Fibrillary Light Chain Proximal Tubulopathy: A Distinct Subtype Within the Spectrum of Light Chain Proximal Tubulopathy

Light chain proximal tubulopathy (LCPT) is a rare kidney disorder associated with monoclonal gammopathy, traditionally defined by crystalline inclusions in proximal tubular epithelial cells. A poorly recognized variant, fibrillary LCPT, is characterized by large nonamyloid fibrillar aggregates but has remained inconsistently classified, leading to diagnostic uncertainty. We aimed to clarify its clinicopathologic features and refine its position within the LCPT spectrum. We retrospectively analyzed 41 biopsy-proven LCPT cases, reclassified by ultrastructural features into crystalline LCPT (n = 22), fibrillary LCPT (n = 11), amyloid LCPT (n = 2), and LCPT with lysosomal indigestion (n = 6). Fibrillary LCPT showed irregular cytoplasmic fibrils measuring 6 to 18 nm in diameter, arranged in intersecting, fishbone-like, or compact bundle-like patterns, confined to proximal tubular epithelial cells. These fibrils were Congo red negative and not apparent on light microscopy. Conventional immunofluorescence (IF) on frozen tissue was uniformly negative in fibrillary LCPT, and pronase-digested paraffin IF detected κ restriction in only 7 of 11 cases; immunoelectron microscopy confirmed κ light chain labeling in all paraffin IF-negative cases, yielding 100% diagnostic sensitivity. Clinically, most fibrillary LCPT cases were associated with monoclonal gammopathy of renal significance (72.7%), with the remainder linked to multiple myeloma (27.3%). This subtype was commonly associated with Fanconi syndrome and reduced estimated glomerular filtration rate, with a subset of cases developing acute kidney injury. Following clone-directed therapy, a majority of patients achieved stable renal function, and 85% showed improvement in tubular dysfunction, although proteinuria reduction was less pronounced than in crystalline LCPT. Fibrillary LCPT represents a distinct, nonamyloid entity characterized by Congo red-negative fibrils, κ light chain restriction, and frequent association with Fanconi syndrome and monoclonal gammopathy of renal significance. We propose a refined 4-tier ultrastructural classification comprising 4 LCPT subtypes (crystalline LCPT, fibrillary LCPT, amyloid LCPT, and LCPT with lysosomal indigestion) to improve diagnostic precision and guide management.