Calcium channel blockers and hypertension: evolving perspective--1996

In recent years, calcium channel blockers (CCBs) have been used extensively in the United States and elsewhere as antihypertensive agents, and their availability has been an important advance in the management of hypertension. As antihypertensive agents, the CCBs thus appear considerably more versatile than most previous vasodilators. The available studies indicate that CCBs are metabolically neutral and do not exacerbate dyslipidemia or impair glucose tolerance. In contrast to diuretics and beta-blockers, CCBs do not appear to alter insulin sensitivity. The CCBs also differ from previous vasodilators because of their favorable accompanying effects on the heart and kidney. Despite the attributes of CCBs enumerated earlier, a number of recent retrospective analyses by Psaty et al. (JAMA 1995;274:620-625) have suggested that CCBs may be detrimental and may promote adverse cardiovascular events. I have recently reviewed the results of Psaty's meta-analysis and report (Arch Intern Med 1995;155: 2150-2156). I have emphasized that it is the rate of drug delivery into the systemic circulation that produces profound effects on the hemodynamic and neurohumoral responses to a dihydropyridine CCB drug. During chronic treatment with dihydropyridines, major fluctuations in blood pressure (rapid onset and offset of antihypertensive effects) during the dosing interval may persist for drugs and formulations that are short acting. In contrast, slow-release formulations of otherwise rapidly absorbed dihydropyridines achieve a more gradual and sustained antihypertensive effect. It is probable that newer CCB formulations that do not provoke intermittent sympathetic activation and do not evoke a cardioacceleratory response would not be expected to promote adverse cardiovascular events.

Direct evidence that thromboxane mimetic U44069 preferentially constricts the afferent arteriole

The thromboxane A2 (TXA2) mimetic U44069 has been demonstrated to reduce the GFR and filtration fraction of the normal isolated perfused rat kidney markedly, suggesting a predominant constriction of preglomerular vessels. To assess this possibility directly, effects of U44069 on the renal microvessels of the isolated perfused hydronephrotic kidney were examined. At 10(-6) mol/L, U44069 elicited a 27 +/- 2% decrease in afferent arteriolar (AA) diameter (from 18.8 +/- 0.3 to 13.7 +/- 0.3 micron, P < 0.001). In contrast, efferent arteriolar (EA) diameter decreased by only 9 +/- 1% (from 16.4 +/- 0.5 to 15.0 +/- 0.5 micron, P < 0.001). These effects on both AA and EA were completely reversed by the TXA2 receptor antagonist SQ29548. The calcium antagonist diltiazem reversed U44069-induced AA constriction by 83 +/- 5%. The U44069-induced EA constriction was insensitive to the vasodilator action of diltiazem at concentrations from 10(-8) to 10(-6) mol/L, but at 10(-5) mol/L, diltiazem increased the EA diameter significantly, albeit modestly. Nifedipine also reversed the U44069-induced AA constriction (81 +/- 7%), but failed to inhibit the EA constriction at concentrations from 10(-9) to 10(-6) mol/L. These findings constitute the first direct evidence that a TXA2 agonist preferentially constricts the afferent arteriole. Furthermore, the ability of both the calcium antagonist and SQ29548 to reverse the renal microvascular actions of TXA2 agonists suggests a potential utility of these agents in ameliorating TXA2-induced renal hemodynamic abnormalities.

Alcohol's impact on kidney function

Both acute and chronic alcohol consumption can compromise kidney function, particularly in conjunction with established liver disease. Investigators have observed alcohol-related changes in the structure and function of the kidneys and impairment in their ability to regulate the volume and composition of fluid and electrolytes in the body. Chronic alcoholic patients may experience low blood concentrations of key electrolytes as well as potentially severe alterations in the body's acid-base balance. In addition, alcohol can disrupt the hormonal control mechanisms that govern kidney function. By promoting liver disease, chronic drinking has further detrimental effects on the kidneys, including impaired sodium and fluid handling and even acute kidney failure.

Calcium channel blockers and hypertension: 2. Safety issues

As the safety of calcium channel blockers continues to be debated, it is important to realize that not all calcium channel blockers are alike. Safety, and efficacy, depend on the kinetic as well as the pharmacologic properties of the drug.

Autosomal dominant primary hyperparathyroidism and jaw tumor syndrome associated with renal hamartomas and cystic kidney disease: linkage to 1q21-q32 and loss of the wild type allele in renal hamartomas

Hereditary hyperparathyroidism-jaw tumor syndrome (HPT-JT) is an autosomal dominant disease (OMIM 145001) that has recently been mapped to chromosomal region 1q21-q32 (HRPT2). Here we report two families with HPT-JT syndrome in which adult renal hamartomas or cystic kidney disease were prominent associated features, possibly representing a new phenotypic variant of the HPT-JT syndrome. In the first family, renal lesions were present in five out of six affected individuals, whereas HPT and JT were seen in four and two cases, respectively. In the second family, JT was found in three of the five affected individuals and two affected members also exhibited polycystic kidney disease. The possibility of the latter cosegregating as a separate autosomal dominant gene can not be ruled out. A sex-dependent penetrance of primary HPT, resulting in predominantly male-affected cases was evident in the two families. Twenty microsatellite markers in the HRPT2 region were typed, in addition to markers in the multiple endocrine neoplasia (MEN) types 1 and 2 regions at 11q13 and 10q11. The disease in these two kindreds was linked to five markers in the 1q21-q32 region (logarithm-of-odds scores: 3.2-4.2), whereas linkage to the MEN1 and MEN2 regions was excluded. Meiotic recombinations detected in affected individuals placed the locus telomeric of D1S215, thus narrowing the HRPT2 region from > 60 to approximately 34 centimorgans. Loss of heterozygosity was studied in seven renal hamartomas from two affected individuals in the first family, as well as in a jaw tumor and a parathyroid tumor from the second family. All renal hamartomas showed loss of heterozygosity at the 1q21-q32 region. The losses invariably involved the wild type allele derived from the unaffected parent, suggesting the inactivation of a tumor suppressor gene in this region.

Altered myogenic responsiveness of the renal microvasculature in experimental hypertension

Recent investigations have delineated the renal microvascular responsiveness to pressure, by using isolated afferent arterioles, juxtamedullary nephrons, and isolated perfused hydronephrotic kidneys. Both afferent arterioles and interlobular arteries (ILA) manifest pressure-dependent vasoconstrictor responses to elevated renal arterial pressure. Several recent studies have indicated that the afferent arteriole adjacent to the glomerulus constricts primarily in response to tubuloglomerular feedback signals, whereas the afferent arteriole near the ILA is under the dominant influence of myogenic tone. Furthermore, the responsiveness of the ILA to pressure is dependent on the basal diameter, with the smaller diameter (distal) segments demonstrating more marked responses than do the larger (proximal) segments. The myogenic afferent arteriolar response is shifted to higher perfusion pressure in spontaneously hypertensive rat (SHR) kidneys, and blunted both in Dahl salt-sensitive rats and in Goldblatt renal hypertensive rats. This altered responsiveness of the afferent arteriole may account for the alterations in renal blood flow autoregulation, namely, resetting toward higher pressures in SHR, and impairment in Dahl salt-sensitive rats and Goldblatt hypertensive rats Distal ILA segments vasoconstricted similarly in response to pressure both in SHR and in Wistar-Kyoto rats (WKY), whereas proximal ILA segments did not exhibit vasoconstriction in either strain. The intermediate ILA segment from SHR kidneys manifests more prominent myogenic vasoconstriction than does that from WKY rat kidneys. The enhanced myogenic responsiveness of the intermediate ILA segment may act in concert with afferent arteriolar vasoconstriction to prevent glomerular hypertension in superficial nephrons. Finally, the myogenic vasoconstriction of renal microvessels is mediated in part by voltage-dependent calcium channels, and the altered myogenic response may be associated with modified activity of voltage-dependent calcium channels. Thus, the myogenic preglomerular tone constitutes a pivotal determinant of renal autoregulation, and teleologically may also play an important role in protecting glomeruli from barotrauma in hypertension, whereas the functional myogenic element is soon reinforced by an element of "structural autoregulation' of preglomerular resistance vessels.

The benefits of ACE inhibitors and calcium antagonists in slowing progressive renal failure: focus on fixed-dose combination antihypertensive therapy

During the past two decades, major investigative interest has been focused on the determinants of chronic renal disease and interventions to retard the inexorable progression to end-stage renal disease. Recent studies have provided a theoretic framework for anticipating that angiotensin-converting enzyme (ACE) inhibitors, and possibly calcium antagonists, may preferentially retard the progression of renal disease. Whereas the majority of available clinical trials have assessed the effects of ACE inhibitors in patients with insulin-dependent diabetes mellitus (IDDM), there are relatively few long-term studies that have evaluated the renal protective effects of ACE inhibitors and calcium antagonists in patients with nondiabetic renal disease. Although clinical trials have been initiated using both of these drug classes as monotherapy, theoretical considerations suggest that fixed-dose combinations of an ACE inhibitor and a calcium antagonist might be appealing as renal protective agents. Several lines of evidence suggest that the renal microcirculatory effects of coadministration of both agents should be complementary. Similarly, recent observations suggest that the two classes may act in a complementary manner to countervail pathogenetic mechanisms at the level of the mesangium. A recent study in type II diabetic patients demonstrated that combination therapy with an ACE inhibitor and a calcium antagonist induced the greatest reduction in proteinuria, and reduced the rate of decline in glomerular filtration rate (GFR) more than did either agent alone at the same level of blood pressure reduction. Based on such considerations, recent randomized prospective studies have been initiated to compare the renal protective effects of combination calcium antagonist-ACE inhibitor therapy versus monotherapy with agents of either of these two antihypertensive classes.

Newer approaches to antihypertensive therapy. Use of fixed-dose combination therapy

Despite the availability of many newer antihypertensive agents, hypertensive patients remain at higher risk of premature death than the general population. This persistence of morbidity and mortality may be accounted for by the frequent failure to achieve adequate blood pressure reduction despite an extensive array of available antihypertensive agents. Such considerations have led to reassessment of the potential role of fixed-dose combination agents in the antihypertensive armamentarium. The rationale for combination therapy relates to the concept that antihypertensive efficacy may be enhanced when 2 classes of agents are combined. In addition, combination therapy enhances tolerability-1 drug of a fixed combination can antagonize some of the adverse effects of the second drug. Fixed-dose combination therapy simplifies the treatment regimen, preventing treatment failures that might result from missed doses. An additional novel concept is the possibility of enhancing salutary effects on target organs, including regressing left ventricular hypertension and retarding progression of renal disease, by combination therapy over and above the effects expected from the fall in arterial pressure alone. The recent approval by the Food and Drug Administration of 2 fixed-dose angiotensin-converting enzyme inhibitor/calcium antagonist combinations has focused attention on and prompted reexamination of this issue.

Force-length properties in stable skeletal muscle fibers--theoretical considerations

Differences in the force-length (F-L) properties between sarcomeres and fibers have been associated with the supposed unstable nature of the sarcomere F-L relation on the descending limb (i.e. at sarcomere lengths greater than optimal length). Recently, it has been suggested that sarcomere behavior in a fiber is stable during contractions on the descending limb of the F-L relation; therefore, a factor other than sarcomere instability must be responsible for the observed differences in the F-L relations of sarcomeres and fibers. The purpose of this study was to determine theoretically the F-L relation of a muscle fiber when sarcomeres were at a stable, steady-state length. Three models of muscle fibers are presented; each model contains sarcomeres with different mechanical properties which have been observed experimentally. Results of these theoretical considerations demonstrate that sarcomeres with the classic F-L properties as measured by Gordon et al. (J. Physiol. 184, 170-192, 1966) cannot predict the F-L relation exhibited by fibers. The addition of cross-bridge stiffness properties to the classic sarcomere F-L relation still does not explain the differences between the sarcomere and fiber F-L relations. However, if history dependent sarcomere properties are used, the fiber F-L relation exhibits an elongated plateau and greater forces on the descending limb compared to the classic sarcomere F-L relation; and the fiber F-L relation corresponds qualitatively to experimental findings.

Phase I trial of interleukin 2 in combination with the soluble tumor necrosis factor receptor p75 IgG chimera

Our purpose was to determine the effective biological dose and/or maximum tolerated dose of recombinant human tumor necrosis factor receptor:IgG chimera (rhuTNFR:Fc; Immunex, Seattle, WA) in combination with interleukin 2 (IL-2) with regard to reduction in IL-2 toxicity and modulation of biological effects of high-dose IL-2 administration. Twenty-four patients with metastatic cancer were treated with escalating doses of rhuTNFR:Fc at 1, 1, 5, 10, and 20 mg/m2 i.v. on days 1 and 15 (dose levels 1-5) or 10, 20, and 30 mg/m2 days 1 and 15 plus 50% dose on days 3, 5, 17, and 19 (dose levels 6-8) prior to IL-2 at doses of 300,000 IU/kg (dose level 1) and 600,000 IU/kg (dose levels 2-8) i.v. every 8 h on days 1-5 and 15-19. The t1/2 of rhuTNFR in patients receiving IL-2 was 72 h. The median number of IL-2 doses was 24, and central nervous system, skin, and cardiac arrhythmias were the major dose-limiting toxicities. TNF bioactivity was inhibited, and the polymorphonuclear leukocyte chemotactic defect normally seen with IL-2 was not observed. Increases in C-reactive protein, IL-6, IL-8, and IL-1 receptor antagonist levels were partially suppressed relative to historical controls, whereas peripheral blood mononuclear cell phenotypes, urinary nitrate, endothelial adhesion molecule expression in skin biopsies, and cellular infiltrates in tumor biopsies were consistent with findings in patients treated with IL-2 alone. Four patients developed thyroid dysfunction. There were five responses: two complete responses (both melanoma) and three partial responses (response rate, 21%). rhuTNFR:Fc may modulate the toxicity and some of the biological effects of IL-2 while preserving antitumor activity. Dose level 6 (10 mg/m2 on days 1 and 15, and 5 mg/m2 on days 3, 5, 17, and 19) has been chosen for a randomized, double-blind, placebo-controlled trial of IL-2 with and without rhuTNFR:Fc.

Impairment of afferent arteriolar myogenic responsiveness in the galactose-fed rat is prevented by tolrestat

By permitting the separation of increased aldose reductase activity from hyperglycaemia and insulin deficiency, galactose-fed rats have constituted a useful model for investigating diabetic complications. Such rats manifest an impaired afferent arteriolar responsiveness to pressure similar to that of rats 4 to 6 weeks after induction of diabetes with streptozotocin. In the present study, we investigated whether treatment of galactose-fed rats with the aldose reductase inhibitor tolrestat prevent this autoregulatory defect and whether the blunted afferent arteriolar responsiveness to pressure is associated with impaired responsiveness to angiotensin II. Pressure-induced vasoconstriction of afferent arterioles was assessed in kidneys made hydronephrotic to allow direct visualization of renal microvessels by computer-assisted image processing. Vessel diameters were quantitated following stepwise increments of renal perfusion pressure (RAP; from 80 to 180 mm Hg) in kidneys of control rats and rats fed a diet for 2 weeks with 50% galactose with or without tolrestat. Subsequent to the pressure studies, angiotensin II (0.3 nmol/l) was added to the perfusate, and vessel diameters were reassessed. Control rats exhibited progressive afferent arteriolar vasoconstriction when RAP was increased from 80 to 180 mm Hg (-17.2 +/- 1.0%; p < 0.001). In contrast, myogenic responses to increases in pressure were absent in the arterioles of the galactose-fed rats (-4.1 +/- 1.9%; N.S.). Treatment with tolrestat completely prevented this impairment in afferent arteriolar responsiveness (-16.5 +/- 1.8%; p < 0.001). The angiotensin II-induced vasoconstriction did not differ between control rats and galactose-fed rats. We conclude that increased aldose reductase activity contributes to impaired renal auto-regulation in galactose-fed rats, a model of diabetic nephropathy, but is not involved in the loss of afferent arteriolar responsiveness to angiotensin II.

Aging and the kidney

A host of abnormalities of renal structure and function accompanies advancing age. An appreciation of methodologic considerations, including population selection, that might confound the assessment of the effects of aging on renal function has prompted a recent reappraisal. Earlier studies assessed the effects of aging by utilizing cross-sectional studies and institutionalized elderly subjects, with their attendant drawbacks. Recent longitudinal studies have utilized appropriate patient cohorts, selected for lock of renal disease, including potential kidney transplant donors. These studies indicate that the morphological and functional changes of aging tend to be less marked than previously thought. The common denominator of these functional changes is a diminution in renal reserve, along with constraints on the kidney's ability to respond appropriately to challenges of either excesses or deficits. Although these alterations are unlikely to be of major clinical consequence under everyday conditions, they attain clinical significance when residual renal function is challenged by the superimposition of an acute illness. Finally, it should be emphasized that elderly patients frequently suffer from comorbid conditions, such as hypertension and heart disease, that may be additive to the changes of aging, thereby amplifying these abnormalities.

Monoclonal antibody-based methods for quantitation of hemoglobins: application to evaluating patients with sickle cell anemia treated with hydroxyurea

High-titer monoclonal antibodies (mAb) were raised against chromatographically purified human hemoglobin (Hb) species. These mAb were specific for either Hb A, Hb F, Hb S or Hb C. Based on these antibodies, which were directly conjugated with either fluorochromes or an enzyme (horseradish peroxidase), we developed immunoassays for determining the Hb profile in the peripheral blood; an enzyme-linked immunosorbent assay (ELISA) for determining the absolute and relative quantities of various Hb species and one-step immunolabeling for fluorescence microscopic and flow cytometric analyses of the distribution of RBC with respect to their Hb types. We utilized these methods for monitoring the Hb F level and the percentage of Hb F-containing cells in patients with sickle cell anemia undergoing treatment with hydroxyurea.

Stability of muscle fibers on the descending limb of the force-length relation. A theoretical consideration

For the past 40 years it has generally been accepted that the descending limb of the force-length (F-L) relation of muscle fibers is unstable; strong sarcomeres are thought to shorten onto the ascending limb of the F-L relation at the expense of weak sarcomeres which are stretched beyond the thin-thick myofilament overlap. This unstable behavior has not been demonstrated by direct observation but has been inferred indirectly, based on the negative slope of the F-L relation. Intuitively, the idea that the sarcomere length within skeletal muscle is unstable at any length within the normal working range would not be advantageous. Therefore, the purpose of this study was to identify analytically the mechanical conditions for which sarcomeres in a muscle fiber are stable. It was found that the mechanical conditions required for sarcomere and fiber stability could be associated with known properties of skeletal muscle fibers. Furthermore, it could be demonstrated that a fiber composed of a large number of sarcomeres can be stable, and still exhibit an apparently unstable (negatively sloped) descending limb of the F-L curve.

Gamma knife pallidotomy in advanced Parkinson's disease

Posteroventral pallidotomy as a treatment for Parkinson's disease (PD) has been the subject of increasing interest. We treated 4 nondemented patients with advanced PD, 2 with severe bradykinesia and a declining response to medication, and 2 with marked clinical fluctuations. All patients received 180 Gy delivered in one sitting to the right posteroventral pallidum site, used by Laitinen and colleagues, adjusted as needed, to avoid the optic tract. Only 1 patient changed significantly. Dyskinesia completely resolved on the side contralateral to the lesion in this patient. This same patient also became transiently demented and psychotic. The other 3 patients suffered no clearly identifiable beneficial or harmful effects. Follow-up magnetic resonance imaging scans of the brain at 1 year revealed lesions exactly where targeted although of unequal sizes. Our negative experience forces us to conclude that either larger volumes of tissue must be ablated, that physiologic monitoring is required for placing a lesion, that our subjects were poor candidates for the procedure, or that surgical ablation and radiation cause tissue damage of different types with different results.

Renal Parenchymal Hypertension: current concepts of pathogenesis and management

Renal parenchymal disease is a common but often unrecognized cause of hypertension. Chronic renal disease and systemic hypertension may coexist in two distinct settings. First, essential hypertension is an important cause of chronic renal disease. Second, renal parenchymal disease is a well-established cause of secondary hypertension. Renal parenchymal disease is the most common cause of secondary hypertension, accounting for 2.5% to 5.0% of all cases of systemic hypertension. Secondary hypertension may also accelerate the decline in renal function if inadequately controlled. Therefore, hypertension is both a cause and a consequence of renal disease, and it may be difficult to distinguish them clinically.

Disparate effects of calcium antagonists on renal microcirculation

Although calcium antagonists reduce systemic blood pressure, the effects of calcium antagonists on renal preglomerular and postglomerular microcirculation have been suggested to differ. In the present study we examined the vasodilator action of dihydropyridine-type calcium antagonists, including nifedipine, nicardipine, amlodipine, and efonidipine, on afferent and efferent arterioles during angiotensin II (A-II)- and norepinephrine (NE)-induced renal vasoconstriction. Isolated perfused hydronephrotic kidneys were used to directly visualize renal microcirculatory response to calcium antagonists. Both A-II and NE caused marked vasoconstriction of afferent (A-II, 27 +/- 2% decrement; NE, 28 +/- 2% decrement) and efferent arterioles (A-II, 25 +/- 4% decrement; NE, 22 +/- 2% decrement). The subsequent addition of nifedipine, nicardipine, and amlodipine reversed the afferent arteriolar vasoconstriction in a dose-dependent manner, and elicited complete vasodilation at 10(-6) M. In contrast, efferent arteriolar vasoconstriction was relatively refractory to the dilator action of these calcium antagonists; maximal dilation observed at 10(-6) M was 21 +/- 1% (A-II) and 22 +/- 3% (NE) for nifedipine, 25 +/- 3% (A-II) and 20 +/- 6% (NE) for nicardipine, and 39 +/- 6% (A-II) and 37 +/- 3% (NE) for amlodipine. In striking contrast, efonidipine dilated not only afferent arterioles, but also efferent arterioles in a dose-dependent manner. At 10(-6) M, efonidipine completely inhibited the afferent (A-II, 89 +/- 7% reversal; NE, 99 +/- 8% reversal) and efferent arteriolar vasoconstriction (A-II, 93 +/- 4% reversal; NE, 87 +/- 9% reversal). These findings clearly demonstrate that calcium antagonists dilate the afferent arteriole. Unlike the effects on the afferent arteriole, efferent arteriolar responsiveness to calcium antagonists differ, depending on the type of calcium antagonist. The efonidipine-induced efferent arteriolar vasodilation is probably not related to voltageoperated calcium channels, and may act, in concert with blood pressure lowering effect, to ameliorate glomerular capillary hypertension.

Predictive diagnosis of multiple endocrine neoplasia (MEN 1) in four Australian kindreds

BACKGROUND

Multiple endocrine neoplasia type 1 (MEN 1) is a tumour predisposition syndrome that usually manifests in the first four decades of life. It has an autosomal dominant mode of inheritance which means that any new member of a MEN1 kindred has roughly a 50% chance of developing the disorder during their lifetime. The localisation of the MEN1 gene to a small region of chromosome band 11q13 has led to the development of DNA-based predictive diagnosis for this disease.

AIMS

To establish a polymerase chain reaction (PCR)-based system, using simple tandem repeat polymorphisms (STRPs), to predict gene carriers in four Australian MEN 1 kindreds.

METHODS

Six STRP markers flanking the MEN1 region of chromosome band 11q13 were used to screen individuals for a common haplotype in order to determine carrier status.

RESULTS

The accuracy of prediction was calculated to be > 95% in informative individuals.

CONCLUSIONS

DNA-based presymptomatic detection of affected members of MEN 1 kindreds could facilitate their care and reduce the inconvenience and expense of repeated testing of unaffected members. However, due to occasional recombination events or uninformativeness of markers in certain individuals, carrier status cannot always be predicted.

Increased release of kaliuretic peptide during immersion-induced central hypervolemia in cirrhotic humans

Kaliuretic peptide is a recently discovered potent stimulator of potassium and water excretion. Its role in modulating renal water handling in cirrhotic patients has not been defined. The responses of circulating kaliuretic peptide and atrial natriuretic factor in 8 cirrhotic subjects to water immersion were significantly greater (p < 0.05) than those of 7 healthy volunteers. With cessation of immersion, atrial natriuretic factor decreased within 30 min to preimmersion values, whereas kaliuretic peptide remained significantly elevated > 1 h, suggesting a slower clearance for kaliuretic peptide. The peak diuretic response to immersion corresponded in a temporal fashion to the peak circulating concentration of kaliuretic peptide, suggesting a possible physiological role of kaliuretic peptide in modulating volume homeostasis in cirrhotic humans.

Case report: multiple myeloma presenting as a diastolic heart failure with no evidence of amyloidosis

The development of severe right sided congestive heart failure led to a diagnosis of immunoglobulin G (lambda) myeloma with a predominance of light chains. Cardiac catheterization and endomyocardial biopsy showed a severe diastolic dysfunction of both right and left ventricles and extensive myocardial infiltration by intercellular fibrillar tissue, which was not amyloid. This is a rare presentation of immunoglobulin deposition disease associated with immunocytic dyscrasias.