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    "textoCompleto" => "INTRODUCTION <br></br><br></br>Monoclonal gammopathies are a group of diseases characterized by abnormal production of immunoglobulins derived from a same clone of plasma cells&#46; Whole immunoglobulins or any of their components &#40;heavy chains&#44; light chains or both&#41; may be deposited in any tissue&#46; Classification of gammopathies may be seen in table I&#46; <br></br><br></br>Renal involvement is frequently associated to malignant monoclonal gammopathies&#44; mostly associated to light chain <br></br>deposits&#46;1 Traditionally&#44; it has been seen associated to diseases such as myeloma or Waldenstr&#246;m macroglobulinemia&#46;2-4 However&#44; renal light chain deposition has also been reported in benign monoclonal gammopathies&#46;5-11 There are non-malignant conditions in which circulating paraproteins&#44; either light chains&#44; heavy chains or both&#44; may show affinity for the kidney&#44; become deposited in it&#44; and cause renal clinical signs such as nephrotic syndrome&#44; isolated proteinuria&#44; or rapid&#44; progressive renal failure&#46;12 Tubulopathy occurring as Fanconi <br></br>syndrome has also been frequently reported&#46;13 By contrast&#44; malignization of these conditions during follow-up is uncommon&#46;7 <br></br><br></br>A retrospective series comprising patients with renal disease secondary to paraprotein deposition in the setting of &#171;benign&#187; monoclonal gammopathy is reported&#46; Their clinical&#44; histopathological&#44; and evolutionary characteristics are analyzed&#46; <br></br><br></br>PATIENTS <br></br><br></br>Patients from five Spanish nephrology departments were enrolled based on the following criteria&#58; <br></br><br></br>1&#46; Presence of a monoclonal gammopathy with no malignancy criteria&#44; i&#46;e&#46; with less than 10&#37; plasma cells in the bone marrow sample and no extrarenal clinical findings suggesting malignant monoclonal gammopathy&#44; such as anemia&#44; bone lesions&#44; or visceral involvement&#46; <br></br>2&#46; Clinical evidence of renal disease&#46; <br></br>3&#46; Availability of a renal biopsy showing paraprotein deposits&#46; <br></br>4&#46; Finally&#44; detection of a monoclonal component in blood and&#47;or urine was not considered a requirement for diagnosis&#44; but supported it&#46; <br></br><br></br>METHODS <br></br><br></br>Both laboratory and pathology results were evaluated by the source hospital&#46; The monoclonal component was investigated&#44; either in blood or urine&#44; using electrophoresis and subsequent gel immunofixation&#46; Renal histological study was performed using standard techniques for light microscopy and immunofluorescence&#46; For the latter&#44; antisera directed against alpha&#44; gamma&#44; and mu heavy chains&#44; as well as against lambda and kappa light chains were used&#46; Samples were also stained with Congo red and viewed under polarized light&#46; Presence in deposits of a single type of light chain or amyloid substance with immunopathological characteristics of the AL type was considered to suggest monoclonality&#46; <br></br><br></br>Treatment and subsequent follow-up were performed according to the standard procedures or experience of each center&#46; <br></br><br></br>RESULTS <br></br><br></br>Clinical cases <br></br>A total of nine patients&#44; three males &#40;33&#37;&#41; and six females &#40;67&#37;&#41; with a mean age of 59&#46;2 &#177; 12 years&#44; were included in the study&#46; <br></br><br></br>At diagnosis&#44; all patients had microhematuria&#44; proteinuria&#44; and some degree of renal failure&#46; Proteinuria was in the nephrotic range &#40;4 &#177; 1&#46;5 g&#47;day&#41; in seven patients&#44; four of whom eventually experienced a nephrotic syndrome&#46; Mean creatinine levels at diagnosis were 315 &#177; 187 micromol&#47;L&#44; and dialysis was required from the start in two patients &#40;table II&#41;&#46; <br></br><br></br>In no case was the proportion of plasma cells in bone marrow greater than 10&#37;&#46; Laboratory findings showed different presentation forms in both blood and urine immunoelectrophoresis &#40;table III&#41;&#46; <br></br><br></br>Histological presentation forms were diverse&#46; Nodular and mesangiocapillary glomerulopathy were found in four and <br></br>three patients respectively&#44; while tubular lesions alone were seen in one&#44; and a mesangial pattern in the remaining patient &#40;table III&#41;&#46; Amyloidosis was not found in any patient at the time of diagnosis&#46; <br></br><br></br>All nine patients were treated according to the standard procedure and experience at each unit&#46; Only 7 patients were administered regular treatment&#44; because one of the two patients with end-stage renal disease did not receive specific treatment&#44; while the other was treated for only one month &#40;see table II&#41;&#46; The untreated patient &#40;patient 6&#41; had end-stage renal disease that required dialysis form the start&#46; In the remaining patients&#44; treatment regimens lasted from four to eight months and consisted of&#58; prednisone &#40;PDN&#41; monotherapy in two patients&#44; PDN plus melphalan in two patients&#44; and PDN plus melphalan plus plasmapheresis&#44; PDN plus melphalan plus bone marrow autotransplantation&#44; and PDN plus cyclophosphamide each in one patient&#46; <br></br><br></br>Follow-up time ranged from one to 12 years &#40;4&#46;89 &#177; SD 3&#46;69&#41;&#46; Six of the nine patients progressed to chronic renal failure and required regular hemodialysis within 2&#46;4 years &#177; SD 4&#46;3&#46; Renal function stabilized in three cases&#44; and proteinuria disappeared after treatment in more than 50&#37; of patients&#46; No patient progressed to malignancy during the follow-up period&#46; <br></br><br></br>DISCUSSION <br></br><br></br>Our study reports a series of nine patients with benign monoclonal gammopathy and renal involvement secondary to light chain &#40;LC&#41; deposition&#46; <br></br><br></br>Monoclonal gammopathies&#44; while caused by an abnormal proliferation of plasma cells&#44; do not always result from a malignant process either at the time of diagnosis or in a subsequent stage&#46; In 2003&#44; the International Myeloma Working Group14 classified the different monoclonal gammopathies using simple criteria easy to apply in daily clinical practice&#46; The less clinically aggressive stage corresponds to monoclonal gammopathy of undetermined significance &#40;MGUS&#41;&#44; in which the circulating paraprotein&#44; usually found at levels under 3 g&#47;dL&#44; is detected in the absence of significant proliferation &#40;&#60; 10&#37;&#41; of abnormal plasma cells in the bone marrow sample and clinical signs attributable to the hematological process&#46;15-16 If the MGUS label is considered to correspond to cases with no clinical signs attributable to paraprotein deposition&#44; the patients reported here&#44; who had no malignant disease but showed renal involvement secondary to LC deposition&#44; should be excluded from the diagnostic group of MGUS and <br></br>considered to have renal disease from light chain deposition&#46; <br></br><br></br>The probability of a malignant transformation reported in different series ranges from more than 17&#37; at 10 years of follow- up and up to 39&#37; at 25 years of follow-up&#46;9&#44;17 Our study reports a series of nine patients with benign monoclonal gammopathy and renal involvement due to immunoglobulin deposition diagnosed by biopsy in whom no malignization occurred&#44; though the follow-up period was shorter &#40;4&#46;89 years &#177; SD 3&#46;69&#41;&#46; <br></br><br></br>The reason for renal involvement by monoclonal paraproteins is multifactorial and has not been fully elucidated yet&#46;18 While it is more commonly reported in the setting of already established malignant diseases such as myeloma or Waldenstr&#246;m disease&#44;1 renal involvement by LC deposition in gammopathies without hematological criteria of malignancy is not rare and has been reported in anecdotal cases&#44;5&#44;7&#44;8&#44;11 short series&#44; or in larger cohorts also including malignant cases&#46;10&#44;19 <br></br><br></br>Its systemic nature or its association to neuropathy or liver disease have sometimes been reported&#46;20&#44;21 Monoclonal immunoglobulin deposition diseases &#40;MIDD&#41; show a wide variety of glomerular and&#47;or tubular clinical presentations&#44; and also different pathological characteristics&#46;22 Histological findings differentiate three forms depending on the characteristics of the paraprotein deposited&#58; <br></br><br></br>1&#46; Light chains with immunofluorescence positive for kappa or lambda and an ultrastructure in the form of disorganized granular deposits&#46; This would correspond to the light chain deposition disease &#40;LCDD&#41; initially described by Randall&#46;23 These may coexist with deposition of whole immunoglobulins or heavy chains &#40;LHCDD&#41;&#44; <br></br>or heavy chains may only be detected &#40;HCDD&#41;&#46; <br></br>2&#46; Light chains with positive immunofluorescence&#44; usually associated to IgG and C3 and with an ultrastructure of <br></br>organized microtubules&#46; Controversy exists about whether two differentiated clinical and histological subforms <br></br>&#40;fibrillary and immunotactoid glomerulopathy&#41; exist or they are the same disease&#46;24 <br></br>3&#46; Light chain deposit positive to Congo red staining&#58; this corresponds to amyloid AL&#46; It is common in the setting of myeloma or with the clinical picture characteristic of primary amyloidosis&#46; Ultrastructurally&#44; they are organized as fibrils&#46; This variety may coexist with types 1 and 2&#44; but association is uncommon&#46;25 <br></br><br></br>The typical renal presentation of MIDD includes proteinuria&#44; hypertension&#44; and renal failure&#46; Renal failure was found in 88&#37; of our patients&#44; in agreement with other series where renal failure was reported to occur in 92&#37;-96&#37; of patients with pure MIDD&#46;6&#44;10&#44;26&#44;27 However&#44; almost 90&#37; of our patients initially had proteinuria in the nephrotic range&#44; as compared to only 48&#37;-57&#37; in other literature reports&#46; <br></br><br></br>Kappa chains are the light chains predominately deposited in the renal basal membrane&#44; and are identified in 73&#37;-90&#37; of cases&#46;6&#44;10&#44;26 In our series&#44; a similar proportion was found &#40;77&#37;&#41;&#46; <br></br><br></br>While the typical histological presentation is nodular glomerulosclerosis&#44; 1 there may be other presentation forms that should not deviate us from diagnosis&#46; Only four of our nine patients showed nodular glomerulosclerosis in renal histology&#46; <br></br><br></br>Age at diagnosis was similar in our patients to that reported by other authors&#44; approximately the sixth decade of life&#46;10&#44;28 <br></br><br></br>Treatment administered in idiopathic MIDD is usually similar to that given in cases of malignant disease&#58; prednisone&#47;melphalan &#40;the most common&#41; or prednisone&#47;chlorambucil or prednisone&#47;melphalan plus plasma exchange or bone marrow autotransplantation&#46;8 These treatments have been reported to be effective for both idiopathic forms and malignant conditions&#46; Although disappearance of the light chain deposit following chemotherapy has occasionally been reported&#44;1&#44;29 in the largest series stabilization or improvement only occurred in 62&#37;-65&#37; of patients with serum creatinine levels under 350 micromol&#47;L at treatment start&#44; and 82&#37; of patients with higher creatinine values progressed to end-stage renal disease despite treatment&#46;10&#44;27 The initial degree of renal failure&#44; age&#44; underlying hematological disease&#44; or extrarenal paraprotein deposition have also been reported to be prognostic factors&#46;19 Most our patients received steroids&#44; whether or not associated to melphalan&#46; Progression of renal disease was stopped in two patients&#44; and in the patient also treated with plasmapheresis&#44; renal function even improved and stabilized at 8 years of follow-up&#46; The lack of renal function improvement in all other patients was attributed to the advanced degree of renal failure&#46; Three of those patients had baseline creatinine levels higher than 350 micromol&#47;L&#46; <br></br><br></br>As regards proteinuria&#44; values decreased by up to 33&#37; after treatment in the Heilman series&#46; By contrast&#44; proteinuria decreased in more than 50&#37; of our patients&#46; Renal disease prognosis is poor according to Heilman&#44;10 with a five-year survival rate of approximately 37&#37;&#46; Our series showed a similar renal survival of approximately 33&#37;&#46; Unfortunately&#44; no conclusions may be drawn about efficacy with the different treatment regimens because of the small number of patients&#44; the lack of treatment standardization&#44; and the limited follow-up time&#46; <br></br><br></br>CONCLUSION <br></br><br></br>Monoclonal gammopathies&#44; while &#171;benign&#187;&#44; may be associated with renal involvement that may often be overlooked&#46; Renal biopsy plays a very significant role in diagnosis&#44; and it should be reminded that early diagnosis and treatment may improve prognosis&#46; Much larger multicenter studies would be required to establish the optimum therapeutic regimen&#46; <br></br><br></br>Based on the experience reported here and on the literature published&#44; the following considerations could be made&#58; <br></br><br></br>1&#46; That the benign nature of a monoclonal gammopathy does not exclude that it may be causing a secondary <br></br>renal impairment&#46; <br></br>2&#46; That no patient should therefore be diagnosed MGUS without a prior minimal renal study consisting of sediment&#44; <br></br>proteinuria&#44; and estimation of glomerular filtration rate and tubular function&#46; <br></br>3&#46; That&#44; if renal involvement is detected&#44; renal biopsy for verifying whether it is due to light chain deposition should be considered&#46; <br></br>4&#46; That&#44; if deposition is found&#44; chemotherapy should be considered&#44; because renal impairment usually progresses to end-stage renal failure and stabilization of the renal condition has been reported after treatment&#46; <br></br>"
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        "resumen" => "La nefropat&#237;a de las gammapat&#237;as monoclonales es debida principalmente al dep&#243;sito de cadenas ligeras&#46; Aunque se presenta sobre todo en cuadros malignos&#44; tambi&#233;n se ha descrito en pacientes cuya gammapat&#237;a es considerada &#171;benigna&#187;&#46; Se describen las caracter&#237;sticas cl&#237;nicas e histol&#243;gicas de 9 casos de nefropat&#237;a por dep&#243;sitos de cadenas ligeras diagnosticadas en el contexto de una gammapat&#237;a monoclonal sin datos de malignidad&#46; Tres hombres y seis mujeres con edad media de 59&#44;2 &#177; 12&#46; Todos los pacientes presentaban al diagn&#243;stico proteinuria y grados variables de insuficiencia renal con creatinina s&#233;rica media de 315 &#177; 187&#46; Dos requirieron di&#225;lisis desde el inicio&#46; La histolog&#237;a renal mostr&#243; patr&#243;n nodular en 4 casos&#44; mesangiocapilar en 3&#44; lesiones s&#243;lo tubulares en 1 y mesangial en otro&#46; Los dep&#243;sitos renales m&#225;s frecuentes fueron los constituidos por cadenas kappa &#40;67&#37;&#41;&#46; Los tratamientos aplicados fueron&#58; Prednisona en monoterapia &#40;tres casos&#41; o asociada a quimioterapia &#40;melfalan&#44; clorambucil o ciclofosfamid&#41;&#46; En dos casos se a&#241;adieron recambios plasm&#225;ticos o autotrasplante de m&#233;dula &#243;sea&#44; respectivamente&#46; Tras un seguimiento medio de 4&#44;89 &#177; DE&#58; 3&#44;69 a&#241;os observamos desaparici&#243;n de la proteinuria en m&#225;s del 50&#37; de los pacientes y estabilizaci&#243;n o mejor&#237;a de la funci&#243;n renal en 3&#46; Dos de ellos necesitaron terapia renal substitutiva desde el inicio y existi&#243; progresi&#243;n del fallo renal hasta los requerimientos dial&#237;ticos en los cuatro restantes&#46; En caso de gammapat&#237;a monoclonal&#44; incluso de car&#225;cter benigno&#44; debe buscarse una posible afectaci&#243;n renal&#46; La comprobaci&#243;n del dep&#243;sito renal de cadenas ligeras debe hacer plantearse un tratamiento precoz&#44; ya que la evoluci&#243;n a la insuficiencia renal terminal es frecuente&#46;"
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        "resumen" => "Renal involvement is observed frequently in association with malignant gammopathies&#44; mainly those related to light chain deposition&#44; although has also been described in non-malignant monoclonal gammopathy&#46; This study reports the clinicopathological findings and outcome in 9 patients with nephropaty secondary to monoclonal immunoglobulin deposit in absence of malignancy&#46; They were three men and six women and they were 59&#46;2 &#177; 12 years old&#46; All patients presented proteinuria and different levels of renal insufficiency &#40;mean creatinin &#61; 315 &#177; 187 micromol&#47;L&#41; at the moment of diagnostic&#46; Two patients required dialysis at the time of renal biopsy&#46; The pathology studies revealed a nodular sclerosing glomerulopathy in four cases&#44; mesangiocapilary glomerulonephritis in three cases&#44; only tubular lesions in one and mesangial lesions in the other one&#46; The treatment applied was&#58; Prednisone alone &#40;two cases&#41;&#44; with chemotherapy associated &#40;melfalan in two&#44; clorambucil in one and ciclophosphamide in another one&#41;&#46; One patient received plasmapheresis and mycophenolate and another patient undergone a bone marrow authotransplant associated to mycophenolate and prednisone&#46; One of the two patients who required dialysis at the moment of presentation was not treated&#46; After a follow-up of more than 4 years &#40;4&#46;89 &#177; DE&#58; 3&#46;69&#41; renal function improved or remained stable in three patients and proteinuria was dissapaired in more than 50&#37; of patients&#46; Four patients had a worsening of renal function and they required dialysis during the time of follow-up &#40;in 2&#46;4 years &#177; DE&#58; 4&#46;3&#41;&#46; In any case malignitation was observed&#46; Chemotherapy stabilized or improved renal function in 3 of nine patients &#40;33&#37;&#41; with non-malignant monoclonal gammopathy Non-malignant monoclonal gammopathy could go unnoticed&#46; Appearance of abnormalities in renal routine tests deserves more in-depth diagnostic procedures&#44; including renal biopsy&#46; Evolution to end stage renal disease could probably be avoided or reduced in severity with early detection and treatment of this entity&#46;"
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Renal involvement in benign monoclonal gammopathies: an underdiagnosed condition?
Afectación renal en las gammpatías monoclonales benignas: una entidad infradiagnosticada
Rosa Ramosa, Rafael Povedaa, Josep M Grinyóa, Carmen Bernísb, Jordi Arac, Marta Sunyerd, P.. Arrizabalagae
a Nefrología, Ciutat Sanitària i Universitària de Bellvige, L¿Hospitalet del Llobregat, Barcelona, España,
b Nefrología, Hospital de La Princesa, Madrid, Madrid, España,
c Nefrología, Hospital Germans Trías i Pujol, Badalona, Barcelona, España,
d Nefrología, Hospital Virgen del Rocío, Sevilla, Sevilla, España,
e Nefrología, Hospital Clínic i Provincial, Barcelona, Barcelona, España,
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      "es" => array:1 [
        "titulo" => "Afectaci&#243;n renal en las gammpat&#237;as monoclonales benignas&#58; una entidad infradiagnosticada"
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    "textoCompleto" => "INTRODUCTION <br></br><br></br>Monoclonal gammopathies are a group of diseases characterized by abnormal production of immunoglobulins derived from a same clone of plasma cells&#46; Whole immunoglobulins or any of their components &#40;heavy chains&#44; light chains or both&#41; may be deposited in any tissue&#46; Classification of gammopathies may be seen in table I&#46; <br></br><br></br>Renal involvement is frequently associated to malignant monoclonal gammopathies&#44; mostly associated to light chain <br></br>deposits&#46;1 Traditionally&#44; it has been seen associated to diseases such as myeloma or Waldenstr&#246;m macroglobulinemia&#46;2-4 However&#44; renal light chain deposition has also been reported in benign monoclonal gammopathies&#46;5-11 There are non-malignant conditions in which circulating paraproteins&#44; either light chains&#44; heavy chains or both&#44; may show affinity for the kidney&#44; become deposited in it&#44; and cause renal clinical signs such as nephrotic syndrome&#44; isolated proteinuria&#44; or rapid&#44; progressive renal failure&#46;12 Tubulopathy occurring as Fanconi <br></br>syndrome has also been frequently reported&#46;13 By contrast&#44; malignization of these conditions during follow-up is uncommon&#46;7 <br></br><br></br>A retrospective series comprising patients with renal disease secondary to paraprotein deposition in the setting of &#171;benign&#187; monoclonal gammopathy is reported&#46; Their clinical&#44; histopathological&#44; and evolutionary characteristics are analyzed&#46; <br></br><br></br>PATIENTS <br></br><br></br>Patients from five Spanish nephrology departments were enrolled based on the following criteria&#58; <br></br><br></br>1&#46; Presence of a monoclonal gammopathy with no malignancy criteria&#44; i&#46;e&#46; with less than 10&#37; plasma cells in the bone marrow sample and no extrarenal clinical findings suggesting malignant monoclonal gammopathy&#44; such as anemia&#44; bone lesions&#44; or visceral involvement&#46; <br></br>2&#46; Clinical evidence of renal disease&#46; <br></br>3&#46; Availability of a renal biopsy showing paraprotein deposits&#46; <br></br>4&#46; Finally&#44; detection of a monoclonal component in blood and&#47;or urine was not considered a requirement for diagnosis&#44; but supported it&#46; <br></br><br></br>METHODS <br></br><br></br>Both laboratory and pathology results were evaluated by the source hospital&#46; The monoclonal component was investigated&#44; either in blood or urine&#44; using electrophoresis and subsequent gel immunofixation&#46; Renal histological study was performed using standard techniques for light microscopy and immunofluorescence&#46; For the latter&#44; antisera directed against alpha&#44; gamma&#44; and mu heavy chains&#44; as well as against lambda and kappa light chains were used&#46; Samples were also stained with Congo red and viewed under polarized light&#46; Presence in deposits of a single type of light chain or amyloid substance with immunopathological characteristics of the AL type was considered to suggest monoclonality&#46; <br></br><br></br>Treatment and subsequent follow-up were performed according to the standard procedures or experience of each center&#46; <br></br><br></br>RESULTS <br></br><br></br>Clinical cases <br></br>A total of nine patients&#44; three males &#40;33&#37;&#41; and six females &#40;67&#37;&#41; with a mean age of 59&#46;2 &#177; 12 years&#44; were included in the study&#46; <br></br><br></br>At diagnosis&#44; all patients had microhematuria&#44; proteinuria&#44; and some degree of renal failure&#46; Proteinuria was in the nephrotic range &#40;4 &#177; 1&#46;5 g&#47;day&#41; in seven patients&#44; four of whom eventually experienced a nephrotic syndrome&#46; Mean creatinine levels at diagnosis were 315 &#177; 187 micromol&#47;L&#44; and dialysis was required from the start in two patients &#40;table II&#41;&#46; <br></br><br></br>In no case was the proportion of plasma cells in bone marrow greater than 10&#37;&#46; Laboratory findings showed different presentation forms in both blood and urine immunoelectrophoresis &#40;table III&#41;&#46; <br></br><br></br>Histological presentation forms were diverse&#46; Nodular and mesangiocapillary glomerulopathy were found in four and <br></br>three patients respectively&#44; while tubular lesions alone were seen in one&#44; and a mesangial pattern in the remaining patient &#40;table III&#41;&#46; Amyloidosis was not found in any patient at the time of diagnosis&#46; <br></br><br></br>All nine patients were treated according to the standard procedure and experience at each unit&#46; Only 7 patients were administered regular treatment&#44; because one of the two patients with end-stage renal disease did not receive specific treatment&#44; while the other was treated for only one month &#40;see table II&#41;&#46; The untreated patient &#40;patient 6&#41; had end-stage renal disease that required dialysis form the start&#46; In the remaining patients&#44; treatment regimens lasted from four to eight months and consisted of&#58; prednisone &#40;PDN&#41; monotherapy in two patients&#44; PDN plus melphalan in two patients&#44; and PDN plus melphalan plus plasmapheresis&#44; PDN plus melphalan plus bone marrow autotransplantation&#44; and PDN plus cyclophosphamide each in one patient&#46; <br></br><br></br>Follow-up time ranged from one to 12 years &#40;4&#46;89 &#177; SD 3&#46;69&#41;&#46; Six of the nine patients progressed to chronic renal failure and required regular hemodialysis within 2&#46;4 years &#177; SD 4&#46;3&#46; Renal function stabilized in three cases&#44; and proteinuria disappeared after treatment in more than 50&#37; of patients&#46; No patient progressed to malignancy during the follow-up period&#46; <br></br><br></br>DISCUSSION <br></br><br></br>Our study reports a series of nine patients with benign monoclonal gammopathy and renal involvement secondary to light chain &#40;LC&#41; deposition&#46; <br></br><br></br>Monoclonal gammopathies&#44; while caused by an abnormal proliferation of plasma cells&#44; do not always result from a malignant process either at the time of diagnosis or in a subsequent stage&#46; In 2003&#44; the International Myeloma Working Group14 classified the different monoclonal gammopathies using simple criteria easy to apply in daily clinical practice&#46; The less clinically aggressive stage corresponds to monoclonal gammopathy of undetermined significance &#40;MGUS&#41;&#44; in which the circulating paraprotein&#44; usually found at levels under 3 g&#47;dL&#44; is detected in the absence of significant proliferation &#40;&#60; 10&#37;&#41; of abnormal plasma cells in the bone marrow sample and clinical signs attributable to the hematological process&#46;15-16 If the MGUS label is considered to correspond to cases with no clinical signs attributable to paraprotein deposition&#44; the patients reported here&#44; who had no malignant disease but showed renal involvement secondary to LC deposition&#44; should be excluded from the diagnostic group of MGUS and <br></br>considered to have renal disease from light chain deposition&#46; <br></br><br></br>The probability of a malignant transformation reported in different series ranges from more than 17&#37; at 10 years of follow- up and up to 39&#37; at 25 years of follow-up&#46;9&#44;17 Our study reports a series of nine patients with benign monoclonal gammopathy and renal involvement due to immunoglobulin deposition diagnosed by biopsy in whom no malignization occurred&#44; though the follow-up period was shorter &#40;4&#46;89 years &#177; SD 3&#46;69&#41;&#46; <br></br><br></br>The reason for renal involvement by monoclonal paraproteins is multifactorial and has not been fully elucidated yet&#46;18 While it is more commonly reported in the setting of already established malignant diseases such as myeloma or Waldenstr&#246;m disease&#44;1 renal involvement by LC deposition in gammopathies without hematological criteria of malignancy is not rare and has been reported in anecdotal cases&#44;5&#44;7&#44;8&#44;11 short series&#44; or in larger cohorts also including malignant cases&#46;10&#44;19 <br></br><br></br>Its systemic nature or its association to neuropathy or liver disease have sometimes been reported&#46;20&#44;21 Monoclonal immunoglobulin deposition diseases &#40;MIDD&#41; show a wide variety of glomerular and&#47;or tubular clinical presentations&#44; and also different pathological characteristics&#46;22 Histological findings differentiate three forms depending on the characteristics of the paraprotein deposited&#58; <br></br><br></br>1&#46; Light chains with immunofluorescence positive for kappa or lambda and an ultrastructure in the form of disorganized granular deposits&#46; This would correspond to the light chain deposition disease &#40;LCDD&#41; initially described by Randall&#46;23 These may coexist with deposition of whole immunoglobulins or heavy chains &#40;LHCDD&#41;&#44; <br></br>or heavy chains may only be detected &#40;HCDD&#41;&#46; <br></br>2&#46; Light chains with positive immunofluorescence&#44; usually associated to IgG and C3 and with an ultrastructure of <br></br>organized microtubules&#46; Controversy exists about whether two differentiated clinical and histological subforms <br></br>&#40;fibrillary and immunotactoid glomerulopathy&#41; exist or they are the same disease&#46;24 <br></br>3&#46; Light chain deposit positive to Congo red staining&#58; this corresponds to amyloid AL&#46; It is common in the setting of myeloma or with the clinical picture characteristic of primary amyloidosis&#46; Ultrastructurally&#44; they are organized as fibrils&#46; This variety may coexist with types 1 and 2&#44; but association is uncommon&#46;25 <br></br><br></br>The typical renal presentation of MIDD includes proteinuria&#44; hypertension&#44; and renal failure&#46; Renal failure was found in 88&#37; of our patients&#44; in agreement with other series where renal failure was reported to occur in 92&#37;-96&#37; of patients with pure MIDD&#46;6&#44;10&#44;26&#44;27 However&#44; almost 90&#37; of our patients initially had proteinuria in the nephrotic range&#44; as compared to only 48&#37;-57&#37; in other literature reports&#46; <br></br><br></br>Kappa chains are the light chains predominately deposited in the renal basal membrane&#44; and are identified in 73&#37;-90&#37; of cases&#46;6&#44;10&#44;26 In our series&#44; a similar proportion was found &#40;77&#37;&#41;&#46; <br></br><br></br>While the typical histological presentation is nodular glomerulosclerosis&#44; 1 there may be other presentation forms that should not deviate us from diagnosis&#46; Only four of our nine patients showed nodular glomerulosclerosis in renal histology&#46; <br></br><br></br>Age at diagnosis was similar in our patients to that reported by other authors&#44; approximately the sixth decade of life&#46;10&#44;28 <br></br><br></br>Treatment administered in idiopathic MIDD is usually similar to that given in cases of malignant disease&#58; prednisone&#47;melphalan &#40;the most common&#41; or prednisone&#47;chlorambucil or prednisone&#47;melphalan plus plasma exchange or bone marrow autotransplantation&#46;8 These treatments have been reported to be effective for both idiopathic forms and malignant conditions&#46; Although disappearance of the light chain deposit following chemotherapy has occasionally been reported&#44;1&#44;29 in the largest series stabilization or improvement only occurred in 62&#37;-65&#37; of patients with serum creatinine levels under 350 micromol&#47;L at treatment start&#44; and 82&#37; of patients with higher creatinine values progressed to end-stage renal disease despite treatment&#46;10&#44;27 The initial degree of renal failure&#44; age&#44; underlying hematological disease&#44; or extrarenal paraprotein deposition have also been reported to be prognostic factors&#46;19 Most our patients received steroids&#44; whether or not associated to melphalan&#46; Progression of renal disease was stopped in two patients&#44; and in the patient also treated with plasmapheresis&#44; renal function even improved and stabilized at 8 years of follow-up&#46; The lack of renal function improvement in all other patients was attributed to the advanced degree of renal failure&#46; Three of those patients had baseline creatinine levels higher than 350 micromol&#47;L&#46; <br></br><br></br>As regards proteinuria&#44; values decreased by up to 33&#37; after treatment in the Heilman series&#46; By contrast&#44; proteinuria decreased in more than 50&#37; of our patients&#46; Renal disease prognosis is poor according to Heilman&#44;10 with a five-year survival rate of approximately 37&#37;&#46; Our series showed a similar renal survival of approximately 33&#37;&#46; Unfortunately&#44; no conclusions may be drawn about efficacy with the different treatment regimens because of the small number of patients&#44; the lack of treatment standardization&#44; and the limited follow-up time&#46; <br></br><br></br>CONCLUSION <br></br><br></br>Monoclonal gammopathies&#44; while &#171;benign&#187;&#44; may be associated with renal involvement that may often be overlooked&#46; Renal biopsy plays a very significant role in diagnosis&#44; and it should be reminded that early diagnosis and treatment may improve prognosis&#46; Much larger multicenter studies would be required to establish the optimum therapeutic regimen&#46; <br></br><br></br>Based on the experience reported here and on the literature published&#44; the following considerations could be made&#58; <br></br><br></br>1&#46; That the benign nature of a monoclonal gammopathy does not exclude that it may be causing a secondary <br></br>renal impairment&#46; <br></br>2&#46; That no patient should therefore be diagnosed MGUS without a prior minimal renal study consisting of sediment&#44; <br></br>proteinuria&#44; and estimation of glomerular filtration rate and tubular function&#46; <br></br>3&#46; That&#44; if renal involvement is detected&#44; renal biopsy for verifying whether it is due to light chain deposition should be considered&#46; <br></br>4&#46; That&#44; if deposition is found&#44; chemotherapy should be considered&#44; because renal impairment usually progresses to end-stage renal failure and stabilization of the renal condition has been reported after treatment&#46; <br></br>"
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        "resumen" => "La nefropat&#237;a de las gammapat&#237;as monoclonales es debida principalmente al dep&#243;sito de cadenas ligeras&#46; Aunque se presenta sobre todo en cuadros malignos&#44; tambi&#233;n se ha descrito en pacientes cuya gammapat&#237;a es considerada &#171;benigna&#187;&#46; Se describen las caracter&#237;sticas cl&#237;nicas e histol&#243;gicas de 9 casos de nefropat&#237;a por dep&#243;sitos de cadenas ligeras diagnosticadas en el contexto de una gammapat&#237;a monoclonal sin datos de malignidad&#46; Tres hombres y seis mujeres con edad media de 59&#44;2 &#177; 12&#46; Todos los pacientes presentaban al diagn&#243;stico proteinuria y grados variables de insuficiencia renal con creatinina s&#233;rica media de 315 &#177; 187&#46; Dos requirieron di&#225;lisis desde el inicio&#46; La histolog&#237;a renal mostr&#243; patr&#243;n nodular en 4 casos&#44; mesangiocapilar en 3&#44; lesiones s&#243;lo tubulares en 1 y mesangial en otro&#46; Los dep&#243;sitos renales m&#225;s frecuentes fueron los constituidos por cadenas kappa &#40;67&#37;&#41;&#46; Los tratamientos aplicados fueron&#58; Prednisona en monoterapia &#40;tres casos&#41; o asociada a quimioterapia &#40;melfalan&#44; clorambucil o ciclofosfamid&#41;&#46; En dos casos se a&#241;adieron recambios plasm&#225;ticos o autotrasplante de m&#233;dula &#243;sea&#44; respectivamente&#46; Tras un seguimiento medio de 4&#44;89 &#177; DE&#58; 3&#44;69 a&#241;os observamos desaparici&#243;n de la proteinuria en m&#225;s del 50&#37; de los pacientes y estabilizaci&#243;n o mejor&#237;a de la funci&#243;n renal en 3&#46; Dos de ellos necesitaron terapia renal substitutiva desde el inicio y existi&#243; progresi&#243;n del fallo renal hasta los requerimientos dial&#237;ticos en los cuatro restantes&#46; En caso de gammapat&#237;a monoclonal&#44; incluso de car&#225;cter benigno&#44; debe buscarse una posible afectaci&#243;n renal&#46; La comprobaci&#243;n del dep&#243;sito renal de cadenas ligeras debe hacer plantearse un tratamiento precoz&#44; ya que la evoluci&#243;n a la insuficiencia renal terminal es frecuente&#46;"
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        "resumen" => "Renal involvement is observed frequently in association with malignant gammopathies&#44; mainly those related to light chain deposition&#44; although has also been described in non-malignant monoclonal gammopathy&#46; This study reports the clinicopathological findings and outcome in 9 patients with nephropaty secondary to monoclonal immunoglobulin deposit in absence of malignancy&#46; They were three men and six women and they were 59&#46;2 &#177; 12 years old&#46; All patients presented proteinuria and different levels of renal insufficiency &#40;mean creatinin &#61; 315 &#177; 187 micromol&#47;L&#41; at the moment of diagnostic&#46; Two patients required dialysis at the time of renal biopsy&#46; The pathology studies revealed a nodular sclerosing glomerulopathy in four cases&#44; mesangiocapilary glomerulonephritis in three cases&#44; only tubular lesions in one and mesangial lesions in the other one&#46; The treatment applied was&#58; Prednisone alone &#40;two cases&#41;&#44; with chemotherapy associated &#40;melfalan in two&#44; clorambucil in one and ciclophosphamide in another one&#41;&#46; One patient received plasmapheresis and mycophenolate and another patient undergone a bone marrow authotransplant associated to mycophenolate and prednisone&#46; One of the two patients who required dialysis at the moment of presentation was not treated&#46; After a follow-up of more than 4 years &#40;4&#46;89 &#177; DE&#58; 3&#46;69&#41; renal function improved or remained stable in three patients and proteinuria was dissapaired in more than 50&#37; of patients&#46; Four patients had a worsening of renal function and they required dialysis during the time of follow-up &#40;in 2&#46;4 years &#177; DE&#58; 4&#46;3&#41;&#46; In any case malignitation was observed&#46; Chemotherapy stabilized or improved renal function in 3 of nine patients &#40;33&#37;&#41; with non-malignant monoclonal gammopathy Non-malignant monoclonal gammopathy could go unnoticed&#46; Appearance of abnormalities in renal routine tests deserves more in-depth diagnostic procedures&#44; including renal biopsy&#46; Evolution to end stage renal disease could probably be avoided or reduced in severity with early detection and treatment of this entity&#46;"
      ]
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