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Attieh RM, Yang Y, Rosenstock JL. Updates on the Diagnosis and Management of Fibrillary Glomerulonephritis. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:374-383. [PMID: 39084762 DOI: 10.1053/j.akdh.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 03/15/2024] [Accepted: 03/25/2024] [Indexed: 08/02/2024]
Abstract
Fibrillary glomerulonephritis (FGN) is a rare kidney disease typically affecting individuals in middle age, frequently presenting with advanced renal failure, proteinuria, and hypertension. FGN can be associated with autoimmune diseases, hepatitis C infection, and malignancies. Its exact pathogenesis remains elusive, and the exact role of DnaJ homolog subfamily B member 9 is yet to be determined. On renal biopsy, FGN exhibits distinctive Congo-red-negative, nonbranching fibrils, approximately 20 nm in diameter. DnaJ homolog subfamily B member 9 immunohistochemical staining has become a gold standard for diagnosis. Atypical variants exist, including congophilic, monotypic, and crescentic FGN, highlighting the disease's heterogeneity. Treatment with immunosuppression, including rituximab, has shown variable success, with no standard therapy established. FGN often leads to end-stage kidney disease, with a median progression time of 2-4 years postdiagnosis. Kidney transplantation is a viable option for FGN-related end-stage kidney disease, but recurrence in transplanted kidneys is not rare.
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Affiliation(s)
- Rose Mary Attieh
- Division of Kidney Diseases and Hypertension, Glomerular Center at Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York
| | - Yihe Yang
- Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York
| | - Jordan L Rosenstock
- Division of Nephrology, Lenox Hill Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New York, NY.
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Hattori K, Shimizu R, Tanaka S, Terashima T, Hiramatsu M, Shimomura T, Ito T, Morinaga T, Terasaki M, Shimizu A, Morozumi K, Tamai H. A case of juvenile-onset fibrillary glomerulonephritis diagnosed by mass spectrometry and immunohistochemistry of DNAJB9. CEN Case Rep 2022; 11:412-416. [PMID: 35199316 DOI: 10.1007/s13730-022-00693-3] [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: 11/29/2021] [Accepted: 02/06/2022] [Indexed: 10/19/2022] Open
Abstract
Fibrillary glomerulonephritis (FGN) is a rare glomerular disease. FGN is characterized by the deposition of randomly arranged, nonbranching microfibrils in the mesangium and glomerular basement membrane. The discovery of DNAJ homolog subfamily B member 9 (DNAJB9) in 2017 was a breakthrough, and DNAJB9 has been proven to be extremely useful for the definitive diagnosis of FGN. While FGN often occurs in middle-aged individuals, this case was diagnosed at a relatively young age of 17. We performed renal biopsy, and light microscopic study revealed mesangial proliferation with expansion and subepithelial deposits. Electron microscopic study showed glomerular deposition of randomly oriented nonbranching fibrils with a mean of 20 nm. However, direct first scarlet stain for amyloidosis was weakly positive. Therefore, we confirmed the diagnosis of FGN and eliminated the presence of amyloidosis with mass spectrometry. This is the first case in Japan in which the complication of amyloidosis was ruled out with mass spectrometry and FGN was diagnosed using immunostaining and mass spectrometry of DNAJB9. We began treatment with cyclosporine A. One and a half years after the start of the treatment, kidney function continues to be normal.
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Affiliation(s)
- Keita Hattori
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan.
| | - Ryo Shimizu
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Shoichiro Tanaka
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Takashi Terashima
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Miya Hiramatsu
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Taishi Shimomura
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Takeshi Ito
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Takatoshi Morinaga
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
| | - Mika Terasaki
- Department of Analytic Human Pathology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Nippon Medical School, 1-1-5 Sendagi, Bunkyo-ku, Tokyo, 113-8603, Japan
| | - Kunio Morozumi
- Department of Nephrology, Masuko Memorial Hospital, 35-28 Takegashicho, Nakamura-ku, Nagoya, Aichi, 453-0016, Japan
| | - Hirofumi Tamai
- Department of Nephrology, Anjo Kosei Hospital, 28, higashihirokute, anjocho, Anjo, Aichi, 446-8602, Japan
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Nasr SH, Fogo AB. New developments in the diagnosis of fibrillary glomerulonephritis. Kidney Int 2019; 96:581-592. [PMID: 31227146 DOI: 10.1016/j.kint.2019.03.021] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/28/2019] [Accepted: 03/08/2019] [Indexed: 11/25/2022]
Abstract
Fibrillary glomerulonephritis is a glomerular disease historically defined by glomerular deposition of Congo red-negative, randomly oriented straight fibrils that lack a hollow center and stain with antisera to immunoglobulins. It was initially considered to be an idiopathic disease, but recent studies highlighted association in some cases with autoimmune disease, malignant neoplasm, or hepatitis C viral infection. Prognosis is poor with nearly half of patients progressing to end-stage renal disease within 4 years. There is currently no effective therapy, aside from kidney transplantation, which is associated with disease recurrence in a third of cases. The diagnosis has been hampered by the lack of biomarkers for the disease and the necessity of electron microscopy for diagnosis, which is not widely available. Recently, through the use of laser microdissection-assisted liquid chromatography-tandem mass spectrometry, a novel biomarker of fibrillary glomerulonephritis, DnaJ homolog subfamily B member 9, has been identified. Immunohistochemical studies confirmed the high sensitivity and specificity of DnaJ homolog subfamily B member 9 for this disease; dual immunofluorescence showed its colocalization with IgG in glomeruli; and immunoelectron microscopy revealed its localization to individual fibrils of fibrillary glomerulonephritis. The identification of this tissue biomarker has already entered clinical practice and undoubtingly will improve the diagnosis of this rare disease, particularly in developing countries where electron microscopy is less available. Future research is needed to determine whether DnaJ homolog subfamily B member 9 is an autoantigen or just an associated protein in fibrillary glomerulonephritis, whether it can serve as a noninvasive biomarker, and whether therapies that target this protein are effective in improving prognosis.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Agnes B Fogo
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Wu CK, Leu JG, Yang AH, Tarng DC, Tung HY, Chiang SS. Simultaneous occurrence of fibrillary glomerulonephritis and renal lesions in nonmalignant monoclonal IgM gammopathy. BMC Nephrol 2016; 17:17. [PMID: 26892336 PMCID: PMC4759957 DOI: 10.1186/s12882-015-0198-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 11/28/2015] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Fibrillary glomerulonephritis (FGN) is a rare primary glomerular disease that seldom coexists with other diseases. Membranoproliferative glomerulonephritis is a pathologic finding of renal lesions associated with IgM-secreting monoclonal proliferations. We present a case study of a patient with unusual simultaneous FGN and IgM-related renal disorder in nonmalignant monoclonal IgM gammopathy. CASE PRESENTATION A 63-year-old male presented with nephrotic syndrome and elevated serum creatinine levels. Laboratory examination revealed elevated levels of serum IgM and low C3 levels. Serum and urine immunofixation electrophoresis showed a monoclonal IgM with a kappa light chain. A bone marrow biopsy revealed less than 5 % bone marrow infiltration by lymphoplasmacytic lymphoma, and a renal biopsy revealed mesangiocapillary glomerulonephritis on light microscopy. Immunofluorescent and immunohistochemical staining indicated granular deposits of immunoglobulin G in the mesangium and granular deposits of immunoglobulin M and κ light chains along the capillary wall. Electron microscopy revealed randomly arranged nonbranching fibrils of approximately 15 nm in diameter in the glomerular mesangium and subendothelial electron-dense deposits. According to these results, we confirmed FGN and membranoproliferative glomerulonephritis, which were attributed to monoclonal IgM deposits. CONCLUSION To the best of our knowledge, this is the first report of simultaneous FGN and membranoproliferative glomerulonephritis in nonmalignant IgM monoclonal gammopathy.
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Affiliation(s)
- Chung-Kuan Wu
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95,Wen Chang Rd., Shih Lin District, Taipei, 11101, Taiwan.,Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Jyh-Gang Leu
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95,Wen Chang Rd., Shih Lin District, Taipei, 11101, Taiwan.,School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - An-Hang Yang
- Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Der-Cherng Tarng
- Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan.,Division of Nephrology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiang-Yuen Tung
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95,Wen Chang Rd., Shih Lin District, Taipei, 11101, Taiwan
| | - Shou-Shan Chiang
- Division of Nephrology, Department of Internal Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, 95,Wen Chang Rd., Shih Lin District, Taipei, 11101, Taiwan.
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Alexander MP, Nasr SH, Kurtin PJ, Casey ET, Hernandez LPH, Fidler ME, Sethi S, Cornell LD. Renal extramedullary hematopoiesis: interstitial and glomerular pathology. Mod Pathol 2015; 28:1574-83. [PMID: 26449764 DOI: 10.1038/modpathol.2015.117] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 08/24/2015] [Accepted: 08/29/2015] [Indexed: 11/09/2022]
Abstract
Renal extramedullary hematopoiesis is rarely recognized in the antemortem setting. We identified 14 patients with renal extramedullary hematopoiesis on antemortem specimens from 1994 to 2015. The mean age was 68 years (range 47-87 years); males predominated (M:F=9:5). All presented with renal insufficiency, including five (36%) with acute kidney injury. The mean serum creatinine at biopsy was 2.9 mg/dl (range 1.2-7.3 mg/dl). All had proteinuria (mean 7.9 g/24 h; range 0.5-28; n=13), including 9 with ≥3 g/24 h. Renal extramedullary hematopoiesis appeared histologically as an interstitial infiltrate (n=12) and/or a perirenal infiltrate (n=3) or mass-like lesion (n=1). Five were misdiagnosed as interstitial nephritis. Concurrent glomerular disease was prevalent and included fibrillary-like glomerulonephritis (n=3), chronic thrombotic microangiopathy (n=5), focal segmental glomerulosclerosis (n=6), and diabetic glomerulosclerosis (n=2). All patients had an underlying hematologic malignancy: primary myelofibrosis in 9, myeloproliferative neoplasm not otherwise specified in 1, essential thrombocythemia in 1, polycythemia vera in 1, and plasma cell myeloma in 2. Clinical follow-up was available in 12 patients, mean of 29 months (range 4-120 months). In 10 patients for whom treatment history could be obtained, 9 were treated with chemotherapy, and 1 was treated with steroids. The mean creatinine at last follow-up was 2 mg/dl (range 1.2-3.9 mg/dl) (n=9). Ten patients died in the follow-up period from their underlying hematological disease and had persistent renal disease. The two remaining patients had persistent chronic kidney disease. Renal extramedullary hematopoiesis should be considered in the differential diagnosis of interstitial infiltrates, particularly in the presence of a glomerulopathy and a hematologic malignancy.
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Affiliation(s)
- Mariam P Alexander
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Samih H Nasr
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Paul J Kurtin
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Edward T Casey
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - Loren P Herrera Hernandez
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Mary E Fidler
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Sanjeev Sethi
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Lynn D Cornell
- Division of Anatomic Pathology, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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Menon S, Zeng X, Valentini R. Fibrillary glomerulonephritis and renal failure in a child with systemic lupus erythematosus. Pediatr Nephrol 2009; 24:1577-81. [PMID: 19308460 DOI: 10.1007/s00467-009-1168-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 02/24/2009] [Accepted: 02/27/2009] [Indexed: 11/25/2022]
Abstract
Fibrillary glomerulonephritis (FGN) is a rare immune-mediated glomerulopathy characterized by randomly arranged immunoglobulin (Ig) deposits on electron microscopy. Only seven pediatric cases have been reported, and the incidence in adults is about 1.5%. A 12-year-old boy presented with systemic lupus erythematosus (SLE) with World Health Organization Class IV lupus nephritis. A repeat biopsy carried out due to a poor response to standard immunosuppressive therapy and worsening renal functions revealed diffuse proliferative glomerulonephritis with fibrillary deposits. Despite aggressive immunosuppression with plasmapheresis and rituximab, the patient developed end stage renal disease. This is an atypical pediatric case characterized by SLE-associated FGN and a poor prognosis.
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Affiliation(s)
- Shina Menon
- Pediatric Nephrology, Children's Hospital of Michigan, 3901 Beaubien, Detroit, MI 48201, USA.
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Chirunomula V, Kondle V, Vaddey B, Colvin RB, Kambham N. Crescentic glomerulonephritis with ribbon-like immunofluorescence pattern. Am J Kidney Dis 2009; 54:381-4. [PMID: 19121555 DOI: 10.1053/j.ajkd.2008.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Accepted: 10/29/2008] [Indexed: 11/11/2022]
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