Fibrillary glomerulonephritis combined with chronic inflammatory demyelinating polyneuropathy

A 58-yr-old man presented with leg edema and subacute weakness of his bilateral lower extremities. Urinary and serum immunoelectrophoresis revealed the presence of lambda-type Bence Jones proteins. He was ultimately diagnosed with monoclonal gammopathy of undetermined significance (MGUS). A renal biopsy specimen showed fibrillary glomerulonephritis (FGN), which was randomly arranged as 12-20 m nonbranching fibrils in the basement membranes. Immunofluorescence studies were negative for immunoglobulin (Ig)G, IgM, IgA, C3, and kappa light chains in the capillary walls and mesangial areas. A Congo red stain for amyloid was negative. Electromyography and nerve conduction velocity examinations results were compatible with the presence of demyelinating polyneuropathy. This case showed a rare combination of FGN, without Ig deposition, and MGUS combined with chronic inflammatory demyelinating polyneuropathy (CIDP).

Proteinuria: lesión estructural renal y comparación de métodos / Proteinuria: renal structural injury and comparison of methods / Proteinúria: lesão estrutural renal e comparação de métodos

La proteinuria (PT-ur) es un marcador de enfermedad renal, sin un método de referencia establecido. Mediante electroforesis en gel de poliacrilamida con dodecilsulfato de sodio (SDS-PAGE) con tinción argéntica pueden identificarse de manera no-invasiva perfiles proteicos urinarios (PPU) de tipo glomerular (G), tubular (Tc: completos, Ti: incompletos) y mixtos (GTc, GTi) con fines diagnósticos/pronósticos y de evolución. El objetivo del estudio fue determinar la prevalencia (P) de los PPU para cada nivel de PT-ur obtenido con cuatro métodos diferentes, en pacientes con sospecha de lesión renal. Se procesaron 105 orinas de 24 h de recolección clasificadas mediante tira reactiva (TR) y 2 pacientes con proteinuria de Bence Jones (PBJ)>2 g/L. La cuantificación de PT-ur se realizó con ácido sulfosalicílico (SSA) y Bradford (CBB) "in-house"; cloruro de benzetonio (BZT-Roche) y rojo de pirogallol-molibdato (PRM-Wiener)-Hitachi 917. Se realizó uroproteinograma y SDS-PAGE. Los cuatro métodos presentaron correlación significativa (p<0,05) para PT-ur y una comparación de medias estadísticamente no-significativa en todos los niveles de TR. Para TR negativa (PT-ur en rango normal), la P del Ti fue del 33% y del 16% para GTi. En TR 1+/2+, el GTi de mediana selectividad presentó una P del 33%/30% y el GTc de 26%/57%, respectivamente, que se incrementó al 66% para TR 3+, con escasa-selectividad. Las PBJ presentaron valores estables mediante BZT, con diluciones manuales o realizadas por el equipo. La PT-ur mediante los métodos de cuantificación ensayados resultaron comparables y el BZT mostró PT-ur variables en presencia de PBJ dependiendo de la dilución empleada. En todos los niveles de PT-ur fue posible identificar la P de todas las lesiones estructurales con selectividades progresivamente comprometidas.

Relationship between the catalysis of Bence Jones protein and renal impairment in patients with multiple myeloma / 中国实验血液学杂志

This study was purposed to investigate the relationship between the catalysis of Bence Jones protein (BJP) in urine of patients with multiple myeloma(MM) and toxicity on the renal proximal tubular cells in vitro, and to explore the potential mechanism for the toxicity of BJP to renal impairment in patients with MM. The Michaelis-Menten constant (K(m)) and catalytic constant (k(cat)) of the amidase activity of BJP was calculated by Hanes equation. The LLC-PK1 cells were cultured with different concentration of BJP for 24 h, then proliferation of the cells were determined by MTT method and apoptosis were determined by flow cytometry. The results showed that the BJP from the MM patients with renal impairment significantly inhibited cell proliferation, as compared with that from MM patients without renal impairment. The BJP with higher k(cat) had higher toxicity to LLC-PK1 cells. BJP could induce apoptosis and necrosis of LLC-PK1 cells when reached a certain concentration and this effect enhanced with increase of BJP concentration. It is concluded that the catalysis of BJP and its toxicity to renal tubular epithelial cells has a positive correlation, and toxic effect of BJP on renal tubular epithelial cells results from inhibiting proliferation and inducing apoptosis and necrosis of the cells, which may be one of renal impairment mechanisms in MM patients.

Catalytic activity of Bence Jones proteins in renal impairment of patients with multiple myeloma - review / 中国实验血液学杂志

Renal impairment is one of frequent and serious complications in patients with multiple myeloma (MM) and is associated with a higher incidence of infections and early death rate. The catalytic activity of Bence Jones proteins (BJP) affects the clinical processes of patients with MM, and can lead to renal impairment. Scientists point out that BJP have peptidolytic and nucleolytic activity, which can lead porcine kidney proximal tubule (LLC-PK1) to apoptosis in vitro experiments. By treating the cytotoxic BJP with serine protease inhibitor (DFP), BJP lost not only their catalytic activity, but also the cytotoxic effects. Therefore, further research on BJP will helpful to understand the pathogenesis of renal impairment in MM patients and may provide a new idea and measure for the treatment of MM with renal impairment. This article reviews the basic research and progress on the catalytic activity of BJP.

Insuficiencia renal secundaria a mieloma múltiple in situ tratado con homeopatía / Renal failure secondary to multiple myeloma treated with homeopathy

Se presenta el caso clínico de un paciente masculino, de 26 años de edad, chofer, con padecimento de 10 meses de evolución, el cual inicia con intenso dolor de tipo ardoroso en la región lumbar, tironeante, cortante, que irradia en todos direcciones, mal estado general, cansancio, debilidad muscular intensa.

Multiple myeloma in younger age

A Multiple Myeloma [MM] is rare in younger age group. We report MM in a 30-year-old female, who presented with multiple lytic areas upon skeletal survey, but with negative Bence Jones protein. Bone marrow biopsy confirmed it to be a case of multiple myeloma. Patient was put on chemotherapy and radiography to which she responded and now is ambulatory

Multiple myeloma presenting with bleeding diathesis

Haemostatic defect due to platelet dysfunction rarely occurs in multiple myeloma. This report describes a 71-year old patient with multiple myeloma presented with severe bone pain and bleeding gums. Bone marrow biopsy revealed 65% plasma cells with atypical features. Coagulation profile showed normal prothrombin time and activated partial thromboplastin time whereas bleeding time performed by Ivy method was prolonged to 12 minutes [normal 2 - 7 minutes]

Plasma cell leukemia with pleomorphic plasma cells--a case report.

A case of plasma cell leukemia showing mostly pleomorphic plasma cells in the form of convoluted and multilobated nuclei with some having bilobed nuclei and internuclear bridges is being reported for its rarity of occurrence. Patient presented with congestive cardiac failure and features of nephropathy. There were no lytic lesions in the bone. Serum electrophoresis did not show any M-band while urine electrophoresis demonstrated Bence Jones protein confirming a light chain only type of myeloma. Patient is in remission 5 months after diagnosis. The significance of recognising such pleomorphic plasma cells is discussed.

Myeloma in young age.

Total 14 cases of myeloma in young age group (<40 years) have been reported out of 178 cases of myeloma in a time period of 7 years (1993-1999). Males predominated overfe males. Like adult myeloma, patients presented mostly with the backache, pain in pelvis, lower spine and weakness in about 60% of cases followed by swelling of bone in 40% of cases. One case presented with bleeding gum, malena and hepatosplenomegaly and was diagnosed as plasma cell leukemia. Radiological examination revealed lytic lesion in almost all the cases with fracture femur and rib in 28.57% of cases. Anaemia and raised ESR was noted in all the cases. Myeloma typing revealed IgG myeloma in 10 cases, light chain myeloma in 3 cases and IgA myeloma in one case. None of the patient was traceable after 2 years. Thus our study concludes that myeloma in the young age in India occurs in increased frequency and clinically presents just like adult and elderly myeloma, but serologically are predominantly of IgG type. There is also an increased frequency of solitary plasmacytoma as compared to adult myeloma.

Excreción de proteínas de bajo peso molecular en pacientes con proteinuria a cadena liviana como marcadoras de disfunción renal / Protein excretion of low molecular weight in patients with proteinuria to light chain like marking of renal dysfunction

Se determinó la excreción urinaria de las proteínas de bajo peso molecular (PBPM) beta-2 mocroglobulina(B2m), proteína transportadora de retinol (RBP) y alfa-1 microglobulina(A1m), en 65 pacientes con cadenas livianas monoclonales (CLM) en orina y en 47 con distintas enfermedades renales (DER), para evaluar la utilidad clínica de su determinación y el efecto de la presencia de CLM. Se utilizó inmunonefelometría (Beckman) para la determinación de Kappa, lambda y A1m, inmunoturbidimetría (Roche) para B2m y ELISA para RBP (Randox). La A1m correlacionó con los valores de CLM (r=0.49, p <0.01) y RBP (r=0.33, p <0.05). Las medias de PBPM mostraron diferencia significativa entre ambos grupos (p < 0.05); también entre la presencia o no de insuficiencia renal (IR) (p<0.001). Para A1m la diferencia fue significativa entre pacientes con y sin IR ( p<0.05 para CLM y p < 0.01 para DER). El número de pacientes sin IR con excreción aumentada de A1m mostró diferencias entre CLM y DER ( 80% y 35.7% ; p<0.01). En pacientes con CLM la alta excreción de PBPM en presencia o no de IR indicaría una disfunción tubular. En pacientes con CLM sin insuficiencia renal, A1m podría constituir una herramienta para el diagnóstico precoz de nefrotoxicidad.

Utilidad del método de rojo de pirogalol molibdato en la cuantificación de proteína de Bence Jones / Evaluation of pyrogallol-red molybdate complex performance in the measurement of Bence Jones protein

La cuantificación de proteínas en orina (PU) es un buen marcador para evaluar la función renal. En presencia de cadenas livianas libres monoclonales de inmunoglobulinas en orina (CLLM), o proteína de Bence Jones, el valor de PU provee un índice de la masa tumoral, de fundamental importancia en el monitoreo de pacientes con síndromes linfoproliferativos tales como mieloma múltiple micromolecular, enfermedad por depósito de cadenas livianas, y amiloidosis (AL). La determinación de PU por el método de unión al colorante Rojo de Pirogalol-Molibdato (RPM) es cada vez más utilizada porque es simple de realizar y fácilmente automatizable. El objetivo de éste trabajo es evaluar el comportamiento del método de RPM en la determinación de proteínas totales en muestras de orina compuestas por CLLM exclusivamente y estimar su correlación con otras metodologías de uso habitual. Se seleccionaron 79 muestras de orina de 24 h de recolección que presentaron solamente CLLM por electroinmunofijación (EIF) y por electroforesis en geles de poliacrilamida (SDS-PAGE). Se utilizó la técnica de Bradford con Azul Brillante de Coomasie (ABC), como otro método de unión a colorantes, y el método de Exton con ácido sulfosalicílico al 3 por ciento (ASS), de uso tradicional en éste medio. Para el método de RPM se utilizó un equipo comercial (RANDOX, Urinary Proteins) en un autoanalizador Selectra 2 Vitalab (Wiener). La cuantificación de cadenas livianas kappa y lambda se efectuó por inmunonefelometría (IN) (ARRAY 360 Beckman). El método de RPM tuvo una correlación estadísticamente significativa con el de ABC (r=0,888; ABC = 2,16 x RPM -0,09) y con IN (r= 0,790; IN = 11,9 x RPM + 0,16). El método de ASS correlacionó significativamente con el de ABC (r=0,324; p0,01) y con el de RPM (r=0,556; p<0,01), pero muy débilmente, por lo que no es posible vincularlos entre sí bajo aceptables intervalos de predicción. Se concluye que para la medición de las CLLM en los casos de orinas con concentraciones superiores al límite de linealidad del método de RPM, la mejor opción para evitar reacciones erráticas, es realizar una dilución 1/10 de la muestra

Nephrotoxicity of Bence-Jones proteins: interference in renal epithelial cell acidification

The aim of the present study was to evaluate the acidification of the endosome-lysosome system of renal epithelial cells after endocytosis of two human immunoglobulin lambda light chains (Bence-Jones proteins, BJP) obtained from patients with multiple myeloma. Renal epithelial cell handling of two BJP (neutral and acidic BJP) was evaluated by rhodamine fluorescence. Renal cells (MDCK) were maintained in culture and, when confluent, were incubated with rhodamine-labeled BJP for different periods of time. Photos were obtained with a fluorescence microscope (Axiolab-Zeiss). Labeling density was determined on slides with a densitometer (Shimadzu Dual-Wavelength Flying-Spot Scanner CS9000). Endocytosis of neutral and acidic BJP was correlated with acidic intracellular compartment distribution using acridine orange labeling. We compared the pattern of distribution after incubation of native neutral and acidic BJP and after complete deglycosylation of BJP by periodate oxidation. The subsequent alteration of pI converted neutral BJP to acidic BJP. There was a significant accumulation of neutral BJP in endocytic structures, reduced lysosomal acidification, and a diffuse pattern of acidification. This pattern was reversed after total deglycosylation and subsequent alteration of the pI to an acidic BJP. We conclude that the physicochemical characteristics of BJP interfere with intracellular acidification, possibly explaining the strong nephrotoxicity of neutral BJP. Lysosomal acidification is fundamental for adequate protein processing and catabolism

Mieloma múltiplo: relato de caso / Multiple myeloma: case report

Os autores apresentam um caso clínico de um paciente portador de mieloma múltiplo, com anemia, proteinúria, dores ósseas, velocidade de hemossedimentação elevada, em que faltou a positividade da proteinúria de Bence Jones, e a eletroforese das proteínas plasmáticas não apresentava o pico monocional da doença

The V kappa III subgroup light chain proteins in AL amyloidosis & autoimmune diseases.

BACKGROUND & OBJECTIVES: Light chain associated amyloidosis (AL) is characterized by extracellular deposition of immunoglobulin light chain and its fragments. In vitro and in vivo studies have shown that some light chains are nonamyloidogenic and nonnephrotoxic, whereas others are potentially amyloidogenic. Some light chains are prone to be deposited as rheumatoid materials, and also as nodular amorphous aggregates (light chain deposition diseases). These findings suggest that specific sequence element(s) may control the various kinds of light chain associated diseases. In this study we tried to identify such sequence element(s). METHODS: Two Bence Jones proteins (BJPs), NIG93 and NIG2 of subgroup V kappa III, were characterized and compared with other members of the same subgroup whose sequences are available in the data base. RESULTS: Both NIG93 and NIG2 proteins had sequences characteristics of V kappa IIIa as distinguished from V kappa IIIb, subsubgroup proteins. They also contained several novel substitutions, such as Met-37, Leu-40, Val-58, and IIe-85 in NIG93, and Val-2, His-29, Arg-50, and Ile-72 in NIG2. The data accumulated at present indicate that all members of the V kappa IIIa subsubgroup are related to either AL amyloidosis or rheumatoid arthritis, whereas the V kappa IIIb proteins are related to autoimmune diseases. INTERPRETATION & CONCLUSION: These observations indicate that subgroup-specific residues might be critical for light chain pathogenesis, at least for the V kappa III proteins. Point mutations within these proteins may be another structural element controlling their conformation as well as their pathogenic aggregation.

Nephrotoxicity of Bence-Jones Proteins: correlation with endocytosis by BHK cells and intracellular movement

O objetivo deste trabalho foi avaliar a endocitose de duas proteínas de Bence Jones por células renais, com a finalidade de elucidar a interferência de características físico-químicas na nefrotoxicidade. As proteínas de Bence Jones (denominadas AK e GL) forma purificadas e isoladas da urina de dois pacientes com mieloma múltiplo. Isótopos de ambas as proteínas foram caracterizados como sendo cadeias leves lambda monoclonais humanas. AK, apresentou principalmente pI>7,0, alto conteúdo de galactose e baixo teor de moléculas de ácido siálico. Por outro lado, GL apresentou uma única banda com pI 4,3, maior teor de ácido siálico e baixo teor de galactose, em comparaçäo co AK. Células renais de hamster, BHK(Baby Hamster Kidney) foram mantidas em cultura à temperatura de 37§C, utilizando meio de cultura DMEM suplementado com 10 por cento de sooro fetal bovino, em pH 7,4. Quando confluentes, as células BHK foram incubadas com as duas proteínas dissolvidas em meio isento de soro, durante 1, 5, 15, 30, 60 minutos e 24 horas. Foi omitida a incubaçäo com proteínas de Bence Jones em células usadas como controle. Com o término da incubaçäo, as células foram lavadas, tripsinizadas, centrifugadas e fixadas em soluçäo de paraformaldeído 4, 0 por cento e glutaraldeído 0,5 por cento em tampäp fosfato 0,1M pH 7,4. A seguir, os pellets obtidos foram processados para microscopia e incluídos em LRWhite. Cortes semi-finos foram colhidos e submetidos a reaçöes imunocitoqumícas, utilizando proteína acoplada a ouro coloidal e intensificaçäo pela prata. A detecçäo da amrcaçäo foi avaliada em microscopia de luz. Os resultados mostraram q1ue a proteóna GL tendeu a ser direcionada para localizaçäo pewri-nuclear. Por outro lado, AK demonstrou um comportamento diferente. Os dados indicaram que houve uma contribuiçäo direta das características físico-químicas das proteínas no direcionamento intracelular

Dosaje de cadenas livianas kappa y lambda en orina: su utilidad en el screening de la proteína de Bence Jones / Quantification of kappa and lambda light chains in urin: utility in the screening of Ben Jones protein

El método de elección para identificar proteína de Bence Jones (PBJ) urinarias es la inmunofijación (IF), que resulta costosa y extensa para ser empleada sistemáticamente. En la práctica se utiliza el uroproteinograma (UP) como test de screening, que descarta PBJ en orinas con UP fisiológico. Este método es menos sensible que la IF y presenta falsos negativos. Así pues, con el objeto de mejorar la detección de PBJ durante el screening, se investigó la utilidad del dosaje de cadenas livianas en aquellas orinas con UP fisiológico. Fueron estudiadas muestras de orina de 24 h durante el período 02-97 al 12-98 remitidas para la búsqueda de PBJ. Se empleó el siguiente protocolo: 1) proteinuria cuantitativa por el método de Exton; 2) concentración hasta 100X con concentrador Amicon B15; 3) electroforesis sobre acetato de celulosa de orina concentrada; 4) en orinas con UP fisiológico se efectuó dosaje de kappa y lambda por inmunonefelometría sistema QM300 de Kallestad; 5) si kappa y/o lambda resultaron detectables se realizó IF con equipo comercial. En las orinas con resultados no dosables para ambas cadenas livianas se descartó la PBJ. Según este protocolo, 51 orinas resultaron inicialmente con UP fisiológico; de éstas, 19 presentaron kappa y/o lambda dosables y se procesaron por IF, que detectó PBJ en 8 de ellas. Se puede concluir que el dosaje de cadenas livianas durante el screening de PBJ urinaria aportó información objetiva útil que permitió incrementar el nivel de detección

Immunochemical studies in multiple myeloma.

The study deals with a total of 72 patients with Plasma cell dyscrasias (PCD) selected on the basis of atypical plasmacytosis in the bone marrow aspirate and radiological evidence of osteolytic lesions. Males(48) outnumbered the females (24). Pathological fracture and paraplegia was the commonest presenting symptom encountered in 38 patients. Electrophoresis of serum for 'M' band and Immunoelectrophoretic analysis of the serum revealed IgG myeloma in 40 patients followed by, IgA myeloma(13), Light chain disease (12) and other variants in remaining seven cases. The urinary Bence Jones proteins were detected in a total of 34 cases and was frequently encountered with IgA myeloma (7 out of 13) compared with IgG myeloma (13 out of 40) when analysed in Disc electrophoresis. Kappa light chain was observed in 21 cases and lambda counterpart in nine cases without any clinical significance. One case of solitary myeloma terminated in characteristic multicentric multiple myelomatosis within a span of six months in the sequential follow up study. We recommend the triangular approach to diagnosis of paraproteinemia with a special emphasis on immunoelectrophoresis for typing multiple myeloma and allied disorders along with disc electrophoresis for the demonstration of urinary Bence Jones protein in the routine set up.

The renal and hepatic distribution of Bence Jones proteins depends on glycosylation: a scintigraphic study in rats

The aim of the present study was to evaluate renal and liver distribution of two monoclonal immunoglobulin light chains. The chains were purified individually from the urine of patients with multiple myeloma and characterized as lambda light chains with a molecular mass of 28 kDa. They were named BJg (high amount of galactose residues exposed) and BJs (sialic acid residues exposed) on the basis of carbohydrate content. A scintigraphic study was performed on male Wistar rats weighing 250 g for 60 min after iv administration of 1 mg of each protein (7.4 MBq), as the intact proteins and also after carbohydrate oxidation. Images were obtained with a Siemens gamma camera with a high-resolution collimator and processed with a MicroDelta system. Hepatic and renal distribution were established and are reported as percent of injected dose. Liver uptake of BJg was significantly higher than liver uptake of BJs (94.3 vs 81.4 per cent) P<0.05). This contributed to its greater removal from the intravascular compartment, and consequently lower kidney accumulation of BJg in comparison to BJs (5.7 vs 18.6 per cent) (P<0.05). After carbohydrate oxidation, there was a decrease in hepatic accumulation of both proteins and consequently a higher renal overload. The tissue distribution of periodate-treated BJg was similar to that of native BJs: 82.7 vs 81.4 per cent in the liver and 17.3 vs 18.6 per cent in the kidneys. These observations indicate the important role of sugar residues of Bence Jones proteins for their recognition by specific membrane receptors, which leads to diffedential tissue accumulation and possible toxicity.