1
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Yang D, Yuan L, Ma X, Qi Y, Cheng S, Zhang Y. Histological study of Bactrian camel cryptorchidism and expression of immunoglobulin λ light chain in the testicular and epididymis of cryptorchid Bactrian camel. Reprod Domest Anim 2024; 59:e14512. [PMID: 38069628 DOI: 10.1111/rda.14512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/20/2023] [Accepted: 11/21/2023] [Indexed: 01/26/2024]
Abstract
Lambda light chains (λ-LCs) are frequently responsible for triggering the activation of inflammatory factors in autoimmune disorders, and an increase in their levels will cause various pathological changes in serum. The aim of this study was to determine the histological differences between the epididymis and testis of normal and cryptorchid Bactrian camels and the differences in λ-LC expression in the epididymis and testis of normal and cryptorchid Bactrian camels. Haematoxylin and eosin (H&E) staining was used to examine the pathological changes in cryptorchidism. The gene and protein levels of λ-LC were determined using RT-qPCR and western blot. The distribution of λ-LCs was assessed by immunohistochemistry and immunofluorescence. Compared with that in normal Bactrian camels, the diameter of the epididymal lumen and the thickness of the epithelium were decreased in the epididymis of cryptorchidic animals. Additionally, no sperm was detected in the cavity of the cryptorchidic epididymis. Meanwhile, the expression of λ-LC was significantly increased in the cryptorchidic epididymis at both the mRNA and protein levels (p < .05). The highest protein expression of λ-LC was found in epididymal epithelial halo cells and testicular Sertoli cells. These findings suggested that the structural changes observed in the epididymal epithelium of cryptorchidic camels affect its secretory and absorptive functions. Additionally, the high level of λ-LC expression recorded in halo cells suggested that these cells play an important role in epithelial immunity in cryptorchidic Bactrian camels. Furthermore, the high λ-LC expression levels detected in normal testicular Sertoli cells indicated that λ-LCs may be involved in spermatogenesis. The results of this study provide clues for an in-depth study of immunological sterility in cryptorchidic Bactrian camels.
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Affiliation(s)
- Dapeng Yang
- College of Veterinary Medicine, Gansu Agricultural University, Lanzhou, China
| | - Ligang Yuan
- College of Veterinary Medicine, Gansu Agricultural University, Lanzhou, China
- Gansu Key Laboratory of Animal Generational Physiology and Reproductive Regulation, Lanzhou, China
| | - Xiaojie Ma
- College of Veterinary Medicine, Gansu Agricultural University, Lanzhou, China
| | - Yumei Qi
- College of Veterinary Medicine, Gansu Agricultural University, Lanzhou, China
| | - Shaoyu Cheng
- College of Veterinary Medicine, Gansu Agricultural University, Lanzhou, China
| | - Yong Zhang
- College of Veterinary Medicine, Gansu Agricultural University, Lanzhou, China
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2
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Turgut F, Awad AS, Abdel-Rahman EM. Acute Kidney Injury: Medical Causes and Pathogenesis. J Clin Med 2023; 12:jcm12010375. [PMID: 36615175 PMCID: PMC9821234 DOI: 10.3390/jcm12010375] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/05/2023] Open
Abstract
Acute kidney injury (AKI) is a common clinical syndrome characterized by a sudden decline in or loss of kidney function. AKI is not only associated with substantial morbidity and mortality but also with increased risk of chronic kidney disease (CKD). AKI is classically defined and staged based on serum creatinine concentration and urine output rates. The etiology of AKI is conceptually classified into three general categories: prerenal, intrarenal, and postrenal. Although this classification may be useful for establishing a differential diagnosis, AKI has mostly multifactorial, and pathophysiologic features that can be divided into different categories. Acute tubular necrosis, caused by either ischemia or nephrotoxicity, is common in the setting of AKI. The timely and accurate identification of AKI and a better understanding of the pathophysiological mechanisms that cause kidney dysfunction are essential. In this review, we consider various medical causes of AKI and summarize the most recent updates in the pathogenesis of AKI.
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Affiliation(s)
- Faruk Turgut
- Faculty of Medicine, Mustafa Kemal University, Antakya 31100, Hatay, Turkey
| | - Alaa S. Awad
- Division of Nephrology, University of Florida, Jacksonville, FL 32209, USA
| | - Emaad M. Abdel-Rahman
- Division of Nephrology, University of Virginia, Charlottesville, VA 22908, USA
- Correspondence:
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3
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Sirac C, Batuman V, Sanders PW. The Proximal Tubule Toxicity of Immunoglobulin Light Chains. Kidney Int Rep 2021; 6:1225-1231. [PMID: 34013100 PMCID: PMC8116766 DOI: 10.1016/j.ekir.2021.02.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 01/25/2023] Open
Abstract
Plasma and B cells dyscrasias that overproduce monoclonal immunoglobulin free light chains (FLCs) affect the kidney frequently in various ways. The hematologic dyscrasia responsible for the production of FLCs may or may not meet the criteria for cancer, such as multiple myeloma (MM) or lymphoma, or may remain subclinical. If there is overt malignancy, the accompanying kidney disorder is called myeloma- or lymphoma-associated. If the dyscrasia is subclinical, the associated kidney disorders are grouped as monoclonal gammopathy of renal significance. Glomeruli and tubules may both be involved. The proximal tubule disorders comprise a spectrum of interesting syndromes, which range in severity. This review focuses on the recent insights gained into the patterns and the mechanisms of proximal tubule toxicity of FLCs, including subtle transport disorders, such as proximal tubule acidosis, partial or complete Fanconi syndrome, or severe acute or chronic renal failure. Histologically, there may be crystal deposition in the proximal tubule cells, acute tubule injury, interstitial inflammation, fibrosis, and tubule atrophy. Specific structural alterations in the V domain of FLCs caused by somatic hypermutations are responsible for crystal formation as well as partial or complete Fanconi syndrome. Besides crystal formation, tubulointerstitial inflammation and proximal tubulopathy can be mediated by direct activation of inflammatory pathways through cytokines and Toll-like receptors due to cell stress responses induced by excessive FLC endocytosis into the proximal tubule cells. Therapy directed against the clonal source of the toxic light chain can prevent progression to more severe lesions and may help preserve kidney function.
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Affiliation(s)
- Christophe Sirac
- Unité Mixte de Recherche (UMR) 7276/Institut National de la Santé et de la Recherche Médicale (INSERM) U1262, Centre National de la Recherche Scientifique (CNRS), Université de Limoges, Limoges, France
- Centre National de l’Amylose AL et Autres Maladies par Dépôts d’Immunoglobulines Monoclonales, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Vecihi Batuman
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Veterans Affairs, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
| | - Paul W. Sanders
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Veterans Affairs, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
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4
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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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5
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Nassar S, Taher A, Spear R, Wang F, Madewell JE, Mujtaba B. Multiple Myeloma: Role of Imaging in Diagnosis, Staging, and Treatment Response Assessment. Semin Ultrasound CT MR 2020; 42:184-193. [PMID: 33814104 DOI: 10.1053/j.sult.2020.08.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Multiple myeloma is a common hematologic malignancy of plasma cells. Differentiating multiple myeloma from the precursor stages of monoclonal gammopathy of undetermined significance and smoldering multiple myeloma is very important because the treatment approach is different for each. The diagnosis is mainly clinical, while the role of imaging is confined to the staging process, assessing response to therapy, and monitoring for disease progression. In this article, we examine the role of different imaging modalities in patients with multiple myeloma.
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Affiliation(s)
- Sameh Nassar
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ahmed Taher
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rosario Spear
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | | | - John E Madewell
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Bilal Mujtaba
- Department of Musculoskeletal Imaging, The University of Texas MD Anderson Cancer Center, Houston, TX.
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6
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Upadhyay R, Ying WZ, Nasrin Z, Safah H, Jaimes EA, Feng W, Sanders PW, Batuman V. Free light chains injure proximal tubule cells through the STAT1/HMGB1/TLR axis. JCI Insight 2020; 5:137191. [PMID: 32544092 PMCID: PMC7453901 DOI: 10.1172/jci.insight.137191] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022] Open
Abstract
Free light chains (FLCs) induce inflammatory pathways in proximal tubule cells (PTCs). The role of TLRs in these responses is unknown. Here we present findings on the role of TLRs in FLC-induced PTC injury. We exposed human kidney PTC cultures to κ and λ FLCs and used cell supernatants and pellets for ELISA and gene expression studies. We also analyzed tissues from Stat1-/- and littermate control mice treated with daily i.p. injections of a κ FLC for 10 days. FLCs increased the expression of TLR2, TLR4, and TLR6 via HMGB1, a damage-associated molecular pattern. Countering TLR2, TLR4, and TLR6 through GIT-27 or specific TLR siRNAs reduced downstream cytokine responses. Blocking HMGB1 through siRNA or pharmacologic inhibition, or via STAT1 inhibition, reduced FLC-induced TLR2, TLR4, and TLR6 expression. Blocking endocytosis of FLCs through silencing of megalin/cubilin, with bafilomycin A1 or hypertonic sucrose, attenuated FLC-induced cytokine responses in PTCs. IHC showed decreased TLR4 and TLR6 expression in kidney sections from Stat1-/- mice compared with their littermate controls. PTCs exposed to FLCs released HMGB1, which induced expression of TLR2, TLR4, and TLR6 and downstream inflammation. Blocking FLCs' endocytosis, Stat1 knockdown, HMGB1 inhibition, and TLR knockdown each rescued PTCs from FLC-induced injury.
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Affiliation(s)
- Rohit Upadhyay
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Wei-Zhong Ying
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Zannatul Nasrin
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Hana Safah
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Edgar A. Jaimes
- Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Wenguang Feng
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Paul W. Sanders
- University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - Vecihi Batuman
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Veterans Affairs Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
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7
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Feinberg D, Paul B, Kang Y. The promise of chimeric antigen receptor (CAR) T cell therapy in multiple myeloma. Cell Immunol 2019; 345:103964. [PMID: 31492448 PMCID: PMC6832886 DOI: 10.1016/j.cellimm.2019.103964] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/08/2019] [Accepted: 08/10/2019] [Indexed: 12/19/2022]
Abstract
A cure for multiple myeloma (MM), a malignancy of plasma cells, remains elusive. Nearly all myeloma patients will eventually relapse and develop resistance to currently available treatments. There is an unmet medical need to develop novel and effective therapies that can induce sustained responses. Early phase clinical trials using chimeric antigen receptor (CAR) T cell therapy have shown great promise in the treatment of relapsed and/or refractory MM. In this review article, we provide an overview of the CAR constructs, the gene transfer vector systems, and approaches for T cell activation and expansion. We then summarize the outcomes of several early phase clinical trials of CAR T cell therapy in MM and the novel CAR T targets that are under development. Finally, we explore the potential mechanisms that result in disease relapse after CAR T therapy and propose future directions in CAR T therapy in MM.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Hematopoietic Stem Cell Transplantation/methods
- Humans
- Immunotherapy, Adoptive/methods
- Immunotherapy, Adoptive/trends
- Multiple Myeloma/immunology
- Multiple Myeloma/metabolism
- Multiple Myeloma/therapy
- Neoplasm Recurrence, Local
- Outcome Assessment, Health Care
- Receptors, Antigen, T-Cell/immunology
- Receptors, Antigen, T-Cell/metabolism
- Receptors, Chimeric Antigen/immunology
- Receptors, Chimeric Antigen/metabolism
- T-Lymphocytes/immunology
- T-Lymphocytes/metabolism
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Affiliation(s)
- Daniel Feinberg
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA
| | - Barry Paul
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA
| | - Yubin Kang
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA.
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8
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Rizzieri D, Paul B, Kang Y. Metabolic alterations and the potential for targeting metabolic pathways in the treatment of multiple myeloma. ACTA ACUST UNITED AC 2019; 5. [PMID: 31020046 PMCID: PMC6476731 DOI: 10.20517/2394-4722.2019.05] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Metabolism is defined as the collection of complex biochemical processes that living cells use to generate energy and maintain their growth and survival. Metabolism encompasses the synthesis and breakdown of glucose, fatty acids, and amino acids; the generation of energy (ATP); and oxidative phosphorylation. In cancer cells, metabolism can be commandeered to promote tumor growth and cellular proliferation. These alterations in metabolism have emerged as an additional hallmark of various cancers. In this review we focus on metabolic alterations in multiple myeloma (MM) - a malignancy of plasma cells - including derangements in glycolysis, gluconeogenesis, the tricarboxylic acid cycle, oxidative phosphorylation, and fatty acid/amino acid synthesis and degradation. Particular focus is given to metabolic alterations that contribute to myeloma cell growth, proliferation and drug resistance. Finally, novel approaches that target metabolic pathways for the treatment of MM are discussed.
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Affiliation(s)
- Dustin Rizzieri
- Division of Hematological Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA
| | - Barry Paul
- Division of Hematological Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA
| | - Yubin Kang
- Division of Hematological Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA
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Paul B, Kang S, Zheng Z, Kang Y. The challenges of checkpoint inhibition in the treatment of multiple myeloma. Cell Immunol 2018; 334:87-98. [PMID: 30342750 DOI: 10.1016/j.cellimm.2018.10.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 10/12/2018] [Indexed: 12/22/2022]
Abstract
Despite significant improvements in the overall survival of patients with multiple myeloma (MM) over the past 15 years, the disease remains incurable. Treatment options are limited for patients who have relapsed or are refractory to immunomodulatory drugs (IMiDs), proteasome inhibitors, and monoclonal antibodies. In these patients, immunotherapies such as checkpoint inhibitors, oncolytic vaccines, and chimeric antigen receptor (CAR) T cells provide a potentially effective alternative treatment. While checkpoint inhibitors are effective in prolonging overall survival in some patients with advanced solid cancers and Hodgkin lymphoma, they have not demonstrated significant activity as a single agent in MM. In fact the combination of checkpoint inhibitors with IMiDs was recently found to increase the risk of death in myeloma patients. These challenges highlight the need for a better understanding of immune dysregulation in myeloma patients, and the mechanisms of action of- and resistance to- checkpoint inhibitors. In this review, we summarize immune dysfunction in patients with MM, and review the preclinical and clinical data regarding checkpoint inhibitors in myeloma. We conclude by proposing strategies to improve the efficacy and safety of checkpoint inhibitors in this population.
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Affiliation(s)
- Barry Paul
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA
| | - Shuqi Kang
- University of Illinois College of Medicine at Peoria, Peoria, IL 61605, USA
| | - Zhihong Zheng
- Department of Hematology, Fujian Provincial Key Laboratory of Hematology, Fujian Medical University Union Hospital, Fuzhou, Fujian 350001, China
| | - Yubin Kang
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
Multiple myeloma is a malignancy of terminally differentiated plasma cells, and patients typically present with bone marrow infiltration of clonal plasma cells and monoclonal protein in the serum and/or urine. The diagnosis of multiple myeloma is made when clear end-organ damage attributable to the plasma cell proliferative disorder or when findings that suggest a high likelihood of their development are present. Distinguishing symptomatic multiple myeloma that requires treatment from the precursor stages of monoclonal gammopathy of undetermined significance and smouldering multiple myeloma is important, as observation is the standard for those conditions. Much progress has been made over the past decade in the understanding of disease biology and individualized treatment approaches. Several new classes of drugs, such as proteasome inhibitors and immunomodulatory drugs, have joined the traditional armamentarium (corticosteroids, alkylating agents and anthracyclines) and, along with high-dose therapy and autologous haemopoietic stem cell transplantation, have led to deeper and durable clinical responses. Indeed, an increasing proportion of patients are achieving lasting remissions, raising the possibility of cure for this disease. Success will probably depend on using combinations of effective agents and treating patients in the early stages of disease, such as patients with smouldering multiple myeloma.
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11
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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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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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13
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Yadav P, Cook M, Cockwell P. Current Trends of Renal Impairment in Multiple Myeloma. KIDNEY DISEASES 2016; 1:241-57. [PMID: 27536684 DOI: 10.1159/000442511] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 11/18/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Renal impairment (RI) is a common complication of multiple myeloma (MM). Around 50% of patients with MM have RI at presentation, and up to 5% require dialysis treatment. Severe acute kidney injury (AKI) as a cause of RI is a particular challenge as historically the survival of patients who sustain this complication and require dialysis is very poor. However, in this current period, survival is improving and the focus is on optimum use of novel chemotherapies and the evaluation of extra-corporeal therapies for removal of serum immunoglobulin light chains. SUMMARY RI in patients with MM is commonly associated with excess monoclonal free light chain (FLC) production; myeloma cast nephropathy is the predominant renal pathology in patients presenting with severe RI secondary to AKI. The majority of patients have mild to moderate RI and recover renal function. However, patients with more severe RI, in particular those with a requirement for dialysis, are less likely to recover renal function. Rapid diagnosis and prompt institution of anti-myeloma therapy is an important determinant of renal function recovery, through targeting early and sustained reduction of involved monoclonal FLC. Novel agents are associated with excellent disease response, and bortezomib is now widely used as a first-line agent in the management of MM in patients with severe RI. Extended haemodialysis using high cut-off dialysers is more effective for extracorporeal removal of FLC than plasma exchange, and clinical trials are in process. High-dose chemotherapy with autologous stem cell transplantation does have a role in patients with severe RI but requires careful patient selection. KEY MESSAGES RI is very common in patients with MM, and renal function recovery is associated with improved clinical outcomes. We summarise the epidemiology of MM in the UK, present the impact of RI and renal function recovery on patient outcome, and describe the current management of MM in western countries. FACTS FROM EAST AND WEST (1) A serum creatinine level >2 mg/dl has been reported in 16, 21, 24, and 33% of patients with MM in cohort studies from Japan, Europe, China, and Korea, respectively. A creatinine clearance rate <30 ml/min was observed in 30 and 15% of patients in Chinese and Western MM cohorts, respectively. The commonest cause of severe RI in patients with MM is myeloma cast nephropathy. (2) The efficacy of novel treatments (bortezomib, carfilzomib, thalidomide, and lenalidomide) has predominantly been assessed in Western patients. Bortezomib and dexamethasone are the current standard of care for MM and severe RI in the West. Severe RI is not a contraindication to autologous stem cell transplantation (ASCT). Most of the data are from the West; there are case reports from China describing good outcomes with ASCT. The removal of FLC by high-cut-off hemodialysis is under evaluation in randomized controlled trials (RCTs) in the West. Studies in this area are not yet conducted in China. In China, new treatments, such as bortezomib, are more widely used than before, and favorable results are being reported; however, RCT studies are still needed in this area to confirm the efficacy and safety of this and other novel treatments.
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Affiliation(s)
- Punit Yadav
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham, UK; School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Birmingham Institute of Translational Medicine, Birmingham, UK
| | - Mark Cook
- Birmingham Institute of Translational Medicine, Birmingham, UK; Department of Haematology, Queen Elizabeth Hospital, Birmingham, UK
| | - Paul Cockwell
- Department of Renal Medicine, Queen Elizabeth Hospital, Birmingham, UK; School of Immunity and Infection, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK; Birmingham Institute of Translational Medicine, Birmingham, UK
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Zhou DB, Yu L, Du X, Jin J, Cai Z, Chen F, Ke X, Li X, Wu D, Meng F, Ai H, Zhang J, DeMarco D, Chen N, Mei J, Wang J, Hou J. Lenalidomide plus low-dose dexamethasone in Chinese patients with relapsed or refractory multiple myeloma and renal impairment. Int J Hematol 2015; 101:569-77. [DOI: 10.1007/s12185-015-1771-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 02/25/2015] [Accepted: 02/25/2015] [Indexed: 11/29/2022]
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Case report on renal failure reversal in lambda chain multiple myeloma with bortezomib and dexamethasone. Case Rep Nephrol 2014; 2014:940171. [PMID: 25045553 PMCID: PMC4089941 DOI: 10.1155/2014/940171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2014] [Accepted: 06/05/2014] [Indexed: 12/01/2022] Open
Abstract
Renal failure (RF) reversal in multiple myeloma (MM) is associated with an improved prognosis. Light chain myeloma, serum creatinine (SCr) > 4 mg/dL, extensive proteinuria, early infections, and certain renal biopsy findings are associated with lower rates of RF reversal. Our patient is a 67-year-old female with multiple poor prognostic factors for RF reversal who demonstrated a rapid renal response with bortezomib and dexamethasone (BD) regimen. She presented initially with altered mental status. On exam, she appeared lethargic and dehydrated and had generalized tenderness. She had been taking ibuprofen as needed for pain for a few weeks. Labs showed a white cell count—18,900/μL with no bandemia, hemoglobin 10.8 gm/dL, potassium—6.7 mEq/L, bicarbonate—15 mEq/L, blood urea nitrogen—62 mg/dL, SCr—5.6 mg/dL (baseline: 1.10), and corrected calcium—11.8 mg/dL. A rapid flu test was positive. Imaging studies were unremarkable. Her EKG showed sinus tachycardia and her urinalysis was unremarkable. The unexplained RF in an elderly individual in conjunction with hypercalcemia and anemia prompted a MM work-up; eventually, lambda variant MM was diagnosed. An immediate (4 days) renal response defined as 50% reduction in SCr was noticed after initiation of the BD regimen.
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A case of Fanconi syndrome accompanied by crystal depositions in tubular cells in a patient with multiple myeloma. Kidney Res Clin Pract 2014; 33:112-5. [PMID: 26877961 PMCID: PMC4714179 DOI: 10.1016/j.krcp.2014.04.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Revised: 03/25/2014] [Accepted: 04/18/2014] [Indexed: 11/27/2022] Open
Abstract
Fanconi syndrome (FS) is a rare condition that is characterized by defects in the proximal tubular function. A 48-year-old woman was admitted for evaluation of proteinuria. The patient showed normal anion gap acidosis, normoglycemic glycosuria, hypophosphatemia, and hypouricemia. Thus, her condition was compatible with FS. The M peak was found behind the beta globulin region in urine protein electrophoresis. Upon bone marrow examination, we found that 24% of cells were CD138+ plasma cells with kappa restriction. From a kidney biopsy, we found crystalline inclusions within proximal tubular epithelial cells. Thereafter, she was diagnosed with FS accompanied by multiple myeloma. The patient received chemotherapy and autologous stem cell transplantation, and obtained very good partial hematologic response. However, proximal tubular dysfunction was persistent until 1 year after autologous stem cell transplantation. In short, we report a case of FS accompanied by multiple myeloma, demonstrating crystalline inclusion in proximal tubular cells on kidney biopsy.
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Sengul S, Erturk S, Khan AM, Batuman V. Receptor-associated protein blocks internalization and cytotoxicity of myeloma light chain in cultured human proximal tubular cells. PLoS One 2013; 8:e70276. [PMID: 23894629 PMCID: PMC3720907 DOI: 10.1371/journal.pone.0070276] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Accepted: 06/19/2013] [Indexed: 12/01/2022] Open
Abstract
Background Free light chains (LCs) are among the many ligands that bind to cubilin/megalin for endocytosis via the clathrin-dependent endosomal/lysosomal pathway. Receptor associated protein (RAP), is a 39 kDA high-affinity, chaperone-like ligand for megalin that assists in the proper folding and functioning of megalin/cubilin. Although RAP is known to inhibit ligand binding to megalin/cubilin, its effect on LC endocytosis has not been shown directly. Methods and Principal Findings We investigated whether RAP can block the endocytosis of LC in cultured human proximal tubule cells and whether this can prevent LC cytotoxicity. Immunofluorescence microscopy and flow cytometry showed that fluorescently labeled LC endocytosis was markedly inhibited in HK-2 cells pretreated with human RAP. The effect of RAP was dose-dependent, and was predominantly on endocytosis as it had no effect on the small acid-washable fraction of LC bound to cell membrane. RAP significantly inhibited LC induced cytokine production and phosphorylation of ERK1/2 and p38 MAPK. Prolonged exposure to LC for 48 h resulted in epithelial-to-mesenchymal transformation in HK-2 cells as evidenced by marked reduction in the expression of the epithelial cell marker E-cadherin, and increased the expression of the mesenchymal marker α-SMA, which was also prevented by RAP in the endocytosis medium. Conclusions RAP inhibited LC endocytosis by ∼88% and ameliorated LC-induced cytokine responses and EMT in human PTCs. The results not only provide additional evidence that LCs endocytosis occurs via the megalin/cubilin endocytic receptor system, but also show that blocking LC endocytosis by RAP can protect proximal tubule cells from LC cytotoxicity.
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Affiliation(s)
- Sule Sengul
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Sehsuvar Erturk
- Department of Nephrology, Ankara University School of Medicine, Ankara, Turkey
| | - Altaf M. Khan
- Division of Nephrology, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
| | - Vecihi Batuman
- Division of Nephrology, Tulane University School of Medicine, New Orleans, Louisiana, United States of America
- SLVHCS, VA Medical Center, New Orleans, Louisiana, United States of America
- * E-mail:
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