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Attieh RM, Yang Y, Rosenstock JL. Updates on the Diagnosis and Management of Fibrillary Glomerulonephritis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:374-383. [PMID: 39084762 DOI: 10.1053/j.akdh.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/15/2024] [Accepted: 03/25/2024] [Indexed: 08/02/2024]
Abstract
Fibrillary glomerulonephritis (FGN) is a rare kidney disease typically affecting individuals in middle age, frequently presenting with advanced renal failure, proteinuria, and hypertension. FGN can be associated with autoimmune diseases, hepatitis C infection, and malignancies. Its exact pathogenesis remains elusive, and the exact role of DnaJ homolog subfamily B member 9 is yet to be determined. On renal biopsy, FGN exhibits distinctive Congo-red-negative, nonbranching fibrils, approximately 20 nm in diameter. DnaJ homolog subfamily B member 9 immunohistochemical staining has become a gold standard for diagnosis. Atypical variants exist, including congophilic, monotypic, and crescentic FGN, highlighting the disease's heterogeneity. Treatment with immunosuppression, including rituximab, has shown variable success, with no standard therapy established. FGN often leads to end-stage kidney disease, with a median progression time of 2-4 years postdiagnosis. Kidney transplantation is a viable option for FGN-related end-stage kidney disease, but recurrence in transplanted kidneys is not rare.
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Affiliation(s)
- Rose Mary Attieh
- Division of Kidney Diseases and Hypertension, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York
| | - Yihe Yang
- Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York
| | - Jordan L Rosenstock
- Division of Nephrology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY.
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Da Y, Goh GH, Lau T, Chng WJ, Soekojo CY. Fibrillary Glomerulonephritis and Monoclonal Gammopathy: Potential Diagnostic Challenges. Front Oncol 2022; 12:880923. [PMID: 35692803 PMCID: PMC9174543 DOI: 10.3389/fonc.2022.880923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Fibrillary glomerulonephritis (FGN) is a rare glomerular disease featured by the randomly arranged 12- to 24-nm fibrils under electron microscopy (EM). Up to 10% of FGN patients have monoclonal gammopathy. However, distinguishing between FGN as monoclonal gammopathy of renal significance (MGRS) and FGN from other causes with incidental monoclonal gammopathy of undetermined significance (MGUS) can be challenging, as the current way of demonstrating monoclonality is flawed due to (1) the suboptimal sensitivity of kappa staining by immunofluorescence in frozen tissue (IF-F) as compared to pronase-digested paraffin sections (IF-P), causing incorrect labeling of light chain restriction; (2) the unavailability of immunoglobulin G (IgG) subtyping in some centers; and (3) the unavailability of tests demonstrating the monoclonality of highly variable VH or VL domains in immunoglobulin structures in clinical use. The discovery of DnaJ homolog subfamily B member 9 (DNAJB9) allows diagnosis for FGN with less reliance on EM, and the summary of recent studies revealed that genuine MGRS is extremely rare among FGN. Further research integrating IF-P, IgG subtyping, VH or VL domain monoclonality confirmation, and DNAJB9 as diagnostic modalities, with corresponding clinical data including treatment response and prognosis, is required for a better understanding of this subject.
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Affiliation(s)
- Yi Da
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Giap Hean Goh
- Department of Pathology, National University Hospital, Singapore, Singapore
| | - Titus Lau
- Division of Nephrology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Wee Joo Chng
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Cinnie Yentia Soekojo
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
- *Correspondence: Cinnie Yentia Soekojo,
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Hattori K, Shimizu R, Tanaka S, Terashima T, Hiramatsu M, Shimomura T, Ito T, Morinaga T, Terasaki M, Shimizu A, Morozumi K, Tamai H. A case of juvenile-onset fibrillary glomerulonephritis diagnosed by mass spectrometry and immunohistochemistry of DNAJB9. CEN Case Rep 2022; 11:412-416. [PMID: 35199316 DOI: 10.1007/s13730-022-00693-3] [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: 11/29/2021] [Accepted: 02/06/2022] [Indexed: 10/19/2022] Open
Abstract
Fibrillary glomerulonephritis (FGN) is a rare glomerular disease. FGN is characterized by the deposition of randomly arranged, nonbranching microfibrils in the mesangium and glomerular basement membrane. The discovery of DNAJ homolog subfamily B member 9 (DNAJB9) in 2017 was a breakthrough, and DNAJB9 has been proven to be extremely useful for the definitive diagnosis of FGN. While FGN often occurs in middle-aged individuals, this case was diagnosed at a relatively young age of 17. We performed renal biopsy, and light microscopic study revealed mesangial proliferation with expansion and subepithelial deposits. Electron microscopic study showed glomerular deposition of randomly oriented nonbranching fibrils with a mean of 20 nm. However, direct first scarlet stain for amyloidosis was weakly positive. Therefore, we confirmed the diagnosis of FGN and eliminated the presence of amyloidosis with mass spectrometry. This is the first case in Japan in which the complication of amyloidosis was ruled out with mass spectrometry and FGN was diagnosed using immunostaining and mass spectrometry of DNAJB9. We began treatment with cyclosporine A. One and a half years after the start of the treatment, kidney function continues to be normal.
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Affiliation(s)
- Keita Hattori
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan.
| | - Ryo Shimizu
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Shoichiro Tanaka
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Takashi Terashima
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Miya Hiramatsu
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Taishi Shimomura
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Takeshi Ito
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Takatoshi Morinaga
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Mika Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Kunio Morozumi
- Department of Nephrology, Masuko Memorial Hospital, 35-28 Takegashicho, Nakamura-ku, Nagoya, Aichi, 453-0016, Japan
| | - Hirofumi Tamai
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
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The function of the co-chaperone ERdj4 in diverse (patho-)physiological conditions. Cell Mol Life Sci 2021; 79:9. [PMID: 34950970 PMCID: PMC8702508 DOI: 10.1007/s00018-021-04082-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 12/07/2021] [Accepted: 12/08/2021] [Indexed: 12/16/2022]
Abstract
Accumulation of misfolded proteins in the endoplasmic reticulum (ER) induces a well-orchestrated cellular response to reduce the protein burden within the ER. This unfolded protein response (UPR) is controlled primarily by three transmembrane proteins, IRE1α, ATF6, and PERK, the activity of which is controlled by BiP, the ER-resident Hsp70 protein. Binding of BiP to co-chaperones via their highly conserved J-domains stimulates the intrinsic ATPase activity of BiP, thereby providing the energy necessary for (re-)folding of proteins, or for targeting of misfolded proteins to the degradation pathway, processes specified and controlled by the respective co-chaperone. In this review, our aim is to elucidate the function of the co-chaperone ERDJ4, also known as MDG1, MDJ7, or DNAJB9. Knockout and knockin experiments clearly point to the central role of ERDJ4 in controlling lipogenesis and protein synthesis by promoting degradation of SREBP1c and the assembly of the protein complex mTORC2. Accumulating data reveal that ERDJ4 controls epithelial-to-mesenchymal transition, a central process during embryogenesis, in wound healing, and tumor development. Overexpression of ERdj4 has been shown to improve engraftment of transplanted human stem cells, possibly due to its ability to promote cellular survival in stressed cells. High ERDJ4-plasma levels are specific for fibrillary glomerulonephritis and serve as a diagnostic marker. As outlined in this review, the functions of ERDJ4 are manifold, depending on the cellular (patho-) physiological state, the cellular protein repertoire, and the subcellular localization of ERDJ4.
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Lerner GB, Singer GG, Larsen CP, Caza TN. Immunoglobulin-Negative Fibrillary Glomerulonephritis Masked in Diabetic Nephropathy: A Case Report and Discussion of a Diagnostic Pitfall. GLOMERULAR DISEASES 2021; 2:95-99. [PMID: 36751534 PMCID: PMC9670039 DOI: 10.1159/000520071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/30/2021] [Indexed: 11/19/2022]
Abstract
Introduction Fibrillary glomerulonephritis (FGN) is a rare glomerular disease with poor prognosis, characterized by deposition of randomly arranged fibrillar material measuring 10-30 nm in diameter. This diagnosis is confirmed with DNAJB9 immunohistochemistry as well as ultrastructural examination. Ultrastructurally, the fibrillary material seen in this entity may be confused with diabetic fibrillosis occurring in diabetic nephropathy. Case Presentation We present a case of a 63-year-old African American male with remote hepatitis C virus (HCV) infection and type II diabetes mellitus who presented with chronic kidney disease and nephrotic range proteinuria. A kidney biopsy revealed PAS-positive mesangial matrix expansion consistent with diabetic nephropathy and focal randomly oriented fibril deposition on ultrastructural examination. Immunofluorescence for immunoglobulin G and light chains was negative by both routine and paraffin immunofluorescence. Immunohistochemistry for DNAJB9 was diffusely positive, confirming co-existing FGN. Discussion/Conclusion Patients with diabetic nephropathy and FGN have similar clinicopathologic presentations with a slowly progressive onset of kidney failure and proteinuria. In diabetic patients with fibrillary deposits under ultrastructural examination, concurrence of these disease entities must be considered. In this patient with remote HCV infection that was successfully treated years before, it is possible that in the absence of an FGN trigger, there was a loss of antigenicity with a loss of immunoglobulin staining. Therefore, we recommend DNAJB9 immunostaining for patients with remote HCV infection to avoid this diagnostic pitfall. Further studies are needed to determine the potential role of HCV infection in the initiation and etiopathogenesis of FGN.
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Affiliation(s)
- Gabriel B.W. Lerner
- Departments of Pathology and Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gary G. Singer
- Midwest Nephrology Associates, Saint Peters, Mississippi, USA
| | | | - Tiffany N. Caza
- Arkana Laboratories, Little Rock, Arkansas, USA,*Tiffany N. Caza,
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The Pathophysiological Role of Heat Shock Response in Autoimmunity: A Literature Review. Cells 2021; 10:cells10102626. [PMID: 34685607 PMCID: PMC8533860 DOI: 10.3390/cells10102626] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 09/27/2021] [Accepted: 09/28/2021] [Indexed: 12/16/2022] Open
Abstract
Within the last two decades, there has been increasing evidence that heat-shock proteins can have a differential influence on the immune system. They can either provoke or ameliorate immune responses. This review focuses on outlining the stimulatory as well as the inhibitory effects of heat-shock proteins 27, 40, 70, 65, 60, and 90 in experimental and clinical autoimmune settings.
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Andeen NK, Avasare RS. DNA J homolog subfamily B member 9 and other advances in fibrillary glomerulonephritis. Curr Opin Nephrol Hypertens 2021; 30:294-302. [PMID: 33767057 DOI: 10.1097/mnh.0000000000000706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW Fibrillary glomerulonephritis (FGN) involves ∼1% of native kidney biopsies and is characterized by glomerular deposition of fibrils larger than amyloid (12-24 nm diameter) composed of polyclonal immunoglobulin G (IgG). The recent discovery of DNA J homolog subfamily B member 9 (DNAJB9) in FGN glomerular deposits has contributed a specific and sensitive biomarker, informing morphologic classification and pathogenesis. This review will consider contemporary FGN incidence and genetics, pathogenesis, (lack of) paraprotein association, variants, treatment, and transplantation. RECENT FINDINGS DNAJB9 tissue assays have enabled the identification of morphologic variants and improved classification of fibrillary-like glomerular diseases. Together with paraffin immunofluorescence and IgG subclass studies, these have established that FGN is only rarely monoclonal and these patients usually do not have an monoclonal gammopathy. The discovery of DNAJB9 opens new avenues of investigation into FGN pathogenesis, especially those of the unfolded protein response. Treatment for FGN remains empiric, with some encouraging data on rituximab-based therapy. Transplantation is a good option for patients progressing to end-stage kidney disease. SUMMARY Advances building on the discovery of DNAJB9 in FGN should lead to long-term evolution in targeted treatment and outcome of this glomerular disease.
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Affiliation(s)
| | - Rupali S Avasare
- Department of Medicine, Division of Nephrology and Hypertension, Portland, Oregon, USA
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L'Imperio V, Barreca A, Vergani B, Sinico RA, Pagni F. Destructuring glomerular diseases with structured deposits: challenges in the precision medicine era. J Nephrol 2021; 34:2151-2154. [PMID: 33905115 DOI: 10.1007/s40620-021-01053-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, ASST Monza, University of Milano-Bicocca, Monza, Italy.
| | - Antonella Barreca
- Division of Pathology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Barbara Vergani
- Department of Medicine and Surgery, Pathology, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Renato Alberto Sinico
- Nephrology Unit, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, ASST Monza, University of Milano-Bicocca, Monza, Italy
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Donor-Derived ALECT2 Amyloidosis and Recurrent Fibrillary Glomerulonephritis in a Transplant Allograft. Kidney Med 2021; 3:433-437. [PMID: 34136788 PMCID: PMC8178471 DOI: 10.1016/j.xkme.2020.11.019] [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: 11/23/2022] Open
Abstract
The occurrence of renal amyloidosis and fibrillary glomerulonephritis in the same biopsy specimen is exceptional and poses a diagnostic challenge. We describe the case of a non-Hispanic White patient with end-stage kidney disease due to fibrillary glomerulonephritis who received a second living donor kidney from a Hispanic individual. A 40-month–posttransplantation biopsy performed for an elevated serum creatinine level revealed interstitial congophilic deposits and glomerular noncongophilic fibrillary deposits, in addition to rejection. Separate laser microdissections of the glomerular and interstitial deposits followed by liquid chromatography–tandem mass spectrometry (LC MS/MS) revealed DNAJB9 peptide spectra in glomeruli and a peptide profile consistent with leukocyte chemotactic factor 2 (ALECT2) amyloidosis in the interstitium. Based on these findings, a 2-week–posttransplantation biopsy was re-reviewed and analyzed using LC MS/MS, which revealed a peptide profile consistent with ALECT2 amyloidosis in the interstitium, without peptide spectra for ALECT2 or DNAJB9 in glomeruli. The findings were consistent with donor-derived ALECT2 amyloidosis and recurrent fibrillary glomerulonephritis. At 49 months posttransplantation, allograft function was stable with minimal proteinuria. Thus, LC MS/MS was crucial to establish the accurate diagnosis of these 2 nephropathies characterized by fibrillary deposits. The indolent posttransplantation course suggests that donated kidneys with focal interstitial ALECT2 deposits may be suitable for transplantation but the deposits persist for many years.
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