1
|
Dawson C, Palfreyman E, Parisotto R, D'Rozario J. Incidence of chronic renal injury in patients undergoing autologous stem cell transplant therapy. Intern Med J 2023; 53:1170-1179. [PMID: 36054169 DOI: 10.1111/imj.15910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 08/04/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Haemopoietic stem cell transplant (HSCT) is a well-established treatment option for many haematologic immunologic and oncologic diseases, allowing the safe administration of high-dose chemotherapy. Increased risk of acute renal injury is associated with HSCT; however, the risk of chronic kidney injury in autologous HSCT remains unclear. AIMS This cohort study investigates the incidence of chronic renal injury and its predisposing factors in a single-centre population of 139 patients who underwent autologous HSCT. METHODS Estimated glomerular filtration rate (eGFR) was measured at baseline and at 3, 6, 12 and 24 months following autologous stem cell reinfusion and used as a marker of renal dysfunction. RESULTS A significant reduction in mean eGFR of patients was observed from baseline (80.62 ± 2.97 mL/min) to 24 months (71.54 ± 4.14 mL/min), independent of primary diagnosis (P = 0.0019). At baseline, 12% of the cohort had stage 3 or worse chronic renal injury and this increased to 38% by 24 months. By univariate analysis, age at baseline greater than the mean of 58 years and the occurrence of acute kidney injury during the peritransplant period emerged as predictive factors for the development of chronic kidney disease at 24 months. CONCLUSIONS The current results indicate there is an increased incidence of chronic renal injury in patients who have undergone autologous peripheral blood haemopoietic stem cell transplantation therapy and this injury is potentiated by the autologous stem cell transplant procedure.
Collapse
Affiliation(s)
- Chloe Dawson
- Medical School, Australian National University Medical School, Canberra, Australian Capital Territory, Australia
| | - Emma Palfreyman
- Department of Haematology, The Canberra Hospital and Health Service, Canberra, Australian Capital Territory, Australia
| | - Robin Parisotto
- Bone Marrow Transplant Laboratory, ACT Pathology, Canberra, Australian Capital Territory, Australia
| | - James D'Rozario
- Medical School, Australian National University Medical School, Canberra, Australian Capital Territory, Australia
- Department of Haematology, The Canberra Hospital and Health Service, Canberra, Australian Capital Territory, Australia
| |
Collapse
|
2
|
Roy G, Iordachescu I, Royal V, Lamarche C, Ahmad I, Nadeau-Fredette AC, Laurin LP. Kidney Biopsy Findings Among Allogenic Hematopoietic Stem Cell Transplant Recipients With Kidney Injury: A Case Series. Kidney Med 2023; 5:100674. [PMID: 37492111 PMCID: PMC10363560 DOI: 10.1016/j.xkme.2023.100674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
Rationale and Objective The incidence of kidney disease is high in patients after allogeneic hematopoietic cell transplantation (aHCT). Although rarely performed, kidney biopsy may be useful to make a precise diagnosis because several mechanisms and risk factors can be involved, and to adjust the treatment accordingly. This case series aimed to report the spectrum of biopsy findings from patients with kidney injury after aHCT. Study Design Single-center retrospective case series. Setting and Participants All individuals who underwent a native kidney biopsy, among all adult patients who received aHCT in a tertiary hospital in Montreal (Canada) from January 1, 2010, to December 31, 2020, were identified, and the clinical data were extracted from their medical records. Results A total of 17 patients were included. Indications for biopsy included acute kidney injury (n=6), chronic kidney disease (n=5), nephrotic syndrome (n=4), and subnephrotic proteinuria (n=2). Pathologic findings from the kidney biopsy were heterogenous: 10 patients showed evidence of thrombotic microangiopathy (TMA), 5 of acute tubular injury, and 4 of membranous nephropathy. Cases of acute interstitial nephritis, BK virus nephropathy, immune complex nephropathy, focal and segmental glomerulosclerosis, minimal change disease, and karyomegalic-like interstitial nephritis were also described. Limitations There was no systematic kidney biopsy performed for all patients with kidney injury after aHCT. Only a small proportion of patients with kidney damage underwent biopsy, making the results less generalizable. Conclusions Kidney biopsy is useful in patients with kidney disease after aHCT to make a precise diagnosis and tailor therapy accordingly. This series is one of the few published studies describing pathologic findings of biopsies performed after aHCT in the context of acute kidney injury and chronic kidney disease. TMA was widely present on biopsy even when there was no clinical suspicion of such a diagnosis, suggesting that the current clinical criteria for a diagnosis of TMA are not sensitive enough for kidney-limited TMA.
Collapse
Affiliation(s)
- Guillaume Roy
- Division of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Ilinca Iordachescu
- Division of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
| | - Virginie Royal
- Department of Pathology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
- Department of Pathology and Cellular Biology, University of Montreal, Montreal, Quebec, Canada
| | - Caroline Lamarche
- Division of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Imran Ahmad
- Division of Hematology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Annie-Claire Nadeau-Fredette
- Division of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Louis-Philippe Laurin
- Division of Nephrology, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada
- Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| |
Collapse
|
3
|
Chen RY, Li XZ, Lin Q, Tang HY, Cui NX, Jiang L, Dai XM, Chen WQ, Deng F, Hu SY, Zhu XM. Pathological evaluation of renal complications in children following allogeneic hematopoietic stem cell transplantation: a retrospective cohort study. BMC Pediatr 2023; 23:186. [PMID: 37085779 PMCID: PMC10120150 DOI: 10.1186/s12887-023-03996-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 04/06/2023] [Indexed: 04/23/2023] Open
Abstract
BACKGROUND Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a curative therapy for hematologic malignancies and non-malignant disorders, such as aplastic anemia, fanconi anemia, and certain immune deficiencies. Post-transplantation kidney injury is a common complication and involves a wide spectrum of structural abnormalities, including glomerular (MSPGN, mesangial proliferative glomerulonephritis; FSGS, focal segmental glomerulosclerosis; MPGN, membranoproliferative glomerulonephritis; MCD, minimal change disease), vascular (TMA, thrombotic microangiopathy), and/or tubulointerstitial (TIN, tubulointerstitial nephritis; ATI, acute tubular injury). Renal biopsy is the gold-standard examination for defining multiple etiologies of kidney impairment. Although kidney injury following HSCT has been studied, little is known about the effects of allo-HSCT on renal pathology in pediatric patients. METHODS We retrospectively analyzed renal biopsy specimens from children with kidney injury after allo-HSCT and correlated results with clinical data in the last 10 years. RESULTS Among 25 children (18 males and 7 females), three patients had proteinuria indicating nephrotic syndrome (24-hour urinary total protein/weight > 50 mg/kg/d), nine patients had severely reduced estimated glomerular filtration rate (eGFR < 30 ml/min/1.73 m2) and four patients received kidney replacement therapy (KRT). The main pathologies identified from kidney biopsies were MSPGN (n = 12), FSGS (n = 12), MPGN (n = 5), TMA (n = 4), MCD (n = 3), diffuse glomerular fibrosis (DGF, n = 2), ATI and TIN, in isolation or combined with other pathologies. The median follow-up time was 16.5 (0.5 ~ 68.0) months. Three patients died of recurrent malignancy and/or severe infection, one child developed to end-stage renal disease (ESRD), six patients (24%) had elevated serum creatinine (SCr > 100µmol/l) and nine patients (36%) still had proteinuria. CONCLUSIONS This study evaluates histomorphologic findings from kidney biopsies of pediatric recipients following allo-HSCT. Detailed evaluation of renal biopsy samples is helpful to elucidate the nature of renal insult, and may potentially identify treatable disease processes.
Collapse
Affiliation(s)
- Ru-Yue Chen
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xiao-Zhong Li
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China.
| | - Qiang Lin
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Han-Yun Tang
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Ning-Xun Cui
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Lu Jiang
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xiao-Mei Dai
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Wei-Qing Chen
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Fan Deng
- Department of Nephrology and Immunology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shao-Yan Hu
- Department of Hematology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Xue-Ming Zhu
- Department of Pathology, Children's Hospital of Soochow University, Suzhou, Jiangsu, China
| |
Collapse
|
4
|
Sakai T, Uchida T, Iwama S, Sugisaki K, Yamada M, Inamoto Y, Oda T. Chronic Graft-versus-host Disease-associated Membranous Nephropathy Following Bone Marrow Transplantation, Successfully Treated with Rituximab. Intern Med 2023; 62:269-273. [PMID: 35732451 PMCID: PMC9908386 DOI: 10.2169/internalmedicine.9655-22] [Citation(s) in RCA: 1] [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: 01/18/2023] Open
Abstract
A 67-year-old woman who had undergone bone marrow transplantation 2 years previously for acute myeloid leukemia (AML) developed complications of chronic graft-versus-host disease (cGVHD). She thereafter also developed nephrotic syndrome, and membranous nephropathy (MN) was diagnosed by a renal biopsy. Although the causative antigens of the MN were not detected, immunofluorescence staining showed codominant deposition of immunoglobulins G2 and G3, a finding indicating secondary MN, thereby suggesting an association between MN and cGVHD. Rituximab treatment was initiated, and her nephrotic syndrome gradually improved without relapse of AML. Our present case suggests that rituximab is a safe and effective therapeutic option for cGVHD-associated MN.
Collapse
Affiliation(s)
- Takashi Sakai
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Takahiro Uchida
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Sachiko Iwama
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Kentaro Sugisaki
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Muneharu Yamada
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| | - Yoshihiro Inamoto
- Department of Hematopoietic Stem Cell Transplantation, National Cancer Center Hospital, Japan
| | - Takashi Oda
- Department of Nephrology and Blood Purification, Kidney Disease Center, Tokyo Medical University Hachioji Medical Center, Japan
| |
Collapse
|
5
|
John EE, Roy S, Devasia AJ, Karuppusami R, Jose N, Mani SSR, Eapen JJ, Yusuf S, Thomas A, Valson AT, David VG, Mathews V, Biju George, Varughese S, Alexander S. Patterns of Renal Dysfunction and Profile of Kidney Biopsies in Hematopoietic Stem Cell Transplant Recipients. GLOMERULAR DISEASES 2023; 3:98-115. [PMID: 37064012 PMCID: PMC10098275 DOI: 10.1159/000529699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 02/09/2023] [Indexed: 03/16/2023]
Abstract
Introduction Post hematopoietic stem cell transplant (HSCT), kidney can be subjected to injury by various causes. Of these, graft versus host disease (GvHD) affecting the kidney is an under-recognized entity with no clear guidelines on its diagnosis, clinicopathological manifestations, and outcomes. Material and Methods Out of 2,930 patients who underwent HSCT at our center between 2005 and 2020, kidney biopsy was performed in 19 allogenic and 5 autologous recipients. Results The mean age of the cohort at transplant was 33.2 ± 7 years, and 15 (62%) were males. Median time to kidney biopsy from HSCT was 14 (IQR, 9-30) months. Aplastic anemia was the most common underlying hematological disease (54.2%). All 19 allogenic recipients were classified based on clinicopathological manifestations into either thrombotic microangiopathy (TMA, 12/19 [63%]) or nephrotic syndrome (NS, 7/19 [37%]) pattern. Glomerular tuft "mesangiolysis" was the dominant pattern of injury noted in 9/12 cases of TMA pattern. There was a predominance of acute microangiopathic changes restricted primarily to the glomerular compartment. Of the 7 patients with NS pattern, membranous nephropathy was seen in 4 (57%) and minimal change disease in 3 (43%) patients. Thirty-nine percent (7/18) stained positive for C4d which was predominantly glomerular. Allogenic recipients who did not receive immunosuppression (IS) for renal disease had a lower eGFR at biopsy, a longer latency between withdrawal of GvHD prophylaxis and biopsy, and were significantly at a higher risk of kidney failure (IS: 2/11, 18.1% vs. no IS: 2/6, 33.3%, p = 0.04). "Associated extra-renal GvHD" occurred in 11/19 (57.9%) allogenic recipients. Patients with "associated extra-renal GvHD" had significantly more deaths (6/11, 60% vs. 0, p = 0.02) but comparable renal outcomes. Conclusion Renal GvHD can present with or without "associated extra-renal GvHD" after a prolonged period of withdrawal of GvHD prophylaxis, requiring careful diagnostic vigilance and consideration of IS.
Collapse
Affiliation(s)
| | - Sanjeet Roy
- Department of Pathology, Christian Medical College, Vellore, India
| | - Anup J. Devasia
- Department of Hematology, Christian Medical College, Vellore, India
| | - Reka Karuppusami
- Department of Biostatistics, Christian Medical College, Vellore, India
| | - Nisha Jose
- Department of Nephrology, Christian Medical College, Vellore, India
| | | | | | - Sabina Yusuf
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Athul Thomas
- Department of Nephrology, Christian Medical College, Vellore, India
| | - Anna T. Valson
- Department of Nephrology, Christian Medical College, Vellore, India
| | | | - Vikram Mathews
- Department of Hematology, Christian Medical College, Vellore, India
| | - Biju George
- Department of Hematology, Christian Medical College, Vellore, India
| | | | | |
Collapse
|
6
|
Benoit SW, Khandelwal P, Grimley MS. A case of treatment-resistant membranous nephropathy associated with graft versus host disease successfully treated with daratumumab. Pediatr Transplant 2022; 26:e14263. [PMID: 35249254 DOI: 10.1111/petr.14263] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 01/25/2022] [Accepted: 02/17/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Membranous nephropathy (MN) is the most common cause of glomerulopathy after hematopoietic cell transplantation (HCT), most often occurring in the setting of graft versus host disease (GVHD). Twenty percent of patients will fail to respond to standard therapy and may progress to end stage renal disease. Here we present the case of a pediatric patient who developed chronic oral GVHD more than one-year post-HCT, who subsequently developed nephrotic syndrome (anasarca, nephrotic range proteinuria, hypoalbuminemia) and had a renal biopsy consistent with MN. Treated with ibrutinib for her GVHD, and steroids, tacrolimus, and rituximab for her MN, she failed to achieve even partial remission of her kidney disease after 8 months. Due to steroid toxicity and 0% CD19 cells on lymphocyte subpopulation flow cytometry, the decision was made to trial plasma cell depletion therapy with daratumumab. METHOD She received three doses of daratumumab at weeks 1, 4, and 17. RESULTS Her nephrotic syndrome resolved and her serum albumin was greater than 3.0 gm/dl by week 10. She was weaned off of both steroids and tacrolimus by week 16, at which time she had near-complete remission of her renal disease. CONCLUSION Daratumumab may be an important, novel therapeutic option for post-HCT MN patients who are not responsive to standard therapies.
Collapse
Affiliation(s)
- Stefanie W Benoit
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Pooja Khandelwal
- Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Michael S Grimley
- Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| |
Collapse
|
7
|
Morel A, Buob D, Goujon JM, Belhadj K, Verpont MC, Audard V, Moktefi A. Thrombospondin type-1 domain-containing 7A-related membranous nephropathy associated with glomerular AL amyloidosis. Pathology 2021; 54:654-657. [PMID: 34774302 DOI: 10.1016/j.pathol.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 08/11/2021] [Accepted: 08/17/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Antoine Morel
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire, Innovative Therapy for Immune Disorders, Créteil, France; Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France
| | - David Buob
- Sorbonne Université, AP-HP, Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon, Paris, France
| | - Jean-Michel Goujon
- Département de Pathologie, Unité de Pathologie Ultrastructurale, CHU Poitiers, Poitiers, France; Centre de Référence Maladies Rares Amylose AL et Autres Maladies Par Dépôts D'immunoglobulines Monoclonales, Poitiers, France
| | - Karim Belhadj
- AP-HP, Hôpitaux Universitaires Henri Mondor, Unité Hémopathies Lymphoïdes, Créteil, France; AP-HP, Hôpitaux Universitaires Henri Mondor, Réseau Amylose Mondor, Groupe de Recherche Clinique sur les Amyloses, Amyloid Research Institute, Créteil, France
| | | | - Vincent Audard
- Assistance Publique des Hôpitaux de Paris (AP-HP), Hôpitaux Universitaires Henri Mondor, Service de Néphrologie et Transplantation, Centre de Référence Maladie Rare Syndrome Néphrotique Idiopathique, Fédération Hospitalo-Universitaire, Innovative Therapy for Immune Disorders, Créteil, France; Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France; AP-HP, Hôpitaux Universitaires Henri Mondor, Réseau Amylose Mondor, Groupe de Recherche Clinique sur les Amyloses, Amyloid Research Institute, Créteil, France
| | - Anissa Moktefi
- Université Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U955, Institut Mondor de Recherche Biomédicale (IMRB), Equipe 21, Créteil, France; AP-HP, Hôpitaux Universitaires Henri Mondor, Réseau Amylose Mondor, Groupe de Recherche Clinique sur les Amyloses, Amyloid Research Institute, Créteil, France; AP-HP, Hôpitaux Universitaires Henri Mondor, Département de Pathologie, Créteil, France.
| |
Collapse
|
8
|
Yang LP, Liu X, Zhang XH. [Advances in the diagnosis and management of transplant-associated thrombotic microangiopathy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:693-699. [PMID: 34547882 PMCID: PMC8501284 DOI: 10.3760/cma.j.issn.0253-2727.2021.08.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Indexed: 12/02/2022]
Affiliation(s)
- L P Yang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - X Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| | - X H Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing 100044, China
| |
Collapse
|
9
|
Membranous Glomerulopathy After Autologous Hematopoietic Stem Cell Transplant in a Patient With Multiple Myeloma. Kidney Int Rep 2021; 6:2243-2245. [PMID: 34386678 PMCID: PMC8343790 DOI: 10.1016/j.ekir.2021.05.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 05/24/2021] [Indexed: 11/26/2022] Open
|
10
|
[Chinese consensus on the diagnosis and management of transplant-associated thrombotic microangiopathy (2021)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:177-184. [PMID: 33910301 PMCID: PMC8081937 DOI: 10.3760/cma.j.issn.0253-2727.2021.03.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Indexed: 01/04/2023]
|
11
|
Ainley L, Law S, Heptinstall L, Rodriguez-Justo M, Thomson K, Pepper RJ. Treatment of Concurrent Minimal Change Disease and Epstein Barr Virus-Driven Post-transplant Lymphoproliferative Disorder With Rituximab Following Hematopoietic Stem Cell Transplantation. Kidney Int Rep 2020; 6:224-227. [PMID: 33426402 PMCID: PMC7783564 DOI: 10.1016/j.ekir.2020.10.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/01/2020] [Accepted: 10/13/2020] [Indexed: 12/01/2022] Open
Affiliation(s)
- Louise Ainley
- Department of Hematology, University College Hospital NHS Trust, London, UK
| | - Steven Law
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | | | | | - Kirsty Thomson
- Department of Hematology, University College Hospital NHS Trust, London, UK
| | - Ruth J Pepper
- UCL Department of Renal Medicine, Clinical Kidney Disease, Royal Free Hospital, London, UK
| |
Collapse
|
12
|
Han Y. [How I treat transplant-associated thrombotic microangiopathy]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:272-275. [PMID: 32447928 PMCID: PMC7364922 DOI: 10.3760/cma.j.issn.0253-2727.2020.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Y Han
- Department of Hematology, the First Affiliated Hospital of Soochow University, Jiangsu Institute of Hematology, Suzhou 215006, China
| |
Collapse
|
13
|
Yamada R, Nemoto T, Ohashi K, Tonooka A, Horiguchi SI, Motoi T, Hishima T. Distribution of Transplantation-Associated Thrombotic Microangiopathy (TA-TMA) and Comparison between Renal TA-TMA and Intestinal TA-TMA: Autopsy Study. Biol Blood Marrow Transplant 2019; 26:178-188. [PMID: 31491486 DOI: 10.1016/j.bbmt.2019.08.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 08/19/2019] [Accepted: 08/21/2019] [Indexed: 01/08/2023]
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is an important complication of hematopoietic stem cell transplantation. To date, information regarding the organs that are affected by TA-TMA as confirmed histologically remains limited; the clinicopathologic differences between renal TA-TMA and intestinal TA-TMA have not been examined despite being the well-known and commonly affected sites of TA-TMA. We therefore examined 165 autopsied patients after hematopoietic stem cell transplantation and compared the clinicopathologic factors of renal and intestinal TA-TMA. It was clear that 38 (23%) of our patients had TA-TMA. In the TA-TMA cases, the kidney (61%) and intestine (53%) were commonly affected, and the ileum and right colon were vulnerable. Other organs that we found to be affected by TA-TMA included the stomach (8%), gallbladder (5%), and oral cavity, pharynx, esophagus, liver, heart, urinary bladder, and ureter (all at 3%), and symptoms thought to be caused by TA-TMA of these organs were not observed in any patient. Histologically, TA-TMA only affected the arteriole, or small arteries, regardless of the organ, and the veins or larger arteries were not affected at all. In the kidney, the glomerular capillary was also affected, and mesangiolysis and double contours of the basement membranes were often in evidence. The histologic overlap of renal and intestinal TA-TMA was rare (13%), and the patients in the intestinal TA-TMA group exhibited more frequency of a history of intestinal acute graft-versus-host disease (GVHD) during the clinical course compared with that of the renal TA-TMA group (80% versus 22%, P = .0016). Although TA-TMA can affect many other organs, the frequency of these ancillary events was low, and the clinical effect may have been small. Our results suggest that in comparison to renal TA-TMA, intestinal GVHD could be more closely associated with intestinal TA-TMA as a risk factor.
Collapse
Affiliation(s)
- Rin Yamada
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Tetsuo Nemoto
- Department of Pathology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Kazuteru Ohashi
- Department of Hematology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Akiko Tonooka
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Shin-Ichiro Horiguchi
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Toru Motoi
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Tsunekazu Hishima
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan.
| |
Collapse
|
14
|
Iatrogenic Disease of the Genitourinary Tract. Adv Anat Pathol 2019; 26:171-185. [PMID: 30720471 DOI: 10.1097/pap.0000000000000226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Iatrogenic disease is defined as illness caused by diagnostic procedures or treatment given by health care professionals. More recently described treatment complications involving the genitourinary tract include newly recognized variants of renal carcinoma in the setting of dialysis/end-stage renal disease, treatment effect in genitourinary carcinomas, and medical renal disease caused by drug therapies, including immunotherapy. The objective of this review is to cover iatrogenic inflammatory diseases, pseudotumors and tumors of the kidney, bladder, prostate, testis and paratestis of most interest to surgical pathologists. For this reason, disease caused by the following will not be covered: iatrogenic glomerulonephritis, self-inflicted injury including the introduction of foreign bodies, surgical error, drugs of abuse and herbal medications, and iatrogenic disease in the transplant setting including ischemia/reperfusion injury. Emphasis is placed upon commonly encountered diseases in order to ensure that the review is of utility to practicing pathologists. The clinical context, pathophysiology and histopathology of each disease entity are covered.
Collapse
|
15
|
Girsberger M, Halter JP, Hopfer H, Dickenmann M, Menter T. Kidney Pathology after Hematologic Cell Transplantation-A Single-Center Observation Study of Indication Biopsies and Autopsies. Biol Blood Marrow Transplant 2017; 24:571-580. [PMID: 29155318 DOI: 10.1016/j.bbmt.2017.11.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/08/2017] [Indexed: 12/11/2022]
Abstract
Hematopoietic cell transplantation (HCT) is an increasingly used treatment for hematologic malignancies as well as for nonmalignant diseases. Kidney impairment remains an important early and late post-transplantation complication. Although numerous histopathological changes have been reported, the pathophysiology remains incompletely understood. Furthermore, correlations between clinical findings and morphological changes have not been well studied. Between 2000 and 2016, 17 recipients of allogeneic (n = 12) or autologous (n = 5) HCT underwent kidney biopsy for either proteinuria or deterioration of kidney function at our center. The most common biopsy findings were therapy-related changes with thrombotic microangiopathy (n = 5), calcineurin inhibitor toxicity (n = 4), and membranous glomerulonephritis (n = 3), representing the majority of cases in this category. In addition, kidney findings from 137 autopsies performed between 1995 and March 2017 were analyzed. The most common changes were acute kidney injury (n = 55), most likely due to the patients' premortal deteriorated state, and thrombotic microangiopathy (n = 14). Several cases demonstrated involvement by either infectious agents (n = 6) or tumors (n = 9). Distinct kidney diseases, such as glomerulonephritis, were rare (3% of cases). Uncommon and yet rarely described diagnoses for this patient cohort were IgG4-related tubulointerstitial nephritis and fibrillary nephritis. This study provides a comprehensive overview of the histomorphological findings in kidney biopsy specimens from HCT recipients. Along with treatment-related complications, one putative correlate of chronic GVHD of the kidney could be documented: membranous glomerulonephritis. In contrast, no morphological correlate of acute GVHD of the kidney was identified. Findings at the time of autopsy varied greatly, spanning a wider range than those of indication biopsies.
Collapse
Affiliation(s)
- Michael Girsberger
- Clinic for Transplantation Immunology and Nephrology, University Hospital of Basel, Basel, Switzerland
| | - Jörg P Halter
- Department of Hematology, University Hospital of Basel, Basel, Switzerland
| | - Helmut Hopfer
- Institute of Medical Genetics and Pathology, University Hospital of Basel, Basel, Switzerland
| | - Michael Dickenmann
- Clinic for Transplantation Immunology and Nephrology, University Hospital of Basel, Basel, Switzerland
| | - Thomas Menter
- Institute of Medical Genetics and Pathology, University Hospital of Basel, Basel, Switzerland.
| |
Collapse
|
16
|
Masuzawa N, Nishimura A, Kitani T, Tamagaki K, Sugitani M, Nagoshi H, Kuroda J, Konishi E. A Case of the nephrotic syndrome in bone marrow transplantation recipient, histologically showing overlapped glomerular lesions of thrombotic microangiopathy and membranous nephropathy. Pathol Int 2017; 67:620-625. [PMID: 28940837 DOI: 10.1111/pin.12589] [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: 04/11/2017] [Accepted: 08/24/2017] [Indexed: 11/30/2022]
Abstract
Nephrotic syndrome (NS) rarely occurs in post-hematopoietic stem cell transplantation (HSCT) recipients but represents the renal manifestation of graft-versus-host disease (GVHD). Membranous nephropathy (MN) accounts for almost two thirds of post-HSCT NS and is caused by immune complex deposition. Renal thrombotic microangiopathy (TMA) without fulfillment of clinical criteria for TMA has been underreported because of reduced opportunity for histological examination. However, renal TMA has recently been reported in association with GVHD and humoral immunological reactions. Although both MN and TMA after HSCT are associated with GVHD and immunological abnormalities, these diseases are exceptionally coexistent in renal biopsy specimens. We herein describe a case of post-HSCT NS, histologically showing overlapped lesions of TMA and MN. Renal biopsy specimen after presentation of NS revealed early stage MN and TMA with evidence of chronicity. TMA was thought to have preceded MN, and renal biopsy at the phase of pre-nephrotic proteinuria might reveal earlier histological changes of isolated renal TMA. Detection of subclinical renal TMA earlier by spontaneous renal biopsy can help prevent progression of renal injury or overlapping of other renal pathologies. We also demonstrated Th2 predominant intraglomerular infiltration of lymphocytes by immunohistochemistry.
Collapse
Affiliation(s)
- Naoko Masuzawa
- Division of Surgical Pathology, Department of Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan.,Department of Diagnostic Pathology, Otsu City Hospital, Shiga, Japan
| | - Ayako Nishimura
- Division of Surgical Pathology, Department of Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Takashi Kitani
- Division of Cardiovascular Medicine and Nephrology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Keiichi Tamagaki
- Division of Cardiovascular Medicine and Nephrology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Mio Sugitani
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hisao Nagoshi
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Junya Kuroda
- Division of Hematology and Oncology, Department of Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Eiichi Konishi
- Division of Surgical Pathology, Department of Pathology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| |
Collapse
|
17
|
Affiliation(s)
- Sangeeta Hingorani
- From the Department of Pediatrics, Division of Nephrology, University of Washington School of Medicine, and the Clinical Research Division, Fred Hutchinson Cancer Research Center - both in Seattle
| |
Collapse
|
18
|
Brinkerhoff BT, Houghton DC, Troxell ML. Renal pathology in hematopoietic cell transplant recipients: a contemporary biopsy, nephrectomy, and autopsy series. Mod Pathol 2016; 29:637-52. [PMID: 27015134 DOI: 10.1038/modpathol.2016.61] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 02/14/2016] [Accepted: 02/15/2016] [Indexed: 12/29/2022]
Abstract
Renal injury in hematopoietic cell transplant recipients may be related to a combination of factors including chemotherapy, radiation, infection, immunosuppressive agents, ischemia, and graft-versus-host disease, and can involve glomerular, tubulointerstitial, and vascular structures. We reviewed renal pathology from 67 patients at a single institution (2009-2014), including 14 patients with biopsy for clinical dysfunction, 6 patients with surgical kidney resection for other causes, and 47 autopsy patients. Kidney specimens frequently contained multiple histopathologic abnormalities. Thrombotic microangiopathy, membranous nephropathy, minimal change disease, and focal segmental glomerulosclerosis were the most common glomerular findings. Pathologies not previously reported in the hematopoietic cell transplant setting included collapsing glomerulopathy, antiglomerular basement membrane disease, fibrillary glomerulonephritis, and in the case of two surgical resections distinctive cellular segmental glomerular lesions that defied classification. Kidney specimens frequently demonstrated acute tubular injury, interstitial fibrosis, arteriolar hyaline, and arteriosclerosis. Other kidney findings at autopsy included leukemia and amyloid (both recurrent), diabetic nephropathy, bacterial infection, fungal invasion, and silver deposition along glomerular and tubular basement membranes. Also in the autopsy cohort, C4d immunohistochemistry demonstrated unexpected membranous nephropathy in two patients, yet C4d also colocalized with arteriolar hyaline. This retrospective hematopoietic cell transplant cohort illustrates multifaceted renal injury in patients with renal dysfunction, as well as in patients without clinically recognized kidney injury.
Collapse
Affiliation(s)
- Brian T Brinkerhoff
- Oregon Health & Science University, Department of Pathology, Portland, OR, USA
| | - Donald C Houghton
- Oregon Health & Science University, Department of Pathology, Portland, OR, USA
| | - Megan L Troxell
- Oregon Health & Science University, Department of Pathology, Portland, OR, USA.,Oregon Health & Science University, Knight Cancer Institute, Portland, OR, USA
| |
Collapse
|
19
|
Hiramatsu R, Ubara Y, Sawa N, Hasegawa E, Kawada M, Imafuku A, Sumida K, Mise K, Yamanouchi M, Ueno T, Sekine A, Hayami N, Suwabe T, Hoshino J, Takaichi K, Ohashi K, Fujii T, Wake A, Taniguchi S. Clinicopathological analysis of allogeneic hematopoietic stem cell transplantation–related membranous glomerulonephritis. Hum Pathol 2016; 50:187-94. [DOI: 10.1016/j.humpath.2015.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 12/06/2015] [Accepted: 12/10/2015] [Indexed: 11/29/2022]
|
20
|
Hematopoietic Stem Cell Transplantation. PATHOLOGY OF TRANSPLANTATION 2016. [PMCID: PMC7124099 DOI: 10.1007/978-3-319-29683-8_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
|
21
|
Beyar-Katz O, Davila EK, Zuckerman T, Fineman R, Haddad N, Okasha D, Henig I, Leiba R, Rowe JM, Ofran Y. Adult Nephrotic Syndrome after Hematopoietic Stem Cell Transplantation: Renal Pathology is the Best Predictor of Response to Therapy. Biol Blood Marrow Transplant 2015; 22:975-981. [PMID: 26740372 DOI: 10.1016/j.bbmt.2015.12.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 12/16/2015] [Indexed: 01/28/2023]
Abstract
Nephrotic syndrome (NS) after allogeneic hematopoietic stem cell transplantation (HSCT) is a rare phenomenon usually associated with graft-versus-host disease (GVHD). This systematic review of post-HSCT NS cases reported in the literature aimed to identify risk factors and unique features of the disease in this clinical setting. One hundred sixteen cases of post-HSCT NS published in the English literature between 1988 and 2015 were revealed and analyzed. The median onset of NS was 20.5 months (range, 3 to 174) post-HSCT. NS development was associated with acute or chronic GVHD in 87.2% of cases. Membranous nephropathy (MGN) was the most frequent pathology (65.5%), followed by minimal change disease (MCD) (19%). Complete remission of the NS was achieved in 63.5% of patients (59.1% of MGN cases and 81.3% of MCD cases; P = .15). Patients presenting with MCD recovered at a median of 1.75 months (range, 1 to 12) and with MGN a median of 7 months (range, 1 to 53) (P = .001). NS was treated with corticosteroids alone in 16.8% of patients and with a combination of corticosteroids and other immunosuppressive agents in 73.5% of patients. Univariate analysis failed to identify a single predictive factor of response to therapy. In conclusion, post-HSCT NS usually develops concomitant to GVHD and is associated with high rates of response to therapy. Although most patients were treated with a combination of immunosuppressive drugs, single-agent therapy with steroids may be sufficient in some cases.
Collapse
Affiliation(s)
- Ofrat Beyar-Katz
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | | | - Tsila Zuckerman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Riva Fineman
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Nuhad Haddad
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Doaa Okasha
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Israel Henig
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Ronit Leiba
- Department of Statistics, Rambam Health Care Campus, Haifa, Israel
| | - Jacob M Rowe
- Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel; Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Yishai Ofran
- Department of Hematology and Bone Marrow Transplantation, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| |
Collapse
|
22
|
Sakamoto K, Imamura T, Osone S, Nishimura A, Nishida M, Ishida H, Hosoi H. Hematopoietic stem cell transplantation-associated thrombotic microangiopathy accompanied by renal arteriolar C4d deposition. Pediatr Transplant 2015; 19:E97-100. [PMID: 25735190 DOI: 10.1111/petr.12450] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/02/2015] [Indexed: 01/13/2023]
Abstract
HSCT-associated thrombotic microangiopathy (TA-TMA) is a severe complication with a poor prognosis. Recently, it has been reported that complement system dysregulation, such as CFH autoantibodies and deletions CFH-related genes 3 and 1, induced TA-TMA. In addition, C4d-positive renal arterioles are both a good marker of complement system activation and a useful diagnostic tool for TA-TMA. Because dysregulation of the complement system is associated with TA-TMA, the complement system might be a therapeutic target, such as eculizumab, a terminal complement inhibitor. Herein, we describe an eight-yr-old boy who developed TA-TMA accompanied by severe renal dysfunction. His renal specimen showed diffuse C4d deposition in the renal arterioles, which is consistent with TA-TMA. Although the patient gradually improved without eculizumab, renal arteriolar C4d staining in sample with TA-TMA shows the complement system activation and may guide the target therapy using the eculizumab.
Collapse
Affiliation(s)
- Kenichi Sakamoto
- Department of Pediatrics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | | | | | | | | | | |
Collapse
|
23
|
Byrne-Dugan CJ, Collins AB, Lam AQ, Batal I. Membranous nephropathy as a manifestation of graft-versus-host disease: association with HLA antigen typing, phospholipase A2 receptor, and C4d. Am J Kidney Dis 2014; 64:987-93. [PMID: 25304985 DOI: 10.1053/j.ajkd.2014.09.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Accepted: 07/29/2014] [Indexed: 12/31/2022]
Abstract
Glomerulopathy is an uncommon but increasingly recognized complication of hematopoietic cell transplantation. It typically manifests as membranous nephropathy, less commonly as minimal change disease, and rarely as proliferative glomerulonephritis. There is evidence to suggest that these glomerulopathies might represent manifestations of chronic graft-versus-host disease. In this report, we focus on membranous nephropathy as the most common form of glomerulopathy after hematopoietic cell transplantation. We present a case of membranous nephropathy that developed 483 days post-allogeneic hematopoietic stem cell transplantation in a patient with a history of acute graft-versus-host disease. We also share our experience with 4 other cases of membranous nephropathy occurring after allogeneic hematopoietic stem cell transplantation. Clinicopathologic correlates, including the association with graft-versus-host-disease, HLA antigen typing, glomerular deposition of immunoglobulin G (IgG) subclasses, subepithelial colocalization of IgG deposits with phospholipase A2 receptor staining, C4d deposition along the peritubular capillaries, and treatment, are discussed with references to the literature.
Collapse
Affiliation(s)
- Cathryn J Byrne-Dugan
- Renal Pathology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - A Bernard Collins
- Renal Pathology, Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Albert Q Lam
- Renal Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Ibrahim Batal
- Renal Pathology, Department of Pathology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA.
| |
Collapse
|
24
|
Urinary liver-type fatty acid-binding protein linked with increased risk of acute kidney injury after allogeneic stem cell transplantation. Biol Blood Marrow Transplant 2014; 20:2010-4. [PMID: 25193082 DOI: 10.1016/j.bbmt.2014.08.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 08/27/2014] [Indexed: 01/23/2023]
Abstract
Stem cell transplantation (SCT) involves a great risk of acute kidney injury (AKI). Urinary liver-type fatty acid-binding protein (uL-FABP) is a sensitive biomarker to detect kidney damage before an increase in serum creatinine (Cr); however, the utility of uL-FABP is not fully understood in the platform of SCT. A prospective study was conducted in 84 allogeneic SCT recipients to ascertain a link between the uL-FABP level before preparative procedures and AKI incidence after SCT. The association between them was analyzed using Gray's method and a multivariate Fine-Gray proportional hazards regression model. The recipients were stratified into high and low uL-FABP groups, according to the reference value for healthy subjects (8.4 μg/g Cr). AKI developed more frequently in the high (n = 20) than low (n = 64) group (55.0% versus 26.6% at day 30, P = .005), and high uL-FABP was an independent risk for the emergence of AKI (hazard ratio, 2.78; 95% confidence interval, 1.24 to 6.22, P = .01). In conclusion, increased baseline uL-FABP, which may indicate previous incipient kidney injury, is linked with a high risk of AKI after allogeneic SCT.
Collapse
|
25
|
Abstract
The kidney is subject to a large variety of injurious factors before, during, and after hematopoietic stem cell transplantation (HCT), leading to a high incidence of acute kidney injury in the peritransplant period. Chronic kidney disease is estimated to impact 15% to 20% of HCT recipients. Although renal biopsies may be deferred in the setting of thrombotic microangiopathy, acute self-limited impairment, or slowly progressive functional decline, in many patients renal biopsy yields important diagnostic insight to guide treatment. Light microscopic, immunofluorescence, and ultrastructural analysis often reveals a number of concurrent abnormalities in glomeruli, tubules, interstitium, and vessels. Meta-analysis of the literature reveals that membranous nephropathy is the most commonly reported glomerular lesion in the setting of HCT, followed by minimal change disease. Autopsy and biopsy studies show that clinical criteria lack sensitivity and specificity for renal acute and chronic thrombotic microangiopathy. Viral infection and other causes of interstitial nephritis and tubular injury are important findings in HCT renal biopsies, which in many instances may not be clinically suspected. Given the complexity and variability of HCT protocols, clinicopathologic correlation is needed.
Collapse
|
26
|
Diagnostic and risk criteria for HSCT-associated thrombotic microangiopathy: a study in children and young adults. Blood 2014; 124:645-53. [PMID: 24876561 DOI: 10.1182/blood-2014-03-564997] [Citation(s) in RCA: 257] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Transplant-associated thrombotic microangiopathy (TMA) leads to generalized endothelial dysfunction that can progress to multiorgan injury, and severe cases are associated with poor outcomes after hematopoietic stem cell transplantation (HSCT). Identifying patients at highest risk for severe disease is challenging. We prospectively evaluated 100 consecutive HSCT recipients to determine the incidence of moderate and severe TMA and factors associated with poor overall outcomes. Thirty-nine subjects (39%) met previously published criteria for TMA. Subjects with TMA had a significantly higher nonrelapse mortality (43.6% vs 7.8%, P < .0001) at 1 year post-HSCT compared with those without TMA. Elevated lactate dehydrogenase, proteinuria on routine urinalysis, and hypertension were the earliest markers of TMA. Proteinuria (>30 mg/dL) and evidence of terminal complement activation (elevated sC5b-9) in the blood at the time of TMA diagnosis were associated with very poor survival (<20% at 1 year), whereas all TMA subjects without proteinuria and a normal sC5b-9 serum concentration survived (P < .01). Based on these prospective observations, we conclude that severe TMA occurred in 18% of HSCT recipients in our cohort and propose an algorithm to identify the highest-risk patients who might benefit from prompt clinical interventions.
Collapse
|
27
|
Wu Q, Li X, Lai Y, Peng Z, Liao Y. Chronic kidney disease after autologous stem cell transplantation: analysis of a single center experience. Int Urol Nephrol 2014; 46:1403-10. [PMID: 24668138 DOI: 10.1007/s11255-014-0683-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 02/24/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE Chronic kidney disease (CKD) after allogeneic hematopoietic stem cell transplantation (HSCT) has increasingly been reported. However, CKD after autologous HSCT, especially changes in renal pathology, has rarely been reported. This study aimed to evaluate the frequency of CKD among patients who received autologous HSCT for hematological and nonhematological disorders, and analyze its clinical and pathological features. METHODS We performed a retrospective study to evaluate the frequency of CKD after autologous HSCT and analyzed clinical and pathological features of CKD. Clinical records of patients who underwent autologous HSCT at the First Affiliated Hospital of Guangxi Medical University between May 2000 and November 2010 were screened. Clinical data of those with kidney injury on presentation and follow-up were acquired from hospital records. RESULTS A total of 41 patients who received autologous HSCT were identified. CKD developed in six patients (14.6%). Among the six patients, all had various degrees of proteinuria and three patients had nephrotic syndrome. Impaired renal function occurred in three patients. Three patients with nephrotic syndrome received only prednisone. Two patients obtained complete remission, and one had partial remission. What is particularly worth mentioning is, in two patients who received renal biopsy in our study, the pathological changes were mesangial proliferative glomerulonephritis. CONCLUSIONS Mesangial proliferative glomerulonephritis may not be as uncommon as previously thought in CKD patients after autologous HSCT. Presentation of nephrotic syndrome is common in CKD after HSCT and prednisone alone are effective.
Collapse
Affiliation(s)
- QiaoYuan Wu
- Department of Nephrology, The First Affiliated Hospital, Guangxi Medical University, No. 22, Shuang Yong Lu, Nanning, 530021, Guangxi, China
| | | | | | | | | |
Collapse
|
28
|
Sawinski D. The kidney effects of hematopoietic stem cell transplantation. Adv Chronic Kidney Dis 2014; 21:96-105. [PMID: 24359992 DOI: 10.1053/j.ackd.2013.08.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/20/2013] [Accepted: 08/21/2013] [Indexed: 11/11/2022]
Abstract
Hematopoietic stem cell transplant (HSCT) patients are at risk for acute kidney disease and CKD, which confer excess morbidity and mortality in this patient population. A main cause of acute kidney injury (AKI) in stem cell recipients is prerenal azotemia, but acute tubular necrosis (ATN), obstruction, marrow transfusion toxicity, and hepatic sinusoidal obstruction syndrome also contribute. AKI is an important risk factor for death and CKD among HSCT survivors. CKD is a growing complication of HSCT as more patients are transplanted and survival improves. For most patients, the exact etiology of CKD is never identified, but graft vs host disease and thrombotic microangiopathy are important diagnoses to consider. Stem cell transplant patient survival on dialysis is generally poor, but kidney transplantation is a safe and reasonable option for HSCT recipients who progress to ESRD.
Collapse
|
29
|
Jhaveri KD, Shah HH, Patel C, Kadiyala A, Stokes MB, Radhakrishnan J. Glomerular diseases associated with cancer, chemotherapy, and hematopoietic stem cell transplantation. Adv Chronic Kidney Dis 2014; 21:48-55. [PMID: 24359986 DOI: 10.1053/j.ackd.2013.08.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Revised: 08/16/2013] [Accepted: 08/20/2013] [Indexed: 02/07/2023]
Abstract
Many solid and hematological malignancies have been associated with different glomerular diseases. Several case reports and case series of cancer-associated glomerular diseases have shown that treating the cancer may lead to resolution of the glomerular process. Hence, knowledge and approach to cancer-associated glomerular diseases is important for both the caring nephrologists and the cancer specialists. While membranous nephropathy has been classically associated with solid malignancies, minimal change disease has been commonly described with hematologic malignancies, especially non-Hodgkin's lymphoma. Membranoproliferative glomerulonephritis is increasingly being recognized to be associated with chronic hematologic malignancies such as chronic lymphocytic leukemia. In this article, we review various cancer-associated glomerular diseases and their pathogenesis as well as principles of treatment. In addition, we also review glomerular diseases seen after chemotherapy and hematopoietic stem cell transplantation.
Collapse
|
30
|
Renal arteriolar C4d deposition: a novel characteristic of hematopoietic stem cell transplantation-associated thrombotic microangiopathy. Transplantation 2013; 96:217-23. [PMID: 23698598 DOI: 10.1097/tp.0b013e31829807aa] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND The mechanism of kidney injury in hematopoietic stem cell transplantation (HSCT)-associated thrombotic microangiopathy (TA-TMA) is not completely understood. Renal C4d staining is a marker of classic complement activation and endothelial injury and has been described in preliminary reports of HSCT recipients with TA-TMA. Our objective was to evaluate complement in the pathogenesis of small vessel injury in children receiving HSCT. We hypothesized that kidney tissue from children with TA-TMA would more frequently show C4d deposition compared with HSCT recipients without histologic TA-TMA. METHODS We reviewed kidney specimens (biopsy or autopsy) from children who had undergone HSCT at a single center. Using histologic criteria alone, subjects were divided into TA-TMA (n = 8) and non-TA-TMA (control) groups (n = 12). C4d staining was performed by immunohistochemistry and evaluated on arterioles, peritubular capillaries, glomeruli, and tubular basement membranes. RESULTS Diffuse or focal renal arteriolar C4d staining was more common in subjects with histologic TA-TMA (75%) compared with controls (8%). Rare peritubular capillary C4d staining was present in 50% of TA-TMA samples and was absent in controls. Glomerular C4d staining was seen at a similar frequency in cases and controls, whereas tubular basement membrane staining was less frequently observed and only in subjects with TA-TMA. CONCLUSIONS Arteriolar C4d deposition may be a pathologic marker of TA-TMA, implicating localized complement fixation in HSCT recipients with kidney disease secondary to small vessel injury. Further studies to better characterize the preferential arteriolar C4d staining may identify a renal compartment of injury, possibly explaining the dramatic hypertension seen in TA-TMA.
Collapse
|
31
|
Glomerular diseases seen with cancer and chemotherapy: a narrative review. Kidney Int 2013; 84:34-44. [DOI: 10.1038/ki.2012.484] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2012] [Revised: 12/14/2012] [Accepted: 12/21/2012] [Indexed: 01/01/2023]
|
32
|
Singh N, McNeely J, Parikh S, Bhinder A, Rovin BH, Shidham G. Kidney complications of hematopoietic stem cell transplantation. Am J Kidney Dis 2013; 61:809-21. [PMID: 23291149 DOI: 10.1053/j.ajkd.2012.09.020] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Accepted: 09/08/2012] [Indexed: 12/25/2022]
Abstract
Hematopoietic stem cell transplantation (HSCT) exposes a patient's kidneys to a unique combination of challenges, including high-dose radiation, anemia, chemotherapeutic agents, graft-versus-host disease, opportunistic infections, attenuated and altered immunologic responses, fluid and electrolyte imbalances, and extensive courses of antimicrobial agents. Since the inception of HSCT in the 1950s, there has been increasing interest in defining, determining, and managing the kidney complications that accompany this procedure. In this article, we review the common causes of acute kidney injury and chronic kidney disease that occur with HSCT, including HSCT-associated thrombotic microangiopathy, a distinct cause of chronic kidney disease with a multifactorial cause previously known as bone marrow transplant nephropathy or radiation nephropathy. Additionally, we review other kidney complications, including calcineurin inhibitor nephrotoxicity and chronic graft-versus-host disease-associated glomerulonephritis, that develop post-HSCT. Critically, due to its grave prognosis, it is important to identify HSCT-associated thrombotic microangiopathy early, as well as distinguish it from the other causes of chronic kidney disease.
Collapse
Affiliation(s)
- Neeraj Singh
- Department of Internal Medicine, Division of Nephrology, The Ohio State University College of Medicine and Public Health, Columbus, OH, USA.
| | | | | | | | | | | |
Collapse
|
33
|
Nasr SH, Valeri AM, Sethi S, Fidler ME, Cornell LD, Gertz MA, Lacy M, Dispenzieri A, Rajkumar SV, Kyle RA, Leung N. Clinicopathologic correlations in multiple myeloma: a case series of 190 patients with kidney biopsies. Am J Kidney Dis 2012; 59:786-94. [PMID: 22417785 DOI: 10.1053/j.ajkd.2011.12.028] [Citation(s) in RCA: 148] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Accepted: 12/27/2011] [Indexed: 11/11/2022]
Abstract
BACKGROUND Renal involvement is common in multiple myeloma. In this study, we examined kidney biopsy findings in patients with multiple myeloma and correlated them with their clinical renal and hematologic characteristics. STUDY DESIGN Case series. SETTING & PARTICIPANTS 190 Mayo Clinic patients with multiple myeloma who underwent kidney biopsy between 1997-2011 were identified from our kidney biopsy database. Patients had an established diagnosis of multiple myeloma or multiple myeloma was diagnosed shortly after the results of kidney biopsy, which prompted bone marrow biopsy. PREDICTORS Myeloma cast nephropathy (MCN), AL amyloidosis, and monoclonal immunoglobulin deposition disease (MIDD). OUTCOMES & MEASUREMENTS Renal morphologic changes, clinical renal and hematologic characteristics at kidney biopsy, renal and patient outcomes. RESULTS Paraprotein-associated lesions were seen in 73% of patients; non-paraprotein-associated lesions, in 25%; and no pathology, in 2%. The most common paraprotein-associated lesions were MCN (33%), MIDD (22%), and amyloidosis (21%). The most common non-paraprotein-associated lesions were acute tubular necrosis (9%), hypertensive arteriosclerosis (6%), and diabetic nephropathy (5%). Patients with MIDD were younger than those with MCN or amyloidosis. Urine paraprotein size and bone marrow plasma cell percentage were higher in MCN than amyloidosis or MIDD. Nephrotic syndrome was more common in amyloidosis than MIDD. Percentage of albuminuria was highest in amyloidosis and lowest in MCN. Median kidney survival from kidney biopsy was 20, 30, and 51 months for MCN, amyloidosis, and MIDD, respectively (P = 0.2). Median patient survival from multiple myeloma diagnosis was 44, 58, and 62 months for MCN, amyloidosis, and MIDD, respectively (P = 0.4). LIMITATIONS Retrospective nature. CONCLUSIONS The spectrum of renal lesions in multiple myeloma is more heterogeneous than previously reported. Clinical features favoring amyloidosis over MIDD include older age, absence of kidney failure, presence of nephrotic syndrome, absence of hematuria, and >50% albuminuria.
Collapse
Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN 55905, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
34
|
Graft Versus Host Disease With Glomerular Infiltration of CD8+/Perforin+ Cytotoxic T Lymphocytes Causes Nephrotic Syndrome. Transplantation 2011; 92:e24-5. [DOI: 10.1097/tp.0b013e31822527b3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
35
|
Small vessels, big trouble in the kidneys and beyond: hematopoietic stem cell transplantation–associated thrombotic microangiopathy. Blood 2011; 118:1452-62. [DOI: 10.1182/blood-2011-02-321315] [Citation(s) in RCA: 235] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Abstract
Transplantation-associated thrombotic microangiopathy (TA-TMA) is a challenging diagnosis after hematopoietic stem cell transplantation. Although endothelial injury represents the final common pathway of disease, the exact pathophysiology of TA-TMA remains unclear. Potential causes include infections, chemotherapy, radiation, and calcineurin inhibitors. Recent literature addresses the roles of cytokines, graft-versus-host disease, the coagulation cascade, and complement in the pathogenesis of TA-TMA. Current diagnostic criteria are unsatisfactory, because patients who have received a transplant can have multiple other reasons for the laboratory abnormalities currently used to diagnose TA-TMA. Moreover, our lack of understanding of the exact mechanism of disease limits the development and evaluation of potential treatments. Short- and long-term renal complications contribute to TA-TMA's overall poor prognosis. In light of these challenges, future research must validate novel markers of disease to aid in early diagnosis, guide current and future treatments, prevent long-term morbidity, and improve outcomes. We focus on TA-TMA as a distinct complication of hematopoietic stem cell transplantation, emphasizing the central role of the kidney in this disease.
Collapse
|
36
|
Mii A, Shimizu A, Kaneko T, Fujita E, Fukui M, Fujino T, Utsumi K, Yamaguchi H, Tajika K, Tsuchiya SI, Iino Y, Katayama Y, Fukuda Y. Renal thrombotic microangiopathy associated with chronic graft-versus-host disease after allogeneic hematopoietic stem cell transplantation. Pathol Int 2011; 61:518-27. [PMID: 21884301 DOI: 10.1111/j.1440-1827.2011.02704.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Thrombotic microangiopathy (TMA) is a major complication after hematopoietic stem cell transplantation (HSCT). In this study, we examined the clinical and pathologic features of 2 patients and 5 autopsy cases with HSCT-associated renal TMA to clarify the association between graft-versus-host disease (GVHD) and renal TMA. The median interval between HSCT and renal biopsy or autopsy was 7 months (range 3-42 months). Clinically, acute and chronic GVHD occurred in 7 and 4 patients, respectively. Clinical evidence for TMA was detected in 2 patients, while chronic kidney disease developed in all patients. The main histopathological findings were diffuse endothelial injury in glomeruli, peritubular capillaries (PTCs), and small arteries. In addition, all cases showed glomerulitis, renal tubulitis, and peritubular capillaritis with infiltration of CD3+ T cells and TIA-1+ cytotoxic cells, suggesting that GVHD occurred during the development of TMA. Diffuse and patchy C4d deposition was noted in glomerular capillaries and PTCs, respectively, in 2 biopsy and 2 autopsy cases, suggesting the involvement of antibody-mediated renal endothelial injury in more than 50% of renal TMA cases. In conclusion, the kidney is a potential target of chronic GVHD that may induce the development of HSCT-associated TMA. Importantly, some cases are associated with chronic humoral GVHD.
Collapse
Affiliation(s)
- Akiko Mii
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
37
|
Farris AB, Taheri D, Kawai T, Fazlollahi L, Wong W, Tolkoff-Rubin N, Spitzer TR, Iafrate AJ, Preffer FI, LoCascio SA, Sprangers B, Saidman S, Smith RN, Cosimi AB, Sykes M, Sachs DH, Colvin RB. Acute renal endothelial injury during marrow recovery in a cohort of combined kidney and bone marrow allografts. Am J Transplant 2011; 11:1464-77. [PMID: 21668634 PMCID: PMC3128680 DOI: 10.1111/j.1600-6143.2011.03572.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
An idiopathic capillary leak syndrome ('engraftment syndrome') often occurs in recipients of hematopoietic cells, manifested clinically by transient azotemia and sometimes fever and fluid retention. Here, we report the renal pathology in 10 recipients of combined bone marrow and kidney allografts. Nine developed graft dysfunction on day 10-16 and renal biopsies showed marked acute tubular injury, with interstitial edema, hemorrhage and capillary congestion, with little or no interstitial infiltrate (≤10%) and marked glomerular and peritubular capillary (PTC) endothelial injury and loss by electron microscopy. Two had transient arterial endothelial inflammation; and 2 had C4d deposition. The cells in capillaries were primarily CD68(+) MPO(+) mononuclear cells and CD3(+) CD8(+) T cells, the latter with a high proliferative index (Ki67(+) ). B cells (CD20(+) ) and CD4(+) T cells were not detectable, and NK cells were rare. XY FISH showed that CD45(+) cells in PTCs were of recipient origin. Optimal treatment remains to be defined; two recovered without additional therapy, six were treated with anti-rejection regimens. Except for one patient, who later developed thrombotic microangiopathy and one with acute humoral rejection, all fully recovered within 2-4 weeks. Graft endothelium is the primary target of this process, attributable to as yet obscure mechanisms, arising during leukocyte recovery.
Collapse
Affiliation(s)
- AB Farris
- Pathology Service, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States, Pathology Department and Laboratory Medicine, Emory University, Atlanta, Georgia, United States, Harvard Medical School, Boston
| | - D Taheri
- Pathology Service, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States, Harvard Medical School, Boston
| | - T Kawai
- Transplantation Unit, MGH, Boston, Harvard Medical School, Boston
| | - L Fazlollahi
- Pathology Service, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States, Harvard Medical School, Boston
| | - W. Wong
- Medical Service, MGH, Boston, Harvard Medical School, Boston
| | - N Tolkoff-Rubin
- Medical Service, MGH, Boston, Harvard Medical School, Boston
| | - TR Spitzer
- Medical Service, MGH, Boston, Harvard Medical School, Boston
| | - AJ Iafrate
- Pathology Service, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States, Harvard Medical School, Boston
| | - FI Preffer
- Pathology Service, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States, Harvard Medical School, Boston
| | - SA LoCascio
- Transplantation Biology Research Center, MGH, Boston, Department of Medicine, Surgery, and Microbiology & Immunology, Columbia Center for Translational Immunology, Columbia University, New York City, New York, United States
| | - B Sprangers
- Department of Medicine, Surgery, and Microbiology & Immunology, Columbia Center for Translational Immunology, Columbia University, New York City, New York, United States
| | - S Saidman
- Pathology Service, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States, Harvard Medical School, Boston
| | - RN Smith
- Pathology Service, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States, Harvard Medical School, Boston
| | - AB Cosimi
- Transplantation Unit, MGH, Boston, Harvard Medical School, Boston
| | - M Sykes
- Transplantation Biology Research Center, MGH, Boston, Department of Medicine, Surgery, and Microbiology & Immunology, Columbia Center for Translational Immunology, Columbia University, New York City, New York, United States, Harvard Medical School, Boston
| | - DH Sachs
- Transplantation Biology Research Center, MGH, Boston, Harvard Medical School, Boston
| | - RB Colvin
- Pathology Service, Massachusetts General Hospital (MGH), Boston, Massachusetts, United States, Harvard Medical School, Boston
| |
Collapse
|
38
|
Iguchi E, Minakata T, Tsudo M. A case of membranous nephropathy associated with chronic GVHD successfully treated with rituximab. Bone Marrow Transplant 2011; 47:132-4. [DOI: 10.1038/bmt.2011.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
|
39
|
Mii A, Shimizu A, Masuda Y, Fujino T, Kaneko T, Utsumi K, Arai T, Ishikawa A, Wakamatsu K, Tajika K, Iino Y, Katayama Y, Fukuda Y. Renal thrombotic microangiopathy associated with chronic humoral graft versus host disease after hematopoietic stem cell transplantation. Pathol Int 2010; 61:34-41. [PMID: 21166941 DOI: 10.1111/j.1440-1827.2010.02608.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Thrombotic microangiopathy (TMA) is a known complication of hematopoietic stem cell transplantation (HSCT). The pathogenesis of TMA is controversial but considered to involve various factors such as total body irradiation, use of calcineurin inhibitors for prophylaxis against graft versus host disease (GVHD), viral infection, and GVHD. Herein we describe a case with renal TMA after HSCT, which was probably associated with antibody-mediated endothelial cell injury from chronic GVHD (termed here 'chronic humoral GVHD'). A 49-year-old man presented two years after HSCT with renal dysfunction and proteinuria but without the clinical features of TMA. Histopathological examination of renal biopsy showed chronic glomerular endothelial cell injury with double contour of the glomerular basement membrane, microthrombi and the deposition of complement split product C4d along the glomerular capillaries. Renal tubulitis and peritubular capillaritis were also noted with a multilayered basement membrane and patchy C4d deposition on peritubular capillaries. These findings resemble those of chronic antibody-mediated rejection after kidney transplantation. Furthermore, C4d deposition suggests complement activation. Although circulating anti-blood type and anti-human leukocyte antigen antibodies were not detected, the renal TMA in this case was probably associated with chronic humoral GVHD.
Collapse
Affiliation(s)
- Akiko Mii
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Hu SL. The role of graft-versus-host disease in haematopoietic cell transplantation-associated glomerular disease. Nephrol Dial Transplant 2010; 26:2025-31. [PMID: 20961888 DOI: 10.1093/ndt/gfq645] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Glomerular disease among haematopoietic cell transplantation recipients has been attributed to chronic graft-versus-host disease. Clinical outcomes of this population may be influenced by the haematopoietic cell transplantation conditioning regimen, donor factors and chronic graft-versus-host disease. METHODS In this review, 95 cases of haematopoietic cell transplantation-associated glomerular disease were identified from literature review for analysis. Patient characteristics, the association of chronic graft-versus-host disease with glomerular diseases, and the impact of host and haematopoietic cell transplantation regimen on outcomes were evaluated. RESULTS The median onset of glomerular disease from haematopoietic cell transplantation and from cessation of immunosuppressive agents was 15.5 and 1 month, respectively. Although chronic graft-versus-host disease was common among haematopoietic cell transplant recipients with glomerulonephritis (72%), this was no different from that observed in the overall haematopoietic cell transplantation population. Membranous nephropathy and minimal change disease are the most prevalent glomerular diseases among haematopoietic cell transplantation recipients. Chronic graft-versus-host disease, donor factors and haematopoietic cell transplant regimen did not significantly impact outcomes in this study population. CONCLUSIONS Pathogenic mechanisms in addition to (or other than) chronic graft-versus-host disease are likely contribute to haematopoietic cell transplantation-associated glomerular disease. Further investigation will be required to delineate clearly the pathogenesis.
Collapse
Affiliation(s)
- Susie L Hu
- Division of Kidney Disease and Hypertension, Department of Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
| |
Collapse
|
41
|
Stylianou K, Stratakis S, Mavroeidi V, Petrakis I, Xydakis D, Vardaki E, Stratigis S, Perakis K, Katsarou T, Kanellou P, Xylouri I, Petraki C, Alexandrakis M, Daphnis E. Membranous nephropathy and lupus-like syndrome after hematopoietic cell transplantation: a case report. J Med Case Rep 2010; 4:303. [PMID: 20831803 PMCID: PMC2944192 DOI: 10.1186/1752-1947-4-303] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Accepted: 09/10/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION The kidney is increasingly recognised as a target organ of chronic graft-versus-host disease after hematopoietic cell transplantation in the context of the development of the nephrotic syndrome. Chronic graft-versus-host disease is associated with autoimmune phenomena similar, but not identical, to those observed in various rheumatologic disorders, implicating autoimmunity as an important component of the disease. CASE PRESENTATION We report the case of a 57-year-old Caucasian man who developed the nephrotic syndrome due to membranous nephropathy in association with recurrent chronic graft-versus-host disease, along with a lupus-like syndrome manifested with pancytopenia, hair loss, positive anti-DNA antibodies and sub-epithelial and mesangial immune deposits. To the best of our knowledge, this is the first case reported in the literature. The nephrotic syndrome subsided soon after he was treated with a short course of cyclosporin with steroids. Unfortunately he died seven months later due to a relapse of leukemia. CONCLUSIONS Our case report confirms the notion that chronic graft-versus-host disease is characterized by the appearance of autoimmune phenomena similar, but not identical, to those seen in autoimmune diseases. The decision for more immunosuppression has to be weighed against the need for preservation of the graft versus leukemia phenomenon.
Collapse
Affiliation(s)
- Kostas Stylianou
- Nephrology Department, Heraklion University Hospital, PO Box 1352, 71110 Heraklion, Crete, Greece.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
42
|
A case of chronic kidney disease with thrombotic microangiopathy in a hematopoietic stem cell transplant recipient. Clin Exp Nephrol 2010; 14:474-8. [DOI: 10.1007/s10157-010-0292-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2009] [Accepted: 04/27/2010] [Indexed: 10/19/2022]
|
43
|
Bomback AS, Derebail VK, McGregor JG, Kshirsagar AV, Falk RJ, Nachman PH. Rituximab therapy for membranous nephropathy: a systematic review. Clin J Am Soc Nephrol 2009; 4:734-44. [PMID: 19279120 DOI: 10.2215/cjn.05231008] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND OBJECTIVES The treatment of membranous nephropathy (MN) remains controversial. Rituximab, which selectively targets B cells, has emerged as a possible alternative treatment option with limited toxicity. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The available data on rituximab therapy for MN were reviewed using the MEDLINE database (inception to August 1, 2008), Google Scholar, and selected reference lists. English-language studies investigating the use of rituximab in idiopathic and secondary MN, in native and transplanted kidneys, were included. Study design, subject number, clinical characteristics (diagnosis, previous and concomitant treatment courses, baseline proteinuria, baseline renal function), rituximab protocol, follow-up period, achievement of complete or partial remission, changes in proteinuria and renal function, and adverse effects of therapy were extracted. RESULTS Twenty-one articles were included for review; all were either case reports or case series without controls. More than half of the published cases (50 of 85) came from one center where rituximab was used as primary immunosuppression for idiopathic MN. The available data suggest that rituximab, dosed either as 375 mg/m(2) once weekly for 4 wk or as 1 g on days 1 and 15, achieves a 15 to 20% rate of complete remission and a 35 to 40% rate of partial remission. The drug was well tolerated with minimal adverse events. CONCLUSIONS Although rituximab may prove to be a better treatment option for MN than alkylating agents or calcineurin inhibitors, the current literature only supports using the drug in research protocols. Whether, when, how, and why to use rituximab in MN remains to be determined.
Collapse
Affiliation(s)
- Andrew S Bomback
- Department of Medicine, Division of Nephrology and Hypertension, University of North Carolina Kidney Center, Chapel Hill, North Carolina 27599-7155, USA.
| | | | | | | | | | | |
Collapse
|