1
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Dima D, Khouri J. The role of therapeutic plasma exchange in plasma cell disorders. Ann Hematol 2024:10.1007/s00277-024-05712-0. [PMID: 38558184 DOI: 10.1007/s00277-024-05712-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 03/12/2024] [Indexed: 04/04/2024]
Abstract
Therapeutic plasma exchange (TPE) is an extracorporeal technique where patient's plasma containing pathogenic substances is separated and removed from the whole blood, while the cellular component is returned to the patient mixed with replacement solution via an apheresis machine. Due to its ability to remove pathogenic substances from plasma including immunoglobulins, TPE has proven efficacious in the management of various disorders across different medical disciplines, including plasma cell dyscrasias, which are characterized by the abundant secretion of non-functional immunoglobulins produced by an abnormally proliferating plasma cell clone. This review summarizes the current indications of TPE in plasma cell-related disorders and discusses its application, safety, and therapeutic effects.
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Affiliation(s)
- Danai Dima
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Jack Khouri
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland, OH, USA
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2
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Moretti M, Ferro F, Baldini C, Mosca M, Talarico R. Cryoglobulinemic vasculitis: a 2023 update. Curr Opin Rheumatol 2024; 36:27-34. [PMID: 37916482 DOI: 10.1097/bor.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
PURPOSE OF REVIEW Cryoglobulinemic vasculitis (CV) is an immune complex mediated small vessel vasculitis characterized by the presence of cryoglobulins in serum, often associated with hepatitis C infection, systemic autoimmune diseases or hematological conditions. The focus of this review is to provide an update on new insights into pathogenesis, epidemiology and therapies of infectious and noninfectious type II and type III CV. RECENT FINDINGS The introduction of new antiviral drugs for treatment of hepatitis C infection implied major changes in HCV-related CV, allowing to shed new lights on CV pathogenesis and mechanisms of relapse and, therefore, to increase the relevance of autoimmune diseases in CV epidemiology. Specific B-cell clones are involved in the production of pathogenic immune complexes that leads to small-vessel vasculitis. Therefore, both antiviral treatments [direct-acting antivirals (DAAs) and oral nucleot(s)ide analogues] and targeted anti-CD20 therapies (rituximab) prove to be safe and effective options, leading to a better prognosis. Association of Sjögren syndrome and CV defines a specific phenotype of patients, characterized by severe manifestations and poor outcome. SUMMARY Removing viral stimulation on B-cells through direct-acting antivirals and blocking B-cells proliferation and differentiation with rituximab are the goals of treatment of CV. However, further research is needed to identify prognostic factors of refractory and relapsing disease.
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Affiliation(s)
- Michele Moretti
- Rheumatology Unit, Azienda Ospedaliero Universitaria Pisana, University of Pisa, Pisa, Italy
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3
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Su T, Jin Q, Zhao T, Wang S. 57-year-old woman with purpura fulminans and acute kidney injury. J Clin Pathol 2023; 76:654-657. [PMID: 34893518 DOI: 10.1136/jclinpath-2020-207020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 03/10/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Tao Su
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Renal Pathological Center, Institute of Nephrology, Peking University, Beijing, China
| | - Qizhuang Jin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Renal Pathological Center, Institute of Nephrology, Peking University, Beijing, China
| | - Tao Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Renal Pathological Center, Institute of Nephrology, Peking University, Beijing, China
| | - Suxia Wang
- Renal Pathological Center, Institute of Nephrology, Peking University, Beijing, China
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, China
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4
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Tomkins O, Leblond V, Lunn MP, Viala K, Weil DR, D'Sa S. Investigation and Management of Immunoglobulin M- and Waldenström-Associated Peripheral Neuropathies. Hematol Oncol Clin North Am 2023; 37:761-776. [PMID: 37385714 DOI: 10.1016/j.hoc.2023.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
The immunoglobulin M (IgM)-associated peripheral neuropathies (PN) are a heterogeneous group of disorders representing most paraproteinemic neuropathy cases. They are associated with IgM monoclonal gammopathy of undetermined significance (MGUS) or Waldenström macroglobulinemia. Establishing a causal link between a paraprotein and neuropathy can be challenging but is necessary to adopt an appropriate therapeutic approach. The most common type of IgM-PN is Antimyelin-Associated-Glycoprotein neuropathy, but half of the cases are of other causes. Progressive functional impairment is an indication for treatment, even when the underlying disorder is IgM MGUS, involving either rituximab monotherapy or combination chemotherapy to achieve clinical stabilization.
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Affiliation(s)
- Oliver Tomkins
- Department of Haematology, Centre for Waldenströms Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK. https://twitter.com/tomkinsoliver
| | - Veronique Leblond
- Department of Haematology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Michael P Lunn
- National Hospital for Neurology and Neurosurgery, Queen Square, London WC1N 3BG, UK
| | - Karine Viala
- Department of Clinical Neurophysiology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Damien Roos Weil
- Department of Haematology, Sorbonne University and Pitié Salpêtrière Hospital, 47-83 Bd de l'Hôpital, Paris 75013, France
| | - Shirley D'Sa
- Department of Haematology, Centre for Waldenströms Macroglobulinaemia and Related Conditions, University College London Hospitals NHS Foundation Trust, 250 Euston Road, London NW1 2PG, UK.
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5
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Rajendran N, Rameli PM, Awad H. Risk factors for relapse in non-infectious cryoglobulinemic vasculitis, including type I cryoglobulinemia: a systematic review. Front Immunol 2023; 14:1215345. [PMID: 37483620 PMCID: PMC10361750 DOI: 10.3389/fimmu.2023.1215345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 06/12/2023] [Indexed: 07/25/2023] Open
Abstract
Background Data on non-infectious cryoglobulinemic vasculitis (NICV) is scarce, especially concerning the management of relapses, which are troublesome. We aimed to investigate risk factors for relapse in NICV. Methods A systematic literature search of CINAHL, Embase, MEDLINE, Scopus, and the Web of Science databases was implemented until April 2023. Eligible studies included randomized control trials, observational studies, and case series with ≥4 patients. Two reviewers independently extracted data and assessed the quality of the eligible studies. Results A total of 3,724 articles were retrieved from a database search, with 27 studies meeting the inclusion criteria for review. Most studies (n = 23) detailed relapses, with the time to relapse varying between 1 and 80 months. The relapse rate was reported at 28% in Type I NICV and ranged from 22% to 60% in mixed NICV. Risk factors for relapse in NICV were identified based on the cryoglobulin subtype and correlated with clinical and immunological responses to varying treatment regimens. Type I NICV with an associated lymphoproliferative disorder exhibited a response-relapse pattern. Cutaneous and articular involvement and incomplete clinical and immunological responses to treatment, particularly corticosteroid monotherapy and occasionally rituximab, influence the risk of relapse in Type II and Type III NICV. Conclusion Our findings underscore the significance of attaining both clinical and immunological responses and identifying risk factors for relapse in NICV. Appropriate risk stratification for NICV patients is essential for the successful implementation of effective treatment strategies. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier CRD42023408140.
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Affiliation(s)
- Nithya Rajendran
- Department of Immunology, Beaumont Hospital, Royal College of Surgeons in Ireland (RCSI) Hospital Group, Dublin, Ireland
| | - Puteri Maisarah Rameli
- Department of Acute Medical Assessment Unit (AMAU)/ General Internal Medicine (GIM), St. James’s Hospital, Trinity College Dublin, Dublin, Ireland
| | - Hanaa Awad
- Department of Immunology, Beaumont Hospital, Royal College of Surgeons in Ireland (RCSI) Hospital Group, Dublin, Ireland
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6
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Ghembaza A, Boleto G, Bommelaer M, Karras A, Javaugue V, Bridoux F, Alyanakian MA, Molinier Frenkel V, Ghillani-Dalbin P, Musset L, Barete S, Roosweil D, Choquet S, Le Joncour A, Mirouse A, Lipsker D, Faguer S, Vieira M, Cacoub P, Biard L, Saadoun D. Prognosis and long-term outcomes in type I cryoglobulinemia: A multicenter study of 168 patients. Am J Hematol 2023. [PMID: 37139676 DOI: 10.1002/ajh.26944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/05/2023]
Abstract
Type I cryoglobulinemia (CG) accounts for 10%-15% of all cryoglobulinemias and are exclusively seen in clonal proliferative hematologic conditions. In this multicenter nationwide cohort study, we analyzed the prognosis and long-term outcomes of 168 patients with type I CG (93 (55.4%) IgM and 75 [44.6%] IgG). Five- and 10-year event-free survivals (EFS) were 26.5% (95% CI 18.2%-38.4%) and 20.8% (95% CI 13.1%-33.1%), respectively. In multivariable analysis, factors associated with poorer EFS were renal involvement (HR: 2.42, 95% CI 1.41-4.17, p = .001) and IgG type I CG (HR: 1.96, 95% CI 1.13-3.33, p = 0.016), regardless of underlying hematological disorders. IgG type I CG patients had higher cumulative incidence of relapse (94.6% [95% CI 57.8%-99.4%] vs. 56.6% [95% CI 36.6%-72.4%], p = .0002) and death at 10 years (35.8% [19.8%-64.6%] vs. 71.3% [54.0%-94.2%], p = .01) as compared to IgM CG, respectively. Overall, complete response of type I CG at 6 months was 38.7%, with no significant difference between Igs isotypes. In conclusion, renal involvement and IgG CG were identified as independent poor prognostic factors of type I CG.
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Affiliation(s)
- Amine Ghembaza
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Gonçalo Boleto
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
- Instituto Português de Reumatologia, Lisbon, Portugal
| | - Marin Bommelaer
- Service de Biostatistique et Information Médicale, AP-HP Hôpital Saint-Louis - INSERM, UMR1153, Paris, France
| | - Alexandre Karras
- Département de néphrologie, Hôpital Européen Georges Pompidou, APHP, Paris, France
| | - Vincent Javaugue
- Service de néphrologie et Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
- CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France
| | - Frank Bridoux
- Service de néphrologie et Centre National de référence amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
- CNRS UMR 7276, INSERM UMR 1262, Université de Limoges, Limoges, France
| | - Marie-Alexandra Alyanakian
- Laboratoire d'immunologie, Hôpital Necker-Enfants Malades, AP-HP et Institut Necker-Enfants malades (INEM), Paris, France
| | | | | | - Lucile Musset
- Laboratoire d'immunochimie, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
| | - Stéphane Barete
- Unité fonctionnelle de dermatologie, service de médecine interne, Hôpital Pitié-Salpêtrière, Paris, France
| | - Damien Roosweil
- Service d'hématologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Sylvain Choquet
- Service d'hématologie, Hôpital Pitié-Salpêtrière, Paris, France
| | - Alexandre Le Joncour
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Adrien Mirouse
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Dan Lipsker
- Clinique dermatologique, Université de Strasbourg, Strasbourg, France
| | - Stanislas Faguer
- Département de Néphrologie et Transplantation d'Organes, Centre de Référence des Maladies Rénales Rares, Hôpital Rangueil, Institut National de la Santé et de la Recherche Médicale, UMR 1297, Université Paul Sabatier - Toulouse 3, Toulouse, France
| | - Matheus Vieira
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Patrice Cacoub
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
| | - Lucie Biard
- Service de Biostatistique et Information Médicale, AP-HP Hôpital Saint-Louis - INSERM, UMR1153, Paris, France
| | - David Saadoun
- Sorbonne Universités, Hôpital Pitié-Salpêtrière, Paris, France
- Département de médecine interne et d'immunologie clinique, Paris, France
- AP-HP, Centre de Référence des Maladies Auto-Immunes Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires et de l'Amylose inflammatoire, Paris, France
- Institut national de la santé et de la recherche médicale, INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
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7
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Karam S, Haidous M, Dalle IA, Dendooven A, Moukalled N, Van Craenenbroeck A, Bazarbachi A, Sprangers B. Monoclonal gammopathy of renal significance: Multidisciplinary approach to diagnosis and treatment. Crit Rev Oncol Hematol 2023; 183:103926. [PMID: 36736510 DOI: 10.1016/j.critrevonc.2023.103926] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 01/13/2023] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is a hemato-nephrological term referring to a heterogeneous group of kidney disorders characterized by direct or indirect kidney injury caused by a monoclonal immunoglobulin (MIg) produced by a B cell or plasma cell clone that does not meet current hematologic criteria for therapy. MGRS-associated kidney diseases are diverse and can result in the development of end stage kidney disease (ESKD). The diagnosis is typically made by nephrologists through a kidney biopsy. Many distinct pathologies have been identified and they are classified based on the site or composition of the deposited Mig, or according to histological and ultrastructural findings. Therapy is directed towards the identified underlying clonal population and treatment decisions should be coordinated between hematologists and nephrologists in a multidisciplinary fashion, depend on the type of MGRS, the degree of kidney function impairment and the risk of progression to ESKD.
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Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, MN, United States
| | - Mohammad Haidous
- Department of Medicine, Saint Vincent Charity Medical Center, Cleveland, OH, United States
| | - Iman Abou Dalle
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amélie Dendooven
- Department of Pathology, University Hospital Ghent, Ghent, Belgium
| | - Nour Moukalled
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | - Amaryllis Van Craenenbroeck
- Department of Microbiology, Immunology and Transplantation, Laboratory of Nephrology, KU Leuven, Leuven, Belgium; Division of Nephrology, University Hospitals Leuven, Leuven, Belgium
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon; Department of Anatomy, Cell Biology and Physiological Sciences, American University of Beirut Medical Center, Beirut, Lebanon
| | - Ben Sprangers
- Biomedical Research Institute, Department of Immunology and Infection, University Hasselt, Diepenbeek, Belgium; Department of Nephrology, Ziekenhuis Oost-Limburg, Genk, Belgium.
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8
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Fenoglio R, Sciascia S, Rossi D, Naretto C, Alpa M, Roccatello D. Non HCV-Related Mixed Cryoglobulinemic Vasculitis With Biopsy-Proven Renal Involvement: The Effects of Rituximab. Front Med (Lausanne) 2022; 9:819320. [PMID: 35419372 PMCID: PMC8995745 DOI: 10.3389/fmed.2022.819320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 03/03/2022] [Indexed: 11/17/2022] Open
Abstract
In the countries where HCV infection is still endemic, about 90% of subjects with mixed cryoglobulinemia had previously been infected with HCV and about 80% are RNA positive. Remarkable results in severe HCV-related cryoglobulinemic vasculitis have been obtained with Rituximab. Details of the clinical characteristics and effective treatment of non HCV-related cryogloulinemic syndromes are presently lacking. This paper reports on a prospective single-Center open study aimed at evaluating the clinical presentation and effects of Rituximab administered alone in patients with severe non HCV-related cryoglobulinemic syndrome. The study group included 11 patients followed for at least 6 months. Three patients had type I cryoglobulinemia, 6 had type II and the remaining 2 patients had type III. Mean cryocrit was 2.5%. Four out of 11 patients had symptomatic sicca complex with anti-SSA (Ro)/anti SSB (La) antibodies. All 11 patients presented with biopsy-proven renal involvement, 4 out of 11 with leukocytoclastic vasculitis, and 8 with involvement of the peripheral nervous system. Renal biopsy revealed diffuse membranoproliferative glomerulonephritis (MPGN) in 9 out of 11 patients. Extracapillary proliferation and necrosis of the glomerular tuft was observed in 1 of these 9 cases. Interstitial nephritis together with mesangial expansion and capillary immune deposits were observed in 1 patient. Prevalent interstitial fibrosis and glomerular sclerosis were detected in the remaining case. Patients underwent treatment with rituximab alone. After 6 months we observed a remarkable improvement in the necrotizing skin ulcers and a substantial amelioration of the electrophysiological parameters of motor and sensory peripheral neuropathy. Improvement in both renal function (from 2.8 to 1.4 mg/dl, p < 0.001) and proteinuria (from 4.2 g/24 to 0.4 g/24 h, p < 0.001) was found in 10 out of 11 patients, while 1 could not be fully treated because of a severe infusion reaction and sudden development of anti-Rituximab antibodies. Good renal response was confirmed at the end of follow-up (38.4 months). Three patients had a relapse at 6, 12, and 48 months, respectively. In our cohort the administration of 4 once-weekly infusions of Rituximab followed by 2 more infusions after 1 and 2 months proved to be effective in the management of these rare patients.
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Affiliation(s)
- Roberta Fenoglio
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Savino Sciascia
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Daniela Rossi
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Carla Naretto
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Mirella Alpa
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
| | - Dario Roccatello
- Nephrology and Dialysis Unit (The European Rare Kidney Disease Reference Network, The European Reference Network on Rare and Complex Connective Tissue and Musculoskeletal Diseases, and the European Reference Network That Aims at Improving the Care of Patients With Rare Immunological Disorders), Center of Research of Immunopathology and Rare Diseases- Coordinating Center of the Network for Rare Diseases of Piedmont and Aosta Valley, Department of Clinical and Biological Sciences, University of Turin and S. Giovanni Bosco Hub Hospital, Turin, Italy
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9
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Hesius E, Bunthof K, Steenbergen E, de Kort E, Klein I, Wetzels J. Monoclonal gammopathy of renal significance presenting with cryoglobulinemia type I associated severe thrombotic microangiopathy. Clin Kidney J 2022; 15:1425-1428. [PMID: 35756736 PMCID: PMC9217659 DOI: 10.1093/ckj/sfac078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Indexed: 11/28/2022] Open
Abstract
We report a 53-year-old man who presented with acute renal failure. His medical history revealed a spondyloarthropathy, for which secukinumab was started recently, and a monoclonal gammopathy of unknown significance. Kidney function deteriorated despite the withdrawal of secukinumab and dialysis was started. In the serum, type 1 cryoglobulins were present and a kidney biopsy showed ischaemic glomeruli, with thrombosis of the larger interlobular arteries. Other causes of thrombotic microangiopathy were excluded. Bone marrow immunophenotyping showed 1% monoclonal plasma cells. A diagnosis of monoclonal gammopathy of renal significance was made. Haematological treatment resulted in haematological and renal response.
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Affiliation(s)
- Eva Hesius
- Radboudumc, Department of Hematology, Nijmegen, The Netherlands
| | - Kim Bunthof
- Radboudumc, Department of Nephrology, Nijmegen, The Netherlands
- Bravis Hospital, Department of Internal Medicine, Roosendaal, The Netherlands
| | | | | | - Inge Klein
- Slingeland Hospital, Department of Nephrology, Doetinchem, The Netherlands
| | - Jack Wetzels
- Radboudumc, Department of Nephrology, Nijmegen, The Netherlands
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10
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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] [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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11
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Type 1 cryoglobulinemic neuropathy associated with lymphoplasmacytic lymphoma. Acta Neurol Belg 2021; 121:1887-1890. [PMID: 33104964 DOI: 10.1007/s13760-020-01529-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 10/13/2020] [Indexed: 11/27/2022]
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12
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Han HX, Cao XX, Su W, Shen KN, Zhang L, Zhou DB, Li J. [Clinical characteristics and outcome of patients with type Ⅱ cryoglobulinemia]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:447-451. [PMID: 34384149 PMCID: PMC8295613 DOI: 10.3760/cma.j.issn.0253-2727.2021.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
目的 探讨Ⅱ型冷球蛋白血症患者的临床特征及预后。 方法 回顾性分析2015年5月至2020年1月北京协和医院确诊的61例Ⅱ型冷球蛋白血症患者的临床资料。 结果 61例患者中,男性26例(42.6%),中位诊断年龄为53(28~79)岁。继发病因包括丙型肝炎病毒(HCV)感染(21.3%)、乙型肝炎病毒(HBV)感染(21.3%)、自身免疫性疾病(14.8%)和血液系统肿瘤(11.5%)。31.1%患者为特发性。常见首诊症状包括皮肤紫癜、蛋白尿、血尿、肾功能不全、发热及关节痛。实验室检查显示,中位冷球蛋白水平为215.9(22.0~17 075.8)g/L,54例(88.5%)为IgM单克隆。类风湿因子(RF)升高患者占93.2%,C3下降患者占57.6%,C4下降患者占61.0%。共49例(80.3%)患者接受治疗,总体临床缓解率为75.5%,预计3年总生存率为89.3%。 结论 Ⅱ型冷球蛋白血症是一种多系统受累的全身性疾病,病因以肝炎病毒感染多见。早期诊断和干预对于改善预后有重要意义。
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Affiliation(s)
- H X Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - X X Cao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - W Su
- Department of Clinical Laboratory, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - K N Shen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - L Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - D B Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - J Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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13
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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] [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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14
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Fung WWS, Yip TCF, Wong VWS, Chow KM, Wong GLH, Szeto CC. Clinical Spectrum and Renal Outcome of Cryoglobulinemia in Hong Kong. KIDNEY360 2021; 2:721-728. [PMID: 35373043 PMCID: PMC8791315 DOI: 10.34067/kid.0007532020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 02/17/2021] [Indexed: 02/04/2023]
Abstract
Background Cryoglobulinemia is a systemic disease and the clinical involvement is variable. The long-term renal outcome of cryoglobulinemia remains unclear, and most published series are from the Western world, with a high proportion of chronic hepatitis C. The objective is to determine the prevalence, causes, and renal outcome of cryoglobulinemia in Hong Kong. Methods We reviewed 289 patients with cryoglobulinemia in the public hospital database of Hong Kong between 2000 and 2019. The renal event-free survival, dialysis-free survival, and overall survival were analyzed according to the underlying etiologies, and compared with 7483 patients who tested negative for cryoglobulinemia during the same period. Results Among the patients with cryoglobulinemia, 68 (24%) had chronic hepatitis B, 69 (24%) had hepatitis C, and 14 (5%) paraproteinemia. They were followed for 62.7±58.0 months. The 5-year dialysis-free survival was 68%, 70%, 67%, and 83% for patients with cryoglobulinemia attributed to hepatitis B, hepatitis C, paraproteinemia, and unknown etiology, respectively (P=0.05), and their 5-year overall survival was 61%, 58%, 22%, and 72%, respectively (P=0.002). Among patients with hepatitis B, the group with cryoglobulin had a worse renal event-free survival than those without (36% versus 43%, P=0.005), although their dialysis-free survival and all-cause mortality were similar. For patients with hepatitis C or paraproteinemia, the presence of cryoglobulin did not affect the renal outcome. Conclusions Hepatitis B is a common cause of cryoglobulinemia in southeast Asia, and the presence of cryoglobulinemia is associated with a worse renal event-free survival. The renal prognosis of cryoglobulinemia appears to be affected by the underlying cause, with hepatitis B having a worse renal outcome and patients with paraproteinemia having a worse overall survival than those with other causes of cryoglobulinemia.
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Affiliation(s)
- Winston Wing-Shing Fung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Terry Cheuk-Fung Yip
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Vincent Wai-Sun Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Kai-Ming Chow
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Grace Lai-Hung Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China
| | - Cheuk-Chun Szeto
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China,Department of Nephrology, Li Ka Shing Institute of Health Sciences, The Chinese University of Hong Kong, Shatin, Hong Kong, China
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15
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Kolopp-Sarda MN, Miossec P. Cryoglobulinemic vasculitis: pathophysiological mechanisms and diagnosis. Curr Opin Rheumatol 2021; 33:1-7. [PMID: 33186245 DOI: 10.1097/bor.0000000000000757] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
PURPOSE OF REVIEW Cryoglobulins (CG) are immunoglobulins that precipitate in the cold, and dissolve at 37°C. In vivo, in cold exposed tissues and organs, they can induce vasculitis and occlusive vasculopathy after deposition on vascular endothelium under low temperature and high concentration conditions. Clinical manifestations are cutaneous (purpura, ulcers, vasomotor symptoms, and livedo reticularis), rheumatological (arthralgia and arthritis), and peripheral neuropathy (paresthesia and pain in the lower limbs). In profound organs such as the kidneys, CG deposition is less temperature-dependent, favored by local protein and anion concentrations, and can lead to glomerulonephritis. This review will focus on cryoglobulinemic vasculitis and vascular lesion, and their diagnosis. RECENT FINDINGS The mechanisms of vascular lesions of pathogenic CG in function of CG type and their characteristics are better defined. Optimal conditions for CG detection are critical. The importance of looking for underlying diseases, especially hepatitis C virus status in mixed CG, is reminded. SUMMARY A decision diagram for CG vasculitis diagnosis based on clinical and biological parameters is proposed.
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Affiliation(s)
- Marie N Kolopp-Sarda
- Immunogenomics and inflammation research Unit EA 4130, University of Lyon
- Immunology Laboratory
| | - Pierre Miossec
- Immunogenomics and inflammation research Unit EA 4130, University of Lyon
- Department of Immunology and Rheumatology, Clinical Immunology Unit, Hospices Civils de Lyon, Lyon, France
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16
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Klimko A, Toma GA, Bejinariu N, Secareanu SM, Andreiana I. Acute Kidney Injury in a Patient With Cryoglobulinemia Secondary to Hepatic Mucosa-Associated Lymphoid Tissue Lymphoma: Case Report and Literature Review. Cureus 2020; 12:e10451. [PMID: 33072459 PMCID: PMC7557331 DOI: 10.7759/cureus.10451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
We report a patient with IgM-predominant type I cryoglobulinemia (CG), who presented to our nephrology department with acute kidney injury. He was previously diagnosed with sensorimotor neuropathy, which was in remission with maintenance dose of corticosteroids. Upon admission, there were ulcerated, necrotic cutaneous lesions localized to the inner aspect of the thighs bilaterally. Further workup revealed a mucosa-associated lymphoid tissue lymphoma, causing type I CG. Screening tests for hepatitis viruses were negative at this time. Under treatment with diuretics and high-potency glucocorticoids, the patient had an acceptable recovery of renal function and was referred to oncology for treatment. Unfortunately, three months later the patient succumbed to fulminant hepatitis, presumably secondary to reactivation of an occult hepatitis B/D co-infection. We further conducted a literature review to better describe patient characteristics and renal involvement in type I CG.
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Affiliation(s)
- Artsiom Klimko
- Division of Physiology and Neuroscience, University of Medicine and Pharmacy "Carol Davila", Bucharest, ROU
| | - Georgiana A Toma
- General Medicine, University of Medicine, Pharmacy, Science, and Technology of Târgu Mureş, Târgu Mureş, ROU
| | - Nona Bejinariu
- Department of Pathology, Santomar Oncodiagnostic, Cluj-Napoca, ROU
| | - Silviu-Mihai Secareanu
- Department of Nephrology and Dialysis, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, ROU
| | - Iuliana Andreiana
- Department of Internal Medicine and Nephrology, University of Medicine and Pharmacy "Carol Davila", Bucharest, ROU.,Department of Nephrology and Dialysis, "Dr. Carol Davila" Teaching Hospital of Nephrology, Bucharest, ROU
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17
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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] [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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18
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Zhang LL, Cao XX, Shen KN, Han HX, Zhang CL, Qiu Y, Zhao H, Gao XM, Feng J, Zhang L, Zhou DB, Li J. Clinical characteristics and treatment outcome of type I cryoglobulinemia in Chinese patients: a single-center study of 45 patients. Ann Hematol 2020; 99:1735-1740. [PMID: 32535708 DOI: 10.1007/s00277-020-04123-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 06/01/2020] [Indexed: 01/28/2023]
Abstract
To explore the clinical characteristics and outcomes in Chinese patients with type I cryoglobulinemia (CG), we retrospectively analyzed the clinical data, management, and outcomes of 45 patients diagnosed with type I CG in our hospital from January 2015 to March 2019. In our study, all type I CGs were secondary to hematologic diseases, and monoclonal gammopathy of unknown significance was the most common primary disease, accounting for 48.9% (n = 22). Additionally, B cell non-Hodgkin lymphoma, Waldenström's macroglobulinemia, and multiple myeloma accounted for 24.4% (n = 11), 20.0% (n = 9), and 6.7% (n = 3), respectively. In patients with type I CG, skin damage was the most common symptom, presenting in 57.8% of the patients, followed by peripheral neuropathy (22.2%) and renal involvement (15.6%). Treatment was initiated in 29 patients (64.4%), and the most common choice was a rituximab-based regimen in 13 patients (44.8%), followed by bortezomib-based regimen in 11 patients (37.9%). Clinical symptoms were significantly improved after treatment, and the clinical remission rate was 86.2%, including 34.5% of complete clinical remission, while the laboratory response rate was 88.9%, including 33.3% of complete response and 55.6% of partial response. The expected 1-year overall survival was 97.8%. In conclusion, for patients with multisystemic involvement, such as skin damage, kidney damage, or peripheral neuropathy, the diagnosis of type I CG should be considered, and the underlying disease needs to be explored. Symptoms and primary diseases should be taken into consideration before choosing initial management.
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Affiliation(s)
- Le-le Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Xin-Xin Cao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Kai-Ni Shen
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Hong-Xiao Han
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Cong-Li Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Yu Qiu
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Hao Zhao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Xue-Min Gao
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Jun Feng
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Lu Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Dao-Bin Zhou
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, No. 1 Shuaifuyuan, ,100730, Beijing, People's Republic of China.
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19
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Leung N, Bridoux F, Batuman V, Chaidos A, Cockwell P, D'Agati VD, Dispenzieri A, Fervenza FC, Fermand JP, Gibbs S, Gillmore JD, Herrera GA, Jaccard A, Jevremovic D, Kastritis E, Kukreti V, Kyle RA, Lachmann HJ, Larsen CP, Ludwig H, Markowitz GS, Merlini G, Mollee P, Picken MM, Rajkumar VS, Royal V, Sanders PW, Sethi S, Venner CP, Voorhees PM, Wechalekar AD, Weiss BM, Nasr SH. The evaluation of monoclonal gammopathy of renal significance: a consensus report of the International Kidney and Monoclonal Gammopathy Research Group. Nat Rev Nephrol 2019; 15:45-59. [PMID: 30510265 PMCID: PMC7136169 DOI: 10.1038/s41581-018-0077-4] [Citation(s) in RCA: 266] [Impact Index Per Article: 53.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The term monoclonal gammopathy of renal significance (MGRS) was introduced by the International Kidney and Monoclonal Gammopathy Research Group (IKMG) in 2012. The IKMG met in April 2017 to refine the definition of MGRS and to update the diagnostic criteria for MGRS-related diseases. Accordingly, in this Expert Consensus Document, the IKMG redefines MGRS as a clonal proliferative disorder that produces a nephrotoxic monoclonal immunoglobulin and does not meet previously defined haematological criteria for treatment of a specific malignancy. The diagnosis of MGRS-related disease is established by kidney biopsy and immunofluorescence studies to identify the monotypic immunoglobulin deposits (although these deposits are minimal in patients with either C3 glomerulopathy or thrombotic microangiopathy). Accordingly, the IKMG recommends a kidney biopsy in patients suspected of having MGRS to maximize the chance of correct diagnosis. Serum and urine protein electrophoresis and immunofixation, as well as analyses of serum free light chains, should also be performed to identify the monoclonal immunoglobulin, which helps to establish the diagnosis of MGRS and might also be useful for assessing responses to treatment. Finally, bone marrow aspiration and biopsy should be conducted to identify the lymphoproliferative clone. Flow cytometry can be helpful in identifying small clones. Additional genetic tests and fluorescent in situ hybridization studies are helpful for clonal identification and for generating treatment recommendations. Treatment of MGRS was not addressed at the 2017 IKMG meeting; consequently, this Expert Consensus Document does not include any recommendations for the treatment of patients with MGRS. This Expert Consensus Document from the International Kidney and Monoclonal Gammopathy Research Group includes an updated definition of monoclonal gammopathy of renal significance (MGRS) and recommendations for the use of kidney biopsy and other modalities for evaluating suspected MGRS
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Affiliation(s)
- Nelson Leung
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA.
| | - Frank Bridoux
- Department of Nephrology, Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, France; CNRS UMR7276, Limoges, France; and Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Poitiers, France
| | - Vecihi Batuman
- Veterans Administration Medical Center, New Orleans, LA, USA and Tulane University Medical School, Tulane, LA, USA
| | - Aristeidis Chaidos
- Centre for Haematology, Department of Medicine, Imperial College London and Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Paul Cockwell
- Department of Nephrology, Renal Medicine - University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Vivette D D'Agati
- Department of Pathology, Renal Pathology Laboratory, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Angela Dispenzieri
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Fernando C Fervenza
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jean-Paul Fermand
- Department of Haematology and Immunology, University Hospital St Louis, Paris, France
| | - Simon Gibbs
- The Victorian and Tasmanian Amyloidosis Service, Department of Haematology, Monash Univerity Easter Health Clinical School, Melbourne, Victoria, Australia
| | - Julian D Gillmore
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Guillermo A Herrera
- Department of Pathology and Translational Pathobiology, Louisiana State University Health Sciences Center, Shreveport, LA, USA
| | - Arnaud Jaccard
- Service d'Hématologie et de Thérapie Cellulaire, Centre de Référence des Amyloses Primitives et des Autres Maladies par Dépôts d'Immunoglobuline, CHU Limoges, Limoges, France
| | - Dragan Jevremovic
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | - Vishal Kukreti
- University Health Network, Princess Margaret Cancer Centre, Toronto, Canada
| | - Robert A Kyle
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Helen J Lachmann
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | | | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, Wilhelminenspital, Vienna, Austria
| | - Glen S Markowitz
- Department of Pathology, Renal Pathology Laboratory, Columbia University, College of Physicians and Surgeons, New York, NY, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Peter Mollee
- Haematology Department, Princess Alexandra Hospital and School of Medicine, University of Queensland, Brisbane, Australia
| | - Maria M Picken
- Department of Pathology, Loyola University Medical Center, Maywood, IL, USA
| | - Vincent S Rajkumar
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Virginie Royal
- Department of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montreal, Montreal, Quebec, Canada
| | - Paul W Sanders
- Department of Medicine, University of Alabama at Birmingham and Department of Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Sanjeev Sethi
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Peter M Voorhees
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium System, Charlotte, NC, USA
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Centre for Amyloidosis and Acute Phase Proteins, Division of Medicine, Royal Free Campus, University College London, London, UK
| | - Brendan M Weiss
- Abramson Cancer Center, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Samih H Nasr
- Division of Nephrology, Hematology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Diagnostic and Treatment of Cryoglobulinemiс Vasculitis: What is Important for Real Clinical Practice? Fam Med 2019. [DOI: 10.30841/2307-5112.4.2019.184366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Kolopp-Sarda MN, Nombel A, Miossec P. Cryoglobulins Today: Detection and Immunologic Characteristics of 1,675 Positive Samples From 13,439 Patients Obtained Over Six Years. Arthritis Rheumatol 2019; 71:1904-1912. [PMID: 31136095 DOI: 10.1002/art.41003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 05/23/2019] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Cryoglobulins are cold-precipitating immunoglobulins. Through progress in techniques, we undertook this study to update information on the biologic characteristics of cryoglobulins in a very large population. METHODS A cohort of 13,439 patients was tested for cryoglobulins from January 2010 to December 2016. The analysis included cryoglobulin isotype, clonality, concentration, and IgM rheumatoid factor (IgM-RF) in cryoprecipitate, as well as serum complement and RF. Markers of gammopathy, viral infection, and autoimmunity were also investigated. RESULTS Of the 13,439 patients, 1,675 (12.5%) tested positive for cryoglobulins: 155 patients (9.3%) with type I, 788 (47%) with type II, and 732 (43.7%) with type III cryoglobulins. Nine percent of patients who were retested after initially testing negative for cryoglobulins showed a positive result on a follow-up test (196 of the 2,213 retested patients). In type I cryoglobulins, IgM was more frequent but occurred at lower concentrations than IgG. Mixed cryoglobulins were found in 34.8% of the tested patients who were positive for hepatitis C virus and <5% of those who were positive for hepatitis B virus or HIV. Of the patients with anti-double-stranded DNA, anti-SSA, or anti-cyclic citrullinated peptide autoantibodies, 25.4% tested positive for mixed cryoglobulins, with type III occurring more frequently than type II. Both cryoprecipitate and serum were RF-positive in 21.6% of type II and 10.1% of type III cryoglobulins. A decrease of C4, with or without accompanying decreases of C3 and CH50, was found in 23.6% of cryoglobulin samples. CONCLUSION Obtained with the use of modern assays, our findings from this very large collection of cryoglobulins provide an update on cryoglobulin distribution and characteristics, with minimal selection bias. Despite strict preanalytical conditions, a negative finding for the presence of cryoglobulin must be confirmed in a second sample. RF activity and complement decreases were rarely detected.
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Affiliation(s)
- Marie N Kolopp-Sarda
- Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon and Hospices Civils de Lyon, Lyon, France
| | | | - Pierre Miossec
- Immunogenomics and Inflammation Research Unit EA 4130, University of Lyon and Hospices Civils de Lyon, Lyon, France
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Wright N, Voshtina E, George G, Singavi A, Field J. Cryoglobulinemic vasculitis with interruption of ibrutinib therapy for chronic lymphocytic leukemia (CLL). Int J Hematol 2019; 110:751-755. [PMID: 31494832 DOI: 10.1007/s12185-019-02729-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 08/18/2019] [Accepted: 08/22/2019] [Indexed: 11/29/2022]
Abstract
Chronic lymphocytic leukemia (CLL) can trigger autoimmune phenomena, with immune thrombocytopenia (ITP) the most common presentation. Upon cessation of CLL therapy, including ibrutinib, autoimmune flares can occur. In a 68-year-old man with CLL, ibrutinib was held for 2 weeks prior to elective shoulder surgery. Eleven days after stopping therapy, he presented with a purpuric rash on his right hip, buttock, and lower extremities. He experienced two episodes of seizure activity while hospitalized. MRI brain demonstrated patchy areas of altered signal involving deep white matter and sub-cortical white matter structures concerning for cerebral vasculitis. Although there was no evidence of hemolysis, serum cold agglutinin titer was elevated at > 1:512 and cryoglobulin levels were positive at 36%. He was diagnosed with type I cryoglobulinemia and treated with rituximab, plasmapheresis, methylprednisolone, and ibrutinib was restarted. This regimen resolved his symptoms. A rare complication of CLL is the production of cryoglobulins, which can present at initial diagnosis or in relapsed disease. Our case demonstrates that the cessation of ibrutinib therapy, even for a short time, can precipitate complications. To our knowledge, we report the first case of a patient with well-controlled CLL who rapidly developed cryoglobulinemic vasculitis after stopping ibrutinib therapy.
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Affiliation(s)
- Nicholas Wright
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA. .,, 2139A N 72nd St, Wauwatosa, WI, 53213, USA.
| | - Ensi Voshtina
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Gemlyn George
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Arun Singavi
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA
| | - Joshua Field
- Hematology/Oncology Department, Medical College of Wisconsin Affiliated Hospitals, 9200 West Wisconsin Ave, Milwaukee, WI, 53226, USA
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Mixed Cryoglobulinemia in a Patient with Juvenile Idiopathic Arthritis. Case Rep Rheumatol 2019; 2019:5858106. [PMID: 31281705 PMCID: PMC6590528 DOI: 10.1155/2019/5858106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 05/21/2019] [Indexed: 11/17/2022] Open
Abstract
Cryoglobulinemia is a rare illness of cryoglobulin accumulation in the blood which can typically present with arthralgia, purpura, skin ulcers, glomerulonephritis, and peripheral neuropathy. It is classified as mixed cryoglobulinemia when cryoglobulins contain more than one immune component such as IgM rheumatoid factor and polyclonal IgG. Typically, it presents in the setting of clonal hematologic disease, viral infection, or certain connective tissue diseases. Herein, we report the case of a 24-year-old man diagnosed and treated as mixed cryoglobulinemia in the setting of juvenile idiopathic arthritis (JIA). Investigations for viral etiologies, including HBV, HCV, and HIV, and all serologic tests were negative. Additionally serum protein and urine protein electrophoresis did not reveal monoclonal gammopathy; however, testing for plasma cryoglobulins was positive, and qualitative analysis revealed a faint polyclonal pattern. Thus, he was diagnosed with cryoglobulinemia in the setting of JIA, which has not been reported in the literature before. He dramatically improved upon initiation of rituximab and methotrexate.
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Wen J, Xu F, Li M, Zhou Q, Qu W, Liu Y, Su J, Hu H. Type I cryoglobulinemic vasulitis with eosinophilia: A case report and literature review. Medicine (Baltimore) 2019; 98:e16382. [PMID: 31305439 PMCID: PMC6641847 DOI: 10.1097/md.0000000000016382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Type I monoclonal cryoglobulinemia is usually associated with lymphoproliferative disorders, such as monoclonal gammopathy of undetermined significance (MGUS), myeloma, chronic lymphocytic leukemia (CLL) and lymphoplasmocytic lymphoma (LPL). Clinical symptoms related to Type I cryoglobulin (CG) isotype often include skin, neurological and renal manifestations. PATIENT CONCERNS A 42-year-old woman who initially presented urticaria, palpable purpura in both her upper extremities and legs, eosinophilia and Raynaud phenomenon. Skin biopsy revealed eosinophil infiltration. Monoclonal immunoglobulin (Ig) G-κprotein was detected and CG was also positive. DIAGNOSES The patient was finally diagnosed as MGUS related Type I CG. INTERVENTIONS Cyclophosphamide-dexamethasone-thalidomide (CDT) therapy was initiated. OUTCOMES The treatment relieved the skin symptoms efficiently. LESSONS To our knowledge, this is a rare case of Type I cryoglobulinemic vasulitis with eosinophilia complicated by MGUS, and the effective treatment of cyclophosphamide combined with thalidomide and prednisone may provide a new therapeutic option for cryoglobulinemic vasulitis.
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Affiliation(s)
| | | | - Min Li
- Rheumatology Department, Mianyang center hospital, Mianyang, China
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Coliche V, Sarda MN, Laville M, Chapurlat R, Rheims S, Sève P, Théry-Casari C, Lega JC, Fouque D. Predictive factors of renal involvement in cryoglobulinaemia: a retrospective study of 153 patients. Clin Kidney J 2018; 12:365-372. [PMID: 31198536 PMCID: PMC6543974 DOI: 10.1093/ckj/sfy096] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Indexed: 12/19/2022] Open
Abstract
Background The course of cryoglobulinaemia varies widely, from asymptomatic patients to severe vasculitis syndrome. Renal involvement (RI) is the major prognostic factor, and frequently occurs several years after diagnosis. However, predictive factors for RI are not well known. The aim of our study was to identify RI predictive factors during cryoglobulinaemia. Methods We retrospectively reviewed the clinical charts of a consecutive series of 153 patients positive for cryoglobulinaemia in the University Hospital of Lyon (France). RI was defined either histologically or biologically if cryoglobulinaemia was the only possible cause of nephropathy. Results Among the 153 positive patients (mean age 55 years, 37% male), cryoglobulinaemia was associated with RI in 45 (29%) patients. Sixty-five percent of patients had Type II cryoglobulinaemia, 28% had Type III and 7% had Type I. Autoimmune diseases were the most common aetiology (48%), followed by infectious diseases (18%) and lymphoproliferative disorders (13%). Membranoproliferative glomerulonephritis was the main histological pattern (93% of the 14 histological analyses). A multivariable logistic regression showed that Type II cryoglobulinaemia, a high serum cryoglobulin concentration, the presence of an IgG kappa monoclonal component and diabetes were independently associated with the risk for developing RI. Conclusion We identified several factors predictive of RI in patients with cryoglobulinaemia, which were different from the diagnostic criteria for cryoglobulinaemic vasculitis. This could suggest a specific pathophysiology for RI. We suggest performing an extensive renal monitoring and ensure nephroprotection when a diagnosis of cryoglobulinaemia is made in patients with these predictive factors.
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Affiliation(s)
- Vladimir Coliche
- Department of Nephrology, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Marie-Nathalie Sarda
- Université Claude Bernard Lyon 1, EA 4130, Immunology Laboratory, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Maurice Laville
- Department of Nephrology, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Roland Chapurlat
- Department of Rheumatology, Université Claude Bernard Lyon 1, Inserm 1033, Hôpital Edouard Herriot, Lyon, France
| | - Sylvain Rheims
- Department of Functional Neurology and Epileptology, Université Claude Bernard Lyon 1, Inserm 1028 CNRS UMR 5292, Hôpital Neurologique, Bron, France
| | - Pascal Sève
- Department of Internal Medicine, Université Claude Bernard Lyon 1, Inserm 1052, Hôpital Croix-Rousse, Lyon, France
| | - Clémence Théry-Casari
- Department of Internal and Vascular Medicine, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Jean-Christophe Lega
- Department of Internal and Vascular Medicine, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
| | - Denis Fouque
- Department of Nephrology, Université Claude Bernard Lyon 1, Centre Hospitalier Lyon Sud, Pierre-Bénite, France
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Tang C, Kumar P, Mackinlay N. Cryoglobulin crystals in a patient with chronic lymphocytic leukaemia. Pathology 2018; 50:670-671. [PMID: 30082080 DOI: 10.1016/j.pathol.2018.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/22/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Catherine Tang
- Department of Haematology, Royal North Shore Hospital, St Leonards, NSW, Australia.
| | - Poomahal Kumar
- Department of Haematology, Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Naomi Mackinlay
- Department of Haematology, Royal North Shore Hospital, St Leonards, NSW, Australia
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Abstract
Cryoglobulinaemia refers to the serum presence of cryoglobulins, which are defined as immunoglobulins that precipitate at temperatures <37 °C. Type I cryoglobulinaemia consists of only one isotype or subclass of monoclonal immunoglobulin, whereas type II and type III are classified as mixed cryoglobulinaemia because they include immunoglobulin G (IgG) and IgM. Many lymphoproliferative, infectious and autoimmune disorders have been associated with mixed cryoglobulinaemia; however, hepatitis C virus (HCV) is the aetiologic agent in most patients. The underlying mechanism of the disorder is B cell lymphoproliferation and autoantibody production. Mixed cryoglobulinaemia can cause systemic vasculitis, with manifestations ranging from purpura, arthralgia and weakness to more serious lesions with skin ulcers, neurological and renal involvement. This Primer focuses on mixed cryoglobulinaemia, which has a variable course and a prognosis that is primarily influenced by vasculitis-associated multiorgan damage. In addition, the underlying associated disease in itself may cause considerable mortality and morbidity. Treatment of cryoglobulinaemic vasculitis should be modulated according to the underlying associated disease and the severity of organ involvement and relies on antiviral treatment (for HCV infection), immunosuppression and immunotherapy, particularly anti-CD20 B cell depletion therapies.
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Kolopp-Sarda MN, Miossec P. Cryoglobulins: An update on detection, mechanisms and clinical contribution. Autoimmun Rev 2018. [PMID: 29526627 DOI: 10.1016/j.autrev.2017.11.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Cryoglobulins are immunoglobulins precipitating in cold condition. They are classified in 3 types according to the Brouet classification and may lead to vasculitis of small and medium size vessels. Vasculitis is related to vessel obstruction by monoclonal cryoglobulin aggregates in type I cryoglobulins and immune complex deposition in type II and III mixed cryoglobulins. This phenomenon is favored by low temperature, especially in skin, joints, and peripheral nerves, or increased cryoglobulin concentration in kidneys. For their detection, collection and clotting at 37°C are critical pre-analytical conditions. Cryoglobulin characterization and quantification are important to identify the underlying disease. Since detection and identification of cryoglobulins lack standardization, a protocol for such detection, characterization and quantification is proposed.
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Affiliation(s)
- Marie-Nathalie Kolopp-Sarda
- Department of Immunology and Rheumatology, Immunogenomics and inflammation research Unit EA 4130, University of Lyon, Lyon, France; Immunology Laboratory, University Hospital Lyon, France
| | - Pierre Miossec
- Department of Immunology and Rheumatology, Immunogenomics and inflammation research Unit EA 4130, University of Lyon, Lyon, France.
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Hepatitis C Virus-Associated Aortitis Caused by Type I Cryoglobulins. ACG Case Rep J 2017; 4:e114. [PMID: 29090238 PMCID: PMC5658650 DOI: 10.14309/crj.2017.114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Accepted: 09/13/2017] [Indexed: 11/17/2022] Open
Abstract
Chronic hepatitis C virus infection (HCV) can present with cryoglobulinemic vasculitis, which is primarily associated with type II/III cryoglobulins. Type I cryoglobulins are usually seen in lymphoproliferative disease, and large vessel involvement with this type of vasculitis is rare. A 70-year-old man with chronic HCV presented with abdominal pain, leukocytosis, and rash. Computed tomography angiography showed thickening of the abdominal aorta consistent with large-vessel vasculitis. He was found to have type I cryoglobulinemia and was treated with corticosteroids and ledipasvir/sofosbuvir with rapid resolution of his aortitis. This case emphasizes the need to recognize HCV as a potential etiology of large-vessel vasculitis.
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Sidana S, Rajkumar SV, Dispenzieri A, Lacy MQ, Gertz MA, Buadi FK, Hayman SR, Dingli D, Kapoor P, Gonsalves WI, Go RS, Hwa YL, Leung N, Fonder AL, Hobbs MA, Zeldenrust SR, Russell SJ, Lust JA, Kyle RA, Kumar SK. Clinical presentation and outcomes of patients with type 1 monoclonal cryoglobulinemia. Am J Hematol 2017; 92:668-673. [PMID: 28370486 DOI: 10.1002/ajh.24745] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 03/26/2017] [Accepted: 03/27/2017] [Indexed: 11/10/2022]
Abstract
We describe a series of 102 patients diagnosed from January 1, 1990 to December 31, 2015 with Type 1 monoclonal cryoglobulinemia (MoC). Symptoms were seen in 89 (87%) patients, including: cutaneous symptoms in 64 (63%) patients, with purpura (n = 43, 42%) and ulcers/gangrene (n = 35, 34%) being most common; neurological findings in 33 (32%) patients, most frequently sensory neuropathy (n = 24, 24%); vasomotor symptoms, mainly Raynaud's phenomenon in 25 (25%); arthralgias in 24 (24%); and renal manifestations, primarily glomerulonephritis in 14 (14%) patients. An underlying lymphoproliferative disorder was identified in 94 (92%) subjects; MGUS-39, myeloma-20, lymphoplasmacytic lymphoma-21 and others-14. Treatment was initiated in 73 (72%) patients, primarily for cryoglobulinemia-related symptoms in 57. Treatment regimens consisted of: steroids ± alkylating agents in 29 (40%), novel myeloma therapies in 16 (22%), rituximab with alkylating agents in 12 (16%) and rituximab ± steroids in 11 (15%) patients; 22 patients received plasmapheresis. Six patients underwent autologous stem cell transplant. Cryocrit at treatment initiation, change in cryocrit and time to nadir cryocrit were predictive of symptom improvement. Treatment directed toward the underlying clonal disorder resulted in improvement (n = 47) or stabilization (n = 16) of symptoms in the majority of patients and disappearance of cryoglobulin in over one-half.
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Affiliation(s)
- Surbhi Sidana
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - S. Vincent Rajkumar
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Angela Dispenzieri
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Martha Q. Lacy
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Morie A. Gertz
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Francis K. Buadi
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Suzanne R. Hayman
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - David Dingli
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Prashant Kapoor
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Wilson I. Gonsalves
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Ronald S. Go
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Yi Lisa Hwa
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Nelson Leung
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
- Division of Nephrology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Amie L. Fonder
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Miriam A. Hobbs
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Steven R. Zeldenrust
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Stephen J. Russell
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - John A. Lust
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Robert A. Kyle
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
| | - Shaji K. Kumar
- Division of Hematology; Department of Internal Medicine, Mayo Clinic; Rochester Minnesota USA
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Motwani SS, Herlitz L, Monga D, Jhaveri KD, Lam AQ. Paraprotein-Related Kidney Disease: Glomerular Diseases Associated with Paraproteinemias. Clin J Am Soc Nephrol 2016; 11:2260-2272. [PMID: 27526706 PMCID: PMC5142064 DOI: 10.2215/cjn.02980316] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Paraproteins are monoclonal Igs that accumulate in blood as a result of abnormal excess production. These circulating proteins cause a diversity of kidney disorders that are increasingly being comanaged by nephrologists. In this review, we discuss paraprotein-related diseases that affect the glomerulus. We provide a broad overview of diseases characterized by nonorganized deposits, such as monoclonal Ig deposition disease (MIDD), proliferative GN with monoclonal Ig deposits (PGNMID), and C3 glomerulopathy, as well as those characterized by organized deposits, such as amyloidosis, immunotactoid glomerulopathy, fibrillary GN, and cryoglobulinemic GN, and rarer disorders, such as monoclonal crystalline glomerulopathies, paraprotein-related thrombotic microangiopathies, and membranous-like glomerulopathy with masked IgGκ deposits. This review will provide the nephrologist with an up to date understanding of these entities and highlight the areas of deficit in evidence and future lines of research.
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Affiliation(s)
- Shveta S. Motwani
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Adult Survivorship Program, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Leal Herlitz
- Department of Pathology, Cleveland Clinic, Cleveland, Ohio
| | - Divya Monga
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi; and
| | - Kenar D. Jhaveri
- Division of Kidney Diseases and Hypertension, Hofstra Northwell School of Medicine, Northwell Health, Great Neck, New York
| | - Albert Q. Lam
- Division of Renal Medicine, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Adult Survivorship Program, Dana Farber Cancer Institute, Boston, Massachusetts
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Abstract
Cryoglobulinemia is a distinct entity characterized by the presence of cryoglobulins in the serum. Cryoglobulins differ in their composition, which has an impact on the clinical presentation and the underlying disease that triggers cryoglobulin formation. Cryoglobulinemia is categorized into two main subgroups: type I, which is seen exclusively in clonal hematologic diseases, and type II/III, which is called mixed cryoglobulinemia and is seen in hepatitis C virus infection and systemic diseases such as B-cell lineage hematologic malignancies and connective tissue disorders. Clinical presentation is broad and varies between types but includes arthralgia, purpura, skin ulcers, glomerulonephritis, and peripheral neuropathy. Life-threatening manifestations can develop in a small proportion of patients. A full evaluation for the underlying cause is required, because each type requires a different kind of treatment, which should be tailored on the basis of disease severity, underlying disease, and prior therapies. Relapses can be frequent and can result in significant morbidity and cumulative organ impairment. We explore the spectrum of this heterogeneous disease by discussing the disease characteristics of 5 different patients.
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Arora S, Levitan D, Regmi N, Sidhu G, Gupta R, Nicastri AD, Saggi SJ, Braverman A. Cryoglobulinemia in a patient with chronic lymphocytic leukemia - A case report and review of literature of renal involvement in CLL. Blood Cells Mol Dis 2016; 60:7-11. [PMID: 27519936 DOI: 10.1016/j.bcmd.2016.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 05/21/2016] [Accepted: 05/21/2016] [Indexed: 10/21/2022]
Abstract
The incidence of glomerulonephritis, as a manifestation of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), has always been considered low. Though renal infiltration is usually detected at post-mortem, it does not often interfere with kidney function [1]. Though immunoglobulin (Ig) levels in most CLL patients are subnormal, small monoclonal Ig peaks are occasionally detected in serum. They were present in a number of reported CLL nephropathy patients, and not all were cryoglobulins; serum and glomerular staining were concordant for Ig type [2,3,4]. Myeloma, which secretes monoclonal light chains, causes nephropathy in 25% of patients. But the little presumably secreted by small plasma cell clones, without myeloma, may also be nephrotoxic. The same is true of the low secretory CLL cells, which may occasionally be associated with cryoglobulins and other nephrotoxic Igs [5]. We report a patient with early stage CLL (Rai stage 0) with cryoglobulins, which led to membranoproliferative glomerulonephritis (MPGN), and death. We located reports of 51 patients with CLL-associated nephrotic syndrome or nephropathy, mostly from MPGN related to local Ig deposits. In those patients screened for cryoglobulins, about half tested positive. Many were early stage cases, where MPGN developed long after CLL presentation, and responded to its treatment. As early diagnosis and treatment CLL-related nephropathy may be curative, we propose a prospective study to determine the incidence of hyperalbuminuria development after presentation.
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Affiliation(s)
- Swaty Arora
- Department of Hematology & Oncology, Department of Medicine, State University New York, Downstate, USA.
| | - Daniel Levitan
- Department of Pathology, State University New York, Downstate, USA
| | - Narottam Regmi
- Department of Nephrology, Department of Medicine, State University New York, Downstate, USA
| | - Gurinder Sidhu
- Department of Hematology & Oncology, Department of Medicine, State University New York, Downstate, USA
| | - Raavi Gupta
- Department of Pathology, State University New York, Downstate, USA
| | | | - Subodh J Saggi
- Department of Nephrology, Department of Medicine, State University New York, Downstate, USA
| | - Albert Braverman
- Department of Hematology & Oncology, Department of Medicine, State University New York, Downstate, USA
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DeLyria PA, Avedschmidt SE, Yamada C, Farkash EA. Fatal Cryocrystalglobulinemia With Intravascular and Renal Tubular Crystalline Deposits. Am J Kidney Dis 2016; 67:787-91. [DOI: 10.1053/j.ajkd.2015.11.014] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/29/2015] [Indexed: 11/11/2022]
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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] [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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Cryoglobulinemic membranoproliferative glomerulonephritis associated with mucosa-associated lymphoid tissue lymphoma treated with rituximab. Clin Nephrol Case Stud 2016; 4:1-4. [PMID: 29043134 PMCID: PMC5437996 DOI: 10.5414/cncs108740] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/21/2015] [Indexed: 11/18/2022] Open
Abstract
Cryoglobulinemia and mucosa-associated lymphoid tissue (MALT) lymphoma are diseases characterized by B-cell dysregulation and overproduction of antibodies. Vasculitis and cutaneous manifestations are common, but renal involvement is rare. A 65-year-old woman with type 1 cryoglobulinemia and MALT lymphomas of the right lacrimal and parotid glands successfully treated by excision and chemoradiotherapy, presented with dyspnea on exertion, edema, and hematuria. Renal biopsy findings revealed type 1 cryoglobulinemic glomerulonephritis. She underwent treatment with high-dose oral prednisone and intravenous rituximab with subsequent return of creatinine to baseline levels. To our knowledge, this is the first report of a patient in whom type 1 cryoglobulinemia, multiple MALT lymphomas, and MPGN with IgM cryoglobulin deposits coexist. Evidence for rituximab is sparse with widely varying protocols and mixed results. There is a need for high quality evidence in the treatment of these conditions.
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Perrin F, Dejoie T, Le Gouill S, Roland V, Agard C, Hamidou M, Néel A. [Cold-induced skin lesions]. Rev Med Interne 2015; 37:217-8. [PMID: 26385123 DOI: 10.1016/j.revmed.2015.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 06/04/2015] [Accepted: 06/15/2015] [Indexed: 11/28/2022]
Affiliation(s)
- F Perrin
- Service de médecine interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France.
| | - T Dejoie
- Laboratoire de biochimie, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - S Le Gouill
- Service d'hématologie, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - V Roland
- Service d'hématologie, centre hospitalier de Perpignan, 20, avenue du Languedoc, BP 4052, 66046 Perpignan, France
| | - C Agard
- Service de médecine interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - M Hamidou
- Service de médecine interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
| | - A Néel
- Service de médecine interne, CHU Hôtel-Dieu, 1, place Alexis-Ricordeau, 44093 Nantes cedex 1, France
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[Dermatological manifestations of monoclonal gammopathies: contribution of cutaneous histopathology]. Ann Pathol 2015; 35:281-93. [PMID: 26188671 DOI: 10.1016/j.annpat.2015.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2014] [Accepted: 05/06/2015] [Indexed: 12/19/2022]
Abstract
Skin manifestations associated with monoclonal gammapathy are common and can present with various clinical and pathological aspects. They can be the first events leading to the diagnosis of monoclonal gammapathy. They may be present either as specific lesions, including lymphoplasmacytic or pure plasma cell neoplastic infiltrates and monoclonal immunoglobulin deposits, or as non-specific dermatitis, such as leukocytoclastic vasculitis, neutrophilic dermatoses, mucinoses or xanthomatosis, giving little clues for the diagnosis of the underlying disease.
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Chauvet S, Bridoux F, Ecotière L, Javaugue V, Sirac C, Arnulf B, Thierry A, Quellard N, Milin S, Bender S, Goujon JM, Jaccard A, Fermand JP, Touchard G. Kidney diseases associated with monoclonal immunoglobulin M-secreting B-cell lymphoproliferative disorders: a case series of 35 patients. Am J Kidney Dis 2015; 66:756-67. [PMID: 25987261 DOI: 10.1053/j.ajkd.2015.03.035] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 03/27/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Kidney diseases associated with immunoglobulin M (IgM) monoclonal gammopathy are poorly described, with few data for patient outcomes and renal response. STUDY DESIGN Case series. SETTING & PARTICIPANTS 35 patients from 8 French departments of nephrology were retrospectively studied. Inclusion criteria were: (1) detectable serum monoclonal IgM, (2) estimated glomerular filtration rate (eGFR) < 60mL/min/1.73m(2) and/or proteinuria with protein excretion > 0.5g/d and/or microscopic hematuria, and (3) kidney biopsy showing monoclonal immunoglobulin deposits and/or lymphomatous B-cell renal infiltration. All patients received chemotherapy, including rituximab-based regimens in 8 cases. PREDICTORS Patients were classified into 3 groups according to renal pathology: glomerular AL amyloidosis (group 1; n=11), nonamyloid glomerulopathies (group 2; n=15, including 9 patients with membranoproliferative glomerulonephritis), and tubulointerstitial nephropathies (group 3; n=9, including cast nephropathy in 5, light-chain Fanconi syndrome in 3, and isolated tumor infiltration in 1). OUTCOMES Posttreatment hematologic response (≥50% reduction in serum monoclonal IgM and/or free light chain level) and renal response (≥50% reduction in 24-hour proteinuria or eGFR≥30mL/min/1.73m(2) in patients with glomerular and tubulointerstitial disorders, respectively). RESULTS Nephrotic syndrome was observed in 11 and 6 patients in groups 1 and 2, respectively. Patients in group 3 presented with acute kidney injury (n=7) and/or proximal tubular dysfunction (n=3). Waldenström macroglobulinemia was present in 26 patients (8, 12, and 6 in groups 1, 2, and 3, respectively). Significant lymphomatous interstitial infiltration was observed in 18 patients (4, 9, and 5 patients, respectively). Only 9 of 29 evaluable patients had systemic signs of symptomatic hematologic disease (2, 5, and 2, respectively). In groups 1, 2, and 3, respectively, hematologic response was achieved after first-line treatment in 3 of 9, 9 of 10, and 5 of 6 evaluable patients, while renal response occurred in 5 of 10, 9 of 15, and 5 of 8 evaluable patients. LIMITATIONS Retrospective study; insufficient population to establish the impact of chemotherapy. CONCLUSIONS IgM monoclonal gammopathy is associated with a wide spectrum of renal manifestations, with an under-recognized frequency of tubulointerstitial disorders.
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Affiliation(s)
- Sophie Chauvet
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Frank Bridoux
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France; CNRS UMR 6101, Université de Limoges, Limoges, France.
| | - Laure Ecotière
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Vincent Javaugue
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Christophe Sirac
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; CNRS UMR 6101, Université de Limoges, Limoges, France
| | - Bertrand Arnulf
- Department of Immunology and Hematology, Hôpital Saint-Louis AP-HP, Paris, France
| | - Antoine Thierry
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Nathalie Quellard
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Pathology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Serge Milin
- Department of Pathology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Sébastien Bender
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; CNRS UMR 6101, Université de Limoges, Limoges, France
| | - Jean-Michel Goujon
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Pathology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
| | - Arnaud Jaccard
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; CNRS UMR 6101, Université de Limoges, Limoges, France; Department of Hematology, CHU Limoges, Université de Limoges, Limoges, France
| | - Jean-Paul Fermand
- Department of Immunology and Hematology, Hôpital Saint-Louis AP-HP, Paris, France
| | - Guy Touchard
- Centre national de référence maladies rares amylose AL et autres maladies à dépôts d'immunoglobulines monoclonales, CHU Poitiers, Université de Poitiers, Poitiers, France; Department of Nephrology, Hôpital Jean Bernard, CHU Poitiers, Université de Poitiers, Poitiers, France
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Harel S, Mohr M, Jahn I, Aucouturier F, Galicier L, Asli B, Malphettes M, Szalat R, Brouet JC, Lipsker D, Fermand JP. Clinico-biological characteristics and treatment of type I monoclonal cryoglobulinaemia: a study of 64 cases. Br J Haematol 2014; 168:671-8. [PMID: 25363150 DOI: 10.1111/bjh.13196] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/15/2014] [Indexed: 11/27/2022]
Abstract
This retrospective analysis was conducted in 64 patients diagnosed with type I cryoglobulinaemia (CG) followed at two French centres. Median follow-up was 6·75 years. CG was IgG in 60% and IgM in 40% of all cases and was asymptomatic in 16 patients (25%). Cold-triggered ischaemic skin manifestations were observed in 33 patients (51%). Neurological manifestations were observed in 15 patients and renal manifestations in 13. Most of the patients with necrotic purpura (14/16, P = 0·009) and renal manifestations (11/13, P = 0·057) had IgG CG. IgG CG was associated with monoclonal gammopathy of undetermined significance (MGUS), myeloma, chronic lymphocytic leukaemia and lymphoplasmocytic lymphoma in 18, 13, 5 and 2 patients, respectively. IgM CG was associated with MGUS and Waldenström macroglobulinaemia in 8 and 18 cases, respectively. One third of patients did not receive any specific treatment. Various treatments, including rituximab, were administered to 25/31 patients with IgG CG and 6/25 patients with IgM CG due to CG-related symptoms. Rituximab was ineffective in all cases associated with a predominantly plasmacytic proliferation. To conclude, type I CG has specific clinico-biological characteristics compared to type II CG. Furthermore, there are differences in terms of related manifestations between type I IgG and type I IgM CG.
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Affiliation(s)
- Stephanie Harel
- Département d'Immuno-Hématologie, Hôpital Saint-Louis, Paris, France
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