Randall-type monoclonal immunoglobulin deposition disease: novel insights from a nationwide cohort study

Monoclonal immunoglobulin deposition disease (MIDD) is a rare complication of B-cell clonal disorders, defined by Congo-red negative deposits of monoclonal light chain (LCDD), heavy chain (HCDD), or both (LHCDD). MIDD is a systemic disorder with prominent renal involvement but little attention has been paid to the description of extra-renal manifestations. Moreover, mechanisms of pathogenic immunoglobulin deposition and factors associated with renal and patient survival are ill-defined. We retrospectively studied a nationwide cohort of 255 patients, with biopsy-proven LCDD (n=212) (including pure LCDD [n=154], LCDD with cast nephropathy (CN) [n=58]), HCDD (n=23), or LHCDD (n=20). Hematological diagnosis was monoclonal gammopathy of renal significance in 64% and symptomatic myeloma in 34%. Renal presentation was acute kidney injury in patients with LCCD and CN, and chronic glomerular disease in the other types, 35% of whom had symptomatic extra-renal (mostly hepatic and cardiac) involvement. Sequencing of 18 pathogenic LC showed high isoelectric point values of variable domain complementarity determining regions, possibly accounting for tissue deposition. Among 169 patients who received chemotherapy (bortezomib-based in 58%), 67% achieved serum free light chain (FLC) response, including very good partial response (VGPR) or above in 52 %. Renal response occurred in 62 patients (36%), all of whom had achieved hematological response. FLC response ≥VGPR (OR 4.14, 95%CI 1.75-9.83) and absence of severe interstitial fibrosis (OR 3.45, 95%CI 1.45-8.33) were independent predictors of renal response. This study highlights an unexpected frequency of extra-renal manifestations in MIDD. Rapid diagnosis and achievement of deep FLC response are key factors of prognosis.