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Liang S, Liang D, Zhu X, Liang D, Xu F, Tu Y, Zeng C. Light chain only variant of proliferative glomerulonephritis with monoclonal immunoglobulin deposits: a clinicopathological study of three cases. J Clin Pathol 2024; 77:551-556. [PMID: 37137693 DOI: 10.1136/jcp-2023-208795] [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: 01/23/2023] [Accepted: 04/17/2023] [Indexed: 05/05/2023]
Abstract
AIMS To explore the clinical and pathological features of light chain only variant of proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID-LC). METHODS From January 2010 to December 2022, patients who were diagnosed with PGNMID-LC were selected, and their clinical and pathological features were retrospectively analysed. RESULTS Three males aged 42-61 years old were enrolled. Hypertension was present in three patients, oedema in three patients, anaemia in two patients, proteinuria in three patients, nephrotic syndrome in one patient, microscopic haematuria in three patients, renal insufficiency in two patients and hypocomplementaemia of C3 in one patient. Elevated serum-free LC ratios and plasmacytosis on bone marrow smears were observed in three patients, and κ was identified by serum protein immunofixation electrophoresis in one patient. Renal biopsy showed membranoproliferative glomerulonephritis in two patients and endocapillary proliferative glomerulonephritis in one patient on light microscopy. Immunofluorescence indicated restricted κ LC and C3 distributed in glomeruli. By electron microscopy, electron-dense deposits without substructure were identified predominantly in the mesangial and subendothelial regions and were variable in the subepithelial region. Two patients were treated with plasma cell-directed chemotherapy and achieved haematological complete response or very good partial response, and one of them achieved a renal status of complete remission. One patient treated with immunosuppressive therapy only did not achieve haematological or renal remission. CONCLUSIONS PGNMID-LC is a rare and uniform disease with a high frequency of a detectable pathogenic plasma cell clone and is characterised by glomerular deposition of restricted LC and C3 in renal pathology. Plasma cell-directed chemotherapy may improve haematological and renal prognosis.
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Affiliation(s)
- Shaoshan Liang
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Dongmei Liang
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Xiaodong Zhu
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Dandan Liang
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Feng Xu
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Yuanmao Tu
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Affiliated Jinling Hospital, Medical School, Nanjing University, Nanjing, China
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2
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Miao J, Herrmann SM, Obaidi Z, Caza T, Bonilla M. Paraprotein-Mediated Glomerular Diseases. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:358-373. [PMID: 39084761 DOI: 10.1053/j.akdh.2024.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Revised: 02/25/2024] [Accepted: 02/28/2024] [Indexed: 08/02/2024]
Abstract
Paraproteinemias are a group of complex diseases associated with an overproduction of a monoclonal immunoglobulin that can cause a diversity of kidney disorders and end-organ damage. In this review, we focus on paraprotein-mediated glomerular diseases. Kidney biopsy plays a crucial role in diagnosing these disorders, enabling the identification of specific histological patterns. These lesions are categorized into organized (such as amyloidosis, immunotactoid glomerulopathy, fibrillary glomerulonephritis, cryoglobulinemic glomerulonephritis, and monoclonal crystalline glomerulopathies) and nonorganized deposits (such as monoclonal Ig deposition disease and proliferative glomerulonephritis with monoclonal Ig deposits) based on the characteristics of immunofluorescence findings and the ultrastructural appearance of deposits on electron microscopy. This review aims to provide an update, highlight, and discuss clinicopathological aspects such as definition, epidemiology, clinical manifestations, mechanisms of kidney injury, histological features, and diagnostic procedures.
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Affiliation(s)
- Jing Miao
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - Zainab Obaidi
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL
| | | | - Marco Bonilla
- Department of Medicine, Section of Nephrology, University of Chicago, Chicago, IL.
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3
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Shi S, He K, Liang Y, Yue S. Long-term renal survival of γ3-heavy-chain deposition disease complicated by heart failure: A case report. Clin Case Rep 2024; 12:e9091. [PMID: 38962462 PMCID: PMC11220498 DOI: 10.1002/ccr3.9091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 07/05/2024] Open
Abstract
Key Clinical Message Heavy-chain deposition disease (HCDD), a rare monoclonal immunoglobulin deposition disease, involves truncated heavy-chain deposition in kidneys. Limited long-term data exist. We report a case of renal and cardiac failure with favorable outcomes post bortezomib-based therapy. Stable renal function observed over 4 years suggests efficacy in HCDD with multisystem involvement. Abstract Heavy-chain deposition disease (HCDD) is an extremely rare form of monoclonal immunoglobulin deposition disease (MIDD) that involves the deposition of truncated immunoglobulin heavy chains in the kidneys. Only a few cases of HCDD with a favorable long-term renal prognosis have been reported, resulting in limited long-term follow-up data for this patient population. In this report, we present the case of a 52-year-old patient with nephrotic syndrome who experienced renal failure and cardiac failure. Renal biopsy confirmed the presence of γ3-HCDD and monoclonal Immunoglobulin G (IgG)κ in the serum. The patient exhibited low voltage on electrocardiogram (ECG) and unexplained left ventricular hypertrophy on cardiac ultrasound. The patient underwent eight cycles of bortezomib-based chemotherapy, which led to hematological remission. After 4 years of follow-up, the patient's renal function remained stable, with serum creatinine levels ranging from 0.7 to 0.9 mg/dL and proteinuria of 0.3-0.5 g/24 h. Our findings suggest that bortezomib-based chemotherapy is equally effective in HCDD patients with combined multisystem damage.
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Affiliation(s)
- Shujun Shi
- Renal Division, Department of MedicineLanzhou University Second HospitalLanzhouChina
| | - Kaiying He
- Renal Division, Department of MedicineLanzhou University Second HospitalLanzhouChina
- Lanzhou UniversityLanzhouChina
| | - Yaojun Liang
- Renal Division, Department of MedicineLanzhou University Second HospitalLanzhouChina
| | - Shuling Yue
- Guangzhou KingMed Center for Clinical LaboratoryGuangzhouGuangdongChina
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4
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Eguchi E. Primary adrenal insufficiency developed 22 years after the diagnosis of light and heavy chain deposition disease: a case report. CEN Case Rep 2024:10.1007/s13730-024-00893-z. [PMID: 38767838 DOI: 10.1007/s13730-024-00893-z] [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: 01/18/2024] [Accepted: 05/13/2024] [Indexed: 05/22/2024] Open
Abstract
Monoclonal immunoglobulin deposition diseases (MIDDs), including light and heavy chain deposition disease (LHCDD), are rare and heterogeneous disorders associated with underlying B-cell clonal disorders. Adrenal involvement is a potential extrarenal manifestation of MIDDs; however, limited data are available regarding its prevalence and clinical presentation. Herein, the present report describes, for the first time, a case of primary adrenal insufficiency that developed twenty-two years after a diagnosis of LHCDD had been made. A 69 year-old woman with a 10 year history of hemodialysis suddenly became bedridden after falling down stairs in the absence of focal neurological deficits. Subsequently, she experienced appetite loss, nausea, vomiting, a fever of unknown origin, and unexplained hypotension. Several months later, primary adrenal insufficiency and normal pressure hydrocephalus were diagnosed and successfully managed. The long-term clinical prognosis of MIDDs has not been fully elucidated despite recent advances in the management of the disorders. This report may contribute to improving our understanding of the disease course.
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Affiliation(s)
- Eriko Eguchi
- Department of Internal Medicine, Osaka Roudou Eisei Center Daiichi Hospital, 6-2-2 Mitejima Nishiyodogawa-Ku, Osaka, Osaka, 555-0012, Japan.
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5
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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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6
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Medeiros LJ, Chadburn A, Natkunam Y, Naresh KN. Fifth Edition of the World Health Classification of Tumors of the Hematopoietic and Lymphoid Tissues: B-cell Neoplasms. Mod Pathol 2024; 37:100441. [PMID: 38309432 DOI: 10.1016/j.modpat.2024.100441] [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: 10/03/2023] [Revised: 01/15/2024] [Accepted: 01/23/2024] [Indexed: 02/05/2024]
Abstract
We review B-cell neoplasms in the 5th edition of the World Health Organization classification of hematolymphoid tumors (WHO-HEM5). The revised classification is based on a multidisciplinary approach including input from pathologists, clinicians, and other experts. The WHO-HEM5 follows a hierarchical structure allowing the use of family (class)-level definitions when defining diagnostic criteria are partially met or a complete investigational workup is not possible. Disease types and subtypes have expanded compared with the WHO revised 4th edition (WHO-HEM4R), mainly because of the expansion in genomic knowledge of these diseases. In this review, we focus on highlighting changes and updates in the classification of B-cell lymphomas, providing a comparison with WHO-HEM4R, and offering guidance on how the new classification can be applied to the diagnosis of B-cell lymphomas in routine practice.
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Affiliation(s)
- L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, Texas.
| | - Amy Chadburn
- Department of Pathology and Laboratory Medicine, Weill Cornell Medicine, New York, New York
| | - Yasodha Natkunam
- Department of Pathology, Stanford University School of Medicine, Stanford, California
| | - Kikkeri N Naresh
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle; Section of Pathology, Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle
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7
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Attygalle AD, Chan JKC, Coupland SE, Du MQ, Ferry JA, Jong DD, Gratzinger D, Lim MS, Naresh KN, Nicolae A, Ott G, Rosenwald A, Schuh A, Siebert R. The 5th edition of the World Health Organization Classification of mature lymphoid and stromal tumors - an overview and update. Leuk Lymphoma 2024; 65:413-429. [PMID: 38189838 DOI: 10.1080/10428194.2023.2297939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 08/15/2023] [Indexed: 01/09/2024]
Abstract
The purpose of this review is to give an overview on the conceptual framework and major developments of the upcoming 5th edition of the World Health Organization (WHO) Classification of Haematolymphoid tumours (WHO-HAEM5) and to highlight the most significant changes made in WHO-HAEM5 compared with the revised 4th edition (WHO-HAEM4R) of lymphoid and stromal neoplasms. The changes from the revised 4th edition include the reorganization of entities by means of a hierarchical system that is realized throughout the 5th edition of the WHO classification of tumors of all organ systems, a modification of nomenclature for some entities, the refinement of diagnostic criteria or subtypes, deletion of certain entities, and introduction of new entities. For the first time, tumor-like lesions, mesenchymal lesions specific to lymph node and spleen, and germline predisposition syndromes associated with the lymphoid neoplasms are included in the classification.
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Affiliation(s)
- Ayoma D Attygalle
- Department of Histopathology, The Royal Marsden Hospital, London, UK
| | - John K C Chan
- Department of Pathology, Queen Elizabeth Hospital, Kowloon, Hong Kong, SAR China
| | - Sarah E Coupland
- Department of Molecular and Clinical Cancer Medicine, ISMIB, University of Liverpool, Liverpool, UK
- Liverpool Clinical Laboratories, Liverpool University Hospitals Foundation Trust, Liverpool, UK
| | - Ming-Qing Du
- Department of Pathology, University of Cambridge, Cambridge, UK
| | - Judith A Ferry
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Daphne de Jong
- The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Dita Gratzinger
- Department of Pathology, Stanford University School of Medicine, Stanford, USA
| | - Megan S Lim
- Memorial Sloan Kettering Cancer Center, New York City, NY, USA
| | - Kikkeri N Naresh
- Fred Hutchinson Cancer Center, University of Washington, Seattle, USA
| | - Alina Nicolae
- Department of Pathology, University Hospital of Strasbourg, Strasbourg, France
| | - German Ott
- Department of Clinical Pathology, Robert-Bosch-Krankenhaus, and Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology, Stuttgart, Germany
| | - Andreas Rosenwald
- Institute of Pathology, Julius-Maximilians-UniversitätWürzburg, and Cancer Center Mainfranken, Würzburg, Germany
| | - Anna Schuh
- Department of Oncology, University of Oxford, Oxford, UK
| | - Reiner Siebert
- Institute of Human Genetics, Ulm University and Ulm University Medical Center, Ulm, Germany
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8
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Leung N, Heybeli C. Kidney Transplantation in Multiple Myeloma and Monoclonal Gammopathy of Renal Significance. Semin Nephrol 2024; 44:151497. [PMID: 38485643 DOI: 10.1016/j.semnephrol.2024.151497] [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] [Indexed: 06/30/2024]
Abstract
Recent advances in the treatment of plasma cell disorders (PCDs) have provided a wealth of therapy alternatives and improved overall survival tremendously. Various types of PCDs are associated with kidney injury and end-stage kidney disease in a considerable number of patients. Kidney transplantation (KTx) is the best option for renal replacement therapy in select patients in terms of both quality of life parameters and overall survival. Even with modern therapies, all PCDs carry the risk of hematologic progression, whereas histologic recurrence and graft loss are other prevailing concerns in these patients. The risk of mortality is also higher in some of these disorders compared with KTx recipients who suffer from other causes of kidney disease. Unlike solid cancers, there is no well-defined "waiting time" after hematologic remission before proceeding to KTx. Thus, clinicians are usually reluctant to recommend KTx to patients who develop end-stage kidney disease due to PCDs. This review aims to provide the current evidence on KTx outcomes in patients with monoclonal gammopathy of renal significance and multiple myeloma. Although immunoglobulin light chain amyloidosis is a monoclonal gammopathy of renal significance subtype, KTx outcomes in this group are mentioned in another chapter of this issue.
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Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; Division of Hematology, Mayo Clinic, Rochester, MN.
| | - Cihan Heybeli
- Division of Nephrology, Dokuz Eylül University Hospital, Balcova, Turkey
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9
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Jacquet-Francillon N, Dijoud F, Karlin L, Dietz M, Flaus A, Tordo J. Randall-Type Monoclonal Immunoglobulin Deposition Disease in Bone Scintigraphy. Clin Nucl Med 2023; 48:e611-e613. [PMID: 37883135 DOI: 10.1097/rlu.0000000000004927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
ABSTRACT Bone scintigraphy is recognized as a noninvasive alternative to endomyocardial biopsy for the diagnostic of wild-type (wATTR) and hereditary ATTR amyloidosis (hATTR). Light chain amyloidosis (AL), Randall-type monoclonal immunoglobulin deposition disease , sarcoidosis, hemochromatosis, Fabry disease, and mucopolysaccharidoses are differential diagnosis of ATTR amyloidosis. Bone scintigraphy allows visualization of extracardiac involvements of AL amyloidosis: pleural, retroperitoneal, liver, spleen, and soft tissue. We report the case of a patient who underwent bone scintigraphy for suspected ATTR amyloidosis. Bone scan showed cardiac (Perugini score 2), hepatic, and renal hyperfixation. A cardiac biopsy demonstrated a Randall-type deposit, without amyloid deposit.
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Affiliation(s)
| | - Frédérique Dijoud
- Centre de Biologie et de Pathologie Est, Hospices Civils de Lyon, Lyon
| | - Lionel Karlin
- Department of Hematology, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Matthieu Dietz
- From the Department of Nuclear Medicine, Hospices Civils de Lyon, Lyon
| | - Anthime Flaus
- From the Department of Nuclear Medicine, Hospices Civils de Lyon, Lyon
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10
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Isnard P, Benichou N, Sibon D, Rinsant A, Goujon JM, Touchard G, Ory C, Kaaki S, Colombat M, Do Souto Ferreira L, Avet-Loiseau H, Karras A, Bridoux F, Rabant M. Randall-Type Monoclonal IgE Kappa Light-Heavy Chain Deposition Disease. Kidney Int Rep 2023; 8:1464-1468. [PMID: 37441467 PMCID: PMC10334351 DOI: 10.1016/j.ekir.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 07/15/2023] Open
Affiliation(s)
- Pierre Isnard
- Department of Pathology, Necker Hospital, APHP, Université Paris Cité, Paris, France
| | - Nicolas Benichou
- Department of Nephrology, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - David Sibon
- Lymphoid Malignancies Department, Henri Mondor University Hospital, APHP, Créteil, Paris-Est Créteil University, France
| | - Alexia Rinsant
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Jean-Michel Goujon
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Guy Touchard
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Cécile Ory
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Sihem Kaaki
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Magali Colombat
- Department of Pathology, University Hospital of Toulouse, University Cancer Institute of Toulouse, Toulouse, France
| | | | - Hervé Avet-Loiseau
- Unite de Génomique du Myelome, IUC-Oncopole, University Hospital Toulouse, Toulouse, France
| | - Alexandre Karras
- Department of Nephrology, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - Frank Bridoux
- Department of Nephrology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Marion Rabant
- Department of Pathology, Necker Hospital, APHP, Université Paris Cité, Paris, France
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11
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Midha S, Nadeem O, Selamet U. Updates in Plasma Cell Dyscrasias and Related Monoclonal Immunoglobulin-Mediated Renal Disease. Semin Nephrol 2023; 42:151352. [PMID: 37257390 DOI: 10.1016/j.semnephrol.2023.151352] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Pathogenic roles of monoclonal immunoglobulins in kidney disease have been attributed previously to malignant plasma cell and lymphoproliferative disorders such as multiple myeloma, lymphoplasmacytic lymphoma, chronic lymphocytic leukemia, or amyloid light chain amyloidosis. Improved technology, advancements in molecular diagnostics, and highly sensitive imaging techniques have established the need to redefine monoclonal gammopathies and the kidney disorders that are associated with monoclonal immunoglobulins regardless of tumor burden. This has led to the establishment of monoclonal gammopathy with renal significance (MGRS). MGRS was defined by the International Kidney and Monoclonal Gammopathy Research Group in 2012 as a clonal proliferative disorder that produces a nephrotoxic monoclonal immunoglobulin and does not meet previously defined hematological criteria for treatment of a specific malignancy. MGRS encompasses a wide array of pathologies with knowledge surrounding its incidence, prognosis, and management continuously increasing. This review examines the current evidence on the diagnosis, prognosis, pathogenesis, and therapy of plasma cell dyscrasias and related MGRS.
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Affiliation(s)
- Shonali Midha
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA.
| | - Omar Nadeem
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Umut Selamet
- Department of Medical Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA; Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA
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12
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Nau A, Shen Y, Sanchorawala V, Prokaeva T, Morgan GJ. Complete variable domain sequences of monoclonal antibody light chains identified from untargeted RNA sequencing data. Front Immunol 2023; 14:1167235. [PMID: 37143670 PMCID: PMC10151772 DOI: 10.3389/fimmu.2023.1167235] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 03/31/2023] [Indexed: 05/06/2023] Open
Abstract
Introduction Monoclonal antibody light chain proteins secreted by clonal plasma cells cause tissue damage due to amyloid deposition and other mechanisms. The unique protein sequence associated with each case contributes to the diversity of clinical features observed in patients. Extensive work has characterized many light chains associated with multiple myeloma, light chain amyloidosis and other disorders, which we have collected in the publicly accessible database, AL-Base. However, light chain sequence diversity makes it difficult to determine the contribution of specific amino acid changes to pathology. Sequences of light chains associated with multiple myeloma provide a useful comparison to study mechanisms of light chain aggregation, but relatively few monoclonal sequences have been determined. Therefore, we sought to identify complete light chain sequences from existing high throughput sequencing data. Methods We developed a computational approach using the MiXCR suite of tools to extract complete rearranged IGVL-IGJL sequences from untargeted RNA sequencing data. This method was applied to whole-transcriptome RNA sequencing data from 766 newly diagnosed patients in the Multiple Myeloma Research Foundation CoMMpass study. Results Monoclonal IGVL-IGJL sequences were defined as those where >50% of assigned IGK or IGL reads from each sample mapped to a unique sequence. Clonal light chain sequences were identified in 705/766 samples from the CoMMpass study. Of these, 685 sequences covered the complete IGVL-IGJL region. The identity of the assigned sequences is consistent with their associated clinical data and with partial sequences previously determined from the same cohort of samples. Sequences have been deposited in AL-Base. Discussion Our method allows routine identification of clonal antibody sequences from RNA sequencing data collected for gene expression studies. The sequences identified represent, to our knowledge, the largest collection of multiple myeloma-associated light chains reported to date. This work substantially increases the number of monoclonal light chains known to be associated with non-amyloid plasma cell disorders and will facilitate studies of light chain pathology.
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Affiliation(s)
- Allison Nau
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Yun Shen
- Research Computing Services, Boston University, Boston, MA, United States
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- Section of Hematology and Medical Oncology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Tatiana Prokaeva
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Gareth J. Morgan
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- Section of Hematology and Medical Oncology, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
- Department of Pathology and Laboratory Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
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13
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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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14
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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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15
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A Case of Light Chain Deposition Disease Leading to Acute Liver Failure and Review of Literature. Diseases 2023; 11:diseases11010024. [PMID: 36810539 PMCID: PMC9944111 DOI: 10.3390/diseases11010024] [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: 12/20/2022] [Revised: 01/26/2023] [Accepted: 01/30/2023] [Indexed: 02/04/2023] Open
Abstract
Light chain deposition disease (LCDD) is a monoclonal immunoglobulin deposition disease characterized by light chain deposition in soft tissues and viscera, causing systemic organ dysfunction with an underlying lymphoproliferative disorder. While the kidney is the most affected organ, cardiac and hepatic involvement is also seen with LCDD. Hepatic manifestation can range from mild hepatic injury to fulminant liver failure. Herein, we are presenting a case of an 83-year-old woman with a monoclonal gammopathy of undetermined significance (MGUS), who presented to our institution with acute liver failure progressing to circulatory shock and multiorgan failure. After an extensive workup, a diagnosis of hepatic LCDD was determined. In conjunction with the hematology and oncology department, chemotherapy options were discussed, but given her poor prognosis, the family decided to pursue a palliative route. Though establishing a prompt diagnosis is important for any acute condition, the rarity of this condition, along with paucity of data, makes timely diagnosis and treatment challenging. The available literature shows variable rates of success with chemotherapy for systemic LCDD. Despite chemotherapeutic advances, liver failure in LCDD indicates a dismal prognosis, where further clinical trials are difficult owing to the low prevalence of the condition. In our article, we will also be reviewing previous case reports on this disease.
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16
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The cellular biology of plasma cells: Unmet challenges and opportunities. Immunol Lett 2023; 254:6-12. [PMID: 36646289 DOI: 10.1016/j.imlet.2023.01.005] [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: 11/06/2022] [Revised: 12/27/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
Plasma cells and the antibodies they secrete are paramount for protection against infection but can also be implicated in diseases including autoantibody-mediated disease and multiple myeloma. Plasma cell terminal differentiation relies on a transcriptional switch and on important morphological changes. The cellular and molecular mechanisms underlying these processes are partly understood and how plasma cells manage to survive for long periods of time while secreting large quantities of antibodies remains unclear. In this review we aim to put in perspective what is known about plasma cell cellular biology to highlight the challenges faced by this field of research but also to illustrate how new opportunities may arise from the study of the fundamental mechanisms sustaining plasma cell survival and function.
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17
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Kidney Transplantation in Patients With Monoclonal Gammopathy of Renal Significance. Transplantation 2022; 107:1056-1068. [PMID: 36584374 DOI: 10.1097/tp.0000000000004443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Monoclonal gammopathy of renal significance (MGRS) defines disorders characterized by direct or indirect kidney injury caused by a monoclonal immunoglobulin 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. The current paradigm states that the underlying hematologic condition should be treated and in deep remission before kidney transplantation can be performed because recurrence has been reported for all MGRS-associated kidney diseases. However, we suggest that decisions regarding kidney transplantation in MGRS patients should be individualized considering many factors such as the subtype of MGRS-associated kidney disease, patient age and comorbidity, presence and risk of extrarenal complications, estimated waiting time, the availability of a living kidney donor, and previous hematological treatment and response. Thus, kidney transplantation should be considered even in treatment-naive patients, with hematological treatment initiated after successful kidney transplantation.
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18
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Ravichandran S, Law S, Mahmood S, Wisniowski B, Foard D, Fontana M, Martinez-Naharro A, Whelan C, Hawkins PN, Gillmore JD, Lachmann HJ, Wechalekar AD. Long-term outcomes in light chain deposition disease-analysis of a UK cohort. Am J Hematol 2022; 97:E444-E446. [PMID: 36088630 DOI: 10.1002/ajh.26725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 08/09/2022] [Accepted: 09/01/2022] [Indexed: 01/31/2023]
Affiliation(s)
- Sriram Ravichandran
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Steven Law
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Brenden Wisniowski
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Darren Foard
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Carol Whelan
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
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19
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Gueye S, Gauthier M, Benyahia R, Trape L, Dahri S, Kounde C, Perier T, Meklati L, Guelib I, Faye M, Rostaing L. [Nephropathy associated with monoclonal immunoglobulins: From clonal expansion B to renal toxicity of pathological immunoglobulins]. Nephrol Ther 2022; 18:591-603. [PMID: 36428151 DOI: 10.1016/j.nephro.2022.10.002] [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: 03/02/2022] [Revised: 10/06/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022]
Abstract
Germinal center regulation pathways are often involved in lymphomagenesis and myelomagenesis. Most of the lymphomas (and multiple myeloma) derive from post-germinal center B-cells that have undergone somatic hypermutation and class switch recombination. Hence, B-cell clonal expansion can be responsible for the presence of a monoclonal component (immunoglobulin) of variable titer which, owing to physicochemical properties, can provoke pathologically defined entities of diseases. These diseases can affect any functional part of the kidney, by multiple mechanisms, either well known or not. The presence of renal deposition is influenced by germinal gene involved, immunoglobulin primary structure, post-translational modifications and microenvironmental interactions. The two ways immunoglobulin can cause kidney toxicity are (i) an excess of production (overcoming catabolism power by proximal tubule epithelial cells) with an excess of free light chains within the distal tubules and a subsequent risk of precipitation due to local physicochemical properties; (ii) by structural characteristics that predispose immunoglobulin to a renal disease (whatever their titer). The purpose of this manuscript is to review literature concerning the pathophysiology of renal toxicities of clonal immunoglobulin, from molecular B-cell expansion mechanisms to immunoglobulin renal toxicity.
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Affiliation(s)
- Serigne Gueye
- Service de néphrologie-dialyse, CH de Cahors, France.
| | | | | | - Lucas Trape
- Service de néphrologie-dialyse, CH de Cahors, France
| | - Souad Dahri
- Service de néphrologie-dialyse, CH de Cahors, France
| | | | - Thomas Perier
- Service de néphrologie-dialyse, CH de Cahors, France
| | | | | | - Maria Faye
- Université Cheikh Anta Diop, Dakar, Sénégal
| | - Lionel Rostaing
- Service de néphrologie-dialyse, CH de Cahors, France; Service de néphrologie, hémodialyse, aphérèses et greffe rénale, France; Inserm U563, IFR-BMT, CHU de Purpan, Toulouse, France; Université Grenoble-Alpes, France
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20
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Innocenti S, Bacchi B, Allinovi M, Perfetto F, Antonioli E, Marchionni N, Di Mario C, Caroti L, Cappelli F, Stefàno P. A multidisciplinary case report of multiple myeloma with renal and cardiac involvement: a look beyond amyloidosis. BMC Nephrol 2022; 23:370. [DOI: 10.1186/s12882-022-02984-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 10/23/2022] [Indexed: 11/18/2022] Open
Abstract
Abstract
Background
Multiple myeloma (MM) is a malignant neoplasm associated with kidney involvement in nearly half of the patients. Cast nephropathy, monoclonal immunoglobulin deposition disease (MIDD), and light chain (AL) amyloidosis are the most common monoclonal immunoglobulin-mediated causes of renal injury.
Cardiac involvement is also present in MM, characterized by restrictive cardiomyopathy generated by light chain deposit or amyloid. Thromboembolic complications such as deep vein thrombosis or pulmonary embolism are also described.
Case presentation
We present an unusual multidisciplinary case of a woman with a newly diagnosed MM associated with severe proteinuria and high natriuretic peptide. A renal and fat pad biopsy with Congo red staining were performed but amyloid deposition was not discovered. While immunofluorescence on fresh frozen unfixed tissue was not contributory, the immunofluorescence on fixed tissue and electron microscopy revealed the correct diagnosis.
During subsequent investigations, two intracardiac right-sided masses and massive pulmonary embolism were also detected.
Conclusions
This case highlights that multiple organ involvement in patients with MM may result from a combination of paraprotein-dependent and -independent factors. Moreover, renal diseases induced by monoclonal gammopathies are a group of complex and heterogeneous disorders. Their subtle presentation and their potential multiorgan involvement require the expertise of a multidisciplinary team able to provide the most appropriate diagnostic and therapeutic assessment.
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21
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Martinez-Rivas G, Bender S, Sirac C. Understanding AL amyloidosis with a little help from in vivo models. Front Immunol 2022; 13:1008449. [PMID: 36458006 PMCID: PMC9707859 DOI: 10.3389/fimmu.2022.1008449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/27/2022] [Indexed: 08/01/2023] Open
Abstract
Monoclonal immunoglobulin (Ig) light chain amyloidosis (AL) is a rare but severe disease that may occur when a B or plasma cell clone secretes an excess of free Ig light chains (LCs). Some of these LCs tend to aggregate into organized fibrils with a β-sheet structure, the so-called amyloid fibrils, and deposit into the extracellular compartment of organs, such as the heart or kidneys, causing their dysfunction. Recent findings have confirmed that the core of the amyloid fibrils is constituted by the variable (V) domain of the LCs, but the mechanisms underlying the unfolding and aggregation of this fragment and its deposition are still unclear. Moreover, in addition to the mechanical constraints exerted by the massive accumulation of amyloid fibrils in organs, the direct toxicity of these variable domain LCs, full-length light chains, or primary amyloid precursors (oligomers) seems to play a role in the pathogenesis of the disease. Many in vitro studies have focused on these topics, but the variability of this disease, in which each LC presents unique properties, and the extent and complexity of affected organs make its study in vivo very difficult. Accordingly, several groups have focused on the development of animal models for years, with some encouraging but mostly disappointing results. In this review, we discuss the experimental models that have been used to better understand the unknowns of this pathology with an emphasis on in vivo approaches. We also focus on why reliable AL amyloidosis animal models remain so difficult to obtain and what this tells us about the pathophysiology of the disease.
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22
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Bu L, Javaugue V, Chauvet S, Napier J, Dasari S, Theis JD, Vrana JA, McPhail ED, Nasr SH. Light Chain-Only Immunotactoid Glomerulopathy: A Case Report. Am J Kidney Dis 2022; 81:611-615. [PMID: 36328099 DOI: 10.1053/j.ajkd.2022.08.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022]
Abstract
The monotypic variant of immunotactoid glomerulopathy (ITG), strongly associated with low-grade lymphoproliferative disorders, is characterized histologically by glomerulonephritis and microtubular deposits of monoclonal immunoglobulin G (IgG). We report a patient with high-risk κ light chain multiple myeloma who presented with acute kidney injury, hematuria, proteinuria, and hypocomplementemia. Kidney biopsy revealed immunotactoid glomerulopathy concomitant with κ light chain myeloma cast nephropathy. The glomerular microtubular deposits stained for κ light chain and C3 only. Proteomic analysis of glomeruli and atypical casts detected κ light chain constant domain and a single VL variability subgroup (IGKV3) in both glomeruli and casts (without γ, α, or μ heavy chain or λ light chain). C3, C5, C6, C7, and C9 were detected in glomeruli. No autoantibodies against alternative pathway of complement proteins were detected. Despite clone-directed chemotherapy, the patient remained on dialysis treatment. For this light chain-only variant of immunotactoid glomerulopathy, pathogenesis potentially involves activation of the alternative pathway of complement by a nephrotoxic κ light chain.
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Affiliation(s)
- Lihong Bu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
| | - Vincent Javaugue
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Sophie Chauvet
- Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Department of Nephrology, Paris, France; INSERM UMRS1138, Research Center Cordeliers, Paris Descartes Sorbonne Paris-Cité University, Paris, France
| | - Jerold Napier
- Up Health System Medical Specialists, Marquette, Michigan
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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Monoclonal Gammopathies of Clinical Significance: A Critical Appraisal. Cancers (Basel) 2022; 14:cancers14215247. [PMID: 36358666 PMCID: PMC9659226 DOI: 10.3390/cancers14215247] [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: 09/15/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 11/26/2022] Open
Abstract
Simple Summary Monoclonal gammopathy of clinical significance (MGCS) refers to a recently coined term describing a complex and heterogeneous group of nonmalignant monoclonal gammopathies. These patients are characterized by the presence of a commonly small clone and the occurrence of symptoms that may be associated with the clone or with the monoclonal protein through diverse mechanisms. This is an evolving, challenging, and rapidly changing field. Patients are classified according to the key organ or system involved, with kidneys, skin, nerves, and eyes being the most frequently affected. However, multiorgan involvement may be the most relevant clinical feature at the presentation or during the course. This review delves into the definition, history, differential diagnosis, classification, prognosis, and treatment of this group of entities by analyzing the evidence accumulated to date from a critical perspective. 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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24
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Wang Y, Yan Y, Dong B, Zou W, Li X, Shao C, Jiang L, Wang M, Zuo L. Clinicopathological manifestations of coexistent monoclonal immunoglobulin deposition disease and immunotactoid glomerulopathy. Front Med (Lausanne) 2022; 9:911998. [PMID: 36091681 PMCID: PMC9452626 DOI: 10.3389/fmed.2022.911998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Combination of monoclonal immunoglobulin deposition disease (MIDD) and immunotactoid glomerulopathy (ITG) is a rare form of monoclonal immunoglobulin (MIg)-associated renal disease. We retrospectively reviewed the native kidney biopsy specimens at Peking University People’s Hospital from 2011 to 2020. Five patients were diagnosed as MIDD + ITG. Their clinical and pathological characteristics were studied. The typical clinical features were nephritic syndrome and renal dysfunction with prominent anemia, but hematuria was mild. Unlike single MIDD and single ITG, on light microscopy, segmentally distributed mesangial nodular sclerosis on the basis of mesangial matrix hyperplasia was the major lesion. Others including membranoproliferative glomerulonephritis (MPGN)-like lesion, glomerular basement membrane thickness, and mild to moderate mesangial and endothelial proliferations might presented at the same time and in the same glomeruli. On immunofluorescence, MIg, usually monoclonal light chains, deposited along glomerular basement membranes and tubular basement membranes, while the intact MIg or monoclonal heavy chain deposited in the mesangial regions. Corresponding to the depositions on immunofluorescence, punctate “powdery” deposits along glomerular basement membranes and tubular basement membranes under electronic microscopy indicated the presence of MIDD. Microtubular substructures (diameters of 20–50 nm) exhibiting hollow cores arranged in parallel arrays in mesangial regions indicated the presence of ITG. Patients treated with bortezomib-based regimen seemed to have better outcomes. In conclusion, MIDD + ITG is a rare combination form of MIg-associated renal disease. Accurate diagnosis requires the comprehensive pathological investigations.
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Affiliation(s)
- Yina Wang
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Yu Yan
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
- *Correspondence: Yu Yan,
| | - Bao Dong
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Wanzhong Zou
- Department of Pathology, Peking University Health Science Center, Beijing, China
| | - Xin Li
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Chunying Shao
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Lei Jiang
- Electron Microscope Laboratory, Peking University People’s Hospital, Beijing, China
| | - Mei Wang
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Li Zuo
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
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Klank D, Hoffmann M, Porubsky S, Bergner R. Histological Findings in Kidney Biopsies of Patients with Monoclonal Gammopathy—Always a Surprise. Diagnostics (Basel) 2022; 12:diagnostics12081912. [PMID: 36010261 PMCID: PMC9406481 DOI: 10.3390/diagnostics12081912] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/30/2022] [Accepted: 08/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background: The simultaneous occurrence of impaired kidney function and paraproteinemia is common in our constantly aging society. Both can be independent entities; however, renal insufficiency can also be caused by the paraprotein. We assessed all kidney biopsies in patients with monoclonal gammopathy in our clinic over the past 20 years and evaluated the histological results. Methods: Biopsies were systematically performed in nearly all patients with paraproteinemia and impaired kidney function (n = 178). The histological findings were systematically evaluated and correlated with the initial clinical diagnosis. Results: We found cast nephropathy (CN) in n = 66 (37.1%) biopsies, AL amyloidosis in n = 31 (17.4%) biopsies, monoclonal immunoglobulin deposition disease (MIDD) in n = 7 (3.9%) biopsies and other renal diseases (ORDs) in n = 74 (41.6%) biopsies. In the latter group, paraprotein-associated changes were found in 37 of 74 (50%) patients, whereas paraprotein-independent changes were found in the other half. Whereas, in the group of patients with MGUS, the findings were heterogenous, most of the patients with known multiple myeloma (MM) or B-NHL showed malignancy-associated changes in the kidney. The biopsy changed the diagnoses in a significant proportion of the patients: The group of patients with MM grew from 71 to 112 patients, whereas, in the MGUS group, only 31 of 44 patients remained. Conclusion: Kidney biopsies in patients with paraproteinemia and renal impairment show a wide range of findings that can lead to a change in diagnosis.
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Affiliation(s)
- David Klank
- Medizinische Klinik A, Klinikum der Stadt Ludwigshafen gGmbH, Bremserstrasse 79, 67063 Ludwigshafen, Germany
- Correspondence: ; Tel.: +49-(0)621-503-29561
| | - Martin Hoffmann
- Medizinische Klinik A, Klinikum der Stadt Ludwigshafen gGmbH, Bremserstrasse 79, 67063 Ludwigshafen, Germany
| | - Stefan Porubsky
- Institut für Pathologie, Universitätsklinikum Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Raoul Bergner
- Medizinische Klinik A, Klinikum der Stadt Ludwigshafen gGmbH, Bremserstrasse 79, 67063 Ludwigshafen, Germany
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Heavy Chain/Light Chain Antibody Immunofluorescence to Identify Monoclonal Plasma Cells in a Case of Plasma Cell-Rich Acute Interstitial Nephritis. Kidney Med 2022; 4:100514. [PMID: 35879978 PMCID: PMC9307939 DOI: 10.1016/j.xkme.2022.100514] [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] [Indexed: 11/22/2022] Open
Abstract
Heavy/light chain (HLC) antibodies can be used to quantify intact HLC pairs. In immunofluorescence studies, they allow differentiation of monoclonal versus polyclonal immunoglobulin deposits in kidney diseases that occur in the setting of monoclonal gammopathy. Here, we present a case of a patient with acute kidney injury with first kidney biopsy suggestive of acute interstitial nephritis with a polymorphous infiltrate of plasma cells. Routine immunofluorescence did not show a monotypic plasma cell infiltrate. Serum protein electrophoresis and immunofixation revealed monoclonal immunoglobulin A (IgA) lambda. She improved with steroid therapy, but kidney function worsened after steroids were stopped. She underwent a second kidney biopsy, which showed plasma cell-rich interstitial infiltrate with a population of IgA lambda-restricted plasma cells on routine immunofluorescence. In light of this finding, Hevylite HLC antibody was used to reassess the first biopsy, which confirmed the presence of a population of plasma cells with IgA lambda restriction. Because of the presence of monotypic plasma cells, anti-CD38 monoclonal antibody (daratumumab) was initiated.
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27
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Steward M, Yu JH, Gibbons MA. Sjögren's syndrome as a cause of both lymphoid interstitial pneumonia and light chain deposition disease in a single patient. BMJ Case Rep 2022; 15:e249747. [PMID: 35750435 PMCID: PMC9234793 DOI: 10.1136/bcr-2022-249747] [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] [Accepted: 06/07/2022] [Indexed: 11/04/2022] Open
Abstract
A man in his 70s presents with 12 months of progressive dyspnoea, sicca symptoms and Raynaud's phenomenon. Serological testing and tear duct biopsy confirm Sjögren's syndrome (SS). Bilateral nodular-cystic appearances highly suggestive of lymphoid interstitial pneumonia (LIP) are noted on high-resolution computed tomography (HRCT), supported by a 40% lymphocytosis on bronchoalveolar lavage.Biopsy of a non-characteristic additional pulmonary nodule diagnoses light chain deposition disease (LCDD). Extrapulmonary organ involvement is excluded. Pulmonary function tests are well-preserved, and the patient is kept under active surveillance without requiring immunomodulatory treatment.LIP and LCDD both have a strong association with SS. Identification of these disease associations is crucial as they may result in multiorgan involvement or progression to haematological malignancy. This is the first case published in the literature and highlights that a pragmatic approach to investigations can avoid unnecessary procedures, and that treatment may be guided by symptomology.
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Affiliation(s)
- Matthew Steward
- Department of Respiratory Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
- College of Medicine and Health, University of Exeter Medical School, Exeter, Devon, UK
| | - Johannes H Yu
- College of Medicine and Health, University of Exeter Medical School, Exeter, Devon, UK
| | - Michael A Gibbons
- Department of Respiratory Medicine, Royal Devon and Exeter NHS Foundation Trust, Exeter, Devon, UK
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28
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Anti-programmed cell death-1 monoclonal antibody therapy before or after allogeneic hematopoietic cell transplantation for classic Hodgkin lymphoma: a literature review. Int J Hematol 2022; 116:309-314. [PMID: 35653054 DOI: 10.1007/s12185-022-03391-z] [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: 04/01/2022] [Revised: 05/16/2022] [Accepted: 05/16/2022] [Indexed: 10/18/2022]
Abstract
Approximately 10-30% of patients with classic Hodgkin lymphoma (cHL) have relapsed or refractory (r/r) disease after standard first-line therapy. Clinical trials have shown an acceptable safety profile and high response rate for anti-programmed cell death-1 monoclonal antibodies (anti-PD-1 mAbs) in patients with r/r cHL. Although anti-PD-1 mAbs have significantly increased treatment options for r/r cHL, most patients eventually relapse. In the current era, allogeneic hematopoietic cell transplantation (allo-HCT) is still a clinical option for r/r cHL. Anti-PD-1 mAbs have been explored as bridging therapy to allo-HCT and salvage therapy for relapse after allo-HCT. Although early reports showed increased risks of severe graft-versus-host disease (GVHD) in patients who received anti-PD-1 mAb before or allo-HCT, survival outcomes were favorable, suggesting the feasibility of PD-1 blockade around the time of allo-HCT. Based on clinical and biological data, posttransplant cyclophosphamide-based GVHD prophylaxis is a promising strategy to reduce GVHD and improve survival after allo-HCT following PD-1 blockade. Close monitoring and early intervention are needed for treatment-emergent GVHD following PD-1 blockade after allo-HCT. Further studies with a larger cohort and extended follow-up will provide insights into better patient selection, optimal dosing, and strategies to manage complications of PD-1 blockade in the context of allo-HCT.
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29
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Sethi S, De Vriese AS, Fervenza FC. Acute glomerulonephritis. Lancet 2022; 399:1646-1663. [PMID: 35461559 DOI: 10.1016/s0140-6736(22)00461-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 02/10/2022] [Accepted: 02/28/2022] [Indexed: 12/12/2022]
Abstract
Glomerulonephritis is a heterogeneous group of disorders that present with a combination of haematuria, proteinuria, hypertension, and reduction in kidney function to a variable degree. Acute presentation with full blown nephritic syndrome or rapidly progressive glomerulonephritis is uncommon and is mainly restricted to patients with post-infectious glomerulonephritis, anti-neutrophil cytoplasmic antibodies-associated vasculitis, and anti-glomerular basement membrane disease. Most frequently, patients present with asymptomatic haematuria and proteinuria with or without reduced kidney function. All glomerulonephritis disorders can show periods of exacerbation, but disease flairs characteristically occur in patients with IgA nephropathy or C3 glomerulopathy. The gold standard for the diagnosis of a glomerulonephritis is a kidney biopsy, with a hallmark glomerular inflammation that translates into various histopathological patterns depending on the location and severity of the glomerular injury. Traditionally, glomerulonephritis was classified on the basis of the different histopathological patterns of injury. In the last few years, substantial progress has been made in unravelling the underlying causes and pathogenetic mechanisms of glomerulonephritis and a causal approach to the classification of glomerulonephritis is now favoured over a pattern-based approach. As such, glomerulonephritis can be broadly classified as immune-complex glomerulonephritis (including infection-related glomerulonephritis, IgA nephropathy, lupus nephritis, and cryoglobulinaemic glomerulonephritis), anti-neutrophil cytoplasmic antibodies-associated (pauci-immune) glomerulonephritis, anti-glomerular basement membrane glomerulonephritis, C3 glomerulopathy, and monoclonal immunoglobulin-associated glomerulonephritis. We provide an overview of the clinical presentation, pathology, and the current therapeutic approach of the main representative disorders in the spectrum of glomerulonephritis.
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Affiliation(s)
- Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - An S De Vriese
- Division of Nephrology and Infectious Diseases, AZ Sint-Jan Brugge, Brugge, Belgium; Department of Internal Medicine, Ghent University, Ghent, Belgium
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30
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Sy-Go JPT, Herrmann SM, Seshan SV. Monoclonal Gammopathy-Related Kidney Diseases. Adv Chronic Kidney Dis 2022; 29:86-102.e1. [PMID: 35817530 DOI: 10.1053/j.ackd.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 12/09/2021] [Accepted: 01/18/2022] [Indexed: 11/11/2022]
Abstract
Monoclonal gammopathies occur secondary to a broad range of clonal B lymphocyte or plasma cell disorders, producing either whole or truncated monoclonal immunoglobulins. The kidneys are often affected by these monoclonal proteins, and, although not mutually exclusive, can involve the glomeruli, tubules, interstitium, and vasculature. The nephrotoxic potential of these monoclonal proteins is dependent on a variety of physicochemical characteristics that are responsible for the diverse clinicopathologic manifestations, including glomerular diseases with organized deposits, glomerular diseases with granular deposits, and other lesions, such as C3 glomerulopathy and thrombotic microangiopathy with unique pathophysiologic features. The diseases that involve primarily the tubulointerstitial and vascular compartments are light chain cast nephropathy, light chain proximal tubulopathy, crystal-storing histiocytosis, and crystalglobulin-induced nephropathy with distinct acute and chronic clinicopathologic features. The diagnosis of a monoclonal gammopathy-related kidney disease is established by identification of an underlying active or more commonly, low-grade hematologic malignancy, serologic evidence of a monoclonal gammopathy when detectable, and most importantly, monoclonal protein-induced pathologic lesions seen in a kidney biopsy, confirming the association with the monoclonal protein. Establishing a diagnosis may be challenging at times, particularly in the absence of an overt hematologic malignancy, with or without monoclonal gammopathy, such as proliferative glomerulonephritis with monoclonal immunoglobulin deposits. Overall, the treatment is directed against the underlying hematologic disorder and the potential source of the monoclonal protein.
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Affiliation(s)
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| | - Surya V Seshan
- Department of Anatomic Pathology and Clinical Pathology, Weil Cornell Medical College, New York, NY
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31
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Heybeli C, Alexander MP, Bentall A, Amer H, Buadi F, Dean PG, Dingli D, Dispenzieri A, El Ters M, Gertz MA, Issa N, Kapoor P, Kourelis T, Kukla A, Kumar S, Lacy MQ, Lorenz EC, Muchtar E, Murray D, Nasr SH, Prieto M, Rajkumar V, Schinstock CA, Stegall M, Warsame R, Leung N. Kidney Transplantation in Patients With Monoclonal Gammopathy of Renal Significance (MGRS)-Associated Lesions: A Case Series. Am J Kidney Dis 2022; 79:202-216. [PMID: 34175375 PMCID: PMC8702583 DOI: 10.1053/j.ajkd.2021.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 04/16/2021] [Indexed: 02/03/2023]
Abstract
RATIONALE & OBJECTIVE Data on kidney transplantation outcomes among patients with monoclonal gammopathy of renal significance (MGRS) are lacking. STUDY DESIGN Case series of patients with MGRS, some of whom received clone-directed therapies before kidney transplantation. SETTING & PARTICIPANTS 28 patients who underwent kidney transplantation from 1987 through 2016 after diagnosis with MGRS-associated lesions including light-chain deposition disease (LCDD), C3 glomerulopathy with monoclonal gammopathy (C3G-MG), and light-chain proximal tubulopathy (LCPT). FINDINGS Of the 19 patients with LCDD, 10 were treated before kidney transplantation and 9 were treatment-naive. Among the treated patients with LCDD, 3 (30%) experienced histologic recurrence, 2 (20%) grafts failed, and 2 (20%) died during a median follow-up of 70 (range, 3-162) months after transplant. In the treatment-naive LCDD group, 8 (89%) had histologic recurrence, 6 (67%) grafts failed, and 4 (44%) patients died during a median follow-up of 60 (range, 35-117) months. Of the 5 patients who had a complete response before transplant, none died, and only 1 experienced graft failure, 162 months after transplant. Of 5 patients with C3G-MG, 3 were treatment-naive before transplant. Both patients who were treated before transplant had histologic recurrence, and 1 experienced graft failure and died. Among the 3 patients with treatment-naive C3G-MG, histologic recurrence occurred in all, and graft loss and death were observed in 2 and 1, respectively. In the LCPT group (n=4), histologic recurrence was observed in all 3 patients who did not receive clone-directed therapies before transplant, and 2 of these patients died, 1 with a functioning kidney. The 1 patient with LCPT who received therapy before transplant did not have histologic recurrence or graft loss and survived. LIMITATIONS Small sample size, nonstandardized clinical management, retrospective design. CONCLUSIONS Recurrence is very common in all MGRS-associated lesions after kidney transplant. Achieving a complete hematologic response may reduce the risks of recurrence, graft loss, and death. More studies are needed to determine the effects of hematologic response on outcomes for each MGRS-associated lesion.
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Affiliation(s)
- Cihan Heybeli
- Division of Nephrology, Muş State Hospital, Muş, Turkey
| | | | - Andrew Bentall
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Hatem Amer
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Francis Buadi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Patrick G Dean
- Division of Transplantation Surgery, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mireille El Ters
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Morie A Gertz
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Naim Issa
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Prashant Kapoor
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Taxiarchis Kourelis
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Aleksandra Kukla
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shaji Kumar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Martha Q Lacy
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Elizabeth C Lorenz
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eli Muchtar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Murray
- Department of Laboratory Medicine and Pathology, MN, USA
| | - Samih H Nasr
- Division of Pathology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mikel Prieto
- Division of Transplantation Surgery, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Vincent Rajkumar
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Carrie A Schinstock
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Mark Stegall
- Division of Transplantation Surgery, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rahma Warsame
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA,Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN, USA
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32
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Abstract
Cancer remains a significant cause of morbidity and mortality in kidney transplant recipients, due to long-term immunosuppression. Salient issues to consider in decreasing the burden of malignancy among kidney transplant recipients include pretransplant recipient evaluation, post-transplant screening and monitoring, and optimal treatment strategies for the kidney transplant recipients with cancer. In this review, we address cancer incidence and outcomes, approaches to cancer screening and monitoring pretransplant and post-transplant, as well as treatment strategies, immunosuppressive management, and multidisciplinary approaches in the kidney transplant recipients with cancer.
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33
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Ibáñez Moreno JA, Bacca González JM, Taborda Murillo A, Ospina Ospina S, Arias LF. [Renal involvement in monoclonal gammopathies]. REVISTA ESPANOLA DE PATOLOGIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ANATOMIA PATOLOGICA Y DE LA SOCIEDAD ESPANOLA DE CITOLOGIA 2022; 55:4-11. [PMID: 34980439 DOI: 10.1016/j.patol.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/26/2021] [Accepted: 06/04/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION The kidney is one of the organs most frequently affected by disease processes which produce monoclonal immunoglobins, therefore renal morphological and immunopathological alterations should be clearly recognized. OBJECTIVE To describe the pathological features of renal involvement in monoclonal gammopathies. MATERIAL AND METHODS A descriptive, retrospective and cross-sectional study of renal biopsies studied in a single center during a period of 14 years was carried out. RESULTS 102 cases were included, of which 53% were male patients and the median age was 62.5 years (range 34 - 79). 97% of the biopsies were from native kidneys. The most frequent histopathological diagnosis (31.4%) was myeloma kidney, with kappa being the light chain most frequently deposited (65.6% of cases). AL amyloidosis was the second most common (29.4%) where the lambda chain predominated in 86.6%, followed by light chain deposition disease (20.6%) with the predominance of the kappa chain in 66.6%. CONCLUSIONS The most frequent renal involvement due to monoclonal gammopathies was myeloma kidney with deposition of kappa light chains, followed by AL lambda amyloidosis; these diseases were found more frequently in patients over 50 years of age.
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Affiliation(s)
| | | | | | - Sigifredo Ospina Ospina
- Instituto de Investigaciones Médicas, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Luis Fernando Arias
- Departamento de Patología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
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34
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Filippone EJ, Newman ED, Li L, Gulati R, Farber JL. Thrombotic Microangiopathy, an Unusual Form of Monoclonal Gammopathy of Renal Significance: Report of 3 Cases and Literature Review. Front Immunol 2021; 12:780107. [PMID: 34858436 PMCID: PMC8631422 DOI: 10.3389/fimmu.2021.780107] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 10/22/2021] [Indexed: 12/25/2022] Open
Abstract
Monoclonal gammopathies result from neoplastic clones of the B-cell lineage and may cause kidney disease by various mechanisms. When the underlying clone does not meet criteria for a malignancy requiring treatment, the paraprotein is called a monoclonal gammopathy of renal significance (MGRS). One rarely reported kidney lesion associated with benign paraproteins is thrombotic microangiopathy (TMA), provisionally considered as a combination signifying MGRS. Such cases may lack systemic features of TMA, such as a microangiopathic hemolytic anemia, and the disease may be kidney limited. There is no direct deposition of the paraprotein in the kidney, and the presumed mechanism is disordered complement regulation. We report three cases of kidney limited TMA associated with benign paraproteins that had no other detectable cause for the TMA, representing cases of MGRS. Two of the cases are receiving clone directed therapy, and none are receiving eculizumab. We discuss in detail the pathophysiological basis for this possible association. Our approach to therapy involves first ruling out other causes of TMA as well as an underlying B-cell malignancy that would necessitate direct treatment. Otherwise, clone directed therapy should be considered. If refractory to such therapy or the disease is severe and multisystemic, C5 inhibition (eculizumab or ravulizumab) may be indicated as well.
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Affiliation(s)
- Edward J Filippone
- Divsion of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Eric D Newman
- Divsion of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Li Li
- Department of Pathology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - Rakesh Gulati
- Divsion of Nephrology, Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - John L Farber
- Department of Pathology, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
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35
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Said SM, Best Rocha A, Valeri AM, Paueksakon P, Dasari S, Theis JD, Vrana JA, Obadina MO, Saghafi D, Alexander MP, Sethi S, Larsen CP, Joly F, Dispenzieri A, Bridoux F, Sirac C, Leung N, Fogo AB, McPhail ED, Nasr SH. The characteristics of patients with kidney light chain deposition disease concurrent with light chain amyloidosis. Kidney Int 2021; 101:152-163. [PMID: 34767832 DOI: 10.1016/j.kint.2021.10.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/16/2021] [Accepted: 10/01/2021] [Indexed: 01/01/2023]
Abstract
The type of monoclonal light chain nephropathy is thought to be largely a function of the structural and physiochemical properties of light chains; hence most affected patients have only one light chain kidney disease type. Here, we report the first series of kidney light chain deposition disease (LCDD) concomitant with light chain amyloidosis (LCDD+AL), with or without light chain cast nephropathy (LCCN). Our LCDD+AL cohort consisted of 37 patients (54% females, median age 70 years (range 40-86)). All cases showed Congo red-positive amyloid deposits staining for one light chain isotype on immunofluorescence (62% lambda), and LCDD with diffuse linear staining of glomerular and tubular basement membranes for one light chain isotype (97% same isotype as the amyloidogenic light chain) and ultrastructural non-fibrillar punctate deposits. Twelve of 37 cases (about 1/3 of patients) had concomitant LCCN of same light chain isotype. Proteomic analysis of amyloid and/or LCDD deposits in eight revealed a single light chain variable domain mutable subgroup in all cases (including three with separate microdissections of LCDD and amyloid light chain deposits). Clinical data on 21 patients showed proteinuria (100%), hematuria (75%), kidney insufficiency and nephrotic syndrome (55%). Extra-kidney involvement was present in 43% of the patients. Multiple myeloma occurred in 68% (about 2/3) of these patients; none had lymphoma. On follow up (median 16 months), 63% developed kidney failure and 56% died. The median kidney and patient survivals were 12 and 32 months, respectively. LCDD+AL mainly affected patients 60 years of age or older. Thus, LCDD+AL could be caused by two pathological light chains produced by subclones stemming from one immunoglobulin light chain lambda or kappa rearrangement, with a distinct mutated complementary determining region.
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Affiliation(s)
- Samar M Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Anthony M Valeri
- Division of Nephrology, Columbia University Medical Center, New York, New York, USA
| | - Paisit Paueksakon
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Darius Saghafi
- Allegheny Valley Hospital, Natrona Heights, Pennsylvania, USA
| | | | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Florent Joly
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
| | | | - Frank Bridoux
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, French Reference Center for AL Amyloidosis, Poitiers, France
| | - Christophe Sirac
- Department of Immunology, Joint Research Unit CNRS 7276, INSERM 1262, University of Limoges, French Reference Center for AL Amyloidosis, University Hospital Dupuytren, Limoges, France
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
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Zhang X, Yu XJ, Wang SX, Zhou FD, Zhao MH. Case Report: Lenalidomide as a Second-Line Treatment for Bortezomib-Ineffective Nephrotic Syndrome Caused by LCDD: 2 Case Reports and a Literature Review. Front Med (Lausanne) 2021; 8:706971. [PMID: 34692719 PMCID: PMC8531272 DOI: 10.3389/fmed.2021.706971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 09/13/2021] [Indexed: 01/16/2023] Open
Abstract
Background: Light-chain deposition disease (LCDD) is a rare systemic disorder characterized by the deposition of monoclonal light chains in organs. The kidney is a prominent target of light-chain deposition, with a median time to end-stage renal disease (ESRD) of 2.7 years and 5-year ESRD-free survival of 37%. The therapeutic management of LCDD remains ill-defined. In addition to bortezomib-based therapy as first-line therapy, the effect of lenalidomide on LCDD is rarely reported. Case Presentation: This study describes two male LCDD patients in their 60s with nephrotic syndrome and moderately impaired renal function. One patient had monoclonal IgGλ with underlying MGRS, and another had monoclonal IgGκ with underlying monoclonal gammopathy that developed into symptomatic MM during follow-up. The hallmarks of this disease were consistent with previous reports. Both patients initially received BCD therapy, but no hematological response was observed. Consequently, the nephrotic syndrome was refractory. Sequential Rd therapy was initiated, and partial hematological response and nephrotic remission were observed in the IgGλ patient but absent in the IgGκ patient. Conclusion: Limited reports have demonstrated the effect of lenalidomide in LCDD. We report the outcome of lenalidomide in two cases of bortezomib-resistant LCDD. This treatment might be a beneficial supplement for those unresponsive or intolerant to bortezomib in LCDD, but the effect should be prospectively investigated.
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Affiliation(s)
- Xin Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China
| | - Fu-de Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University First Hospital, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of Chronic Kidney Disease Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, China.,Peking-Tsinghua Center for Life Science, Beijing, China
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37
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Wang D, Wang Y, Sun S. Renal pathological changes after successful treatment of LCDD using cyclophosphamide, thalidomide, and dexamethasone. Ren Fail 2021; 43:1425-1427. [PMID: 34657562 PMCID: PMC8526028 DOI: 10.1080/0886022x.2021.1988967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Di Wang
- Department of Nephrology, Xijing Hospital, the First Affiliated Hospital of Fourth Military Medical University, Xi'an, China
| | - Yan Wang
- Department of Nephrology, Xijing Hospital, the First Affiliated Hospital of Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, the First Affiliated Hospital of Fourth Military Medical University, Xi'an, China
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38
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Treatment of Patients with Monoclonal Gammopathy of Clinical Significance. Cancers (Basel) 2021; 13:cancers13205131. [PMID: 34680279 PMCID: PMC8533809 DOI: 10.3390/cancers13205131] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 09/29/2021] [Accepted: 10/08/2021] [Indexed: 12/17/2022] Open
Abstract
Simple Summary Monoclonal gammopathy of clinical significance (MGCS) is a recently recognized clinical-pathological entity. Symptoms are caused by the presence of a monoclonal protein leading to high comorbidity. The affected organs vary according to the target antigen However, as most of the knowledge relies on case reports or short series; there is a lack of consensus regarding treatment approach. Here, we discuss MGCS other than renal (skin, ocular, neurologic, and bleeding disorders). We provide insights into the pathophysiology, diagnosis, treatment, and follow-up based on clinical cases. Finally, we discuss future directions in this field, such as potential novel therapeutic targets and prognosis of patients with MGCS. Abstract Monoclonal gammopathy of undetermined significance (MGUS) is defined as the presence of a monoclonal protein (M-protein) produced by a small amount of plasma cells. The majority of patients remain asymptomatic; however, a fraction of them develop clinical manifestations related to the monoclonal gammopathy despite not fulfilling criteria of multiple myeloma or other lymphoproliferative disorder. These patients constitute an emerging clinical issue coined as monoclonal gammopathy of clinical significance (MGCS). The mechanisms involved are poorly understood, and literature is scarce regarding management. The clinical spectrum involves symptoms related to renal, neurologic, skin, ocular, or bleeding manifestations, requiring a multidisciplinary approach. Treatment strategies rely on the basis of symptomatic disease and the M-protein isotype. In this review, we focus on MGCS other than renal, as the latter was earliest recognized and better known. We review the literature and discuss management from diagnosis to treatment based on illustrative cases from daily practice.
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39
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Alonso-Titos J, Martínez-Esteban MD, López V, León M, Martin-Reyes G, Ruiz-Esteban P, Hernández D. Monoclonal gammopathy of renal significance: Early diagnosis is key. Nefrologia 2021; 41:502-513. [PMID: 36165133 DOI: 10.1016/j.nefroe.2021.11.008] [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: 01/31/2020] [Accepted: 11/19/2020] [Indexed: 06/16/2023] Open
Abstract
Monoclonal gammopathy of renal significance is a clinical-pathological entity grouping renal disorders secondary to the secretion of a monoclonal immunoglobulin synthesized by a B-cell-derived clone and/or plasma cells in a patient with no diagnostic criteria for multiple myeloma. This term applies to a concept recently introduced owing to the need to differentiate this entity from monoclonal gammopathy of undetermined significance, given the negative prognostic impact of its high morbidity and mortality resulting from both renal and systemic involvement, occasionally even progressing to advanced chronic kidney disease. The renal damage occurs via both direct pathogenic mechanisms, with the deposition of the monoclonal protein in different renal structures, as well as indirect mechanisms, acting as an autoantibody provoking dysregulation of the alternative complement pathway. The detection of this monoclonal protein and an early hematologic study are essential, as is the need for a kidney biopsy to establish the associated nephropathological diagnosis. Consequently, this then leads to the start of specific hematologic treatment to detain the production of the monoclonal protein and minimize renal and systemic injury.
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Affiliation(s)
- Juana Alonso-Titos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - María Dolores Martínez-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Verónica López
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Myriam León
- Pathology Department, Carlos Haya Regional University Hospital, Malaga, Spain
| | - Guillermo Martin-Reyes
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Pedro Ruiz-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Domingo Hernández
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain.
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40
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Nasr SH, Fidler ME, Said SM, Koepplin JW, Altamirano-Alonso JM, Leung N. Immunofluorescence staining for immunoglobulin heavy chain/light chain on kidney biopsies is a valuable ancillary technique for the diagnosis of monoclonal gammopathy-associated kidney diseases. Kidney Int 2021; 100:155-170. [DOI: 10.1016/j.kint.2021.02.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/20/2021] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
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41
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Lin ZS, Zhang X, Li DY, Yu XJ, Qin AB, Dong Y, Zhou FD, Wang S, Zhao MH. Clinicopathological features and outcomes of coexistent light chain cast nephropathy and light chain deposition disease in patients with newly diagnosed multiple myeloma. J Clin Pathol 2021; 75:jclinpath-2021-207449. [PMID: 34187849 DOI: 10.1136/jclinpath-2021-207449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 04/15/2021] [Accepted: 05/03/2021] [Indexed: 11/04/2022]
Abstract
AIMS A varying proportion of patients with multiple myeloma suffer from more than one type of kidney disease simultaneously, of which the most common pattern is coexistent light chain cast nephropathy and light chain deposition disease (LCCN+LCDD). We investigated clinicopathological characteristics and outcomes of LCCN+LCDD in comparison with pure LCCN and pure LCDD. METHODS We retrospectively analysed 45 newly diagnosed multiple myeloma patients with pure LCCN (n=26), LCCN +LCDD (n=9) and pure LCDD (n=10) between 2000 and 2019 at Peking University First Hospital. RESULTS Pathologically, patients with LCCN+LCDD were more likely to have λ light chain isotype and presented atypical features of LCDD including less nodular glomerulosclerosis and less deposit distribution than patients with pure LCDD. In clinical characteristics, patients with LCCN +LCDD and patients with pure LCCN shared similar features. The death-censored renal survival in patients with LCCN +LCDD was similar to patients with pure LCCN but worse than patients with pure LCDD, but the overall survival was much better than patients with LCCN alone and similar to patients with pure LCDD. For patients with pure LCCN, the independent predictor of death-censored renal survival was lactate dehydrogenase, and the independent predictors of overall survival were the mean number of casts and serum albumin. CONCLUSIONS Patients with LCCN+LCDD had similar renal outcome compared with patients with pure LCCN but the overall survival is much better. Thus, for patients with LCCN, especially those with λ restriction, pathologists should carefully evaluate the kidney specimens to exclude the possibility of combined LCDD.
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Affiliation(s)
- Zi-Shan Lin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Xu Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Dan-Yang Li
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Ai-Bo Qin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Yujun Dong
- Department of Haematology, Peking University First Hospital, Beijing, China
| | - Fu-De Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
| | - Suxia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
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42
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Affiliation(s)
- Nelson Leung
- From the Divisions of Nephrology and Hypertension and of Hematology (N.L.) and the Department of Laboratory Medicine and Pathology (S.H.N.), Mayo Clinic, Rochester, MN; and Department of Nephrology and Centre d'Investigation Clinique INSERM 1402, Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, and Centre National de la Recherche Scientifique UMR7276, Université de Limoges, Limoges - all in France (F.B.)
| | - Frank Bridoux
- From the Divisions of Nephrology and Hypertension and of Hematology (N.L.) and the Department of Laboratory Medicine and Pathology (S.H.N.), Mayo Clinic, Rochester, MN; and Department of Nephrology and Centre d'Investigation Clinique INSERM 1402, Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, and Centre National de la Recherche Scientifique UMR7276, Université de Limoges, Limoges - all in France (F.B.)
| | - Samih H Nasr
- From the Divisions of Nephrology and Hypertension and of Hematology (N.L.) and the Department of Laboratory Medicine and Pathology (S.H.N.), Mayo Clinic, Rochester, MN; and Department of Nephrology and Centre d'Investigation Clinique INSERM 1402, Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, and Centre National de la Recherche Scientifique UMR7276, Université de Limoges, Limoges - all in France (F.B.)
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43
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The Clone Wars: Diagnosing and Treating Dysproteinemic Kidney Disease in the Modern Era. J Clin Med 2021; 10:jcm10081633. [PMID: 33921394 PMCID: PMC8069250 DOI: 10.3390/jcm10081633] [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: 03/04/2021] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 11/17/2022] Open
Abstract
Dysproteinemic kidney diseases are disorders that occur as the result of lymphoproliferative (B cell or plasma cell) disorders that cause kidney damage via production of nephrotoxic monoclonal immunoglobulins or their components. These monoclonal immunoglobulins have individual physiochemical characteristics that confer specific nephrotoxic properties. There has been increased recognition and revised characterization of these disorders in the last decade, and in some cases, there have been substantial advances in disease understanding and treatments, which has translated to improved patient outcomes. These disorders still present challenges to nephrologists and patients, since they are rare, and the field of hematology is rapidly changing with the introduction of novel testing and treatment strategies. In this review, we will discuss the clinical presentation, kidney biopsy features, hematologic characteristics and treatment of dysproteinemic kidney diseases.
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44
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Alonso-Titos J, Martínez-Esteban MD, López V, León M, Martin-Reyes G, Ruiz-Esteban P, Hernández D. Monoclonal gammopathy of renal significance: Early diagnosis is key. Nefrologia 2021. [PMID: 33824049 DOI: 10.1016/j.nefro.2020.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Monoclonal gammopathy of renal significance is a clinical-pathological entity grouping renal disorders secondary to the secretion of a monoclonal immunoglobulin synthesized by a B-cell-derived clone and/or plasma cells in a patient with no diagnostic criteria for multiple myeloma. This term applies to a concept recently introduced owing to the need to differentiate this entity from monoclonal gammopathy of undetermined significance, given the negative prognostic impact of its high morbidity and mortality resulting from both renal and systemic involvement, occasionally even progressing to advanced chronic kidney disease. The renal damage occurs via both direct pathogenic mechanisms, with the deposition of the monoclonal protein in different renal structures, as well as indirect mechanisms, acting as an autoantibody provoking dysregulation of the alternative complement pathway. The detection of this monoclonal protein and an early hematologic study are essential, as is the need for a kidney biopsy to establish the associated nephropathological diagnosis. Consequently, this then leads to the start of specific hematologic treatment to detain the production of the monoclonal protein and minimize renal and systemic injury.
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Affiliation(s)
- Juana Alonso-Titos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - María Dolores Martínez-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Verónica López
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Myriam León
- Pathology Department, Carlos Haya Regional University Hospital, Malaga, Spain
| | - Guillermo Martin-Reyes
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Pedro Ruiz-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Domingo Hernández
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain.
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45
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Steinberg AG, Fox LC, Bender S, Batrouney A, Juneja S, Sirac C, Touchard G, Blombery P, Finlay MJ, Bridoux F, Barbour TD. Proliferative Glomerulonephritis With Fibrils, Monoclonal κ Light Chain, and C3 Deposits. Am J Kidney Dis 2021; 78:459-463. [PMID: 33774080 DOI: 10.1053/j.ajkd.2021.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 01/07/2021] [Indexed: 11/11/2022]
Abstract
There is increasing recognition of monoclonal gammopathy as a cause of proliferative glomerulonephritis (GN), including cases in which glomerular deposition of monoclonal immunoglobulin is demonstrated. Recently, proliferative GN with monoclonal immunoglobulin deposits (PGNMID) has incorporated a light chain variant of the disease (termed PGNMID-LC). Intriguingly, glomerular co-deposition of C3 is found in addition to monotypic light chain, implying complement activation via the alternative pathway (AP). We present a unique case of proliferative GN in a 42-year-old man who presented with nephrotic syndrome and was found to have κ light chain multiple myeloma. Immune staining of the glomerulus was positive only for κ light chain and C3, with the striking appearance of nonamyloid fibrils on electron microscopy. Following clonally targeted therapy for myeloma, the renal clinical abnormalities resolved completely. We present detailed molecular studies for light chain and complement and consider local mechanisms whereby monoclonal κ light chain fibrils may have triggered AP activation within the glomerulus.
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Affiliation(s)
- Adam G Steinberg
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia.
| | - Lucy C Fox
- Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Sebastien Bender
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
| | - Ahida Batrouney
- Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Surender Juneja
- Department of Hematology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Christophe Sirac
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
| | - Guy Touchard
- Service de Néphrologie, Hémodialyse et Transplantation Rénale, CIC INSERM 1402, Centre de référence pour l'amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Piers Blombery
- Peter MacCallum Cancer Centre, Parkville, Victoria, Australia
| | - Moira J Finlay
- Department of Anatomical Pathology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Frank Bridoux
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France; Service de Néphrologie, Hémodialyse et Transplantation Rénale, CIC INSERM 1402, Centre de référence pour l'amylose AL et autres maladies par dépôt d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Thomas D Barbour
- Department of Nephrology, Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
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Puttarajappa CM, Schinstock CA, Wu CM, Leca N, Kumar V, Vasudev BS, Hariharan S. KDOQI US Commentary on the 2020 KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Am J Kidney Dis 2021; 77:833-856. [PMID: 33745779 DOI: 10.1053/j.ajkd.2020.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 12/14/2022]
Abstract
Evaluation of patients for kidney transplant candidacy is a comprehensive process that involves a detailed assessment of medical and surgical issues, psychosocial factors, and patients' physical and cognitive abilities with an aim of balancing the benefits of transplantation and potential risks of surgery and long-term immunosuppression. There is considerable variability among transplant centers in their approach to evaluation and decision-making regarding transplant candidacy. The 2020 KDIGO (Kidney Disease: Improving Guidelines Outcome) clinical practice guideline on the evaluation and management of candidates for kidney transplantation provides practice recommendations that can serve as a useful reference guide to transplant professionals. The guideline, covering a broad range of topics, was developed by an international group of experts from transplant and nephrology through a review of literature published until May 2019. A work group of US transplant nephrologists convened by NKF-KDOQI (National Kidney Foundation-Kidney Disease Quality Initiative) chose key topics for this commentary with a goal of presenting a broad discussion to the US transplant community. Each section of this article has a summary of the key KDIGO guideline recommendations, followed by a brief commentary on the recommendations, their clinical utility, and potential implementation challenges. The KDOQI work group agrees broadly with the KDIGO recommendations but also recognizes and highlights the decision-making challenges that arise from lack of high-quality evidence and the need to balance equity with utility of organ transplantation.
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Affiliation(s)
- Chethan M Puttarajappa
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Carrie A Schinstock
- Division of Nephrology & Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Christine M Wu
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Nicolae Leca
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Vineeta Kumar
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Brahm S Vasudev
- Division of Nephrology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Sundaram Hariharan
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA.
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Evidence for Transition From Light Chain Deposition Disease by Immunofluorescence-Only to Classic Light Chain Deposition Disease. Kidney Int Rep 2021; 6:1469-1474. [PMID: 34013128 PMCID: PMC8116763 DOI: 10.1016/j.ekir.2021.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 11/28/2022] Open
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48
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Cohen C, Joly F, Sibille A, Javaugue V, Desport E, Goujon JM, Touchard G, Fermand JP, Sirac C, Bridoux F. Randall-Type Monoclonal Immunoglobulin Deposition Disease: New Insights into the Pathogenesis, Diagnosis and Management. Diagnostics (Basel) 2021; 11:diagnostics11030420. [PMID: 33801393 PMCID: PMC7999117 DOI: 10.3390/diagnostics11030420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/16/2022] Open
Abstract
Randall-type monoclonal immunoglobulin deposition disease (MIDD) is a rare disease that belongs to the spectrum of monoclonal gammopathy of renal significance (MGRS). Renal involvement is prominent in MIDD, but extra-renal manifestations can be present and may affect global prognosis. Recent data highlighted the central role of molecular characteristics of nephrotoxic monoclonal immunoglobulins in the pathophysiology of MIDD, and the importance of serum free light chain monitoring in the diagnosis and follow-up disease. Clone-targeted therapy is required to improve the overall and renal survival, and the achievement of a rapid and deep hematological response is the goal of therapy. This review will focus on the recent progress in the pathogenesis and management of this rare disease.
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Affiliation(s)
- Camille Cohen
- Department of Nephrology Hôpital Necker, and INSERM U830 “Stress and Cancer” Laboratory, Institut Curie, 75015 Paris, France
- Correspondence:
| | - Florent Joly
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
| | - Audrey Sibille
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
| | - Vincent Javaugue
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
- INSERM CIC 1402, 86000 Poitiers, France
- CNRS UMR 7276-CRIBL, University of Limoges, 87000 Limoges, France;
| | - Estelle Desport
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
| | | | - Guy Touchard
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Department of Pathology, CHU Poitiers, 86000 Poitiers, France;
| | - Jean-Paul Fermand
- Department of Immunology and Hematology, Hôpital Saint Louis, 75010 Paris, France;
| | - Christophe Sirac
- CNRS UMR 7276-CRIBL, University of Limoges, 87000 Limoges, France;
| | - Frank Bridoux
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
- INSERM CIC 1402, 86000 Poitiers, France
- CNRS UMR 7276-CRIBL, University of Limoges, 87000 Limoges, France;
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KDIGO Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation. Transplantation 2021; 104:S11-S103. [PMID: 32301874 DOI: 10.1097/tp.0000000000003136] [Citation(s) in RCA: 273] [Impact Index Per Article: 91.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
The 2020 Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline on the Evaluation and Management of Candidates for Kidney Transplantation is intended to assist health care professionals worldwide who evaluate and manage potential candidates for deceased or living donor kidney transplantation. This guideline addresses general candidacy issues such as access to transplantation, patient demographic and health status factors, and immunological and psychosocial assessment. The roles of various risk factors and comorbid conditions governing an individual's suitability for transplantation such as adherence, tobacco use, diabetes, obesity, perioperative issues, causes of kidney failure, infections, malignancy, pulmonary disease, cardiac and peripheral arterial disease, neurologic disease, gastrointestinal and liver disease, hematologic disease, and bone and mineral disorder are also addressed. This guideline provides recommendations for evaluation of individual aspects of a candidate's profile such that each risk factor and comorbidity are considered separately. The goal is to assist the clinical team to assimilate all data relevant to an individual, consider this within their local health context, and make an overall judgment on candidacy for transplantation. The guideline development process followed the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Guideline recommendations are primarily based on systematic reviews of relevant studies and our assessment of the quality of that evidence, and the strengths of recommendations are provided. Limitations of the evidence are discussed with differences from previous guidelines noted and suggestions for future research are also provided.
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Tsushima T, Suzuki T, Terao T, Miura D, Narita K, Takeuchi M, Shimuzu A, Matsue K. Light chain deposition disease involving kidney and liver in a patient with IgD myeloma. BMC Nephrol 2021; 22:40. [PMID: 33485303 PMCID: PMC7824927 DOI: 10.1186/s12882-021-02246-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 01/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background IgD multiple myeloma (MM) is a rare subtype of MM and light chain deposition disease (LCDD) outside the kidney is also a rare and has scarcely been reported. We report herein the details of the first reported case of LCDD involving the kidney and liver co-occurring with IgD myeloma. Case presentation A 66-year-old female with IgD MM presented with rapidly progressive acute renal failure, ascites and pleural effusion. Immunofluorescent study of revealed the characteristic linear deposition of Igκ light chain along the glomerular and tubular basement membrane in kidney. Electron microscopy showed the powdery electron-dense deposits along the tubular and glomerular basement membrane consistent with the diagnosis of LCDD. Laser microdissection followed by mass spectrometry identified only Igκ light chain with more than 95% probability confirm the diagnosis of κ-LCDD but not heavy/light chain deposition disease. Liver biopsy with immunofluorescence study revealed the linear deposition of Igκ chain along the perisinusoidal space indicating the hepatic involvement of κ-LCDD. The patient was successfully treated with combination therapy with bortezomib, cyclophosphamide, dexamethasone, and daratumumab. Conclusions This report emphasizes that prompt biopsy of affected organs and initiation of clone directed therapy led to the correct diagnosis and favorable outcome in patient with LCDD who has extrarenal involvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02246-9.
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Affiliation(s)
- Takafumi Tsushima
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, 929 Higashi-chou, Kamogawa-shi, Chiba, 296-8601, Japan
| | - Tomo Suzuki
- Division of Nephrology, Department of Medicine, Kameda Medical Center, Kamogawa-shi, Chiba, 296-8601, Japan
| | - Toshiki Terao
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, 929 Higashi-chou, Kamogawa-shi, Chiba, 296-8601, Japan
| | - Daisuke Miura
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, 929 Higashi-chou, Kamogawa-shi, Chiba, 296-8601, Japan
| | - Kentaro Narita
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, 929 Higashi-chou, Kamogawa-shi, Chiba, 296-8601, Japan
| | - Masami Takeuchi
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, 929 Higashi-chou, Kamogawa-shi, Chiba, 296-8601, Japan
| | - Akira Shimuzu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Kosei Matsue
- Division of Hematology/Oncology, Department of Internal Medicine, Kameda Medical Center, 929 Higashi-chou, Kamogawa-shi, Chiba, 296-8601, Japan.
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