1
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Bakhshwin A, Herlitz L, Hu S, Raza S, Olevian DC, Mehdi A, Friedman K, Eghtesad B, Hashimoto K, Esfeh JM, El Hag MI. Immunotactoid hepatopathy: A novel entity with histologically proven recurrence post liver transplantation. Am J Transplant 2024; 24:865-871. [PMID: 38145784 DOI: 10.1016/j.ajt.2023.12.019] [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: 07/06/2023] [Revised: 12/07/2023] [Accepted: 12/20/2023] [Indexed: 12/27/2023]
Abstract
Immunotactoid deposition is a rare fibrillary deposition disease that is primarily seen in the kidney and is associated with paraproteinemia. Here, we report a case of hepatic immunotactoid deposition in a 67-year-old male with a history of smoldering myeloma and chronic kidney disease who underwent liver transplantation for metabolic dysfunction-related cirrhosis. Immunotactoid deposition was first identified in the explanted liver and recurred in the allograft within only 7 weeks following transplantation, presenting as ascites with normal liver function tests. The patient's posttransplant course was complicated by proteinuria and renal failure requiring dialysis. Histologic examination of both native and allograft livers demonstrated pink amorphous material occupying sinusoidal spaces that were Congo-red negative and immunoglobulin M Kappa-restricted. Electron microscopy revealed characteristic deposits of electron-dense bundles of hollow microtubules with a 40 nm diameter within the sinusoids and space of Disse, consistent with immunotactoids. Therapy of the patient's underlying plasma-cell dyscrasia utilizing a daratumumab-based regimen showed decreased serum paraproteins, resolution of ascites, and improved kidney function, no longer requiring dialysis, without inducing rejection. The patient continues to respond to treatment 10 months posttransplant.
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Affiliation(s)
- Ahmed Bakhshwin
- Department of Pathology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Leal Herlitz
- Department of Anatomic Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shaomin Hu
- Department of Anatomic Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shahzad Raza
- Department of Hematology and Oncology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dane C Olevian
- Department of Pathology, Anatomy, and Laboratory Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Ali Mehdi
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kenneth Friedman
- Department of Anatomic Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Bijan Eghtesad
- Department of Abdominal transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Koji Hashimoto
- Department of Abdominal transplantation, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jamak Modaresi Esfeh
- Department of Gastroenterology and Transplant Hepatology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mohamed I El Hag
- Department of Anatomic Pathology, Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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2
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Madden B, Singh RD, Haas M, Palma LMP, Sharma A, Vargas MJ, Gross L, Negron V, Nate T, Charlesworth MC, Theis JD, Nasr SH, Nath KA, Fervenza FC, Sethi S. Apolipoprotein E is enriched in dense deposits and is a marker for dense deposit disease in C3 glomerulopathy. Kidney Int 2024; 105:1077-1087. [PMID: 38447879 DOI: 10.1016/j.kint.2024.02.013] [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: 11/06/2023] [Revised: 01/31/2024] [Accepted: 02/02/2024] [Indexed: 03/08/2024]
Abstract
C3 glomerulopathy (C3G) is a rare disease resulting from dysregulation of the alternative pathway of complement. C3G includes C3 glomerulonephritis (C3GN) and dense deposit disease (DDD), both of which are characterized by bright glomerular C3 staining on immunofluorescence studies. However, on electron microscopy (EM), DDD is characterized by dense osmiophilic mesangial and intramembranous deposits along the glomerular basement membranes (GBM), while the deposits of C3GN are not dense. Why the deposits appear dense in DDD and not in C3GN is not known. We performed laser microdissection (LCM) of glomeruli followed by mass spectrometry (MS) in 12 cases each of DDD, C3GN, and pretransplant kidney control biopsies. LCM/MS showed marked accumulation of complement proteins C3, C5, C6, C7, C8, C9 and complement regulating proteins CFHR5, CFHR1, and CFH in C3GN and DDD compared to controls. C3, CFH and CFHR proteins were comparable in C3GN and DDD. Yet, there were significant differences. First, there was a six-to-nine-fold increase of C5-9 in DDD compared to C3GN. Secondly, an unexpected finding was a nine-fold increase in apolipoprotein E (ApoE) in DDD compared to C3GN. Most importantly, immunohistochemical and confocal staining for ApoE mirrored the dense deposit staining in the GBM in DDD but not in C3GN or control cases. Validation studies using 31 C3G cases confirmed the diagnosis of C3GN and DDD in 80.6 % based on ApoE staining. Overall, there is a higher burden of terminal complement pathway proteins in DDD compared to C3GN. Thus, our study shows that dense deposits in DDD are enriched with ApoE compared to C3GN and control cases. Hence, ApoE staining may be used as an adjunct to EM for the diagnosis of DDD and might be valuable when EM is not available.
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Affiliation(s)
- Benjamin Madden
- Mayo Clinic Proteomics Core, Mayo Clinic, Rochester, Minnesota, USA
| | - Raman Deep Singh
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark Haas
- Department of Pathology & Laboratory Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Lilian M P Palma
- Pediatric Nephrology, State University of Campinas (UNICAMP), Campinas, Brazil
| | - Alok Sharma
- Department of Renal Pathology & Electron Microscopy, Dr Lal Path Labs, New Delhi, India
| | - Maria J Vargas
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - LouAnn Gross
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vivian Negron
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Torell Nate
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Karl A Nath
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernando C Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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3
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Cohen AWS, Vilayur E. Fibrillary and immunotactoid glomerulopathies in the Hunter region: a retrospective cohort study. Intern Med J 2023; 53:1837-1845. [PMID: 36305476 DOI: 10.1111/imj.15959] [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: 08/18/2022] [Accepted: 10/10/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Fibrillary (FGN) and immunotactoid (IT) glomerulonephritis are uncommon. AIMS To evaluate the prevalence, clinicopathological correlations and outcomes of FGN and IT in our regional centre in Australia. METHODS We interrogated a renal biopsy database for cases of FGN and IT from 2000 to 2020. Data included demographics, serum creatinine, haematuria status, proteinuria, comorbidities and histopathological findings. RESULTS We had 14 cases of FGN and t of IT. The mean presenting age was 59.8 years, and 42.9% were males. No patients with FGN had dysproteinaemia, whereas both patients with IT had chronic lymphocytic leukaemia. At presentation, 75% of patients with FGN and both patients with IT had haematuria; all had proteinuria. Mean albumin-creatinine ratio at presentation was 254 mg/mmol for FGN and 604 mg/mmol for IT. Mean presenting serum creatinine was 149 μmol/L for FGN and 95 μmol/L for IT. Four patients with FGN (28.6%) received immunomodulatory therapy. The prognosis of FGN was poor, with six patients (46.2%) reaching end-stage kidney disease after a median of 42 months (range 1-96 months). All patients presenting with proteinuria <30 mg/mmol entered complete remission; patients with higher-grade proteinuria exhibited progressive chronic kidney disease. Patients with IT had complete remission with treatment of underlying haematological disease. CONCLUSION FGN is rare, with poor response to immunomodulatory therapy. It carries poor renal prognosis. Less proteinuria at diagnosis may predict a more benign disease course. IT is associated with haematological malignancy and carries better prognosis and response to treatment.
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Affiliation(s)
- Adrienne W S Cohen
- Nephrology and Transplantation Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Eswari Vilayur
- Nephrology and Transplantation Unit, John Hunter Hospital, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, New South Wales, Australia
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4
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Feng Y, Wang W, Li G, Zhang P. A case of membranous immunotactoid glomerulopathy misdiagnosed as membranous nephropathy: significance of electron microscopy in kidney biopsy. Ren Fail 2023; 45:2249102. [PMID: 38532725 DOI: 10.1080/0886022x.2023.2249102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/13/2023] [Indexed: 03/28/2024] Open
Affiliation(s)
- Yunlin Feng
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, 610072 China
- Renal Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Wei Wang
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, 610072 China
| | - Guisen Li
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, 610072 China
| | - Ping Zhang
- Nephrology Department, Sichuan Provincial People's Hospital, Chengdu, 610072 China
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5
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Karam S, Haidous M, Dalle IA, Dendooven A, Moukalled N, Van Craenenbroeck A, Bazarbachi A, Sprangers B. Monoclonal gammopathy of renal significance: Multidisciplinary approach to diagnosis and treatment. Crit Rev Oncol Hematol 2023; 183:103926. [PMID: 36736510 DOI: 10.1016/j.critrevonc.2023.103926] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a hemato-nephrological term referring to a heterogeneous group of kidney disorders characterized by direct or indirect kidney injury caused by a monoclonal immunoglobulin (MIg) produced by a B cell or plasma cell clone that does not meet current hematologic criteria for therapy. MGRS-associated kidney diseases are diverse and can result in the development of end stage kidney disease (ESKD). The diagnosis is typically made by nephrologists through a kidney biopsy. Many distinct pathologies have been identified and they are classified based on the site or composition of the deposited Mig, or according to histological and ultrastructural findings. Therapy is directed towards the identified underlying clonal population and treatment decisions should be coordinated between hematologists and nephrologists in a multidisciplinary fashion, depend on the type of MGRS, the degree of kidney function impairment and the risk of progression to ESKD.
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Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, United States
| | - Mohammad Haidous
- Department of Medicine, Saint Vincent Charity Medical Center, Cleveland, OH, United States
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amélie Dendooven
- Department of Pathology, University Hospital Ghent, Ghent, Belgium
| | - Nour Moukalled
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amaryllis Van Craenenbroeck
- Department of Microbiology, Immunology and Transplantation, Laboratory of Nephrology, KU Leuven, Leuven, Belgium; Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ben Sprangers
- Biomedical Research Institute, Department of Immunology and Infection, University Hasselt, Diepenbeek, Belgium; Department of Nephrology, Ziekenhuis Oost-Limburg, Genk, Belgium.
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6
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Karanfilovski V, Ristovska V, Gjorgjievski N, Nikolov IG, Dzekova-Vidimliski P, Petrushevska G. Immunotactoid Glomerulopathy: A Rare Glomerular Disease Case Study. Indian J Nephrol 2023; 33:140-143. [PMID: 37234440 PMCID: PMC10208538 DOI: 10.4103/ijn.ijn_107_22] [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: 03/20/2022] [Revised: 04/28/2022] [Accepted: 05/13/2022] [Indexed: 11/07/2022] Open
Abstract
Immunotactoid glomerulopathy (ITG) is a rare glomerular disease with variable responsiveness to the immunosuppressive therapy and with uncertain prognosis. ITG was diagnosed in two patients with type 2 diabetes mellitus with nephrotic syndrome and chronic kidney disease. The absence of diabetic retinopathy in the first case and the recent onset of diabetes in the second case accompanied with sudden increase in the 24-hour proteinuria and rapid decline in kidney function, prompted us to perform kidney biopsy. The electron microscopy set the diagnosis of ITG in both cases. There is no consensus for the treatment of ITG. The first patient was treated with combination of steroids and mycophenolate mofetil with reduction of the 24-hour proteinuria, but with persistence of the chronic kidney disease. The second patient received high doses of steroids with continuous deterioration of kidney function with the need of hemodialysis treatment.
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Affiliation(s)
- Vlatko Karanfilovski
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Vesna Ristovska
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Nikola Gjorgjievski
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Igor G. Nikolov
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Pavlina Dzekova-Vidimliski
- University Hospital of Nephrology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
| | - Gordana Petrushevska
- Institute of Pathology, Medical Faculty, Ss. Cyril and Methodius University- Skopje, Republic of North Macedonia
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7
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Doraiswamy M, Parikh SV, Brodsky S. A Rare Case of Recurrent Immunotactoid Glomerulonephritis. Cureus 2023; 15:e35136. [PMID: 36949975 PMCID: PMC10026602 DOI: 10.7759/cureus.35136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2023] [Indexed: 02/20/2023] Open
Abstract
Immunotactoid glomerulopathy is an uncommon cause of glomerular disease that results from deposits derived from immunoglobulins. This rare disease can occur in native kidneys and in transplant patients. They are present only in 0.5% to 1.4% of native kidney biopsies. Treatment of this disease is directed at the underlying monoclonal gammopathy, infection, and B-cell lymphoproliferative disorders. Prognosis is very guarded with 50% of people developing ESRD within five years of diagnosis. We present an interesting, rare case of recurrent immunotactoid glomerulonephritis which responded appropriately to rituximab therapy.
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Affiliation(s)
- Mohankumar Doraiswamy
- Department of Internal Medicine, Arkansas College of Osteopathic Medicine, Fort Smith, USA
- Depatment of Internal Medicine, Mercy Health, Fort Smith, USA
| | - Samir V Parikh
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, USA
| | - Sergey Brodsky
- Department of Pathology, The Ohio State University Wexner Medical Center, Columbus, USA
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8
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Sugita E, Sonoda H, Ryuzaki M, Hashiguchi A, Tokuyama H, Wakino S, Kanda T, Itoh H. Diagnosis of monoclonal immunotactoid glomerulopathy with positive λ chain by immunoelectron microscopy. CEN Case Rep 2023; 12:7-13. [PMID: 35699924 PMCID: PMC9892404 DOI: 10.1007/s13730-022-00714-1] [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: 12/19/2021] [Accepted: 05/24/2022] [Indexed: 02/05/2023] Open
Abstract
We report the case of a 73-year-old-man who developed immunotactoid glomerulopathy (ITG). ITG is a rare disease characterized by proliferative glomerulonephritis and capillary wall deposits with a 10-60 nm diameter microtubular substructure. In monoclonal ITG, immunofluorescence analysis typically exhibits IgG with light chain restriction. Recent reviews recommend distinguishing monoclonal ITG from polyclonal ITG because monoclonal ITG is associated with a higher incidence of hematological disorders and better responsiveness to clone-directed therapy and renal prognosis. In our case, IgG, IgA, and IgM were negative by routine immunofluorescence; however, immunoelectron microscopy revealed positive λ chain. At 6 months after renal biopsy, the IgG λ chain was detected in the serum and urine, reflecting possible monoclonality. Therefore, it is useful to perform immunoelectron microscopy and follow-up with serum and urine protein electrophoresis and immunofixation to diagnose monoclonal ITG, even when routine immunofluorescence shows negative or nonspecific findings.
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Affiliation(s)
- Erina Sugita
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Homare Sonoda
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Masaki Ryuzaki
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Akinori Hashiguchi
- Department of Pathology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Hirobumi Tokuyama
- Department of Internal Medicine, Tokyo Dental University Ichikawa General Hospital, 5-11-13 Sugano, Ishikawa-shi, Chiba, 272-8513, Japan
| | - Shu Wakino
- Division of Nephrology, Department of Internal Medicine, Tokushima University School of Medicine, 2-50-1 Kuramoto-cho, Tokushima-shi, Tokushima, 770-8503, Japan
| | - Takeshi Kanda
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan.
| | - Hiroshi Itoh
- Division of Endocrinology, Metabolism and Nephrology, Department of Internal Medicine, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
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9
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Sethi S, Palma LMP, Theis JD, Fervenza FC. Proteomic Analysis of Complement Proteins in Glomerular Diseases. Kidney Int Rep 2023; 8:827-836. [PMID: 37069992 PMCID: PMC10105064 DOI: 10.1016/j.ekir.2023.01.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 01/18/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Introduction Complement plays an important role in the pathogenesis of glomerulonephritis (GN). Even though the underlying etiology of GN might be different, complement activation with subsequent glomerular deposition of complement proteins result in glomerular injury and progression of the lesions. Routine immunofluorescence microscopy (IF) includes staining for only complement factors C3c and C1q. Therefore, with regard to evaluation of the complement pathways, routine kidney biopsy provides only limited information. Methods In this study, using laser microdissection of glomeruli followed by mass spectrometry, complement proteins and pathways involved in GN were analyzed. Results We found that C3 followed by C9 are the most abundant complement proteins in GN, indicating activation of classical or lectin or alternative, and terminal pathways, either exclusively or in a combination of pathways. Furthermore, depending on the type of GN, C4A and/or C4B were also present. Therefore, membranous nephropathy (MN), fibrillary GN, and infection-related GN showed C4A dominant pathways, whereas lupus nephritis (LN), proliferative GN with monoclonal Ig deposits, monoclonal Ig deposition disease (MIDD), and immunotactoid glomerulopathy showed C4B dominant pathways. Significant deposition of complement regulatory proteins, factor H-related protein-1 (FHR-1) and factor H-related protein-5 (FHR-5), were also detected in most GN. Conclusions This study shows accumulation of specific complement proteins in GN. The complement pathways, complement proteins, and the amount of complement protein deposition are variable in different types of GN. Selective targeting of complement pathways may be a novel option in the treatment of GN.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
- Correspondence: Sanjeev Sethi, Mayo Clinic, 200 1st Street SW, Rochester, Minnesota 55905, USA
| | | | - Jason D. Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
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10
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Rago A, Pettorini L, Andriani A, Caravita di Toritto T. Immunotactoid glomerulopathy and chronic lymphocytic leukemia: The need for a multidisciplinary approach. EJHAEM 2022; 4:266-268. [PMID: 36819169 PMCID: PMC9928648 DOI: 10.1002/jha2.592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 09/22/2022] [Indexed: 12/15/2022]
Abstract
Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in western countries. The association between CLL and glomerular disease (GD) is rare. The most frequent GD associated with CLL is membranoproliferative membranous glomerulonephritis (GN) (MPGN) (45%) types I and II, followed by membranous glomerulonephritis, with the same reports of immunotactoid glomerulopathy (ITG). We report a case of ITG diagnosed on kidney biopsy in a CLL patient and the response of renal parameters to drug treatment for CLL. The patient was treated with several lines of therapies with a good response.
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Affiliation(s)
- Angela Rago
- Haematology Unit, ASL ROMA 1Santo Spirito Hospital of RomeRomeItaly
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11
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Bu L, Javaugue V, Chauvet S, Napier J, Dasari S, Theis JD, Vrana JA, McPhail ED, Nasr SH. Light Chain-Only Immunotactoid Glomerulopathy: A Case Report. Am J Kidney Dis 2022; 81:611-615. [PMID: 36328099 DOI: 10.1053/j.ajkd.2022.08.025] [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: 05/25/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022]
Abstract
The monotypic variant of immunotactoid glomerulopathy (ITG), strongly associated with low-grade lymphoproliferative disorders, is characterized histologically by glomerulonephritis and microtubular deposits of monoclonal immunoglobulin G (IgG). We report a patient with high-risk κ light chain multiple myeloma who presented with acute kidney injury, hematuria, proteinuria, and hypocomplementemia. Kidney biopsy revealed immunotactoid glomerulopathy concomitant with κ light chain myeloma cast nephropathy. The glomerular microtubular deposits stained for κ light chain and C3 only. Proteomic analysis of glomeruli and atypical casts detected κ light chain constant domain and a single VL variability subgroup (IGKV3) in both glomeruli and casts (without γ, α, or μ heavy chain or λ light chain). C3, C5, C6, C7, and C9 were detected in glomeruli. No autoantibodies against alternative pathway of complement proteins were detected. Despite clone-directed chemotherapy, the patient remained on dialysis treatment. For this light chain-only variant of immunotactoid glomerulopathy, pathogenesis potentially involves activation of the alternative pathway of complement by a nephrotoxic κ light chain.
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Affiliation(s)
- Lihong Bu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
| | - Vincent Javaugue
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Sophie Chauvet
- Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Department of Nephrology, Paris, France; INSERM UMRS1138, Research Center Cordeliers, Paris Descartes Sorbonne Paris-Cité University, Paris, France
| | - Jerold Napier
- Up Health System Medical Specialists, Marquette, Michigan
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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12
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Wang Y, Yan Y, Dong B, Zou W, Li X, Shao C, Jiang L, Wang M, Zuo L. Clinicopathological manifestations of coexistent monoclonal immunoglobulin deposition disease and immunotactoid glomerulopathy. Front Med (Lausanne) 2022; 9:911998. [PMID: 36091681 PMCID: PMC9452626 DOI: 10.3389/fmed.2022.911998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Combination of monoclonal immunoglobulin deposition disease (MIDD) and immunotactoid glomerulopathy (ITG) is a rare form of monoclonal immunoglobulin (MIg)-associated renal disease. We retrospectively reviewed the native kidney biopsy specimens at Peking University People’s Hospital from 2011 to 2020. Five patients were diagnosed as MIDD + ITG. Their clinical and pathological characteristics were studied. The typical clinical features were nephritic syndrome and renal dysfunction with prominent anemia, but hematuria was mild. Unlike single MIDD and single ITG, on light microscopy, segmentally distributed mesangial nodular sclerosis on the basis of mesangial matrix hyperplasia was the major lesion. Others including membranoproliferative glomerulonephritis (MPGN)-like lesion, glomerular basement membrane thickness, and mild to moderate mesangial and endothelial proliferations might presented at the same time and in the same glomeruli. On immunofluorescence, MIg, usually monoclonal light chains, deposited along glomerular basement membranes and tubular basement membranes, while the intact MIg or monoclonal heavy chain deposited in the mesangial regions. Corresponding to the depositions on immunofluorescence, punctate “powdery” deposits along glomerular basement membranes and tubular basement membranes under electronic microscopy indicated the presence of MIDD. Microtubular substructures (diameters of 20–50 nm) exhibiting hollow cores arranged in parallel arrays in mesangial regions indicated the presence of ITG. Patients treated with bortezomib-based regimen seemed to have better outcomes. In conclusion, MIDD + ITG is a rare combination form of MIg-associated renal disease. Accurate diagnosis requires the comprehensive pathological investigations.
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Affiliation(s)
- Yina Wang
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Yu Yan
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
- *Correspondence: Yu Yan,
| | - Bao Dong
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Wanzhong Zou
- Department of Pathology, Peking University Health Science Center, Beijing, China
| | - Xin Li
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Chunying Shao
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Lei Jiang
- Electron Microscope Laboratory, Peking University People’s Hospital, Beijing, China
| | - Mei Wang
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Li Zuo
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
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13
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Takahashi H, Sano T, Kawamura S, Sano K, Miyasaka R, Yamazaki T, Sakakibara M, Abe T, Hashimoto K, Nagaoka M, Kamata M, Naito S, Aoyama T, Moriya R, Takeuchi Y. Long-term clinical course of immunotactoid glomerulopathy complicated with diffuse large B-cell lymphoma. CEN Case Rep 2022; 11:184-190. [PMID: 34569002 PMCID: PMC9061912 DOI: 10.1007/s13730-021-00648-0] [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: 02/01/2021] [Accepted: 09/15/2021] [Indexed: 11/25/2022] Open
Abstract
We report a case of immunotactoid glomerulopathy (ITG) complicated with diffuse large B-cell lymphoma (DLBCL). A 68-year-old woman presented with leg edema and was diagnosed with nephrotic syndrome (NS). Renal biopsy revealed ITG. We treated the patient with prednisolone (20 mg/day) and she achieved complete remission of NS. Steroids were gradually reduced. After 1 year, the patient presented with a breast mass determined on biopsy to be DLBCL. She underwent six cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) therapy. Follow-up revealed complete remission of both DLBCL and ITG. NS recurred after 5 years and she was simultaneously diagnosed with recurrence of DLBCL in bone marrow. She underwent four cycles of R-EPOCH (rituximab, etoposide, prednisolone, vincristine, cyclophosphamide, doxorubicin) therapy and entered remission for DLBCL. NS improved, but the treatment did not lead to remission. After 2 additional years, NS and DLBCL recurred again. She was administered rituximab and NS improved, although proteinuria tended to increase thereafter. One year later, we started prednisolone (10 mg/day), and proteinuria tended to decrease. She is currently undergoing outpatient follow-up. This case suggests that ITG with MGUS should be treated with the possibility of developing malignant hematological disease during the course.
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Affiliation(s)
- Haruka Takahashi
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan.
| | - Takashi Sano
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Sayumi Kawamura
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Keiko Sano
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Ryoma Miyasaka
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takuya Yamazaki
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Mayuko Sakakibara
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Tetsuya Abe
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Keiko Hashimoto
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Miki Nagaoka
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Mariko Kamata
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shokichi Naito
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Togo Aoyama
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Rika Moriya
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Yasuo Takeuchi
- Department of Nephrology, Kitasato University School of Medicine, Sagamihara, Japan
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14
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Cho H. Diagnosis and management of monoclonal gammopathy of clinical significance. Blood Res 2022; 57:20-26. [PMID: 35483921 PMCID: PMC9057659 DOI: 10.5045/br.2022.2022035] [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] [Received: 02/05/2022] [Revised: 02/20/2022] [Accepted: 02/21/2022] [Indexed: 11/17/2022] Open
Abstract
The term "monoclonal gammopathy of clinical significance" (MGCS) refers to any plasma cell or B-cell clonal disorder that does not meet the current criteria for malignant disorders but produces a monoclonal protein that directly or indirectly results in organ damage. The most commonly affected organs are the kidneys, nerves, and skin. This review summarizes the current classification of MGCS and its diagnostic and treatment approaches.
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Affiliation(s)
- Hyungwoo Cho
- Department of Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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15
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Fourdinier O, Ulrich M, Karras A, Olagne J, Buob D, Audard V, Vigneau C, Gibier JB, Guerrot D, Massy Z, Vuiblet V, Rabot N, Goujon JM, Cordonnier C, Choukroun G, Titeca-Beauport D. Glomerulonephritis with non-Randall-type, non-cryoglobulinemic monoclonal immunoglobulin G deposits [PGNMID and ITG]. Clin Kidney J 2022; 15:1727-1736. [PMID: 36003672 PMCID: PMC9394706 DOI: 10.1093/ckj/sfac085] [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: 11/04/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Glomerulonephritis (GN) with non-Randall-type, non-cryoglobulinemic monoclonal immunoglobulin G deposits encompasses rare diseases [proliferative GN with non-organized deposits (PGNMID) and immunotactoid GN] that cannot be distinguished without ultrastructural analysis by electron microscopy (EM).
Methods
Here, we report and analyze the prognosis of 41 EM-proven (PGNMID for 39/41) and 22 non-EM-proven/DNAJB9-negative cases, diagnosed between 2001 and 2019 in 12 French nephrology centers.
Results
Median serum creatinine (SCr) at presentation was 150 [92-256] μmol/L. The predominant histological pattern was membranoproliferative GN (79%), with IgG3 (74%) kappa (78%) deposits the most frequently observed. Disease presentation and patient management were similar between EM-proven and non-EM-proven cases. A serum monoclonal spike was detected for 21 patients and 10 had an underlying hematological malignancy. First-line therapy was mixed between clone-targeted therapy (n = 33), corticosteroids (n = 9), and RAAS-inhibitors (n = 19). After six months, nine patients achieved complete and 23 partial renal recovery. In univariate analysis, renal recovery was associated with baseline SCr (OR 0.70, p = 0.07). After a median follow-up of 52 [35–74] months, 38% of patients had progressed to end-stage kidney disease independently associated with baseline SCr (HR 1.41, p = 0.003) and glomerular crescentic proliferation (HR 4.38, p = 0.004).
Conclusions
Our results confirm that non-cryoglobulinemic and non-Randall GN with monoclonal IgG deposits are rarely associated with hematological malignancy. The prognosis is uncertain but may be improved by early introduction of a specific therapy.
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Affiliation(s)
- Ophélie Fourdinier
- Department of Nephrology, Dialysis and Transplantation, University Hospital, and MP3CV Research Laboratory, Jules Verne Picardie University, Amiens, France
| | - Marc Ulrich
- Department of Nephrology, Hôpital Jean Bernard, Valenciennes, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Jérôme Olagne
- Department of Nephrology and Transplantation, Department of Pathology, University Hospital, Strasbourg, France
| | - David Buob
- Department of Pathology, Hôpital Tenon, APHP, Paris, France
| | - Vincent Audard
- Department of Nephrology and Transplantation, Henri Mondor University Hospital, APHP, and Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U 955, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Cécile Vigneau
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000 Rennes, France
| | | | | | - Ziad Massy
- Department of Nephrology, Ambroise Paré Hospital, APHP, Boulogne Billancourt, Paris, and Inserm Unit 1018, Team 5, CESP, Versailles Saint-Quentin-en-Yvelines University, Paris Saclay University, Villejuif, France
| | - Vincent Vuiblet
- Department of Nephrology and Transplantation, University Hospital, Reims, France
| | - Nolwenn Rabot
- Department of Nephrology, University Hospital, Tours, France
| | - Jean-Michel Goujon
- Department of Nephrology, and Department of Pathology and Ultrastructural Pathology, University Hospital, Poitiers, France
| | | | - Gabriel Choukroun
- Department of Nephrology, Dialysis and Transplantation, University Hospital, and MP3CV Research Laboratory, Jules Verne Picardie University, Amiens, France
| | - Dimitri Titeca-Beauport
- Department of Nephrology, Dialysis and Transplantation, University Hospital, and MP3CV Research Laboratory, Jules Verne Picardie University, Amiens, France
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16
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Sy-Go JPT, Herrmann SM, Seshan SV. Monoclonal Gammopathy-Related Kidney Diseases. Adv Chronic Kidney Dis 2022; 29:86-102.e1. [PMID: 35817530 DOI: 10.1053/j.ackd.2022.01.004] [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: 07/14/2021] [Revised: 12/09/2021] [Accepted: 01/18/2022] [Indexed: 11/11/2022]
Abstract
Monoclonal gammopathies occur secondary to a broad range of clonal B lymphocyte or plasma cell disorders, producing either whole or truncated monoclonal immunoglobulins. The kidneys are often affected by these monoclonal proteins, and, although not mutually exclusive, can involve the glomeruli, tubules, interstitium, and vasculature. The nephrotoxic potential of these monoclonal proteins is dependent on a variety of physicochemical characteristics that are responsible for the diverse clinicopathologic manifestations, including glomerular diseases with organized deposits, glomerular diseases with granular deposits, and other lesions, such as C3 glomerulopathy and thrombotic microangiopathy with unique pathophysiologic features. The diseases that involve primarily the tubulointerstitial and vascular compartments are light chain cast nephropathy, light chain proximal tubulopathy, crystal-storing histiocytosis, and crystalglobulin-induced nephropathy with distinct acute and chronic clinicopathologic features. The diagnosis of a monoclonal gammopathy-related kidney disease is established by identification of an underlying active or more commonly, low-grade hematologic malignancy, serologic evidence of a monoclonal gammopathy when detectable, and most importantly, monoclonal protein-induced pathologic lesions seen in a kidney biopsy, confirming the association with the monoclonal protein. Establishing a diagnosis may be challenging at times, particularly in the absence of an overt hematologic malignancy, with or without monoclonal gammopathy, such as proliferative glomerulonephritis with monoclonal immunoglobulin deposits. Overall, the treatment is directed against the underlying hematologic disorder and the potential source of the monoclonal protein.
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Affiliation(s)
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| | - Surya V Seshan
- Department of Anatomic Pathology and Clinical Pathology, Weil Cornell Medical College, New York, NY
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17
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Tang X, Wan F, Yu J, Li X, Yang R, Zhu B. Clinicopathological characteristics of patients with paraproteinemia and renal damage. Eur J Med Res 2021; 26:68. [PMID: 34217367 PMCID: PMC8255003 DOI: 10.1186/s40001-021-00538-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/22/2021] [Indexed: 12/26/2022] Open
Abstract
Background This study aimed to analyze the clinicopathological characteristics of patients with paraproteinemia and renal damage. Methods Ninety-six patients from 2014 to 2018 with paraproteinemia and renal damage were enrolled and the clinical data, renal pathology, treatment and prognosis data were collected. Results A total of 96 patients (54 male and 42 female), accounting for 2.7% of all renal biopsies, were enrolled in this study. Among them, 42 were monoclonal gammopathy of renal significance (MGRS), 21 were renal monotypic immunoglobulin alone (renal monoIg), and 19 were monoclonal gammopathy of undetermined significance (MGUS). Individuals with multiple myeloma (MM) accounted for the fewest number of patients (n = 14). In the MGRS group, the main diseases were amyloidosis (n = 25) and cryoglobulinemic glomerulonephritis (n = 7), while in the MM group, the main diseases were cast nephropathy (n = 9) and light chain deposit disease (n = 3). In the MGUS group, it was mainly IgA nephropathy (IgAN, n = 10) and idiopathic membranous nephropathy (n = 5); while in the renal monoIg group, most of the cases were IgAN (n = 19). Chemotherapy was mainly administered to patients in the MM group, while immunosuppression therapy was mostly administered to patients in the renal monoIg group. Most patients with renal monoIg exhibited a major response, followed by the patients with MGUS and MGRS, while most of the patients with MM had a partial response but none had a major response. Approximately more than half (57.1%) of the patients with MM progressed to end-stage renal disease (ESRD), followed by MGRS (33.3%); however, the mortality rate was low in both the MGRS and MM groups. The survival analysis reviewed that serum creatinine, hemoglobin levels, and the serum κ/λ ratio were independent risk factors for ESRD in patients with MGRS. Conclusions The clinicopathological changes in patients with MGRS were between those in patients with MM and MGUS. The treatment for MGRS and MM was more intensive, and the overall mortality rate was low. Both MGUS and renal monoIg alone exhibited slighter clinicopathological features than MGRS and MM, and the treatment was focused mostly on primary renal diseases.
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Affiliation(s)
- Xuanli Tang
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China.
| | - Feng Wan
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Jin Yu
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Xiaohong Li
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Ruchun Yang
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Bin Zhu
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
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18
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Shimizu Y, Wakabayashi K, Iwasaki H, Kishida C, Seki S, Okuma T, Iwakami N, Iwasawa T, Maekawa H, Tomino Y, Wada R, Suzuki Y. Immunotactoid Glomerulopathy with Nontuberculous Mycobacterial Infection: A Novel Association. Case Rep Nephrol Dial 2021; 11:136-146. [PMID: 34250031 PMCID: PMC8255749 DOI: 10.1159/000515583] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Accepted: 03/01/2021] [Indexed: 12/23/2022] Open
Abstract
A 70-year-old woman underwent a renal biopsy due to nephrotic syndrome. She had suffered from nontuberculous mycobacterial infection (NTM) for 14 years. The patient was diagnosed as having membranoproliferative glomerulonephritis (MPGN) type 3 and immunoglobulin (Ig)-associated MPGN based upon LM/erythromycin and IF findings, respectively. In high-magnification imaging, electron-dense deposits showed immunotactoid glomerulopathy (ITG). There was no evidence of hematological cancer, and the patient improved after receiving treatments for NTM. To the best of our knowledge, this patient is the first to show an association between ITG and NTM. Although ITG is generally considered as related to lymphoproliferative disease, it is suggested that ITG is driven by bacterial infection and is a potential outcome of Ig-associated MPGN.
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Affiliation(s)
- Yoshio Shimizu
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan.,Shizuoka Medical Research Center for Disaster, Juntendo University, Izunokuni, Japan
| | - Keiichi Wakabayashi
- Division of Nephrology, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Hiroyuki Iwasaki
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Chiaki Kishida
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Sayaka Seki
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Teruyuki Okuma
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Naoko Iwakami
- Division of Respiratory Medicine, Department of Internal Medicine, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Takumi Iwasawa
- Shizuoka Medical Research Center for Disaster, Juntendo University, Izunokuni, Japan
| | - Hiroshi Maekawa
- Department of Surgery, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Yasuhiko Tomino
- Asian Pacific Renal Research Promotion Office, Medical Corporation SHOWAKI, Tokyo, Japan
| | - Ryo Wada
- Division of Pathology, Juntendo University Shizuoka Hospital, Izunokuni, Japan
| | - Yusuke Suzuki
- Department of Nephrology, Juntendo University Faculty of Medicine, Tokyo, Japan
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19
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Yamashita M, Lin MY, Hou J, Ren KY, Haas M. The Continuing Need for Electron Microscopy in Examination of Medical Renal Biopsies: Examples in Practice. GLOMERULAR DISEASES 2021; 1:145-159. [PMID: 36751496 PMCID: PMC9677721 DOI: 10.1159/000516831] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 04/23/2021] [Indexed: 12/24/2022]
Abstract
Background For the better part of the past 6 decades, transmission electron microscopy (EM), together with routine light microscopy and immunofluorescence and/or immunohistochemistry (IHC), has been an essential component of the diagnostic workup of medical renal biopsies, particularly native renal biopsies, with increasing frequency in renal allograft biopsies as well. Studies performed prior to the year 2000 have indeed shown that a substantial fraction of renal biopsies cannot be accurately diagnosed without EM. Still, EM remains costly and labor-intensive, and with increasing pressure to reduce healthcare costs, some centers are de-emphasizing diagnostic EM. This trend has been coupled with advances in IHC and other methods in renal biopsy diagnosis over the past 2-3 decades. Summary Nonetheless, it has been our experience that the diagnostic value of EM in the comprehensive evaluation of renal biopsies remains similar to what it was 20-30 years ago. In this review, we provide several key examples from our practice where EM was essential in making the correct renal biopsy diagnosis, ranging from relatively common glomerular lesions to rare diseases. Key Messages EM remains an important component of the diagnostic evaluation of medical renal biopsies. Failure to perform EM in certain cases will result in an incorrect diagnosis, with possible clinical consequences. We strongly recommend that tissue for EM be taken and stored in an appropriate fixative and ultrastructural studies be performed for all native renal biopsies, as well as appropriate renal allograft biopsies as recommended by the Banff consortium.
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20
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Affiliation(s)
- Nelson Leung
- From the Divisions of Nephrology and Hypertension and of Hematology (N.L.) and the Department of Laboratory Medicine and Pathology (S.H.N.), Mayo Clinic, Rochester, MN; and Department of Nephrology and Centre d'Investigation Clinique INSERM 1402, Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, and Centre National de la Recherche Scientifique UMR7276, Université de Limoges, Limoges - all in France (F.B.)
| | - Frank Bridoux
- From the Divisions of Nephrology and Hypertension and of Hematology (N.L.) and the Department of Laboratory Medicine and Pathology (S.H.N.), Mayo Clinic, Rochester, MN; and Department of Nephrology and Centre d'Investigation Clinique INSERM 1402, Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, and Centre National de la Recherche Scientifique UMR7276, Université de Limoges, Limoges - all in France (F.B.)
| | - Samih H Nasr
- From the Divisions of Nephrology and Hypertension and of Hematology (N.L.) and the Department of Laboratory Medicine and Pathology (S.H.N.), Mayo Clinic, Rochester, MN; and Department of Nephrology and Centre d'Investigation Clinique INSERM 1402, Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, and Centre National de la Recherche Scientifique UMR7276, Université de Limoges, Limoges - all in France (F.B.)
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21
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Aucouturier P, D'Agati VD, Ronco P. A Fresh Perspective on Monoclonal Gammopathies of Renal Significance. Kidney Int Rep 2021; 6:2059-2065. [PMID: 34386655 PMCID: PMC8343799 DOI: 10.1016/j.ekir.2021.04.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/15/2021] [Accepted: 04/19/2021] [Indexed: 11/20/2022] Open
Abstract
Monoclonal gammopathies of renal significance (MGRS) encompass a remarkable variety of kidney diseases that result from intrinsic nephrotoxic properties of certain monoclonal Igs or their subunits. Effective disease-modifying treatments rely on the targeting of a malignant B-cell clone that may be demonstrable but often is quite hypothetical. Hence, convincing arguments for the genuine monoclonal character of the causative mono-isotypic Ig tissue deposits is needed for design of appropriate treatment strategies. The purpose of this article was to critically analyze distinct situations of suspected MGRS that occur in the practice of pathologists, nephrologists, hematologists, and immunologists. A particular focus of interest is the group of conditions known as proliferative glomerulonephritis with mono-isotypic immunoglobulin deposits (PGNMIDs), which illustrates the difficulties and ambiguities surrounding a definitive assignment of MGRS status.
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Affiliation(s)
- Pierre Aucouturier
- Hôpital St-Antoine, Département d'Immunologie Biologique, AP-HP, and Sorbonne Université / Inserm UMRS 938, Paris, France
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | - Pierre Ronco
- Sorbonne Université / Inserm UMRS 1155, Paris, France; Service de Néphrologie Centre Hospitalier du Mans, Le Mans, France
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22
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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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23
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Hogan JJ, Vogl DT. Untangling immunotactoid glomerulopathy in the MGRS era. Kidney Int 2021; 99:303-305. [PMID: 33509349 DOI: 10.1016/j.kint.2020.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 12/31/2022]
Abstract
Immunotactoid glomerulopathy (ITG) is a rare disease diagnosed by kidney biopsy showing characteristic microtubules, often in parallel arrays, in glomeruli on electron microscopy. Most cases are caused by lymphoproliferative disorders that produce monoclonal immunoglobulins that cause kidney damage, but these disorders do not meet criteria for overt malignancy. The published literature on ITG is limited. In this issue of Kidney International, 2 manuscripts provide significant insight into the clinical presentation, pathology, and treatment of ITG.
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Affiliation(s)
- Jonathan J Hogan
- Division of Nephrology Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
| | - Dan T Vogl
- Abramson Cancer Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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24
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Kudose S, Canetta P, Andeen NK, Stokes MB, Batal I, Markowitz GS, D’Agati VD, Santoriello D. Diagnostic Approach to Glomerulonephritis With Fibrillar IgG Deposits and Light Chain Restriction. Kidney Int Rep 2021; 6:936-945. [PMID: 33912743 PMCID: PMC8071626 DOI: 10.1016/j.ekir.2021.01.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 12/03/2020] [Accepted: 01/04/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction The pathologic approach to glomerulonephritis (GN) with fibrillar IgG deposits and light chain restriction remains a diagnostic challenge. Method All GN with fibrillar deposits of IgG and apparent light chain restriction on standard immunofluorescence on frozen tissue (IF-F) accessioned at the Columbia Renal Pathology Laboratory from 2012 to 2019 were identified. Additional studies including staining for Congo red, DNAJB9, IgG subtypes, and immunofluorescence on pronase-digested paraffin sections (IF-P) were performed. Result Based on the results, biopsy samples were reclassified as polytypic DNAJB9-positive fibrillary glomerulonephritis (pFGN, n = 14), monotypic DNAJB9-positive FGN (mFGN, n = 7), GN with polytypic DNAJB9-negative fibrillar IgG deposits (n = 2), and GN with monotypic DNAJB9-negative fibrillar IgG deposits (n = 6). Among DNAJB9-positive FGN samples, IgG subtype staining was able to exclude monotypic deposits by demonstrating reactivity for ≥2 IgG subtypes (usually IgG1 and IgG4) in 67% (14 of 21), including 9 that would have been misclassified as monotypic by IF-F and IF-P alone. Monotypic DNAJB9-positive fibrillary glomerulonephritis (FGN) was not associated with monoclonal gammopathy in 5 of 6 patients. GN with monotypic DNAJB9-negative fibrillar IgG deposits exhibited focal parallel fibril alignment and frequent association with chronic lymphocytic leukemia, but lacked the diagnostic microtubules of immunotactoid GN. Conclusion A systematic diagnostic approach with ancillary techniques is essential for proper classification and assignment of monoclonal gammopathy of renal significance status in cases of GN with fibrillary IgG deposits and light chain restriction by IF-F.
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Affiliation(s)
- Satoru Kudose
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Pietro Canetta
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center, New York, New York, USA
| | - Nicole K. Andeen
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - M. Barry Stokes
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Glen S. Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vivette D. D’Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
- Correspondence: Dominick Santoriello, Department of Pathology, Columbia University Irving Medical Center, 630 West 168th Street, Room VC14-224, New York, New York 10032, USA.
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25
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Quattrocchio G, Barreca A, Vaccarino A, Del Vecchio G, De Simone E, Fenoglio R, Ferro M, Pagliaro M, Pini M, Manes M, Roccatello D. Monoclonal Gammopathy of Renal Significance: Clinical and Histological Efficacy of a Bortezomib-Based Regimen. Front Med (Lausanne) 2020; 7:587345. [PMID: 33392216 PMCID: PMC7772466 DOI: 10.3389/fmed.2020.587345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 11/23/2020] [Indexed: 12/20/2022] Open
Abstract
Monoclonal Gammopathy of Renal Significance (MGRS) is a group of heterogeneous disorders characterized by renal dysfunction secondary to the production of a monoclonal immunoglobulin by a nonmalignant B cell or plasma cell clone. We report the clinical and histological outcomes of two patients with biopsy-proven MGRS: one patient showed membranoproliferative glomerulonephritis with monoclonal k-light chain and C3 deposits, the second patient showed immunotactoid glomerulopathy. Both patients were treated with a 9-month chemotherapy protocol including bortezomib, cyclophosphamide, and dexamethasone. Renal biospy was repeated after 1 year. The estimated glomerular filtration rate (eGFR) increased from 22.5 (baseline) to 40 ml/min per 1.73 m2 after 12 months, then to 51.5 ml/min per 1.73 m2 after 24 months; proteinuria decreased from 4.85 (baseline) to 0.17 g/day after 12 months, then to 0.14 g/day after 24 months. Repeat renal biopsies showed a dramatic improvement of the glomerular proliferative lesions and near complete disappearance of the immune deposits. A bortezomib-based treatment proved very effective and was well-tolerated in the two patients presenting with clinically and histologically aggressive MGRS.
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Affiliation(s)
| | - Antonella Barreca
- Division of Pathology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Antonella Vaccarino
- Hematology and Thrombotic Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | | | | | - Roberta Fenoglio
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Michela Ferro
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Maria Pagliaro
- Hematology and Thrombotic Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | - Massimo Pini
- Hematology and Thrombotic Diseases, San Giovanni Bosco Hospital, Turin, Italy
| | - Massimo Manes
- Nephrology and Dialysis Unit, Umberto Parini Hospital, Aosta, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit, San Giovanni Bosco Hospital, Turin, Italy.,Center of Research of Immunopathology and Rare Diseases (CMID), Department of Rare, Immunologic, Hematologic and Immunohematologic Diseases, San Giovanni Bosco Hospital, University of Turin, Turin, Italy
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26
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Dispenzieri A. Monoclonal gammopathies of clinical significance. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:380-388. [PMID: 33275738 PMCID: PMC7727544 DOI: 10.1182/hematology.2020000122] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
"Monoclonal gammopathy of clinical significance" (MGCS) is the term used to describe nonmalignant monoclonal gammopathies causing important disease. MGCS is the differential diagnosis for any patient presenting with what appears to be a monoclonal gammopathy of undetermined significance but is also experiencing other unexplained symptoms. Broadly, these conditions can be separated into symptoms and signs referable to the nerves, the kidneys, and the skin. The first step in making these diagnoses is to consider them. With a particular condition in mind, the next step is to order those tests that can help confirm or dismiss a particular diagnosis. Nearly all of the renal and dermatologic conditions are diagnosed by renal and skin biopsies, respectively. The importance of a highly competent renal pathologist and dermatopathologist cannot be underestimated. Biopsy is less specific for the neuropathic conditions. Because several of the MGCSs are syndromes, recognizing other manifestations is also key. Treatment recommendations for many of these conditions are anecdotal because of their rarity, but for several of the conditions, IV immunoglobulin, rituximab, and plasma cell-directed therapy are the best options.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology and Division of Clinical Chemistry, Mayo Clinic, Rochester, MN
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27
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Vanga A, Magoon S, Kowalewska J, Mussarat S. Fibrilo-Tactoid Glomerulonephritis: A Possible Novel Morphological Variant. Case Rep Nephrol Dial 2020; 10:154-162. [PMID: 33363217 PMCID: PMC7747065 DOI: 10.1159/000510871] [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] [Received: 05/13/2020] [Accepted: 08/12/2020] [Indexed: 11/19/2022] Open
Abstract
Fibrillary and immunotactoid glomerulonephritis are infrequent causes of primary nephrotic range proteinuria and are poorly understood. Recent significant developments include the discovery of DNA JB9 antigen in fibrillary glomerulonephritis. Here, we present a case of a middle-aged woman who presented with nephrotic range proteinuria, hematuria, and normal renal function. Renal biopsy revealed fibrils that were randomly arranged on electron microscopy. They were of small size and congo red negative similar to the ones found in fibrillary glomerulonephritis, but were also DNA JB 9 negative, and had a hollow core like in immunotactoid glomerulopathy. Though we try to classify these conditions into either immunotactoid glomerulonephropathy (ITGN) or fibrillary glomerulonephritis (FGN), there are scenarios such as this case where it does not fit into either and is probably an overlap or intermediate variant of these two conditions. Pathological features of these glomerulonephrites are discussed together with their clinical implications, treatment choices, and diagnostic importance.
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Affiliation(s)
- Amaresh Vanga
- Department of Nephrology and Hypertension, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Sandeep Magoon
- Department of Nephrology and Hypertension, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Jolanta Kowalewska
- Department of Pathology, Eastern Virginia Medical School, Norfolk, Virginia, USA
| | - Saad Mussarat
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, Virginia, USA
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28
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Herrera GA. Renal amyloidosis with emphasis on the diagnostic role of electron microscopy. Ultrastruct Pathol 2020; 44:325-341. [PMID: 33167761 DOI: 10.1080/01913123.2020.1844355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Our understanding of renal diseases with structured deposits has improved in the last two decades with the development of new diagnostic techniques that also changed the role of ultrastructural pathology in diagnostic decision-making. This review article addresses the current role of electron microscopy in the evaluation of structured deposits and discusses the impact of new developments. The diagnosis in a subset of structured deposits, amyloidosis, relies on morphologic and tinctorial characteristics at the light microscopic level. Congo red staining of tissue with demonstrable birefringence upon polarization has been regarded as the mainstay during tissue evaluation; however, there are pitfalls that must be considered, and electron microscopy remains a crucial adjunct investigative tool. Ultrastructurally the amyloid fibrils are unique with their characteristic appearance. They are randomly arranged, rigid, criss-crossing, non-branching, 7-15 nm (0.07-0.15 um) in diameter and of variable length. The morphology of fibrils is very similar in the different types of amyloidosis. By scanning electron microscopy amyloid fibrils appear artfully displayed. Immunofluorescence and immunohistochemical stains can be used to characterize the type of amyloidosis while mass spectroscopy is extremely useful in cases where typing of the amyloid using the above-mentioned techniques is difficult or equivocal.
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29
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Nasr SH, Kudose SS, Said SM, Santoriello D, Fidler ME, Williamson SR, Damgard SE, Sethi S, Leung N, D'Agati VD, Markowitz GS. Immunotactoid glomerulopathy is a rare entity with monoclonal and polyclonal variants. Kidney Int 2020; 99:410-420. [PMID: 32818517 DOI: 10.1016/j.kint.2020.07.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 06/27/2020] [Accepted: 07/16/2020] [Indexed: 01/25/2023]
Abstract
Immunotactoid glomerulopathy (ITG) is a rare form of glomerulonephritis for which our understanding is limited to case reports and small case series. Herein we describe the clinical, pathologic, and outcome characteristics of 73 patients with ITG who typically presented with proteinuria, hematuria, and renal insufficiency. Hematologic disorders were present in 66% of patients, including lymphoma in 41% (mainly chronic lymphocytic leukemia/small lymphocytic lymphoma), monoclonal gammopathy in 20%, and multiple myeloma in 6%. Light microscopy revealed endocapillary proliferative (35%), membranoproliferative (29%) and membranous (29%) patterns of glomerular involvement. Electron microscopy revealed characteristic microtubular deposits with a diameter of 14-60 nm, hollow cores, frequent parallel alignment, and a predominant distribution outside of the lamina densa of the glomerular basement membrane. Importantly, immunofluorescence revealed IgG-dominant staining which was light chain and IgG subclass restricted in 67% of cases, indicating monoclonal composition. This finding was used to distinguish monoclonal and polyclonal variants of ITG. As compared to polyclonal, monoclonal ITG had a higher incidence of lymphoma (53% vs. 11%), multiple myeloma (8% vs. 0), and monoclonal gammopathy (22% vs. 16%). Monoclonal ITG was more commonly treated with clone-directed therapy, which was associated with more frequent remission and less frequent end stage kidney disease. Thus, a third of ITG cases are polyclonal but a quarter of these cases are associated with hematologic conditions, underscoring the need for hematologic evaluation in all patients with ITG. Hence, based on these distinctions, ITG should be subclassified into monoclonal and polyclonal variants. Prognosis of ITG is good if the underlying hematologic condition is treated.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Satoru S Kudose
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | - Samar M Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | - Mary E Fidler
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sean R Williamson
- Department of Pathology, Henry Ford Health System, Detroit, Michigan, USA
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | - Glen S Markowitz
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
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30
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Pathophysiology and management of monoclonal gammopathy of renal significance. Blood Adv 2020; 3:2409-2423. [PMID: 31409583 DOI: 10.1182/bloodadvances.2019031914] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/09/2019] [Indexed: 12/17/2022] Open
Abstract
Recent years have witnessed a rapid growth in our understanding of the pathogenic property of monoclonal proteins. It is evident that some of these small monoclonal proteins are capable of inducing end-organ damage as a result of their intrinsic physicochemical properties. Hence, an umbrella term, monoclonal gammopathy of clinical significance (MGCS), has been coined to include myriad conditions attributed to these pathogenic proteins. Because kidneys are the most commonly affected organ (but skin, peripheral nerves, and heart can also be involved), we discuss MGRS exclusively in this review. Mechanisms of renal damage may involve direct or indirect effects. Renal biopsy is mandatory and demonstration of monoclonal immunoglobulin in kidney, along with the corresponding immunoglobulin in serum or urine, is key to establish the diagnosis. Pitfalls exist at each diagnostic step, and a high degree of clinical suspicion is required to diagnose MGRS. Recognition of MGRS by hematologists and nephrologists is important, because timely clone-directed therapy improves renal outcomes. Autologous stem cell transplant may benefit selected patients.
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31
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Javaugue V, Dufour-Nourigat L, Desport E, Sibille A, Moulin B, Bataille P, Bindi P, Garrouste C, Mariat C, Karlin L, Nouvier M, Goujon JM, Gnemmi V, Fermand JP, Touchard G, Bridoux F. Results of a nation-wide cohort study suggest favorable long-term outcomes of clone-targeted chemotherapy in immunotactoid glomerulopathy. Kidney Int 2020; 99:421-430. [PMID: 32739419 DOI: 10.1016/j.kint.2020.06.039] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 05/29/2020] [Accepted: 06/11/2020] [Indexed: 12/12/2022]
Abstract
Immunotactoid glomerulopathy is a rare disease defined by glomerular microtubular immunoglobulin deposits. Since management and long-term outcomes remain poorly described, we retrospectively analyzed results of 27 adults from 21 departments of nephrology in France accrued over 19 years. Inclusion criteria were presence of glomerular Congo red-negative monotypic immunoglobulin deposits with ultrastructural microtubular organization, without evidence for cryoglobulinemic glomerulonephritis. Baseline manifestations of this cohort included: proteinuria (median 6.0 g/day), nephrotic syndrome (70%), microscopic hematuria (74%) and hypertension (56%) with a median serum creatinine of 1.5 mg/dL. Nineteen patients had detectable serum and/or urine monoclonal gammopathy. A bone marrow and/or peripheral blood clonal disorder was identified in 18 cases (16 lymphocytic and 2 plasmacytic disorders). Hematologic diagnosis was chronic/small lymphocytic lymphoma in 13, and monoclonal gammopathy of renal significance in 14 cases. Kidney biopsy showed atypical membranous in 16 or membranoproliferative glomerulonephritis in 11 cases, with microtubular monotypic IgG deposits (kappa in 17 of 27 cases), most commonly IgG1. Identical intracytoplasmic microtubules were observed in clonal lymphocytes from 5 of 10 tested patients. Among 21 patients who received alkylating agents, rituximab-based or bortezomib-based chemotherapy, 18 achieved a kidney response. After a median follow-up of 40 months, 16 patients had sustained kidney response, 7 had reached end-stage kidney disease, and 6 died. Chronic/small lymphocytic lymphoma appears as a common underlying condition in immunotactoid glomerulopathy, but clonal detection remains inconstant with routine techniques in patients with monoclonal gammopathy of renal significance. Thus, early diagnosis and hematological response after clone-targeted chemotherapy was associated with favorable outcomes. Hence, thorough pathologic and hematologic workup is key to the management of immunotactoid glomerulopathy.
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Affiliation(s)
- Vincent Javaugue
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; Centre National de la Recherche Scientifique UMR 7276, Institut National de la Santé et de la Recherche Médicale UMR 1262, Contrôle de la réponse immune B et lymphoproliférations, Limoges, France; Department of Nephrology, Centre National de Reference "Amylose AL et autres maladies à dépôt d'immunoglobulines monoclonales," Poitiers, France; Institut National de la Santé et de la Recherche Médicale CIC 1402, Centre Hospitalier Universitaire, Poitiers, France.
| | - Léa Dufour-Nourigat
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Estelle Desport
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; Department of Nephrology, Centre National de Reference "Amylose AL et autres maladies à dépôt d'immunoglobulines monoclonales," Poitiers, France
| | - Audrey Sibille
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; Department of Nephrology, Centre National de Reference "Amylose AL et autres maladies à dépôt d'immunoglobulines monoclonales," Poitiers, France
| | - Bruno Moulin
- Department of Nephrology, Centre Hospitalier Universitaire, Strasbourg, France
| | - Pierre Bataille
- Department of Nephrology, Centre Hospitalier Général, Boulogne-sur-Mer, France
| | - Pascal Bindi
- Department of Nephrology, Centre Hospitalier Général, Verdun, France
| | - Cyril Garrouste
- Department of Nephrology, Centre Hospitalier Universitaire, Clermont-Ferrand, France
| | - Christophe Mariat
- Department of Nephrology, Centre Hospitalier Universitaire, Saint-Etienne, France
| | - Lionel Karlin
- Department of Clinical Hematology, Centre Hospitalier Universitaire Lyon Sud, Hospices Civils de Lyon, Pierre-Benite, France
| | - Mathilde Nouvier
- Department of Nephrology, Centre Hospitalier Universitaire Lyon Sud, Hospices Civils de Lyon, Pierre-Benite, France
| | - Jean-Michel Goujon
- Department of Nephrology, Centre National de Reference "Amylose AL et autres maladies à dépôt d'immunoglobulines monoclonales," Poitiers, France; Department of Pathology and Ultrastructural Pathology, Centre Hospitalier Universitaire, Poitiers, France
| | - Viviane Gnemmi
- Department of Pathology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Jean-Paul Fermand
- Department of Immunology and Hematology, Hôpital Saint Louis, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Guy Touchard
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; Department of Nephrology, Centre National de Reference "Amylose AL et autres maladies à dépôt d'immunoglobulines monoclonales," Poitiers, France
| | - Frank Bridoux
- Department of Nephrology and Renal Transplantation, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France; Centre National de la Recherche Scientifique UMR 7276, Institut National de la Santé et de la Recherche Médicale UMR 1262, Contrôle de la réponse immune B et lymphoproliférations, Limoges, France; Department of Nephrology, Centre National de Reference "Amylose AL et autres maladies à dépôt d'immunoglobulines monoclonales," Poitiers, France; Institut National de la Santé et de la Recherche Médicale CIC 1402, Centre Hospitalier Universitaire, Poitiers, France
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32
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Klomjit N, Alexander MP, Zand L. Fibrillary Glomerulonephritis and DnaJ Homolog Subfamily B Member 9 (DNAJB9). ACTA ACUST UNITED AC 2020; 1:1002-1013. [DOI: 10.34067/kid.0002532020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 07/02/2020] [Indexed: 11/27/2022]
Abstract
Fibrillary GN (FGN) is a rare glomerular disease that is diagnosed based on the presence of fibrils in glomeruli. The fibrils are typically noncongophilic, randomly oriented, and measure 12–24 nm. Traditionally, electron microscopy (EM) has been an important tool to aid in the diagnosis of FGN by identifying the fibrils and to distinguish it from other entities that could mimic FGN. However, recently DnaJ homolog subfamily B member 9 (DNAJB9) has emerged as both a specific and sensitive biomarker in patients with FGN. It allows prompt diagnosis and alleviates reliance on EM. DNAJB9 is a cochaperone of heat shock protein 70 and is involved in endoplasmic reticulum protein-folding pathways. But its role in the pathogenesis of FGN remains elusive. DNAJB9 may act as a putative antigen or alternatively it may secondarily bind to misfolded IgG in the glomeruli. These hypotheses need future studies to elucidate the role of DNAJB9 in the pathogenesis of FGN. The treatment regimen for FGN has been limited due to paucity of studies. Most patients receive combination immunosuppressive regimens. Rituximab has been studied the most in FGN and it may delay disease progression. Prognosis of FGN remains poor and 50% require dialysis within 2 years of diagnosis. Despite its poor prognosis in native kidneys, the rate of recurrence post-transplantation is low (20%) and patient as well as allograft outcomes are similar to patients without FGN.
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33
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Kuang C, Quann K, Liman AK, Frye R, Alshoubaki N, Ramkumar M, Liman AD. A rare case of MGRS with immunotactoid glomerulopathy responding to bortezomib, dexamethasone, and rituximab. Clin Case Rep 2020; 8:1984-1987. [PMID: 33088534 PMCID: PMC7562843 DOI: 10.1002/ccr3.3044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 05/27/2020] [Accepted: 05/28/2020] [Indexed: 11/08/2022] Open
Abstract
Patients with monoclonal gammopathy of renal significance should be treated with clone-directed therapy against sources of monoclonal proteins in order to prevent progression to more advanced monoclonal gammopathies and renal failure.
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Affiliation(s)
- Chaoyuan Kuang
- Hematology/Oncology section VA Pittsburgh Healthcare System Pittsburgh PA USA.,UPMC Hillman Cancer Center Pittsburgh PA USA
| | - Kevin Quann
- Hematology/Oncology section VA Pittsburgh Healthcare System Pittsburgh PA USA.,UPMC Hillman Cancer Center Pittsburgh PA USA
| | - Agnes K Liman
- Pathology and Laboratory Medicine VA Pittsburgh Healthcare System Pittsburgh PA USA
| | - Roy Frye
- Pathology and Laboratory Medicine VA Pittsburgh Healthcare System Pittsburgh PA USA
| | | | - Mohan Ramkumar
- Renal section VA Pittsburgh Healthcare System Pittsburgh PA USA
| | - Andrew D Liman
- Hematology/Oncology section VA Pittsburgh Healthcare System Pittsburgh PA USA
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34
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Sethi S, Fervenza FC. Standardized classification and reporting of glomerulonephritis. Nephrol Dial Transplant 2020; 34:193-199. [PMID: 30124958 DOI: 10.1093/ndt/gfy220] [Citation(s) in RCA: 61] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2018] [Accepted: 06/07/2018] [Indexed: 11/13/2022] Open
Abstract
A kidney biopsy is done to determine the etiology of the glomerulonephritis (GN) and the severity of the lesion, to identify whether other lesions, related to or not related to the GN, are present on the kidney biopsy and finally to ascertain the extent of chronicity of the GN. The etiology of GN is based on the classification of GN into five groups: immune complex-mediated GN, antineutrophil cytoplasmic antibody (ANCA)-associated GN, anti-glomerular basement membrane (GBM) GN, monoclonal immunoglobulin-mediated GN and C3 glomerulopathy. Immune complex GN includes multiple specific diseases such as lupus nephritis, IgA nephropathy, infection-related GN and fibrillary GN. ANCA GN, anti-GBM GN and C3 glomerulopathy are specific diseases in themselves, while monoclonal Ig GN includes proliferative GN with monoclonal Ig deposits and monoclonal Ig deposition disease. Thus identification of the class of GN and within it the specific disease determines the etiology of GN. Ancillary studies may be required to confirm the etiology of GN. The severity of the GN is revealed by the pattern of injury, such as crescentic, necrotizing, diffuse proliferative, exudative, membranoproliferative, mesangial proliferative or a sclerosing GN. Secondary diagnosis either related or unrelated to the GN, such as diabetic glomerulosclerosis, acute tubular necrosis or thrombotic microangiopathy, may also be present. The secondary diagnosis may sometimes be the reason for the kidney biopsy. The chronicity of GN is determined by evaluating the extent of glomerulosclerosis, tubular atrophy and interstitial fibrosis and vascular sclerosis present on the biopsy. This review summarizes the approach to standardizing a kidney biopsy report that includes these components in a logical and sequential manner.
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Affiliation(s)
- Sanjeev Sethi
- Department of Internal Medicine, Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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35
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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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Leung N, Bridoux F, Batuman V, Chaidos A, Cockwell P, D'Agati VD, Dispenzieri A, Fervenza FC, Fermand JP, Gibbs S, Gillmore JD, Herrera GA, Jaccard A, Jevremovic D, Kastritis E, Kukreti V, Kyle RA, Lachmann HJ, Larsen CP, Ludwig H, Markowitz GS, Merlini G, Mollee P, Picken MM, Rajkumar VS, Royal V, Sanders PW, Sethi S, Venner CP, Voorhees PM, Wechalekar AD, Weiss BM, Nasr SH. The evaluation of monoclonal gammopathy of renal significance: a consensus report of the International Kidney and Monoclonal Gammopathy Research Group. Nat Rev Nephrol 2019; 15:45-59. [PMID: 30510265 PMCID: PMC7136169 DOI: 10.1038/s41581-018-0077-4] [Citation(s) in RCA: 283] [Impact Index Per Article: 56.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The term monoclonal gammopathy of renal significance (MGRS) was introduced by the International Kidney and Monoclonal Gammopathy Research Group (IKMG) in 2012. The IKMG met in April 2017 to refine the definition of MGRS and to update the diagnostic criteria for MGRS-related diseases. Accordingly, in this Expert Consensus Document, the IKMG redefines MGRS as a clonal proliferative disorder that produces a nephrotoxic monoclonal immunoglobulin and does not meet previously defined haematological criteria for treatment of a specific malignancy. The diagnosis of MGRS-related disease is established by kidney biopsy and immunofluorescence studies to identify the monotypic immunoglobulin deposits (although these deposits are minimal in patients with either C3 glomerulopathy or thrombotic microangiopathy). Accordingly, the IKMG recommends a kidney biopsy in patients suspected of having MGRS to maximize the chance of correct diagnosis. Serum and urine protein electrophoresis and immunofixation, as well as analyses of serum free light chains, should also be performed to identify the monoclonal immunoglobulin, which helps to establish the diagnosis of MGRS and might also be useful for assessing responses to treatment. Finally, bone marrow aspiration and biopsy should be conducted to identify the lymphoproliferative clone. Flow cytometry can be helpful in identifying small clones. Additional genetic tests and fluorescent in situ hybridization studies are helpful for clonal identification and for generating treatment recommendations. Treatment of MGRS was not addressed at the 2017 IKMG meeting; consequently, this Expert Consensus Document does not include any recommendations for the treatment of patients with MGRS. This Expert Consensus Document from the International Kidney and Monoclonal Gammopathy Research Group includes an updated definition of monoclonal gammopathy of renal significance (MGRS) and recommendations for the use of kidney biopsy and other modalities for evaluating suspected MGRS
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Affiliation(s)
- Nelson Leung
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Frank Bridoux
- Department of Nephrology, Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France; CNRS UMR7276, Limoges, France; and Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Poitiers, France
| | - Vecihi Batuman
- Veterans Administration Medical Center, New Orleans, LA, USA and Tulane University Medical School, Tulane, LA, USA
| | - Aristeidis Chaidos
- Centre for Haematology, Department of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Paul Cockwell
- Department of Nephrology, Renal Medicine - University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Vivette D D'Agati
- Department of Pathology, Renal Pathology Laboratory, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Angela Dispenzieri
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fernando C Fervenza
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jean-Paul Fermand
- Department of Haematology and Immunology, University Hospital St Louis, Paris, France
| | - Simon Gibbs
- The Victorian and Tasmanian Amyloidosis Service, Department of Haematology, Monash Univerity Easter Health Clinical School, Melbourne, Victoria, Australia
| | - Julian D Gillmore
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Guillermo A Herrera
- Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Arnaud Jaccard
- Service d'Hématologie et de Thérapie Cellulaire, Centre de Référence des Amyloses Primitives et des Autres Maladies par Dépôts d'Immunoglobuline, CHU Limoges, Limoges, France
| | - Dragan Jevremovic
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | - Vishal Kukreti
- University Health Network, Princess Margaret Cancer Centre, Toronto, Canada
| | - Robert A Kyle
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Helen J Lachmann
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | | | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - Glen S Markowitz
- Department of Pathology, Renal Pathology Laboratory, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Peter Mollee
- Haematology Department, Princess Alexandra Hospital and School of Medicine, University of Queensland, Brisbane, Australia
| | - Maria M Picken
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
| | - Vincent S Rajkumar
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Virginie Royal
- Department of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montreal, Montreal, Quebec, Canada
| | - Paul W Sanders
- Department of Medicine, University of Alabama at Birmingham and Department of Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Sanjeev Sethi
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Peter M Voorhees
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium System, Charlotte, NC, USA
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Brendan M Weiss
- Abramson Cancer Center, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Samih H Nasr
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Nasr SH, Larsen CP, Sirac C, Theis JD, Domenger C, Chauvet S, Javaugue V, Hogan JJ, Said SM, Dasari S, Vrana JA, McPhail ED, Cornell LD, Vilaine E, Massy ZA, Boffa JJ, Buob D, Toussaint S, Guincestre T, Touchard G, D'Agati VD, Leung N, Bridoux F. Light chain only variant of proliferative glomerulonephritis with monoclonal immunoglobulin deposits is associated with a high detection rate of the pathogenic plasma cell clone. Kidney Int 2019; 97:589-601. [PMID: 32001067 DOI: 10.1016/j.kint.2019.10.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 09/25/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
Abstract
IgG (mainly IgG3) is the most commonly involved isotype in proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID). Here we describe the first series of PGNMID with deposition of monoclonal immunoglobulin light chain only (PGNMID-light chain). This multicenter cohort of 17 patients presented with nephritic or nephrotic syndrome with underlying hematologic conditions of monoclonal gammopathy of renal significance (71%) or multiple myeloma (29%). Monoclonal immunoglobulin was identified by serum and urine immunofixation in 65% and 73%, respectively, with abnormal serum free light chain in 83%, and a detectable bone marrow plasma cell clone in 88% of patients. Renal biopsy showed a membranoproliferative pattern in most patients. By immunofluorescence, deposits were restricted to glomeruli and composed of restricted light chain (kappa in 71%) and C3, with granular appearance and subendothelial, mesangial and subepithelial distribution by electron microscopy. Proteomic analysis in four cases of kappa PGNMID-light chain revealed spectra for kappa constant and variable domains, without evidence of Ig heavy chains; spectra for proteins of the alternative pathway of complement and terminal complex were detected in three. The classical pathway was not detected in three cases. After median follow up of 70 months, the renal response was dependent on a hematologic response and occurred in six of ten patients treated with plasma cell-directed chemotherapy but none of five patients receiving other therapies. Thus, PGNMID-light chain differs from PGNMID-IgG by higher frequency of a detectable pathogenic plasma cell clone. Hence, proper recognition is crucial as anti-myeloma agents may improve renal prognosis. Activation of an alternative pathway of complement by monoclonal immunoglobulin light chain likely plays a role in its pathogenesis.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | | | - Christophe Sirac
- Department of Immunology, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, French Reference Center for AL Amyloidosis, University Hospital Dupuytren, Limoges, France
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Camille Domenger
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
| | - Sophie Chauvet
- Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Department of Nephrology, Paris, France; INSERM UMRS1138, Research Center Cordeliers, Paris Descartes Sorbonne Paris-Cité University, Paris, France
| | - Vincent Javaugue
- Department of Immunology, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, French Reference Center for AL Amyloidosis, University Hospital Dupuytren, Limoges, France; Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
| | - Jonathan J Hogan
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Samar M Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Eve Vilaine
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology, Ambroise Paré Hospital, Boulogne-Billancourt, France; Inserm U1018 Team5 UVSQ, University Paris Saclay, Villejuif, France
| | - Ziad A Massy
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology, Ambroise Paré Hospital, Boulogne-Billancourt, France; Inserm U1018 Team5 UVSQ, University Paris Saclay, Villejuif, France
| | - Jean-Jacques Boffa
- Assistance Publique-Hôpitaux de Paris, Department of Nephrology, Hôpital Tenon, Paris Sorbonne University, Paris, France
| | - David Buob
- Assistance Publique-Hôpitaux de Paris, Department of Pathology, Hôpital Tenon, Paris Sorbonne University, Paris, France
| | - Stéphanie Toussaint
- Department of Nephrology, Bourg-en-Bresse General Hospital, Bourg-en-Bresse, France
| | | | - Guy Touchard
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
| | - Vivette D D'Agati
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank Bridoux
- Department of Immunology, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, French Reference Center for AL Amyloidosis, University Hospital Dupuytren, Limoges, France; Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
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38
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Fung AWS, Sugumar V, Ren AH, Kulasingam V. Emerging role of clinical mass spectrometry in pathology. J Clin Pathol 2019; 73:61-69. [PMID: 31690564 DOI: 10.1136/jclinpath-2019-206269] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 10/14/2019] [Indexed: 12/20/2022]
Abstract
Mass spectrometry-based assays have been increasingly implemented in various disciplines in clinical diagnostic laboratories for their combined advantages in multiplexing capacity and high analytical specificity and sensitivity. It is now routinely used in areas including reference methods development, therapeutic drug monitoring, toxicology, endocrinology, paediatrics, immunology and microbiology to identify and quantify biomolecules in a variety of biological specimens. As new ionisation methods, instrumentation and techniques are continuously being improved and developed, novel mass spectrometry-based clinical applications will emerge for areas such as proteomics, metabolomics, haematology and anatomical pathology. This review will summarise the general principles of mass spectrometry and specifically highlight current and future clinical applications in anatomical pathology.
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Affiliation(s)
- Angela W S Fung
- Department of Pathology and Laboratory Medicine, St Paul's Hospital, Vancouver, British Columbia, Canada.,Department of Pathology and Laboratory Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Vijithan Sugumar
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Annie He Ren
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Vathany Kulasingam
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada .,Clinical Biochemistry, University Health Network, Toronto, Ontario, Canada
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39
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Ohashi A, Kumagai J, Nagahama K, Fujisawa H. Case of immunotactoid glomerulopathy showing high responsiveness to steroids therapy despite severe pathological features. BMJ Case Rep 2019; 12:12/7/e229751. [PMID: 31350228 PMCID: PMC6663160 DOI: 10.1136/bcr-2019-229751] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
A 72-year-old woman presented with nephrotic proteinuria and moderate haematuria. Renal pathology was compatible with immunotactoid glomerulopathy (ITG), for which there is no consensus for appropriate therapy. We, therefore, postponed immunosuppressive therapy. After 4 years, the patient’s renal function started to decline and renal pathology was re-evaluated, revealing a pathological change from mesangial proliferative glomerulonephritis to endocapillary proliferative glomerulonephritis. Treatment with oral prednisolone (30 mg/day) was initiated. Within 5 weeks, complete remission of proteinuria was obtained (proteinuria 6.02 g/gCr to 0.12 g/gCr), and the patient’s renal function stabilised. Generally, responsiveness to immunosuppressive therapy is poor in patients with ITG, and the present case represented a very rare clinical course. Some previous cases have indicated susceptibility to the therapy, regardless of the severity of renal damage. As a possible distinct entity that determines susceptibility to immunosuppressive therapy, we suggest the presence of a latent lymphoproliferative disease with no significant haematological symptoms.
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Affiliation(s)
- Atsuki Ohashi
- Nephrology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | - Jiro Kumagai
- Pathology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
| | | | - Hajime Fujisawa
- Nephrology, Yokohama City Minato Red Cross Hospital, Yokohama, Japan
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40
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Nasr SH, Fogo AB. New developments in the diagnosis of fibrillary glomerulonephritis. Kidney Int 2019; 96:581-592. [PMID: 31227146 DOI: 10.1016/j.kint.2019.03.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/28/2019] [Accepted: 03/08/2019] [Indexed: 11/25/2022]
Abstract
Fibrillary glomerulonephritis is a glomerular disease historically defined by glomerular deposition of Congo red-negative, randomly oriented straight fibrils that lack a hollow center and stain with antisera to immunoglobulins. It was initially considered to be an idiopathic disease, but recent studies highlighted association in some cases with autoimmune disease, malignant neoplasm, or hepatitis C viral infection. Prognosis is poor with nearly half of patients progressing to end-stage renal disease within 4 years. There is currently no effective therapy, aside from kidney transplantation, which is associated with disease recurrence in a third of cases. The diagnosis has been hampered by the lack of biomarkers for the disease and the necessity of electron microscopy for diagnosis, which is not widely available. Recently, through the use of laser microdissection-assisted liquid chromatography-tandem mass spectrometry, a novel biomarker of fibrillary glomerulonephritis, DnaJ homolog subfamily B member 9, has been identified. Immunohistochemical studies confirmed the high sensitivity and specificity of DnaJ homolog subfamily B member 9 for this disease; dual immunofluorescence showed its colocalization with IgG in glomeruli; and immunoelectron microscopy revealed its localization to individual fibrils of fibrillary glomerulonephritis. The identification of this tissue biomarker has already entered clinical practice and undoubtingly will improve the diagnosis of this rare disease, particularly in developing countries where electron microscopy is less available. Future research is needed to determine whether DnaJ homolog subfamily B member 9 is an autoantigen or just an associated protein in fibrillary glomerulonephritis, whether it can serve as a noninvasive biomarker, and whether therapies that target this protein are effective in improving prognosis.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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41
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Cao Q, Qi H, Yao L, Liu Q. Monoclonal gammopathy of renal significance: clinical manifestation, pathogenic characteristic and treatment. Panminerva Med 2019; 62:38-53. [PMID: 30848114 DOI: 10.23736/s0031-0808.19.03609-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a group of renal disorders caused by a monoclonal immunoglobulin (MIg) secreted by a dangerous plasmatic/B-cell clone hyperplasia through MIg deposition or dysfunction of complement pathway, with increasing risk of progress to end stage renal disease (ESRD) and the underlying hematologic malignancy. The combination of renal biopsy, complete laboratory examination and bone marrow biopsy is an indispensable diagnostic tool for MGRS to identify accurately and unequivocally the pathogenic monoclonal MIg and provide guidance to treatment. Treatment of MGRS is composed of conventional therapy, chemotherapy, and stem cell transplantation to target the underlying clone and eliminate the noxious MIg on the basis of clinical data of some retrospective studies and a small amount of prospective trial. In addition, it is worthwhile point out assessment of therapeutic effect is significantly relevant for renal and overall prognosis. Thus, by comprehensively analyzing the clinical manifestations and pathogenic characteristic of MGRS, early recognition and prompt treatment can improve the prognosis and prevent post-translation recurrence with multidisciplinary cooperation.
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Affiliation(s)
- Qin Cao
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, China
| | - Huimeng Qi
- Department of General Practice, The First Hospital of China Medical University, Shenyang, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Qiang Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China -
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42
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Monoclonal gammopathy of clinical significance: a novel concept with therapeutic implications. Blood 2018; 132:1478-1485. [DOI: 10.1182/blood-2018-04-839480] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/22/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract
Monoclonal gammopathy is a common condition, particularly in the elderly. It can indicate symptomatic multiple myeloma or another overt malignant lymphoid disorder requiring immediate chemotherapy. More frequently, it results from a small and/or quiescent secreting B-cell clone, is completely asymptomatic, and requires regular monitoring only, defining a monoclonal gammopathy of unknown significance (MGUS). Sometimes, although quiescent and not requiring any treatment per se, the clone is associated with potentially severe organ damage due to the toxicity of the monoclonal immunoglobulin or to other mechanisms. The latter situation is increasingly observed but still poorly recognized and frequently undertreated, although it often requires rapid specific intervention to preserve involved organ function. To improve early recognition and management of these small B-cell clone–related disorders, we propose to introduce the concept of monoclonal gammopathy of clinical significance (MGCS). This report identifies the spectrum of MGCSs that are classified according to mechanisms of tissue injury. It highlights the diversity of these disorders for which diagnosis and treatment are often challenging in clinical practice and require a multidisciplinary approach. Principles of management, including main diagnostic and therapeutic procedures, are also described. Importantly, efficient control of the underlying B-cell clone usually results in organ improvement. Currently, it relies mainly on chemotherapy and other anti–B-cell/plasma cell agents, which should aim at rapidly producing the best hematological response.
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43
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Sethi S, Rajkumar SV, D'Agati VD. The Complexity and Heterogeneity of Monoclonal Immunoglobulin-Associated Renal Diseases. J Am Soc Nephrol 2018; 29:1810-1823. [PMID: 29703839 DOI: 10.1681/asn.2017121319] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Monoclonal gammopathies are characterized by the overproduction of monoclonal Ig (MIg) detectable in the serum or urine resulting from a clonal proliferation of plasma cells or B lymphocytes. The underlying hematologic conditions range from malignant neoplasms of plasma cells or B lymphocytes, including multiple myeloma and B-cell lymphoproliferative disorders, to nonmalignant small clonal proliferations. The term MGUS implies presence of an MIg in the setting of a "benign" hematologic condition without renal or other end organ damage. The term MGRS was recently introduced to indicate monoclonal gammopathy with MIg-associated renal disease in the absence of hematologic malignancy. Most MIg-associated renal diseases result from the direct deposition of nephrotoxic MIg or its light- or heavy-chain fragments in various renal tissue compartments. Immunofluorescence microscopy is essential to identify the offending MIg and define its tissue distribution. Mass spectrometry is helpful in difficult cases. Conditions caused by direct tissue deposition of MIg include common disorders, such as cast nephropathy, amyloidosis, and MIg deposition diseases, as well as uncommon disorders, such as immunotactoid glomerulopathy, proliferative GN with MIg deposits, light-chain proximal tubulopathy, and the rare entities of crystal-storing histiocytosis and crystalglobulinemia. Indirect mechanisms of MIg-induced renal disease can cause C3 glomerulopathy or thrombotic microangiopathy without tissue MIg deposits. Treatment of MIg-associated renal disease is aimed at eliminating the clonal plasma cell or B-cell population as appropriate. Both the renal and the underlying hematologic disorders influence the management and prognosis of MIg-associated renal diseases.
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Affiliation(s)
| | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Vivette D D'Agati
- Department of Pathology, College of Physicians and Surgeons, Columbia University, New York, New York
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44
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Leung N, Drosou ME, Nasr SH. Dysproteinemias and Glomerular Disease. Clin J Am Soc Nephrol 2018; 13:128-139. [PMID: 29114004 PMCID: PMC5753301 DOI: 10.2215/cjn.00560117] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 09/20/2017] [Indexed: 01/12/2023]
Abstract
Dysproteinemia is characterized by the overproduction of an Ig by clonal expansion of cells from the B cell lineage. The resultant monoclonal protein can be composed of the entire Ig or its components. Monoclonal proteins are increasingly recognized as a contributor to kidney disease. They can cause injury in all areas of the kidney, including the glomerular, tubular, and vascular compartments. In the glomerulus, the major mechanism of injury is deposition. Examples of this include Ig amyloidosis, monoclonal Ig deposition disease, immunotactoid glomerulopathy, and cryoglobulinemic GN specifically from types 1 and 2 cryoglobulins. Mechanisms that do not involve Ig deposition include the activation of the complement system, which causes complement deposition in C3 glomerulopathy, and cytokines/growth factors as seen in thrombotic microangiopathy and precipitation, which is involved with cryoglobulinemia. It is important to recognize that nephrotoxic monoclonal proteins can be produced by clones from any of the B cell lineages and that a malignant state is not required for the development of kidney disease. The nephrotoxic clones that do not meet requirement for a malignant condition are now called monoclonal gammopathy of renal significance. Whether it is a malignancy or monoclonal gammopathy of renal significance, preservation of renal function requires substantial reduction of the monoclonal protein. With better understanding of the pathogenesis, clone-directed strategies, such as rituximab against CD20 expressing B cell and bortezomib against plasma cell clones, have been used in the treatment of these diseases. These clone-directed therapies been found to be more effective than immunosuppressive regimens used in nonmonoclonal protein-related kidney diseases.
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Affiliation(s)
- Nelson Leung
- Divisions of Nephrology and Hypertension and
- Hematology and
| | | | - Samih H. Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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Carrara C, Ferucci E, Emili S, Toukatly MN, Nicosia RF, Alpers CE. Immunotactoid Glomerulopathy of 10-Years' Duration: Insights Gained From Sequential Biopsies. Kidney Int Rep 2017; 2:978-983. [PMID: 29270507 PMCID: PMC5733877 DOI: 10.1016/j.ekir.2017.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Camillo Carrara
- Department of Pathology, University of Washington Medical Center, Seattle, Washington, USA.,IRCCS-Mario Negri Institute for Pharmacological Research, Clinical Research Center for Rare Diseases Aldo & Cele Daccò, Bergamo, Italy
| | | | | | - Mirna N Toukatly
- Department of Pathology, University of Washington Medical Center, Seattle, Washington, USA
| | - Roberto F Nicosia
- Department of Pathology, University of Washington Medical Center, Seattle, Washington, USA.,Pathology and Laboratory Medicine Service, VA Puget Sound Health Care System, Seattle, Washington, USA
| | - Charles E Alpers
- Department of Pathology, University of Washington Medical Center, Seattle, Washington, USA
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46
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Gammapatías monoclonales de significado renal. Nefrologia 2017; 37:465-477. [DOI: 10.1016/j.nefro.2017.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 01/02/2023] Open
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47
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Gameiro J, Jorge S, Lopes JA. Renal Involvement in Multiple Myeloma. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10312017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Multiple myeloma (MM) is a plasma cell disorder that represents almost 10% of haematologic malignancies. Renal impairment, one of the most common complications of MM that occurs in 20–50% of patients, can present in a variety of forms and is associated with increased mortality. Myeloma cast nephropathy is the most common cause of kidney disease in MM patients, presenting as acute kidney injury in the majority of patients. The recent introduction of new chemotherapy agents, autologous stem cell transplantation, and the development of novel techniques of light chain removal have been associated with improved renal and patient outcomes in MM patients. Nevertheless, dialysis-dependent patients with MM have higher mortality than other dialysis patients and may be considered for kidney transplantation only if sustained remission has been achieved and sustained for at least 3 years, bearing in mind the risk of disease recurrence.
The authors review the most frequent renal manifestations associated with MM, namely myeloma cast nephropathy, light-chain amyloidosis, and monoclonal immunoglobulin deposition disease, focussing on the therapeutic options for acute and chronic kidney disease.
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Affiliation(s)
- Joana Gameiro
- Service of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Sofia Jorge
- Service of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - José António Lopes
- Service of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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Miki K, Sumida M, Iwadoh K, Honda K, Murakami T. Recurrence of Immunotactoid Glomerulopathy with Monoclonal IgG3κ Deposits after Kidney Transplant. ACTA ACUST UNITED AC 2017. [DOI: 10.17352/aot.000006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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49
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Correia SO, Santos S, Malheiro J, Cabrita A, Martins LS, Santos J. Monoclonal gammopathy of renal significance: Diagnostic workup. World J Nephrol 2017; 6:72-78. [PMID: 28316940 PMCID: PMC5339639 DOI: 10.5527/wjn.v6.i2.72] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/08/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
The clinical spectrum of diseases associated with monoclonal gammopathies is wide and they are most commonly the consequence of renal deposition of monoclonal immunoglobulin or its components. The differential diagnosis is difficult and renal biopsy is essential. To distinguish many of these pathologies is necessary to use techniques that are not always available, even in tertiary central hospitals. This review will discuss the clinical presentation, pathologic features, treatment, prognosis and common diagnostic difficulties of these entities.
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Sethi S, Yachoui R, Murray DL, Radhakrishnan J, Alexander MP. Cryofibrinogen-Associated Glomerulonephritis. Am J Kidney Dis 2017; 69:302-308. [DOI: 10.1053/j.ajkd.2016.08.031] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/17/2016] [Indexed: 11/11/2022]
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