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Zhang H, Zhang C, Su H. Concurrent Crystalline Light-Chain Proximal Tubulopathy and Membranous Nephropathy: A Case Report and Literature Review. Kidney Med 2024; 6:100816. [PMID: 38720788 PMCID: PMC11077163 DOI: 10.1016/j.xkme.2024.100816] [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] [Indexed: 05/12/2024] Open
Abstract
Light-chain proximal tubulopathy (LCPT) is typically characterized by the intracytoplasmic deposition of light chains within the proximal tubular epithelial cells, which is usually classified into crystalline and noncrystalline subgroups. Membranous nephropathy (MN) is a common glomerular disease characterized by diffused subepithelial electron-dense deposits along the capillary loop accompanied by the effacement and microvillus transformation of the foot process. Here, we report a biopsy-confirmed case of a concurrence of LCPT with crystals (κ light chains restricted) and antigen-undetermined MN in a male patient. The patient presented with low-molecular-weight proteinuria, increased serum creatinine levels, and incomplete Fanconi syndrome. To our knowledge, this is the first report of a concurrence of LCPT and independent MN of unknown target antigens, which may enrich our recognition of monoclonal gammopathy of renal significance with synchronous MN.
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Affiliation(s)
- Huizi Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Chunyun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
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Tsuyuki T, Uramatsu T, Shimizu M, Ishi T, Tsuji K, Nakashima J, Katafuchi E, Nakayama T, Uesugi N, Muta K, Nishino T. Improvement of Light Chain Proximal Tubulopathy without Crystals in IgGλ-type Monoclonal Gammopathy of Undetermined Significance Using Bortezomib and Dexamethasone. Intern Med 2024; 63:693-698. [PMID: 37438138 PMCID: PMC10982019 DOI: 10.2169/internalmedicine.1835-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/18/2023] [Indexed: 07/14/2023] Open
Abstract
A 70-year-old woman with acute kidney injury, a high serum Creatinine (Cr) level (3.91 mg/dL), and proteinuria (protein/Cr ratio 1.59 g/gCr) was admitted. Serum IgG λ-type and urinary λ-type M proteins were observed. A bone marrow examination indicated monoclonal gammopathy of undetermined significance (MGUS). A renal biopsy showed distended proximal tubular cells, and immunofluorescence identified tissue positive for proximal tubular cell λ light chains. Electron microscopy identified fibril-like structures in the lysosomes. The patient was diagnosed with light chain proximal tubulopathy without crystals in IgG λ-type MGUS and treated with bortezomib and dexamethasone therapy, which improved her renal function.
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Affiliation(s)
| | | | | | - Takuma Ishi
- Department of Nephrology, Nagasaki University Hospital, Japan
| | - Kiyokazu Tsuji
- Department of Nephrology, JCHO Isahaya General Hospital, Japan
| | - Jun Nakashima
- Department of Hematology, JCHO Isahaya General Hospital, Japan
| | - Eisuke Katafuchi
- Department of Pathology, University of Occupational and Environmental Health School, Japan
| | - Toshiyuki Nakayama
- Department of Pathology, University of Occupational and Environmental Health School, Japan
| | - Noriko Uesugi
- Department of Pathology, Fukuoka University Hospital, Japan
| | - Kumiko Muta
- Department of Nephrology, Nagasaki University Hospital, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Hospital, Japan
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Shokripour M, Hosseini SE, Omidifar N, Mokhtari M, Safaei A. Cytogenetic, Clinical, Hematologic, Demographic, Immunohistochemical, and Flow Cytometry Characteristics of Patients with Plasma Cell Neoplasm in Five Years: A First Report from Iran. IRANIAN JOURNAL OF MEDICAL SCIENCES 2024; 49:77-87. [PMID: 38356489 PMCID: PMC10862103 DOI: 10.30476/ijms.2023.96892.2855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Revised: 02/19/2023] [Accepted: 03/04/2023] [Indexed: 02/16/2024]
Abstract
Background The aggregation of clonal plasma cells causes plasma cell neoplasms, which vary in severity and clinical outcomes. The present research focused on the epidemiological, clinical, immunologic, and cytogenetic characteristics of plasma cell neoplasms. Methods In this five-year retrospective cross-sectional study, demographic information such as age and sex, calcium elevation, renal insufficiency, anemia, and bone lesion (CRAB) characteristics, as well as laboratory data including bone marrow and peripheral blood film results, immunohistochemistry, flow cytometry, and cytogenetic study outcomes were collected at Shiraz University of Medical Sciences, Shiraz, Iran. The collected data were analyzed using SPSS Statistics software (version 20.0). Descriptive statistics were reported as numbers, percentages, and mean±SD. Results 417 newly diagnosed plasma cell neoplasm patients were confirmed by bone marrow or other tissue biopsy tests. 279 patients were men (66.9%). The most prevalent age group was 60-64 years old (18.46%). Plasma cell myeloma (PCM) affected 355 (85.13%) patients, while monoclonal gammopathy of undetermined significance (MGUS) affected 6 (1.43%) patients. Solitary plasmacytoma was seen in 56 (13.42%) patients. At the time of diagnosis, 119 (33.52%) of 355 PCM patients were asymptomatic, whereas 236 (66.47%) patients had at least one CRAB symptom, 55 (15.49%) had two or more, and 14 (3.94%) had three or more. There were 7 (1.97%) cases of amyloidosis. Cytogenetic abnormalities were found in 51.28% (40/78) of the patients. Twenty-one individuals (52.5%) were hyperdiploid with multiple trisomy, while 19 (47.50%) were not. Conclusion When diagnosed, Iranian PCM patients might have more advanced disease. PCM was more prevalent in young adults, and hyperdiploid was the most common cytogenetic finding in this investigation.
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Affiliation(s)
- Mansoureh Shokripour
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Seyed Ehsan Hosseini
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Navid Omidifar
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Biotechnology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maral Mokhtari
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Akbar Safaei
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Zhu L, Wang L, Shi H, Jiang L, Li X, Shao C, Yan Y, Dong B, Zou W, Zuo L. Combined crystal-storing histiocytosis, light chain proximal tubulopathy, and light chain crystalline podocytopathy in a patient with multiple myeloma: a case report and literature review. Ren Fail 2023; 45:2145970. [PMID: 36632756 PMCID: PMC9848311 DOI: 10.1080/0886022x.2022.2145970] [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] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Crystal-storing histiocytosis (CSH), light chain proximal tubulopathy (LCPT), and light chain crystalline podocytopathy (LCCP) are rare complications of multiple myeloma (MM) or monoclonal gammopathy of renal significance, and their diagnoses are challenging. CASE PRESENTATION In this case, a 69-year-old Chinese woman presented with suspicious Fanconi syndrome with renal insufficiency. Immunofixation electrophoresis of both serum and urine revealed elevated immunoglobulin G kappa (IgGkappa) and kappa light chain. Bone marrow aspirate revealed 15% plasma cells with considerable cytoplasmic granular inclusions and needle-shaped crystals. Renal biopsy confirmed the final pathologic diagnosis of kappa-restricted CSH, combined LCPT and LCCP by immunoelectron microscopy. A number of special casts were present which could easily be misdiagnosed as light chain cast nephropathy. Immunofluorescence on frozen tissue presented false negative for kappa light chain, as ultimately proven by paraffin-embedded tissue after pronase digestion. MM and CSH were diagnosed, and two cycles of chemotherapy were given. The patient subsequently refused further chemotherapy, and her renal function remained relatively stable during a 2.5-year follow-up period. CONCLUSIONS In conclusion, we report a rare case of generalized kappa-restricted CSH involving bone marrow and kidney, combined with LCPT and LCCP, provide a comprehensive summary of renal CSH, and propose a new nomenclature of monoclonal immunoglobulin-induced crystalline nephrology. The presentation of monoclonal immunoglobulin and Fanconi syndrome should suggest the presence of monoclonal immunoglobulin-induced crystalline nephrology. Use of paraffin-embedded tissue after pronase digestion and immunoelectron microscopy is beneficial to improve the sensitivity of diagnosis.
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Affiliation(s)
- Li Zhu
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Lei Wang
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Hongxia Shi
- Electron Microscope Lab, Peking University People’s Hospital, Beijing, China,National Clinical Research Center for Hematologic Disease, Peking University People’s Hospital, Peking University Institute of Hematology, Beijing, China
| | - Lei Jiang
- Electron Microscope Lab, Peking University People’s Hospital, 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
| | - Yu Yan
- Department of Nephrology, Peking University People’s Hospital, Beijing, China,CONTACT Yu Yan
| | - Bao Dong
- Department of Nephrology, Peking University People’s Hospital, Beijing, China,Bao Dong Department of Nephrology, Peking University People’s Hospital, No.11 Xizhimen South Street, Xicheng District, Beijing, 100044, China
| | - Wanzhong Zou
- 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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5
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Pathological characteristics of light chain crystalline podocytopathy. Kidney Int 2023; 103:616-626. [PMID: 36581019 DOI: 10.1016/j.kint.2022.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/14/2022] [Accepted: 11/17/2022] [Indexed: 12/28/2022]
Abstract
Monoclonal immunoglobulin light chain (LC) crystalline inclusions within podocytes are rare, poorly characterized entities. To provide more insight, we now present the first clinicopathologic series of LC crystalline podocytopathy (LCCP) encompassing 25 patients (68% male, median age 56 years). Most (80%) patients presented with proteinuria and chronic kidney disease, with nephrotic syndrome in 28%. Crystalline keratopathy and Fanconi syndrome were present in 22% and 10%, respectively. The hematologic condition was monoclonal gammopathy of renal significance (MGRS) in 55% and multiple myeloma in 45%. The serum monoclonal immunoglobulin was IgG κappa in 86%. Histologically, 60% exhibited focal segmental glomerulosclerosis (FSGS), often collapsing. Ultrastructurally, podocyte LC crystals were numerous with variable effacement of foot processes. Crystals were also present in proximal tubular cells as light chain proximal tubulopathy (LCPT) in 80% and in interstitial histiocytes in 36%. Significantly, frozen-section immunofluorescence failed to reveal the LC composition of crystals in 88%, requiring paraffin-immunofluorescence or immunohistochemistry, with identification of kappa LC in 87%. The LC variable region gene segment, determined by mass spectrometry of glomeruli or bone marrow plasma cell sequencing, was IGKV1-33 in four and IGKV3-20 in one. Among 21 patients who received anti-plasma cell-directed chemotherapy, 50% achieved a kidney response, which depended on a deep hematologic response. After a median follow-up of 36 months, 26% progressed to kidney failure and 17% died. The mean kidney failure-free survival was 57.6 months and was worse in those with FSGS. In sum, LCCP is rare, mostly associates with IgG κappa MGRS, and frequently has concurrent LCPT, although Fanconi syndrome is uncommon. Paraffin-immunofluorescence and electron microscopy are essential to prevent misdiagnosis as primary FSGS since kidney survival depends on early diagnosis and subsequent clone-directed therapy.
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6
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Crystal-induced collapsing podocytopathy and light chain proximal tubulopathy in monoclonal gammopathy of renal significance. J Nephrol 2022; 35:2127-2130. [PMID: 35687268 DOI: 10.1007/s40620-022-01362-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/19/2022] [Indexed: 10/18/2022]
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Eymieux S, Miquelestorena-Standley E, Rabot N, Maisons V, Touchard G, Blanchard E. Crystalline podocytopathy and tubulopathy linked to kappa light chain deposits in a context of smoldering multiple myeloma. Clin Kidney J 2022; 15:351-353. [PMID: 35145650 PMCID: PMC8824780 DOI: 10.1093/ckj/sfab197] [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: 08/12/2021] [Indexed: 11/18/2022] Open
Abstract
A 42-year-old man with smoldering immunoglobulin G kappa multiple myeloma showed a heavy proteinuria composed of free light chain, prompting performance of a kidney biopsy. Electron microscopy revealed numerous rhomboid-shaped crystals labelled by the anti-kappa in immunogold, notably in the cytoplasm of podocytes, establishing the diagnosis of crystalline podocytopathy. This case illustrates a rare form of monoclonal gammopathy of renal significance, and highlights the key role of electron microscopy and immunogold to better elucidate the location and composition of crystals.
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Affiliation(s)
- Sébastien Eymieux
- Unité de Biologie cellulaire et microscopie électronique, hôpital Bretonneau CHRU de Tours, Tours, France
| | | | | | - Valentin Maisons
- EA4245-Transplantation, Immunologie, Inflammation, Université de Tours, Tours, France
| | - Guy Touchard
- Service d'Anatomie et Cytologie Pathologiques, CHRU Poitiers, Poitiers, France
| | - Emmanuelle Blanchard
- Unité de Biologie cellulaire et microscopie électronique, hôpital Bretonneau CHRU de Tours, Tours, France
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Menè P, Moioli A, Stoppacciaro A, Lai S, Festuccia F. Acute Kidney Injury in Monoclonal Gammopathies. J Clin Med 2021; 10:jcm10173871. [PMID: 34501317 PMCID: PMC8432219 DOI: 10.3390/jcm10173871] [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: 06/30/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 01/07/2023] Open
Abstract
Monoclonal gammopathies (MG) encompass a variety of disorders related to clonal expansion and/or malignant transformation of B lymphocytes. Deposition of free immunoglobulin (Ig) components (light or heavy chains, LC/HC) within the kidney during MG may result over time in multiple types and degrees of injury, including acute kidney injury (AKI). AKI is generally a consequence of tubular obstruction by luminal aggregates of LC, a pattern known as “cast nephropathy”. Monoclonal Ig LC can also be found as intracellular crystals in glomerular podocytes or proximal tubular cells. Proliferative glomerulonephritis with monoclonal Ig deposits is another, less frequent form of kidney injury with a sizable impact on renal function. Hypercalcemia (in turn related to bone reabsorption triggered by proliferating plasmacytoid B cells) may lead to AKI via functional mechanisms. Pharmacologic treatment of MG may also result in additional renal injury due to local toxicity or the tumor lysis syndrome. The present review focuses on AKI complicating MG, evaluating predictors, risk factors, mechanisms of damage, prognosis, and options for treatment.
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Affiliation(s)
- Paolo Menè
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy; (A.M.); (F.F.)
- Correspondence: ; Tel.: +39-(06)-3377-5949
| | - Alessandra Moioli
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy; (A.M.); (F.F.)
| | - Antonella Stoppacciaro
- Division of Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy;
| | - Silvia Lai
- Division of Nephrology, Department of Translational and Precision Medicine, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Francescaromana Festuccia
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy; (A.M.); (F.F.)
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9
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Buxeda A, Said S, Nasr SH, Soler MJ, Howard MT, Maguire LJ, Fervenza FC. Crystal-Induced Podocytopathy Producing Collapsing Focal Segmental Glomerulosclerosis in Monoclonal Gammopathy of Renal Significance: A Case Report. Kidney Med 2021; 3:659-664. [PMID: 34401732 PMCID: PMC8350840 DOI: 10.1016/j.xkme.2021.03.007] [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] [Indexed: 11/20/2022] Open
Abstract
Monoclonal gammopathy–associated crystalline podocytopathy causing collapsing focal segmental glomerulosclerosis (FSGS) is very rare and has been associated with pamidronate therapy. We present the case of a 53-year-old man with vision loss secondary to corneal crystals deposition, nephrotic-range proteinuria, and reduced glomerular filtration rate without associated comorbid conditions. Two kidney biopsies were initially reported as primary FSGS but the patient did not respond to high-dose corticosteroid immunosuppression therapy. Repeat review of biopsies with additional electron microscopy analysis revealed crystalline inclusions in podocytes leading to collapsing FSGS. Subsequent workup revealed an immunoglobulin G κ serum monoclonal protein. Bone marrow biopsy revealed 5% κ-restricted plasma cells with cytoplasmic crystalline inclusions. To our knowledge, this is the first case of monoclonal gammopathy of clinical significance manifesting as crystalline podocytopathy leading to collapsing FSGS and keratopathy leading to vision loss. Crystalline podocytopathy should be considered in the differential diagnosis of collapsing glomerulopathy, and careful ultrastructural examination of the kidney biopsy specimen is crucial to establish this diagnosis.
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Affiliation(s)
- Anna Buxeda
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, MN
- Division of Nephrology, Hospital del Mar, Barcelona, Spain
| | - Samar Said
- Division of Anatomic Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Samih H. Nasr
- Division of Anatomic Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - María José Soler
- Division of Nephrology, Hospital Vall d’Hebrón, Barcelona, Spain
| | - Mathew T. Howard
- Laboratory Medicine and Pathology, Mayo Clinic College of Medicine, Rochester, MN
| | - Leo J. Maguire
- Department of Ophthalmology, Mayo Clinic College of Medicine, Rochester, MN
| | - Fernando C. Fervenza
- Division of Nephrology and Hypertension, Mayo Clinic College of Medicine, Rochester, MN
- Address for Correspondence: Fernando C. Fervenza, MD, PhD, Mayo Clinic, Division of Nephrology and Hypertension, Mayo 19, 200 First St SW, Rochester, MN 55905.
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10
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Hamza WM, AlEssa AM. Coincidental light chain induced proximal tubulopathy with lupus nephritis: a case report and review of the literature. J Med Case Rep 2021; 15:388. [PMID: 34344460 PMCID: PMC8335886 DOI: 10.1186/s13256-021-02990-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 06/29/2021] [Indexed: 12/04/2022] Open
Abstract
Background We report a case of light chain proximal tubulopathy associated with lupus nephritis in a patient known to have systemic lupus erythematosus. The kidney can be injured in several ways in any of these disorders. Light chain proximal tubulopathy is a rare form of renal tubular injury that may occur in and complicate plasma cell dyscrasia, characterized by cytoplasmic inclusions of the monoclonal light chain within proximal tubular cells. Lupus nephritis is a common form of renal injury as it occurs in about 25–50% of adult patients with systemic lupus erythematosus. Case presentation We present a 57-year-old African patient known to have systemic lupus erythematosus and hypertension presented with a new complaint of microscopic hematuria. A renal biopsy was performed and revealed lupus nephritis class II concurrently associated with light chain induced proximal tubulopathy. A subsequent bone marrow biopsy was performed, which revealed multiple myeloma. Conclusions We report a case of coincidental lupus nephritis and proximal tubulopathy featuring a combined constellation of rare histopathological features that might add to the relationship between systemic lupus and paraproteinemia.
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Affiliation(s)
- Wael Mostafa Hamza
- Department of Pathology and Laboratory Medicine, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia.
| | - Ahmed Mohammed AlEssa
- Department of Pathology and Laboratory Medicine, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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11
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Combined light chain crystalline tubulopathy, podocytopathy, and histiocytosis associated with Bence-Jones κ protein diagnosed via immuno-electron microscopy. CEN Case Rep 2021; 10:453-458. [PMID: 33675012 DOI: 10.1007/s13730-021-00588-9] [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: 11/24/2020] [Accepted: 02/19/2021] [Indexed: 10/22/2022] Open
Abstract
We herein report a case of a combined crystalline light chain tubulopathy, podocytopathy, histiocytosis, and cast nephropathy in a patient with monoclonal gammopathy of renal significance (MGRS). A 66-year-old female with impaired renal function was referred to our department. Despite intravenous fluid resuscitation, the kidney function worsened progressively; thus, a kidney biopsy was performed. The kidney biopsy revealed light chain proximal tubulopathy (LCPT) with crystals, light chain crystal podocytopathy (LCCP), crystal-storing histiocytosis (CSH), and light chain cast nephropathy (LCCN). Of note, LCCP and CSH were diagnosed via electron microscopy. Serum and urine immunoelectrophoresis (IEP) revealed the presence of monoclonal Bence-Jones protein and free κ light chains. Bone marrow aspiration showed < 10% plasma cell proliferation. Thus, we had encountered a rare case in which a variety of kidney lesions were combined with MGRS. Most of the LCPT, LCCP, and CSH cases show monoclonal IgG κ, while our case showed Bence-Jones protein κ.
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12
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Hanna RM, Abdelnour L, Zuckerman JE, Ferrey AJ, Pai A, Vahabzadeh K, Wilson J, Torres EA, Kalantar-Zadeh K, Kurtz IB. Refractory scleroderma renal crisis precipitated after high-dose oral corticosteroids and concurrent intravitreal injection of bevacizumab. SAGE Open Med Case Rep 2020; 8:2050313X20952650. [PMID: 32913652 PMCID: PMC7443985 DOI: 10.1177/2050313x20952650] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 07/29/2020] [Indexed: 12/17/2022] Open
Abstract
Scleroderma renal crisis is a serious complication that can develop in certain patients with systemic sclerosis. Some risks have been identified as potential triggers of scleroderma renal crisis, including the high-dose oral corticosteroids. Here, we present a patient who developed clinically severe systemic sclerosis and scleroderma renal crisis after exposure to oral corticosteroids and intravitreal vascular endothelial growth factor blockade with bevacizumab for cotton wool spots. The patient's scleroderma renal crisis was severe, progressive, and refractory to the standard of care therapy: oral captopril. Biopsy showed a diffuse thrombotic microangiopathy and findings consistent with scleroderma renal crisis. We hypothesize that depletion of systemic vascular endothelial growth factor with intravitreal anti-vascular endothelial growth factor injections likely contributed to the particularly severe presentation seen in this case. Though the finding of a monoclonal gammopathy of undetermined significance is another complicating factor, this case suggests that vascular endothelial growth factor inhibition may be a newly recognized trigger of scleroderma renal crisis.
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Affiliation(s)
- Ramy M Hanna
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
- UC Irvine School of Medicine, Orange,
CA, USA
| | - Lama Abdelnour
- Division of Nephrology, Department of
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jonathan E Zuckerman
- Department of Pathology and Laboratory
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Antoney J Ferrey
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Alex Pai
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | | | - James Wilson
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Everado A Torres
- Department of Medicine, University of
California Irvine, Irvine, CA, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Department of
Medicine, University of California Irvine, Irvine, CA, USA
| | - Ira B Kurtz
- Division of Nephrology, Department of
Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Brain Research Institute, Westwood, CA,
USA
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13
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Menè P, De Alexandris L, Moioli A, Raffa S, Stoppacciaro A. Monoclonal Gammopathies of Renal Significance: Renal Biopsy and Beyond. Cancers (Basel) 2020; 12:cancers12071741. [PMID: 32629844 PMCID: PMC7407125 DOI: 10.3390/cancers12071741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/22/2020] [Accepted: 06/28/2020] [Indexed: 12/27/2022] Open
Abstract
Monoclonal Gammopathies of Renal Significance (MGRS) are a rather heterogeneous group of renal disorders caused by a circulating monoclonal (MC) immunoglobulin (Ig) component, often in the absence of multiple myeloma (MM) or another clinically relevant lymphoproliferative disorder. Nevertheless, substantial kidney damage could occur, despite the "benign" features of the bone-marrow biopsy. One example is renal amyloidosis, often linked to a small clone of plasma cells, without the invasive features of MM. However, patients with amyloidosis may present with a nephrotic syndrome and renal failure, eventually leading to end-stage kidney disease. At the same time, other organs, such as the heart and the liver, may be severely damaged by Ig light chains or amyloid deposits, occasionally resulting in fatal arrhythmias and/or organ failure. Acute kidney injury (AKI) may as well result from massive excretion of MC proteins, with deposition disease in glomeruli or renal tubules, not rarely obstructed by luminal aggregates, or "casts". Proliferative glomerulonephritis with monoclonal Ig deposits is another, less frequent clinical presentation of an MGRS. The present review deals with the implications of MGRS for renal function and prognosis, and the potential of tools, such as the renal biopsy, for assessing clinical risk and guiding therapy of the underlying condition.
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Affiliation(s)
- Paolo Menè
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035–1039, 00189 Rome, Italy
- Correspondence: ; Tel.: +39-(06)-3377-5949
| | - Lorenzo De Alexandris
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
| | - Alessandra Moioli
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
| | - Salvatore Raffa
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
| | - Antonella Stoppacciaro
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
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14
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Gupta RK, Arend LJ, BK A, Narsipur S, Bhargava R. Crystalglobulin-associated nephropathy presenting as MGRS in a case of monoclonal B-cell lymphocytosis: a case report. BMC Nephrol 2020; 21:184. [PMID: 32423442 PMCID: PMC7236346 DOI: 10.1186/s12882-020-01818-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 04/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Crystalglobulin-associated nephropathy (CAN), a rare subtype of monoclonal gammopathy, usually associated with multiple myeloma and occasionally monoclonal gammopathy of uncertain significance (MGUS), is characterized by occluding monoclonal pseudothrombi within renal glomerular capillaries and/or interstitial arterioles. Ultrastructurally, these pseudothrombi are unique for having a crystalline substructure. We describe a case of an adult patient with monoclonal B-cell lymphocytosis (MBL) and acute renal failure whose kidney biopsy revealed a rare diagnosis of CAN. CASE PRESENTATION A 63-year old male presented with a 2-month history of edema, arthralgia and malaise. He had acute kidney injury with hematoproteinuria on urine analysis. Serum and urine protein electrophoresis were both negative. A renal biopsy however revealed features of CAN. Organomegaly, bone pain and lymphadenopathy were absent. A repeat serum electrophoresis was positive for IgA kappa and a free light chain assay showed elevated free kappa light chains. Flow cytometry done subsequently revealed a diagnosis of MBL, chronic lymphocytic leukemia (CLL) type. CONCLUSION CAN in association with MBL/CLL has not been previously described in literature, and our case highlights yet another instance of monoclonal gammopathy of renal significance (MGRS) where a small B-cell clone resulted in extensive renal pathology without systemic manifestations.
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Affiliation(s)
- Rajib K. Gupta
- Department of Pathology, SUNY Upstate Medical University, 750 E Adams Street, Syracuse, NY 13210 USA
| | - Lois J. Arend
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Anupama BK
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY USA
| | - Sriram Narsipur
- Department of Medicine and Nephrology, SUNY Upstate Medical University, Syracuse, NY USA
| | - Ramya Bhargava
- Department of Nephrology, SUNY Upstate Medical University, Syracuse, NY USA
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Cao Q, Qi H, Yao L, Liu Q. Monoclonal gammopathy of renal significance: clinical manifestation, pathogenic characteristic and treatment. Panminerva Med 2019; 62:38-53. [PMID: 30848114 DOI: 10.23736/s0031-0808.19.03609-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a group of renal disorders caused by a monoclonal immunoglobulin (MIg) secreted by a dangerous plasmatic/B-cell clone hyperplasia through MIg deposition or dysfunction of complement pathway, with increasing risk of progress to end stage renal disease (ESRD) and the underlying hematologic malignancy. The combination of renal biopsy, complete laboratory examination and bone marrow biopsy is an indispensable diagnostic tool for MGRS to identify accurately and unequivocally the pathogenic monoclonal MIg and provide guidance to treatment. Treatment of MGRS is composed of conventional therapy, chemotherapy, and stem cell transplantation to target the underlying clone and eliminate the noxious MIg on the basis of clinical data of some retrospective studies and a small amount of prospective trial. In addition, it is worthwhile point out assessment of therapeutic effect is significantly relevant for renal and overall prognosis. Thus, by comprehensively analyzing the clinical manifestations and pathogenic characteristic of MGRS, early recognition and prompt treatment can improve the prognosis and prevent post-translation recurrence with multidisciplinary cooperation.
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Affiliation(s)
- Qin Cao
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang, China
| | - Huimeng Qi
- Department of General Practice, The First Hospital of China Medical University, Shenyang, China
| | - Li Yao
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China
| | - Qiang Liu
- Department of Nephrology, The First Hospital of China Medical University, Shenyang, China -
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