1
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Muchtar E, Wisniowski B, Geyer S, Palladini G, Milani P, Merlini G, Schönland S, Veelken K, Hegenbart U, Leung N, Dispenzieri A, Kumar SK, Kastritis E, Dimopoulos MA, Liedtke M, Ulloa P, Sanchorawala V, Szalat R, Dooley K, Landau H, Petrlik E, Lentzsch S, Coltoff A, Bladé J, Cibeira MT, Cohen O, Foard D, Gillmore J, Lachmann H, Wechalekar A, Gertz MA. Graded Organ Response and Progression Criteria for Kidney Immunoglobulin Light Chain Amyloidosis. JAMA Oncol 2024:2821927. [PMID: 39088206 PMCID: PMC11295065 DOI: 10.1001/jamaoncol.2024.2629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 03/14/2024] [Indexed: 08/02/2024]
Abstract
Importance Kidney light chain (AL) amyloidosis is associated with a risk of progression to kidney replacement therapy (KRT) and death. Several studies have shown that a greater reduction in proteinuria following successful anticlonal therapy is associated with improved outcomes. Objective To validate graded kidney response criteria and their association with kidney and overall survival (OS). Design, Setting, and Participants This retrospective, multicenter cohort was conducted at 10 referral centers for amyloidosis from 2010 to 2015 and included patients with kidney AL amyloidosis that was evaluable for kidney response and who achieved at least hematologic partial response within 12 months of diagnosis. The median follow-up was 69 (54-88) months. Data analysis was conducted in 2023. Exposure Four kidney response categories based on the reduction in pretreatment 24-hour urine protein (24-hour UP) levels: complete response (kidCR, 24-hour UP ≤200 mg), very good partial response (kidVGPR, >60% reduction in 24-hour UP), partial response (kidPR, 31%-60% reduction), and no response (kidNR, ≤30% reduction). Kidney response was assessed at landmark points (6, 12, and 24 months) and best kidney response. Main Outcomes and Measures Cumulative incidence of progression to KRT and OS. Results Seven-hundred and thirty-two patients (335 women [45.8%]) were included, with a median (IQR) age of 63 (55-69) years. The median (IQR) baseline 24-hour proteinuria and estimated glomerular filtration rate was 5.3 (2.8-8.5) g per 24 hours and 72 (48-92) mL/min/1.73m2, respectively. In a competing-risk analysis, the 5-year cumulative incidence rates of progression to KRT decreased with deeper kidney responses as early as 6 months from therapy initiation (11%, 12%, 2.1%, and 0% for kidNR, kidPR, kidVGPR, and kidCR, respectively; P = .002) and were maintained at 12 months and 24 months and best kidney response. Patients able to achieve kidCR/kidVGPR by 24 months and at best response had significantly better OS compared with kidPR/kidNR. Kidney progression, defined as a 25% or greater decrease in estimated glomerular filtration rate, was associated with cumulative incidence of progression to KRT and OS. Conclusions and Relevance The results of this cohort study suggest that graded kidney response criteria offers clinically and prognostically meaningful information for treating patients with kidney AL amyloidosis. The response criteria potentially inform kidney survival based on the depth of reduction in 24-hour proteinuria levels and demonstrate an OS advantage for those able to achieve kidCR/kidVGPR compared with kidPR/kidNR. Taken together, achievement of at least kidVGPR by 12 months is needed to ultimately improve kidney and patient survival.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Brendan Wisniowski
- National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, England
| | - Susan Geyer
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Giovanni Palladini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Paolo Milani
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Stefan Schönland
- Medical Department V, Amyloidosis Center, University of Heidelberg, Germany
| | - Kaya Veelken
- Medical Department V, Amyloidosis Center, University of Heidelberg, Germany
| | - Ute Hegenbart
- Medical Department V, Amyloidosis Center, University of Heidelberg, Germany
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | | | - Shaji K. Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Michaela Liedtke
- Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California
| | - Patricia Ulloa
- Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California
| | - Vaishali Sanchorawala
- Section of Hematology and Oncology, Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Raphael Szalat
- Section of Hematology and Oncology, Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Katharine Dooley
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Heather Landau
- Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Erica Petrlik
- Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Suzanne Lentzsch
- Division of Hematology/Oncology, Columbia University Medical Center, New York, New York
| | - Alexander Coltoff
- Division of Hematology/Oncology, Columbia University Medical Center, New York, New York
| | - Joan Bladé
- Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain
| | - M. Teresa Cibeira
- Department of Hematology, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain
| | - Oliver Cohen
- National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, England
| | - Darren Foard
- National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, England
| | - Jullian Gillmore
- National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, England
| | - Helen Lachmann
- National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, England
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, England
| | - Morie A. Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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Xue B, Li L, Ma S. Multiple myeloma with secondary amyloidosis: Dysphagia as the first symptom: A case report. Medicine (Baltimore) 2024; 103:e38968. [PMID: 38996132 PMCID: PMC11245242 DOI: 10.1097/md.0000000000038968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/14/2024] Open
Abstract
RATIONALE Multiple myeloma (MM) with secondary amyloidosis (AL) is a rare clonal plasma cell proliferation disease, which causes dysfunction of multiple organs and tissues. We report a case of dysphagia as the first symptom in a patient with MM and secondary AL. PATIENT CONCERNS The patient was a 73-year-old female, was admitted to our hospital, because of progressive dysphagia for 4 months and limb weakness for 1 month. DIAGNOSES The bone marrow smear and pathology diagnosis revealed the presence of MM, while the biceps myopathy diagnosis indicated AL. INTERVENTIONS The VCD regimen consisted of bortezomib at a dosage of 1.9 mg on days 1, 8, 15, and 22, cyclophosphamide 0.4 g on days 1, 8, and 15, and dexamethasone at a dosage of 40 mg on days 1, 8, 15, and 22. The patient simultaneously received comprehensive treatment including anti-infective therapy, enhanced cardiac function, and nutritional support. OUTCOMES The M protein in the blood and urine protein were negative, indicating a reduction in bone marrow plasma cells to 2%. Flow cytometric analysis revealed a minimal percentage 0.04%. As a result, complete remission was achieved. LESSONS The clinical manifestations of MM exhibit a wide range, with the symptoms of secondary injury causing significant disturbing, while the atypical symptoms of extramedullary manifestations pose challenges in diagnosing the disease.
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Affiliation(s)
- Bing Xue
- Department of Geriatrics, Zibo Central Hospital of Shandong University, Zibo, Shandong, China
| | - Liang Li
- Department of Gastrointestinal Surgery, Zibo Central Hospital of Shandong University, Zibo, Shandong, China
| | - Shanshan Ma
- Department of Geriatrics, Zibo Central Hospital of Shandong University, Zibo, Shandong, China
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Lopedote P, Evans B, Marchetti A, Chen T, Moscvin M, Boullt S, Bolli N, Bianchi G. Clonal hematopoiesis of indeterminate potential in patients with immunoglobulin light-chain AL amyloidosis. Blood Adv 2024; 8:3427-3436. [PMID: 38652890 PMCID: PMC11259929 DOI: 10.1182/bloodadvances.2024012840] [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: 02/02/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 04/25/2024] Open
Abstract
ABSTRACT Immunoglobulin light-chain (AL) amyloidosis is characterized by the deposition of misfolded monoclonal free light chains, with cardiac complications accounting for patient mortality. Clonal hematopoiesis of indeterminate potential (CHIP) has been associated with worse cardiovascular outcomes in the general population. Its significance in AL amyloidosis remains unclear. We collected clinical information and outcome data on 76 patients with a diagnosis of AL amyloidosis who underwent deep targeted sequencing for myeloid neoplasia-associated mutations between April 2018 and August 2023. Variant allele frequency was set at 2% to call CHIP-associated mutations. CHIP mutations were present in patients with AL amyloidosis at a higher frequency compared with age-matched control individuals. Sixteen patients (21%) had at least 1 CHIP mutation. DNMT3A was the most frequent mutation (7/16; 44%). Compared with patients without CHIP, patients with CHIP had a higher prevalence of t(11;14) translocation (69% vs 25%, respectively; P = .004). Furthermore, among patients with renal involvement, those with CHIP had a lower Palladini renal stage (P = .001). At a median follow-up of 32.5 months, the presence of CHIP was not associated with worse overall survival or major organ dysfunction progression-free survival. Larger studies and longer follow-up are needed to better define the impact of CHIP in patients with AL amyloidosis.
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Affiliation(s)
- Paolo Lopedote
- Department of Medicine, St. Elizabeth's Medical Center, Boston University, Boston, MA
| | - Benjamin Evans
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Alfredo Marchetti
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
| | - Tianzeng Chen
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Maria Moscvin
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Samuel Boullt
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
| | - Niccolò Bolli
- Department of Oncology and Onco-Hematology, University of Milan, Milan, Italy
- Hematology Division, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giada Bianchi
- Amyloidosis Program, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Boston, MA
- Division of Hematology, Brigham and Women's Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Aguilan JT, Lim J, Racine-Brzostek S, Fischer J, Silvescu C, Cornett S, Nieves E, Mendu DR, Aliste CM, Semple S, Angeletti R, Weiss LM, Cole A, Prystowsky M, Pullman J, Sidoli S. Effect of dynamic exclusion and the use of FAIMS, DIA and MALDI-mass spectrometry imaging with ion mobility on amyloid protein identification. Clin Proteomics 2024; 21:47. [PMID: 38961380 PMCID: PMC11223398 DOI: 10.1186/s12014-024-09500-w] [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: 03/18/2024] [Accepted: 06/26/2024] [Indexed: 07/05/2024] Open
Abstract
Amyloidosis is a disease characterized by local and systemic extracellular deposition of amyloid protein fibrils where its excessive accumulation in tissues and resistance to degradation can lead to organ failure. Diagnosis is challenging because of approximately 36 different amyloid protein subtypes. Imaging methods like immunohistochemistry and the use of Congo red staining of amyloid proteins for laser capture microdissection combined with liquid chromatography tandem mass spectrometry (LMD/LC-MS/MS) are two diagnostic methods currently used depending on the expertise of the pathology laboratory. Here, we demonstrate a streamlined in situ amyloid peptide spatial mapping by Matrix Assisted Laser Desorption Ionization-Mass Spectrometry Imaging (MALDI-MSI) combined with Trapped Ion Mobility Spectrometry for potential transthyretin (ATTR) amyloidosis subtyping. While we utilized the standard LMD/LC-MS/MS workflow for amyloid subtyping of 31 specimens from different organs, we also evaluated the potential introduction in the MS workflow variations in data acquisition parameters like dynamic exclusion, or testing Data Dependent Acquisition combined with High-Field Asymmetric Waveform Ion Mobility Spectrometry (DDA FAIMS) versus Data Independent Acquisition (DIA) for enhanced amyloid protein identification at shorter acquisition times. We also demonstrate the use of Mascot's Error Tolerant Search and PEAKS de novo sequencing for the sequence variant analysis of amyloidosis specimens.
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Affiliation(s)
- Jennifer T Aguilan
- Laboratory for Macromolecular Analysis and Proteomics Facility, Albert Einstein College of Medicine, New York, 10461, USA
- Department of Pathology, Albert Einstein College of Medicine, New York, 10461, USA
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - Jihyeon Lim
- Janssen Research and Development, Malvern, PA, USA
| | | | | | | | | | - Edward Nieves
- Laboratory for Macromolecular Analysis and Proteomics Facility, Albert Einstein College of Medicine, New York, 10461, USA
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Damodara Rao Mendu
- Clinical Chemistry Laboratory, Mount Sinai School of Medicine, New York, USA
| | - Carlos-Madrid Aliste
- Laboratory for Macromolecular Analysis and Proteomics Facility, Albert Einstein College of Medicine, New York, 10461, USA
- Department of Systems and Computational Biology, Albert Einstein College of Medicine, New York, 10461, USA
| | | | - Ruth Angeletti
- Laboratory for Macromolecular Analysis and Proteomics Facility, Albert Einstein College of Medicine, New York, 10461, USA
| | - Louis M Weiss
- Department of Pathology, Albert Einstein College of Medicine, New York, 10461, USA
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - Adam Cole
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - Michael Prystowsky
- Department of Pathology, Albert Einstein College of Medicine, New York, 10461, USA
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - James Pullman
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - Simone Sidoli
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
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Yang J, Farhath MFF, Tian H, Yang L, Liu D. A patient with AL amyloidosis presenting with refractory tuberculosis, chest tightness and hypotension: case report. BMC Pulm Med 2024; 24:311. [PMID: 38956518 PMCID: PMC11220948 DOI: 10.1186/s12890-024-03127-1] [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: 01/23/2024] [Accepted: 06/24/2024] [Indexed: 07/04/2024] Open
Abstract
INTRODUCTION Immunoglobulin light chain (AL) amyloidosis presents a clinical spectrum characterized by diverse manifestations and involvement of multiple organs, posing a significant diagnostic challenge for physicians. METHODS AND RESULTS We present a case of a patient admitted to our hospital due to recurrent cough and sputum, which was initially diagnosed as refractory tuberculosis. Throughout his hospitalization, the patient experienced distressing symptoms, including uncontrollable chest tightness, hypotension, and fever. Noteworthy observations included a persistent elevation in cardiac biomarkers, indicative of cardiac damage. Bronchoalveolar lavage revealed the presence of various pathogenic microorganisms, while bone marrow flow cytometry demonstrated the existence of clonal plasma cells. Additionally, the urine free light chain assay detected the presence of M protein, and the positive congo red staining of the abdominal wall fat biopsy confirmed amyloid deposition in the tissues. Taking into account the patient's clinical presentation and the examination findings, we reached a conclusive diagnosis of immunoglobulin light chain (AL) amyloidosis. CONCLUSION This case serves as a reminder for physicians to consider rare diseases like AL amyloidosis when patients present with symptoms involving multiple organ systems such as heart, lung and kidney that are unresponsive to conventional treatment options.
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Affiliation(s)
- Jun Yang
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Department of Pulmonary and Critical Care Medicine, Langzhong People's Hospital, Langzhong, Sichuan, China
| | - Mohamed Fahim Fathima Farhath
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Huohuan Tian
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Linhui Yang
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dan Liu
- Department of Pulmonary and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
- State Key Laboratory of Respiratory Health and Multimorbidity, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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6
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Signorovitch J, Zhang J, Brown D, Dunnmon P, Xiu L, Done N, Hsu K, Barbachano Y, Lousada I. Pathway for Development and Validation of Multi-domain Endpoints for Amyloid Light Chain (AL) Amyloidosis. Ther Innov Regul Sci 2024; 58:600-609. [PMID: 38632158 PMCID: PMC11169055 DOI: 10.1007/s43441-024-00641-6] [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: 07/28/2023] [Accepted: 03/08/2024] [Indexed: 04/19/2024]
Abstract
Immunoglobin light chain (AL) amyloidosis is a rare disease in which a plasma cell dyscrasia leads to deposition of insoluble amyloid fibrils in multiple organs. To facilitate development of new therapies for this heterogenous disease, a public-private partnership was formed between the nonprofit Amyloidosis Research Consortium and the US Food and Drug Administration Center for Drug Evaluation and Research. In 2020, the Amyloidosis Forum launched an initiative to identify clinical trial endpoints and analytic strategies across affected organ systems and life impacts via specialized working groups. This review summarizes the proceedings of the Statistical Group and proposes a pathway for development and validation of multi-domain endpoints (MDEs) for potential use in AL amyloidosis clinical trials. Specifically, drawing on candidate domain-specific endpoints recommended by each organ-specific working group, different approaches to constructing MDEs were considered. Future studies were identified to assess the validity, meaningfulness and performance of MDEs through use of natural history and clinical trial data. Ultimately, for drug development, the context of use in a regulatory evaluation, the specific patient population, and the investigational therapeutic mechanism should drive selection of appropriate endpoints. MDEs for AL amyloidosis, once developed and validated, will provide important options for advancing patient-focused drug development in this multi-system disease.
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Affiliation(s)
| | - Jialu Zhang
- US Food and Drug Administration, Silver Spring, USA
| | - David Brown
- UK Medicines & Healthcare Products Regulatory Agency, London, UK
| | | | - Liang Xiu
- Janssen Research & Development, Raritan, USA
| | | | - Kristen Hsu
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA
| | | | - Isabelle Lousada
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA.
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7
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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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8
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Morfino P, Aimo A, Franzini M, Vergaro G, Castiglione V, Panichella G, Limongelli G, Emdin M. Pathophysiology of Cardiac Amyloidosis. Heart Fail Clin 2024; 20:261-270. [PMID: 38844297 DOI: 10.1016/j.hfc.2024.02.002] [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] [Indexed: 06/09/2024]
Abstract
Amyloidosis refers to a heterogeneous group of disorders sharing common pathophysiological mechanisms characterized by the extracellular accumulation of fibrillar deposits consisting of the aggregation of misfolded proteins. Cardiac amyloidosis (CA), usually caused by deposition of misfolded transthyretin or immunoglobulin light chains, is an increasingly recognized cause of heart failure burdened by a poor prognosis. CA manifests with a restrictive cardiomyopathy which progressively leads to biventricular thickening, diastolic and then systolic dysfunction, arrhythmias, and valvular disease. The pathophysiology of CA is multifactorial and includes increased oxidative stress, mitochondrial damage, apoptosis, impaired metabolism, and modifications of intracellular calcium balance.
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Affiliation(s)
| | - Alberto Aimo
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Maria Franzini
- Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Pisa, Italy
| | - Giuseppe Vergaro
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Vincenzo Castiglione
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giorgia Panichella
- Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy.
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9
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Desantis F, Miotto M, Milanetti E, Ruocco G, Di Rienzo L. Computational evidences of a misfolding event in an aggregation-prone light chain preceding the formation of the non-native pathogenic dimer. Proteins 2024; 92:797-807. [PMID: 38314653 DOI: 10.1002/prot.26672] [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: 09/25/2023] [Revised: 01/09/2024] [Accepted: 01/19/2024] [Indexed: 02/06/2024]
Abstract
Antibody light chain amyloidosis is a disorder in which protein aggregates, mainly composed of immunoglobulin light chains, deposit in diverse tissues impairing the correct functioning of organs. Interestingly, due to the high susceptibility of antibodies to mutations, AL amyloidosis appears to be strongly patient-specific. Indeed, every patient will display their own mutations that will make the proteins involved prone to aggregation thus hindering the study of this disease on a wide scale. In this framework, determining the molecular mechanisms that drive the aggregation could pave the way to the development of patient-specific therapeutics. Here, we focus on a particular patient-derived light chain, which has been experimentally characterized. We investigated the early phases of the aggregation pathway through extensive full-atom molecular dynamics simulations, highlighting a structural rearrangement and the exposure of two hydrophobic regions in the aggregation-prone species. Next, we moved to consider the pathological dimerization process through docking and molecular dynamics simulations, proposing a dimeric structure as a candidate pathological first assembly. Overall, our results shed light on the first phases of the aggregation pathway for a light chain at an atomic level detail, offering new structural insights into the corresponding aggregation process.
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Affiliation(s)
- Fausta Desantis
- The Open University Affiliated Research Centre at Istituto Italiano di Tecnologia, Genova, Italy
- Istituto Italiano di Tecnologia (IIT), Center for Life Nano & Neuro Science, Roma, Italy
| | - Mattia Miotto
- Istituto Italiano di Tecnologia (IIT), Center for Life Nano & Neuro Science, Roma, Italy
| | - Edoardo Milanetti
- Istituto Italiano di Tecnologia (IIT), Center for Life Nano & Neuro Science, Roma, Italy
- Department of Physics, Sapienza University of Rome, Rome, Italy
| | - Giancarlo Ruocco
- Istituto Italiano di Tecnologia (IIT), Center for Life Nano & Neuro Science, Roma, Italy
- Department of Physics, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Di Rienzo
- Istituto Italiano di Tecnologia (IIT), Center for Life Nano & Neuro Science, Roma, Italy
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Bibas M, Sarosiek S, Castillo JJ. Waldenström Macroglobulinemia - A State-of-the-Art Review: Part 1: Epidemiology, Pathogenesis, Clinicopathologic Characteristics, Differential Diagnosis, Risk Stratification, and Clinical Problems. Mediterr J Hematol Infect Dis 2024; 16:e2024061. [PMID: 38984103 PMCID: PMC11232678 DOI: 10.4084/mjhid.2024.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 06/19/2024] [Indexed: 07/11/2024] Open
Abstract
Waldenström macroglobulinemia (WM) is an infrequent variant of lymphoma, classified as a B-cell malignancy identified by the presence of IgM paraprotein, infiltration of clonal, small lymphoplasmacytic B cells in the bone marrow, and the MYD88 L265P mutation, which is observed in over 90% of cases. The direct invasion of the malignant cells into tissues like lymph nodes and spleen, along with the immune response related to IgM, can also lead to various health complications, such as cytopenias, hyperviscosity, peripheral neuropathy, amyloidosis, and Bing-Neel syndrome. Chemoimmunotherapy has historically been considered the preferred treatment for WM, wherein the combination of rituximab and nucleoside analogs, alkylating drugs, or proteasome inhibitors has exhibited notable efficacy in inhibiting tumor growth. Recent studies have provided evidence that Bruton Tyrosine Kinase inhibitors (BTKI), either used independently or in conjunction with other drugs, have been shown to be effective and safe in the treatment of WM. The disease is considered to be non-curable, with a median life expectancy of 10 to 12 years.
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Affiliation(s)
- Michele Bibas
- Department of Clinical Research, Hematology. National Institute for Infectious Diseases "Lazzaro Spallanzani" IRCSS Rome Italy
| | - Shayna Sarosiek
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Jorge J Castillo
- Bing Center for Waldenström's Macroglobulinemia, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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11
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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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12
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Clerc OF, Datar Y, Cuddy SAM, Bianchi G, Taylor A, Benz DC, Robertson M, Kijewski MF, Jerosch-Herold M, Kwong RY, Ruberg FL, Liao R, Di Carli MF, Falk RH, Dorbala S. Prognostic Value of Left Ventricular 18F-Florbetapir Uptake in Systemic Light-Chain Amyloidosis. JACC Cardiovasc Imaging 2024:S1936-878X(24)00189-X. [PMID: 39001731 DOI: 10.1016/j.jcmg.2024.05.002] [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: 11/29/2023] [Revised: 04/22/2024] [Accepted: 05/02/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Positron emission tomography/computed tomography (PET/CT) with 18F-florbetapir, a novel amyloid-targeting radiotracer, can quantify left ventricular (LV) amyloid burden in systemic light-chain (AL) amyloidosis. However, its prognostic value is not known. OBJECTIVES The authors' aim was to evaluate the prognostic value of LV amyloid burden quantified by 18F-florbetapir PET/CT, and to identify mechanistic pathways mediating its association with outcomes. METHODS A total of 81 participants with newly diagnosed AL amyloidosis underwent 18F-florbetapir PET/CT imaging. Amyloid burden was quantified using 18F-florbetapir LV uptake as percent injected dose. The Mayo stage for AL amyloidosis was determined using troponin T, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and free light chain levels. Major adverse cardiac events (MACE) were defined as all-cause death, heart failure hospitalization, or cardiac transplantation within 12 months. RESULTS Among participants (median age, 61 years; 57% males), 36% experienced MACE, increasing from 7% to 63% across tertiles of LV amyloid burden (P < 0.001). LV amyloid burden was associated with MACE (HR: 1.46; 95% CI: 1.16-1.83; P = 0.001). However, this association became nonsignificant when adjusted for Mayo stage. In mediation analysis, the association between LV amyloid burden and MACE was mediated by NT-proBNP (P < 0.001), a marker of cardiomyocyte stretch and heart failure, and a component of Mayo stage. CONCLUSIONS In this first study to link cardiac 18F-florbetapir uptake to subsequent outcomes, LV amyloid burden estimated by percent injected dose predicted MACE in AL amyloidosis. This effect was not independent of Mayo stage and was mediated primarily through NT-proBNP. These findings provide novel insights into the mechanism linking myocardial amyloid deposits to MACE.
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Affiliation(s)
- Olivier F Clerc
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yesh Datar
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah A M Cuddy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Giada Bianchi
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexandra Taylor
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dominik C Benz
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Matthew Robertson
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marie Foley Kijewski
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Jerosch-Herold
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raymond Y Kwong
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA; Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Ronglih Liao
- Amyloidosis Program, Stanford University, Stanford, California, USA
| | - Marcelo F Di Carli
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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13
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Bellofiore C, Palladini G, Milani P. Options for Rescue Treatment of Patients with AL Amyloidosis Exposed to Upfront Daratumumab. Curr Oncol Rep 2024:10.1007/s11912-024-01561-2. [PMID: 38896184 DOI: 10.1007/s11912-024-01561-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE OF REVIEW This review aims to assess the therapeutic strategies available for relapsed/refractory patients with immunoglobulin light chain (AL) amyloidosis who received upfront daratumumab-based regimens. RECENT FINDINGS The treatment landscape of AL amyloidosis has changed radically thanks to the introduction in the upfront setting of daratumumab in combination with bortezomib, cyclophosphamide and dexamethasone (DaraCyBorD) which improved patients' outcomes increasing the rate of hematologic and organ responses. However, many patients eventually relapse or are refractory to daratumumab and the best salvage therapy is not well defined yet. In this contest, we reviewed the available therapeutic options after daratumumab failure, and we look towards the current advances in Bcl-2 inhibitors, novel immunotherapeutic agents as chimeric antigen receptor (CAR-T) therapy and bispecific antibodies (bsAbs). Relapsed/refractory AL amyloidosis represent an unmet clinical need and novel targeted drugs require urgent prospective assessment.
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Affiliation(s)
- Claudia Bellofiore
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy
| | - Giovanni Palladini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy
| | - Paolo Milani
- Department of Molecular Medicine, University of Pavia, Pavia, Italy.
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy.
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Basset M, Schönland SO, Obici L, Günther J, Riva E, Dittrich T, Milani P, Ferretti VV, Pasquinucci E, Foli A, Kimmich C, Nanci M, Bellofiore C, Benigna F, Beimler J, Benvenuti P, Fabris F, Mussinelli R, Nuvolone M, Klersy C, Albertini R, Merlini G, Hegenbart U, Palladini G, Blank N. Development and Validation of Staging Systems for AA Amyloidosis. J Am Soc Nephrol 2024; 35:782-794. [PMID: 38512269 PMCID: PMC11164117 DOI: 10.1681/asn.0000000000000339] [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: 03/28/2023] [Accepted: 03/13/2024] [Indexed: 03/22/2024] Open
Abstract
Key Points Patients with AA amyloidosis and age ≥65 years, eGFR <45 ml/min per 1.73 m2, and N -terminal type-B natriuretic peptide >1000 ng/L and/or type-B natriuretic peptide >130 ng/L at diagnosis have poorer survival. Proteinuria >3.0 g/24 hours and eGFR <35 ml/min per 1.73 m2 identify patients at high risk of progression to end-stage kidney failure. Prognostic stratification in AA amyloidosis can be easily made by staging systems, similarly to AL and transthyretin amyloidosis. Background The kidney is involved in almost 100% of cases of AA amyloidosis, a rare disease caused by persistent inflammation with long overall survival but frequent progression to kidney failure. Identification of patients with advanced disease at diagnosis is difficult, given the absence of validated staging systems. Methods Patients with newly diagnosed AA amyloidosis from the Pavia (n =233, testing cohort) and Heidelberg (n =243, validation cohort) centers were included in this study. Cutoffs of continuous variables were determined by receiver operating characteristic analysis predicting death or dialysis at 24 months. Prognostic factors included in staging systems were identified by multivariable models in the testing cohort. Results Age ≥65 years, eGFR <45 ml/min per 1.73 m2, and elevated natriuretic peptides (type-B natriuretic peptide >130 ng/L and/or N -terminal type-B natriuretic peptide >1000 ng/L) were associated with overall survival and included in the staging system (all with simplified coefficients 1). Mean 36-month overall survival was lower with higher staging system scores (score 0–1: 92%; score 2: 72%; score 3: 32%). These results were confirmed in the validation cohort. For kidney failure, variables selected to enter in the staging system model were proteinuria >3 g/24 hour and eGFR <35 ml/min per 1.73 m2 (both with simplified coefficients 1). The 36-month cumulative incidence of kidney failure was higher with higher staging system scores (score 0: 0%; score 1: 24%; score 2: 51%). Again, similar results were obtained in validation cohort. Conclusions We identified and validated biomarker-based staging systems for overall survival and kidney failure in AA amyloidosis.
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Affiliation(s)
- Marco Basset
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Stefan O. Schönland
- Division of Hematology, Oncology and Rheumatology, Amyloidosis Center, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Laura Obici
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Janine Günther
- Division of Hematology, Oncology and Rheumatology, Amyloidosis Center, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Eloisa Riva
- Hematology Department, Facultad de Medicina, Hospital de Clinicas, Montevideo, Uruguay
| | - Tobias Dittrich
- Division of Hematology, Oncology and Rheumatology, Amyloidosis Center, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Virginia Valeria Ferretti
- Biostatistics and Clinical Trial Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | | | - Andrea Foli
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Christoph Kimmich
- Department of Oncology and Hematology, Klinikum Oldenburg, University Medicine Oldenburg, Oldenburg, Germany
| | - Martina Nanci
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
| | - Claudia Bellofiore
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Hematology Unit, Ospedale Garibaldi, Catania, Italy
| | - Francesca Benigna
- Laboratory of Clinical Chemistry, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Jörg Beimler
- Division of Nephrology, Amyloidosis Center, Department of Internal Medicine I, Heidelberg University Hospital, Heidelberg, Germany
| | - Pietro Benvenuti
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Francesca Fabris
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Institute of Cardiology, Maggiore Hospital, Crema, Italy
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Mario Nuvolone
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Catherine Klersy
- Biostatistics and Clinical Trial Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Riccardo Albertini
- Laboratory of Clinical Chemistry, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Ute Hegenbart
- Division of Hematology, Oncology and Rheumatology, Amyloidosis Center, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo,” Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Norbert Blank
- Division of Hematology, Oncology and Rheumatology, Amyloidosis Center, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
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Delrue C, Dendooven A, Vandendriessche A, Speeckaert R, De Bruyne S, Speeckaert MM. Advancing Renal Amyloidosis Care: The Role of Modern Diagnostic Techniques with the Potential of Enhancing Patient Outcomes. Int J Mol Sci 2024; 25:5875. [PMID: 38892061 PMCID: PMC11172584 DOI: 10.3390/ijms25115875] [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: 04/30/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Renal amyloidosis is a set of complex disorders characterized by the deposition of amyloid proteins in the kidneys, which causes gradual organ damage and potential kidney failure. Recent developments in diagnostic methods, particularly mass spectrometry and proteome profiling, have greatly improved the accuracy of amyloid typing, which is critical for disease management. These technologies provide extensive insights into the specific proteins involved, allowing for more targeted treatment approaches and better patient results. Despite these advances, problems remain, owing to the heterogeneous composition of amyloid proteins and the varying efficacy of treatments based on amyloid type. Access to sophisticated diagnostics and therapy varies greatly, highlighting the global difference in renal amyloidosis management. Future research is needed to investigate next-generation sequencing and gene-editing technologies, like clustered regularly interspaced short palindromic repeats (CRISPR), which promise more profound insights into the genetic basis of amyloidosis.
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Affiliation(s)
- Charlotte Delrue
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Amélie Dendooven
- Department of Pathology, Ghent University Hospital, 9000 Ghent, Belgium; (A.D.); (A.V.)
- Faculty of Medicine, University of Antwerp, 2610 Wilrijk, Belgium
| | | | | | - Sander De Bruyne
- Department of Laboratory Medicine, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Marijn M. Speeckaert
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium;
- Research Foundation-Flanders (FWO), 1000 Brussels, Belgium
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16
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Maru K, Singh A, Jangir R, Jangir KK. Amyloid detection in neurodegenerative diseases using MOFs. J Mater Chem B 2024; 12:4553-4573. [PMID: 38646795 DOI: 10.1039/d4tb00373j] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Neurodegenerative diseases (amyloid diseases such as Alzheimer's and Parkinson's), stemming from protein misfolding and aggregation, encompass a spectrum of disorders with severe systemic implications. Timely detection is pivotal in managing these diseases owing to their significant impact on organ function and high mortality rates. The diverse array of amyloid disorders, spanning localized and systemic manifestations, underscores the complexity of these conditions and highlights the need for advanced detection methods. Traditional approaches have focused on identifying biomarkers using imaging techniques (PET and MRI) or invasive procedures. However, recent efforts have focused on the use of metal-organic frameworks (MOFs), a versatile class of materials known for their unique properties, in revolutionizing amyloid disease detection. The high porosity, customizable structures, and biocompatibility of MOFs enable their integration with biomolecules, laying the groundwork for highly sensitive and specific biosensors. These sensors have been employed using electrochemical and photophysical techniques that target amyloid species under neurodegenerative conditions. The adaptability of MOFs allows for the precise detection and quantification of amyloid proteins, offering potential advancements in early diagnosis and disease management. This review article delves into how MOFs contribute to detecting amyloid diseases by categorizing their uses based on different sensing methods, such as electrochemical (EC), electrochemiluminescence (ECL), fluorescence, Förster resonance energy transfer (FRET), up-conversion luminescence resonance energy transfer (ULRET), and photoelectrochemical (PEC) sensing. The drawbacks of MOF biosensors and the challenges encountered in the field are also briefly explored from our perspective.
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Affiliation(s)
- Ketan Maru
- Sardar Vallabhbhai National Institute of Technology, Ichchanath, Surat-395 007, Gujarat, India.
| | - Amarendra Singh
- Sardar Vallabhbhai National Institute of Technology, Ichchanath, Surat-395 007, Gujarat, India.
| | - Ritambhara Jangir
- Sardar Vallabhbhai National Institute of Technology, Ichchanath, Surat-395 007, Gujarat, India.
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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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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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19
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Lavatelli F, Natalello A, Marchese L, Ami D, Corazza A, Raimondi S, Mimmi MC, Malinverni S, Mangione PP, Palmer MT, Lampis A, Concardi M, Verona G, Canetti D, Arbustini E, Bellotti V, Giorgetti S. Truncation of the constant domain drives amyloid formation by immunoglobulin light chains. J Biol Chem 2024; 300:107174. [PMID: 38499153 PMCID: PMC11016911 DOI: 10.1016/j.jbc.2024.107174] [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: 12/08/2023] [Revised: 03/07/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
AL amyloidosis is a life-threatening disease caused by deposition of immunoglobulin light chains. While the mechanisms underlying light chains amyloidogenesis in vivo remain unclear, several studies have highlighted the role that tissue environment and structural amyloidogenicity of individual light chains have in the disease pathogenesis. AL natural deposits contain both full-length light chains and fragments encompassing the variable domain (VL) as well as different length segments of the constant region (CL), thus highlighting the relevance that proteolysis may have in the fibrillogenesis pathway. Here, we investigate the role of major truncated species of the disease-associated AL55 light chain that were previously identified in natural deposits. Specifically, we study structure, molecular dynamics, thermal stability, and capacity to form fibrils of a fragment containing both the VL and part of the CL (133-AL55), in comparison with the full-length protein and its variable domain alone, under shear stress and physiological conditions. Whereas the full-length light chain forms exclusively amorphous aggregates, both fragments generate fibrils, although, with different kinetics, aggregate structure, and interplay with the unfragmented protein. More specifically, the VL-CL 133-AL55 fragment entirely converts into amyloid fibrils microscopically and spectroscopically similar to their ex vivo counterpart and increases the amorphous aggregation of full-length AL55. Overall, our data support the idea that light chain structure and proteolysis are both relevant for amyloidogenesis in vivo and provide a novel biocompatible model of light chain fibrillogenesis suitable for future mechanistic studies.
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Affiliation(s)
- Francesca Lavatelli
- Department of Molecular Medicine, Institute of Biochemistry, University of Pavia, Pavia, Italy; Research Area, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Antonino Natalello
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, Milan, Italy.
| | - Loredana Marchese
- Pathology Unit, Fondazione IRCSS Policlinico San Matteo, Pavia, Italy
| | - Diletta Ami
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, Milan, Italy
| | - Alessandra Corazza
- Department of Medicine (DAME), University of Udine, Udine, Italy; Istituto Nazionale Biostrutture e Biosistemi, Roma, Italy
| | - Sara Raimondi
- Department of Molecular Medicine, Institute of Biochemistry, University of Pavia, Pavia, Italy
| | - Maria Chiara Mimmi
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Silvia Malinverni
- Department of Molecular Medicine, Institute of Biochemistry, University of Pavia, Pavia, Italy
| | - P Patrizia Mangione
- Department of Molecular Medicine, Institute of Biochemistry, University of Pavia, Pavia, Italy; Research Area, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Manel Terrones Palmer
- Department of Biotechnology and Biosciences, University of Milano-Bicocca, Milan, Italy
| | - Alessio Lampis
- Department of Molecular Medicine, Institute of Biochemistry, University of Pavia, Pavia, Italy
| | - Monica Concardi
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Guglielmo Verona
- Department of Molecular Medicine, Institute of Biochemistry, University of Pavia, Pavia, Italy; Centre for Amyloidosis, Division of Medicine, University College London, London, UK
| | - Diana Canetti
- Centre for Amyloidosis, Division of Medicine, University College London, London, UK
| | - Eloisa Arbustini
- Transplant Research Area and Centre for Inherited Cardiovascular Diseases, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Vittorio Bellotti
- Research Area, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sofia Giorgetti
- Department of Molecular Medicine, Institute of Biochemistry, University of Pavia, Pavia, Italy; Research Area, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
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20
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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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21
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Ruberg FL, Maurer MS. Cardiac Amyloidosis Due to Transthyretin Protein: A Review. JAMA 2024; 331:778-791. [PMID: 38441582 PMCID: PMC11167454 DOI: 10.1001/jama.2024.0442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2024]
Abstract
Importance Systemic amyloidosis from transthyretin (ATTR) protein is the most common type of amyloidosis that causes cardiomyopathy. Observations Transthyretin (TTR) protein transports thyroxine (thyroid hormone) and retinol (vitamin A) and is synthesized predominantly by the liver. When the TTR protein misfolds, it can form amyloid fibrils that deposit in the heart causing heart failure, heart conduction block, or arrhythmia such as atrial fibrillation. The biological processes by which amyloid fibrils form are incompletely understood but are associated with aging and, in some patients, affected by inherited variants in the TTR genetic sequence. ATTR amyloidosis results from misfolded TTR protein deposition. ATTR can occur in association with normal TTR genetic sequence (wild-type ATTR) or with abnormal TTR genetic sequence (variant ATTR). Wild-type ATTR primarily manifests as cardiomyopathy while ATTR due to a genetic variant manifests as cardiomyopathy and/or polyneuropathy. Approximately 50 000 to 150 000 people in the US have heart failure due to ATTR amyloidosis. Without treatment, heart failure due to ATTR amyloidosis is associated with a median survival of approximately 5 years. More than 130 different inherited genetic variants in TTR exist. The most common genetic variant is Val122Ile (pV142I), an allele with an origin in West African countries, that is present in 3.4% of African American individuals in the US or approximately 1.5 million persons. The diagnosis can be made using serum free light chain assay and immunofixation electrophoresis to exclude light chain amyloidosis combined with cardiac nuclear scintigraphy to detect radiotracer uptake in a pattern consistent with amyloidosis. Loop diuretics, such as furosemide, torsemide, and bumetanide, are the primary treatment for fluid overload and symptomatic relief of patients with ATTR heart failure. An ATTR-directed therapy that inhibited misfolding of the TTR protein (tafamidis, a protein stabilizer), compared with placebo, reduced mortality from 42.9% to 29.5%, reduced hospitalizations from 0.7/year to 0.48/year, and was most effective when administered early in disease course. Conclusions and Relevance ATTR amyloidosis causes cardiomyopathy in up to approximately 150 000 people in the US and tafamidis is the only currently approved therapy. Tafamidis slowed progression of ATTR amyloidosis and improved survival and prevented hospitalization, compared with placebo, in people with ATTR-associated cardiomyopathy.
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Affiliation(s)
- Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Boston University Chobanian & Avedisian School of Medicine, Boston Medical Center, Boston, Massachusetts
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | - Mathew S Maurer
- Cardiac Amyloidosis Program, Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, and NewYork-Presbyterian Hospital, New York
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22
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Beyoglu MA, Sahin MF, Turkkan S, Turhan N, Demirag F, Yekeler E. An Unusual Diagnosis in a Single-Lung Transplant Recipient: Secondary Amyloidosis. EXP CLIN TRANSPLANT 2024; 22:246-248. [PMID: 36259624 DOI: 10.6002/ect.2022.0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Silicosis, a progressive, fibrotic occupational lung disease with no known treatment, is an uncommon indication for lung transplant. There is a paucity of research on patients with silicosis who have received lung transplants. The long-term consequences of the native lung in patients with severe chronic silicosis who have had a single-lung transplant are also of interest. We present a case of amyloidosis in a patient who underwent a single-lung transplant for silicosis.
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Affiliation(s)
- Muhammet Ali Beyoglu
- From the Department of General Thoracic Surgery and Lung Transplantation Ankara City Hospital, Ankara, Turkey
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23
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Wong S, West ME, Morgan GJ. Kinetic evidence for multiple aggregation pathways in antibody light chain variable domains. Protein Sci 2024; 33:e4871. [PMID: 38100259 PMCID: PMC10868443 DOI: 10.1002/pro.4871] [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: 08/28/2023] [Revised: 12/01/2023] [Accepted: 12/11/2023] [Indexed: 12/17/2023]
Abstract
Aggregation of antibody light chain proteins is associated with the progressive disease light chain amyloidosis. Patient-derived amyloid fibrils are formed from light chain variable domain residues in non-native conformations, highlighting a requirement that light chains unfold from their native structures in order to aggregate. However, mechanistic studies of amyloid formation have primarily focused on the self-assembly of natively unstructured peptides, and the role of native state unfolding is less well understood. Using a well-studied light chain variable domain protein known as WIL, which readily aggregates in vitro under conditions where the native state predominates, we asked how the protein concentration and addition of pre-formed fibril "seeds" alter the kinetics of aggregation. Monitoring aggregation with thioflavin T fluorescence revealed a distinctly non-linear dependence on concentration, with a maximum aggregation rate observed at 8 μM protein. This behavior is consistent with formation of alternate aggregate structures in the early phases of amyloid formation. Addition of N- or C-terminal peptide tags, which did not greatly affect the folding or stability of the protein, altered the concentration dependence of aggregation. Aggregation rates increased in the presence of pre-formed seeds, but this effect did not eliminate the delay before aggregation and became saturated when the proportion of seeds added was greater than 1 in 1600. The complexity of aggregation observed in vitro highlights how multiple species may contribute to amyloid pathology in patients.
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Affiliation(s)
- Sherry Wong
- Boston University Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Madeline E West
- Boston University Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Gareth J Morgan
- Boston University Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
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24
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Brown CR, Bergin JD, Deal DN. Amyloidosis and Considerations for the Hand Surgeon. J Hand Surg Am 2024; 49:260-266. [PMID: 38043036 DOI: 10.1016/j.jhsa.2023.10.013] [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: 04/21/2023] [Revised: 09/27/2023] [Accepted: 10/02/2023] [Indexed: 12/04/2023]
Abstract
Amyloidosis can lead to cardiac, renal, and other multiorgan failure. New treatments have become available that can prolong survival but rely on early diagnosis. Manifestations of amyloidosis in hand surgery include carpal tunnel syndrome, trigger finger, peripheral neuropathy, and spontaneous distal biceps rupture. Often, these can predate systemic amyloidosis, offering hand surgeons an opportunity to diagnose patients with amyloidosis before systemic disease, refer them for treatment, and potentially alter disease course and prolong survival. In this review, we describe the pathophysiology and two most common subtypes of amyloidosis seen by hand surgeons. We provide guidance on biopsy practices and referral for patients with amyloidosis. Lastly, we provide a brief overview of the treatments for amyloidosis and their effect on disease course.
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Affiliation(s)
- Chelsea R Brown
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA.
| | - James D Bergin
- Department of Cardiology, University of Virginia, Charlottesville, VA
| | - D Nicole Deal
- Department of Orthopedic Surgery, University of Virginia, Charlottesville, VA
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25
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Bukhari S, Khan SZ, Ghoweba M, Khan B, Bashir Z. Arrhythmias and Device Therapies in Cardiac Amyloidosis. J Clin Med 2024; 13:1300. [PMID: 38592132 PMCID: PMC10932014 DOI: 10.3390/jcm13051300] [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: 01/13/2024] [Revised: 02/20/2024] [Accepted: 02/22/2024] [Indexed: 04/10/2024] Open
Abstract
Cardiac amyloidosis is caused by amyloid fibrils that deposit in the myocardial interstitium, causing restrictive cardiomyopathy and eventually death. The electromechanical, inflammatory, and autonomic changes due to amyloid deposition result in arrhythmias. Atrial fibrillation is by far the most common arrhythmia. The rate control strategy is generally poorly tolerated due to restrictive filling physiology and heart rate dependance, favoring adoption of the rhythm control strategy. Anticoagulation for stroke prophylaxis is warranted, irrespective of CHA2DS2-VASc score in patients with a favorable bleeding profile; data on left appendage closure devices are still insufficient. Ventricular arrhythmias are also not uncommon, and the role of implantable cardioverter-defibrillator in cardiac amyloidosis is controversial. There is no evidence of improvement in outcomes when used for primary prevention in these patients. Bradyarrhythmia is most commonly associated with sudden cardiac death in cardiac amyloidosis. Pacemaker implantation can help provide symptomatic relief but does not confer mortality benefit.
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Affiliation(s)
- Syed Bukhari
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Syed Zamrak Khan
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Mohamed Ghoweba
- Department of Cardiovascular Medicine, Section of Vascular Medicine, Cleveland Clinic Foundation, Cleveland, OH 44195, USA; (S.Z.K.); (M.G.)
| | - Bilal Khan
- Department of Hospital Medicine, Temple University-Jeanes Campus, Philadelphia, PA 19111, USA;
| | - Zubair Bashir
- Department of Hospital Medicine, Alpert Medical School of Brown University, Providence, RI 02903, USA;
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26
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Norisyam Y, Zairul Anuar KB, Ohn KM, Moharzudi M. Rare vertebral pathological fracture in primary amyloidosis. BMJ Case Rep 2024; 17:e258973. [PMID: 38388204 PMCID: PMC10884212 DOI: 10.1136/bcr-2023-258973] [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] [Indexed: 02/24/2024] Open
Abstract
Spinal involvement in primary amyloidosis is an exceedingly rare condition, presenting with typical pathological fracture symptoms that are often indistinguishable from other pathologies such as bone metastasis, metabolic disorders and infections. Histopathological studies for tissue diagnosis are the cornerstone of a definitive diagnosis, leading to successful treatment. Early diagnosis and intervention play a pivotal role in the care of patients with amyloidosis. Here, we present a unique case of a pathological fracture in the L4 vertebra following minor trauma. This fracture manifested with pain, instability and limitations in daily activities in a patient who had already been diagnosed with systemic amyloidosis and was undergoing chemotherapy. This case represents a distinct instance of vertebral involvement in amyloidosis and was managed with both chemotherapy and surgical intervention to address the spinal pathology, resulting in favourable outcomes.
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Affiliation(s)
- Yusoff Norisyam
- Department of Orthopaedic, Hospital Sultan Ismail, Johor Bharu, Johor Darul Ta'zim, Malaysia
| | | | - Khin Maung Ohn
- Orthopaedic Surgery, Universiti Malaysia Sabah, Kota Kinabalu, Sabah, Malaysia
| | - Mohamed Moharzudi
- Department of Pathology, Hospital Queen Elizabeth, Kota Kinabalu, Sabah, Malaysia
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27
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Rinauro DJ, Chiti F, Vendruscolo M, Limbocker R. Misfolded protein oligomers: mechanisms of formation, cytotoxic effects, and pharmacological approaches against protein misfolding diseases. Mol Neurodegener 2024; 19:20. [PMID: 38378578 PMCID: PMC10877934 DOI: 10.1186/s13024-023-00651-2] [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: 03/02/2023] [Accepted: 08/17/2023] [Indexed: 02/22/2024] Open
Abstract
The conversion of native peptides and proteins into amyloid aggregates is a hallmark of over 50 human disorders, including Alzheimer's and Parkinson's diseases. Increasing evidence implicates misfolded protein oligomers produced during the amyloid formation process as the primary cytotoxic agents in many of these devastating conditions. In this review, we analyze the processes by which oligomers are formed, their structures, physicochemical properties, population dynamics, and the mechanisms of their cytotoxicity. We then focus on drug discovery strategies that target the formation of oligomers and their ability to disrupt cell physiology and trigger degenerative processes.
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Affiliation(s)
- Dillon J Rinauro
- Centre for Misfolding Diseases, Yusuf Hamied Department of Chemistry, University of Cambridge, Cambridge, CB2 1EW, UK
| | - Fabrizio Chiti
- Section of Biochemistry, Department of Experimental and Clinical Biomedical Sciences, University of Florence, 50134, Florence, Italy
| | - Michele Vendruscolo
- Centre for Misfolding Diseases, Yusuf Hamied Department of Chemistry, University of Cambridge, Cambridge, CB2 1EW, UK.
| | - Ryan Limbocker
- Department of Chemistry and Life Science, United States Military Academy, West Point, NY, 10996, USA.
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28
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Zhang X, Tang F, Gao YY, Song DZ, Liang J. Hepatomegaly and jaundice as the presenting symptoms of systemic light-chain amyloidosis: A case report. World J Gastrointest Oncol 2024; 16:550-556. [PMID: 38425387 PMCID: PMC10900159 DOI: 10.4251/wjgo.v16.i2.550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/11/2023] [Accepted: 12/26/2023] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND Light chain (AL) amyloidosis is a plasma cell dyscrasia characterized by the pathologic production and extracellular tissue deposition of fibrillar proteins derived from immunoglobulin AL fragments secreted by a clone of plasma cells, which leads to progressive dysfunction of the affected organs. The two most commonly affected organs are the heart and kidneys, and liver is rarely the dominant affected organ with only 3.9% of cases, making them prone to misdiagnosis and missed diagnosis. CASE SUMMARY A 65-year-old woman was admitted with a 3-mo history of progressive jaundice and marked hepatomegaly. Initially, based on enhanced computed tomography scan and angiography, Budd-Chiari syndrome was considered and balloon dilatation of significant hepatic vein stenoses was performed. However, additional diagnostic procedures, including liver biopsy and bone marrow-examination, revealed immunoglobulin kapa AL amyloidosis with extensive liver involvement and hepatic vascular compression. The disease course was progressive and fatal, and the patient eventually died 5 mo after initial presentation of symptoms. CONCLUSION AL amyloidosis with isolated liver involvement is very rare, and can be easily misdiagnosed as a vascular disease.
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Affiliation(s)
- Xu Zhang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin 300170, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, China
| | - Fei Tang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin 300170, China
- Tianjin Key Laboratory of Extracorporeal Life Support for Critical Diseases, Artificial Cell Engineering Technology Research Center, Tianjin Institute of Hepatobiliary Disease, Tianjin 300170, China
| | - Yan-Ying Gao
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin 300170, China
| | - De-Zhao Song
- Department of Interventional Radiology, The Third Central Hospital of Tianjin, Tianjin 300170, China
| | - Jing Liang
- Department of Gastroenterology and Hepatology, The Third Central Hospital of Tianjin, Tianjin 300170, China
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29
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De Michieli L, Cipriani A, Iliceto S, Dispenzieri A, Jaffe AS. Cardiac Troponin in Patients With Light Chain and Transthyretin Cardiac Amyloidosis: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2024; 6:1-15. [PMID: 38510286 PMCID: PMC10950441 DOI: 10.1016/j.jaccao.2023.12.006] [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: 08/31/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 03/22/2024] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative disease caused by amyloid fibril deposition in the myocardium; the 2 forms that most frequently involve the heart are amyloid light chain (AL) and amyloid transthyretin (ATTR) amyloidosis. Cardiac troponin (cTn) is the biomarker of choice for the detection of myocardial injury and is frequently found to be elevated in patients with CA, particularly with high-sensitivity assays. Multiple mechanisms of myocardial injury in CA have been proposed, including cytotoxic effect of amyloid precursors, interstitial amyloid fibril infiltration, coronary microvascular dysfunction, amyloid- and non-amyloid-related coronary artery disease, diastolic dysfunction, and heart failure. Regardless of the mechanisms, cTn values have relevant prognostic (and potentially diagnostic) implications in both AL and ATTR amyloidosis. In this review, the authors discuss the significant aspects of cTn biology and measurement methods, potential mechanisms of myocardial injury in CA, and the clinical application of cTn in the management of both AL and ATTR amyloidosis.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | | | - Allan S. Jaffe
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota, USA
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30
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Bai J, Li X, Zhao J, Zong H, Yuan Y, Wang L, Zhang X, Ke Y, Han L, Xu J, Ma B, Zhang B, Zhu J. Re-Engineering Therapeutic Anti-Aβ Monoclonal Antibody to Target Amyloid Light Chain. Int J Mol Sci 2024; 25:1593. [PMID: 38338870 PMCID: PMC10855199 DOI: 10.3390/ijms25031593] [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: 12/15/2023] [Revised: 01/18/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Amyloidosis involves the deposition of misfolded proteins. Even though it is caused by different pathogenic mechanisms, in aggregate, it shares similar features. Here, we tested and confirmed a hypothesis that an amyloid antibody can be engineered by a few mutations to target a different species. Amyloid light chain (AL) and β-amyloid peptide (Aβ) are two therapeutic targets that are implicated in amyloid light chain amyloidosis and Alzheimer's disease, respectively. Though crenezumab, an anti-Aβ antibody, is currently unsuccessful, we chose it as a model to computationally design and prepare crenezumab variants, aiming to discover a novel antibody with high affinity to AL fibrils and to establish a technology platform for repurposing amyloid monoclonal antibodies. We successfully re-engineered crenezumab to bind both Aβ42 oligomers and AL fibrils with high binding affinities. It is capable of reversing Aβ42-oligomers-induced cytotoxicity, decreasing the formation of AL fibrils, and alleviating AL-fibrils-induced cytotoxicity in vitro. Our research demonstrated that an amyloid antibody could be engineered by a few mutations to bind new amyloid sequences, providing an efficient way to reposition a therapeutic antibody to target different amyloid diseases.
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Affiliation(s)
- Jingyi Bai
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
| | - Xi Li
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
| | - Jun Zhao
- Cancer and Inflammation Program, National Cancer Institute, Frederick, MD 21702, USA;
| | - Huifang Zong
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
- Jecho Biopharmaceutical Institute, Shanghai 200240, China;
| | - Yuan Yuan
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
| | - Lei Wang
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
| | - Xiaoshuai Zhang
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
| | - Yong Ke
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
| | - Lei Han
- Jecho Biopharmaceutical Institute, Shanghai 200240, China;
| | - Jianrong Xu
- School of Medicine, Shanghai Jiao Tong University, Shanghai 200025, China;
| | - Buyong Ma
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
| | - Baohong Zhang
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
| | - Jianwei Zhu
- Engineering Research Center of Cell & Therapeutic Antibody, Ministry of Education, School of Pharmacy, Shanghai Jiao Tong University, Shanghai 200240, China; (J.B.); (X.L.); (H.Z.); (Y.Y.); (L.W.); (X.Z.); (Y.K.); (J.Z.)
- Jecho Biopharmaceutical Institute, Shanghai 200240, China;
- Jecho Laboratories, Inc., Frederick, MD 21704, USA
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Anand SK, Sanchorawala V, Verma A. Systemic Amyloidosis and Kidney Transplantation: An Update. Semin Nephrol 2024; 44:151496. [PMID: 38490903 DOI: 10.1016/j.semnephrol.2024.151496] [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] [Indexed: 03/17/2024]
Abstract
Amyloidosis is a heterogeneous disorder characterized by abnormal protein aggregate deposition that often leads to kidney involvement and end-stage kidney disease. With advancements in diagnostic techniques and treatment options, the prevalence of patients with amyloidosis requiring chronic dialysis has increased. Kidney transplantation is a promising avenue for extending survival and enhancing quality of life in these patients. However, the complex and heterogeneous nature of amyloidosis presents challenges in determining optimal referral timing for transplantation and managing post-transplantation course. This review focuses on recent developments and outcomes of kidney transplantation for amyloidosis-related end-stage kidney disease. This review also aims to guide clinical decision-making and improve management of patients with amyloidosis-associated kidney disease, offering insights into optimizing patient selection and post-transplant care for favorable outcomes.
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Affiliation(s)
- Shankara K Anand
- Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA; Section of Hematology and Oncology, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Ashish Verma
- Renal Section, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA; Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA; Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA.
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32
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Aimo A, Camerini L, Fabiani I, Morfino P, Panichella G, Barison A, Pucci A, Castiglione V, Vergaro G, Sinagra G, Emdin M. Valvular heart disease in patients with cardiac amyloidosis. Heart Fail Rev 2024; 29:65-77. [PMID: 37735319 PMCID: PMC10904406 DOI: 10.1007/s10741-023-10350-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed condition caused by the deposition of misfolded proteins, namely immunoglobulin light chains and transthyretin, in the extracellular spaces of the heart. Any cardiovascular structure can be affected by amyloid infiltration, including the valves. Amyloid accumulation within the cardiac valves may lead to their structural and functional impairment, with a profound impact on patients' prognosis and quality of life. The most common forms of valvular disease in CA are aortic stenosis (AS), mitral regurgitation (MR), and tricuspid regurgitation (TR). CA and AS share similar risk factors, disease mechanisms, and remodeling patterns, which make their diagnosis particularly challenging. Patients with both CA and AS experience worse outcomes than CA or AS alone, and transcatheter aortic valve replacement may represent a useful therapeutic strategy in this population. Data on MR and TR are quite limited and mainly coming from case reports or small series. This review paper will summarize our current understanding on the epidemiology, disease mechanisms, echocardiographic features, clinical implications, and therapeutic options of AS, MR, and TR in patients with CA.
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Affiliation(s)
- Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy.
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | - Lara Camerini
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Paolo Morfino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
| | - Giorgia Panichella
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
| | - Andrea Barison
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Angela Pucci
- Histopathology Department, University Hospital of Pisa, Pisa, Italy
| | - Vincenzo Castiglione
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Wang J, Zhao Y, Liao P, Huang S, Huang Y, Chen S, Li Y, Zhong L. Immune checkpoint expression patterns on T cell subsets in light-chain amyloidosis: VISTA, PD-1, and TIGIT as potential therapeutic targets. BLOOD SCIENCE 2024; 6:e00181. [PMID: 38226018 PMCID: PMC10789457 DOI: 10.1097/bs9.0000000000000181] [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: 08/21/2023] [Accepted: 12/21/2023] [Indexed: 01/17/2024] Open
Abstract
Amyloid light chain (AL) amyloidosis is a rare plasma cell dyscrasia with dismal prognosis. This study aims to investigate the T-cell immune checkpoint expression patterns in systemic AL amyloidosis and its relationship with clinicobiological traits. We examined the frequencies of V-domain immunoglobulin suppressor of T cell activation+ (VISTA+), programmed cell death 1+ (PD-1+), T cell immunoglobulin and mucin-domain-containing-3+ (Tim-3+), T cell immunoreceptor with Ig and ITIM domains+ (TIGIT+) T cells in peripheral blood (PB) and bone marrow (BM) from 19 patients with newly diagnosed AL amyloidosis. Patients with AL amyloidosis had significantly higher percentages of VISTA+ and PD-1+ T cells in PB than healthy individuals (HIs), with no statistical differences in BM. The percentages of some double-positive T cells in PB were also considerably higher in AL amyloidosis than those in HIs. Additionally, the patients with renal involvement had more PD-1+ and TIGIT+ T cells than the patients without, and PD-1+CD3+%, PD-1+CD4+%, PD-1+Treg% were positively correlated with 24-hour proteinuria levels. Furthermore, the AL amyloidosis patients had higher counts of PD-1+ Treg in PB than multiple myeloma (MM) patients, while the MM patients had higher counts of TIGIT+ T cells than AL amyloidosis patients. Collectively, this is the first report of elevated proportions of VISTA+ and PD-1+ T cells in PB of AL amyloidosis patients, indicating an immunosuppressive milieu, and the increased PD-1+ and TIGIT+ T cells were associated with renal damage. VISTA, PD-1, and TIGIT may be potential targets for reversing T-cell exhaustion in 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
| | - Yujie Zhao
- Key Laboratory for Regenerative Medicine of Ministry of Education, Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
| | - Pengjun Liao
- Department of Hematology, Guangdong Provincial People’s Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Shuxin Huang
- Key Laboratory for Regenerative Medicine of Ministry of Education, Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
| | - Youxue Huang
- Key Laboratory for Regenerative Medicine of Ministry of Education, Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
| | - Shaohua Chen
- Key Laboratory for Regenerative Medicine of Ministry of Education, Institute of Hematology, School of Medicine, Jinan University, Guangzhou, China
| | - Yangqiu Li
- Key Laboratory for Regenerative Medicine of Ministry of Education, Institute of Hematology, School of Medicine, Jinan University, Guangzhou, 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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Deng Z, Wang Y, Qin C, Sheng Z, Xu T, Qiu X. Expression and Clinical Significance of Non B Cell-Derived Immunoglobulins in the Urinary System and Male Reproductive System. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2024; 1445:101-117. [PMID: 38967753 DOI: 10.1007/978-981-97-0511-5_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
The urinary system comprises kidneys, ureters, bladder, and urethra with its primary function being excretion, referring to the physiological process of transporting substances that are harmful or surplus out of the body. The male reproductive system consists of gonads (testis), vas deferens, and accessory glands such as the prostate. According to classical immunology theory, the tissues and organs mentioned above are not thought to produce immunoglobulins (Igs), and any Ig present in the relevant tissues under physiological and pathological conditions is believed to be derived from B cells. For instance, most renal diseases are associated with uncontrolled inflammation caused by pathogenic Ig deposited in the kidney. Generally, these pathological Igs are presumed to be produced by B cells. Recent studies have demonstrated that renal parenchymal cells can produce and secrete Igs, including IgA and IgG. Glomerular mesangial cells can express and secrete IgA, which is associated with cell survival and adhesion. Likewise, human podocytes demonstrate the ability to produce and secrete IgG, which is related to cell survival and adhesion. Furthermore, renal tubular epithelial cells also express IgG, potentially involved in the epithelial-mesenchymal transition (EMT). More significantly, renal cell carcinoma, bladder cancer, and prostate cancer have been revealed to express high levels of IgG, which promotes tumour progression. Given the widespread Ig expression in the urinary and male reproductive systems, continued efforts to elucidate the roles of Igs in renal physiological and pathological processes are necessary.
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Affiliation(s)
- Zhenling Deng
- Department of Nephrology, Peking University Third Hospital, Beijing, China
| | - Yue Wang
- Peking University Third Hospital, Beijing, China
| | - Caipeng Qin
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Zhengzuo Sheng
- Department of Thoracic Surgery, Fu Xing Hospital, Capital Medical University, Beijing, China
| | - Tao Xu
- Department of Urology, Peking University People's Hospital, Beijing, China
| | - Xiaoyan Qiu
- Department of Immunology, School of Basic Medical Sciences, Peking University, Beijing, China
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35
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Alnasser SM, Alharbi KS, Almutairy AF, Almutairi SM, Alolayan AM. Autologous Stem Cell Transplant in Hodgkin's and Non-Hodgkin's Lymphoma, Multiple Myeloma, and AL Amyloidosis. Cells 2023; 12:2855. [PMID: 38132175 PMCID: PMC10741865 DOI: 10.3390/cells12242855] [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: 11/12/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 12/23/2023] Open
Abstract
Human body cells are stem cell (SC) derivatives originating from bone marrow. Their special characteristics include their capacity to support the formation and self-repair of the cells. Cancer cells multiply uncontrollably and invade healthy tissues, making stem cell transplants a viable option for cancer patients undergoing high-dose chemotherapy (HDC). When chemotherapy is used at very high doses to eradicate all cancer cells from aggressive tumors, blood-forming cells and leukocytes are either completely or partially destroyed. Autologous stem cell transplantation (ASCT) is necessary for patients in those circumstances. The patients who undergo autologous transplants receive their own stem cells (SCs). The transplanted stem cells first come into contact with the bone marrow and then undergo engraftment, before differentiating into blood cells. ASCT is one of the most significant and innovative strategies for treating diseases. Here we focus on the treatment of Hodgkin's lymphoma, non-Hodgkin's lymphoma, multiple myeloma, and AL amyloidosis, using ASCT. This review provides a comprehensive picture of the effectiveness and the safety of ASCT as a therapeutic approach for these diseases, based on the currently available evidence.
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Affiliation(s)
- Sulaiman Mohammed Alnasser
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Khalid Saad Alharbi
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
| | - Ali F. Almutairy
- Department of Pharmacology and Toxicology, Unaizah College of Pharmacy, Qassim University, Buraydah 51452, Saudi Arabia; (K.S.A.); (A.F.A.)
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36
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Broggini L, Barzago MM, Speranzini V, Schulte T, Sonzini F, Giono M, Romeo M, Milani P, Caminito S, Mazzini G, Rognoni P, Merlini G, Pappone C, Anastasia L, Nuvolone M, Palladini G, Diomede L, Ricagno S. Nanobodies counteract the toxicity of an amyloidogenic light chain by stabilizing a partially open dimeric conformation. J Mol Biol 2023; 435:168320. [PMID: 37865287 DOI: 10.1016/j.jmb.2023.168320] [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: 06/22/2023] [Revised: 09/18/2023] [Accepted: 10/16/2023] [Indexed: 10/23/2023]
Abstract
Light chain amyloidosis (AL) is a systemic disease where fibrillar deposition of misfolded immunoglobulin light chains (LCs) severely affects organ function and results in poor prognosis for patients, especially when heart involvement is severe. Particularly relevant in this context is the cardiotoxicity exerted by still uncharacterized soluble LC species. Here, with the final goal of identifying alternative therapeutic strategies to tackle AL amyloidosis, we produced five llama-derived nanobodies (Nbs) specific against H3, a well-characterized amyloidogenic and cardiotoxic LC from an AL patient with severe cardiac involvement. We found that Nbs are specific and potent agents capable of abolishing H3 soluble toxicity in C. elegans in vivo model. Structural characterization of H3-Nb complexes revealed that the protective effect of Nbs is related to their ability to bind to the H3 VL domain and stabilise an unexpected partially open LC dimer in which the two VL domains no longer interact with each other. Thus, while identifying potent inhibitors of LC soluble toxicity, we also describe the first non-native structure of an amyloidogenic LC that may represent a crucial step in toxicity and aggregation mechanisms.
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Affiliation(s)
- Luca Broggini
- Institute of Molecular and Translational Cardiology, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Italy
| | - Maria Monica Barzago
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via M. Negri 2, Milano 20156, Italy
| | | | - Tim Schulte
- Institute of Molecular and Translational Cardiology, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Italy
| | - Federica Sonzini
- Institute of Molecular and Translational Cardiology, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Italy; Department of Biosciences, Università degli Studi di Milano, Milan 20133, Italy
| | - Matteo Giono
- Department of Biosciences, Università degli Studi di Milano, Milan 20133, Italy
| | - Margherita Romeo
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via M. Negri 2, Milano 20156, Italy
| | - Paolo Milani
- Amyloidosis Treatment and Research Center, Fondazione IRCCS Policlinico San Matteo, Università Degli Studi di Pavia, Pavia 27100, Italy
| | - Serena Caminito
- Amyloidosis Treatment and Research Center, Fondazione IRCCS Policlinico San Matteo, Università Degli Studi di Pavia, Pavia 27100, Italy
| | - Giulia Mazzini
- Amyloidosis Treatment and Research Center, Fondazione IRCCS Policlinico San Matteo, Università Degli Studi di Pavia, Pavia 27100, Italy
| | - Paola Rognoni
- Amyloidosis Treatment and Research Center, Fondazione IRCCS Policlinico San Matteo, Università Degli Studi di Pavia, Pavia 27100, Italy
| | - Giampaolo Merlini
- Amyloidosis Treatment and Research Center, Fondazione IRCCS Policlinico San Matteo, Università Degli Studi di Pavia, Pavia 27100, Italy
| | - Carlo Pappone
- Institute of Molecular and Translational Cardiology, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Italy; Arrhythmia and Electrophysiology Department, IRCCS Policlinico San Donato, San Donato, Milan 20097, Italy; Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Luigi Anastasia
- Institute of Molecular and Translational Cardiology, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Italy; Faculty of Medicine and Surgery, Vita-Salute San Raffaele University, Milan 20132, Italy
| | - Mario Nuvolone
- Amyloidosis Treatment and Research Center, Fondazione IRCCS Policlinico San Matteo, Università Degli Studi di Pavia, Pavia 27100, Italy
| | - Giovanni Palladini
- Amyloidosis Treatment and Research Center, Fondazione IRCCS Policlinico San Matteo, Università Degli Studi di Pavia, Pavia 27100, Italy
| | - Luisa Diomede
- Department of Molecular Biochemistry and Pharmacology, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Via M. Negri 2, Milano 20156, Italy
| | - Stefano Ricagno
- Institute of Molecular and Translational Cardiology, IRCCS Policlinico San Donato, Piazza Malan 2, 20097 San Donato Milanese, Italy; Department of Biosciences, Università degli Studi di Milano, Milan 20133, Italy.
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Tentolouris A, Ntanasis-Stathopoulos I, Gavriatopoulou M, Andreadou I, Terpos E. Monoclonal Gammopathy of Undetermined Cardiovascular Significance; Current Evidence and Novel Insights. J Cardiovasc Dev Dis 2023; 10:484. [PMID: 38132652 PMCID: PMC10743961 DOI: 10.3390/jcdd10120484] [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: 10/14/2023] [Revised: 11/28/2023] [Accepted: 12/02/2023] [Indexed: 12/23/2023] Open
Abstract
Monoclonal gammopathy of undetermined significance (MGUS) is a premalignant condition characterized by the presence of low levels of a monoclonal protein in the serum and a low percentage of clonal plasma cells in the bone marrow. MGUS may progress to multiple myeloma or other plasma cell disorders at a rate of 1% annually. However, MGUS may also have adverse effects on the cardiovascular system independent of its malignant potential. Emerging data have shown that MGUS is associated with cardiovascular disease. The mechanisms underlying this association are not fully understood but may involve genetic abnormalities, vascular calcification, cryoglobulinemia, cold agglutinin disease, autoantibodies and the direct or indirect effects of the monoclonal protein on the vascular endothelium. Herein, we review current evidence in this field and we suggest that patients with MGUS may benefit from regular cardiovascular risk assessment to prevent severe cardiovascular complications, in parallel with close hematological follow-up to monitor potential disease progression.
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Affiliation(s)
- Anastasios Tentolouris
- First Department of Propaedeutic Internal Medicine and Diabetes Center, School of Medicine, National and Kapodistrian University of Athens, Laiko General Hospital, 11527 Athens, Greece;
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 11528 Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 11528 Athens, Greece
| | - Ioanna Andreadou
- Laboratory of Pharmacology, Faculty of Pharmacy, National and Kapodistrian University of Athens, 15771 Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, School of Medicine, National and Kapodistrian University of Athens, Alexandra General Hospital, 11528 Athens, Greece
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Klimtchuk ES, Peterle D, Bullitt EA, Connors LH, Engen JR, Gursky O. Role of complementarity-determining regions 1 and 3 in pathologic amyloid formation by human immunoglobulin κ1 light chains. Amyloid 2023; 30:364-378. [PMID: 37216473 PMCID: PMC10663386 DOI: 10.1080/13506129.2023.2212397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/24/2023] [Accepted: 05/04/2023] [Indexed: 05/24/2023]
Abstract
BACKGROUND Immunoglobulin light chain (LC) amyloidosis is a life-threatening disease complicated by vast numbers of patient-specific mutations. We explored 14 patient-derived and engineered proteins related to κ1-family germline genes IGKVLD-33*01 and IGKVLD-39*01. METHODS Hydrogen-deuterium exchange mass spectrometry analysis of conformational dynamics in recombinant LCs and their fragments was integrated with studies of thermal stability, proteolytic susceptibility, amyloid formation and amyloidogenic sequence propensity. The results were mapped on the structures of native and fibrillary proteins. RESULTS Proteins from two κ1 subfamilies showed unexpected differences. Compared to their germline counterparts, amyloid LC related to IGKVLD-33*01 was less stable and formed amyloid faster, whereas amyloid LC related to IGKVLD-39*01 had similar stability and formed amyloid slower, suggesting different major factors influencing amyloidogenesis. In 33*01-related amyloid LC, these factors involved destabilization of the native structure and probable stabilization of amyloid. The atypical behavior of 39*01-related amyloid LC stemmed from increased dynamics/exposure of amyloidogenic segments in βC'V and βEV that could initiate aggregation and decreased dynamics/exposure near the Cys23-Cys88 disulfide. CONCLUSIONS The results suggest distinct amyloidogenic pathways for closely related LCs and point to the complementarity-defining regions CDR1 and CDR3, linked via the conserved internal disulfide, as key factors in amyloid formation.
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Affiliation(s)
- Elena S. Klimtchuk
- Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston MA 02118, United States
| | - Daniele Peterle
- Department of Chemistry and Chemical Biology, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, United States
| | - Esther A. Bullitt
- Department of Physiology & Biophysics, Boston University Chobanian and Avedisian School of Medicine, W302, 700 Albany Street, Boston, MA, 02118, United States
| | - Lawreen H. Connors
- Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston MA 02118, United States
| | - John R. Engen
- Department of Chemistry and Chemical Biology, Northeastern University, 360 Huntington Avenue, Boston, MA, 02115, United States
| | - Olga Gursky
- Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston MA 02118, United States
- Department of Physiology & Biophysics, Boston University Chobanian and Avedisian School of Medicine, W302, 700 Albany Street, Boston, MA, 02118, United States
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Lyng CS, Gude E, Hodt A, Knudsen EC. First Norwegian case of hereditary ATTR amyloidosis with a novel transthyretin variant. SCAND CARDIOVASC J 2023; 57:2174269. [PMID: 36734834 DOI: 10.1080/14017431.2023.2174269] [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] [Indexed: 02/04/2023]
Abstract
An earlier healthy 64-year-old man with previous surgery for bilateral carpal tunnel syndrome (CTS) in his 50s, presented with dyspnoea on exertion. Cardiac amyloidosis was suspected due to "red flag" signs and symptoms. Further investigations with scintigraphy and genetic testing confirmed the diagnosis of hereditary ATTR variant (ATTRv) amyloidosis. This is the first case report of ATTRv amyloidosis in a patient of Norwegian origin and is caused by the mutation E54A (p.E74A) in the transthyretin (TTR) gene. This mutation is previously not reported in international databases. Transthyretin amyloid cardiomyopathy (ATTR-CM) is an underdiagnosed disease with a poor prognosis. Early recognition remains essential to afford the best treatment efficacy.
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Affiliation(s)
| | - Einar Gude
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Anders Hodt
- Department of Nuclear Medicine, Oslo University Hospital, Ullevål, Oslo, Norway
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Kastritis E, Misra A, Gurskyte L, Kroi F, Verhoek A, Vermeulen J, Ammann E, Lam A, Cote S, Wechalekar AD. Assessing the prognostic utility of hematologic response for overall survival in patients with newly diagnosed AL amyloidosis: results of a meta-analysis. HEMATOLOGY (AMSTERDAM, NETHERLANDS) 2023; 28:2157581. [PMID: 36607151 DOI: 10.1080/16078454.2022.2157581] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Amyloid light-chain (AL) amyloidosis is a rare disease characterized by amyloid fibril deposits made up of toxic light chains causing progressive organ dysfunction and death. Recent studies suggest that hematologic response may be an important prognostic indicator of overall survival (OS) in AL amyloidosis. The aim of this study was to evaluate the trial-level association between hematologic complete response (CR) or very good partial response or better (≥ VGPR) and OS in newly diagnosed patients. METHODS Studies were identified via systematic literature review. Pooled effect estimates were generated by a random-effects model. RESULTS Nine observational studies reporting hematologic CR or ≥VGPR and OS hazard ratios (HRs) were included in the meta-analysis. Achieving hematologic CR was associated with improved OS (HR, 0.21; 95% confidence interval [CI] 0.13-0.34). Achieving ≥ VGPR was also associated with improved OS (HR 0.21; 95% CI 0.17-0.26). Results of a sensitivity analysis excluding one outlier study revealed no heterogeneity and a better overall HR estimate. Potential limitations of this meta-analysis include the small number of eligible studies (consistent with the rarity of the disease) and inconsistencies in reporting of results. CONCLUSIONS Overall, our findings support the use of deep hematologic response (CR or ≥VGPR) as a clinical trial endpoint in newly diagnosed AL amyloidosis. This study provides evidence that early hematologic response is a strong patient-level surrogate for long-term OS in patients with AL amyloidosis receiving frontline therapy. Structured data collection of depth of response in future trials will further strengthen these observations.
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Affiliation(s)
- Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | | | | | - Eric Ammann
- Janssen Global Services, LLC, Raritan, NJ, USA
| | - Annette Lam
- Janssen Global Services, LLC, Raritan, NJ, USA
| | - Sarah Cote
- Janssen Global Services, LLC, Raritan, NJ, USA
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Gholami A. Alzheimer's disease: The role of proteins in formation, mechanisms, and new therapeutic approaches. Neurosci Lett 2023; 817:137532. [PMID: 37866702 DOI: 10.1016/j.neulet.2023.137532] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 10/03/2023] [Accepted: 10/18/2023] [Indexed: 10/24/2023]
Abstract
Alzheimer's disease (AD) is a progressive neurological disorder that affects the central nervous system (CNS), leading to memory and cognitive decline. In AD, the brain experiences three main structural changes: a significant decrease in the quantity of neurons, the development of neurofibrillary tangles (NFT) composed of hyperphosphorylated tau protein, and the formation of amyloid beta (Aβ) or senile plaques, which are protein deposits found outside cells and surrounded by dystrophic neurites. Genetic studies have identified four genes associated with autosomal dominant or familial early-onset AD (FAD): amyloid precursor protein (APP), presenilin 1 (PS1), presenilin 2 (PS2), and apolipoprotein E (ApoE). The formation of plaques primarily involves the accumulation of Aβ, which can be influenced by mutations in APP, PS1, PS2, or ApoE genes. Mutations in the APP and presenilin (PS) proteins can cause an increased amyloid β peptides production, especially the further form of amyloidogenic known as Aβ42. Apart from genetic factors, environmental factors such as cytokines and neurotoxins may also have a significant impact on the development and progression of AD by influencing the formation of amyloid plaques and intracellular tangles. Exploring the causes and implications of protein aggregation in the brain could lead to innovative therapeutic approaches. Some promising therapy strategies that have reached the clinical stage include using acetylcholinesterase inhibitors, estrogen, nonsteroidal anti-inflammatory drugs (NSAIDs), antioxidants, and antiapoptotic agents. The most hopeful therapeutic strategies involve inhibiting activity of secretase and preventing the β-amyloid oligomers and fibrils formation, which are associated with the β-amyloid fibrils accumulation in AD. Additionally, immunotherapy development holds promise as a progressive therapeutic approach for treatment of AD. Recently, the two primary categories of brain stimulation techniques that have been studied for the treatment of AD are invasive brain stimulation (IBS) and non-invasive brain stimulation (NIBS). In this article, the amyloid proteins that play a significant role in the AD formation, the mechanism of disease formation as well as new drugs utilized to treat of AD will be reviewed.
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Affiliation(s)
- Amirreza Gholami
- Department of Biology, Faculty of Natural Sciences, University of Tabriz, Tabriz, Iran.
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Dou X, Liu Y, Liao A, Zhong Y, Fu R, Liu L, Cui C, Wang X, Lu J. Patient Journey Toward a Diagnosis of Light Chain Amyloidosis in a National Sample: Cross-Sectional Web-Based Study. JMIR Form Res 2023; 7:e44420. [PMID: 37917132 PMCID: PMC10654903 DOI: 10.2196/44420] [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] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 11/03/2023] Open
Abstract
BACKGROUND Systemic light chain (AL) amyloidosis is a rare and multisystem disease associated with increased morbidity and a poor prognosis. Delayed diagnoses are common due to the heterogeneity of the symptoms. However, real-world insights from Chinese patients with AL amyloidosis have not been investigated. OBJECTIVE This study aimed to describe the journey to an AL amyloidosis diagnosis and to build an in-depth understanding of the diagnostic process from the perspective of both clinicians and patients to obtain a correct and timely diagnosis. METHODS Publicly available disease-related content from social media platforms between January 2008 and April 2021 was searched. After performing data collection steps with a machine model, a series of disease-related posts were extracted. Natural language processing was used to identify the relevance of variables, followed by further manual evaluation and analysis. RESULTS A total of 2204 valid posts related to AL amyloidosis were included in this study, of which 1968 were posted on haodf.com. Of these posts, 1284 were posted by men (median age 57, IQR 46-67 years); 1459 posts mentioned renal-related symptoms, followed by heart (n=833), liver (n=491), and stomach (n=368) symptoms. Furthermore, 1502 posts mentioned symptoms related to 2 or more organs. Symptoms for AL amyloidosis most frequently mentioned by suspected patients were nonspecific weakness (n=252), edema (n=196), hypertrophy (n=168), and swelling (n=140). Multiple physician visits were common, and nephrologists (n=265) and hematologists (n=214) were the most frequently visited specialists by suspected patients for initial consultation. Additionally, interhospital referrals were also commonly seen, centralizing in tertiary hospitals. CONCLUSIONS Chinese patients with AL amyloidosis experienced referrals during their journey toward accurate diagnosis. Increasing awareness of the disease and early referral to a specialized center with expertise may reduce delayed diagnosis and improve patient management.
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Affiliation(s)
- Xuelin Dou
- Hematology Department, Peking University People's Hospital, Beijing, China
| | - Yang Liu
- Hematology Department, Peking University People's Hospital, Beijing, China
| | - Aijun Liao
- Hematology Department, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yuping Zhong
- Hematology Department, Qingdao Municipal Hospital, Qingdao University, Qingdao, China
| | - Rong Fu
- Hematology Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Lihong Liu
- Hematology Department, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Canchan Cui
- Medical Affairs, Xi'an Janssen Pharmaceutical Ltd, Beijing, China
| | - Xiaohong Wang
- Medical Affairs, Xi'an Janssen Pharmaceutical Ltd, Shanghai, China
| | - Jin Lu
- Hematology Department, Peking University People's Hospital, Beijing, China
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Sarosiek S, Lee MH, Doros G, Edwards CV, Quillen K, Brauneis D, Shelton AC, Sanchorawala V, Sloan JM. Safety and Efficacy of Propylene Glycol-Free Melphalan in Patients with AL Amyloidosis Undergoing Autologous Stem Cell Transplantation: Results of a Phase II Study. Transplant Cell Ther 2023; 29:695.e1-695.e7. [PMID: 37607644 DOI: 10.1016/j.jtct.2023.08.018] [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: 06/08/2023] [Accepted: 08/15/2023] [Indexed: 08/24/2023]
Abstract
Patients with systemic light chain (AL) amyloidosis undergoing treatment with high-dose melphalan and autologous stem cell transplantation (HDM/SCT) may develop renal and cardiac toxicities potentially exacerbated by the co-solvent propylene glycol in conventional melphalan formulations. We investigated the safety and efficacy of propylene glycol-free melphalan (PGF-Mel) during HDM/SCT in patients with AL amyloidosis (ClinicalTrials.gov identifier NCT02994784). The primary objective of this phase II, open-label study was evaluation for renal dysfunction, new cardiac arrhythmias, and postural hypotension related to autonomic dysfunction. Secondary objectives included time to neutrophil and platelet engraftment, treatment-related mortality (TRM), overall hematologic response, organ response, and number of peritransplantation hospitalizations. Twenty-eight patients with AL amyloidosis enrolled, of whom 27 underwent HDM/SCT. PGF-Mel at 140 to 200 mg/m2 was administered i.v. in 2 equally divided doses. Patients were monitored for up to 30 days after the last administration of PGF-Mel to assess for treatment-related toxicity. Patients were followed for 12 months from the time of treatment with HDM/SCT for evaluation of hematologic and organ responses. Kaplan-Meier analysis was used to estimate progression-free survival. Two patients (7%) developed renal dysfunction, 5 (19%) experienced new cardiac arrhythmias, and 3 (11%) developed orthostatic hypotension. All patients achieved neutrophil and platelet engraftment, at a median of 10 days and 17 days post-HDM/SCT, respectively. TRM on day +100 was 0%. Peritransplantation hospitalization was required for 23 patients (85%). The most common nonhematologic adverse events were diarrhea (93%), fatigue (82%), and nausea (74%). At 6 months post-HDM/SCT, hematologic complete response or very good partial response occurred in 66% of the patients. At 12 months post-HDM/SCT, renal response occurred in 12 of 23 (52%) patients with renal involvement, and cardiac response occurred in 3 of 11 (27%) patients with evaluable cardiac involvement. Our data indicate that PGF-Mel is safe and efficacious as a high-dose conditioning regimen for autologous SCT in patients with AL amyloidosis.
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Affiliation(s)
- Shayna Sarosiek
- Bing Center for Waldenström Macroglobulinemia, Dana-Farber Cancer Institute, Boston, Massachusetts
| | - Michelle H Lee
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Gheorghe Doros
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts; Department of Biostatistics, Boston University School of Public Health, Boston, Massachusetts
| | - Camille Vanessa Edwards
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts; Stem Cell Transplant Program of Section of Hematology and Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts; Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Karen Quillen
- Department of Hematology and Oncology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Dina Brauneis
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Anthony C Shelton
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Vaishali Sanchorawala
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts; Stem Cell Transplant Program of Section of Hematology and Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts; Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - John Mark Sloan
- Section of Hematology and Medical Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts; Stem Cell Transplant Program of Section of Hematology and Oncology, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts; Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts.
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Mauermann ML, Clarke JO, Litchy WJ, Obici L, Lousada I, Gertz MA. Peripheral Nervous, Hepatic, and Gastrointestinal Endpoints for AL Amyloidosis Clinical Trials: Report from the Amyloidosis Forum Multi-organ System Working Group. Adv Ther 2023; 40:4695-4710. [PMID: 37658177 PMCID: PMC10567953 DOI: 10.1007/s12325-023-02637-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/03/2023] [Indexed: 09/03/2023]
Abstract
Systemic immunoglobulin light chain (AL) amyloidosis is a heterogeneous rare disease driven by a destructive monoclonal gammopathy and typified by misfolded immunoglobulin light and/or heavy chains which aggregate and deposit in organs as insoluble amyloid fibrils. Disease heterogeneity is driven by the degree of multi-systemic involvement; cardiac, renal, neurological, and gastrointestinal (GI) systems are affected to varying degrees in different patients. While prognosis is primarily driven by hematologic response to treatment and outcomes associated with cardiac events and overall survival, the involvement of the peripheral nervous, hepatic, and GI systems can also have a significant impact on patients. The Amyloidosis Forum ( https://amyloidosisforum.org ) is a public-private partnership between the nonprofit Amyloidosis Research Consortium ( www.arci.org ) and the US Food and Drug Administration (FDA) Center for Drug Evaluation and Research formed to advance drug development for the treatment of systemic amyloid disorders. A series of virtual workshops focused on the development of novel, patient-relevant endpoint components and analytical strategies for clinical trials in AL amyloidosis. This review summarizes the proceedings and recommendations of the Multi-Systemic Working Group which identified, reviewed, and prioritized endpoints relevant to the impacts of AL amyloidosis on the peripheral nervous, hepatic, and GI systems. The Working Group comprised amyloidosis experts, patient representatives, statisticians, and representatives from the FDA, Medicines and Healthcare products Regulatory Agency (MHRA), and pharmaceutical companies. Prioritized neuropathy/autonomic endpoints included a modified form of the Neuropathy Impairment Score (NIS + 7) and the Composite Autonomic Symptom Score (COMPASS-31), respectively. Alkaline phosphatase was identified as the most relevant indicator of liver involvement and disease progression. Following extensive review of potential GI endpoints, the Working Group identified multiple exploratory endpoints. These recommended components will be further explored through evaluation of clinical trial datasets and possible integration into composite endpoint analysis.
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Affiliation(s)
| | | | | | - Laura Obici
- University of Pavia, IRCCS University Hospital Policlinico San Matteo, Pavia, Italy
| | - Isabelle Lousada
- Amyloidosis Research Consortium, 320 Nevada Street, Suite 210, Newton, MA, 02460, USA.
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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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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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Napolitano A, De Michieli L, Sinigiani G, Berno T, Cipriani A, Spiezia L. Thromboembolic and Bleeding Events in Transthyretin Amyloidosis and Coagulation System Abnormalities: A Review. J Clin Med 2023; 12:6640. [PMID: 37892778 PMCID: PMC10607836 DOI: 10.3390/jcm12206640] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 10/29/2023] Open
Abstract
Transthyretin amyloidosis (ATTR) is a group of diseases caused by the deposition of insoluble fibrils derived from misfolded transthyretin, which compromises the structure and function of various organs, including the heart. Thromboembolic events and increased bleeding risk are among the most important complications of ATTR, though the underlying mechanisms are not yet fully understood. Transthyretin plays a complex role in the coagulation cascade, contributing to the activation and regulation of the coagulation and fibrinolytic systems. The prevalence of atrial fibrillation, cardiac mechanical dysfunction, and atrial myopathy in patients with ATTR may contribute to thrombosis, though such events may also occur in patients with a normal sinus rhythm and rarely in properly anticoagulated patients. Haemorrhagic events are modest and mainly linked to perivascular amyloid deposits with consequent capillary fragility and coagulation anomalies, such as labile international-normalised ratio during anticoagulant therapy. Therefore, it is paramount to carefully stratify the thrombotic and haemorrhagic risks, especially when initiating anticoagulant therapy. Our review aims to ascertain the prevalence of thromboembolic and haemorrhagic events in ATTR and identify potential risk factors and predictors and their impact on antithrombotic therapy.
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Affiliation(s)
- Angela Napolitano
- General Internal Medicine & Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, 35128 Padova, Italy;
| | - Laura De Michieli
- Department of Cardiothoracic and Vascular Sciences & Public Health, Padova University Hospital, 35128 Padova, Italy; (L.D.M.); (G.S.); (A.C.)
| | - Giulio Sinigiani
- Department of Cardiothoracic and Vascular Sciences & Public Health, Padova University Hospital, 35128 Padova, Italy; (L.D.M.); (G.S.); (A.C.)
| | - Tamara Berno
- Haematology Unit, Department of Medicine, Padova University Hospital, 35128 Padova, Italy;
| | - Alberto Cipriani
- Department of Cardiothoracic and Vascular Sciences & Public Health, Padova University Hospital, 35128 Padova, Italy; (L.D.M.); (G.S.); (A.C.)
| | - Luca Spiezia
- General Internal Medicine & Thrombotic and Haemorrhagic Diseases Unit, Department of Medicine, Padova University Hospital, 35128 Padova, Italy;
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Korell F, Schönland S, Schmitt A, Jansen M, Farid K, Müller-Tidow C, Dreger P, Schmitt M, Hegenbart U. First third-generation CAR T cell application targeting CD19 for the treatment of systemic IgM AL amyloidosis with underlying marginal zone lymphoma. Biomark Res 2023; 11:91. [PMID: 37838756 PMCID: PMC10576295 DOI: 10.1186/s40364-023-00532-2] [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: 08/23/2023] [Accepted: 10/06/2023] [Indexed: 10/16/2023] Open
Abstract
Light chain amyloidosis (AL) is a rare disease caused by the generalized deposition of misfolded free light chains. Patients with immunoglobulin M gammopathy (IgM) and indolent B-cell lymphoma such as marginal zone lymphoma (MZL) may in some instances develop AL amyloidosis. So far, CAR T cells for AL amyloidosis have only been reported utilizing the B cell maturation antigen as target, while CD19 has so far not been used in AL amyloidosis.We report the case of a 71-year-old male, diagnosed with systemic AL kappa amyloidosis and MZL, receiving third-generation CAR T cell therapy targeting CD19. Prior treatment included bendamustine/rituximab and cyclophosphamide/ dexamethasone with subsequent autologous stem cell transplantation. CAR T application was well tolerated despite heart and kidney amyloid manifestations, and only early low-grade procedure-specific toxicities were observed. A continuous decrease in IgM, kappa light chains and kappa-to-lambda light chain difference was observed in the patient from day + 30 on, resulting in a deep hematological response six months after treatment.In summary, we present a novel case of CAR T cell treatment with third generation CD19 directed infusion for AL amyloidosis with an underlying secretory active B cell lymphoma, showing that this is an effective treatment modality and can be applied to patients with subsequent AL amyloidosis.
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Affiliation(s)
- Felix Korell
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Stefan Schönland
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Anita Schmitt
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Madelaine Jansen
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Kiavasch Farid
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Peter Dreger
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Michael Schmitt
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Ute Hegenbart
- Department of Hematology & Oncology, Amyloidosis Center, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany.
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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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50
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De Michieli L, Sinigiani G, De Gaspari M, Branca A, Rizzo S, Basso C, Trentin L, Iliceto S, Perazzolo Marra M, Cipriani A, Berno T. Light-chain cardiac amyloidosis for the non-expert: pearls and pitfalls. Intern Emerg Med 2023; 18:1879-1886. [PMID: 37338717 PMCID: PMC10543940 DOI: 10.1007/s11739-023-03335-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
Cardiac amyloidosis (CA) is an uncommon, progressive, and fatal disease; the two main forms that can affect the heart are transthyretin CA and light chain CA (AL-CA). AL-CA is a medical urgency for which a diagnostic delay can be catastrophic for patients' outcome. In this manuscript, we focus on the pearls and pitfalls that are relevant to achieve a correct diagnosis and to avoid diagnostic and therapeutical delays. Through the aid of three unfortunate clinical cases, some fundamental diagnostic aspects are addressed, including the following: first, a negative bone scintigraphy does not exclude CA, with patients with AL-CA frequently showing no or mild cardiac uptake, and its execution should not delay hematological tests; second, fat pad biopsy does not have a 100% sensitivity for AL amyloidosis and, if negative, further investigations should be performed, particularly if the pre-test probability is high. Third, Congo Red staining is not sufficient to reach a definitive diagnosis and amyloid fibrils typing with mass spectrometry, immunohistochemistry, or immunoelectron microscopy is crucial. To achieve a timely and correct diagnosis, all the necessary investigations must be performed, always considering the yield and diagnostic accuracy of each examination.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy.
| | - Giulio Sinigiani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
| | - Monica De Gaspari
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Antonio Branca
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
| | - Stefania Rizzo
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Tamara Berno
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
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