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  Table of Contents    
ORIGINAL ARTICLE  
Year : 2011  |  Volume : 54  |  Issue : 1  |  Page : 55-58
Light chain immunofluorescence in various nephropathies


1 Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad - 500 082, Andhra Pradesh, India
2 Department of Nephrology, Nizam's Institute of Medical Sciences, Hyderabad - 500 082, Andhra Pradesh, India

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Date of Web Publication7-Mar-2011
 

   Abstract 

Context: Light chain immunofluoresence (IF) in renal biopsy is routinely used in the diagnosis of light chain deposition disease (LCDD), amyloidosis and cast nephropathy. Light chain predominance has also been reported in certain glomerulopathies like IgA nephropathy. However, pathogenesis of this pattern of deposition in various glomerulopathies is uncertain. Aim: To discuss the pathogenesis and utility of light chain IF in nephropathies. Setting and Design: Retrospective study. Materials and Methods: The pattern of light chain IF and light microscopic diagnosis in 306 cases of various nephropathies was reviewed. Direct IF was done in all these cases with commercial fluorescence (Fluoresciene Isothiocynate ) conjugated polyclonal rabbit anti-human antisera against IgM, IgG, IgA, C3, C1q, kappa and lambda light chains. Results: Light chain deposits were seen in 240 (78.43%) cases. In IgA nephropathy, lupus nephritis and post-infectious glomerulonephritis (PIGN), lambda positivity was more as compared to kappa. Light chain deposits in LCDD and membranous nephropathy were more kappa type. The IF pattern in amyloidosis was not consistent. Conclusion: The pathogenesis of light chain predominance in glomerulopathies is not clear and it depends on isoelectric point and size of the immune complex. Light chain IF should be performed routinely in all the renal biopsies.

Keywords: Glomerulopathy, immunofluorescence, light chain immun-ofluorescence, pathogenesis, renal biopsy

How to cite this article:
Uppin MS, Prayaga AK, Srinivas B H, Rapur R, Desai M, Dakshina Murthy K V. Light chain immunofluorescence in various nephropathies. Indian J Pathol Microbiol 2011;54:55-8

How to cite this URL:
Uppin MS, Prayaga AK, Srinivas B H, Rapur R, Desai M, Dakshina Murthy K V. Light chain immunofluorescence in various nephropathies. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Dec 16];54:55-8. Available from: http://www.ijpmonline.org/text.asp?2011/54/1/55/77325



   Introduction Top


Light chain immunoflurosence (IF) in renal biopsy is routinely used in the diagnosis of light chain deposition disease (LCDD), amyloidosis and cast nephropathy. Apart from these, presence of light chains, particularly the lambda light chains, has been demonstrated in IgA nephropathy. [1] Orfila et al. [2] have demonstrated the presence of kappa and lambda chain deposits in lupus nephritis, membranous nephropathy and endocapillary proliferative glomerulonephritis (GN). The pathogenesis of light chain deposits in these glomerulopathies is uncertain. In our institute, light chain IF is routinely performed for all the renal biopsies. In the present study, we report our IF findings of light chain deposits in 306 cases of various nephropathies. This is a retrospective study to evaluate the pathogenesis and utility of light chain IF in the diagnosis of various glomerulopathies.


   Materials and Methods Top


All the renal biopsies from January 2006 to October 2009 were included in the study. Clinical data including presenting features and relevant investigations were obtained from medical records. The light microscopic features of all the cases were reviewed [hematoxylin and eosin (H and E), per-iodic acid Schiff stain (PAS), Masson Trichrome and Silver methanamine]. Direct IF was done in all these cases with commercial fluorescence (FITC) conjugated polyclonal rabbit anti-human antisera against IgM, IgG, IgA, C3, C1q, kappa and lambda light chains (DakoCytomation Lab ,Copenhagen, Denmark). The slides were incubated with appropriate antisera for 30 minutes and then wet mounted with nonfluorescence mounting medium. The slides were examined under Nikon microscope with ultraviolet light of 420 nm wavelength. The fluorescence intensity was graded from 0 to 3+ for each type of antibody. The IF findings were noted in the cases of IgA nephropathy, lupus nephritis, membranous nephropathy, post-infectious GN (PIGN), membrano-proliferative GN, amyloidosis, LCDD and myeloma cast nephropathy. By light microscopy and IF, the changes observed in glomerulopathies were characteristic for each diagnostic category. Electron microscopy was not done in any of the cases.


   Results Top


The study included a total of 306 cases. The positivity for light chains was observed in 240 (78.43%) cases. Of these, kappa and lambda chains were present in 85.8 and 90.4% cases, respectively. Twenty-seven cases were monotypic for kappa light chains and 38 cases were monotypic for lambda light chains. The light chain IF findings in each category along with clinical parameters are summarized in [Table 1]. There is no significant difference in the distribution of light chains with clinical presentation, except lambda light chain positivity which was more frequent with nephritic presentation (42%).
Table 1: Details of light chain IF and clinical parameters in various nephropathies

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Chart 1 shows age distribution with light chain positivity. According to the chart pattern, the monoclonal pattern (either kappa or lambda) is more frequent with increasing age. Chart 2 shows distribution of light chains based on gender. It was seen that k + l and l chains were more frequent in females than males. Most of the female patients with k and l positivity were of lupus nephritis.

In IgA nephropathy, mesangial positivity for light chains was seen in (38/58) 65.5% cases [Figure 1]. Of the 16 cases, where both kappa and lambda were positive, the intensity for lambda light chains was stronger in 6 cases. PIGN showed positivity in 27.9% cases. Positivity for lambda chain (81.8%) was more frequent than kappa chains (72.2%). In contrast, in membranous nephropathy, kappa positivity was more frequent than lambda [Figure 2]. Lupus nephritis showed mesangial and granular basement membrane deposits of light chains in 89.9% cases. Lambda light chains were more intense and frequent than kappa. Isolated lambda deposits were seen in seven cases, whereas none of the cases showed isolated kappa deposition.
Figure 1: Mesangial staining in IgA nephropathy; anti-lambda (IF, ×200)

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Figure 2: Granular staining along the basement membrane in membranous nephropathy; anti-kappa (IF, ×200). Inset: Higher magnification of the same

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Of the nine cases of amyloidosis, two each showed monotypic positivity for kappa and lambda chains [Figure 3]. Three of the cases showed positivity for both the chains in equal intensity, whereas three other cases were both negative. Immunohistochemistry was not available to classify it as Amyloid associated (AA) and AMyloid light chain (AL) amyloidosis. All the patients of amyloidosis were elderly (age group 37-65 years) and presented as nephrotic syndrome. Two of the patients had past history of tuberculosis (TB) and two other were on treatment for rheumatoid arthritis (RA).
Figure 3: Nodular deposits in amyloidosis; anti-lambda (IF, ×400)

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Light chain deposits in LCDD were more of kappa type. Of these five cases, the characteristic nodular glomerulosclerosis was seen in four patients, whereas one patient showed only mesangial expansion. The diagnosis was made on the basis of IF and bone marrow findings which showed plasmacytosis. The casts of myeloma kidney were positive for both kappa and lambda light chains [Figure 4].
Figure 4: Myeloma cast nephropathy showing positivity for the tubular casts; anti-lambda (IF, ×400)

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   Discussion Top


Light chains are polypeptides synthesized by plasma cells and assembled with heavy chains to form the various classes of immunoglobulins. Kidney is the major site for catabolism of these chains as they pass through glomeruli and are reabsorbed by tubular epithelium.

The isoelectric point (pI) of the light chain may be an important determinant of its potential for inducing renal damage. These light chains have a cationic charge at acidic urine pH in the distal nephron. This allows them to interact with anionic Tamm-Horsfall mucoprotein, thereby forming obstructing casts. [3] This explains the deposition of light chains in LCDD and myeloma. [4] However, the pathogenesis of their deposition in other glomerulopathies is not clear. The presence of predominant lambda chain deposition in IgA nephropathy has been well described in literature. [1],[5] Our findings are in concordance with these studies.

The normal serum kappa/lambda ratio is 2:1, and technically, kappa chain deposits are expected predominantly. But the contradictory findings are attributed to differences in multimeric nature, size of immune complexes and anionic charge. [6]

Light chain deposits in other nephropathies have been mentioned by a few authors. [2],[5],[7] However, the results in these studies are not consistent. Orfila et al.[2] showed predominant kappa positivity in membranous GN, whereas equal positivity was mentioned by Lai et al. [5] In contrast; we found that kappa chain deposition is more frequent than that of lambda chain. This can be explained by the normal kappa predominance in serum. The presence of monotypic kappa positivity could indicate an underlying fibrillary GN in these cases. Fibrillary GN is known to have isolated membrane thickening and electron microscopic investigation is necessary for confirming the diagnosis. [8] Moreover, a diagnosis of amyloidosis also needs to be ruled out with monotypic lambda chain positivity with membranous pattern on light microscopy. However, the granular positivity along the basement membrane, as seen in our cases, is more in favor of primary membranous GN than amyloidosis.

We observed predominant lambda light chain deposits in lupus nephritis. These findings are in agreement with those of Orfila et al[2] and Lai et al. [5]

Cases of PIGN showed predominant lambda positivity in our study. This is comparable to the findings of Lai and contrary to the observation of Orfila et al.[2] who observed predominant kappa staining.

Proliferative GN with monoclonal immunoglobulin deposits is a recently described entity. [8] The light microscopic pattern can be in the form of endocapillary proliferation, membranoproliferative glomerulonephritis (MPGN) or membranous GN. However, there is a distinct EM pattern for each of these with IF deposition of a subtype light chain. Our investigations are incomplete to subclassify similar cases in the present study into this particular category.

There was no consistent pattern of light chain IF in amyloidosis. The same has been documented in literature. [9],[10] Four patients had prior history of chronic disease (TB and RA) which suggests that the amyloidosis was of secondary type. The routine IF does not necessarily distinguish AL from AA type of amyloidosis. Nonspecific staining for light chains can be seen in AA amyloid, and AL type does not always show predominance of one type of light chains. [10] So, immunohistochemistry is mandatory to distinguish primary from secondary amyloidosis.

The present study carries certain drawbacks including absence of EM findings, serum levels of light chains and follow-up clinical data. This is a limitation to arrive at a complete diagnosis in each of the cases showing monoclonal light chain deposition.

The findings of our study support the pathogenetic aspects of light chain deposition in various glomerulopathies. In the absence of IF, a light microscopic diagnosis of LCDD is not possible. One can argue about its utility in specific entities like systemic lupus erythematosus (SLE) and IgA nephropathy in poor resource settings.

In the present study, monoclonal light chain positivity with kappa is seen in males and with lambda in females more frequently. The frequency of lambda light chains in females could be due to more number of cases of lupus nephritis with lambda positivity. The frequency of positivity is more in age group more than 50 years. All the LCDD patients presented with nephritic features. Based on the study, we can suggest that it is prudent to include light chains in IF panel for all the renal biopsies in patients more than 50 years of age with nephritic presentation. Failure to include will result in missing LCDD in these patients.

 
   References Top

1.Lai KN, Chui SH, Lai FM, Lam CW. Predominant synthesis of IgA with lambda light chain in IgA Nephropathy. Kidney Int 1988;33:584-9.  Back to cited text no. 1
[PUBMED]    
2.Orfila C, Rakotoarivony J, Manuel Y, Suc JM. Immunofluoresence characterization of light chains in human nephropathies. Virchows Archiv A Pathol Anat Histopathol 1988;412:591-4.  Back to cited text no. 2
    
3.McKenzie JK, McQueen EG. Immunofluorescence localization of Tamm-Horsfall mucoprotein in human kidney. J Clin Pathol 1969;22:334-9.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Rao TK, Nicastri AD, Chen CK, Rosenthal J, Brown C, Delano BG, et al. Membranoproliferative glomerulonephritis (MPGN) an unusual manifestation of multiple myeloma. Kidney Int 1978;14:659.  Back to cited text no. 4
    
5.Lai KN, Chan KW, Mac-Moune F, Ho CP, Yan KW, Lam CW, et al. The immunochemical characterization of the light chains in the mesangial IgA deposits in IgA nephropathy. Am J Clin Pathol 1986;85:548-51.  Back to cited text no. 5
[PUBMED]    
6.Monteiro RC, Halbwachs-Mecarelli L, Roque-Barreira MC, Noel L-H, Berger J, Lesavre P. Charge and size of mesangial IgA in IgA nephropathy. Kidney Int 1985;28:666-71.  Back to cited text no. 6
    
7.Herdman RC, Hong R, Michael AF, Good RA. Light chain distribution in immune deposits on glomeruli of kidneys in human renal disease. J Clin Invest 1967;46:141-6.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Samih H, Nasr SH, Satoskar A, Markowitz GS, Valeri AM, Appel GB, et al. Proliferative Glomerulonephritis with Monoclonal IgG Deposits. J Am Soc Nephrol 2009;20:2055-64.  Back to cited text no. 8
    
9.Alpers CE, Rennke HG, Hopper J Jr, Biava CG. Fibrillary glomerulonephritis: An entity with unusual immunofluorescence features. Kidney Int 1987;31:781-9.  Back to cited text no. 9
[PUBMED]    
10.Satoskar AA, Burdge K, Cowden DJ, Nadasdy GM, Heber LA, Nadasdy T. Typing of Amyloidosis in Renal Biopsies Diagnostic pitfalls. Arch Pathol Lab Med 2007;131:917-22.  Back to cited text no. 10
    

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Correspondence Address:
Megha S Uppin
Department of Pathology, Nizam's Institute Medical Sciences, Hyderabad - 500 082, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.77325

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