Cryoglobulinemic glomerulonephritis (CGN)

Transcription

1 KIDNEY BIOPSY TEACHING CASE Cryoglobulinemic Glomerulopathy Complicating Helicobacter pylori Associated Gastric Mucosa Associated Lymphoid Tissue Lymphoma Ammar Almehmi, MD, MPH, 1 and Timothy A. Fields, MD, PhD 2 INDEX WORDS: Cryoglobulin; glomerulonephritis; Helicobacter pylori; mucosa-associated lymphoid tissue (MALT); membranoproliferative; monocytes. Cryoglobulinemic glomerulonephritis (CGN) is highly associated with hepatitis C virus infection and results from the glomerular deposition of cryoprecipitable immune complexes known as cryoglobulins. The kidney disease causing cryoglobulins most commonly contain a mix of monoclonal immunoglobulin M (IgM) with rheumatoid factor activity and polyclonal IgG. Other etiologic factors may underlie this disease, including other infectious agents. This report reviews a case in which CGN was a presenting clinical manifestation of an occult Helicobacter pylori related mucosaassociated lymphoid tissue (MALT) lymphoma. The discussion highlights important clinical aspects and pathological findings in CGN, and a discussion of the pathophysiological state emphasizes both the direct effects of cryoglobulin deposition and the prominent role of monocyte recruitment in glomerular injury. Although H pylori associated lymphoma is a rare cause of CGN, it is important to consider it in patients presenting with cryoglobulinemia and kidney disease. CASE REPORT Clinical History A 66-year-old woman presented with a 7-month history of fatigue, arthralgias, and leg swelling. Physical examination showed blood pressure of 165/86 mm Hg, mild palpable From the 1 Department of Internal Medicine, Division of Nephrology, and 2 Department of Pathology and Laboratory Medicine and The Kidney Institute, The University of Kansas Medical Center, Kansas City, KS. Received November 17, Accepted in revised form April 28, Originally published online as doi: / j.ajkd on June 18, Address correspondence to Ammar Almehmi, MD, MPH, The Kidney Institute, The University of Kansas Medical Center, 3901 Rainbow Blvd, MS 3002, Kansas City, KS aalmehmi@kumc.edu 2009 by the National Kidney Foundation, Inc /09/ $36.00/0 doi: /j.ajkd purpura on the lower extremities, and 3 pitting edema to midthigh level. No organomegaly or lymphadenopathy was noted. Laboratory tests showed the following values: hemoglobin, 8.8 g/dl (88 g/l); white blood cell count, / L ( /L); platelets, / L ( /L); creatinine, 2.2 mg/dl (194 mol/l), with an estimated glomerular filtration rate of 24 ml/min/1.73 m 2 (0.40 ml/s/1.73 m 2 ); albumin, 2.2 g/dl (22 g/l); total protein, 5.6 g/dl (56 g/l), and microscopic hematuria and proteinuria (protein, 7 g/24 h). Serological workup showed positive rheumatoid factor (1:640), erythrocyte sedimentation rate of 55 mm/h, and decreased complement components C3 and C4 (C3, 32.7 mg/dl [0.327 g/l]; C4 1.7 mg/dl [ g/l]). Serum electrophoresis showed hypoalbuminemia, and immunofixation electrophoresis showed monoclonal IgM. Free light chain analysis showed an increased light chain level of 2.82 mg/dl (reference, 0.33 to 1.94 mg/dl) and normal light chain level at 1.09 mg/dl (reference, 0.57 to 2.63 mg/dl), with a / ratio of Serum CG precipitated at 4 C, with a cryocrit of 8%. Immunofixation electrophoresis of resuspended cryoprecipitate showed monoclonal IgM and polyclonal IgG (Fig 1). Hepatitis virus serological test results were negative, as were laboratory test results for antinuclear antibodies, antineutrophil cytoplasmic antibodies, and urine protein electrophoresis. A workup for anemia showed a positive test result for fecal occult blood, low serum iron level (20 g/dl [3.6 mol/l]), and iron saturation of 23%. The endoscopic gastric mucosal biopsy specimen was remarkable for the presence of H pylori and dense lymphoid infiltration of the lamina propria (Fig 2). Lymphoid cells were CD20- and Ig -positive (Fig 2), with coexpression of CD43 and Bcl2 (not shown). The diagnosis of extranodal marginal zone B-cell lymphoma of MALT type was made. No cytogenetic abnormalities were detected. A bone marrow biopsy specimen and aspirate showed normocellular marrow with no excess blasts or plasma cells. The patient was treated with rituximab and antibiotics for the H pylori infection. However, her kidney function continued to deteriorate and she required hemodialysis. The patient underwent ultrasoundguided kidney biopsy. Kidney Biopsy Light Microscopy Light microscopy showed 10 glomeruli, including 1 that was globally sclerotic. Most (7 of 9) of the remaining glomeruli showed lobular accentuation with global mesangioendocapillary proliferation (Fig 3A to C) associated with glomerular basement membrane reduplication (double con- 770 American Journal of Kidney Diseases, Vol 54, No 4 (October), 2009: pp

2 Cryoglobulinemic Glomerulonephritis 771 arrows), and C3 (not shown). There also was intraluminal staining for IgA (2 to 3 ), immunoglobulin and (2 to 3 ), and C1q (1 to 2 ; not shown). There was granular segmental capillary loop and mesangial staining for IgG (1 to 2 ; Fig 4A, arrowheads) and IgM (2 to 3 ; Fig 4B, arrowheads), as well as C3 (2 to 3 ), immunoglobulin (2 ), and immunoglobulin (trace to 1 ; not shown). Figure 1. Immunofixation electrophoresis of cryoprecipitate. The cryoprecipitate was resuspended in normal saline, processed by using agarose electrophoresis, and stained by using standard immunofixation techniques for immunoglobulin G (IgG), IgA, IgM, Ig, and Ig, as indicated. Single bands in the IgM and Ig lanes reflect the presence of monoclonal IgM, and the smear in the IgG lane is indicative of the presence of polyclonal IgG. The first lane contains serum as a standard. tours; Fig 3C, arrowheads). There were no crescents or tuft necrosis. Intracapillary leukocytes, mainly mononuclear cells, were noted. Some glomerular tufts contained amorphous, eosinophilic, periodic acid Schiff positive material filling the intraluminal space ( thrombi ; Fig 3A and B, arrows). Arteries and arterioles showed no evidence of vasculitis. Congo red stain was negative (not shown). Immunofluorescence Microscopy Immunofluorescence microscopy showed segmental 3 intraluminal staining for IgG (Fig 4A, arrows), IgM (Fig 4B, Electron Microscopy Transmission electron microscopy showed scattered electron-dense deposits that were predominantly subendothelial in location (Fig 4C and D, arrows). Occasional mesangial and very rare subepithelial deposits also were present. Some deposits showed a vague tubular substructure (Fig 4D, arrow). There was marked glomerular basement membrane reduplication (Fig 4C and D, arrowheads) and diffuse visceral epithelial cell foot-process effacement. No tubuloreticular inclusions were present. Diagnosis CGN secondary to type II cryoglobulinemia. Clinical Follow-up The hospital course was complicated by acute respiratory failure and atrial fibrillation with rapid ventricular response. Transthoracic echocardiography showed severe left ventricular dysfunction with an estimated ejection fraction of 30%. The patient declined further treatment and was discharged to hospice. DISCUSSION Cryoglobulinemia (CG) is characterized by the presence of circulating immunoglobulin that precipitates in cold temperature and resolubilizes upon warming to 37 C. 1 Although the term cryoglobulins was first used by Lerner and Watson 2 Figure 2. Light microscopic evaluation of the gastric mucosal biopsy specimen. (A) Hematoxylin and eosin stained section of gastric mucosal biopsy shows dense lymphoid infiltrate; (B) immunohistochemical stain for Helicobacter pylori shows organisms within and on the surface epithelium; (C) immunohistochemical stain shows CD20 expression in the lymphoid cells (brown); and in situ hybridization shows (D) immunoglobulin (Ig ) expression within most of the infiltrating lymphocytes (black) and (E) few scattered lymphoid cells expressing Ig (black).

3 772 Almehmi and Fields Figure 3. Light microscopy of the renal biopsy specimen shows membranoproliferative changes. (A) Hematoxylin and eosin, (B) periodic acid Schiff, and (C) Jones silver-stained images of glomerulus show endocapillary proliferation with lobular accentuation, capillary thrombi consisting of cryoglobulins (arrows), and thickened capillary loops with double contours (arrowheads). The bar represents 25 m. in 1947, Wintrobe and Buell 3 described a case of myeloma with cryoprecipitable serum in Until the late 1980s, the underlying cause of the CG was undetermined in approximately 30% of cases; this subset of CG has been referred to as primary or essential CG. 4 Secondary CG is associated with a particular underlying disease, including lymphoproliferative, autoimmune, and infectious diseases. Since the early 1990s, many cases of CG have been linked to hepatitis C virus infection. Consequently, the number of cases classified as essential CG has decreased significantly. 5 Immunologic characterization of CG is helpful for diagnostic and prognostic purposes. In 1974, Brouet et al 6 classified CG into 3 types based on the content of immunoglobulin in the cryoprecipitate. In sum, type I CG is a monoclonal disorder typically associated with underlying lymphoproliferative disease. Types II and III CG show mixed CGs, ie, containing a mixture of an anti-igg (rheumatoid factor) and polyclonal IgG, and often are associated with infections or autoimmune diseases. In type II CG, the anti-igg is a monoclonal IgM, typically, and in type III CG, the anti-igg is polyclonal IgM. The classic presentation of purpura, weakness, and arthralgia (Meltzer s triad) 7 with renal involvement is more common in mixed CG, Figure 4. Renal biopsy specimen using immunofluorescence and electron microscopy. Immunofluorescence microscopy shows intense segmental deposits of (A) immunoglobulin G (IgG) and (B) IgM, corresponding to the large glomerular intracapillary cryoglobulins (arrows) and granular subendothelial deposition of immune complexes within capillary loops (arrowheads). The bar represents 50 m. (C, D) Electron microscopy shows subendothelial deposit (arrows) and glomerular basement membrane reduplication (arrowheads). (D) The large deposit shows a vaguely organized tubular substructure (original magnification: [C] 7,100; [D] 22,000).

4 Cryoglobulinemic Glomerulonephritis 773 whereas type I CG more commonly presents with complications related to hyperviscosity. 5,8,9 Kidney involvement in CG is seen in approximately 20% of patients at the time of diagnosis 5 and is most common in type II CG, especially when circulating monoclonal IgM is present. 6 Most cases of CGN are diagnosed in the fifth and sixth decades of life, with more women being affected than men. 10 The most common kidney findings include hematuria (41%), nephrotic syndrome (21%), acute nephritis (14%), chronic kidney disease (12%), and acute kidney failure (9%). 4 The time between disease onset and kidney manifestation is approximately 2.5 years. 4 Arterial hypertension is seen in more than 80% of patients at the time of onset of the kidney disease. 10,11 The classic pathological finding on light microscopy is a membranoproliferative glomerulonephritis pattern with intraluminal thrombi, as described in this patient. 11 Immunofluorescence staining typically shows intraluminal material and discontinuous granular staining of peripheral capillaries for the same immune components present in cryoglobulins. 1,11 Furthermore, electron microscopy predominantly shows subendothelial and intraluminal deposits, some with an approximately 25- to 30-nm diameter tubular substructure. 12 Although the majority of patients with CG have no symptoms, affected patients, especially with mixed CG, tend to develop signs and symptoms related to vasculitis. The frequency of extrarenal signs and symptoms in patients with detectable disease has been reported: cutaneous purpura (95%), arthralgia (85%), fever (60%), hepatosplenomegaly (95%), neuropathy (40%), and abdominal pain (30%). 13 The association between hepatitis C virus infection and CGN has been well documented 14 ; however, a connection between H pylori infection and CGN has been reported only rarely. 15 Chronic gastric infection with H pylori can result in the production of circulating mixed cryoglobulins in more than 40% of infected patients, but these cryoglobulins typically do not cause symptoms. 16 Sustained antigenic stimulation by H pylori can lead to lymphoid transformation and the development of gastric MALT lymphoma, 17 which can produce monoclonal cryoprecipitable immunoglobulin. 15 In this case, a monoclonal IgM with rheumatoid factor activity was produced, resulting in mixed (type II) CG capable of causing kidney injury. Notably, the other reported patient with H pylori associated CGN showed gastric MALT lymphoma and an associated monoclonal immunoglobulin as a component of a mixed CG. 15 Two other cases of CG associated with MALT lymphoma have been reported, 18,19 although only 1 patient showed evidence of CGN. 19 In that case, the patient s lymphoma was in the small intestine, and there was a concurrent Ascaris lumbricoides infection. 19 As with other causes of CGN, the pathogenesis of H pylori associated CGN is related to B-cell synthesis of cryoglobulins. 20 Circulating cryoglobulins escape the mononuclear phagocytic clearing system and deposit in glomeruli, 21 with particular affinity for the mesangial matrix. 14 These deposits interact with mesangial and endothelial cells, leading to a sequence of signaling events that results in proliferation, leukocyte (especially monocyte) infiltration, and glomerular basement membrane injury. 14,22 Studies have implicated a number of molecules as mediators of these pathological events. Recently, CGN animal models showed that mesangial cells upregulate expression of important mediators of glomerular injury, including tissue plasminogen activator, plasminogen activator inhibitor-1, and transforming growth factor. 23 In addition, podocyte upregulation of Toll-like receptor 4 in CGN may be important in monocyte recruitment and activation. 20 Although complement fixation is postulated to be important for injury in many types of glomerulonephritis, 24 animal studies have suggested that complement activity may not be critical for CGN. 25 Nuclear factor- B may be involved in CGN pathogenesis because incubation of mesangial cells with immunoglobulin light chains results in nuclear factor- B activation and induction of target genes, including the potent and specific chemoattractant monocyte chemotactic peptide-1 (MCP-1). 22,26 Monocytes are believed to be critical in the pathogenesis of CGN. Of glomerulonephritides, CGN typically shows the highest number of glomerular monocytes, and the extent of infiltration is directly proportional to proteinuria. 27 Glomerular MCP-1 expression is increased in CGN and accompanied by increased urinary MCP Glomerular MCP-1 can recruit monocytes into sites of CG deposition, 28 where it is postulated that these leukocytes bind immune complexes

5 774 through surface Fc receptors 29 and release reactive oxygen species and lysosomal enzymes that cause glomerular injury. 27,28,30 ACKNOWLEDGEMENTS We thank Drs Lowell Tilzer and David N. Howell for helpful discussions and Christy Stevenson for preparing the electron microscopy and immunofluorescence images. Support: This work was supported by a research fellowship from the National Kidney Foundation. Financial Disclosure: None. REFERENCES 1. D Amico G, Fornasieri A: Cryoglobulinemic glomerulonephritis: A membranoproliferative glomerulonephritis induced by hepatitis C virus. Am J Kidney Dis 25: , Lerner AB, Watson CJ: Studies of cryoglobulins. I. Unusual purpura associated with the presence of high concentration of cryoglobulin (cold precipitable serum globulin). Am J Med Sci 214: , Wintrobe MM, Buell MV: Hyperproteinemia associated with multiple myeloma. 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