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Progression of Monoclonal Gammopathy with Undetermined Significance to Multiple Myeloma Diagnosed by Kidney Biopsy: A Case Report.

Kim JH, Kim JW, Kim YN, Kim HI, Kim JY, Kwon GY, Kim K, Jang HR - Case Rep Nephrol Dial (2015)

Bottom Line: During the follow-ups, azotemia and tubular proteinuria were aggravated without elevation of M-protein.Kidney biopsy showed intratubular and glomerular inclusions associated with plasma cell dysplasia.The patient's renal function and tubular proteinuria were markedly improved after chemotherapy.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea.

ABSTRACT
Monoclonal gammopathy with undetermined significance (MGUS) carries a risk of progression to multiple myeloma, and progression is usually diagnosed with changes in M-protein or bone marrow biopsy. We report a case of 62-year-old female patient showing MGUS progression to multiple myeloma without significant changes in M-protein but diagnosed by kidney biopsy. During the follow-ups, azotemia and tubular proteinuria were aggravated without elevation of M-protein. Kidney biopsy showed intratubular and glomerular inclusions associated with plasma cell dysplasia. The progression of MGUS to multiple myeloma was diagnosed by this kidney biopsy. The patient's renal function and tubular proteinuria were markedly improved after chemotherapy.

No MeSH data available.


Related in: MedlinePlus

Features of the second kidney biopsy. a Under light microscopy, tubular epithelial cells contained vacuolated cytoplasm (arrows) accompanied by minimal interstitial fibrosis and mild mononuclear infiltration. Periodic acid-Schiff stain. ×400. b–d Electron microscopy revealed electron-dense intracytoplasmic inclusions in the epithelial cells of some tubules as well as in the urinary space and the podocytes of some glomeruli (black and white arrows). These inclusions were variable in size and ovoid to angular in shape. Original magnifications, ×6,000, ×3,000, and ×7,000, respectively. e Immunofluorescent staining for κ is negative in glomeruli. ×200. f Immunofluorescent staining for λ is negative in glomeruli. ×200.
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Figure 1: Features of the second kidney biopsy. a Under light microscopy, tubular epithelial cells contained vacuolated cytoplasm (arrows) accompanied by minimal interstitial fibrosis and mild mononuclear infiltration. Periodic acid-Schiff stain. ×400. b–d Electron microscopy revealed electron-dense intracytoplasmic inclusions in the epithelial cells of some tubules as well as in the urinary space and the podocytes of some glomeruli (black and white arrows). These inclusions were variable in size and ovoid to angular in shape. Original magnifications, ×6,000, ×3,000, and ×7,000, respectively. e Immunofluorescent staining for κ is negative in glomeruli. ×200. f Immunofluorescent staining for λ is negative in glomeruli. ×200.

Mentions: Two years later (in July 2013), the level of serum creatinine rose to 1.68 mg/dl, and the spot urine protein-to-creatinine ratio was 1.34 mg/mg. After 2 more months, her serum creatinine level rose again to 1.78 mg/dl, the spot urine protein-to-creatinine ratio rose to 1.66 mg/mg, and the spot urine albumin-to-creatinine ratio was 269.21 μg/mg. The amount of serum M-protein decreased to 0.27 g/dl from 0.30 g/dl measured 6 months previously. However, the serum κ/λ FLC ratio was elevated from 27.1 to 39.84 caused by elevation of serum κ FLC level to 586.47 mg/l. No other symptoms or signs, such as hypercalcemia, bone pain, or anemia, suggested progression to multiple myeloma. A second kidney biopsy was performed, and the light microscopy result showed minimal tubular atrophy and acute tubular damage accompanied by minimal interstitial fibrosis and mild mononuclear infiltration. However, the electron microscope examination revealed that some tubular epithelial cells and podocytes were filled with electron-dense intracytoplasmic inclusions, which were also found in the urinary space (fig. 1). That result suggested Bence-Jones crystalline nephropathy associated with plasma cell dyscrasia. Therefore, the patient received a thorough hematologic workup even though the level of M-protein had not increased.


Progression of Monoclonal Gammopathy with Undetermined Significance to Multiple Myeloma Diagnosed by Kidney Biopsy: A Case Report.

Kim JH, Kim JW, Kim YN, Kim HI, Kim JY, Kwon GY, Kim K, Jang HR - Case Rep Nephrol Dial (2015)

Features of the second kidney biopsy. a Under light microscopy, tubular epithelial cells contained vacuolated cytoplasm (arrows) accompanied by minimal interstitial fibrosis and mild mononuclear infiltration. Periodic acid-Schiff stain. ×400. b–d Electron microscopy revealed electron-dense intracytoplasmic inclusions in the epithelial cells of some tubules as well as in the urinary space and the podocytes of some glomeruli (black and white arrows). These inclusions were variable in size and ovoid to angular in shape. Original magnifications, ×6,000, ×3,000, and ×7,000, respectively. e Immunofluorescent staining for κ is negative in glomeruli. ×200. f Immunofluorescent staining for λ is negative in glomeruli. ×200.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4608663&req=5

Figure 1: Features of the second kidney biopsy. a Under light microscopy, tubular epithelial cells contained vacuolated cytoplasm (arrows) accompanied by minimal interstitial fibrosis and mild mononuclear infiltration. Periodic acid-Schiff stain. ×400. b–d Electron microscopy revealed electron-dense intracytoplasmic inclusions in the epithelial cells of some tubules as well as in the urinary space and the podocytes of some glomeruli (black and white arrows). These inclusions were variable in size and ovoid to angular in shape. Original magnifications, ×6,000, ×3,000, and ×7,000, respectively. e Immunofluorescent staining for κ is negative in glomeruli. ×200. f Immunofluorescent staining for λ is negative in glomeruli. ×200.
Mentions: Two years later (in July 2013), the level of serum creatinine rose to 1.68 mg/dl, and the spot urine protein-to-creatinine ratio was 1.34 mg/mg. After 2 more months, her serum creatinine level rose again to 1.78 mg/dl, the spot urine protein-to-creatinine ratio rose to 1.66 mg/mg, and the spot urine albumin-to-creatinine ratio was 269.21 μg/mg. The amount of serum M-protein decreased to 0.27 g/dl from 0.30 g/dl measured 6 months previously. However, the serum κ/λ FLC ratio was elevated from 27.1 to 39.84 caused by elevation of serum κ FLC level to 586.47 mg/l. No other symptoms or signs, such as hypercalcemia, bone pain, or anemia, suggested progression to multiple myeloma. A second kidney biopsy was performed, and the light microscopy result showed minimal tubular atrophy and acute tubular damage accompanied by minimal interstitial fibrosis and mild mononuclear infiltration. However, the electron microscope examination revealed that some tubular epithelial cells and podocytes were filled with electron-dense intracytoplasmic inclusions, which were also found in the urinary space (fig. 1). That result suggested Bence-Jones crystalline nephropathy associated with plasma cell dyscrasia. Therefore, the patient received a thorough hematologic workup even though the level of M-protein had not increased.

Bottom Line: During the follow-ups, azotemia and tubular proteinuria were aggravated without elevation of M-protein.Kidney biopsy showed intratubular and glomerular inclusions associated with plasma cell dysplasia.The patient's renal function and tubular proteinuria were markedly improved after chemotherapy.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, Sungkyunkwan University School of Medicine, Seoul, Korea.

ABSTRACT
Monoclonal gammopathy with undetermined significance (MGUS) carries a risk of progression to multiple myeloma, and progression is usually diagnosed with changes in M-protein or bone marrow biopsy. We report a case of 62-year-old female patient showing MGUS progression to multiple myeloma without significant changes in M-protein but diagnosed by kidney biopsy. During the follow-ups, azotemia and tubular proteinuria were aggravated without elevation of M-protein. Kidney biopsy showed intratubular and glomerular inclusions associated with plasma cell dysplasia. The progression of MGUS to multiple myeloma was diagnosed by this kidney biopsy. The patient's renal function and tubular proteinuria were markedly improved after chemotherapy.

No MeSH data available.


Related in: MedlinePlus