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Tso ACY, Chng WJ, Goh YT, Ooi MG, Chen Y, Nagarajan C, Tan D, Acharyya S, Ong KH. Daratumumab-Based Therapeutic Approaches and Clinical Outcomes in Multiple Myeloma and other Plasma Cell Dyscrasias: Insights from a Nationwide Real-World Chart Review Study. Clin Hematol Int 2024; 6:53-66. [PMID: 39417013 PMCID: PMC11477938 DOI: 10.46989/001c.124362] [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: 06/01/2024] [Accepted: 07/26/2024] [Indexed: 10/19/2024] Open
Abstract
Singapore leads Southeast Asia in the routine use of daratumumab for multiple myeloma and other plasma cell dyscrasias. This retrospective review analyzed 112 patients who received daratumumab between 2012 and 2020. Tolerability, and efficacy based on prior lines (PL) of therapy, cytogenetic risk group, and the presence of renal impairment were presented. Infusion-related reactions occurred in 26.8% of patients. Grades 1 and 2 hematological and non-hematological adverse events were observed in 14.3% and 33.9% of patients, respectively. After a median follow-up of 16.9 months, there was no significant difference in overall response rates (ORR) (86% versus 76.3%, p = 0.082) or depth of response (≥ complete response (CR), 35.1% versus 28.9%, p = 0.469) between myeloma patients with and without renal dysfunction. Newly diagnosed and relapsed/refractory patients had an ORR of 92% and 76.3%, and a ≥ VGPR (very good partial response) rate of 80% and 55.3%, respectively. Median progression-free survival (PFS) was better for patients with 0/1 PL compared to ≥ 2 PLs (19.8 versus 6.2 months, p < 0.001), with a deeper response (≥ CR, 38.5% versus 16.7%, p = 0.033). Forty-six and a half percentage of patients had high-risk FISH abnormalities, and those with 0/1 PL had a significantly better ORR than those with ≥ 2 PLs (83.3% vsersus 47.1%, p = 0.022), achieving an ORR similar to that of the general cohort (80.2%, p = 0.905). In conclusion, positioning daratumumab in earlier lines of therapy leads to better outcomes and may mitigate the impact of high-risk FISH abnormalities.
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Affiliation(s)
| | - Wee Joo Chng
- HaematologyNational University Cancer Institute, Singapore
| | | | - Melissa G Ooi
- HaematologyNational University Cancer Institute, Singapore
| | | | | | - Daryl Tan
- Clinic for Lymphoma, Myeloma and Blood Disorders
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Nasr SH, Sirac C, Leung N, Bridoux F. Monoclonal immunoglobulin crystalline nephropathies. Kidney Int 2024; 106:201-213. [PMID: 38723749 DOI: 10.1016/j.kint.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 02/18/2024] [Accepted: 02/27/2024] [Indexed: 05/22/2024]
Abstract
Monoclonal Ig crystalline nephropathies are rare lesions resulting from precipitation of monoclonal Igs in the kidney as crystalline inclusions. They can be categorized into lesions with predominant intracellular crystals (light chain [LC] proximal tubulopathy, LC crystal-storing histiocytosis, and LC crystalline podocytopathy) and lesions with predominant extracellular crystals (crystalglobulin-induced nephropathy and crystalline variant of LC cast nephropathy). The majority of these lesions are associated with low tumor burden lymphoproliferative disorders, with the exception of crystalline variant of LC cast nephropathy. Extrarenal involvement (e.g., skin and cornea) is frequent. Kidney biopsy is the cornerstone for diagnosis, which often requires electron microscopy and antigen retrieval. A thorough hematologic workup and evaluation of extrarenal involvement is mandatory for management. Treatment of these lesions is with clone-directed therapy, with the goal of achieving hematologic very good partial response or complete response, which preserves or improves kidney function. In vitro and in vivo studies, animal models, and novel sequencing techniques have been invaluable tools to understand the pathogenesis of LC proximal tubulopathy and can be used to increase our limited knowledge of the pathogenesis of the other monoclonal Ig crystalline nephropathies. This review provides an update on the pathology, renal and hematologic characteristics, extrarenal manifestations, prognosis, treatment, and pathogenesis of monoclonal Ig crystalline nephropathies.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Christophe Sirac
- Control of the Immune Response B and Lymphoproliferation, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, Limoges, France; Centre de Référence de l'Amylose AL et des autres Maladies par Dépôts d'Imunoglobuline Monoclonale, University Hospital Dupuytren, Limoges, France
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Frank Bridoux
- Control of the Immune Response B and Lymphoproliferation, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, Limoges, France; Centre de Référence de l'Amylose AL et des autres Maladies par Dépôts d'Imunoglobuline Monoclonale, University Hospital Dupuytren, Limoges, France; Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
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Ferla V, Farina F, Perini T, Marcatti M, Ciceri F. Monoclonal Antibodies in Smoldering Multiple Myeloma and Monoclonal Gammopathy of Undetermined Significance: Current Status and Future Directions. Pharmaceuticals (Basel) 2024; 17:901. [PMID: 39065751 PMCID: PMC11279454 DOI: 10.3390/ph17070901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 06/27/2024] [Accepted: 07/01/2024] [Indexed: 07/28/2024] Open
Abstract
Monoclonal antibodies (MoAbs) targeting several cellular receptors have significantly improved the prognosis of multiple myeloma (MM). Their high effectiveness and safety raise the question of whether earlier therapeutic intervention in monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma (SMM) influences the natural course of the disease. MM is preceded by clinically recognized conditions such as MGUS and SMM. Numerous studies are investigating the disease biology and immune profile of SMM and MGUS to unravel the intricate relationship between immunosurveillance and disease progression. The standard approach to MGUS and SMM remains close observation. Early studies indicate benefits in terms of progression or even survival for promptly treating high-risk SMM patients. Ongoing debates are focused on which patients with SMM and MGUS to treat, as well as on determining the optimal therapeutic approach. The first approach aims to cure by attempting to eliminate the pathological clone, while the second approach is preventive, aiming to manage disease progression to active MM and restore the immune system. In this review, we focus on the available and emerging data on early treatment, particularly with MoAbs alone or in combination with other therapies, in SMM and MGUS patients.
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Affiliation(s)
- Valeria Ferla
- Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (F.F.); (T.P.); (M.M.); (F.C.)
| | - Francesca Farina
- Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (F.F.); (T.P.); (M.M.); (F.C.)
| | - Tommaso Perini
- Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (F.F.); (T.P.); (M.M.); (F.C.)
- Age Related Diseases Laboratory, Division of Genetics and Cell Biology, IRCSS San Raffaele Scientific Institute, 20132 Milan, Italy
| | - Magda Marcatti
- Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (F.F.); (T.P.); (M.M.); (F.C.)
| | - Fabio Ciceri
- Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, 20132 Milan, Italy; (F.F.); (T.P.); (M.M.); (F.C.)
- Faculty of Medicine and Surgery, Vita-Salute IRCCS San Raffaele University, 20132 Milan, Italy
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Wang Y, Chen D, Hu R, Zhang Y, Liang D, Xu F, Liu F, Zhu X, Lin Y, Yang X, Liu X, Xing G, Liang S, Zeng C. Clinicopathological Characteristics of Light and Heavy Chain Deposition Disease: A Case Series. Am J Kidney Dis 2024:S0272-6386(24)00757-1. [PMID: 38750878 DOI: 10.1053/j.ajkd.2024.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 02/19/2024] [Accepted: 03/09/2024] [Indexed: 07/04/2024]
Abstract
RATIONALE & OBJECTIVE Light and heavy chain deposition disease (LHCDD) is a rare form of monoclonal immunoglobulin (Ig) deposition disease, and limited clinical data are available characterizing this condition. Here we describe the clinicopathological characteristics and outcomes of LHCDD. STUDY DESIGN Case series. SETTING & PARTICIPANTS 13 patients with biopsy-proven LHCDD diagnosed between January 2008 and December 2022 at one of 2 Chinese medical centers. FINDINGS Among the 13 patients described, 6 were men and 7 were women, with a mean age of 52.6±8.0 years. Patients presented with hypertension (76.9%), anemia (84.6%), increased serum creatinine concentrations (84.6%; median, 1.7mg/dL), proteinuria (100%; average urine protein, 3.0g/24h), nephrotic syndrome (30.8%), and microscopic hematuria (76.9%). Serum immunofixation electrophoresis showed monoclonal Ig for 11 patients (84.6%). Serum free light chain ratios were abnormal in 11 patients (84.6%), and heavy/light chain ratios were abnormal in 9 of 10 patients (90%) with available data. Five patients were diagnosed with multiple myeloma. A histological diagnosis of nodular mesangial sclerosis was made in 10 patients (76.9%). Immunofluorescence demonstrated deposits of IgG subclass in 7 patients (γ-κ, n=4; γ-λ, n=3) and IgA in 5 patients (α-κ, n=2; α-λ, n=3). Six patients underwent IgG subclass staining (γ1, n=3; γ2, n=2; γ3, n=1). The deposits of IgD-κ were confirmed by mass spectrometry in 1 patient. Among 12 patients for whom data were available during a median of 26.5 months, 11 received chemotherapy and 1 received conservative treatment. One patient died, and disease progressed to kidney failure in 3 (25%). Among the 9 patients evaluable for hematological and kidney disease progression, 5 (56%) had a hematologic response and 1 (11%) exhibited improvement in kidney disease. LIMITATIONS Retrospective descriptive study, limited number of patients, urine protein electrophoresis or immunofixation electrophoresis test results missing for most patients. CONCLUSIONS In this case series of LHCDD, light and heavy chain deposition in kidney tissues were most frequent with monoclonal IgG1-κ. Among patients with evaluable data, more than half had a hematologic response, but a kidney response was uncommon.
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Affiliation(s)
- Yujie Wang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Dacheng Chen
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Ruimin Hu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou
| | - Yuan Zhang
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, China
| | - Dandan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Feng Xu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Feng Liu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Xiaodong Zhu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Yao Lin
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Nanjing Medical University, Nanjing
| | - Xue Yang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Xumeng Liu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Guolan Xing
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou.
| | - Shaoshan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing.
| | - Caihong Zeng
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing.
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Bnaya A, Ganzel C, Shavit L. Successful Treatment with Daratumumab of a Patient with Monoclonal Lambda Light Chain Disease Presenting as Nephrotic Syndrome and Crescentic Glomerulonephritis. Acta Haematol 2024; 147:598-603. [PMID: 38228095 PMCID: PMC11441376 DOI: 10.1159/000536283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 01/11/2024] [Indexed: 01/18/2024]
Abstract
INTRODUCTION Monoclonal immunoglobulin deposition diseases (MIDDs) are a group of systemic diseases, characterized by deposition of monoclonal immunoglobulin predominantly in the kidney. In the absence of overt hematologic disease, MIDDs are classified as a part of monoclonal gammopathy of renal significance. Patients with MIDD may present with a nephrotic syndrome and kidney function impairment. Treatment usually includes anti-plasma cell therapy. CASE PRESENTATION We report a case of a 54-year-old female who presented with nephrotic syndrome related to light chain deposition disease of lambda type. Due to a complicated clinical course (including cardiac injury and thromboembolic stroke), plasma cell-targeted therapy was stopped. A few months later, the patient presented with severe acute kidney injury. Kidney biopsy revealed crescentic glomerulonephritis, and immunofluorescence staining was positive for lambda chain. Treatment with daratumumab was initiated resulting in stabilization of kidney function and partial nephrotic syndrome remission. CONCLUSION This case highlights an uncommon histologic manifestation in a patient diagnosed with light chain deposition disease. Furthermore, it underscores the significance of plasma cell-targeted therapy and the favorable clinical and hematological response observed with daratumumab.
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Affiliation(s)
- Alon Bnaya
- Department of Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel
- Hadassah-Hebrew University Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Chezi Ganzel
- Hadassah-Hebrew University Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Hematology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Linda Shavit
- Department of Nephrology, Shaare Zedek Medical Center, Jerusalem, Israel
- Hadassah-Hebrew University Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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6
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Kousios A, Blakey S, Moran L, Atta M, Charif R, Duncan N, Smith A, Tam FWK, Levy JB, Chaidos A, Roufosse C. Non-crystalline light chain proximal tubulopathy, a morphologically protean entity. Nephrol Dial Transplant 2023; 38:2576-2588. [PMID: 37120733 PMCID: PMC10615624 DOI: 10.1093/ndt/gfad085] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND Light chain proximal tubulopathy (LCPT) is a rare form of paraprotein-related disease, occurring in two main histopathological forms: crystalline and non-crystalline. The clinicopathological features, treatment strategies and outcomes, especially of the non-crystalline form, are not well described. METHODS We conducted a single-centre retrospective case series of 12 LCPT patients, 5 crystalline and 7 non-crystalline, between 2005 and 2021. RESULTS The median age was 69.5 years (range 47-80). Ten patients presented with CKD and significant proteinuria (median estimated glomerular filtration rate of 43.5 ml/min/1.73 m2; urine protein:creatinine ratio 328 mg/mmol). Only six patients had known haematological disease at the time of renal biopsy. Multiple myeloma (MM) was diagnosed in seven patients cases and monoclonal gammopathy of renal significance (MGRS) in five patients. A clone was detected in all cases combining serum/urine electrophoresis and free light chain (LC) assays. Crystalline and non-crystalline variants had similar clinical presentations. For the non-crystalline variant, a diagnosis was reached based on a combination of CKD without another cause, haematological workup, LC restriction on immunofluorescence and abnormalities on electron microscopy (EM). Nine of 12 patients received clone-directed treatment. Patients who achieved haematological response (including all non-crystalline LCPT) had improved renal outcomes over a median follow-up of 79 months. CONCLUSIONS The non-crystalline variant may go unrecognised because of its subtle histopathological features and requires EM to distinguish it from 'excessive LC resorption without tubular injury'. Clone-directed treatment with good haematological response improves renal outcomes in both variants but limited data exist in MGRS. Multicentre prospective studies are needed to better define the clinicopathological characteristics associated with poor outcomes and optimize treatment strategies in patients with MGRS.
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Affiliation(s)
- Andreas Kousios
- Imperial College, Centre for Inflammatory Disease, Dept Immunology and Inflammation, Faculty of Medicine, London, UK
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Sarah Blakey
- Imperial College, Centre for Inflammatory Disease, Dept Immunology and Inflammation, Faculty of Medicine, London, UK
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Linda Moran
- North West London Pathology, Charing Cross Hospital, London, UK
| | - Maria Atta
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Rawya Charif
- Imperial College, Centre for Inflammatory Disease, Dept Immunology and Inflammation, Faculty of Medicine, London, UK
| | - Neill Duncan
- Imperial College, Centre for Inflammatory Disease, Dept Immunology and Inflammation, Faculty of Medicine, London, UK
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Andrew Smith
- North West London Pathology, Charing Cross Hospital, London, UK
| | - Frederick W K Tam
- Imperial College, Centre for Inflammatory Disease, Dept Immunology and Inflammation, Faculty of Medicine, London, UK
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Jeremy B Levy
- Imperial College, Centre for Inflammatory Disease, Dept Immunology and Inflammation, Faculty of Medicine, London, UK
- West London Renal and Transplant Centre, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Aristeidis Chaidos
- Department of Haematology, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
- Hugh and Josseline Langmuir Centre for Myeloma Research, Centre for Haematology, Department of Immunology and Inflammation, Imperial College London, UK
| | - Candice Roufosse
- Imperial College, Centre for Inflammatory Disease, Dept Immunology and Inflammation, Faculty of Medicine, London, UK
- North West London Pathology, Charing Cross Hospital, London, UK
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7
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Kastritis E, Terpos E, Symeonidis A, Labropoulou V, Delimpasi S, Mancuso K, Zamagni E, Katodritou E, Rivolti E, Kyrtsonis MC, Roussou M, Fotiou D, Theodorakakou F, Ntanasis-Stathopoulos I, Hatjiharissi E, Kanellias N, Migkou M, Cheliotis G, Manousou K, Gavriatopoulou M, Dimopoulos MA. Prospective phase 2 trial of daratumumab with dexamethasone in patients with relapsed/refractory multiple myeloma and severe renal impairment or on dialysis: The DARE study. Am J Hematol 2023; 98:E226-E229. [PMID: 37340832 DOI: 10.1002/ajh.27001] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 06/22/2023]
Affiliation(s)
- Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Argiris Symeonidis
- Hematology Division, Department of Internal Medicine, University of Patras, Medical School, Patras, Greece
| | - Vasiliki Labropoulou
- Hematology Division, Department of Internal Medicine, University of Patras, Medical School, Patras, Greece
| | - Sosana Delimpasi
- Department of Hematology and Bone Marrow Transplantation Unit, Evangelismos Hospital, Athens, Greece
| | - Katia Mancuso
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Elena Zamagni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Eirini Katodritou
- Department of Hematology, Theagenio Cancer Hospital, Thessaloniki, Greece
| | - Elena Rivolti
- Department of Hematology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Marie-Christine Kyrtsonis
- First Department of Propedeutic Internal Medicine, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Roussou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evdoxia Hatjiharissi
- First Department of Internal Medicine, Division of Hematology, AHEPA University Hospital, Aristotle University of Thessaloniki, School of Medicine, Thessaloniki, Greece
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | | | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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Esposito P, Picciotto D, Costigliolo F, Russo E, Macciò L, Cenacchi G, Cagnetta A, Cea M, Lemoli RM, Viazzi F. Daratumumab in the treatment of C3 glomerulopathy with monoclonal gammopathy: a case report and literature review. Front Med (Lausanne) 2023; 10:1266172. [PMID: 37724175 PMCID: PMC10505429 DOI: 10.3389/fmed.2023.1266172] [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: 07/24/2023] [Accepted: 08/21/2023] [Indexed: 09/20/2023] Open
Abstract
Although rare, C3 glomerulopathy (C3G) is increasingly recognized thanks to the currently available diagnostic skills. C3G is not a single disease but a group of disorders with distinct pathogenesis and progression. Thus, an essential step for its management remains an in-depth characterization of the specific form and the identification of underlying conditions, which may also impact treatment choices as well. Among these entities, an emerging condition is the association of C3G with monoclonal gammopathy, which confers poor outcomes. Overall, diagnosis of C3G remains challenging, and determining the appropriate treatment remains unclear. Conventional immunosuppressive therapy has proven ineffective in such cases, while clone-directed therapies have shown promising results in small interventional studies and case series. Here, we report a case of a patient affected by C3G with monoclonal gammopathy of renal significance who experienced rapid deterioration of kidney function requiring replacement therapy. After the failure of first-line treatment, a switch to the anti-CD38 therapy with daratumumab resulted in the progressive improvement of the patient's kidney function, leading to the discontinuation of hemodialysis after approximately 10 months. Serial renal biopsies were also performed to study the disease's evolution in response to the treatment. Based on the description of this single case, we have comprehensively reviewed available studies on daratumumab use in patients with C3G associated with monoclonal gammopathy to provide insights for the design of prospective studies which aim to enhance the management of such poor prognosis disease.
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Affiliation(s)
- Pasquale Esposito
- Unit of Nephrology, Dialysis, and Transplantation, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, Genoa, Italy
| | - Daniela Picciotto
- Unit of Nephrology, Dialysis, and Transplantation, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Francesca Costigliolo
- Unit of Nephrology, Dialysis, and Transplantation, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Elisa Russo
- Unit of Nephrology, Dialysis, and Transplantation, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, Genoa, Italy
| | - Lucia Macciò
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, Genoa, Italy
| | - Giovanna Cenacchi
- Biotechnology and Methods in Laboratory Medicine, Department of Experimental, Diagnostic and Specialty Medicine (DIMES), University of Bologna, Bologna, Italy
| | - Antonia Cagnetta
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Clinic of Hematology, Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, Genoa, Italy
| | - Michele Cea
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Clinic of Hematology, Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, Genoa, Italy
| | - Roberto M. Lemoli
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Clinic of Hematology, Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, Genoa, Italy
| | - Francesca Viazzi
- Unit of Nephrology, Dialysis, and Transplantation, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine and Medical Specialties (DiMI), University of Genoa, Genoa, Italy
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9
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Theodorakakou F, Fotiou D, Gavriatopoulou M, Ntanasis-Stathopoulos I, Spiliopoulou V, Malandrakis P, Migkou M, Eleutherakis-Papaiakovou E, Kanellias N, Terpos E, Dimopoulos MA, Kastritis E. Prevalence of MGCS Among Patients With Monoclonal Gammopathies. Hemasphere 2023; 7:e908. [PMID: 37275739 PMCID: PMC10234460 DOI: 10.1097/hs9.0000000000000908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 05/03/2023] [Indexed: 06/07/2023] Open
Affiliation(s)
- Foteini Theodorakakou
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | | | - Vassiliki Spiliopoulou
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | | | - Nikolaos Kanellias
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, Alexandra Hospital, National and Kapodistrian University of Athens, Greece
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10
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Karam S, Haidous M, Dalle IA, Dendooven A, Moukalled N, Van Craenenbroeck A, Bazarbachi A, Sprangers B. Monoclonal gammopathy of renal significance: Multidisciplinary approach to diagnosis and treatment. Crit Rev Oncol Hematol 2023; 183:103926. [PMID: 36736510 DOI: 10.1016/j.critrevonc.2023.103926] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a hemato-nephrological term referring to a heterogeneous group of kidney disorders characterized by direct or indirect kidney injury caused by a monoclonal immunoglobulin (MIg) produced by a B cell or plasma cell clone that does not meet current hematologic criteria for therapy. MGRS-associated kidney diseases are diverse and can result in the development of end stage kidney disease (ESKD). The diagnosis is typically made by nephrologists through a kidney biopsy. Many distinct pathologies have been identified and they are classified based on the site or composition of the deposited Mig, or according to histological and ultrastructural findings. Therapy is directed towards the identified underlying clonal population and treatment decisions should be coordinated between hematologists and nephrologists in a multidisciplinary fashion, depend on the type of MGRS, the degree of kidney function impairment and the risk of progression to ESKD.
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Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, United States
| | - Mohammad Haidous
- Department of Medicine, Saint Vincent Charity Medical Center, Cleveland, OH, United States
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amélie Dendooven
- Department of Pathology, University Hospital Ghent, Ghent, Belgium
| | - Nour Moukalled
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amaryllis Van Craenenbroeck
- Department of Microbiology, Immunology and Transplantation, Laboratory of Nephrology, KU Leuven, Leuven, Belgium; Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ben Sprangers
- Biomedical Research Institute, Department of Immunology and Infection, University Hasselt, Diepenbeek, Belgium; Department of Nephrology, Ziekenhuis Oost-Limburg, Genk, Belgium.
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11
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Pianko MJ, Tiutan T, Derkach A, Flynn J, Salvatore SP, Jaffer-Sathick I, Rossi AC, Lahoud O, Hultcrantz M, Shah UA, Maclachlan K, Chung DJ, Shah GL, Landau HJ, Korde N, Mailankody S, Lesokhin A, Tan C, Scordo M, Jaimes EA, Giralt SA, Usmani S, Hassoun H. Assessment of renal outcome following therapy in monoclonal immunoglobulin deposition disease: Emphasizing the need for a consensus approach. Am J Hematol 2023; 98:421-431. [PMID: 36588413 PMCID: PMC10329474 DOI: 10.1002/ajh.26801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 11/07/2022] [Accepted: 11/28/2022] [Indexed: 01/03/2023]
Abstract
Monoclonal immunoglobulin deposition disease (MIDD), often associated with plasma cell dyscrasias, predominantly affects the kidneys. In this disease, hematologic response (HR) to treatment can be reliably assessed by International Myeloma Working Group (IMWG) consensus criteria, while uniform criteria for assessing renal response are lacking. We report a retrospective analysis of renal outcomes among 34 patients with MIDD. With most patients treated with bortezomib and autologous stem cell transplantation, 26 of 28 (94%) achieved very good partial HR or better. We demonstrate that both IMWG (based on estimated glomerular filtration rate, eGFR) and amyloid (based on proteinuria) criteria are needed to capture renal response: among 28 evaluable patients, 6 (21%) had isolated proteinuria, while 13 (46%) had isolated decreased eGFR. Using both criteria, which were concordant in patients with both decreased eGFR and proteinuria, 22 of 28 patients (79%) achieved a renal response, including 2 of 7 discontinuing dialyses. All 6 patients (100%) with isolated proteinuria and 7 of 13 (54%) with isolated decreased eGFR achieved renal response, suggesting that isolated proteinuria is an early manifestation of MIDD associated with reversible renal damage. Baseline eGFR predicted renal response (p = .02 by quartile) and survival (p = .02), while HR (CR vs. non-CR) did not, probably because of high HR rate. With a median follow-up of 110 months, the median overall survival was 136 months (95% CI: 79-NR) and median renal survival had not been reached. Prospective studies using uniform renal response criteria are needed to optimize the management of MIDD.
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Affiliation(s)
- Matthew J. Pianko
- Michigan Medicine, University of Michigan Health, Ann Arbor, MI, United States
| | - Timothy Tiutan
- New York-Presbyterian – Weill Cornell Medical Center, New York, NY, United States
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Andriy Derkach
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Jessica Flynn
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Steven P. Salvatore
- New York-Presbyterian – Weill Cornell Medical Center, New York, NY, United States
| | - Insara Jaffer-Sathick
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Adriana C. Rossi
- New York-Presbyterian – Weill Cornell Medical Center, New York, NY, United States
| | - Oscar Lahoud
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Malin Hultcrantz
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Urvi A. Shah
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Kylee Maclachlan
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - David J. Chung
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Gunjan L. Shah
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Heather J. Landau
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Neha Korde
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Sham Mailankody
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Alexander Lesokhin
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Carlyn Tan
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Michael Scordo
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Edgar A. Jaimes
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Sergio A. Giralt
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Saad Usmani
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
| | - Hani Hassoun
- Memorial Sloan Kettering Cancer Center, Weill Cornell Medical School, New York, NY, United States
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12
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Ríos-Tamayo R, Paiva B, Lahuerta JJ, López JM, Duarte RF. Monoclonal Gammopathies of Clinical Significance: A Critical Appraisal. Cancers (Basel) 2022; 14:5247. [PMID: 36358666 PMCID: PMC9659226 DOI: 10.3390/cancers14215247] [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: 09/15/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 11/26/2022] Open
Abstract
Monoclonal gammopathies of clinical significance (MGCSs) represent a group of diseases featuring the association of a nonmalignant B cells or plasma cells clone, the production of an M-protein, and singularly, the existence of organ damage. They present a current framework that is difficult to approach from a practical clinical perspective. Several points should be addressed in order to move further toward a better understanding. Overall, these entities are only partially included in the international classifications of diseases. Its definition and classification remain ambiguous. Remarkably, its real incidence is unknown, provided that a diagnostic biopsy is mandatory in most cases. In fact, amyloidosis AL is the final diagnosis in a large percentage of patients with renal significance. On the other hand, many of these young entities are syndromes that are based on a dynamic set of diagnostic criteria, challenging a timely diagnosis. Moreover, a specific risk score for progression is lacking. Despite the key role of the clinical laboratory in the diagnosis and prognosis of these patients, information about laboratory biomarkers is limited. Besides, the evidence accumulated for many of these entities is scarce. Hence, national and international registries are stimulated. In particular, IgM MGCS deserves special attention. Until now, therapy is far from being standardized, and it should be planned on a risk and patient-adapted basis. Finally, a comprehensive and coordinated multidisciplinary approach is needed, and specific clinical trials are encouraged.
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Affiliation(s)
- Rafael Ríos-Tamayo
- Hospital Universitario Puerta de Hierro, Fundación para la Investigación Biomédica del Hospital Universitario Puerta de Hierro-Majadahonda, 28222 Majadahonda, Spain
| | - Bruno Paiva
- Centro de Investigación Médica Aplicada, Instituto de Investigación Sanitaria de Navarra, Clínica Universidad de Navarra, 31008 Pamplona, Spain
| | - Juan José Lahuerta
- Hospital Universitario 12 de Octubre, Instituto de Investigación del Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | - Joaquín Martínez López
- Hospital Universitario 12 de Octubre, Instituto de Investigación del Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | - Rafael F. Duarte
- Hospital Universitario Puerta de Hierro, Fundación para la Investigación Biomédica del Hospital Universitario Puerta de Hierro-Majadahonda, 28222 Majadahonda, Spain
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13
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Benoit SW, Khandelwal P, Grimley MS. A case of treatment-resistant membranous nephropathy associated with graft versus host disease successfully treated with daratumumab. Pediatr Transplant 2022; 26:e14263. [PMID: 35249254 DOI: 10.1111/petr.14263] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 01/25/2022] [Accepted: 02/17/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Membranous nephropathy (MN) is the most common cause of glomerulopathy after hematopoietic cell transplantation (HCT), most often occurring in the setting of graft versus host disease (GVHD). Twenty percent of patients will fail to respond to standard therapy and may progress to end stage renal disease. Here we present the case of a pediatric patient who developed chronic oral GVHD more than one-year post-HCT, who subsequently developed nephrotic syndrome (anasarca, nephrotic range proteinuria, hypoalbuminemia) and had a renal biopsy consistent with MN. Treated with ibrutinib for her GVHD, and steroids, tacrolimus, and rituximab for her MN, she failed to achieve even partial remission of her kidney disease after 8 months. Due to steroid toxicity and 0% CD19 cells on lymphocyte subpopulation flow cytometry, the decision was made to trial plasma cell depletion therapy with daratumumab. METHOD She received three doses of daratumumab at weeks 1, 4, and 17. RESULTS Her nephrotic syndrome resolved and her serum albumin was greater than 3.0 gm/dl by week 10. She was weaned off of both steroids and tacrolimus by week 16, at which time she had near-complete remission of her renal disease. CONCLUSION Daratumumab may be an important, novel therapeutic option for post-HCT MN patients who are not responsive to standard therapies.
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Affiliation(s)
- Stefanie W Benoit
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Pooja Khandelwal
- Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Michael S Grimley
- Division of Bone Marrow Transplantation and Immunodeficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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