cme on renal pathology, 17th december 08, pune indian society of renal and transplantation pathology...

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 -7

Dr. BHAVANA MEHTA

Consultant pathologist

Supratech micropath laboratory and

research institute, Ahmedabad

SUPRATECH MICROPATH

LABORATORY & RESEARCH INSTITUTE



Clinical details

• 38 yrs, male

• Renal transplant-5 yrs back

• On cyclosporin ,Azoran, steroids

• S cr- gradually increased upto 3.0, urine protein++

• Renal biopsy done



CASE 1

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Provisional Diagnosis

Post transplant myeloma cast nephropathy



Why cast nephropathy in post Tx

Allograft nephropathyARFDrug related cast



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



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



Other disease with myeloma casts

• Acinar cell carcinoma, pancreas

• Waldenstrom macroglobulinemia

• B cell lymphomas

• Thyroid carcinoma



History retrieved

•H/o basic disease-Myeloma kidney diagnosed in 2001

•Urine-Bence John’s protein present

•Protein electrophoresis –M band present



Final diagnosis

Relapse of myeloma cast nephropathy, renal graft.

Donor-sisterNo family historyPost transplant period-no problem till 5

yrs



Post Tx myeloma cast nephropathy

• 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



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 MM- Better post Transplant period



Reasons to present this case

Young Patient to have MMNo Bone marrow involvementIntraabdominal mass-reported as Multiple

myelomaLate graft dysfunction-5 yrsPresently on Thalidomide and doing well

patient

cme on renal pathology, 17th december 08, pune indian society of renal and transplantation pathology...

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