKI (odds ratio [OR]: 1.014, 95% confidence interval [CI] 1.003-1.025, P = 0.011). Conclusion Patients with COVID-19-related ARDS display a proximal tubular dysfunction before the onset of AKI, which predicts AKI. Proximal tubular damage seems an important mechanism of COVID-19-induced nephropathy. Analysis of urinary proteins is a reliable noninvasive tool to assess proximal tubular dysfunction in the ICU.
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Affiliation(s)
- Mickaël Bobot
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, AP-HM, Marseille, France
- INSERM, INRAE, C2VN, Aix-Marseille Université, Marseille, France
- CERIMED, Aix-Marseille Université, Marseille, France
| | - Xavier Heim
- INSERM, INRAE, C2VN, Aix-Marseille Université, Marseille, France
- Laboratoire d’Immunologie, Hôpital de la Conception, AP-HM, France
| | - Howard Max
- Département d’Anesthésie-Réanimation, AP-HM, CHU Timone, Aix-Marseille Université, Marseille, France
| | - José Boucraut
- Département d’Anesthésie-Réanimation, AP-HM, CHU Timone, Aix-Marseille Université, Marseille, France
- INT UMR CNRS 7286, Aix-Marseille Université, Marseille, France
| | - Pierre Simeone
- Département d’Anesthésie-Réanimation, AP-HM, CHU Timone, Aix-Marseille Université, Marseille, France
- CNRS, Institut des Neurosciences de la Timone, UMR7289, Marseille, France
| | - Claire Stein
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation; Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Aix-Marseille Université, France
| | - Lionel Velly
- Département d’Anesthésie-Réanimation, AP-HM, CHU Timone, Aix-Marseille Université, Marseille, France
- CNRS, Institut des Neurosciences de la Timone, UMR7289, Marseille, France
| | - Nicolas Bruder
- Département d’Anesthésie-Réanimation, AP-HM, CHU Timone, Aix-Marseille Université, Marseille, France
| | - Jean-Marie Forel
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation; Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Aix-Marseille Université, France
| | - Sami Hraiech
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation; Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Aix-Marseille Université, France
| | - Christophe Guervilly
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation; Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Aix-Marseille Université, France
| | - Julien Carvelli
- Service de Réanimation et Surveillance Continue, Hôpital de la Timone, AP-HM, Marseille, France
| | - Marc Gainnier
- INSERM, INRAE, C2VN, Aix-Marseille Université, Marseille, France
- Service de Réanimation et Surveillance Continue, Hôpital de la Timone, AP-HM, Marseille, France
| | - Jean-Louis Mège
- Laboratoire d’Immunologie, Hôpital de la Conception, AP-HM, France
| | - Sophie Chopinet
- Service de Chirurgie Générale et Transplantation Hépatique, Hôpital de la Timone, LIIE, CERIMED, Aix-Marseille Université, Marseille, France
| | - Noémie Jourde-Chiche
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, AP-HM, Marseille, France
- INSERM, INRAE, C2VN, Aix-Marseille Université, Marseille, France
| | - Laurent Papazian
- Assistance Publique - Hôpitaux de Marseille, Hôpital Nord, Médecine Intensive Réanimation; Centre d'Etudes et de Recherches sur les Services de Santé et qualité de vie EA 3279, Aix-Marseille Université, France
| | - Stéphane Burtey
- Centre de Néphrologie et Transplantation Rénale, Hôpital de la Conception, AP-HM, Marseille, France
- INSERM, INRAE, C2VN, Aix-Marseille Université, Marseille, France
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Lim SM, Wijeratne N, Choy KW, Nguyen TTH, Setiawan L, Loh TP. A review of clinical guidelines, laboratory recommendations and external quality assurance programs for monoclonal gammopathy testing. Crit Rev Clin Lab Sci 2024; 61:107-126. [PMID: 37776896 DOI: 10.1080/10408363.2023.2257306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 09/06/2023] [Indexed: 10/02/2023]
Abstract
Monoclonal gammopathy (MG) is a spectrum of diseases ranging from the benign asymptomatic monoclonal gammopathy of undetermined significance to the malignant multiple myeloma. Clinical guidelines and laboratory recommendations have been developed to inform best practices in the diagnosis, monitoring, and management of MG. In this review, the pathophysiology, relevant laboratory testing recommended in clinical practice guidelines and laboratory recommendations related to MG testing and reporting are examined. The clinical guidelines recommend serum protein electrophoresis, serum immunofixation and serum free light chain measurement as initial screening. The laboratory recommendations omit serum immunofixation as it offers limited additional diagnostic value. The laboratory recommendations offer guidance on reporting findings beyond monoclonal protein, which was not required by the clinical guidelines. The clinical guidelines suggested monitoring total IgA concentration by turbidimetry or nephelometry method if the monoclonal protein migrates in the non-gamma region, whereas the laboratory recommendations make allowance for involved IgM and IgG. Additionally, several external quality assurance programs for MG protein electrophoresis and free light chain testing are also appraised. The external quality assurance programs show varied assessment criteria for protein electrophoresis reporting and unit of measurement. There is also significant disparity in reported monoclonal protein concentrations with wide inter-method analytical variation noted for both monoclonal protein quantification and serum free light chain measurement, however this variation appears smaller when the same method was used. Greater harmonization among laboratory recommendations and reporting format may improve clinical interpretation of MG testing.
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Affiliation(s)
| | - Nilika Wijeratne
- Dorevitch Pathology, Melbourne, Australia
- School of Clinical Sciences at Monash Health, Department of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia
- Eastern Health Pathology, Eastern Health, Box Hill, Australia
- Dorevitch Pathology, Heidelberg, Australia
| | | | | | - Lyana Setiawan
- Dharmais Hospital National Cancer Centre, West Jakarta, Indonesia
| | - Tze Ping Loh
- National University Hospital, Singapore, Singapore
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5
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Morales-García LJ, Lillo Rodríguez RM, Pacheco-Delgado MS. Freelite and Kloneus assays in free light chain measurements in patients with renal impairment. Clin Biochem 2023:110610. [PMID: 37429509 DOI: 10.1016/j.clinbiochem.2023.110610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Revised: 05/14/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Serum free light chain (FLC) quantification is a diagnostic criterion for monoclonal gammopathy and its values in patients with renal impairment are different from those in healthy subjects. The aim of this study was to evaluate Freelite and Kloneus assays in these patients METHODS: In this retrospective study, serum samples from 226 patients with chronic kidney disease (CKD) of stages 2-5 were measured with a Freelite assay on the Optilite system and with a Kloneus assay on the AU5800 system and compared with controls without renal impairment. RESULTS Both kappa FLC (K-FLC) and lambda FLC (L-FLC) concentrations increased with Kloneus and Freelite assays with each increment in CKD stage. In patients with CKD, Kloneus detected lower concentrations of K-FLC (median: 20.4 mg/L; 95% range: 9.8-57.2) than Freelite (median: 36.5 mg/L; 95% range: 16.5-137.7) and higher concentrations of L-FLC (median: 32.2 mg/L; 95% range: 14.4-96.7) than Freelite (median: 25.4 mg/L; 95% range: 11.9-86.0). This resulted in significantly different kappa/lambda ratios (K/L-FLC) in patients with CKD for the two tests. The Freelite K/L-FLC in the CKD group (median: 1.50; min-max: 0.66-3.45) was significantly increased compared with healthy controls, and the Kloneus K/L-FLC in the CKD group (median: 0.63; 95% min-max: 0.34-1.01) was slightly lower. CONCLUSIONS These findings demonstrate that Freelite and Kloneus assays provide higher but not parallel values when FLCs are measured in patients with CKD, so an increase in K/L-FLC was observed in the case of Freelite, and we found a slight decrease in the case of Kloneus.
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Affiliation(s)
- Luis J Morales-García
- Department of Clinical Laboratory, Hospital Universitario de Fuenlabrada, Camino del Molino 2, 28942 Fuenlabrada (Madrid), Spain.
| | - Rosa M Lillo Rodríguez
- Department of Clinical Laboratory, Hospital Universitario de Fuenlabrada, Camino del Molino 2, 28942 Fuenlabrada (Madrid), Spain.
| | - María S Pacheco-Delgado
- Department of Clinical Laboratory, Hospital Universitario de Fuenlabrada, Camino del Molino 2, 28942 Fuenlabrada (Madrid), Spain.
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6
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Abstract
The term monoclonal gammopathies of renal significance (MGRS) encompasses a group of renal histopathological lesions fulfilling two criteria: (a) they are caused by nephrotoxic monoclonal immunoglobulins and (b) the monoclonal immunoglobulins are produced by small B-cell or plasma cell clones which do not meet the criteria for multiple myeloma or malignant lymphoma. Here, we provide a review of the MGRS definition and related terminology and elaborate on the diagnostic approach and treatment principles from the general physician perspective.
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Affiliation(s)
| | - Andreas Kousios
- Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK and honorary senior clinical lecturer, Imperial College, London, UK
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7
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Lewis E, Lee H, Fine N, Miller R, Hahn C, Tay J, Chhibber S, Mahe E, Jimenez-Zepeda VH. Monoclonal Gammopathy of Undetermined Significance in Patients With Transthyretin Amyloidosis (ATTR): Analysis Using the iStopMM Criteria. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:211-217. [PMID: 36621346 DOI: 10.1016/j.clml.2022.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/20/2022] [Accepted: 12/21/2022] [Indexed: 12/26/2022]
Abstract
INTRODUCTION To identify the prevalence of monoclonal gammopathy of undetermined significance (MGUS) in patients with transthyretin amyloid (ATTR). We used the iStopMM study revised reference ranges for serum free light-chain (sFLC) corrected for eGFR to identify ATTR patients with light-chain MGUS (LC-MGUS). Characteristics and frequencies of the ATTR cohort with underlying MGUS was compared to a cohort of MGUS patients without ATTR. PATIENTS AND METHODS A retrospective analysis of ATTR and MGUS patients evaluated at our center between January 2014 to December 2021. A total of 149, predominantly male (87.5%) ATTR patients with a median age of 82 were included. This cohort was compared to 228 MGUS patients. RESULTS Of the 149 ATTR patients, 27 (18.1%) had coexisting MGUS. Among ATTR patients with MGUS, 12/27 (44%) had LC-MGUS based on sFLC abnormalities assessed using the iStopMM reference ranges. Of the MGUS only cohort, 44/228 (19.3%) met criteria for LC-MGUS. Utilizing the iStopMM reference ranges, 6 ATTR patients did not meet criteria for abnormal sFLCs, uncovering a 20% false-positive rate. CONCLUSION We noted higher rates of MGUS, particularly LC-MGUS, among ATTR patients when compared to our MGUS only cohort. The high prevalence remained after utilizing the iStopMM sFLC corrected for eGFR reference ranges. Additionally, 6 ATTR patients with renal-dysfunction would have met MGUS criteria if not evaluated using the iStopMM revised measures. These findings emphasize careful interpretation of sFLC abnormalities and encourage providers to keep ATTR on the differential when work-up uncovers sFLC aberrations.
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Affiliation(s)
- Ellen Lewis
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada
| | - Holly Lee
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada
| | - Nowell Fine
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Robert Miller
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Christopher Hahn
- Division of Neurology, Department of Clinical Neurosciences, Charbonneau Cancer Research Institute, Calgary, AB, Canada
| | - Jason Tay
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada; Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Charbonneau Cancer Research Institute, Calgary, AB, Canada
| | - Sameer Chhibber
- Division of Neurology, Department of Clinical Neurosciences, Charbonneau Cancer Research Institute, Calgary, AB, Canada
| | - Etienne Mahe
- Department of Pathology and Lab Medicine, Calgary, AB, Canada
| | - Victor H Jimenez-Zepeda
- Department of Medical Oncology and Hematology, Tom Baker Cancer Center, Calgary, AB, Canada; Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Charbonneau Cancer Research Institute, Calgary, AB, Canada.
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8
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Absmeier RM, Rottenaicher GJ, Svilenov HL, Kazman P, Buchner J. Antibodies gone bad - the molecular mechanism of light chain amyloidosis. FEBS J 2023; 290:1398-1419. [PMID: 35122394 DOI: 10.1111/febs.16390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/19/2022] [Accepted: 02/03/2022] [Indexed: 12/19/2022]
Abstract
Light chain amyloidosis (AL) is a systemic disease in which abnormally proliferating plasma cells secrete large amounts of mutated antibody light chains (LCs) that eventually form fibrils. The fibrils are deposited in various organs, most often in the heart and kidney, and impair their function. The prognosis for patients diagnosed with AL is generally poor. The disease is set apart from other amyloidoses by the huge number of patient-specific mutations in the disease-causing and fibril-forming protein. The molecular mechanisms that drive the aggregation of mutated LCs into fibrils have been enigmatic, which hindered the development of efficient diagnostics and therapies. In this review, we summarize our current knowledge on AL amyloidosis and discuss open issues.
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Affiliation(s)
- Ramona M Absmeier
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Georg J Rottenaicher
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Hristo L Svilenov
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Pamina Kazman
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Johannes Buchner
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
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Gueye S, Gauthier M, Benyahia R, Trape L, Dahri S, Kounde C, Perier T, Meklati L, Guelib I, Faye M, Rostaing L. [Nephropathy associated with monoclonal immunoglobulins: From clonal expansion B to renal toxicity of pathological immunoglobulins]. Nephrol Ther 2022; 18:591-603. [PMID: 36428151 DOI: 10.1016/j.nephro.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 10/06/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022]
Abstract
Germinal center regulation pathways are often involved in lymphomagenesis and myelomagenesis. Most of the lymphomas (and multiple myeloma) derive from post-germinal center B-cells that have undergone somatic hypermutation and class switch recombination. Hence, B-cell clonal expansion can be responsible for the presence of a monoclonal component (immunoglobulin) of variable titer which, owing to physicochemical properties, can provoke pathologically defined entities of diseases. These diseases can affect any functional part of the kidney, by multiple mechanisms, either well known or not. The presence of renal deposition is influenced by germinal gene involved, immunoglobulin primary structure, post-translational modifications and microenvironmental interactions. The two ways immunoglobulin can cause kidney toxicity are (i) an excess of production (overcoming catabolism power by proximal tubule epithelial cells) with an excess of free light chains within the distal tubules and a subsequent risk of precipitation due to local physicochemical properties; (ii) by structural characteristics that predispose immunoglobulin to a renal disease (whatever their titer). The purpose of this manuscript is to review literature concerning the pathophysiology of renal toxicities of clonal immunoglobulin, from molecular B-cell expansion mechanisms to immunoglobulin renal toxicity.
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Affiliation(s)
- Serigne Gueye
- Service de néphrologie-dialyse, CH de Cahors, France.
| | | | | | - Lucas Trape
- Service de néphrologie-dialyse, CH de Cahors, France
| | - Souad Dahri
- Service de néphrologie-dialyse, CH de Cahors, France
| | | | - Thomas Perier
- Service de néphrologie-dialyse, CH de Cahors, France
| | | | | | - Maria Faye
- Université Cheikh Anta Diop, Dakar, Sénégal
| | - Lionel Rostaing
- Service de néphrologie-dialyse, CH de Cahors, France; Service de néphrologie, hémodialyse, aphérèses et greffe rénale, France; Inserm U563, IFR-BMT, CHU de Purpan, Toulouse, France; Université Grenoble-Alpes, France
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10
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Xing Y, Yan J, Yu Z, Zhao J, Wang Y, Li X, Qin Y, Sun S. High-cutoff hemodialysis in multiple myeloma patients with acute kidney injury. Front Oncol 2022; 12:1024133. [PMID: 36387107 PMCID: PMC9645355 DOI: 10.3389/fonc.2022.1024133] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 10/06/2022] [Indexed: 10/27/2023] Open
Abstract
Multiple myeloma (MM), an incurable hematological malignancy with clonal proliferation of plasma cells, is mainly characterized by excessive production of monoclonal immunoglobulins and free light chains (FLCs). Kidney injury is one of the main clinical manifestations and is also a significant predictor of the prognosis of symptomatic MM patients, especially those who require dialysis-supported treatment. Overproduction of FLCs is the trigger for kidney injury, as they can induce the transcription of inflammatory and profibrotic cytokines in the proximal tubule and bind to Tamm-Horsfall protein in the distal tubules to form casts that obstruct the tubules, leading to kidney injury and even renal fibrosis. In addition to traditional antimyeloma treatment, high-cutoff hemodialysis (HCO-HD), which can effectively remove FLCs in vitro, has attracted much attention in recent years. Due to its greater membrane pore size, it has significant advantages in removing larger molecules and can be applied in rhabdomyolysis, sepsis, and even myeloma cast nephropathy. However, mounting questions have recently been raised regarding whether HCO-HD can truly provide clinical benefits in MM patients with acute kidney injury (AKI). Therefore, in this study, we discussed the pathological causes of AKI secondary to MM and summarized the current situation of HCO-HD in MM patients compared with other available extracorporeal techniques. In addition, pivotal clinical trials that reflect the ability of the clearance of FLCs and the side effects of HCO-HD are highlighted, and the relevant protocol of HCO-HD is also provided to assist clinicians in decision-making.
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Affiliation(s)
| | | | | | | | | | | | | | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi’an, Shaanxi, China
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11
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A method to obtain purified free light chain monomers and dimers from urine samples of patients with multiple myeloma. Immunol Res 2022; 70:844-849. [DOI: 10.1007/s12026-022-09314-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Accepted: 08/20/2022] [Indexed: 11/05/2022]
Abstract
AbstractAntibody light chains are synthesized in excess by plasma cells, and this excess can be secreted into biological fluids as dimers or monomers in various proportions. Structural differences between monomers or dimers of free light chains (FLC) can affect their biological functions and possibly their pathogenicity. They also may exhibit differential immune reactivity, perhaps explaining discrepant quantifications when measured by different immunoreagents. Having purified FLC monomers and dimers available can be useful for studying their properties. Here we propose a simple preparatory procedure to purify FLC monomers and dimers from urine samples of patients with plasma cell disorders. Two representative urine samples containing lambda or kappa FLC were loaded into a nonreducing sodium dodecyl sulfate–polyacrylamide gel electrophoresis (SDS-PAGE). The gel strips containing separate monomers and dimers were excised, electroeluted, and the FLC recovered. The FLC were recovered from SDS-PAGE gel in sufficient amounts to be quantified by UV and two automated nephelometric assays immunochemical. The procedure was found to be simple, reproducible, and with a high yield, thus offering the opportunity to compare different assays. Not all urine samples are suitable for this procedure, but this approach allows for the purification of FLC monomers and dimers from many selected urine samples which maintain their oligomeric organization.
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12
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Badgujar SB, Rane AM, Palav AA, Kumar S, Dabholkar AP, Sawant SA, Tandale BU, Daftary SB, Sawant NP, Lala S. A simple scheme for large scale purification of urine - Derived Bence Jones Kappa protein. J Chromatogr B Analyt Technol Biomed Life Sci 2022; 1210:123452. [PMID: 36108402 DOI: 10.1016/j.jchromb.2022.123452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 09/02/2022] [Accepted: 09/03/2022] [Indexed: 10/31/2022]
Abstract
We have investigated and optimized purification process, suitable for industrial scale, to obtain high purity grade Bence Jones Kappa Protein ('BJK-Protein'), while preserving its physiological properties and functions. BJK-Protein was obtained from a biological waste product i.e. human urine of renal failure patients. Isolated 'BJK-Protein' was analyzed by electrophoresis, western blotting, double immunodiffusion, SEC-HPLC assay and Mass Spectrometry (MS). The relative molecular mass of 'BJK-Protein' is 23054.2 Da. Moreover, dimer forms of 'BJK-Protein' were also detected in SDS-PAGE and mass spectrum corresponding to 46054.4 Da. The results of western blotting, immunoelectrophoresis, SEC-HPLC assay, and mass spectrometry analysis indicate a high purity (>99 %) of 'BJK-Protein'. Peptide mass fingerprint analysis of 'BJK-Protein' yielded peptides that partially matches the known database sequences of kappa variable region (KV139_HUMAN) of immunoglobulin. This protein was found to be stable up to 20 months at 2-8 °C temperature and also found negative for major undesirable viral markers as well as bacterial endotoxin. With this purification approach, the cost of purified 'BJK-Protein' is significantly reduced as compared to the current market price of Kappa light chain available in international market.
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Affiliation(s)
- Shamkant B Badgujar
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India.
| | - Arti M Rane
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India
| | - Aditi A Palav
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India
| | - Saurabh Kumar
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India
| | - Anil P Dabholkar
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India
| | - Satish A Sawant
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India
| | - Babasaheb U Tandale
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India
| | - Siddharth B Daftary
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India
| | - Narendra P Sawant
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India
| | - Sanjeev Lala
- Laboratory of Native Antigens, Research and Development Division, Advy Chemical Private Limited, Thane 400604, Maharashtra, India
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13
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Abroud H, Beldi‐Ferchiou A, Audard V, Lemonnier F, Le Bras F, Belhadj K, Moktefi A, Poullot E, El Karoui K, Dupuis J, Maarek A, Roulin L, Delfau‐Larue M, Oghina S, Kharoubi M, Bézard M, Zaroui A, Damy T, Molinier‐Frenkel V. Evaluation of a new ELISA assay for monoclonal free-light chain detection in patients with cardiac amyloidosis. EJHAEM 2022; 3:828-837. [PMID: 36051065 PMCID: PMC9421952 DOI: 10.1002/jha2.516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Revised: 06/08/2022] [Accepted: 06/10/2022] [Indexed: 11/27/2022]
Abstract
The causal protein of amyloid light-chain (AL) amyloidosis is a monoclonal immunoglobulin free light chain (mFLC), which must be quantified in the serum for patient diagnosis and monitoring. Several manufacturers commercialize immunoassays that quantify total kappa (κ) and lambda (λ) FLC, but results can differ greatly between these tests. Here, we compared a recently developed enzyme-linked immunosorbent assay (ELISA) (Sebia) with N-Latex immunonephelometry (Siemens) in 96 patients diagnosed with AL amyloidosis (histologically confirmed) and 48 non-AL patients sent to our referral center for suspicion of cardiac amyloidosis. ELISA free-light chain difference (dFLC) were lower than N-Latex values, and agreement between methods was reduced in the case of involved λ FLC. Diagnosis sensitivity and specificity were >85% with both assays. A receiver operating characteristic analysis indicated that ELISA performances could be improved by using a higher value for the lower limit of the κ/λ ratio. We also assessed Freelite (The Binding Site) in a subgroup of these same AL patients, including 18 cases with normal κ/λ ratio by at least one assay. Only two patients had normal κ/λ ratio with all three assays. Overall, ELISA demonstrated slightly lower sensitivity than N-Latex but may be an alternative to nephelometry/turbidimetry in certain difficult cases.
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Affiliation(s)
- Hajer Abroud
- Département d'Hématologie‐ImmunologieAP‐HP, Hopital Henri MondorCreteilFrance
| | - Asma Beldi‐Ferchiou
- Département d'Hématologie‐ImmunologieAP‐HP, Hopital Henri MondorCreteilFrance
- INSERMIMRBUniv Paris Est CreteilCreteilFrance
| | - Vincent Audard
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Service de Néphrologie et TransplantationAP‐HP, Hopital Henri MondorCreteilFrance
| | - François Lemonnier
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Unité Hémopathies LymphoïdesAP‐HP, Hopital Henri MondorCreteilFrance
| | - Fabien Le Bras
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Unité Hémopathies LymphoïdesAP‐HP, Hopital Henri MondorCreteilFrance
| | - Karim Belhadj
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Unité Hémopathies LymphoïdesAP‐HP, Hopital Henri MondorCreteilFrance
| | - Anissa Moktefi
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Département de PathologieAP‐HP, Hopital Henri MondorCreteilFrance
| | - Elsa Poullot
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Département de PathologieAP‐HP, Hopital Henri MondorCreteilFrance
| | - Khalil El Karoui
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Service de Néphrologie et TransplantationAP‐HP, Hopital Henri MondorCreteilFrance
| | - Jehan Dupuis
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Unité Hémopathies LymphoïdesAP‐HP, Hopital Henri MondorCreteilFrance
| | - Alizée Maarek
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Unité Hémopathies LymphoïdesAP‐HP, Hopital Henri MondorCreteilFrance
| | - Louise Roulin
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Unité Hémopathies LymphoïdesAP‐HP, Hopital Henri MondorCreteilFrance
| | - Marie‐Hélène Delfau‐Larue
- Département d'Hématologie‐ImmunologieAP‐HP, Hopital Henri MondorCreteilFrance
- INSERMIMRBUniv Paris Est CreteilCreteilFrance
| | - Silvia Oghina
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Département de CardiologieAP‐HP, Hopital Henri MondorCreteilFrance
| | - Mounira Kharoubi
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Département de CardiologieAP‐HP, Hopital Henri MondorCreteilFrance
| | - Mélanie Bézard
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Département de CardiologieAP‐HP, Hopital Henri MondorCreteilFrance
| | - Amira Zaroui
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Département de CardiologieAP‐HP, Hopital Henri MondorCreteilFrance
| | - Thibaud Damy
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
- Département de CardiologieAP‐HP, Hopital Henri MondorCreteilFrance
- INSERM, IMRB, CEPiaAUniv Paris Est CreteilCreteilFrance
| | - Valérie Molinier‐Frenkel
- Département d'Hématologie‐ImmunologieAP‐HP, Hopital Henri MondorCreteilFrance
- INSERMIMRBUniv Paris Est CreteilCreteilFrance
- French Referral Centre for Cardiac AmyloidosisCardiogen NetworkGRC Amyloid Research InstituteHenri Mondor HospitalCreteilFrance
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14
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Hu M, Wang Q, Liu B, Ma Q, Zhang T, Huang T, Lv Z, Wang R. Chronic Kidney Disease and Cancer: Inter-Relationships and Mechanisms. Front Cell Dev Biol 2022; 10:868715. [PMID: 35663394 PMCID: PMC9158340 DOI: 10.3389/fcell.2022.868715] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/26/2022] [Indexed: 12/20/2022] Open
Abstract
Chronic kidney disease (CKD) has been recognized as an increasingly serious public health problem globally over the decades. Accumulating evidence has shown that the incidence rate of cancer was relatively higher in CKD patients than that in general population, which, mechanistically, may be related to chronic inflammation, accumulation of carcinogenic compounds, oxidative stress, impairment of DNA repair, excessive parathyroid hormone and changes in intestinal microbiota, etc. And in patients with cancer, regardless of tumor types or anticancer treatment, it has been indicated that the morbidity and incidence rate of concomitant CKD was also increased, suggesting a complex inter-relationship between CKD and cancer and arousing increasing attention from both nephrologists and oncologists. This narrative review focused on the correlation between CKD and cancer, and underlying molecular mechanisms, which might provide an overview of novel interdisciplinary research interests and the potential challenges related to the screening and treatment of CKD and cancer. A better understanding of this field might be of help for both nephrologists and oncologists in the clinical practice.
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Affiliation(s)
- Mengsi Hu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qianhui Wang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Bing Liu
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Qiqi Ma
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Tingwei Zhang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Tongtong Huang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
| | - Zhimei Lv
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Rong Wang
- Department of Nephrology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, China
- Department of Nephrology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
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15
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Mizuno S, Kitayama C, Mashiko S, Sanada S. Renal recovery following daratumumab, lenalidomide, and dexamethasone therapy in a patient with newly diagnosed dialysis-dependent multiple myeloma. CEN Case Rep 2021; 11:265-268. [PMID: 34817845 DOI: 10.1007/s13730-021-00668-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 11/17/2021] [Indexed: 12/01/2022] Open
Abstract
An 81-year-old Japanese woman was diagnosed with Bence Jones protein κ-type multiple myeloma with acute kidney injury and severe anemia, complicated by congestive heart failure with triple vessel coronary artery disease. Her serum κ-free light-chain (FLC) level was 49,400 mg/L and κ/λ ratio was extremely high at 2373. Her kidney function deteriorated rapidly and required hemodialysis before initiating chemotherapy. A combination therapy of daratumumab (16 mg/kg), lenalidomide, and dexamethasone was initiated as a first-line treatment; the infusion rate of daratumumab was adjusted to reduce the heart load. The level of κ-FLC was rapidly reduced by 75% in only one week and by 99% after three weeks. Furthermore, she was dialysis-independent after the fourth dose of daratumumab. We report the first case of untreated patient with myeloma who had been successfully treated with daratumumab, lenalidomide, and dexamethasone therapy even in dialysis requiring state. Daratumumab may benefit patients with acute kidney injury caused by multiple myeloma, owing to the immediate need of FLC level reduction. Daratumumab and lenalidomide combination therapy could be a valuable treatment option for patients requiring dialysis when bortezomib may be hesitate to use due to severe heart disease.
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Affiliation(s)
- Shinichi Mizuno
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, 3-16-1, Tsutsumimachi, Aoba-Ku, Sendai, Miyagi, 981-8501, Japan.
| | - Chigusa Kitayama
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, 3-16-1, Tsutsumimachi, Aoba-Ku, Sendai, Miyagi, 981-8501, Japan
| | - Shigeto Mashiko
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, 3-16-1, Tsutsumimachi, Aoba-Ku, Sendai, Miyagi, 981-8501, Japan
| | - Satoru Sanada
- Department of Nephrology, Japan Community Health Care Organization Sendai Hospital, 3-16-1, Tsutsumimachi, Aoba-Ku, Sendai, Miyagi, 981-8501, Japan
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16
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Morgan GJ, Buxbaum JN, Kelly JW. Light Chain Stabilization: A Therapeutic Approach to Ameliorate AL Amyloidosis. HEMATO 2021; 2:645-659. [PMID: 35757512 PMCID: PMC9218996 DOI: 10.3390/hemato2040042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Non-native immunoglobulin light chain conformations, including aggregates, appear to cause light chain amyloidosis pathology. Despite significant progress in pharmacological eradication of the neoplastic plasma cells that secrete these light chains, in many patients impaired organ function remains. The impairment is apparently due to a subset of resistant plasma cells that continue to secrete misfolding-prone light chains. These light chains are susceptible to the proteolytic cleavage that may enable light chain aggregation. We propose that small molecules that preferentially bind to the natively folded state of full-length light chains could act as pharmacological kinetic stabilizers, protecting light chains against unfolding, proteolysis and aggregation. Although the sequence of the pathological light chain is unique to each patient, fortunately light chains have highly conserved residues that form binding sites for small molecule kinetic stabilizers. We envision that such stabilizers could complement existing and emerging therapies to benefit light chain amyloidosis patients.
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Affiliation(s)
- Gareth J. Morgan
- Section of Hematology and Medical Oncology, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
- The Amyloidosis Center, Boston University School of Medicine, Boston, MA 02118, USA
- Correspondence:
| | - Joel N. Buxbaum
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Jeffery W. Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA 92037, USA
- The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, CA 92037, USA
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17
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Ungari M, Ghiringhelli P, Marchi G, Fisogni S, Lavazza A, Molteni A, Malberti F, Bertoni R, Trombatore M, Ferrero G, Gusolfino MD, Varotti E, Tanzi G, Manotti L. Combined renal proximal tubulopathy and crystal storing histiocytosis in a patient with κ light chain multiple myeloma. Pathologica 2021; 113:285-293. [PMID: 34463673 DOI: 10.32074/1591-951x-154] [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: 06/19/2020] [Accepted: 07/13/2020] [Indexed: 11/30/2022] Open
Abstract
Multiple myeloma accounts for 10-15% of all hematologic malignancies, and 20% of deaths related to cancers of the blood and bone marrow. Diagnosis is defined by the presence of a serum monoclonal spike (M-spike) of more than 3 g/dL or more than 10% clonal plasma cells in the bone marrow and at least one myeloma-defining event, such as hypercalcemia, anemia, bone lesions, or renal impairment. The kidney is a major target organ, and renal impairment is frequently the first manifestation of the disease. Renal damage occurs in up to 40% of patients and 10-20% will require dialysis. Monoclonal immunoglobulin light chains are the major causes of renal complications in multiple myeloma. Glomerular disease, with the deposition of monoclonal immunoglobulins or their components, includes monoclonal immunoglobulin deposition disease, AL or AH amyloidosis, type I cryoglobulinemia, proliferative glomerulonephritis with monoclonal IgG deposits, immunotactoid glomerulopathy, and fibrillary glomerulonephritis. In addition, tubulointerstitial diseases with the deposition of monoclonal immunoglobulins or their components, are constituted by light chain cast nephropathy, light chain proximal tubulopathy, and crystal-storing histiocytosis. We report the case of a 66-year-old woman who presented with albumin-predominant moderate proteinuria and renal failure. Serum and urine immunofixation electrophoresis showed monoclonal κ light chain in both. Renal biopsy confirmed κ-restricted crystal-storing renal disease involving proximal tubular epithelial cells and crystal storing histiocytosis. Multiple myeloma with crystal storing histiocytosis was discovered in bone marrow biopsy. Thus, we present an unusual case of a myeloma patient presenting light chain proximal tubulopathy and crystal-storing histiocytosis both in the kidney and in the bone marrow.
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Affiliation(s)
| | | | | | | | - Antonio Lavazza
- Virology Unit of IZSLER, Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia- Romagna, Brescia, Italy
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18
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Light chain cast nephropathy caused by plasmablastic lymphoma of the bladder. Clin Nephrol Case Stud 2021; 9:72-80. [PMID: 34235044 PMCID: PMC8259465 DOI: 10.5414/cncs110339] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 06/04/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction: Plasmablastic lymphoma (PBL) is a rare form of B-cell lymphoma typically seen in patients with underlying immunosuppression such as HIV, autoimmune disease, and organ transplantation. PBL in HIV-positive patients usually originates from the gastrointestinal tract, with a predilection for the oral cavity. Bladder involvement by PBL is exceedingly rare, and cast nephropathy due to κ light chain-secreting PBL has not been reported previously. Case report: We report a patient who presented with acute kidney injury (AKI) in the setting of HIV, and was found to have a bladder tumor. Bladder pathology revealed a high-grade PBL with κ light chain restriction. Renal biopsy showed κ light chain cast nephropathy, presumably secondary to κ light chain-secreting PBL. Conclusion: Although the prognosis of PBL is poor, our patient recovered from AKI, achieved complete hematologic remission with chemotherapy, and underwent successful autologous stem cell transplant.
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19
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Morgan GJ. Barriers to Small Molecule Drug Discovery for Systemic Amyloidosis. Molecules 2021; 26:3571. [PMID: 34208058 PMCID: PMC8230685 DOI: 10.3390/molecules26123571] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 06/04/2021] [Accepted: 06/08/2021] [Indexed: 11/16/2022] Open
Abstract
Inhibition of amyloid fibril formation could benefit patients with systemic amyloidosis. In this group of diseases, deposition of amyloid fibrils derived from normally soluble proteins leads to progressive tissue damage and organ failure. Amyloid formation is a complex process, where several individual steps could be targeted. Several small molecules have been proposed as inhibitors of amyloid formation. However, the exact mechanism of action for a molecule is often not known, which impedes medicinal chemistry efforts to develop more potent molecules. Furthermore, commonly used assays are prone to artifacts that must be controlled for. Here, potential mechanisms by which small molecules could inhibit aggregation of immunoglobulin light-chain dimers, the precursor proteins for amyloid light-chain (AL) amyloidosis, are studied in assays that recapitulate different aspects of amyloidogenesis in vitro. One molecule reduced unfolding-coupled proteolysis of light chains, but no molecules inhibited aggregation of light chains or disrupted pre-formed amyloid fibrils. This work demonstrates the challenges associated with drug development for amyloidosis, but also highlights the potential to combine therapies that target different aspects of amyloidosis.
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Affiliation(s)
- Gareth J Morgan
- Section of Hematology and Medical Oncology, Amyloidosis Center, Department of Medicine, School of Medicine, Boston University, Boston, MA 02118, USA
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20
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Gigante A, Pellicano C, Leodori G, Napodano C, Vantaggio L, Gulli F, Marino M, Visentini M, Rosato E, Basile U. Serum and urine free light chains measurements in patients with systemic sclerosis: novel biomarkers for disease activity. Clin Exp Immunol 2021; 205:135-141. [PMID: 33934349 DOI: 10.1111/cei.13611] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/11/2021] [Accepted: 04/11/2021] [Indexed: 12/14/2022] Open
Abstract
Circulating free light chains (FLCs), considered biomarkers of B cell activity, are frequently elevated in patients affected by systemic inflammatory autoimmune diseases. As the systemic sclerosis (SSc) clinical course can be variable, this study is aimed at evaluating FLCs levels in affected individuals as biomarkers of disease activity. We assessed FLC levels in serum and urine of 72 SSc patients and 30 healthy controls (HC). Results were analyzed in comparison with overall clinical and laboratory findings, disease activity index (DAI) and disease severity scale (DSS). SSc patients displayed increased levels of κ and λ FLC in serum significantly higher than HC (p = 0.0001) alongside the mean values of free κ/λ ratio and κ + λ sum (p = 0.0001). SSc patients showed increased free κ in urine with a κ/λ higher than HC (p = 0.0001). SSc patients with increased κ + λ in serum showed that erythro-sedimentation rate (p = 0.034), C-reactive protein (p = 0.003), DAI (p = 0.024) and DSS (p = 0.015) were higher if compared to SSc patients with normal levels of FLC. A positive linear correlation was found between serum levels of free κ and DAI (r = 0.29, p = 0.014). In addition, SSc patients with increased free κ in urine had higher DAI (p = 0.048) than SSc patients with normal κ levels. Our results strengthen the role of serum FLC as useful biomarker in clinical practice to early diagnosis and monitor disease activity, showing for the first time that also urine FLC levels correlated with disease activity in SSc patients.
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Affiliation(s)
- Antonietta Gigante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Chiara Pellicano
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Giorgia Leodori
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Cecilia Napodano
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy
| | - Lorenzo Vantaggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Francesca Gulli
- Laboratorio di Patologia Clinica, Ospedale Madre Giuseppina Vannini, Rome, Italy
| | - Mariapaola Marino
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario 'A. Gemelli' IRCCS, Rome, Italy
| | - Marcella Visentini
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Edoardo Rosato
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Umberto Basile
- Area Diagnostica di Laboratorio, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario 'A. Gemelli', IRCCS, Rome, Italy
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21
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Bridoux F, Cockwell P, Glezerman I, Gutgarts V, Hogan JJ, Jhaveri KD, Joly F, Nasr SH, Sawinski D, Leung N. Kidney injury and disease in patients with haematological malignancies. Nat Rev Nephrol 2021; 17:386-401. [PMID: 33785910 DOI: 10.1038/s41581-021-00405-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/29/2021] [Indexed: 02/07/2023]
Abstract
Acute kidney injury (AKI) is common in patients with cancer, especially in those with haematological malignancies. Kidney injury might be a direct consequence of the underlying haematological condition. For example, in the case of lymphoma infiltration or extramedullary haematopoiesis, it might be caused by a tumour product; in the case of cast nephropathy it might be due to the presence of monoclonal immunoglobulin; or it might result from tumour complications, such as hypercalcaemia. Kidney injury might also be caused by cancer treatment, as many chemotherapeutic agents are nephrotoxic. High-intensity treatments, such as high-dose chemotherapy followed by haematopoietic stem cell transplantation, not only increase the risk of infection but can also cause AKI through various mechanisms, including viral nephropathies, engraftment syndrome and sinusoidal obstruction syndrome. Some conditions, such as thrombotic microangiopathy, might also result directly from the haematological condition or the treatment. Novel immunotherapies, such as immune checkpoint inhibitors and chimeric antigen receptor T cell therapy, can also be nephrotoxic. As new therapies for haematological malignancies with increased anti-tumour efficacy and reduced toxicity are developed, the number of patients receiving these treatments will increase. Clinicians must gain a good understanding of the different mechanisms of kidney injury associated with cancer to better care for these patients.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France.,CNRS, UMR7276, Limoges, France.,Centre de référence Amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, Poitiers, France
| | - Paul Cockwell
- Department of Nephrology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Ilya Glezerman
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Victoria Gutgarts
- Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Weill Cornell Medical College, New York, NY, USA
| | - Jonathan J Hogan
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kenar D Jhaveri
- Division of Kidney Diseases and Hypertension, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, USA
| | - Florent Joly
- Department of Nephrology, and Centre d'Investigation Clinique (CIC INSERM 1402), Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Deirdre Sawinski
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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Hyponatremia in Patients with Hematologic Diseases. J Clin Med 2020; 9:jcm9113721. [PMID: 33228240 PMCID: PMC7699475 DOI: 10.3390/jcm9113721] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/10/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022] Open
Abstract
Hyponatremia is the most common electrolyte disorder in clinical practice and is associated with increased morbidity and mortality. It is frequently encountered in hematologic patients with either benign or malignant diseases. Several underlying mechanisms, such as hypovolemia, infections, toxins, renal, endocrine, cardiac, and liver disorders, as well as the use of certain drugs appear to be involved in the development or the persistence of hyponatremia. This review describes the pathophysiology of hyponatremia and discusses thoroughly the contributing factors and mechanisms that may be encountered specifically in patients with hematologic disorders. The involvement of the syndrome of inappropriate antidiuretic hormone (SIADH) secretion and renal salt wasting syndrome (RSWS) in the development of hyponatremia in such patients, as well as their differential diagnosis and management, are also presented. Furthermore, the distinction between true hyponatremia and pseudohyponatremia is explained. Finally, a practical algorithm for the evaluation of hyponatremia in hematologic patients, as well as the principles of hyponatremia management, are included in this review.
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Parmar MS. (F)utility of urine Bence Jones proteins for "routine" screening for plasma cell dyscrasia. Diagnosis (Berl) 2020; 8:dx-2020-0104. [PMID: 33189080 DOI: 10.1515/dx-2020-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/30/2020] [Indexed: 11/15/2022]
Abstract
Testing urine for Bence Jones Protein (BJP) had been a time old procedure used for screening and monitoring of monoclonal disorders since its description. However, has poor sensitivity and despite advances in diagnostic methods of monoclonal disorders it is being continued to be requested in individuals for evaluation of myeloma or plasma cell disorders. Effective utilization and minimizing untimely or unnecessary investigations is important in the evaluation and management of any medical condition. Though, we are hard-wired during our education with some "trigger" or "peculiar" words that make us jump to actions too quickly, without comprehending the actual problem. Supporting evidence is presented to avoid reflexive use of multiple tests and utilize tests that improve utilization, reduce waste, and uphold the Choosing Wisely principles in providing optimal care to the patients.
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Affiliation(s)
- Malvinder S Parmar
- Northern Ontario School of Medicine, Sudbury & Thunder Bay, East Timmins, ON, Canada
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24
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Zhang PL, Herrera GA, Liu B. Monoclonal glomerulopathy with features of cryoglobulinemic glomerulopathy in murine multiple myeloma model. Ultrastruct Pathol 2020; 44:387-394. [PMID: 33135540 DOI: 10.1080/01913123.2020.1841349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In vivo and animal models of monoclonal light chain-associated renal diseases are limited. The Vk*MYC transgenic model with multiple myeloma in 50-70 weeks old mice with renal involvement has been reported before, but detailed renal pathologic changes have not been well documented. This study fully investigated pathologic changes in the kidneys of Vk*MYC transgenic model using light microscopy, immunofluorescence stains for kappa and lambda light chains, and electron microscopy. Compared to the kidneys of wild-type mice, the kidneys of transgenic mice showed either mesangial segmental expansion, some with associated hypercellularity, and/or thrombotic obstruction of glomerular capillaries. The glomeruli revealed stronger lambda staining than kappa light chain staining. Six out of 12 kidneys from transgenic mice showed abundant electron-dense deposits when examined ultrastructurally. The deposits were located in glomerular capillary lumina in three cases. Large luminal and subendothelial deposits were characterized by randomly disposed microtubular structures measuring up to 16 nm in diameter, with overall features most consistent with cryoglobulins. In summary, about 50% of kidneys from the Vk*MYC mice with myeloma had features most consistent with monoclonal cryoglobulinemic glomerulopathy.
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Affiliation(s)
- Ping L Zhang
- Division of Anatomic Pathology, Beaumont Laboratories, Beaumont Health , Royal Oak, MI, USA
| | | | - Bei Liu
- Department of Microbiology and Immunology, Hollings Cancer Center, Medical University of South Carolina , Charleston, SC, USA.,Department of Internal Medicine/Division of Hematology, Ohio State University , Columbus, OH, USA
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25
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Copur S, Onal EM, Afsar B, Ortiz A, van Raalte DH, Cherney DZ, Rossing P, Kanbay M. Diabetes mellitus in chronic kidney disease: Biomarkers beyond HbA1c to estimate glycemic control and diabetes-dependent morbidity and mortality. J Diabetes Complications 2020; 34:107707. [PMID: 32861562 DOI: 10.1016/j.jdiacomp.2020.107707] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 12/13/2022]
Abstract
Diabetes mellitus (DM) is the leading cause of chronic kidney disease (CKD). Optimal glycemic control contributes to improved outcomes in patients with DM, particularly for microvascular damage, but blood glucose levels are too variable to provide an accurate assessment and instead markers averaging long-term glycemic load are used. The most established glycemic biomarker of long-term glycemic control is HbA1c. Nevertheless, HbA1c has pitfalls that limit its accuracy to estimate glycemic control, including the presence of altered red blood cell survival, hemoglobin glycation and suboptimal performance of HbA1c assays. Alternative methods to evaluate glycemic control in patients with DM include glycated albumin, fructosamine, 1-5 anhydroglucitol, continuous glucose measurement, self-monitoring of blood glucose and random blood glucose concentration measurements. Accordingly, our aim was to review the advantages and pitfalls of these methods in the context of CKD.
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Affiliation(s)
- Sidar Copur
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Emine M Onal
- Department of Medicine, Koc University School of Medicine, Istanbul, Turkey
| | - Baris Afsar
- Department of Medicine, Division of Nephrology, Suleyman Demirel University School of Medicine, Isparta, Turkey
| | - Alberto Ortiz
- Dialysis Unit, School of Medicine, IIS-Fundacion Jimenez Diaz, Universidad Autónoma de Madrid, Avd. Reyes Católicos 2, 28040 Madrid, Spain
| | - Daniel H van Raalte
- Diabetes Center, Department of Internal Medicine, Amsterdam University Medical Center, location VUMC, Amsterdam, the Netherlands
| | - David Z Cherney
- Toronto General Hospital Research Institute, UHN, Toronto, Canada; Departments of Physiology and Pharmacology and Toxicology, University of Toronto, Ontario, Canada
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark; University of Copenhagen, Copenhagen, Denmark
| | - Mehmet Kanbay
- Department of Medicine, Division of Nephrology, Koc University School of Medicine, Istanbul, Turkey.
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26
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Doe-Williams S, Hixson LJ, Pfeiffer DC. Massive Hepatomegaly Secondary to Amyloidosis with Normal Liver Chemistries. Case Rep Gastroenterol 2020; 14:271-278. [PMID: 32518538 PMCID: PMC7265701 DOI: 10.1159/000507612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 03/30/2020] [Indexed: 11/19/2022] Open
Abstract
Amyloid light chain (AL) amyloidosis is a disease of misfolded, fibrous proteins, either kappa or lambda subtype, that can be deposited into one or more organs, caused by a proliferation of plasma cells. The liver is uncommonly the main organ system affected and rarely the only organ affected by amyloid deposition. With hepatic involvement, the most common presenting findings are hepatomegaly and elevation of serum alkaline phosphatase. We report a case of a 50-year-old male who presented to our gastroenterology clinic with marked hepatomegaly secondary to hepatic amyloidosis, in concert with bone marrow involvement and nephrotic syndrome. Biopsies in conjunction with Congo red staining demonstrated 95% replacement of hepatic structure and 80% replacement of bone marrow with amyloid deposition. Despite these findings, liver chemistries, renal function, and blood count were normal. Our case presents not only the rare finding of primary hepatic amyloidosis but also an atypical presentation of this disorder. Although rare, AL amyloidosis should be in a differential diagnosis of any patient who presents with unexplained hepatomegaly, nephrotic-range proteinuria, heart failure with preserved ejection fraction, fatigue, weight loss or a history of monoclonal gammopathy of undetermined significance.
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Affiliation(s)
- Sarah Doe-Williams
- WWAMI Medical Education Program, University of Washington School of Medicine and the University of Idaho, Moscow, Idaho, USA
| | - Lee J Hixson
- St Joseph Regional Medical Center, Lewiston, Idaho, USA
| | - David C Pfeiffer
- WWAMI Medical Education Program and Department of Biological Sciences, University of Idaho, Moscow, Idaho, USA
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27
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Multiple morphological phenotypes of monoclonal immunoglobulin disease on renal biopsy: Significance of treatment. Clin Nephrol Case Stud 2020; 8:17-24. [PMID: 32318322 PMCID: PMC7171697 DOI: 10.5414/cncs110052] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 02/14/2020] [Indexed: 11/18/2022] Open
Abstract
Plasma cell dyscrasias frequently involve the kidney causing renal dysfunction. Multiple morphologic manifestations of κ light chain disease occurring simultaneously in the same kidney biopsy are uncommon and suggest local microenvironment effects in addition to structural properties of the light chain. A 61-year-old female presented with new onset renal failure and proteinuria. Serological workup revealed monoclonal gammopathy with elevated κ : λ ratio of 1,371. Renal biopsy revealed several paraprotein manifestations including κ light chain deposition disease, monoclonal fibrillary glomerulonephritis, cryocrystalglobulenemia and fibrillar/microtubular cast nephropathy. There was also incidental leukocyte chemotactic factor 2 amyloidosis (ALECT 2), negative for κ light chain and confirmed by immunohistochemistry (IHC). Bone marrow biopsy revealed 10 - 20% κ restricted plasma cells. The patient received 10 cycles of CyBorD (cyclophosphamide, bortezomib, and dexamethasone) chemotherapy. Renal function improved with decreased κ : λ ratio. Repeat bone marrow biopsy showed no evidence of abnormal plasma cells by IHC. The renal recovery demonstrates there may be response to chemotherapy irrespective of the morphologic manifestations of light chain-related injury. Additionally, if amyloid is not demonstrated to be of light chain origin, other amyloid types should be considered.
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28
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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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29
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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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30
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Dvanajscak Z, Cossey LN, Larsen CP. A practical approach to the pathology of renal intratubular casts. Semin Diagn Pathol 2020; 37:127-134. [PMID: 32147230 DOI: 10.1053/j.semdp.2020.02.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 01/28/2020] [Accepted: 02/10/2020] [Indexed: 12/27/2022]
Abstract
The identification and proper characterization of pathologic renal intratubular casts can be an arduous task, especially since they often admixed with non-pathologic casts, obfuscating debris and inflammation. The list of pathologic intratubular casts is long, and they can be easily missed or misdiagnosed without a thorough understanding of their pathophysiology and morphologic variety. Correct characterization of tubular casts is important since each cast type has a unique pathogenic mechanism, with specific treatment and prognostic implications. This review discusses the clinicopathologic characteristics of the six most common pathologic casts: light chain, hemoglobin, myoglobin, red cell, neutrophilic and bile casts. We also discuss hyaline and uromodulin casts, the commonly encountered "benign" cast types that share certain histologic features with pathologic casts. We limit the discussion to proteinaceous and cellular intratubular casts, with crystalline casts discussed in a separate review within the same journal issue. While not exhaustive, this review covers pathogenesis, clinical and prognostic significance, and a practical discussion of the histomorphologic spectrum of each cast type, along with commonly encountered pitfalls.
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Affiliation(s)
- Zeljko Dvanajscak
- Renal Pathology Division, Arkana Laboratories, 10810 Executive Center Dr., Suite 100, Little Rock, AR 72211, United States.
| | - L Nicholas Cossey
- Renal Pathology Division, Arkana Laboratories, 10810 Executive Center Dr., Suite 100, Little Rock, AR 72211, United States
| | - Christopher P Larsen
- Renal Pathology Division, Arkana Laboratories, 10810 Executive Center Dr., Suite 100, Little Rock, AR 72211, United States
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31
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Caponi L, Romiti N, Koni E, Fiore AD, Paolicchi A, Franzini M. Inter-assay variability in automated serum free light chain assays and their use in the clinical laboratory. Crit Rev Clin Lab Sci 2019; 57:73-85. [PMID: 31612753 DOI: 10.1080/10408363.2019.1670133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Serum κ and λ free light chain levels are markers of plasma cell proliferation, and their measurements have been included in recent guidelines by the International Myeloma Working Group for the management of patients with plasma cellular dyscrasias. Five in vitro diagnostic methods for the immunochemical quantification of serum free light chains (FLC) are available, three based on polyclonal antibodies (Freelite®, The Binding Site; FLC ELISA κ and λ, Sebia; human κ and λ FLC, Diazyme Laboratories) and two on monoclonal antibodies (N Latex FLC, Siemens Healthineers; Seralite®, Sebia). Several studies have shown that these methods cannot be used interchangeably for the follow-up of patients because measured κ and λ FLC concentrations may differ significantly, especially at high levels. Because no international reference material for the measurement of FLC is available, it is not possible to establish which method is the most accurate. For this reason, knowledge about the analytical and diagnostic performances of the assays used is important. The aim of this review is to describe the main analytical features of the κ and λ FLC assays and how they may influence the clinical use of these parameters.
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Affiliation(s)
- Laura Caponi
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Nadia Romiti
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Elona Koni
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Annarita Di Fiore
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Aldo Paolicchi
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Maria Franzini
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
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33
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Sekulic M, Waikar S, Motwani SS, Weins A, Rennke HG. Chromogranin A Tubulopathy: Differing Histopathologic Patterns of Acute Tubular Injury in the Setting of Neuroendocrine Neoplasms. Kidney Int Rep 2019; 4:1085-1093. [PMID: 31440699 PMCID: PMC6698283 DOI: 10.1016/j.ekir.2019.04.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/29/2019] [Indexed: 02/01/2023] Open
Abstract
Introduction Neoplasms of neuroendocrine derivation or differentiation may express specific peptides, some of which are capable of producing clinical symptomatology and others used as biomarkers: one such peptide being chromogranin A (CGA). Herein, we describe histopathologic changes present in kidney specimens from patients with such neoplasms, and illustrate 2 patterns of acute tubular injury (ATI) attributable to CGA. Methods Eleven patients with a history of a neoplasm of neuroendocrine derivation or differentiation and having histopathologic sampling of the kidney were retrospectively identified, 3 of whom had ATI with either engorgement of the proximal tubular epithelium by resorbed material or tubular cast formation. Results Two patterns of ATI were observed. One characterized by acutely injured proximal tubular cells engorged with resorption granules that expressed CGA via immunoperoxidase staining. Another pattern was characterized by intraluminal tubular cast material associated with ATI that did not exhibit restriction of immunoglobulin light chains (LCs), but immunoperoxidase staining for CGA revealed that the cast material was composed of the neuroendocrine-associated peptide. The level of serum CGA does not appear to necessarily equate to developing either of these 2 patterns of ATI. Conclusions Patients with a neoplasm of neuroendocrine derivation or differentiation may develop ATI, and in certain cases may be secondary to CGA renal tubular deposition.
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Affiliation(s)
- Miroslav Sekulic
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sushrut Waikar
- Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shveta S Motwani
- Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Astrid Weins
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Helmut G Rennke
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Lo Sasso B, Agnello L, Bivona G, Bellia C, Ciaccio M. Cerebrospinal Fluid Analysis in Multiple Sclerosis Diagnosis: An Update. ACTA ACUST UNITED AC 2019; 55:medicina55060245. [PMID: 31167509 PMCID: PMC6630948 DOI: 10.3390/medicina55060245] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Revised: 04/10/2019] [Accepted: 05/30/2019] [Indexed: 01/11/2023]
Abstract
Multiple sclerosis (MS) is an immune-mediated demyelinating disease of the central nervous system (CNS) with brain neurodegeneration. MS patients present heterogeneous clinical manifestations in which both genetic and environmental factors are involved. The diagnosis is very complex due to the high heterogeneity of the pathophysiology of the disease. The diagnostic criteria have been modified several times over the years. Basically, they include clinical symptoms, presence of typical lesions detected by magnetic resonance imaging (MRI), and laboratory findings. The analysis of cerebrospinal fluid (CSF) allows an evaluation of inflammatory processes circumscribed to the CNS and reflects changes in the immunological pattern due to the progression of the pathology, being fundamental in the diagnosis and monitoring of MS. The detection of the oligoclonal bands (OCBs) in both CSF and serum is recognized as the “gold standard” for laboratory diagnosis of MS, though presents analytical limitations. Indeed, current protocols for OCBs assay are time-consuming and require an operator-dependent interpretation. In recent years, the quantification of free light chain (FLC) in CSF has emerged to assist clinicians in the diagnosis of MS. This article reviews the current knowledge on CSF biomarkers used in the diagnosis of MS, in particular on the validated assays and on the alternative biomarkers of intrathecal synthesis.
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Affiliation(s)
- Bruna Lo Sasso
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, 90100 Palermo, Italy.
| | - Luisa Agnello
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, 90100 Palermo, Italy.
| | - Giulia Bivona
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, 90100 Palermo, Italy.
| | - Chiara Bellia
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, 90100 Palermo, Italy.
| | - Marcello Ciaccio
- Institute of Clinical Biochemistry, Clinical Molecular Medicine and Laboratory Medicine, Department of Biomedicine, Neuroscience and Advanced Diagnostics, University of Palermo, 90100 Palermo, Italy.
- Department Laboratory Medicine, University-Hospital, 90100 Palermo, Italy.
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Martellosio JP, Leleu X, Roblot P, Martin M, Puyade M. Dosage des chaînes légères libres : indications et méthodes. Rev Med Interne 2019; 40:297-305. [DOI: 10.1016/j.revmed.2019.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 01/04/2019] [Accepted: 01/20/2019] [Indexed: 12/18/2022]
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Cao Q, Qi H, Yao L, Liu Q. Monoclonal gammopathy of renal significance: clinical manifestation, pathogenic characteristic and treatment. Panminerva Med 2019; 62:38-53. [PMID: 30848114 DOI: 10.23736/s0031-0808.19.03609-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a group of renal disorders caused by a monoclonal immunoglobulin (MIg) secreted by a dangerous plasmatic/B-cell clone hyperplasia through MIg deposition or dysfunction of complement pathway, with increasing risk of progress to end stage renal disease (ESRD) and the underlying hematologic malignancy. The combination of renal biopsy, complete laboratory examination and bone marrow biopsy is an indispensable diagnostic tool for MGRS to identify accurately and unequivocally the pathogenic monoclonal MIg and provide guidance to treatment. Treatment of MGRS is composed of conventional therapy, chemotherapy, and stem cell transplantation to target the underlying clone and eliminate the noxious MIg on the basis of clinical data of some retrospective studies and a small amount of prospective trial. In addition, it is worthwhile point out assessment of therapeutic effect is significantly relevant for renal and overall prognosis. Thus, by comprehensively analyzing the clinical manifestations and pathogenic characteristic of MGRS, early recognition and prompt treatment can improve the prognosis and prevent post-translation recurrence with multidisciplinary cooperation.
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Affiliation(s)
- Qin Cao
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, China
| | - Huimeng Qi
- Department of General Practice, The First Hospital of China Medical University, Shenyang, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Qiang Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China -
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Napodano C, Pocino K, Rigante D, Stefanile A, Gulli F, Marino M, Basile V, Rapaccini GL, Basile U. Free light chains and autoimmunity. Autoimmun Rev 2019; 18:484-492. [PMID: 30844547 DOI: 10.1016/j.autrev.2019.03.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The study of free light chains (FLCs) has grown as area of enormous interest for many clinicians with the aim of disclosing the exact biological role and potential use of FLCs in the clinical routine. Moreover, the attention given to immunological functions of FLCs has sparked a new light into their pathogenic contribution in different chronic autoimmune-based inflammatory diseases. The release of intracellular antigens following cell death or ineffective clearance of apoptotic debris, modification of self-antigens, and molecular mimicry may trigger the production of immunoglobulins after activation and polyclonal expansion of B cells, by which FLCs are released. The discovery of polyclonal FLCs as potential biomarkers started with the observation of their increased concentrations in a variety of biological fluids related to patients with autoimmune diseases. This review deals with the use of polyclonal FLCs for identifying severity and monitoring outcome after treatment in some autoimmune diseases, namely systemic lupus erythematosus, myasthenia gravis, systemic sclerosis, rheumatoid arthritis and Sjögren's syndrome, as supported by the fact that levels of FLCs correlate with both B cell activation markers and other specific markers of disease activity. In a near future, following the evidence shown, FLCs might probably work as early prognostic markers of severity and also as indicators of response to treatment or early assessment of relapse in selected autoimmune diseases.
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Affiliation(s)
- Cecilia Napodano
- Area Gastroenterologia e Oncologia Medica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Krizia Pocino
- Area Gastroenterologia e Oncologia Medica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Donato Rigante
- Institute of Pediatrics, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Università Cattolica Sacro Cuore, Rome, Italy.
| | - Annunziata Stefanile
- Area Diagnostica di Laboratorio, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Gulli
- Clinical Pathology Laboratory, Ospedale Madre Giuseppina Vannini, Rome, Italy
| | - Mariapaola Marino
- Institute of General Pathology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Valerio Basile
- Department of Experimental Medicine and Surgery, (")Tor Vergata" University Hospital, Rome, Italy
| | - Gian Ludovico Rapaccini
- Area Gastroenterologia e Oncologia Medica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Umberto Basile
- Area Diagnostica di Laboratorio, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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Singh N, Pattanashetti N, Joshi K, Kohli HS, Gupta KL, Ramachandran R. Missed Monoclonal Disease Manifesting in Early Post-renal Transplant Period. Indian J Nephrol 2019; 29:65-69. [PMID: 30814798 PMCID: PMC6375021 DOI: 10.4103/ijn.ijn_384_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
A 63-year-old diabetic gentleman with microvascular complications presented with advanced azotemia and anemia. He was stabilized with blood transfusion and hemodialysis. With the probable diagnosis of diabetic nephropathy-related end-stage renal disease, he underwent kidney transplantation. He had delayed graft function. Graft biopsy done on the 2nd postoperative day showed acute tubular necrosis. Graft biopsy repeated after 2 weeks for persistent graft dysfunction showed myeloma cast nephropathy (MCN) and light chain proximal tubulopathy. Work-up for multiple myeloma was positive. He was started on plasmapheresis and chemotherapy. However, he suffered sudden cardiac death during dialysis after 1 week. The presence of MCN in the early graft biopsy implies that it must have been the cause for his native kidney failure. Thus, renal failure in a diabetic should not always be presumed to be due to diabetic nephropathy, and kidney biopsy should be done in diabetics with atypical features.
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Affiliation(s)
- N Singh
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - N Pattanashetti
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K Joshi
- Department of Pathology, Medicos Centre, Chandigarh, India
| | - H S Kohli
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - K L Gupta
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - R Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Ito K, Hara S, Yamada K, Zoshima T, Mizushima I, Fujii H, Miyazaki R, Kawai Y, Yachie A, Nagata M, Izui S, Yamagishi M, Kawano M. A case report of crystalline light chain inclusion-associated kidney disease affecting podocytes but without Fanconi syndrome: A clonal analysis of pathological monoclonal light chain. Medicine (Baltimore) 2019; 98:e13915. [PMID: 30702553 PMCID: PMC6380839 DOI: 10.1097/md.0000000000013915] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
RATIONALE Crystalline light chain inclusion-associated kidney disease affects mainly tubular epithelial cells and is often clinically manifested as Fanconi syndrome. However, only very few case reports about the crystalline deposits within the podocytes are available, and the nature of the pathogenic monoclonal light chain implicated in these cases is still unknown. We report a case of crystalline inclusion-associated kidney disease manifested as crystalline podocytopathy in which we identified the complete structure of the pathogenic monoclonal light chain as belonging to the germ-line gene of Vκ1-39. PATIENT CONCERNS We describe a 65-year-old woman with crystalline light chain inclusion-associated kidney disease showing mild proteinuria and renal insufficiency with monoclonal gammopathy of undetermined significance without Fanconi syndrome. She had crystalline inclusions mainly within podocytes, tubular epithelial cells and histiocytes in the kidney. Light microscopy showed vacuolation of podocytes and tubular epithelial cells, while eosin negative pale needle-like crystals were present within these cells. Electron microscopy showed accumulation of club-like crystals with high electron density in podocytes, proximal tubular epithelial cells and interstitial histiocytes. Clonal analysis revealed that a pathogenic monoclonal light chain was derived from germline gene, Vκ1-39. DIAGNOSES The diagnosis of crystalline light chain inclusion-associated kidney disease was made. INTERVENTIONS AND OUTCOMES Bortezomib and dexamethasone were started and her renal function improved to eGFR 36 mL/min/1.73 m after 9 courses of therapy. LESSONS Patients with light chain crystalline podocytopathy may have a similar pathogenic monoclonal light chain derived from the same germline gene, Vκ1-39, to that of patients with light chain proximal tubulopathy.
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Affiliation(s)
- Kiyoaki Ito
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Satoshi Hara
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Kazunori Yamada
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Takeshi Zoshima
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Ichiro Mizushima
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Hiroshi Fujii
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
| | | | - Yasukazu Kawai
- Department of Hematology and Oncology, Fukui Prefectural Hospital, Fukui
| | - Akihiro Yachie
- Department of Pediatrics, Kanazawa University Graduate School of Medicine, Kanazawa
| | - Michio Nagata
- Department of Kidney and Vascular Pathology, Faculty of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Shozo Izui
- Department of Pathology and Immunology, University Medical Center, University of Geneva, Switzerland
| | - Masakazu Yamagishi
- Division of Cardiology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa, Japan
| | - Mitsuhiro Kawano
- Division of Rheumatology, Department of Internal Medicine, Kanazawa University Graduate School of Medicine, Kanazawa
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Kanzaki G, Okabayashi Y, Nagahama K, Ohashi R, Tsuboi N, Yokoo T, Shimizu A. Monoclonal Immunoglobulin Deposition Disease and Related Diseases. J NIPPON MED SCH 2019; 86:2-9. [DOI: 10.1272/jnms.jnms.2019_86-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Go Kanzaki
- Department of Analytic Human Pathology, Nippon Medical School
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine
| | - Yusuke Okabayashi
- Department of Analytic Human Pathology, Nippon Medical School
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine
| | | | - Ryuji Ohashi
- Department of Diagnostic Pathology, Nippon Medical School Hospital
| | - Nobuo Tsuboi
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine
| | - Takashi Yokoo
- Division of Nephrology and Hypertension, Department of Internal Medicine, The Jikei University School of Medicine
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School
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41
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Kishi S, Obata F, Miki H, Matsuura M, Nishimura K, Tamaki M, Kishi F, Murakami T, Abe H, Nagai K, Abe M, Doi T. Lambda Light Chain Non-crystalline Proximal Tubulopathy with IgD Lambda Myeloma. Intern Med 2018; 57:3597-3602. [PMID: 30101939 PMCID: PMC6355399 DOI: 10.2169/internalmedicine.1323-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Light Chain Proximal Tubulopathy (LCPT) is a rare form of paraprotein-related kidney disease in which monoclonal free light chains damage the proximal renal tubular epithelial cells. We herein report the case of a 78-year-old woman who presented with anemia and kidney dysfunction. Serum and urine protein electrophoresis analyses revealed a monoclonal IgD and λ free light chains. Proximal tubular injury and the accumulation of λ light chains were found by kidney biopsy. Electron microscopy revealed no organized structure suggestive of crystals. LCPT was caused by IgD lambda myeloma and bortezomib and dexamethasone therapy led to very good partial response (VGPR) without a worsening of the kidney function.
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Affiliation(s)
- Seiji Kishi
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Fumiaki Obata
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Hirokazu Miki
- Division of Transfusion Medicine and Cell Therapy, Tokushima University Hospital, Japan
| | - Motokazu Matsuura
- Department of Nephrology, Tokushima Red Cross Hospital, Komatsushima, Japan
| | - Kenji Nishimura
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Masanori Tamaki
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Fumi Kishi
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Taichi Murakami
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Hideharu Abe
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Kojiro Nagai
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Masahiro Abe
- Department of Hematology, Endocrinology and Metabolism, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Toshio Doi
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
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Renal Dysfunction and Recovery following Initial Treatment of Newly Diagnosed Multiple Myeloma. Int J Nephrol 2018; 2018:4654717. [PMID: 30254762 PMCID: PMC6145056 DOI: 10.1155/2018/4654717] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 06/11/2018] [Accepted: 08/26/2018] [Indexed: 01/18/2023] Open
Abstract
Introduction Renal insufficiency (RI) in Multiple Myeloma (MM) portends a higher tumor burden and worse prognosis. Reversal of RI in newly diagnosed MM (NDMM) improves patient outcomes, but it is unknown if there is a disparity in renal recovery in NDMM between African Americans (AA) and non-African Americans. Methods A retrospective chart review was conducted of 690 patients with NDMM at Rush University Medical Center from 2005 to 2016. 118 patients (59 AA and 59 non-AA) with NDMM and an estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m2 at the time of diagnosis were identified and analyzed. The time to best renal response and best eGFR achieved during initial myeloma therapy were tabulated. Results Median eGFR at the time of diagnosis was similar between the AA and non-AA groups (47.89 versus 51.95, p=0.56). Median absolute change in eGFR after initial therapy was significantly higher in the AA (+33.64) versus the non-AA group (+21.07, p=0.00183). This difference remained whether the baseline eGFR at diagnosis was <90 or <60 mL/min/1.73 m2. Discussion AA patients with NDMM treated in the era of novel agents have greater improvement in renal function in comparison to non-AA patients, regardless of myeloma response. The biological underpinnings for this disparity require further investigation.
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Can Concurrent Abnormalities in Free Light Chains and Immunoglobulin Concentrations Identify a Target Population for Immunoglobulin Trials in Sepsis?*. Crit Care Med 2017; 45:1829-1836. [DOI: 10.1097/ccm.0000000000002627] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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44
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Basile U, Gulli F, Gragnani L, Napodano C, Pocino K, Rapaccini GL, Mussap M, Zignego AL. Free light chains: Eclectic multipurpose biomarker. J Immunol Methods 2017; 451:11-19. [PMID: 28931470 DOI: 10.1016/j.jim.2017.09.005] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 07/21/2017] [Accepted: 09/15/2017] [Indexed: 12/14/2022]
Abstract
The production of antibodies is accompanied by a slight excess of synthesis of κ and λ immunoglobulin light chains; small amounts of them are released in the peripheral blood and can also be found in various body fluids, such as synovial fluid, cerebrospinal fluid, urine and saliva. They are rapidly filtered by the glomerulus and >99% are reabsorbed from the cells of the proximal convoluted tubule, making them present in the urine in only trace amounts. The production of an excess of protein without a reason or a specific function in a biological system is rare. Free light chains, considered for years a waste product of Ig synthesis, are currently known to be very active molecules, able to bind antigens as well as whole immunoglobulin and helping to develop specific antibody affinity. The ability of free light chains to activate mast cells and then become an active part of the pathogenic mechanisms of chronic inflammatory diseases has increased interest in their clinical use, both as an attractive therapeutic target or as a biochemical marker of disease evolution or remission. This is an overview of relevant scientific interest that immunoglobulin light chains κ and λ have attracted over the years, a report on the progress in knowledge about their structure and function, with a special focus on their biological meaning and potential clinical utility in different diseases.
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Affiliation(s)
- Umberto Basile
- Department of Laboratory Medicine of the Catholic University of Sacred Heart, Rome, Italy.
| | - Francesca Gulli
- Department of Laboratory Medicine of the Catholic University of Sacred Heart, Rome, Italy
| | - Laura Gragnani
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Cecilia Napodano
- Department of Laboratory Medicine of the Catholic University of Sacred Heart, Rome, Italy
| | - Krizia Pocino
- Department of Laboratory Medicine of the Catholic University of Sacred Heart, Rome, Italy
| | | | - Michele Mussap
- Department of Laboratory Medicine, IRCCS-AOU San Martino, Genoa, Italy
| | - Anna Linda Zignego
- Center for Systemic Manifestations of Hepatitis Viruses (MaSVE), Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Latosinska A, Hulko M, Speidel R, Mischak H, Storr M, Krause B. Removal of Cell-Activating Substances Using Dialyzers With Various Permeability Profiles. Artif Organs 2017; 42:78-87. [DOI: 10.1111/aor.12952] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 12/24/2022]
Affiliation(s)
| | - Michael Hulko
- Gambro Dialysatoren GmbH (part of Baxter International Inc.), Research & Development; Hechingen Germany
| | - Rose Speidel
- Gambro Dialysatoren GmbH (part of Baxter International Inc.), Research & Development; Hechingen Germany
| | | | - Markus Storr
- Gambro Dialysatoren GmbH (part of Baxter International Inc.), Research & Development; Hechingen Germany
| | - Bernd Krause
- Gambro Dialysatoren GmbH (part of Baxter International Inc.), Research & Development; Hechingen Germany
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46
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The role of free kappa and lambda light chains in the pathogenesis and treatment of inflammatory diseases. Biomed Pharmacother 2017; 91:632-644. [DOI: 10.1016/j.biopha.2017.04.121] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 04/08/2017] [Accepted: 04/27/2017] [Indexed: 12/12/2022] Open
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47
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Kozlovskaya LV, Rameev VV, Androsova TV, Kogarko IN, Kogarko BS, Mrykhin NN, Rekhtina IG. [Oligosecretory monoclonal gammopathy with renal involvement]. TERAPEVT ARKH 2017; 88:82-87. [PMID: 28139565 DOI: 10.17116/terarkh2016881282-87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The article deals with the so-called monoclonal gammopathy of undetermined significance (MGUS), which is being actively explored in the world and has been recently investigated in Russia. It indicates the principles of identifying the phenotypes of MGUS and criteria for assessing the risk of its progression to cancer. There is an update on the possible involvement of monoclonal proteins in the pathogenesis of certain non-neoplastic kidney diseases, renal injuries in particular. The paper gives their classification and enumerates differential diagnostic techniques, including the Freelite method, a highly sensitive one to determine free light chains (FLC), prognostic criteria, and approaches to treating each separate form in relation to the phenotype of a monoclonal protein. The authors present their own data on detection rates for MGUS at a multidisciplinary hospital and a clinical case of MGUS-associated membranoproliferative glomerulonephritis, by justifying a treatment regimen containing bortezomib (velcade).
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Affiliation(s)
- L V Kozlovskaya
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - V V Rameev
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - T V Androsova
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - I N Kogarko
- N.N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow, Russia
| | - B S Kogarko
- N.N. Semenov Institute of Chemical Physics, Russian Academy of Sciences, Moscow, Russia
| | - N N Mrykhin
- I.M. Sechenov First Moscow State Medical University, Ministry of Health of Russia, Moscow, Russia
| | - I G Rekhtina
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
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Rosner MH, Edeani A, Yanagita M, Glezerman IG, Leung N. Paraprotein-Related Kidney Disease: Diagnosing and Treating Monoclonal Gammopathy of Renal Significance. Clin J Am Soc Nephrol 2016; 11:2280-2287. [PMID: 27526705 PMCID: PMC5142062 DOI: 10.2215/cjn.02920316] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Paraprotein-related kidney disease represents a complex group of diseases caused by an abnormal paraprotein secreted by a clone of B cells. The disease manifestations range from tubulopathies, such as the Fanconi syndrome, to a spectrum of glomerular diseases that can present with varying degrees of proteinuria and renal dysfunction. Diagnosis of these diseases can be challenging because of the wide range of manifestations as well as the relatively common finding of a serum paraprotein, especially in elderly patients. Thus, renal biopsy along with detailed hematologic workup is essential to link the presence of the paraprotein to the associated renal disease. Recent advances in treatment with more effective and targeted chemotherapies, as well as stem cell transplantation, have improved the renal and overall prognosis for many of these disorders.
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Affiliation(s)
- Mitchell H. Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia
| | - Amaka Edeani
- Kidney Diseases Branch, National Institute of Diabetes, Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland
| | - Motoko Yanagita
- Department of Nephrology, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Ilya G. Glezerman
- Renal Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
- Department of Medicine, Weill Cornell Medical College, New York, New York; and
| | - Nelson Leung
- Divisions of Nephrology and Hypertension and
- Hematology, Mayo Clinic, Rochester, Minnesota
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Doshi M, Lahoti A, Danesh FR, Batuman V, Sanders PW. Paraprotein-Related Kidney Disease: Kidney Injury from Paraproteins-What Determines the Site of Injury? Clin J Am Soc Nephrol 2016; 11:2288-2294. [PMID: 27526707 PMCID: PMC5142058 DOI: 10.2215/cjn.02560316] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Disorders of plasma and B cells leading to paraproteinemias are associated with a variety of renal diseases. Understanding the mechanisms of injury and associated nephropathies provides a framework that aids clinicians in prompt diagnosis and appropriate adjunctive treatment of these disorders. Glomerular diseases that may be associated with paraproteinemias include amyloid deposition, monoclonal Ig deposition disease, proliferative GN with monoclonal Ig deposits, C3 glomerulopathy caused by alterations in the complement pathway, immunotactoid glomerulopathy, fibrillary GN, and cryoglobulinemia. Tubular lesions include the classic Fanconi syndrome, light-chain proximal tubulopathy, interstitial fibrosis, and cast nephropathy. These paraproteinemic renal diseases are distinct in their pathogenesis as well as their urinary and kidney biopsy findings. Renal pathology is usually initiated by deposition and direct involvement of the intact monoclonal Ig or Ig fragments with resident cells of the nephron. Our review summarizes current insights into the underlying molecular pathogenesis of these interesting kidney lesions.
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Affiliation(s)
- Mona Doshi
- Division of Nephrology, Wayne State University School of Medicine, Detroit, Michigan
| | - Amit Lahoti
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Farhad R. Danesh
- Section of Nephrology, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Vecihi Batuman
- Department of Medicine, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana
- Department of Medicine, Tulane University Medical School, New Orleans, Louisiana
| | - Paul W. Sanders
- Department of Medicine, Nephrology Research and Training Center and
- Department of Cell, Developmental and Integrative Biology, University of Alabama at Birmingham, Birmingham, Alabama; and
- Department of Medicine, Veterans Affairs Medical Center, Birmingham, Alabama
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50
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Gavriatopoulou M, Terpos E, Kastritis E, Dimopoulos MA. Current treatments for renal failure due to multiple myeloma. Expert Opin Pharmacother 2016; 17:2165-2177. [PMID: 27646819 DOI: 10.1080/14656566.2016.1236915] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Renal impairment (RI) is one of the most common complication of multiple myeloma (MM). RI is present in almost 20% of MM patients at diagnosis and in 40%-50% of patients during the course of their disease. Areas covered: Biology along with tools for diagnosis and management of RI are reported in this paper. Papers published in PubMed and reported abstracts up to May 2016 were used. Expert opinion: Moderate and severe RI increases the risk of early death; thus rapid intervention and initiation of anti-myeloma treatment is essential and improves renal outcomes in RI patients. Bortezomib and dexamethasone triplet combinations are the current standard of therapy for MM patients with acute kidney injury due to cast nephropathy; they offer high rates of both anti-myeloma response and renal recovery. Thalidomide and lenalidomide may be used in bortezomib refractory patients. In the relapsed/refractory setting additional treatment options such as carfilzomib, pomalidomide and monoclonal antibodies are available; however, there is limited data for their effects on patients with RI. High dose melphalan with autologous stem cell transplantation should be considered in otherwise eligible patients with RI. Finally, high cut-off hemodialysis membranes do not seem to offer significant additive effects on anti-myeloma therapies.
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Affiliation(s)
- Maria Gavriatopoulou
- a Department of Clinical Therapeutics, School of Medicine , National and Kapodistrian University of Athens , Athens , Greece
| | - Evangelos Terpos
- a Department of Clinical Therapeutics, School of Medicine , National and Kapodistrian University of Athens , Athens , Greece
| | - Efstathios Kastritis
- a Department of Clinical Therapeutics, School of Medicine , National and Kapodistrian University of Athens , Athens , Greece
| | - Meletios A Dimopoulos
- a Department of Clinical Therapeutics, School of Medicine , National and Kapodistrian University of Athens , Athens , Greece
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