Plasma-cell myeloma and macroglobulinemia. I. Physicochemical, immunochemical and isotopic turnover studies of the abnormal serum and urinary proteins

STRUCTURAL STUDIES OF HUMAN 7S GAMMA-GLOBULIN (G IMMUNOGLOBULIN). FURTHER OBSERVATIONS OF A NATURALLY OCCURRING PROTEIN RELATED TO THE CRYSTALLIZABLE (FAST) FRAGMENT

1. Detailed physical, chemical, and immunologic studies of a protein closely related to the Fc fragment and heavy chain of G immunoglobulin (IgG), and elaborated by a subject with a lymphoproliferative disorder are presented. 2. The protein, which has a molecular weight of 51,000, was cleaved into two half molecules by reduction and alkylation. 3. The protein has few if any of the antigenic determinants of the antigen-binding (Fab) papain fragment of IgG, and has a striking similarity in its antigenic properties to the Fc fragment. 4. Fingerprint patterns resemble those of the crystallizable (Fc) fragment, and lack several peptides found in the heavy chain. 5. These findings suggest that the Fc fragment may be a real structural unit of IgG, and raise the possibility of the existence of three different types of polypeptide chains in G immunoglobulin.

Effect of urinary pH and diatrizoate on Bence Jones protein nephrotoxicity in the rat

Both low urinary pH and radiocontrast agents may intensify myeloma nephrotoxicity. To study the effects of these factors, we determined inulin clearances (CIn) before and after infusions of human Bence Jones protein (BJP) in male Sprague-Dawley rats in a dose previously shown to be nephrotoxic. Rats that drank 0.15 M NaHCO3 for 48 hr before study had no change in CIn (+3 +/- 20%) after BJP unlike those that drank 0.15 M NH4Cl (-33 +/- 14%, P less than 0.05); urinary pH differed (7.6 +/- 0.1 vs. 6.2 +/- 0.1, P less than 0.05), but urinary flow rates did not. The acidifying regimen was used in all subsequent groups. Infusion of diatrizoate (DTZ) after BJP produced a further decrease in CIn (-85 +/- 8%, P less than 0.05). In contrast, infusion of albumin, which raised plasma protein concentration to that seen in BJP-infused rats, did not change CIn (+39 +/- 17%). Infusion of beta-lactoglobulin also led to a greater decrease in CIn after DTZ (-35 +/- 9 vs. -67 +/- 8%, P less than 0.05), but myoglobin did not (-58 +/- 7 vs. -54 +/- 12%). Urinary pH and flow rate did not differ between any DTZ-infused group and its appropriate control. These data suggest that aciduria independent of urinary flow rate increases the nephrotoxicity of BJP. In this setting, DTZ further intensifies the nephrotoxicity of BJP as well as some but not all filterable proteins.

Nephrotoxicity of Bence Jones proteins in the rat: importance of protein isoelectric point

Bence Jones proteins (BJP) were isolated from the urine of 12 patients with multiple myeloma and various degrees of renal dysfunction. Proteins were characterized as to type (six type lambda and five type kappa), isoelectric point (pI), and secondary structure by circular dichroism (CD). Clinical renal function was more impaired with type-lambda proteins and with proteins of pI greater than 5.7. CD studies distinguished kappa from lambda proteins in most cases but did not correlate with nephrotoxicity. Protein dimer preparations were tested for nephrotoxicity in aciduric, hydropenic, female, Sprague Dawley rats by following renal function and morphology over 6 hours after injection i.p. of 300 mg of protein. Twelve rats of urine pH less than 5.5 injected with four BJP of pI less than 5.7 showed a mean rise in SUN of 5.3 mg/dl and in creatinine of 0.06 mg/dl, compared with a mean rise of 28.0 mg/dl (SUN) and 0.75 mg/dl (creatinine) in 21 rats injected with seven BJP of pI greater than 5.7 (P less than 0.01). Seven sodium-bicarbonate-fed rats of urine pH greater than 8 injected with a BJP of pI 6.2 showed mean rise in SUN of 1.8 mg/dl and in creatinine of 0.01 mg/dl, compared with 19.3 mg/dl (SUN) and 0.55 mg/dl (creatinine) in 7 aciduric rats injected with the same BJP (P = 0.009). Morphologic and immunohistologic studies showed distal cast formation in 9 rats with acute deterioration in renal function. It is concluded that BJP of pI greater than urine pH are acutely nephrotoxic in the rat by a mechanism that may involve a charge interaction in the distal nephron.

Renal plasmacytoma

Plasmacytoma, a localized extramedullary mass of plasma cells, is one manifestation of multiple myeloma. Renal plasmacytomas are rare lesions with neovascularity on arteriogram. This may cause confusion with the much more common renal cell carcinoma unless the clinician is aware of this entity. A case is presented, the literature reviewed, and problems in management discussed.