Mechanisms of renal failure in plasma cell dyscrasias in Ig-dependent and -independent categories
| Ig-dependent mechanisms . | |
|---|---|
| Mechanism . | Details . |
| Cast nephropathy (myeloma kidney) | Risk factors include light chain myeloma with > 10 g/day of monoclonal Ig excretion, IgD myeloma, volume depletion, sepsis, medications (see “Medication toxicity” below) |
| MIDD | Often associated with kappa light chains. Systemic syndrome may be present. |
| AL amyloidosis | Often associated with nephrotic-range albuminuria and lambda light chains. Systemic syndrome may be present. |
| Glomerulonephritis | Membranoproliferative, diffuse proliferative, crescentic, cryoglobulinemic all recognized |
| Tubulointerstitial nephritis | May also result from non-Ig mechanisms. |
| Minimal change or membranous glomerulopathy | Albuminuria is typically present, in addition to light chain proteinuria |
| Henoch-Scholein purpura/IgA nephropathy | Associated with IgA myeloma |
| Immunotactoid and fibrillary glomerulopathy | Rare conditions |
| Intracapillary monoclonal deposits of IgM thrombi | Associated with Waldenström macroglobulinemia |
| TMA | Paraprotein causes endothelial injury with resulting TMA |
| Hyperviscosity syndrome | Most common with Waldenström macroglobulinemia |
| Ig-dependent mechanisms . | |
|---|---|
| Mechanism . | Details . |
| Cast nephropathy (myeloma kidney) | Risk factors include light chain myeloma with > 10 g/day of monoclonal Ig excretion, IgD myeloma, volume depletion, sepsis, medications (see “Medication toxicity” below) |
| MIDD | Often associated with kappa light chains. Systemic syndrome may be present. |
| AL amyloidosis | Often associated with nephrotic-range albuminuria and lambda light chains. Systemic syndrome may be present. |
| Glomerulonephritis | Membranoproliferative, diffuse proliferative, crescentic, cryoglobulinemic all recognized |
| Tubulointerstitial nephritis | May also result from non-Ig mechanisms. |
| Minimal change or membranous glomerulopathy | Albuminuria is typically present, in addition to light chain proteinuria |
| Henoch-Scholein purpura/IgA nephropathy | Associated with IgA myeloma |
| Immunotactoid and fibrillary glomerulopathy | Rare conditions |
| Intracapillary monoclonal deposits of IgM thrombi | Associated with Waldenström macroglobulinemia |
| TMA | Paraprotein causes endothelial injury with resulting TMA |
| Hyperviscosity syndrome | Most common with Waldenström macroglobulinemia |
| Ig-independent mechanisms . | |
|---|---|
| Mechanism . | Details . |
| Volume depletion or sepsis | Can cause acute tubular necrosis and/or precipitate cast nephropathy |
| Hypercalcemia | Can precipitate cast nephropathy |
| Tumor lysis syndrome | Uric acid or phosphate nephropathy |
| Medication toxicity | Zoledronate: acute renal failure |
| Pamidronate: collapsing focal segmental glomerulosclerosis | |
| Nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, loop diuretics, or IV contrast can precipitate cast nephropathy | |
| Direct parenchymal invasion by plasma cells | Associated with advanced or aggressive myeloma |
| Pyelonephritis | Immunodeficiency from myeloma, deficient Ig, and chemotherapy all contribute |
| Ig-independent mechanisms . | |
|---|---|
| Mechanism . | Details . |
| Volume depletion or sepsis | Can cause acute tubular necrosis and/or precipitate cast nephropathy |
| Hypercalcemia | Can precipitate cast nephropathy |
| Tumor lysis syndrome | Uric acid or phosphate nephropathy |
| Medication toxicity | Zoledronate: acute renal failure |
| Pamidronate: collapsing focal segmental glomerulosclerosis | |
| Nonsteroidal anti-inflammatory drugs, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, loop diuretics, or IV contrast can precipitate cast nephropathy | |
| Direct parenchymal invasion by plasma cells | Associated with advanced or aggressive myeloma |
| Pyelonephritis | Immunodeficiency from myeloma, deficient Ig, and chemotherapy all contribute |
Ig indicates immunoglobulin; MIDD, monoclonal Ig deposition disease; TMA, thrombotic microangiopathy; and IV, intravenous.