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Park K, Kwon SH. Monoclonal gammopathy of renal significance from the perspective of nephrologists. Blood Res 2024; 59:28. [PMID: 39133392 PMCID: PMC11319560 DOI: 10.1007/s44313-024-00027-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Accepted: 07/04/2024] [Indexed: 08/13/2024] Open
Abstract
Kidney disease is a frequent complication of multiple myeloma and other malignancies associated with monoclonal gammopathies. Additionally, dysproteinemia-related kidney disease can occur independently of overt multiple myeloma or hematologic malignancies. Monoclonal gammopathy of renal significance (MGRS) is a spectrum of disorders in which a monoclonal immunoglobulin produced by a benign or premalignant B-cell or plasma cell clone causes kidney damage. MGRS-associated renal disease manifests in various forms, including immunoglobulin-associated amyloidosis, monoclonal immunoglobulin deposition diseases (light chain, heavy chain, and combined light and heavy chain deposition diseases), proliferative glomerulonephritis with monoclonal immunoglobulin deposits, C3 glomerulopathy with monoclonal gammopathy, and light chain proximal tubulopathy. Although MGRS is a nonmalignant or premalignant hematologic condition, it has significant renal implications that often lead to progressive kidney damage and, eventually, end-stage kidney disease. This review discusses the epidemiology, pathogenesis, and management of MGRS and focuses on the perspective of nephrologists.
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Affiliation(s)
- Kootae Park
- Division of Nephrology, Hyonam Kidney Laboratory, Soonchunhyang University Hospital, 59 Daesagwan-Ro, Yongsan-Gu, Seoul, South Korea
| | - Soon Hyo Kwon
- Division of Nephrology, Hyonam Kidney Laboratory, Soonchunhyang University Hospital, 59 Daesagwan-Ro, Yongsan-Gu, Seoul, South Korea.
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2
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Xu Q, Chen G, Wen Y, Shi X, Ye W, Qin Y, Li X. Acquired Fanconi syndrome in mixed cryoglobulinemia patients: a single-center case series. Clin Rheumatol 2024; 43:2329-2336. [PMID: 38730122 DOI: 10.1007/s10067-024-06997-2] [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: 02/22/2024] [Revised: 04/09/2024] [Accepted: 05/03/2024] [Indexed: 05/12/2024]
Abstract
PURPOSE Cryoglobulinemia is a pathological condition characterized by the presence of cryoglobulins in the blood, with cryoglobulinemic glomerulonephritis being the most frequent form of renal involvement. Fanconi syndrome presents as a generalized dysfunction of the proximal tubule, characterized by the presence of polyuria, phosphaturia, glycosuria, proteinuria, proximal renal tubular acidosis, and osteomalacia. We aimed to present five cases co-occurring with Fanconi syndrome and cryoglobulinemia. METHODS We retrospectively summarized the cases of five patients with Fanconi syndrome and cryoglobulinemia at Peking Union Medical College Hospital from January 2012 to June 2022. The clinical features, diagnosis, treatment, and prognosis were systematically analyzed. RESULTS All five patients exhibited typical features of Fanconi syndrome, and cryoglobulinemia was concurrently detected in all cases. These patients also exhibit positive anti-nuclear antibody spectrum and hyperglobulinemia, and IgM constitutes the predominant monoclonal component in cryoglobulins. In addition to supplemental treatment, timely immunosuppressive therapy may potentially benefit the long-term renal prognosis of patients with this condition. CONCLUSION Our findings highlight the rare co-occurrence of Fanconi syndrome and cryoglobulinemia in clinical practice. Despite the lack of causal evidence, the coexistence of Fanconi syndrome and tubulointerstitial injury is also noteworthy in patients with cryoglobulinemia, underscoring the importance of thorough evaluation and tailored management in patients presenting with overlapping renal manifestations. Key Points • Patients with mixed cryoglobulinemia can clinically present with tubulointerstitial injury, specifically manifesting as Fanconi syndrome. • In addition to typical symptoms of Fanconi syndrome, these patients also exhibit positive anti-nuclear antibody spectrum and hyperglobulinemia, while IgM constitutes the monoclonal component in cryoglobulins. • Timely immunosuppressive therapy may improve long-term renal prognosis in these patients.
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Affiliation(s)
- Qiuyu Xu
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
- 4 + 4 Medical Doctor Program, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, 100730, People's Republic of China
| | - Gang Chen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
| | - Yubing Wen
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Xiaohu Shi
- Department of Traditional Chinese Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science, Beijing, 100730, People's Republic of China
| | - Wenling Ye
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Yan Qin
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, People's Republic of China.
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Wang L, Liu C, Song H, Yuan J, Zha Y, Deng Y. Update on kidney injury caused by multiple myeloma. Ann Hematol 2024:10.1007/s00277-024-05860-3. [PMID: 38942949 DOI: 10.1007/s00277-024-05860-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 06/20/2024] [Indexed: 06/30/2024]
Abstract
Multiple myeloma (MM) is a form of clonal plasma cell malignancy that associates with clinical manifestations such as anemia, hypercalcemia, bone pain, and renal impairment. Approximately 20-50% of MM patients at initial diagnosis experience renal injury, a vital complication that significantly influences prognosis and quality of life. This review seeks to clarify the multifaceted mechanisms of renal injury in MM, scrutinizing the pathogenic role of monoclonal proteins, the impact of hypercalcemia, and direct renal infiltration by plasma cells. Furthermore, it evaluates current diagnostic approaches, reviews management strategies, and highlights potential avenues for future research. By incorporating the latest scientific evidence and insights, this article aims to provide a comprehensive understanding of MM-associated renal impairment, offering a valuable resource for researchers and clinicians in handling this complex complication.
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Affiliation(s)
- Linhui Wang
- Department of Hematology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Chen Liu
- Department of Hematology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Haiyan Song
- Department of Hematology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Jing Yuan
- Department of Hematology, Guizhou Provincial People's Hospital, Guiyang, China
| | - Yan Zha
- Department of Nephrology, Guizhou Provincial People's Hospital, Guiyang, China.
- NHC Key Laboratory of Pulmonary Immunological Disease, Guizhou Provincial People's Hospital, Guiyang, China.
| | - Yiyao Deng
- Department of Nephrology, Guizhou Provincial People's Hospital, Guiyang, China.
- NHC Key Laboratory of Pulmonary Immunological Disease, Guizhou Provincial People's Hospital, Guiyang, China.
- Department of Nephrology, The First Medical Centre, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Centre for Kidney Diseases, Beijing Key Laboratory of Kidney Diseases, Beijing, China.
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He H, Wang Z, Xu J, Liu Y, Shao Y, Hou Y, Gu J, Hu R, Xing G. Clinicopathological characteristics and prognosis in patients with monoclonal gammopathy and renal damage in central China: a multicenter retrospective cohort study. Sci Rep 2024; 14:7667. [PMID: 38561447 PMCID: PMC10984969 DOI: 10.1038/s41598-024-58467-z] [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: 01/05/2024] [Accepted: 03/29/2024] [Indexed: 04/04/2024] Open
Abstract
Renal involvement is common in monoclonal gammopathy (MG); however, the same patient may have both MG and non-paraprotein-associated renal damage. Accordingly, distinguishing the cause of renal damage is necessary because of the different clinical characteristics and associated treatments. In this multicenter retrospective cohort study, we described the clinicopathological characteristics and prognosis of 703 patients with MG and renal damage in central China. Patients were classified as having MG of renal significance (MGRS), MG of undetermined significance (MGUS), or hematological malignancy. 260 (36.98%), 259 (36.84%), and 184 (26.17%) had MGRS, MGUS, and hematological malignancies, respectively. Amyloidosis was the leading pattern of MGRS (74.23%), followed by thrombotic microangiopathy (8.85%) and monoclonal immunoglobulin deposition disease (8.46%). Membranous nephropathy was the leading diagnosis of MGUS (39.38%). Renal pathological findings of patients with hematological malignancies included paraprotein-associated lesions (84.78%) and non-paraprotein-associated lesions (15.22%). The presence of nephrotic syndrome and an abnormal free light chain (FLC) ratio were independently associated with MGRS. The overall survival was better in patients with MGUS than in those with MGRS or hematological malignancies.
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Affiliation(s)
- Huimin He
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Zheng Wang
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Jiayun Xu
- Department of Nephrology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Yun Liu
- Department of Nephrology, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, Henan, China
| | - Yeqing Shao
- Department of Nephrology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, Henan, China
| | - Yulong Hou
- Department of Nephrology, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, Henan, China
| | - Jinping Gu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China
| | - Ruimin Hu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
| | - Guolan Xing
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, China.
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Tsuyuki T, Uramatsu T, Shimizu M, Ishi T, Tsuji K, Nakashima J, Katafuchi E, Nakayama T, Uesugi N, Muta K, Nishino T. Improvement of Light Chain Proximal Tubulopathy without Crystals in IgGλ-type Monoclonal Gammopathy of Undetermined Significance Using Bortezomib and Dexamethasone. Intern Med 2024; 63:693-698. [PMID: 37438138 PMCID: PMC10982019 DOI: 10.2169/internalmedicine.1835-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Accepted: 05/18/2023] [Indexed: 07/14/2023] Open
Abstract
A 70-year-old woman with acute kidney injury, a high serum Creatinine (Cr) level (3.91 mg/dL), and proteinuria (protein/Cr ratio 1.59 g/gCr) was admitted. Serum IgG λ-type and urinary λ-type M proteins were observed. A bone marrow examination indicated monoclonal gammopathy of undetermined significance (MGUS). A renal biopsy showed distended proximal tubular cells, and immunofluorescence identified tissue positive for proximal tubular cell λ light chains. Electron microscopy identified fibril-like structures in the lysosomes. The patient was diagnosed with light chain proximal tubulopathy without crystals in IgG λ-type MGUS and treated with bortezomib and dexamethasone therapy, which improved her renal function.
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Affiliation(s)
| | | | | | - Takuma Ishi
- Department of Nephrology, Nagasaki University Hospital, Japan
| | - Kiyokazu Tsuji
- Department of Nephrology, JCHO Isahaya General Hospital, Japan
| | - Jun Nakashima
- Department of Hematology, JCHO Isahaya General Hospital, Japan
| | - Eisuke Katafuchi
- Department of Pathology, University of Occupational and Environmental Health School, Japan
| | - Toshiyuki Nakayama
- Department of Pathology, University of Occupational and Environmental Health School, Japan
| | - Noriko Uesugi
- Department of Pathology, Fukuoka University Hospital, Japan
| | - Kumiko Muta
- Department of Nephrology, Nagasaki University Hospital, Japan
| | - Tomoya Nishino
- Department of Nephrology, Nagasaki University Hospital, Japan
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Su T, Jin Q, Zhao T, Wang S. 57-year-old woman with purpura fulminans and acute kidney injury. J Clin Pathol 2023; 76:654-657. [PMID: 34893518 DOI: 10.1136/jclinpath-2020-207020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 03/10/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Renal Pathological Center, Institute of Nephrology, Peking University, Beijing, China
| | - Qizhuang Jin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Renal Pathological Center, Institute of Nephrology, Peking University, Beijing, China
| | - Tao Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Renal Pathological Center, Institute of Nephrology, Peking University, Beijing, China
| | - Suxia Wang
- Renal Pathological Center, Institute of Nephrology, Peking University, Beijing, China
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
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Mazur P, Dumnicka P, Tisończyk J, Ząbek-Adamska A, Drożdż R. SDS Electrophoresis on Gradient Polyacrylamide Gels as a Semiquantitative Tool for the Evaluation of Proteinuria. Diagnostics (Basel) 2023; 13:diagnostics13091513. [PMID: 37174905 PMCID: PMC10177418 DOI: 10.3390/diagnostics13091513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/16/2023] [Accepted: 04/20/2023] [Indexed: 05/15/2023] Open
Abstract
Proteinuria is an important sign of kidney diseases. Different protein patterns in urine associated with glomerular, tubular and overload proteinuria may be differentiated using the immunochemical detection of indicator proteins or via urinary proteins electrophoresis. Our aim was to characterize sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) using commercially available 4-20% gradient gels as a method to detect and differentiate proteinuria. Our laboratory-based study used excess urine samples collected for routine diagnostic purposes from adult patients of a tertiary-care hospital, including patients with albumin/creatinine < 30 mg/g and patients with dipstick proteinuria. The limit of albumin detection was estimated to be 3 mg/L. In 93 samples with albumin/creatinine < 30 mg/g, an albumin fraction was detected in 87% of samples with a minimum albumin concentration of 2.11 mg/L. The separation of 300 urine samples of patients with proteinuria revealed distinct protein patterns differentiated using the molecular weights of the detected proteins: glomerular (albumin and higher molecular weights) and two types of tubular proteinuria ("upper" ≥20 kDa and "lower" with lower molecular weights). These patterns were associated with different values of the glomerular filtration rate (median 66, 71 and 31 mL/min/1.72 m2, respectively, p = 0.004) and different proportions of multiple myeloma and nephrological diagnoses. As confirmed using tandem mass spectrometry and western blot, the SDS-PAGE protein fractions contained indicator proteins including immunoglobulin G, transferrin (glomerular proteinuria), α1-microglobulin, retinol-binding protein, neutrophil gelatinase-associated lipocalin, cystatin C, and β2-microglobulin (tubular), immunoglobulin light chain, myoglobin, and lysozyme (overflow). SDS-PAGE separation of urine proteins on commercially available 4-20% gradient gels is a reliable technique to diagnose proteinuria and differentiate between its main clinically relevant types.
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Affiliation(s)
- Paulina Mazur
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, 30-688 Kraków, Poland
| | - Paulina Dumnicka
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, 30-688 Kraków, Poland
| | - Joanna Tisończyk
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, 30-688 Kraków, Poland
| | - Anna Ząbek-Adamska
- Department of Diagnostics, University Hospital in Kraków, 30-688 Kraków, Poland
| | - Ryszard Drożdż
- Department of Medical Diagnostics, Faculty of Pharmacy, Jagiellonian University Medical College, 30-688 Kraków, Poland
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Diagnostic and Prognostic Comparison of Immune-Complex-Mediated Membranoproliferative Glomerulonephritis and C3 Glomerulopathy. Cells 2023; 12:cells12050712. [PMID: 36899849 PMCID: PMC10000503 DOI: 10.3390/cells12050712] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/19/2023] [Accepted: 02/21/2023] [Indexed: 02/27/2023] Open
Abstract
Membranoproliferative glomerulonephritis (MPGN) is subdivided into immune-complex-mediated glomerulonephritis (IC-MPGN) and C3 glomerulopathy (C3G). Classically, MPGN has a membranoproliferative-type pattern, but other morphologies have also been described depending on the time course and phase of the disease. Our aim was to explore whether the two diseases are truly different, or merely represent the same disease process. All 60 eligible adult MPGN patients diagnosed between 2006 and 2017 in the Helsinki University Hospital district, Finland, were reviewed retrospectively and asked for a follow-up outpatient visit for extensive laboratory analyses. Thirty-seven (62%) had IC-MPGN and 23 (38%) C3G (including one patient with dense deposit disease, DDD). EGFR was below normal (≤60 mL/min/1.73 m2) in 67% of the entire study population, 58% had nephrotic range proteinuria, and a significant proportion had paraproteins in their serum or urine. A classical MPGN-type pattern was seen in only 34% of the whole study population and histological features were similarly distributed. Treatments at baseline or during follow-up did not differ between the groups, nor were there significant differences observed in complement activity or component levels at the follow-up visit. The risk of end-stage kidney disease and survival probability were similar in the groups. IC-MPGN and C3G have surprisingly similar characteristics, kidney and overall survival, which suggests that the current subdivision of MPGN does not add substantial clinical value to the assessment of renal prognosis. The high proportion of paraproteins in patient sera or in urine suggests their involvement in disease development.
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Miki K, Shimamura Y, Maeda T, Moniwa N, Ogawa Y, Shimizu T, Hayashi T, Sakai H, Takizawa H. Successful renal recovery from multiple myeloma-associated crystalline light chain cast nephropathy and accompanying acute kidney injury with early use of bortezomib-based therapy: a case report and literature review. CEN Case Rep 2023; 12:56-62. [PMID: 35854043 PMCID: PMC9892411 DOI: 10.1007/s13730-022-00721-2] [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: 03/28/2022] [Accepted: 07/05/2022] [Indexed: 02/05/2023] Open
Abstract
Crystalline light chain cast nephropathy is a rare distinct morphologic variant of light chain cast nephropathy which is the most common renal lesion associated with multiple myeloma. It is often related to high myeloma tumor burden, severe acute kidney injury, and an unfavorable prognosis. A 79-year-old Japanese man was referred to our medical center with anemia, proteinuria, and acute exacerbation of the serum creatinine accompanying anuria. A renal biopsy showed crystalline cast filling the tubular lumens, injured tubular cells, and inflammatory cells infiltration of interstitium. Serum and urine immunofixation detected a monoclonal protein (IgA-λ and Bence-Jones Protein-λ, respectively), and bone marrow examination observed 64% of plasma cells. IgA-λ type multiple myeloma-associated crystalline light chain cast nephropathy and accompanying acute kidney injury were confirmed. Hydration and emergency hemodialysis were immediately introduced, and the treatment with bortezomib and dexamethasone was initiated. The patient showed successful recovery in renal manifestations. We suggest that early use with bortezomib-based therapy should be considered for patients with acute kidney injury caused by multiple myeloma-associated crystalline light chain cast nephropathy.
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Affiliation(s)
- Kosuke Miki
- Department of Hematology, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan.
| | | | - Takuto Maeda
- Department of Nephrology, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan
| | - Norihito Moniwa
- Department of Nephrology, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan
| | - Yayoi Ogawa
- Hokkaido Renal Pathology Center, Sapporo, Japan
| | - Taku Shimizu
- Department of Hematology, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan
| | - Toshiaki Hayashi
- Department of Hematology, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan
| | - Hajime Sakai
- Department of Hematology, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan
| | - Hideki Takizawa
- Department of Nephrology, Teine Keijinkai Medical Center, Sapporo, Hokkaido, Japan
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Bayrakci N, Özkan G, Akpinar S, Ediz B, Yilmaz A, Çelikkol A. Procollagen C-proteinase enhancer-1 and renal failure in multiple myeloma. Int Urol Nephrol 2022; 54:3033-3038. [PMID: 36173536 DOI: 10.1007/s11255-022-03378-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 09/25/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Renal involvement is present in approximately 50% of multiple myeloma (MM) cases and is associated with a poor prognosis. Procollagen C-Proteinase Enhancer 1 (PCPE-1) is an extracellular matrix glycoprotein that has been shown to increase collagen production by enhancing the activity of Procollagen C-Proteinase (PCP) involved in collagen fibrillogenesis and contribute to the fibrotic process. This study investigates the relationship between PCPE-1 and renal function in myeloma patients. METHODS Eighty-one adults, consisting of 61 patients diagnosed with MM and 20 healthy controls, were included in this cross-sectional study. The MM patients with renal injury (RI) were classified as "MM-RI( +)" and those with no RI as "MM-RI(-)". RESULTS The median serum PCPE-1 level was 10.7 (5.0-39.4) ng/mL for the entire study population, 9.9 (5.0-13.6) ng/mL for the control group, 10.0 (6.4-22.5) ng/mL for the MM-RI(-) group, and 11.4 (8.1-39.4) ng/mL for the MM-RI( +) group. The difference between the control group and MM-RI( +) group was statistically significant (p < 0.013). PCPE-1 levels negatively correlated with estimated glomerular filtration rate (eGFR), serum albumin, and hemoglobin levels but positively correlated with serum creatinine and CRP levels in the entire study population. Among MM patients, only serum phosphorus and beta-2-microglobulin (β2M) were positively correlated with PCPE-1. PCPE-1 levels was not affected by other parameters in the entire study population and in the MM group. CONCLUSIONS Although serum PCPE-1 was higher in the MM-RI( +) group, it was thought to be associated with low GFR reflecting non-specific kidney injury rather than myeloma-related kidney injury.
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Affiliation(s)
- Nergiz Bayrakci
- Department of Nephrology, School of Medicine, Tekirdag Namik Kemal University, 59030, Tekirdağ, Turkey.
| | - Gülsüm Özkan
- Department of Nephrology, School of Medicine, Tekirdag Namik Kemal University, 59030, Tekirdağ, Turkey
| | - Seval Akpinar
- Department of Hematology, School of Medicine, Tekirdag Namik Kemal University, Tekirdağ, Turkey
| | - Bartu Ediz
- Department of Internal Medicine, School of Medicine, Tekirdag Namik Kemal University, Tekirdağ, Turkey
| | - Ahsen Yilmaz
- Department of Biochemistry, School of Medicine, Tekirdag Namik Kemal University, Tekirdağ, Turkey
| | - Aliye Çelikkol
- Department of Biochemistry, School of Medicine, Tekirdag Namik Kemal University, Tekirdağ, Turkey
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11
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Klank D, Hoffmann M, Porubsky S, Bergner R. Histological Findings in Kidney Biopsies of Patients with Monoclonal Gammopathy—Always a Surprise. Diagnostics (Basel) 2022; 12:diagnostics12081912. [PMID: 36010261 PMCID: PMC9406481 DOI: 10.3390/diagnostics12081912] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 07/30/2022] [Accepted: 08/06/2022] [Indexed: 11/24/2022] Open
Abstract
Background: The simultaneous occurrence of impaired kidney function and paraproteinemia is common in our constantly aging society. Both can be independent entities; however, renal insufficiency can also be caused by the paraprotein. We assessed all kidney biopsies in patients with monoclonal gammopathy in our clinic over the past 20 years and evaluated the histological results. Methods: Biopsies were systematically performed in nearly all patients with paraproteinemia and impaired kidney function (n = 178). The histological findings were systematically evaluated and correlated with the initial clinical diagnosis. Results: We found cast nephropathy (CN) in n = 66 (37.1%) biopsies, AL amyloidosis in n = 31 (17.4%) biopsies, monoclonal immunoglobulin deposition disease (MIDD) in n = 7 (3.9%) biopsies and other renal diseases (ORDs) in n = 74 (41.6%) biopsies. In the latter group, paraprotein-associated changes were found in 37 of 74 (50%) patients, whereas paraprotein-independent changes were found in the other half. Whereas, in the group of patients with MGUS, the findings were heterogenous, most of the patients with known multiple myeloma (MM) or B-NHL showed malignancy-associated changes in the kidney. The biopsy changed the diagnoses in a significant proportion of the patients: The group of patients with MM grew from 71 to 112 patients, whereas, in the MGUS group, only 31 of 44 patients remained. Conclusion: Kidney biopsies in patients with paraproteinemia and renal impairment show a wide range of findings that can lead to a change in diagnosis.
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Affiliation(s)
- David Klank
- Medizinische Klinik A, Klinikum der Stadt Ludwigshafen gGmbH, Bremserstrasse 79, 67063 Ludwigshafen, Germany
- Correspondence: ; Tel.: +49-(0)621-503-29561
| | - Martin Hoffmann
- Medizinische Klinik A, Klinikum der Stadt Ludwigshafen gGmbH, Bremserstrasse 79, 67063 Ludwigshafen, Germany
| | - Stefan Porubsky
- Institut für Pathologie, Universitätsklinikum Mainz, Langenbeckstrasse 1, 55131 Mainz, Germany
| | - Raoul Bergner
- Medizinische Klinik A, Klinikum der Stadt Ludwigshafen gGmbH, Bremserstrasse 79, 67063 Ludwigshafen, Germany
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Isse N, Nakahara K, Sasai R. IgD lambda multiple myeloma causing hyperammonaemia with possibly reduced ammonium excretion. BMJ Case Rep 2022; 15:e248245. [PMID: 35858739 PMCID: PMC9305694 DOI: 10.1136/bcr-2021-248245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 11/03/2022] Open
Abstract
A man in his 70s presented with impaired consciousness due to hyperammonaemia while investigating multiple tumours in his brain, chest, spine and right adrenal gland. He did not have any disorders causing hyperammonaemia, such as liver dysfunction, urea-producing bacterial infection or any medications interfering with ammonium metabolism. Blood and urine tests in addition to tumour biopsy specimens confirmed immunoglobulin D lambda multiple myeloma. His general status responded to chemotherapy using bortezomib, dexamethasone and daratumumab, and he subsequently regained full consciousness and a normalised serum ammonia level. He, unfortunately, died of refractory multiple myeloma with hyperammonaemia. The autopsy specimen revealed lambda light-chain deposits in the distal tubule epithelium with cast precipitation and intact liver cells. Urine osmolality gap analysis suggested possibly reduced urinary ammonium excretion, but further investigation is necessary to elucidate the significance of pathological renal characteristics in multiple myeloma with hyperammonaemia.
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Affiliation(s)
- Naohi Isse
- General Medicine, Okayama Kyoritsu General Hospital, Okayama, Okayama, Japan
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13
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Jung M, Lee H, Moon KC. Morphometric Analysis of Lysosomes in the Renal Tubule in Monoclonal Gammopathy Using Transmission Electron Microscopy: "Mottled Appearance" and Beyond. MICROSCOPY AND MICROANALYSIS : THE OFFICIAL JOURNAL OF MICROSCOPY SOCIETY OF AMERICA, MICROBEAM ANALYSIS SOCIETY, MICROSCOPICAL SOCIETY OF CANADA 2022; 28:1-9. [PMID: 35437138 DOI: 10.1017/s1431927622000587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Lysosomal “mottled appearance”, or uneven electron-dense content related to monoclonal gammopathy (MG), has been mainly described in light chain proximal tubulopathy (LCPT). We aimed to determine the ultrastructural characteristics of lysosomal mottled appearance in kidney biopsies and its association with LCPT and MG. Seventy-seven biopsies were grouped into LCPT (n = 5), MG conditions other than LCPT (n = 43), and non-MG conditions (n = 29). The mottled lysosomes in the renal tubules were evaluated using transmission electron microscopy and morphometric analysis. Mottled lysosomes were more prevalent (% of present cases) and frequent (no. of mottled lysosomes/20,000× ultramicroscopic field) in the LCPT group (100% and 8.20 ± 4.15/field) than in the MG (41.9% and 1.13 ± 2.05/field) and non-MG (37.9% and 0.80 ± 1.44/field) groups. In morphometric analysis of all mottled lysosomes (n = 520) detected from the 34 biopsies (5 LCPT, 18 MG, and 11 non-MG), we found that mottled lysosomes were larger, more irregular, and more electron-dense for the LCPT group than for the MG and non-MG groups. Therefore, mottled lysosomes can be present in disorders other than LCPT or even without MG. The morphological characteristics of mottled lysosomes could provide objective guidance for the diagnosis of LCPT.
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Affiliation(s)
- Minsun Jung
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul03722, Republic of Korea
- Department of Pathology, Seoul National University College of Medicine, Seoul03080, Republic of Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul03080, Republic of Korea
- Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul03080, Republic of Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University College of Medicine, Seoul03080, Republic of Korea
- Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul03080, Republic of Korea
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Büttner-Herold M, Krieglstein N, Chuva T, Minuth K, Pfister F, Daniel C, Klewer M, Büttner A, Ferrazzi F, Bertz S, Amann K. Light Chain Restriction in Proximal Tubules-Implications for Light Chain Proximal Tubulopathy. Front Med (Lausanne) 2022; 9:723758. [PMID: 35419374 PMCID: PMC8995435 DOI: 10.3389/fmed.2022.723758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Monoclonal gammopathy (MG) causes various nephropathies, which may suffice for cytoreductive therapy even in the absence of diagnostic criteria for multiple myeloma or B-cell non-Hodgkin lymphoma. The aim of this study was to better understand the significance of light chain (LC) restriction or crystals (LC-R/C) in proximal tubules in the spectrum of LC-induced nephropathies. A consecutive cohort of 320 renal specimens with a history of B-cell dyscrasia was characterized. Special attention was paid to immunohistochemical LC restriction in proximal tubules, tubular crystals or constipation, and ultrastructural findings. Complementary cell culture experiments were performed to assess the role of LC concentrations in generating LC restriction. Light chain restriction or crystals in proximal tubules was found in a quarter of analyzed cases (81/316) and was associated with another LC-induced disease in 70.4% (57/81), especially LC cast-nephropathy (cast-NP) and interstitial myeloma infiltration. LC restriction without significant signs of acute tubular injury was observed in 11.1% (9/81). LC-R/C was not associated with inferior renal function compared to the remainder of cases, when cases with accompanying cast-NP were excluded. Besides crystals, cloudy lysosomes were significantly associated with LC-R/C on an ultrastructural level. In summary, LC-R/C is frequent and strongly associated with cast-NP, possibly indicating that a high load of clonal LC is responsible for this phenomenon, supported by the observation that LC restriction can artificially be generated in cell culture. This and the lack of significant tubular injury in a subgroup imply that in part LC-R/C is a tubular trafficking phenomenon rather than an independent disease process.
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Affiliation(s)
- Maike Büttner-Herold
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Nathalie Krieglstein
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Teresa Chuva
- Department of Nephrology, Portuguese Institute of Oncology, Porto, Portugal
| | - Kaija Minuth
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Frederick Pfister
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Christoph Daniel
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Monika Klewer
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Anke Büttner
- School of Psychology, College of Life and Environmental Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Fulvia Ferrazzi
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany.,Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Simone Bertz
- Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
| | - Kerstin Amann
- Department of Nephropathology, Institute of Pathology, Friedrich-Alexander-University Erlangen-Nuremberg, Erlangen, Germany
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15
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Ibáñez Moreno JA, Bacca González JM, Taborda Murillo A, Ospina Ospina S, Arias LF. [Renal involvement in monoclonal gammopathies]. REVISTA ESPANOLA DE PATOLOGIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE ANATOMIA PATOLOGICA Y DE LA SOCIEDAD ESPANOLA DE CITOLOGIA 2022; 55:4-11. [PMID: 34980439 DOI: 10.1016/j.patol.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/26/2021] [Accepted: 06/04/2021] [Indexed: 06/14/2023]
Abstract
INTRODUCTION The kidney is one of the organs most frequently affected by disease processes which produce monoclonal immunoglobins, therefore renal morphological and immunopathological alterations should be clearly recognized. OBJECTIVE To describe the pathological features of renal involvement in monoclonal gammopathies. MATERIAL AND METHODS A descriptive, retrospective and cross-sectional study of renal biopsies studied in a single center during a period of 14 years was carried out. RESULTS 102 cases were included, of which 53% were male patients and the median age was 62.5 years (range 34 - 79). 97% of the biopsies were from native kidneys. The most frequent histopathological diagnosis (31.4%) was myeloma kidney, with kappa being the light chain most frequently deposited (65.6% of cases). AL amyloidosis was the second most common (29.4%) where the lambda chain predominated in 86.6%, followed by light chain deposition disease (20.6%) with the predominance of the kappa chain in 66.6%. CONCLUSIONS The most frequent renal involvement due to monoclonal gammopathies was myeloma kidney with deposition of kappa light chains, followed by AL lambda amyloidosis; these diseases were found more frequently in patients over 50 years of age.
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Affiliation(s)
| | | | | | - Sigifredo Ospina Ospina
- Instituto de Investigaciones Médicas, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
| | - Luis Fernando Arias
- Departamento de Patología, Facultad de Medicina, Universidad de Antioquia, Medellín, Colombia
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16
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Cell spinpods are a simple inexpensive suspension culture device to deliver fluid shear stress to renal proximal tubular cells. Sci Rep 2021; 11:21296. [PMID: 34716334 PMCID: PMC8556299 DOI: 10.1038/s41598-021-00304-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/05/2021] [Indexed: 02/06/2023] Open
Abstract
Rotating forms of suspension culture allow cells to aggregate into spheroids, prevent the de-differentiating influence of 2D culture, and, perhaps most importantly of all, provide physiologically relevant, in vivo levels of shear stress. Rotating suspension culture technology has not been widely implemented, in large part because the vessels are prohibitively expensive, labor-intensive to use, and are difficult to scale for industrial applications. Our solution addresses each of these challenges in a new vessel called a cell spinpod. These small 3.5 mL capacity vessels are constructed from injection-molded thermoplastic polymer components. They contain self-sealing axial silicone rubber ports, and fluoropolymer, breathable membranes. Here we report the two-fluid modeling of the flow and stresses in cell spinpods. Cell spinpods were used to demonstrate the effect of fluid shear stress on renal cell gene expression and cellular functions, particularly membrane and xenobiotic transporters, mitochondrial function, and myeloma light chain, cisplatin and doxorubicin, toxicity. During exposure to myeloma immunoglobulin light chains, rotation increased release of clinically validated nephrotoxicity cytokine markers in a toxin-specific pattern. Addition of cisplatin or doxorubicin nephrotoxins reversed the enhanced glucose and albumin uptake induced by fluid shear stress in rotating cell spinpod cultures. Cell spinpods are a simple, inexpensive, easily automated culture device that enhances cellular functions for in vitro studies of nephrotoxicity.
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Minato M, Murakami T, Takahashi N, Ono H, Nishimura K, Tamaki M, Nagai K, Abe H, Iwano M, Joh K, Doi T. Glucocorticoid-dependent Tubulointerstitial Nephritis with IgM-positive Plasma Cells Presenting with Intracellular Crystalline Inclusions within the Rough Endoplasmic Reticulum. Intern Med 2021; 60:3129-3136. [PMID: 33840699 PMCID: PMC8545643 DOI: 10.2169/internalmedicine.7118-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Tubulointerstitial nephritis (TIN) with IgM-positive plasma cells (IgMPC-TIN) is an autoimmune kidney disease characterized by IgM/CD138-double-positive plasma cell infiltration in the tubulointerstitium. A 50-year-old man developed IgMPC-TIN and presented with crystalline inclusions in the rough endoplasmic reticulum. Intracellular crystal formation is a rare finding in paraprotein-related kidney diseases, but this case showed no pathogenic monoclonal immunoglobulin. Prednisolone (PSL, 30 mg) improved the TIN, but PSL tapering resulted in the recurrence of TIN. Combination therapy with 15 mg PSL and 150 mg mizoribine ultimately stabilized TIN. This case offers original evidence concerning the pathophysiology and treatment strategy of IgMPC-TIN.
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Affiliation(s)
- Masanori Minato
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Taichi Murakami
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
- Department of Nephrology, Ehime Prefectural Central Hospital, Japan
| | - Naoki Takahashi
- Department of Nephrology, Faculty of Medical Science, University of Fukui, Japan
| | - Hiroyuki Ono
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Kenji Nishimura
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Masanori Tamaki
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Kojiro Nagai
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Hideharu Abe
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
| | - Masayuki Iwano
- Department of Nephrology, Faculty of Medical Science, University of Fukui, Japan
| | - Kensuke Joh
- Department of Pathology, The Jikei University School of Medicine, Japan
| | - Toshio Doi
- Department of Nephrology, Tokushima University Graduate School of Biomedical Science, Japan
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18
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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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19
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Menè P, Moioli A, Stoppacciaro A, Lai S, Festuccia F. Acute Kidney Injury in Monoclonal Gammopathies. J Clin Med 2021; 10:jcm10173871. [PMID: 34501317 PMCID: PMC8432219 DOI: 10.3390/jcm10173871] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/25/2021] [Accepted: 08/26/2021] [Indexed: 01/07/2023] Open
Abstract
Monoclonal gammopathies (MG) encompass a variety of disorders related to clonal expansion and/or malignant transformation of B lymphocytes. Deposition of free immunoglobulin (Ig) components (light or heavy chains, LC/HC) within the kidney during MG may result over time in multiple types and degrees of injury, including acute kidney injury (AKI). AKI is generally a consequence of tubular obstruction by luminal aggregates of LC, a pattern known as “cast nephropathy”. Monoclonal Ig LC can also be found as intracellular crystals in glomerular podocytes or proximal tubular cells. Proliferative glomerulonephritis with monoclonal Ig deposits is another, less frequent form of kidney injury with a sizable impact on renal function. Hypercalcemia (in turn related to bone reabsorption triggered by proliferating plasmacytoid B cells) may lead to AKI via functional mechanisms. Pharmacologic treatment of MG may also result in additional renal injury due to local toxicity or the tumor lysis syndrome. The present review focuses on AKI complicating MG, evaluating predictors, risk factors, mechanisms of damage, prognosis, and options for treatment.
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Affiliation(s)
- Paolo Menè
- Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy; (A.M.); (F.F.)
- Correspondence: ; Tel.: +39-(06)-3377-5949
| | - Alessandra Moioli
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy; (A.M.); (F.F.)
| | - Antonella Stoppacciaro
- Division of Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy;
| | - Silvia Lai
- Division of Nephrology, Department of Translational and Precision Medicine, “Sapienza” University of Rome, 00161 Rome, Italy;
| | - Francescaromana Festuccia
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035-1039, 00189 Rome, Italy; (A.M.); (F.F.)
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20
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Hantavirus infection-induced B cell activation elevates free light chains levels in circulation. PLoS Pathog 2021; 17:e1009843. [PMID: 34379707 PMCID: PMC8382192 DOI: 10.1371/journal.ppat.1009843] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 08/23/2021] [Accepted: 07/27/2021] [Indexed: 12/17/2022] Open
Abstract
In humans, orthohantaviruses can cause hemorrhagic fever with renal syndrome (HFRS) or hantavirus pulmonary syndrome (HPS). An earlier study reported that acute Andes virus HPS caused a massive and transient elevation in the number of circulating plasmablasts with specificity towards both viral and host antigens suggestive of polyclonal B cell activation. Immunoglobulins (Igs), produced by different B cell populations, comprise heavy and light chains; however, a certain amount of free light chains (FLCs) is constantly present in serum. Upregulation of FLCs, especially clonal species, associates with renal pathogenesis by fibril or deposit formations affecting the glomeruli, induction of epithelial cell disorders, or cast formation in the tubular network. We report that acute orthohantavirus infection increases the level of Ig FLCs in serum of both HFRS and HPS patients, and that the increase correlates with the severity of acute kidney injury in HFRS. The fact that the kappa to lambda FLC ratio in the sera of HFRS and HPS patients remained within the normal range suggests polyclonal B cell activation rather than proliferation of a single B cell clone. HFRS patients demonstrated increased urinary excretion of FLCs, and we found plasma cell infiltration in archival patient kidney biopsies that we speculate to contribute to the observed FLC excreta. Analysis of hospitalized HFRS patients’ peripheral blood mononuclear cells showed elevated plasmablast levels, a fraction of which stained positive for Puumala virus antigen. Furthermore, B cells isolated from healthy donors were susceptible to Puumala virus in vitro, and the virus infection induced increased production of Igs and FLCs. The findings propose that hantaviruses directly activate B cells, and that the ensuing intense production of polyclonal Igs and FLCs may contribute to acute hantavirus infection-associated pathological findings. Orthohantaviruses are globally spread zoonotic pathogens, which can cause hemorrhagic fever with renal syndrome (HFRS) and hantavirus pulmonary syndrome (HPS) with significant burden to human health. The pathogenesis mechanisms of orthohantavirus-caused diseases are not known in detail; however, excessive immune response towards the virus with concomitant pathological effects against host tissues appears to be a contributing factor. Here we report an increase of free immunoglobulin (Ig) light chains (FLCs), components required to make complete Ig molecules, in blood of acute HFRS and HPS. Samples collected during acute HFRS demonstrated increased FLCs levels in the urine and blood of patients hospitalized due the disease. Furthermore, the FLC levels positively correlated with markers of acute kidney injury. In addition, our results show that orthohantaviruses can infect and activate B cells to produce FLCs as well as whole Igs, which provides a mechanistic explanation of the increased FLC levels in patients. Taken together, our results suggest that aberrant antibody responses might play a role in the pathogenesis of orthohantavirus infections.
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21
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Clinical Mass Spectrometry Discovered Human IgG Sialylation as a Potential Biosignature for Kidney Function. J Pers Med 2021; 11:jpm11080761. [PMID: 34442405 PMCID: PMC8401842 DOI: 10.3390/jpm11080761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 07/27/2021] [Accepted: 07/28/2021] [Indexed: 02/06/2023] Open
Abstract
Immunoglobulin G (IgG) N-glycosylation was discovered to have an association with inflammation status, which has the potential to be a novel biomarker for kidney diseases. In this study, we applied an ultra-high performance liquid chromatography–tandem mass spectrometry (UHPLC-MS/MS) method to plasma and urine samples from 57 individuals with different levels of kidney function. Natural abundances of total IgG, IgG1, IgG2, and IgG3 subclasses in plasma showed positive correlations to the estimated glomerular filtration rates (eGFRs). Eighteen IgG glycopeptides also showed positive correlations. In contrast, higher IgG amounts were found in urine samples from participants with lower eGFR values. After normalizing IgG glycopeptides from plasma to their respective protein amounts, H4N4F1S1-IgG1 (r = 0.37, p = 0.0047, significant) and H5N4F1S1-IgG1 (r = 0.25, p = 0.063, marginally significant) were the two glycopeptides that still had positive correlations with eGFRs. The results showed that the UHPLC-MS/MS method is capable of investigating IgG profiles, and monitoring IgG and glycosylation patterns is worthy of further clinical application for kidney disease.
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22
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Kidney Transplantation and Monoclonal Gammopathy of Undetermined Significance. Transplant Direct 2021; 7:e723. [PMID: 34263021 PMCID: PMC8274733 DOI: 10.1097/txd.0000000000001176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 11/26/2022] Open
Abstract
Plasma cell disorders are one of the most common hematologic malignancies. Monoclonal gammopathy of undetermined significance (MGUS) is defined by a serum monoclonal protein <3 g/dL, bone marrow plasma cell infiltration <10%, and most importantly absence of end-organ damage. The prevalence of MGUS in general population is estimated to be 1%–4% and its frequency increases with age with 3% among people above 50 y of age. The risk of progression to clinically significant plasma cell dyscrasia is estimated to be 1% per year. With aging population and increasing use of transplantation for the management of kidney disease in older adults, MGUS is being identified during the evaluation for kidney transplant candidacy or during the postkidney transplant follow-up. MGUS in patients with end-stage renal disease (ESRD) undergoing evaluation for kidney transplant can pose a complex management dilemma. In this article, we review the current state of knowledge about the prevalence of MGUS in ESRD population and the impact of kidney transplantation on the progression of MGUS to clinically significant plasma cell disorder. We make recommendations for the screening of ESRD patients undergoing kidney transplant evaluation and the management of MGUS after renal transplant.
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23
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Lin ZS, Zhang X, Yu XJ, Wang S, Wang SX, Dong YJ, Zhou FD, Zhao MH. Crystalline appearance in light chain cast nephropathy is associated with higher early mortality in patients with newly diagnosed multiple myeloma. Int Immunopharmacol 2021; 98:107875. [PMID: 34146864 DOI: 10.1016/j.intimp.2021.107875] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 05/26/2021] [Accepted: 06/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Light chain cast nephropathy (LCCN) is the most common kidney lesion in multiple myeloma patients. LCCN may exhibit a crystalline appearance. The frequency and clinical significance of crystalline LCCN are not well understood. Here, we report the first retrospective study of crystalline LCCN. METHODS Twenty-six patients with LCCN were enrolled. We studied the clinicopathological features and outcomes of LCCN patients and compared ordinary LCCN patients (n = 18) with crystalline LCCN patients (n = 8). RESULTS Crystalline LCCN was not rare (8/26, 30.8%) in our study. The median age of LCCN patients was 57.5 (range, 41-75) years. No patients presented with nephrotic syndrome. No significant differences in clinical features were observed between the two groups. All crystalline LCCN patients suffered from advanced multiple myeloma and acute kidney injury. There was a dominance of the λ isotype (7/8, 87.5%) in patients with crystalline LCCN. Patients with ordinary LCCN had significantly higher scores of tubular atrophy and acute tubular injury than those with crystalline LCCN. The crystalline casts of 5 crystalline LCCN patients stained negative with antihuman Tamm-Horsfall glycoprotein. There were no significant differences in the median overall survival between the crystalline LCCN group and the ordinary LCCN group (6.0 months vs. 35.0 months, p = 0.173). However, crystalline LCCN patients had higher early mortality than ordinary LCCN patients (50.0% vs 11.1%, p = 0.03). CONCLUSION Crystalline LCCN patients had higher early mortality than ordinary LCCN patients. Thus, for patients with LCCN, crystalline appearance should be screened carefully.
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Affiliation(s)
- Zi-Shan Lin
- Renal Division, Department of Medicine, Peking University First Hospital, PR China; Institute of Nephrology, Peking University, PR China; Renal Pathology Center, Institute of Nephrology, Peking University, PR China; Key Laboratory of Renal Disease, Ministry of Health of China, PR China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, PR China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, PR China
| | - Xu Zhang
- Renal Division, Department of Medicine, Peking University First Hospital, PR China; Institute of Nephrology, Peking University, PR China; Renal Pathology Center, Institute of Nephrology, Peking University, PR China; Key Laboratory of Renal Disease, Ministry of Health of China, PR China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, PR China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, PR China; Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing 100034, PR China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, PR China; Institute of Nephrology, Peking University, PR China; Renal Pathology Center, Institute of Nephrology, Peking University, PR China; Key Laboratory of Renal Disease, Ministry of Health of China, PR China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, PR China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, PR China
| | - Shuang Wang
- Renal Division, Department of Medicine, Peking University First Hospital, PR China; Institute of Nephrology, Peking University, PR China; Renal Pathology Center, Institute of Nephrology, Peking University, PR China; Key Laboratory of Renal Disease, Ministry of Health of China, PR China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, PR China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, PR China; Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing 100034, PR China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, PR China; Institute of Nephrology, Peking University, PR China; Renal Pathology Center, Institute of Nephrology, Peking University, PR China; Key Laboratory of Renal Disease, Ministry of Health of China, PR China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, PR China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, PR China; Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing 100034, PR China
| | - Yu-Jun Dong
- Department of Hematology, Peking University First Hospital, Beijing 100034, PR China
| | - Fu-De Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, PR China; Institute of Nephrology, Peking University, PR China; Renal Pathology Center, Institute of Nephrology, Peking University, PR China; Key Laboratory of Renal Disease, Ministry of Health of China, PR China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, PR China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, PR China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, PR China; Institute of Nephrology, Peking University, PR China; Renal Pathology Center, Institute of Nephrology, Peking University, PR China; Key Laboratory of Renal Disease, Ministry of Health of China, PR China; Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, PR China; Research Units of Diagnosis and Treatment of Immune-mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing 100034, PR China; Peking-Tsinghua Center for Life Sciences, Beijing 100034, PR China
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24
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Nie S, Wang M, Wan Q, Kong Y, Ou J, Jia N, Zhang X, Luo F, Liu X, Wang L, Cao Y, Chen R, Zhao M, Chan DYL, Wang G. Kidney Biopsy in Patients With Monoclonal Gammopathy: A Multicenter Retrospective Cohort Study. Front Med (Lausanne) 2021; 8:687149. [PMID: 34109201 PMCID: PMC8180861 DOI: 10.3389/fmed.2021.687149] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/23/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives: To analyze the clinical characteristics and renal pathological manifestations of patients with monoclonal gammopathy (MG) and kidney injury. Methods: This was a multicenter retrospective cohort study conducted at four tertiary hospitals in China. The study population comprised patients with MG admitted from January 1 2013 to December 31 2020. Hospitalization records, laboratory data, and kidney biopsy reports of all patients were collected from the electronic hospital information systems. The study outcomes included kidney disease progression and major hemorrhagic complications after kidney biopsy. Results: We identified 1,164 patients with MG, 782 (67.2%) of whom had underlying kidney injury. Of 101 patients who underwent kidney biopsy, 16 had malignant neoplasms. Amyloid nephropathy was the most common finding (n = 34, 33.7%), followed by membranous nephropathy (n = 18, 17.8%) and membranoproliferative nephritis (n = 8, 7.9%). Among 85 patients with non-malignant hematologic conditions who underwent kidney biopsy, 43 had MG of renal significance (MGRS) related lesions and 42 had MG-unrelated lesions. The risk of kidney disease progression was higher in patients with kidney injury than in patients without kidney injury. Conclusion: Among patients with MG and kidney injury, only 12.9% underwent kidney biopsy and more than 40% of these patients had MG-unrelated lesions. A kidney biopsy is safe and essential to maximize the possibility of correct diagnosis for patients with clinically suspected MG of renal significance (MGRS).
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Affiliation(s)
- Sheng Nie
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mengyi Wang
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qijun Wan
- Center for Nephrology and Urology Shenzhen University, The First Affiliated Hospital of Shenzhen University, Shenzhen University, Shenzhen, China.,Department of Nephrology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Yaozhong Kong
- The First People's Hospital of Foshan, Foshan, China
| | - Jun Ou
- Division of Nephrology, Affiliated Hospital of Guilin Medical University, Guilin, China
| | - Nan Jia
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaodong Zhang
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fan Luo
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoting Liu
- Kingmed Diagnostic Laboratory Ltd, Guangzhou, China
| | - Lin Wang
- Kingmed Diagnostic Laboratory Ltd, Guangzhou, China
| | - Yue Cao
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Ruixuan Chen
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Mingpeng Zhao
- Assisted Reproductive Technology Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - David Yiu Leung Chan
- Assisted Reproductive Technology Unit, Department of Obstetrics and Gynaecology, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
| | - Guobao Wang
- State Key Laboratory of Organ Failure Research, National Clinical Research Center for Kidney Disease, Guangdong Provincial Clinical Research Center for Kidney Disease, Nanfang Hospital, Southern Medical University, Guangzhou, China
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25
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Sirac C, Batuman V, Sanders PW. The Proximal Tubule Toxicity of Immunoglobulin Light Chains. Kidney Int Rep 2021; 6:1225-1231. [PMID: 34013100 PMCID: PMC8116766 DOI: 10.1016/j.ekir.2021.02.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 01/25/2023] Open
Abstract
Plasma and B cells dyscrasias that overproduce monoclonal immunoglobulin free light chains (FLCs) affect the kidney frequently in various ways. The hematologic dyscrasia responsible for the production of FLCs may or may not meet the criteria for cancer, such as multiple myeloma (MM) or lymphoma, or may remain subclinical. If there is overt malignancy, the accompanying kidney disorder is called myeloma- or lymphoma-associated. If the dyscrasia is subclinical, the associated kidney disorders are grouped as monoclonal gammopathy of renal significance. Glomeruli and tubules may both be involved. The proximal tubule disorders comprise a spectrum of interesting syndromes, which range in severity. This review focuses on the recent insights gained into the patterns and the mechanisms of proximal tubule toxicity of FLCs, including subtle transport disorders, such as proximal tubule acidosis, partial or complete Fanconi syndrome, or severe acute or chronic renal failure. Histologically, there may be crystal deposition in the proximal tubule cells, acute tubule injury, interstitial inflammation, fibrosis, and tubule atrophy. Specific structural alterations in the V domain of FLCs caused by somatic hypermutations are responsible for crystal formation as well as partial or complete Fanconi syndrome. Besides crystal formation, tubulointerstitial inflammation and proximal tubulopathy can be mediated by direct activation of inflammatory pathways through cytokines and Toll-like receptors due to cell stress responses induced by excessive FLC endocytosis into the proximal tubule cells. Therapy directed against the clonal source of the toxic light chain can prevent progression to more severe lesions and may help preserve kidney function.
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Affiliation(s)
- Christophe Sirac
- Unité Mixte de Recherche (UMR) 7276/Institut National de la Santé et de la Recherche Médicale (INSERM) U1262, Centre National de la Recherche Scientifique (CNRS), Université de Limoges, Limoges, France
- Centre National de l’Amylose AL et Autres Maladies par Dépôts d’Immunoglobulines Monoclonales, Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Vecihi Batuman
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Veterans Affairs, Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
| | - Paul W. Sanders
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Veterans Affairs, Birmingham Veterans Affairs Health Care System, Birmingham, Alabama, USA
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26
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Bridoux F, Leung N, Belmouaz M, Royal V, Ronco P, Nasr SH, Fermand JP. Management of acute kidney injury in symptomatic multiple myeloma. Kidney Int 2021; 99:570-580. [PMID: 33440212 DOI: 10.1016/j.kint.2020.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/23/2020] [Accepted: 11/03/2020] [Indexed: 01/15/2023]
Abstract
Symptomatic multiple myeloma is commonly complicated by acute kidney injury through various mechanisms. The most frequent is the precipitation of monoclonal free light chains with uromodulin in the distal tubules, defining light chain cast nephropathy. Early diagnosis and identification of the cause of acute kidney injury are required for optimizing management and avoiding chronic kidney injury that strongly affects quality of life and patient survival. In light chain cast nephropathy, often manifesting with severe acute kidney injury, renal recovery requires urgent intervention based on vigorous rehydration, correction of precipitating factors, and efficient anti-plasma cell chemotherapy to rapidly reduce the secretion of nephrotoxic free light chains. Currently, the association of the proteasome inhibitor bortezomib with high-dose dexamethasone is the standard regimen in newly diagnosed patients. The addition of another drug such as cyclophosphamide or an immunodulatory agent may improve free light chain response but raises tolerance concerns in frail patients. Further studies are warranted to confirm the role of anti-CD38 monoclonal antibodies, whose efficacy and tolerance have been documented in patients without renal impairment. Despite controversial results from randomized studies, recent data suggest that in patients with light chain cast nephropathy and acute kidney injury requiring dialysis, the combination of chemotherapy with free light chain removal through high-cutoff hemodialysis may increase renal response recovery rates. Kidney biopsy may be helpful in guiding management and assessing renal prognosis that appears to depend on the extent of cast formation and interstitial fibrosis/tubular atrophy. Because of continuous improvement in life expectancy of patients with multiple myeloma, renal transplantation is likely to be increasingly considered in selected candidates.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France; Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France.
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed Belmouaz
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
| | - Pierre Ronco
- Nephrology Department, Assistance Publique - Hôpitaux de Paris, Hôpital Tenon, Paris, France; Sorbonne Université and Institut National de la Santé Et de la Recherche Médicale (INSERM), Unité Mixte de Recherche S 1135, Paris, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jean Paul Fermand
- Department of Hematology and Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, INSERM UMR 1126, Paris, France; Intergroupe Francophone du Myélome (IFM), Paris, France
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27
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Lin ZS, Yu XJ, Qin AB, Liu MY, Wang SX, Zhou FD, Zhao MH. Coexistent light chain deposition disease, light chain cast nephropathy, and vascular light chain amyloidosis in a patient with IgD lambda multiple myeloma. Int Urol Nephrol 2021; 53:1729-1731. [PMID: 33404783 DOI: 10.1007/s11255-020-02744-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/02/2020] [Indexed: 12/30/2022]
Affiliation(s)
- Zi-Shan Lin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, P.R. 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; Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, People's Republic of China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, P.R. 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; Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, People's Republic of China
| | - Ai-Bo Qin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, P.R. 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; Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, People's Republic of China
| | - Meng-Yao Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, P.R. 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; Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, People's Republic of China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, P.R. 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; Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, People's Republic of China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Fu-De Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, P.R. 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; Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, People's Republic of China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, 100034, P.R. 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; Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, 100034, People's Republic of China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100034, People's Republic of China
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28
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Parmar MS. (F)utility of urine Bence Jones proteins for "routine" screening for plasma cell dyscrasia. Diagnosis (Berl) 2020; 8:dx-2020-0104. [PMID: 33189080 DOI: 10.1515/dx-2020-0104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Accepted: 09/30/2020] [Indexed: 11/15/2022]
Abstract
Testing urine for Bence Jones Protein (BJP) had been a time old procedure used for screening and monitoring of monoclonal disorders since its description. However, has poor sensitivity and despite advances in diagnostic methods of monoclonal disorders it is being continued to be requested in individuals for evaluation of myeloma or plasma cell disorders. Effective utilization and minimizing untimely or unnecessary investigations is important in the evaluation and management of any medical condition. Though, we are hard-wired during our education with some "trigger" or "peculiar" words that make us jump to actions too quickly, without comprehending the actual problem. Supporting evidence is presented to avoid reflexive use of multiple tests and utilize tests that improve utilization, reduce waste, and uphold the Choosing Wisely principles in providing optimal care to the patients.
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Affiliation(s)
- Malvinder S Parmar
- Northern Ontario School of Medicine, Sudbury & Thunder Bay, East Timmins, ON, Canada
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29
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Pathophysiology and management of monoclonal gammopathy of renal significance. Blood Adv 2020; 3:2409-2423. [PMID: 31409583 DOI: 10.1182/bloodadvances.2019031914] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/09/2019] [Indexed: 12/17/2022] Open
Abstract
Recent years have witnessed a rapid growth in our understanding of the pathogenic property of monoclonal proteins. It is evident that some of these small monoclonal proteins are capable of inducing end-organ damage as a result of their intrinsic physicochemical properties. Hence, an umbrella term, monoclonal gammopathy of clinical significance (MGCS), has been coined to include myriad conditions attributed to these pathogenic proteins. Because kidneys are the most commonly affected organ (but skin, peripheral nerves, and heart can also be involved), we discuss MGRS exclusively in this review. Mechanisms of renal damage may involve direct or indirect effects. Renal biopsy is mandatory and demonstration of monoclonal immunoglobulin in kidney, along with the corresponding immunoglobulin in serum or urine, is key to establish the diagnosis. Pitfalls exist at each diagnostic step, and a high degree of clinical suspicion is required to diagnose MGRS. Recognition of MGRS by hematologists and nephrologists is important, because timely clone-directed therapy improves renal outcomes. Autologous stem cell transplant may benefit selected patients.
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30
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Upadhyay R, Ying WZ, Nasrin Z, Safah H, Jaimes EA, Feng W, Sanders PW, Batuman V. Free light chains injure proximal tubule cells through the STAT1/HMGB1/TLR axis. JCI Insight 2020; 5:137191. [PMID: 32544092 PMCID: PMC7453901 DOI: 10.1172/jci.insight.137191] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 06/10/2020] [Indexed: 12/14/2022] Open
Abstract
Free light chains (FLCs) induce inflammatory pathways in proximal tubule cells (PTCs). The role of TLRs in these responses is unknown. Here we present findings on the role of TLRs in FLC-induced PTC injury. We exposed human kidney PTC cultures to κ and λ FLCs and used cell supernatants and pellets for ELISA and gene expression studies. We also analyzed tissues from Stat1-/- and littermate control mice treated with daily i.p. injections of a κ FLC for 10 days. FLCs increased the expression of TLR2, TLR4, and TLR6 via HMGB1, a damage-associated molecular pattern. Countering TLR2, TLR4, and TLR6 through GIT-27 or specific TLR siRNAs reduced downstream cytokine responses. Blocking HMGB1 through siRNA or pharmacologic inhibition, or via STAT1 inhibition, reduced FLC-induced TLR2, TLR4, and TLR6 expression. Blocking endocytosis of FLCs through silencing of megalin/cubilin, with bafilomycin A1 or hypertonic sucrose, attenuated FLC-induced cytokine responses in PTCs. IHC showed decreased TLR4 and TLR6 expression in kidney sections from Stat1-/- mice compared with their littermate controls. PTCs exposed to FLCs released HMGB1, which induced expression of TLR2, TLR4, and TLR6 and downstream inflammation. Blocking FLCs' endocytosis, Stat1 knockdown, HMGB1 inhibition, and TLR knockdown each rescued PTCs from FLC-induced injury.
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Affiliation(s)
- Rohit Upadhyay
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Wei-Zhong Ying
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Zannatul Nasrin
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Hana Safah
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Edgar A. Jaimes
- Department of Medicine, Renal Service, Memorial Sloan Kettering Cancer Center, New York, New York, USA
| | - Wenguang Feng
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Paul W. Sanders
- University of Alabama at Birmingham, Birmingham, Alabama, USA
- Department of Veterans Affairs Medical Center, Birmingham, Alabama, USA
| | - Vecihi Batuman
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
- Department of Veterans Affairs Southeast Louisiana Veterans Health Care System, New Orleans, Louisiana, USA
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31
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Matsumura H, Furukawa Y, Nakagaki T, Furutani C, Osanai S, Noguchi K, Odaka M, Yohda M, Ohtani H, Michishita Y, Kawabata Y, Kitabayashi A, Ikeda S, Nara M, Komatsuda A, Takahashi N, Wakui H. Multiple Myeloma-Associated Ig Light Chain Crystalline Cast Nephropathy. Kidney Int Rep 2020; 5:1595-1602. [PMID: 32954087 PMCID: PMC7486178 DOI: 10.1016/j.ekir.2020.06.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/10/2020] [Accepted: 06/23/2020] [Indexed: 01/09/2023] Open
Affiliation(s)
- Hirotoshi Matsumura
- Department of Life Science, Graduate School of Engineering Science, Akita University, Akita, Japan
| | - Yusuke Furukawa
- Department of Life Science, Graduate School of Engineering Science, Akita University, Akita, Japan
| | - Takashi Nakagaki
- Department of Life Science, Graduate School of Engineering Science, Akita University, Akita, Japan
| | - Chikako Furutani
- Department of Life Science, Graduate School of Engineering Science, Akita University, Akita, Japan
| | - Sayaka Osanai
- Department of Life Science, Graduate School of Engineering Science, Akita University, Akita, Japan
| | - Keiichi Noguchi
- Instrumentation Analysis Center, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Masafumi Odaka
- Department of Life Science, Graduate School of Engineering Science, Akita University, Akita, Japan
| | - Masafumi Yohda
- Department of Biotechnology and Life Science, Graduate School of Engineering, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Hiroshi Ohtani
- Department of Nephrology, Akita Kousei Medical Center, Akita, Japan
| | | | | | | | - Sho Ikeda
- Department of Hematology, Nephrology, and Rheumatology, Graduate School of Medicine, Akita University, Akita, Japan
| | - Mizuho Nara
- Department of Hematology, Nephrology, and Rheumatology, Graduate School of Medicine, Akita University, Akita, Japan
| | - Atsushi Komatsuda
- Department of Hematology, Nephrology, and Rheumatology, Graduate School of Medicine, Akita University, Akita, Japan
| | - Naoto Takahashi
- Department of Hematology, Nephrology, and Rheumatology, Graduate School of Medicine, Akita University, Akita, Japan
| | - Hideki Wakui
- Department of Life Science, Graduate School of Engineering Science, Akita University, Akita, Japan
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32
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Menè P, De Alexandris L, Moioli A, Raffa S, Stoppacciaro A. Monoclonal Gammopathies of Renal Significance: Renal Biopsy and Beyond. Cancers (Basel) 2020; 12:cancers12071741. [PMID: 32629844 PMCID: PMC7407125 DOI: 10.3390/cancers12071741] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 06/22/2020] [Accepted: 06/28/2020] [Indexed: 12/27/2022] Open
Abstract
Monoclonal Gammopathies of Renal Significance (MGRS) are a rather heterogeneous group of renal disorders caused by a circulating monoclonal (MC) immunoglobulin (Ig) component, often in the absence of multiple myeloma (MM) or another clinically relevant lymphoproliferative disorder. Nevertheless, substantial kidney damage could occur, despite the "benign" features of the bone-marrow biopsy. One example is renal amyloidosis, often linked to a small clone of plasma cells, without the invasive features of MM. However, patients with amyloidosis may present with a nephrotic syndrome and renal failure, eventually leading to end-stage kidney disease. At the same time, other organs, such as the heart and the liver, may be severely damaged by Ig light chains or amyloid deposits, occasionally resulting in fatal arrhythmias and/or organ failure. Acute kidney injury (AKI) may as well result from massive excretion of MC proteins, with deposition disease in glomeruli or renal tubules, not rarely obstructed by luminal aggregates, or "casts". Proliferative glomerulonephritis with monoclonal Ig deposits is another, less frequent clinical presentation of an MGRS. The present review deals with the implications of MGRS for renal function and prognosis, and the potential of tools, such as the renal biopsy, for assessing clinical risk and guiding therapy of the underlying condition.
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Affiliation(s)
- Paolo Menè
- Division of Nephrology, Sant’Andrea University Hospital, Via di Grottarossa 1035–1039, 00189 Rome, Italy
- Correspondence: ; Tel.: +39-(06)-3377-5949
| | - Lorenzo De Alexandris
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
| | - Alessandra Moioli
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
| | - Salvatore Raffa
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
| | - Antonella Stoppacciaro
- Divisions of Nephrology, General Pathology, and Pathology, Department of Clinical and Molecular Medicine, “Sapienza” University of Rome, 00189 Rome, Italy; (L.D.A.); (A.M.); (S.R.); (A.S.)
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33
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New Markers of Renal Failure in Multiple Myeloma and Monoclonal Gammopathies. J Clin Med 2020; 9:jcm9061652. [PMID: 32486490 PMCID: PMC7355449 DOI: 10.3390/jcm9061652] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/22/2020] [Accepted: 05/23/2020] [Indexed: 01/18/2023] Open
Abstract
* Correspondence: kasiajanda@op [...].
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34
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Chanukuppa V, Paul D, Taunk K, Chatterjee T, Sharma S, Shirolkar A, Islam S, Santra MK, Rapole S. Proteomics and functional study reveal marginal zone B and B1 cell specific protein as a candidate marker of multiple myeloma. Int J Oncol 2020; 57:325-337. [PMID: 32377723 DOI: 10.3892/ijo.2020.5056] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Accepted: 02/10/2020] [Indexed: 11/06/2022] Open
Abstract
Multiple myeloma (MM) is a plasma cell‑associated cancer and accounts for 13% of all hematological malignancies, worldwide. MM still remains an incurable plasma cell malignancy with a poor prognosis due to a lack of suitable markers. Therefore, discovering novel markers and targets for diagnosis and therapeutics of MM is essential. The present study aims to identify markers associated with MM malignancy using patient‑derived MM mononuclear cells (MNCs). Label‑free quantitative proteomics analysis revealed a total of 192 differentially regulated proteins, in which 79 proteins were upregulated and 113 proteins were found to be downregulated in MM MNCs as compared to non‑hematological malignant samples. The identified differentially expressed candidate proteins were analyzed using various bioinformatics tools, including Ingenuity Pathway Analysis (IPA), Protein Analysis THrough Evolutionary Relationships (PANTHER), Search Tool for the Retrieval of Interacting Genes/Proteins (STRING) and Database for Annotation, Visualization and Integrated Discovery (DAVID) to determine their biological context. Among the 192 candidate proteins, marginal zone B and B1 cell specific protein (MZB1) was investigated in detail using the RPMI-8226 cell line model of MM. The functional studies revealed that higher expression of MZB1 is associated with promoting the progression of MM pathogenesis and could be established as a potential target for MM in the future.
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Affiliation(s)
- Venkatesh Chanukuppa
- Proteomics Laboratory, National Centre for Cell Science, Pune, Maharashtra 411007, India
| | - Debasish Paul
- Savitribai Phule Pune University, Pune, Maharashtra 411007, India
| | - Khushman Taunk
- Proteomics Laboratory, National Centre for Cell Science, Pune, Maharashtra 411007, India
| | - Tathagata Chatterjee
- Army Hospital (Research and Referral), Dhaula Kuan, New Delhi, Delhi 110010, India
| | | | - Amey Shirolkar
- Proteomics Laboratory, National Centre for Cell Science, Pune, Maharashtra 411007, India
| | - Sehbanul Islam
- Savitribai Phule Pune University, Pune, Maharashtra 411007, India
| | - Manas K Santra
- Cancer Biology and Epigenetics Laboratory, National Centre for Cell Science, Pune, Maharashtra 411007, India
| | - Srikanth Rapole
- Proteomics Laboratory, National Centre for Cell Science, Pune, Maharashtra 411007, India
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Jung M, Lee Y, Lee H, Moon KC. Clinicopathological characteristics of light chain proximal tubulopathy in Korean patients and the diagnostic usefulness of immunohistochemical staining for immunoglobulin light chain. BMC Nephrol 2020; 21:146. [PMID: 32326898 PMCID: PMC7178968 DOI: 10.1186/s12882-020-01813-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 04/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Light chain proximal tubulopathy (LCPT) is a rare paraproteinemic renal disease that has been mostly reported in Western patients. LCPT is characterized by the accumulation of immunoglobulin (Ig)-light chain (LC) in the proximal tubule. Immunohistochemical staining for Ig-LC has not been investigated in the context of LCPT. We reported the clinicopathological characteristics and Ig-LC immunoexpression of patients with LCPT for the first time in Korea. METHODS We reviewed the clinicopathological findings of 5 Korean patients diagnosed with LCPT between 2016 and 2018. In addition, immunohistochemical staining for κ-LC and λ-LC was conducted on paraffin-embedded tissues. RESULTS The median age was 63 years, and the male-to-female ratio was 3:2. The primary renal manifestations were either azotemia or tubular proteinuria. All patients were diagnosed with multiple myeloma with monoclonal κ-LC (#1-2) or λ-LC (#3-5) in the serum and urine. Kidney biopsies revealed diverse and subtle alterations of the proximal tubule, including crystallization, vacuolization, and/or swelling. Electron microscopy revealed crystals in patients #1-2 and non-crystalline particles within numerous/large/dysmorphic lysosomes in patients #3-5. Ig-LC restriction was demonstrated in the proximal tubule as κ-type in patients #1-2 and as λ-type in patients #3-5 by immunohistochemistry and immunofluorescence. Immunohistochemical staining showed diffuse positivity to κ- and λ-LC, although immunofluorescent staining for κ-LC was focal and weak. LCPT has diverse clinicopathological characteristics and subtle morphological alterations, which necessitate ancillary tests for diagnosis. CONCLUSIONS We introduced immunohistochemical staining for Ig-LC as a useful tool for the diagnosis of LCPT, especially in the case of κ-type crystals.
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Affiliation(s)
- Minsun Jung
- Department of Pathology, Seoul National University Hospital, Seoul, 03080, Republic of Korea
| | - Youngeun Lee
- Department of Pathology, Seoul National University Hospital, Seoul, 03080, Republic of Korea
| | - Hajeong Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, 03080, Republic of Korea.,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea
| | - Kyung Chul Moon
- Department of Pathology, Seoul National University Hospital, Seoul, 03080, Republic of Korea. .,Kidney Research Institute, Medical Research Center, Seoul National University College of Medicine, Seoul, 03080, Republic of Korea.
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36
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Multiple morphological phenotypes of monoclonal immunoglobulin disease on renal biopsy: Significance of treatment. Clin Nephrol Case Stud 2020; 8:17-24. [PMID: 32318322 PMCID: PMC7171697 DOI: 10.5414/cncs110052] [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: 11/19/2019] [Accepted: 02/14/2020] [Indexed: 11/18/2022] Open
Abstract
Plasma cell dyscrasias frequently involve the kidney causing renal dysfunction. Multiple morphologic manifestations of κ light chain disease occurring simultaneously in the same kidney biopsy are uncommon and suggest local microenvironment effects in addition to structural properties of the light chain. A 61-year-old female presented with new onset renal failure and proteinuria. Serological workup revealed monoclonal gammopathy with elevated κ : λ ratio of 1,371. Renal biopsy revealed several paraprotein manifestations including κ light chain deposition disease, monoclonal fibrillary glomerulonephritis, cryocrystalglobulenemia and fibrillar/microtubular cast nephropathy. There was also incidental leukocyte chemotactic factor 2 amyloidosis (ALECT 2), negative for κ light chain and confirmed by immunohistochemistry (IHC). Bone marrow biopsy revealed 10 - 20% κ restricted plasma cells. The patient received 10 cycles of CyBorD (cyclophosphamide, bortezomib, and dexamethasone) chemotherapy. Renal function improved with decreased κ : λ ratio. Repeat bone marrow biopsy showed no evidence of abnormal plasma cells by IHC. The renal recovery demonstrates there may be response to chemotherapy irrespective of the morphologic manifestations of light chain-related injury. Additionally, if amyloid is not demonstrated to be of light chain origin, other amyloid types should be considered.
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Abstract
AIM Analysis of etiology, clinical and morphological manifestations, approaches to therapy and prognosis of membranoproliferative glomerulonephritis (MPGN). MATERIALS AND METHODS Cases of MPGN were retrospectively identified in the period 2000-2017 with subsequent analysis of etiology, clinical data and morphology (including deposits of immunoglobulins (Ig) and C3 complement fractions). The achievement of complete and partial remissions (PR, CR), overall survival, progression (by composite endpoint: decrease in the estimated GFR (eGFR) ≥50% from the baseline or eGFR <15 ml/min/1.73 m2 or the onset of dialysis). RESULTS 214 cases of MPGN entered the study with the average age of 44±16 years. Most patients had nephrotic syndrome and significant hematuria. In 58.4% of cases, eGFR was <60 mL/min/1.73 m2, and every fifth patient had CKD 4 or 5 stages. The prevalence of MPGN among all biopsy-confirmed glomerulopathies was 9.3%. Idiopathic MPGN (iMPGN) was detected in 30.4% of cases, secondary MSGN (sMPGN) - in 69.6% (autoimmune diseases - 34.1%, infectious diseases - 16.4%, monoclonal gammopathies - 9.3%, complement-mediated damage - 9.8%). Ig+C3+MPGN was mainly associated with autoimmune diseases and infections; C3-glomerulopathy or thrombotic microangiopathy were most often causes of Ig-C3+MPGN; Ig-C3-/Ig+C3-MPGN had heterogeneous etiology. The median follow-up period was 28 [7; 37] months. The 10-year total cumulative patient and renal survival rates were 71 and 50%, respectively (without differences between sMPGN and iMPGN). The frequency of the PR/CR was 50% (iMPGN - 46.2%, sMPGN - 51.3%) depending on the etiology of the MPGN (p=0.049). The cumulative 10-year progression-free renal survival was nearly 100% in cases with PR/CR and 0% in non-responders. CONCLUSION MPGN is a severe variant of glomerular damage with a heterogeneous etiological structure and an unfavorable prognosis. Targeted clinical and morphological diagnostics of MPGN allows to identify the cause of the disease in most cases. This approach is reliable for the adequate treatment choice and improvement of outcomes in MPGN.
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Affiliation(s)
- V A Dobronravov
- Research Institute of Nephrology, I.P. Pavlov First Saint Petersburg State Medical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
| | - A V Smirnov
- Research Institute of Nephrology, I.P. Pavlov First Saint Petersburg State Medical University of the Ministry of Health of the Russian Federation, Saint Petersburg, Russia
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Kishi S, Obata F, Miki H, Matsuura M, Nishimura K, Tamaki M, Kishi F, Murakami T, Abe H, Nagai K, Abe M, Doi T. Lambda Light Chain Non-crystalline Proximal Tubulopathy with IgD Lambda Myeloma. Intern Med 2018; 57:3597-3602. [PMID: 30101939 PMCID: PMC6355399 DOI: 10.2169/internalmedicine.1323-18] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Light Chain Proximal Tubulopathy (LCPT) is a rare form of paraprotein-related kidney disease in which monoclonal free light chains damage the proximal renal tubular epithelial cells. We herein report the case of a 78-year-old woman who presented with anemia and kidney dysfunction. Serum and urine protein electrophoresis analyses revealed a monoclonal IgD and λ free light chains. Proximal tubular injury and the accumulation of λ light chains were found by kidney biopsy. Electron microscopy revealed no organized structure suggestive of crystals. LCPT was caused by IgD lambda myeloma and bortezomib and dexamethasone therapy led to very good partial response (VGPR) without a worsening of the kidney function.
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Affiliation(s)
- Seiji Kishi
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Fumiaki Obata
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Hirokazu Miki
- Division of Transfusion Medicine and Cell Therapy, Tokushima University Hospital, Japan
| | - Motokazu Matsuura
- Department of Nephrology, Tokushima Red Cross Hospital, Komatsushima, Japan
| | - Kenji Nishimura
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Masanori Tamaki
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Fumi Kishi
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Taichi Murakami
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Hideharu Abe
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Kojiro Nagai
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Masahiro Abe
- Department of Hematology, Endocrinology and Metabolism, Graduate School of Biomedical Sciences, Tokushima University, Japan
| | - Toshio Doi
- Department of Nephrology, Graduate School of Biomedical Sciences, Tokushima University, Japan
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Mii A, Shimizu A, Takada D, Tsuruoka S. Proliferative glomerulonephritis with unusual microlamellar organized deposits related to monoclonal immunoglobulin G3 (IgG3) kappa. CEN Case Rep 2018; 7:320-324. [PMID: 29987665 DOI: 10.1007/s13730-018-0351-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 07/02/2018] [Indexed: 12/12/2022] Open
Abstract
A 71-year-old woman presented with massive proteinuria and microhematuria. Renal biopsy showed diffuse global membranoproliferative and endocapillary proliferative lesions with leukocytic infiltration and an irregular duplication of the glomerular basement membrane on light microscopy. Immunofluorescence study showed granular deposits of monoclonal immunoglobulin G3 (IgG3) kappa, C3, and C1q in the glomeruli. Electron microscopy revealed unique structurally organized microlamellar electron-dense deposits. There was no evidence of systemic diseases such as paraproteinemia, cryoglobulinemia, or systemic lupus erythematosus. Following renal biopsy, the oral administration of mizoribine in addition to predonisolone gradually improved the patient's clinical status. So far, partial remission has continued for a year, and she has not been affected with hematopoietic or lymphoproliferative disorders. We report a case of proliferative glomerulonephritis with unusual microlamellar organized deposits related to monoclonal IgG3 kappa. Our case was immunologically identical to proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID). Therefore, we concluded that our case should be categorized as an atypical form of PGNMID, though it was difficult to diagnose using the usual diagnostic approach to glomerular diseases with organized deposits.
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Affiliation(s)
- Akiko Mii
- Department of Nephrology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan.
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, Tokyo, Japan
| | - Daisuke Takada
- Department of Nephrology, Kita-Asaka Station Clinic, Saitama, Japan.,Department of Nephrology, Tama Nagayama Takada Clinic, Tokyo, Japan
| | - Shuichi Tsuruoka
- Department of Nephrology, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan
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40
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Kinoshita Y, Fukumoto S. X-Linked Hypophosphatemia and FGF23-Related Hypophosphatemic Diseases: Prospect for New Treatment. Endocr Rev 2018; 39:274-291. [PMID: 29381780 DOI: 10.1210/er.2017-00220] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/23/2018] [Indexed: 12/21/2022]
Abstract
Phosphate plays essential roles in many biological processes, and the serum phosphate level is tightly controlled. Chronic hypophosphatemia causes impaired mineralization of the bone matrix and results in rickets and osteomalacia. Fibroblast growth factor 23 (FGF23) is a bone-derived hormone that regulates phosphate metabolism. FGF23 excess induces hypophosphatemia via impaired phosphate reabsorption in the renal proximal tubules and decreased phosphate absorption in the intestines. There are several types of genetic and acquired FGF23-related hypophosphatemic diseases. Among these diseases, X-linked hypophosphatemia (XLH), which is caused by inactivating mutations in the phosphate-regulating endopeptidase homolog, X-linked (PHEX) gene, is the most prevalent form of genetic FGF23-related hypophosphatemic rickets. Another clinically relevant form of FGF23-related hypophosphatemic disease is tumor-induced osteomalacia (TIO), a paraneoplastic syndrome associated with FGF23-producing tumors. A combination of active vitamin D and phosphate salts is the current medical therapy used to treat patients with XLH and inoperative TIO. However, this therapy has certain efficacy- and safety-associated limitations. Several measures to inhibit FGF23 activity have been considered as possible new treatments for FGF23-related hypophosphatemic diseases. In particular, a humanized monoclonal antibody for FGF23 (burosumab) is a promising treatment in patients with XLH and TIO. This review will focus on the phosphate metabolism and the pathogenesis and treatment of FGF23-related hypophosphatemic diseases.
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Affiliation(s)
- Yuka Kinoshita
- Division of Nephrology and Endocrinology, Department of Medicine, The University of Tokyo Hospital, Tokyo, Japan
| | - Seiji Fukumoto
- Fujii Memorial Institute of Medical Sciences, Institute of Advanced Medical Sciences, Tokushima University, Tokushima, Japan
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41
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Mulay SR, Shi C, Ma X, Anders HJ. Novel Insights into Crystal-Induced Kidney Injury. KIDNEY DISEASES 2018; 4:49-57. [PMID: 29998119 DOI: 10.1159/000487671] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 02/14/2018] [Indexed: 01/04/2023]
Abstract
Background The entity of crystal nephropathies encompasses a spectrum of different kidney injuries induced by crystal-formed intrinsic minerals, metabolites, and proteins or extrinsic dietary components and drug metabolites. Depending on the localization and dynamics of crystal deposition, the clinical presentation can be acute kidney injury, progressive chronic kidney disease, or renal colic. Summary The molecular mechanisms involving crystal-induced injury are diverse and remain poorly understood. Type 1 crystal nephropathies arise from crystals in the vascular lumen (cholesterol embolism) or the vascular wall (atherosclerosis) and involve kidney infarcts or chronic ischemia, respectively. Type 2 crystal nephropathies arise from intratubular crystal deposition causing obstruction, interstitial inflammation, and tubular cell injury. NLRP3 inflammasome and necroptosis drive renal necroinflammation in acute settings. Type 3 is represented by crystal and stone formation in the draining urinary tract, i.e., urolithiasis, causing renal colic and chronic obstruction. Key Messages Dissecting the types of injury is the first step towards a better understanding of the pathophysiology of crystal nephropathies. Crystal-induced acti-vation of the inflammasome and necroptosis, crystal adhesion, crystallization inhibitors, extratubulation, and granulo-ma formation are only a few of certainly many involved pathomechanisms that deserve further studies to eventually form the basis for innovative cures for these diseases.
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Affiliation(s)
- Shrikant R Mulay
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU Munich, Munich, Germany
| | - Chongxu Shi
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU Munich, Munich, Germany
| | - Xiaoyuan Ma
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU Munich, Munich, Germany
| | - Hans Joachim Anders
- Division of Nephrology, Medizinische Klinik und Poliklinik IV, Klinikum der Universität München, LMU Munich, Munich, Germany
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42
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Mori A, Watanabe S, Tsuruga K, Joh K, Tanaka H. Free light chain-associated Fanconi syndrome in an adolescent. Pediatr Int 2017; 59:1281-1282. [PMID: 29205674 DOI: 10.1111/ped.13430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 08/11/2017] [Accepted: 10/02/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Ayaka Mori
- Department of Pediatrics, Hirosaki University Hospital, Hirosaki, Japan
| | - Shojiro Watanabe
- Department of Pediatrics, Hirosaki University Hospital, Hirosaki, Japan
| | - Kazushi Tsuruga
- Department of Pediatrics, Hirosaki University Hospital, Hirosaki, Japan
| | - Kensuke Joh
- Department of Pathology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Hiroshi Tanaka
- Department of Pediatrics, Hirosaki University Hospital, Hirosaki, Japan.,Department of School Health Science, Hirosaki University Faculty of Education, Hirosaki, Japan
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Pirozzi N, Stoppacciaro A, Menè P. Dominant C3 glomerulopathy: new roles for an old actor in renal pathology. J Nephrol 2017; 31:503-510. [PMID: 29151252 DOI: 10.1007/s40620-017-0458-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/31/2017] [Indexed: 12/14/2022]
Abstract
Recently, a number of reports have described dominant C3 deposits in renal biopsies of patients with infection-related glomerulonephritis (GN). While acute post-infectious GN and membranoproliferative GN are commonly characterized by immune deposits containing C3 and/or C4, the absence of immunoglobulin (Ig) and/or immune complexes at light or electron microscopy is a rather unusual observation. Dominant C3 deposition is believed to result from the alternative pathway of complement activation via the C3bBb "tickover" convertase. The actual occurrence of C3 glomerulopathy could be underestimated, since infection-related GN often quickly subsides without the need for a renal biopsy. A more thorough understanding of the pathways that lead to complement assembly and deposition within the kidney is needed to support a new classification of complement-related lesions, including entities such as dense deposit disease, (atypical) hemolytic-uremic syndrome, dominant C1q, CFHR5, C4d, and C3 glomerulopathies. We will briefly review recent work in this area, focusing on GN with selective complement C3 deposits.
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Affiliation(s)
- Nicola Pirozzi
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy
- Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy
| | - Antonella Stoppacciaro
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy
- Division of Pathology, Sant'Andrea University Hospital, Rome, Italy
| | - Paolo Menè
- Department of Clinical and Molecular Medicine, University of Rome "La Sapienza", Rome, Italy.
- Chair and Division of Nephrology, Sant'Andrea University Hospital, Rome, Italy.
- UOC Nefrologia, A.O. Sant'Andrea, Via di Grottarossa 1035-1039, 00189, Rome, Italy.
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44
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Faiman B. Disease and Symptom Care: A Focus on Specific Needs of Patients With Multiple Myeloma. Clin J Oncol Nurs 2017; 21:3-6. [PMID: 28945733 DOI: 10.1188/17.cjon.s5.3-6] [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: 11/17/2022]
Abstract
Patients with multiple myeloma (MM) often deal with short- and long-term side effects of the treatment and disease sequelae. Reasons for inadequately managed symptoms are multifactorial (e.g., the patient may fear treatment interruption, the clinician does not assess or address the symptoms) and can affect patients' ability to remain on the recommended treatment. This article provides background surrounding this supplement's development and describes the importance of symptom assessment and management.
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45
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Brigle K, Pierre A, Finley-Oliver E, Faiman B, Tariman J, Miceli T, Board A. Myelosuppression, Bone Disease, and Acute Renal Failure: Evidence-Based Recommendations for Oncologic Emergencies. Clin J Oncol Nurs 2017; 21:60-76. [DOI: 10.1188/17.cjon.s5.60-76] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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46
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Faiman B, Doss D, Colson K, Mangan P, King T, Tariman J, Board A. Renal, GI, and Peripheral Nerves: Evidence-Based Recommendations for the Management of Symptoms and Care for Patients With Multiple Myeloma. Clin J Oncol Nurs 2017; 21:19-36. [DOI: 10.1188/17.cjon.s5.19-36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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47
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Gammapatías monoclonales de significado renal. Nefrologia 2017; 37:465-477. [DOI: 10.1016/j.nefro.2017.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2016] [Revised: 03/13/2017] [Accepted: 03/14/2017] [Indexed: 01/02/2023] Open
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48
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Thrombotic microangiopathy associated with monoclonal gammopathy following autologous hematopoietic stem cell transplantation for neuroblastoma in a young child. Bone Marrow Transplant 2017; 52:1662-1664. [PMID: 28825693 DOI: 10.1038/bmt.2017.181] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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49
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Best Rocha A, Larsen CP. Membranous Glomerulopathy With Light Chain-Restricted Deposits: A Clinicopathological Analysis of 28 Cases. Kidney Int Rep 2017; 2:1141-1148. [PMID: 29270522 PMCID: PMC5733688 DOI: 10.1016/j.ekir.2017.07.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/17/2017] [Accepted: 07/24/2017] [Indexed: 02/07/2023] Open
Abstract
Introduction Membranous glomerulopathy (MG) is a common cause of nephrotic syndrome that results from the formation of immune complexes along the subepithelial aspect of the glomerular basement membranes. Although it is most frequently caused by polytypic deposits, cases with light chain isotype-restricted deposits are rarely seen. Methods We conducted a retrospective analysis of 28 cases of MG that showed light chain isotype restriction. Results The mean age at diagnosis was 62.2 years and the male-to-female ratio was 1. All patients presented with proteinuria (73.1% nephrotic range), and the mean serum creatinine was 1.5 mg/dl. Six patients had an underlying lymphoproliferative disorder (LPD), 2 had autoimmune disease, and 1 patient was positive for both hepatitis B and syphilis. Only 1 of the patients with an LPD had a detectable monoclonal Ig. Four patients (14.3%) showed focal proliferation or crescents, 3 of whom had an underlying LPD. Kappa (κ) restriction was seen in 26 of 28 patients (85.7%). Staining for IgG subclasses was performed in 19 cases, 14 of which showed positive staining for a single subclass. PLA2R was positive in 7 of 27 cases. 30% of PLA2R-negative patients and 28.6% of those with positive staining for a single IgG subclass had an associated LPD. Discussion The majority of MG cases with light chain isotype-restricted deposits lack a recognizable secondary etiology. However, the absence of PLA2R positivity, positive staining for a single IgG subclass, and presence of focal proliferation are worrisome histopathologic features that should prompt a thorough clinical workup to exclude the presence of an underlying LPD.
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50
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Khalighi MA, Revelo MP, Abraham JD, Shihab F, Ahmed F. Light Chain Podocytopathy Mimicking Recurrent Focal Segmental Glomerulosclerosis. Am J Transplant 2017; 17:824-829. [PMID: 27775221 DOI: 10.1111/ajt.14088] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 10/06/2016] [Accepted: 10/09/2016] [Indexed: 01/25/2023]
Abstract
Kidney injury related to paraproteinemia is common and typically occurs after the fourth decade of life in association with an underlying plasma cell dyscrasia or other lymphoproliferative disease. Kidney transplantation in paraprotein-related kidney disease can be successful in conjunction with treatment of the underlying hematopoietic process; however, when hematologic response to therapy is not achieved, recurrent kidney injury is frequently seen. We describe a young male patient who presented at the age of 23 years with end-stage kidney disease thought to be secondary to focal segmental glomerulosclerosis; this patient ultimately received two kidney allografts. He experienced recurrent proteinuria in both kidneys, with a biopsy from his second allograft showing kappa-restricted crystalline light chain podocytopathy, which was identified in both his native and first allograft kidneys upon retrospective review. Recurrent light chain podocytopathy has not been previously reported but poses a diagnostic challenge as it can mimic focal segmental glomerulosclerosis, particularly in young patients in whom paraprotein-related kidney injury is usually not suspected.
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Affiliation(s)
- M A Khalighi
- Department of Pathology, University of Utah, Salt Lake City, UT
| | - M P Revelo
- Department of Pathology, University of Utah, Salt Lake City, UT
| | - J D Abraham
- Division of Nephrology, University of Utah, Salt Lake City, UT
| | - F Shihab
- Division of Nephrology, University of Utah, Salt Lake City, UT
| | - F Ahmed
- Division of Nephrology, University of Utah, Salt Lake City, UT
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