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Successful treatment with bortezomib and dexamethasone for proliferative glomerulonephritis with monoclonal IgG deposits in multiple myeloma: a case report

View Article: PubMed Central - PubMed

ABSTRACT

Background: Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) is a form of renal involvement by monoclonal IgG deposits that was found in mesangial, subendothelial or subepithelial regions. The distribution of glomerular deposits was completely different from that in monoclonal immunoglobulin deposition disease. PGNMID is reported to be rarely associated with a hematological malignancy. Previously, only five cases of PGNMID with multiple myeloma have been reported. However, the pathogenic relationship between PGNMID and multiple myeloma was unclear because a detailed description was not provided. We report that a patient with PGNMID associated with multiple myeloma was treated with bortezomib and dexamethasone and underwent the second renal biopsy after treatment, showing that chemotherapy was effective for PGNMID clinically and pathologically.

Case presentation: A 75-year-old man presented with progressive leg edema, had nephrotic range proteinuria, hypoalbuminemia, moderate renal failure, and occult blood in his urine. Electrophoresis results showed serum and urinary monoclonal spikes of IgGκ type immunoglobulin. A renal biopsy specimen showed lobular mesangial proliferation with mesangiolysis, glomerular micro-aneurysm, and endocapillary hypercellularity. Immunofluorescence results revealed strong granular capillary and mesangial staining for IgG1, C3 and κ light chain in glomeruli without tubular deposits of any immunoglobulin. Electron microscopy also showed dense granular deposits in subendothelial and mesangial areas. PGNMID associated with multiple myeloma (IgGκ type) was diagnosed on the basis of a subsequent bone marrow examination. Bortezomib and dexamethasone therapy significantly reduced proteinuria and elevated serum albumin level. Eight months later, the second renal biopsy showed no active lesions and that the IgG1 and κ light chain deposits had drastically disappeared.

Conclusions: This is the first case of PGNMID with multiple myeloma successfully treated with bortezomib and dexamethasone in which comparative renal biopsies were performed before and after treatment. Our findings suggest the pathogenesis of PGNMID and therapeutic options for PGNMID.

No MeSH data available.


Clinical course. After initiating prednisolone therapy, this patient underwent four cycles of BD therapy (bortezomib at 1.3 mg/m2/week, and dexamethasone at 20 mg/week), followed by bortezomib maintenance therapy (1.3 mg/m2, biweekly). The κ/λ ratio, urinary protein (UP), and eGFR (calculated using equations for Japanese [26]) results are shown over the course of treatment
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Fig2: Clinical course. After initiating prednisolone therapy, this patient underwent four cycles of BD therapy (bortezomib at 1.3 mg/m2/week, and dexamethasone at 20 mg/week), followed by bortezomib maintenance therapy (1.3 mg/m2, biweekly). The κ/λ ratio, urinary protein (UP), and eGFR (calculated using equations for Japanese [26]) results are shown over the course of treatment

Mentions: After his first kidney biopsy but before his diagnosis of MM, this patient received methyl-prednisolone pulse therapy for 2 days. After his diagnosis of MM, he was started on weekly BD therapy (bortezomib at 1.3 mg/m2/week, dexamethasone at 20 mg/week, 4-week treatment per cycle). Prior to initiating BD therapy, his serum albumin was 2.7 g/dL, creatinine was 1.52 mg/dL, κ/λ ratio was >186, and urinalysis showed 12.3 g/g of protein and 2+ occult blood. After the first BD course, laboratory test results improved remarkably, with serum albumin of 3.2 g/dL, creatinine of 1.42 mg/dL, κ/λ ratio of 5.09, and urine protein of 2.16 g/g. After the fourth course of BD therapy, serum albumin was 3.6 g/dL, creatinine was 1.00 mg/dL, κ/λ ratio was 1.10, and urinalysis showed 0.25 g/g protein without occult blood (Fig. 2). This patient underwent four cycles of BD therapy followed by bortezomib maintenance therapy (1.3 mg/m2, biweekly). No adverse effects were observed and the laboratory results were stable.Fig. 2


Successful treatment with bortezomib and dexamethasone for proliferative glomerulonephritis with monoclonal IgG deposits in multiple myeloma: a case report
Clinical course. After initiating prednisolone therapy, this patient underwent four cycles of BD therapy (bortezomib at 1.3 mg/m2/week, and dexamethasone at 20 mg/week), followed by bortezomib maintenance therapy (1.3 mg/m2, biweekly). The κ/λ ratio, urinary protein (UP), and eGFR (calculated using equations for Japanese [26]) results are shown over the course of treatment
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC5382661&req=5

Fig2: Clinical course. After initiating prednisolone therapy, this patient underwent four cycles of BD therapy (bortezomib at 1.3 mg/m2/week, and dexamethasone at 20 mg/week), followed by bortezomib maintenance therapy (1.3 mg/m2, biweekly). The κ/λ ratio, urinary protein (UP), and eGFR (calculated using equations for Japanese [26]) results are shown over the course of treatment
Mentions: After his first kidney biopsy but before his diagnosis of MM, this patient received methyl-prednisolone pulse therapy for 2 days. After his diagnosis of MM, he was started on weekly BD therapy (bortezomib at 1.3 mg/m2/week, dexamethasone at 20 mg/week, 4-week treatment per cycle). Prior to initiating BD therapy, his serum albumin was 2.7 g/dL, creatinine was 1.52 mg/dL, κ/λ ratio was >186, and urinalysis showed 12.3 g/g of protein and 2+ occult blood. After the first BD course, laboratory test results improved remarkably, with serum albumin of 3.2 g/dL, creatinine of 1.42 mg/dL, κ/λ ratio of 5.09, and urine protein of 2.16 g/g. After the fourth course of BD therapy, serum albumin was 3.6 g/dL, creatinine was 1.00 mg/dL, κ/λ ratio was 1.10, and urinalysis showed 0.25 g/g protein without occult blood (Fig. 2). This patient underwent four cycles of BD therapy followed by bortezomib maintenance therapy (1.3 mg/m2, biweekly). No adverse effects were observed and the laboratory results were stable.Fig. 2

View Article: PubMed Central - PubMed

ABSTRACT

Background: Proliferative glomerulonephritis with monoclonal IgG deposits (PGNMID) is a form of renal involvement by monoclonal IgG deposits that was found in mesangial, subendothelial or subepithelial regions. The distribution of glomerular deposits was completely different from that in monoclonal immunoglobulin deposition disease. PGNMID is reported to be rarely associated with a hematological malignancy. Previously, only five cases of PGNMID with multiple myeloma have been reported. However, the pathogenic relationship between PGNMID and multiple myeloma was unclear because a detailed description was not provided. We report that a patient with PGNMID associated with multiple myeloma was treated with bortezomib and dexamethasone and underwent the second renal biopsy after treatment, showing that chemotherapy was effective for PGNMID clinically and pathologically.

Case presentation: A 75-year-old man presented with progressive leg edema, had nephrotic range proteinuria, hypoalbuminemia, moderate renal failure, and occult blood in his urine. Electrophoresis results showed serum and urinary monoclonal spikes of IgGκ type immunoglobulin. A renal biopsy specimen showed lobular mesangial proliferation with mesangiolysis, glomerular micro-aneurysm, and endocapillary hypercellularity. Immunofluorescence results revealed strong granular capillary and mesangial staining for IgG1, C3 and κ light chain in glomeruli without tubular deposits of any immunoglobulin. Electron microscopy also showed dense granular deposits in subendothelial and mesangial areas. PGNMID associated with multiple myeloma (IgGκ type) was diagnosed on the basis of a subsequent bone marrow examination. Bortezomib and dexamethasone therapy significantly reduced proteinuria and elevated serum albumin level. Eight months later, the second renal biopsy showed no active lesions and that the IgG1 and κ light chain deposits had drastically disappeared.

Conclusions: This is the first case of PGNMID with multiple myeloma successfully treated with bortezomib and dexamethasone in which comparative renal biopsies were performed before and after treatment. Our findings suggest the pathogenesis of PGNMID and therapeutic options for PGNMID.

No MeSH data available.