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Ofori K, Soderquist CR, Murty VV, Park D, Vlad G, Leeman‐Neill RJ, Lentzsch S, Alobeid B, Bhagat G. The clinical and pathological features of plasma cell myeloma post solid organ transplantation. Am J Hematol 2020; 95:1531-1541. [PMID: 32864761 DOI: 10.1002/ajh.25988] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/25/2020] [Accepted: 08/27/2020] [Indexed: 12/18/2022]
Abstract
Plasma cell neoplasms (PCNs), comprising plasma cell myelomas (PCMs) and plasmacytomas, which occur after solid organ transplantation, represent rare subtypes of monomorphic post-transplant lymphoproliferative disorders (M-PTLDs). Data regarding the clinical and pathological features of post-transplant (PT)-PCMs are limited. To gain a better understanding of disease biology, we performed comprehensive immunophenotypic analysis, reviewed cytogenetic analysis results and evaluated clinical outcomes of PT-PCMs diagnosed and treated at our institution. Fifteen PT-PCM (M: F - 4:1) and two PT-MGUS (two males) cases were identified. The median age of PT-PCM patients was 68 years (29-79 years) and PCMs presented at a median of 9.7 years (0.5-24.7 years) after transplantation. The PT-PCMs accounted for 11.6% of all M-PTLDs and the period prevalence was 9/3108 (0.29%), 3/1071 (0.28%), 2/1345 (0.15%) and 1/878 (0.11%) post kidney, heart, liver and lung transplantation. Lytic bone disease was observed in 1/11 (9%) patients. Marrow plasma cell infiltration ranged from 10%-70% (median 20%), with 10/15 (67%) and 5/15 (33%) cases manifesting immature and plasmablastic morphology. The immunophenotype of all cases and cytogenetic abnormalities, identified in 60% of cases, were similar to multiple myeloma (MM) of immunocompetent individuals. All PT-PCMs were EBER negative. Ten of 11 (91%) patients with active MM were treated, all with proteasome inhibitor-based therapy. Treatment response and 5-year overall survival (54.5%) was comparable to MM of immunocompetent individuals. However, the survival of patients with plasmablastic PCMs was inferior to those with immature PCMs. 0ur findings indicate PT-PCMs to be predominantly late onset PTLDs that have similar clinicopathologic characteristics as conventional MM.
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Affiliation(s)
- Kenneth Ofori
- Department of Pathology and Cell Biology Columbia University Irving Medical Center New York New York US
| | - Craig R. Soderquist
- Department of Pathology and Cell Biology Columbia University Irving Medical Center New York New York US
| | - Vundavalli V. Murty
- Department of Pathology and Cell Biology Columbia University Irving Medical Center New York New York US
| | - David Park
- Department of Pathology and Cell Biology Columbia University Irving Medical Center New York New York US
| | - George Vlad
- Department of Pathology and Cell Biology Columbia University Irving Medical Center New York New York US
| | - Rebecca J. Leeman‐Neill
- Department of Pathology and Cell Biology Columbia University Irving Medical Center New York New York US
| | - Suzanne Lentzsch
- Division of Hematology/Oncology Columbia University Irving Medical Center New York City New York US
| | - Bachir Alobeid
- Department of Pathology and Cell Biology Columbia University Irving Medical Center New York New York US
| | - Govind Bhagat
- Department of Pathology and Cell Biology Columbia University Irving Medical Center New York New York US
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Monoclonal Gammopathies After Renal Transplantation: A Single-center Study. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:e468-e473. [PMID: 32340914 DOI: 10.1016/j.clml.2020.02.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 02/20/2020] [Accepted: 02/27/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Plasma cell disorders (PCDs) are clonal plasma cell disorders that include conditions such as monoclonal gammopathy of undetermined significance (MGUS), monoclonal gammopathy of renal significance (MGRS), multiple myeloma (MM), smoldering MM (SMM), solitary plasmacytoma, and light-chain (AL) amyloidosis. The risk factors associated with and the clinical course of PCDs after renal transplantation is not well established although immunosuppressive protocols may impact the incidence and natural history of PCDs posttransplant. PATIENTS AND METHODS This single-center retrospective study evaluated patients with a history of renal transplant who developed a PCD between January 1, 2014-December 31, 2018. RESULT A total of 41 patients met the inclusion criteria including 29 with MGUS and 12 with symptomatic PCD (4 with MM, 2 with SMM, 4 with MGRS, 1 with AL amyloidosis, and 1 with solitary plasmacytoma). The median follow-up of survivors was 41.6 months. Three patients (1 with MGUS and 2 with MGRS) progressed to MM during the follow-up period. There was a male preponderance in both groups. There was no correlation between the donor and immunosuppressive regimen and the development of a PCD. Patients with symptomatic PCD had higher serum creatinine and M-protein levels at diagnosis and higher free light chain ratio and plasma cell burden. There was also a higher percentage of allograft failure noted in the symptomatic PCD subset 50% (n = 6), whereas only 23% (n = 7) of patients had allograft failure in the MGUS group. CONCLUSION This study shows the importance of considering monoclonal gammopathy in the differential of renal dysfunction after kidney transplant and the need to follow these patients closely to monitor for progression to symptomatic PCD.
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Rana R, Cockwell P, Pratt G, Cook M, Drayson M, Vydianath B, Neil D, Pinney JH. Post-transplant Monoclonal Gammopathy of Renal Significance: A Case Series. Transplant Proc 2020; 52:857-864. [PMID: 32143865 DOI: 10.1016/j.transproceed.2019.12.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 11/13/2019] [Accepted: 12/06/2019] [Indexed: 11/17/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a new concept with evolving evidence for treatment. MGRS in the transplant kidney is a rare cause of renal transplant dysfunction that can lead to graft loss. Most cases of post-transplant MGRS are due to recurrent disease. Clone-specific chemotherapy is required to target the underlying clone, and this may improve graft survival; however, this can be challenging, as most patients are elderly with age-related comorbidities and may have complications associated with increasing immunosuppression. Here, we report 3 cases of renal allograft MGRS, and each case highlights different challenges in the diagnosis and management of this condition.
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Affiliation(s)
- Ritika Rana
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, United Kingdom.
| | - Paul Cockwell
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Guy Pratt
- Department of Haematology, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Mark Cook
- Department of Haematology, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Mark Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, United Kingdom
| | - Bindu Vydianath
- Department of Histopathology, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Desley Neil
- Department of Histopathology, University Hospitals Birmingham, Birmingham, United Kingdom
| | - Jennifer H Pinney
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, United Kingdom
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The Evolution of Monoclonal Gammopathy of Undetermined Significance in Kidney Transplant Recipients. Transplant Direct 2019; 5:e489. [PMID: 31723584 PMCID: PMC6791600 DOI: 10.1097/txd.0000000000000937] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 08/04/2019] [Indexed: 11/28/2022] Open
Abstract
It is unclear if immunosuppression increases the likelihood of malignant transformation of monoclonal gammopathy of undetermined significance (MGUS) and whether adverse renal outcomes in kidney transplant recipients with MGUS are more frequent.
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Sečník P, Jabor A, Lavríková P, Sečník J, Malíková P, Pokorná E, Franeková J. Immunoglobulin abnormalities in 1677 solid organ transplant recipients. Implications for posttransplantation follow-up. Transpl Immunol 2019; 57:101229. [PMID: 31398462 DOI: 10.1016/j.trim.2019.101229] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Posttransplant lymphoproliferative disorder (PTLD) is a severe complication of solid organ transplantation (SOT). However, there is no consensus on PTLD screening methods. Gammopathies (GP), which occur in 10-25% of SOT recipients, have been linked to subsequent development of PTLD. Therefore, GP detection methods, such as serum protein electrophoresis (SPE), serum protein immunofixation (SIFE), urine protein immunofixation (UIFE) and the quantitative measurement of serum free light chains (SFLC) are candidate methods for PTLD screening. OBJECTIVE We aimed to assess the frequency of PTLD and GP, association of GP with subsequent PTLD, allograft loss or death and the diagnostic performance of SPE/SIFE in PTLD screening. The main objective was to explore, whether GP detection methods can be used to enhance the efficiency of PTLD screening and to formulate a concise algorithm for posttransplantation (post-Tx) follow-up. METHODS We performed a cohort study on 1677 SOT recipients with SPE/SIFE data who underwent kidney, liver, heart, pancreas, Langerhans islets or multiple organ transplantation at the Institute of Clinical and Experimental Medicine between 1966 and 2015. The median (IQR) of follow-up time was 8.0 (4.0-12.0) years. RESULTS The frequencies of PTLD and GP in SOT recipients were 2.8% and 6.4%, respectively. The frequencies of transient GP, GP of undetermined significance and malignant GP were 33%, 63% and 4% respectively. The median time between SOT and GP detection was 2.0 (interquartile range 1.0-7.0) years. GP was associated with a significantly higher risk of PTLD, allograft loss and death, with hazard ratios (95% confidence intervals) of a 6.06 (2.51-14.64), 2.61 (1.49-4.6) and 1.99 (1.2-3.3), respectively. Additionally, GP was associated with 2.98-fold increased risk of allograft loss in kidney transplant patients. SPE diagnostic sensitivity and specificity for PTLD were 14.8% and 93.9%, respectively. PTLD was diagnosed more often and earlier if SPE/SIFE was included in the post-Tx follow-up. CONCLUSIONS GP after SOT is associated with a high risk of PTLD, allograft loss and poor survival. The combination of SPE, SIFE, SFLC and UIFE is optimal for GP detection. These methods aid in identifying patients who are at risk for PTLD or allograft damage and should be included in regular post-Tx follow-up.
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Affiliation(s)
- Peter Sečník
- 3rd Faculty of Medicine, Charles University, Ruská 2411/87, Prague, Czech Republic.
| | - Antonín Jabor
- 3rd Faculty of Medicine, Charles University, Ruská 2411/87, Prague, Czech Republic; Department of Laboratory Methods, Institute for Clinical and Experimental Medicine, Vídeňská 1958/9, Prague, Czech Republic
| | - Petra Lavríková
- 3rd Faculty of Medicine, Charles University, Ruská 2411/87, Prague, Czech Republic; Department of Laboratory Methods, Institute for Clinical and Experimental Medicine, Vídeňská 1958/9, Prague, Czech Republic
| | - Juraj Sečník
- Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Neo, Blickagången 16, Sweden
| | - Pavlína Malíková
- Department of Laboratory Methods, Institute for Clinical and Experimental Medicine, Vídeňská 1958/9, Prague, Czech Republic
| | - Eva Pokorná
- Department of Organ Harvesting and Transplantation Databases, Institute for Clinical and Experimental Medicine, Vídeňská 1958/9, Prague, Czech Republic
| | - Janka Franeková
- 3rd Faculty of Medicine, Charles University, Ruská 2411/87, Prague, Czech Republic; Department of Laboratory Methods, Institute for Clinical and Experimental Medicine, Vídeňská 1958/9, Prague, Czech Republic
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de Rooij E, Verheul R, de Vreede M, de Jong Y. Cytomegalovirus infection with pulmonary embolism, splenic vein thrombosis and monoclonal gammopathy of undetermined significance: a case and systematic review. BMJ Case Rep 2019; 12:12/3/e226448. [PMID: 30837233 DOI: 10.1136/bcr-2018-226448] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
A 62-year-old immunocompetent woman was admitted with cytomegalovirus (CMV) infection, pulmonary embolism, splenic vein thrombosis and monoclonal gammopathy of undetermined significance (MGUS). Anticoagulation therapy was started. Two months later, seroconversion of CMV IgM to IgG was observed, while the monoclonal protein was no longer detectable. This suggests a relationship between acute CMV infection, transient MGUS and thrombosis. In accordance with current best practice guidelines for provoked venous thromboembolism (VTE), anticoagulation therapy could be discontinued after 3 months instead of 6 for unprovoked VTE, thereby reducing unnecessary time at risk of bleeding complications. While the relationships between CMV and both MGUS and thrombosis have been described independently, we are first to describe these three conditions occurring simultaneously.Furthermore, we provide a systematic review on the relation between CMV, MGUS and thrombosis.
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Affiliation(s)
- Esther de Rooij
- Department of Internal Medicine, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Rolf Verheul
- Department of Clinical Chemistry and Laboratory Medicine, LabWest, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Mariëlle de Vreede
- Department of Haematology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Ype de Jong
- Department of Internal Medicine, Haaglanden Medical Center, Den Haag, The Netherlands
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Cowan AJ, Johnson CK, Libby EN. Plasma cell diseases and organ transplant: A comprehensive review. Am J Transplant 2018; 18:1046-1058. [PMID: 29524307 DOI: 10.1111/ajt.14731] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 02/28/2018] [Accepted: 03/04/2018] [Indexed: 01/25/2023]
Abstract
Plasma cell diseases are a class of hematologic diseases that are sometimes present as preexisting diagnoses prior to organ transplantation, causative factors leading to a need for organ transplantation, or may occur posttransplant as part of the spectrum of posttransplant lymphoproliferative disorders. Herein, we review the most common plasma cell diseases, both as coexisting with other causes of organ failure, but also as a primary underlying cause for organ failure. In many cases, treatment of the underlying clonal disease may be indicated before proceeding with organ transplant. This review aims to provide current and relevant data regarding the management of these conditions in the organ transplant patient, for transplant providers, and those who take care of these patients.
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Affiliation(s)
- Andrew J Cowan
- Division of Medical Oncology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | | | - Edward N Libby
- Division of Medical Oncology, University of Washington, Seattle, WA, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
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Gammapatías monoclonales de significado renal. Nefrologia 2017; 37:465-477. [DOI: 10.1016/j.nefro.2017.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 01/02/2023] Open
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Short-term outcome and quality of life in kidney transplant recipient with monoclonal gammopathy. CEN Case Rep 2017; 5:168-172. [PMID: 28508971 DOI: 10.1007/s13730-016-0218-1] [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: 02/29/2016] [Accepted: 03/14/2016] [Indexed: 10/22/2022] Open
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is the common pre-malignant B cell disorders with a general prevalence of 3-5 % at age over 50. Because of the potential malignant transformation and immune insufficiency, pre-transplant MGUS recipient should be carefully followed after allograft transplantation. The post-transplant prognosis and quality of life (QOL) in patient with MGUS have not yet been fully determined. The aim of this study is to evaluate function and pathology of the renal allograft and self-assessment QOL changes during 2 years after transplantation in our case of MGUS-bearing recipient. We here studied the clinical course and QOL improvement before and 20 months after transplant in a 56-year-old woman, who had pre-existing MGUS and underwent living donor kidney transplantation. After the renal allograft transplant, the patients maintained normal GFR and had neither acute rejections nor histologic evidence of renal injuries related to the monoclonal gammopathy on the protocol biopsy of 1 year post-transplant. During further 20 months follow-up, the pre-transplant MGUS remained uneventful without any hematologic abnormalities and other medical complications, i.e., infection. Evaluation of QOL using a self-assessment questionnaire showed significant improvement for physical and mental items on both 6 and 18 months post-transplant. The renal transplant thus successfully provided a greater satisfaction for the recipient on both physical and mental health aspects. Our observations suggest that renal transplantation is beneficial even in those who had pre-existing MGUS if managed and followed carefully, which ultimately could significantly improve the patient QOL.
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