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Bridoux F, Leung N, Nasr SH, Jaccard A, Royal V. Kidney disease in multiple myeloma. Presse Med 2025; 54:104264. [PMID: 39662762 DOI: 10.1016/j.lpm.2024.104264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2024] [Accepted: 11/14/2024] [Indexed: 12/13/2024] Open
Abstract
Renal disease is a frequent complication of symptomatic multiple myeloma, that increases morbidity and reduces quality of life and overall survival. It may result from various lesions, the most frequent being light chain cast nephropathy (LCCN), related to precipitation of monoclonal free light chains (FLC) with uromodulin in distal tubules. Rapid identification of the type of kidney disease with appropriate management is key. LCCN typically reveals the underlying myeloma and manifests with severe acute kidney injury, high serum FLC level (>500 mg/l) and predominant light chain proteinuria (urine albumin/creatinine ratio <10 %). Urgent therapy is required, based on vigorous fluid expansion, correction of precipitating factors and introduction of efficient anti-myeloma therapy which choice should consider renal elimination of each agent and patient frailty. Early and deep reduction in serum FLC level conditions renal recovery, warranting assessment of efficacy by serial serum FLC level monitoring. In newly diagnosed patients, the combination of bortezomib, high-dose dexamethasone and an anti-CD38 monoclonal antibody is commonly used. The benefit to risk balance of quadruplets incorporating cyclophosphamide or an immunodulatory agent requires to be evaluated in prospective studies. In patients with severe acute kidney injury, reinforcing chemotherapy with FLC removal through plasma exchange or high-cutoff hemodialysis may increase the probability of renal response, despite controversial data from randomized trials. Histological assessment of the extent of cast formation and interstitial fibrosis/tubular atrophy may help evaluating renal prognosis and refining therapy. Thanks to improved overall survival, renal transplantation may be considered in selected candidates with end-stage kidney 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 de Poitiers, Université de Poitiers, Poitiers, France.
| | - Nelson Leung
- Department of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Arnaud Jaccard
- Department of Hematology and Cellular Therapy, Centre de référence maladies rares «Amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales», Centre Hospitalier Universitaire de Limoges, Limoges, France
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
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Narimiya T, Hayashi H, Ogata S, Hara S, Okamoto A, Takahashi K, Koide S, Inaguma D, Hasegawa M, Tomita A, Yuzawa Y, Tsuboi N. Clinical characteristics of monoclonal immunoglobulin-associated renal disease: a retrospective cohort study. Clin Exp Nephrol 2025; 29:259-268. [PMID: 39546082 DOI: 10.1007/s10157-024-02552-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 08/14/2024] [Indexed: 11/17/2024]
Abstract
INTRODUCTION Clinical epidemiological data on monoclonal gammopathy of renal significance (MGRS) are lacking. In this retrospective observational study, MGRS was compared with B-cell or plasma cell malignancies (BCM/PCM) with renal involvement to clarify differences in their clinical features. METHODS Among the 1408 renal biopsies performed at our hospital, 25 MGRS and 18 BCM/PCM patients were identified. We investigated baseline characteristics and hematologic parameters of MGRS in reference to BCM/PCM using multivariable analysis. Cox proportional hazards analysis was performed for end-stage kidney disease (ESKD) and all-cause mortality. RESULTS Comparing the MGRS with the BCM/PCM, mean differences in creatinine level, estimated glomerular filtration rate, and clonal bone marrow plasma cell percentage were - 2.76 mg/dL, 27.72 mL/min/1.73 m2, and - 18.86%, respectively (all P < 0.001). MGRS group had a predominance of glomerular lesions such as immunoglobulin-associated amyloidosis, cryoglobulinemic GN, and MIDD, and a lower risk of acute kidney injury/acute renal disease compared to BCM/PCM. During a median observation period of 23.7 months, clone-directed therapy was performed in 32.0% of patients in the MGRS group, compared to 83.3% of patients in the BCM/PCM group. Compared with BCM/PCM, MGRS had a hazard ratio of 0.66 (95% confidence interval (CI) 0.23-1.92, P = 0.45) for ESKD and 0.33 (95% CI 0.11-1.03, P = 0.06) for death in multivariate logistic regression analysis. CONCLUSIONS The clinical characteristics of MGRS and BCM/PCM with monoclonal immunoglobulin-associated renal disease are disparate. Understanding these differences is crucial for developing tailored clinical approaches and therapeutic strategies to improve patient outcome.
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Affiliation(s)
- Toshiyuki Narimiya
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Hiroki Hayashi
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan.
| | - Soshiro Ogata
- Department of Preventive Medicine and Epidemiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Shigeo Hara
- Department of Pathology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Akinao Okamoto
- Department of Hematology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Kazuo Takahashi
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
- Department of Biomedical Molecular Sciences, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Shigehisa Koide
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Daijo Inaguma
- Department of Nephrology, Fujita Health University Bantane Hospital, Nagoya, Aichi, Japan
| | - Midori Hasegawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Akihiro Tomita
- Department of Hematology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yukio Yuzawa
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Naotake Tsuboi
- Department of Nephrology, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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Kozakowski N, Agis H, Krauth MT, Simonitsch-Klupp I, Schiefer AI, Grünberger B, Farkas HA, Zodl H, Bridoux F, Pascal V. Exploratory Immunosequencing of an Intracapillary Monoclonal Deposits Disease in a Patient With Subacute Neuro-Renal Syndrome. Kidney Int Rep 2025; 10:256-259. [PMID: 39810789 PMCID: PMC11725791 DOI: 10.1016/j.ekir.2024.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 10/10/2024] [Accepted: 10/14/2024] [Indexed: 01/16/2025] Open
Affiliation(s)
| | - Hermine Agis
- Medical University of Vienna, Division Haematology and Haemostaseology, Department Internal Medicine I, Vienna, Austria
| | - Maria-Theresa Krauth
- Medical University of Vienna, Division Haematology and Haemostaseology, Department Internal Medicine I, Vienna, Austria
| | | | - Ana-Iris Schiefer
- Medical University of Vienna, Department of Pathology, Vienna, Austria
| | - Birgit Grünberger
- Department of Internal Medicine, Landesklinikum Wiener Neustadt, Haematology and Internal Oncology, Wiener Neustadt, Austria
| | - Helene Andersson Farkas
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Herbert Zodl
- Department of Internal Medicine, Cardiology and Nephrology, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - Frank Bridoux
- Department of Nephrology, Dialysis, and Renal Transplantation, CHU Poitiers, Poitiers, France
- Centre national de référence Amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
| | - Virginie Pascal
- Department of Immunology and Immunogenetics, Centre Hospitalier Universitaire de Limoges, Limoges, France
- Centre national de référence Amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
- Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France
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Mancuso K, Mina R, Rocchi S, Antonioli E, Petrucci MT, Fazio F, Gozzetti A, Salvini M, Cartia CS, Bertuglia G, Patriarca F, Dalla Palma AB, Barbato S, De Cicco G, Bigi F, Favero E, Tacchetti P, Pantani L, Rizzello I, Puppi M, Talarico M, Solli V, Kanapari A, Cavo M, Zamagni E. Clinical Presentation and Long-Term Survival Outcomes of Patients With Monoclonal Gammopathy of Renal Significance (MGRS): A Multicenter Retrospective Study. Cancer Med 2024; 13:e70266. [PMID: 39587728 PMCID: PMC11588855 DOI: 10.1002/cam4.70266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 09/11/2024] [Accepted: 09/17/2024] [Indexed: 11/27/2024] Open
Abstract
INTRODUCTION MGRS are new rare clinical entities, whose recognition and optimal management is evolving. METHODS To implement real-life data, we retrospectively analysed a multicentre cohort of 60 patients with renal biopsy-proven MGRS receiving mainly novel treatments (between 2006 and 2021) in eight Italian centres. Based on renal biopsy, patients were divided into two subgroups: AL amyloidosis (70%, n = 42) and other-MGRS (30%, n = 18). RESULTS Baseline characteristics follow typical manifestations of MGRS disorders in terms of small clonal burden, laboratory and clinical features. More patients with AL amyloidosis had monotypic lambda light-chain disease, estimated glomerular filtration rate (eGFR) ≥ 60 mL/min and nephrotic proteinuria than other-MGRS group. The most widely used drug was bortezomib, and about one-third of patients underwent ASCT. Overall response rate was 86% with no differences in the two subgroups. However, high-quality hematologic responses ≥very good partial response (VGPR) were greater in AL amyloidosis than in other-MGRS group (67% vs 28%, p = 0.015). The depth of haematological response influenced renal response, obtained in 32 (59%) of evaluable patients, similarly in the subgroups. Indeed, 75% patients with ≥ VGPR (p = 0.049) and none with stable disease (p ≤ 0.001) obtained a renal response. No association between renal response and histotypes (p = 0.9) or type of first-line therapy (p = 0.3) was found. At a median follow-up of 54.4 months (IQR 24.8-102.8), median progression-free survival (PFS) was 100.1 months (95% CI 34.9-NR), and median overall survival not reached (95% CI 129.8-NR). No significant difference emerged between the two groups in terms of survival outcomes. Achieving ≥ VGPR was confirmed as the main independent predictor of prolonged PFS in the general population (HR = 0.29, p = 0.023) and AL amyloidosis group (HR 0.23; p = 0.023). Preserved renal function at diagnosis was predictive of improved PFS in the AL amyloidosis group (eGFR ≥ 60 mL/min: HR = 0.003; p = 0.018; eGFR 30-60 mL/min: HR = 0.04, p = 0.046). CONCLUSION Further research is warranted to develop standardised response criteria and treatment strategies to improve MGRS management.
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Affiliation(s)
- K. Mancuso
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - R. Mina
- Myeloma Unit, Division of HematologyUniversity of Turin and Azienda Ospedaliero‐Universitaria (AOU) Città della Salute e della Scienza di TorinoTorinoItaly
| | - S. Rocchi
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - E. Antonioli
- Hematology DepartmentCareggi HospitalFlorenceItaly
| | - M. T. Petrucci
- Hematology–Azienda Policlinico Umberto I‐Department of Translational and Precision Medicine–Sapienza, University of RomeRomaItaly
| | - F. Fazio
- Hematology–Azienda Policlinico Umberto I‐Department of Translational and Precision Medicine–Sapienza, University of RomeRomaItaly
| | - A. Gozzetti
- Department of Medical Science, Surgery and Neuroscience, HematologyUniversity of SienaSienaItaly
| | - M. Salvini
- UOC Ematologia, ASST Sette LaghiOspedale di Circolo e Fondazione MacchiVareseItaly
| | - C. S. Cartia
- Division of HematologyFondazione IRCCS Policlinico San MatteoPaviaItaly
| | - G. Bertuglia
- Myeloma Unit, Division of HematologyUniversity of Turin and Azienda Ospedaliero‐Universitaria (AOU) Città della Salute e della Scienza di TorinoTorinoItaly
| | - F. Patriarca
- Clinica Ematologica, Azienda Sanitaria Universitaria Friuli Centrale, Dipartimento di MedicinaUniversità di UdineUdineItaly
| | - A. B. Dalla Palma
- Hematology and BMT UnitAzienda Ospedaliero‐Universitaria di ParmaParmaItaly
| | - S. Barbato
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - G. De Cicco
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - F. Bigi
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - E. Favero
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - P. Tacchetti
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
| | - L. Pantani
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
| | - I. Rizzello
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - M. Puppi
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - M. Talarico
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - V. Solli
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - A. Kanapari
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - M. Cavo
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
| | - E. Zamagni
- IRCCS Azienda Ospedaliero‐Universitaria di BolognaIstituto di Ematologia “Seràgnoli”BolognaItaly
- Dipartimento di Scienze Mediche e ChirurgicheUniversità di BolognaBolognaItaly
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Cai X, Zou W, Chen H, Xing C, Yu X. A case of heavy-chain deposition disease with good long-term renal survival and a literature review. BMC Nephrol 2024; 25:312. [PMID: 39300330 PMCID: PMC11414148 DOI: 10.1186/s12882-024-03755-z] [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: 02/27/2024] [Accepted: 09/11/2024] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Monoclonal immunoglobulin deposition disease (MIDD) is characterized by the deposition of nonamyloid monoclonal immunoglobulin and its free fragment light chain and/or heavy chain in systemic tissues and organs, and the kidney is most vulnerable organs. MIDD can be divided into three types: light-chain deposition disease (LCDD), light and heavy chain deposition disease (LHCDD), and heavy-chain deposition disease (HCDD), of which LHCDD and HCDD are rarer (Bridoux et al. in Kidney Int 2015;87:698-711; Preud'homme et al. in Kidney Int 1994;46:965-72). Poor outcome in most HCDD, but in this paper, we will report a case of HCDD with good long-term renal survival and review the literature for reference. CASE PRESENTATION A 32-year-old man presented to our department with skin laxity and nephritic syndrome, accompanied by an significant increase of serum creatinine and received short-term hemodialysis treatment. Both the blood and urine free light chain ratio increased significantly. Renal biopsy showed mesangial nodular glomerulosclerosis on light microscopy, and immunofluorescence staining showed positivity for γ-heavy chain (HC), with negative light chain (LC) staining; the diagnosis was considered HCDD. After six courses of bortezomib combined with dexamethasone chemotherapy and thalidomide 100 mg/day, the renal function gradually recovered, while also with proteinuria and hematuria significantly improved. The blood and urine free light chain ratio decreased to normal. Until now, the patient has been followed for four years, and long-term renal survival has been observed. CONCLUSION Herein, we report a case presenting with proteinuria, hematuria, renal impairment, and skin laxity, and a renal biopsy showed linear IgG deposition in the glomerular basement membranes and tubular basement membrane. However, they ultimately proved to have HCDD. Bortezomib combined with dexamethasone, and oral thalidomide led to a good long-term renal survival. We also provide a review of currently available literature, and this is the first large-scale review summarizing the characteristics of HCDD up to date.
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Affiliation(s)
- Xiaoqing Cai
- Department of Nephrology, People's Hospital of Yueqing, Yueqing Hospital Affiliated to Wenzhou Medical University, Yueqing, Zhejiang, 325600, China
| | - Wenli Zou
- Urology & Nephrology Center, Department of Nephrology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, 310000, China
| | - Huaihuai Chen
- Department of Nephrology, People's Hospital of Yueqing, Yueqing Hospital Affiliated to Wenzhou Medical University, Yueqing, Zhejiang, 325600, China
| | - Chaonian Xing
- Department of Nephrology, People's Hospital of Yueqing, Yueqing Hospital Affiliated to Wenzhou Medical University, Yueqing, Zhejiang, 325600, China
| | - Xuguang Yu
- Department of Nephrology, People's Hospital of Yueqing, Yueqing Hospital Affiliated to Wenzhou Medical University, Yueqing, Zhejiang, 325600, China.
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Shi S, He K, Liang Y, Yue S. Long-term renal survival of γ3-heavy-chain deposition disease complicated by heart failure: A case report. Clin Case Rep 2024; 12:e9091. [PMID: 38962462 PMCID: PMC11220498 DOI: 10.1002/ccr3.9091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 05/10/2024] [Accepted: 05/18/2024] [Indexed: 07/05/2024] Open
Abstract
Key Clinical Message Heavy-chain deposition disease (HCDD), a rare monoclonal immunoglobulin deposition disease, involves truncated heavy-chain deposition in kidneys. Limited long-term data exist. We report a case of renal and cardiac failure with favorable outcomes post bortezomib-based therapy. Stable renal function observed over 4 years suggests efficacy in HCDD with multisystem involvement. Abstract Heavy-chain deposition disease (HCDD) is an extremely rare form of monoclonal immunoglobulin deposition disease (MIDD) that involves the deposition of truncated immunoglobulin heavy chains in the kidneys. Only a few cases of HCDD with a favorable long-term renal prognosis have been reported, resulting in limited long-term follow-up data for this patient population. In this report, we present the case of a 52-year-old patient with nephrotic syndrome who experienced renal failure and cardiac failure. Renal biopsy confirmed the presence of γ3-HCDD and monoclonal Immunoglobulin G (IgG)κ in the serum. The patient exhibited low voltage on electrocardiogram (ECG) and unexplained left ventricular hypertrophy on cardiac ultrasound. The patient underwent eight cycles of bortezomib-based chemotherapy, which led to hematological remission. After 4 years of follow-up, the patient's renal function remained stable, with serum creatinine levels ranging from 0.7 to 0.9 mg/dL and proteinuria of 0.3-0.5 g/24 h. Our findings suggest that bortezomib-based chemotherapy is equally effective in HCDD patients with combined multisystem damage.
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Affiliation(s)
- Shujun Shi
- Renal Division, Department of MedicineLanzhou University Second HospitalLanzhouChina
| | - Kaiying He
- Renal Division, Department of MedicineLanzhou University Second HospitalLanzhouChina
- Lanzhou UniversityLanzhouChina
| | - Yaojun Liang
- Renal Division, Department of MedicineLanzhou University Second HospitalLanzhouChina
| | - Shuling Yue
- Guangzhou KingMed Center for Clinical LaboratoryGuangzhouGuangdongChina
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Wang Y, Chen D, Hu R, Zhang Y, Liang D, Xu F, Liu F, Zhu X, Lin Y, Yang X, Liu X, Xing G, Liang S, Zeng C. Clinicopathological Characteristics of Light and Heavy Chain Deposition Disease: A Case Series. Am J Kidney Dis 2024:S0272-6386(24)00757-1. [PMID: 38750878 DOI: 10.1053/j.ajkd.2024.03.021] [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: 08/01/2023] [Revised: 02/19/2024] [Accepted: 03/09/2024] [Indexed: 07/04/2024]
Abstract
RATIONALE & OBJECTIVE Light and heavy chain deposition disease (LHCDD) is a rare form of monoclonal immunoglobulin (Ig) deposition disease, and limited clinical data are available characterizing this condition. Here we describe the clinicopathological characteristics and outcomes of LHCDD. STUDY DESIGN Case series. SETTING & PARTICIPANTS 13 patients with biopsy-proven LHCDD diagnosed between January 2008 and December 2022 at one of 2 Chinese medical centers. FINDINGS Among the 13 patients described, 6 were men and 7 were women, with a mean age of 52.6±8.0 years. Patients presented with hypertension (76.9%), anemia (84.6%), increased serum creatinine concentrations (84.6%; median, 1.7mg/dL), proteinuria (100%; average urine protein, 3.0g/24h), nephrotic syndrome (30.8%), and microscopic hematuria (76.9%). Serum immunofixation electrophoresis showed monoclonal Ig for 11 patients (84.6%). Serum free light chain ratios were abnormal in 11 patients (84.6%), and heavy/light chain ratios were abnormal in 9 of 10 patients (90%) with available data. Five patients were diagnosed with multiple myeloma. A histological diagnosis of nodular mesangial sclerosis was made in 10 patients (76.9%). Immunofluorescence demonstrated deposits of IgG subclass in 7 patients (γ-κ, n=4; γ-λ, n=3) and IgA in 5 patients (α-κ, n=2; α-λ, n=3). Six patients underwent IgG subclass staining (γ1, n=3; γ2, n=2; γ3, n=1). The deposits of IgD-κ were confirmed by mass spectrometry in 1 patient. Among 12 patients for whom data were available during a median of 26.5 months, 11 received chemotherapy and 1 received conservative treatment. One patient died, and disease progressed to kidney failure in 3 (25%). Among the 9 patients evaluable for hematological and kidney disease progression, 5 (56%) had a hematologic response and 1 (11%) exhibited improvement in kidney disease. LIMITATIONS Retrospective descriptive study, limited number of patients, urine protein electrophoresis or immunofixation electrophoresis test results missing for most patients. CONCLUSIONS In this case series of LHCDD, light and heavy chain deposition in kidney tissues were most frequent with monoclonal IgG1-κ. Among patients with evaluable data, more than half had a hematologic response, but a kidney response was uncommon.
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Affiliation(s)
- Yujie Wang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Dacheng Chen
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Ruimin Hu
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou
| | - Yuan Zhang
- Department of Nephrology, Affiliated Hospital of Nantong University, Nantong, China
| | - Dandan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Feng Xu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Feng Liu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Xiaodong Zhu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Yao Lin
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Nanjing Medical University, Nanjing
| | - Xue Yang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Xumeng Liu
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing
| | - Guolan Xing
- Department of Nephrology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou.
| | - Shaoshan Liang
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing.
| | - Caihong Zeng
- National Clinical Research Center for Kidney Diseases, Jinling Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing.
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De La Flor JC, Monroy-Condori M, Apaza-Chavez J, Arenas-Moncaleano I, Díaz F, Guerra-Torres XE, Morales-Montoya JL, Lerma-Verdejo A, Sandoval E, Villa D, Vieru CM. Monoclonal Gammopathy of Renal Significance with Deposits of Infrequent Morphology: Two Case Reports of Light and Heavy Chain Deposition Disease with Atypical Presentation and Literature Review. MEDICINES (BASEL, SWITZERLAND) 2023; 10:55. [PMID: 37887262 PMCID: PMC10608252 DOI: 10.3390/medicines10100055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/02/2023] [Accepted: 09/26/2023] [Indexed: 10/28/2023]
Abstract
BACKGROUND Monoclonal immunoglobulin deposition disease (MIDD) includes three entities: light chain deposition disease (LCDD), heavy chain deposition disease (HCDD) and light and heavy chain deposition disease (LHCDD). The renal presentation can manifest with varying degrees of proteinuria and/or nephrotic syndrome, microhematuria, and often leads to end-stage renal disease. Given the rarity of LHCDD, therapeutic approaches for this condition remain inconclusive, as clinical trials are limited. CASE PRESENTATION We report two male patients with underlying monoclonal gammopathy of renal significance (MGRS) associated with LHCDD lesions. Both cases had non-nephrotic proteinuria, moderately impaired renal function, and normal levels of C3 and C4. Light microscopy of the renal biopsies in both patients did not show lesions of nodular glomerulosclerosis. Immunofluorescence showed a staining pattern with interrupted linear IgA-κ in patient #1 and IgA-λ in patient #2 only along the glomerular basement membrane (GBM). Electron microscopy of patient #1 revealed electrodense deposits in the subendothelial and mesangial areas only along the GBM. DISCUSSION In this case series, we discuss the clinical, analytical, and histopathological findings of two rare cases of LHCDD. Both patients exhibited IgA monoclonality and were diagnosed with monoclonal gammopathy of undetermined significance (MGUS) by the hematology department at the time of renal biopsy. Treatment with steroids and cytotoxic agents targeting the clone cells responsible for the deposition disease resulted in a favorable renal and hematologic response.
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Affiliation(s)
- José C. De La Flor
- Department of Nephrology, Hospital Central de la Defensa, 28046 Madrid, Spain
| | - Maribel Monroy-Condori
- Section of Nephrology and Hypertension, Hospital General Universitario Nuestra Señora del Prado, 45600 Talavera de la Reina, Spain; (M.M.-C.); (I.A.-M.); (X.E.G.-T.); (J.L.M.-M.)
| | | | - Iván Arenas-Moncaleano
- Section of Nephrology and Hypertension, Hospital General Universitario Nuestra Señora del Prado, 45600 Talavera de la Reina, Spain; (M.M.-C.); (I.A.-M.); (X.E.G.-T.); (J.L.M.-M.)
| | - Francisco Díaz
- Department of Anatomic Pathology, Hospital Gregorio Marañón, 28007 Madrid, Spain; (F.D.); (C.-M.V.)
| | - Xavier E. Guerra-Torres
- Section of Nephrology and Hypertension, Hospital General Universitario Nuestra Señora del Prado, 45600 Talavera de la Reina, Spain; (M.M.-C.); (I.A.-M.); (X.E.G.-T.); (J.L.M.-M.)
| | - Jorge L. Morales-Montoya
- Section of Nephrology and Hypertension, Hospital General Universitario Nuestra Señora del Prado, 45600 Talavera de la Reina, Spain; (M.M.-C.); (I.A.-M.); (X.E.G.-T.); (J.L.M.-M.)
| | - Ana Lerma-Verdejo
- Department of Hematology, Hospital General Nuestra Señora del Prado, 45600 Talavera de la Reina, Spain;
| | - Edna Sandoval
- Department of Hematology, Hospital Central de la Defensa, 28046 Madrid, Spain;
| | - Daniel Villa
- Department of Nephrology, Hospital Clínica Universiad Navarra, 31009 Pamplona, Spain;
| | - Coca-Mihaela Vieru
- Department of Anatomic Pathology, Hospital Gregorio Marañón, 28007 Madrid, Spain; (F.D.); (C.-M.V.)
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9
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Isnard P, Benichou N, Sibon D, Rinsant A, Goujon JM, Touchard G, Ory C, Kaaki S, Colombat M, Do Souto Ferreira L, Avet-Loiseau H, Karras A, Bridoux F, Rabant M. Randall-Type Monoclonal IgE Kappa Light-Heavy Chain Deposition Disease. Kidney Int Rep 2023; 8:1464-1468. [PMID: 37441467 PMCID: PMC10334351 DOI: 10.1016/j.ekir.2023.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 04/01/2023] [Accepted: 04/03/2023] [Indexed: 07/15/2023] Open
Affiliation(s)
- Pierre Isnard
- Department of Pathology, Necker Hospital, APHP, Université Paris Cité, Paris, France
| | - Nicolas Benichou
- Department of Nephrology, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - David Sibon
- Lymphoid Malignancies Department, Henri Mondor University Hospital, APHP, Créteil, Paris-Est Créteil University, France
| | - Alexia Rinsant
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Jean-Michel Goujon
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Guy Touchard
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Cécile Ory
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Sihem Kaaki
- Department of Pathology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Magali Colombat
- Department of Pathology, University Hospital of Toulouse, University Cancer Institute of Toulouse, Toulouse, France
| | | | - Hervé Avet-Loiseau
- Unite de Génomique du Myelome, IUC-Oncopole, University Hospital Toulouse, Toulouse, France
| | - Alexandre Karras
- Department of Nephrology, Georges Pompidou European Hospital, APHP, Université Paris Cité, Paris, France
| | - Frank Bridoux
- Department of Nephrology, Center Hospitalier Universitaire de Poitiers, Center National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d'Immunoglobulines Monoclonales, Université de Poitiers, Poitiers, France
| | - Marion Rabant
- Department of Pathology, Necker Hospital, APHP, Université Paris Cité, Paris, France
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10
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Anders HJ, Kitching AR, Leung N, Romagnani P. Glomerulonephritis: immunopathogenesis and immunotherapy. Nat Rev Immunol 2023; 23:453-471. [PMID: 36635359 PMCID: PMC9838307 DOI: 10.1038/s41577-022-00816-y] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2022] [Indexed: 01/14/2023]
Abstract
'Glomerulonephritis' (GN) is a term used to describe a group of heterogeneous immune-mediated disorders characterized by inflammation of the filtration units of the kidney (the glomeruli). These disorders are currently classified largely on the basis of histopathological lesion patterns, but these patterns do not align well with their diverse pathological mechanisms and hence do not inform optimal therapy. Instead, we propose grouping GN disorders into five categories according to their immunopathogenesis: infection-related GN, autoimmune GN, alloimmune GN, autoinflammatory GN and monoclonal gammopathy-related GN. This categorization can inform the appropriate treatment; for example, infection control for infection-related GN, suppression of adaptive immunity for autoimmune GN and alloimmune GN, inhibition of single cytokines or complement factors for autoinflammatory GN arising from inborn errors in innate immunity, and plasma cell clone-directed or B cell clone-directed therapy for monoclonal gammopathies. Here we present the immunopathogenesis of GN and immunotherapies in use and in development and discuss how an immunopathogenesis-based GN classification can focus research, and improve patient management and teaching.
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Affiliation(s)
- Hans-Joachim Anders
- Division of Nephrology, Department of Medicine IV, University Hospital, Ludwig Maximilian University Munich, Munich, Germany.
| | - A Richard Kitching
- Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, VIC, Australia
- Department of Nephrology, Monash Health, Clayton, VIC, Australia
- Department of Paediatric Nephrology, Monash Health, Clayton, VIC, Australia
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Paola Romagnani
- Department of Experimental and Biomedical Sciences "Mario Serio", University of Florence, Florence, Italy
- Nephrology and Dialysis Unit, Meyer Children's Hospital IRCCS, Florence, Italy
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11
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Kumar A, Roychowdhury A, Sengupta M, Basu K, Abraham A, Chatterjee U, Mukherjee S. Heavy chain deposition disease in a case of clear cell renal cell carcinoma- A jack in the box. INDIAN J PATHOL MICR 2023; 66:587-590. [PMID: 37530345 DOI: 10.4103/ijpm.ijpm_397_21] [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] [Indexed: 08/03/2023] Open
Abstract
Renal cell carcinoma (RCC) is the most common subtype of adult renal tumors, and its detection rate in the early stages has been increased in the dawn of advanced imaging modalities. Nephrectomy is the mainstay of treatment; determination of tumor category and staging is the primary concern of oncopathologists. Non-neoplastic renal parenchyma is overlooked majority of times and thus misses the opportunity to detect concomitant medical renal diseases which also predict the renal outcome in the postoperative era. Although any kind of glomerular or extraglomerular pathology may be encountered, vascular changes in the form of arterionephrosclerosis are the commonest one. Here, we take the opportunity to report an unusual association of heavy chain deposition disease (HCDD) with clear cell subtypes of renal cell carcinoma in a 48-year-old male of Indian ethnicity.
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Affiliation(s)
- Abhishek Kumar
- Department of Nephrology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
| | - Arpita Roychowdhury
- Department of Nephrology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
| | - Moumita Sengupta
- Department of Pathology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
| | - Keya Basu
- Department of Pathology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
| | | | - Uttara Chatterjee
- Department of Pathology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
| | - Sriranjan Mukherjee
- Department of Pathology, IPGME and R and SSKM Hospital, Kolkata, West Bengal, India
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12
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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: 1.0] [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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13
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Gueye S, Gauthier M, Benyahia R, Trape L, Dahri S, Kounde C, Perier T, Meklati L, Guelib I, Faye M, Rostaing L. [Nephropathy associated with monoclonal immunoglobulins: From clonal expansion B to renal toxicity of pathological immunoglobulins]. Nephrol Ther 2022; 18:591-603. [PMID: 36428151 DOI: 10.1016/j.nephro.2022.10.002] [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: 03/02/2022] [Revised: 10/06/2022] [Accepted: 10/12/2022] [Indexed: 11/23/2022]
Abstract
Germinal center regulation pathways are often involved in lymphomagenesis and myelomagenesis. Most of the lymphomas (and multiple myeloma) derive from post-germinal center B-cells that have undergone somatic hypermutation and class switch recombination. Hence, B-cell clonal expansion can be responsible for the presence of a monoclonal component (immunoglobulin) of variable titer which, owing to physicochemical properties, can provoke pathologically defined entities of diseases. These diseases can affect any functional part of the kidney, by multiple mechanisms, either well known or not. The presence of renal deposition is influenced by germinal gene involved, immunoglobulin primary structure, post-translational modifications and microenvironmental interactions. The two ways immunoglobulin can cause kidney toxicity are (i) an excess of production (overcoming catabolism power by proximal tubule epithelial cells) with an excess of free light chains within the distal tubules and a subsequent risk of precipitation due to local physicochemical properties; (ii) by structural characteristics that predispose immunoglobulin to a renal disease (whatever their titer). The purpose of this manuscript is to review literature concerning the pathophysiology of renal toxicities of clonal immunoglobulin, from molecular B-cell expansion mechanisms to immunoglobulin renal toxicity.
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Affiliation(s)
- Serigne Gueye
- Service de néphrologie-dialyse, CH de Cahors, France.
| | | | | | - Lucas Trape
- Service de néphrologie-dialyse, CH de Cahors, France
| | - Souad Dahri
- Service de néphrologie-dialyse, CH de Cahors, France
| | | | - Thomas Perier
- Service de néphrologie-dialyse, CH de Cahors, France
| | | | | | - Maria Faye
- Université Cheikh Anta Diop, Dakar, Sénégal
| | - Lionel Rostaing
- Service de néphrologie-dialyse, CH de Cahors, France; Service de néphrologie, hémodialyse, aphérèses et greffe rénale, France; Inserm U563, IFR-BMT, CHU de Purpan, Toulouse, France; Université Grenoble-Alpes, France
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14
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Wang Y, Yan Y, Dong B, Zou W, Li X, Shao C, Jiang L, Wang M, Zuo L. Clinicopathological manifestations of coexistent monoclonal immunoglobulin deposition disease and immunotactoid glomerulopathy. Front Med (Lausanne) 2022; 9:911998. [PMID: 36091681 PMCID: PMC9452626 DOI: 10.3389/fmed.2022.911998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/29/2022] [Indexed: 11/13/2022] Open
Abstract
Combination of monoclonal immunoglobulin deposition disease (MIDD) and immunotactoid glomerulopathy (ITG) is a rare form of monoclonal immunoglobulin (MIg)-associated renal disease. We retrospectively reviewed the native kidney biopsy specimens at Peking University People’s Hospital from 2011 to 2020. Five patients were diagnosed as MIDD + ITG. Their clinical and pathological characteristics were studied. The typical clinical features were nephritic syndrome and renal dysfunction with prominent anemia, but hematuria was mild. Unlike single MIDD and single ITG, on light microscopy, segmentally distributed mesangial nodular sclerosis on the basis of mesangial matrix hyperplasia was the major lesion. Others including membranoproliferative glomerulonephritis (MPGN)-like lesion, glomerular basement membrane thickness, and mild to moderate mesangial and endothelial proliferations might presented at the same time and in the same glomeruli. On immunofluorescence, MIg, usually monoclonal light chains, deposited along glomerular basement membranes and tubular basement membranes, while the intact MIg or monoclonal heavy chain deposited in the mesangial regions. Corresponding to the depositions on immunofluorescence, punctate “powdery” deposits along glomerular basement membranes and tubular basement membranes under electronic microscopy indicated the presence of MIDD. Microtubular substructures (diameters of 20–50 nm) exhibiting hollow cores arranged in parallel arrays in mesangial regions indicated the presence of ITG. Patients treated with bortezomib-based regimen seemed to have better outcomes. In conclusion, MIDD + ITG is a rare combination form of MIg-associated renal disease. Accurate diagnosis requires the comprehensive pathological investigations.
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Affiliation(s)
- Yina Wang
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Yu Yan
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
- *Correspondence: Yu Yan,
| | - Bao Dong
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Wanzhong Zou
- Department of Pathology, Peking University Health Science Center, Beijing, China
| | - Xin Li
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Chunying Shao
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Lei Jiang
- Electron Microscope Laboratory, Peking University People’s Hospital, Beijing, China
| | - Mei Wang
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
| | - Li Zuo
- Department of Nephrology, Peking University People’s Hospital, Beijing, China
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15
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Fourdinier O, Ulrich M, Karras A, Olagne J, Buob D, Audard V, Vigneau C, Gibier JB, Guerrot D, Massy Z, Vuiblet V, Rabot N, Goujon JM, Cordonnier C, Choukroun G, Titeca-Beauport D. Glomerulonephritis with non-Randall-type, non-cryoglobulinemic monoclonal immunoglobulin G deposits [PGNMID and ITG]. Clin Kidney J 2022; 15:1727-1736. [PMID: 36003672 PMCID: PMC9394706 DOI: 10.1093/ckj/sfac085] [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: 11/04/2021] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Glomerulonephritis (GN) with non-Randall-type, non-cryoglobulinemic monoclonal immunoglobulin G deposits encompasses rare diseases [proliferative GN with non-organized deposits (PGNMID) and immunotactoid GN] that cannot be distinguished without ultrastructural analysis by electron microscopy (EM).
Methods
Here, we report and analyze the prognosis of 41 EM-proven (PGNMID for 39/41) and 22 non-EM-proven/DNAJB9-negative cases, diagnosed between 2001 and 2019 in 12 French nephrology centers.
Results
Median serum creatinine (SCr) at presentation was 150 [92-256] μmol/L. The predominant histological pattern was membranoproliferative GN (79%), with IgG3 (74%) kappa (78%) deposits the most frequently observed. Disease presentation and patient management were similar between EM-proven and non-EM-proven cases. A serum monoclonal spike was detected for 21 patients and 10 had an underlying hematological malignancy. First-line therapy was mixed between clone-targeted therapy (n = 33), corticosteroids (n = 9), and RAAS-inhibitors (n = 19). After six months, nine patients achieved complete and 23 partial renal recovery. In univariate analysis, renal recovery was associated with baseline SCr (OR 0.70, p = 0.07). After a median follow-up of 52 [35–74] months, 38% of patients had progressed to end-stage kidney disease independently associated with baseline SCr (HR 1.41, p = 0.003) and glomerular crescentic proliferation (HR 4.38, p = 0.004).
Conclusions
Our results confirm that non-cryoglobulinemic and non-Randall GN with monoclonal IgG deposits are rarely associated with hematological malignancy. The prognosis is uncertain but may be improved by early introduction of a specific therapy.
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Affiliation(s)
- Ophélie Fourdinier
- Department of Nephrology, Dialysis and Transplantation, University Hospital, and MP3CV Research Laboratory, Jules Verne Picardie University, Amiens, France
| | - Marc Ulrich
- Department of Nephrology, Hôpital Jean Bernard, Valenciennes, France
| | - Alexandre Karras
- Department of Nephrology, Hôpital Européen Georges Pompidou, Assistance Publique - Hôpitaux de Paris (APHP), Paris, France
| | - Jérôme Olagne
- Department of Nephrology and Transplantation, Department of Pathology, University Hospital, Strasbourg, France
| | - David Buob
- Department of Pathology, Hôpital Tenon, APHP, Paris, France
| | - Vincent Audard
- Department of Nephrology and Transplantation, Henri Mondor University Hospital, APHP, and Univ Paris Est Créteil, Institut National de la Santé et de la Recherche Médicale (INSERM) U 955, Institut Mondor de Recherche Biomédicale (IMRB), Créteil, France
| | - Cécile Vigneau
- Univ Rennes, CHU Rennes, Inserm, EHESP, Irset (Institut de recherche en santé, environnement et travail) - UMR_S 1085, F-35000 Rennes, France
| | | | | | - Ziad Massy
- Department of Nephrology, Ambroise Paré Hospital, APHP, Boulogne Billancourt, Paris, and Inserm Unit 1018, Team 5, CESP, Versailles Saint-Quentin-en-Yvelines University, Paris Saclay University, Villejuif, France
| | - Vincent Vuiblet
- Department of Nephrology and Transplantation, University Hospital, Reims, France
| | - Nolwenn Rabot
- Department of Nephrology, University Hospital, Tours, France
| | - Jean-Michel Goujon
- Department of Nephrology, and Department of Pathology and Ultrastructural Pathology, University Hospital, Poitiers, France
| | | | - Gabriel Choukroun
- Department of Nephrology, Dialysis and Transplantation, University Hospital, and MP3CV Research Laboratory, Jules Verne Picardie University, Amiens, France
| | - Dimitri Titeca-Beauport
- Department of Nephrology, Dialysis and Transplantation, University Hospital, and MP3CV Research Laboratory, Jules Verne Picardie University, Amiens, France
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16
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Rao Q, Xu R, Wan Q. Immunoglobulin heavy chain gene rearrangement in heavy chain deposition disease suggests it is a plasma cell disease: a case report. J Int Med Res 2022; 50:3000605221086428. [PMID: 35301906 PMCID: PMC8943313 DOI: 10.1177/03000605221086428] [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: 12/03/2022] Open
Abstract
Heavy chain deposition disease (HCDD) is characterized by the deposition of truncated monoclonal immunoglobulin heavy chains along glomerular basement membranes. Truncated heavy chains are thought to be associated with plasma cell disease (PCD), but previous bone marrow cytology tests showed that only 30% of HCDD cases are related to PCDs. We report the first known use of immunoglobulin heavy chain (IGH) gene rearrangement to diagnose a patient with γ3-HCDD, although bone marrow morphology test identified no abnormalities. Our findings provide strong evidence for a correlation between PCDs and HCDD, which could help understand the genetic background underlying abnormal heavy chains and assess disease prognosis. Further, concordant with previous findings, bortezomib-based chemotherapy had a good therapeutic effect in our patient. We summarize the experience of diagnosing and treating a case of HCDD, and combine this with a literature review to further explore the correlation between PCDs and HCDD, which has important clinical value.
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Affiliation(s)
- Qingqing Rao
- Graduate School of Shenzhen University, Shenzhen 518060, Guangdong, China.,Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen 518000, Guangdong, China
| | - Ricong Xu
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen 518000, Guangdong, China
| | - Qijun Wan
- Department of Nephrology, Shenzhen Second People's Hospital, First Affiliated Hospital of Shenzhen University, Shenzhen 518000, Guangdong, China
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17
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Affiliation(s)
- Nelson Leung
- From the Divisions of Nephrology and Hypertension and of Hematology (N.L.) and the Department of Laboratory Medicine and Pathology (S.H.N.), Mayo Clinic, Rochester, MN; and Department of Nephrology and Centre d'Investigation Clinique INSERM 1402, Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, and Centre National de la Recherche Scientifique UMR7276, Université de Limoges, Limoges - all in France (F.B.)
| | - Frank Bridoux
- From the Divisions of Nephrology and Hypertension and of Hematology (N.L.) and the Department of Laboratory Medicine and Pathology (S.H.N.), Mayo Clinic, Rochester, MN; and Department of Nephrology and Centre d'Investigation Clinique INSERM 1402, Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, and Centre National de la Recherche Scientifique UMR7276, Université de Limoges, Limoges - all in France (F.B.)
| | - Samih H Nasr
- From the Divisions of Nephrology and Hypertension and of Hematology (N.L.) and the Department of Laboratory Medicine and Pathology (S.H.N.), Mayo Clinic, Rochester, MN; and Department of Nephrology and Centre d'Investigation Clinique INSERM 1402, Centre de Référence Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, and Centre National de la Recherche Scientifique UMR7276, Université de Limoges, Limoges - all in France (F.B.)
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The Clone Wars: Diagnosing and Treating Dysproteinemic Kidney Disease in the Modern Era. J Clin Med 2021; 10:jcm10081633. [PMID: 33921394 PMCID: PMC8069250 DOI: 10.3390/jcm10081633] [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: 03/04/2021] [Revised: 03/23/2021] [Accepted: 03/25/2021] [Indexed: 11/17/2022] Open
Abstract
Dysproteinemic kidney diseases are disorders that occur as the result of lymphoproliferative (B cell or plasma cell) disorders that cause kidney damage via production of nephrotoxic monoclonal immunoglobulins or their components. These monoclonal immunoglobulins have individual physiochemical characteristics that confer specific nephrotoxic properties. There has been increased recognition and revised characterization of these disorders in the last decade, and in some cases, there have been substantial advances in disease understanding and treatments, which has translated to improved patient outcomes. These disorders still present challenges to nephrologists and patients, since they are rare, and the field of hematology is rapidly changing with the introduction of novel testing and treatment strategies. In this review, we will discuss the clinical presentation, kidney biopsy features, hematologic characteristics and treatment of dysproteinemic kidney diseases.
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Cohen C, Joly F, Sibille A, Javaugue V, Desport E, Goujon JM, Touchard G, Fermand JP, Sirac C, Bridoux F. Randall-Type Monoclonal Immunoglobulin Deposition Disease: New Insights into the Pathogenesis, Diagnosis and Management. Diagnostics (Basel) 2021; 11:diagnostics11030420. [PMID: 33801393 PMCID: PMC7999117 DOI: 10.3390/diagnostics11030420] [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: 02/04/2021] [Revised: 02/18/2021] [Accepted: 02/22/2021] [Indexed: 11/16/2022] Open
Abstract
Randall-type monoclonal immunoglobulin deposition disease (MIDD) is a rare disease that belongs to the spectrum of monoclonal gammopathy of renal significance (MGRS). Renal involvement is prominent in MIDD, but extra-renal manifestations can be present and may affect global prognosis. Recent data highlighted the central role of molecular characteristics of nephrotoxic monoclonal immunoglobulins in the pathophysiology of MIDD, and the importance of serum free light chain monitoring in the diagnosis and follow-up disease. Clone-targeted therapy is required to improve the overall and renal survival, and the achievement of a rapid and deep hematological response is the goal of therapy. This review will focus on the recent progress in the pathogenesis and management of this rare disease.
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Affiliation(s)
- Camille Cohen
- Department of Nephrology Hôpital Necker, and INSERM U830 “Stress and Cancer” Laboratory, Institut Curie, 75015 Paris, France
- Correspondence:
| | - Florent Joly
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
| | - Audrey Sibille
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
| | - Vincent Javaugue
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
- INSERM CIC 1402, 86000 Poitiers, France
- CNRS UMR 7276-CRIBL, University of Limoges, 87000 Limoges, France;
| | - Estelle Desport
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
| | | | - Guy Touchard
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Department of Pathology, CHU Poitiers, 86000 Poitiers, France;
| | - Jean-Paul Fermand
- Department of Immunology and Hematology, Hôpital Saint Louis, 75010 Paris, France;
| | - Christophe Sirac
- CNRS UMR 7276-CRIBL, University of Limoges, 87000 Limoges, France;
| | - Frank Bridoux
- Department of Nephrology, CHU Poitiers, 86000 Poitiers, France; (F.J.); (A.S.); (V.J.); (E.D.); (G.T.); (F.B.)
- Centre National de Référence Maladies Rares: Amylose AL et Autres Maladies à Dépôts d’Immunoglobulines Monoclonales, 86000 Poitiers, France
- INSERM CIC 1402, 86000 Poitiers, France
- CNRS UMR 7276-CRIBL, University of Limoges, 87000 Limoges, France;
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Bridoux F, Leung N, Belmouaz M, Royal V, Ronco P, Nasr SH, Fermand JP. Management of acute kidney injury in symptomatic multiple myeloma. Kidney Int 2021; 99:570-580. [PMID: 33440212 DOI: 10.1016/j.kint.2020.11.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/23/2020] [Accepted: 11/03/2020] [Indexed: 01/15/2023]
Abstract
Symptomatic multiple myeloma is commonly complicated by acute kidney injury through various mechanisms. The most frequent is the precipitation of monoclonal free light chains with uromodulin in the distal tubules, defining light chain cast nephropathy. Early diagnosis and identification of the cause of acute kidney injury are required for optimizing management and avoiding chronic kidney injury that strongly affects quality of life and patient survival. In light chain cast nephropathy, often manifesting with severe acute kidney injury, renal recovery requires urgent intervention based on vigorous rehydration, correction of precipitating factors, and efficient anti-plasma cell chemotherapy to rapidly reduce the secretion of nephrotoxic free light chains. Currently, the association of the proteasome inhibitor bortezomib with high-dose dexamethasone is the standard regimen in newly diagnosed patients. The addition of another drug such as cyclophosphamide or an immunodulatory agent may improve free light chain response but raises tolerance concerns in frail patients. Further studies are warranted to confirm the role of anti-CD38 monoclonal antibodies, whose efficacy and tolerance have been documented in patients without renal impairment. Despite controversial results from randomized studies, recent data suggest that in patients with light chain cast nephropathy and acute kidney injury requiring dialysis, the combination of chemotherapy with free light chain removal through high-cutoff hemodialysis may increase renal response recovery rates. Kidney biopsy may be helpful in guiding management and assessing renal prognosis that appears to depend on the extent of cast formation and interstitial fibrosis/tubular atrophy. Because of continuous improvement in life expectancy of patients with multiple myeloma, renal transplantation is likely to be increasingly considered in selected candidates.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France; Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France.
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed Belmouaz
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
| | - Pierre Ronco
- Nephrology Department, Assistance Publique - Hôpitaux de Paris, Hôpital Tenon, Paris, France; Sorbonne Université and Institut National de la Santé Et de la Recherche Médicale (INSERM), Unité Mixte de Recherche S 1135, Paris, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jean Paul Fermand
- Department of Hematology and Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, INSERM UMR 1126, Paris, France; Intergroupe Francophone du Myélome (IFM), Paris, France
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21
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Complement-mediated kidney diseases. Mol Immunol 2020; 128:175-187. [DOI: 10.1016/j.molimm.2020.10.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/16/2020] [Accepted: 10/19/2020] [Indexed: 12/19/2022]
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Matsuura Y, Goto T, Tamayama Y, Nakamura Y, Oyama J, Ishioka H, Yoshikawa K, Nakaya I, Soma J. First case report of monoclonal IgG3-heavy-chain glomerulonephritis with microtubular structures. CEN Case Rep 2020; 10:236-240. [PMID: 33156494 DOI: 10.1007/s13730-020-00550-1] [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: 08/24/2020] [Accepted: 10/18/2020] [Indexed: 10/23/2022] Open
Abstract
Our patient was a 69-year-old woman admitted to our hospital for heavy proteinuria and hematuria. A renal biopsy showed findings similar to those of membranoproliferative glomerulonephritis associated with nodular lesions, and immunofluorescence showed marked deposits of IgG, C1q, and C3 on the peripheral capillary walls. IgG3 alone was observed on IgG subclass staining with no κ or λ light chains, and Congo red staining was negative. These findings suggested IgG3-heavy-chain deposition disease (HCDD). However, we did not find a deletion of the first heavy-chain constant domain, which is commonly observed in HCDD. Electron microscopy showed randomly arranged subendothelial microtubular structures with diameters of 70-90 nm. Altogether, the diagnosis of HCDD could not be made, although monoclonal IgG3 deposits in glomeruli were observed. This is the first case report of monoclonal IgG3-heavy-chain glomerulonephritis with subendothelial-based, randomly arranged microtubular structures with diameters of 70-90 nm.
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Affiliation(s)
- Yuki Matsuura
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Japan.
| | - Taijiro Goto
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Japan
| | - Yoshihiko Tamayama
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Japan
| | - Yuki Nakamura
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Japan
| | - Junji Oyama
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Japan
| | - Hirotaka Ishioka
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Japan
| | - Kazuhiro Yoshikawa
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Japan
| | - Izaya Nakaya
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Japan
| | - Jun Soma
- Department of Nephrology and Rheumatology, Iwate Prefectural Central Hospital, 1-4-1, Ueda, Morioka, Japan
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Affiliation(s)
- Ankur Jain
- Vardhman Mahavir Medical College and Safdarjung Hospital, Department of Hematology, New Delhi, India
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24
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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: 40] [Impact Index Per Article: 8.0] [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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25
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Turner M, Crawford A, Winterbottom C, Flossmann O, Alchi B, Soares M, Bhandary U. Heavy chain deposition disease presenting with raised anti-GBM antibody levels; a case report. BMC Nephrol 2020; 21:175. [PMID: 32398029 PMCID: PMC7216388 DOI: 10.1186/s12882-020-01837-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022] Open
Abstract
Background Monoclonal immunoglobulin deposition disease (MIDD) is a rare condition accounting for < 1% of histopathological diagnoses made on kidney biopsy1. The best outcomes are seen in those diagnosed and treated promptly, but delay to diagnosis is common with the largest series reporting a median time from onset of renal impairment to diagnosis of 12 months2. Here, we report a case of the heavy chain subset of MIDD presenting with positive anti-glomerular basement membrane (anti-GBM) antibodies obscuring the true diagnosis. Case presentation Here, we present a challenging case presenting with oedema, haematoproteiuria, and new renal impairment. Anti-GBM antibodies were positive and prompted treatment as atypical anti-GBM disease. However, they were ultimately proven to be monoclonal and secondary to myeloma. The final diagnosis facilitated effective myeloma treatment which led to complete remission and independence from renal replacement therapy. Conclusions This case reinforces the importance of comprehensive histopathological and haematological assessment in making the correct diagnosis. Here it facilitated effective treatment and recovery of renal function.
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Affiliation(s)
- Michael Turner
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK.
| | - Anna Crawford
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK
| | | | - Oliver Flossmann
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK
| | - Bassam Alchi
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK
| | - Maria Soares
- Department of Cellular Pathology, John Radcliffe Hospital, Headley Way, Oxford, UK
| | - Umanath Bhandary
- Renal Unit, Royal Berkshire Hospital, London Road, Reading, Berkshire, UK
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26
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Heavy Lifting: Nomenclature and Novel Therapy for Gamma Heavy Chain Disease and Other Heavy Chain Disorders. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2020; 20:493-498. [PMID: 32245744 DOI: 10.1016/j.clml.2020.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 02/18/2020] [Accepted: 02/27/2020] [Indexed: 11/21/2022]
Abstract
Heavy chain disorders are rare B-cell disorders and include heavy chain disease, heavy chain deposition disease, and heavy chain amyloidosis. These disorders share the pathognomonic finding of a truncated immunoglobulin heavy chain without an associated light chain in the serum or urine in the case of heavy chain disease or in the tissues in the case of heavy chain deposition disease and heavy chain amyloidosis but are clinically distinct entities. The clinical recognition and systematic approaches to these disorders are challenging because of the rarity of the diseases, lack of consensus on treatment approaches, and minimal data with novel therapy. Herein we present a review of the literature and 5 consecutive cases at a single institution of gamma heavy chain disease and heavy chain deposition disease treated with novel agents including regimens of CRd (cyclophosphamide, lenalidomide, and dexamethasone), CyBorD (cyclophosphamide, bortezomib, and dexamethasone), R-CVP (rituximab, cyclophosphamide, vincristine, and dexamethasone), BR (bendamustine and rituximab), V-EPOCH (bortezomib, etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin), and autologous hematopoietic stem cell transplantation.
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27
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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: 0.8] [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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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: 0.4] [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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29
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Rovin BH, Caster DJ, Cattran DC, Gibson KL, Hogan JJ, Moeller MJ, Roccatello D, Cheung M, Wheeler DC, Winkelmayer WC, Floege J, Alpers CE, Ayoub I, Bagga A, Barbour SJ, Barratt J, Chan DT, Chang A, Choo JCJ, Cook HT, Coppo R, Fervenza FC, Fogo AB, Fox JG, Glassock RJ, Harris D, Hodson EM, Hogan JJ, Hoxha E, Iseki K, Jennette JC, Jha V, Johnson DW, Kaname S, Katafuchi R, Kitching AR, Lafayette RA, Li PK, Liew A, Lv J, Malvar A, Maruyama S, Mejía-Vilet JM, Mok CC, Nachman PH, Nester CM, Noiri E, O'Shaughnessy MM, Özen S, Parikh SM, Park HC, Peh CA, Pendergraft WF, Pickering MC, Pillebout E, Radhakrishnan J, Rathi M, Ronco P, Smoyer WE, Tang SC, Tesař V, Thurman JM, Trimarchi H, Vivarelli M, Walters GD, Wang AYM, Wenderfer SE, Wetzels JF. Management and treatment of glomerular diseases (part 2): conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2020; 95:281-295. [PMID: 30665569 DOI: 10.1016/j.kint.2018.11.008] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/30/2018] [Accepted: 11/01/2018] [Indexed: 02/06/2023]
Abstract
In November 2017, the Kidney Disease: Improving Global Outcomes (KDIGO) initiative brought a diverse panel of experts in glomerular diseases together to discuss the 2012 KDIGO glomerulonephritis guideline in the context of new developments and insights that had occurred over the years since its publication. During this KDIGO Controversies Conference on Glomerular Diseases, the group examined data on disease pathogenesis, biomarkers, and treatments to identify areas of consensus and areas of controversy. This report summarizes the discussions on primary podocytopathies, lupus nephritis, anti-neutrophil cytoplasmic antibody-associated nephritis, complement-mediated kidney diseases, and monoclonal gammopathies of renal significance.
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Affiliation(s)
- Brad H Rovin
- Division of Nephrology, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.
| | - Dawn J Caster
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Daniel C Cattran
- Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Keisha L Gibson
- University of North Carolina Kidney Center at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jonathan J Hogan
- Division of Nephrology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marcus J Moeller
- Division of Nephrology and Clinical Immunology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany
| | - Dario Roccatello
- CMID (Center of Research of Immunopathology and Rare Diseases), and Division of Nephrology and Dialysis (ERK-Net member), University of Turin, Italy
| | | | | | - Wolfgang C Winkelmayer
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Jürgen Floege
- Division of Nephrology, Rheinisch-Westfälische Technische Hochschule, University of Aachen, Aachen, Germany.
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30
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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: 335] [Impact Index Per Article: 55.8] [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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31
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Zhang Y, Li X, Liang D, Xu F, Liang S, Zhu X, Zheng N, Huang X, Liu Z, Zeng C. Heavy Chain Deposition Disease: Clinicopathologic Characteristics of a Chinese Case Series. Am J Kidney Dis 2019; 75:736-743. [PMID: 31699519 DOI: 10.1053/j.ajkd.2019.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 08/04/2019] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Heavy chain deposition disease (HCDD) is a rare consequence of monoclonal immunoglobulin deposition disease that has not been well characterized in non-white populations. To explore the clinicopathologic characteristics and outcomes of HCDD in Chinese individuals, we report on a case series assembled in a single center in China. STUDY DESIGN Case series. SETTING & PARTICIPANTS 25 patients with biopsy-proven HCDD were studied retrospectively. RESULTS 14 men and 11 women with an average age of 50.3 years were studied. The patients presented with hypertension (76%), edema (96%), anemia (84%), serum creatinine level > 1.2mg/dL (68%), nephrotic-range proteinuria (56%), and microscopic hematuria (80%). One (4%) patient had multiple myeloma diagnosed. Serum immunofixation electrophoresis showed that 10 of 21 (48%) patients were positive for monoclonal immunoglobulin. Hypocomplementemia of C3 was found in 68% of patients. Nodular mesangial sclerosis was identified in all patients by using light microscopy. Using immunofluorescence, all 25 patients had deposition of heavy chains of immunoglobulin G class (γ1, 13; γ2, 2; γ3, 6; γ4, 2; γ1 and γ4, 1; and γ2 and γ4, 1). During an average of 40.1 months of follow-up of 20 patients, 65% had improved kidney function, 10% had worsening kidney function, and 25% progressed to kidney failure. Mean values for kidney and patient survival were 37.8 and 40.1 months, respectively. Kidney survival was higher among patients who received chemotherapy. LIMITATIONS Retrospective study, single-center experience. CONCLUSIONS In this case series of HCDD in a single center in China, the heavy chain deposits seen in the kidney biopies of all individuals were of immunoglobulin G class. Chemotherapy improved kidney function, especially among individuals in an early stage of the disease.
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Affiliation(s)
- Yuan Zhang
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China
| | - Xiaomei Li
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China
| | - Dandan Liang
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China
| | - Feng Xu
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China
| | - Shaoshan Liang
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China
| | - Xiaodong Zhu
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China
| | - Nanjun Zheng
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China
| | - Xianghua Huang
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China
| | - Zhihong Liu
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China
| | - Caihong Zeng
- Jinling Hospital Department of Nephrology, Nanjing Medical University, Nanjing, PR, China.
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32
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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: 2.7] [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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33
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Singh L, Subbiah AK, Singh G, Bagchi S, Dinda AK, Agarwal SK. Monoclonal gammopathy of renal significance with heavy-chain deposition disease in renal allograft: challenges in the diagnosis and management. Transpl Int 2019; 32:769-770. [PMID: 31081947 DOI: 10.1111/tri.13461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Lavleen Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Arun Kumar Subbiah
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Geetika Singh
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Soumita Bagchi
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Amit Kumar Dinda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Kumar Agarwal
- Department of Nephrology, All India Institute of Medical Sciences, New Delhi, India
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34
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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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35
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Nasr SH, Sirac C, Bridoux F, Javaugue V, Bender S, Rinsant A, Kaaki S, Pinault E, Dasari S, Alexander MP, Said SM, Hogan JJ, Dispenzieri A, Touchard G, McPhail ED, Leung N. Heavy Chain Fibrillary Glomerulonephritis: A Case Report. Am J Kidney Dis 2019; 74:276-280. [PMID: 30955945 DOI: 10.1053/j.ajkd.2019.01.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 01/21/2019] [Indexed: 11/11/2022]
Abstract
Heavy chain amyloidosis and heavy chain deposition disease are the only known kidney diseases caused by the deposition of truncated immunoglobulin heavy chains. Fibrillary glomerulonephritis typically results from deposition of DNAJB9 (DnaJ heat shock protein family [Hsp40] member B9) and polytypic immunoglobulin G (IgG). We describe a patient with monoclonal gammopathy (IgG with λ light chain) who developed DNAJB9-negative fibrillary glomerulonephritis leading to end-stage kidney disease, with recurrence in 2 kidney allografts. Pre- and postmortem examination showed glomerular deposition of Congo red-negative fibrillar material that was determined to be immunoglobulin heavy chain. We propose the term "heavy chain fibrillary glomerulonephritis" to describe this lesion, which appears to be a rare kidney complication of monoclonal gammopathy. The diagnosis should be suspected when the kidney biopsy shows fibrillary glomerulonephritis with negative staining for immunoglobulin light chains and DNAJB9; the diagnosis can be confirmed using immunochemical and molecular studies.
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Affiliation(s)
- Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
| | - Christophe Sirac
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France.
| | - Frank Bridoux
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Vincent Javaugue
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France; Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Sebastien Bender
- Department of Immunology, National Center for Scientific Research, Joint Research Unit 7276, University of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France
| | - Alexia Rinsant
- Department of Pathology, University Hospital of Poitiers, Poitiers, France
| | - Sihem Kaaki
- Department of Pathology, University Hospital of Poitiers, Poitiers, France
| | - Emilie Pinault
- University of Limoges, BISCEm Mass Spectrometry Platform, F-87000 Limoges, France
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Samar M Said
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Jonathan J Hogan
- Division of Nephrology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Guy Touchard
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN
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36
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Sudo M, Wakamatsu T, Ishikawa T, Habuka M, Hosojima M, Yamamoto S, Ito Y, Imai N, Kaneko Y, Shimizu A, Narita I. Successful treatment of gamma 1 heavy chain deposition disease with bortezomib and dexamethasone. HUMAN PATHOLOGY: CASE REPORTS 2019. [DOI: 10.1016/j.ehpc.2019.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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37
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Randall-type monoclonal immunoglobulin deposition disease: novel insights from a nationwide cohort study. Blood 2019; 133:576-587. [DOI: 10.1182/blood-2018-09-872028] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 12/15/2018] [Indexed: 12/27/2022] Open
Abstract
Abstract
Monoclonal immunoglobulin deposition disease (MIDD) is a rare complication of B-cell clonal disorders, defined by Congo red negative–deposits of monoclonal light chain (LCDD), heavy chain (HCDD), or both (LHCDD). MIDD is a systemic disorder with prominent renal involvement, but little attention has been paid to the description of extrarenal manifestations. Moreover, mechanisms of pathogenic immunoglobulin deposition and factors associated with renal and patient survival are ill defined. We retrospectively studied a nationwide cohort of 255 patients, with biopsy-proven LCDD (n = 212) (including pure LCDD [n = 154], LCDD with cast nephropathy (CN) [n = 58]), HCDD (n = 23), or LHCDD (n = 20). Hematological diagnosis was monoclonal gammopathy of renal significance in 64% and symptomatic myeloma in 34%. Renal presentation was acute kidney injury in patients with LCCD and CN, and chronic glomerular disease in the other types, 35% of whom had symptomatic extrarenal (mostly hepatic and cardiac) involvement. Sequencing of 18 pathogenic LC showed high isoelectric point values of variable domain complementarity determining regions, possibly accounting for tissue deposition. Among 169 patients who received chemotherapy (bortezomib-based in 58%), 67% achieved serum free light chain (FLC) response, including very good partial response (VGPR) or above in 52%. Renal response occurred in 62 patients (36%), all of whom had achieved hematological response. FLC response ≥ VGPR and absence of severe interstitial fibrosis were independent predictors of renal response. This study highlights an unexpected frequency of extrarenal manifestations in MIDD. Rapid diagnosis and achievement of deep FLC response are key factors of prognosis.
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38
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α1-Heavy Chain Deposition Disease With Negative Immunofluorescence Staining on Renal Biopsy. Kidney Int Rep 2019; 4:178-183. [PMID: 30596184 PMCID: PMC6308384 DOI: 10.1016/j.ekir.2018.09.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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39
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Wang CH, Hogan JJ. Monoclonal Gammopathies and Kidney Disease: Searching for Significance. Clin J Am Soc Nephrol 2018; 13:1781-1782. [PMID: 30442863 PMCID: PMC6302335 DOI: 10.2215/cjn.12401018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Christina Hao Wang
- Division of Nephrology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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40
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Cassol CA, Rao PK, Braga JR. Acute renal failure in a patient with PR3-ANCA and monoclonal immunoglobulin deposition disease: Case report. Medicine (Baltimore) 2018; 97:e13799. [PMID: 30593167 PMCID: PMC6314724 DOI: 10.1097/md.0000000000013799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Acute renal failure developing over a short period of time with evidence of glomerular disease by urine sediment microscopy characterizes the clinical syndrome of rapidly progressive glomerulonephritis (RPGN), of which the most common causes are ANCA-associated glomerulonephritis (GN), immune-complex mediated GN and anti-GBM disease. PATIENT CONCERNS This was a middle-aged gentleman who presented with acute renal failure and a positive PR3-ANCA. DIAGNOSIS Renal biopsy showed an unusual combination of PR3-ANCA GN with focal crescents, monoclonal immunoglobulin deposition disease (MIDD) and mesangial IgA deposition on renal biopsy. INTERVENTIONS Serum and urine protein electrophoresis (UPEP) and immunofixation showed no detectable monoclonal paraprotein; bone marrow biopsy was negative for plasma cell neoplasia. He received high dose steroids and rituximab. OUTCOMES The patient did not respond to treatment and progressed to end-stage renal failure within 2 months after presentation. LESSONS To our knowledge, the simultaneous occurrence of MIDD, PR3-ANCA and mesangial IgA has not been reported. This case highlights not only the diagnostic but also the therapeutic challenges that such a complex case presentation poses to clinicians, where the culprit may not always be what would seem most obvious (such as ANCA in a patient with RPGN) but may, in fact, be an underlying and unsuspected disease, or possibly a combination of both.
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Affiliation(s)
- Clarissa A. Cassol
- Department of Pathology, Renal Pathology Division, the Ohio State University Wexner Medical Center
| | - Pawan K. Rao
- Department of Internal Medicine, St. Joseph's Hospital Health Center, Syracuse, NY, USA
| | - Juarez R. Braga
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Canada
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41
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Monoclonal gammopathy of clinical significance: a novel concept with therapeutic implications. Blood 2018; 132:1478-1485. [DOI: 10.1182/blood-2018-04-839480] [Citation(s) in RCA: 121] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 06/22/2018] [Indexed: 12/12/2022] Open
Abstract
Abstract
Monoclonal gammopathy is a common condition, particularly in the elderly. It can indicate symptomatic multiple myeloma or another overt malignant lymphoid disorder requiring immediate chemotherapy. More frequently, it results from a small and/or quiescent secreting B-cell clone, is completely asymptomatic, and requires regular monitoring only, defining a monoclonal gammopathy of unknown significance (MGUS). Sometimes, although quiescent and not requiring any treatment per se, the clone is associated with potentially severe organ damage due to the toxicity of the monoclonal immunoglobulin or to other mechanisms. The latter situation is increasingly observed but still poorly recognized and frequently undertreated, although it often requires rapid specific intervention to preserve involved organ function. To improve early recognition and management of these small B-cell clone–related disorders, we propose to introduce the concept of monoclonal gammopathy of clinical significance (MGCS). This report identifies the spectrum of MGCSs that are classified according to mechanisms of tissue injury. It highlights the diversity of these disorders for which diagnosis and treatment are often challenging in clinical practice and require a multidisciplinary approach. Principles of management, including main diagnostic and therapeutic procedures, are also described. Importantly, efficient control of the underlying B-cell clone usually results in organ improvement. Currently, it relies mainly on chemotherapy and other anti–B-cell/plasma cell agents, which should aim at rapidly producing the best hematological response.
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42
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Chavarot N, Battistella M, Vignon M, Baron M, Girerd S, Jachiet M, Asli B, Galicier L, Malphettes M. Cutis laxa for diagnosis of γ1-heavy-chain deposition disease: Report of four cases. J Dermatol 2018; 45:1211-1215. [PMID: 30035313 DOI: 10.1111/1346-8138.14544] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 06/08/2018] [Indexed: 11/30/2022]
Abstract
Heavy-chain deposition disease (HCDD) is characterized by tissue deposits of a truncated monoclonal immunoglobulin heavy-chain (HC) on basement membranes. Diagnosis is usually made on kidney biopsy, showing nodular glomerulosclerosis with HC deposits which can be missed, resulting in delay in diagnosis. We report four γ1-HCDD patients presenting with cutis laxa, hypocomplementemia and hypoalbuminemia. In two patients, unsuspected HCDD was revealed by cutis laxa and diagnosis was made on skin biopsy. In all patients, serum albumin and complement represented surrogate markers for disease monitoring. In γ-HCDD, extrarenal manifestations such as cutis laxa may precede renal injury and are precious tools for an early diagnosis, which is crucial to avoid progression of irreversible renal and elastic tissue damage.
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Affiliation(s)
- Nathalie Chavarot
- Department of Clinical Immunology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, INSERM UMRS_1165, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Maxime Battistella
- Department of Pathology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, INSERM UMRS_1165, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Marguerite Vignon
- Department of Clinical Immunology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, INSERM UMRS_1165, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Marine Baron
- Department of Clinical Immunology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, INSERM UMRS_1165, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Sophie Girerd
- Department of Nephrology and Kidney Transplantation, University Hospital, Vandoeuvre-les-Nancy, France
| | - Marie Jachiet
- Department of Dermatology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Bouchra Asli
- Department of Internal Medicine, Hôpital Edouard Herriot, Lyon, France
| | - Lionel Galicier
- Department of Clinical Immunology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, INSERM UMRS_1165, Paris Diderot University, Sorbonne Paris Cité, Paris, France
| | - Marion Malphettes
- Department of Clinical Immunology, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris, INSERM UMRS_1165, Paris Diderot University, Sorbonne Paris Cité, Paris, France
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43
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Bender S, Ayala MV, Javaugue V, Bonaud A, Cogné M, Touchard G, Jaccard A, Bridoux F, Sirac C. Comprehensive molecular characterization of a heavy chain deposition disease case. Haematologica 2018; 103:e557-e560. [PMID: 30026336 DOI: 10.3324/haematol.2018.196113] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Sébastien Bender
- Centre National de la recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges.,Centre National de l'Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire de Limoges
| | - Maria Victoria Ayala
- Centre National de la recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges
| | - Vincent Javaugue
- Centre National de la recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges.,Centre National de l'Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire de Limoges.,Service de Néphrologie et Transplantation, Centre Hospitalier Universitaire de Poitiers
| | - Amélie Bonaud
- Institut national de la santé et de la recherche médicale INSERM UMR996 - Cytokines, Chimiokines, Immunopathologie, Université Paris-Sud et Université Paris-Saclay
| | - Michel Cogné
- Centre National de la recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges.,Centre National de l'Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire de Limoges
| | - Guy Touchard
- Service de Néphrologie et Transplantation, Centre Hospitalier Universitaire de Poitiers
| | - Arnaud Jaccard
- Centre National de la recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges.,Centre National de l'Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire de Limoges.,Service d'Hématologie Clinique, Centre Hospitalier Universitaire de Limoges, France
| | - Frank Bridoux
- Centre National de la recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges.,Centre National de l'Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire de Limoges.,Service de Néphrologie et Transplantation, Centre Hospitalier Universitaire de Poitiers
| | - Christophe Sirac
- Centre National de la recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges .,Centre National de l'Amylose AL et Autres Maladies par Dépôt d'Immunoglobulines Monoclonales, Centre Hospitalier Universitaire de Limoges
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44
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Gumber R, Cohen JB, Palmer MB, Kobrin SM, Vogl DT, Wasserstein AG, Nasta SD, Bleicher MB, Bloom RD, Dember L, Cohen A, Weiss BM, Hogan JJ. A clone-directed approach may improve diagnosis and treatment of proliferative glomerulonephritis with monoclonal immunoglobulin deposits. Kidney Int 2018; 94:199-205. [DOI: 10.1016/j.kint.2018.02.020] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/24/2018] [Accepted: 02/08/2018] [Indexed: 11/16/2022]
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45
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Sethi S, Rajkumar SV, D'Agati VD. The Complexity and Heterogeneity of Monoclonal Immunoglobulin-Associated Renal Diseases. J Am Soc Nephrol 2018; 29:1810-1823. [PMID: 29703839 DOI: 10.1681/asn.2017121319] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Monoclonal gammopathies are characterized by the overproduction of monoclonal Ig (MIg) detectable in the serum or urine resulting from a clonal proliferation of plasma cells or B lymphocytes. The underlying hematologic conditions range from malignant neoplasms of plasma cells or B lymphocytes, including multiple myeloma and B-cell lymphoproliferative disorders, to nonmalignant small clonal proliferations. The term MGUS implies presence of an MIg in the setting of a "benign" hematologic condition without renal or other end organ damage. The term MGRS was recently introduced to indicate monoclonal gammopathy with MIg-associated renal disease in the absence of hematologic malignancy. Most MIg-associated renal diseases result from the direct deposition of nephrotoxic MIg or its light- or heavy-chain fragments in various renal tissue compartments. Immunofluorescence microscopy is essential to identify the offending MIg and define its tissue distribution. Mass spectrometry is helpful in difficult cases. Conditions caused by direct tissue deposition of MIg include common disorders, such as cast nephropathy, amyloidosis, and MIg deposition diseases, as well as uncommon disorders, such as immunotactoid glomerulopathy, proliferative GN with MIg deposits, light-chain proximal tubulopathy, and the rare entities of crystal-storing histiocytosis and crystalglobulinemia. Indirect mechanisms of MIg-induced renal disease can cause C3 glomerulopathy or thrombotic microangiopathy without tissue MIg deposits. Treatment of MIg-associated renal disease is aimed at eliminating the clonal plasma cell or B-cell population as appropriate. Both the renal and the underlying hematologic disorders influence the management and prognosis of MIg-associated renal diseases.
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Affiliation(s)
| | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Vivette D D'Agati
- Department of Pathology, College of Physicians and Surgeons, Columbia University, New York, New York
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46
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Sirac C, Herrera GA, Sanders PW, Batuman V, Bender S, Ayala MV, Javaugue V, Teng J, Turbat-Herrera EA, Cogné M, Touchard G, Leung N, Bridoux F. Animal models of monoclonal immunoglobulin-related renal diseases. Nat Rev Nephrol 2018; 14:246-264. [DOI: 10.1038/nrneph.2018.8] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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47
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Leung N, Drosou ME, Nasr SH. Dysproteinemias and Glomerular Disease. Clin J Am Soc Nephrol 2018; 13:128-139. [PMID: 29114004 PMCID: PMC5753301 DOI: 10.2215/cjn.00560117] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 09/20/2017] [Indexed: 01/12/2023]
Abstract
Dysproteinemia is characterized by the overproduction of an Ig by clonal expansion of cells from the B cell lineage. The resultant monoclonal protein can be composed of the entire Ig or its components. Monoclonal proteins are increasingly recognized as a contributor to kidney disease. They can cause injury in all areas of the kidney, including the glomerular, tubular, and vascular compartments. In the glomerulus, the major mechanism of injury is deposition. Examples of this include Ig amyloidosis, monoclonal Ig deposition disease, immunotactoid glomerulopathy, and cryoglobulinemic GN specifically from types 1 and 2 cryoglobulins. Mechanisms that do not involve Ig deposition include the activation of the complement system, which causes complement deposition in C3 glomerulopathy, and cytokines/growth factors as seen in thrombotic microangiopathy and precipitation, which is involved with cryoglobulinemia. It is important to recognize that nephrotoxic monoclonal proteins can be produced by clones from any of the B cell lineages and that a malignant state is not required for the development of kidney disease. The nephrotoxic clones that do not meet requirement for a malignant condition are now called monoclonal gammopathy of renal significance. Whether it is a malignancy or monoclonal gammopathy of renal significance, preservation of renal function requires substantial reduction of the monoclonal protein. With better understanding of the pathogenesis, clone-directed strategies, such as rituximab against CD20 expressing B cell and bortezomib against plasma cell clones, have been used in the treatment of these diseases. These clone-directed therapies been found to be more effective than immunosuppressive regimens used in nonmonoclonal protein-related kidney diseases.
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Affiliation(s)
- Nelson Leung
- Divisions of Nephrology and Hypertension and
- Hematology and
| | | | - Samih H. Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
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48
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Alegría-Landa V, Cerroni L, Kutzner H, Requena L. Paraprotein deposits in the skin. J Am Acad Dermatol 2017; 77:1145-1158. [PMID: 28985955 DOI: 10.1016/j.jaad.2017.07.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/19/2017] [Accepted: 07/23/2017] [Indexed: 02/04/2023]
Abstract
Cutaneous manifestations secondary to paraprotein deposits in the skin include a group of different disorders that although rare, may be the first clinical manifestation of the underlying hematologic dyscrasia. In this article we review the clinical manifestations and histopathologic findings of the processes that result from specific deposition of the paraprotein in different structures of the skin. Paraneoplastic processes frequently associated with hematologic malignancies will not be covered in this review. Some of the disorders included here result from deposition of the intact paraprotein in the skin, whereas in other cases the lesions are due to deposition of modified paraproteins in the form of amyloid substance, cryoglobulins, or crystalglobulins. Cutaneous amyloidoma refers to nodular dermal deposits of amyloid derived from immunoglobulin light chains produced by local plasma cells in the absence of systemic amyloidosis. Dermatologists and dermatopathologists should be aware of the clinical and histopathologic features of these rare disorders because sometimes the cutaneous lesions are the first sign of an underlying silent hematologic malignancy with paraproteinemia.
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Affiliation(s)
| | - Lorenzo Cerroni
- Dermatopathology Research Unit, Medical University of Graz, Graz, Austria
| | - Heinz Kutzner
- Dermatopathologie Friedrichschafen, Friedrichschafen, Germany
| | - Luis Requena
- Department of Dermatology, Fundación Jiménez Diaz, Universidad Autónoma, Madrid, Spain.
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Katsuno T, Mizuno S, Mabuchi M, Tsuboi N, Komatsuda A, Maruyama S. Long-term renal survival of γ3-heavy chain deposition disease: a case report. BMC Nephrol 2017; 18:239. [PMID: 28716013 PMCID: PMC5512846 DOI: 10.1186/s12882-017-0645-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 06/28/2017] [Indexed: 01/08/2023] Open
Abstract
Background Monoclonal immunoglobulin deposition disease (MIDD) is characterized by the non-amyloid deposition of monoclonal immunoglobulin fragments in the basement membranes. Heavy chain deposition disease (HCDD) is a type of MIDD. HCDD is an extremely rare disease, and only three cases have been reported in Japan up to the present. The prognosis of HCDD is very poor, and optimal treatment has not been established. Only a few cases of HCDD with favorable long-term renal prognosis have been reported to date. Case presentation The authors describe a 61-year-old woman who presented with massive proteinuria, progressive kidney impairment, and hypocomplementemia. Kidney biopsy was performed for a precise diagnosis. On light microscopy, glomerules were lobulated and presented with nodular sclerosing glomerulopathy with membranoproliferative glomerulonephritis-like features. Immunofluorescence studies were positive for IgG, C3, and C1q within the mesangial nodules and in a linear distribution along the capillary walls without associated deposition of light chains. Staining for IgG showed the presence of linear deposits along tubular basement membranes. The analysis of the IgG subclass stain demonstrated intense positivity for IgG3 only. Electron microscopy revealed non-organized electron-dense deposits in the expanded mesangial area and inner aspect of the glomerular basement membranes. In accordance with the histological findings, we diagnosed γ3-HCDD. There was no evidence of plasma cell dyscrasia as a result of bone marrow aspiration. Serum and urine monoclonal proteins were not detected by immunoelectrophoresis and immunofixation electrophoresis. The serum free light chain ratio was within normal range. At first, prednisolone was administrated at a dose of 40 mg/day. However, a therapeutic effect was not observed. Urinary protein was not decreased and renal function further deteriorated. Therefore, melphalan plus prednisolone (MP) therapy was initiated. After 4 courses of MP therapy, the clinical parameters, including proteinuria, serum creatinine, albumin, and complement level (C3 and C4) were ameliorated. To date, the patient has been followed for 28 months, and long-term renal survival has been observed. Conclusions In this case, hematologic disease such as multiple myeloma was not detected; however, MP therapy was effective. Recently, the novel concept of monoclonal gammopathy of renal significance (MGRS) has been reported. MIDD, which includes HCDD, is one category of MGRS. In MGRS, aggressive chemotherapy may induce favorable renal outcomes.
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Affiliation(s)
- Takayuki Katsuno
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.
| | - Shige Mizuno
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.,Department of Internal Medicine, Kaikoukai Jyousai Hospital, Nagoya, Japan
| | - Masatsuna Mabuchi
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan.,Department of Nephrology, Konan Kosei Hospital, Konan, Japan
| | - Naotake Tsuboi
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
| | - Atsushi Komatsuda
- Department of Hematology, Nephrology, Rheumatology, Akita University Graduate School of Medicine, Akita, Japan
| | - Shoichi Maruyama
- Department of Nephrology, Nagoya University Graduate School of Medicine, 65 Tsurumai-cho, Showa-ku, Nagoya, 466-8550, Japan
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50
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Javaugue V, Bouteau I, Sirac C, Quellard N, Diolez J, Colombo A, Desport E, Ecotière L, Goujon JM, Fermand JP, Touchard G, Jaccard A, Bridoux F. [Classification and therapeutic management of monoclonal gammopathies of renal significance]. Rev Med Interne 2017; 39:161-170. [PMID: 28457684 DOI: 10.1016/j.revmed.2017.03.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/11/2017] [Indexed: 10/19/2022]
Abstract
Two categories of renal disorders associated with monoclonal gammopathies are to be distinguished, according to the characteristics of the underlying B-cell clone. The first group of renal diseases always occurs in the setting of high tumor mass with production of large amounts of monoclonal immunoglobulins. The main complication is the so-called myeloma cast nephropathy, which almost invariably complicates high tumor mass myeloma. The second group includes all renal disorders caused by a monoclonal immunoglobulin secreted by a nonmalignant B-cell clone, and currently referred as a "monoclonal gammopathy of renal significance (MGRS)". This term was introduced to distinguish monoclonal gammopathies that are responsible for the development of kidney damage from those that are truly benign. The spectrum of renal diseases in MGRS is wide and its classification relies on the localization of renal lesions, either glomerular or tubular, and on the pattern of ultrastructural organization of immunoglobulin deposits. Physicochemical characteristics of the pathogenic monoclonal immunoglobulin are probably involved in their propensity to deposit or precipitate in the kidney, as illustrated by the high rate of recurrence of each specific type after kidney transplantation. Early diagnosis and efficient chemotherapy targeting the causal B-cell clone are mandatory to improve renal prognosis and patient survival.
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Affiliation(s)
- V Javaugue
- Service de néphrologie, hémodialyse et transplantation rénale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France; CNRS-UMR 7276, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, université de Limoges, 87000 Limoges, France.
| | - I Bouteau
- Service de néphrologie, hémodialyse et transplantation rénale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - C Sirac
- CNRS-UMR 7276, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, université de Limoges, 87000 Limoges, France
| | - N Quellard
- Service de pathologie ultrastructurale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 86021 Poitiers, France
| | - J Diolez
- Service de néphrologie, hémodialyse et transplantation rénale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - A Colombo
- Service de néphrologie, hémodialyse et transplantation rénale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - E Desport
- Service de néphrologie, hémodialyse et transplantation rénale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - L Ecotière
- Service de néphrologie, hémodialyse et transplantation rénale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France
| | - J-M Goujon
- Service de pathologie ultrastructurale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 86021 Poitiers, France; Laboratoire d'anatomopathologie, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 86021 Poitiers, France
| | - J-P Fermand
- Service d'immunologie et d'hématologie, hôpital Saint-Louis, 75010 Paris, France
| | - G Touchard
- Service de néphrologie, hémodialyse et transplantation rénale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France; Service de pathologie ultrastructurale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 86021 Poitiers, France
| | - A Jaccard
- Service d'hématologie, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Limoges, 87000 Limoges, France
| | - F Bridoux
- Service de néphrologie, hémodialyse et transplantation rénale, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, CHU de Poitiers, 2, rue de la Milétrie, 86021 Poitiers, France; CNRS-UMR 7276, centre national de référence maladies rares : amylose AL et autres maladies par dépôts d'immunoglobulines monoclonales, université de Limoges, 87000 Limoges, France
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