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SUPRATECH MICROPATH
LABORATORY & RESEARCH INSTITUTE
Case -7
Dr. BHAVANA MEHTA
Consultant pathologist
Supratech micropath laboratory and
research institute, Ahmedabad
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
Clinical details
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38 yrs, male
Renal transplant-5 yrs back
On cyclosporin ,Azoran, steroids
S cr- gradually increased upto 3.0,
urine protein++
• Renal biopsy done
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
CASE 1
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CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
•
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
•
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
•
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
Provisional Diagnosis
Post transplant myeloma cast
nephropathy
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
Why cast nephropathy in post Tx
Allograft nephropathy
ARF
Drug related cast
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
Pathogenesis of myeloma cast
nephropathy
 Common in multiple myeloma
 Due to over production and precipitation of light
chain
 Resistant to degradation due to structural changes
 Increased urinary calcium due to hypercalcemia
 Acute renal failure due to other disease (volume
depletion
 Drug related –loop diuretics by increasing luminal
NaCl
 Radiocontrast media interacting with light chains
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
What are myeloma casts?
• Precipitated light chains in distal and
collecting tubules +other filtered
proteins+Tamm-Horsfall mucoprotein
which a protein normally secreted by cells
of thick ascending loop of Henle and
constitute matrix of all urinary casts
• Disruption of BM of tubule-leakage-cellular
reaction
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
Other disease with myeloma
casts
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Acinar cell carcinoma, pancreas
Waldenstrom macroglobulinemia
B cell lymphomas
Thyroid carcinoma
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
History retrieved
•H/o basic disease-Myeloma kidney
diagnosed in 2001
•Urine-Bence John’s protein present
•Protein electrophoresis –M band
present
CME on Renal Pathology,
17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
Final diagnosis
 Relapse of myeloma cast nephropathy,
renal graft.
Donor-sister
No family history
Post transplant period-no problem till 5
yrs
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
Post Tx myeloma cast
nephropathy
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Usually Tx not considered in myeloma pt.
Becasuse of risk of recurrence & relapse
If in remission for 1 yr, considered for Tx
Usually recurrence noted within 2 yrs
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
Post Tx myeloma cast
nephropathy
• One case reported in early transplant period
associated with thrombotic microangiopathy
• Upto 10 cases of MM and few with AL
amyloidosis received Tx- more post Tx
mortality
• With recent treatments available for MMBetter post Transplant period
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
Reasons to present this case
Young Patient to have MM
No Bone marrow involvement
Intraabdominal mass-reported as Multiple
myeloma
Late graft dysfunction-5 yrs
Presently on Thalidomide and doing well
patient
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008
CME on Renal Pathology, 17th December 08, Pune
Indian Society of Renal and Transplantation Pathology in collaboration with Indian Society of Nephrology (ISN) -ISNCON 2008