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Arai S, Matsui R, Ono W, Asakawa S, Yamazaki O, Tamura Y, Terasaki M, Hagiwara K, Nakagawa T, Ohashi R, Shimizu A, Shibata S, Fujigaki Y. Discontinuing Hemodialysis through Corticosteroid Treatment in a Patient with Cryofibrinogen-associated Glomerulonephritis. Intern Med 2024; 63:1899-1905. [PMID: 37926528 PMCID: PMC11272508 DOI: 10.2169/internalmedicine.2897-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 09/24/2023] [Indexed: 11/07/2023] Open
Abstract
Cryofibrinogen-associated glomerulonephritis (CryoFiGN) is rare, and its diagnosis is difficult while treatment is not established. We herein report an elderly woman with CryoFiGN who experienced recurrent purpura and nephritic features that subsequently progressed to nephrotic syndrome and required hemodialysis during the 18-month clinical course. The patient was treated with corticosteroids, which led to the discontinuation of hemodialysis. The diagnosis of CryoFiGN was based on the clinical presentation, characteristic glomerular deposits, and results of laser microdissection and liquid chromatography-tandem mass spectrometry of the glomeruli. This case highlights the potential utility of corticosteroids as a treatment option for patients with CryoFiGN, even after hemodialysis.
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Affiliation(s)
- Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Rena Matsui
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Wataru Ono
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Shinichiro Asakawa
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Osamu Yamazaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Mika Terasaki
- Department of Analytical Human Pathology, Nippon Medical School, Japan
| | - Kanade Hagiwara
- Department of Urology, Teikyo University School of Medicine, Japan
| | - Tohru Nakagawa
- Department of Urology, Teikyo University School of Medicine, Japan
| | - Ryuji Ohashi
- Department of Integrated Diagnostic Pathology, Nippon Medical School, Japan
| | - Akira Shimizu
- Department of Analytical Human Pathology, Nippon Medical School, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
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Gant CM, Koelman CA, Nguyen TQ, Abrahams AC, Wetzels JFM, Duineveld C, Jak M, Minnema MC, Klein SK, Jacobs JFM, Bosma RJ. Cryoglobulinemic Vasculitis in Disguise: Cryofibrinogenemia as Variant of Monoclonal Gammopathy of Renal Significance. Am J Kidney Dis 2024; 83:415-419. [PMID: 37734685 DOI: 10.1053/j.ajkd.2023.07.017] [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: 11/15/2022] [Revised: 07/13/2023] [Accepted: 07/22/2023] [Indexed: 09/23/2023]
Abstract
Monoclonal gammopathy with cryoactivity (ie, cryoglobulins) that causes glomerulonephritis is considered within the spectrum of monoclonal gammopathy of renal significance. Cryofibrinogenemia (cryoactivity of coagulation factors) is very rarely associated with glomerulonephritis. We present a 39-year-old woman with a relapsing nephrotic syndrome. Laboratory investigation detected cryofibrinogen; the precipitate consisted of fibrinogen and a monoclonal immunoglobulin (M-protein; IgG-λ), and the latter was also detected in serum (4g/L). Initial conventional immunosuppressive therapy resulted in temporary renal remission. In view of the M-protein, subsequent therapy consisted of bortezomib/dexamethasone and high-dose melphalan followed by autologous hematopoietic stem cell transplantation, and resulted in a very good partial hematological response and temporary renal remission. However, after hematological and renal relapse, we performed unique experiments to clarify the role of the M-protein. Mixing patient serum with donor plasma resulted in cryoactivity, composed of M-protein+fibrinogen. Patient plasma deprived of M-protein did not have cryoactivity. Therefore, cryoactivity was dependent on the M-protein. We started lenalidomide, which resulted in very good partial hematological and renal remission. Thus, cryofibrinogenemia can be the consequence of an M-protein, which we suggest should be defined as monoclonal gammopathy of renal significance.
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Affiliation(s)
- Christina M Gant
- Internal Medicine/Nephrology, Meander Medical Centre, Amersfoort, The Netherlands.
| | - Carin A Koelman
- Laboratory Medical Immunology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Tri Q Nguyen
- Pathology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Alferso C Abrahams
- Nephrology and Hypertension, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jack F M Wetzels
- Nephrology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Caroline Duineveld
- Nephrology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Margot Jak
- Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Monique C Minnema
- Hematology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Saskia K Klein
- Hematology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Joannes F M Jacobs
- Laboratory Medical Immunology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Renate J Bosma
- Internal Medicine/Nephrology, Meander Medical Centre, Amersfoort, The Netherlands
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Mori M, Katayama K, Joh K, Ishikawa E, Dohi K. Type VI collagen-related nephropathy. Clin Kidney J 2022; 16:195-196. [PMID: 36726445 PMCID: PMC9871854 DOI: 10.1093/ckj/sfac126] [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: 04/25/2022] [Indexed: 02/04/2023] Open
Affiliation(s)
- Mutsuki Mori
- Department of Nephrology, Saiseikai Matsusaka General Hospital, Matsusaka, Japan,Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
| | | | - Kensuke Joh
- Department of Pathology, Jikei University School of Medicine, Tokyo, Japan
| | - Eiji Ishikawa
- Department of Nephrology, Saiseikai Matsusaka General Hospital, Matsusaka, Japan
| | - Kaoru Dohi
- Department of Cardiology and Nephrology, Mie University Graduate School of Medicine, Tsu, Japan
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Santiago MB, Melo BS. Cryofibrinogenemia: What Rheumatologists Should Know. Curr Rheumatol Rev 2022; 18:186-194. [PMID: 35339184 DOI: 10.2174/1573397118666220325110737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/13/2021] [Accepted: 01/31/2022] [Indexed: 11/22/2022]
Abstract
Cryofibrinogenemia refers to the presence of cryofibrinogen in plasma. This protein has the property of precipitating at lower temperatures. Cryofibrinogenemia is a rare disorder, clinically characterized by skin lesions, such as ulcers, necrosis, livedo reticularis, arthralgia, thrombosis, and limb ischemia. These features are most often observed in rheumatological practice and consist in the differential diagnoses of antiphospholipid syndrome, primary vasculitis, thrombotic thrombocytopenic purpura, and cryoglobulinemia. Classical histopathological findings include the presence of thrombi within the lumen of blood vessels of the skin without vasculitis. To date, there are no validated classification criteria. Management includes corticosteroids, immunosuppressive therapy, anticoagulants, and fibrinolytic agents. This narrative review aims to make physicians, particularly rheumatologists, aware of existence of this underdiagnosed condition. There are no epidemiological studies evaluating the prevalence of cryofibrinogenemia in different rheumatological disorders. Studies are also required to investigate if certain features of rheumatological diseases are related to the presence of cryofibrinogenemia.
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Affiliation(s)
- Mittermayer B Santiago
- Hospital Santa Izabel, Praça Almeida Couto 500, CEP: 40.000-000, Salvador, Bahia, Brazil.
- Serviços Especializados em Reumatologia da Bahia, Rua Conde Filho, 117, CEP: 40150-150, Salvador, Bahia, Brazil.
- Serviço de Reumatologia do Hospital Universitário Professor Edgard Santos, Rua Augusto Viana, CEP: 40110-060, Salvador, Bahia, Brazil.
- Escola Bahiana de Medicina e Saúde Pública, Av. Dom João VI, 275, CEP: 40290-000, Salvador, Bahia, Brazil
| | - Bartira Souza Melo
- Hospital Santa Izabel, Praça Almeida Couto 500, CEP: 40.000-000, Salvador, Bahia, Brazil
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Menter T, Hopfer H. Renal Disease in Cryoglobulinemia. GLOMERULAR DISEASES 2021; 1:92-104. [PMID: 36751424 PMCID: PMC9677724 DOI: 10.1159/000516103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/19/2021] [Indexed: 11/19/2022]
Abstract
Background Renal disease in cryoglobulinemia is difficult to grasp and diagnose because it is rare, serological testing is challenging and prone to artifacts, and its morphology is shared by other renal diseases resulting in a spectrum of differential diagnoses. On occasion, a definitive diagnosis cannot even be rendered after immunofluorescence and electron microscopic studies. Summary Based on kidney biopsies seen in our routine diagnostic and referral practice, we discuss and illustrate various morphological patterns of renal injury associated with cryoglobulins. We outline key pathophysiologic and clinical aspects associated with cryoglobulinemia induced renal disease and describe morphologic changes with a focus on electron microscopy. We present our practical, morphology-based approach to diagnostic decision-making with special consideration of differential diagnoses and disease mimickers. Since cryoglobulins are rarely tested for prior to kidney biopsy, pathologists and clinicians alike must have a high level of suspicion when interpreting renal biopsies and managing patients. Key Messages Cryoglobulinemia-associated glomerulonephritis (GN) is a multifactorial disease which is important to recognize for clinical practice. Morphological features suggestive of cryoglobulinemia-associated GN include a pattern of membranoproliferative GN with abundance of monocytes and the presence of (pseudo)thrombi. By electron microscopy, the main diagnostic features are a prominent infiltration of monocytes/macrophages and the presence of mesangial and subendothelial deposits with frequently curved microtubular/cylindrical and annular substructures.
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Morimoto N, Nagahama K, Oyama S, Tsuura Y, Fukutomi T, Terai A, Tanabe M, Otani M, Shioji S, Hirasawa S, Aki S, Aoyagi M, Tanaka H. Immunotactoid glomerulonephritis in a patient with cold agglutinins: causal association or mere coincidence? CEN Case Rep 2021; 10:515-522. [PMID: 33847918 DOI: 10.1007/s13730-021-00600-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 04/05/2021] [Indexed: 11/28/2022] Open
Abstract
We report a case of immunotactoid glomerulonephritis (ITG) in a patient with cold agglutinins. An 86-year-old Japanese male with a history of hypertension, dyslipidemia, and gastric malignancy presented to our hospital for the evaluation of proteinuria and hematuria. He had an elevated blood pressure of 200/77 mmHg and edema of the lower extremities. Initial blood test results revealed an impaired renal function (creatinine, 1.37 mg/dL) and hypoalbuminemia (albumin, 2.6 g/dL). His estimated daily urinary protein was 5.89 g/g creatinine, meeting the diagnostic criteria for nephrotic syndrome. The selectivity index for proteinuria indicated low selectivity (0.329). We conducted a renal biopsy to identify the cause of nephrotic syndrome. Immunofluorescence microscopy demonstrated positive staining of IgM, C4, and C1q. Electron microscopy exhibited mesangial expansion with inflammatory cells and a lobular structure, suggesting membranoproliferative glomerulonephritis. Subendothelial deposits containing microtubular structures with a diameter of approximately 30-200 nm were found, concurrent with the criteria for the diagnosis of ITG. Screening for lymphoproliferative diseases and immunological abnormalities revealed a positive direct Coombs test result and the presence of cold agglutinins. Paraproteinemia was absent. The similarities between cold agglutinin disease and ITG, including the production of autoantibodies and involvement of complement pathways, raise the possibility that cold agglutinins played a role in the development of ITG; however, we were unable to prove it due to difficulties in detecting cold agglutinins on renal histology. We discuss the possible implications for pathogenesis considering prior reports on nephrotic syndrome being potentially associated with cold agglutinins.
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Affiliation(s)
- Nobuhisa Morimoto
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan.
| | - Kiyotaka Nagahama
- Department of Pathology, Kyorin University School of Medicine, Tokyo, Japan
| | - Sakino Oyama
- Department of Nephrology, Tokyo Metropolitan Bokuto General Hospital, Tokyo, Japan
| | - Yukio Tsuura
- Department of Pathology, Yokosuka Kyosai Hospital, Kanagawa, Japan
| | - Toshiyuki Fukutomi
- Department of Pharmacology and Toxicology, Kyorin University School of Medicine, Tokyo, Japan
| | - Ayumi Terai
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Madoka Tanabe
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Megumi Otani
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Shingo Shioji
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Suguru Hirasawa
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Shota Aki
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Makoto Aoyagi
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
| | - Hiroyuki Tanaka
- Department of Nephrology, Yokosuka Kyosai Hospital, 1-16 Yonegahamadori, Yokosuka, Kanagawa, 238-8558, Japan
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Palma LMP, Sethi S. Thrombotic microangiopathy and their mimickers. Nephrol Dial Transplant 2020; 37:840-843. [PMID: 32964928 DOI: 10.1093/ndt/gfaa230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Indexed: 11/15/2022] Open
Affiliation(s)
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Ibuki E, Shiraishi A, Sofue T, Kushida Y, Kadota K, Honda K, Kang D, Joh K, Minamino T, Haba R. Characteristic electron-microscopic features of cryofibrinogen-associated glomerulonephritis: a case report. BMC Nephrol 2020; 21:27. [PMID: 31996260 PMCID: PMC6988214 DOI: 10.1186/s12882-020-1696-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 01/20/2020] [Indexed: 12/04/2022] Open
Abstract
Background Cryofibrinogenemia is a rare disorder that mainly affects the skin and occasionally the kidney. However, there are few published reports of cryofibrinogenemia-associated renal pathology. We therefore report a patient with cryofibrinogen-associated glomerulonephritis. Samples from this patient were examined by electron microscopy, laser microdissection, and liquid chromatography-tandem mass spectrometry (LC-MS/MS). Case presentation A 78-year-old Japanese man presented with declining renal function, proteinuria, and gross hematuria. Kidney biopsy showed a membranoproliferative pattern with crescent formation and dominant C3c deposition in which subendothelial deposits with uniquely organized electron-microscopic features were observed. Additional ultrastructural analysis of cryoprecipitates extracted from plasma revealed similar structures of the glomerular subendothelial deposits. LC-MS/MS identified an increase in fibrinogen α, β, and γ chains, fibronectin, filamin-A, and C3. The glomerular lesions were diagnosed as cryofibrinogen-associated glomerulonephritis on the basis of these findings. Conclusions Although there are few reports of cryofibrinogen-associated glomerulonephritis, we believe that accurate diagnosis can be achieved by performing LC-MS/MS and ultrastructural analysis.
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Affiliation(s)
- Emi Ibuki
- Department of Diagnostic Pathology, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan.
| | - Aiko Shiraishi
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Kagawa University, Kagawa, Japan
| | - Tadashi Sofue
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Kagawa University, Kagawa, Japan
| | - Yoshio Kushida
- Department of Diagnostic Pathology, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Kyuichi Kadota
- Department of Diagnostic Pathology, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
| | - Kazuho Honda
- Division of Microscopic Anatomy, Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| | - Dedong Kang
- Division of Microscopic Anatomy, Department of Anatomy, Showa University School of Medicine, Tokyo, Japan
| | - Kensuke Joh
- Department of Pathology, Jikei University School of Medicine, Tokyo, Japan
| | - Tetsuo Minamino
- Division of Nephrology and Dialysis, Department of Cardiorenal and Cerebrovascular Medicine, Kagawa University, Kagawa, Japan
| | - Reiji Haba
- Department of Diagnostic Pathology, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan
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Sudo M, Sakamaki Y, Hosojima M, Yamamoto S, Ito Y, Imai N, Kaneko Y, Goto S, Li CP, Shimizu A, Narita I. Cryofibrinogen-associated glomerulonephritis diagnosed by mass spectrometry and immunoelectron microscopy. HUMAN PATHOLOGY: CASE REPORTS 2019. [DOI: 10.1016/j.ehpc.2018.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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