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Mignano SE, Pascal V, Odioemene NE, Forehand W, Javaugue V, Said SM, Sethi S, Sirac C, Nasr SH. Monoclonal Immunoglobulin Crystalline Membranous Nephropathy. Am J Kidney Dis 2024; 84:120-125. [PMID: 38266972 DOI: 10.1053/j.ajkd.2023.11.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 10/10/2023] [Accepted: 11/15/2023] [Indexed: 01/26/2024]
Abstract
Monoclonal immunoglobulin (MIg) crystalline nephropathies are rare lesions resulting from precipitation of MIgs in the kidney as intracellular or extracellular crystals. We describe a patient with multiple myeloma (IgGλ) and diabetes who presented with nephrotic range proteinuria. Kidney biopsy revealed membranous nephropathy superimposed on diabetic glomerulosclerosis. Glomeruli were negative for PLA2R, THSD7A, and NELL-1. Ultrastructurally, the subepithelial deposits were composed of crystals (ranging from rhomboid to rod to needle shaped), which failed to stain for immunoglobulins by routine immunofluorescence but stained for IgG+λ by paraffin immunofluorescence after pronase digestion. RNA-based immunoglobulin repertoire sequencing performed on bone marrow aspirate identified an IgGλ (γ1) clone, which was highly atypical, combining an extensively mutated (23.6%) Ig heavy chain derived from the IGHV1-24 with low pI and unusual mutations and a light chain derived from an extremely rare germline gene (IGLV10-54). This report expands the pathologic spectrum of MIg crystalline nephropathies by describing a unique case of crystalline nephropathy with IgGλ deposits manifesting as membranous nephropathy.
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Affiliation(s)
- Salvatore E Mignano
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Virginie Pascal
- Department of Immunology and Immunogenetics, Centre Hospitalier Universitaire de Limoges, Limoges, France; Control of the immune response B and lymphoproliferation, CNRS UMR 7276, INSERM UMR 1262, University of Limoges, Centre de référence de l'amylose AL et autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France
| | | | | | - Vincent Javaugue
- Control of the immune response B and lymphoproliferation, CNRS UMR 7276, INSERM UMR 1262, University of Limoges, Centre de référence de l'amylose AL et autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France; 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
| | - Samar M Said
- Department of Pathology, Olmsted County Medical Center, Rochester, Minnesota
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Christophe Sirac
- Control of the immune response B and lymphoproliferation, CNRS UMR 7276, INSERM UMR 1262, University of Limoges, Centre de référence de l'amylose AL et autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France.
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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De la Flor JC, Rodríguez-Doyágüez P, Villa D, Zamora R, Díaz F. Double Hit of Hydroxichloroquine and Amiodarone Induced Renal Phospholipidosis in a Patient with Monoclonal Gammopathy and Sclerodermiform Syndrome: A Case Report and Review of the Literature. Med Sci (Basel) 2024; 12:25. [PMID: 38804381 PMCID: PMC11130959 DOI: 10.3390/medsci12020025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 05/03/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024] Open
Abstract
Phospholipidosis is a rare disorder which consists of an excessive intracellular accumulation of phospholipids and the appearance of zebra bodies or lamellar bodies when looking at them using electron microscopy. This disease is associated with certain genetic diseases or is secondary to drugs or toxins. Drug-induced phospholipidosis encompasses many types of pharmaceuticals, most notably chloroquine, amiodarone or ciprofloxacin. Clinically and histologically, renal involvement can be highly variable, with the diagnosis not being made until the zebra bodies are seen under an electron microscope. These findings may require genetic testing to discount Fabry disease, as its histological findings are indistinguishable. Most of the chemicals responsible are cationic amphiphilic drugs, and several mechanisms have been hypothesized for the formation of zebra bodies and their pathogenic significance. However, the relationship between drug toxicity and phospholipid accumulation, zebra bodies and organ dysfunction remains enigmatic, as do the renal consequences of drug withdrawal. We present, to our knowledge, the first case report of acute renal injury with a monoclonal gammopathy of renal significance, lesions, and sclerodermiform syndrome, with zebra bodies that were associated with the initiation of a hydroxychloroquine and amiodarone treatment, as an example of drug-induced-phospholipidosis.
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Affiliation(s)
- José C. De la Flor
- Department of Nephrology, Hospital Central Defense Gomez Ulla, 28047 Madrid, Spain
| | | | - Daniel Villa
- Department of Nephrology, Clinica Universidad de Navarra, 28027 Madrid, Spain;
| | - Rocío Zamora
- Department of Nephrology, Hospital Universitario General Villalba, 28400 Madrid, Spain;
| | - Francisco Díaz
- Department of Anatomic Pathology, Hospital Gregorio Marañón, 28008 Madrid, Spain;
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Zhang H, Zhang C, Su H. Concurrent Crystalline Light-Chain Proximal Tubulopathy and Membranous Nephropathy: A Case Report and Literature Review. Kidney Med 2024; 6:100816. [PMID: 38720788 PMCID: PMC11077163 DOI: 10.1016/j.xkme.2024.100816] [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: 05/12/2024] Open
Abstract
Light-chain proximal tubulopathy (LCPT) is typically characterized by the intracytoplasmic deposition of light chains within the proximal tubular epithelial cells, which is usually classified into crystalline and noncrystalline subgroups. Membranous nephropathy (MN) is a common glomerular disease characterized by diffused subepithelial electron-dense deposits along the capillary loop accompanied by the effacement and microvillus transformation of the foot process. Here, we report a biopsy-confirmed case of a concurrence of LCPT with crystals (κ light chains restricted) and antigen-undetermined MN in a male patient. The patient presented with low-molecular-weight proteinuria, increased serum creatinine levels, and incomplete Fanconi syndrome. To our knowledge, this is the first report of a concurrence of LCPT and independent MN of unknown target antigens, which may enrich our recognition of monoclonal gammopathy of renal significance with synchronous MN.
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Affiliation(s)
- Huizi Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Chunyun Zhang
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
| | - Hua Su
- Department of Nephrology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, P.R. China
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Xu J, Wang X, Weng Q, Feng X, Pan X. First case report of PLA2R-related monotypic (IgG-κ positive) membranous nephropathy concurrent with leukocyte chemotactic factor 2 amyloidosis. BMC Nephrol 2023; 24:283. [PMID: 37752421 PMCID: PMC10523664 DOI: 10.1186/s12882-023-03331-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 09/11/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Membranous nephropathy (MN) is a major pattern of nephrotic syndrome (NS) in adults. Some MN have secondary causes and some may be accompanied with other glomerular diseases. MN patients coexisting with amyloidosis are very rare, and mostly was polytypic MN. Herein, we describe the first report which identifying monotype PLA2R-MN (κ light chain) concurrent with leukocyte chemotactic factor 2 amyloidosis (ALECT2). This rare case highlights the importance of renal pathology for diagnosis. CASE PRESENTATION We describe a case of a 60-year-old male patient with persistent proteinuria and low serum albumin for nine months. No monoclonal component was revealed by serum and urine immunofixation electrophoresis but serum PLA2R antibody was positive. The patient was empirically treated with Leflunomide and Losartan, but edema was not improved. The diagnosis of renal pathology is PLA2R-related monotypic (IgG-κ positive) MN concurrent with ALECT2. Methylprednisolone, cyclosporine A and anticoagulant (rivaroxaban) were prescribed resulting in a complete remission of NS. CONCLUSIONS MN patients concurrent with ALECT2 presented massive proteinuria or NS. When nephrotic range proteinuria is present in ALECT2, it is important to consider that it may be due to a concomitant underlying nephropathy especially MN and treated according to MN will get good therapeutic effect.
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Affiliation(s)
- Jing Xu
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xinlu Wang
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Qinjie Weng
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Xiaobei Feng
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
- Department of Nephrology, Institute of Nephrology, 197, Ruijin Er Road, Shanghai, China, 200025.
| | - Xiaoxia Pan
- Department of Nephrology, Shanghai Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
- Department of Nephrology, Institute of Nephrology, 197, Ruijin Er Road, Shanghai, China, 200025.
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Turcotte AE, Glass WF, Lin JS, Burger JA. Membranous nephropathy in chronic lymphocytic leukemia responsive to ibrutinib: A case report. Leuk Res Rep 2023; 20:100377. [PMID: 37457553 PMCID: PMC10338352 DOI: 10.1016/j.lrr.2023.100377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 06/08/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Membranous nephropathy (MN) is an uncommon renal presentation in patients with chronic lymphocytic leukemia (CLL), and as such, there is no standard therapy for these patients. A few cases of MN in CLL have been described with varying success in MN treatment involving alkylating agents and fludarabine. Here we report the first case of MN in a patient with CLL treated with ibrutinib with complete renal response. This presentation underlines the importance of recognizing rare glomerular diseases that may occur with CLL and offers a new therapeutic avenue to the treatment of CLL-associated MN.
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Affiliation(s)
- Anna-Eve Turcotte
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - William F. Glass
- Department of Pathology and Laboratory Medicine, University of Texas Health Science Center McGovern Medical School, Houston, TX, United States of America
- Division of Anatomic Pathology, Department of Pathology, The University of Virginia School of Medicine, Charlottesville, Virginia, United States of America
| | - Jamie S. Lin
- Section of Nephrology, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
| | - Jan A. Burger
- Department of Leukemia, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States of America
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Relapse of Monoclonal Gammopathy of Renal Significance after mRNA COVID-19 Vaccination: A Case Report. Life (Basel) 2023; 13:life13030734. [PMID: 36983889 PMCID: PMC10057448 DOI: 10.3390/life13030734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/04/2023] [Accepted: 03/07/2023] [Indexed: 03/12/2023] Open
Abstract
This case report represents the first suspected case of light chain deposition disease relapse associated with mRNA COVID-19 vaccination. The 75-year-old female patient of Greek ethnicity was admitted to the clinic for the investigation of worsening renal function detected on routine lab examinations, two weeks after she received the second dose of the Moderna COVID-19 vaccine (mRNA-1273). Rapidly progressive glomerulonephritis and anemia were the most notable findings. She had a history of LCDD, which had remained stable for four years. Serum protein immunofixation showed monoclonal kappa zones, and a bone marrow biopsy revealed 5% plasma cell infiltration. These, along with other investigations, established the diagnosis of LCDD recurrence. The patient was started on chemotherapy, which improved her immunological profile, but not her renal function. The patient has remained on hemodialysis since. The association between mRNA vaccinations and LCDD relapse may be grounds for investigations into the pathophysiology of MGRS, given the patient’s previous long-term remission. This case report is not intended to directly inform changes in clinical practice. We must stress the importance of following all standardized vaccination protocols, especially in immunocompromised patients.
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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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Lovato E, Gangemi C, Krampera M, Visco C, Ferrarini I. Case Report: Rapid renal response to venetoclax monotherapy in a CLL patient with secondary membranous glomerulonephritis. Front Oncol 2023; 13:1108994. [PMID: 37152058 PMCID: PMC10160354 DOI: 10.3389/fonc.2023.1108994] [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: 11/27/2022] [Accepted: 03/27/2023] [Indexed: 05/09/2023] Open
Abstract
Membranous glomerulonephritis (MGN) is a rare extra-hematological autoimmune complication of chronic lymphocytic leukemia (CLL), clinically characterized by nephrotic-range proteinuria and, less frequently, renal failure. Because of the rarity of this condition, there is no standardized treatment. Chlorambucil and fludarabine-based regimens, possibly combined with rituximab, have been historically the most frequent therapeutic approaches, with renal response obtained in about two-third of the patients. However, responses are often transient and partial. Here we describe the first patient with rituximab-refractory, CLL-related MGN successfully treated with the Bcl-2 antagonist venetoclax. Nephrotic syndrome resolved as soon as three months after venetoclax initiation, with no unexpected toxicities. At the last follow-up, 17 months after venetoclax start, renal response persists, with proteinuria below 0.5 g/24 hours. This case suggests that targeted agents, particularly Bcl-2 antagonists, might be suitable options for patients with renal autoimmune disorders arising in the context of CLL.
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Affiliation(s)
- Ester Lovato
- Section of Hematology, Department of Medicine, University of Verona, Verona, Italy
| | - Concetta Gangemi
- Division of Nephrology and Dialysis, University Hospital of Verona, Verona, Italy
| | - Mauro Krampera
- Section of Hematology, Department of Medicine, University of Verona, Verona, Italy
| | - Carlo Visco
- Section of Hematology, Department of Medicine, University of Verona, Verona, Italy
| | - Isacco Ferrarini
- Section of Hematology, Department of Medicine, University of Verona, Verona, Italy
- *Correspondence: Isacco Ferrarini,
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Liu M, Yu X, Wang S, Qin A, Zhou F, Zhao M. Proliferative glomerulonephritis with monoclonal immunoglobulin deposits: an entity associated with distinct diseases and comparison between IgG1 and IgG3 subtypes. J Nephrol 2022; 35:2363-2372. [PMID: 35460458 DOI: 10.1007/s40620-022-01317-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/21/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of the study was to investigate the clinicopathological characteristics and prognosis of proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) and determine the differences between PGNMID associated with extrarenal disease and without clear etiology as well as the differences between IgG1 and IgG3 subtypes. METHODS Data from 46 patients with PGNMID observed from January 2014 to September 2021 in Peking University First Hospital were retrospectively analyzed, including 36 patients without clear etiology (Group A) and 10 patients with extrarenal disease (Group B). RESULTS At presentation patients showed proteinuria (95.7%), hematuria (89.1%), renal insufficiency (73.9%), and hypocomplementemia of C3 or C4 (35.6%). Monoclonal immunoglobulin or cell clones were detected in 22.2% of patients (10/45). The monoclonal immunoglobulins deposited in kidney were IgG3 in 40 patients, IgG1 in 5, and IgM in one. Monoclonal IgG1 deposits were more common in Group B than in Group A (4/10 vs. 1/36, p = 0.006). The intensity of glomerular C3 deposition and the frequency of subendothelial deposits in IgG3 subtype were significantly higher than those in IgG1 subtype. During a median follow-up time of 12.2 (range 1-61) months, a higher level of serum creatinine at biopsy and a higher percentage of global glomerulosclerosis were independent predictors of end-stage kidney disease. CONCLUSIONS PGNMID associated with extrarenal disease was more likely to have monoclonal IgG1 deposits. PGNMID of IgG3 subtype differs from IgG1 subtype by higher intensity of glomerular C3 deposition and higher frequency of subendothelial deposits. Serum creatinine and global glomerulosclerosis were independent prognostic predictors of ESKD in PGNMID.
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Affiliation(s)
- Mengyao Liu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Xiaojuan Yu
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Suxia Wang
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Laboratory of Electron Microscopy, Pathological Centre, Peking University First Hospital, Beijing, 100034, People's Republic of China
| | - Aibo Qin
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
| | - Fude Zhou
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China.
- Institute of Nephrology, Peking University, Beijing, China.
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China.
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China.
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China.
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University First Hospital, Beijing, China
- Institute of Nephrology, Peking University, Beijing, China
- Renal Pathology Center, Institute of Nephrology, Peking University, Beijing, China
- Key Laboratory of Renal Disease, Ministry of Health of China, Beijing, China
- Key Laboratory of CKD Prevention and Treatment, Ministry of Education of China, Beijing, China
- Peking-Tsinghua Center for Life Sciences, Beijing, 100034, People's Republic of China
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L'Imperio V, Cazzaniga G, Vergani B, Smith AJ, Alberici F, Pagni F. Monoclonal Gammopathy of Renal Significance: A Molecular Middle Earth between Oncology, Nephrology, and Pathology. KIDNEY DISEASES (BASEL, SWITZERLAND) 2022; 8:446-457. [PMID: 36590677 PMCID: PMC9798844 DOI: 10.1159/000527056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 09/06/2022] [Indexed: 11/05/2022]
Abstract
Background The renal biopsy represents a cornerstone in the definition of monoclonal gammopathy of renal significance (MGRS), helping in identifying patients with sub-detectable neoplastic clones (MGUS) that would deserve aggressive chemotherapies. However, the rising complexity of this onco-nephrology field is significantly challenging the daily work of nephrologists and nephropathologists, leading to the formation of ultra-specialized international centers with dedicated personnel/instrumentation and stressing the need for a better understanding of the underlying molecular landscape of these entities. Summary In this setting, the application of proteomic techniques, some with in situ capabilities (e.g., MALDI-MS imaging), for the investigation of the most challenging MGRS is progressively shedding light on the pathobiology of these diseases, providing new insights in the diagnosis and prognosis of these cases. This transformation is further enhanced by the application of next-generation digital pathology platforms, leading to a significant improvement of the cultural background for physicians thanks to second opinions, database and atlas creation, enhancement of diagnostic reports, with obvious repercussions for patients both in terms of turnaround time and appropriateness. Key Messages The present review is aimed at bridging the gap between clinical questions (i.e., a better characterization of MGRS) and the molecular landscape of onco-nephrology entities.
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Affiliation(s)
- Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Giorgio Cazzaniga
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Barbara Vergani
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy
| | - Andrew James Smith
- Department of Medicine and Surgery, Clinical Proteomics and Metabolomics Unit, University of Milano - Bicocca, Monza, Italy
| | - Federico Alberici
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy,Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, ASST Monza, San Gerardo Hospital, University of Milan-Bicocca, Monza, Italy,*Fabio Pagni,
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Kudose S, Jagannathan G, Santoriello D, Sekulic M, Batal I, Stokes MB, D’Agati VD, Markowitz GS. Validation Study on the Utility of Immunoglobulin Heavy/Light Chain Immunofluorescence in Kidney Biopsies with Potential MGRS Lesions. Kidney Int Rep 2022; 7:1119-1122. [PMID: 35570997 PMCID: PMC9091611 DOI: 10.1016/j.ekir.2022.01.1071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/31/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022] Open
Affiliation(s)
- Satoru Kudose
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
- Correspondence: Satoru Kudose, Department of Pathology and Cell Biology, Columbia University Irving Medical Center, Room VC14-238, 630 West 168th Street, New York, New York 10032, USA.
| | - Geetha Jagannathan
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Dominick Santoriello
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Miroslav Sekulic
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Ibrahim Batal
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - M. Barry Stokes
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Vivette D. D’Agati
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Glen S. Markowitz
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
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Isiktas Sayilar E, Kiremitci S, Ergun I, Ensari A. Membranous Nephropathy with Lambda Light Chain Restriction: A Rare Form with Serum Negative and Tissue Positive PLA2R Ab. Nephron Clin Pract 2021; 146:377-380. [DOI: 10.1159/000520943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/11/2021] [Indexed: 11/19/2022] Open
Abstract
Membranous nephropathy (MN) is the most common cause of nephrotic syndrome in adults. Subepithelial polyclonal immunoglobulin deposits and >70% M-type phospholipase A2 receptor antibody positivity are typical findings in idiopathic MN. A 58-year-old female patient was admitted with clinical presentation of nephrotic syndrome. Autoimmune diseases, infections, and malignancies were ruled out after clinical and laboratory evaluations. Diagnostic work-up revealed serum PLA2R antibody negativity and diffuse thickening of glomerular capillary wall on biopsy, while glomerular capillary wall IgG, C3, and Lambda monotypic light chain deposition and PLA2R1 positivity were detected by immunofluorescence and immunohistochemical examination, respectively. Following prednisolone treatment, creatinine and proteinuria were markedly regressed. The MN cases with a light chain deposits are rare and experience regarding their treatment are insufficient.
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13
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Li M, Xu G. An update of proliferative glomerulonephritis with monoclonal immunoglobulin deposits. Clin Kidney J 2021; 15:1041-1048. [PMID: 35664272 PMCID: PMC9155251 DOI: 10.1093/ckj/sfab269] [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: 07/07/2021] [Indexed: 11/14/2022] Open
Abstract
Abstract
As aging increases, monoclonal gammopathy is becoming more common, and monoclonal gammopathy of renal significance (MGRS) is gaining attention due to frequent renal involvement. Among MGRS, proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID) is a special category. The disease was first described in 2004, and the research history on it is relatively short. Compared with other MGRS, the detection rate of circulating clones is lower in patients with PGNMID, which is easy to be missed and misdiagnosed in clinical work. In this review, the etiology and clinical features of PGNMID are discussed. It is noted that PGNMID is not only associated with MGRS, but also with malignancy, infection, and other factors. PGNMID is not a disease exclusive to the elderly, young people can also develop this disease. Due to the low detection rate of circulating clones in most patients, confirmation of the disease needs to be combined with renal pathology, which emphasizes the importance of completing light and heavy chain subtype staining. Treatment options for patients with PGNMID differ by etiology. For MGRS-associated PGNMID, the current treatment is primarily empirical and more research evidence is needed to fill the treatment gap.
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Affiliation(s)
- Manna Li
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, China
| | - Gaosi Xu
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, China
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14
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Caza TN, Al-Rabadi LF, Beck LH. How Times Have Changed! A Cornucopia of Antigens for Membranous Nephropathy. Front Immunol 2021; 12:800242. [PMID: 34899763 PMCID: PMC8662735 DOI: 10.3389/fimmu.2021.800242] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
The identification of the major target antigen phospholipase A2 receptor (PLA2R) in the majority of primary (idiopathic) cases of membranous nephropathy (MN) has been followed by the rapid identification of numerous minor antigens that appear to define phenotypically distinct forms of disease. This article serves to review all the known antigens that have been shown to localize to subepithelial deposits in MN, as well as the distinctive characteristics associated with each subtype of MN. We will also shed light on the novel proteomic approaches that have allowed identification of the most recent antigens. The paradigm of an antigen normally expressed on the podocyte cell surface leading to in-situ immune complex formation, complement activation, and subsequent podocyte injury will be discussed and challenged in light of the current repertoire of multiple MN antigens. Since disease phenotypes associated with each individual target antigens can often blur the distinction between primary and secondary disease, we encourage the use of antigen-based classification of membranous nephropathy.
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Affiliation(s)
| | - Laith F. Al-Rabadi
- Department of Internal Medicine (Nephrology & Hypertension), University of Utah, Salt Lake City, UT, United States
| | - Laurence H. Beck
- Department of Medicine (Nephrology), Boston University School of Medicine and Boston Medical Center, Boston, MA, United States
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15
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Nasr SH, Fidler ME, Said SM, Koepplin JW, Altamirano-Alonso JM, Leung N. Immunofluorescence staining for immunoglobulin heavy chain/light chain on kidney biopsies is a valuable ancillary technique for the diagnosis of monoclonal gammopathy-associated kidney diseases. Kidney Int 2021; 100:155-170. [DOI: 10.1016/j.kint.2021.02.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/20/2021] [Accepted: 02/25/2021] [Indexed: 10/21/2022]
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16
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Ahmed S, Blanco P, MacDonald DA, Hundemer GL. The Case | Nephrotic syndrome in a patient with chronic lymphocytic leukemia. Kidney Int 2021; 99:777-778. [PMID: 33637210 DOI: 10.1016/j.kint.2020.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/23/2020] [Accepted: 08/26/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Sumaiya Ahmed
- Department of Medicine, The Ottawa Hospital; Ottawa, Ontario, Canada
| | - Paula Blanco
- Department of Pathology and Laboratory Medicine, The Ottawa Hospital; Ottawa, Ontario, Canada
| | - David A MacDonald
- Division of Hematology, Department of Medicine, The Ottawa Hospital; Ottawa, Ontario, Canada
| | - Gregory L Hundemer
- Division of Nephrology, Department of Medicine, The Ottawa Hospital; Ottawa, Ontario, Canada.
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17
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Pathophysiology and management of monoclonal gammopathy of renal significance. Blood Adv 2020; 3:2409-2423. [PMID: 31409583 DOI: 10.1182/bloodadvances.2019031914] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 05/09/2019] [Indexed: 12/17/2022] Open
Abstract
Recent years have witnessed a rapid growth in our understanding of the pathogenic property of monoclonal proteins. It is evident that some of these small monoclonal proteins are capable of inducing end-organ damage as a result of their intrinsic physicochemical properties. Hence, an umbrella term, monoclonal gammopathy of clinical significance (MGCS), has been coined to include myriad conditions attributed to these pathogenic proteins. Because kidneys are the most commonly affected organ (but skin, peripheral nerves, and heart can also be involved), we discuss MGRS exclusively in this review. Mechanisms of renal damage may involve direct or indirect effects. Renal biopsy is mandatory and demonstration of monoclonal immunoglobulin in kidney, along with the corresponding immunoglobulin in serum or urine, is key to establish the diagnosis. Pitfalls exist at each diagnostic step, and a high degree of clinical suspicion is required to diagnose MGRS. Recognition of MGRS by hematologists and nephrologists is important, because timely clone-directed therapy improves renal outcomes. Autologous stem cell transplant may benefit selected patients.
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18
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Batko K, Malyszko J, Jurczyszyn A, Vesole DH, Gertz MA, Leleu X, Suska A, Krzanowski M, Sułowicz W, Malyszko JS, Krzanowska K. The clinical implication of monoclonal gammopathies: monoclonal gammopathy of undetermined significance and of renal significance. Nephrol Dial Transplant 2020; 34:1440-1452. [PMID: 30169860 DOI: 10.1093/ndt/gfy259] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Indexed: 12/23/2022] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) has introduced a new perspective to several well-known disease entities impacting nephrology, haematology and pathology. Given the constantly changing disease spectrum of these entities, it is clinically imperative to establish diagnostic and treatment pathways supported by evidence-based medicine. MGRS is a disease of the kidney, secondary to plasma cell clonal proliferation or immune dysfunction, requiring therapeutic intervention to eradicate the offending clone. To fully understand the disease(s), it is prerequisite to determine the significance of the findings. The diagnostic work up should be extensive due to the wide heterogeneity of clinical presentation, ultimately necessitating kidney biopsy. Particular patient profiles such as AL amyloidosis, which may be diagnosed through biopsies of other tissues/organs, may be an exception. Treatment decisions should be formulated by multi-disciplinary consensus: nephrologists, haematologists and pathologists. The ultimate goal in managing MGRS is eradication of the offending plasma cell clone which requires targeted chemotherapy and, in eligible cases, haematopoietic stem cell transplantation. We present a review of diagnostic procedures, treatment options and advances in the last few years in the management of MGRS in an effort to acquaint specialists with this new face of several older diseases.
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Affiliation(s)
- Krzysztof Batko
- Departament of Nephrology, Jagiellonian University Medical College, Kraków, Poland
| | - Jolanta Malyszko
- Department of Nephrology, Dialysis and Internal Medicine, Warsaw Medical University, Warszawa, Poland
| | - Artur Jurczyszyn
- Departament of Hematology, Jagiellonian University Medical College, Kraków, Poland
| | - David H Vesole
- Myeloma DIvision, John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Xavier Leleu
- Service d`Hematologie CHU, Hopital de la Miletrie, Poitiers, France
| | - Anna Suska
- Departament of Hematology, Jagiellonian University Medical College, Kraków, Poland
| | - Marcin Krzanowski
- Departament of Nephrology, Jagiellonian University Medical College, Kraków, Poland
| | - Władysław Sułowicz
- Departament of Nephrology, Jagiellonian University Medical College, Kraków, Poland
| | - Jacek S Malyszko
- 1st Department of Nephrology, Medical University, Bialystok, Poland
| | - Katarzyna Krzanowska
- Departament of Nephrology, Jagiellonian University Medical College, Kraków, Poland
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19
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Zuo C, Zhu Y, Xu G. An update to the pathogenesis for monoclonal gammopathy of renal significance. Crit Rev Oncol Hematol 2020; 149:102926. [PMID: 32199132 DOI: 10.1016/j.critrevonc.2020.102926] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Revised: 12/20/2019] [Accepted: 03/02/2020] [Indexed: 11/24/2022] Open
Abstract
Monoclonal gammopathy of renal significance (MGRS) is characterized by the nephrotoxic monoclonal immunoglobulin (MIg) secreted by an otherwise asymptomatic or indolent B-cell or plasma cell clone, without hematologic criteria for treatment. The spectrum of MGRS-associated disorders is wide, including non-organized deposits or inclusions such as C3 glomerulopathy with monoclonal glomerulopathy (MIg-C3G), monoclonal immunoglobulin deposition disease, proliferative glomerulonephritis with monoclonal immunoglobulin deposits and organized deposits like immunoglobulin related amyloidosis, type I and type II cryoglobulinaemic glomerulonephritis, light chain proximal tubulopathy, and so on. Kidney biopsy should be conducted to identify the exact disease associated with MGRS. These MGRS-associated diseases can involve one or more renal compartments, including glomeruli, tubules and vessels. Hydrophobic residues replacement, N-glycosylated, increase in isoelectric point in MIg causes it to transform from soluble form to tissue deposition, causing glomerular damage. Complement deposition is found in MIg-C3G, which is caused by an abnormality of the alternative pathway and may involve multiple factors including complement component 3 nephritic factor, anti-complement factor auto-antibodies or MIg which directly cleaves C3. The effect of transforming growth factor beta and platelet-derived growth factor-β on mesangial extracellular matrix is associated with glomerular and tubular basement membrane thickening, nodular glomerulosclerosis, and interstitial fibrosis. Furthermore, inflammatory factors, growth factors and virus infection may play an important role in the development of the diseases. In this review, for the first time, we discussed current highlights in the mechanism of MGRS-related lesions.
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Affiliation(s)
- Chao Zuo
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China; Grade 2016, the Second Clinical Medical College of Nanchang University, Nanchang, China
| | - Yuge Zhu
- Grade 2016, the First Clinical Medical College of Nanchang University, Nanchang, China
| | - Gaosi Xu
- Department of Nephrology, the Second Affiliated Hospital of Nanchang University, Nanchang, China.
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20
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An update to the pathogenesis for monoclonal gammopathy of renal significance. Ann Hematol 2020; 99:703-714. [PMID: 32103323 DOI: 10.1007/s00277-020-03971-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 02/18/2020] [Indexed: 01/16/2023]
Abstract
Monoclonal gammopathy of renal significance (MGRS) is characterized by the nephrotoxic monoclonal immunoglobulin secreted by an otherwise asymptomatic or indolent B cell or plasma cell clone, without hematologic criteria for treatment. These MGRS-associated diseases can involve one or more renal compartments, including glomeruli, tubules, and vessels. Hydrophobic residue replacement, N-glycosylated, increase in isoelectric point in monoclonal immunoglobulin (MIg) causes it to transform from soluble form to tissue deposition, and consequently resulting in glomerular damage. In addition to MIg deposition, complement deposition is also found in C3 glomerulopathy with monoclonal glomerulopathy, which is caused by an abnormality of the alternative pathway and may involve multiple factors including complement component 3 nephritic factor, anti-complement factor auto-antibodies, or MIg which directly cleaves C3. Furthermore, inflammatory factors, growth factors, and virus infection may also participate in the development of the diseases. In this review, for the first time, we discussed current highlights in the mechanism of MGRS-related lesions.
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21
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Higashihara T, Okada A, Nakamura Y, Saigusa H, Homma S, Matsumura M, Kusano T, Shimizu A, Takano H. Proliferative Glomerulonephritis with Monoclonal Immunoglobulin Deposits without Conspicuous Mesangial Proliferation, Complicated with Squamous Cell Lung Carcinoma. Intern Med 2020; 59:557-562. [PMID: 31611527 PMCID: PMC7056369 DOI: 10.2169/internalmedicine.2993-19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We performed a renal biopsy for nephrotic syndrome in a patient with squamous cell lung carcinoma, which can worsen the prognosis. Chemoradiation therapy was effective for the cancer and proteinuria; we thus inferred that the nephrotic syndrome had been closely associated with the carcinoma. A pathological analysis of the kidney showed monoclonality for λ chain, satisfying the diagnostic criteria of proliferative glomerulonephritis with monoclonal immunoglobulin deposits (PGNMID); however, conspicuous mesangial proliferation was not observed. This is the first case of PGNMID complicated with lung carcinoma; furthermore, our findings underscore the importance of examining renal lesions and assessing monoclonality in cancer patients.
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MESH Headings
- Aged
- Antibodies, Monoclonal/blood
- Carcinoma, Non-Small-Cell Lung/complications
- Carcinoma, Non-Small-Cell Lung/diagnosis
- Carcinoma, Non-Small-Cell Lung/physiopathology
- Carcinoma, Non-Small-Cell Lung/radiotherapy
- Carcinoma, Squamous Cell/complications
- Carcinoma, Squamous Cell/diagnosis
- Carcinoma, Squamous Cell/physiopathology
- Carcinoma, Squamous Cell/radiotherapy
- Cell Proliferation/drug effects
- Epithelial Cells/drug effects
- Glomerulonephritis, Membranoproliferative/diagnosis
- Glomerulonephritis, Membranoproliferative/etiology
- Glomerulonephritis, Membranoproliferative/physiopathology
- Humans
- Immunoglobulin G/blood
- Male
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Affiliation(s)
- Takaaki Higashihara
- Department of Nephrology, Tokyo Teishin Hospital, Japan
- Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Japan
| | - Akira Okada
- Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Japan
| | - Yasuna Nakamura
- Department of Nephrology, Tokyo Teishin Hospital, Japan
- Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Japan
| | - Hanako Saigusa
- Department of Nephrology, Tokyo Teishin Hospital, Japan
- Divison of Nephrology and Endocrinology, The University of Tokyo Graduate School of Medicine, Japan
| | - Shiko Homma
- Department of Nephrology, Tokyo Teishin Hospital, Japan
| | | | - Taiko Kusano
- Department of Nephrology, Tokyo Teishin Hospital, Japan
| | - Akira Shimizu
- Department of Analytic Human Pathology, Graduate School of Medicine, Nippon Medical School, Japan
| | - Hideki Takano
- Department of Nephrology, Tokyo Teishin Hospital, Japan
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22
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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: 277] [Impact Index Per Article: 55.4] [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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23
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24
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Bridoux F, Javaugue V, Nasr SH, Leung N. Proliferative glomerulonephritis with monoclonal immunoglobulin deposits: a nephrologist perspective. Nephrol Dial Transplant 2019; 36:208-215. [DOI: 10.1093/ndt/gfz176] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 07/26/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Proliferative glomerulonephritis (GN) with monoclonal immunoglobulin deposits (PGNMIDs) is a recently described entity among the spectrum of monoclonal gammopathy of renal significance (MGRS). The disease is renal limited and manifests with chronic glomerular disease, altered renal function and albuminuria, sometimes in the nephrotic range. Acute nephritic syndrome is rare. PGNMID occurs mostly in the sixth decade, but it may affect young adults. Histologically, PGNMID is characterized predominantly by membranoproliferative GN and less frequently by diffuse endocapillary GN, mesangioproliferative GN or atypical membranous GN. Immunofluorescence and electron microscopic studies are the cornerstone of diagnosis, showing granular deposits involving glomeruli only, and composed of monotypic immunoglobulin G (IgG), with a single heavy chain subclass (most commonly IgG3) and light chain (LC) restriction (usually κ), admixed with complement deposits. PGNMID variants with monotypic LC-only, IgA or IgM deposits are uncommon. Ultrastructurally, deposits are amorphous with predominant subendothelial and mesangial distribution. PGNMID should be distinguished from type 1 cryoglobulinemic GN and immunotactoid GN, which share some common pathological features. Contrary to other MGRS lesions, the rate of detection of the nephrotoxic monoclonal Ig in the serum or urine, and of an abnormal bone marrow B-cell clone, is only ∼30%. Renal prognosis is poor, with progression to end-stage renal disease in 25% of patients within 30 months and frequent early recurrence on the renal allograft. The pathophysiology of PGNMID is unclear and its treatment remains challenging. However, recent studies indicate that clone-targeted chemotherapy may significantly improve renal outcomes, opening future perspectives for the management of this rare disease.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, Centre de Référence Maladies Rares « Amylose AL et autres maladies par dépôts d’immunoglobulines monoclonales », Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, and CNRS UMR 7276-INSERM 1262, Limoges, France
| | - Vincent Javaugue
- Department of Nephrology, Centre de Référence Maladies Rares « Amylose AL et autres maladies par dépôts d’immunoglobulines monoclonales », Centre Hospitalier Universitaire et Université de Poitiers, Poitiers, and CNRS UMR 7276-INSERM 1262, Limoges, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Nelson Leung
- Division of Nephrology and Hypertension and Division of Hematology, Mayo Clinic, Rochester, MN, USA
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25
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Ramachandran R, Inamdar N, Bharati J, Yadav AK, Kumar A, Prakash G, Nada R, Rathi M, Kohli HS, Gupta KL, Jha V. Membranous nephropathy with light chain restricted deposits. Nephrology (Carlton) 2018; 23:791-796. [PMID: 29633425 DOI: 10.1111/nep.13268] [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] [Accepted: 04/01/2018] [Indexed: 10/17/2022]
Abstract
The literature on membranous nephropathy (MN) with monoclonal deposits on immunofluorescence (IF) and their outcome is very scarce. We report our experience of managing five patients with this clinical entity. The mean age of the patients was 33.2 ± 6.55 years. The mean proteinuria, serum albumin and serum creatinine was 5.73 ± 2.17 g/day, 2.86 ± 0.51 g/dL and 1.34 ± 1.19 mg/dL, respectively. None of the patients had a lymphoproliferative disorder. Only one patient had an elevated free light chain ratio. Four (80%) patients were M-type phospholipase A2 receptor (PLA2R) negative (tissue and serum), and one (20%) was PLA2R related. Three (60%) cases had monoclonal IgG3/k, one IgG3/λ, whereas one patient with PLA2R positivity had an IgG3/IgG4k subtype. Two (67%) patients treated with cyclical cyclophosphamide and steroids (cCYC/GC) achieved complete remission and one patient (33%) with elevated baseline creatinine had a reduction in serum creatinine with persistent proteinuria at the end of the 12th month of follow-up. One patient with PLA2R positive MN was treated with Rituximab and is in complete remission. The patient with an elevated free light chain at baseline was treated with Bortezomib/Thalidomide/Dexamethasone, had complete remission at 12 months, however, had a progressive rise in creatinine over the next 40 months of follow-up. The current series, though limited by numbers, documents the efficacy of conventional therapies in non-malignant associated MN with monoclonal deposits on IF.
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Affiliation(s)
- Raja Ramachandran
- Department of Nephrology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Neeraj Inamdar
- Department of Nephrology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Joyita Bharati
- Department of Nephrology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashok K Yadav
- Department of Nephrology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashwani Kumar
- Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Gaurav Prakash
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Manish Rathi
- Department of Nephrology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harbir Singh Kohli
- Department of Nephrology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Krishan L Gupta
- Department of Nephrology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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