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Pornchai A, Moua T. Dyspnea and cough in a 68-year-old female with light chain deposition disease. Respir Med Case Rep 2023; 43:101839. [PMID: 37021143 PMCID: PMC10068249 DOI: 10.1016/j.rmcr.2023.101839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 01/31/2023] [Accepted: 03/17/2023] [Indexed: 03/28/2023] Open
Abstract
Light chain deposition disease (LCDD) is a rare hematologic disorder characterized by non-amyloid monoclonal immunoglobulin light chain deposition in multiple organs. Pulmonary LCDD (PLCDD) is an uncommon manifestation of LCDD usually seen in middle-aged patients presenting with radiologic cystic and nodular findings. We report the case of a 68-year-old female who presented with shortness of breath and atypical chest pain. Chest computerized tomography (CT) scan revealed numerous diffuse but basilar predominant pulmonary cysts and mild bronchiectasis without nodular disease. Given concomitant abnormal renal function and hepatic laboratory indices, she underwent biopsy of both organs confirming the presence of LCDD. Directed chemotherapy was initiated and stabilized renal and hepatic progression, but on follow-up imaging, pulmonary disease appeared worse. While therapeutic options targeting other organ involvement are available, their directed efficacy for progressive lung disease is not well known.
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Affiliation(s)
| | - Teng Moua
- Corresponding author. Division of Pulmonary and Critical Care Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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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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Huang J, Sun C, Su H, Zhang C, Xiong J. Bortezomib-Based Chemotherapy with Autologous Stem Cell Transplantation for Monoclonal Gammopathy of Renal Significance: A Case Report and Literature Review. Kidney Blood Press Res 2019; 44:858-869. [PMID: 31352451 DOI: 10.1159/000501314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 06/02/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The term monoclonal gammopathy of renal significance (MGRS) was introduced in 2012 to emphasize kidney lesions in monoclonal gammopathy patients. Bortezomib-based chemotherapy has become the first-line treatment for MGRS. OBJECTIVES The objective of this study was to investigate whether the strategy of combining chemotherapy with autologous stem cell transplantation (ASCT) could improve prognosis and decrease functional kidney impairment in patients with MGRS. METHODS We reported the case of a 44-year-old Asian patient who was diagnosed with MGRS and received 5 cycles of Velcade® (a trade name for bortezomib), thalidomide, and dexamethasone therapy (VTD therapy), and subsequently underwent ASCT. In addition, we performed a literature review and summarized the latest advances in the characterization, treatment, and prognosis of MGRS. RESULTS The patient was diagnosed with light chain deposition disease by renal biopsy. After 5 cycles of VTD therapy, the patient had a very good partial response characterized by the resolution of M-protein (20.2% before treatment vs. 2.5% after treatment), remission of the level of serum free lambda (FLAM; over 80% decline), and normalization of the serum free light chain (sFLC) ratio (κ to λ). He also had a renal response characterized by a decreased serum creatinine level (1.61 vs.1.34 mg/dL) and less severe proteinuria (6.77 g/24 h vs.1.264 g/24 h) after chemotherapy. Importantly, after ASCT, the patient achieved a complete response (CR) characterized by a negative serum immunofixation electrophoresis (IFE) result and a dramatic decrement in FLAM (over 90%). Furthermore, 6 months after ASCT, the patient still remained in stable condition with a negative IFE result, normal sFLC ratio, and low level of serum creatinine (1.31 mg/dL) and proteinuria (0.339 g/24 h). In our retrospective literature analysis, we found that MGRS patient survival time and renal outcome had been markedly improved by current therapies due to the popularization of bortezomib-based chemotherapy and ASCT. CONCLUSIONS The patient successfully achieved CR after VTD therapy followed by ASCT. However, this treatment is controversial, and a standard therapy recommendation for MGRS has not been established. Bortezomib-based chemotherapy combined with ASCT may have prospects for the treatment of MGRS, but the exact effects of ASCT remain unclear and should be thoroughly investigated.
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Affiliation(s)
- Jing Huang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chunyan Sun
- Department of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Chun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Xiong
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,
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Mohan M, Buros A, Mathur P, Gokden N, Singh M, Susanibar S, Jo Kamimoto J, Hoque S, Radhakrishnan M, Matin A, Davis C, Grazziutti M, Thanendrarajan S, van Rhee F, Zangari M, Davies F, Morgan G, Epstein J, Barlogie B, Schinke C. Clinical characteristics and prognostic factors in multiple myeloma patients with light chain deposition disease. Am J Hematol 2017; 92:739-745. [PMID: 28383130 DOI: 10.1002/ajh.24756] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 03/24/2017] [Accepted: 04/03/2017] [Indexed: 12/14/2022]
Abstract
Light chain deposition disease (LCDD) is characterized by monotypic immunoglobulin depositions which will eventually lead to loss of organ function if left untreated. While the kidney is almost always affected, the presence and degree of LCDD in other organs vary. Ten to thirty percent of LCDD patients have underlying Multiple Myeloma (MM), yet outcome and prognostic markers in this particular patient group are still lacking. Here, we analyzed 69 patients with MM and biopsy proven LCDD and report on renal and extra-renal involvement and its impact on prognosis as well as renal response depending on hematologic response. Coexisting light chain diseases such as AL amyloid and cast nephropathy were found in 30% of patients; those with LCDD and concurrent amyloid tended to have shorter survival. Cardiac involvement by LCDD was seen in one-third of our patients and was associated with shorter overall survival; such patients also had a significantly higher risk of treatment-related mortality (TRM) after stem cell transplant (SCT) compared to LCDD patients without cardiac involvement. This study highlights that MM patients with LCDD present with different clinical features compared to previously reported LCDD cohorts. Rapid initiation of treatment is necessary to prevent progressive renal disease and worse outcome. Coexisting light chain diseases and cardiac involvement are more common than previously reported and confer worse clinical outcome, emphasizing the need for careful patient careful patient evaluation and treatment selection.
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Affiliation(s)
- Meera Mohan
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Amy Buros
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Pankaj Mathur
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Neriman Gokden
- Department of Pathology; University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Manisha Singh
- Division for Nephrology; Department of Medicine, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Sandra Susanibar
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Jorge Jo Kamimoto
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Shadiqul Hoque
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | | | - Aasiya Matin
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Cynthia Davis
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Monica Grazziutti
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | | | - Frits van Rhee
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Maurizio Zangari
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Faith Davies
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Gareth Morgan
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Joshua Epstein
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Bart Barlogie
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
| | - Carolina Schinke
- Myeloma Institute, University of Arkansas for Medical Sciences; Little Rock Arkansas
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Rekhtina IG, Mendeleeva LP, Biryukova LS. [Light-chain deposition disease is a hematologic problem]. TERAPEVT ARKH 2017; 89:38-42. [PMID: 28252625 DOI: 10.17116/terarkh201789138-42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
AIM To analyze clinical and laboratory data and treatment results in patients with light-chain deposition disease (LCDD). SUBJECTS AND METHODS Nine patients with LCDD and kidney injury were examined. The diagnosis was based on the results of light and immunofluorescence microscopy of renal biopsy specimens. All the patients received bortezomib, cyclophosphamide, and dexamethasone (VCD) induction therapy. RESULTS Six patients were diagnosed with multiple myeloma; in 3 patients LCDD was considered within monoclonal gammopathy manly involving the kidney. By the initiation of therapy, all the patients were diagnosed as having chronic kidney disease (Stage III (n=2), Stage IV (n=2), and dialysis-related renal failure (n=5)). After the VCD treatment, 7 of 9 patients achieved a hematologic response. Second-line therapy with lenalidomide proved to be effective in the other 2 cases. Five patients achieved complete remission; 3 had a very good partial remission. Thereafter, 2 patients received high-dose melphalan chemotherapy and autologous hematopoietic stem cell transplantation. Better renal function was noted in only 2 cases. CONCLUSION Despite the high efficiency of therapy aimed to reduce monoclonal light chains; improved renal function was observed in only 2 (22%) patients. Such low rates of a renal response were due to the late initiation of therapy.
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Affiliation(s)
- I G Rekhtina
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - L P Mendeleeva
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - L S Biryukova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
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Rekhtina IG, Mendeleeva LP, Stolyarevich ES, Galtseva IV, Povilaitite PE, Biryukova LS. [Secondary monoclonal gammopathy after bone marrow autotransplantation as a cause of worse renal function in light chain immunoglobulin deposition disease]. TERAPEVT ARKH 2016; 88:80-83. [PMID: 27296267 DOI: 10.17116/terarkh201688680-83] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper describes a clinical case of a female woman with nephropathy due to light chain deposition disease caused by secretion of κ Bence-Jones protein. Complete immunochemical remission was achieved after induction therapy using a bortezomib + cyclophosphamide + dexamethasone regimen. Renal function remained unchanged (glomerular filtration rate 16 ml/min), there was a reduction in proteinuria from 5.8 to 2.6 g/day. High-dose melphalan (200 mg/m2) chemotherapy with peripheral blood stem cell autotransplantation was performed as consolidation of remission. A year posttransplantation, there was no secretion of κ light chains; however, monoclonal IgG lambda emerged in a quantity of 3.2 g/l. At the same period, nephrotic syndrome became progressive (daily proteinuria 12 g) and dialysis-dependent renal failure developed. A repeat renal biopsy specimen revealed changes, suggesting that there was a decrease in renal deposits of κ light chains. Simultaneously with this, the obvious negative trend as progressive nephrosclerosis and fixation of IgG and λ light chains in the glomeruli (in the sclerotic areas) cause IgGλ monoclonal protein to be involved in the genesis of further kidney injury. Attention is also paid to different characteristics of capillary wall deposits by density (according to the electron microscopic findings), which may point to their different qualitative composition and possibly different formation duration. Papaprotein Gλ disappeared after a year without therapy, suggesting its reactivity. The findings confirm that worse renal function is caused by the action of paraprotein Gλ due to secondary (after autologous hematopoietic stem cells transplantation) monoclonal gammopathy.
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Affiliation(s)
- I G Rekhtina
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - L P Mendeleeva
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | - E S Stolyarevich
- A.I. Evdokimov Moscow State University of Medicine and Dentistry, Ministry of Health of Russia, Moscow, Russia
| | - I V Galtseva
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
| | | | - L S Biryukova
- Hematology Research Center, Ministry of Health of Russia, Moscow, Russia
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Sivaraj D, Green MM, Ciftci AM, Zahid MF, Johns AA, Ross M, Gasparetto C. Can We Cure Light Chain Deposition Disease of the Kidneys?-A Review and Case Report of a Patient Treated With a Triple Transplant Approach. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:e95-e100. [PMID: 27101986 DOI: 10.1016/j.clml.2016.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2016] [Revised: 03/01/2016] [Accepted: 03/21/2016] [Indexed: 02/06/2023]
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Hematologic Response and Stabilization of Renal Function in a Patient With Light Chain Deposition Disease After Lenalidomide Treatment: A Novel Therapeutic Approach? CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:e179-81. [DOI: 10.1016/j.clml.2014.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2013] [Revised: 04/11/2014] [Accepted: 06/04/2014] [Indexed: 11/22/2022]
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Tovar N, Cibeira MT, Rosiñol L, Solé M, Larrea CF, Escoda L, Rovira M, Bladé J. Bortezomib/dexamethasone followed by autologous stem cell transplantation as front line treatment for light-chain deposition disease. Eur J Haematol 2012; 89:340-4. [DOI: 10.1111/j.1600-0609.2012.01821.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/07/2012] [Indexed: 11/30/2022]
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JIMENEZ-ZEPEDA VH. Light chain deposition disease: novel biological insights and treatment advances. Int J Lab Hematol 2012; 34:347-55. [DOI: 10.1111/j.1751-553x.2012.01419.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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