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Razzouk R, Khattab N, Hoteit M, Kfoury H, Saleh M, Tanios B, El-Cheikh J, Mallat S. A rare case of IgA lambda multiple myeloma in a 32-year-old woman with t(14;16) translocation associated with kidney injury and non-albumin proteinuria. BMC Nephrol 2024; 25:165. [PMID: 38755555 PMCID: PMC11100155 DOI: 10.1186/s12882-024-03600-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/06/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Multiple myeloma (MM) is a malignant disorder characterized by monoclonal differentiated plasma cells. While it is more commonly diagnosed in elderly individuals, it can also affect younger populations, though with a lower incidence. CASE PRESENTATION Here, we present the case of a 32-year-old woman diagnosed with IgA lambda MM. She presented with fatigue, nausea, acute kidney injury (AKI) with a rapid increase in creatinine, and anemia. A kidney biopsy was done to rule out a rapidly progressive glomerular disease and a diagnosis was thus reached. A genetic workup revealed t(14;16) translocation and an extra copy of TP53. The patient received aggressive intravenous steroids and intravenous fluid resuscitation, resulting in an improvement in renal function. Treatment with daratumumab in combination with bortezomib, thalidomide, and dexamethasone was initiated and well tolerated. Despite the generally poor prognosis of IgA MM, our case emphasizes the importance of considering MM in young patients with unexplained kidney injury. CONCLUSION Early recognition and prompt intervention are essential in managing MM patients, especially in those with high-risk cytogenetic abnormalities. This case serves as a reminder for clinicians to maintain a high index of suspicion for MM, even in younger populations, when presented with unexplained kidney injury.
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Affiliation(s)
- Ranim Razzouk
- Department of Internal Medicine, Division of Nephrology and Hypertension, American University of Beirut Medical Center, Beirut, Lebanon
| | - Nour Khattab
- Department of Internal Medicine, Division of Nephrology and Hypertension, American University of Beirut Medical Center, Beirut, Lebanon
| | - Maysaa Hoteit
- Department of Internal Medicine, Division of Nephrology and Hypertension, American University of Beirut Medical Center, Beirut, Lebanon
| | - Hala Kfoury
- Department of Pathology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Mustafa Saleh
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Bassem Tanios
- Department of Internal Medicine, Division of Nephrology and Hypertension, American University of Beirut Medical Center, Beirut, Lebanon
| | - Jean El-Cheikh
- Division of Hematology/Oncology, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Samir Mallat
- Department of Internal Medicine, Division of Nephrology and Hypertension, American University of Beirut Medical Center, Beirut, Lebanon.
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2
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Manoharan A, Ballambattu VB, Palani R. Genetic architecture of preeclampsia. Clin Chim Acta 2024; 558:119656. [PMID: 38583550 DOI: 10.1016/j.cca.2024.119656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/04/2024] [Accepted: 04/04/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Aarthi Manoharan
- Department of Medical Biotechnology, Kirumampakkam, Puducherry 607403, India.
| | | | - Ramya Palani
- Department of Obstetrics and Gynecology, Aarupadai Veedu Medical College and Hospital, Vinayaka Mission's Research Foundation (DU), Kirumampakkam, Puducherry 607403, India
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3
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Noorani B, Menon RM, Chen X, Marsh KC, Huang W, Gupta S, Dobkowska E, Marbury T, Salem AH. Venetoclax pharmacokinetics in participants with end-stage renal disease undergoing haemodialysis. Br J Clin Pharmacol 2024; 90:748-758. [PMID: 37855131 DOI: 10.1111/bcp.15935] [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: 08/18/2023] [Revised: 10/06/2023] [Accepted: 10/11/2023] [Indexed: 10/20/2023] Open
Abstract
AIMS Renal insufficiency is a common comorbidity in patients with haematological malignancies. This study aimed to assess how end-stage renal disease (ESRD) might affect the pharmacokinetics of venetoclax, a Bcl-2 inhibitor, in participants with ESRD undergoing haemodialysis. METHODS Venetoclax was administered as a single 100-mg dose to 6 female participants with ESRD (estimated glomerular filtration rate <15 mL/min) both prior to haemodialysis and between haemodialysis days and 7 healthy female participants with normal renal function (estimated glomerular filtration rate >90 mL/min). Intensive pharmacokinetic and protein binding samples were collected from all participants. Arterial and venous samples were collected from ESRD participants during haemodialysis to assess the effect of haemodialysis on venetoclax pharmacokinetics. Pharmacokinetic parameters were estimated using noncompartmental methods. RESULTS There was no difference in plasma venetoclax concentrations between arterial and venous samples, suggesting that haemodialysis did not affect the pharmacokinetics of venetoclax. The fraction unbound (fu ) of venetoclax was ~2-fold higher for participants with ESRD compared to participants with normal renal function. The unbound maximum plasma concentration and area under the plasma concentration-time curve from time 0 to 48 h were comparable between ESRD and normal function groups. The mean half-life ranged from 10.4 to 12.2 h across groups, demonstrating that ESRD did not affect the half-life of venetoclax. No new safety signals were observed during this study. CONCLUSION ESRD and dialysis do not alter unbound venetoclax plasma concentrations. No pharmacokinetics driven dose adjustment is needed for patients with renal insufficiency.
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Affiliation(s)
| | | | - Xin Chen
- AbbVie, Inc., North Chicago, Illinois, USA
| | | | - Weize Huang
- Genentech Inc., South San Francisco, California, USA
| | | | - Edyta Dobkowska
- Pharmacyclics, an AbbVie company in Switzerland, Schaffhausen, Switzerland
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4
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Maddipati V, Sankhyan P, Goswami DP, Mahajan A. Pulmonary hypertension in patients with multiple myeloma: A comprehensive review. Pulm Circ 2023; 13:e12210. [PMID: 37063748 PMCID: PMC10098295 DOI: 10.1002/pul2.12210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 02/02/2023] [Accepted: 03/08/2023] [Indexed: 04/18/2023] Open
Abstract
Multiple myeloma (MM) is a common hematological malignancy resulting from clonal proliferation of plasma cells and is defined by criteria set forth by the international myeloma working group. Pulmonary hypertension (PH) is defined by an elevated mean pulmonary artery pressure >20 mmHg measured during right heart catheterization. Echocardiography-diagnosed PH is relatively common in patients with MM and has been associated with increased mortality, morbidity, and poor stem cell transplant outcomes. PH in patients with MM (PH-MM) is usually multifactorial in origin. MM disease-specific factors, host comorbidities, and treatment-related adverse effects are the key factors for the development of PH-MM. Pragmatically, patients with PH-MM can be grouped into either (i) PH in patients with a new diagnosis of MM or (ii) PH that develops or worsens along the way of MM treatment. In the latter group, drug-induced PH, venous thromboembolism, pulmonary veno occlusive disease, and cardiotoxicity should be considered as possible causes. PH-MM should be evaluated and managed in a multidisciplinary setting. Select individuals with PH-MM could be considered for pulmonary vasodilators at PH-specialized centers.
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Affiliation(s)
- Veeranna Maddipati
- Division of Pulmonary and Critical Care Medicine, Pulmonary Vascular MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Pratyaksha Sankhyan
- Division of Pulmonary and Critical Care MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Durga P. Goswami
- Department of Internal MedicineEast Carolina UniversityGreenvilleNorth CarolinaUSA
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5
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Singh G, Whitaker BM, Wu AHB, Xu H, Bollag RJ. Serum Free Light Chain Quantification Testing: Comparison of Two Methods for Disease Monitoring. J Appl Lab Med 2022; 7:1290-1301. [DOI: 10.1093/jalm/jfac068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 07/01/2022] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Levels of free immunoglobulin light chains in serum and urine are a sensitive measure of dysregulated immunoglobulin synthesis. The development of an assay for free light chains in serum was a major advance in laboratory testing for monoclonal gammopathies. The original assay by The Binding Site, called Freelite®, has been in common use in laboratory monitoring of monoclonal gammopathies. Two clinical entities, myeloma-defining condition and light chain-predominant multiple myeloma, rely on quantitative measurements of serum free light chains.
Methods
Using polyclonal antisera specific to free light chains, Diazyme Laboratories developed a latex immunoturbidimetric assay for quantification of human kappa and lambda serum free light chains. We evaluated the Diazyme assay by comparing the results of kappa and lambda free light chain quantification, and kappa/lambda ratio with the results on the same specimens by the Freelite method. We also compared the correlation of the 2 methods to evaluate response to treatment and to changes in clinical status of patients with multiple myeloma.
Results
The results of Freelite and Diazyme methods are comparable. There was no statistically significant difference in the performance of the 2 assays for quantification of light chains, kappa/lambda ratio, or correlation of clinical parameters from patients with multiple myeloma at various stages of monitoring the disease in 2 geographically diverse laboratory and clinical environments.
Conclusions
The Diazyme method is comparable to Freelite and provides an opportunity to add the test to front-end automation and improvement in efficiency of the assay.
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Affiliation(s)
- Gurmukh Singh
- Department of Pathology, Medical College of Georgia at Augusta University , Augusta, GA 30912 , USA
| | - Brooke M Whitaker
- Department of Pathology, Medical College of Georgia at Augusta University , Augusta, GA 30912 , USA
| | - Alan H B Wu
- Department of Laboratory Medicine, University of California at San Francisco, 1001 Potrero Ave., SFGH 5 , San Francisco CA 94110 , USA
| | - Hongyan Xu
- Department of Population Health Sciences, Medical College of Georgia at Augusta University , Augusta, GA 30912 , USA
| | - Roni J Bollag
- Department of Pathology, Medical College of Georgia at Augusta University , Augusta, GA 30912 , USA
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6
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Multiple Myeloma with Skin and Renal Involvement and Anaplasma Phagocytophilum Co-Infection in a Dog. ACTA VET-BEOGRAD 2022. [DOI: 10.2478/acve-2022-0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
An 11-year-old male Cocker Spaniel was presented with acute onset of apathy, polyuria and polydipsia. Blood examination showed hypoalbuminemia and hyperglobulinemia, while electrophoresis revealed monoclonal gammopathy. Subsequent tests showed glycosuria, proteinuria, a positive serology test for Anaplasma spp. and ultrasonographical changes of the liver and spleen. Urine electrophoresis confirmed the presence of Bence-Jones protein. The dog’s condition deteriorated, and the dog had developed skin lesions on the neck and body. The owner decided to euthanize the dog and agreed to bone marrow and skin biopsy. Bone marrow cytology revealed an increased number of plasma cells and several cellular atypia. Histopathology of the skin lesions showed a round cell tumor of lymphoid or plasmacytoid origin. Subsequent immunohistology supported the diagnosis of multiple myeloma cutaneous involvement.
This case report describes unusual features observed in a dog with multiple myeloma.
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Cutrim ÉMM, Neves PDMDM, Campos MAG, Wanderley DC, Teixeira-Júnior AAL, Muniz MPR, Ladchumananandasivam FR, Gomes OV, Vasco RFV, Brito DJDA, Lages JS, Salgado-Filho N, Guedes FL, de Almeida JB, Magalhães M, Araújo SDA, Silva GEB. Collapsing Glomerulopathy: A Review by the Collapsing Brazilian Consortium. Front Med (Lausanne) 2022; 9:846173. [PMID: 35308512 PMCID: PMC8927620 DOI: 10.3389/fmed.2022.846173] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/08/2022] [Indexed: 01/10/2023] Open
Abstract
Collapsing glomerulopathy (CG) is a clinicopathologic entity characterized by segmentar or global collapse of the glomerulus and hypertrophy and hyperplasia of podocytes. The Columbia classification of 2004 classified CG as a histological subtype of focal segmental glomerulosclerosis (FSGS). A growing number of studies have demonstrated a high prevalence of CG in many countries, especially among populations with a higher proportion of people with African descent. The present study is a narrative review of articles extracted from PubMed, Medline, and Scielo databases from September 1, 2020 to December 31, 2021. We have focused on populational studies (specially cross-sectional and cohort articles). CG is defined as a podocytopathy with a distinct pathogenesis characterized by strong podocyte proliferative activity. The most significant risk factors for CG include APOL1 gene mutations and infections with human immunodeficiency virus and severe acute respiratory syndrome coronavirus 2. CG typically presents with more severe symptoms and greater renal damage. The prognosis is notably worse than that of other FSGS subtypes.
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Affiliation(s)
| | | | | | - Davi Campos Wanderley
- Nephropathology Institute, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | | | | | | | - Orlando Vieira Gomes
- University Hospital, Federal University of Vale do São Francisco, Petrolina, Brazil
| | | | | | | | | | - Felipe Leite Guedes
- University Hospital, Federal University of Rio Grande do Norte, Natal, Brazil
| | | | - Marcelo Magalhães
- Laboratory of Genomic and Histocompatibility Studies, University Hospital, Federal University of Maranhão, São Luís, Brazil
| | | | - Gyl Eanes Barros Silva
- University Hospital, Federal University of Maranhão, São Luís, Brazil
- *Correspondence: Gyl Eanes Barros Silva,
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8
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Kundu S, Jha SB, Rivera AP, Flores Monar GV, Islam H, Puttagunta SM, Islam R, Sange I. Multiple Myeloma and Renal Failure: Mechanisms, Diagnosis, and Management. Cureus 2022; 14:e22585. [PMID: 35371791 PMCID: PMC8958144 DOI: 10.7759/cureus.22585] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/05/2022] Open
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9
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Ungari M, Ghiringhelli P, Marchi G, Fisogni S, Lavazza A, Molteni A, Malberti F, Bertoni R, Trombatore M, Ferrero G, Gusolfino MD, Varotti E, Tanzi G, Manotti L. Combined renal proximal tubulopathy and crystal storing histiocytosis in a patient with κ light chain multiple myeloma. Pathologica 2021; 113:285-293. [PMID: 34463673 DOI: 10.32074/1591-951x-154] [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: 06/19/2020] [Accepted: 07/13/2020] [Indexed: 11/30/2022] Open
Abstract
Multiple myeloma accounts for 10-15% of all hematologic malignancies, and 20% of deaths related to cancers of the blood and bone marrow. Diagnosis is defined by the presence of a serum monoclonal spike (M-spike) of more than 3 g/dL or more than 10% clonal plasma cells in the bone marrow and at least one myeloma-defining event, such as hypercalcemia, anemia, bone lesions, or renal impairment. The kidney is a major target organ, and renal impairment is frequently the first manifestation of the disease. Renal damage occurs in up to 40% of patients and 10-20% will require dialysis. Monoclonal immunoglobulin light chains are the major causes of renal complications in multiple myeloma. Glomerular disease, with the deposition of monoclonal immunoglobulins or their components, includes monoclonal immunoglobulin deposition disease, AL or AH amyloidosis, type I cryoglobulinemia, proliferative glomerulonephritis with monoclonal IgG deposits, immunotactoid glomerulopathy, and fibrillary glomerulonephritis. In addition, tubulointerstitial diseases with the deposition of monoclonal immunoglobulins or their components, are constituted by light chain cast nephropathy, light chain proximal tubulopathy, and crystal-storing histiocytosis. We report the case of a 66-year-old woman who presented with albumin-predominant moderate proteinuria and renal failure. Serum and urine immunofixation electrophoresis showed monoclonal κ light chain in both. Renal biopsy confirmed κ-restricted crystal-storing renal disease involving proximal tubular epithelial cells and crystal storing histiocytosis. Multiple myeloma with crystal storing histiocytosis was discovered in bone marrow biopsy. Thus, we present an unusual case of a myeloma patient presenting light chain proximal tubulopathy and crystal-storing histiocytosis both in the kidney and in the bone marrow.
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Affiliation(s)
| | | | | | | | - Antonio Lavazza
- Virology Unit of IZSLER, Istituto Zooprofilattico Sperimentale della Lombardia e dell'Emilia- Romagna, Brescia, Italy
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10
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Kim CS, Kim B, Suh SH, Oh TR, Kim M, Choi HS, Bae EH, Ma SK, Han KD, Kim SW. Risk of Kidney Failure in Patients With Cancer: A South Korean Population-Based Cohort Study. Am J Kidney Dis 2021; 79:507-517.e1. [PMID: 34416352 DOI: 10.1053/j.ajkd.2021.06.024] [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: 08/12/2020] [Accepted: 06/09/2021] [Indexed: 12/24/2022]
Abstract
RATIONALE & OBJECTIVE Reduced kidney function is associated with an increased risk of cancer; however, it is unclear if cancer increases the risk of kidney failure with replacement therapy (KFRT). We assessed the risk of KFRT among patients with various types of cancer collectively and with specific types of cancer. STUDY DESIGN Retrospective population-based cohort study. SETTING & PARTICIPANTS A total of 2,473,095 participants with (n = 824,365) or without (n = 1,648,730) cancer registered in the Korean National Health Insurance Service database. PREDICTORS Cancer and cancer subtypes defined using International Classification of Diseases, 10th Revision, Clinical Modification, codes. OUTCOMES Primary outcome was KFRT defined as the initiation of hemodialysis or peritoneal dialysis or kidney transplantation. ANALYTICAL APPROACH For each patient with cancer, 2 controls matched for age, sex, estimated glomerular filtration rate, diabetes, and hypertension were included. To address the competing risk of death, a competing risk survival analysis was conducted using the Fine and Gray method. RESULTS Occurrence of KFRT was higher in patients with cancer than in controls without cancer (incidence rates of 1.07 vs 0.51 cases per 1,000 person-years). Competing risk analysis showed that cancer was significantly associated with an increased risk of KFRT after adjusting for other potential predictors (adjusted hazard ratio, 2.29 [95% CI, 2.20-2.39]). Multiple myeloma, leukemia, lymphoma, and kidney, ovarian, and liver cancer were most significantly associated with an increased KFRT risk, with multiple myeloma conferring the highest risk across age and sex groups. All subgroups of patients with cancer (based on age, sex, smoking, alcohol, exercise, obesity, and comorbid conditions) exhibited a higher risk of KFRT. LIMITATIONS Causal association between cancer and kidney outcomes could not be confirmed. CONCLUSIONS Patients with cancer, particularly those with multiple myeloma, exhibited an increased risk of KFRT after accounting for the competing risk of death.
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Affiliation(s)
- Chang Seong Kim
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Bongseong Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea
| | - Sang Heon Suh
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Tae Ryom Oh
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Minah Kim
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Hong Sang Choi
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Eun Hui Bae
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Seong Kwon Ma
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea.
| | - Soo Wan Kim
- Department of Internal Medicine, Chonnam National University Medical School and Chonnam National University Hospital, Gwangju, Korea.
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11
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Castellon C, Onkarappa Mangala Y, Perez Rodriguez A, Chaquette R, Meleveedu KS. First case report of tumor lysis syndrome and acute renal failure after selinexor use in multiple myeloma. Leuk Lymphoma 2021; 62:3536-3539. [PMID: 34369242 DOI: 10.1080/10428194.2021.1961230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Chrystina Castellon
- Department of Medicine, Division of Hematology/Oncology, Roger Williams Medical Center, Providence, RI, USA
| | - Yashvin Onkarappa Mangala
- Department of Medicine, Division of Hematology/Oncology, Roger Williams Medical Center, Providence, RI, USA
| | - Audrik Perez Rodriguez
- Department of Medicine, Division of Hematology/Oncology, Roger Williams Medical Center, Providence, RI, USA
| | - Raymond Chaquette
- Department of Medicine, Division of Hematology/Oncology, Roger Williams Medical Center, Providence, RI, USA
| | - Kapil S Meleveedu
- Department of Medicine, Division of Hematology/Oncology, Roger Williams Medical Center, Providence, RI, USA
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12
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Matthai SM, Alexander S, Jacob S, Duhli N, David VG, Varughese S. Crystals, crystals everywhere but not a clue till late… Light chain crystalline proximal tubulopathy with concomitant myeloma cast nephropathy. INDIAN J PATHOL MICR 2021; 63:463-466. [PMID: 32769341 DOI: 10.4103/ijpm.ijpm_756_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The renal diseases commonly associated with myeloma include primary amyloidosis, cast nephropathy, and light chain deposition disease. Less frequent forms of renal involvement encountered in the course of myeloma are crystalline and non-crystalline proximal tubulopathies, neoplastic plasma cell infiltration, and immunoglobulin crystallization in interstitial histiocytes and glomerular cells including podocytes. Light chain proximal tubulopathy (LCPT) caused by aggregation of non-crystalline and rarely crystalline deposits of monoclonal light chains in the cytoplasm of proximal tubular epithelial cells, accounts for less than 5% of monoclonal gammopathy-associated kidney diseases. We report the case of a 48-year-old Indian woman with multiple myeloma, who presented with acute kidney injury and nephrotic syndrome, in whom the renal biopsy revealed widespread crystalline inclusions in extraglomerular and glomerular compartments. We present illustrative light microscopic (LM) and diagnostic electron microscopic (EM) findings of this case which enabled a diagnosis of crystalline LCPT, crystal storing histiocytosis, and crystalline podocytopathy occurring synchronously with myeloma cast nephropathy. While documenting this unique juxtapositioning of multicompartmental paraproteinemic renal injury in multiple myeloma, diagnosed after EM analysis of the patient's renal biopsy, we discuss the pathogenetic pathways of this condition along with the clinical implications. Due to intrinsic structural properties of the crystals, they frequently escape detection by routine LM, necessitating EM analysis for their diagnosis. Given the prognostic implications of tubulopathies complicating myeloma, LCPT is a critically important diagnosis, highlighting the need for a comprehensive renal biopsy evaluation inclusive of EM for the practice of precision medicine in such scenarios.
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Affiliation(s)
- Smita Mary Matthai
- Department of Pathology, Central Electron Microscopy Facility, Wellcome Trust Research Laboratory, Christian Medical College, Vellore, Tamil Nadu, India
| | - Suceena Alexander
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Shibu Jacob
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Neelaveni Duhli
- Department of General Pathology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Vinoi George David
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India
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13
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Clinical Presentation, Renal Histopathological Findings, and Outcome in Patients with Monoclonal Gammopathy and Kidney Disease. Int J Nephrol 2021; 2021:8859340. [PMID: 34094600 PMCID: PMC8137312 DOI: 10.1155/2021/8859340] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 04/14/2021] [Accepted: 04/22/2021] [Indexed: 11/21/2022] Open
Abstract
Monoclonal gammopathies are associated with acute and chronic kidney injury. Nephrotoxicity of the secreted monoclonal (M)-protein is related to its biological properties and blood concentration. Little is known about epidemiology, clinical manifestations, and outcome of monoclonal gammopathies in patients with kidney disease. We retrospectively collected data about demographics, clinical manifestations, and renal histological lesions of all patients (n = 1334) who underwent kidney biopsy between January 2000 and March 2017. Monoclonal gammopathy was detected in 174 (13%) patients with a mean age of 66.4 ± 13.1 years. The spectrum of monoclonal gammopathies comprised monoclonal gammopathy of undetermined significate (MGUS) (52.8%), multiple myeloma (MM) (25.2%), primary amyloidosis (AL) (9.1%), smoldering MM (SMM) (4%), non-Hodgkin lymphoma (NHL) (6.8%), and Hodgkin lymphoma (HL) (1.7%). Monoclonal gammopathy of renal significance (MGRS) accounted for 6.5% in patients with MGUS and 14.2% in patients with SMM. Evaluation of kidney biopsy revealed that M-protein was directly involved in causing kidney injury in MM (93.1%). MM was the only gammopathy significantly associated with an increased risk of kidney injury (odds ratio [OR] = 47.5, CI 95%, 13.7–164.9; P ≤ 0.001). While there were no significant differences in the progression toward end-stage renal disease or dialysis (P = 0.776), monoclonal gammopathies were associated with a different risk of death (P = 0.047) at the end of the follow-up. In conclusion, monoclonal gammopathy was a frequent finding (13%) in patients who underwent kidney biopsy. M-protein was secreted by both premalignant (56.8%) and malignant (43.2%) lymphoproliferative clones. Kidney biopsy had a key role in identifying MGRS in patients with MGUS (6.5%) and SMM (14.2%). Among monoclonal gammopathies, only MM was significantly associated with biopsy-proven kidney injury. The rate of end-stage renal disease or dialysis was similar among monoclonal gammopathies, whereas NHL, MM, and SMM showed a higher rate of deaths.
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14
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Izekor BE, Kulkarni P, Powell PR, Hall J, Garland RC. Relapsing Multiple Myeloma Presenting as Cardiac Tamponade and Obstructive Uropathy. Cureus 2021; 13:e14503. [PMID: 34007756 PMCID: PMC8123921 DOI: 10.7759/cureus.14503] [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: 11/17/2022] Open
Abstract
Cardiac tamponade is a rare manifestation of relapsing extramedullary multiple myeloma and portends poor prognosis. No cases of cardiac tamponade with co-occurring renal obstruction from plasmacytoma have been reported in the literature, making this case a unique presentation of relapsing multiple myeloma. The presence of known malignancy should not limit our differential diagnosis when evaluating patients with signs of cardiac tamponade.
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Affiliation(s)
- Bright E Izekor
- Internal Medicine, Baylor Scott & White Medical Center - Temple, Temple, USA
| | - Pruthali Kulkarni
- Internal Medicine, Baylor Scott & White Medical Center - Temple, Temple, USA
| | | | - James Hall
- Hematology and Medical Oncology, Baylor Scott & White Medical Center - Temple, Temple, USA
| | - Rex C Garland
- Hematology and Medical Oncology, Baylor Scott & White Medical Center - Temple, Temple, USA
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Mohyuddin GR, Koehn K, Shune L, Aziz M, Abdallah AO, McClune B, Ganguly S, McGuirk J, Kambhampati S. Renal insufficiency in multiple myeloma: a systematic review and meta-analysis of all randomized trials from 2005-2019. Leuk Lymphoma 2021; 62:1386-1395. [PMID: 33416412 DOI: 10.1080/10428194.2020.1867725] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Clinical trials may be inconsistent in their enrollment and reporting of patients with multiple myeloma (MM) who have renal insufficiency (RI). We performed a systematic review of all MM randomized clinical trials (RCT) from 2005-2019 to evaluate reporting of prevalence, eligibility criteria and outcomes of patients with RI and MM. One-hundred and twenty-three RCTs were included. Only 30% of studies clearly reported on the proportion of patients who had RI. Only 68.2% reported eligibility criteria pertaining to RI, with no uniformity in the reported criteria. The relative risk (RR) of disease progression or death in patients with RI was higher than those without, RR of 1.20 (1.003-1.431) for relapsed/refractory and 1.07 (1.001-1.046) for newly diagnosed. There is inconsistent reporting and enrollment of patients with RI on MM RCT's. We advocate for higher enrollment of patients with RI and transparent reporting of their eligibility criteria and outcomes.
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Affiliation(s)
- Ghulam Rehman Mohyuddin
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Kelly Koehn
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Leyla Shune
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Muhammad Aziz
- Department of Medicine, University of Toledo, Toledo, OH, USA
| | - Al-Ola Abdallah
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Brian McClune
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Siddhartha Ganguly
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Joseph McGuirk
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, Kansas, USA
| | - Suman Kambhampati
- Department of Hematology and Oncology, Kansas City Veterans Affairs Medical Center, Kansas City, MO, USA
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16
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Yong ZH, Yu XJ, Lin ZS, Zhou FD, Cen XN, Wang SX, Zhao MH. Myeloma cast nephropathy with diffuse amyloid casts without systemic amyloidosis: two cases report. BMC Nephrol 2021; 22:6. [PMID: 33407225 PMCID: PMC7789149 DOI: 10.1186/s12882-020-02204-x] [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: 09/07/2020] [Accepted: 12/07/2020] [Indexed: 12/05/2022] Open
Abstract
Background Multiple myeloma (MM) is a plasma-cell derived hematologic malignant disease. The malignant proliferating plasma cells secrete massive monoclonal immunoglobulins which lead to various pathologic types of renal injury. Myeloma cast nephropathy (MCN) is the most common histopathologic lesion with the worst renal prognosis. Rarely, the free light chains in the protein casts can form amyloid fibrils. Here, we reported two rare cases of MCN with diffuse amyloid casts. Case presentation Case 1: A 54-year-old Chinese man presented with a 4-year history of multiple myeloma, proteinuria and hematuria. He had monoclonal IgAλ plus free λ spike in both serum and urine. He had been on chemotherapy for 4 years and maintained normal serum creatinine until 11 months ago. Then, his renal function deteriorated and he went on hemodialysis 4 months before admission. Renal biopsy showed diffuse amyloid casts in the tubular lumens, without any obvious amyloid deposits in other kidney compartments or signs of extra-renal amyloidosis. The amyloid fibrils formed around mononuclear cells which were CD68 negative. According to the morphology and location, these mononuclear cells were considered as tubular epithelial cells. The patient was maintained on chemotherapy and hemodialysis. He died 8 months after renal biopsy. Case 2: A 58-year-old Chinese man presented with a one-and-a-half-year history of proteinuria and slowly rising serum creatinine. He had monoclonal IgDλ spike in both serum and urine. Amyloid casts were observed in the tubular lumens and mononuclear cells could be identified in the center of some casts. There were no amyloid deposits in other kidney compartments and no sign of systemic amyloidosis. The patient also had fine granular deposits along the tubular basement membrane with λ linear staining along tubular basement membrane suggesting light chain deposition disease. He was treated with bortezomib-based chemotherapy followed by lenalidomide-based chemotherapy and achieved very good partial remission (VGPR). After 27 months of follow-up, the patient still showed no signs of systemic amyloidosis. Conclusions These 2 cases of MCN with diffuse amyloid casts have different histopathologic characteristics from the usual myeloma casts and tubular epithelial cells might play important roles in the pathogenesis.
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Affiliation(s)
- Zi-Hao Yong
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.,Peking University, Beijing, 100871, People's Republic of China.,Peking-Tsinghua Center for Life Sciences, Beijing, People's Republic of China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China. .,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China. .,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China. .,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China. .,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.
| | - Zi-Shan Lin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Fu-de Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China
| | - Xi-Nan Cen
- Department of Hematology, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.,Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, People's Republic of China.,Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, 100034, People's Republic of China.,Key laboratory of Renal Disease, Ministry of Health of China, Beijing, 100034, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, 100034, People's Republic of China.,Peking-Tsinghua Center for Life Sciences, Beijing, People's Republic of China
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17
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Tarragón B, Ye N, Gallagher M, Sen S, Portolés JM, Wang AY. Effect of high cut-off dialysis for acute kidney injury secondary to cast nephropathy in patients with multiple myeloma: a systematic review and meta-analysis. Clin Kidney J 2020; 14:1894-1900. [PMID: 34345412 PMCID: PMC8323139 DOI: 10.1093/ckj/sfaa220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 09/18/2020] [Indexed: 12/03/2022] Open
Abstract
Background Acute kidney injury (AKI) caused by cast nephropathy is associated with increased morbidity and mortality among patients with multiple myeloma (MM). High cut-off haemodialysis (HCO-HD) has proven to be effective in the removal of serum light chains but the effect on clinical outcomes, especially renal recovery, remains uncertain. Methods A systematic review and meta-analysis were performed examining all randomized controlled trials (RCTs) and observational studies (OBSs) assessing the effect of HCO-HD on clinical outcomes of patients with MM complicated by cast nephropathy–induced severe AKI. The primary outcome was all-cause mortality at the end of the study. The secondary outcomes included all-cause mortality at 12 months, HD independence and serum kappa and lambda light chain reduction. Pooled analysis was performed using random effects models. Results We identified five studies, comprising two RCTs and three retrospective cohort studies, including 276 patients with a mean follow-up of 18.7 months. The majority of the studies were of suboptimal quality and underpowered. Compared with patients treated with conventional HD, HCO-HD was not associated with a survival benefit at 12 months {five studies, 276 patients, relative risk [RR] 1.02 [95% confidence interval (CI) 0.76–1.35], I2 = 33.9%} or at the end of the studies at an average of 34 months [five studies, 276 patients, RR 1.32 (95% CI 0.71–2.45), I2 = 62.0%]. There was no difference in HD independence at 90 days [two trials, 78 patients, RR 2.23 (95% CI 1.09–4.55)], 6 months [two studies, 188 patients, RR 1.19 (95% CI 0.68–2.06)] or 12 months [two studies, 188 patients, RR 1.14 (95% CI 0.58–2.26)]. Patients receiving HCO dialysis, however, had a greater reduction in serum kappa [two studies, 188 patients, weighted mean difference (WMD) 46.7 (95% CI 38.6–54.7), I2 = 52.0%] and lambda [two studies, 188 patients, WMD 50.3 (95% CI 21.4–79.3), I2 = 95.1%] light chain levels. Conclusion Current evidence from RCTs and OBSs suggests HCO dialysis is able to reduce serum free light chains but makes no significant improvement in all-cause mortality and renal outcomes compared with conventional HD for patients with myeloma cast nephropathy. However, there is a trend towards better renal outcomes with the use of HCO dialysis. The lack of long-term data and the small sample sizes of the included studies limit this analysis. Therefore further large-scale RCTs with longer follow-up are needed to assess the effect of HCO dialysis on clinical outcomes in patients with myeloma cast nephropathy.
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Affiliation(s)
- Blanca Tarragón
- Department of Nephrology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.,Renal and Metabolic Division, George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Nan Ye
- Renal and Metabolic Division, George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,Division of Nephrology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Martin Gallagher
- Renal and Metabolic Division, George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia
| | - Shaundeep Sen
- Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia.,Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jose Maria Portolés
- Department of Nephrology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.,REDInREN Instituto Salud Carlos III 016/009/009, Public Health Research Network, Madrid, Spain
| | - Amanda Y Wang
- Renal and Metabolic Division, George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,Department of Renal Medicine, Concord Repatriation General Hospital, Concord, NSW, Australia.,Concord Clinical School, The University of Sydney, Sydney, NSW, Australia
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18
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Hazim AZ, Ruan GJ, Issa M. 57-Year-Old Woman With Fatigue and Dyspnea. Mayo Clin Proc 2020; 95:2755-2759. [PMID: 33276845 DOI: 10.1016/j.mayocp.2020.04.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/29/2020] [Accepted: 04/02/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Antonious Z Hazim
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Gordon J Ruan
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Meltiady Issa
- Advisor to residents and Consultant in Hospital Internal Medicine, Mayo Clinic, Rochester, MN.
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19
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Chopra R, Santana de Roberts R, Batal I, Batra S, Jim B. Light chain proximal tubulopathy with cast nephropathy in monoclonal gammopathy of renal significance. BMJ Case Rep 2020; 13:13/6/e234361. [PMID: 32595131 DOI: 10.1136/bcr-2020-234361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Kidney tubular disorders due to monoclonal immunoglobulin light chains are common manifestations of B-cell neoplasm. Cast nephropathy (CN) is the most frequent type of these disorders and may present with acute kidney injury (AKI) due to the presence of excess light chains in the distal tubules. Light chain proximal tubulopathy (LCPT) is an uncommon form of renal disease and may present as Fanconi syndrome due to proximal tubular cell damage by intracellular deposition of light chains. The concomitant disorder of both CN and LCPT is rare given the inherent differences in the biochemical properties of the immunoglobulin light chains of each disorder. We report a 64-year-old man who presented with AKI and Fanconi syndrome who was discovered to have both CN and LCPT due to the underlying disorder of monoclonal gammopathy of renal significance and who has responded favourably with conventional chemotherapy. We also review the existing literature on this interesting subject.
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Affiliation(s)
- Rebaika Chopra
- Medicine, James J Peters VA Medical Center, Bronx, New York, USA
| | | | - Ibrahim Batal
- Pathology, NewYork-Presbyterian Hospital, New York, New York, USA
| | - Sachin Batra
- Medicine, James J Peters VA Medical Center, Bronx, New York, USA
| | - Belinda Jim
- Medicine, Jacobi Medical Center, Bronx, New York, USA
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20
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Whole-exome sequencing in multiplex preeclampsia families identifies novel candidate susceptibility genes. J Hypertens 2020; 37:997-1011. [PMID: 30633125 DOI: 10.1097/hjh.0000000000002023] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Preeclampsia is a common and serious heritable disorder of human pregnancy. Although there have been notable successes in identification of maternal susceptibility genes a large proportion of the heritability of preeclampsia remains unaccounted for. It is has been postulated that rare variation may account for some of this missing heritability. In this study, we performed whole-exome sequencing (WES) in multiplex families to identify rare exonic risk variants. METHODS We conducted WES in 244 individuals from 34 Australian/New Zealand multiplex preeclampsia families. Variants were tested for association with preeclampsia using a threshold model and logistic regression. RESULTS We found significant association for two moderately rare missense variants, rs145743393 (Padj = 0.0032, minor allele frequency = 0.016) in the chromosome 1 open reading frame 35 (C1orf35) gene, and rs34270076 (Padj = 0.0128, minor allele frequency = 0.024) in the pyroglutamylated RFamide peptide receptor (QRFPR) gene. To replicate these associations we performed imputation in our Australian genome wide association scan for preeclampsia and found no significant exonic variants in either C1orf35 or QRFPR. However, 11 variants demonstrating nominal significance (P < 0.05) in the genomic region between QRFPR and annexin A5 (ANXA5) were identified. We further leveraged publicly available genome-wide available summary data from the UK Biobank to investigate association of these two variants with the underlying clinical phenotypes of preeclampsia and detected nominal association of the QRFPR variant (rs34270076, P = 0.03) with protein levels in females. CONCLUSION The study represents the first to use WES in multiplex families for preeclampsia and identifies two novel genes (QRFPR and C1orf35) not previously associated with preeclampsia and find nominal association of rs34270076 with protein levels, a key clinical feature of preeclampsia. We find further support for ANXA5 previously associated with pregnancy complications, including preeclampsia.
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21
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Cuddy SA, Falk RH. Amyloidosis as a Systemic Disease in Context. Can J Cardiol 2020; 36:396-407. [DOI: 10.1016/j.cjca.2019.12.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022] Open
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22
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Kogler W, Canha C, Makary R, Omman R, Isache CL. Multiple myeloma with extensive AL amyloidosis presenting as chronic diarrhoea. BMJ Case Rep 2020; 13:13/1/e232934. [PMID: 31919068 DOI: 10.1136/bcr-2019-232934] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
We present a 52-year-old man admitted to the hospital with diarrhoea and lower extremity weakness ongoing for the past 3 months. The patient was found to have malabsorptive diarrhoea, hypoproliferative anaemia and renal insufficiency with proteinuria. Extensive workup was performed including a bone marrow biopsy with 20% plasma cells, renal and duodenal biopsies with Congo-red staining revealed amyloid deposition. The patient was diagnosed with multiple myeloma and amyloidosis with gastrointestinal, kidney and nerve involvement explaining his presentation with diarrhoea, renal insufficiency and weakness. Throughout his admission, there were incidental findings of asymptomatic hypoglycaemia (serum blood glucose <40 mg/dL), which was later found to be caused by anti-insulin monoclonal antibodies produced by the neoplastic plasma cells. This is an extremely rare manifestation of multiple myeloma with only a few cases reported in the literature.
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Affiliation(s)
- William Kogler
- Internal Medicine, UF Health Jacksonville, Jacksonville, Florida, USA
| | - Catarina Canha
- Internal Medicine, UF Health Jacksonville, Jacksonville, Florida, USA
| | - Raafat Makary
- Pathology, University of Florida Health Science Center Jacksonville, Jacksonville, Florida, USA
| | - Reeba Omman
- Pathology, University of Florida Health Science Center Jacksonville, Jacksonville, Florida, USA
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23
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Cejalvo MJ, Legarda M, Abella E, Cabezudo E, Encinas C, García‐Feria A, Gironella M, Iñigo B, Martín J, Ribas P, Ruíz MÁ, González Y, Vicuña I, Ramírez Á, Fernández P, Rubia J. Single‐agent daratumumab in patients with relapsed and refractory multiple myeloma requiring dialysis: results of a Spanish retrospective, multicentre study. Br J Haematol 2019; 190:e289-e292. [DOI: 10.1111/bjh.16286] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- María J. Cejalvo
- Department of Hematology University Hospital Doctor Peset Valencia Spain
| | - Mario Legarda
- Department of Hematology University Hospital Doctor Peset Valencia Spain
| | - Eugenia Abella
- Department of Hematology Hospital del Mar Barcelona Spain
| | - Elena Cabezudo
- Department of Hematology Hospital Sant Joan de Déu Barcelona Spain
| | | | | | | | - Belén Iñigo
- Department of Hematology Hospital Clínico San Carlos Madrid Spain
| | - Jesús Martín
- Department of Hematology Hospital Virgen del Rocío Sevilla Spain
| | - Paz Ribas
- Department of Hematology University Hospital Doctor Peset Valencia Spain
| | - Mª Ángeles Ruíz
- Department of Hematology Hospital Francesc Borja Gandía Spain
| | - Yolanda González
- Department of Hematology Instituto Catalán de Oncología Girona Spain
| | - Isabel Vicuña
- Department of Hematology Hospital La Princesa Madrid Spain
| | - Ángel Ramírez
- Department of Hematology Hospital Central de Asturias Oviedo Spain
| | | | - Javier Rubia
- Department of Hematology University Hospital Doctor Peset Valencia Spain
- Internal Medicine School of Medicine and Dentistry Catholic University of Valencia Valencia Spain
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24
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Reiter T, Knafl D, Agis H, Mechtler K, Wagner L, Winnicki W. Structural analysis of urinary light chains and proteomic analysis of hyaline tubular casts in light chain associated kidney disorders. PeerJ 2019; 7:e7819. [PMID: 31592189 PMCID: PMC6778432 DOI: 10.7717/peerj.7819] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 09/03/2019] [Indexed: 11/20/2022] Open
Abstract
Background Monoclonal overproduction of kappa and/or lambda light chains might result in renal light chain deposition disease. Light chain associated cast nephropathy and renal AL-amyloidosis represent two further pathologies going along with monoclonal gammopathy of renal significance and multiple myeloma. While cast nephropathy often manifests with acute kidney injury, AL-amyloidosis is rather accompanied with chronic kidney disease. Methods Urine samples were collected from 17 patients with multiple myeloma or monoclonal gammopathy. The urine sediment was stained for cast morphology by H/E and light chain immunofluorescence. Following micro-selection of casts under microscope, proteomic analysis of casts was performed by mass spectrometry. Sucrose gradient sedimentation was employed and light chain architecture examined by immunoblotting. Uromodulin was measured by ELISA in sucrose gradient fractions. Results Urinary casts were observed of about 30 µm in diameter by H/E staining and under immunofluorescence microscopy. Casts with a diameter of 20 µm were observed as a novel variant. Proteome analysis showed that in addition to the expected light chain variants produced by the malignant clone of plasma cells, also histones such as H2B and cathepsin B were contained. Uromodulin was not detectable in urinary casts of all patients. All eleven patients with lambda light chains showed predominant dimerized light chains in the urine immunoblot. Six patients with kappa light chains presented with predominantly monomeric forms of light chains in the immunoblot. The densitometric evaluated ratio of lambda dimers vs. monomers was significantly higher (2.12 ± 0.75) when compared with the ratio of kappa dimers vs. monomers (0.64 ± 0.47), p = 0.00001. Aggregates of light chains separated in part into denser sucrose fractions. Conclusion This work on urinary casts and light chains demonstrates that hyaline tubular casts represent a complex formation of protein-protein aggregates with histones and cathepsin B identified as novel cast components. Apart from the proteomic composition of the casts, also the formation of the light chains and aggregates is of relevance. Dimerized light chains, which are typical for lambda paraproteins, might be less dialyzable than monomeric forms and may therefore identify patients less responsive to high cut-off dialysis.
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Affiliation(s)
- Thomas Reiter
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Daniela Knafl
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Hermine Agis
- Department of Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Karl Mechtler
- ProtChem Facility, IMP-IMBA, Research Institute of Molecular Pathology, Vienna, Austria
| | - Ludwig Wagner
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Winnicki
- Department of Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
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25
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Kumar P, Borz-Baba C, Raissi S. "D" is for Dilemma. Cureus 2019; 11:e5669. [PMID: 31720145 PMCID: PMC6823037 DOI: 10.7759/cureus.5669] [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: 11/05/2022] Open
Abstract
Immunoglobulin D (IgD) monoclonal gammopathy is a rare subtype of multiple myeloma (MM) associated with a worse prognosis compared with other variants of MM. A 61-year-old man with no known past medical history presented with complaints of abdominal pain, nausea, and vomiting for three weeks. Physical examination revealed mild epigastric tenderness. Laboratory data demonstrated a significantly elevated creatinine with minimal proteinuria and small abnormality in the gamma fraction. Ultrasound of the kidneys described normal-sized kidneys. Serum-free light chains and immunofixation were consistent with IgD kappa monoclonal gammopathy. Kidney biopsy revealed cast nephropathy. Bone marrow biopsy was remarkable for sheets of CD 38+ plasma cells comprising approximately 80% of the marrow cells. Recognizing the atypical presentation of IgD MM is crucial to facilitate early diagnosis and management and improve the prognosis of this subtype of MM.
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Affiliation(s)
- Pirkash Kumar
- Internal Medicine, Saint Mary's Hospital, Waterbury, USA
| | | | - Sina Raissi
- Medicine, Saint Mary's Hospital, Waterbury, USA
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26
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Kawamoto S, Hidaka Y, Kaneko Y, Misawa H, Nagahori K, Yoshino A, Okamura T, Ban S, Ueda Y, Takeda T. Remission of light chain proximal tubulopathy in IgG λ-type multiple myeloma by lenalidomide and dexamethasone therapy. CEN Case Rep 2019; 8:159-165. [PMID: 30721454 PMCID: PMC6620366 DOI: 10.1007/s13730-019-00382-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/24/2019] [Indexed: 01/18/2023] Open
Abstract
Light chain proximal tubulopathy is a rare manifestation of monoclonal gammopathy. A 73-year-old Japanese woman was noted to have urinary protein and hypertension on health examination and visited the regional clinic. She was noted to have IgG λ M protein and suspected of multiple myeloma. She was referred to us with massive proteinuria (7.5 g/g creatinine) and Bence Jones proteinuria without renal dysfunction. A renal biopsy revealed no glomerular abnormalities, but a tubular cast was observed partially in tubules without tubular atrophy or a crystalline structure. Direct Fast Scarlet staining was absent both in glomerulus and vascular wall. Immunofluorescence revealed λ light chain (LC) staining in the proximal tubules. Electron microscopy revealed nonspecific findings including increased lysosomes with irregular contours and mottled appearance. A bone marrow biopsy revealed plasma cell proliferation (35%) and multiple myeloma immunoglobulin G λ type. She showed progressive anemia and decrease of eGFR with elevated level of urinary β-2 microglobulin. She was treated with lenalidomide + dexamethasone (Ld). With Ld therapy, she achieved hematologic and nephrologic remission reducing the free LC, λ/κ ratio, urinary protein level, and urinary β-2 microglobulin level.
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Affiliation(s)
- Shinya Kawamoto
- Department of Nephrology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan.
| | - Yuji Hidaka
- Department of Nephrology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Yu Kaneko
- Department of Nephrology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Hideo Misawa
- Department of Nephrology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Katsuhiro Nagahori
- Department of Nephrology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Atsunori Yoshino
- Department of Nephrology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Takamitsu Okamura
- Department of Internal Medicine, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Shinichi Ban
- Department of Pathology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Yoshihiko Ueda
- Department of Pathology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan
| | - Tetsuro Takeda
- Department of Nephrology, Dokkyo Medical University Saitama Medical Center, 2-1-50 Minamikoshigaya, Koshigaya, Saitama, 343-8555, Japan
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Significance of urinary albumin excretion in patients with cast nephropathy
. Clin Nephrol 2019; 92:81-88. [PMID: 31232268 PMCID: PMC6637393 DOI: 10.5414/cn109630] [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] [Accepted: 07/12/2019] [Indexed: 11/18/2022] Open
Abstract
Background: This study was performed to determine whether the urinary albumin excretion rate (%UAE) could distinguish myeloma cast nephropathy (MCN) without glomerular amyloid deposition from MCN with glomerular amyloid deposition. Materials and methods: We retrospectively reviewed clinicopathological data on 16 patients with MCN diagnosed by renal biopsy at Toranomon Hospital from 2004 to 2014. Results: A total of 10 patients had pure MCN without glomerular amyloid deposition (group 1), and 6 patients had MCN with glomerular amyloid deposition (group 2). In all 10 patients from group 1, the underlying disease was multiple myeloma (MM), while 4 patients had MM, and 2 patients had lymphoplasmacytic lymphoma/Waldenström macroglobulinemia (LPL/WM) in group 2. Total protein did not show a significant difference between the two groups, but serum albumin was significantly higher in group 1 than group 2 (p = 0.0101). Serum-adjusted calcium did not show a significant difference between the groups, while serum creatinine (Cre) was significantly higher in group 1 than group 2 (p = 0.0343). Although urinary protein excretion did not differ significantly between the groups, the %UAE was significantly lower in group 1 than group 2 (p = 0.00198). In group 2, 3 of the 4 patients with MM died within 15 months of diagnosis, but the 2 patients with LPL/WM are alive after 32 months. In group 1, only 1 patient died (of unknown causes) within 15 months after diagnosis. Conclusion: In patients with MCN, %UAE may be a useful marker for the detection of coexistence of glomerular lesions, such as amyloidosis, which are associated with a poor outcome.
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Abstract
OBJECTIVES The relationship between mortality and pre-ESRD (end-stage renal disease) nephrology care in incident ESRD patients with multiple myeloma (MM) as the primary cause of renal failure has not been examined. MATERIALS AND METHODS Among 439,206 incident US hemodialysis patients with MM as the primary cause of ESRD (June 1, 2005 to May 31, 2009) identified using the US Renal Data System, adjusted odds ratios (OR) for reported pre-ESRD nephrology care for ESRD due to MM (n=4561) versus other causes (n=434,645) were calculated. The association of pre-ESRD nephrology care with subsequent mortality in MM-ESRD patients was examined. RESULTS MM-ESRD patients were less likely to have any predialysis nephrology care in the year before initiation of dialysis (34.8% vs. 58.5%; OR=0.38; 95% confidence interval [CI], 0.34-0.43) compared with patients with ESRD due to other causes. MM-ESRD patients compared with others were more likely to have catheters on first dialysis (91.8% vs. 75.6%; OR=4.15; 95% CI, 3.54-4.86). Incident MM-ESRD patients receiving predialysis care for ≥6 months had significantly lower 1-year mortality (hazard ratio 0.89; 95% CI, 0.82-0.97 and 0.88; 95% CI, 0.80-0.96, respectively), relative to those without this care. A catheter for dialysis access was associated with a 1.6-fold increase in 1-year mortality in incident MM-ESRD (hazard ratio 1.55; 95% CI, 1.32-1.83). CONCLUSIONS MM-ESRD patients were less likely to have predialysis nephrology care and more likely to use catheters on first dialysis. However, predialysis care is independently associated with lower mortality in MM-ESRD patients. Predialysis care should be prioritized in MM patients approaching ESRD.
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Shah S, Ibrahim M, Delaney M, Schey S, Bygrave C, Streetly M, Benjamin R. Risk of relapse of multiple myeloma following kidney transplantation. Clin Kidney J 2019; 12:216-223. [PMID: 30976399 PMCID: PMC6452174 DOI: 10.1093/ckj/sfy137] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/18/2018] [Indexed: 11/13/2022] Open
Abstract
Background Autologous stem cell transplantation (ASCT) and novel therapies have improved the prognosis for patients with multiple myeloma (MM). For those who undergo ASCT while on dialysis, a similar survival compared with the overall MM population has been reported. Therefore, for patients achieving remission following ASCT, kidney transplantation is an attractive option, offering an improved quality of life and significant economic advantage. Method This case series investigates the outcome of five patients who underwent an ASCT for MM with subsequent kidney transplantation between 2006 and 2012. Results Four patients presented with end-stage renal disease (ESRD) and one progressed to ESRD shortly after diagnosis. Induction chemotherapy regimens with novel agents including thalidomide and bortezomib were utilized. Following attainment of very good partial remission or complete remission, high-dose melphalan ASCTs were performed after a median of 10 months. Kidney transplantation (living donor n = 3, deceased donor n = 2) with tacrolimus-based immunosuppression regimens was completed at a median of 27 months after ASCT. Patients 1 and 3 experienced relapse of myeloma at 6 and 16 months after kidney transplantation. Patients 2, 4 and 5 remain alive at 55 months (median) after kidney transplantation with no evidence of relapse. Conclusion Forty percent of our cohort experienced a relapse in MM within 2 years of kidney transplantation. Death-censored graft survival and patient survival were 80% at 4 years. Our study adds to the growing literature supporting kidney transplantation following successful ASCT for MM and is useful when counselling patients regarding renal and haematological outcomes.
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Affiliation(s)
| | | | - Michael Delaney
- East Kent Hospital University NHS Foundation Trust, Kent, UK
| | - Steve Schey
- King's College Hospital NHS Trust, London, UK
| | - Ceri Bygrave
- Cardiff and Vale University Health Board, Cardiff, UK
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Shima H, Okamoto T, Tashiro M, Inoue T, Masaki C, Tada H, Takamatsu N, Kawahara K, Okada K, Doi T, Minakuchi J, Kawashima S. Alogliptin-Induced Minimal Change Nephrotic Syndrome and Interstitial Nephritis. Kidney Med 2019; 1:75-78. [PMID: 32734188 PMCID: PMC7380391 DOI: 10.1016/j.xkme.2019.03.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Alogliptin is one of the dipeptidyl peptidase-4 inhibitors used to treat patients with type 2 diabetes. Little is known about the nephrotoxicity associated with alogliptin, such as nephrotic syndrome or interstitial nephritis. We report a biopsy-proven rare case of minimal change nephrotic syndrome and interstitial nephritis induced by alogliptin. A 68-year-old man who had been prescribed alogliptin was hospitalized for nephrotic syndrome. On admission, serum creatinine level was elevated with increased urinary β2-microglobulin and N-acetyl-β-d-glucosaminidase excretion. Kidney biopsy revealed minor glomerular abnormalities and interstitial nephritis, and gallium-67 scintigraphy showed uptake in both kidneys. A drug lymphocyte stimulation test for alogliptin was positive. With discontinuation of alogliptin treatment alone, serum creatinine level normalized in parallel with urine β2-microglobulin and N-acetyl-β-d-glucosaminidase levels. In addition, complete remission of nephrotic syndrome was observed. Drug-induced dual pathology has not been previously reported with alogliptin. In summary, clinicians should keep in mind that alogliptin can induce minimal change nephrotic syndrome and interstitial nephritis.
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Affiliation(s)
- Hisato Shima
- Department of Kidney Disease, Kawashima Hospital, Tokushima
| | | | - Manabu Tashiro
- Department of Kidney Disease, Kawashima Hospital, Tokushima
| | - Tomoko Inoue
- Department of Kidney Disease, Kawashima Hospital, Tokushima
| | - Chiaki Masaki
- Department of Laboratory, Kawashima Hospital, Tokushima
| | - Hiroaki Tada
- Department of Laboratory, Kawashima Hospital, Tokushima
| | | | | | | | - Toshio Doi
- Department of Kidney Disease, Kawashima Hospital, Tokushima
| | - Jun Minakuchi
- Department of Kidney Disease, Kawashima Hospital, Tokushima
| | - Shu Kawashima
- Department of Kidney Disease, Kawashima Hospital, Tokushima
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Donati G, Zappulo F, Croci Chiocchini AL, Comai G, Zamagni E, La Manna G. Early use of PEPA dialyzer for light chains removal and for the recovery from myeloma cast nephropathy: A case report. Hemodial Int 2019; 23:E97-E99. [PMID: 30791209 DOI: 10.1111/hdi.12733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 11/30/2022]
Abstract
Chemotherapy and extracorporeal treatment reduce serum free light chains (FLCs) allowing the recovery of acute kidney injury (AKI) caused by myeloma cast nephropathy (MCN). We report the first case of recovery from AKI in a patient with MCN who underwent the removal of FLCs using the PEPA filter, with an undisclosed cut-off, combined with chemotherapy for multiple myeloma (MM).
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Affiliation(s)
- Gabriele Donati
- Nephrology Dialysis and Renal Transplantation Unit, L. & A. Seràgnoli, S.Orsola University Hospital, Bologna, Italy
| | - Fulvia Zappulo
- Nephrology Dialysis and Renal Transplantation Unit, L. & A. Seràgnoli, S.Orsola University Hospital, Bologna, Italy
| | - Anna Laura Croci Chiocchini
- Nephrology Dialysis and Renal Transplantation Unit, L. & A. Seràgnoli, S.Orsola University Hospital, Bologna, Italy
| | - Giorgia Comai
- Nephrology Dialysis and Renal Transplantation Unit, L. & A. Seràgnoli, S.Orsola University Hospital, Bologna, Italy
| | - Elena Zamagni
- Hematology and Oncology Unit, L. & A. Seràgnoli, S.Orsola University Hospital, Bologna, Italy
| | - Gaetano La Manna
- Nephrology Dialysis and Renal Transplantation Unit, L. & A. Seràgnoli, S.Orsola University Hospital, Bologna, Italy
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32
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Walk JC, Ayati BP, Holstein SA. Modeling the Effects of Multiple Myeloma on Kidney Function. Sci Rep 2019; 9:1726. [PMID: 30741957 PMCID: PMC6370764 DOI: 10.1038/s41598-018-38129-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 12/11/2018] [Indexed: 12/13/2022] Open
Abstract
Multiple myeloma (MM), a plasma cell cancer, is associated with many health challenges, including damage to the kidney by tubulointerstitial fibrosis. We develop a mathematical model which captures the qualitative behavior of the cell and protein populations involved. Specifically, we model the interaction between cells in the proximal tubule of the kidney, free light chains, renal fibroblasts, and myeloma cells. We analyze the model for steady-state solutions to find a mathematically and biologically relevant stable steady-state solution. This foundational model provides a representation of dynamics between key populations in tubulointerstitial fibrosis that demonstrates how these populations interact to affect patient prognosis in patients with MM and renal impairment.
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Affiliation(s)
- Julia C Walk
- Concordia College, Department of Mathematics, Moorhead, 56562, USA.
| | - Bruce P Ayati
- University of Iowa, Department of Mathematics, Iowa City, 52242, USA.,University of Iowa, Program in Applied Mathematical and Computational Sciences, Iowa City, 52242, USA.,University of Iowa, Department of Orthopaedics and Rehabilitation, Iowa City, 52242, USA
| | - Sarah A Holstein
- University of Nebraska Medical Center, Division of Oncology & Hematology, Omaha, 68198, USA
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33
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Antlanger M, Dust T, Reiter T, Böhm A, Lamm WW, Gornicec M, Willenbacher E, Nachbaur D, Weger R, Rabitsch W, Rasoul-Rockenschaub S, Worel N, Lechner D, Greinix H, Keil F, Gisslinger H, Agis H, Krauth MT. Impact of renal impairment on outcomes after autologous stem cell transplantation in multiple myeloma: a multi-center, retrospective cohort study. BMC Cancer 2018; 18:1008. [PMID: 30342509 PMCID: PMC6195957 DOI: 10.1186/s12885-018-4926-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 10/10/2018] [Indexed: 11/10/2022] Open
Abstract
Background Renal impairment (RI) is a negative prognostic factor in Multiple Myeloma (MM) and affected patients are often excluded from autologous stem cell transplantation (ASCT). However, it remains unclear whether historically inferior outcome data still hold true. Methods From a total of 475 eligible MM patients who had undergone ASCT between 1998 and 2016, 374 were included in this multi-centric retrospective cohort study. Renal function was determined both at the time of MM diagnosis and ASCT by estimated glomerular filtration rate (eGFR according to the MDRD formula, RI defined as eGFR < 60 ml/min/1.73m2). Patients were categorized into 3 groups: A) no RI diagnosis and ASCT, B) RI at diagnosis with normalization before ASCT and C) RI both at the time of diagnosis and ASCT. Log-rank testing was used for overall and progression-free survival (OS, PFS) analysis. Conclusion While severe RI at MM diagnosis confers a risk of shorter OS, MM progression after ASCT is not affected by any stage of renal failure. It can be concluded that ASCT can be safely carried out in MM patients with mild to moderate RI and should be pro-actively considered in those with severe RI. Results When comparing all groups, no difference in OS and PFS was found (p = 0.319 and p = 0.904). After further stratification according to the degree of RI at the time of diagnosis, an OS disadvantage was detected for patients with an eGFR < 45 ml/min/m2. PFS was not affected by any RI stage. Electronic supplementary material The online version of this article (10.1186/s12885-018-4926-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marlies Antlanger
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Tobias Dust
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiter
- Department of Internal Medicine III, Division of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Alexandra Böhm
- Hanusch Hospital, 3rd Medical Department, Division of Hematology and Oncology, Vienna, Austria.,Elisabethinen Hospital, Department of Internal Medicine I, Division of Hematology and Oncology, Linz, Austria
| | - Wolfgang W Lamm
- Department of Internal Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Max Gornicec
- Department of Internal Medicine, Division of Hematology, Medical University of Graz, Graz, Austria
| | - Ella Willenbacher
- Medical University of Innsbruck, Internal Medicine V, Hematology and Oncology, Innsbruck, Austria
| | - David Nachbaur
- Medical University of Innsbruck, Internal Medicine V, Hematology and Oncology, Innsbruck, Austria
| | - Roman Weger
- Medical University of Innsbruck, Internal Medicine V, Hematology and Oncology, Innsbruck, Austria
| | - Werner Rabitsch
- Department of Internal Medicine I, Bone Marrow Transplantation Unit, Medical University of Vienna, Vienna, Austria
| | - Susanne Rasoul-Rockenschaub
- Medical University of Vienna, Center for Medical Statistics, Informatics and Intelligent Systems (CeMSIIS), Vienna, Austria
| | - Nina Worel
- Department of Blood Group Serology and Transfusion Medicine, Medical University of Vienna, Vienna, Austria
| | - Daniel Lechner
- Elisabethinen Hospital, Department of Internal Medicine I, Division of Hematology and Oncology, Linz, Austria
| | - Hildegard Greinix
- Department of Internal Medicine, Division of Hematology, Medical University of Graz, Graz, Austria
| | - Felix Keil
- Hanusch Hospital, 3rd Medical Department, Division of Hematology and Oncology, Vienna, Austria
| | - Heinz Gisslinger
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | - Hermine Agis
- Department of Internal Medicine I, Division of Oncology, Medical University of Vienna, Vienna, Austria
| | - Maria-Theresa Krauth
- Department of Internal Medicine I, Division of Hematology and Hemostaseology, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
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Abstract
PURPOSE OF REVIEW Myeloma kidney and amyloid light-chain (AL) amyloidosis remain the principal kidney complications of paraproteins. In this review, we update readers to many of the recent advances which have occurred in the care and outcomes for patients with these presentations. RECENT FINDINGS Myeloma kidney has historically caused a severe acute kidney injury with very poor outcomes. The combination of new diagnostic techniques, enabling a rapid diagnosis and novel chemotherapy agents has transformed these poor outcomes for the better. Two multicentre randomized controlled trials have recently evaluated if the removal of free light chains by high cut-off haemodialysis improves renal outcomes beyond effective chemotherapy alone. Although we await the full articles of these studies to be published, abstracts suggested the studies will have contradictory primary results. In the field of AL amyloidosis, there are now novel criteria for the risk stratification of kidney outcomes which can be used in combination with markers of early kidney response to provide clinicians with powerful tools to guide patient discussions. SUMMARY Across both AL amyloidosis and myeloma kidney patient outcomes continue to improve. Principally this improvement has been driven by the continuing development of novel chemotherapy agents in this field.
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35
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Timchenko MA, Timchenko AA. Influence of a Single Point Mutation in the Constant Domain of the Bence-Jones Protein bif on Its Aggregation Properties. BIOCHEMISTRY. BIOKHIMIIA 2018; 83:107-118. [PMID: 29618297 DOI: 10.1134/s0006297918020037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Multiple myeloma nephropathy occurs due to the aggregate formation by monoclonal immunoglobulin light chains (Bence-Jones proteins) in kidneys of patients with multiple myeloma. The mechanism of amyloid deposit formation is still unclear. Earlier, the key role in the fibril formation has been assigned to the variable domains that acquired amyloidogenic properties as a result of somatic mutations. However, fibril formation by the Bence-Jones protein BIF was found to be the function of its constant domain. The substitution of Ser177 by Asn in the constant domain of the BIF protein is most likely an inherited than a somatic mutation. To study the role of this mutation in amyloidogenesis, the recombinant Bence-Jones protein BIF and its mutant with the N177S substitution typical for the known immunoglobulin Cκ allotypes Km1, Km1,2, and Km3 were isolated. The morphology of aggregates formed by the recombinant proteins under conditions similar to those occurring during the protein transport in bloodstream and its filtration into the renal glomerulus, in the distal tubules, and in the proximal renal tubules was analyzed by atomic force microscopy. The nature of the aggregates formed by BIF and its N177S mutant during incubation for 14 days at 37°C strongly differed and depended on both pH and the presence of a reducing agent. BIF formed fibrils at pH 7.2, 6.5, and 10.1, while the N177S mutant formed fibrils only at alkaline pH 10.1. The refolding of both proteins in the presence of 5 mM dithiothreitol resulted in the formation of branched structures.
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Affiliation(s)
- M A Timchenko
- Institute of Theoretical and Experimental Biophysics, Russian Academy of Sciences, Pushchino, Moscow Region, 142290, Russia.
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36
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Sirac C, Herrera GA, Sanders PW, Batuman V, Bender S, Ayala MV, Javaugue V, Teng J, Turbat-Herrera EA, Cogné M, Touchard G, Leung N, Bridoux F. Animal models of monoclonal immunoglobulin-related renal diseases. Nat Rev Nephrol 2018; 14:246-264. [DOI: 10.1038/nrneph.2018.8] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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A case of tumor lysis syndrome and acute renal failure associated with elotuzumab treatment in multiple myeloma. Clin Nephrol Case Stud 2017; 5:78-81. [PMID: 29318105 PMCID: PMC5715206 DOI: 10.5414/cncs109165] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 09/05/2017] [Indexed: 11/18/2022] Open
Abstract
Renal dysfunction is a common comorbidity of multiple myeloma. However, tumor lysis syndrome is a rare cause of renal dysfunction in multiple myeloma. Elotuzumab is a newly US FDA-approved monoclonal antibody used in the treatment of refractory multiple myeloma. To our knowledge, elotuzumab has not been associated with a case of tumor lysis syndrome. We present the case of a patient who developed clinical tumor lysis syndrome 1 week after treatment with elotuzumab accompanied by renal failure with hyperphosphatemia, hyperkalemia, and profound hyperuricemia. His course was further complicated by significant epistaxis from the accumulation of dabigatran in acute renal failure. In spite of treatment with rasburicase and hemodiafiltration, the patient decompensated and eventually died. Risk factors for the development of tumor lysis syndrome in multiple myeloma are discussed.
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Gastelum ZN, Biggs DM, Scott A. Multiple Myeloma Presenting as Acute Renal Failure in the Absence of Other Characteristic Features. Cureus 2017; 9:e1703. [PMID: 29159010 PMCID: PMC5690288 DOI: 10.7759/cureus.1703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This case report describes a 54-year-old, asymptomatic man who presented with hyperkalemia on routine lab testing who was later found to have acute renal failure, unresponsive to fluid resuscitation, with minimal improvement after hemodialysis. After a comprehensive evaluation ruled out common causes of acute renal failure, the patient underwent testing with a bone survey, urine protein electrophoresis (UPEP), serum protein electrophoresis (SPEP), and immunoelectrophoresis for suspected plasma cell dyscrasia and received plasmapheresis for hyperviscosity syndrome and nephrotoxicity, which resulted in improved renal function. Lab results showed monoclonal gammopathy, elevated serum free light chains, and Bence Jones protein in the urine with a follow-up bone marrow biopsy indicating plasma cell dyscrasia. The patient received a diagnosis of multiple myeloma (MM) and was started on chemotherapy and immunosuppression. In patients presenting with acute renal failure with an evaluation ruling out prerenal and postrenal causes, multiple myeloma should be considered.
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Affiliation(s)
| | | | - Aaron Scott
- Hematology and Oncology, University of Arizona Cancer Center
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39
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Rekhtina IG, Mendeleeva LP, Biderman BV, Solovyev MV, Sudarikov AB. [Uromodulin gene polymorphisms in patients with cast nephropathy in multiple myeloma]. TERAPEVT ARKH 2017; 89:68-71. [PMID: 28914853 DOI: 10.17116/terarkh201789868-71] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AIM To investigate the nature of mutations in exons 4 and 5 of the uromodulin (UM) gene, including in the area encoding the domain of 8 cysteines (D8C), in patients with multiple myeloma (MM) with the secretion of monoclonal light chains (LC) in cast nephropathy (CN) and without kidney injury. SUBJECTS AND METHODS The investigation enrolled 24 patients in MM remission, who were observed to have monoclonal LC secretion at onset. Group 1 included 14 patients with CN; Group 2 consisted of 10 patients with normal renal function (a comparison group). The compared groups did not differ in the number of serum and urinary monoclonal LCs. Genomic DNA was extracted from the peripheral blood samples of patients. The nucleotide sequence of exons 4 and 5 of the UM gene was determined by the Sanger method. RESULTS No differences were found in the frequency of polymorphisms depending on the severity of kidney injury. The missense mutation p.142R>R/Q in the UM gene, which had not been previously described, was discovered. CONCLUSION The patients with MM were not found to have statistically significant differences in the frequency and nature of polymorphisms of exons 4 and 5 in the UM gene, including in the area encoding D8C, in CN without kidney injury.
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Affiliation(s)
- I G Rekhtina
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - L P Mendeleeva
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - B V Biderman
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - M V Solovyev
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - A B Sudarikov
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
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Gameiro J, Jorge S, Lopes JA. Renal Involvement in Multiple Myeloma. EUROPEAN MEDICAL JOURNAL 2017. [DOI: 10.33590/emj/10312017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Multiple myeloma (MM) is a plasma cell disorder that represents almost 10% of haematologic malignancies. Renal impairment, one of the most common complications of MM that occurs in 20–50% of patients, can present in a variety of forms and is associated with increased mortality. Myeloma cast nephropathy is the most common cause of kidney disease in MM patients, presenting as acute kidney injury in the majority of patients. The recent introduction of new chemotherapy agents, autologous stem cell transplantation, and the development of novel techniques of light chain removal have been associated with improved renal and patient outcomes in MM patients. Nevertheless, dialysis-dependent patients with MM have higher mortality than other dialysis patients and may be considered for kidney transplantation only if sustained remission has been achieved and sustained for at least 3 years, bearing in mind the risk of disease recurrence.
The authors review the most frequent renal manifestations associated with MM, namely myeloma cast nephropathy, light-chain amyloidosis, and monoclonal immunoglobulin deposition disease, focussing on the therapeutic options for acute and chronic kidney disease.
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Affiliation(s)
- Joana Gameiro
- Service of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - Sofia Jorge
- Service of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
| | - José António Lopes
- Service of Nephrology and Renal Transplantation, Department of Medicine, Centro Hospitalar Lisboa Norte, Lisbon, Portugal
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Gameiro J, Jorge S, Lopes JA, da Costa AG. Pulmonary-renal syndrome as a clinical expression of multiple myeloma. Nefrologia 2017; 37:445-446. [DOI: 10.1016/j.nefro.2016.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/25/2016] [Accepted: 10/26/2016] [Indexed: 10/20/2022] Open
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Le TX, Wolf JL, Peralta CA, Webber AB. Kidney Transplantation for Kidney Failure Due to Multiple Myeloma: Case Reports. Am J Kidney Dis 2017; 69:858-862. [DOI: 10.1053/j.ajkd.2016.12.023] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 12/26/2016] [Indexed: 01/21/2023]
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Zhao P, Chen Y, Yue Z, Yuan Y, Wang X. Bone marrow mesenchymal stem cells regulate stemness of multiple myeloma cell lines via BTK signaling pathway. Leuk Res 2017; 57:20-26. [PMID: 28273548 DOI: 10.1016/j.leukres.2017.02.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 02/18/2017] [Accepted: 02/22/2017] [Indexed: 01/10/2023]
Abstract
Bone marrow mesenchymal stem cells (BM-MSCs) are key components of bone marrow microenvironment. Although the importances of BM-MSCs activation in myeloma cells growth, development, progression, angiogenesis are well known, their role in the regulation of myeloma stemness is unclear. In this study, myeloma cell lines (LP-1, U266) were co-cultured with BM-MSCs, we found that BM-MSCs could up-regulate the expression of key stemness genes and proteins (OCT4, SOX2, NANOG) and increase clonogenicity. Similarly, the mechanisms underlying the BM-MSC activation of myeloma stemness remain unclear. Here, we found that PCI-32765, a Bruton tyrosine kinase (BTK) inhibitor, treatment significantly down- regulate expression of key stemness genes and proteins in vitro co-culture system. Together, our results revealed that BM-MSCs could increase myeloma stemness via activation of the BTK signal pathway.
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Affiliation(s)
- Pan Zhao
- Department of Hematology and Blood and Marrow Transplantation, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Yafang Chen
- Department of Hematology and Blood and Marrow Transplantation, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Zhijie Yue
- Department of Hematology and Blood and Marrow Transplantation, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Ying Yuan
- Department of Hematology and Blood and Marrow Transplantation, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China
| | - Xiaofang Wang
- Department of Hematology and Blood and Marrow Transplantation, Tianjin Medical University Cancer Institute and Hospital, National Clinical Research Center for Cancer, Tianjin Key Laboratory of Cancer Prevention and Therapy, Tianjin's Clinical Research Center for Cancer, Tianjin, China.
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44
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de Vries JC, Oortgiesen B, Hemmelder MH, van Roon E, Kibbelaar RE, Veeger N, Hoogendoorn M. Restoration of renal function in patients with newly diagnosed multiple myeloma is not associated with improved survival: a population-based study. Leuk Lymphoma 2017; 58:1-9. [DOI: 10.1080/10428194.2016.1277385] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Joost C. de Vries
- Department of Hematology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Berdien Oortgiesen
- Department of Clinical Pharmacy & Pharmacology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Marc H. Hemmelder
- Department of Nephrology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | - Eric van Roon
- Department of Clinical Pharmacy & Pharmacology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Robby E. Kibbelaar
- Department of Pathology, Pathology Friesland, Leeuwarden, The Netherlands
| | - Nic Veeger
- Department of Epidemiology, MCL Academy, Leeuwarden, The Netherlands
| | - Mels Hoogendoorn
- Department of Hematology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
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Kurien AA, Fernando ME. Amyloid Proximal Tubulopathy and Amyloid Casts: An Unusual Finding in Multiple Myeloma. Indian J Nephrol 2017; 28:160-163. [PMID: 29861568 PMCID: PMC5952456 DOI: 10.4103/ijn.ijn_297_16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patients with multiple myeloma (MM) often develop renal manifestations. The majority of cases present as cast nephropathy, amyloid light-chain (AL) amyloidosis, and monoclonal immunoglobulin deposition disease. AL amyloidosis usually involves the glomeruli, blood vessels, and interstitium. It is extremely uncommon to find isolated intratubular deposition of AL amyloid. Our patient presented with rapid worsening of renal function due to isolated intratubular deposition of AL amyloid, where the biopsy revealed amyloid proximal tubulopathy and amyloid cast nephropathy. Our case provides new insights into the complicated pathophysiology of the abnormal light chains in MM. This case is, to our knowledge, the second case of amyloid proximal tubulopathy reported in literature.
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Affiliation(s)
- A A Kurien
- Department of Pathology, Renopath Center for Renal and Urological Pathology, Chennai, Tamil Nadu, India
| | - M E Fernando
- Department of Nephrology, Government Stanley Medical College, Chennai, Tamil Nadu, India
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Lee EJ, Lee SY, Park SY, Kim Y, Choi JS, Kim MJ, Park JH, Lee JE, Kwon GY, Kim YG. Crystalline podocytopathy and tubulopathy without overt glomerular proteinuria in a patient with multiple myeloma. Kidney Res Clin Pract 2016; 35:259-262. [PMID: 27957423 PMCID: PMC5142260 DOI: 10.1016/j.krcp.2016.06.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 05/31/2016] [Accepted: 06/02/2016] [Indexed: 12/18/2022] Open
Abstract
Crystalline nephropathy is a rare yet well-known condition associated with multiple myeloma and other light chain–secreting disorders. Paraproteins that are resistant to proteolysis crystallize within proximal tubular cells and cause light-chain proximal tubulopathy, which presents clinically as Fanconi syndrome. Podocytes are rarely affected, and the crystalline inclusions within podocytes are typically precipitated, yielding significant glomerular proteinuria. Here we report a case of extensive crystalline inclusions primarily within podocytes and proximal tubules that presented only with Fanconi syndrome and renal insufficiency. Despite the presence of extensive crystalline inclusions in podocytes and diffuse foot process effacement, the patient had no clinical evidence suggestive of podocyte injury.
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Affiliation(s)
- Eun Jeong Lee
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Su Yeon Lee
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - So Young Park
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yonjin Kim
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Shin Choi
- Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Mi Jeoung Kim
- Graduate School of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ji Hyeon Park
- Department of Nephrology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea; Department of Medicine, National Police Hospital, Seoul, Korea
| | - Jung Eun Lee
- Department of Nephrology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Ghee Young Kwon
- Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yoon-Goo Kim
- Department of Nephrology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Finkel KW, Cohen EP, Shirali A, Abudayyeh A. Paraprotein-Related Kidney Disease: Evaluation and Treatment of Myeloma Cast Nephropathy. Clin J Am Soc Nephrol 2016; 11:2273-2279. [PMID: 27526708 PMCID: PMC5142056 DOI: 10.2215/cjn.01640216] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Nearly 50% of patients with multiple myeloma develop renal disease, most commonly from AKI caused by cast nephropathy. Development of AKI is associated with poor 1-year survival and reduces the therapeutic options available to patients. There is a great need for more effective therapies. Cast nephropathy is caused by the interaction and aggregation of filtered free light chains and Tamm-Horsfall protein causing intratubular obstruction and damage. The key to treating cast nephropathy is rapid lowering of free light chains, because this correlates with renal recovery. Newer chemotherapy agents rapidly lower free light chains and have been referred to as renoprotective. There is additional great interest in using extracorporeal therapies to remove serum free light chains. Small trials initially showed benefit of therapeutic plasma exchange to improve renal outcomes in cast nephropathy, but a large randomized trial of therapeutic plasma exchange failed to show benefit. A newer technique is extended high-cutoff hemodialysis. This modality uses a high molecular weight cutoff filter to remove free light chains. To date, trials of high-cutoff hemodialysis use in patients with cast nephropathy have been encouraging. However, there are no randomized trials showing the benefit of high-cutoff hemodialysis when used in addition to newer chemotherapeutic regimens. Until these studies are available, high-cutoff hemodialysis cannot be recommended as standard of care.
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Affiliation(s)
- Kevin W. Finkel
- Department of Medicine, Division of Renal Diseases and Hypertension, University of Texas Health Science Center at Houston McGovern Medical School, Houston, Texas
- Department of General Internal Medicine, Nephrology Section, University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Eric P. Cohen
- Nephrology Section, Baltimore Veterans Affairs Medical Center, University of Maryland School of Medicine, Baltimore, Maryland; and
| | - Anushree Shirali
- Department of Medicine, Section of Nephrology, Yale University Medical School, New Haven, Connecticut
| | - Ala Abudayyeh
- Department of General Internal Medicine, Nephrology Section, University of Texas MD Anderson Cancer Center, Houston, Texas
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Gallan AJ, Khalighi MA. Lambda Light Chain Crystalline Cast Nephropathy and Proximal Tubulopathy. Kidney Int Rep 2016; 1:316-320. [PMID: 29142933 PMCID: PMC5678630 DOI: 10.1016/j.ekir.2016.08.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Abstract
Cast nephropathy is the most common manifestation of renal injury in patients with multiple myeloma but is rarely reported in other conditions. We are reporting our experience in caring for a teenager with a metastatic neuroendocrine carcinoma who developed rapidly progressive kidney injury that advanced to end-stage renal disease. On renal biopsy extensive tubular necrosis and intratubular eosinophilic casts were noted. This previously unreported finding should prompt oncologists to closely monitor for such a complication in patients with secretory tumors. Whether early plasmapheresis could be of benefit, as has been tried in multiple myeloma, remains to be determined.
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50
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Pharmacokinetics, safety, and efficacy of lenalidomide plus dexamethasone in patients with multiple myeloma and renal impairment. Cancer Chemother Pharmacol 2016; 78:173-82. [PMID: 27286995 DOI: 10.1007/s00280-016-3068-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 05/31/2016] [Indexed: 10/21/2022]
Abstract
PURPOSE Renal impairment (RI) is a common comorbidity in multiple myeloma (MM). Current dose adjustments recommended for renally excreted lenalidomide are based on data from noncancer patients. This study evaluated the pharmacokinetics, safety, efficacy, and exposure-response for lenalidomide plus dexamethasone in patients with relapsed/refractory MM and stable RI using the recommended dose adjustments. METHODS This phase 2 multicenter, open-label study stratified patients into 5 groups based on creatinine clearance (CrCl) calculated by Cockcroft-Gault equation: normal renal function (CrCl > 80 mL/min), mild RI (50 ≤ CrCl ≤ 80 mL/min), moderate RI (30 ≤ CrCl < 50 mL/min), severe RI (CrCl < 30 mL/min), and end-stage renal disease requiring hemodialysis. Dosing was based on the lenalidomide label. RESULTS Among 38 patients, the median age was 68 (range 62-74) years, and poorer renal function was associated with older age, more advanced disease, and more lines of prior therapy. Lenalidomide clearance declined with decreased CrCl. Mean lenalidomide area under plasma concentration-time curve (AUC) was within ±25 % of the target AUC in each group. Overall response was 76 %, and safety profiles were similar across groups, with no exposure-dependent trend in efficacy or toxicity. Estimated glomerular filtration rates calculated using the simplified Modification of Diet in Renal Disease equation highly correlated with lenalidomide clearance and, in 87 % of patients, would lead to assigning the same starting dose of lenalidomide as CrCl. CONCLUSIONS In patients with stable renal function, the recommended dose adjustments achieved proper plasma exposure and similar safety and efficacy across renal groups.
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