1
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Dunton A, Jain S. Cryocrystalglobulinemia Leading to Multi-Organ Failure in Chronic Lymphocytic Leukemia Achieving Complete Renal Recovery. J Hematol 2023; 12:287-293. [PMID: 38188472 PMCID: PMC10769646 DOI: 10.14740/jh1212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 12/07/2023] [Indexed: 01/09/2024] Open
Abstract
Cryocrystalglobulinemia (CCG) is a rare and fatal subset of type I cryoglobulinemia that is classically associated with an underlying monoclonal gammopathy. Cryocrystalglobulins are created when immunoglobulins self-assemble into extracellular crystal arrays, which often leads to severe systemic hypoperfusion and occlusive vasculopathy that culminates in multi-organ failure. Most commonly, the resultant ischemia manifests as cutaneous lesions and renal insufficiency, which can progress to fulminant kidney failure requiring renal replacement therapy. CCG is commonly associated with lymphoproliferative disorders and is most frequently reported in the literature in context of plasma cell dyscrasias with minimal cases describing CCG secondary to other types of lymphoid neoplasms, especially those that attain complete organ recovery. We report a unique case of a patient who presented with multi-organ failure, including cryoglobulinemic glomerulonephritis (CryoGN) consistent with monoclonal gammopathy of renal significance (MGRS), who was found to have type I IgG kappa CCG due to chronic lymphocytic leukemia (CLL). With the assistance of plasmapheresis, hemodialysis, and clone-directed therapy, the patient achieved complete renal recovery. We highlight this uncommon entity to emphasize the clinical importance of early diagnosis and timely treatment given CCG's significant morbidity and mortality.
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Affiliation(s)
- Ashley Dunton
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL 60612, USA
| | - Shivi Jain
- Department of Internal Medicine, Division of Hematology, Oncology, and Cellular Therapy, Rush University Medical Center, Chicago, IL 60612, USA
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2
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Li JP, Du YT, Guo C, Rao XR, Li S. IgA nephropathy to proliferative glomerulonephritis with monoclonal IgAκ deposits: a pattern switch. J Nephrol 2023; 36:2375-2380. [PMID: 36913081 PMCID: PMC10638190 DOI: 10.1007/s40620-023-01583-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 01/13/2023] [Indexed: 03/14/2023]
Abstract
We report the case of a 31-year-old male who presented with repeated episodes of nephritic-nephrotic syndrome in concomitance with infection. IgA was diagnosed and was initially responsive to treatment with immunosuppressors but further disease flare did not respond to treatment. Based on three consecutive renal biopsies over 8 years, a pattern switch from endocapillary proliferative IgA nephropathy to membranous proliferative glomerulonephritis with monoclonal IgAκ deposits was observed. Bortezomib-dexamethasone combination therapy finally led to a favorable renal response. This case provides new insights into the pathophysiological mechanisms of proliferative glomerulonephritis with monoclonal immunoglobin deposits (PGNMID), highlighting the importance of repeat renal biopsies and routine evaluation of monoclonal immunoglobin deposits in proliferative glomerulonephritis with refractory nephrotic syndrome.
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Affiliation(s)
- Jin-Pu Li
- Renal Division, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St. Xicheng District, Beijing, People's Republic of China
| | - Ya-Ting Du
- Renal Division, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St. Xicheng District, Beijing, People's Republic of China
| | - Chuan Guo
- Renal Division, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St. Xicheng District, Beijing, People's Republic of China
| | - Xiang-Rong Rao
- Renal Division, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St. Xicheng District, Beijing, People's Republic of China.
| | - Shen Li
- Renal Division, Guang'anmen Hospital, China Academy of Chinese Medical Sciences, No. 5 Beixiange St. Xicheng District, Beijing, People's Republic of China.
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3
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Angioi A, Lepori N, Derudas D, Floris M, Mascia G, Cabiddu G, Pani A. [Classification and Management of MGRS Related Diseases]. G Ital Nefrol 2023; 40:2023-S81. [PMID: 38007837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/28/2023]
Abstract
Monoclonal Gammopathies of Renal Significance (MGRS) are a complex group of disorders characterized by the production of aberrant monoclonal proteins that interact with kidney structures, causing tissue damage. Unlike neoplastic forms, kidney damage in MGRS does not correlate with clone mass or circulating monoclonal protein levels, conferring unique pre-neoplastic or non-neoplastic properties to the responsible clones. This manuscript explores the heterogeneity of monoclonal proteins involved, varying from full immunoglobulins to free light chains (FLC), and how they result in a spectrum of kidney lesions with differing prognoses. We also elaborate on diagnostic challenges, emphasizing the indispensable role of kidney biopsy, including advanced techniques like laser microdissection and mass spectrometry (LMD/MS) for deposit characterization, particularly in ambiguous or complex cases. Clinical management and treatment considerations, including the necessity for clone identification, are also discussed.
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Affiliation(s)
- Andrea Angioi
- SCDU Nefrologia, Dialisi e Trapianto Renale ARNAS G. Brotzu, Cagliari
| | - Nicola Lepori
- SCDU Nefrologia, Dialisi e Trapianto Renale ARNAS G. Brotzu, Cagliari
| | | | - Matteo Floris
- SCDU Nefrologia, Dialisi e Trapianto Renale ARNAS G. Brotzu, Cagliari
| | - Giacomo Mascia
- SCDU Nefrologia, Dialisi e Trapianto Renale ARNAS G. Brotzu, Cagliari
| | | | - Antonello Pani
- SCDU Nefrologia, Dialisi e Trapianto Renale ARNAS G. Brotzu, Cagliari
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4
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Qin AB, Yu XJ, Zheng XZ, Wang SX, Zhou FD, Zhao MH. Lessons for the clinical nephrologist: a rare case with MGRS characterized by combined crystalline light chain proximal tubulopathy and crystal-storing histiocytosis responding to daratumumab. J Nephrol 2023; 36:1203-1207. [PMID: 36856974 DOI: 10.1007/s40620-023-01584-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 01/13/2023] [Indexed: 03/02/2023]
Affiliation(s)
- Ai-Bo Qin
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiao-Juan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Xi-Zi Zheng
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, Beijing, 100034, China
| | - Fu-de Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, China. .,Institute of Nephrology, Peking University, Beijing, China. .,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China. .,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China. .,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China. .,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, No. 8, Xishiku Street, Xicheng District, Beijing, China.,Institute of Nephrology, Peking University, Beijing, China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases, Chinese Academy of Medical Sciences, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Beijing, China
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5
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Kaur J, Valisekka SS, Hameed M, Bandi PS, Varma S, Onwughalu CJ, Ibrahim H, Mongia H. Monoclonal Gammopathy of Undetermined Significance: A Comprehensive Review. Clin Lymphoma Myeloma Leuk 2023; 23:e195-e212. [PMID: 36966041 DOI: 10.1016/j.clml.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 02/13/2023] [Accepted: 02/16/2023] [Indexed: 02/24/2023]
Abstract
Monoclonal Gammopathy of Undetermined Significance (MGUS) is an asymptomatic premalignant plasma cell dyscrasia with a predominate rise of the IgG immunoglobulin fraction without end-organ damage, often diagnosed incidentally. Despite its progression into various subsequent forms of hematological malignancies, MGUS remains underdiagnosed. A literature search was conducted using the Medline, Cochrane, Embase, and Google Scholar databases, including articles published until December 2022. Keywords used encompassed "Monoclonal Gammopathy of Undetermined Significance," "Plasma Cell dyscrasia," "Monoclonal gammopathy of renal significance," and "IgM Monoclonal gammopathy of Undetermined Significance," This study aimed to conduct a critical review to update knowledge regarding the pathophysiology, risk factors, clinical features, diagnostic protocols, complications, and current and novel treatments for MGUS. We recommend a multidisciplinary approach to manage MGUS due to the complexity of the illness's etiology, diagnosis, and therapy. This comprehensive review also highlights future prospects, such as developing screening protocols for at-risk populations, prevention of disease progression by early diagnosis through genome-wide association studies, and management using Daratumumab and NSAIDs.
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Affiliation(s)
- Jasneet Kaur
- Internal Medicine, Nassau University Medical Center, East Meadow, New York, USA..
| | | | - Maha Hameed
- Internal Medicine, Florida State University/Sarasota Memorial Hospital, Sarasota, Florida, USA.
| | | | | | | | - Hany Ibrahim
- Ain Shams University, Faculty of Medicine, Cairo, Egypt.
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6
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Lafargue MC, Cohen C. [Latest updates on immunotactoid glomerulopathy and fibrillary glomerulonephritis]. Bull Cancer 2023:S0007-4551(23)00041-3. [PMID: 36803980 DOI: 10.1016/j.bulcan.2022.12.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/10/2022] [Accepted: 12/18/2022] [Indexed: 02/17/2023]
Abstract
Various hematologic malignancies can lead to renal complications. The most common of these hemopathies to affect the kidney is multiple myeloma, however an increasing number of kidney diseases are associated with other monoclonal gammopathies. It is recognized that clones in small abundance can be responsible for severe organ damage, thus the concept of monoclonal gammopathy of renal significance (MGRS) has emerged. Although the hemopathy in these patients is more consistent with monoclonal gammopathy of undetermined significance (MGUS) than with multiple myeloma, the diagnosis of a renal complication changes the therapeutic management. Preservation and restoration of renal function is possible with treatment targeting the responsible clone. In this article, we take as an example immunotactoid and fibrillary glomerulopathies, two distinct entities with different etiologies and consequently different management. Immunotactoid glomerulopathy is most often associated with monoclonal gammopathy or chronic lymphocytic leukemia, the deposits on renal biopsy are monotypic, and treatment is therefore based on clone targeting. Fibrillary glomerulonephritis, on the other hand, is caused by autoimmune diseases or solid cancers. Deposits on renal biopsy are in the vast majority polyclonal. There is a specific immunohistochemical marker, DNAJB9, and treatment is less well established.
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Affiliation(s)
- Marie-Camille Lafargue
- Université Paris Cité, Assistance Publique-hôpitaux de Paris, hôpital Necker, service de néphrologie, 149, rue de Sèvres, 75015 Paris, France
| | - Camille Cohen
- Inserm U1151 « mechanisms and therapeutic strategies of chronic kidney diseases », hôpital Necker, université Paris Cité, service de néphrologie et transplantation rénale, hôpital Necker, Assistance Publique-hôpitaux de Paris, Paris, France.
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7
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Randone P, Burdese M, Barreca A, Oliva S, Sanna E, Abbasciano I, Anania P, Boaglio E, Biancone L. The Matter of Kidney Biopsy in Monoclonal Gammopathy of Renal Significance: A Case Report of a New Pattern of Immunoglobulin-Storing Histiocytosis. Case Rep Nephrol Dial 2023; 13:191-196. [PMID: 38107466 PMCID: PMC10723809 DOI: 10.1159/000533913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 08/30/2023] [Indexed: 12/19/2023] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) represents a group of disorders, characterized by paraproteinemia which causes renal damage. These disorders never meet the diagnostic criteria for multiple myeloma (MM) or lymphoproliferative disease. Crystal-storing histiocytosis is one of the rarest patterns of MGRS, characterized by an accumulation of light chains of crystals within histiocyte's cytoplasm, located in bone marrow or other extramedullary sites such as the kidney, cornea, or thyme. A very few cases have been described as immunoglobulin-storing histiocytosis (IgSH) without evidence of crystals. In the recent literature, only 3 cases of IgSH have been described so far, none renal. In all cases, these very peculiar histopathological patterns are associated with lymphoproliferative or plasma cellular disorders. Here, we report a very unusual IgSH pattern in a kidney biopsy, which led to prompt detection and early therapeutic intervention, in a patient with otherwise misdiagnosed MGRS.
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Affiliation(s)
- Paolo Randone
- Division of Nephrology Dialysis and Transplantation, Renal Transplantation Center, “A. Vercellone,” Città della Salute e della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Manuel Burdese
- Division of Nephrology Dialysis and Transplantation, Renal Transplantation Center, “A. Vercellone,” Città della Salute e della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Antonella Barreca
- Division of Pathology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Stefania Oliva
- Myeloma Unit, Division of Hematology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Enrico Sanna
- Division of Nephrology Dialysis and Transplantation, Renal Transplantation Center, “A. Vercellone,” Città della Salute e della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Isabella Abbasciano
- Division of Nephrology Dialysis and Transplantation, Renal Transplantation Center, “A. Vercellone,” Città della Salute e della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Patrizia Anania
- Division of Nephrology Dialysis and Transplantation, Renal Transplantation Center, “A. Vercellone,” Città della Salute e della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Elena Boaglio
- Division of Nephrology Dialysis and Transplantation, Renal Transplantation Center, “A. Vercellone,” Città della Salute e della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
| | - Luigi Biancone
- Division of Nephrology Dialysis and Transplantation, Renal Transplantation Center, “A. Vercellone,” Città della Salute e della Scienza Hospital and Department of Medical Sciences, University of Turin, Turin, Italy
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8
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L'Imperio V, Cazzaniga G, Vergani B, Smith AJ, Alberici F, Pagni F. Monoclonal Gammopathy of Renal Significance: A Molecular Middle Earth between Oncology, Nephrology, and Pathology. Kidney Dis (Basel) 2022; 8:446-457. [PMID: 36590677 PMCID: PMC9798844 DOI: 10.1159/000527056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022]
Abstract
Background The renal biopsy represents a cornerstone in the definition of monoclonal gammopathy of renal significance (MGRS), helping in identifying patients with sub-detectable neoplastic clones (MGUS) that would deserve aggressive chemotherapies. However, the rising complexity of this onco-nephrology field is significantly challenging the daily work of nephrologists and nephropathologists, leading to the formation of ultra-specialized international centers with dedicated personnel/instrumentation and stressing the need for a better understanding of the underlying molecular landscape of these entities. Summary In this setting, the application of proteomic techniques, some with in situ capabilities (e.g., MALDI-MS imaging), for the investigation of the most challenging MGRS is progressively shedding light on the pathobiology of these diseases, providing new insights in the diagnosis and prognosis of these cases. This transformation is further enhanced by the application of next-generation digital pathology platforms, leading to a significant improvement of the cultural background for physicians thanks to second opinions, database and atlas creation, enhancement of diagnostic reports, with obvious repercussions for patients both in terms of turnaround time and appropriateness. Key Messages The present review is aimed at bridging the gap between clinical questions (i.e., a better characterization of MGRS) and the molecular landscape of onco-nephrology entities.
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Affiliation(s)
- Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Giorgio Cazzaniga
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Barbara Vergani
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Andrew James Smith
- Department of Medicine and Surgery, Clinical Proteomics and Metabolomics Unit, University of Milano - Bicocca, Monza, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy,Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy,*Fabio Pagni,
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9
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Terinte-Balcan G, Stefan G, Stancu S, Wang S, Gherghiceanu M. Crystal-induced collapsing podocytopathy and light chain proximal tubulopathy in monoclonal gammopathy of renal significance. J Nephrol 2022; 35:2127-30. [PMID: 35687268 DOI: 10.1007/s40620-022-01362-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 05/19/2022] [Indexed: 10/18/2022]
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10
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Alom MS, Grewal R, Passero FC, Goldman B, Choung HYG. Light chain deposition disease masquerading as smoking-associated nodular glomerulosclerosis with deposits identified by electron microscopy only. CEN Case Rep 2022; 11:448-452. [PMID: 35316527 DOI: 10.1007/s13730-022-00698-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/10/2022] [Indexed: 10/18/2022] Open
Abstract
Light chain deposition disease (LCDD) is a form of monoclonal gammopathy of renal significance. The diagnosis is based on the immunofluorescence (IF) findings of linear monoclonal light chain staining of basement membranes throughout the kidney, which appear as non-organized, granular punctate to powdery electron dense deposits by electron microscopy (EM). Although "LCDD by IF only" without EM deposits has been well-described, LCDD identified by EM with negative IF is very rare and hardly mentioned in the literature. Herein we describe a case of lambda-type LCDD that appeared negative by IF and showed light microscopic findings of nodular glomerulosclerosis, which was initially attributed to the patient's history of significant tobacco use and uncontrolled hypertension. However, EM later showed powdery electron dense material in focal glomerular and tubular basement membranes and mesangium. Subsequent bone marrow analysis revealed greater than 60% lambda-restricted plasma cells. We report this case to illustrate that within the differential diagnosis of nodular sclerosis, monoclonal immunoglobulin deposition disease (MIDD) should remain in the differential even if immunofluorescence appears negative as EM can prove to be crucial in identifying cases of MIDD.
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Affiliation(s)
- Md Saiful Alom
- Division of Nephrology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Rickinder Grewal
- Division of Nephrology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Frank C Passero
- Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | - Bruce Goldman
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box 626, Rochester, NY, 14642, USA
| | - Hae Yoon Grace Choung
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, University of Rochester School of Medicine and Dentistry, 601 Elmwood Ave, Box 626, Rochester, NY, 14642, USA.
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11
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Sy-Go JPT, Herrmann SM, Seshan SV. Monoclonal Gammopathy-Related Kidney Diseases. Adv Chronic Kidney Dis 2022; 29:86-102.e1. [PMID: 35817530 DOI: 10.1053/j.ackd.2022.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 12/09/2021] [Accepted: 01/18/2022] [Indexed: 11/11/2022]
Abstract
Monoclonal gammopathies occur secondary to a broad range of clonal B lymphocyte or plasma cell disorders, producing either whole or truncated monoclonal immunoglobulins. The kidneys are often affected by these monoclonal proteins, and, although not mutually exclusive, can involve the glomeruli, tubules, interstitium, and vasculature. The nephrotoxic potential of these monoclonal proteins is dependent on a variety of physicochemical characteristics that are responsible for the diverse clinicopathologic manifestations, including glomerular diseases with organized deposits, glomerular diseases with granular deposits, and other lesions, such as C3 glomerulopathy and thrombotic microangiopathy with unique pathophysiologic features. The diseases that involve primarily the tubulointerstitial and vascular compartments are light chain cast nephropathy, light chain proximal tubulopathy, crystal-storing histiocytosis, and crystalglobulin-induced nephropathy with distinct acute and chronic clinicopathologic features. The diagnosis of a monoclonal gammopathy-related kidney disease is established by identification of an underlying active or more commonly, low-grade hematologic malignancy, serologic evidence of a monoclonal gammopathy when detectable, and most importantly, monoclonal protein-induced pathologic lesions seen in a kidney biopsy, confirming the association with the monoclonal protein. Establishing a diagnosis may be challenging at times, particularly in the absence of an overt hematologic malignancy, with or without monoclonal gammopathy, such as proliferative glomerulonephritis with monoclonal immunoglobulin deposits. Overall, the treatment is directed against the underlying hematologic disorder and the potential source of the monoclonal protein.
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Affiliation(s)
| | - Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
| | - Surya V Seshan
- Department of Anatomic Pathology and Clinical Pathology, Weil Cornell Medical College, New York, NY
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12
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Shieh M, Giannini JA, Combs SA, Shaffi SK, Messias NC, Teixeira JP. Proliferative glomerulonephritis with monoclonal immunoglobulin deposits triggered by COVID-19: a case report. CEN Case Rep 2022. [PMID: 35122206 DOI: 10.1007/s13730-022-00687-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/23/2022] [Indexed: 10/30/2022] Open
Abstract
Acute kidney injury (AKI) frequently complicates corona virus disease 2019 (COVID-19) and is associated with significant mortality. Kidney disease in COVID-19 is usually due to acute tubular injury, but a variety of glomerular processes, especially collapsing glomerulopathy, have been increasingly described. Until recently, proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) had not been reported in the setting of COVID-19. We present a case of dialysis-dependent AKI developing soon after symptomatic COVID-19 which, on kidney biopsy, was found to be due to PGNMID with IgG3 kappa deposits. As is typical of PGNMID, a search for evidence of extra-renal monoclonal immunoglobulin or clonal lymphocyte population was negative. However, the patient had a favorable response to anti-plasma cell therapy and was ultimately able to stop hemodialysis. Though monoclonal gammopathy of renal significance (MGRS) is usually not associated with infection, other cases of post-viral MGRS, including PGNMID, have been previously reported. PGNMID has recently been linked specifically to COVID-19, with this representing one of only four cases reported thus far. Though causality between the preceding viral infection and the subsequent glomerulonephritis cannot be proven in these reports, nephrologists should be aware that not all kidney disease occurring in the aftermath of COVID-19 is due to tubular injury or collapsing glomerulopathy. As such, kidney biopsy should be routinely considered in the setting of COVID-19-associated glomerular disease as findings may change management. In the case of COVID-19-associated PGNMID data to guide treatment are limited, but our report suggests that anti-plasma cell therapy may be effective.
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13
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Alonso-Titos J, Martínez-Esteban MD, López V, León M, Martin-Reyes G, Ruiz-Esteban P, Hernández D. Monoclonal gammopathy of renal significance: Early diagnosis is key. Nefrologia 2021; 41:502-513. [PMID: 36165133 DOI: 10.1016/j.nefroe.2021.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 11/19/2020] [Indexed: 06/16/2023] Open
Abstract
Monoclonal gammopathy of renal significance is a clinical-pathological entity grouping renal disorders secondary to the secretion of a monoclonal immunoglobulin synthesized by a B-cell-derived clone and/or plasma cells in a patient with no diagnostic criteria for multiple myeloma. This term applies to a concept recently introduced owing to the need to differentiate this entity from monoclonal gammopathy of undetermined significance, given the negative prognostic impact of its high morbidity and mortality resulting from both renal and systemic involvement, occasionally even progressing to advanced chronic kidney disease. The renal damage occurs via both direct pathogenic mechanisms, with the deposition of the monoclonal protein in different renal structures, as well as indirect mechanisms, acting as an autoantibody provoking dysregulation of the alternative complement pathway. The detection of this monoclonal protein and an early hematologic study are essential, as is the need for a kidney biopsy to establish the associated nephropathological diagnosis. Consequently, this then leads to the start of specific hematologic treatment to detain the production of the monoclonal protein and minimize renal and systemic injury.
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Affiliation(s)
- Juana Alonso-Titos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - María Dolores Martínez-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Verónica López
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Myriam León
- Pathology Department, Carlos Haya Regional University Hospital, Malaga, Spain
| | - Guillermo Martin-Reyes
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Pedro Ruiz-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Domingo Hernández
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain.
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Weng Q, Xu J, Shen P, Xu T, Gao C, Xie J, Ren H, Pan X. Fulminant type I cryoglobulinemic glomerulonephritis with unique ultrastructural plugs: a case report. Int J Hematol 2021; 114:620-625. [PMID: 34302594 DOI: 10.1007/s12185-021-03194-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Type I cryoglobulinemia is a rare disease which affects the skin, central nervous system and kidneys. It is usually associated with lymphoproliferative disorders such as multiple myeloma, lymphoma and monoclonal gammopathy of renal significance. Proteinuria and membranoproliferative glomerulonephritis are the most common renal manifestations; Case presentation: Here we report the case of a female patient in her late 40 s who had proteinuria accompanied by Raynaud's phenomenon, high blood and plasma viscosity, hearing loss, and cardiac and central nervous system involvement. Monoclonal immunoglobulin G-λ protein was detected and serum was positive for cryoglobulin. Renal biopsy revealed massive cryo-plugs with unique ultrastructural appearance in the glomerular and peritubular capillary lumina. Immunofluorescence showed predominant IgG3/λ deposition in cryo-plugs. As reported, the clinical manifestations of this patient resulted from cryoprecipitate and hyperviscosity syndrome; Conclusion: Cryoglobulinemia should be considered as a possible diagnosis in patients with Raynaud's phenomenon, hyperviscosity syndrome and monoclonal immunoglobulin.
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Affiliation(s)
- Qinjie Weng
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Jing Xu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Pingyan Shen
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Tian Xu
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Chenni Gao
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Jingyuan Xie
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Hong Ren
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China
| | - Xiaoxia Pan
- Department of Nephrology, Institute of Nephrology, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai, 200025, China.
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15
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Sugimoto Y, Fujimoto M, Machida H, Nagaharu K, Murata T, Tsukada T. Light chain proximal tubulopathy diagnosed solely by electron microscopy of a renal biopsy specimen in a patient with monoclonal gammopathy of undetermined significance. Int J Hematol 2021; 114:303-4. [PMID: 34275065 DOI: 10.1007/s12185-021-03193-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 10/20/2022]
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16
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Tang X, Wan F, Yu J, Li X, Yang R, Zhu B. Clinicopathological characteristics of patients with paraproteinemia and renal damage. Eur J Med Res 2021; 26:68. [PMID: 34217367 PMCID: PMC8255003 DOI: 10.1186/s40001-021-00538-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 06/22/2021] [Indexed: 12/26/2022] Open
Abstract
Background This study aimed to analyze the clinicopathological characteristics of patients with paraproteinemia and renal damage. Methods Ninety-six patients from 2014 to 2018 with paraproteinemia and renal damage were enrolled and the clinical data, renal pathology, treatment and prognosis data were collected. Results A total of 96 patients (54 male and 42 female), accounting for 2.7% of all renal biopsies, were enrolled in this study. Among them, 42 were monoclonal gammopathy of renal significance (MGRS), 21 were renal monotypic immunoglobulin alone (renal monoIg), and 19 were monoclonal gammopathy of undetermined significance (MGUS). Individuals with multiple myeloma (MM) accounted for the fewest number of patients (n = 14). In the MGRS group, the main diseases were amyloidosis (n = 25) and cryoglobulinemic glomerulonephritis (n = 7), while in the MM group, the main diseases were cast nephropathy (n = 9) and light chain deposit disease (n = 3). In the MGUS group, it was mainly IgA nephropathy (IgAN, n = 10) and idiopathic membranous nephropathy (n = 5); while in the renal monoIg group, most of the cases were IgAN (n = 19). Chemotherapy was mainly administered to patients in the MM group, while immunosuppression therapy was mostly administered to patients in the renal monoIg group. Most patients with renal monoIg exhibited a major response, followed by the patients with MGUS and MGRS, while most of the patients with MM had a partial response but none had a major response. Approximately more than half (57.1%) of the patients with MM progressed to end-stage renal disease (ESRD), followed by MGRS (33.3%); however, the mortality rate was low in both the MGRS and MM groups. The survival analysis reviewed that serum creatinine, hemoglobin levels, and the serum κ/λ ratio were independent risk factors for ESRD in patients with MGRS. Conclusions The clinicopathological changes in patients with MGRS were between those in patients with MM and MGUS. The treatment for MGRS and MM was more intensive, and the overall mortality rate was low. Both MGUS and renal monoIg alone exhibited slighter clinicopathological features than MGRS and MM, and the treatment was focused mostly on primary renal diseases.
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Affiliation(s)
- Xuanli Tang
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China.
| | - Feng Wan
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Jin Yu
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Xiaohong Li
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Ruchun Yang
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
| | - Bin Zhu
- Department of Nephrology, Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou TCM Hospital Affiliated to Zhejiang Chinese Medical University, Hangzhou, 310007, China
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L'Imperio V, Barreca A, Vergani B, Sinico RA, Pagni F. Destructuring glomerular diseases with structured deposits: challenges in the precision medicine era. J Nephrol 2021; 34:2151-2154. [PMID: 33905115 DOI: 10.1007/s40620-021-01053-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, ASST Monza, University of Milano-Bicocca, Monza, Italy.
| | - Antonella Barreca
- Division of Pathology, Città della Salute e della Scienza Hospital, Turin, Italy
| | - Barbara Vergani
- Department of Medicine and Surgery, Pathology, ASST Monza, University of Milano-Bicocca, Monza, Italy
| | - Renato Alberto Sinico
- Nephrology Unit, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, ASST Monza, University of Milano-Bicocca, Monza, Italy
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18
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Lindemann C, Enders P, Brinkkoetter PT, Völker LA. Crystalline deposits in the cornea and various areas of the kidney as symptoms of an underlying monoclonal gammopathy: a case report. BMC Nephrol 2021; 22:117. [PMID: 33823814 PMCID: PMC8025562 DOI: 10.1186/s12882-021-02309-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 03/16/2021] [Indexed: 11/21/2022] Open
Abstract
Background Plasma cell dyscrasias (PCD) are characterized by an abnormal production of intact monoclonal immunoglobulins or parts such as heavy or light chains. In most cases, the monoclonal protein (also termed paraprotein) is produced by a clonal plasma cell population. The production of monoclonal proteins can result in deposits of various types and localization depending on the type, amount, and electrochemical properties of the paraprotein. One histopathologic presentation, albeit rare, are crystalline deposits. They can form in various organs and hence cause a wide spectrum of symptoms. Case presentation A 49-year-old man presented to the emergency department with eyestrain and foreign body sensation after overhead drilling. Examination of the eyes revealed crystalline deposits in the cornea of both eyes. After additional diagnostic testing, deposits were attributed to free light chains. Monoclonal gammopathy of undetermined significance (MGUS) was diagnosed according to serum electrophoresis and immunofixation. Four years later, new onset of proteinuria was detected. A percutaneous biopsy of the kidney showed severe light chain podocytopathy with secondary focal segmental glomerulosclerosis (FSGS) and light chain proximal tubulopathy (LCPT). In these lesions, crystalline deposits identical to the corneal deposits were found in ultrastructural and immunofluorescent analysis. The patient was diagnosed with monoclonal gammopathy of renal significance (MGRS), and a plasma cell directed therapy was initiated. Conclusions PCD can present with a wide array of symptoms and are notoriously difficult to diagnose. Extrarenal manifestations such as crystalline deposits in the cornea are one possible manifestation. The case presented herein emphasizes the notion that extrarenal paraprotein deposits warrant a thorough search for the underlying clonal disease. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-021-02309-x.
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Affiliation(s)
- C Lindemann
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, (CMMC), University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str 62, D-50937, Cologne, Germany
| | - P Enders
- Department of Ophthalmology, Medical Faculty and University Hospital of Cologne, University of Cologne, Kerpener Str 62, D-50937, Cologne, Germany
| | - P T Brinkkoetter
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, (CMMC), University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str 62, D-50937, Cologne, Germany.,Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany
| | - L A Völker
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, (CMMC), University of Cologne, Faculty of Medicine and University Hospital Cologne, Kerpener Str 62, D-50937, Cologne, Germany. .,Cologne Cluster of Excellence on Cellular Stress Responses in Ageing-Associated Diseases, Cologne, Germany.
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19
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Alonso-Titos J, Martínez-Esteban MD, López V, León M, Martin-Reyes G, Ruiz-Esteban P, Hernández D. Monoclonal gammopathy of renal significance: Early diagnosis is key. Nefrologia 2021. [PMID: 33824049 DOI: 10.1016/j.nefro.2020.11.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Monoclonal gammopathy of renal significance is a clinical-pathological entity grouping renal disorders secondary to the secretion of a monoclonal immunoglobulin synthesized by a B-cell-derived clone and/or plasma cells in a patient with no diagnostic criteria for multiple myeloma. This term applies to a concept recently introduced owing to the need to differentiate this entity from monoclonal gammopathy of undetermined significance, given the negative prognostic impact of its high morbidity and mortality resulting from both renal and systemic involvement, occasionally even progressing to advanced chronic kidney disease. The renal damage occurs via both direct pathogenic mechanisms, with the deposition of the monoclonal protein in different renal structures, as well as indirect mechanisms, acting as an autoantibody provoking dysregulation of the alternative complement pathway. The detection of this monoclonal protein and an early hematologic study are essential, as is the need for a kidney biopsy to establish the associated nephropathological diagnosis. Consequently, this then leads to the start of specific hematologic treatment to detain the production of the monoclonal protein and minimize renal and systemic injury.
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Affiliation(s)
- Juana Alonso-Titos
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - María Dolores Martínez-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Verónica López
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Myriam León
- Pathology Department, Carlos Haya Regional University Hospital, Malaga, Spain
| | - Guillermo Martin-Reyes
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Pedro Ruiz-Esteban
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain
| | - Domingo Hernández
- Nephrology Department, Carlos Haya Regional University Hospital and University of Malaga, IBIMA, REDinREN (RD16/0009/0006), Malaga, Spain.
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Ono E, Ishii A, Higashi Y, Koita N, Ayaki T, Tanigaki K, Takayanagi S, Kondo N, Sakai K, Endo S, Yokoi H, Matsubara T, Minamiguchi S, Nishino I, Takahashi R, Yanagita M. Monoclonal gammopathy of renal significance (MGRS)-related AL amyloidosis complicated by amyloid myopathy: a case report. BMC Nephrol 2021; 22:74. [PMID: 33639890 PMCID: PMC7916314 DOI: 10.1186/s12882-021-02272-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 02/18/2021] [Indexed: 12/05/2022] Open
Abstract
Background Lately, monoclonal gammopathy of renal significance (MGRS) has been defined as a group of renal disorders that are strongly associated with monoclonal protein, including amyloid immunoglobulin light chain (AL) amyloidosis. Amyloid myopathy is rare (1.5% of all patients with amyloidosis) and the prognosis is poor. Furthermore, only approximately 20% of patients with amyloid myopathy are reported to have renal involvement, indicating a lack of data in the literature. Case presentation Here, we report a rare case of MGRS-related AL amyloidosis complicated by amyloid myopathy that presented with muscle weakness in the upper and lower limbs, neck and fingers, and nephrotic syndrome. Blood, urine, and bone marrow examination revealed monoclonal gammopathy of undetermined significance (MGUS) (Bence Jones protein-lambda). Muscle biopsy of the vastus lateralis muscle demonstrated amyloid proteins in the sarcolemma and in the blood vessel walls on Congo red staining, suggesting amyloid myopathy, and tiny inclusions in fibers on modified Gomori trichrome stain. Although we thought they were reminiscent of nemaline bodies, we could not confirm the nature of this structure. Renal biopsy demonstrated amyloid proteins in the mesangial region, part of the capillary walls, and the blood vessel walls on direct fast scarlet staining. As these amyloid proteins were positive for p-component staining and negative for amyloid A staining, β2-microglobulin, and pre-albumin, and as lambda light chains were positive in the mesangial region, we diagnosed the patient with MGRS-related AL amyloidosis. Although he was treated with melphalan and dexamethasone, his symptoms did not improve. Conclusions AL amyloidosis involving the kidneys and muscles has a poor prognosis, and a delayed diagnosis of amyloid myopathy is common because of its rarity and frequent misdiagnosis, which increases organ function deterioration. Therefore, early detection, therapeutic intervention, and careful follow-up are crucial.
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Affiliation(s)
- Erina Ono
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Akira Ishii
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Yoshiaki Higashi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Natsuko Koita
- Department of Neurology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takashi Ayaki
- Department of Neurology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Katsuya Tanigaki
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shunsuke Takayanagi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Naoya Kondo
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Kaoru Sakai
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Shuichiro Endo
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Hideki Yokoi
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Takeshi Matsubara
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Sachiko Minamiguchi
- Department of Diagnostic Pathology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry (NCNP), 4-1-1 Ogawa-Higashi, Kodaira, Tokyo, 187-8502, Japan
| | - Ryosuke Takahashi
- Department of Neurology, Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
| | - Motoko Yanagita
- Department of Nephrology, Graduate School of Medicine, Kyoto University, 54 Shogoin Kawahara-cho, Sakyo-ku, Kyoto, 606-8507, Japan
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Malhotra R, Guleria P, Barwad A, Pramanik R, Tandon N. A unique case of light chain (AL) amyloidosis masquerading as hypophosphatemic osteomalacia. Osteoporos Int 2021; 32:387-392. [PMID: 32910218 DOI: 10.1007/s00198-020-05622-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/01/2020] [Indexed: 01/22/2023]
Abstract
Light chain (AL) amyloidosis is the result of a clonal plasma cell disorder which causes organ damage by deposition of misfolded light chains. Kidney is a common site of amyloid deposition. Proteinuria, usually in nephrotic range and unexplained renal insufficiency are the main manifestations of renal injury. We report a unique case of renal involvement by AL amyloidosis masquerading as metabolic bone disease. 38 year old male patient presented with progressively increasing diffuse bony pains, low backache and proximal weakness of both lower limbs since two years. On investigation, he was detected to have hypophosphatemic osteomalacia due to renal phosphate loss which was fibroblast growth factor 23 (FGF23)- independent. He also had nephrotic range low molecular weight proteinuria. Renal biopsy to ascertain the aetiology revealed deposition of amyloid fibrils in the glomerular mesangium on electron microscopy. Its characterization by immunofluorescence (IF) was consistent with immunoglobulin light chain (AL) amyloidosis. In the absence of a demonstrable plasma cell clone on bone marrow biopsy, we made a diagnosis of monoclonal gammopathy of renal significance (MGRS). He was treated with chemotherapy following which there was symptomatic improvement and reduction in phosphaturia. This case describes a unique presentation of renal injury due to AL amyloidosis masquerading as hypophosphatemic osteomalacia. The aim of this report is to highlight that hypophosphatemia in adults is usually acquired and treatment of underlying etiology results in cure, unlike in children where genetic counseling and phosphate replacement is the mainstay of treatment.
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Affiliation(s)
- R Malhotra
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India.
| | - P Guleria
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - A Barwad
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - R Pramanik
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - N Tandon
- Department of Endocrinology and Metabolism, All India Institute of Medical Sciences, New Delhi, India
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Campdesuner V, Teklie Y, Lattanzio N, Lorenzo C, Bell S, Rodriguez Y, Sastry A. A case of immunotactoid glomerulopathy in a patient with monoclonal gammopathy of renal significance. J Community Hosp Intern Med Perspect 2021; 11:60-64. [PMID: 33552417 PMCID: PMC7850321 DOI: 10.1080/20009666.2020.1831744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Monoclonal gammopathy of renal significance is a relatively new diagnosis that attributes kidney disease to damage caused by a monoclonal protein. There is growing recognition of this disease in patients previously diagnosed with monoclonal gammopathy of undetermined significance, as they increasingly develop clinically significant renal impairment requiring treatment. We outline a case of a patient presenting with worsening renal function, found to have a circulating monoclonal protein and ultimately diagnosed with a subtype of monoclonal gammopathy of renal significance referred to as immunotactoid glomerulopathy. Abbreviations: MGUS: Monoclonal gammopathy of undetermined significance; M-protein: Monoclonal protein; MM: Multiple myeloma; MGRS: Monoclonal gammopathy of renal significance; MGCS: Monoclonal gammopathy of clinical significance; CKD: Chronic kidney disease; C3 and C4: Complement 3 and complement 4, respectively; EF: Ejection fraction; CT: Computed tomography; IgG: Immunoglobulin G; GFR: Glomerular filtration rate; PET: Positron emission tomography; MRI: Magnetic Resonance Imaging.
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Affiliation(s)
- Victoria Campdesuner
- Florida State University Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Yeshanew Teklie
- Florida State University Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Natalia Lattanzio
- Florida State University Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Christian Lorenzo
- Florida State University Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Stephen Bell
- Florida State University Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Yorlenis Rodriguez
- Florida State University Internal Medicine Residency, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Ashok Sastry
- Nephrology, Sarasota Memorial Hospital, Sarasota, FL, USA
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23
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Liu MY, Wang SX, Dong Y, Zhou FD, Zhao MH. Pregnancy-associated proliferative glomerulonephritis with monoclonal immunoglobulin deposits. J Nephrol 2021; 34:1669-1672. [PMID: 33428097 DOI: 10.1007/s40620-020-00894-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 10/28/2020] [Indexed: 10/22/2022]
Abstract
We report a young woman presented with nephrotic syndrome and normotension during every pregnancy and achieved complete remissions after the deliveries. We thus inferred that her nephrotic syndrome was closely associated with pregnancy. Kidney biopsies were perfromed and showed different histologic patterns: the first biopsy showed a pattern of endocapillary proliferative glomerulonephritis; the second biopsy revealed proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) with features of membranous nephropathy. With regard to presentation during the second trimester of pregnancy, achieving complete remission after delivery, and no relapse during the follow-up period, pregnancy associated PGNMID is suggested. To our best knowledge, this is the first reported case of PGNMID associated with pregnancy.
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Affiliation(s)
- Meng-Yao Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China
| | - Su-Xia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China.,Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Ying Dong
- Department of Pathology, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Fu-De Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China. .,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, People's Republic of China. .,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China. .,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China.
| | - Ming-Hui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, People's Republic of China.,Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, People's Republic of China.,Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, People's Republic of China.,Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, People's Republic of China.,Peking-Tsinghua Center for Life Sciences, Beijing, 100034, People's Republic of China
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Kim C, Brealey J, Jobert A, Nolan J. A case of monoclonal gammopathy of renal significance presenting as atypical amyloidosis with IgA lambda paraproteinemia. J Pathol Transl Med 2020; 54:504-507. [PMID: 33153243 PMCID: PMC7674760 DOI: 10.4132/jptm.2020.09.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 09/18/2020] [Indexed: 11/29/2022] Open
Abstract
Monoclonal gammopathy of renal significance is defined as any B cell or plasma cell clonal lymphoproliferation which neither causes tumor complications nor meets any current hematological criteria for specific therapy, with one or more kidney lesions related to the produced monoclonal immunoglobulin, such as amyloidosis. A 50-year-old male presented with heavy proteinuria and blood tests showing IgA and Lambda paraproteinemia. Light microscopy showed mesangial eosinophilic ground substance extending into the capillary loops, and positive staining within the glomeruli and vessel walls for amyloid P immunohistochemistry was also noted. Immunofluorescence showed positive staining for IgA and Lambda in the mesangia and capillary loops. Electron microscopy exhibited organized fibrils measuring 4–5 nm in diameter in the mesangia, glomerular basement membranes and vessel walls. We interpreted the overall findings as atypical renal amyloidosis with IgA and Lambda deposition on immunofluorescence. Further amyloid typing using laser microdissection-liquid chromatography and mass spectrometry will be useful.
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Affiliation(s)
- Chankyung Kim
- Department of Anatomical Pathology, SA Pathology, Adelaide, Australia
| | - John Brealey
- Department of Anatomical Pathology, SA Pathology, Adelaide, Australia
| | - Anjelo Jobert
- Central and Northern Adelaide Renal Transplantation Services, Royal Adelaide Hospital, Adelaide, Australia
| | - James Nolan
- Department of Anatomical Pathology, SA Pathology, Adelaide, Australia
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25
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Mansour M, Young D, Ilyas M, Tolaymat A. Common presentation of micro hematuria and proteinuria in an uncommon disease: Answers. Pediatr Nephrol 2020; 35:2103-2105. [PMID: 32346767 DOI: 10.1007/s00467-020-04566-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Marwa Mansour
- University of Florida College of Medicine, Jacksonville, FL, USA.
| | - Danielle Young
- University of Florida College of Medicine, Jacksonville, FL, USA
| | - Mohammad Ilyas
- University of Florida College of Medicine, Jacksonville, FL, USA
| | - Asad Tolaymat
- University of Florida College of Medicine, Jacksonville, FL, USA
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26
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Affiliation(s)
- Ankur Jain
- Vardhman Mahavir Medical College and Safdarjung Hospital, Department of Hematology, New Delhi, India
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27
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Liang D, Liu J, Liang S, Xu F, Cheng Z, Huang X, Zeng C, Liu Z. Types of M protein and clinicopathological profiles in patients with monoclonal gammopathy of renal significance. J Nephrol 2020; 34:1137-1146. [PMID: 32725498 DOI: 10.1007/s40620-020-00817-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/22/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND The development of renal disease in patients with monoclonal gammopathy of renal significance (MGRS) depends on the pathogenicity of the secreted monoclonal protein (M protein). However, the correlation between the types of M proteins and clinical and renal pathological features is still unclear. METHODS A total of 148 patients with detectable serum M protein and biopsy-proven MGRS were recruited. The patients were categorized according to the heavy and light chain types of M protein in the serum. RESULTS Among 148 patients, the most common M protein was IgGλ, followed by IgAλ and IgGκ. According to the type of heavy chain, patients with IgM-MGRS were more likely to have renal dysfunction, anemia and hypocomplementemia than patients with IgG-MGRS and IgA-MGRS. The λ light chain was predominant in patients with IgG-MGRS and IgA-MGRS, whereas the κ light chain was predominant in patients with IgM-MGRS. The most common renal lesion was amyloidosis in patients with IgG-MGRS and IgA-MGRS, while it was cryoglobulinemic glomerulonephritis in patients with IgM-MGRS. According to the type of light chain, patients with κ light chain were more likely to be male and to have renal dysfunction, anemia and hypocomplementemia than those with λ light chain. The types of heavy chain and light chain of M protein were not associated with patient or renal survival. CONCLUSION The clinicopathological features were distinct in patients with different types of M protein. Integration of the types of M protein and renal pathologic findings may shed light on individual management of patients with MGRS.
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Affiliation(s)
- Dandan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Clinical Medical College of Nanjing Medical University, 305 East Zhongshan Road, Nanjing, China
| | - Jing Liu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Shaoshan Liang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Feng Xu
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhen Cheng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xianghua Huang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases, Jinling Clinical Medical College of Nanjing Medical University, 305 East Zhongshan Road, Nanjing, China. .,National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China.
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28
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Flavell AL, Fullinfaw RO, Smith ER, Holt SG, Finlay MJ, Barbour TD. Noninfectious mixed cryoglobulinaemic glomerulonephritis and monoclonal gammopathy of undetermined significance: a coincidental association? BMC Nephrol 2020; 21:293. [PMID: 32703171 PMCID: PMC7376917 DOI: 10.1186/s12882-020-01941-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/09/2020] [Indexed: 12/18/2022] Open
Abstract
Background Cryoglobulins are cold-precipitable immunoglobulins that may cause systemic vasculitis including cryoglobulinaemic glomerulonephritis (CGN). Type 1 cryoglobulins consist of isolated monoclonal immunoglobulin (mIg), whereas mixed cryoglobulins are typically immune complexes comprising either monoclonal (type 2) or polyclonal (type 3) Ig with rheumatoid activity against polyclonal IgG. Only CGN related to type 1 cryoglobulins has been clearly associated with monoclonal gammopathy of undetermined significance (MGUS) using the conventional serum-, urine- or tissue-based methods of paraprotein detection. Case presentation We present four patients with noninfectious mixed (type 2 or 3) CGN and MGUS. Two patients had type 2 cryoglobulinaemia, one had type 3 cryoglobulinaemia, and one lacked definitive typing of the serum cryoprecipitate. The serum monoclonal band was IgM-κ in all four cases. Treatments included corticosteroids, cyclophosphamide, plasma exchange, and rituximab. At median 3.5 years’ follow-up, no patient had developed a haematological malignancy or advanced chronic kidney disease. Other potential causes of mixed cryoglobulinaemia were also present in our cohort, notably primary Sjögren’s syndrome in three cases. Conclusion Our study raises questions regarding the current designation of type 2 CGN as a monoclonal gammopathy of renal significance, and the role of clonally directed therapies for noninfectious mixed CGN outside the setting of haematological malignancy.
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Affiliation(s)
- Adam L Flavell
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.
| | - Robert O Fullinfaw
- Department of Chemical Pathology, The Royal Melbourne Hospital, Parkville, Australia
| | - Edward R Smith
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Stephen G Holt
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
| | - Moira J Finlay
- Department of Medicine, The University of Melbourne, Melbourne, Australia.,Department of Anatomical Pathology, The Royal Melbourne Hospital, Parkville, Australia
| | - Thomas D Barbour
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Australia
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29
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Gupta RK, Arend LJ, BK A, Narsipur S, Bhargava R. Crystalglobulin-associated nephropathy presenting as MGRS in a case of monoclonal B-cell lymphocytosis: a case report. BMC Nephrol 2020; 21:184. [PMID: 32423442 PMCID: PMC7236346 DOI: 10.1186/s12882-020-01818-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Accepted: 04/19/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Crystalglobulin-associated nephropathy (CAN), a rare subtype of monoclonal gammopathy, usually associated with multiple myeloma and occasionally monoclonal gammopathy of uncertain significance (MGUS), is characterized by occluding monoclonal pseudothrombi within renal glomerular capillaries and/or interstitial arterioles. Ultrastructurally, these pseudothrombi are unique for having a crystalline substructure. We describe a case of an adult patient with monoclonal B-cell lymphocytosis (MBL) and acute renal failure whose kidney biopsy revealed a rare diagnosis of CAN. CASE PRESENTATION A 63-year old male presented with a 2-month history of edema, arthralgia and malaise. He had acute kidney injury with hematoproteinuria on urine analysis. Serum and urine protein electrophoresis were both negative. A renal biopsy however revealed features of CAN. Organomegaly, bone pain and lymphadenopathy were absent. A repeat serum electrophoresis was positive for IgA kappa and a free light chain assay showed elevated free kappa light chains. Flow cytometry done subsequently revealed a diagnosis of MBL, chronic lymphocytic leukemia (CLL) type. CONCLUSION CAN in association with MBL/CLL has not been previously described in literature, and our case highlights yet another instance of monoclonal gammopathy of renal significance (MGRS) where a small B-cell clone resulted in extensive renal pathology without systemic manifestations.
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Affiliation(s)
- Rajib K. Gupta
- Department of Pathology, SUNY Upstate Medical University, 750 E Adams Street, Syracuse, NY 13210 USA
| | - Lois J. Arend
- Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, MD USA
| | - Anupama BK
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY USA
| | - Sriram Narsipur
- Department of Medicine and Nephrology, SUNY Upstate Medical University, Syracuse, NY USA
| | - Ramya Bhargava
- Department of Nephrology, SUNY Upstate Medical University, Syracuse, NY USA
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30
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van Kruijsdijk RCM, Abrahams AC, Nguyen TQ, Minnema MC, Jacobs JFM, Limper M. Clone-directed therapy for proliferative glomerulonephritis with monoclonal immunoglobulin depositions: is it always necessary? : Two case reports and literature review. J Nephrol 2020; 33:611-7. [PMID: 32221859 DOI: 10.1007/s40620-020-00723-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/12/2020] [Indexed: 11/21/2022]
Abstract
Monoclonal gammopathy of renal significance (MGRS) encompasses a group of disorders in which a monoclonal immunoglobulin (M-protein) secreted by a B-cell or plasma cell clone causes renal disease. Proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a form of MGRS where M-protein is deposited in the glomerulus. Although evidence is limited, the current consensus is that therapy for PGNMID should be directed against the underlying clone. However, it is conceivable that there is heterogeneity in the renal prognosis of PGNMID and that not all patients have need for clone-directed therapy. Here, we report two cases of PGNMID with IgM-kappa gammopathy. In one case of a 53-year-old woman the glomerulonephritis resolved without clone-directed therapy. In the other case of a 34-year-old woman clone-directed therapy was discontinued due to adverse effects. Although no hematological response was achieved, the PGNMID resolved. In both cases there are no signs of a recurrent glomerulonephritis in over 3 years of follow-up. Here, we review the literature and suggest that some PGNMID patients have a favorable renal prognosis in whom clone-directed therapy can be withheld or postponed. Further research is warranted to yield predictors to identify these patients and to better understand the disease course of PGNMID.
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31
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Zuo C, Zhu Y, Xu G. An update to the pathogenesis for monoclonal gammopathy of renal significance. Crit Rev Oncol Hematol 2020; 149:102926. [PMID: 32199132 DOI: 10.1016/j.critrevonc.2020.102926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 12/20/2019] [Accepted: 03/02/2020] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is characterized by the nephrotoxic monoclonal immunoglobulin (MIg) secreted by an otherwise asymptomatic or indolent B-cell or plasma cell clone, without hematologic criteria for treatment. The spectrum of MGRS-associated disorders is wide, including non-organized deposits or inclusions such as C3 glomerulopathy with monoclonal glomerulopathy (MIg-C3G), monoclonal immunoglobulin deposition disease, proliferative glomerulonephritis with monoclonal immunoglobulin deposits and organized deposits like immunoglobulin related amyloidosis, type I and type II cryoglobulinaemic glomerulonephritis, light chain proximal tubulopathy, and so on. Kidney biopsy should be conducted to identify the exact disease associated with MGRS. These MGRS-associated diseases can involve one or more renal compartments, including glomeruli, tubules and vessels. Hydrophobic residues replacement, N-glycosylated, increase in isoelectric point in MIg causes it to transform from soluble form to tissue deposition, causing glomerular damage. Complement deposition is found in MIg-C3G, which is caused by an abnormality of the alternative pathway and may involve multiple factors including complement component 3 nephritic factor, anti-complement factor auto-antibodies or MIg which directly cleaves C3. The effect of transforming growth factor beta and platelet-derived growth factor-β on mesangial extracellular matrix is associated with glomerular and tubular basement membrane thickening, nodular glomerulosclerosis, and interstitial fibrosis. Furthermore, inflammatory factors, growth factors and virus infection may play an important role in the development of the diseases. In this review, for the first time, we discussed current highlights in the mechanism of MGRS-related lesions.
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Affiliation(s)
- Chao Zuo
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China; Grade 2016, the Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Yuge Zhu
- Grade 2016, the First Clinical Medical College of Nanchang University, Nanchang, China
| | - Gaosi Xu
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China.
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32
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Zuo C, Zhu Y, Xu G. An update to the pathogenesis for monoclonal gammopathy of renal significance. Ann Hematol 2020; 99:703-14. [PMID: 32103323 DOI: 10.1007/s00277-020-03971-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 02/18/2020] [Indexed: 01/16/2023]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is characterized by the nephrotoxic monoclonal immunoglobulin secreted by an otherwise asymptomatic or indolent B cell or plasma cell clone, without hematologic criteria for treatment. These MGRS-associated diseases can involve one or more renal compartments, including glomeruli, tubules, and vessels. Hydrophobic residue replacement, N-glycosylated, increase in isoelectric point in monoclonal immunoglobulin (MIg) causes it to transform from soluble form to tissue deposition, and consequently resulting in glomerular damage. In addition to MIg deposition, complement deposition is also found in C3 glomerulopathy with monoclonal glomerulopathy, which is caused by an abnormality of the alternative pathway and may involve multiple factors including complement component 3 nephritic factor, anti-complement factor auto-antibodies, or MIg which directly cleaves C3. Furthermore, inflammatory factors, growth factors, and virus infection may also participate in the development of the diseases. In this review, for the first time, we discussed current highlights in the mechanism of MGRS-related lesions.
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33
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Wang LY, Li X, Shen M, Chen SL, Huang ZX. [The 474th case: anemia, ostealgia, proteinuria]. Zhonghua Nei Ke Za Zhi 2020; 59:161-4. [PMID: 32074693 DOI: 10.3760/cma.j.issn.0578-1426.2020.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 49-year-old woman was admitted to hospital with intermittent dizziness and fatigue for 7 years. The symptoms were aggravated and accompanied by bone pain for more than 4 months. She was referred to our hospital. Laboratory tests and imaging findings suggested that acquired Fanconi Syndrome (FS) was associated with smoldering multiple myeloma (MM). Renal biopsy and electron microscopy confirmed the diagnosis of proximal light chain tubular disease (LCPT). LCPT causes proximal tubular dysfunction, which is characterized by the cytoplasmic crystal deposition usually kappa monoclonal light chain in the proximal tubule. MM with FS and LCPT is less common in clinical practice because it is difficult to diagnose. This is a typical case focusing on the differential diagnosis of monoclonal gammopathy of renal significance(MGRS) such as LCPT and plasma cells diseases.
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34
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Lai Z, Kumar T, Zhao R, Li W, Kanaan HD, Zhang PL, Liu B. Monoclonal Gammopathy of Renal Significance and its Associated Experimental Models. Ann Clin Lab Sci 2019; 49:439-447. [PMID: 31471332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a state of circulating monoclonal immunoglobulin (Ig) and light chains that cause kidney injury without definite evidence of multiple myeloma (MM). Although chemotherapy is used to treat many variants of MGRS and has been recently recommended, relatively limited clinical validation studies are available. A few transgenic models of MM reveal renal deposition of monoclonal Ig and light chains. We have demonstrated that the XBP1s-transgenic mouse model from early plasma cell dyscrasia to MM reveals monoclonal IgG/kappa deposition at the subendothelial spaces of the glomeruli, mimicking proliferative glomerulonephritis with monoclonal immunoglobulin deposits. Inhibition of a key immune-modulator, gp96/grp94, genetically or pharmacologically results in a significant reduction of plasma cells within the bone marrow and reduced renal deposition of monoclonal IgG and kappa light chain. This article will review the emerging role of in vitro and animal models from plasma cell dyscrasia to MM in understanding the renal deposition of monoclonal Ig and light chains, along with its potential treatment strategies.
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Affiliation(s)
- Zongshan Lai
- Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI
| | - Tripti Kumar
- Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI
| | - Ran Zhao
- Department of Microbiology and Immunology, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
| | - Wei Li
- Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI
| | - Hassan D Kanaan
- Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI
| | - Ping L Zhang
- Department of Anatomic Pathology, William Beaumont Hospital, Royal Oak, MI
| | - Bei Liu
- Department of Microbiology and Immunology, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, USA
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35
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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36
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Vignon M, Bridoux F, Fermand JP. [Monoclonal gammopathy related disorders]. Rev Prat 2018; 68:792-796. [PMID: 30869335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Monoclonal gammopathy related disorders. The presence of a monoclonal immunoglobulin in serum or urine reflects the existence of an abnormal clone of B cells. In case of large tumor mass, patient need treatment. Sometimes, the clone is nearly undetectable, but gammopathy is associated with complications not directly related to tumor cells but to the presence of the monoclonal immunoglobulin. Most often, lesions result from the deposit of monoclonal immunoglobulin, organized or not. Other mechanisms include autoantibody activity, immune complex formation or deregulation of the complement system. Finally, in some cases, the physiopathology remains to be determined. The downstream complications of gammopathies are protean and can affect various organs, mainly the kidney, the skin and the peripheral nervous system. A delayed diagnosis may be life-threatening or functional. A rigorous clinical examination, and appropriate explorations are therefore necessary in order to put in place a suitable therapy, targeting most often the underlying clone.
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Affiliation(s)
- Marguerite Vignon
- Service d'immunologiehématologie, hôpital Saint-Louis, Paris, France
| | | | - Jean-Paul Fermand
- Service d'immunologiehématologie, hôpital Saint-Louis, Paris, France
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37
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Hirashio S, Arima T, Satoh A, Mandai K, Hara S, Masaki T. A case of immunotactoid glomerulopathy with false-negative IgG staining. BMC Nephrol 2018; 19:143. [PMID: 29907095 PMCID: PMC6003039 DOI: 10.1186/s12882-018-0931-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 05/24/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Immunotactoid glomerulopathy (ITG) is a rare glomerulonephritis characterized by microtubular deposits. Immunofluorescence findings are necessary to differentiate ITG from other proliferative glomerular diseases. The characteristic tubular structure on electron microscopy is essential for a definitive diagnosis, and the diameter of the structure has been traditionally used for differentiating between ITG and other types of glomerulonephritis with organized deposits. In recent years, the disease concept of monoclonal gammopathy of renal significance, which is associated with M protein produced by plasma cell tumors, has been proposed. CASE PRESENTATION This was a peculiar case of ITG with underlying monoclonal gammopathy in which IgG showed a false-negative result with immunofluorescence using frozen sections. Additional examinations using a different clone of the anti-IgG antibody revealed typical IgG staining. C4d was strongly positive, consistent with immune complex type glomerulonephritis. CONCLUSIONS This case highlights unusual features of ITG, and provides a practical hint to avoid a diagnostic pitfall.
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Affiliation(s)
- Shuma Hirashio
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 7348551, Japan.,Department of Nephrology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Takahiro Arima
- Department of Nephrology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Ayaka Satoh
- Department of Nephrology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Kouichi Mandai
- Department of Diagnostic Pathology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Shigeo Hara
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 7348551, Japan.
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Hirashio S, Satoh A, Arima T, Mandai K, Awaya T, Oshima K, Hara S, Masaki T. Favorable effect of bortezomib in dense deposit disease associated with monoclonal gammopathy: a case report. BMC Nephrol 2018; 19:108. [PMID: 29724182 PMCID: PMC5934801 DOI: 10.1186/s12882-018-0905-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 04/22/2018] [Indexed: 11/10/2022] Open
Abstract
Background Complement component 3 (C3) glomerulopathy, which includes dense deposit disease (DDD) and C3 glomerulonephritis, is caused by dysregulation of the alternative complement pathway. In most cases, C3 glomerulopathy manifests pathologically with membranoproliferative glomerulonephritis-like features. An association between C3 glomerulopathy and monoclonal gammopathy was recently reported in several cases, raising the possibility that C3 glomerulopathy is the underlying pathological process in monoclonal gammopathy of renal significance. Case presentation We herein report a case of monoclonal gammopathy-induced DDD that improved histologically and clinically with chemotherapy including bortezomib. Our case is the first in which treatment response can be linked to the histological response. Potential pathological insights are also discussed. Conclusions Rapid and efficient chemotherapy has the potential to limit renal damage in monoclonal gammopathy-associated DDD.
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Affiliation(s)
- Shuma Hirashio
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 7348551, Japan.,Department of Nephrology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Ayaka Satoh
- Department of Nephrology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Takahiro Arima
- Department of Nephrology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Kouichi Mandai
- Department of Diagnostic Pathology, National Hospital Organization Higashihiroshima Medical Center, Hiroshima, Japan
| | - Tadasuke Awaya
- Department of Hematology, Hiroshima University Hospital, Hiroshima, Japan
| | - Kumi Oshima
- Department of Hematology, Hiroshima University Hospital, Hiroshima, Japan
| | - Shigeo Hara
- Department of Diagnostic Pathology, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Takao Masaki
- Department of Nephrology, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima, 7348551, Japan.
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Abstract
Multiple myeloma (MM) is one of the most important clonal malignant plasma cell disorders and renal involvement is associated with poor prognosis. Although there are several reasons for renal impairment in MM, the main cause is the toxic effects of monoclonal proteins. Although cast nephropathy is the best known and unchallenged diagnosis for hematologists and pathologists, the renal effects of monoclonal gammopathy can be various. Monoclonal gammopathy of renal significance was proposed by the International Kidney and Monoclonal Gammopathy Research Group for renal lesions in monoclonal gammopathy in recent years. Renal lesions in monoclonal gammopathy can be grouped as follows: light chain (cast) nephropathy, acute tubular injury/necrosis, tubulointerstitial nephritis, amyloidosis, monoclonal Ig deposition diseases, immunotactoid glomerulopathy, type I cryoglobulinemia, proliferative glomerulonephritis with monoclonal IgG deposits, C3 glomerulopathy with monoclonal gammopathy, and crystal-storing histiocytosis, considering the previous and new terminology. In this study, renal involvement of monoclonal gammopathies, in terms of previous and new terminology, was reviewed.
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Affiliation(s)
- Şadiye Mehtat Ünlü
- Dokuz Eylül University Faculty of Medicine, Department of Pathology, İzmir, Turkey
| | - Hayri Özsan
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
| | - Sülen Sarıoğlu
- Dokuz Eylül University Faculty of Medicine, Department of Pathology, İzmir, Turkey
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Katsuno T, Mizuno S, Mabuchi M, Tsuboi N, Komatsuda A, Maruyama S. Long-term renal survival of γ3-heavy chain deposition disease: a case report. BMC Nephrol 2017; 18:239. [PMID: 28716013 PMCID: PMC5512846 DOI: 10.1186/s12882-017-0645-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 06/28/2017] [Indexed: 01/08/2023] Open
Abstract
Background Monoclonal immunoglobulin deposition disease (MIDD) is characterized by the non-amyloid deposition of monoclonal immunoglobulin fragments in the basement membranes. Heavy chain deposition disease (HCDD) is a type of MIDD. HCDD is an extremely rare disease, and only three cases have been reported in Japan up to the present. The prognosis of HCDD is very poor, and optimal treatment has not been established. Only a few cases of HCDD with favorable long-term renal prognosis have been reported to date. Case presentation The authors describe a 61-year-old woman who presented with massive proteinuria, progressive kidney impairment, and hypocomplementemia. Kidney biopsy was performed for a precise diagnosis. On light microscopy, glomerules were lobulated and presented with nodular sclerosing glomerulopathy with membranoproliferative glomerulonephritis-like features. Immunofluorescence studies were positive for IgG, C3, and C1q within the mesangial nodules and in a linear distribution along the capillary walls without associated deposition of light chains. Staining for IgG showed the presence of linear deposits along tubular basement membranes. The analysis of the IgG subclass stain demonstrated intense positivity for IgG3 only. Electron microscopy revealed non-organized electron-dense deposits in the expanded mesangial area and inner aspect of the glomerular basement membranes. In accordance with the histological findings, we diagnosed γ3-HCDD. There was no evidence of plasma cell dyscrasia as a result of bone marrow aspiration. Serum and urine monoclonal proteins were not detected by immunoelectrophoresis and immunofixation electrophoresis. The serum free light chain ratio was within normal range. At first, prednisolone was administrated at a dose of 40 mg/day. However, a therapeutic effect was not observed. Urinary protein was not decreased and renal function further deteriorated. Therefore, melphalan plus prednisolone (MP) therapy was initiated. After 4 courses of MP therapy, the clinical parameters, including proteinuria, serum creatinine, albumin, and complement level (C3 and C4) were ameliorated. To date, the patient has been followed for 28 months, and long-term renal survival has been observed. Conclusions In this case, hematologic disease such as multiple myeloma was not detected; however, MP therapy was effective. Recently, the novel concept of monoclonal gammopathy of renal significance (MGRS) has been reported. MIDD, which includes HCDD, is one category of MGRS. In MGRS, aggressive chemotherapy may induce favorable renal outcomes.
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Affiliation(s)
- Takayuki Katsuno
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Shige Mizuno
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.,Department of Internal Medicine, Kaikoukai Jyousai Hospital, Nagoya, Japan
| | - Masatsuna Mabuchi
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.,Department of Nephrology, Konan Kosei Hospital, Konan, Japan
| | - Naotake Tsuboi
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Atsushi Komatsuda
- Department of Hematology, Nephrology, Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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Mahmood U, Isbel N, Mollee P, Mallett A, Govindarajulu S, Francis R. Monoclonal gammopathy of renal significance triggering atypical haemolytic uraemic syndrome. Nephrology (Carlton) 2017; 22 Suppl 1:15-17. [PMID: 28176474 DOI: 10.1111/nep.12934] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Haemolytic uraemic syndrome is a rare condition with an overall incidence of one to two cases in a population of 100 000 and approximately 10% of these cases are classified as atypical. Atypical haemolytic uraemic syndrome (aHUS) is a thrombotic microangiopathy (TMA) characterized by microangiopathic haemolytic anaemia (MAHA), thrombocytopenia and acute kidney injury. aHUS can be genetic, acquired or idiopathic (negative genetic screening and no environmental triggers). We describe a case of aHUS triggered by monoclonal gammopathy of renal significance (MGRS) successfully treated with plasmapheresis and a bortezomib-based chemotherapy regimen, resulting in marked improvement in renal function and other markers of haemolysis. This patient has been in remission for more than 2 years currently.
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Affiliation(s)
- Usman Mahmood
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
| | - Nicole Isbel
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
| | - Peter Mollee
- Department of Haematology, Princess Alexandra Hospital, Queensland, Australia
| | - Andrew Mallett
- Royal Brisbane and Women's Hospital, Queensland, Australia
| | | | - Ross Francis
- Department of Nephrology, Princess Alexandra Hospital, Queensland, Australia
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Correia SO, Santos S, Malheiro J, Cabrita A, Martins LS, Santos J. Monoclonal gammopathy of renal significance: Diagnostic workup. World J Nephrol 2017; 6:72-78. [PMID: 28316940 PMCID: PMC5339639 DOI: 10.5527/wjn.v6.i2.72] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/08/2016] [Accepted: 01/14/2017] [Indexed: 02/06/2023] Open
Abstract
The clinical spectrum of diseases associated with monoclonal gammopathies is wide and they are most commonly the consequence of renal deposition of monoclonal immunoglobulin or its components. The differential diagnosis is difficult and renal biopsy is essential. To distinguish many of these pathologies is necessary to use techniques that are not always available, even in tertiary central hospitals. This review will discuss the clinical presentation, pathologic features, treatment, prognosis and common diagnostic difficulties of these entities.
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Khandelwal A, Trinkaus MA, Ghaffar H, Jothy S, Goldstein MB. A case report of unusually long lag time between immunotactoid glomerulopathy (itg) diagnosis and diffuse large B-cell lymphoma (DLBCL) development. BMC Nephrol 2016; 17:140. [PMID: 27686684 PMCID: PMC5043628 DOI: 10.1186/s12882-016-0349-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 09/15/2016] [Indexed: 11/19/2022] Open
Abstract
Background Immunotactoid glomerulopathy (ITG) is a rare cause of proteinuria characterized by organized microtubular deposits in the glomerulus. ITG has been associated with underlying lymphoproliferative disorders and any renal impairment may be reversible with treatment of the concomitant hematologic malignancy. This case is the first reported in literature where diffuse large B cell lymphoma developed two years following the initial ITG diagnosis. Case presentation A 55-year-old woman with a history of well-controlled diabetes mellitus and thalassemia trait presented with proteinuria (830 mg/day) in 2010. Initially, she was managed with renin-angiotensin-aldosterone-system blockade. In 2012, the proteinuria worsened (4.3 g/day) and a renal biopsy showed immunotactoid glomerulopathy (Fig. 1). Despite extensive work up, no lymphoproliferative disorder was initially found. In January 2014, the patient presented with a soft-palate mass found on biopsy to be diffuse large B-cell lymphoma. She received 6 cycles of R-CHOP, 4 cycles of high dose methotrexate chemotherapy for CNS prophylaxis and 30 Gy of Intensity Modulated Radiation Therapy. Follow-up revealed complete remission of diffuse large B-cell lymphoma and resolution of proteinuria from the ITG. Conclusion As we recognize that patients with ITG may develop hematopoietic neoplasms, close long-term monitoring is important. Moreover, treatment of the lymphoproliferative disorder can allow for complete remission of ITG.
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Affiliation(s)
- Aditi Khandelwal
- Department of Medicine, University of Toronto, Suite RFE 3-805, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Martina A Trinkaus
- Department of Laboratory Medicine, St. Michael's Hospital and Department of Laboratory Medicine and Pathobiology, Univesity of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Hassan Ghaffar
- Department of Laboratory Medicine, St. Michael's Hospital and Department of Laboratory Medicine and Pathobiology, Univesity of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Serge Jothy
- Department of Laboratory Medicine, St. Michael's Hospital and Department of Laboratory Medicine and Pathobiology, Univesity of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Marc B Goldstein
- Department of Laboratory Medicine, St. Michael's Hospital and Department of Laboratory Medicine and Pathobiology, Univesity of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
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Zaidan M, Plasse F, Rabant M, Javaugue V, Knebelmann B, Alyanakian MA, Joly D, Nochy D, Bridoux F. [Renal involvement during type 1 cryoglobulinemia]. Nephrol Ther 2016; 12 Suppl 1:S71-81. [PMID: 26972092 DOI: 10.1016/j.nephro.2016.01.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Cryoglobulins are circulating immunoglobulins that precipitate with cold temperature and dissolve with rewarming. Type 1 cryoglobulinemia is composed of a single monoclonal immunoglobulin and is associated with renal involvement in up to 40% of cases. Type 1 cryoglobulinemia is related to an underlying B-cell haematological malignancy in 60% of patients. In the remaining cases, in the absence of criteria for malignancy, the diagnosis of monoclonal gammopathy of renal significance should be established. The clinical and biological setting and histological features of type 1 cryoglobulinemia are globally similar to those of mixed cryoglobulinemia. In case of haematological malignancy, the treatment is guided by the nature of the underlying disease, and aims at inducing haematological remission, which is necessary for the renal response. The management of monoclonal gammopathy of renal significance has been clarified by an international consensus group and is based on the nature of the underlying clone. In case of monoclonal cryoglobulinemia associated with a plasma-cell clone (IgG or IgA), the treatment is based on the combination of bortezomib, cyclophosphamide and dexamethasone. In case of IgM monoclonal cryoglobulinemia, the treatment is similar to that of Waldenström macroglobulinemia, and is based on rituximab. The clinical course of renal monoclonal cryoglobulinemia is intimately associated with the haematological response, and is usually favourable.
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Affiliation(s)
- Mohamad Zaidan
- Service de néphrologie-transplantation adultes, hôpital Necker, AP-HP, 149, rue de Sèvres, 75015 Paris, France; Université Paris Descartes, 12, rue de l'École-de-Médecine, 75006 Paris, France.
| | - Florent Plasse
- Service de néphrologie, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France; Centre national de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Marion Rabant
- Université Paris Descartes, 12, rue de l'École-de-Médecine, 75006 Paris, France; Service d'anatomie pathologique, hôpital Necker, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - Vincent Javaugue
- Service de néphrologie, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France; Centre national de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - Bertrand Knebelmann
- Service de néphrologie-transplantation adultes, hôpital Necker, AP-HP, 149, rue de Sèvres, 75015 Paris, France; Université Paris Descartes, 12, rue de l'École-de-Médecine, 75006 Paris, France
| | - Marie-Alexandra Alyanakian
- Université Paris Descartes, 12, rue de l'École-de-Médecine, 75006 Paris, France; Service d'immunologie biologique, hôpital Necker, AP-HP, 149, rue de Sèvres, 75015 Paris, France
| | - Dominique Joly
- Service de néphrologie-transplantation adultes, hôpital Necker, AP-HP, 149, rue de Sèvres, 75015 Paris, France; Université Paris Descartes, 12, rue de l'École-de-Médecine, 75006 Paris, France
| | - Dominique Nochy
- Université Paris Descartes, 12, rue de l'École-de-Médecine, 75006 Paris, France; Service d'anatomie pathologique, hôpital européen Georges-Pompidou, AP-HP, 20, rue Leblanc, 75015 Paris, France
| | - Frank Bridoux
- Service de néphrologie, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France; Centre national de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
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Kapoulas S, Raptis V, Papaioannou M. New aspects on the pathogenesis of renal disorders related to monoclonal gammopathies. Nephrol Ther 2015; 11:135-43. [PMID: 25861714 DOI: 10.1016/j.nephro.2014.12.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 12/10/2014] [Accepted: 12/11/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND Multiple myeloma and other related monoclonal gammopathies are frequently encountered conditions associated with renal damage, especially in elderly population. They are arising from clonal proliferation of plasma cells in bone marrow producing various quantities of abnormal monoclonal immunoglobulins, or their components/fragments. SUMMARY These abnormal proteins differ from normal immunoglobulins in the amino acid sequence and in the three-dimensional structure of the molecule, which may determine their toxicity. Kidney seems to be a target organ as a major catabolic site. The pathology of renal disease is highly heterogeneous involving a variety of different mechanisms, which are divided into immunoglobulin dependent and immunoglobulin independent mechanisms. The Ig-dependent mechanisms may involve the four components of the kidney parenchyma, and the primary structure of these proteins determine the pattern of renal disease. KEY MESSAGE This review summarizes the existing literature in the pathobiology of multiple myeloma, and the pathological properties of the M-proteins, focusing on the mechanisms of the renal manifestations related to these abnormal proteins, especially glomerular injury. Also it supports the opinion that monoclonal gammopathy of undetermined significance (MGUS) should not be used in cases where there is proven renal impairment due to these proteins, even if it is mild and does not meet the current criteria.
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Affiliation(s)
- Stergios Kapoulas
- Section of nephrology and hypertension, 1st department of internal medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Stilponos Kyriakidi 1, 54636 Thessaloniki, Greece
| | - Vasileios Raptis
- Section of nephrology and hypertension, 1st department of internal medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Stilponos Kyriakidi 1, 54636 Thessaloniki, Greece.
| | - Maria Papaioannou
- Section of hematology, 1st department of internal medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Stilponos Kyriakidi 1, 54636 Thessaloniki, Greece
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