Kidney Res Clin Pract > Volume 43(2); 2024 > Article
Park, Ryou, Chae, Kim, Lee, Kim, Choi, and Park: Rapidly progressive glomerulonephritis in the elderly: a case of cryoglobulinemic glomerulopathy not to be overlooked
In very elderly patients (older than 80 years), the primary cause of rapidly progressive glomerulonephritis (RPGN) is pauci-immune necrotizing glomerulopathy, followed by anti-glomerular basement membrane (GBM) disease, amyloidosis, light-chain cast nephropathy, and focal segmental glomerulosclerosis [1]. Cryoglobulinemic glomerulopathy (CG), a subtype of monoclonal gammopathy of renal significance (MGRS), is a very rare kidney disease with unknown incidence and prevalence [2]. Type 1 CG mainly consists of monoclonal immunoglobulin (mIg), mostly IgM. It is associated with plasma cell disorders while type II and III CG are classified as mixed cryoglobulinemia, including both IgG and IgM [2,3]. MGRS is characterized by the proliferation of B lymphocytes or small plasma cell clones producing mIg and its components (light or heavy chains) [2,3]. Most kidney diseases associated with MGRS are glomerular disorders with light-chain proximal tubulopathy and crystal-storing histiocytosis [3] classified by mIg deposits’ characteristics on electron microscopy. MGRS is defined as nephrotoxic mIg deposition in the kidney that can lead to acute kidney injury [4,5]. Proactive etiological evaluation through kidney biopsy is required for MGRS presenting with RPGN features, as the treatment should be determined by the nature of the clone producing nephrotoxic mIg [6]. We report a case of MGRS associated with type I CG in an elderly patient with diabetic nephropathy demonstrating a distinct RPGN pattern.
An 86-year-old female patient was referred from a local clinic due to uncontrolled generalized edema. The patient’s significant medical history included 7 years of diabetes and hypertension, both managed with medication. She reported the use of diuretics prescribed at a private clinic for a month without achieving control of her edema. One month prior, her serum creatinine level was 1.07 mg/dL and her estimated glomerular filtration rate was 47 mL/min/1.73m2. She appeared to be in good health except for presenting with grade 4 edema in both legs. Upon admission, her serum creatinine had risen to 2.36 mg/dL (Table 1). Initially, her albumin/globulin (A/G) ratio showed a reversal at 0.89. Serum electrophoresis did not show a monoclonal peak with increases in alpha 1/2 and beta 2 fractions (Fig. 1A). Serum immuno-fixation electrophoresis also showed a normal immune typing pattern. Her serum cryoglobulin was negative. Autoimmune tests were negative for anti-GBM antibody (Ab), anti-proteinase 3 Ab, and anti-myeloperoxidase Ab. Despite treating the edema with diuretics, there was no improvement. Renal ultrasound and computed tomography revealed decreased sizes of both kidneys with echogenicity consistent with renal parenchymal diseases (Fig. 1C). Kidney biopsy was delayed due to the patient’s advanced age, existing diabetic kidney disease, and aspirin use. However, as there was no response to steroid treatment and RPGN was clinically suspected, a kidney biopsy was eventually performed. The kidney biopsy revealed type I CG combined with diabetic nephropathy that was consistent with membranoproliferative glomerulonephritis characterized by increased mesangial matrix and cellularity having lobular accentuation and hyaline intraluminal thrombi (Fig. 1D). Immunofluorescence microscopy showed intraluminal staining for Ig lambda (Fig. 1E), but not kappa (not shown). There also was intraluminal staining for C1q and a predominance of IgM (Figs. 1F, G, respectively). Electron microscopy revealed that some tubular basement membranes were thickened and multilayered. The interstitium exhibited edema and infiltration by inflammatory cells (Figs. 1H, I). Bone marrow biopsy demonstrated no evidence of monoclonal hematologic disease (Fig. 1J). Since initiating continuous renal replacement therapy (CRRT) due to her rapid deterioration of renal function with metabolic acidosis and oliguria, the patient’s condition continued to worsen throughout her admission.
Despite treatment with CRRT, plasmapheresis, and pulse methylprednisolone, her renal function, hematologic anomalies, and systemic condition deteriorated further (Fig. 1B). This report was approved from the Institutional Review Board of the Catholic University of Korea, Seoul St. Mary's Hospital (No.KC23ZASI0826). Written informed consent was obtained from the patient for the publication of this report including all clinical images.
For MGRS-related diseases, clone-directed therapy such as bortezomib and ofatumumab, which were not prescribed in this patient, would have resulted in better outcomes than high-dose prednisolone treatment [6]. In this report, we diagnosed MGRS with type 1 CG presenting with intractable edema, a reversed serum A/G ratio, and a full-fledged nephrotic syndrome, which led to renal failure and ultimately the patient’s death. Recognizing MGRS is crucial for managing end-organ damage and improving patient survival, potentially leading to better treatments with fewer adverse effects, even in very old patients [1]. Early diagnosis is key to successfully treating RPGN, including MGRS. However, this can be particularly challenging in the elderly, especially for those with hypertension and diabetes as these patients often present with typical or minimal clinical symptoms [7]. The diagnosis may be challenging because the hallmark of cryoglobulinemia is the detection of cryoglobulins in the serum. However, cases of CG without serological evidence of cryoglobulins are often diagnosed by anatomopathological findings in renal biopsy [8].
In conclusion, our case report emphasizes the importance of considering MGRS as a potential cause of RPGN in elderly patients, even if they have underlying renal diseases. It underscores the significance of conducting a kidney biopsy to accurately determine the cause of kidney injury, thereby facilitating proper and timely treatment.

Notes

Conflicts of interest

All authors have no conflicts of interest to declare.

Data sharing statement

The data presented in this study are available upon reasonable request to the corresponding author.

Authors’ contributions

Conceptualization, Data curation: HP, CWP

Methodology: SR, SYC, EAK, JMK, YK, YJC

Writing–original draft: HP

Writing–review & editing: All authors

All authors read and approved the final manuscript.

Figure 1.

Comprehensive clinical and pathological profile of the patient.

(A) Serum electrophoresis does not show a monoclonal peak. (B) The clinical course of the patient. (C) Abdominal computed tomgraphy scan shows decreased sizes of both kidneys (right, 9.6 × 5.6 cm and left, 9.0 × 4.5 cm) with irregular contours, indicating chronic renal parenchymal disease. Kidney biopsy reveals (D) type I cryoglobulinemic glomerulopathy combined with diabetic nephropathy, consistent with membranous proliferative glomerulonephritis characterized by increased mesangial matrix and cellularity having lobular accentuation and hyaline intraluminal thrombi (×400). (E) Immunofluorescence microscopy (×400) shows intraluminal staining for immunoglobulin lambda. (F) Intraluminal staining for C1q (×400). (G) Predominant IgM is observed (×400). (H, I) Electron microscopy (×6,000) reveals thickened and multilayered tubular basement membranes (I, arrow). The interstitium shows edema and infiltration of inflammatory cells. (J) CD138-stained bone marrow slide (×20) exhibits a hypo-cellular pattern with plasma cells accounting for approximately 3% of all nucleated elements, slightly elevated compared to the normal range of 0% to 1%. However, it does not meet the criteria for plasma cell myeloma or other B cell/plasma cell proliferative disorders. No evidence of amyloidosis or kappa, lambda restriction was found in the bone marrow examination.
A/G, albumin/globulin; BM, bone marrow; Cr, creatinine; CRRT, continuous renal replacement therapy; H&E, hematoxylin and eosin; IgM, immunoglobulin M; LDH, lactate dehydrogenase; MPD, methylprednisolone; PD, prednisolone; PLT, platelet; PP, plasmapheresis.
j-krcp-23-332f1.jpg
Table 1.
Laboratory findings of the patient on admission
Laboratory test Value Reference
Hemoglobin (g/dL) 9.6 12.0–16.0
Hematocrit (%) 29.9 34.0–49.0
White blood cell (×106/L) 6,150 4,000–10,000
Platelet (×109/L) 184 150–450
Blood urea nitrogen (mg/dL) 47.4 6.0–20
Creatinine (mg/dL) 2.36 0.5–0.9
Sodium (mmol/L) 140 136–145
Potassium (mmol/L) 4.7 3.5–5.1
Chloride (mmol/L) 108 98–110
Calcium (mg/dL) 7.7 8.6–10.2
Total protein (g/dL) 5.1 6.6–8.7
Albumin (g/dL) 2.6 3.5–5.2
Alkaline phosphatase (U/L) 107 35–104
Aspartate aminotransferase (U/L) 23 0–32
Alanine aminotransferase (U/L) 15 0–33
Lactate dehydrogenase (U/L) 242 0–250
Parathormone (pg/mL) 106 15–65
Vitamin D 25 OH (pg/mL) 20.89 19.9–79.3
IgG (mg/mL) 547 700–1,600
IgM (mg/mL) 102 40–230
IgA (mg/mL) 244 70–400
Kappa lambda ratio 0.63 0.26–1.65

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