1
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Wang J, Li J, Zhong L. Current status and prospect of anti-amyloid fibril therapy in AL amyloidosis. Blood Rev 2024; 66:101207. [PMID: 38692939 DOI: 10.1016/j.blre.2024.101207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/11/2024] [Accepted: 04/14/2024] [Indexed: 05/03/2024]
Abstract
Amyloid light-chain (AL) amyloidosis is a rare hematological disease that produces abnormal monoclonal immunoglobulin light chains to form amyloid fibrils that are deposited in tissues, resulting in organ damage and dysfunction. Advanced AL amyloidosis has a very poor prognosis with a high risk of early mortality. The combination of anti-plasma cell therapy and amyloid fibrils clearance is the optimal treatment strategy, which takes into account both symptoms and root causes. However, research on anti-amyloid fibrils lags far behind research on anti-plasma cells, and there is currently no approved treatment that could clear amyloid fibrils. Nevertheless, anti-amyloid fibril therapies are being actively investigated recently and have shown potential in clinical trials. In this review, we aim to outline the preclinical work and clinical efficacy of fibril-directed therapies for AL amyloidosis.
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Affiliation(s)
- Jinghua Wang
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Liye Zhong
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
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2
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Pozzan M, Indennidate C, Varrà GG, Sinagra G, Merlo M, Pagura L. Amyloidosis and Amyloidogenesis: One Name, Many Diseases. Heart Fail Clin 2024; 20:249-260. [PMID: 38844296 DOI: 10.1016/j.hfc.2024.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Amyloidosis is a heterogenous group of disorders, caused by the deposition of insoluble fibrils derived from misfolded proteins in the extracellular space of various organs. These proteins have an unstable structure that causes them to misfold, aggregate, and deposit as amyloid fibrils with the pathognomonic histologic property of green birefringence when viewed under cross-polarized light after staining with Congo red. Amyloid fibrils are insoluble and degradation-resistant; resistance to catabolism results in progressive tissue amyloid accumulation. The outcome of this process is organ disfunction independently from the type of deposited protein, however there can be organ that are specifically targeted from certain proteins.
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Affiliation(s)
- Marco Pozzan
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy
| | - Carla Indennidate
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy
| | - Guerino Giuseppe Varrà
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy
| | - Marco Merlo
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy; European Reference Network for Rare Low Prevalence and Complex Diseases of the Heart-ERN GUARD Heart Via P. Valdoni 7 Trieste 34100, Italy.
| | - Linda Pagura
- Division of Cardiac Surgery, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Via P. Valdoni 7, Trieste 34100, Italy
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3
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Sanchorawala V. Systemic Light Chain Amyloidosis. N Engl J Med 2024; 390:2295-2307. [PMID: 38924733 DOI: 10.1056/nejmra2304088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Affiliation(s)
- Vaishali Sanchorawala
- From the Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston Medical Center, Boston
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4
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Chompoopong P, Mauermann ML, Siddiqi H, Peltier A. Amyloid Neuropathy: From Pathophysiology to Treatment in Light-Chain Amyloidosis and Hereditary Transthyretin Amyloidosis. Ann Neurol 2024. [PMID: 38923548 DOI: 10.1002/ana.26965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/20/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024]
Abstract
Amyloid neuropathy is caused by deposition of insoluble β-pleated amyloid sheets in the peripheral nervous system. It is most common in: (1) light-chain amyloidosis, a clonal non-proliferative plasma cell disorder in which fragments of immunoglobulin, light or heavy chain, deposit in tissues, and (2) hereditary transthyretin (ATTRv) amyloidosis, a disorder caused by autosomal dominant mutations in the TTR gene resulting in mutated protein that has a higher tendency to misfold. Amyloid fibrils deposit in the endoneurium of peripheral nerves, often extensive in the dorsal root ganglia and sympathetic ganglia, leading to atrophy of Schwann cells in proximity to amyloid fibrils and blood-nerve barrier disruption. Clinically, amyloid neuropathy is manifested as a length-dependent sensory predominant neuropathy associated with generalized autonomic failure. Small unmyelinated nerves are involved early and prominently in early-onset Val30Met ATTRv, whereas other ATTRv and light-chain amyloidosis often present with large- and small-fiber involvement. Nerve conduction studies, quantitative sudomotor axon testing, and intraepidermal nerve fiber density are useful tools to evaluate denervation. Amyloid deposition can be demonstrated by tissue biopsy of the affected organ or surrogate site, as well as bone-avid radiotracer cardiac imaging. Treatment of light-chain amyloidosis has been revolutionized by monoclonal antibodies and stem cell transplantation with improved 5-year survival up to 77%. Novel gene therapy and transthyretin stabilizers have revolutionized treatment of ATTRv, improving the course of neuropathy (less change in the modified Neuropathy Impairment Score + 7 from baseline) and quality of life. With great progress in amyloidosis therapies, early diagnosis and presymptomatic testing for ATTRv family members has become paramount. ANN NEUROL 2024.
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Affiliation(s)
| | | | - Hasan Siddiqi
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda Peltier
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
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5
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Frye Naharro E, Peterson D, Yohe SL, Linden MA. Application and pitfalls of immunophenotyping in challenging plasma cell neoplasms: a case series. Hum Pathol 2024:S0046-8177(24)00120-5. [PMID: 38909710 DOI: 10.1016/j.humpath.2024.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 06/15/2024] [Accepted: 06/20/2024] [Indexed: 06/25/2024]
Abstract
Multiple myeloma (MM) is an incurable malignant plasma cell neoplasm, representing the second most common hematopoietic cancer. As plasma cell neoplasms are clonal and often secrete a monoclonal protein (M-spike), laboratory diagnosis is usually straightforward, especially when ancillary studies such as immunohistochemistry, flow cytometry, and protein electrophoresis are available in addition to microscopic examination. Despite the repertoire of diagnostic tools, rare cases pose diagnostic dilemmas, especially when reagent antibodies do not react as expected, extent of disease is patchy, or when disease occurs in unique age groups. In this retrospective study, we report a series of challenging diagnostic cases, discussing aberrant findings and comparing them to more classic counterparts. Twelve cases collected during routine clinical sign-out were reanalyzed and include examples of MGUS, classic multiple myeloma, t(11;14) rearranged myeloma, minimal residual disease, AA and AL amyloidosis, truncated light chain, non-secretory and non-producer myeloma, biphenotypic myeloma, oligoclonal expansion after bone marrow transplant, and plasma cell leukemia in a young adult. This cohort showcases the diversity of atypical presentations of plasma cell neoplasms, and we highlight standardized approaches to workup to avoid diagnostic pitfalls.
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Affiliation(s)
- Elena Frye Naharro
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN and
| | | | - Sophia L Yohe
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN and
| | - Michael A Linden
- Division of Hematopathology, Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN and
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6
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Xing Y, Li X, Zhao J, Wu H, Zhao L, Zheng W, Sun S. Advancing precision medicine in immunoglobulin light-chain amyloidosis: a novel prognostic model incorporating multi-organ indicators. Intern Emerg Med 2024:10.1007/s11739-024-03621-8. [PMID: 38743128 DOI: 10.1007/s11739-024-03621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 04/17/2024] [Indexed: 05/16/2024]
Abstract
To develop a more accurate prognostic model that incorporates indicators of multi-organ involvement for immunoglobulin light-chain (AL) Amyloidosis patients. Biopsy-proven AL amyloidosis patients between January 1, 2012, and February 28, 2023, were enrolled and randomly divided into a training set and a test set at a ratio of 7:3. Prognostic indicators that comprehensively cover cardiac, renal, and hepatic involvement were identified in the training set by random survival forest (RSF). Then, RSF and Cox models were established. The Concordance index (C-index) and integrated brier scores (IBS) were applied to evaluate the models' performance in the test set. Besides, the net reclassification index (NRI) and integrated discrimination improvement (IDI) were calculated. A total of 173 eligible patients were included. After a median follow-up of 25.9 (9.2, 50.3) months, 48 (27.7%) patients died. Creatine kinase-MB, estimated glomerular filtration rate ≤ 50 mL/min/1.73 m2, interventricular septum ≥ 15 mm, ejection fraction, alanine aminotransferase and Live involved were selected to develop prediction models. The RSF model based on the above indicators achieved C-index and IBS values of 0.834 (95% CI 0.725-0.915) and 0.151 (95% CI 0.1402-0.181), respectively. At last, the NRI and IDI of the RSF model were 0.301 (95% CI 0.048-0.546, P = 0.012) and 0.157 (95% CI 0.041-0.269, P < 0.001) at 5-year by comparing the RSF model with the Cox model which is based on the Mayo 2012 staging system. The RSF model that incorporates indicators of multi-organ involvement had a great performance, which may be helpful for physicians' decision-making and more accurate overall survival prediction.
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Affiliation(s)
- Yan Xing
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No.127 Chang Le West Road, Xi'an, 710032, Shaanxi, China
| | - Xiayin Li
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No.127 Chang Le West Road, Xi'an, 710032, Shaanxi, China
| | - Jin Zhao
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No.127 Chang Le West Road, Xi'an, 710032, Shaanxi, China
| | - Hao Wu
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No.127 Chang Le West Road, Xi'an, 710032, Shaanxi, China
| | - Lijuan Zhao
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No.127 Chang Le West Road, Xi'an, 710032, Shaanxi, China
| | - Wanting Zheng
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No.127 Chang Le West Road, Xi'an, 710032, Shaanxi, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, The Fourth Military Medical University, No.127 Chang Le West Road, Xi'an, 710032, Shaanxi, China.
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7
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Long X, An N, Li C, Zhu H, Li H, Yu Q, Que Y, Xu M, Li Z, Chen W, Wang S, Wang D, Li C. Case report: Light-chain amyloidosis responsive to selinexor in combination with daratumumab and dexamethasone (SDd) therapy. Front Med (Lausanne) 2024; 11:1363805. [PMID: 38756941 PMCID: PMC11096580 DOI: 10.3389/fmed.2024.1363805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2023] [Accepted: 04/15/2024] [Indexed: 05/18/2024] Open
Abstract
The outcome of AL amyloidosis remains poor, particularly in patients with advanced organ involvement which takes long time to recovery. We conducted an observational study of two patients with AL amyloidosis treated with SDd regimen. Both patients successfully achieved significant hematological and organ responses without severe adverse events, and the time to organ response was remarkably shorter than previously reported. Notably, an over 15% reduction in interventricular septal thickness (IVST) was observed in patient#2 within 6 months. Up to now, SDd therapy has not been previously reported in AL amyloidosis and may be a promising option for these patients.
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Affiliation(s)
- Xiaolu Long
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Ning An
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chunhui Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Hui Zhu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Haojie Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qiuxia Yu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yimei Que
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Menglei Xu
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhe Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wei Chen
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Shuai Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Di Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, China
| | - Chunrui Li
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
- Immunotherapy Research Center for Hematologic Diseases of Hubei Province, Wuhan, Hubei, China
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8
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Stern LK, Grodin JL, Maurer MS, Ruberg FL, Patel AR, Khouri MG, Roth LR, Aras MA, Bhardwaj A, Bhattacharya P, Brailovsky Y, Drachman BM, Ebong IA, Fine NM, Gaggin H, Gopal D, Griffin J, Judge D, Kim P, Mitchell J, Mitter SS, Mohan RC, Ramos H, Reyentovich A, Sheikh FH, Sperry B, Carter S, Urey M, Vaishnav J, Vest AR, Kittleson MM, Patel JK. The Cardiac Amyloidosis Registry Study (CARS): Rationale, Design and Methodology. J Card Fail 2024; 30:669-678. [PMID: 37907148 DOI: 10.1016/j.cardfail.2023.09.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 09/19/2023] [Accepted: 09/28/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND CARS (Cardiac Amyloidosis Registry Study) is a multicenter registry established in 2019 that includes patients with transthyretin (ATTR, wild-type and variant) and light chain (AL) cardiac amyloidosis (CA) evaluated at major amyloidosis centers between 1997 and 2025. CARS aims to describe the natural history of CA with attention to clinical and diagnostic variables at the time of diagnosis, real-world treatment patterns, and associated outcomes of patients in a diverse cohort that is more representative of the at-risk population than that described in CA clinical trials. METHODS AND RESULTS This article describes the design and methodology of CARS, including procedures for data collection and preliminary results. As of February 2023, 20 centers in the United States enrolled 1415 patients, including 1155 (82%) with ATTR and 260 (18%) with AL CA. Among those with ATTR, wild-type is the most common ATTR (71%), and most of the 305 patients with variant ATTR have the p.V142I mutation (68%). A quarter of the total population identifies as Black. More individuals with AL are female (39%) compared to those with ATTR (13%). CONCLUSIONS CARS will answer crucial clinical questions about CA natural history and permit comparison of different therapeutics not possible through current clinical trials. Future international collaboration will further strengthen the validity of observations of this increasingly recognized condition.
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Affiliation(s)
- Lily K Stern
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Mathew S Maurer
- Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine and Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Ayan R Patel
- Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Michel G Khouri
- Division of Cardiology, Duke University Hospital, Durham, NC, USA
| | - Lori R Roth
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - Mandar A Aras
- Division of Cardiology, Department of Medicine, Division of Cardiology, University of California, San Francisco, CA, USA
| | - Anju Bhardwaj
- Department of Advanced Cardiopulmonary Therapies and Transplantation, McGovern Medical School, University of Texas-Houston, Houston, TX, USA
| | - Priyanka Bhattacharya
- Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA
| | - Yevgeniy Brailovsky
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Brian M Drachman
- Division of Cardiology, Department of Medicine, Penn Presbyterian Medical Center, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Imo A Ebong
- Division of Cardiology, Department of Medicine, Division of Cardiology, University of California, Davis, CA, USA
| | - Nowell M Fine
- Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Hanna Gaggin
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Deepa Gopal
- Section of Cardiovascular Medicine, Department of Medicine and Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Jan Griffin
- Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, NY, USA; Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Daniel Judge
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Paul Kim
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Joshua Mitchell
- Cardiovascular Division, John T. Milliken Department of Internal Medicine, Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, MO, USA
| | - Sumeet S Mitter
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rajeev C Mohan
- Division of Cardiology, Scripps Clinic, San Diego, CA, USA
| | - Hannia Ramos
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Alex Reyentovich
- The Leon H. Charney Division of Cardiology, NYU Langone Health, New York, New York, USA
| | - Farooq H Sheikh
- Infiltrative Cardiomyopathy and Advanced Heart Failure Programs, MedStar Heart and Vascular Institute, Georgetown University, Washington, DC, USA
| | - Brett Sperry
- Saint Luke's Mid America Heart Institute and the University of Kansas City-Missouri, Kansas City, Missouri, USA
| | - Spencer Carter
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Marcus Urey
- Division of Cardiology, Department of Medicine, University of California, San Diego, San Diego, CA, USA
| | - Joban Vaishnav
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD 21205, USA
| | - Amanda R Vest
- Division of Cardiology, The CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Michelle M Kittleson
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA
| | - Jignesh K Patel
- Department of Cardiology, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, USA.
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9
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Ríos-Tamayo R, Lecumberri R, Cibeira MT, González-Calle V, Alonso R, Domingo-González A, Landete E, Encinas C, Iñigo B, Blanchard MJ, Alejo E, Krsnik I, Gómez-Bueno M, Garcia-Pavia P, Segovia-Cubero J, Rosiñol L, Lahuerta JJ, Martínez-López J, Bladé J. A Simple Frailty Score Predicts Survival and Early Mortality in Systemic AL Amyloidosis. Cancers (Basel) 2024; 16:1689. [PMID: 38730641 PMCID: PMC11083900 DOI: 10.3390/cancers16091689] [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: 04/08/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/13/2024] Open
Abstract
Systemic AL amyloidosis is a challenging disease for which many patients are considered frail in daily clinical practice. However, no study has so far addressed frailty and its impact on the outcome of these patients. We built a simple score to predict mortality based on three frailty-associated variables: age, ECOG performance status (<2 vs. ≥2) and NT-proBNP (<8500 vs. ≥8500 ng/L). Four-hundred and sixteen consecutive newly diagnosed patients diagnosed at ten sites from the Spanish Myeloma Group were eligible for the study. The score was developed in a derivation cohort from a referral center, and it was externally validated in a multicenter cohort. Multivariate analysis showed that the three variables were independent predictors of survival. The score was able to discriminate four groups of patients in terms of overall survival and early mortality in both cohorts. Comorbidity was also analyzed with the Charlson comorbidity index, but it did not reach statistical significance in the model. A nomogram was created to easily estimate the mortality risk of each patient at each time point. This score is a simple, robust, and efficient approach to dynamically assess frailty-dependent mortality both at diagnosis and throughout follow-up. The optimal treatment for frail AL amyloidosis patients remains to be determined but we suggest that the estimation of frailty-associated risk could complement current staging systems, adding value in clinical decision-making in this complex scenario.
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Affiliation(s)
- Rafael Ríos-Tamayo
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, 28222 Madrid, Spain
| | - Ramón Lecumberri
- Clínica Universidad de Navarra, CCUN, IDISNA, Universidad de Navarra, 31008 Pamplona, Spain
| | - María Teresa Cibeira
- Hospital Clinic de Barcelona, IDIBAPS, Universitat de Barcelona, 08007 Barcelona, Spain
| | - Verónica González-Calle
- University Hospital of Salamanca (HUS/IBSAL), CIBERONC, Center for Cancer Research-IBMCC (USAL-CSIC), 37007 Salamanca, Spain
| | - Rafael Alonso
- Hospital Universitario 12 de Octubre, Instituto de Investigación del Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | | | - Elena Landete
- Hospital Universitario Infanta Leonor, 28040 Madrid, Spain
| | - Cristina Encinas
- Hospital General Universitario Gregorio Marañón, IiSGM, 28009 Madrid, Spain
| | - Belén Iñigo
- Hospital Clínico San Carlos, 28040 Madrid, Spain
| | | | - Elena Alejo
- University Hospital of Salamanca (HUS/IBSAL), CIBERONC, Center for Cancer Research-IBMCC (USAL-CSIC), 37007 Salamanca, Spain
| | - Isabel Krsnik
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, 28222 Madrid, Spain
| | - Manuel Gómez-Bueno
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, 28222 Madrid, Spain
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, 28222 Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), 28029 Madrid, Spain
| | - Javier Segovia-Cubero
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, 28222 Madrid, Spain
| | - Laura Rosiñol
- Hospital Clinic de Barcelona, IDIBAPS, Universitat de Barcelona, 08007 Barcelona, Spain
| | - Juan-José Lahuerta
- Hospital Universitario 12 de Octubre, Instituto de Investigación del Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | - Joaquín Martínez-López
- Hospital Universitario 12 de Octubre, Instituto de Investigación del Hospital Universitario 12 de Octubre, 28041 Madrid, Spain
| | - Joan Bladé
- Hospital Clinic de Barcelona, IDIBAPS, Universitat de Barcelona, 08007 Barcelona, Spain
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10
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Haran A, Vaxman I, Gatt ME, Lebel E. Immune Therapies in AL Amyloidosis-A Glimpse to the Future. Cancers (Basel) 2024; 16:1605. [PMID: 38672686 PMCID: PMC11048972 DOI: 10.3390/cancers16081605] [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: 03/20/2024] [Revised: 04/16/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Light-chain (AL) amyloidosis is a rare plasma cell disorder characterized by the deposition of misfolded immunoglobulin light chains in target organs, leading to multi-organ dysfunction. Treatment approaches have historically mirrored but lagged behind those of multiple myeloma (MM). Recent advancements in MM immunotherapy are gradually being evaluated and adopted in AL amyloidosis. This review explores the current state of immunotherapeutic strategies in AL amyloidosis, including monoclonal antibodies, antibody-drug conjugates, bispecific antibodies, and chimeric antigen receptor T-cell therapy. We discuss the unique challenges and prospects of these therapies in AL amyloidosis, including the exposure of frail AL amyloidosis patients to immune-mediated toxicities such as cytokine release syndrome (CRS) and immune effector-cell-associated neurotoxicity syndrome (ICANS), as well as their efficacy in promoting rapid and deep hematologic responses. Furthermore, we highlight the need for international initiatives and compassionate programs to provide access to these promising therapies and address critical unmet needs in AL amyloidosis management. Finally, we discuss future directions, including optimizing treatment sequencing and mitigating toxicities, to improve outcomes for AL amyloidosis patients.
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Affiliation(s)
- Arnon Haran
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (M.E.G.)
| | - Iuliana Vaxman
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva 49100, Israel;
| | - Moshe E. Gatt
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (M.E.G.)
| | - Eyal Lebel
- Department of Hematology, Hadassah Hebrew University Medical Center, Jerusalem 91120, Israel; (A.H.); (M.E.G.)
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11
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Li X, Yu Y, Yu H, Chen M, Zhang X, Wu Y. Minimal residual disease in systemic light chain amyloidosis: a systematic review and meta-analysis. J Cancer Res Clin Oncol 2024; 150:193. [PMID: 38619663 PMCID: PMC11018658 DOI: 10.1007/s00432-024-05733-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 03/30/2024] [Indexed: 04/16/2024]
Abstract
PURPOSE Minimal residual disease (MRD) is a validated prognostic factor in several hematological malignancies. However, its role in systemic light chain (AL) amyloidosis remains controversial, and this systematic review and meta-analysis aims to fill this gap. METHODS We searched for relevant studies on Pubmed, Embase, and Cochrane Controlled Register of Trials, nine studies involving 451 patients were included and meta-analyzed. This systematic review has been registered in PROSPERO (CRD42023494169). RESULTS Our study found that in the group of patients who achieved very good partial response (VGPR) or better, MRD negativity was correlated with higher cardiac and renal response rates [pooled risk ratio (RR) = 0.74 (95% CI 0.62-0.89), 0.74 (95% CI 0.64-0.87), respectively]. Patients with MRD positivity had a higher hematologic progression rate within two years after MRD detection [pooled RR = 10.31 (95% CI 2.02-52.68)]; and a higher risk of hematologic + organ progression in the first year [pooled RR = 12.57 (95% CI 1.73-91.04)]. Moreover, MRD negativity was correlated with a better progression-free survival (PFS) [pooled hazard ratio (HR) = 0.27 (95% CI 0.17-0.45)]; but it did not significantly improve the overall survival (OS) [pooled HR = 0.34 (95% CI 0.11-1.07)]. CONCLUSION In AL amyloidosis, our study supports that MRD negativity correlates with higher cardiac or renal response rates and indicates a better PFS in the follow-up. However, the correlation between OS and the status of MRD is not significant.
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Affiliation(s)
- Xuefeng Li
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Yu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hongbin Yu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mengran Chen
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xin Zhang
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yu Wu
- Department of Hematology and Institute of Hematology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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12
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Palladini G, Liedtke M, Zago W, Dolan P, Kinney GG, Gertz MA. The mechanism of action, pharmacological characteristics, and clinical utility of the amyloid depleter birtamimab for the potential treatment of AL amyloidosis. Leuk Lymphoma 2024:1-11. [PMID: 38600883 DOI: 10.1080/10428194.2024.2337803] [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: 12/04/2023] [Accepted: 03/27/2024] [Indexed: 04/12/2024]
Abstract
Amyloid light chain (AL) amyloidosis is a progressive plasma cell disorder caused by amyloid deposition resulting in organ damage and failure. Current standard-of-care treatments target clonal plasma cells, the source of misfolded light chains (amyloid precursors), yet only half of patients with advanced disease survive ≥6 months. The amyloid depleter birtamimab is an investigational humanized monoclonal antibody that binds misfolded κ and λ light chains with high specificity and was designed to neutralize soluble toxic light chain aggregates and promote phagocytic clearance of deposited amyloid. Post hoc analyses from the Phase 3 VITAL trial suggested birtamimab plus standard of care confers a survival benefit in patients with advanced (Mayo Stage IV) AL amyloidosis. AFFIRM-AL (NCT04973137), a Phase 3 confirmatory trial of birtamimab plus standard of care in patients with Mayo Stage IV AL amyloidosis, is ongoing. This review summarizes birtamimab's mechanism of action, attributes, and potential clinical utility.
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Affiliation(s)
- Giovanni Palladini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | | | | | - Phil Dolan
- Prothena Biosciences Inc, Brisbane, CA, USA
| | | | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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13
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De Michieli L, Stoppa G, Sinigiani G, Previato L, Lorenzoni G, Salvalaggio A, Berno T, Perazzolo Marra M, Briani C, Iliceto S, Biggeri A, Catelan D, Cipriani A. Hospitalization-based epidemiology of systemic and cardiac amyloidosis in the Veneto Region, Italy. Int J Cardiol 2024; 400:131804. [PMID: 38262481 DOI: 10.1016/j.ijcard.2024.131804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/27/2023] [Accepted: 01/18/2024] [Indexed: 01/25/2024]
Abstract
AIM Defining the epidemiology of systemic and cardiac amyloidosis (CA) is a contemporary challenge. The present study aimed to estimate incidence and time trends in amyloidosis-related hospitalizations (AH) in Veneto Region (5 million inhabitants, Northeastern Italy). METHODS International Classification of Diseases (ICD-9) codes were used to identify AH in Veneto from 2010 to 2020. AH were defined as any hospitalization with a discharge summary reporting an ICD-9 code for systemic amyloidosis. Hospitalization for CA was defined as records with ICD-9 code for systemic amyloidosis and ICD-9 code for heart failure,cardiomyopathy or arrhythmia. Hospital/outpatient encounters for carpal tunnel syndrome (CTS) surgeries also were extracted. AH incidence was estimated using a buffer of 5 years. RESULTS In the time range 2015-2020, the incidence rate of AH was 23.5 cases per 106 (95% confidence interval, CI, 21.8; 25.3), mainly affecting patients>65 years (76.2%) and males (63.5%), with a progressively increasing trend (percent annual increase 17%, 95% CI 12; 22%). The 10 year prevalence of AH in 2020 was 124.5 per 106 (95% CI 114.9; 134.8). In 2020, annual hospitalized prevalent cases of CA were about 70% of all cases (159/228), mainly patients >65 years and males. Among patients with multiple CTS surgeries, a subsequent code for cardiac disease was found in 913 after a median of 3.9 years, more frequently in men than in women (463/6.526 7.1% versus 450/11.406 3.9%). CONCLUSIONS In Veneto, we recorded a significantly increasing trend in the incidence of AH, with concordant increasing prevalence estimates.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Giorgia Stoppa
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy; Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Giulio Sinigiani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | | | - Giulia Lorenzoni
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Alessandro Salvalaggio
- Padova Neuroscience Center (PNC), University of Padua, Italy; Department of Neurosciences, University of Padua, Italy
| | - Tamara Berno
- Ematology Unit, University Hospital of Padua, Italy
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy; Cardiology Unit, University Hospital of Padua, Italy
| | - Chiara Briani
- Department of Neurosciences, University of Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy; Cardiology Unit, University Hospital of Padua, Italy
| | - Annibale Biggeri
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Dolores Catelan
- Unit of Biostatistics, Epidemiology and Public Health, Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy; Cardiology Unit, University Hospital of Padua, Italy.
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14
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Baljevic M, Sengsayadeth S. Relapsed systemic light chain amyloidosis - in search of a higher bar. Bone Marrow Transplant 2024; 59:441-443. [PMID: 38263391 DOI: 10.1038/s41409-024-02203-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/25/2024]
Affiliation(s)
- Muhamed Baljevic
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Salyka Sengsayadeth
- Vanderbilt-Ingram Cancer Center, Vanderbilt University Medical Center, Nashville, TN, USA
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15
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Edwards CV, Ferri GM, Villegas-Galaviz J, Ghosh S, Bawa PS, Wang F, Klimtchuk E, Ajayi TB, Morgan GJ, Prokaeva T, Staron A, Ruberg FL, Sanchorawala V, Giadone RM, Murphy GJ. Abnormal global longitudinal strain and reduced serum inflammatory markers in cardiac AL amyloidosis patients without significant amyloid fibril deposition. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2024:2024.03.14.584987. [PMID: 38558967 PMCID: PMC10980073 DOI: 10.1101/2024.03.14.584987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background Cardiac dysfunction in AL amyloidosis is thought to be partly related to the direct impact of AL LCs on cardiomyocyte function, with the degree of dysfunction at diagnosis as a major determinant of clinical outcomes. Nonetheless, mechanisms underlying LC-induced myocardial toxicity are not well understood. Methods We identified gene expression changes correlating with human cardiac cells exposed to a cardiomyopathy-associated κAL LC. We then sought to confirm these findings in a clinical dataset by focusing on clinical parameters associated with the pathways dysregulated at the gene expression level. Results Upon exposure to a cardiomyopathy-associated κAL LC, cardiac cells exhibited gene expression changes related to myocardial contractile function and inflammation, leading us to hypothesize that there could be clinically detectable changes in GLS on echocardiogram and serum inflammatory markers in patients. Thus, we identified 29 patients with normal IVSd but abnormal cardiac biomarkers suggestive of LC-induced cardiac dysfunction. These patients display early cardiac biomarker staging, abnormal GLS, and significantly reduced serum inflammatory markers compared to patients with clinically evident amyloid fibril deposition. Conclusion Collectively, our findings highlight early molecular and functional signatures of cardiac AL amyloidosis, with potential impact for developing improved patient biomarkers and novel therapeutics.
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16
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Yamada E, Umemoto T, Taguchi T, Onishi I, Yamamoto A, Tsukamoto K, Ibara T, Sasaki T, Kaburagi H, Maejima Y, Sasano T, Ohashi K, Yoshii T, Nimura A, Fujita K. Prevalence of amyloid deposition and cardiac amyloidosis in shoulder disease compared to carpal tunnel syndrome. JSES Int 2024; 8:349-354. [PMID: 38464439 PMCID: PMC10920152 DOI: 10.1016/j.jseint.2023.11.009] [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] [Indexed: 03/12/2024] Open
Abstract
Background Cardiac amyloidosis is a fatal disease of severe heart failure caused by the accumulation of amyloid in the myocardium. This disease is often advanced by the time cardiac symptoms appear; therefore, early detection and treatment are critical for a good prognosis. Recently, it has been suggested that cardiac amyloidosis is implicated in several orthopedic diseases, including carpal tunnel syndrome (CTS), which is often reported to precede cardiac dysfunction. Shoulder disease has also been suggested to be associated with cardiac amyloidosis; however, there have been no reports investigating the rate of amyloid deposition in shoulder specimens and the simultaneous prevalence of cardiac amyloidosis. Herein, we investigated the prevalence of intraoperative specimen amyloid deposition and cardiac amyloidosis in shoulder disease and CTS to determine the usefulness of shoulder specimen screening as a predictor of cardiac amyloidosis development. Methods A total of 41 patients undergoing arthroscopic shoulder surgery and 33 patients undergoing CTS surgery were enrolled in this study. The shoulder group included rotator cuff tears, contracture of the shoulder, synovitis, and calcific tendonitis. In the shoulder group, a small sample of synovium and the long head of the biceps brachii tendon were harvested, while the transverse carpal ligament was harvested from the CTS group. The intraoperative specimens were pathologically examined for amyloid deposition, and patients with amyloid deposition were examined for the presence of cardiac amyloidosis by cardiac evaluation. Results In the shoulder group, three cases (7.3%) of transthyretin amyloid deposition were found, all of which involved rotator cuff tears. None of these three cases with amyloid deposition were associated with cardiac amyloidosis. When examining the specimens, the amyloid deposition rate in the long head of the biceps brachii tendon was higher than that in the synovium. In the CTS group, 12 cases (36.4%) of transthyretin amyloid deposition were observed. Of these cases, seven underwent cardiac evaluation and two were identified with cardiac amyloidosis. Conclusion While the prevalence of amyloid deposition and cardiac amyloidosis in the CTS group was consistent with previous reports, the shoulder group showed a lower deposition rate and no concomitant cardiac amyloidosis. Therefore, it remains debatable whether investigating amyloid deposition in samples obtained from shoulder surgery is beneficial for the early detection of cardiac amyloidosis.
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Affiliation(s)
- Eriku Yamada
- Department of Orthopedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tomoyuki Umemoto
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Towako Taguchi
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Iichiroh Onishi
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akiko Yamamoto
- Department of Orthopedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Kazuya Tsukamoto
- Department of Orthopedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Takuya Ibara
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toru Sasaki
- Department of Orthopedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Hidetoshi Kaburagi
- Department of Orthopedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Yasuhiro Maejima
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Tetsuo Sasano
- Department of Cardiovascular Medicine, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Kenichi Ohashi
- Department of Human Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Toshitaka Yoshii
- Department of Orthopedic and Spinal Surgery, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Akimoto Nimura
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Koji Fujita
- Department of Functional Joint Anatomy, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
- Division of Medical Design Innovations, Open Innovation Center, Institute of Research Innovation, Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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17
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Hughes MS, Lentzsch S. Safety and Efficacy of Subcutaneous Daratumumab in Systemic AL Amyloidosis. Ther Clin Risk Manag 2023; 19:1063-1074. [PMID: 38164204 PMCID: PMC10758190 DOI: 10.2147/tcrm.s325859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 12/04/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction Systemic AL amyloidosis, a plasma cell dyscrasia, is characterized by the production of misfolded immunoglobulin light chain. These misfolded proteins aggregate into amyloid fibrils and deposit throughout the body, resulting in widespread organ dysfunction and ultimately death. Achieving rapid and maximal elimination of the plasma cell clone is crucial to long-term survival. Daratumumab, an anti-CD38 monoclonal antibody delivered intravenously, has been swiftly incorporated into standard first-line treatment regimens. A novel formulation of daratumumab has been developed that can be injected subcutaneously. Areas Covered As a retrospective qualitative review of prior publications involving daratumumab, this work briefly summarizes the existing data regarding the safety and efficacy of subcutaneous (SC) daratumumab, compared to intravenous (IV) daratumumab. SC daratumumab appears to deliver the same disease benefit as IV daratumumab to patients with decreased infusion-related reactions (IRRs), decreased time for administration, and similar rates of adverse events (AEs) intrinsically related to daratumumab. Expert Opinion SC daratumumab is preferred over IV daratumumab, but the clinical situation ultimately should determine route of administration. Further investigation into cost-effectiveness benefit is warranted.
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Affiliation(s)
- Michael Sang Hughes
- Department of Hematology-Oncology, Columbia University Irving Medical Center, New York, NY, USA
| | - Suzanne Lentzsch
- Department of Hematology-Oncology, Columbia University Irving Medical Center, New York, NY, USA
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18
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Mellqvist UH, Cai Q, Hester LL, Grövdal M, Börsum J, Rahman I, Ammann EM, Hansson M. Epidemiology and clinical outcomes of light-chain amyloidosis in Sweden: A nationwide population-based study. Eur J Haematol 2023; 111:697-705. [PMID: 37533343 DOI: 10.1111/ejh.14063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
OBJECTIVES This study evaluated data from six Swedish national registries to fill current evidence gaps on the epidemiology, clinical burden, and overall survival (OS) associated with light-chain (AL) amyloidosis. METHODS Patients newly diagnosed with AL amyloidosis were identified using six linked Swedish nationwide population-based registers. For each case, individuals from the general population were selected and matched with a maximum ratio of 1:5 based on age, sex, calendar year, and county. RESULTS 846 patients newly diagnosed with AL amyloidosis and 4227 demographically matched individuals were identified. From 2011 to 2019, annual AL amyloidosis incidence increased from 10.5 to 15.1 cases per million. At baseline, patients with AL amyloidosis had a significantly higher disease burden including higher rates of cardiac and renal failure relative to the comparison group. Among patients with AL amyloidosis, 21.5% had incident heart failure and 17.1% had incident renal failure after initial diagnosis. Median OS for patients with AL amyloidosis was 56 months versus not reached in the matched general population comparison group. CONCLUSION The incidence of newly diagnosed AL amyloidosis in Sweden increased over time with AL amyloidosis being associated with a higher risk of cardiac/renal failure and all-cause mortality compared with the general population.
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Affiliation(s)
- Ulf-Henrik Mellqvist
- Section of Hematology and Coagulation, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Qian Cai
- Janssen Global Services, Titusville, New Jersey, USA
| | - Laura L Hester
- Janssen Research & Development, Horsham, Pennsylvania, USA
| | | | | | | | | | - Markus Hansson
- Department of Hematology, Sahlgrenska Academy, Göteborg University and Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Hematology, Skåne University Hospital, Lund, Sweden
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19
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Gustine JN, Staron A, Mendelson L, Joshi T, Gopal DM, Siddiqi OK, Ruberg FL, Sanchorawala V. Predictors of treatment response and survival outcomes in patients with advanced cardiac AL amyloidosis. Blood Adv 2023; 7:6080-6091. [PMID: 37581513 PMCID: PMC10582303 DOI: 10.1182/bloodadvances.2023010324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/31/2023] [Accepted: 06/20/2023] [Indexed: 08/16/2023] Open
Abstract
Patients with advanced cardiac immunoglobulin light chain (AL) amyloidosis have a poor prognosis. Early hematologic and cardiac responses can prolong survival, but predictors of these outcomes have yet to be clarified. We report on 142 patients with newly diagnosed stage IIIb AL amyloidosis. After a median follow-up of 60 months, the median overall survival (OS) was 9 months. Independent baseline factors associated with shorter OS were symptom onset to diagnosis >6 months (hazard ratio [HR], 1.94; P = .003); bone marrow plasmacytosis ≥ 10% (HR, 1.98; P = .01); troponin I > 0.635 ng/mL (HR, 1.62; P = .04); New York Heart Association class III or IV (HR, 1.67; P = .04); and 6-minute walk test distance < 200 m (HR, 1.85; P = .01). Early hematologic (within 1 month) and cardiac (within 3 months) responses were significantly associated with longer survival. In a 1-month landmark analysis, patients with a hematologic very good partial response, partial response, and no response had a median OS of 47, 25, and 5 months, respectively (P < .0001). Patients with cardiac response at 3 months had significantly longer OS (47 vs 11 months; P < .0001). On multivariable modeling, bortezomib use was associated with early hematologic and cardiac responses and longer OS. Symptom onset to diagnosis duration of >6 months and difference between the involved and uninvolved free light chain > 350 mg/L were independently associated with lower odds of an early cardiac response. This study identified factors predictive of treatment outcomes and survival in advanced cardiac AL amyloidosis.
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Affiliation(s)
- Joshua N. Gustine
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Andrew Staron
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Lisa Mendelson
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Tracy Joshi
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Deepa M. Gopal
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Omar K. Siddiqi
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Frederick L. Ruberg
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
- Section of Cardiovascular Medicine, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
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20
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Gertz MA, Cohen AD, Comenzo RL, Kastritis E, Landau HJ, Libby EN, Liedtke M, Sanchorawala V, Schönland S, Wechalekar A, Zonder JA, Palladini G, Walling J, Guthrie S, Nie C, Karp C, Jin Y, Kinney GG, Merlini G. Birtamimab plus standard of care in light-chain amyloidosis: the phase 3 randomized placebo-controlled VITAL trial. Blood 2023; 142:1208-1218. [PMID: 37366170 PMCID: PMC10644097 DOI: 10.1182/blood.2022019406] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/28/2023] Open
Abstract
Amyloid light-chain (AL) amyloidosis is a rare, typically fatal disease characterized by the accumulation of misfolded immunoglobulin light chains (LCs). Birtamimab is an investigational humanized monoclonal antibody designed to neutralize toxic LC aggregates and deplete insoluble organ-deposited amyloid via macrophage-induced phagocytosis. VITAL was a phase 3 randomized, double-blind, placebo-controlled clinical trial assessing the efficacy and safety of birtamimab + standard of care (SOC) in 260 newly diagnosed, treatment-naive patients with AL amyloidosis. Patients received 24 mg/kg IV birtamimab + SOC or placebo + SOC every 28 days. The primary composite end point was the time to all-cause mortality (ACM) or centrally adjudicated cardiac hospitalization ≥91 days after the first study drug infusion. The trial was terminated early after an interim futility analysis; there was no significant difference in the primary composite end point (hazard ratio [HR], 0.826; 95% confidence interval [CI], 0.574-1.189; log-rank P = .303). A post hoc analysis of patients with Mayo stage IV AL amyloidosis, those at the highest risk of early mortality, showed significant improvement in the time to ACM with birtamimab at month 9 (HR, 0.413; 95% CI, 0.191-0.895; log-rank P = .021). At month 9, 74% of patients with Mayo stage IV AL amyloidosis treated with birtamimab and 49% of those given placebo survived. Overall, the rates of treatment-emergent adverse events (TEAEs) and serious TEAEs were generally similar between treatment arms. A confirmatory phase 3 randomized, double-blind, placebo-controlled clinical trial of birtamimab in patients with Mayo stage IV AL amyloidosis (AFFIRM-AL; NCT04973137) is currently enrolling. The VITAL trial was registered at www.clinicaltrials.gov as #NCT02312206.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
| | - Adam D. Cohen
- Abramson Cancer Center, The Hospital of the University of Pennsylvania, Philadelphia, PA
| | | | - Efstathios Kastritis
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Heather J. Landau
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Edward N. Libby
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
| | | | | | - Stefan Schönland
- Medical Department V, Amyloidosis Center, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Ashutosh Wechalekar
- Division of Medicine, National Amyloidosis Centre, University College of London, Royal Free Hospital, London, United Kingdom
| | - Jeffrey A. Zonder
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Detroit, MI
| | - Giovanni Palladini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | | | | | - Christie Nie
- Prothena Biosciences Inc, South San Francisco, CA
| | - Carol Karp
- Prothena Biosciences Inc, South San Francisco, CA
| | - Yuying Jin
- Prothena Biosciences Inc, South San Francisco, CA
| | | | - Giampaolo Merlini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | - VITAL Study Investigators
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN
- Abramson Cancer Center, The Hospital of the University of Pennsylvania, Philadelphia, PA
- Divison of Hematology and Oncology, Tufts Medical Center, Boston, MA
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Medicine, Adult Bone Marrow Transplantation Service, Memorial Sloan Kettering Cancer Center, New York, NY
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, WA
- Division of Medical Oncology, Department of Medicine, University of Washington, Seattle, WA
- Stanford Cancer Institute, Stanford, CA
- Amyloidosis Center, Boston University School of Medicine, Boston, MA
- Medical Department V, Amyloidosis Center, Universitätsklinikum Heidelberg, Heidelberg, Germany
- Division of Medicine, National Amyloidosis Centre, University College of London, Royal Free Hospital, London, United Kingdom
- Department of Oncology, Barbara Ann Karmanos Cancer Institute, Detroit, MI
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
- Prothena Biosciences Inc, South San Francisco, CA
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21
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Bergantim R, Caetano A, Silva FF, Tavares I, Ferreira M, Jaime AR, Esteves GV. Diagnosis and referral of patients with AL amyloidosis in Portugal: results from a Delphi panel. Porto Biomed J 2023; 8:e231. [PMID: 37846303 PMCID: PMC10575365 DOI: 10.1097/j.pbj.0000000000000231] [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: 04/13/2023] [Revised: 07/24/2023] [Accepted: 07/26/2023] [Indexed: 10/18/2023] Open
Abstract
Light chain amyloidosis (AL) is a complex disorder defined by the extracellular deposition of insoluble amyloid fibrils formed by intact or fragmented immunoglobulin light chains, leading to cell dysfunction, rapid organ deterioration, and, ultimately, death. Although the clinical presentation of AL is directly connected to organ involvement, signs and symptoms of AL are frequently nonspecific, misinterpreted, and late recognized. Thus, an early diagnosis combined with effective therapies to cease disease progression and rescue organ function is essential. The aim of this study was to assess the knowledge and characterize the current clinical practice regarding AL diagnosis and referral among Portuguese physicians. A Delphi-like panel (one round only) with a group of national experts from different medical specialties (cardiology, hematology, internal medicine, nephrology, and neurology) was carried out online, in which 30 statements were classified using a 4-point Likert scale. For each statement, the consensus level was set at 70% for "fully agree/disagree" and the majority level was defined as >70% in agreement or disagreement. Although the results suggest the existence of adequate general knowledge of AL amyloidosis, they also disclosed the necessity to raise awareness for this disease. Overall, this Delphi panel revealed a high lack of consensus regarding the diagnosis and early management of patients with AL among different specialties despite the qualified majority obtained in 26 statements. An optimized strategy for AL early diagnosis, transversal to several medical fields, is urgently needed. Moreover, referral centers with access to diagnostic technology and a network of diverse specialties should be established to foster an early diagnosis and better disease approach to boost the possibility of a better outcome for patients with AL.
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Affiliation(s)
- Rui Bergantim
- Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
- i3S - Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
- Cancer Drug Resistance Group, Institute of Molecular Pathology and Immunology of the University of Porto (IPATIMUP), Porto, Portugal
- Department of Hematology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - André Caetano
- Hospital de Egas Moniz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal
| | | | - Isabel Tavares
- Faculty of Medicine of the University of Porto (FMUP), Porto, Portugal
- i3S - Institute for Research and Innovation in Health, University of Porto, Porto, Portugal
- Nephrology Service, Centro Hospitalar e Universitário de São João, Porto, Portugal
| | - Manuela Ferreira
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
| | - Ana R. Jaime
- Medical Department—Hematology, Janssen-Cilag, S.A., Lisbon, Portugal
| | - Graça V. Esteves
- Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte, Lisbon, Portugal
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22
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Hegenbart U, Aus dem Siepen F, Schönland S. [Light chain amyloidosis]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:842-847. [PMID: 37540260 DOI: 10.1007/s00108-023-01568-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/05/2023]
Abstract
Light chain amyloidosis (AL) is a rare protein deposition disease. It is caused by a clonal plasma cell or B‑cell disease in the bone marrow. With the exception of the central nervous system, all organs can be affected by amyloid deposits. Cardiac involvement is the most frequent organ manifestation that leads to significantly increased mortality when it is diagnosed at an advanced stage. The causal treatment of AL amyloidosis is reduction of amyloidogenic light chains by chemotherapy. Early diagnosis of the disease is essential to reduce early mortality, to effectively treat patients and to prevent further deterioration of organ function. New treatment approaches for AL amyloidosis are aimed at inhibiting amyloid formation or degradation of amyloid in organs.
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Affiliation(s)
- Ute Hegenbart
- Amyloidose-Zentrum, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland.
| | - Fabian Aus dem Siepen
- Klinik für Kardiologie, Angiologie und Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Stefan Schönland
- Amyloidose-Zentrum, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Deutschland
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23
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Medarametla GD, Kahlon RS, Mahitha L, Shariff S, Vakkalagadda NP, Chopra H, Kamal MA, Patel N, Sethi Y, Kaka N. Cardiac amyloidosis: evolving pathogenesis, multimodal diagnostics, and principles of treatment. EXCLI JOURNAL 2023; 22:781-808. [PMID: 37720240 PMCID: PMC10502203 DOI: 10.17179/excli2023-6284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/24/2023] [Indexed: 09/19/2023]
Abstract
Amyloidosis is a protein deposition disorder in which insoluble fibril structures accumulate in the bodily tissues damaging the organ function. Cardiac amyloidosis is a severe but under-reported medical condition characterized by the accumulation of amyloid in the extracellular area of the myocardium, which results in thickening and stiffening of ventricular walls. Cardiac amyloidosis has recently gained much attention with its slowly surging incidence. With this study, we seek to comprehensively compile the pathophysiology and clinical picture of cardiac amyloidosis subtypes, extending a clinically oriented, up-to-date clinical approach to diagnosis and therapy. Cardiac amyloidosis can be caused by rare genetic mutations which may be inherited or acquired. The growing incidence can be attributed to advancements in imaging methods and other diagnostic modalities. Most occurrences of cardiac amyloidosis result from two forms of precursor protein: transthyretin [TTR] amyloid and immunoglobulin-derived light-chain amyloid. Prompt identification of cardiac amyloidosis can facilitate the implementation of evolving therapeutic interventions to enhance the outcomes. The modalities for the management of CA have evolved significantly in the last ten years. Apart from therapies for modifying disease and heart failure, a myriad of novel therapeutic approaches that target specific aspects of the disease, including gene therapies, are being researched. These aim at impeding its progression and improving clinical outcomes. See also Figure 1(Fig. 1).
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Affiliation(s)
| | | | - Lampimukhi Mahitha
- Pear Research, Dehradun, India
- Rangaraya Medical College, Kakinada, Andhra Pradesh, India
| | - Sanobar Shariff
- Pear Research, Dehradun, India
- Yerevan State Medical University, Yerevan, Armenia
| | | | - Hitesh Chopra
- Department of Biosciences, Saveetha School of Engineering, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu-602105, India
| | - Mohammad Amjad Kamal
- Institutes for Systems Genetics, Frontiers Science Center for Disease-Related Molecular Network, West China Hospital, Sichuan University, China
- King Fahd Medical Research Center, King Abdulaziz University, Saudi Arabia
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Bangladesh
- Enzymoics, 7 Peterlee Place, Hebersham, NSW 2770; Novel Global Community Educational Foundation, Australia
| | - Neil Patel
- Pear Research, Dehradun, India
- GMERS Medical College, Himmatnagar, Gujarat, India
| | - Yashendra Sethi
- Pear Research, Dehradun, India
- Government Doon Medical College, Dehradun, Uttarakhand, India
| | - Nirja Kaka
- Pear Research, Dehradun, India
- GMERS Medical College, Himmatnagar, Gujarat, India
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24
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Nakano Y, Kawamoto R, Ito E, Matukawa K. A Case of Cholestatic Liver Involvement Secondary to Amyloid Light Chain Amyloidosis With New-Onset Hypercholesterolemia and Elevated Gamma-Glutamyltransferase Level. Cureus 2023; 15:e44001. [PMID: 37746441 PMCID: PMC10516705 DOI: 10.7759/cureus.44001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Amyloid light chain (AL) amyloidosis is a rare disorder caused by the deposit of misfolded light chain proteins. AL amyloidosis causes multiple organ involvement and rarely causes fatal liver failure. We present a 68-year-old man who showed cholestatic liver injury and was diagnosed with AL amyloidosis. Due to rapidly progressing cholestatic liver involvement, the patient died five days after the renal biopsy. Preclinically, there was hypercholesterolemia, and levels of gamma-glutamyltransferase (GGT) were elevated. Previous studies have suggested hypercholesterolemia and elevated GGT levels in patients with AL amyloidosis and liver involvement; however, its clinical relevance remains unknown. Our report suggests that in addition to serum kappa/lambda, the combination of new-onset GGT level elevation and hypercholesterolemia could be preclinical characteristics of cholestatic liver involvement in AL amyloidosis.
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Affiliation(s)
- Yuta Nakano
- Department of Nephrology, Ome Municipal General Hospital, Tokyo, JPN
- Department of Nephrology, Tokyo Medical and Dental University, Tokyo, JPN
| | - Ryosuke Kawamoto
- Department of Nephrology, Ome Municipal General Hospital, Tokyo, JPN
| | - Eisaku Ito
- Department of Pathology, Ome Municipal General Hospital, Tokyo, JPN
| | - Kayoko Matukawa
- Department of Nephrology, Ome Municipal General Hospital, Tokyo, JPN
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25
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Morfino P, Aimo A, Castiglione V, Chianca M, Vergaro G, Cipolla CM, Fedele A, Emdin M, Fabiani I, Cardinale D. Cardiovascular toxicity from therapies for light chain amyloidosis. Front Cardiovasc Med 2023; 10:1212983. [PMID: 37476571 PMCID: PMC10354454 DOI: 10.3389/fcvm.2023.1212983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Accepted: 06/23/2023] [Indexed: 07/22/2023] Open
Abstract
Amyloid light-chain (AL) amyloidosis is a hematological disorder characterized by abnormal proliferation of a plasma cell clone producing monoclonal free light chains that misfold and aggregate into insoluble fibrils in various tissues. Cardiac involvement is a common feature leading to restrictive cardiomyopathy and poor prognosis. Current first-line treatments aim at achieving hematological response by targeting the plasma cell clones, and these have been adapted from multiple myeloma therapy. Patients with AL amyloidosis often exhibit multiorgan involvement, making them susceptible to cancer therapy-related cardiovascular toxicity. Managing AL amyloidosis is a complex issue that requires enhanced knowledge of the cardio-oncological implications of hematological treatments. Future research should focus on implementing and validating primary and secondary prevention strategies and understanding the biochemical basis of oncological therapy-related damage to mitigate cardiovascular toxicity.
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Affiliation(s)
- Paolo Morfino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Vincenzo Castiglione
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michela Chianca
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Carlo Maria Cipolla
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
| | - Antonella Fedele
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Iacopo Fabiani
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant’Anna, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Daniela Cardinale
- Cardioncology Unit, Cardioncology and Second Opinion Division, European Institute of Oncology, I.R.C.C.S., Milan, Italy
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26
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Xie W, Wang Q, Zhou F, Wang S, Sun Y, Cen X, Ren H, Qiu Z, Dong Y. Clinical characteristics and prognosis of a Chinese cohort with systemic light chain amyloidosis: a single-center study. Int J Hematol 2023:10.1007/s12185-023-03617-8. [PMID: 37247070 DOI: 10.1007/s12185-023-03617-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/30/2023]
Abstract
Light chain amyloidosis is a plasma cell dyscrasia characterized by deposition of misfolded amyloid fibrils in tissues, leading to multi-organ dysfunction. We retrospectively analyzed 335 patients (median age, 60 years) with systemic light chain amyloidosis in the First Hospital of Peking University from 2011 to 2021. Involved organs were the kidney (92.8%), heart (57.9%), liver (12.8%) and peripheral nervous system (6.3%). Chemotherapy was administered to 55.8% (187/335) of patients, among whom 94.7% received novel agent-based regimens. Hematologic response (≥ very good partial response) was achieved in 63.4% of patients who received chemotherapy. Only 18.2% of patients received autologous hematopoietic stem cell transplant (ASCT). Among transplant-eligible patients, the overall survival of ASCT recipients was better than those who received chemotherapy only. The median overall survival of the patients with light chain amyloidosis was 77.5 months. Estimated glomerular filtration rate and Mayo 2012 stage were independent prognostic factors for overall survival in multivariate analysis. Although the younger age and high ratio of renal involvement might contribute to the favorable prognosis of this cohort, the role of novel agents and ASCT is also discernible. This study will provide a comprehensive perspective on progress in treatment of light chain amyloidosis in China.
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Affiliation(s)
- Weiwei Xie
- Department of Hematology, Peking University First Hospital, No. 7 Xi Shi Ku Street, Xi Cheng District, Beijing, 100034, People's Republic of China
| | - Qian Wang
- Department of Hematology, Peking University First Hospital, No. 7 Xi Shi Ku Street, Xi Cheng District, Beijing, 100034, People's Republic of China
| | - Fude Zhou
- Department of Nephrology, Peking University First Hospital, Beijing, People's Republic of China
| | - Suxia Wang
- Laboratory of Electron Microscopy, Pathological Center, Peking University First Hospital, Beijing, People's Republic of China
| | - Yuhua Sun
- Department of Hematology, Peking University First Hospital, No. 7 Xi Shi Ku Street, Xi Cheng District, Beijing, 100034, People's Republic of China
| | - Xinan Cen
- Department of Hematology, Peking University First Hospital, No. 7 Xi Shi Ku Street, Xi Cheng District, Beijing, 100034, People's Republic of China
| | - Hanyun Ren
- Department of Hematology, Peking University First Hospital, No. 7 Xi Shi Ku Street, Xi Cheng District, Beijing, 100034, People's Republic of China
| | - Zhixiang Qiu
- Department of Hematology, Peking University First Hospital, No. 7 Xi Shi Ku Street, Xi Cheng District, Beijing, 100034, People's Republic of China.
| | - Yujun Dong
- Department of Hematology, Peking University First Hospital, No. 7 Xi Shi Ku Street, Xi Cheng District, Beijing, 100034, People's Republic of China.
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27
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Zhang L, Li S, Liu B, Wang J, Mu Y, Zhou X, Liu H. Prognostic Factors and Survival of Chinese Patients with Cardiac Amyloidosis. DISEASE MARKERS 2023; 2023:3070017. [PMID: 37228893 PMCID: PMC10205418 DOI: 10.1155/2023/3070017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/14/2022] [Accepted: 09/21/2022] [Indexed: 05/27/2023]
Abstract
Purpose To identify the survival and prognostic factors for cardiac amyloidosis (CA) in Chinese patients. Methods This was a prospective cohort study of 72 patients diagnosed with CA and admitted to the PLA General Hospital between November 2017 and April 2021. Demographic, clinical, laboratory, electrocardiographic, conventional ultrasound, endocardial LS during LV systole (LV ENDO LSsys), and myocardial strain data were recorded. Survival was assessed. All-cause mortality was the endpoint. Follow-up was censored on September 30, 2021. Results The mean follow-up was 17.1 ± 12.9 months. Among the 72 patients, 39 died, 23 survived, and 10 were lost to follow-up. Mean survival for all patients was 24.7 ± 2.2 months. Mean survival was 32.7 ± 2.4 months among patients with NYHA class II, 26.6 ± 3.4 months for NYHA class III, and 5.8 ± 1.1 months for NYHA class IV. The multivariate Cox proportional hazard regression model showed that NYHA class (HR = 3.42, 95% CI: 1.36-8.65, P = 0.002), log-proBNP level (HR = 1.40, 95% CI: 1.17-5.83, P = 0.03), and ENDO LSsys of the LV basal level (HR = 1.25, 95% CI: 1.05-1.95, P = 0.004) were independent prognostic factors for CA. Conclusion NYHA class, proBNP level, and ENDO LSsys of the LV basal level were independently associated with the survival of patients with CA.
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Affiliation(s)
- Lu Zhang
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Sulei Li
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Bohan Liu
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Jing Wang
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Yang Mu
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Xuan Zhou
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
| | - Hongbin Liu
- Department of Cardiology, The Second Medical Center & National Clinical Research Center for Geriatric Diseases, Chinese PLA General Hospital, Beijing, China
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28
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Hartley MJ, Gounder P, Oliphant H. Spontaneous periocular ecchymosis: a major review. Orbit 2023; 42:124-129. [PMID: 36374198 DOI: 10.1080/01676830.2022.2142944] [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: 11/16/2022]
Abstract
Periocular ecchymosis, or periocular bruising, is a common clinical finding. Periocular skin is thin with an extensive vascular network, making this anatomical region prone to bruising. The most common etiology is trauma, but rarely, patients can present with spontaneous periocular ecchymosis (SPE). The pathophysiology of SPE is complex and varied. In this literature review of 121 articles, we assessed the frequency and variety of causation of this infrequent entity. The main finding was that by far the most common diagnosis causing SPE is amyloidosis and neoplasm, most notably neuroblastoma. Amyloidosis accounted for 23% articles (28/121) and neuroblastoma for 17% articles (21/121). Overall, neoplastic processes accounted for 30% of the articles (36/121), raised intracranial pressure and vascular malformations for 19% of the articles (23/121), migraine and atypical headache for 7% of the articles (8/121), while iatrogenic accounted for 5% of the articles (6/121). Through exploration and appreciation of the pathophysiology, we hope to foster a greater understanding in the clinician to establish underlying etiology, from benign to life-threatening, when presented with SPE.
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Affiliation(s)
- Matthew J Hartley
- Newcastle Eye Centre, Royal Victoria Infirmary, Newcastle-Upon-Tyne, UK
| | - Pav Gounder
- Royal Sussex County Hospital, Sussex Eye Hospital, Brighton, UK
| | - Huw Oliphant
- Royal Sussex County Hospital, Sussex Eye Hospital, Brighton, UK
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29
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Kittleson MM, Ruberg FL, Ambardekar AV, Brannagan TH, Cheng RK, Clarke JO, Dember LM, Frantz JG, Hershberger RE, Maurer MS, Nativi-Nicolau J, Sanchorawala V, Sheikh FH. 2023 ACC Expert Consensus Decision Pathway on Comprehensive Multidisciplinary Care for the Patient With Cardiac Amyloidosis: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2023; 81:1076-1126. [PMID: 36697326 DOI: 10.1016/j.jacc.2022.11.022] [Citation(s) in RCA: 96] [Impact Index Per Article: 96.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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30
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Abdelghany M, Abdelhamid M, Allam A, El Etriby A, Hafez S, Ragy H, Sobhy M. Detection and Diagnosis of Cardiac Amyloidosis in Egypt. Cardiol Ther 2023; 12:197-213. [PMID: 36611101 PMCID: PMC9986164 DOI: 10.1007/s40119-022-00299-x] [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: 11/18/2022] [Accepted: 12/16/2022] [Indexed: 01/09/2023] Open
Abstract
Cardiac amyloidosis is a life-threatening disease that occurs when amyloid proteins, most commonly immunoglobulin light chain or transthyretin, mutate or become unstable, misfold, deposit as amyloid fibrils, and accumulate in the myocardium. Early diagnosis of cardiac amyloidosis is hindered by insufficient awareness, specifically regarding clinical red flags and diagnostic pathways. Cardiac amyloidosis diagnosis comprises two important phases, clinical suspicion (phase one) followed by definitive diagnosis (phase two). Each phase is associated with specific clinical techniques. For example, clinical features, electrocardiography, echocardiography, and cardiac magnetic resonance imaging serve to raise suspicion of cardiac amyloidosis and facilitate early diagnosis, whereas laboratory tests (i.e., blood or urine electrophoresis with immunofixation), biopsy, scintigraphy-based nuclear imaging, and genetic testing provide a definitive diagnosis of cardiac amyloidosis. In Egypt, both the lack of cardiac amyloidosis awareness amongst healthcare providers and the unavailability of clinical expertise for the use of diagnostic techniques must be overcome to improve the prognosis of cardiac amyloidosis in the region. Previously published diagnostic algorithms for cardiac amyloidosis have amalgamated techniques that can raise clinical suspicions of cardiac amyloidosis with those that definitively diagnose cardiac amyloidosis. Though such algorithms have been successful in developed countries, diagnostic tools like echocardiography, scintigraphy, and cardiac magnetic resonance imaging are not ubiquitously available across Egyptian facilities. This review presents the current state of knowledge regarding cardiac amyloidosis in Egypt and outlines a new diagnostic algorithm which leverages regional nuclear imaging expertise. Importantly, the proposed diagnostic algorithm guides accurate amyloid-typing to mitigate misdiagnosis and erroneous treatment selection and improve the cardiac amyloidosis diagnostic accuracy in Egypt.
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Affiliation(s)
- Mohamed Abdelghany
- Department of Cardiology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Magdy Abdelhamid
- Department of Cardiology, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Adel Allam
- Department of Cardiology, Faculty of Medicine, Azhar University, Cairo, Egypt
| | - Adel El Etriby
- Department of Cardiology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Hany Ragy
- National Heart Institute, Giza, Egypt.
| | - Mohamed Sobhy
- Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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31
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Mahadevia H, Ponvilawan B, Sharma P, Al-Obaidi A, Qasim H, Koyi J, Anwer F, Raza S. Advancements and future trends of immunotherapy in light-chain amyloidosis. Crit Rev Oncol Hematol 2023; 183:103917. [PMID: 36696931 DOI: 10.1016/j.critrevonc.2023.103917] [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: 08/30/2022] [Revised: 12/05/2022] [Accepted: 01/20/2023] [Indexed: 01/23/2023] Open
Abstract
Light-chain (AL) amyloidosis is a type of plasma cell neoplasm with abnormal monoclonal immunoglobulin light-chain production and their subsequent deposition in tissues causing end-organ damage. In addition to existing treatments including autologous stem cell transplantation, there is a need for other approaches for eradicating abnormal plasma cells and amyloid tissue deposits. Treatment strategies of AL amyloidosis are mostly based on medications that are effective in multiple myeloma due to similar cell of origin. Daratumumab along with proteasome inhibitors and corticosteroids has become standard of care for AL amyloidosis. Another appealing approach is disassembling amyloid deposits with hope to potentially reverse the damage done by the disease. This was met with promising results for CAEL-101 and birtamimab. Although still in early stages, novel treatment options in pipeline, including antibody-drug conjugates, bispecific T-cell engagers, and chimeric antigen receptor T cell therapy may diversify the treatment armamentarium of AL amyloidosis in the future.
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Affiliation(s)
- Himil Mahadevia
- Department of Internal Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA.
| | - Ben Ponvilawan
- Department of Internal Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA.
| | - Parth Sharma
- Department of Internal Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA.
| | - Ammar Al-Obaidi
- Department of Hematology/Oncology, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA.
| | - Hana Qasim
- Department of Internal Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA.
| | - Jagadish Koyi
- Department of Internal Medicine, University of Missouri-Kansas City, 2411 Holmes St, Kansas City, MO 64108, USA.
| | - Faiz Anwer
- Taussig Cancer Center, Cleveland Clinic, 10201 Carnegie Ave, Cleveland, OH 44106, USA.
| | - Shahzad Raza
- Taussig Cancer Center, Cleveland Clinic, 10201 Carnegie Ave, Cleveland, OH 44106, USA.
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Murphy P. A Case of Disseminated Systemic Light-Chain Amyloidosis with Coagulopathy. Am J Med 2023; 136:e51. [PMID: 36796957 DOI: 10.1016/j.amjmed.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 06/19/2022] [Indexed: 02/16/2023]
Affiliation(s)
- Philip Murphy
- Department of Haematology, Beaumont Hospital, Dublin, Ireland.
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Sanchorawala V. Eureka Moment-Innovation Comes of an Age in Light Chain Amyloidosis. JCO Oncol Pract 2023; 19:276-277. [PMID: 36854072 DOI: 10.1200/op.23.00033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023] Open
Affiliation(s)
- Vaishali Sanchorawala
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, MA
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Quock TP, D'Souza A, Broder MS, Bognar K, Chang E, Tarbox MH. In-hospital mortality in amyloid light chain amyloidosis: analysis of the Premier Healthcare Database. J Comp Eff Res 2023; 12:e220185. [PMID: 36476016 PMCID: PMC10288963 DOI: 10.2217/cer-2022-0185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Aim: Describe the clinical and economic burden of hospitalizations for amyloid light chain (AL) amyloidosis. Materials & methods: This retrospective analysis used nationally representative hospital discharge data (2017-2020) to report discharge status, resource use and costs for hospitalizations among patients with AL amyloidosis. Results: Of 1341 patients identified, 92% were discharged alive and 8% experienced in-hospital death. Compared with the average US hospital stay during 2017-2019 (4.7 days, mean costs of $13,046 and mean charges of $54,496), hospital stays for AL amyloidosis were longer and costlier (9.7 days, $27,098.61, $111,233.91), especially in patients with in-hospital death (12.2 days, $44,966, $182,338.18). Conclusion: AL amyloidosis is associated with significant clinical and economic burden.
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Affiliation(s)
- Tiffany P Quock
- Health Economics and Outcomes Research, Prothena Biosciences Inc, South San Francisco, CA 94080, USA
| | - Anita D'Souza
- Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Michael S Broder
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA 90212, USA
| | - Katalin Bognar
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA 90212, USA
| | - Eunice Chang
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA 90212, USA
| | - Marian H Tarbox
- Real World Evidence, PHAR (Partnership for Health Analytic Research), Beverly Hills, CA 90212, USA
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Palladini G, Schönland S, Merlini G, Milani P, Jaccard A, Bridoux F, Dimopoulos MA, Ravichandran S, Hegenbart U, Roeloffzen W, Cibeira MT, Agis H, Minnema MC, Bergantim R, Hájek R, João C, Leonidakis A, Cheliotis G, Sonneveld P, Kastritis E, Wechalekar A. The management of light chain (AL) amyloidosis in Europe: clinical characteristics, treatment patterns, and efficacy outcomes between 2004 and 2018. Blood Cancer J 2023; 13:19. [PMID: 36697388 PMCID: PMC9876983 DOI: 10.1038/s41408-023-00789-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/27/2022] [Accepted: 01/10/2023] [Indexed: 01/27/2023] Open
Abstract
Systemic light-chain (AL) amyloidosis is a rare and debilitating disease. Advances have been made in new treatments in recent years, yet real-world data on the management of the disease are scarce. EMN23 is a retrospective, observational study of patients who initiated first-line treatment in 2004-2018 in Europe, presenting the demographics, clinical characteristics, treatment patterns, and outcomes, from 4480 patients. Regimens based on bortezomib were the most frequently used as first-line therapy; only 6.2% of the patients received autologous stem cell transplant. Hematologic responses improved post-2010 (67.1% vs 55.6% pre-2010). The median overall survival (OS) was 48.8 (45.2-51.7) months; 51.4 (47.3-57.7) months pre-2010 and 46.7 (41.3-52.2) months post-2010. Early mortality was 13.4% and did not improve (11.4% vs 14.4% pre- and post-2010); furthermore, it remained high in patients with advanced cardiac disease (over 39% for stage IIIb). There was a significant improvement for stage IIIa (14.2 vs 30.7 months, p = 0.0170) but no improvement for stage IIIb patients (5.0 vs 4.5 months). This European real-world study of AL-amyloidosis emphasizes the unmet needs of early diagnosis, and the lack of improvement in survival outcomes of the frail stage IIIb population, despite the introduction of new therapies in recent years.
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Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation "Instituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Stefan Schönland
- Medical Department V, Amyloidosis Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation "Instituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation "Instituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Arnaud Jaccard
- National Amyloidosis Center and Hematology Unit, CHU Limoges, Limoges, France
| | | | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Ute Hegenbart
- Medical Department V, Amyloidosis Center Heidelberg, University of Heidelberg, Heidelberg, Germany
| | - Wilfried Roeloffzen
- Amyloidosis Centre of Expertise Department of Internal Medicine, Faculty of Medical Sciences, University Medical Center Groningen, Groningen, Netherlands
| | - M Teresa Cibeira
- Amyloidosis and Myeloma Unit, Department of Hematology, Hospital Clinic de Barcelona, IDIBAPS, Barcelona, Spain
| | - Hermine Agis
- Department of Internal Medicine I, Division of Oncology, Medical University Vienna, Vienna, Austria
| | - Monique C Minnema
- Department of Hematology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rui Bergantim
- Clinical Hematology, Centro Hospitalar São João, Porto, Portugal; i3S - Instituto de Investigação e Inovação em Saúde, University of Porto, Porto, Portugal; Cancer Drug Resistance Group, IPATIMUP - Institute of Molecular Pathology and Immunology of the University of Porto, Porto, Portugal; Clinical Hematology, FMUP - Faculty of Medicine, University of Porto, Porto, Portugal
| | - Roman Hájek
- Department of Haematooncology, University Hospital Ostrava, and Department of Haematooncology, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Cristina João
- Hematology Department, Champalimaud Center for the Unknown, Lisbon, Portugal
| | | | | | | | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece.
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Sabinot A, Ghetti G, Pradelli L, Bellucci S, Lausi A, Palladini G. State-of-the-art review on AL amyloidosis in Western Countries: Epidemiology, health economics, risk assessment and therapeutic management of a rare disease. Blood Rev 2023; 59:101040. [PMID: 36697295 DOI: 10.1016/j.blre.2023.101040] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 12/19/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023]
Abstract
Amyloidosis is the term to define a broad array of rare protein misfolding syndromes. Among them, light chain (AL) amyloidosis is the most common, affecting roughly 10 people per million/year. The core purpose of the present literature review is to shed light on the academic and clinical knowledge on the condition, encompassing its i) epidemiology, ii) economic burden, and iii) quality of life consequences. The areas of interest are Europe and North America. Literature search was primarily performed on Embase® and finally integrated with additional, deemed eligible, sources. Pre-defined PICOS criteria were employed for the inclusion and exclusion processes. A total of 64 studies were comprehensively included in the current literature review as compliant with the inclusion criteria. The results were presented according to the outcomes of interest and eventually triangulated and compared to available literature studies. A broad picture on the main aspects of AL amyloidosis is delivered.
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Zanwar S, Gertz MA, Muchtar E. Immunoglobulin Light Chain Amyloidosis: Diagnosis and Risk Assessment. J Natl Compr Canc Netw 2023; 21:83-90. [PMID: 36630897 PMCID: PMC10164359 DOI: 10.6004/jnccn.2022.7077] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/22/2022] [Indexed: 01/13/2023]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a clonal plasma cell disorder with multiple clinical presentations. The diagnosis of AL amyloidosis requires a high index of suspicion, making a delay in diagnosis common, which contributes to the high early mortality seen in this disease. Establishing the diagnosis of AL amyloidosis requires the demonstration of tissue deposition of amyloid fibrils. A bone marrow biopsy and fat pad aspirate performed concurrently have a high sensitivity for the diagnosis of AL amyloidosis and negate the need for organ biopsies in most patients. An accurate diagnosis requires amyloid typing via additional testing, including tissue mass spectrometry. Prognostication for AL amyloidosis is largely driven by the organs impacted. Cardiac involvement represents the single most important prognostic marker, and the existing staging systems are driven by cardiac biomarkers. Apart from organ involvement, plasma cell percentage on the bone marrow biopsy, specific fluorescence in situ hybridization findings, age at diagnosis, and performance status are important prognostic markers. This review elaborates on the diagnostic testing and prognostication for patients with newly diagnosed AL amyloidosis.
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Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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Kreiniz N, Gertz MA. Bad players in AL amyloidosis in the current era of treatment. Expert Rev Hematol 2023; 16:33-49. [PMID: 36620914 PMCID: PMC9905376 DOI: 10.1080/17474086.2023.2166924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 01/06/2023] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Systemic AL amyloidosis (ALA) is a clonal plasma cell (PC) disease characterized by deposition of amyloid fibrils in different organs and tissues. Traditionally, the prognosis of ALA is poor and is primarily defined by cardiac involvement. The modern prognostic models are based on cardiac markers and free light chain difference (dFLC). Cardiac biomarkers have low specificity and are dependent on renal function, volume status, and cardiac diseases other than ALA. New therapies significantly improved the prognosis of the disease. The advancements in technologies - cardiac echocardiography (ECHO) and cardiac MRI (CMR), as well as new biological markers, relying on cardiac injury, inflammation, endothelial damage, and clonal and non-clonal PC markers are promising. AREAS COVERED An update on the prognostic significance of cardiac ALA, number of involved organs, response to treatment, including minimal residual disease (MRD), ECHO, MRI, and new biological markers will be discussed. The literature search was done in PubMed and Google Scholar, and the most recent and relevant data are included. EXPERT OPINION Prospective multicenter trials, evaluating multiple clinical and laboratory parameters, should be done to improve the risk assessment models in ALA in the modern era of therapy.
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Affiliation(s)
- Natalia Kreiniz
- Division of Hematology, Bnai Zion Medical Centre, Haifa, Israel
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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39
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Current Understanding of Systemic Amyloidosis and Underlying Disease Mechanisms. Am J Cardiol 2022; 185 Suppl 1:S2-S10. [PMID: 36549788 DOI: 10.1016/j.amjcard.2022.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022]
Abstract
Amyloidosis is a group of diverse disorders caused by misfolded proteins that aggregate into insoluble fibrils and ultimately cause organ damage. In medical practice, amyloidosis classification is based on the amyloid precursor protein type, of which amyloid immunoglobulin light chain, amyloid transthyretin, amyloid leukocyte chemotactic factor 2, and amyloid derived from serum amyloid A protein are the most common. Distinct mechanisms appear to be predominantly operational in the pathogenesis of particular types of amyloidosis, including increased protein precursor synthesis, somatic or germ line mutations, and inherent instability in the precursor protein in its wild form. An increased supply of misfolded proteins and/or a decreased capacity of the protein quality control systems can result in an imbalance that leads to increased circulation of misfolded proteins. Although the detection of mature fibrils is the basis for diagnosis of amyloidosis, a growing body of evidence has implicated the prefibrillar species as proteotoxic and key contributors to the development of the disease.
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40
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Fedotov SA, Khrabrova MS, Anpilova AO, Dobronravov VA, Rubel AA. Noninvasive Diagnostics of Renal Amyloidosis: Current State and Perspectives. Int J Mol Sci 2022; 23:ijms232012662. [PMID: 36293523 PMCID: PMC9604123 DOI: 10.3390/ijms232012662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022] Open
Abstract
Amyloidoses is a group of diseases characterized by the accumulation of abnormal proteins (called amyloids) in different organs and tissues. For systemic amyloidoses, the disease is related to increased levels and/or abnormal synthesis of certain proteins in the organism due to pathological processes, e.g., monoclonal gammopathy and chronic inflammation in rheumatic arthritis. Treatment of amyloidoses is focused on reducing amyloidogenic protein production and inhibition of its aggregation. Therapeutic approaches critically depend on the type of amyloidosis, which underlines the importance of early differential diagnostics. In fact, the most accurate diagnostics of amyloidosis and its type requires analysis of a biopsy specimen from the disease-affected organ. However, absence of specific symptoms of amyloidosis and the invasive nature of biomaterial sampling causes the late diagnostics of these diseases, which leads to a delayed treatment, and significantly reduces its efficacy and patient survival. The establishment of noninvasive diagnostic methods and discovery of specific amyloidosis markers are essential for disease detection and identification of its type at earlier stages, which enables timely and targeted treatment. This review focuses on current approaches to the diagnostics of amyloidoses, primarily with renal involvement, and research perspectives in order to design new specific tests for early diagnosis.
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Affiliation(s)
- Sergei A. Fedotov
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg 199034, Russia
| | - Maria S. Khrabrova
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Research Institute of Nephrology, Pavlov University, St. Petersburg 197101, Russia
| | - Anastasia O. Anpilova
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Research Institute of Nephrology, Pavlov University, St. Petersburg 197101, Russia
| | | | - Aleksandr A. Rubel
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Department of Genetics and Biotechnology, St. Petersburg State University, St. Petersburg 199034, Russia
- Correspondence: ; Tel.: +7-812-428-40-09
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Richards D, Millns H, Cookson L, Lukas MA. An observational, non-interventional study for the follow-up of patients with amyloidosis who received miridesap followed by dezamizumab in a phase 1 study. Orphanet J Rare Dis 2022; 17:259. [PMID: 35810311 PMCID: PMC9271258 DOI: 10.1186/s13023-022-02405-7] [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: 12/08/2021] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Abstract
Background Miridesap depletes circulating serum amyloid P (SAP) and dezamizumab (anti-SAP monoclonal antibody) targets SAP on amyloid deposits, triggering amyloid removal. In a phase 1, first-in-human study (FIHS), progressive amyloid removal was observed in some patients after ≤ 3 cycles of miridesap/dezamizumab. Methods This observational, non-interventional study in patients who received miridesap/dezamizumab during the FIHS (planned follow-up: 5 years) evaluated response to treatment based on routine assessments of disease status and key organ function. In a post hoc analysis, patients responding to treatment in the FIHS during follow-up were identified as responders and further categorized as sustained or declining responders.
Results In the FIHS, 17/23 patients were treatment responders. Of these patients, seven (immunoglobulin light chain [AL], n = 6; serum amyloid A, n = 1) were considered sustained responders and ten (fibrinogen-a alpha chain [AFib], n = 5; AL, n = 4; apolipoprotein A-I, n = 1) were considered declining responders. We primarily present responder patient-level data for functional, cardiac, laboratory and imaging assessments conducted during the follow-up period, with non-responder data presented as supplementary. Conclusion No further development of miridesap/dezamizumab is planned in amyloidosis. However, long-term follow-up of these patients may provide insight into whether active removal of amyloid deposits has an impact on disease progression. Trial registration ClinicalTrials.gov, NCT01777243. Registered 28 January 2013, https://clinicaltrials.gov/ct2/show/study/NCT01777243. Supplementary Information The online version contains supplementary material available at 10.1186/s13023-022-02405-7.
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42
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Gustine JN, Staron A, Szalat R, Mendelson L, Joshi T, Ruberg FL, Siddiqi O, Gopal DM, Edwards CV, Havasi A, Kaku M, Lau KHV, Berk JL, Sloan JM, Sanchorawala V. Predictors of hematologic response and survival with stem cell transplantation in AL amyloidosis: a 25-year longitudinal study. Am J Hematol 2022; 97:1189-1199. [PMID: 35731907 DOI: 10.1002/ajh.26641] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/17/2022] [Accepted: 06/20/2022] [Indexed: 11/07/2022]
Abstract
High-dose melphalan and stem cell transplantation (HDM/SCT) is an effective treatment for selected patients with AL amyloidosis. We report the long-term outcomes of 648 patients with AL amyloidosis treated with HDM/SCT over 25 years. Hematologic CR was achieved by 39% of patients. The median duration of hematologic CR was 12.3 years, and 45% of patients with a hematologic CR had no evidence of a recurrent plasma cell dyscrasia at 15 years after HDM/SCT. With a median follow-up interval of 8 years, the median event-free survival (EFS) and overall survival (OS) were 3.3 and 7.6 years, respectively. Patients with a hematologic CR had a median OS of 15 years, and 30% of these patients survived >20 years. On multivariable analysis, dFLC >180 mg/L and BM plasma cells >10% were independently associated with shorter EFS, whereas BNP >81 pg/mL, troponin I >0.1 ng/mL, and serum creatinine >2.0 mg/dL were independently associated with shorter OS. We developed a prognostic score for EFS, which incorporated dFLC >180 mg/L and BMPC% >10% as adverse risk factors. Patients with low-risk (0 factors), intermediate-risk (1 factor), and high-risk (2 factors) disease had median EFS estimates of 5.3, 2.8, and 1.0 years, respectively (p<0.001). The 100-day treatment-related mortality rate was 3% in the latest treatment period (2012-2021), and the 25-year risk of t-MDS/AML was 3%. We conclude that HDM/SCT induces durable hematologic responses and prolonged survival with improved safety in selected patients with AL amyloidosis. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Joshua N Gustine
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Raphael Szalat
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Lisa Mendelson
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Tracy Joshi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Omar Siddiqi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Deepa M Gopal
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Cardiovascular Medicine, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Camille V Edwards
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Andrea Havasi
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Nephrology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Michelle Kaku
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - K H Vincent Lau
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - John L Berk
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Pulmonology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - J Mark Sloan
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA.,Sections of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, MA, USA
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43
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Gertz MA. Immunoglobulin light chain amyloidosis: 2022 update on diagnosis, prognosis, and treatment. Am J Hematol 2022; 97:818-829. [PMID: 35429180 DOI: 10.1002/ajh.26569] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 12/15/2022]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include heart failure with preserved ejection fraction, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical smoldering multiple myeloma or monoclonal gammopathy of undetermined significance (MGUS)." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for the diagnosis of AL amyloidosis. Invasive organ biopsy is not required in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP or BNP), serum troponin T (or I), and difference between involved and uninvolved immunoglobulin free light chain values are used to classify patients into four groups of similar size; median survivals are 73, 35, 15, and 5 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Current first-line therapy with the best outcome is daratumumab, bortezomib, cyclophosphamide, and dexamethasone. The goal of therapy is a complete response (CR). In patients failing to achieve this depth of response options for consolidation include pomalidomide, stem cell transplantation, venetoclax, and bendamustine. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy prior to the development of end-stage organ failure. Trials of antibodies to catabolize deposited fibrils are underway.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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44
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Wu Y, Pu C, Zhu W, He C, Fei J, Hu H. A Risk Score to Diagnose Cardiac Involvement and Provide Prognosis Information in Patients at Risk of Cardiac Light-Chain Amyloidosis. Front Cardiovasc Med 2022; 9:817456. [PMID: 35355963 PMCID: PMC8959494 DOI: 10.3389/fcvm.2022.817456] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/14/2022] [Indexed: 12/14/2022] Open
Abstract
Background Cardiac light-chain amyloidosis (AL CA) portends poor prognosis. Contrast cardiac magnetic resonance (CMR) with late gadolinium enhancement (LGE) imaging is an important tool in recognizing AL CA. But contraindications to contrast CMR would significantly restrict its clinical application value. Our study aims to construct a convenient risk score to help identify cardiac involvement in patients at risk of AL CA. Moreover, we also investigate whether this risk score could provide prognosis information. Materials and Methods Sixty-three patients at risk of AL CA were retrospectively included in our study. Basic clinical characters, lab results, 12-lead electrocardiogram data, and cardiac magnetic resonance image data were collected. AL CA was diagnosed according to typical CA LGE pattern. Logistic analysis was used to figure out predictive parameters of AL CA and their β coefficients, further constructing the risk score. Receiver operating characteristics (ROC) curve was used to find the cut-off point best distinguishing AL CA+ from AL CA–patients. Bootstrapping was used for internal validation. All patients were divided into high-risk and low-risk group according to the diagnostic cut-off point, and followed up for survival information. Kaplan-Meier plots and log-rank test were performed to analyze if this score had prognostic value. Results The risk score finally consisted of 4 parameters: pericardial effusion (PE) (1 point), low electrocardiographic QRS voltages (LQRSV) (1 point), CMR-derived impaired global radial strain (GRS) (<15.14%) (1 point) and increased left ventricular maximum wall thickness (LVMWT) (>13 mm) (2 points). Total score ranged from 0 to 5 points. A cut-off point of 1.5 showed highest accuracy in diagnosing AL CA with an AUC of 0.961 (95% CI: 0.924–0.997, sensitivity: 90.6%, specificity: 83.9%). Kaplan-Meier plots and log-rank test showed that the high-risk group had significantly poor overall survival rates. Conclusion In patients at risk of AL CA, a risk score incorporating the presence of PE, LQRSV, and CMR-derived impaired GRS and increased LVMWT is predictive of a diagnosis of AL CA by LGE criteria. This risk score may be helpful especially when contrast CMR is not available or contraindicated, and further studies should be considered to validate this score.
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Affiliation(s)
- Yan Wu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Cailing Pu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Wenchao Zhu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chengbin He
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingle Fei
- Department of Radiology, Lishui Central Hospital, Lishui, China
| | - Hongjie Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Hongjie Hu
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Akhtar Z, Leung LWM, Kontogiannis C, Chung I, Bin Waleed K, Gallagher MM. Arrhythmias in Chronic Kidney Disease. Eur Cardiol 2022; 17:e05. [PMID: 35321526 PMCID: PMC8924956 DOI: 10.15420/ecr.2021.52] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/06/2021] [Indexed: 11/04/2022] Open
Abstract
Arrhythmias cause disability and an increased risk of premature death in the general population but far more so in patients with renal failure. The association between the cardiac and renal systems is complex and derives in part from common causality of renal and myocardial injury from conditions including hypertension and diabetes. In many cases, there is a causal relationship, with renal dysfunction promoting arrhythmias and arrhythmias exacerbating renal dysfunction. In this review, the authors expand on the challenges faced by cardiologists in treating common and uncommon arrhythmias in patients with renal failure using pharmacological interventions, ablation and cardiac implantable device therapies. They explore the most important interactions between heart rhythm disorders and renal dysfunction while evaluating the ways in which the coexistence of renal dysfunction and cardiac arrhythmia influences the management of both.
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Affiliation(s)
- Zaki Akhtar
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Lisa WM Leung
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Christos Kontogiannis
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Isaac Chung
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Khalid Bin Waleed
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Mark M Gallagher
- Department of Cardiology, St George’s University Hospitals NHS Foundation Trust, London, UK
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Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo", Department of Molecular Medicine, University of Pavia, Pavia, Italy
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Muchtar E, Drake MT, Leung N, Dispenzieri A, Lacy MQ, Buadi FK, Dingli D, Hayman SR, Kapoor P, Hwa YL, Fonder A, Hobbs M, Gonsalves W, Kourelis TV, Warsame R, Russell S, Go RS, Binder M, Kyle RA, Rajkumar SV, Kumar SK, Gertz MA. Hypovitaminosis D Is Prevalent in Patients With Renal AL Amyloidosis and Associated With Renal Outcome. Front Endocrinol (Lausanne) 2022; 13:891712. [PMID: 35800433 PMCID: PMC9253369 DOI: 10.3389/fendo.2022.891712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/11/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Vitamin D deficiency is common, but no data have been reported on vitamin D levels in light chain (AL) amyloidosis. PATIENTS AND METHODS In this exploratory study, stored serum samples from 173 patients with newly diagnosed AL amyloidosis were analyzed for vitamin studies which included 25-hydroxyvitamin D [25(OH)D], 1,25-dihydroxyvitamin D [1,25(OH)2D] and vitamin D binding protein (DBP). Measurements were made by liquid chromatography-tandem mass spectrometry. Kidney survival and overall survival (OS) were assessed in association to vitamin D status. RESULTS Cardiac and kidney involvement occurred in 69% and 63% of patients, respectively. 25(OH)D deficiency (<20 ng/mL) was seen in 56.6% of the patients and was notably found among patients with heavy proteinuria (96%), hypoalbuminemia (84.3%) and morbidly obese patients (68.3%). Heavy proteinuria (>5 gr/24-h) and vitamin D supplementation were independent predictors of 25(OH)D level on nominal multivariate regression analysis. 1,25(0H)2D deficiency was noted in 37.6% of patients and was independently associated with low eGFR and hypoalbuminemia. Progression to ESRD occurred in 23.7% of evaluable patients. Patients who progressed to ESRD had lower serum 25(OH)D and 1,25(OH)2D levels compared to those who did not progress to ESRD. On a multivariate analysis, severe 25(OH)D deficiency was an independent predictor of progression to ESRD as was renal stage, while 1,25(OH)2D deficiency was not. CONCLUSIONS Hypovitaminosis D is common in AL amyloidosis, particularly among patients with heavy proteinuria. Severe 25(OH)D deficiency at time of diagnosis predicts progression to ESRD.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
- *Correspondence: Eli Muchtar,
| | - Matthew T. Drake
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
- Department of Endocrinology and Kogod Center of Aging, Mayo Clinic College of Medicine, Rochester, MN, United States
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, United States
| | | | - Martha Q. Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Francis K. Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | | | - Prashant Kapoor
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Amie Fonder
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Miriam Hobbs
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Wilson Gonsalves
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | | | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Stephen Russell
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Ronald S. Go
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Moritz Binder
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Robert A. Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | | | - Shaji K. Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | - Morie A. Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
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Morgan GJ, Buxbaum JN, Kelly JW. Light Chain Stabilization: A Therapeutic Approach to Ameliorate AL Amyloidosis. HEMATO 2021; 2:645-659. [PMID: 35757512 PMCID: PMC9218996 DOI: 10.3390/hemato2040042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Non-native immunoglobulin light chain conformations, including aggregates, appear to cause light chain amyloidosis pathology. Despite significant progress in pharmacological eradication of the neoplastic plasma cells that secrete these light chains, in many patients impaired organ function remains. The impairment is apparently due to a subset of resistant plasma cells that continue to secrete misfolding-prone light chains. These light chains are susceptible to the proteolytic cleavage that may enable light chain aggregation. We propose that small molecules that preferentially bind to the natively folded state of full-length light chains could act as pharmacological kinetic stabilizers, protecting light chains against unfolding, proteolysis and aggregation. Although the sequence of the pathological light chain is unique to each patient, fortunately light chains have highly conserved residues that form binding sites for small molecule kinetic stabilizers. We envision that such stabilizers could complement existing and emerging therapies to benefit light chain amyloidosis patients.
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Affiliation(s)
- Gareth J. Morgan
- Section of Hematology and Medical Oncology, Department of Medicine, Boston University School of Medicine, Boston, MA 02118, USA
- The Amyloidosis Center, Boston University School of Medicine, Boston, MA 02118, USA
- Correspondence:
| | - Joel N. Buxbaum
- Department of Molecular Medicine, The Scripps Research Institute, La Jolla, CA 92037, USA
| | - Jeffery W. Kelly
- Department of Chemistry, The Scripps Research Institute, La Jolla, CA 92037, USA
- The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, CA 92037, USA
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