C1 Esterase Inhibitor Deficiency Research Articles

C1 esterase inhibitor and the contact system in COVID-19.

SummaryCoronavirus disease 2019 (COVID‐19) is frequently associated with severe systemic consequences, including vasculitis, a hyperinflammatory state and hypercoagulation. The mechanisms leading to these life‐threatening abnormalities are multifactorial. Based on the analysis of publicly available interactomes, we propose that severe acute respiratory syndrome coronavirus‐2 infection directly causes a deficiency in C1 esterase inhibitor, a pathogen‐specific mechanism that may help explain significant systemic abnormalities in patients with COVID‐19.

Co-occurrence between C1 esterase inhibitor deficiency and autoimmune disease: a systematic literature review

BackgroundHereditary angioedema (HAE) is caused by a SERPING1 gene defect resulting in decreased (Type I) or dysfunctional (Type II) C1 esterase inhibitor (C1-INH). The prevalence of autoimmune diseases (ADs) in patients with HAE appears to be higher than the general population. A systematic literature review was conducted to examine the co-occurrence between HAE and ADs.MethodsPubMed/EMBASE were searched for English-language reviews, case reports, observational studies, retrospective studies, and randomized controlled trials up to 04/15/2018 (04/15/2015-04/15/2018 for EMBASE) that mentioned patients with HAE Type I or II and comorbid ADs. Non-human or in vitro studies and publications of C1-INH deficiency secondary to lymphoproliferative disorders or angiotensin-converting-enzyme inhibitors were excluded.ResultsOf the 2880 records screened, 76 met the eligibility criteria and 155 individual occurrences of co-occurring HAE and AD were mentioned. The most common ADs were systemic lupus erythematosus (30 mentions), thyroid disease (21 mentions), and glomerulonephritis (16 mentions). When ADs were grouped by MedDRA v21.0 High Level Terms, the most common were: Lupus Erythematosus and Associated Conditions, n = 52; Endocrine Autoimmune Disorders, n = 21; Gastrointestinal Inflammatory Conditions, n = 16; Glomerulonephritis and Nephrotic Syndrome, n = 16; Rheumatoid Arthritis and Associated Conditions, n = 11; Eye, Salivary Gland and Connective Tissue Disorders, n = 10; and Immune and Associated Conditions Not Elsewhere Classified, n = 5.ConclusionsBased on literature reports, systemic lupus erythematosus is the most common AD co-occurring with HAE Type I and II. Cause and effect for co-occurring HAE and AD has not been clinically established but could be related to lack of sufficient C1-INH function.

Study of angiopoietin and plasminogen genes in hereditary angioedema.

To investigate the presence of the Angiopoietin 1 (ANGPT1) and Plasminogen (PLG) mutations in patients with Hereditary Angioedema (HAE) and normal C1 esterase inhibitor (C1-INH) levels, who do not harbor the F12 gene mutation. Patients clinically diagnosed with HAE but without C1-INH deficiency or dysfunction and F12 gene mutation were evaluated. DNA extraction, quantification, and dilution were performed at a concentration of 100 ng/µL, followed by a DNA amplification (PCR) for molecular evaluation of exon 2 of the ANGPT1 gene and exon 9 of the PLG gene for identification of mutations c.807G>T / p.A119S and c.988A>G / p.K330E, respectively. The PCR product was evaluated in 1% agarose gel electrophoresis. Sequencing was performed using the Sanger method. The electropherograms were analyzed using the FASTA® program. DNA samples from 15 women were sequenced. Their ages ranged from 10 to 60 years and the normal C1 esterase and C4 inhibitor serum levels ranged from 22 to 39 mg/dL and from 10 to 40 mg/dL, respectively. No mutations were detected in the analyzed exons of ANGPT1 and PLG. However, a single-nucleotide polymorphism (SNP) was detected in two homozygotic and five heterozygotic patients. Further studies are needed to evaluate these SNPs and scrutinize their potential for use as molecular markers of HAE and as novel therapeutic targets.

Perioperative Management of Patients With Hereditary Angioedema With Special Considerations for Cardiopulmonary Bypass.

Hereditary angioedema (HAE) is a rare autosomal dominant disorder mostly due to the deficiency of C1-esterase inhibitor (C1-INH). Reduced C1-INH activity below ~38% disrupts homeostasis of bradykinin (BK) formation by increasing kallikrein activation and causes recurrent angioedema attacks affecting the face, extremities, genitals, bowels, oropharynx, and larynx. HAE symptoms can be debilitating and potentially life-threatening. The recent clinical developments of biological and pharmacological agents have immensely improved acute and long-term care of patients with moderate-to-severe HAE. The therapies are given as on-demand and/or prophylaxis, and self-administration is highly recommended and performed with some agents via intravenous or subcutaneous route. Perioperative clinicians need to be familiar with the symptoms and diagnosis of HAE as well as available therapies because of the potential need for airway management, sedation, or anesthesia for various medical and surgical procedures and postoperative care. Cardiovascular surgery using cardiopulmonary bypass is a unique condition in which heparinized blood comes into direct contact with an artificial surface while pulmonary circulation, a major reserve of angiotensin-converting enzyme (ACE), becomes excluded. These changes result in systemic kallikrein activation and BK formation even in non-HAE patients. The objectives of this review are (1) to review pathophysiology of HAE and laboratory testing, (2) to summarize pertinent pharmacological data on the prophylactic and on-demand treatment strategies, and (3) to discuss available clinical data for perioperative management in cardiovascular surgery.

Features of diagnostics and clinical approaches to case management of patients with hereditary angioedema without C1 esterase inhibitor deficiency. Analysis of the clinical case

This article describes the clinical, biochemical and genetic features of hereditary angioedema (HAE) with normal level and functional activity of C1 esterase inhibitor. The discussion includes pathogenesis, diagnostics and case management of patients with hereditary angioedema without C1 esterase inhibitor deficiency. The materials of few scientific sources about patients with HAE without C1 esterase inhibitor deficiency in stages and our own clinical case (the female patient of fertile age with a confirmed mutation associated with factor XII (Hageman) deficiency) was given. The article describes the current state of the issue of the algorithm of primary diagnostics and differential diagnostics of HAE without C1 esterase inhibitor deficiency based on international and Russian data. It has been suggested that the new understanding of pathogenesis and treatment of patients with HAE without C1 esterase inhibitor deficiency is encouraging and becoming accessible to the medical society.

Features of diagnostics and clinical approaches to case management of patients with hereditary angioedema without C1 esterase inhibitor deficiency. Analysis of the clinical case

This article describes the clinical, biochemical and genetic features of hereditary angioedema (HAE) with normal level and functional activity of C1 esterase inhibitor. The discussion includes pathogenesis, diagnostics and case management of patients with hereditary angioedema without C1 esterase inhibitor deficiency. The materials of few scientific sources about patients with HAE without C1 esterase inhibitor deficiency in stages and our own clinical case (the female patient of fertile age with a confirmed mutation associated with factor XII (Hageman) deficiency) was given. The article describes the current state of the issue of the algorithm of primary diagnostics and differential diagnostics of HAE without C1 esterase inhibitor deficiency based on international and Russian data. It has been suggested that the new understanding of pathogenesis and treatment of patients with HAE without C1 esterase inhibitor deficiency is encouraging and becoming accessible to the medical society.

A novel functional C1 inhibitor activity assay in dried blood spot for diagnosis of Hereditary angioedema

BackgroundHereditary angioedema (HAE) is a rare genetic disease caused by deficiency or dysfunction of C1 esterase inhibitor (C1-INH). Timely and accurate diagnosis is an ongoing challenge. Measurement of plasma C1-INH activity is currently the critical standard test. We describe a novel and highly robust point-of-care assay to quantify C1-INH activity in dried blood spot (DBS). MethodsC1-INH was extracted from 3 mm punches of DBS samples and incubated with excess amount of C1 esterase (C1s). The mixture was subsequentially incubated with C1s substrate, followed by liquid chromatography-tandem mass spectrometry (LC-MS/MS) quantitation of the enzyme reaction product. ResultsThe assay was validated within a quantification range from 100 to 1500 mU/mL. The intra-day precision and accuracy ranged from 4.0% to 11.6% and −11.1% to −2.1%, and the inter-day precision and accuracy were 8.1–13.1% and −10.3% to 0.9%, respectively. Normal C1-INH activity (n = 103) ranged from 311 to 1090 mU/mL, whereas 23 out of 24 HAE patients exhibited C1-INH activity lower than 100 mU/mL. ConclusionDBS specimen collection for measurement of functional C1-INH activity in a physician’s office is straightforward and not limited by logistic considerations and therefore, appropriate for the diagnosis of HAE in high throughput diagnostic laboratories.

Lanadelumab for the prevention of attacks in hereditary angioedema

ABSTRACTIntroduction: Hereditary angioedema (HAE) with C1 esterase inhibitor deficiency (C1-INH-HAE) is a rare disease that manifests with cutaneous and/or submucosal swellings due to uncontrolled activation of the contact/kinin system. Attacks recur with unpredictable frequency and severity, laryngeal edema is potentially lethal, and the disease burden may severely disrupt patients’ lives.Areas covered: This review provides an overview of lanadelumab, a human monoclonal antibody targeted against plasma kallikrein that was recently approved for prevention of symptoms in C1-INH-HAE.Expert opinion: The phase III HELP Study demonstrated the efficacy of lanadelumab in reducing HAE attacks. These positive results are being further confirmed in the open-label extension study. This agent addresses some of the limitations of existing prophylactic options as tolerability issues, the need for intravenous administration and frequent dosing. Therefore, lanadelumab can profoundly improve the quality of life of patients with C1-INH-HAE.

Idiopathic anaphylaxis.

Idiopathic anaphylaxis (IA) is defined as anaphylaxis without any identifiable precipitating agent or event. The clinical manifestations of IA are the same as allergen-associated (immunologic) anaphylaxis and include urticaria, angioedema, hypotension, tachycardia, wheezing, stridor, pruritus, nausea, vomiting, flushing, diarrhea, dysphagia, light-headedness, and loss of consciousness. Patients usually tend to have the same manifestations on repeated episodes. IA is a prednisone-responsive disease that is ultimately a diagnosis of exclusion. Approximately 40% of patients are atopic. Serum tryptase (or urine histamine or its metabolite) will be elevated acutely, but, if elevated in the absence of anaphylaxis, should suggest alternative diagnoses, including indolent systemic mastocytosis. A focused history, examination, and follow-up will dictate whether a patient's symptoms may be attributable to disorders that mimic anaphylaxis, such as indolent systemic mastocytosis, carcinoid syndrome, pheochromocytoma, hereditary angioedema or acquired C1 esterase inhibitor deficiency, or panic attacks. The presence of urticaria may help limit the differential diagnosis because urticaria does not usually accompany any of the above-mentioned disorders, except for indolent systemic mastocytosis. IA is classified according to the symptoms as well as the frequency of attacks. Patients who experience six or more episodes in a year, or two or more episodes in 2 months are classified as having IA-frequent (IA-F). Patients who experience fewer episodes are classified as having IA-infrequent (IA-I). This distinction is important because patients with IA-F will initially require prednisone as disease-modifying therapy, whereas most patients who with IA-I will not require prednisone. Patients with IA must carry and know when and how to self-administer epinephrine.

Acquired C1-Esterase Inhibitor Deficiency Associated with Burkitt Lymphoma

Acquired C1-Esterase Inhibitor Deficiency Associated with Burkitt Lymphoma

Subcutaneous C1 inhibitor for prevention of attacks of hereditary angioedema: additional outcomes and subgroup analysis of a placebo-controlled randomized study

BackgroundHereditary angioedema (HAE) is a debilitating disorder resulting from C1-esterase inhibitor (C1-INH) deficiency. In the COMPACT phase 3 study the prophylactic use of a subcutaneous C1 inhibitor (C1-INH [SC], HAEGARDA®, CSL Behring) twice weekly significantly reduced the frequency of acute edema attacks. Analysis of treatment effects by subgroups, onset of effect, and other exploratory analysis have not been reported.MethodsThis is a post hoc exploratory analysis on data from the randomized, placebo-controlled COMPACT study. 90 patients with C1-INH-HAE were randomized to 1 of 4 treatment sequences: C1-INH (SC) 40 or 60 IU/kg of body weight twice weekly for 16 weeks, preceded or followed by a placebo period. The pre-specified primary efficacy endpoint was the time-normalized number of HAE attacks, and pre-specified secondary efficacy endpoints were the percentage of patients with a certain treatment response (≥ 50% reduction on C1-INH (SC) versus placebo in the time-normalized number of attacks) and the time-normalized number of use of rescue medication. Pre-specified exploratory endpoints included severity of attacks, alone and combined with rescue medication use. Post hoc analyses included exploration of onset of effect and clinical assessment of patients with < 50% of response.ResultsSubgroup findings by various patient characteristics showed a consistent preventive effect of C1-INH (SC). In a post hoc analysis of attacks, the onset of the preventive effect within the first 2 weeks after treatment initiation in COMPACT showed that 10/43 patients (23%) experienced attacks of any severity with 60 IU/kg versus 34/42 patients (81%) with placebo. The need for rescue medication was tenfold lower with 60 IU/kg (35 treated attacks) versus placebo (358 treated attacks). A qualitative analysis of the 4 patients treated with 60 IU/kg and with < 50% reduction of attacks demonstrated a reduction in severity of attacks, rescue medication use, and symptom days which was considered a clinically meaningful treatment effect.ConclusionsC1-INH (SC) prophylaxis demonstrated a preventive treatment effect with evidence of benefit within 2 weeks. A consistent treatment effect at recommended C1-INH (SC) dosing was evident in all subgroups of patients with type I/II HAE and by various measures of disease and treatment burden.Trial registration EU Clinical Trials Register, 2013-000916-10, Registered 10 December 2013, https://www.clinicaltrialsregister.eu/ctr-search/trial/2013-000916-10; ClinicalTrials.gov Register, NCT01912456, Registered 31 July 2013, https://clinicaltrials.gov/ct2/show/NCT01912456.

Hereditary angioedema: an update on causes, manifestations and treatment.

Hereditary angioedema is a rare genetic disorder caused by deficiency of C1 esterase inhibitor (C1-INH) and characterized by recurrent episodes of severe swelling that affect the limbs, face, intestinal tract and airway. Since laryngeal oedema can be life-threatening as a result of asphyxiation, correct diagnosis and management of hereditary angioedema is vital. Hereditary angioedema attacks are mediated by bradykinin, the production of which is regulated by C1-INH. Hereditary angioedema therapy relies on treatment of acute attacks, and short- and long-term prophylaxis. Acute treatment options include C1-INH concentrate, icatibant and ecallantide. Self-administration of treatment is recommended and is associated with increased quality of life of patients with hereditary angioedema. Advances in diagnosis and management have improved the outcomes and quality of life of patients with hereditary angioedema.

C1 Esterase Inhibitor Activity Is Reduced in the Acute Phase Following Burn Injury: A Prospective Observational Study

Hereditary angioedema has been attributed to an inherited deficiency of C1 esterase inhibitor that increases vascular permeability. The role of C1 esterase inhibitor in burn patients has not been described previously. In this study, we attempted to identify the relationship between serial changes of C1 esterase inhibitor activity and the clinical course in major burn patients. This study was a single-center, prospective, observational study. C1 esterase inhibitor activity values were serially examined in major burn patients admitted into the burn center from April 2014 to December 2016. Inclusion criteria were age ≥16 years old and %TBSA burned ≥20%. This study included 38 patients with major burn. C1 esterase inhibitor activity after burn dropped acutely on days 1 and 2 but increased immediately until days 3 to 5, after which it continued to gradually increase to above the reference value. C1 esterase inhibitor activity on admission showed significant inverse correlation with the volume of infusion per body weight required in the first 24 hours after injury and %TBSA burned (r = -0.405, P = 0.01; r = -0.375, P = 0.02, respectively). C1 esterase inhibitor activity on admission was significantly lower in the nonsurvivors than in the survivors during the 28-day evaluation period (59% vs 90%, P = 0.01). These findings suggest that C1 esterase inhibitor may play a critical role in regulating vascular permeability in the acute phase following the burn injury.

A review of kallikrein inhibitor lanadelumab in hereditary angioedema.

Hereditary angioedema with C1 esterase inhibitor deficiency is a rare disorder characterized by unpredictable swelling of the face, larynx and gastrointestinal tract. Kallikreins are serine proteases that cleave kininogens to produce bradykinin leading to inflammation. A new prophylactic drug is lanadelumab (DX-2930, SHP-643), a recombinant, fully human IgG1 monoclonal antibody kallikrein inhibitor. Pharmacokinetics show a half-life of 14 days with a dose-dependent effect. Completed trials for lanadelumab include two Phase III studies with updated efficacy in preventing angioedema in hereditary angioedema patients. Ongoing data show the safety of the targeted therapy along with less frequent administration requirements. Information on long-term safety is still needed, as well as, further studies on the correlation of subcutaneous administered dosing requirements and severity of side effects.

C1 Esterase Inhibitor Deficiency: A Case Report and Review of Literature

C1 Esterase Inhibitor Deficiency: A Case Report and Review of Literature

Gene therapy for C1 esterase inhibitor deficiency in a Murine Model of Hereditary angioedema.

Hereditary angioedema (HAE) is a life-threatening, autosomal dominant disorder characterized by unpredictable, episodic swelling of the face, upper airway, oropharynx, extremities, genitalia, and gastrointestinal tract. Almost all cases of HAE are caused by mutations in the SERPING1 gene resulting in a deficiency in functional plasma C1 esterase inhibitor (C1EI), a serine protease inhibitor that normally inhibits proteases in the contact, complement, and fibrinolytic systems. Current treatment of HAE includes long-term prophylaxis with attenuated androgens or human plasma-derived C1EI and management of acute attacks with human plasma-derived or recombinant C1EI, bradykinin, and kallikrein inhibitors, each of which requires repeated administration. As an approach to effectively treat HAE with a single treatment, we hypothesized that a one-time intravenous administration of an adeno-associated virus (AAV) gene transfer vector expressing the genetic sequence of the normal human C1 esterase inhibitor (AAVrh.10hC1EI) would provide sustained circulating C1EI levels sufficient to prevent angioedema episodes. To study the efficacy of AAVrh.10hC1EI, we used CRISPR/Cas9 technology to create a heterozygote C1EI-deficient mouse model (S63±) that shares characteristics associated with HAE in humans including decreased plasma C1EI and C4 levels. Phenotypically, these mice have increased vascular permeability of skin and internal organs. Systemic administration of AAVrh.10hC1EI to the S63± mice resulted in sustained human C1EI activity levels above the predicted therapeutic levels and correction of the vascular leak in skin and internal organs. A single treatment with AAVrh.10hC1EI has the potential to provide long-term protection from angioedema attacks in affected individuals.

Perioperative management of a patient with hereditary angioedema(HAE) undergoing endometrial ablation: A case report and review of literature

Introduction: HAE is a rare autosomal dominant disorder caused by deficiency of C1 esterase inhibitor. It is clinically characterised by recurrent face, skin or extremity swelling and gastrointestinal concerns and respiratory system failure. HAE manifestations in the upper respiratory system may lead to asphyxiation which is the primary cause of death. There are many known HAE episode inciting factors as medical or dental operations, stress, menstruation, infections or certain medications as estrogen containing pills. Perioperative prophylaxis with Danazol and C1 inhibitor concentrate (C1-INH) are commonly used to prevent angioedema episodes. Airway oedema and hypovolaemic shock due to the tissue leak of fluids are specially significant in the perioperative period, challenging even the most experienced anaesthesiologist.

Co-Occurrence of C1 Esterase Inhibitor Deficiency and Autoimmune Disease: A Systematic Literature Review

Co-Occurrence of C1 Esterase Inhibitor Deficiency and Autoimmune Disease: A Systematic Literature Review

Lanadelumab for the Prophylactic Treatment of Hereditary Angioedema with C1 Inhibitor Deficiency: A Review of Preclinical and Phase I Studies.

Hereditary angioedema (HAE) with C1 esterase inhibitor (C1-INH) deficiency (C1-INH-HAE) is a rare disease characterized by diminished levels or dysfunctional activity of C1-INH, leading to dysregulated plasma kallikrein activity within the kallikrein–kinin pathway. Symptoms manifest as painful, potentially life-threatening swelling of subcutaneous tissues throughout the body and/or submucosal edema in the upper airway or gastrointestinal tract. Attacks recur with unpredictable frequency, intensity, and duration, placing a heavy burden on patients’ daily lives. Despite improved availability of medications for on-demand treatment during attacks and prophylaxis of future attacks, unmet needs remain. Lanadelumab, a fully human monoclonal antibody, may help address some of the limitations of existing prophylactic options (e.g., the need for intravenous administration or frequent dosing). Preclinical studies demonstrate that it is highly potent and specifically inhibits plasma kallikrein, and findings from phase Ia and Ib studies suggest this agent is well tolerated and provides sustained inhibition of plasma kallikrein, allowing for less frequent dosing. The phase III HELP Study (NCT02586805) evaluating the efficacy and safety of lanadelumab in preventing HAE attacks has been completed, and its open-label extension (NCT02741596) is ongoing. Lanadelumab is now approved in the USA and Canada for prophylaxis to prevent attacks of HAE in patients aged ≥ 12 years. This review provides an overview of the discovery and clinical development of lanadelumab, from preclinical through phase Ib studies, characterizing its safety/tolerability, efficacy, and pharmacokinetic and pharmacodynamic profiles. It also highlights how this agent may positively impact clinical care of patients with C1-INH-HAE.

Monoclonal Gammopathy of Clinical Significance - a Single Center Experience

IntroductionMonoclonal gammopathy of clinical significance (MGCS) is a newly described entity that defines clinical conditions and organ damage resulting from the effects of monoclonal proteins (Fermand et al., 2018). In MGCS, the underlying clone burden resembles an MGUS state, and does not meet criteria for multiple myeloma or lymphoma. A wide spectrum of conditions has been described in MGCS (Fermand et al., 2018). In this retrospective study, our purpose was to identify the incidences of patients with MGCS at our hematology clinics.MethodsWe collaborated with three clinicians who see the majority of MGUS patients at the University of Calgary Medical Group clinics (UCMG). Patients who were referred and diagnosed with MGUS at the hematology clinic at UCMG since 2014 were assessed. The diagnosis of MGUS and MGCS were made based on consensus criteria (Rajkumar et al., 2014) and the recent publication (Fermand et al., 2018). Retrospective chart reviews were performed and cases with MGCS were analyzed. MGUS risk stratification score was calculated per previous reports (Katzmann et al., 2013; Kyle et al., 2018). Hematological response was assessed using the International Myeloma Working Group criteria (Rajkumar et al., 2014), and renal response was measured using KDIGO guidelines (Radhakrishnan & Cattran, 2012).ResultsA total of 606 MGUS patients were seen at our clinic from February 2014 to June 2018. Patients who had MGUS and co-existing conditions which met MGCS criteria (Fermand et al., 2018) were evaluated. There were 25 MGCS patients identified. Median age at diagnosis was 60, and 28% were female. Clinical characteristics are outlined in Table 1. Three patients had light chain MGUS. Among the non-light chain MGUS patients, there were 11 high-intermediate risk (55%), 1 intermediate risk (5%), 5 low-intermediate risk (25%), and 3 low risk MGUS (15%). At the time of analysis all patients were alive, and 3 patients have progressed. Median follow up was 2 years (0-16 years).Renal involvement was the most common with 14 patients having biopsy proven renal pathologies that met criteria for monoclonal gammopathy of renal significance (MGRS) (Leung et al., 2012). Four patients had neuropathies, including Anti-MAG, chronic inflammatory demyelinating polyneuropathy (CIDP), distal acquired demyelinating symmetric neuropathy (DADS-M), and autonomic neuropathy. Three patients had skin manifestations (Schnitzler syndrome, necrobiotic xanthogranuloma, scleromyxedema), 1 patient had corneal involvement (crystalline keratopathy), 1 patient had gastrointestinal manifestation (mixed light chain deposition disease), 1 patient had acquired C1 esterase inhibitor deficiency with angioedema, and 1 patient was diagnosed with Sweet syndrome in 1993 which had led to her original monoclonal gammopathy workup.Five out of the 14 patients with MGRS received plasma cell directed chemotherapy, and 1 patient with crystalloid podocytopathy underwent auto-stem cell transplant. Of these 5 patients, 4 had renal response. Treatment for other MGCS cases are indicated in Table 1.Discussion and ConclusionOur series demonstrates that cases of MGCS represent a small minority within our larger MGUS cohort. The most common organ involvements seen in our MGCS patients were renal, nerve and skin. One of the major diagnostic challenges is confirming that the organ dysfunction and MGUS co-exist by true association, and not by coincidence. In our patient cohort, tissue biopsies were obtained when possible (all renal, skin, and GI cases), and others were diagnosed through review with local experts and relying on published literature.The distinction of MGCS from MGUS is important, as it may change treatment decisions. In renal diseases associated with monoclonal gammopathy, referred to as MGRS, renal prognosis is poor and clone directed treatment is associated with improved renal outcomes (Fermand et al., 2013). As prospective or randomized trials are unavailable for MGRS or MGCS, the treatments given at our center were determined on a case-by-case basis relying on expert opinions, local experiences, and a recent guideline (Fermand et al., 2013). Interdisciplinary care is required for both the diagnosis and management of MGCS. Further studies with long term follow-up are needed. [Display omitted] DisclosuresMcCulloch:Takeda: Other: Travel expenses; Celgene: Honoraria. Neri:Janssen: Consultancy, Honoraria; Celgene: Consultancy, Honoraria.