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Vogel J, Carpinteiro A, Luedike P, Buehning F, Wernhart S, Rassaf T, Michel L. Current Therapies and Future Horizons in Cardiac Amyloidosis Treatment. Curr Heart Fail Rep 2024; 21:305-321. [PMID: 38809394 PMCID: PMC11333534 DOI: 10.1007/s11897-024-00669-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/20/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Cardiac amyloidosis (CA) is a condition characterized by misfolding and extracellular deposition of proteins, leading to organ dysfunction. While numerous forms of CA exist, two subtypes dominate clinical prevalence: Transthyretin amyloid (ATTR) and immunoglobulin light chain amyloid. RECENT FINDINGS The current scientific landscape reflects the urgency to advance therapeutic interventions with over 100 ongoing clinical trials. Heart failure treatment is affected by CA phenotype with poor tolerance of otherwise frequently used medications. Treating comorbidities including atrial fibrillation and valvular disease remains a challenge in CA, driven by technical difficulties and uncertain outcomes. Tafamidis is the first ATTR-stabilizer approved with a rapidly growing rate of clinical use. In parallel, various new therapeutic classes are in late-stage clinical trials including silencers, antibodies and genetic therapy. Managing CA is a critical challenge for future heart failure care. This review delineates the current standard-of-care and scientific landscape of CA therapy.
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Affiliation(s)
- Julia Vogel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Florian Buehning
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Simon Wernhart
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
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Naqvi A, Bonert M, Finley C, Czarnecka-Kujawa K, Yasufuku K, Schwock J, Kulasingam V, John R, Ko HM. Role of EBUS-TBNA/EUS-FNA and mass spectrometry for diagnosis and typing of lymph node amyloidosis: 10-year experience in two tertiary care academic centers. Cancer Cytopathol 2023; 131:724-734. [PMID: 37641237 DOI: 10.1002/cncy.22751] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND The objectives of this study were to investigate the utility of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA)/endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for the diagnosis of amyloidosis coupled with the feasibility of mass spectrometry (MS) for amyloid subtyping. METHODS All patients who had amyloid diagnosed by EBUS-TBNA/EUS-FNA at two tertiary care centers from 2011 to 2020 were retrieved along with the MS subtype, clinical findings, and outcomes. RESULTS Eight patients were included: seven underwent EBUS-TBNA of mediastinal lymph nodes, and one underwent EUS-FNA of a periportal lymph node. Ages ranged from 37 to 79 years (median, 69 years), with equal numbers of men and women. Presenting clinical history included one case each of follicular lymphoma, lymphoplasmacytic lymphoma, rheumatoid arthritis, possible sarcoid, cirrhosis, and chronic renal insufficiency, and one case each of suspected pulmonary and cardiac amyloidosis. All cases showed waxy, amorphous material on direct smears (n = 5) or ThinPrep slides (n = 3), which were confirmed as amyloid on Congo Red staining. Immunohistochemistry showed dominant lambda staining in two of three cases. MS was performed in all cases and identified five of the light-chain (AL) type, one of the heavy-chain/AL type, and two suggestive of AL amyloidosis. Bone marrow biopsy performed in seven patients demonstrated that three had monoclonal plasma cells and one had lymphoplasmacytic lymphoma. Two of four patients with systemic amyloidosis received chemotherapy and remained alive, whereas three with localized disease remained stable under observation. CONCLUSIONS EBUS-TBNA/EUS-FNA is effective for amyloidosis diagnosis and provides adequate material for ancillary tests, including MS, which can identify the precursor amyloidogenic protein, leading to appropriate patient management.
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Affiliation(s)
- Asghar Naqvi
- Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Michael Bonert
- Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Christian Finley
- Thoracic Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Katarzyna Czarnecka-Kujawa
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Kazuhiro Yasufuku
- Division of Thoracic Surgery, University Health Network, Toronto, Ontario, Canada
| | - Joerg Schwock
- Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Vathany Kulasingam
- Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Rohan John
- Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
| | - Hyang-Mi Ko
- Laboratory Medicine Program, University Health Network, Toronto, Ontario, Canada
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Moreno JCA, Eyzaguirre E, Qiu S. Amyloid goiter secondary to familial Mediterranean fever with E148Q mutation: A unique case. Chronic Dis Transl Med 2023; 9:266-268. [PMID: 37711865 PMCID: PMC10497809 DOI: 10.1002/cdt3.79] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 04/30/2023] [Accepted: 05/29/2023] [Indexed: 09/16/2023] Open
Affiliation(s)
- Juan C. A. Moreno
- Department of PathologyThe University of Texas Medical BranchGalvestonTexasUSA
| | - Eduardo Eyzaguirre
- Department of PathologyThe University of Texas Medical BranchGalvestonTexasUSA
| | - Suimin Qiu
- Department of PathologyThe University of Texas Medical BranchGalvestonTexasUSA
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Abstract
Various types of systemic amyloidosis can wreak havoc on the architecture and functioning of the kidneys. Amyloidosis should be suspected in patients with worsening kidney function, proteinuria, and multisystem involvement, but isolated kidney involvement also is possible. Confirming the amyloidosis type and specific organ dysfunction is of paramount importance to select the appropriately tailored treatment and aim for better survival while avoiding treatment-associated toxicities. Amyloid renal staging in light chain amyloidosis amyloidosis helps inform prognosis and risk for end-stage kidney disease. Biomarker-based staging systems and response assessment guide the therapeutic strategy and allow the timely identification of refractory or relapsing disease so that patients can be switched to salvage therapy. Kidney transplantation is a viable option for selected patients with amyloidosis. Because of the complex nature of the pathophysiology and treatment of amyloidosis, a multidisciplinary team-based approach should be used in the care of these patients.
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Affiliation(s)
- Ralph Nader
- Renal, Electrolyte and Hypertension Division, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Avital Angel-Korman
- Nephrology and Hypertension Institute, Samson Assuta University Hospital, Ashdod, Israel; Faculty of Health Sciences, Ben Gurion University of the Negev, Beersheba, Israel
| | - Andrea Havasi
- Amyloidosis Center, Boston University School of Medicine, Boston, MA; Clinical Research, Alnylam Pharmaceuticals, Cambridge, MA.
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Ceglarz K, Gozdowska J, Świder R, Kosieradzki M, Zduńczyk D, Durlik M. Difficulties in the Diagnosis of Fibrinogen Aα-Chain Amyloidosis-Literature Review and Case Report of a Patient After Kidney Transplantation. Transplant Proc 2023; 55:644-648. [PMID: 36966081 DOI: 10.1016/j.transproceed.2023.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 02/19/2023] [Indexed: 03/27/2023]
Abstract
BACKGROUND Amyloidosis is a very heterogeneous disease. Correct diagnosis is extremely important because of the various treatment options for different types of amyloidosis. This study presents a case report and literature review of the misdiagnosis of fibrinogen Aα-chain amyloidosis (AFib amyloidosis). CASE PRESENTATION We report a 65-year-old man diagnosed with proteinuria in 2009. The kidney biopsy revealed the presence of Congo red-stained amyloid deposits. During differential diagnosis, amyloid deposits were discovered in adipose tissue and gingiva. Bone marrow trephine biopsy showed a predominance of lambda chains presenting plasmocytes. Based on performed medical examination, light chain amyloidosis was identified. Therefore, the patient received high-dose melphalan and underwent successful autologous peripheral blood stem cell transplantation. However, proteinuria, worsening of the kidneys' function, and incorrect levels of free light chains were still observed. In 2019, due to continuous treatment failure, a previously acquired kidney biopsy was examined by mass spectrometry, and numerous fibrinogen deposits were identified. Recommended DNA analysis revealed that the patient had AFib amyloidosis. Therefore, chemotherapy treatment was abandoned, and successful kidney transplantation was performed. CONCLUSION Today, it is essential for medical practitioners to remember the possibility of rare and hereditary types of amyloidosis. There are multiple cases where a diagnosis was wrong or delayed because of the atypical course of the disease, the coexistence of another disease, and the rarity of AFib amyloidosis, and all of these reasons may result in the wrong treatment that will delay the right therapy. However, with the new, more precise diagnostics methods, such situations will become rare.
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Affiliation(s)
- Katarzyna Ceglarz
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Poland
| | - Jolanta Gozdowska
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Poland.
| | - Robert Świder
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Poland
| | - Maciej Kosieradzki
- Department of General and Transplantation Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Dorota Zduńczyk
- Department of Hematology, Oncology and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Durlik
- Department of Transplantation Medicine, Nephrology and Internal Medicine, Medical University of Warsaw, Poland
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Ream S, Ma J, Rodriguez T, Sarabia-Gonzalez A, Alvarado LA, Dwivedi AK, Mukherjee D. Ethnic/racial differences in risk factors and clinical outcomes among patients with amyloidosis. Am J Med Sci 2023; 365:232-241. [PMID: 36543303 DOI: 10.1016/j.amjms.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 10/21/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Cardiac amyloidosis is caused by abnormal extracellular deposition of insoluble fibrils in cardiac tissue. It can be fatal when untreated and is often underdiagnosed. Understanding the ethnic/racial differences in risk factors is critical for early diagnosis and treatment to improve clinical outcomes. METHODS We performed a retrospective cross-sectional study utilizing the National Inpatient Sample database from 2015 to 2018 using ICD-10-CM codes. The primary variables of interest were race/ethnicity and amyloidosis subtypes, while the primary outcomes were in-hospital mortality, gastrointestinal bleeding, renal failure, and hospital length-of-stay. RESULTS Amyloidosis was reported in 0.17% of all hospitalizations (N = 19,678,415). Of these, 0.09% were non-Hispanic whites, 0.04% were non-Hispanic blacks, and 0.02% were Hispanic. Hospitalizations with ATTR amyloidosis subtype were frequently observed in older individuals and males with coronary artery disease, whereas AL amyloidosis subtype was associated with non-Hispanic whites, congestive heart failure, and longer hospital length of stay. Renal failure was associated with non-Hispanic blacks (adjusted relative risk [RR] = 1.31, p < 0.001), Hispanics (RR = 1.08, p = 0.028) and had an increased risk of mortality. Similarly, the hospital length of stay was longer with non-Hispanic blacks (RR = 1.19, p < 0.001) and Hispanics (RR = 1.05, p = 0.03) compared to non-Hispanic whites. Hispanics had a reduced risk of mortality (RR = 0.77, p = 0.028) compared to non-Hispanic whites and non-Hispanic blacks, and no significant difference in mortality was seen between non-Hispanic whites and non-Hispanic blacks (RR = 1.00, p = 0.963). CONCLUSIONS Our findings highlight significant ethnic/racial differences in risk factors and outcomes among amyloidosis-related US hospitalizations that can possibly be used for early detection, treatment, and better clinical outcomes.
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Affiliation(s)
- Sarah Ream
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Jennifer Ma
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Tayana Rodriguez
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Alejandro Sarabia-Gonzalez
- Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, United States
| | - Luis A Alvarado
- Biostatitsics and Epidemiology Consulting Lab (BECL), Office of Research, Texas Tech University of Health Sciences Center, El Paso, TX, United States
| | - Alok Kumar Dwivedi
- Biostatitsics and Epidemiology Consulting Lab (BECL), Office of Research, Texas Tech University of Health Sciences Center, El Paso, TX, United States; Department of Molecular and Translational Medicine, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX, United States
| | - Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Sciences Center at El Paso, TX, United States.
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Kraus MJ, Smits JM, Meyer AL, Strelniece A, van Kins A, Boeken U, Reinecke A, Provaznik Z, Van Caenegem O, Ancion A, Berchtold-Herz M, Van Cleemput JJA, Haverich A, Laufer G, Gummert J, Karck M, Warnecke G, Raake PW, Frey N, Kreusser MM. Outcomes in patients with cardiac amyloidosis undergoing heart transplantation: the eurotransplant experience. J Heart Lung Transplant 2023; 42:778-785. [PMID: 36710093 DOI: 10.1016/j.healun.2023.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/14/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND When advanced heart failure occurs in cardiac amyloidosis, prognosis is poor. In this setting heart transplantation (HTX) is a treatment option for selected patients. We here present the results of post-transplantation outcomes in cardiac amyloidosis within the Eurotransplant area, investigating possible predictors of survival. METHODS Of 115 patients undergoing HTX due to cardiac amyloidosis in the Eurotransplant region between November 1987 and May 2020, detailed assessment prior to transplantation was available in 85 patients. The present study was conducted in a retrospective approach. Primary endpoint was mortality after HTX. Baseline variables were entered in a Cox proportional hazards model with the primary endpoint as a dependent variable. RESULTS Median overall survival following HTX was 6.3 years in the overall collective and the subgroup. Univariate Cox proportional hazards model revealed a significant relationship between overall survival and the transplantation period (2008 to 2020 vs 1987 to 2007; median survival 9.7 years vs 1.8 years, hazard ratio 0.45, p = 0.01). Further predictors were albumin concentration (hazard ratio 0.92, p < 0.001), and systolic blood pressure (hazard ratio 0.96, p < 0.001). The transplant period as well as albumin concentration remained significant independent predictors in the AL sub cohort in a multivariate Cox proportional hazards model. CONCLUSIONS HTX is a viable treatment option for patients at an advanced stage of cardiac amyloidosis as overall survival after transplantation has improved in the modern age. Patients at a very advanced stage of the disease, indicated by low serum albumin and blood pressure, show worse outcomes following HTX. Optimal timing and careful patient selection may therefore be particularly important to further improve post-HTX survival in amyloidosis patients.
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Affiliation(s)
- Martin J Kraus
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany.
| | | | - Anna L Meyer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | | | | | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Alexander Reinecke
- Department of Cardiology, Angiology and Intensive Care, University of Kiel, Kiel, Germany
| | - Zdenek Provaznik
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Oliver Van Caenegem
- Cardiovascular Department, Intensive Care Unit, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium (deceased)
| | - Arnaud Ancion
- Cardiology, Centre Hospitalier Universitaire Sart-Tilman, Liège, Belgium
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany; Department of Medicine, University Heart Center Freiburg, Freiburg, Germany
| | | | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Guenther Laufer
- Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Jan Gummert
- Heart and Diabetes Center Nord-Rhein-Westfalen, Ruhr University Bochum, Bochum, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Philip W Raake
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany; Department of Cardiology, University Hospital of Augsburg, Augsburg Germany
| | - Norbert Frey
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
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Zhao L, Ren G, Guo J, Chen W, Xu W, Huang X. The clinical features and outcomes of systemic light chain amyloidosis with hepatic involvement. Ann Med 2022; 54:1226-1232. [PMID: 35481407 PMCID: PMC9067946 DOI: 10.1080/07853890.2022.2069281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES To evaluate the clinical characteristics and prognostic factors of hepatic systemic light chain (AL) amyloidosis. METHODS Eighty-eight patients diagnosed AL amyloidosis with hepatic involvement between June 2004 and January 2019 were analysed retrospectively. RESULTS The median age of the patients was 55 years old, and the male to female ratio was 2.8:1.The main clinical manifestations include edema, digestive symptoms, weight loss, fatigue and ascites. Fifty-one patients received treatment, 42 patients were suitable for therapeutic efficacy evaluation and 25 (59.5%) achieved haematologic response. The median survival time was nine months, and the survival rates at one year, three years and five years were 33.0%, 11.4% and 6.8%, respectively. The risk of death was 6.6 times that of those who did not achieve haematologic response. Multivariate analysis showed that baseline NT-proBNP ≥ 1800 pg/ml and total bilirubin ≥ 34.2 umol/L were predictive of all-cause death. CONCLUSIONS Systemic light chain amyloidosis with hepatic involvement is associated with poor survival but rarely has specific manifestations. The significant increase of NT-proBNP and hyperbilirubinemia indicate a poor prognosis. Vigilance should be raised to the relevant clinical manifestations, early diagnosis and timely treatment can improve the prognosis. KEY MESSAGESSystemic light chain amyloidosis with hepatic involvement is associated with poor survival but rarely has specific manifestations.The significant increase of NT-proBNP and hyperbilirubinemia indicate a poor prognosis.
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Affiliation(s)
- Liang Zhao
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Guisheng Ren
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Jinzhou Guo
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Wencui Chen
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Weiwei Xu
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xianghua Huang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Russe-Russe JR, Abramowitz C, Pellegrini JR, Alvarez Betancourt A, Cohen R, Baldino M, Crandall R, Kagolanu D, Mejia J, Rizvon K. COVID-19 Exposure Unmasking Systemic Amyloidosis With Hepatic Predominance. Cureus 2022; 14:e31092. [DOI: 10.7759/cureus.31092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/04/2022] [Indexed: 11/06/2022] Open
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Wechalekar AD, Fontana M, Quarta CC, Liedtke M. AL Amyloidosis for Cardiologists: Awareness, Diagnosis, and Future Prospects: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2022; 4:427-441. [PMID: 36444232 PMCID: PMC9700258 DOI: 10.1016/j.jaccao.2022.08.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 11/17/2022] Open
Abstract
Amyloid light chain (AL) amyloidosis is a rare, debilitating, often fatal disease. Symptoms of cardiomyopathy are common presenting features, and patients often are referred to cardiologists. Cardiac amyloid infiltration is the leading predictor of death. However, the variable presentation and perceived rarity of the disease frequently lead to delay in suspecting amyloidosis as a cause of heart failure, leading to misdiagnoses and a marked delay in diagnosis, with devastating consequences for the patient. A median time from symptom onset to correct diagnosis of about 2 years is often too long when median survival from diagnosis for patients with AL amyloidosis and cardiomyopathy is 4 months to 2 years. The authors highlight the challenges to diagnosis, identify gaps in the current knowledge, and summarize novel treatments on the horizon to raise awareness about the critical need for early recognition of symptoms and diagnosis of AL amyloidosis aimed at accelerating treatment and improving outcomes for patients.
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Key Words
- AL amyloidosis
- AL, amyloid light chain
- ASCT, autologous stem cell transplantation
- ATTR, transthyretin
- CMR, cardiac magnetic resonance imaging
- CR, complete response
- CyBorD, cyclophosphamide-bortezomib-dexamethasone
- FLC, free light chain
- Ig, immunoglobulin
- LGE, late gadolinium enhancement
- NT-proBNP, N-terminal pro–brain natriuretic peptide
- PCD, plasma cell dyscrasia
- QoL, quality of life
- VGPR, very good partial response
- awareness
- diagnosis
- future therapies
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Affiliation(s)
| | - Marianna Fontana
- National Amyloidosis Centre, London, United Kingdom
- Royal Free London NHS Foundation Trust, London, United Kingdom
| | - C. Cristina Quarta
- Alexion Pharmaceuticals, AstraZeneca Rare Disease, Boston, Massachusetts, USA
| | - Michaela Liedtke
- Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
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Huang H, He H, Qin Y, Du J, Song J. Independent prognostic value of left ventricular mass index in patients with light-chain amyloidosis. Acta Cardiol 2022; 77:815-821. [PMID: 36196999 DOI: 10.1080/00015385.2022.2118414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Echocardiographic-determined left ventricular mass index (LVMI) provides quantitative information on left-ventricular structure. However, its prognostic value on light-chain (AL) amyloidosis has not been clearly defined. METHODS We included 99 patients with newly diagnosed AL amyloidosis between July 2013 and March 2022. Clinical features and echocardiographic parameters were collected. RESULTS LVMI ≥113.4 g/m2 was predictive for overall survival (OS) and progression-free survival (PFS) with respective hazard ratios (HRs) of 2.87 (95% CI: 1.04-7.79) and 2.91 (95% CI: 1.25-6.68). Patients in the LVMI-high group had higher NT-proBNP, cTnT, and FLC-diff levels. They were more likely to be cardiac involved and have increased mean left ventricular wall thickness, decreased left ventricular ejection fraction, and higher proportion of patients with pericardial effusion. In subgroup analysis, LVMI-high group was associated with a reduced OS [HR: 4.74 (95% CI: 1.26-17.77)] and PFS [HR: 7.16 (95% CI: 2.10-24.40)] in patients with cardiac amyloidosis (CA). Besides, LVMI-high was associated with a reduced OS [HR: 3.58 (95% CI: 1.17-11.02)] and PFS [HR: 4.79 (95% CI: 1.77-12.94), p = 0.00] among patients staged of II or III (Mayo 2004), as well as reduced OS [HR: 22.65 (95% CI: 1.66-299.31)] and PFS [HR: 18.73 (95% CI: 2.36-148.35)] among patients staged of III or IV (Mayo 2012). CONCLUSIONS LVMI is a reliable prognostic indicator of survival. A cut-off of LVMI (113.4 g/m2) was prognostic for OS and PFS. Importantly, LVMI was able to identify a subset of patients with poorer prognosis in the context of CA or in the late stages according to the biomarker staging systems.
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Affiliation(s)
- Hejing Huang
- Department of Ultrasound, Second Affiliated Hospital of Naval Medical University (Changzheng Hospital), Shanghai, China
| | - Haiyan He
- Department of Hematology, The Myeloma & Lymphoma Center, Second Affiliated Hospital of Naval Medical University (Changzheng Hospital), Shanghai, China
| | - Yingyi Qin
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Juan Du
- Department of Hematology, The Myeloma & Lymphoma Center, Second Affiliated Hospital of Naval Medical University (Changzheng Hospital), Shanghai, China
| | - Jialin Song
- Department of Ultrasound, Second Affiliated Hospital of Naval Medical University (Changzheng Hospital), Shanghai, China
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Kumar S, Grell GR, Joseph G, Wang JC. Axillary Lymphadenopathy as an Initial Presentation of Systemic Amyloidosis: A Case Report and Literature Review. J Investig Med High Impact Case Rep 2022; 10:23247096221133191. [PMID: 36300416 PMCID: PMC9619915 DOI: 10.1177/23247096221133191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Amyloidosis rarely presents as localized lymphadenopathy. Various studies have elucidated the varied presentation and manifestations of this interesting disease. We reviewed the literature and found 36 cases of primary amyloidosis with lymph node enlargement as a presentation, and 17 of the 36 cases (47%) had systemic involvement on further work up. We describe a patient who presented with an isolated right axillary mass. Clinical examination and radiology were indicative of a lymph node enlargement with no evidence of malignancy in the breasts or lungs. Histopathological examination was indicative of amyloidosis. A further work up including serum, urine biochemistry, cardiac work up, bone marrow examination, and a kidney biopsy revealed systemic amyloidosis. Patient was treated with daratumumab and CyBorD (cyclophosphamide, bortezomib, and dexamethasone) followed by a stem cell transplantation. Patient is in remission for 1 year, at the time of submission of this report. Therefore, we conclude (1) systemic amyloidosis presenting as an isolated lymph node enlargement is rare, (2) a structured systemic work up is imperative for early diagnosis and proper management of amyloidosis, when there is an index of suspicion, and (3) use of novel therapeutic options such as CD38 + antibody (daratumumab) and stem cell transplant have positive impact on disease outcomes.
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Affiliation(s)
- Suneet Kumar
- Interfaith Medical Center, One Brooklyn
Health, Brooklyn, NY, USA
| | - Gilda-Rae Grell
- Interfaith Medical Center, One Brooklyn
Health, Brooklyn, NY, USA
| | - Gardith Joseph
- Brookdale University Hospital and
Medical Center, One Brooklyn Health, Brooklyn, NY, USA
| | - Jen C. Wang
- Brookdale University Hospital and
Medical Center, One Brooklyn Health, Brooklyn, NY, USA, Jen C. Wang, MD, Department of Hematology
and Oncology, Brookdale University Hospital and Medical Center, One Brooklyn
Health, 1 Brookdale Plaza, Brooklyn, NY 11212, USA.
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13
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Feitosa V, Neves P, Jorge L, Noronha I, Onuchic L. Renal amyloidosis: a new time for a complete diagnosis. Braz J Med Biol Res 2022; 55:e12284. [PMID: 36197414 PMCID: PMC9529046 DOI: 10.1590/1414-431x2022e12284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/12/2022] [Indexed: 11/22/2022] Open
Abstract
Amyloidoses are a group of disorders in which soluble proteins aggregate and deposit extracellularly in tissues as insoluble fibrils, causing organ dysfunction. Clinical management depends on the subtype of the protein deposited and the affected organs. Systemic amyloidosis may stem from anomalous proteins, such as immunoglobulin light chains or serum amyloid proteins in chronic inflammation or may arise from hereditary disorders. Hereditary amyloidosis consists of a group of rare conditions that do not respond to chemotherapy, hence the identification of the amyloid subtype is essential for diagnosis, prognosis, and treatment. The kidney is the organ most frequently involved in systemic amyloidosis. Renal amyloidosis is characterized by acellular pathologic Congo red-positive deposition of amyloid fibrils in glomeruli, vessels, and/or interstitium. This disease manifests with heavy proteinuria, nephrotic syndrome, and progression to end-stage kidney failure. In some situations, it is not possible to identify the amyloid subtype using immunodetection methods, so the diagnosis remains indeterminate. In cases where hereditary amyloidosis is suspected or cannot be excluded, genetic testing should be considered. Of note, laser microdissection/mass spectrometry is currently the gold standard for accurate diagnosis of amyloidosis, especially in inconclusive cases. This article reviews the clinical manifestations and the current diagnostic landscape of renal amyloidosis.
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Affiliation(s)
- V.A. Feitosa
- Divisão de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil,Divisão de Medicina Molecular, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - P.D.M.M. Neves
- Divisão de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil,Divisão de Medicina Molecular, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - L.B. Jorge
- Divisão de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - I.L. Noronha
- Divisão de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
| | - L.F. Onuchic
- Divisão de Nefrologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil,Divisão de Medicina Molecular, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brasil
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14
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Bywater L, Gist AC, Muthalaly RG, Loh J, Simpson I, White AJ, Lim AKH. Systemic amyloidosis in a patient presenting with myopathy, peripheral oedema and proteinuria. Med J Aust 2022; 217:232-234. [PMID: 35924379 PMCID: PMC9544606 DOI: 10.5694/mja2.51667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | | | - Andy KH Lim
- Monash Health Melbourne VIC
- Monash University Melbourne VIC
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15
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Wang S, Sun J, Lu Q, Li H, Zhang Y. Late-Onset Hereditary Transthyretin Amyloidosis Val30Met in an Elderly Person in a Non-Endemic Area. Int Med Case Rep J 2022; 15:299-306. [PMID: 35734096 PMCID: PMC9208636 DOI: 10.2147/imcrj.s357236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/18/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Shun Wang
- Department of Cardiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xian, Shaanxi, People’s Republic of China
- Correspondence: Shun Wang, Department of Cardiovascular Medicine, The First Affiliated Hospital of Xi’an Jiao Tong University, Xi’an, People’s Republic of China, Email
| | - Jingping Sun
- Department of Cardiology, The Cleveland Clinic Foundation, Cleveland, OH, USA
- Jingping Sun, Cardiology Department, The Cleveland Clinic Foundation, Cleveland, OH, USA, Tel +1 346-719-7412, Email
| | - Qun Lu
- Department of Cardiology, The First Affiliated Hospital of Xi’an Jiaotong University, Xian, Shaanxi, People’s Republic of China
| | - Hao Li
- ICU, The First Affiliated Hospital of Xi’an Jiaotong University, Xian, Shaanxi, People’s Republic of China
| | - Yun Zhang
- Department of Imaging Medicine, The First Affiliated Hospital of Xi’an Jiaotong University, Xian, Shaanxi, People’s Republic of China
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16
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Maroun BZ, Allam S, Chaulagain CP. Multidisciplinary supportive care in systemic light chain amyloidosis. Blood Res 2022; 57:106-116. [PMID: 35593003 PMCID: PMC9242830 DOI: 10.5045/br.2022.2021227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 04/30/2022] [Accepted: 05/04/2022] [Indexed: 11/17/2022] Open
Abstract
The immunoglobulin light-chain amyloidosis is a multisystemic disease which manifests by damage to the vital organs by light chain-derived amyloid fibril. Traditionally, the treatment has been directed to the underlying plasma cell clone with or without high dose chemotherapy followed by autologous stem cell transplantation using melphalan based conditioning. Now with the approval of highly tolerable anti-CD38 monoclonal antibody daratumumab based anti-plasma cell therapy in 2021, high rates of hematologic complete responses are possible even in patients who are otherwise deemed not a candidate for autologous stem cell transplantation. However, despite the progress, there remains a limitation in the strategies to improve symptoms particularly in patients with advanced cardiac involvement, those with nephrotic syndrome and autonomic dysfunction due to underlying systemic AL amyloidosis. The symptoms can be an ordeal for the patients and their caregivers and effective strategies are urgently needed to address them. The supportive care is aimed to counteract the symptoms of the disease and the effects of the treatment on involved organs’ function and preserve patients’ quality of life. Here we discuss multidisciplinary approach in a system-based fashion to address the symptom management in this dreadful disease. In addition to achieving excellent anti-plasma cell disease control, using treatment directed to remove amyloid from the vital organs can theoretically hasten recovery of the involved organs thereby improving symptoms at a faster pace. Ongoing phase III clinical trials of CAEL-101 and Birtamimab will address this question.
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Affiliation(s)
- Bou Zerdan Maroun
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston FL, USA
| | - Sabine Allam
- Faculty of Medicine, University of Balamand, Beirut, Lebanon
| | - Chakra P Chaulagain
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston FL, USA
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17
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A case of medical liability involving an unexpected systemic amyloidosis. Leg Med (Tokyo) 2022; 56:102049. [DOI: 10.1016/j.legalmed.2022.102049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 02/09/2022] [Accepted: 02/21/2022] [Indexed: 12/22/2022]
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18
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Rimbas RC, Balinisteanu A, Magda SL, Visoiu SI, Ciobanu AO, Beganu E, Nicula AI, Vinereanu D. New Advanced Imaging Parameters and Biomarkers-A Step Forward in the Diagnosis and Prognosis of TTR Cardiomyopathy. J Clin Med 2022; 11:2360. [PMID: 35566485 PMCID: PMC9101617 DOI: 10.3390/jcm11092360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative disorder characterized by extracellular myocardial deposits of amyloid fibrils, with poor outcome, leading to heart failure and death, with significant treatment expenditure. In the era of a novel therapeutic arsenal of disease-modifying agents that target a myriad of pathophysiological mechanisms, timely and accurate diagnosis of ATTR-CM is crucial. Recent advances in therapeutic strategies shown to be most beneficial in the early stages of the disease have determined a paradigm shift in the screening, diagnostic algorithm, and risk classification of patients with ATTR-CM. The aim of this review is to explore the utility of novel specific non-invasive imaging parameters and biomarkers from screening to diagnosis, prognosis, risk stratification, and monitoring of the response to therapy. We will summarize the knowledge of the most recent advances in diagnostic, prognostic, and treatment tailoring parameters for early recognition, prediction of outcome, and better selection of therapeutic candidates in ATTR-CM. Moreover, we will provide input from different potential pathways involved in the pathophysiology of ATTR-CM, on top of the amyloid deposition, such as inflammation, endothelial dysfunction, reduced nitric oxide bioavailability, oxidative stress, and myocardial fibrosis, and their diagnostic, prognostic, and therapeutic implications.
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Affiliation(s)
- Roxana Cristina Rimbas
- Cardiology and Cardiovascular Surgery Department, University and Emergency Hospital, 050098 Bucharest, Romania; (R.C.R.); (A.B.); (A.O.C.); (E.B.); (D.V.)
- Cardiology Department, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania; (S.I.V.); (A.I.N.)
| | - Anca Balinisteanu
- Cardiology and Cardiovascular Surgery Department, University and Emergency Hospital, 050098 Bucharest, Romania; (R.C.R.); (A.B.); (A.O.C.); (E.B.); (D.V.)
- Cardiology Department, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania; (S.I.V.); (A.I.N.)
| | - Stefania Lucia Magda
- Cardiology and Cardiovascular Surgery Department, University and Emergency Hospital, 050098 Bucharest, Romania; (R.C.R.); (A.B.); (A.O.C.); (E.B.); (D.V.)
- Cardiology Department, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania; (S.I.V.); (A.I.N.)
| | - Simona Ionela Visoiu
- Cardiology Department, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania; (S.I.V.); (A.I.N.)
| | - Andrea Olivia Ciobanu
- Cardiology and Cardiovascular Surgery Department, University and Emergency Hospital, 050098 Bucharest, Romania; (R.C.R.); (A.B.); (A.O.C.); (E.B.); (D.V.)
- Cardiology Department, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania; (S.I.V.); (A.I.N.)
| | - Elena Beganu
- Cardiology and Cardiovascular Surgery Department, University and Emergency Hospital, 050098 Bucharest, Romania; (R.C.R.); (A.B.); (A.O.C.); (E.B.); (D.V.)
| | - Alina Ioana Nicula
- Cardiology Department, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania; (S.I.V.); (A.I.N.)
- Radiology Department, University and Emergency Hospital, 050098 Bucharest, Romania
| | - Dragos Vinereanu
- Cardiology and Cardiovascular Surgery Department, University and Emergency Hospital, 050098 Bucharest, Romania; (R.C.R.); (A.B.); (A.O.C.); (E.B.); (D.V.)
- Cardiology Department, University of Medicine and Pharmacy Carol Davila, 020021 Bucharest, Romania; (S.I.V.); (A.I.N.)
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19
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Derman B, Castillo JJ, Sarosiek S, Beksac M. When a Monoclonal Gammopathy Is Not Multiple Myeloma. Am Soc Clin Oncol Educ Book 2022; 42:1-10. [PMID: 35394823 DOI: 10.1200/edbk_349643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Our knowledge of monoclonal gammopathies is continuously evolving. Once accepted as a possible precursor condition to multiple myeloma, monoclonal gammopathies as an entity are now associated with many renal, neurologic, and dermatologic disorders of clinical significance. This change has created a challenge for patients and clinicians, as a monoclonal gammopathy may be a harbinger not of multiple myeloma but of other lymphoproliferative disorders such as light-chain amyloidosis and Waldenström macroglobulinemia. Early recognition of monoclonal gammopathies along with a careful workup are essential in determining the next steps in the care of a given patient. Recognition has become all the more important as we understand how to triage the 4% to 9% of patients with monoclonal gammopathies depending on age, with the goal of limiting overdiagnosis and misdiagnosis. In this review, we focus on treatment strategies for patients with monoclonal gammopathies that are not multiple myeloma, including smoldering multiple myeloma, light-chain amyloidosis, and Waldenström macroglobulinemia.
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Affiliation(s)
| | - Jorge J Castillo
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Shayna Sarosiek
- Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Meral Beksac
- Department of Hematology, Cebeci Hospital, Ankara University Dikimevi, Ankara, Turkey
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20
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Moshe-Lilie O, Banks G, Medvedova E, Masri A, Chahin N. Coexisting Sporadic Late Onset Nemaline Myopathy and Amyloid Myopathy – Incidental or Related? Neuromuscul Disord 2022; 32:533-538. [DOI: 10.1016/j.nmd.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/21/2022] [Accepted: 03/22/2022] [Indexed: 12/01/2022]
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21
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Stelmach-Gołdyś A, Zaborek-Łyczba M, Łyczba J, Garus B, Pasiarski M, Mertowska P, Małkowska P, Hrynkiewicz R, Niedźwiedzka-Rystwej P, Grywalska E. Physiology, Diagnosis and Treatment of Cardiac Light Chain Amyloidosis. J Clin Med 2022; 11:jcm11040911. [PMID: 35207184 PMCID: PMC8880759 DOI: 10.3390/jcm11040911] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/27/2022] [Accepted: 02/02/2022] [Indexed: 02/04/2023] Open
Abstract
AL (light-chain) amyloidosis is a systemic disease in which amyloid fibers are formed from kappa or lambda immunoglobulin light chains, or fragments thereof, produced by a neoplastic clone of plasmocytes. The produced protein is deposited in tissues and organs in the form of extracellular deposits, which leads to impairment of their functions and, consequently, to death. Despite the development of research on pathogenesis and therapy, the mortality rate of patients with late diagnosed amyloidosis is 30%. The diagnosis is delayed due to the complex clinical picture and the slow progression of the disease. This is the type of amyloidosis that most often contributes to cardiac lesions and causes cardiac amyloidosis (CA). Early diagnosis and correct identification of the type of amyloid plays a crucial role in the planning and effectiveness of therapy. In addition to standard histological studies based on Congo red staining, diagnostics are enriched by tests to determine the degree of cardiac involvement. In this paper, we discuss current diagnostic methods used in cardiac light chain amyloidosis and the latest therapies that contribute to an improved patient prognosis.
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Affiliation(s)
- Agnieszka Stelmach-Gołdyś
- Department of Immunology, Faculty of Health Sciences, Jan Kochanowski University, 25-317 Kielce, Poland; (A.S.-G.); (B.G.); (M.P.)
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland
| | - Monika Zaborek-Łyczba
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (M.Z.-Ł.); (J.Ł.); (P.M.); (E.G.)
| | - Jakub Łyczba
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (M.Z.-Ł.); (J.Ł.); (P.M.); (E.G.)
| | - Bartosz Garus
- Department of Immunology, Faculty of Health Sciences, Jan Kochanowski University, 25-317 Kielce, Poland; (A.S.-G.); (B.G.); (M.P.)
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland
| | - Marcin Pasiarski
- Department of Immunology, Faculty of Health Sciences, Jan Kochanowski University, 25-317 Kielce, Poland; (A.S.-G.); (B.G.); (M.P.)
- Department of Hematology, Holy Cross Cancer Centre, 25-734 Kielce, Poland
| | - Paulina Mertowska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (M.Z.-Ł.); (J.Ł.); (P.M.); (E.G.)
| | - Paulina Małkowska
- Institute of Biology, University of Szczecin, 71-412 Szczecin, Poland; (P.M.); (R.H.)
| | - Rafał Hrynkiewicz
- Institute of Biology, University of Szczecin, 71-412 Szczecin, Poland; (P.M.); (R.H.)
| | | | - Ewelina Grywalska
- Department of Experimental Immunology, Medical University of Lublin, 20-093 Lublin, Poland; (M.Z.-Ł.); (J.Ł.); (P.M.); (E.G.)
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22
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Ishimitsu A, Tojo A, Hirao J, Yokoyama S, Ohira T, Murayama Y, Ishimitsu T, Kang D, Honda K, Ehara T, Ishida K, Ueda Y. AL-Kappa Primary Amyloidosis with Apolipoprotein A-IV Deposition. Intern Med 2022; 61:871-876. [PMID: 35296622 PMCID: PMC8987257 DOI: 10.2169/internalmedicine.7955-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
A 70-year-old woman with complaints of edema, general malaise, and hypotension was diagnosed with renal amyloidosis, and laser microdissection mass spectrometry revealed her amyloidosis to predominantly comprise the apolipoprotein A-IV type. The M-protein turned from negative to positive during the course, and a bone marrow biopsy showed smoldering myeloma. Treatment with bortezomib and dexamethasone failed to save her from heart failure six months after the onset. Western blotting of urine samples at the time of the renal biopsy showed that amyloid light-chain κ amyloidosis had been present since the onset. Unlike the myeloma, Congo red staining was positive in the plasma cells of the bone marrow.
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Affiliation(s)
- Akira Ishimitsu
- Department of Nephrology & Hypertension, Dokkyo Medical University, Japan
| | - Akihiro Tojo
- Department of Nephrology & Hypertension, Dokkyo Medical University, Japan
| | - Jun Hirao
- Department of Nephrology & Hypertension, Dokkyo Medical University, Japan
| | - Shohei Yokoyama
- Department of Nephrology & Hypertension, Dokkyo Medical University, Japan
| | - Takehiro Ohira
- Department of Nephrology & Hypertension, Dokkyo Medical University, Japan
| | - Yoshiki Murayama
- Department of Nephrology & Hypertension, Dokkyo Medical University, Japan
| | | | - Dedong Kang
- Department of Anatomy, Showa University School of Medicine, Japan
| | - Kazuho Honda
- Department of Anatomy, Showa University School of Medicine, Japan
| | - Takashi Ehara
- Department of Pathology, Shinshu University School of Medicine, Japan
| | - Kazuyuki Ishida
- Department of Diagnostic Pathology, Dokkyo Medical University, Japan
| | - Yoshihiko Ueda
- Department of Pathology, Dokkyo Medical University Saitama Medical Center, Japan
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23
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Grigoletti SS, Zuchinali P, Lemieux-Blanchard É, Béchard S, Lemieux B, Ribeiro PAB, Tournoux F. Focused review on nutritional status of patients with immunoglobulin light chain amyloidosis. Curr Probl Cancer 2022; 46:100833. [DOI: 10.1016/j.currproblcancer.2021.100833] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/19/2021] [Accepted: 12/15/2021] [Indexed: 12/26/2022]
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24
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Dispenzieri A, Kastritis E, Wechalekar AD, Schönland SO, Kim K, Sanchorawala V, Landau HJ, Kwok F, Suzuki K, Comenzo RL, Berg D, Liu G, Kumar A, Faller DV, Merlini G. A randomized phase 3 study of ixazomib-dexamethasone versus physician's choice in relapsed or refractory AL amyloidosis. Leukemia 2022; 36:225-235. [PMID: 34168284 PMCID: PMC8727292 DOI: 10.1038/s41375-021-01317-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 05/26/2021] [Accepted: 06/02/2021] [Indexed: 12/14/2022]
Abstract
In the first phase 3 study in relapsed/refractory AL amyloidosis (TOURMALINE-AL1 NCT01659658), 168 patients with relapsed/refractory AL amyloidosis after 1-2 prior lines were randomized to ixazomib (4 mg, days 1, 8, 15) plus dexamethasone (20 mg, days 1, 8, 15, 22; n = 85) or physician's choice (dexamethasone ± melphalan, cyclophosphamide, thalidomide, or lenalidomide; n = 83) in 28-day cycles until progression or toxicity. Primary endpoints were hematologic response rate and 2-year vital organ deterioration or mortality rate. Only the first primary endpoint was formally tested at this interim analysis. Best hematologic response rate was 53% with ixazomib-dexamethasone vs 51% with physician's choice (p = 0.76). Complete response rate was 26 vs 18% (p = 0.22). Median time to vital organ deterioration or mortality was 34.8 vs 26.1 months (hazard ratio 0.53; 95% CI, 0.32-0.87; p = 0.01). Median treatment duration was 11.7 vs 5.0 months. Adverse events of clinical importance included diarrhea (34 vs 30%), rash (33 vs 20%), cardiac arrhythmias (26 vs 15%), nausea (24 vs 14%). Despite not meeting the first primary endpoint, all time-to-event data favored ixazomib-dexamethasone. These results are clinically relevant to this relapsed/refractory patient population with no approved treatment options.
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Affiliation(s)
- Angela Dispenzieri
- grid.66875.3a0000 0004 0459 167XDivision of Hematology, Mayo Clinic, Rochester, NY USA
| | - Efstathios Kastritis
- grid.5216.00000 0001 2155 0800Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ashutosh D. Wechalekar
- grid.83440.3b0000000121901201National Amyloidosis Centre, Royal Free London NHS Foundation Trust, University College London, London, UK
| | - Stefan O. Schönland
- grid.5253.10000 0001 0328 4908Department of Medicine V (Hematology, Oncology and Rheumatology), Amyloidosis Center Heidelberg, Heidelberg University Hospital, Heidelberg, Germany
| | - Kihyun Kim
- grid.264381.a0000 0001 2181 989XDivision of Hematology/Oncology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, MA USA
| | - Heather J. Landau
- grid.51462.340000 0001 2171 9952Memorial Sloan Kettering Cancer Center, New York, NY USA
| | - Fiona Kwok
- grid.413252.30000 0001 0180 6477Clinical Haematology, Westmead Hospital, Sydney, NSW Australia
| | - Kenshi Suzuki
- grid.414929.30000 0004 1763 7921Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Raymond L. Comenzo
- grid.67033.310000 0000 8934 4045John C. Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA USA
| | - Deborah Berg
- grid.419849.90000 0004 0447 7762Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA USA
| | - Guohui Liu
- grid.419849.90000 0004 0447 7762Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA USA
| | - Arun Kumar
- grid.419849.90000 0004 0447 7762Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA USA
| | - Douglas V. Faller
- grid.419849.90000 0004 0447 7762Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA USA
| | - Giampaolo Merlini
- grid.8982.b0000 0004 1762 5736Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, Department of Molecular Medicine, University of Pavia, Pavia, Italy
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25
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Chandrashekar P, Desai AK, Trachtenberg BH. Targeted treatments of AL and ATTR amyloidosis. Heart Fail Rev 2021; 27:1587-1603. [PMID: 34783948 DOI: 10.1007/s10741-021-10180-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/12/2021] [Indexed: 12/22/2022]
Abstract
The therapeutic landscape for cardiac amyloidosis is rapidly evolving. In the last decade, our focus has shifted from dealing with the inevitable complications of continued extracellular infiltration of amyloid fibrils to earlier identification of these patients with prompt initiation of targeted therapy to prevent further deposition. Although much of the focus on novel targeted therapies is within the realm of transthyretin amyloidosis, light chain amyloidosis has benefited due to an overlap particularly in the final common pathway of fibrillogenesis and extraction of amyloid fibrils from the heart. Here, we review the targeted therapeutics for transthyretin and light chain amyloidosis. For transthyretin amyloidosis, the list of current and future therapeutics continues to evolve; and therefore, it is crucial to become familiar with the underlying mechanistic pathways of the disease. Although targeted therapeutic choices in AL amyloidosis are largely driven by the hematology team, the cardiac adverse effect profiles of these therapies, particularly in those with advanced amyloidosis, provide an opportunity for early recognition to prevent decompensation and can help inform recommendations regarding therapy changes when required.
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Affiliation(s)
- Pranav Chandrashekar
- Amyloidosis Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Anish K Desai
- Department of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Barry H Trachtenberg
- Methodist DeBakey Heart and Vascular Center, Houston, TX, USA. .,Cardio-Oncology and Cardiac Amyloidosis Program, Advanced Heart Failure Fellowship Program, Methodist DeBakey Heart and Vascular Centers, J.C. Walter Transplant Center, Houston, USA.
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Velayati S, Belkin A, Sidhu Kumar G, Tharayil ZJ, Kumar N, Patel S. Kidney-limited AL amyloidosis: a case report and review of the literature. J Community Hosp Intern Med Perspect 2021; 11:698-702. [PMID: 34567468 PMCID: PMC8462866 DOI: 10.1080/20009666.2021.1942624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/09/2021] [Indexed: 11/01/2022] Open
Abstract
Amyloidosis involves the deposition of abnormal proteins in various tissues and results in progressive organ dysfunction, commonly affecting multiple organs. Two types of systemic amyloidosis are AA and AL; the former is associated with acute phase reactions and the latter is composed of light chain immunoglobulins. This disease commonly affects the kidneys and is evidenced by massive proteinuria. A biopsy is the gold standard of diagnosis, with Congo Red staining revealing an apple-green birefringence under polarized light. Although the kidneys are frequently affected in this disease, it is rare that amyloidosis is limited to the kidneys without involvement of other organs. We present an 83-year-old female with bilateral lower extremity swelling for several months who was found to have 12.374 grams of protein in a 24-hour urine sample and a large amount of free lambda chains. A renal biopsy demonstrated renal amyloidosis of the AL type. Serum immunofixation and flow cytometry were unremarkable for any plasma dyscrasia; a bone marrow biopsy did not reveal systemic amyloidosis and imaging with PET/CT scan did not show evidence of other organ involvement. She was diagnosed with renal-limited amyloidosis and started on bortezomib, melphalan, and steroids. Clinicians should be aware of the signs and symptoms of amyloidosis, specifically its ability to present with unusual involvement of individual organs.
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Affiliation(s)
- Sara Velayati
- Department of Internal Medicine, Long Island Community Hospital, Patchogue, NY, USA
| | - Alexander Belkin
- Department of Internal Medicine, Long Island Community Hospital, Patchogue, NY, USA
| | | | - Zubin J Tharayil
- Department of Internal Medicine, Long Island Community Hospital, Patchogue, NY, USA
| | - Neeru Kumar
- Department of nephrology, Brookhaven Nephrology Associates, P.C, Patchogue, NY, USA
| | - Samir Patel
- Department of hematology-oncology, Cancer and Blood Specialists, Patchogue, New York, USA
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Yan W, Cao Y, Liao A, Yang W, Li J, Wang H. A prognostic staging system for light-chain amyloidosis using hepatic and renal indicator data from 1,064 Chinese patients. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1347. [PMID: 34532484 PMCID: PMC8422138 DOI: 10.21037/atm-21-4033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/16/2021] [Indexed: 11/06/2022]
Abstract
Background Light-chain (AL) amyloidosis frequently involves severe multiple end-organ damage, thus affecting prognosis. As the current disease staging system is based only on cardiac indicators, we propose a new staging system based on multiple organ indicators to supplement the existing system. Methods Patients with AL amyloidosis (n=1,064) from 18 Chinese hospitals were enrolled and divided into test and validation cohorts (4:1). Multivariate analyses were performed to identify the clinical and laboratory factors for inclusion in the new staging system. Results A score of 1 was assigned for each of the following-the difference between the involved and uninvolved free light chains ≥100 mg/L, estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m2, total bilirubin (Tbil) ≥18 µmol/L, cardiac troponin I ≥0.06 µg/L, and N-terminal pro-brain natriuretic peptide (NT-proBNP) ≥3,600 pg/mL-to divide the patients into five disease stages (0 to IV). There were 220 (20.7%), 291 (27.3%), 251 (23.6%), 178 (16.7%), and 124 (11.7%) patients with stage 0, I, II, III, and IV disease, respectively. Patients with stage II, III, and IV disease had a median overall survival (OS) of 56.9 months [95% confidence interval (CI), 33.9-not reached (NR)], 18.6 months (95% CI, 33.9-NR), and 6.5 months (95% CI, 8.0-24.6) (P<0.001), respectively. The 3-year survival estimates for patients with stages 0, I, II, III, and IV were 90.7%, 71.4%, 59.4%, 39.0%, and 22.1%, respectively. Conclusions The new staging system has been developed that incorporates plasma cell-related characteristics in addition to cardiac, renal, and hepatic function parameters. It enhances the risk stratification of patients with AL amyloidosis and is useful when multiple organs are involved.
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Affiliation(s)
- Wei Yan
- Department of Hematology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yanze Cao
- Neusoft Research Institute, Northeastern University, Shenyang, China
| | - Aijun Liao
- Department of Hematology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Wei Yang
- Department of Hematology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Huihan Wang
- Department of Hematology, Shengjing Hospital of China Medical University, Shenyang, China
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Simões MV, Fernandes F, Marcondes-Braga FG, Scheinberg P, Correia EDB, Rohde LEP, Bacal F, Alves SMM, Mangini S, Biolo A, Beck-da-Silva L, Szor RS, Marques W, Oliveira ASB, Cruz MW, Bueno BVK, Hajjar LA, Issa AFC, Ramires FJA, Coelho OR, Schmidt A, Pinto IMF, Rochitte CE, Vieira MLC, Mesquita CT, Ramos CD, Soares-Junior J, Romano MMD, Mathias W, Garcia MI, Montera MW, de Melo MDT, Silva SME, Garibaldi PMM, de Alencar AC, Lopes RD, de Ávila DX, Viana D, Saraiva JFK, Canesin MF, de Oliveira GMM, Mesquita ET. Position Statement on Diagnosis and Treatment of Cardiac Amyloidosis - 2021. Arq Bras Cardiol 2021; 117:561-598. [PMID: 34550244 PMCID: PMC8462947 DOI: 10.36660/abc.20210718] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Marcus V. Simões
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Fabio Fernandes
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Fabiana G. Marcondes-Braga
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Philip Scheinberg
- Hospital da Beneficência Portuguesa de São PauloSão PauloSPBrasilHospital da Beneficência Portuguesa de São Paulo, São Paulo, SP – Brasil
| | - Edileide de Barros Correia
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Luis Eduardo P. Rohde
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
- Hospital Moinhos de VentoPorto AlegreRSBrasilHospital Moinhos de Vento, Porto Alegre, RS – Brasil
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil
| | - Fernando Bacal
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Silvia Marinho Martins Alves
- Pronto Socorro Cardiológico de PernambucoRecifePEBrasilPronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE – Brasil
- Universidade de PernambucoRecifePEBrasilUniversidade de Pernambuco (UPE), Recife, PE – Brasil
| | - Sandrigo Mangini
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Andréia Biolo
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
| | - Luis Beck-da-Silva
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil
| | - Roberta Shcolnik Szor
- Fundação Faculdade de MedicinaSão PauloSPBrasilFundação Faculdade de Medicina, São Paulo, SP – Brasil
- Universidade de São PauloSão PauloSPBrasilInstituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Wilson Marques
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Acary Souza Bulle Oliveira
- Universidade Federal de São PauloSão PauloSPBrasilUniversidade Federal de São Paulo, São Paulo, SP – Brasil
| | - Márcia Waddington Cruz
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilHospital Universitário Clementino Fraga Filho (HUCFF) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | - Bruno Vaz Kerges Bueno
- Faculdade de Ciências Médicas da Santa Casa de São PauloSão PauloSPBrasilFaculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP – Brasil
| | - Ludhmila Abrahão Hajjar
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Universidade de São PauloSão PauloSPBrasilInstituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Aurora Felice Castro Issa
- Instituto Nacional de CardiologiaRio de JaneiroRJBrasilInstituto Nacional de Cardiologia, Rio de Janeiro, RJ – Brasil
| | - Felix José Alvarez Ramires
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Otavio Rizzi Coelho
- Universidade Estadual de CampinasCampinasSPBrasilFaculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil
| | - André Schmidt
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | | | - Carlos Eduardo Rochitte
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital do CoraçãoSão PauloSPBrasilHospital do Coração (HCor), São Paulo, SP – Brasil
- Hospital Pró-CardíacoRio de JaneiroRJBrasilHospital Pró-Cardíaco, Rio de Janeiro, RJ – Brasil
| | - Marcelo Luiz Campos Vieira
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Cláudio Tinoco Mesquita
- Universidade Federal FluminenseRio de JaneiroRJBrasilUniversidade Federal Fluminense (UFF), Rio de Janeiro, RJ – Brasil
| | - Celso Dario Ramos
- Universidade Estadual de CampinasCampinasSPBrasilFaculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil
| | - José Soares-Junior
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Minna Moreira Dias Romano
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Wilson Mathias
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Marcelo Iório Garcia
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilHospital Universitário Clementino Fraga Filho (HUCFF) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | | | | | | | - Pedro Manoel Marques Garibaldi
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Aristóteles Comte de Alencar
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | | | - Diane Xavier de Ávila
- Hospital Pró-CardíacoRio de JaneiroRJBrasilHospital Pró-Cardíaco, Rio de Janeiro, RJ – Brasil
- Complexo Hospitalar de NiteróiRio de JaneiroRJBrasilComplexo Hospitalar de Niterói, Rio de Janeiro, RJ – Brasil
- Hospital e Maternidade Christóvão da GamaSanto AndréSPBrasilHospital e Maternidade Christóvão da Gama, Santo André, SP – Brasil
- Hospital Universitário Antônio PedroRio de JaneiroRJBrasilHospital Universitário Antônio Pedro (Huap), Rio de Janeiro, RJ – Brasil
| | - Denizar Viana
- Universidade do Estado do Rio de JaneiroRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ – Brasil
| | - José Francisco Kerr Saraiva
- Sociedade Campineira de Educação e InstruçãoCampinasSPBrasilSociedade Campineira de Educação e Instrução, Campinas, SP – Brasil
| | - Manoel Fernandes Canesin
- Universidade Estadual de LondrinaLondrinaPRBrasilHospital Universitário da Universidade Estadual de Londrina, Londrina, PR – Brasil
| | - Glaucia Maria Moraes de Oliveira
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilUniversidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | - Evandro Tinoco Mesquita
- Universidade Federal FluminenseRio de JaneiroRJBrasilUniversidade Federal Fluminense (UFF), Rio de Janeiro, RJ – Brasil
- Centro de Ensino e Treinamento Edson de Godoy BuenoRio de JaneiroRJBrasilCentro de Ensino e Treinamento Edson de Godoy Bueno/UHG, Rio de Janeiro, RJ – Brasil
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Rybinski B, Kocoglu M. Hepatic AL Amyloidosis without Significant Light Chain Elevation in a Patient Treated with CyBorD Plus Daratumumab. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e933241. [PMID: 34421115 PMCID: PMC8404164 DOI: 10.12659/ajcr.933241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Patient: Female, 60-year-old
Final Diagnosis: Amyloid light-chain amyloidosis • hepatic amyloidosis
Symptoms: Abdominal pain • anemia • emesis
Medication: —
Clinical Procedure: Bone marrow biopsy • exploratory laparotomy • hepatectomy • stem cell transplant
Specialty: Hematology • Oncology
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Affiliation(s)
- Brad Rybinski
- Department of Internal Medicine, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mehmet Kocoglu
- Bone Marrow & Stem Cell Transplantation/Plasma Cell Dyscrasias Division, University of Maryland Marlene and Stewart Greenebaum Cancer Center, Baltimore, MD, USA
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Anand BG, Prajapati KP, Ansari M, Yadav DK, Temgire M, Kar K. Genesis of Neurotoxic Hybrid Nanofibers from the Coassembly of Aromatic Amino Acids. ACS APPLIED MATERIALS & INTERFACES 2021; 13:36722-36736. [PMID: 34327979 DOI: 10.1021/acsami.1c04161] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
Considering the relevance of accumulation and self-assembly of metabolites and aftermath of biological consequences, it is important to know whether they undergo coassembly and what properties the resultant hybrid higher-order structures would exhibit. This work reveals the inherent tendency of aromatic amino acids to undergo a spontaneous coassembly process under physiologically mimicked conditions, which yields neurotoxic hybrid nanofibers. Resultant hybrid nanostructures resembled the β-structured conformers stabilized by H-bonds and π-π stacking interactions, which were highly toxic to human neuroblastoma cells. The hybrid nanofibers also showed strong cross-seeding potential that triggered in vitro aggregation of diverse globular proteins and brain extract components, converting the native structures into cross-β-rich amyloid aggregates. The heterogenic nature of the hybrid nanofibers seems crucial for their higher toxicity and faster cross-seeding potential as compared to the homogeneous amino acid nanofibers. Our findings reveal the importance of aromaticity-driven optimized intermolecular arrangements for the coassembly of aromatic amino acids, and the results may provide important clues to the fundamental understanding of metabolite accumulation-related complications.
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Affiliation(s)
- Bibin Gnanadhason Anand
- Biophysical and Biomaterials Research Laboratory, School of Life Sciences, Jawaharlal Nehru University, New Delhi 110067, India
| | - Kailash Prasad Prajapati
- Biophysical and Biomaterials Research Laboratory, School of Life Sciences, Jawaharlal Nehru University, New Delhi 110067, India
| | - Masihuzzaman Ansari
- Biophysical and Biomaterials Research Laboratory, School of Life Sciences, Jawaharlal Nehru University, New Delhi 110067, India
| | - Deepak Kumar Yadav
- Biophysical and Biomaterials Research Laboratory, School of Life Sciences, Jawaharlal Nehru University, New Delhi 110067, India
| | - Mayur Temgire
- Department of Chemical Engineering, Indian Institution of Technology Bombay, Powai, Mumbai 400076, India
| | - Karunakar Kar
- Biophysical and Biomaterials Research Laboratory, School of Life Sciences, Jawaharlal Nehru University, New Delhi 110067, India
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London ZN. A Structured Approach to the Diagnosis of Peripheral Nervous System Disorders. ACTA ACUST UNITED AC 2021; 26:1130-1160. [PMID: 33002996 DOI: 10.1212/con.0000000000000922] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
PURPOSE OF REVIEW Neuroanatomic localization and pattern recognition can be used to diagnose both focal lesions and generalized disorders of the peripheral nervous system. This article describes the nature and pattern of sensory and motor deficits associated with lesions of specific spinal nerve roots, plexus, or peripheral nerves. It also describes the patterns of sensory and motor deficits that suggest multifocal or generalized disorders of the motor neurons, sensory neurons, and peripheral nerves. RECENT FINDINGS The pattern of sensory and motor deficits may be used to distinguish lesions of the peripheral nervous system from those of the central nervous system. The spinal roots, nerve plexus, and peripheral nerves supply specific muscles and receive sensory input from distinctive cutaneous regions. Focal lesions of these structures therefore produce characteristic patterns of sensory and motor deficits. Multifocal or generalized disorders of the peripheral nervous system may be distinguished by categorizing their sensory and motor involvement, proximal and distal predominance, and degree of symmetry. Serum tests, CSF analysis, electrodiagnostic studies, MRI, ultrasound, nerve biopsy, and skin biopsy have unique roles in the diagnosis of suspected neuromuscular disorders. SUMMARY A structured approach to the diagnosis of nerve and motor neuron disorders can lead to hypothesis-driven diagnostic testing. Ancillary tests should be reserved for cases in which confirming or refuting a diagnosis will change patient management.
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Yabe M, Ozkaya N, de Jong D, Aypar U, Ritorto MS, Barbé E, Miedema IHC, Sen F, Chapman JR, Landau HJ, Dogan A. Localized Peritumoral AL Amyloidosis Associated With Mantle Cell Lymphoma With Plasmacytic Differentiation. Am J Surg Pathol 2021; 45:939-944. [PMID: 33739787 PMCID: PMC8192423 DOI: 10.1097/pas.0000000000001684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is characterized by the deposition of amyloid fibers derived from pathologic immunoglobulin light chains. Although systemic plasma cell neoplasms are the most common cause of AL amyloidosis, a subset of cases is caused by B-cell lymphoproliferative disorders such as lymphoplasmacytic lymphoma or extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue. Recently, SOX11-negative IGH hypermutated mantle cell lymphoma (MCL) is recognized to show frequent plasmacytic differentiation and indolent clinical course. Here, we report 3 cases of peritumoral AL amyloidosis associated with SOX11-negative MCL. All 3 cases showed cyclin D1 expression by immunohistochemistry and CCND1 translocation as detected by fluorescence in situ hybridization analysis. Peritumoral AL amyloidosis was observed at the biopsy sites in the gastrointestinal tract, a supraclavicular lymph node, and a cervical lymph node, and all presented with marked plasmacytic differentiation of lymphoma cells. None of the cases showed evidence of bone marrow involvement by morphology and immunophenotyping. None of the patients had distant organ involvement with systemic amyloidosis. All 3 patients had an indolent clinical course and are alive with disease at the time of the last follow-up (range: 48 to 74 mo). Our findings show that MCL with plasmacytic differentiation can cause amyloid deposition and CCND1 abnormalities should be performed in all cases of extramedullary AL amyloidosis. Recognition of indolent MCL as a cause of peritumoral AL amyloidosis may have important clinical management implications.
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Affiliation(s)
- Mariko Yabe
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Neval Ozkaya
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Daphne de Jong
- Department of Pathology, Amsterdam UMC, location VU University Medical Center, Amsterdam, The Netherlands
| | - Umut Aypar
- Cytogenetic Service, Department of Pathology, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - M. Stella Ritorto
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ellis Barbé
- Department of Pathology, Amsterdam UMC, location VU University Medical Center, Amsterdam, The Netherlands
| | - Iris H. C. Miedema
- Department of Pathology, Amsterdam UMC, location VU University Medical Center, Amsterdam, The Netherlands
| | - Filiz Sen
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Jessica R. Chapman
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Heather J. Landau
- Myeloma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Ahmet Dogan
- Hematopathology Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Inomata T, Tahara N, Nakamura K, Endo J, Ueda M, Ishii T, Kitano Y, Koyama J. Diagnosis of wild-type transthyretin amyloid cardiomyopathy in Japan: red-flag symptom clusters and diagnostic algorithm. ESC Heart Fail 2021; 8:2647-2659. [PMID: 34137515 PMCID: PMC8318452 DOI: 10.1002/ehf2.13473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/09/2021] [Accepted: 05/31/2021] [Indexed: 01/04/2023] Open
Abstract
Wild‐type transthyretin amyloid cardiomyopathy (ATTRwt‐CM) is caused by the deposition of wild‐type transthyretin (TTR) amyloid fibrils in the heart. The age at diagnosis of ATTRwt‐CM is reported to be approximately 70–80 years, and patients commonly present with non‐disease‐specific cardiac abnormalities, such as heart failure with preserved ejection fraction and diastolic dysfunction. The disease can be fatal if left untreated, with an approximate survival of 3–5 years from diagnosis. An oral TTR stabilizer, tafamidis, has enabled early intervention for the treatment of ATTRwt‐CM. However, awareness of ATTRwt‐CM remains low, and misdiagnosis and a delay in diagnosis are common. This review discusses the epidemiology, characteristics, treatment strategy, and red‐flag symptoms and signs of ATTRwt‐CM based on the published literature, as well as recent advances in diagnostic modalities that enable early and accurate diagnosis of the disease. We also discuss an algorithm for early and accurate diagnosis of ATTRwt‐CM in daily clinical practice. In our diagnostic algorithm, a suspected diagnosis of ATTRwt‐CM should be triggered by unexplained left ventricular hypertrophy (LVH), which is LVH that cannot be explained by an increased afterload due to hypertension or valvular disease. In addition, heart failure symptoms, laboratory test results (N‐terminal pro‐B‐type natriuretic peptide, high‐sensitivity troponin T, or high‐sensitivity troponin I), electrocardiogram and imaging (echocardiogram or cardiac magnetic resonance) data, age (≥60 years), and medical history suggestive of ATTRwt‐CM (e.g. carpal tunnel syndrome) should be examined. Detailed examinations using bone scintigraphy and monoclonal protein detection tests followed by tissue biopsy, amyloid typing, and TTR genetic testing are warranted for a definite diagnosis of ATTRwt‐CM.
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Affiliation(s)
- Takayuki Inomata
- Department of Cardiovascular Medicine, Kitasato University Kitasato Institute Hospital, 5-9-1, Shirokane, Minato-ku, Tokyo, 108-8642, Japan
| | - Nobuhiro Tahara
- Division of Cardiovascular Medicine, Department of Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Kazufumi Nakamura
- Department of Cardiovascular Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Jin Endo
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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Volz MJ, Pleger ST, Weber A, Geis NA, Hamed S, Mereles D, Hegenbart U, Katus HA, Frey N, Raake PW, Kreusser MM. Initial experience with percutaneous mitral valve repair in patients with cardiac amyloidosis. Eur J Clin Invest 2021; 51:e13473. [PMID: 33326601 DOI: 10.1111/eci.13473] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/07/2020] [Accepted: 12/12/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Percutaneous mitral valve repair (PMVR) is a therapeutic option for severe mitral regurgitation (MR) in patients with heart failure due to differential aetiologies. However, only little is known about the safety and efficacy of this procedure in patients with amyloid cardiomyopathy. METHODS Five patients with cardiac amyloidosis and moderate to severe or severe MR undergoing PMVR were analysed retrospectively and compared to seven patients with cardiac amyloidosis and severe MR without intervention. Clinical and functional data, renal function and cardiac biomarkers as well as established risk scores for cardiac amyloidosis were assessed. Primary endpoint was the reduction in MR one year after PMVR. Secondary endpoints were safety, overall mortality after 12 months compared with the control group, as well as changes in clinical and functional parameters. RESULTS Amyloidosis risk assessment documented amyloid cardiomyopathy at an advanced stage in all patients. Procedural, technical and device success of PMVR were all 100% and residual MR remained mild to moderate at 12 months follow-up (P = .038 vs before PMVR). Differences in survival compared with the control (no PMVR) group pointed to a possible survival benefit in the PMVR group (P = .02). CONCLUSION PMVR is a feasible and safe procedure in patients with cardiac amyloidosis and might carry a possible survival benefit in this patient group.
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Affiliation(s)
- Martin J Volz
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Sven T Pleger
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Andreas Weber
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Nicolas A Geis
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Sonja Hamed
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Derliz Mereles
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany
| | - Ute Hegenbart
- Division of Hematology and Oncology, Department of Internal Medicine V, University of Heidelberg, Heidelberg, Germany
| | - Hugo A Katus
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Norbert Frey
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Philip W Raake
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Division of Cardiology, Department of Internal Medicine III, University of Heidelberg, Heidelberg, Germany.,DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
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Morisaki S, Tsuchida S, Konishi E, Katoh N, Takahashi Y, Takahashi K. Localized Immunoglobulin Light-Chain Amyloidosis of the Ulnar Nerve. Case Rep Neurol 2021; 13:305-311. [PMID: 34177537 PMCID: PMC8215969 DOI: 10.1159/000515475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 02/13/2021] [Indexed: 11/19/2022] Open
Abstract
Amyloidosis is a disorder caused by extracellular tissue deposition of insoluble fibrils. Amyloidosis can be divided into systemic or localized disease. Primary systemic amyloidosis is a multisystem disease caused by the deposition of amyloid in various tissues. Localized amyloidosis has different characteristics than those of systemic amyloidosis. In this paper, we present the case of a middle-aged woman who presented with worsening ulnar nerve palsy. Electrophysiological examination and MRI indicated a tumor surrounding the ulnar nerve in the forearm. However, the operative findings revealed that ulnar nerve fascicles were replaced with a yellow tissue, which was diagnosed as amyloid light-chain λ amyloidosis, based on histopathological examination. Systemic amyloidosis was ruled out after the screening examinations. This paper is the first report of the ulnar nerve as the sole site of localized immunoglobulin light-chain amyloidosis manifestation.
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Affiliation(s)
| | - Shinji Tsuchida
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Japan
| | - Eiichi Konishi
- Department of Surgical Pathology, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Japan
| | - Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University, Matsumoto, Japan
| | - Yusuke Takahashi
- Department of Medicine (Neurology and Rheumatology), Shinshu University, Matsumoto, Japan
| | - Kenji Takahashi
- Department of Orthopaedics, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kamigyo-ku, Japan
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Abstract
Light-chain amyloidosis (AL) is a fatal disorder wherein the immunoglobulin light chain misfolds and aggregates, leading to amyloid plaques in various organs. Patient-specific mutations in the light chain variable domain (VL) are tightly linked to amyloidosis, but how these mutations drive AL is unknown. In recent work, Rottenaicher et al. analyze five mutations found in the VL of a patient with cardiac AL. Their data suggest that decreased VL stability and increased flexibility in the core of the VL, caused by mutations outside of this core, could be key to aggregation and highlight the delicate balancing act required for antibody maturation to enable antigen recognition while not altering protein biophysics.
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Abstract
Often considered a rare disease, cardiac amyloidosis is increasingly recognized by practicing clinicians. The increased rate of diagnosis is in part due the aging of the population and increasing incidence and prevalence of cardiac amyloidosis with advancing age, as well as the advent of noninvasive methods using nuclear scintigraphy to diagnose transthyretin cardiac amyloidosis due to either variant or wild type transthyretin without a biopsy. Perhaps the most important driver of the increased awareness is the elucidation of the biologic mechanisms underlying the pathogenesis of cardiac amyloidosis which have led to the development of several effective therapies with differing mechanisms of actions. In this review, the mechanisms underlying the pathogenesis of cardiac amyloidosis due to light chain (AL) or transthyretin (ATTR) amyloidosis are delineated as well as the rapidly evolving therapeutic landscape that has emerged from a better pathophysiologic understanding of disease development.
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Affiliation(s)
- Jan M. Griffin
- Division of Cardiology, Cardiovascular Research Laboratory
for the Elderly, Columbia University Irving Medical Center, New York, NY
| | - Hannah Rosenblum
- Division of Cardiology, Cardiovascular Research Laboratory
for the Elderly, Columbia University Irving Medical Center, New York, NY
| | - Mathew S. Maurer
- Division of Cardiology, Cardiovascular Research Laboratory
for the Elderly, Columbia University Irving Medical Center, New York, NY
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Goto S, Mahara K, Beussink-Nelson L, Ikura H, Katsumata Y, Endo J, Gaggin HK, Shah SJ, Itabashi Y, MacRae CA, Deo RC. Artificial intelligence-enabled fully automated detection of cardiac amyloidosis using electrocardiograms and echocardiograms. Nat Commun 2021; 12:2726. [PMID: 33976142 PMCID: PMC8113484 DOI: 10.1038/s41467-021-22877-8] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 12/23/2020] [Indexed: 01/19/2023] Open
Abstract
Patients with rare conditions such as cardiac amyloidosis (CA) are difficult to identify, given the similarity of disease manifestations to more prevalent disorders. The deployment of approved therapies for CA has been limited by delayed diagnosis of this disease. Artificial intelligence (AI) could enable detection of rare diseases. Here we present a pipeline for CA detection using AI models with electrocardiograms (ECG) or echocardiograms as inputs. These models, trained and validated on 3 and 5 academic medical centers (AMC) respectively, detect CA with C-statistics of 0.85-0.91 for ECG and 0.89-1.00 for echocardiography. Simulating deployment on 2 AMCs indicated a positive predictive value (PPV) for the ECG model of 3-4% at 52-71% recall. Pre-screening with ECG enhance the echocardiography model performance at 67% recall from PPV of 33% to PPV of 74-77%. In conclusion, we developed an automated strategy to augment CA detection, which should be generalizable to other rare cardiac diseases.
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Affiliation(s)
- Shinichi Goto
- One Brave Idea and Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Keitaro Mahara
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Lauren Beussink-Nelson
- Division of Cardiology, Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Hidehiko Ikura
- Department of Cardiology, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Yoshinori Katsumata
- Department of Cardiology, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Jin Endo
- Department of Cardiology, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Hanna K Gaggin
- Harvard Medical School, Boston, MA, USA
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Sanjiv J Shah
- Division of Cardiology, Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Yuji Itabashi
- Department of Cardiology, Keio University School of Medicine, Shinjuku, Tokyo, Japan
| | - Calum A MacRae
- One Brave Idea and Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Rahul C Deo
- One Brave Idea and Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Center for Digital Health Innovation and Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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Prabakaran R, Rawat P, Thangakani AM, Kumar S, Gromiha MM. Protein aggregation: in silico algorithms and applications. Biophys Rev 2021; 13:71-89. [PMID: 33747245 PMCID: PMC7930180 DOI: 10.1007/s12551-021-00778-w] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 01/01/2021] [Indexed: 01/08/2023] Open
Abstract
Protein aggregation is a topic of immense interest to the scientific community due to its role in several neurodegenerative diseases/disorders and industrial importance. Several in silico techniques, tools, and algorithms have been developed to predict aggregation in proteins and understand the aggregation mechanisms. This review attempts to provide an essence of the vast developments in in silico approaches, resources available, and future perspectives. It reviews aggregation-related databases, mechanistic models (aggregation-prone region and aggregation propensity prediction), kinetic models (aggregation rate prediction), and molecular dynamics studies related to aggregation. With a multitude of prediction models related to aggregation already available to the scientific community, the field of protein aggregation is rapidly maturing to tackle new applications.
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Affiliation(s)
- R. Prabakaran
- Department of Biotechnology, Indian Institute of Technology Madras, Chennai, Tamil Nadu India
| | - Puneet Rawat
- Department of Biotechnology, Indian Institute of Technology Madras, Chennai, Tamil Nadu India
| | - A. Mary Thangakani
- Department of Biotechnology, Indian Institute of Technology Madras, Chennai, Tamil Nadu India
| | - Sandeep Kumar
- Biotherapeutics Discovery, Boehringer Ingelheim Pharmaceutical Inc., Ridgefield, CT USA
| | - M. Michael Gromiha
- Department of Biotechnology, Indian Institute of Technology Madras, Chennai, Tamil Nadu India
- School of Computing, Institute of Innovative Research, Tokyo Institute of Technology, Yokohama, Kanagawa Japan
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40
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Hara A, Minaga K, Watanabe T. Diffuse Pancreas Swelling in a Patient With Multiple Myeloma. Gastroenterology 2021; 160:e6-e9. [PMID: 32569765 DOI: 10.1053/j.gastro.2020.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 06/08/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Akane Hara
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
| | - Kosuke Minaga
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan.
| | - Tomohiro Watanabe
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama, Japan
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41
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Molecular mechanism of amyloidogenic mutations in hypervariable regions of antibody light chains. J Biol Chem 2021; 296:100334. [PMID: 33508322 PMCID: PMC7949129 DOI: 10.1016/j.jbc.2021.100334] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 01/14/2021] [Accepted: 01/22/2021] [Indexed: 12/14/2022] Open
Abstract
Systemic light chain (AL) amyloidosis is a fatal protein misfolding disease in which excessive secretion, misfolding, and subsequent aggregation of free antibody light chains eventually lead to deposition of amyloid plaques in various organs. Patient-specific mutations in the antibody VL domain are closely linked to the disease, but the molecular mechanisms by which certain mutations induce misfolding and amyloid aggregation of antibody domains are still poorly understood. Here, we compare a patient VL domain with its nonamyloidogenic germline counterpart and show that, out of the five mutations present, two of them strongly destabilize the protein and induce amyloid fibril formation. Surprisingly, the decisive, disease-causing mutations are located in the highly variable complementarity determining regions (CDRs) but exhibit a strong impact on the dynamics of conserved core regions of the patient VL domain. This effect seems to be based on a deviation from the canonical CDR structures of CDR2 and CDR3 induced by the substitutions. The amyloid-driving mutations are not necessarily involved in propagating fibril formation by providing specific side chain interactions within the fibril structure. Rather, they destabilize the VL domain in a specific way, increasing the dynamics of framework regions, which can then change their conformation to form the fibril core. These findings reveal unexpected influences of CDR-framework interactions on antibody architecture, stability, and amyloid propensity.
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42
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Nitsche C, Scully PR, Patel KP, Kammerlander AA, Koschutnik M, Dona C, Wollenweber T, Ahmed N, Thornton GD, Kelion AD, Sabharwal N, Newton JD, Ozkor M, Kennon S, Mullen M, Lloyd G, Fontana M, Hawkins PN, Pugliese F, Menezes LJ, Moon JC, Mascherbauer J, Treibel TA. Prevalence and Outcomes of Concomitant Aortic Stenosis and Cardiac Amyloidosis. J Am Coll Cardiol 2021; 77:128-139. [PMID: 33181246 PMCID: PMC7805267 DOI: 10.1016/j.jacc.2020.11.006] [Citation(s) in RCA: 196] [Impact Index Per Article: 65.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Older patients with severe aortic stenosis (AS) are increasingly identified as having cardiac amyloidosis (CA). It is unknown whether concomitant AS-CA has worse outcomes or results in futility of transcatheter aortic valve replacement (TAVR). OBJECTIVES This study identified clinical characteristics and outcomes of AS-CA compared with lone AS. METHODS Patients who were referred for TAVR at 3 international sites underwent blinded research core laboratory 99mtechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy (Perugini grade 0: negative; grades 1 to 3: increasingly positive) before intervention. Transthyretin-CA (ATTR) was diagnosed by DPD and absence of a clonal immunoglobulin, and light-chain CA (AL) was diagnosed via tissue biopsy. National registries captured all-cause mortality. RESULTS A total of 407 patients (age 83.4 ± 6.5 years; 49.8% men) were recruited. DPD was positive in 48 patients (11.8%; grade 1: 3.9% [n = 16]; grade 2/3: 7.9% [n = 32]). AL was diagnosed in 1 patient with grade 1. Patients with grade 2/3 had worse functional capacity, biomarkers (N-terminal pro-brain natriuretic peptide and/or high-sensitivity troponin T), and biventricular remodeling. A clinical score (RAISE) that used left ventricular remodeling (hypertrophy/diastolic dysfunction), age, injury (high-sensitivity troponin T), systemic involvement, and electrical abnormalities (right bundle branch block/low voltages) was developed to predict the presence of AS-CA (area under the curve: 0.86; 95% confidence interval: 0.78 to 0.94; p < 0.001). Decisions by the heart team (DPD-blinded) resulted in TAVR (333 [81.6%]), surgical AVR (10 [2.5%]), or medical management (65 [15.9%]). After a median of 1.7 years, 23% of patients died. One-year mortality was worse in all patients with AS-CA (grade: 1 to 3) than those with lone AS (24.5% vs. 13.9%; p = 0.05). TAVR improved survival versus medical management; AS-CA survival post-TAVR did not differ from lone AS (p = 0.36). CONCLUSIONS Concomitant pathology of AS-CA is common in older patients with AS and can be predicted clinically. AS-CA has worse clinical presentation and a trend toward worse prognosis, unless treated. Therefore, TAVR should not be withheld in AS-CA.
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Affiliation(s)
- Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Paul R Scully
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Cardiology Department, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Kush P Patel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Andreas A Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Carolina Dona
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Tim Wollenweber
- Department of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Nida Ahmed
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - George D Thornton
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | | | | | - Muhiddin Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Mullen
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Guy Lloyd
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Queen Mary University London, London, United Kingdom
| | | | | | - Francesca Pugliese
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Queen Mary University London, London, United Kingdom
| | - Leon J Menezes
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; UCL/ULCH NIHR Biomedical Research Centre, London, United Kingdom
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Julia Mascherbauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom.
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Yilmaz A, Bauersachs J, Bengel F, Büchel R, Kindermann I, Klingel K, Knebel F, Meder B, Morbach C, Nagel E, Schulze-Bahr E, Aus dem Siepen F, Frey N. Diagnosis and treatment of cardiac amyloidosis: position statement of the German Cardiac Society (DGK). Clin Res Cardiol 2021; 110:479-506. [PMID: 33459839 PMCID: PMC8055575 DOI: 10.1007/s00392-020-01799-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 12/21/2020] [Indexed: 12/15/2022]
Abstract
Systemic forms of amyloidosis affecting the heart are mostly light-chain (AL) and transthyretin (ATTR) amyloidoses. The latter is caused by deposition of misfolded transthyretin, either in wild-type (ATTRwt) or mutant (ATTRv) conformation. For diagnostics, specific serum biomarkers and modern non-invasive imaging techniques, such as cardiovascular magnetic resonance imaging (CMR) and scintigraphic methods, are available today. These imaging techniques do not only complement conventional echocardiography, but also allow for accurate assessment of the extent of cardiac involvement, in addition to diagnosing cardiac amyloidosis. Endomyocardial biopsy still plays a major role in the histopathological diagnosis and subtyping of cardiac amyloidosis. The main objective of the diagnostic algorithm outlined in this position statement is to detect cardiac amyloidosis as reliably and early as possible, to accurately determine its extent, and to reliably identify the underlying subtype of amyloidosis, thereby enabling subsequent targeted treatment.
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Affiliation(s)
- A Yilmaz
- Sektion für Herzbildgebung, Klinik für Kardiologie, Universitätsklinikum Münster, Von-Esmarch-Str. 48, 48149, Münster, Germany.
| | - J Bauersachs
- Klinik für Kardiologie und Angiologie, Medizinische Hochschule Hannover, Hannover, Germany
| | - F Bengel
- Klinik für Nuklearmedizin, Medizinische Hochschule Hannover, Hannover, Germany
| | - R Büchel
- Klinik für Nuklearmedizin, Universitätsspital Zürich, Zurich, Switzerland
| | - I Kindermann
- Klinik für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin), Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg, Germany
| | - K Klingel
- Institut für Pathologie und Neuropathologie, Universität Tübingen, Tübingen, Germany
| | - F Knebel
- Medizinische Klinik m.S. Kardiologie und Angiologie, Charite Universitätsmedizin Berlin Campus Mitte, Berlin, Germany
| | - B Meder
- Klinik für Innere Medizin III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - C Morbach
- Klinik für Innere Medizin III, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - E Nagel
- Interdisziplinäres Amyloidosezentrum Nordbayern, Deutsches Zentrum für Herzinsuffizienz, Medizinische Klinik I der Universität Würzburg, Würzburg, Germany
| | - E Schulze-Bahr
- Institut für Experimentelle und translationale kardiovaskuläre Bildgebung, Universitätsklinikum Frankfurt, Frankfurt, Germany
| | - F Aus dem Siepen
- Institut für Genetik von Herzerkrankungen (IfGH), Universitätsklinikum Münster, Münster, Germany
| | - N Frey
- Klinik für Innere Medizin III, Schwerpunkt Kardiologie und Angiologie, Universitätsklinikum Schleswig-Holstein, Kiel, Germany.,Kommission für Klinische Kardiovaskuläre Medizin, Deutsche Gesellschaft für Kardiologie, Düsseldorf, Germany
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Monoclonal Gammopathies of 'Neurological Significance': Paraproteinemic Neuropathies. Can J Neurol Sci 2021; 48:616-625. [PMID: 33397535 DOI: 10.1017/cjn.2020.278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES To study the clinical profile and outcomes of patients with paraproteinemic neuropathy (PPN) and to explore the utility of nerve conduction studies (NCSs) to differentiate between the demyelinating subtypes. METHODS We did a retrospective analysis of patients diagnosed with PPN between January 2010 and December 2019 in an inpatient setting. The study population consisted of patients above 16 years of age presenting with clinical features suggestive of chronic peripheral neuropathy and on evaluation was found to have PPN. RESULTS A total of 74 patients were identified. The patients were predominantly in the 6th decade, and the majority were males. The subtypes of PPN were monoclonal gammopathy of undetermined significance (MGUS) (45.9%), POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes) (24.3%), solitary plasmacytoma (17.6%), multiple myeloma (8.1%), and AL amyloidosis (4.1%). There are specific features on NCS which can help in identifying POEMS syndrome and IgM MGUS. The majority of patients with PPN tend to stabilize or improve with treatment; however, many have a severe residual disability. New terminology and classification of these entities as 'monoclonal gammopathies of neurological significance' can aid in early diagnosis and the development of effective treatment, to prevent residual disability. CONCLUSION PPN has a heterogeneous spectrum of clinical, biochemical, and electrophysiological features. NCS can help distinguish POEMS syndrome and IgM MGUS from other demyelinating subtypes.
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Abstract
The organs affected most commonly by AL amyloidosis are the kidneys and heart, however, liver and gastrointestinal (GI) tract are also commonly affected. Symptoms of GI amyloidosis often mimic those of other GI disorders; having a keen awareness of the need to evaluate for amyloidosis is critical in avoiding delay in diagnosis and intervention. GI and liver involvement is associated with significant complications, and challenges in symptomatic management. As with all AL-related organ disease, early systemic treatment can prevent progression of tissue damage and improve outcomes.
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Affiliation(s)
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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46
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Ballegaard M, Nelson LM, Gimsing P. Comparing neuropathy in multiple myeloma and AL amyloidosis. J Peripher Nerv Syst 2020; 26:75-82. [PMID: 33368817 DOI: 10.1111/jns.12428] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 12/05/2020] [Accepted: 12/16/2020] [Indexed: 01/01/2023]
Abstract
Peripheral neuropathy (PN) is frequent in patients with monoclonal gammopathy due to plasma cell dyscrasia, but little is known about the comparative impact of nerve dysfunction in different disorders. We compared clinical and laboratory results between two diagnostic groups. We recruited 76 untreated multiple myeloma (MM) and 27 AL amyloidosis (ALA) patients for evaluation of symptoms, clinical findings and nerve conduction studies (NCS). We diagnosed significant PN using total neuropathy scores (TNS > 7) in 17.6% of MM and 48.1% of ALA patients and in 27.7% of MM and 35.7% of ALA patients using NCS findings. TNS score grades were significantly higher in the AL amyloidosis patients (Fisher's exact test: P = .02) but a NCS based PN diagnosis was not significantly different (Fisher's exact test: P = .13). A significantly higher TNS vibration (P = .04) and pin (P = .02) sensory sign and TNS reflex (P = .04) sign score was found in amyloidosis patients. Likewise, quantitative sensory thresholds for vibration was higher in amyloidosis patients (Welsh ANOVA: P = .01). NCS revealed signs of more frequent axonal tibial neuropathy with significantly lower motor response amplitudes (P = .02) and resulting higher TNS scores (P = .002), while sural nerve sensory response amplitudes were without significant difference (P = .86). We found more severe TNS grades of PN in AL amyloidosis patients compared with MM patients. We also found higher sensory symptoms scores and higher thresholds for vibration but similar sensory involvement using NCS. The NCS exclusively showed signs of an axonal neuropathy.
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Affiliation(s)
- Martin Ballegaard
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Neurology, Zealand University Hospital, Roskilde, Denmark
| | | | - Peter Gimsing
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,Department of Haematology, Rigshospitalet, Copenhagen, Denmark
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Abstract
PURPOSE OF REVIEW This article provides a summary of the autonomic neuropathies, including neuropathies associated with diabetes mellitus, neuropathies due to amyloid deposition, immune-mediated autonomic neuropathies (including those associated with a paraneoplastic syndrome), inherited autonomic neuropathies, and toxic autonomic neuropathies. The presenting features, diagnostic investigations, and natural history of these neuropathies are discussed. RECENT FINDINGS Recent findings in autonomic peripheral neuropathy include data on the epidemiology and atypical presentations of diabetic autonomic neuropathy, treatment-induced neuropathy of diabetes mellitus, the presentation of immune-mediated neuropathies, and advances in hereditary neuropathy associated with amyloidosis and other hereditary neuropathies. SUMMARY Knowledge and recognition of the clinical features of the autonomic neuropathies, combined with appropriate laboratory and electrophysiologic testing, will facilitate accurate diagnosis and management.
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Vallat JM, Duchesne M, Corcia P, Richard L, Ghorab K, Magy L, Mathis S. The Wide Spectrum of Pathophysiologic Mechanisms of Paraproteinemic Neuropathy. Neurology 2020; 96:214-225. [PMID: 33277411 DOI: 10.1212/wnl.0000000000011324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 10/08/2020] [Indexed: 11/15/2022] Open
Abstract
Monoclonal gammopathy is encountered quite frequently in the general population. This type of hematologic abnormality may be mild, referred to as monoclonal gammopathy of undetermined significance or related to different types of hematologic malignancies. The association of a peripheral neuropathy with monoclonal gammopathy is also fairly common, and hemopathy may be discovered in an investigation of peripheral neuropathy. In such a situation, it is essential to determine the exact nature of the hematologic process in order not to miss a malignant disease and thus initiate the appropriate treatment (in conjunction with hematologists and oncologists). In this respect, nerve biopsy (discussed on a case-by-case basis) is of great value in the management of such patients. We therefore propose to present the objectives and main interests of nerve biopsy in this situation.
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Affiliation(s)
- Jean-Michel Vallat
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France.
| | - Mathilde Duchesne
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Philippe Corcia
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Laurence Richard
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Karima Ghorab
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Laurent Magy
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
| | - Stéphane Mathis
- From the Department of Neurology (J.-M.V., M.D., L.R., K.G., L.M.), National Reference Center for "Rare Peripheral Neuropathies," Dupuytren University Hospital (CHU Limoges), University of Limoges; Department of Pathology (M.D.), Limoges University Hospital (CHU Limoges), University of Limoges; Department of Neurology and ALS Reference Center (P.C.), Bretonneau University Hospital (CHU Tours), University of Tours; and Department of Neurology (S.M.), Nerve-Muscle Unit, 4 Pellegrin University Hospital (CHU Bordeaux), University of Bordeaux, France
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Bonderman D, Pölzl G, Ablasser K, Agis H, Aschauer S, Auer-Grumbach M, Binder C, Dörler J, Duca F, Ebner C, Hacker M, Kain R, Kammerlander A, Koschutnik M, Kroiss AS, Mayr A, Nitsche C, Rainer PP, Reiter-Malmqvist S, Schneider M, Schwarz R, Verheyen N, Weber T, Zaruba MM, Badr Eslam R, Hülsmann M, Mascherbauer J. Diagnosis and treatment of cardiac amyloidosis: an interdisciplinary consensus statement. Wien Klin Wochenschr 2020; 132:742-761. [PMID: 33270160 PMCID: PMC7732807 DOI: 10.1007/s00508-020-01781-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023]
Abstract
The prevalence and significance of cardiac amyloidosis have been considerably underestimated in the past; however, the number of patients diagnosed with cardiac amyloidosis has increased significantly recently due to growing awareness of the disease, improved diagnostic capabilities and demographic trends. Specific therapies that improve patient prognosis have become available for certain types of cardiac amyloidosis. Thus, the earliest possible referral of patients with suspicion of cardiac amyloidosis to an experienced center is crucial to ensure rapid diagnosis, early initiation of treatment, and structured patient care. This requires intensive collaboration across several disciplines, and between resident physicians and specialized centers. The aim of this consensus statement is to provide guidance for the rapid and efficient diagnosis and treatment of light-chain amyloidosis and transthyretin amyloidosis, which are the most common forms of cardiac amyloidosis.
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Affiliation(s)
- Diana Bonderman
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria.
| | - Gerhard Pölzl
- Department of Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Klemens Ablasser
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Hermine Agis
- Department of Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Stefan Aschauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Michaela Auer-Grumbach
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christina Binder
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jakob Dörler
- Department of Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Franz Duca
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Christian Ebner
- Internal Department II of Cardiology, Angiology and Internal Intensive Medicine, Elisabethinen Hospital, Linz, Austria
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, Department of Radiology and Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Renate Kain
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Andreas Kammerlander
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Matthias Koschutnik
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Nitsche
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | | | - Matthias Schneider
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Roland Schwarz
- Specialist in Internal Medicine and Cardiology, Ried im Innkreis, Austria
| | - Nicolas Verheyen
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Thomas Weber
- Department of Internal Medicine 2 (Cardiology & Intensive Care), University Teaching Hospital Klinikum Wels-Grieskirchen, Wels, Austria
| | - Marc Michael Zaruba
- Department of Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Roza Badr Eslam
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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50
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Thaisetthawatkul P, Dyck PJB. Peripheral Nervous System Involvement. Hematol Oncol Clin North Am 2020; 34:1091-1098. [DOI: 10.1016/j.hoc.2020.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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