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Zeng Y, Liu R, Li S, Wei J, Luo F, Chen Y, Zhou D. Analysis of risk factors and development of a nomogram prediction model for renal tubular acidosis in primary Sjogren syndrome patients. Arthritis Res Ther 2024; 26:151. [PMID: 39175019 PMCID: PMC11340110 DOI: 10.1186/s13075-024-03383-w] [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: 05/21/2024] [Accepted: 08/05/2024] [Indexed: 08/24/2024] Open
Abstract
OBJECTIVE To investigate the risk factors of renal tubular acidosis (RTA) in patients with primary Sjögren's syndrome (pSS) and create a personalized nomogram for predicting pSS-RTA patients. METHOD Data from 99 pSS patients who underwent inpatient treatment at our hospital from January 2012 to January 2024 were retrospectively collected and analyzed. Bootstrap resampling technique, single-factor, and multi-factor logistic regression analyses were used to explore the risk factors for pSS-RTA. A nomogram was developed based on the results of the multivariate logistic model. The model was evaluated through receiver operating characteristic curve, C-index, calibration curve, and decision curve analysis. In addition, we graded the severity of pSS-RTA patients and used univariate analysis to assess the relationship between pSS-RTA severity and risk factors. RESULTS A multivariate logistic regression analysis revealed that concurrent thyroid disease, long symptom duration, subjective dry mouth, and positive RF were independent risk factors for pSS-RTA patients. Based on them, a personalized nomogram predictive model was established. With a p-value of 0.657 from the Hosmer-Lemeshow test, the model demonstrated a good fit. The AUC values in the training and validation groups were 0.912 and 0.896, indicating a strong discriminative power of the nomogram. The calibration curves for the training and validation groups closely followed the diagonal line with a slope of 1, confirming the model's reliable predictive ability. Furthermore, the decision curve analysis showed that the nomogram model had a net benefit in predicting pSS-RTA, emphasizing its clinical value.This study did not find an association between the severity of pSS-RTA and risk factors. DISCUSSION We developed a nomogram to predict RTA occurrence in pSS patients, and it is believed to provide a foundation for early identification and intervention for high-risk pSS patients.
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Affiliation(s)
- Yanzhen Zeng
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Runzhi Liu
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Shuyi Li
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Jingwen Wei
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Fei Luo
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Yongkang Chen
- The First Clinical College, Xuzhou Medical University, Jiangsu Province, China
| | - Dongmei Zhou
- Rheumatology And Immunology Department, The Affiliated Hospital Of Xuzhou Medical University, Jiangsu Province, China.
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Rajendran N, Rameli PM, Awad H. Risk factors for relapse in non-infectious cryoglobulinemic vasculitis, including type I cryoglobulinemia: a systematic review. Front Immunol 2023; 14:1215345. [PMID: 37483620 PMCID: PMC10361750 DOI: 10.3389/fimmu.2023.1215345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Background Data on non-infectious cryoglobulinemic vasculitis (NICV) is scarce, especially concerning the management of relapses, which are troublesome. We aimed to investigate risk factors for relapse in NICV. Methods A systematic literature search of CINAHL, Embase, MEDLINE, Scopus, and the Web of Science databases was implemented until April 2023. Eligible studies included randomized control trials, observational studies, and case series with ≥4 patients. Two reviewers independently extracted data and assessed the quality of the eligible studies. Results A total of 3,724 articles were retrieved from a database search, with 27 studies meeting the inclusion criteria for review. Most studies (n = 23) detailed relapses, with the time to relapse varying between 1 and 80 months. The relapse rate was reported at 28% in Type I NICV and ranged from 22% to 60% in mixed NICV. Risk factors for relapse in NICV were identified based on the cryoglobulin subtype and correlated with clinical and immunological responses to varying treatment regimens. Type I NICV with an associated lymphoproliferative disorder exhibited a response-relapse pattern. Cutaneous and articular involvement and incomplete clinical and immunological responses to treatment, particularly corticosteroid monotherapy and occasionally rituximab, influence the risk of relapse in Type II and Type III NICV. Conclusion Our findings underscore the significance of attaining both clinical and immunological responses and identifying risk factors for relapse in NICV. Appropriate risk stratification for NICV patients is essential for the successful implementation of effective treatment strategies. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023408140.
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Affiliation(s)
- Nithya Rajendran
- Department of Immunology, Beaumont Hospital, Royal College of Surgeons in Ireland (RCSI) Hospital Group, Dublin, Ireland
| | - Puteri Maisarah Rameli
- Department of Acute Medical Assessment Unit (AMAU)/ General Internal Medicine (GIM), St. James’s Hospital, Trinity College Dublin, Dublin, Ireland
| | - Hanaa Awad
- Department of Immunology, Beaumont Hospital, Royal College of Surgeons in Ireland (RCSI) Hospital Group, Dublin, Ireland
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De La Flor Merino JC, Apaza J, Díaz F, Sandoval E, Valga F, Villa D, Marschall A, Abascal ML, Rivas A, Cieza M. An Unusual Case of Seronegative Cryoglobulinemic Glomerulonephritis with Dominant Organized IgA Deposits Associated with Staphylococcal Infection: Casual or Causal Relationship? GLOMERULAR DISEASES 2023; 3:140-147. [PMID: 37901697 PMCID: PMC10601932 DOI: 10.1159/000531737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/22/2023] [Indexed: 10/31/2023]
Abstract
Introduction Cryoglobulinemia refers to the presence of cryoglobulins (CGs) in the serum, encompassing a group of diseases caused by the type of circulating GC. Cryoglobulinemic glomerulonephritis (CryoGN) is the principal manifestation of renal involvement. The diagnosis may be challenging because the hallmark of cryoglobulinemia is the detection of CG in the serum. However, cases of CryoGN without serological evidence of CGs are not uncommon in clinical practice, often diagnosed by anatomopathological findings in the renal biopsy. Case Presentation We report the case of an 86-year-old male who developed renal impairment, nephritic syndrome, and nephrotic-range proteinuria, without serological evidence of CGs, associated with staphylococcal bacteremia without apparent focus. Renal biopsy and pathological examination showed a membranoproliferative glomerulonephritis pattern with CD61-negative pseudothrombi. Immunofluorescence microscopy showed atypical IgA-dominant deposits. Electron microscopy revealed amorphous subendothelial and mesangial deposits and organized electrodense deposits within capillary loops (pseudothrombi) with microtubular substructure measuring 20-40 nm in thickness. These findings were consistent with seronegative CryoGN and microtubular organized atypical IgA-dominant deposits. Discussion In this report, we discuss the clinical, analytical, and histopathological findings of a rare case of CryoGN without serological evidence of CGs. Regarding the etiology that triggered the glomerular disease in our patient, we conducted an exhaustive study in order to determine the underlying cause of CryoGN. At the time of biopsy, the patient had an active staphylococcal bacteremia. There are reports that postulate that staphylococcal antigens drive activation of immune system and in consequence, could cause this rare form of IgA-dominant glomerulonephritis with cryoglobulinemic features. After ruling out other causes of cryoglobulinemia, we discuss a plausible causal relationship of the staphylococcal infection in the pathogenesis of CryoGN in our patient.
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Affiliation(s)
| | | | - Francisco Díaz
- Department of Anatomic Pathology, Hospital Gregorio Marañón, Madrid, Spain
| | - Edna Sandoval
- Department of Hematology, Hospital Central Defense Gomez Ulla, Madrid, Spain
| | - Francisco Valga
- Department of Nephrology, Hospital Universitario Doctor Negrin de Gran Canarias, Las Palmas de Gran Canaria, Spain
| | - Daniel Villa
- Department of Nephrology, Clinica Universidad de Navarra, Pamplona, Spain
| | - Alexander Marschall
- Department of Cardiology, Hospital Central Defense Gomez Ulla, Madrid, Spain
| | | | - Andrea Rivas
- Department of Nephrology, Hospital Nacional Cayetano Heredia, Lima, Peru
| | - Michael Cieza
- Chief of the Teaching Coordination Unit Universidad Peruana Cayetano Heredia, Lima, Peru
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Faisatjatham S, Uaprasert N, Iampenkhae K, Udomkarnjananun S. Detectable serum IgM monoclonal gammopathy in non-hepatitis-associated mixed cryoglobulinemic glomerulonephritis: A case report and literature review. SAGE Open Med Case Rep 2022; 10:2050313X221140648. [PMID: 36507058 PMCID: PMC9726840 DOI: 10.1177/2050313x221140648] [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: 05/12/2022] [Accepted: 11/02/2022] [Indexed: 12/12/2022] Open
Abstract
Cryoglobulinemia is the presence of circulating cryoglobulin which can cause systemic vasculitis and glomerulonephritis. Monoclonal gammopathy of renal significance is strongly associated with type I cryoglobulinemia, but the role of detectable serum monoclonal gammopathy in mixed (type II) cryoglobulinemia is not clearly established. We report a case of a 71-year-old woman who presented with skin rash, leg edema, and azotemia. Investigations showed a positive result for rheumatoid factor, low complement C4 level, positive result for serum cryoglobulin, and positive M-spike on serum protein electrophoresis and IgM kappa monoclonal gammopathy on serum immunofixation. Kidney biopsy revealed membranoproliferative glomerulonephritis, polytypic IgM-dominant deposits in an immunofluorescence study, and microtubular substructures in an electron microscopic study. After an extensive workup, no evidence of myeloma or lymphoma was found. A diagnosis of monoclonal gammopathy of renal significance-associated mixed cryoglobulinemic glomerulonephritis was made. Due to the detectable IgM kappa monoclonal gammopathy in the patient's serum, clonal-directed therapy was administered. The patient had been in clinical remission after treatment with clone-directed therapy with cyclophosphamide and steroids. The literature review for cases of type II cryoglobulinemic glomerulonephritis that have detectable serum monoclonal gammopathy are summarized in this study.
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Affiliation(s)
- Surasak Faisatjatham
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand,Department of Medicine, Khon Kaen Hospital, Khon Kaen, Thailand
| | - Noppacharn Uaprasert
- Division of Hematology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kroonpong Iampenkhae
- Department of Pathology, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Suwasin Udomkarnjananun
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand,Suwasin Udomkarnjananun, Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, 1873, Rama 4 Road, Pathumwan, Bangkok 10330, Thailand.
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Assem NM, Mohammed AI, Barry HMA, El Sayed IET, Elmadbouh I. Serum cystatin C is an early renal dysfunction biomarker in patients with hepatitis C virus. EGYPTIAN LIVER JOURNAL 2022; 12:67. [DOI: 10.1186/s43066-022-00231-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 11/15/2022] [Indexed: 11/25/2022] Open
Abstract
Abstract
Background
Hepatitis C virus (HCV) may induce extrahepatic manifestations as acute or chronic renal dysfunction. The aim was to evaluate the diagnostic role of some biomarkers as cystatin C, cryoglobulins, rheumatoid factor (RF), and complement C3 for extrahepatic renal affection in newly diagnosed patients with HCV infection.
Methods
Blood and urine were collected from randomized individuals screened for new HCV infection (n=400). The studied populations were divided into 3 groups: control group I: thirty healthy individuals not suffering from either liver or kidney diseases, group IIa: thirty HCV patients who have positive HCV antibody test but showed negative PCR test, and group IIb: thirty HCV patients who showed positive results for both HCV antibody and PCR tests.
Results
In HCV group IIb, levels of serum total bilirubin, AST and ALT, and urine albumin/creatinine ratio were increased whereas serum albumin and creatinine clearance were decreased versus other groups. However, the levels of blood urea nitrogen and serum creatinine were still within the normal range in all groups. In HCV group IIb, cystatin C, cryoglobulins, and RF levels were increased; meanwhile, serum creatinine/cystatin C ratio and complement 3 levels were decreased compared to the other groups. HCV-infected patients significantly had higher serum cystatin C (>1.24 mg/L, P<0.001) and lower creatinine/cystatin C ratio (<70.1μMol/mg, P=0.002), and cystatin C was significantly correlated with liver and kidney parameters.
Conclusion
High serum cystatin C and low creatinine/cystatin C ratio may be early indicators of mild renal dysfunction with normal serum levels of creatinine in HCV-infected individuals.
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Concomitant Nephrotic Syndrome and Cryoglobulinemia in a Case of Malignant Mesothelioma. Case Rep Nephrol 2022; 2022:8677293. [PMID: 36213871 PMCID: PMC9534674 DOI: 10.1155/2022/8677293] [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: 07/23/2022] [Accepted: 08/30/2022] [Indexed: 11/18/2022] Open
Abstract
Malignant pleural mesothelioma is rarely associated with nephrotic syndrome. Cryoglobulinemia is found in various pathological statuses, such as hepatitis C virus infection but rarely in malignant neoplasms. We recently encountered a patient with malignant mesothelioma coincident with nephrotic syndrome and cryoglobulinemia in the course of chemotherapy. A 60-year-old man employed as a building painter was diagnosed with malignant mesothelioma by lung biopsy two years earlier and was started on chemotherapy. Nivolumab seemed effective in controlling mesothelioma, but skin immune-related adverse events occurred during the course of treatment. After discontinuation of nivolumab and administration of gemcitabine as an alternative therapy, the patient was referred to a nephrologist because of the subsequent development of edema, renal injury, and proteinuria. Following the investigation, he was diagnosed with nephrotic syndrome and cryoglobulinemia with C4-dominant cold activation. However, a percutaneous renal biopsy could not be performed due to persistent severe cough induced by pleural involvement. The patient died a little over three years after the pathological diagnosis of pleural mesothelioma. Our case had three key features nephrotic syndrome was possibly associated with malignant mesothelioma; cryoglobulinemia occurred in malignant mesothelioma; and concomitant nephrotic syndrome and cryoglobulinemia occurred after chemotherapy. Unfortunately, our rare case lacks a basis in renal pathology or evidence of links between the pathogenesis of malignant mesothelioma, cryoglobulinemia, and nephrotic syndrome. This case does not provide a causal mechanism, but may be worth adding to the case list as one of the rare renal involvement in a patient with malignant mesothelioma.
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Recommendations for evaluation and diagnosis of extra-glandular manifestations of primary sjogren syndrome: results of an epidemiologic systematic review/meta-analysis and a consensus guideline from the Brazilian Society of Rheumatology (articular, pulmonary and renal). Adv Rheumatol 2022; 62:18. [PMID: 35650656 DOI: 10.1186/s42358-022-00248-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 05/15/2022] [Indexed: 11/10/2022] Open
Abstract
Sjogren's Syndrome (SS) is an autoimmune disease characterized by lymphocytic infiltration of the exocrine glands and other organs, associated with sicca syndrome but also with systemic involvement with varying degrees of severity. Despite their importance, these systemic manifestations are not routinely evaluated and there is no homogenous approach to their diagnosis or evaluation. To close this gap, a panel of experts from the Brazilian Society of Rheumatology conducted a systematic review and meta-analysis on the identification of epidemiologic and clinical features of these manifestations and made recommendations based on the findings. Agreement between the experts was achieved using the Delphi method. The first part of this guideline summarizes the most important topics, and 11 recommendations are provided for the articular, pulmonary, and renal care of SS patients.
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Li CY, Li YM, Tian M. Serum-negative Sjogren's syndrome with minimal lesion nephropathy as the initial presentation: A case report. World J Clin Cases 2022; 10:4625-4631. [PMID: 35663069 PMCID: PMC9125292 DOI: 10.12998/wjcc.v10.i14.4625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/24/2021] [Accepted: 03/16/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Primary Sjogren's syndrome (pSS) is an autoimmune disease, and renal involvement has been considered to be one of the systemic complications of pSS. Patients who have sjogren's syndrome with renal disease as the first manifestation and no exocrine gland involvement or autoantibodies can be missed clinically.
CASE SUMMARY We here in report an unusual case of a primary Sjogren's syndrome in a 43-year-old female who had minimal lesion nephropathy as the initial presentation, and the patient was negative for serum anti-SSA and anti-SSB antibodies and did not have signs of exocrine gland involvement. The patient’s Sjogren's syndrome was confirmed by a minor salivary gland biopsy (MSGB) and a filter paper test. the patient’s oedema subsided, and the patient’s urinary protein resolved, showing that the treatment was effective.
CONCLUSION MSGB should be considered if pSS is suspected in patients who do not have the typical pSS symptoms or who are positive for the specific autoantibodies.
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Affiliation(s)
- Chun-Yan Li
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Yi-Man Li
- Department of Nephrology, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
| | - Mei Tian
- Department of Rheumatology, Affiliated Hospital of Zunyi Medical University, Zunyi 563003, Guizhou Province, China
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Javaugue V, Valeri AM, Sathick IJ, Said SM, Damgard SE, Murray DL, Klobucher T, Andeen NK, Sethi S, Fervenza FC, Leung N, Nasr SH. The characteristics of seronegative and seropositive non-hepatitis-associated cryoglobulinemic glomerulonephritis. Kidney Int 2022; 102:382-394. [PMID: 35513122 DOI: 10.1016/j.kint.2022.03.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/15/2022] [Accepted: 03/30/2022] [Indexed: 12/14/2022]
Abstract
cryoglobulinemic glomerulonephritis (CryoGN) are not well-defined and cases with undetectable serum cryoglobulin (seronegative CryoGN) have not been investigated. Corresponding author: To resolve this, we retrospectively identified 81 patients with biopsy-proven non-hepatitis CryoGN, including 22 with seronegative CryoGN. The median age was 61 years and 76% presented with nephritic syndrome. A hematologic condition was found in 89% of patients, including monoclonal gammopathy of renal significance (65%) and symptomatic lymphoproliferative disorder (35%). In the seropositive group, 56% had type II, 29% type I, 8% type III cryoglobulin. Extrarenal manifestations, mostly of skin, were present in 64% and were significantly less common in seronegative CryoGN. Glomerular deposits by immunofluorescence were IgM dominant (84%) and polytypic (70%) in the seropositive group, whereas 52% of seronegative cases had monotypic deposits (i.e., type I cryoglobulin). Ultrastructurally, the deposits were organized in 77% of cases. Substructure appearance significantly differed according to the type of CryoGN, forming most commonly short cylindrical structures in type II and other organized substructures in type I CryoGN. Most patients were treated with clone-directed therapy. On follow up (median 33 months), 77% had partial or complete remission, 10% reached kidney failure and 14% died. Predictors of kidney failure on univariate analysis were AKIN stage 3, positive rheumatoid factor and biclonal gammopathy at diagnosis. We conclude that most CryoGN cases (types I and II) are due to hematologic condition and are associated with favorable outcome after clone-directed therapy. Seronegative CryoGN accounts for about a quarter of cases and is mostly a kidney-limited disease. Thus, further investigations are needed to unravel the pathophysiology of seronegative CryoGN.
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Affiliation(s)
- Vincent Javaugue
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France.
| | - Anthony M Valeri
- Division of Nephrology, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Insara Jaffer Sathick
- Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Samar M Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Tyler Klobucher
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nicole K Andeen
- Department of Pathology, Oregon Health & Science University, Portland, Oregon, USA
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Fernando C Fervenza
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA; Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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Zhang X, Yu XJ, An CW, Yong ZH, Wang SX, Zhou FD, Zhao MH. Clinicopathological Spectrum of Cryoglobulinemic Glomerulonephritis without Evidence of Autoimmunity Disorders: A Retrospective Study from a Single Institute of China. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:253-263. [PMID: 35702704 PMCID: PMC9149548 DOI: 10.1159/000522537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 02/08/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Cryoglobulinemic glomerulonephritis (Cryo-GN), caused by circulating cryoglobulins, has varied etiology and clinical-pathologic manifestations. This study aimed to investigate the clinicopathological spectrum and outcome of patients with various Cryo-GN in China. METHODS A retrospective review of 74 Chinese patients with biopsy-proven cryoglobulin-related renal lesions in Peking University First Hospital from 2010 to 2020 was performed. RESULTS The mean age at diagnosis was 52.9 ± 15.0 years, and the female-to-male ratio was about 2/5. For the etiology screening, serum/urine monoclonal immunoglobulin could be detected on immunofixation electrophoresis in 34% of patients, including 6 patients who had hematological malignancies. Fifty-seven percent of patients had HBV infection, far more than HCV infection (5%). Ten percent of patients had other infections, and 27% of patients were classified as essential or idiopathic. Eleven out of the 15 patients with type II cryoglobulinemia had a consistent monotype of serum monoclonal immunoglobulins and monoclonal cryoprecipitate. The clinical manifestations were similar between various types of cryoglobulinemia. Hematuria, proteinuria, hypertension, anemia, and chronic renal insufficiency were the most common features. Fifty-three percent of patients presented with nephrotic syndrome, and 32% experienced acute kidney injury. Hypocomplementemia, serum-positive rheumatoid factor activity, and skin lesions were reported in 45%, 29%, and 28% of patients, respectively. After a median of 24 months follow-up, 18 patients reached end-stage kidney disease. The clone-targeted treatment could retard the renal deterioration compared with immunosuppressive therapy. CONCLUSIONS This was the largest single-center, clinicopathological retrospective study of Cryo-GN in China. Our data strongly support the association between monoclonal gammopathy and type II Cryo-GN. The renal responsive rate of immunosuppressant therapy is still suboptimal. The clone-targeted treatment shows promising effects in patients with type I or II Cryo-GN.
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Affiliation(s)
- Xin Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Renal Pathology Center, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Xiao-juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Renal Pathology Center, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Chong-wen An
- Clinical Laboratory, Peking University First Hospital, Beijing, China
| | - Zi-hao Yong
- Peking-Tsinghua Center for Life Sciences, Beijing, China
| | - Su-xia Wang
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Fu-de Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Renal Pathology Center, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Ming-hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Institute of Nephrology, Peking University, Renal Pathology Center, Institute of Nephrology, Peking University, Key Laboratory of Renal Disease, Ministry of Health of China, Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, China
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Menter T, Hopfer H. Renal Disease in Cryoglobulinemia. GLOMERULAR DISEASES 2021; 1:92-104. [PMID: 36751424 PMCID: PMC9677724 DOI: 10.1159/000516103] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/19/2021] [Indexed: 11/19/2022]
Abstract
Background Renal disease in cryoglobulinemia is difficult to grasp and diagnose because it is rare, serological testing is challenging and prone to artifacts, and its morphology is shared by other renal diseases resulting in a spectrum of differential diagnoses. On occasion, a definitive diagnosis cannot even be rendered after immunofluorescence and electron microscopic studies. Summary Based on kidney biopsies seen in our routine diagnostic and referral practice, we discuss and illustrate various morphological patterns of renal injury associated with cryoglobulins. We outline key pathophysiologic and clinical aspects associated with cryoglobulinemia induced renal disease and describe morphologic changes with a focus on electron microscopy. We present our practical, morphology-based approach to diagnostic decision-making with special consideration of differential diagnoses and disease mimickers. Since cryoglobulins are rarely tested for prior to kidney biopsy, pathologists and clinicians alike must have a high level of suspicion when interpreting renal biopsies and managing patients. Key Messages Cryoglobulinemia-associated glomerulonephritis (GN) is a multifactorial disease which is important to recognize for clinical practice. Morphological features suggestive of cryoglobulinemia-associated GN include a pattern of membranoproliferative GN with abundance of monocytes and the presence of (pseudo)thrombi. By electron microscopy, the main diagnostic features are a prominent infiltration of monocytes/macrophages and the presence of mesangial and subendothelial deposits with frequently curved microtubular/cylindrical and annular substructures.
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Hong R, Xu D, Hsieh E, Xiang Y, Zhao J, Wang Q, Tian X, Li M, Zhao Y, Zeng X. Factors Associated With Renal Involvement in Primary Sjögren's Syndrome: A Meta-Analysis. Front Med (Lausanne) 2020; 7:614482. [PMID: 33324667 PMCID: PMC7726424 DOI: 10.3389/fmed.2020.614482] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 10/29/2020] [Indexed: 11/29/2022] Open
Abstract
Background: Renal impairment is a critical complication in primary Sjögren's syndrome (pSS), resulting in chronic renal disease and even death. This meta-analysis was designed to find out the relevant factors of renal involvement in pSS. Methods: PubMed, EMBASE, Cochrane Library, Scopus, and Web of Science were systemically searched until August 30, 2019. Studies were selected according to inclusion criteria, and data was extracted by two researchers independently. The Newcastle-Ottawa Scale was applied for quality assessment. Random- and fixed-effects models were used in this meta-analysis based on the result of the heterogeneity test. Meanwhile, a sensitivity analysis was conducted to investigate the cause of heterogeneity. Publication bias was shown in the funnel plot and evaluated further by Begg's and Egger's tests. Results: Of the 9,989 articles identified, five articles enrolling 1,867 pSS patients were included in the final analysis, 533 with and 1,334 without renal involvement. There was no statistical significance in age and gender between these two groups. According to the meta-analysis, anti-SSB antibody, and arthralgia showed a significant association with renal involvement in pSS, the overall odds ratio (OR) values of which were 1.51 (95% CI, 1.16–1.95) and 0.59 (95% CI, 0.46–0.74), respectively. On the other hand, the overall OR values of anti-SSA antibody, rheumatoid factor, dry eyes, and labial salivary gland biopsy were just 0.90 (95% CI, 0.49–1.64), 1.05 (95% CI, 0.59–1.86), 0.60 (95% CI, 0.34–1.06), and 1.38 (95% CI, 0.98–1.95), respectively. Conclusion: The presence of anti-SSB antibody is positively associated with renal involvement in pSS, while arthralgia is inversely associated. Large-scale prospective cohort studies are needed in the future to identify further risk factors.
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Affiliation(s)
- Ruping Hong
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Dong Xu
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Evelyn Hsieh
- Section of Rheumatology, Allergy and Immunology, Yale University School of Medicine, New Haven, CT, United States
| | - Yirong Xiang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Jiuliang Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Qian Wang
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xinping Tian
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Mengtao Li
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Yan Zhao
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Xiaofeng Zeng
- Department of Rheumatology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Science, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Abstract
Primary Sjögren syndrome is an autoimmune disorder characterized by lymphoplasmacytic infiltration of the exocrine (salivary and lachrymal) glands resulting in sicca symptoms (dryness). Systemic complications can occur in primary Sjögren syndrome, but renal involvement is rare, affecting<10% patients. The most frequent form of nephropathy in primary Sjögren syndrome is tubulointerstitial nephritis, where infiltration of the kidney by plasma cells is a key feature and shows similarity to the lymphoplasmacytic infiltration of the salivary glands. Electrolyte disturbances may occur in primary Sjögren syndrome, such as renal distal tubular acidosis, diabetes insipidus, Gitelman syndrome, or Fanconi syndrome. Glomerular involvement is less frequently detected in patients with primary Sjögren syndrome, but can take the form of membranoproliferative glomerulonephritis secondary to cryoglobulinaemia. The renal prognosis in patients with primary Sjögren syndrome and TIN or glomerular disease is usually good, but the risk of chronic kidney disease remains significant for some patients. Appropriate screening must be performed at least once a year in patients with systemic primary Sjögren syndrome in order to facilitate the early detection of renal complications. In this Review, we discuss the epidemiology, pathophysiology, differential diagnosis, and treatment of renal disease in primary Sjögren syndrome.
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Affiliation(s)
- Hélène François
- Département d'Urgences Néphrologiques et Transplantation Rénale, INSERM UMR_S 1155, Hôpital Tenon, Sorbonne université, AP-HP, Paris, France.
| | - Xavier Mariette
- Inserm, CEA, rheumatology department, centre de recherche en immunologie des infections virales et des maladies auto-immunes, université Paris-Saclay, hôpital Bicêtre, AP-HP, 94270 Le Kremlin-Bicêtre, France
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14
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Flavell AL, Fullinfaw RO, Smith ER, Holt SG, Finlay MJ, Barbour TD. Noninfectious mixed cryoglobulinaemic glomerulonephritis and monoclonal gammopathy of undetermined significance: a coincidental association? BMC Nephrol 2020; 21:293. [PMID: 32703171 PMCID: PMC7376917 DOI: 10.1186/s12882-020-01941-3] [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: 03/01/2020] [Accepted: 07/09/2020] [Indexed: 12/18/2022] Open
Abstract
Background Cryoglobulins are cold-precipitable immunoglobulins that may cause systemic vasculitis including cryoglobulinaemic glomerulonephritis (CGN). Type 1 cryoglobulins consist of isolated monoclonal immunoglobulin (mIg), whereas mixed cryoglobulins are typically immune complexes comprising either monoclonal (type 2) or polyclonal (type 3) Ig with rheumatoid activity against polyclonal IgG. Only CGN related to type 1 cryoglobulins has been clearly associated with monoclonal gammopathy of undetermined significance (MGUS) using the conventional serum-, urine- or tissue-based methods of paraprotein detection. Case presentation We present four patients with noninfectious mixed (type 2 or 3) CGN and MGUS. Two patients had type 2 cryoglobulinaemia, one had type 3 cryoglobulinaemia, and one lacked definitive typing of the serum cryoprecipitate. The serum monoclonal band was IgM-κ in all four cases. Treatments included corticosteroids, cyclophosphamide, plasma exchange, and rituximab. At median 3.5 years’ follow-up, no patient had developed a haematological malignancy or advanced chronic kidney disease. Other potential causes of mixed cryoglobulinaemia were also present in our cohort, notably primary Sjögren’s syndrome in three cases. Conclusion Our study raises questions regarding the current designation of type 2 CGN as a monoclonal gammopathy of renal significance, and the role of clonally directed therapies for noninfectious mixed CGN outside the setting of haematological malignancy.
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Affiliation(s)
- Adam L Flavell
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.
| | - Robert O Fullinfaw
- Department of Chemical Pathology, The Royal Melbourne Hospital, Parkville, Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Moira J Finlay
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Anatomical Pathology, The Royal Melbourne Hospital, Parkville, Australia
| | - Thomas D Barbour
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
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15
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Kolopp-Sarda MN, Nombel A, Miossec P. Cryoglobulins Today: Detection and Immunologic Characteristics of 1,675 Positive Samples From 13,439 Patients Obtained Over Six Years. Arthritis Rheumatol 2019; 71:1904-1912. [PMID: 31136095 DOI: 10.1002/art.41003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/23/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Cryoglobulins are cold-precipitating immunoglobulins. Through progress in techniques, we undertook this study to update information on the biologic characteristics of cryoglobulins in a very large population. METHODS A cohort of 13,439 patients was tested for cryoglobulins from January 2010 to December 2016. The analysis included cryoglobulin isotype, clonality, concentration, and IgM rheumatoid factor (IgM-RF) in cryoprecipitate, as well as serum complement and RF. Markers of gammopathy, viral infection, and autoimmunity were also investigated. RESULTS Of the 13,439 patients, 1,675 (12.5%) tested positive for cryoglobulins: 155 patients (9.3%) with type I, 788 (47%) with type II, and 732 (43.7%) with type III cryoglobulins. Nine percent of patients who were retested after initially testing negative for cryoglobulins showed a positive result on a follow-up test (196 of the 2,213 retested patients). In type I cryoglobulins, IgM was more frequent but occurred at lower concentrations than IgG. Mixed cryoglobulins were found in 34.8% of the tested patients who were positive for hepatitis C virus and <5% of those who were positive for hepatitis B virus or HIV. Of the patients with anti-double-stranded DNA, anti-SSA, or anti-cyclic citrullinated peptide autoantibodies, 25.4% tested positive for mixed cryoglobulins, with type III occurring more frequently than type II. Both cryoprecipitate and serum were RF-positive in 21.6% of type II and 10.1% of type III cryoglobulins. A decrease of C4, with or without accompanying decreases of C3 and CH50, was found in 23.6% of cryoglobulin samples. CONCLUSION Obtained with the use of modern assays, our findings from this very large collection of cryoglobulins provide an update on cryoglobulin distribution and characteristics, with minimal selection bias. Despite strict preanalytical conditions, a negative finding for the presence of cryoglobulin must be confirmed in a second sample. RF activity and complement decreases were rarely detected.
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Affiliation(s)
- Marie N Kolopp-Sarda
- Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon and Hospices Civils de Lyon, Lyon, France
| | | | - Pierre Miossec
- Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon and Hospices Civils de Lyon, Lyon, France
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16
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Chen YP, Cheng H, Rui HL, Dong HR. Cryoglobulinemic vasculitis and glomerulonephritis: concerns in clinical practice. Chin Med J (Engl) 2019; 132:1723-1732. [PMID: 31283654 PMCID: PMC6759094 DOI: 10.1097/cm9.0000000000000325] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2019] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Cryoglobulinemia often causes systemic vasculitis, thereby damaging to skin and internal organs including kidneys, even life-threatening. This review aimed to introduce the advances in understanding, detection, and treatment of this disease in recent years, with a particular concern to clinical practice. DATA SOURCES All the data in this review were from the English or Chinese literature in the PubMed and China National Knowledge Infrastructure databases as of March 2019. STUDY SELECTION This review selected important original articles, meaningful reviews, and some reports on cryoglobulinemia published in recent years and in history, as well as the guidelines for treatment of underlying diseases which lead to cryoglobulinemia. RESULTS Diagnosis of cryoglobulinemia relies on serum cryoglobulin test, in which to ensure that the blood sample temperature is not less than 37°C in the entire pre-analysis phase is the key to avoid false negative results. Cryoglobulinemic vasculitis (Cryo Vas), including cryoglobulinemic glomerulonephritis (Cryo GN), usually occurs in types II and III mixed cryoglobulinemia, and can also be seen in type I cryoglobulinemia caused by monoclonal IgG3 or IgG1. Skin purpura, positive serum rheumatoid factor, and decreased serum levels of C4 and C3 are important clues for prompting types II and III Cryo Vas. Renal biopsy is an important means for diagnosis of Cryo GN, while membranous proliferative GN is the most common pathological type of Cryo GN. In recent years, great advances have been made in the treatment of Cryo Vas and its underlying diseases, and this review has briefly introduced these advances. CONCLUSIONS Laboratory examinations of serum cryoglobulins urgently need standardization. The recent advances in the diagnosis and treatment of Cryo Vas and GN need to be popularized among the clinicians in related disciplines.
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Affiliation(s)
- Yi-Pu Chen
- Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Beijing 100029, China
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17
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Xia W, Gao B, Duan L, Li Y, Wen Y, Chen L, Li X, Zheng F, Li M. Clinical significance of C4d deposition in renal tissues from patients with primary Sjögren's syndrome-a preliminary study. BMC Nephrol 2019; 20:189. [PMID: 31138153 PMCID: PMC6540533 DOI: 10.1186/s12882-019-1341-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 04/17/2019] [Indexed: 01/06/2023] Open
Abstract
Background To evaluate renal expression of C4d, a complement component in the classical/mannose binding lectin (MBL) pathway, in patients with primary Sjögren’s syndrome (pSS)-associated renal impairments. Methods We retrospectively reviewed the clinical and pathological data from 39 patients with pSS presenting with renal impairments. C4d was examined in paraffin-embedded biopsy tissues using immunohistochemistry. Glomerular C4d positive was defined when > 75% glomeruli were globally stained. Tubulointerstitial C4d (TI-C4d) were scored semi-quantitatively as 0 (absent), 1 (spotty or weak), 2 (patchy) and 3 (diffuse). A TI-C4d score ≥ 2 was considered TI-C4d positive and included in the TI-C4d+ group and vice versa. Peritubular capillary (PTC) C4d was scored as 0 (absent), 1 (0~10%, minimal), 2 (10%~ 50%, focal), and 3 (> 50%, diffuse). Results Glomerular C4d deposition was observed in all 8 patients with pSS-related membranous nephropathy (MN) without obvious C1q deposition. Two of 5 patients with mesangial proliferative glomerulonephritis and 1 of 2 patients with IgA nephropathy had mild mesangial C4d deposition. Sixteen patients (6 glomerular dominant and 10 tubulointerstitial dominant) presented TI-C4d score ≥ 2. Patients in the TI-C4d+ group exhibited a higher serum creatinine level at the time of renal biopsy (TI-C4d+ 132.5 [89.7, 165.5] vs. TI-C4d− 83.0 [70.7, 102.0] μmol/L, P = 0.008). PTC C4d was observed in 12 patients, with each of minimal, focal and diffuse staining being noted in 4 patients. Conclusions The MBL pathway of complement activation was potentially involved in pSS-related MN. Tubulointerstitial C4d might be a pathological marker of severe renal injury in patients with pSS-related renal impairments. Electronic supplementary material The online version of this article (10.1186/s12882-019-1341-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Wenli Xia
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China.,Department of Nephrology, Beijing Jishuitan Hospital, Fourth Clinical College, Peking University, Beijing, 100035, China
| | - Bixia Gao
- Renal Division, Department of Medicine, Institute of Nephrology, Key Laboratory of Renal Disease, Ministry of Health of China, Peking University First Hospital, Peking University, Beijing, 100034, China
| | - Lin Duan
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Yan Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Yubing Wen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Limeng Chen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Falei Zheng
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China
| | - Mingxi Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, No. 1 Shuaifuyuan, Wangfujing Street, Beijing, 100730, China.
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Albawaliz A, Bahaj W, Abughanimeh OK, Noman A, Kujtan L. A Case of Prostate Cancer Presenting with Rash. Cureus 2019; 11:e4734. [PMID: 31355093 PMCID: PMC6649886 DOI: 10.7759/cureus.4734] [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: 03/29/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022] Open
Abstract
Mixed cryoglobulinemia (MC) is well known for its association with chronic hepatitis C virus (HCV) infection. However, it has also been linked to autoimmune disorders and hematological malignancies, particularly of B-cell lymphoid origin. Association with solid malignancies is poorly described in the literature. Non-HCV-related MC, in the setting of prostate cancer, has been reported only twice. Here, we describe a case of MC in a prostate cancer patient complicated by membranoproliferative glomerulonephritis (MPGN) that responded well to plasma exchange therapy and treatment with both corticosteroids and rituximab.
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Affiliation(s)
- Anas Albawaliz
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | - Waled Bahaj
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Kansas City, USA
| | | | - Anas Noman
- Internal Medicine, University of Missouri-Kansas City School of Medicine, Truman Medical Center, Kansas City, USA
| | - Lara Kujtan
- Hematology / Oncology, University of Missouri-Kansas City School of Medicine, Kansas City, USA
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19
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Luo J, Xu S, Lv Y, Huang X, Zhang H, Zhu X, Wang X. Clinical features and potential relevant factors of renal involvement in primary Sjögren's syndrome. Int J Rheum Dis 2019; 22:182-190. [PMID: 30411528 PMCID: PMC6587856 DOI: 10.1111/1756-185x.13429] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 08/27/2018] [Accepted: 10/04/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To investigate distinct features of renal involvement in patients with primary Sjögren's syndrome (pSS) and to identify potential factors associated with renal involvement. METHODS Four hundred and thrity-four pSS patients from the Rheumatology Department of the First Affiliated Hospital of Wenzhou Medical University from 2013 to 2017 were included in a cross-sectional study. Patients with renal involvement were compared with their age- and gender-matched controls (pSS without renal involvement). Demographic, clinical, histological, nephritic, immunological features of renal involvement in pSS were systematically analyzed. Possible factors related to renal involvement were identified using multivariate logistic regression analyses. RESULTS One hundred and ninety-two pSS patients (88.48%) with renal involvement were women with mean age of nearly 58 years and mean disease duration of above 4 years. Clinical manifestation, serologic and immunological features and renal biopsy class of the pSS patients with renal involvement were presented. By multivariate analyses, xerophthalmia, histological positivity for lower salivary gland biopsy (LSGB), anti-SSA/Ro52-positive, reduced complement 3 (C3) levels, hypoalbuminemia and anemia retained significant association with renal involvement in pSS (all P < 0.05). CONCLUSION In addition to LSGB pattern, anti-SSA/Ro52-positivity, reduced C3 levels, hypoalbuminemia and anemia, also indicate significant association with renal involvement in pSS. Therefore, early vigilance is required for patients with these clinical manifestations.
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Affiliation(s)
- Jing Luo
- Rheumatology DepartmentThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Shihao Xu
- Department of UltrasonographyThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Yinqiu Lv
- Rheumatology DepartmentThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Xinshi Huang
- Rheumatology DepartmentThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Huxiang Zhang
- Department of PathologyThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Xiaochun Zhu
- Rheumatology DepartmentThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouChina
| | - Xiaobing Wang
- Rheumatology DepartmentThe First Affiliated Hospital of Wenzhou Medical UniversityWenzhouChina
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20
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Coliche V, Sarda MN, Laville M, Chapurlat R, Rheims S, Sève P, Théry-Casari C, Lega JC, Fouque D. Predictive factors of renal involvement in cryoglobulinaemia: a retrospective study of 153 patients. Clin Kidney J 2018; 12:365-372. [PMID: 31198536 PMCID: PMC6543974 DOI: 10.1093/ckj/sfy096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Indexed: 12/19/2022] Open
Abstract
Background The course of cryoglobulinaemia varies widely, from asymptomatic patients to severe vasculitis syndrome. Renal involvement (RI) is the major prognostic factor, and frequently occurs several years after diagnosis. However, predictive factors for RI are not well known. The aim of our study was to identify RI predictive factors during cryoglobulinaemia. Methods We retrospectively reviewed the clinical charts of a consecutive series of 153 patients positive for cryoglobulinaemia in the University Hospital of Lyon (France). RI was defined either histologically or biologically if cryoglobulinaemia was the only possible cause of nephropathy. Results Among the 153 positive patients (mean age 55 years, 37% male), cryoglobulinaemia was associated with RI in 45 (29%) patients. Sixty-five percent of patients had Type II cryoglobulinaemia, 28% had Type III and 7% had Type I. Autoimmune diseases were the most common aetiology (48%), followed by infectious diseases (18%) and lymphoproliferative disorders (13%). Membranoproliferative glomerulonephritis was the main histological pattern (93% of the 14 histological analyses). A multivariable logistic regression showed that Type II cryoglobulinaemia, a high serum cryoglobulin concentration, the presence of an IgG kappa monoclonal component and diabetes were independently associated with the risk for developing RI. Conclusion We identified several factors predictive of RI in patients with cryoglobulinaemia, which were different from the diagnostic criteria for cryoglobulinaemic vasculitis. This could suggest a specific pathophysiology for RI. We suggest performing an extensive renal monitoring and ensure nephroprotection when a diagnosis of cryoglobulinaemia is made in patients with these predictive factors.
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Affiliation(s)
- Vladimir Coliche
- Department of Nephrology, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Marie-Nathalie Sarda
- Université Claude Bernard Lyon 1, EA 4130, Immunology Laboratory, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Maurice Laville
- Department of Nephrology, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Roland Chapurlat
- Department of Rheumatology, Université Claude Bernard Lyon 1, Inserm 1033, Hôpital Edouard Herriot, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Université Claude Bernard Lyon 1, Inserm 1028 CNRS UMR 5292, Hôpital Neurologique, Bron, France
| | - Pascal Sève
- Department of Internal Medicine, Université Claude Bernard Lyon 1, Inserm 1052, Hôpital Croix-Rousse, Lyon, France
| | - Clémence Théry-Casari
- Department of Internal and Vascular Medicine, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Jean-Christophe Lega
- Department of Internal and Vascular Medicine, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Denis Fouque
- Department of Nephrology, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
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Macroglobulinemia de Waldenström presentándose como glomerulonefritis membranoproliferativa crioglobulinémica tipo II. Nefrologia 2018; 38:439-441. [DOI: 10.1016/j.nefro.2017.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Accepted: 09/04/2017] [Indexed: 12/22/2022] Open
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22
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Spatola L, Generali E, Angelini C, Badalamenti S, Selmi C. HCV-negative mixed cryoglobulinemia and kidney involvement: in-depth review on physiopathological and histological bases. Clin Exp Med 2018; 18:465-471. [PMID: 29956004 DOI: 10.1007/s10238-018-0514-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 06/21/2018] [Indexed: 11/28/2022]
Abstract
Type II mixed cryoglobulinemia without evidence of HCV infection but rather with renal involvement has been occasionally described. The pathogenesis of cryoglobulinemic kidney disease is most likely related to immune complex deposition including cryoglobulins, and cryoaggregation after cold exposure could play a pivotal role in clinical expression of cryoglobulinemia. In these cases, acute kidney injury and proteinuria remain the most frequent clinical expression of a cryoglobulinemic glomerulonephritis. Type II cryoglobulinemia with the laboratory finding of both monoclonal and polyclonal cryoglobulins is the most prevalent bio-humoral pattern among HCV-negative phenotypes with renal involvement, while type III cryoglobulinemia with polyclonal Ig is rare. Histological data in renal biopsies support the hypothesis that regardless of the HCV status cryoglobulinemia vasculitis share the same frequent pathological finding of membranoproliferative glomerulonephritides, but other histological patterns have also been observed in a minority of cases. In HCV-negative mixed cryoglobulinaemia, the paraneoplastic origin of the immune dysfunction should be ruled out and sporadic cases have been reported, while there is no cumulative evidence on the prevalence of these tumour-associated manifestations. Moving from the classification criteria and the etiopathogenesis of mixed cryoglobulinaemia, we provide a comprehensive review of the literature on the appearance of the disease with kidney injury in association with malignancies or autoimmune disorders without HCV coexistence.
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Affiliation(s)
- Leonardo Spatola
- Unit of Nephrology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Elena Generali
- Unit of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - Claudio Angelini
- Unit of Nephrology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Salvatore Badalamenti
- Unit of Nephrology, Humanitas Clinical and Research Center, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Carlo Selmi
- Unit of Rheumatology and Clinical Immunology, Humanitas Clinical and Research Center, Rozzano, Milan, Italy.,BIOMETRA Department, University of Milan, Milan, Italy
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Montero N, Favà A, Rodriguez E, Barrios C, Cruzado JM, Pascual J, Soler MJ. Treatment for hepatitis C virus-associated mixed cryoglobulinaemia. Cochrane Database Syst Rev 2018; 5:CD011403. [PMID: 29734473 PMCID: PMC6494545 DOI: 10.1002/14651858.cd011403.pub2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Hepatitis C virus (HCV)-associated mixed cryoglobulinaemia is the manifestation of an inflammation of small and medium-sized vessels produced by a pathogenic IgM with rheumatoid factor activity generated by an expansion of B-cells. The immune complexes formed precipitate mainly in the skin, joints, kidneys or peripheral nerve fibres. Current therapeutic approaches are aimed at elimination of HCV infection, removal of cryoglobulins and also of the B-cell clonal expansions. The optimal treatment for it has not been established. OBJECTIVES This review aims to look at the benefits and harms of the currently available treatment options to treat the HCV-associated mixed cryoglobulinaemia with active manifestations of vasculitis (cutaneous or glomerulonephritis). SEARCH METHODS We searched the Cochrane Kidney and Transplant Specialised Register to 30 November 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA All randomised controlled trials (RCTs) and quasi-RCTs looking at interventions directed at treatment of HCV-associated cryoglobulinaemic vasculitis (immunosuppressive medications and plasma exchange therapy) have been included. DATA COLLECTION AND ANALYSIS Two authors independently assessed the retrieved titles and abstracts. Authors of included studies were contacted to obtain missing information. Statistical analyses were performed using random effects models and results expressed as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI). The planned primary outcomes were kidney disease, skin vasculitis, musculoskeletal symptoms, peripheral joint arthralgia, peripheral neuropathies, liver involvement, interstitial lung involvement, widespread vasculitis and death. Other planned outcomes were: therapy duration, laboratory findings, adverse effects, antiviral therapy failure, B-cell lymphoma, endocrine disorders and costs of treatment. MAIN RESULTS Ten studies were included in the review (394 participants). None of them evaluated direct-acting antivirals. Seven studies were single-centre studies and three were multicentre. The duration of the studies varied from six to 36 months. The risk of bias was generally unclear or low. Three different interventions were examined: use of rituximab (3 studies, 118 participants); interferon (IFN) (IFN compared to other strategies (5 studies, 223 participants); six IFN months versus one year (1 study, 36 participants), and immunoadsorption apheresis versus only immunosuppressive therapy (1 study, 17 participants).The use of rituximab may slightly improve skin vasculitis (2 studies, 78 participants: RR 0.57, 95% CI 0.28 to 1.16; moderate certainty evidence) and made little of no difference to kidney disease (moderate certainty evidence). In terms of laboratory data, the effect of rituximab was uncertain for cryocrit (MD -2.01%, 95% CI -10.29% to 6.27%, low certainty evidence) and HCV replication. Rituximab may slightly increase infusion reactions compared to immunosuppressive medication (3 studies, 118 participants: RR 4.33, 95%CI 0.76 to 24.75, moderate certainty evidence) however discontinuations of the treatment due to adverse reactions were similar (3 studies, 118 participants: RR 0.97, 95% CI 0.22 to 4.36, moderate certainty evidence).Effects of lFN on clinical symptoms were evaluated only in narrative results. When laboratory parameters were assessed, IFN made little or no difference in levels of alanine transaminase (ALT) at six months (2 studies, 39 participants: MD -5.89 UI/L, 95%CI -55.77 to 43.99); rheumatoid factor activity at six months (1 study, 13 participants: MD 97.00 UI/mL, 95%CI -187.37 to 381.37), or C4 levels at 18 months (2 studies, 49 participants: MD -0.04 mg/dL, 95%CI -2.74 to 2.67). On the other hand, at 18 months IFN may probably decrease ALT (2 studies, 39 participants: MD -28.28 UI/L, 95%CI -48.03 to -8.54) and Ig M (-595.75 mg/dL, 95%CI -877.2 to -314.3), but all with low certainty evidence. One study reported infusion reactions may be higher in IFN group compared to immunosuppressive therapy (RR 27.82, 95%CI 1.72 to 449.18), and IFN may lead to higher discontinuations of the treatment due to adverse reactions (4 studies, 148 participants: RR 2.32, 95%CI 0.91 to 5.90) with low certainty evidence. Interferon therapy probably improved skin vasculitis (3 studies, 95 participants: RR 0.60, 95% CI 0.36 to 1.00) and proteinuria (2 studies, 49 participants: MD -1.98 g/24 h, 95% CI -2.89 to -1.07), without changing serum creatinine at 18 months (2 studies, 49 participants: MD -30.32 μmol/L, 95%CI -80.59 to 19.95).Six months versus one year treatment with IFN resulted in differences terms of the maintenance of the response, 89% of patients in the six months group presented a relapse and only 11% maintained a long-term response at one year, while in the one year group only 78% relapsed and long-term response was observed in 22%. The one-year therapy was linked to a higher number of side-effects (severe enough to cause the discontinuation of treatment in two cases) than the six-month schedule.One study reported immunoadsorption apheresis had uncertain effects on skin vasculitis (RR 0.44, 95% CI 0.05 to 4.02), peripheral neuropathies (RR 2.70, 95%CI 0.13 to 58.24), and peripheral joint arthralgia (RR 2.70, 95%CI 0.13 to 58.24), cryocrit (MD 0.01%, 95%CI -1.86 to 1.88) at six months, and no infusion reactions were reported. However when clinical scores were evaluated, they reported changes were more favourable in immunoadsorption apheresis with higher remission of severe clinical complications (80% versus 33%, P = 0.05) compared to immunosuppressive treatment alone.In terms of death, it was not possible to present a pooled intervention effect estimate because most of the studies reported no deaths, or did not report death as an outcome. AUTHORS' CONCLUSIONS To treat HCV-associated mixed cryoglobulinaemia, it may be beneficial to eliminate HCV infection by using antiviral treatment and to stop the immune response by using rituximab. For skin vasculitis and for some laboratory findings, it may be appropriate to combine antiviral treatment with deletion of B-cell clonal expansions by using of rituximab. The applicability of evidence reviewed here is limited by the absence of any studies with direct-acting antivirals, which are urgently needed to guide therapy.
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Affiliation(s)
- Nuria Montero
- Hospital Universitari de BellvitgeDepartment of NephrologyFeixa Illarga s/nL'Hospitalet de LlobregatBarcelonaSpain08907
| | - Alexandre Favà
- Hospital Universitari de BellvitgeDepartment of NephrologyFeixa Illarga s/nL'Hospitalet de LlobregatBarcelonaSpain08907
| | - Eva Rodriguez
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
| | - Clara Barrios
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
| | - Josep M Cruzado
- Hospital Universitari de BellvitgeDepartment of NephrologyFeixa Illarga s/nL'Hospitalet de LlobregatBarcelonaSpain08907
| | - Julio Pascual
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
| | - Maria Jose Soler
- Hospital del Mar‐IMIMDepartment of NephrologyPasseig Maritim 25‐29BarcelonaBarcelonaSpain08003
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24
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Yamanaka M, Fujigaki Y, Kono H, Nagura M, Arai S, Tamura Y, Ota T, Shibata S, Kondo F, Yamaguchi Y, Uchida S. A patient presenting with isolated hematuria and renal dysfunction as rare manifestation of cryoglobulinemic glomerulonephritis in the course of autoimmune diseases including Sjögren's syndrome. CEN Case Rep 2018; 7:211-216. [PMID: 29671215 DOI: 10.1007/s13730-018-0329-y] [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: 03/01/2018] [Accepted: 04/09/2018] [Indexed: 11/29/2022] Open
Abstract
Autoimmune diseases are sometimes associated with immune-mediated renal diseases and cryoglobulinemia is one of the causes. Cryoglobulinemia and cryoglobulinemic glomerulonephritis associated with primary Sjögren's syndrome are most frequent condition among non-hepatitis C virus-related condition. Its typical renal manifestation shows high amount of proteinuria with microscopic hematuria and renal insufficiency. We describe a case of 72-year-old woman with Hashimoto disease, autoimmune hepatitis, Sjögren's syndrome, and immune-related pancytopenia complicated by cryoglobulinemic glomerulonephritis. Before kidney biopsy, tubulointerstitial nephritis probably due to Sjögren's syndrome was suspected because of persistent hematuria without significant proteinuria and developing mild renal dysfunction over 6 months. The developing renal dysfunction associated with isolated hematuria is uncommon in glomerular diseases. Kidney biopsy, however, revealed established membranoproliferative glomerulonephritis with subendothelial deposits consisting of tubular structures with IgM, IgG, and C3 staining. Corticosteroids plus mycophenolate mofetil therapy successfully normalized renal function. Physician should not overlook cryoglobulinemic glomerulonephritis, which is potentially poor prognosis, even if urinalysis shows only persistent isolated hematuria in patients with autoimmune diseases.
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Affiliation(s)
- Masaki Yamanaka
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yoshihide Fujigaki
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan.
| | - Hajime Kono
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Michito Nagura
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Shigeyuki Arai
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yoshifuru Tamura
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Tatsuru Ota
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Shigeru Shibata
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Fukuo Kondo
- Department of Pathology, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Yutaka Yamaguchi
- Department of Pathology, Teikyo University Hospital, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
| | - Shunya Uchida
- Department of Internal Medicine, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi-ku, Tokyo, Japan
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25
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Kolopp-Sarda MN, Miossec P. Cryoglobulins: An update on detection, mechanisms and clinical contribution. Autoimmun Rev 2018. [PMID: 29526627 DOI: 10.1016/j.autrev.2017.11.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cryoglobulins are immunoglobulins precipitating in cold condition. They are classified in 3 types according to the Brouet classification and may lead to vasculitis of small and medium size vessels. Vasculitis is related to vessel obstruction by monoclonal cryoglobulin aggregates in type I cryoglobulins and immune complex deposition in type II and III mixed cryoglobulins. This phenomenon is favored by low temperature, especially in skin, joints, and peripheral nerves, or increased cryoglobulin concentration in kidneys. For their detection, collection and clotting at 37°C are critical pre-analytical conditions. Cryoglobulin characterization and quantification are important to identify the underlying disease. Since detection and identification of cryoglobulins lack standardization, a protocol for such detection, characterization and quantification is proposed.
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Affiliation(s)
- Marie-Nathalie Kolopp-Sarda
- Department of Immunology and Rheumatology, Immunogenomics and inflammation research Unit EA 4130, University of Lyon, Lyon, France; Immunology Laboratory, University Hospital Lyon, France
| | - Pierre Miossec
- Department of Immunology and Rheumatology, Immunogenomics and inflammation research Unit EA 4130, University of Lyon, Lyon, France.
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26
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Sayiner M, Golabi P, Farhat F, Younossi ZM. Dermatologic Manifestations of Chronic Hepatitis C Infection. Clin Liver Dis 2017; 21:555-564. [PMID: 28689593 DOI: 10.1016/j.cld.2017.03.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Chronic hepatitis C virus (HCV) infection is associated with various extrahepatic manifestations, including dermatologic involvement mostly caused by immune complexes. Mixed cryoglobulinemia has a strong relationship with HCV with 95% of these patients being infected with HCV. Lichen planus is a disease of the squamous epithelium and may affect any part of the skin, with 4% to 24% of patients with lichen planus reported to have chronic HCV infection. Porphyria cutanea tarda is the most common form of porphyria, and it is thought that HCV interferes with iron stores, which can promote porphyria cutanea tarda. Finally, necrolytic acral erythema is a rare, psoriasis-like disease closely associated with HCV.
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Affiliation(s)
- Mehmet Sayiner
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA; Department of Medicine, Center for Liver Disease, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Pegah Golabi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Freba Farhat
- Department of Medicine, Center for Liver Disease, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA
| | - Zobair M Younossi
- Betty and Guy Beatty Center for Integrated Research, Inova Health System, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA; Department of Medicine, Center for Liver Disease, Inova Fairfax Hospital, Claude Moore Health Education and Research Building, 3rd Floor, 3300 Gallows Road, Falls Church, VA 22042, USA.
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27
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Abstract
Patients with chronic hepatitis C virus (HCV) infection frequently present with extrahepatic manifestations covering a large spectrum, involving different organ systems leading to the concept of systemic HCV infection. These manifestations include autoimmune phenomena and frank autoimmune and/or rheumatic diseases and may dominate the course of chronic HCV infection. Chronic HCV infection causes liver inflammation affecting the development of hepatic diseases. HCV is also a lymphotropic virus that triggers B cells and promotes favorable conditions for B lymphocyte proliferation, including mixed cryoglobulinemia (MC) and MC vasculitis, which is the most prominent extrahepatic manifestation of chronic HCV infection. HCV may also promote a low-grade chronic systemic inflammation that may affect the development of some extrahepatic manifestations, particularly cardiovascular and cerebral vascular diseases. Recognition of extrahepatic symptoms of HCV infection could facilitate early diagnosis and treatment. The development of direct-acting antiviral agents (DDAs) has revolutionized HCV treatment. DDAs, as well as new B-cell-depleting or B-cell-modulating monoclonal antibodies, will expand the panorama of treatment options for HCV-related extrahepatic manifestations including cryoglobulinemic vasculitis. In this context, a proactive, integrated approach to HCV therapy should maximize the benefits of HCV therapy, even when liver disease is mild.
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Affiliation(s)
- E Rosenthal
- Service de Médecine Interne, Hôpital de l'Archet, CHU de Nice, Nice; Université de Nice-Sophia Antipolis, Nice, France COREVIH PACA EST, CHU de Nice, France
| | - P Cacoub
- Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, and Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Paris, France INSERM, UMR_S 959, Paris, France CNRS, FRE3632, Paris, France AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France
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28
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Brito-Zerón P, Theander E, Baldini C, Seror R, Retamozo S, Quartuccio L, Bootsma H, Bowman SJ, Dörner T, Gottenberg JE, Mariette X, Bombardieri S, de Vita S, Mandl T, Ng WF, Kruize AA, Tzioufas A, Vitali C, Buyon J, Izmirly P, Fox R, Ramos-Casals M, on behalf of the EULAR Sjögren Synd. Early diagnosis of primary Sjögren’s syndrome: EULAR-SS task force clinical recommendations. Expert Rev Clin Immunol 2015; 12:137-56. [DOI: 10.1586/1744666x.2016.1109449] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
Primary Sjögren syndrome (pSS) is an autoimmune disorder characterized by lymphoplasmacytic infiltration of the exocrine (salivary and lachrymal) glands that results in sicca symptoms (dryness of the eyes and mouth). Systemic complications can occur in pSS, but renal involvement is rare, affecting <10% patients. The most frequent form of nephropathy in pSS is tubulointerstitial nephritis (TIN), in which infiltration of the kidney by plasma cells is a key feature and shows similarity to the lymphoplasmacytic infiltration of the salivary glands. Electrolyte disturbances may occur in pSS, such as renal distal tubular acidosis, diabetes insipidus, Gitelman syndrome or Fanconi syndrome. Glomerular involvement is less frequently detected in patients with pSS, but usually takes the form of membranoproliferative glomerulonephritis secondary to cryoglobulinaemia. The renal prognosis in patients with pSS and TIN or glomerular disease is usually favourable, but the risk of chronic kidney disease remains high in patients with TIN. Appropriate screening must be performed at least once a year in patients with systemic pSS in order to facilitate the early detection of renal complications. In this Review we discuss the epidemiology, pathophysiology, differential diagnosis and treatment of renal disease in pSS.
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Affiliation(s)
- Hélène François
- Department of Nephrology, Dialysis, and Transplantation, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Saclay, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Paris, France
| | - Xavier Mariette
- Department of Rheumatology, Hôpitaux Universitaires Paris-Sud, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris-Saclay, IMVA Centre of Immunology of Viral Infections and Autoimmune Diseases, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Paris, France
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30
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Anand A, Krishna GG, Sibley RK, Kambham N. Sjögren Syndrome and Cryoglobulinemic Glomerulonephritis. Am J Kidney Dis 2015; 66:532-5. [DOI: 10.1053/j.ajkd.2014.11.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 11/23/2014] [Indexed: 12/28/2022]
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31
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Zaidan M, Terrier B, Pozdzik A, Frouget T, Rioux-Leclercq N, Combe C, Lepreux S, Hummel A, Noël LH, Marie I, Legallicier B, François A, Huart A, Launay D, Kaplanski G, Bridoux F, Vanhille P, Makdassi R, Augusto JF, Rouvier P, Karras A, Jouanneau C, Verpont MC, Callard P, Carrat F, Hermine O, Léger JM, Mariette X, Senet P, Saadoun D, Ronco P, Brochériou I, Cacoub P, Plaisier E. Spectrum and Prognosis of Noninfectious Renal Mixed Cryoglobulinemic GN. J Am Soc Nephrol 2015; 27:1213-24. [PMID: 26260165 DOI: 10.1681/asn.2015020114] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 06/16/2015] [Indexed: 12/22/2022] Open
Abstract
Noninfectious mixed cryoglobulinemic GN (MCGN) has been poorly investigated. We analyzed presentation and outcome of 80 patients with biopsy-proven MCGN, which were identified in the retrospective French CryoVas survey. MCGN was related to primary Sjögren's syndrome in 22.5% of patients and to lymphoproliferative disorders in 28.7% of patients, and was defined as essential in 48.8% of patients. At presentation, hematuria, proteinuria ≥1 g/d, hypertension, and renal failure were observed in 97.4%, 84.8%, 85.3%, and 82.3% of cases, respectively. Mean±eGFR was 39.5±20.4 ml/min per 1.73 m(2) Membranoproliferative GN was the predominant histologic pattern, observed in 89.6% of cases. Renal interstitium inflammatory infiltrates were observed in 50% of cases. First-line treatment consisted of steroids alone (27.6%) or in association with rituximab (21.1%), alkylating agents (36.8%) or a combination of cyclophosphamide and rituximab (10.5%). After a mean follow-up of 49.9±45.5 months, 42.7% of patients relapsed with a renal flare in 75% of cases. At last follow-up, mean eGFR was 50.2±26.1 ml/min per 1.73 m(2)with 9% of patients having reached ESRD; 59% and 50% of patients achieved complete clinical and renal remission, respectively. A rituximab+steroids regimen prevented relapses more effectively than steroids alone or a cyclophosphamide+steroids combination did, but was associated with a higher rate of early death when used as first-line therapy. Severe infections and new-onset B-cell lymphoma occurred in 29.1% and 8.9% of cases, respectively; 24% of patients died. In conclusion, noninfectious MCGN has a poor long-term outcome with severe infections as the main cause of death.
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Affiliation(s)
- Mohamad Zaidan
- Departments of Nephrology-Transplantation, Institut Necker Enfants Malades, Paris, France; Paris Descartes University, Sorbonne Paris Cité, Paris, France
| | - Benjamin Terrier
- Paris Descartes University, Sorbonne Paris Cité, Paris, France; Department of Internal Medicine, National Referral Center for Rare Systemic Autoimmune Diseases, Cochin Hospital, Paris, France
| | - Agnieszka Pozdzik
- Department of Nephrology, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | | | - Christian Combe
- Department of Nephrology, University Hospital, Bordeaux, France
| | | | | | | | | | | | | | - Antoine Huart
- Department of Nephrology and Organ Transplant, Rangueil Hospital, Toulouse, France
| | - David Launay
- University of Medicine, Lille, France; Regional University Hospital, Lille, Department of Internal Medicine and Clinical Immunology, Lille, France National Referral Center for Rare Systemic Autoimmune Diseases (Systemic Sclerosis), Lille, France; EA2686, Lille Inflammation Research International Center, Lille, France
| | - Gilles Kaplanski
- Department of Clinical Immunology and Internal Medicine, La Conception Hospital, Marseille, France
| | - Frank Bridoux
- Department of Nephrology, University Hospital, Poitiers, France
| | | | - Raifah Makdassi
- Department of Nephrology, University Hospital, Amiens, France
| | - Jean-François Augusto
- Department of Nephrology, Dialysis, Transplantation, University Hospital, Angers, France
| | | | - Alexandre Karras
- Department of Nephrology, Georges Pompidou European Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Chantal Jouanneau
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche_S 1155, Paris, France
| | - Marie-Christine Verpont
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche_S 1155, Paris, France
| | | | - Fabrice Carrat
- Department of Public Health, Saint-Antoine Hospital, Paris, France; Université Pierre et Marie Curie, Paris, France; Institut National de la Santé et de la Recherche Médicale, U1136, Paris, France
| | | | - Jean-Marc Léger
- Neurology, La Pitié-Salpêtrière Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Xavier Mariette
- Department of Rheumatology, Université Paris-Sud; University Hospital, Paris-Sud, Le Kremlin-Bicêtre, France
| | | | - David Saadoun
- Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France; Inflammation-Immunopathology-Biotherapy Department, Paris, France Sorbonne Universités, Paris, France; and
| | - Pierre Ronco
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche_S 1155, Paris, France; Nephrology and Dialysis, Assistance Publique - Hôpitaux de Paris, Tenon Hospital, Paris, France; Sorbonne Universités, Tenon Hospital, Paris, France
| | | | - Patrice Cacoub
- Groupe Hospitalier Pitié-Salpêtrière, Department of Internal Medicine and Clinical Immunology, Paris, France; Inflammation-Immunopathology-Biotherapy Department, Paris, France Sorbonne Universités, Paris, France; and
| | - Emmanuelle Plaisier
- Institut National de la Santé et de la Recherche Médicale, Unité Mixte de Recherche_S 1155, Paris, France; Nephrology and Dialysis, Assistance Publique - Hôpitaux de Paris, Tenon Hospital, Paris, France; Sorbonne Universités, Tenon Hospital, Paris, France
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Ghetie D, Mehraban N, Sibley CH. Cold Hard Facts of Cryoglobulinemia. Rheum Dis Clin North Am 2015; 41:93-108, viii-ix. [DOI: 10.1016/j.rdc.2014.09.008] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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33
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Porres-Aguilar M, Rodriguez-Castro CE, Osvaldo P, Saifuddin F, Siddiqui T, Fan J, Mukherjee D, Pema K, Abbas A. Finger necrosis due to cryoglobulinemic vasculitis in association with membranous nephropathy. Proc AMIA Symp 2015; 28:72-4. [PMID: 25552807 PMCID: PMC4264719 DOI: 10.1080/08998280.2015.11929195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Cryoglobulinemic vasculitis is a small vessel vasculitis that has been associated with chronic infections and autoimmune, lymphoproliferative, and neoplastic disorders. When no significant etiological factors are identified, it is called essential mixed cryoglobulinemia. A detailed and thorough laboratory investigation is required to exclude all possible causes of cryoglobulin formation. Although cryoglobulin testing is simple, careful temperature regulation is needed to avoid false-negative results. Consensus diagnosis should be developed and implemented for appropriate cryoglobulin detection and accurate clinical diagnosis for cryoglobulinemic vasculitis. Here we present an interesting, first-ever case report of a 54-year-old Hispanic-American woman with essential mixed cryoglobulinemia presenting with significant digital necrosis in association with membranous nephropathy.
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Affiliation(s)
- Mateo Porres-Aguilar
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Carlos E Rodriguez-Castro
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Padilla Osvaldo
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Fátima Saifuddin
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Tariq Siddiqui
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Jerry Fan
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Debabrata Mukherjee
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Kanchan Pema
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
| | - Aamer Abbas
- Department of Internal Medicine (Porres-Aguilar, Rodriguez-Castro, Pema), the Department of Pathology (Osvaldo), and the Division of Cardiovascular Diseases (Siddiqui, Mukherjee, Abbas), Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas; medical student, Texas Tech University Health Sciences Center/Paul L. Foster School of Medicine, El Paso, Texas (Fan); and the Department of Internal Medicine, Jinnah Postgraduate Medical Centre, Karachi, Pakistan (Saifuddin)
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Montero N, Barrios C, Rodriguez E, Pascual J, Soler MJ. Treatment for hepatitis C virus-associated cryoglobulinaemic vasculitis. Hippokratia 2014. [DOI: 10.1002/14651858.cd011403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nuria Montero
- Hospital Universitari de Bellvitge; Department of Nephrology; Feixa LLarga s/n Barcelona Spain 08907
| | - Clara Barrios
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
| | - Eva Rodriguez
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
| | - Julio Pascual
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
| | - Maria Jose Soler
- Hospital del Mar-IMIM; Department of Nephrology; Passeig Maritim 25-29 Barcelona Barcelona Spain 08003
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Szél E, Szolnoky G, Korom I, Bata-Csörgő Z, Adamkovich N, Annus JK, Kovács L, Krenács L, Meszes A, Modok S, Ondrik Z, Kemény L. What can vasculitic leg ulcers implicate? Int Wound J 2014; 13:1027-8. [PMID: 25185508 DOI: 10.1111/iwj.12312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 05/14/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Edit Szél
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary.
| | - Győző Szolnoky
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - Irma Korom
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | | | - Nóra Adamkovich
- Department of Hematology, Second Department of Internal Medicine and Cardiology Centre, University of Szeged, Szeged, Hungary
| | - János K Annus
- Neurology Department, University of Szeged, Szeged, Hungary
| | - László Kovács
- Department of Rheumatology, University of Szeged, Szeged, Hungary
| | - László Krenács
- Laboratory of Tumor Pathology and Molecular Diagnostics, Szeged, Hungary
| | - Angéla Meszes
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
| | - Szabolcs Modok
- Department of Hematology, Second Department of Internal Medicine and Cardiology Centre, University of Szeged, Szeged, Hungary
| | - Zoltán Ondrik
- First Department of Internal Medicine, University of Szeged, Szeged, Hungary.,Diaverum Dialysis Centre, Szeged, Hungary
| | - Lajos Kemény
- Department of Dermatology and Allergology, University of Szeged, Szeged, Hungary
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Anis S, Abbas K, Mubarak M, Ahmed E, Bhatti S, Muzaffar R. Vasculitis with renal involvement in essential mixed cryoglobulinemia: Case report and mini-review. World J Clin Cases 2014; 2:160-166. [PMID: 24868518 PMCID: PMC4023312 DOI: 10.12998/wjcc.v2.i5.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 02/17/2014] [Accepted: 04/11/2014] [Indexed: 02/05/2023] Open
Abstract
The discovery of a strong association between hepatitis C virus (HCV) infection and mixed cryoglobulinemia (MC) has led to an increasingly rare diagnosis of idiopathic essential MC (EMC). The incidence of EMC is high in regions where there is a comparatively low HCV infection burden and low in areas of high infection prevalence, including HCV. The diagnosis of EMC requires an extensive laboratory investigation to exclude all possible causes of cryoglobulin formation. In addition, although cryoglobulin testing is simple, improper testing conditions will result in false negative results. Here, we present a 46-year-old female patient with a case of EMC with dermatological and renal manifestations, highlighting the importance of extensive investigation to reach a proper diagnosis. We review the need for appropriate laboratory testing, which is often neglected in clinical practice and which can result in false negative results. This review also emphasizes the significance of an extended testing repertoire necessary for better patient management. Despite a strong association of MC with HCV infection and other causes that lead to cryoglobulin formation, EMC remains a separate entity. Correct diagnosis requires proper temperature regulation during sample handling, as well as characterization and quantification of the cryoprecipitate. Inclusion of rheumatoid factor activity and complement levels in the cryoglobulin test-panel promotes better patient management and monitoring. Consensus guidelines should be developed and implemented for cryoglobulin detection and the diagnosis of cryoglobulinemic syndrome, which will reduce variability in inter-laboratory reporting.
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Caster DJ, Summersgill JT, Paueksakon P, Massung RF, Shieh WJ, McLeish KR. Mixed cryoglobulinemia and secondary membranoproliferative glomerulonephritis associated with ehrlichiosis. CEN Case Rep 2014; 3:178-182. [PMID: 28509195 DOI: 10.1007/s13730-014-0113-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2013] [Accepted: 02/17/2014] [Indexed: 12/31/2022] Open
Abstract
Ehrlichiosis is a tick-borne disease with diverse clinical presentations, ranging in severity from a flu-like illness with fever and myalgias to a serious systemic disease with multisystem organ failure. Nephrotic syndrome has been reported previously in two cases of human ehrlichiosis. A kidney biopsy revealed minimal change disease in one of those patients. Herein, we present the case of a 40-year-old man with ehrlichiosis who developed nephrotic syndrome, cryoglobulinemia, and secondary membranoproliferative glomerulonephritis (MPGN). The patient originally presented with shortness of breath, diffuse myalgias, headache, and lower extremity edema. He subsequently developed acute kidney injury and underwent kidney biopsy which showed MPGN and acute tubular injury. A tick-borne disease panel was positive for IgM and IgG to Ehrlichia chaffeensis. Serum testing revealed type 3 mixed cryoglobulinemia with no evidence of hepatitis C infection. The cryoprecipitate contained IgM and IgG antibodies to E. chaffeensis. Cryoglobulinemia is frequently associated with infections, particularly hepatitis C; however, our case is the first to describe ehrlichiosis associated with cryoglobulinemia and secondary MPGN.
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Affiliation(s)
- Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, 570 South Preston Street - 102 South, Donald Baxter Research Bldg, Louisville, KY, 40202, USA.
| | - James T Summersgill
- Department of Medicine, University of Louisville School of Medicine, 570 South Preston Street - 102 South, Donald Baxter Research Bldg, Louisville, KY, 40202, USA
| | - Paisit Paueksakon
- Department of Pathology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert F Massung
- Rickettsial Zoonoses Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Wun-Ju Shieh
- Infectious Diseases Pathology Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA
| | - Kenneth R McLeish
- Department of Medicine, University of Louisville School of Medicine, 570 South Preston Street - 102 South, Donald Baxter Research Bldg, Louisville, KY, 40202, USA.,Robley Rex VAMC, Louisville, KY, USA
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Bhagat M, Sehra ST, Shahane A, Kwan M. Utility of immunologic testing in suspected rheumatologic disease. Curr Allergy Asthma Rep 2014; 14:405. [PMID: 24370946 DOI: 10.1007/s11882-013-0405-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
The use of diagnostic testing in the clinical practice of medicine has been a shifting landscape from the time that the first blood test was utilized. This is no different in the field of immunology and in particular rheumatology. As the field of immunology is relatively young, the clinical tests are not well established and therefore guidelines for use are still under debate. In this review, we seek to look at some of the key autoantibodies, as well as other tests that are available to diagnose suspected rheumatologic disease, and examine how to best use these tests in the clinic. In particular, we will focus on the anti-nuclear antibodies, anti-neutrophil cytoplasmic antibodies, complement, cryoglobulins, rheumatoid factor, and anti-citrullinated protein antibodies.
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Affiliation(s)
- Monica Bhagat
- Division of Pulmonary, Allergy, and Critical Care, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Néel A, Perrin F, Decaux O, Dejoie T, Tessoulin B, Halliez M, Mahé B, Lamy T, Fakhouri F, Jego P, Agard C, Vigneau C, Guenet L, Grosbois B, Moreau P, Hamidou M. Long-term outcome of monoclonal (type 1) cryoglobulinemia. Am J Hematol 2014; 89:156-61. [PMID: 24532335 DOI: 10.1002/ajh.23608] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 09/18/2013] [Accepted: 09/30/2013] [Indexed: 12/29/2022]
Abstract
The aim of this study is to investigate long-term outcome of symptomatic type 1 cryoglobulinemia (CG) and its determinants. Retrospective cohort study was conducted in two French University Hospitals. Patients with type 1 CG were identified using laboratory databases. Inclusion criterion was the presence of persistent symptoms of CG. Among 227 screened patients, 36 were included. Skin or vasomotor symptoms were the most frequent features (75%). Nephropathy and neuropathy occurred in 30% and 47% of cases, respectively. The underlying B cell disease (BCD) was a nonmalignant monoclonal gammopathy (NMMG) in 13 (36%) and a hematologic malignancy (HM) in 23 (64%; Waldenstrom macroglobulinemia (WM) in 12, low-grade non-Hodgkin lymphoma (NHL) in 6, multiple myeloma (MM) in 4, and chronic lymphocytic leukemia in 1 patient. Severe manifestations affected half the patients and were more frequent with IgG (82 vs. 30% (P = 0.006)). At last follow-up, 64% of patients had suffered no hematologic manifestation. Potent chemotherapeutic regimens were mainly used in HM. For patients with NMMG, WM, or NHL, fludarabine or rituximab-based regimens appeared to yield better responses. Five-year survival rate was 82%. In multivariate analysis, mortality was significantly higher in older patients (HR: 1.17 per year [95% CI: 1.06-1.28], P = 0.001) and those with nephropathy (HR: 8.9 [95% CI: 1.9-43], P = 0.006). Kidney disease, infections, Richter's transformation, and second malignancies were important sources of morbi-mortality. Despite its limitations, this series provide novel information regarding type 1 CG. Further studies are needed to improve its management. To date, therapeutic strategy should be tailored according to patient's characteristics (age, comorbidities, underlying BCD), and therapeutic target.
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Affiliation(s)
- Antoine Néel
- CHU Nantes; Service de Médecine Interne; F 44093 Nantes France
| | - François Perrin
- CHU Nantes; Service de Médecine Interne; F 44093 Nantes France
| | - Olivier Decaux
- CHU Rennes; Service de Médecine Interne; F 35033 Rennes France
| | - Thomas Dejoie
- CHU Nantes; Laboratoire de Biochimie; F 44093 Nantes France
| | | | - Maxime Halliez
- CHU Nantes; Laboratoire de Biochimie; F 44093 Nantes France
| | - Béatrice Mahé
- CHU Nantes; Service d'Hématologie; F 44093 Nantes France
| | - Thierry Lamy
- CHU Rennes; Service d'Hématologie; F 35033 Rennes France
| | - Fadi Fakhouri
- CHU Nantes; Service de Néphrologie; F 44093 Nantes France
| | - Patrick Jego
- CHU Rennes; Service de Médecine Interne; F 35033 Rennes France
| | - Christian Agard
- CHU Nantes; Service de Médecine Interne; F 44093 Nantes France
- Inserm UMR1087; Université de Nantes; F 44000 Nantes France
| | - Cécile Vigneau
- CHU Rennes; Service de Néphrologie; F 35033 Rennes France
- Univ Rennes 1; Faculté de Médecine, Laboratoire KYCA; UMR 6290 F35043 Rennes
| | | | | | | | - Mohamed Hamidou
- CHU Nantes; Service de Médecine Interne; F 44093 Nantes France
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Bazari H, Mahindra AK, Farkash EA. Case records of the Massachusetts General Hospital. Case 3-2014. A 61-year-old woman with gastrointestinal symptoms, anemia, and acute kidney injury. N Engl J Med 2014; 370:362-73. [PMID: 24450895 DOI: 10.1056/nejmcpc1214220] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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41
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Retamozo S, Díaz-Lagares C, Bosch X, Bové A, Brito-Zerón P, Gómez ME, Yagüe J, Forns X, Cid MC, Ramos-Casals M. Life-Threatening Cryoglobulinemic Patients With Hepatitis C: Clinical Description and Outcome of 279 Patients. Medicine (Baltimore) 2013; 92:273-284. [PMID: 23974248 PMCID: PMC4553974 DOI: 10.1097/md.0b013e3182a5cf71] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cryoglobulinemia is characterized by a wide range of causes, symptoms, and outcomes. Hepatitis C virus (HCV) infection is detected in 30%-100% of patients with cryoglobulins. Although more than half the patients with cryoglobulinemic vasculitis present a relatively benign clinical course, some may present with potentially life-threatening situations. We conducted the current study to analyze the clinical characteristics and outcomes of HCV patients presenting with life-threatening cryoglobulinemic vasculitis. We evaluated 181 admissions from 89 HCV patients diagnosed with cryoglobulinemic vasculitis consecutively admitted to our department between 1995 and 2010. In addition, we performed a systematic analysis of cases reported to date through a MEDLINE search.The following organ involvements were considered to be potentially life-threatening in HCV patients with cryoglobulinemic vasculitis: cryoglobulinemic, biopsy-proven glomerulonephritis presenting with renal failure; gastrointestinal vasculitis; pulmonary hemorrhage; central nervous system (CNS) involvement; and myocardial involvement. A total of 279 patients (30 from our department and 249 from the literature search) fulfilled the inclusion criteria: 205 presented with renal failure, 45 with gastrointestinal vasculitis, 38 with CNS involvement, 18 with pulmonary hemorrhage, and 3 with myocardial involvement; 30 patients presented with more than 1 life-threatening cryoglobulinemic manifestation. There were 146 (52%) women and 133 (48%) men, with a mean age at diagnosis of cryoglobulinemia of 54 years (range, 25-87 yr) and a mean age at life-threatening involvement of 55 years (range, 25-87 yr). In 232 (83%) patients, life-threatening involvement was the first clinical manifestation of cryoglobulinemia. Severe involvement appeared a mean of 1.2 years (range, 1-11 yr) after the diagnosis of cryoglobulinemic vasculitis. Patients were followed for a mean of 14 months (range, 3-120 mo) after the diagnosis of life-threatening cryoglobulinemia. Sixty-three patients (22%) died. The main cause of death was sepsis (42%) in patients with glomerulonephritis, and cryoglobulinemic vasculitis itself in patients with gastrointestinal, pulmonary, and CNS involvement (60%, 57%, and 62%, respectively). In conclusion, HCV-related cryoglobulinemia may result in progressive (renal involvement) or acute (pulmonary hemorrhage, gastrointestinal ischemia, CNS involvement) life-threatening organ damage. The mortality rate of these manifestations ranges between 20% and 80%. Unfortunately, this may be the first cryoglobulinemic involvement in almost two-thirds of cases, highlighting the complex management and very elevated mortality of these cases.
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Affiliation(s)
- Soledad Retamozo
- From Josep Font Laboratory of Autoimmune Diseases (SR, CDL, AB, PBZ, MEG, MRC) and Vasculitis Research Unit (MCC), Department of Autoimmune Diseases; Department of Internal Medicine (XB); Department of Immunology (JY); and Viral Hepatitis Unit (XF), Department of Hepatology; CIBERehd, Hospital Clínic, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
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42
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Zaidan M, Mariotte E, Galicier L, Arnulf B, Meignin V, Vérine J, Mahr A, Azoulay É. Vasculitic emergencies in the intensive care unit: a special focus on cryoglobulinemic vasculitis. Ann Intensive Care 2012; 2:31. [PMID: 22812447 PMCID: PMC3488028 DOI: 10.1186/2110-5820-2-31] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 06/24/2012] [Indexed: 12/25/2022] Open
Abstract
Vasculitis is characterized by the infiltration of vessel walls by inflammatory leukocytes with reactive damage and subsequent loss of vessel integrity. The clinical course of systemic vasculitis may be punctuated by acute life-threatening manifestations that require intensive care unit (ICU) admission. Furthermore, the diagnosis may be established in the ICU after admission for a severe inaugural symptom, mostly acute respiratory failure. Among the systemic vasculitides, cryoglobulinemic vasculitis (CV) has been rarely studied in an ICU setting. Severe CV-related complications may involve the kidneys, lungs, heart, gut, and/or central nervous system. The diagnosis of CV in the ICU may be delayed or completely unrecognized. A high level of suspicion is critical to obtain a timely and accurate diagnosis and to initiate appropriate treatment. We describe severe acute manifestations of CV based on six selected patients admitted to our ICU. That all six patients survived suggests the benefit of prompt ICU admission of patients with severe CV.
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Affiliation(s)
- Mohamad Zaidan
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Eric Mariotte
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Bertrand Arnulf
- Department of Immuno-Hematology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Véronique Meignin
- Department of Pathology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Jérôme Vérine
- Department of Pathology, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Alfred Mahr
- Department of Internal Medicine, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
| | - Élie Azoulay
- Department of Medical Intensive Care Unit, Hôpital Saint-Louis, AP-HP, Université Paris-7 Diderot, Paris, France
- AP-HP, Hôpital Saint-Louis, Medical ICU, University Paris-7 Paris-Diderot, UFR de Médecine, 1 avenue Claude Vellefaux, 75010 Paris, France
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43
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Hepatitis C virus infection and mixed cryoglobulinemia. Clin Dev Immunol 2012; 2012:502156. [PMID: 22844322 PMCID: PMC3403343 DOI: 10.1155/2012/502156] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2012] [Accepted: 06/11/2012] [Indexed: 12/21/2022]
Abstract
Hepatitis C virus (HCV) chronic infection is recognized as the major cause of mixed cryoglobulinemia (MC). Its persistence represents a continuous stimulus for host immune system with production of circulating immune complexes (ICs), one-third of them with cryoprecipitate property. Several factors contribute to the biological activities of ICs, many of which are not completely known. Among them, complement factors play a crucial role in the cold-insoluble ICs-mediated vasculitis, involving primarily small blood vessels in different tissues including skin, kidney, peripheral, and central nervous system. Liver represents the major target of HCV infection with inflammatory infiltrates, resembling secondary lymphoid follicles. Cytokine like CXCL13 contribute to B-cell homing in intraportal lymphoid aggregates, in which B-cell clonal selection may arise. B-cell clonal expansion starts as an antigen-driven event and expands towards indolent and malignant B-cell proliferation. Occurrence of intrahepatic B-cell clonalities correlates with extrahepatic clinical manifestations of HCV infection. In this context, cryoglobulinemic patients should be considered a peculiar HCV-infected population that needs a clinical multidisciplinary approach and more articulated therapeutic measures.
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Choudhry M, Rao N, Juneja R. Successful treatment of cryoglobulinaemia with rituximab. CASE REPORTS IN NEPHROLOGY AND UROLOGY 2012. [PMID: 23197959 PMCID: PMC3482085 DOI: 10.1159/000339400] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Cryoglobulinaemia is a systemic inflammatory condition characterised by immune complex-mediated small-to-medium-sized vasculitis. It has a wide variety of presentations ranging from bruising, neuropathy, and hepatosplenomegaly to acute renal failure. Mixed cryoglobulinaemia is the most common type and is strongly associated with hepatitis C. Management approaches include use of cyclophosphamide, prednisolone, and plasmapheresis, with differing views on alternative treatments in resistant cases. Rituximab has emerged as an attractive option in resistant cases on account of its potent immunosuppressive effects on B cells. We describe a case of type 2 mixed cryoglobulinaemia in association with non-Hodgkin's lymphoma resistant to standard treatments which responded well to rituximab. This case is remarkable as mixed cryoglobulinaemia associated with non-Hodgkin's lymphoma presenting with nephritis is unusual, and, contrary to the high rate of recurrence in lymphoma-related cryoglobulinaemia, our patient has not shown any recurrence over 24 months. This highlights an alternative treatment modality which can be used in patients not responsive to existing managements for this condition with benefits of minimal side effects and no oncogenetic potential.
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Affiliation(s)
- M Choudhry
- Department of Renal Medicine, Flinders Medical Centre, Bedford Park, S.A., Australia
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45
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Abstract
Cryoglobulins are immunoglobulins that precipitate in vitro at temperatures less than 37°C and produce organ damage through two main pathways: vascular sludging (hyperviscosity syndrome, mainly in type I cryoglobulinaemia) and immune-mediated mechanisms (principally vasculitis, in mixed cryoglobulinaemia). Cryoglobulinaemia is associated with many illnesses, which can be broadly grouped into infections, autoimmune disorders, and malignancies; the most common cause is infection with hepatitis C virus. Mixed cryoglobulinaemic syndrome is diagnosed when a patient has typical organ involvement (mainly skin, kidney, or peripheral nerve) and circulating cryoglobulins. Cutaneous purpura is the most common manifestation of cryoglobulinaemic vasculitis. The most frequently affected internal organs are the peripheral nerves, kidneys, and joints. The course varies widely and prognosis is influenced by both cryoglobulinaemic damage to vital organs and by comorbidities associated with underlying diseases. More than 90% of cases of cryoglobulinaemia have a known underlying cause; therefore treatment is focused on the cause of the disorder rather than merely symptomatic relief. Studies suggest that both combined or sequential antiviral therapies and targeted biological treatments might be more effective than monotherapy.
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Affiliation(s)
- Manuel Ramos-Casals
- Josep Font Laboratory of Autoimmune Diseases, Institut Clínic de Medicina I Dermatologia, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain
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46
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Cacoub P. [Kidney involvement in mixed cryoglobulinemia: which treatment?]. Presse Med 2011; 41:254-9. [PMID: 22192935 DOI: 10.1016/j.lpm.2011.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Accepted: 11/14/2011] [Indexed: 10/21/2022] Open
Abstract
A kidney involvement is found in 20 to 56% of patients presenting with a cryoglobulinemic vasculitis, type II IgMk, associated to hepatitis C virus infection (HCV). Patients present with a membrano-proliferative glomerulonephritis. In HCV-associated cases, treatment guidelines are adapted to the severity of the disease. In severe forms, including those with kidney involvement, treatment starts with rituximab then an optimal antiviral combination. In non-HCV cases combination with steroids, immunosuppressants and plasmapheresis showed variable efficacy. Retrospective analysis of rituximab showed a great efficacy in more than 80% patients with an increased risk of severe infections (14.1/100 patient-years), particularly in patients over 70 years, with a renal insufficiency and previously treated with high dose steroids.
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Affiliation(s)
- Patrice Cacoub
- Université Pierre-et-Marie-Curie-Paris-6, CNRS, UMR 7087, 75013 Paris, France.
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Ronco P, Plaisier E, Aucouturier P. Ig-related renal disease in lymphoplasmacytic disorders: an update. Semin Nephrol 2011; 30:557-69. [PMID: 21146121 DOI: 10.1016/j.semnephrol.2010.09.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Ig-related renal diseases occurring in lymphoplasmacytic disorders (LPD) cover a wide spectrum of renal lesions. Except for cast nephropathy, which is almost specific for multiple myeloma, similar renal lesions caused by deposition or precipitation of monoclonal Ig-related material may occur in the various types of LPD. Because the secreted Ig provides the link between the LPD and the kidney disease, the renal outcome is linked to efficacy of chemotherapy. In the past 10 years, considerable advances have occurred in chemotherapy regimens with the advent of new classes of drugs, which already result in markedly improved renal and vital survival.
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Affiliation(s)
- Pierre Ronco
- Assistance Publique - Hôpitaux de Paris, Hôpital Tenon, Service de Néphrologie et Dialyses, Paris, France.
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Foessel L, Besancenot JF, Blaison G, Magy-Bertrand N, Jaussaud R, Etienne Y, Maurier F, Audia S, Martin T. Clinical spectrum, treatment, and outcome of patients with type II mixed cryoglobulinemia without evidence of hepatitis C infection. J Rheumatol 2011; 38:716-22. [PMID: 21239761 DOI: 10.3899/jrheum.100898] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The clinical spectrum, etiologies, and best therapeutic approaches of type II mixed cryoglobulinemia (MC) not associated with hepatitis C virus (HCV) infection have been poorly described to date. We studied the clinical presentation and outcome of patients with type II MC with no evidence of HCV. METHODS This was a multicenter retrospective study on the clinical presentation and outcome of patients with type II MC without evidence of HCV infection. Only patients with symptomatic MC were included. RESULTS Thirty-three patients were included (median followup 67.2 mo). Extensive investigations for associated diseases were performed at presentation. MC was related to an autoimmune disease in 14 patients, to a lymphoid malignancy in 4 patients, and to an infectious disease in 2 patients, while MC was classified as essential (primary) in 13. Essential MC tended to be more severe than secondary disease with, in particular, more frequent renal and peripheral nerve involvement. Most patients were treated with steroid with or without immunosuppressive agents, mainly cyclophosphamide. These treatments were unable to induce sustained remission. One patient was successfully treated with lenalidomide. Seven patients with nonmalignant MC were treated with rituximab; 2 had a sustained complete remission, 3 improved greatly but relapsed within 5 months, and 2 experienced a disease flare. CONCLUSION An important proportion of non HCV-related type II MC remains essential. Efforts should be made to find other etiologies than HCV, because treatments with steroid and immunosuppressants are not satisfactory, especially in severe forms. In these situations anti-CD20 therapy may present the best option but should be used with caution. New agents such as lenalidomide remain to be evaluated.
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Affiliation(s)
- Laure Foessel
- Department of Clinical Immunology, National Referral Center or Autoimmune Diseases, University of Strasbourg, Strasbourg, France
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Abstract
Paraneoplastic glomerulonephritis is a rare complication of malignancy that is frequently mistaken for idiopathic glomerulonephritis. Failure to recognize paraneoplastic glomerulonephritis can subject patients to ineffective and potentially harmful therapy. The pathology of paraneoplastic glomerulonephritis varies between different types of malignancies. This Review discusses the association of glomerulonephritis with both solid tumors and hematological malignancies. The pathogenetic mechanisms of many glomerular lesions seem to relate to altered immune responses in the presence of a malignancy. Studies in the Buffalo/Mna rat model of spontaneous thymoma and nephrotic syndrome indicate that polarization of the immune response toward a T-helper-2 (T(H)2) profile has an important role in the development of thymoma-associated glomerular lesions. Furthermore, overexpression of the T(H)2 cytokine interleukin 13 in rats induces minimal change disease. Such findings from experimental studies might facilitate the identification of biomarkers that can distinguish paraneoplastic glomerulonephritis from idiopathic and other secondary glomerulonephritides. This Review describes potential pathogenetic mechanisms for paraneoplastic glomerulonephritides associated with different malignancies and highlights the need for a multidisciplinary approach to the management of patients with paraneoplastic glomerulonephritis.
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Dahan K, Albert C, Arlet JB, Callard P, Ronco P. Non-Randall proliferative glomerulonephritis with humps and monotypic IgG deposits in primary Sjögren's syndrome: a first case report. NDT Plus 2010; 3:558-63. [PMID: 25949467 PMCID: PMC4421420 DOI: 10.1093/ndtplus/sfq147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2010] [Accepted: 07/14/2010] [Indexed: 11/14/2022] Open
Abstract
Renal involvement is frequent in patients suffering from primary Sjögren's syndrome (pSS). Tubulointerstitial infiltration is the most common renal lesion, while glomerular involvement is rare. We report the case of a 50-year-old woman with pSS who developed renal failure due to an unusual proliferative glomerulonephritis with humps and monotypic IgG1-kappa deposits. Searches for cryoglobulinaemia, anti-double-stranded DNA and anti-neutrophil cytoplasmic antibodies were negative. Serum protein electrophoresis and immunofixation revealed no monoclonal immunoglobulin. Extensive work-up excluded associated infectious, collagen or lymphoproliferative disease. This case adds to the spectrum of pSS-related glomerular disease which is reviewed in depth.
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Affiliation(s)
- Karine Dahan
- AP-HP, Hôpital Tenon , Service de Néphrologie et Dialyses, F-75020, Paris , France
| | - Catherine Albert
- AP-HP, Hôpital Tenon , Service de Néphrologie et Dialyses, F-75020, Paris , France ; Hôpital de Chartres , Service de Néphrologie, Chartres , France
| | - Jean-Benoît Arlet
- AP-HP, Hôpital Tenon , Service de Néphrologie et Dialyses, F-75020, Paris , France
| | - Patrice Callard
- AP-HP, Hôpital Tenon , Service d'Anatomie pathologique, F-75020, Paris , France
| | - Pierre Ronco
- AP-HP, Hôpital Tenon , Service de Néphrologie et Dialyses, F-75020, Paris , France ; UPMC Univ Paris 06, Paris , France ; INSERM , UMR_S702, F-75020, Paris , France
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