Progressive Renal Failure Due to Recurrent Attacks of Polyclonal Light-Chain Cast Nephropathy Induced by Recurrent Chest Infections Ablated by Rituximab
Background: Cast nephropathy is reported only with monoclonal light-chain gammopathy. The case: A 38-year-old white male was referred for management of progressive renal failure (serum creatinine at 294 μmol/L). He had cigarette-induced bronchiectasis and 2 attacks of partially resolving acute renal injury associated with chest bacterial infections 2 years and 1 month ago. Ultrasonography revealed 9 cm kidneys with thin and echogenic cortex. Autoimmune diseases and lymphoproliferative disorders/myeloma were excluded by laboratory and radiological tests as well as bone marrow biopsy. Kidney biopsy showed focal segmental glomerulosclerosis with distal tubules studied with PAS-ive casts surrounded by inflammatory cells, and moderate interstitial fibrosis. Immunohistochemical studies did not show glomerular immune deposits, yet antibody to both light chain Kappa and Lambda were detected in those casts and the intratubular epithelial droplets. Hence, after control of his infections and cigarette cessation, he was treated with yearly Rituximab infusions. Despite having 2 subsequent attacks of chest infections, over 2 years of follow-up, he did not experience new renal injury or deterioration. Conclusion: In predisposed individuals, recurrent infection can induce polyclonal light-chain cast nephropathy which is amenable to Rituximab.
References
[1]
Lusco, M.A., Fogo, A.B., Najafian, B. and Alpers, C.E. (2016) AJKD Atlas of Renal Pathology: Light Chain Cast Nephropathy. American Journal of Kidney Diseases, 67, e17-e18. https://doi.org/10.1053/j.ajkd.2016.01.002
[2]
Menè, P., Stoppacciaro, A., Lai, S. and Festuccia, F. (2022) Light Chain Cast Nephropathy in Multiple Myeloma: Prevalence, Impact and Management Challenges. International Journal of Nephrology and Renovascular Disease, 15, 173-183. https://doi.org/10.2147/ijnrd.s280179
[3]
Royal, V., Leung, N., Troyanov, S., Nasr, S.H., Écotière, L., LeBlanc, R., et al. (2020) Clinicopathologic Predictors of Renal Outcomes in Light Chain Cast Nephropathy: A Multicenter Retrospective Study. Blood, 135, 1833-1846. https://doi.org/10.1182/blood.2019003807
[4]
Dispenzieri, A., Gertz, M.A., Therneau, T.M. and Kyle, R.A. (2001) Retrospective Cohort Study of 148 Patients with Polyclonal Gammopathy. Mayo Clinic Proceedings, 76, 476-487. https://doi.org/10.4065/76.5.476
[5]
Beuvon, C., Martin, M., Baillou, C., Roblot, P. and Puyade, M. (2021) Etiologies of Polyclonal Hypergammaglobulinemia: A Scoping Review. European Journal of Internal Medicine, 90, 119-121. https://doi.org/10.1016/j.ejim.2021.05.023
[6]
Sethi, S., Haas, M., Markowitz, G.S., D’Agati, V.D., Rennke, H.G., Jennette, J.C., et al. (2015) Mayo Clinic/Renal Pathology Society Consensus Report on Pathologic Classification, Diagnosis, and Reporting of Gn. Journal of the American Society of Nephrology, 27, 1278-1287. https://doi.org/10.1681/asn.2015060612
[7]
Zhao, E.J., Cheng, C.V., Mattman, A. and Chen, L.Y.C. (2021) Polyclonal Hypergammaglobulinaemia: Assessment, Clinical Interpretation, and Management. The Lancet Haematology, 8, e365-e375. https://doi.org/10.1016/s2352-3026(21)00056-9
[8]
Buadi, F., Hsing, A.W., Katzmann, J.A., Pfeiffer, R.M., Waxman, A., Yeboah, E.D., et al. (2011) High Prevalence of Polyclonal Hypergamma-Globulinemia in Adult Males in Ghana, Africa. American Journal of Hematology, 86, 554-558. https://doi.org/10.1002/ajh.22040
[9]
Kumar, S., Larson, D.R., Dispenzieri, A., Therneau, T.M., Murray, D.L., Leif Bergsagel, P., et al. (2019) Polyclonal Serum Free Light Chain Elevation Is Associated with Increased Risk of Monoclonal Gammopathies. Blood Cancer Journal, 9, Article No. 49. https://doi.org/10.1038/s41408-019-0210-z
[10]
Sun, L.J., Dong, H.R., Xu, X.Y., Wang, G.Q., Cheng, H. and Chen, Y.P. (2021) Two Kinds of Rare Light Chain Cast Nephropathy Caused by Multiple Myeloma: Case Reports and Literature Review. BMC Nephrology, 22, Article No. 42. https://doi.org/10.1186/s12882-021-02250-z
[11]
Buch, M.H., Smolen, J.S., Betteridge, N., Breedveld, F.C., Burmester, G., Dörner, T., et al. (2011) Updated Consensus Statement on the Use of Rituximab in Patients with Rheumatoid Arthritis. Annals of the Rheumatic Diseases, 70, 909-920. https://doi.org/10.1136/ard.2010.144998
[12]
Randall, K.L. (2016) Rituximab in Autoimmune Diseases. Australian Prescriber, 39, 131-134. https://doi.org/10.18773/austprescr.2016.053
[13]
El-Reshaid, K., El-Reshaid, W., Al-Bader, S., Sallam, H., Hakim, A. and Al-Attiyah, R. (2018) New Protocols for Treatment of Class IV Lupus Nephritis with Emphasis on Rituximab as the Sole Maintenance Therapy. Kuwait Medical Journal, 50, 343-350.
