1
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Ungericht M, Groaz V, Messner M, Schuetz T, Brunelli L, Zaruba MM, Lener D, Stocker E, Bauer A, Kroiss AS, Mayr A, Röcken C, Poelzl G. Correlation of 99mTc-DPD bone scintigraphy with histological amyloid load in patients with ATTR cardiac amyloidosis. Amyloid 2024; 31:22-31. [PMID: 37530216 DOI: 10.1080/13506129.2023.2239986] [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: 02/26/2023] [Accepted: 07/18/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND The significance of measuring 99mTc-labelled-3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) in transthyretin (ATTR) cardiac amyloidosis has not been adequately studied. This single-centre observational study evaluated the correlation between 99mTc-DPD scintigraphy and histological amyloid load in endomyocardial biopsy (EMB). METHODS Twenty-eight patients with biopsy-proven ATTR amyloidosis and concomitantly available 99mTc-DPD scintigraphy were included. Visual Perugini scoring, and (semi-)quantitative analysis of cardiac 99mTc-DPD uptake by planar whole-body imaging and single photon emission computed tomography (SPECT/CT) using regions of interest (ROI) were performed. From this, heart-to-whole-body ratio (H/WB) and heart-to-contralateral-chest ratio (H/CL) were calculated. The histological amyloid load was quantified using two different staining methods. RESULTS Increased cardiac tracer uptake was documented in all patients (planar: ROImean 129 ± 37 cps; SPECT/CT: ROImean 369 ± 142 cps). Histological amyloid load (19 ± 13%) significantly correlated with Perugini score (r = 0.69, p < .001) as well as with cardiac 99mTc-DPD uptake (planar: r = 0.64, p < .001; H/WB: r = 0.50, p = .014; SPECT/CT: r = 0.53, p = .008; H/CL: r = 0.43, p = .037) (results are shown for correlations with Congo Red-staining). CONCLUSION In ATTR, cardiac 99mTc-DPD uptake significantly correlated with histological amyloid load in EMB. Further studies are needed to implement thresholds in cardiac 99mTc-DPD uptake measurements for risk stratification and guidance of therapy.
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Affiliation(s)
- Maria Ungericht
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Valeria Groaz
- Department of Emergency Medicine, Klinik Arlesheim, Arlesheim, Switzerland
| | - Moritz Messner
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Schuetz
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Luca Brunelli
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marc-Michael Zaruba
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Lener
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Eva Stocker
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Axel Bauer
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Röcken
- Department of Pathology, Christian-Albrechts-University, Kiel, Germany
| | - Gerhard Poelzl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
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2
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Jang SY, Byun JM, Yoon SS, Paeng JC, Lee SP, Koh Y. Lenalidomide as a treatment for patients with AL amyloidosis and cardiac involvement. Blood Res 2023; 58:242-245. [PMID: 38151962 PMCID: PMC10758634 DOI: 10.5045/br.2023.2023194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/29/2023] Open
Affiliation(s)
- Seo Yoon Jang
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Ja Min Byun
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Chul Paeng
- Department of Nuclear Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Pyo Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Youngil Koh
- Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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3
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Heim X, Hubert AM, Raouak I, Nzepa AC, Mege JL, Delmont E, Attarian S, Koric L, Pelletier J, Brodovitch A, Boucraut J. Validation of ELISA assays for the calculation of FLC indices for the diagnosis of intrathecal immunoglobulin synthesis. Clin Chem Lab Med 2023; 61:1623-1629. [PMID: 37015059 DOI: 10.1515/cclm-2022-0602] [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: 06/22/2022] [Accepted: 03/20/2023] [Indexed: 04/06/2023]
Abstract
OBJECTIVES Define the cutoff thresholds of the Kappa (K) and Lambda (L) free light chains (FLC) indices for the detection of intrathecal immunoglobulin synthesis (IIS) using the new K and L FLC ELISA from SEBIA. The reference technique, which is not readily standardized between laboratories, is based on the demonstration of oligoclonal banding (OCB) in cerebrospinal fluid (CSF) which is absent in serum. For the past 6 years, we have also routinely calculated the K FLC index using The Binding Site (TBS) reagents on an Optilite instrument, an approach increasingly used as an alternative and/or a complement to electrophoretic analysis. METHODS We analyzed 391 serum/CSF pairs divided into three groups. The first group were cases without OCB and with normal albumin CSF/serum ratio (n=174). The second group were cases with specific OCB (n=73). The last group included patients with increased albumin CSF/sera ratio without OCB (n=142). RESULTS Analysis of the first group determined that the cutoffs for detection of IIS are respectively 2.55 and 1.02 for the K FLC and L FLC indices. Of the 73 cases with IIS, only 2 had a K FLC index below this threshold (sensitivity of 97.26%), while 16 out of 73 cases (78.08%) and 13 out of 72 cases (81.94%) had an IgG and L FLC index below the cutoffs, respectively. Additionally, we illustrate equivalent performances for prediction of the presence of OCB between SEBIA and TBS methods. CONCLUSIONS Sebia K FLC and L FLC assays are adequate alternative methods for the diagnosis of IIS.
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Affiliation(s)
- Xavier Heim
- Immunology Laboratory, CHU Timone AP-HM, Marseille, France
| | | | - Issam Raouak
- Immunology Laboratory, CHU Timone AP-HM, Marseille, France
| | | | | | - Emilien Delmont
- Referral Centre for Neuromuscular Diseases and ALS, CHU Timone, Marseille, France
| | - Shahram Attarian
- Referral Centre for Neuromuscular Diseases and ALS, CHU Timone, Marseille, France
| | - Lejla Koric
- Department of Neurology and Neuropsychology, CHU Timone, AP-HM and UMR 7249, CNRS, Centrale Marseille, Institut Fresnel, AMU, Marseille, France
| | - Jean Pelletier
- Department of Neurology, CHU Timone, APHM, Marseille, and CRMBM/UMR CNRS 7339, AMU, Marseille, France
| | | | - José Boucraut
- Immunology Laboratory, CHU Timone AP-HM, Marseille, France
- AMU, Institut de Neurosciences des Systèmes (INS, UMR1106), Marseille, France
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4
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Yan J, Wang D, Zhao J, Zhou M, Huang B, Xing Y, Guo WF, Sun S. Clinical characteristics and prognostic value of renal immune complex deposition in patients with light chain amyloidosis. Front Oncol 2022; 12:949702. [PMID: 36313726 PMCID: PMC9608106 DOI: 10.3389/fonc.2022.949702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Accepted: 09/22/2022] [Indexed: 07/28/2023] Open
Abstract
Although patients with light chain amyloidosis (AL) may present with co-deposition of amyloid and immune complexes (ICs) in renal biopsies, data on clinical characteristics and prognostic value of renal IC deposition are limited. A total of 73 patients with AL amyloidosis who were newly diagnosed by renal biopsy in Xijing Hospital (Xi'an, China) were divided into two groups (IC and non-IC groups). As a result, renal IC deposition was found in 26% of patients. Patients with IC deposition were associated with more urinary protein excretion and lower serum albumin. Notably, patients in the non-IC group achieved higher hematological overall response rate (81.5% vs. 47.4%, p = 0.007) and ≥VGPR rate (75.9% vs. 39.8%, p = 0.004) compared with those in IC group. Renal response rate was also higher in the non-IC group (63% vs. 31.6%, p = 0.031). With the median follow-up time of 19 months, a significantly worse overall survival was observed in patients with the IC group as compared with those without renal IC deposition in the Kaplan-Meier analysis (p = 0.036). Further multivariate analysis demonstrated that renal immune complex deposition was associated with worse overall survival in patients with AL amyloidosis (HR 5.927, 95% CI 2.148-16.356, p = 0.001).
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Affiliation(s)
- Jipeng Yan
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Di Wang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Jin Zhao
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Meilan Zhou
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Boyong Huang
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Yan Xing
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
| | - Wei-Feng Guo
- School of Electrical Engineering, Zhengzhou University, Zhengzhou, China
- State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, Guangzhou, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi’an, China
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5
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Sandfeld-Paulsen B, Aggerholm-Pedersen N, Samson MH, Møller HJ. A Cohort Study of Free Light Chain Ratio in Combination with Serum Protein Electrophoresis as a First-Line Test in General Practice. Cancers (Basel) 2022; 14:cancers14122930. [PMID: 35740597 PMCID: PMC9221199 DOI: 10.3390/cancers14122930] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/08/2022] [Accepted: 06/13/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Multiple Myeloma (MM) can be a diagnostic challenge as it often presents with unspecific symptoms in patients in general practice. Serum-free light chain (sFLC) ratio is suggested to replace urine protein electrophoresis (UPE) in the diagnostic work-up of myeloma. We aimed to investigate the performance of the sFLC ratio in general practice (GP) compared to UPE in a low prevalence cohort of 13,210 patients from general practice. We found that sFLC ratio performs in line with UPE; however, we observed a pronounced number of false-positive tests. Therefore, local instrument-dependent adjustment of reference ranges/decision limits should be considered to avoid an unnecessarily high number of false-positive tests. Abstract Multiple Myeloma (MM) often present with unspecific symptoms, which can lead to diagnostic delay. Serum-free light chain (sFLC) ratio is suggested to replace urine protein electrophoresis (UPE) in the diagnostic work-up of myeloma. We aimed to investigate the performance of the sFLC-ratio in general practice (GP) compared to UPE, just as we explored different sFLC-ratio cut-offs’ influence on diagnostic values. In a cohort of 13,210 patients from GP measures of sFLC-ratio, serum protein electrophoresis (SPE), or UPE were compared to diagnoses of incident M-component related diseases acquired from Danish health registers. UPE and sFLC-ratio equally improved diagnostic values when combined with SPE (sensitivity: SPE and UPE: 95.6 (90.6–98.4); SPE and sFLC-ratio: 95.1 (90.2–98.0)). The addition of the sFLC-ratio to SPE resulted in the identification of 13 patients with MGUS, light chain disease and amyloidosis, which was in line with the addition of UPE to SPE. The number of false-positive tests was UPE and SPE: 364 (11%) and sFLC-ratio and SPE: 677(19%). Expanding sFLC-ratio reference range to 0.26–4.32 resulted in a significant reduction in false positives n = 226 (6%) without loss of patients with clinical plasma cell dyscrasias. sFLC-ratio improves the diagnostic value of SPE in GP. However, due to low specificity and a large number of false positives, expanded cut-off values should be considered.
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Affiliation(s)
- Birgitte Sandfeld-Paulsen
- Department of Clinical Biochemistry, Aarhus University Hospital, 8200 Aarhus, Denmark; (M.H.S.); (H.J.M.)
- Correspondence:
| | - Ninna Aggerholm-Pedersen
- Department of Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark;
- Department of Experimental Oncology, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Mie Hessellund Samson
- Department of Clinical Biochemistry, Aarhus University Hospital, 8200 Aarhus, Denmark; (M.H.S.); (H.J.M.)
| | - Holger Jon Møller
- Department of Clinical Biochemistry, Aarhus University Hospital, 8200 Aarhus, Denmark; (M.H.S.); (H.J.M.)
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6
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Jamal S, Kichloo A, Bailey B, Singh J, Virk H, Soni R, Wani F, Ajmal M, Ananthaneni S, Edigin E, Sudhakar R, Kanjwal K. Clinical Outcomes and Disease Burden in Amyloidosis Patients with and Without Atrial Fibrillation-Insight from the National Inpatient Sample Database. J Innov Card Rhythm Manag 2021; 12:4542-4549. [PMID: 34234988 PMCID: PMC8225306 DOI: 10.19102/icrm.2021.120605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/05/2021] [Indexed: 01/09/2023] Open
Abstract
Amyloidosis is a systemic illness that affects multiple organ systems, including the cardiovascular, renal, gastrointestinal, and pulmonary systems. Common manifestations include restrictive cardiomyopathy, arrhythmias, nephrotic syndrome, and gastrointestinal hemorrhage. It is unknown whether coexisting atrial fibrillation (AF) worsens the disease burden and outcomes in patients with systemic amyloidosis. In this study, those with a diagnosis of amyloidosis with and without coexisting AF were identified by querying the Healthcare Cost and Utilization Project—specifically, the National Inpatient Sample for the year 2016—based on International Classification of Diseases, 10th Revision, Clinical Modification codes. During 2016, a total of 2,997 patients were admitted with a diagnosis of amyloidosis, including 918 with concurrent AF. Greater rates of mortality (7.4% vs. 5.6%); heart block (6.8% vs. 2.8%); cardiogenic shock (5% vs. 1.6%); placement of an implantable cardioverter-defibrillator, cardiac resynchronization therapy device, or permanent pacemaker (14.5% vs. 4.5%); renal failure (29% vs. 21%); heart failure (66% vs. 30%); and bleeding complications (5.7% vs. 2.8%) were observed in patients with a diagnosis of amyloidosis and coexisting AF when compared with in patients without AF. Interestingly, patients with amyloidosis without comorbid AF had greater odds of associated stroke relative to those with concurrent AF (7.9% vs. 3.4%).
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Affiliation(s)
- Shakeel Jamal
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Beth Bailey
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Jagmeet Singh
- Division of Nephrology, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Hafeez Virk
- Division of Cardiovascular Medicine, Albert Einstein College of Medicine, Philadelphia, PA, USA
| | - Ronak Soni
- Division of Cardiovascular Medicine, University of Toledo, College of Medicine, Toledo, OH, USA
| | - Farah Wani
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Muhammad Ajmal
- Division of Cardiovascular Medicine, University of Arizona, College of Medicine, Tucson, AZ, USA
| | - Sindhura Ananthaneni
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Ehizogie Edigin
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL, USA
| | - Rajeev Sudhakar
- Division of Cardiovascular Medicine, Ascension Medical Group, Central Michigan University, Saginaw, MI, USA
| | - Khalil Kanjwal
- Division of Electrophysiology, McLaren Greater Lansing Hospital, Michigan State University, Lansing, MI, USA
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7
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Rezk T, Fontana M, Gillmore JD. A review of the criteria for non-invasive diagnosis of cardiac transthyretin amyloidosis. Expert Opin Orphan Drugs 2021. [DOI: 10.1080/21678707.2021.1898371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Tamer Rezk
- National Amyloidosis Centre, University College London, London, UK
- Departement of Nephrology, UCL Department of Nephrology, Division of Medicine, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, UK
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8
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Drosou ME, Vaughan LE, Muchtar E, Buadi FK, Dingli D, Dispenzieri A, Fonder AL, Gertz MA, Go RS, Gonsalves WI, Hayman SR, Hobbs MA, Hwa YL, Kapoor P, Kourelis T, Kumar S, Kyle RA, Lacy MQ, Lin Y, Lopez CL, Lust JA, Rajkumar SV, Russell SJ, Sidana S, Siddiqui MA, Sidiqi MH, Warsame R, Leung N. Comparison of the current renal staging, progression and response criteria to predict renal survival in AL amyloidosis using a Mayo cohort. Am J Hematol 2021; 96:446-454. [PMID: 33428787 DOI: 10.1002/ajh.26092] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 11/09/2022]
Abstract
Three sets of criteria (International Society of Amyloidosis [ISA], Palladini and Kastritis) were independently developed for staging, progression and response criteria to predict renal survival in patients with AL amyloidosis. We evaluated these criteria using a cohort of 495 newly diagnosed AL amyloidosis patients with renal involvement using time to event competing risk analysis at baseline, 3, 6 and 12 months after treatment. Only Palladini and Kastritis had a staging system and both predicted a higher risk of end stage renal disease (ESRD) in the stage III vs stage I patients but only the Palladini model was predictive for stage II patients. At 3 months, risk of ESRD was significantly higher for Palladini and ISA renal progression (hazard ratio [HR] 2.8 [95% CI: 1.5-5.3, p = .001] and 2.5 [CI: 1.4-4.6, p = .004, respectively]), but renal response was not significantly protective; conversely, the risk of ESRD was not significantly higher for the Kastritis renal progression, but was significantly protective for the Kastritis renal responders (HR 0.38 [95% CI: 0.17-0.84], p = .017). Both progression and response with ISA, Palladini and Kastritis criteria were predictive of ESRD at 6 months and 12 months. While the Palladini staging criteria at baseline, and the ISA and Palladini criteria for progression at 3 months performed better than the Kastritis criteria at baseline and 3 months post-treatment, the Kastritis criteria performed better for response 3 months after treatment. All three sets of criteria performed well at and after 6 months post-treatment. These differences are important when choosing endpoints for clinical trials.
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Affiliation(s)
| | - Lisa E. Vaughan
- Department of Biomedical Statistics and Informatics Mayo Clinic Rochester Minnesota
| | - Eli Muchtar
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | - David Dingli
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | | | | | - Ronald S. Go
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | | | | | - Yi L. Hwa
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | | | - Shaji Kumar
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | | | - Yi Lin
- Division of Hematology Mayo Clinic Rochester Minnesota
| | - Camden L. Lopez
- Department of Biomedical Statistics and Informatics Mayo Clinic Rochester Minnesota
| | - John A. Lust
- Department of Biomedical Statistics and Informatics Mayo Clinic Rochester Minnesota
| | | | | | - Surbhi Sidana
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | | | - Rahma Warsame
- Division of Hematology Mayo Clinic Rochester Minnesota
| | - Nelson Leung
- Division of Nephrology And Hypertension Mayo Clinic Rochester Minnesota
- Division of Hematology Mayo Clinic Rochester Minnesota
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9
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Kastritis E, Fotiou D, Theodorakakou F, Dialoupi I, Migkou M, Roussou M, Karatrasoglou EA, Tselegkidi MI, Ntalianis A, Kanellias N, Eleutherakis-Papaiakovou E, Ntanasis-Stathopoulos I, Gakiopoulou C, Papanikolaou A, Papathoma A, Spyropoulou-Vlachou M, Psimenou E, Stamatelopoulos K, Gavriatopoulou M, Terpos E, Dimopoulos MA. Timing and impact of a deep response in the outcome of patients with systemic light chain (AL) amyloidosis. Amyloid 2021; 28:3-11. [PMID: 32713209 DOI: 10.1080/13506129.2020.1798224] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
A rapid and deep haematologic response is fundamental in order to improve outcomes of patients with AL amyloidosis. We evaluated the impact of timing and depth of haematologic response at early time points (at 1 and 3 months from the start of therapy) in 227 consecutive previously untreated AL patients, who received bortezomib-based primary therapy. After 1 month of therapy, 30.5% had ≥VGPR, 28% PR and 36% no response (NR), with 11% having iFLC <20 mg/L and 15% dFLC <10 mg/L. Deep haematologic response at 1 month (either ≥VGPR or iFLC <20 mg/L or dFLC <10 mg/L), was associated with a high organ response rate. The survival of patients with ≥VGPR was significantly better than those with PR and NR at 1-month landmark (p < .001) but this benefit was mainly driven by those with iFLC <20 mg/L. The depth of haematologic response at 1 month was significant across all Mayo stages. At 3 months, 46% of the patients had not significantly improved the depth of their response but even patients that improved their response from an iFLC ≥20 mg/L at 1 month to iFLC <20 mg/L at 3 months still had inferior outcome to those with an early deep response. Thus, in patients with AL amyloidosis, a very rapid and deep response is crucial, especially for those at high risk, targeting very low FLC levels within the first month of therapy.
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Affiliation(s)
- Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Ioanna Dialoupi
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Roussou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Eleni A Karatrasoglou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Irini Tselegkidi
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Argyrios Ntalianis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | - Charikleia Gakiopoulou
- 1st Department of Pathology, National and Kapodistrian University of Athens, Athens, Greece
| | | | | | | | - Erasmia Psimenou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Evangelos Terpos
- 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
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10
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Muchtar E, Gertz MA, Lacy MQ, Leung N, Buadi FK, Dingli D, Hayman SR, Go RS, Kapoor P, Gonsalves W, Kourelis TV, Warsame R, Hwa YL, Fonder A, Hobbs M, Russell S, Lust JA, Siddiqui M, Rajkumar SV, Kyle RA, Kumar SK, Dispenzieri A. Refining amyloid complete hematological response: Quantitative serum free light chains superior to ratio. Am J Hematol 2020; 95:1280-1287. [PMID: 32681737 DOI: 10.1002/ajh.25940] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
Response assessment in light chain (AL) amyloidosis is based on serum and urine monoclonal protein studies. Newly diagnosed patients (n = 373) who achieved very good partial response or complete response (CR) to first line therapy were assessed for the survival impact of each of the monoclonal protein studies. At end of therapy (EOT), negative serum/urine immunofixation (IFE) was achieved in 61% of patients, 72% achieved normal serum free light chain ratio (sFLCR), and the median involved free light chain (iFLC) and difference between involved to uninvolved light chain (dFLC) were 17 mg/L and 5 mg/L, respectively. Overall, 46% of patients achieved a CR at EOT. At EOT, iFLC ≤20 mg/L and dFLC ≤10 mg/L were additive in survival discrimination to negative serum/urine IFE and were independent predictors of overall survival. In contrast, normalization of sFLCR did not add survival discrimination to serum/urine IFE and was not independent predictor of survival. We propose a new definition for hematological CR to include serum/urine IFE negativity plus iFLC ≤20 mg/L or dFLC ≤10 mg/L, instead of the current definition of serum/urine IFE negativity and normal sFLCR. Complete response using dFLC ≤10 mg/L had the best performance in those with significant renal dysfunction and by light chain isotype, making it the preferred partner to IFE. Validation of these results in a multicenter cohort is warranted.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | | | - Nelson Leung
- Division of Hematology Mayo Clinic Rochester Minnesota
- Division of Nephrology and Hypertension Mayo Clinic Rochester Minnesota
| | | | - David Dingli
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | - Ronald S. Go
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | | | | | - Rahma Warsame
- Division of Hematology Mayo Clinic Rochester Minnesota
| | - Yi Lisa Hwa
- Division of Hematology Mayo Clinic Rochester Minnesota
| | - Amie Fonder
- Division of Hematology Mayo Clinic Rochester Minnesota
| | - Miriam Hobbs
- Division of Hematology Mayo Clinic Rochester Minnesota
| | | | - John A. Lust
- Division of Hematology Mayo Clinic Rochester Minnesota
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11
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Inyushin M, Zayas-Santiago A, Rojas L, Kucheryavykh L. On the Role of Platelet-Generated Amyloid Beta Peptides in Certain Amyloidosis Health Complications. Front Immunol 2020; 11:571083. [PMID: 33123145 PMCID: PMC7567018 DOI: 10.3389/fimmu.2020.571083] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/15/2020] [Indexed: 12/15/2022] Open
Abstract
As do many other immunity-related blood cells, platelets release antimicrobial peptides that kill bacteria, fungi, and even certain viruses. Here we review the literature suggesting that there is a similarity between the antimicrobials released by other blood cells and the amyloid-related Aβ peptide released by platelets. Analyzing the literature, we also propose that platelet-generated Aβ amyloidosis may be more common than currently recognized. This systemic Aβ from a platelet source may participate in various forms of amyloidosis in pathologies ranging from brain cancer, glaucoma, skin Aβ accumulation, and preeclampsia to Alzheimer’s disease and late-stage Parkinson’s disease. We also discuss the advantages and disadvantages of specific animal models for studying platelet-related Aβ. This field is undergoing rapid change, as it evaluates competing ideas in the light of new experimental observations. We summarized both in order to clarify the role of platelet-generated Aβ peptides in amyloidosis-related health disorders, which may be helpful to researchers interested in this growing area of investigation.
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Affiliation(s)
- Mikhail Inyushin
- Department of Physiology, Universidad Central del Caribe, Bayamon, Puerto Rico
| | - Astrid Zayas-Santiago
- Department of Pathology & Laboratory Medicine, Universidad Central del Caribe, Bayamon, Puerto Rico
| | - Legier Rojas
- Department of Physiology, Universidad Central del Caribe, Bayamon, Puerto Rico
| | - Lilia Kucheryavykh
- Department of Biochemistry, Universidad Central del Caribe, Bayamon, Puerto Rico
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12
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Dittrich T, Kimmich C, Hegenbart U, Schönland SO. Prognosis and Staging of AL Amyloidosis. Acta Haematol 2020; 143:388-400. [PMID: 32570242 DOI: 10.1159/000508287] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022]
Abstract
The treatment options for systemic light chain amyloidosis (AL) are currently widening in an unprecedented way, brought about by an expanding arsenal of anti-myeloma therapy as well as by novel approaches to target toxic light chains and, most recently, deposited amyloid directly. In this context, accurate estimates of prognosis in AL, which allow for reliable patient advice and for example comparison of different therapies, are particularly important to clinicians. Some biomarkers and especially the genetic background of the underlying clonal disease as evaluated by interphase fluorescence in situ hybridization even have predictive value, enabling an appropriate treatment selection. Derived from the most frequently involved organs in AL, heart and kidney, this review focuses on overall survival and renal survival. A comprehensive overview and summary of reported prognostic factors and biomarkers in AL is given and the most important and validated factors are highlighted. Finally, established staging systems in AL as well as validated and perspective response criteria are presented.
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Affiliation(s)
- Tobias Dittrich
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Christoph Kimmich
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Ute Hegenbart
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan O Schönland
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, Heidelberg, Germany,
- Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany,
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13
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Xu Z, Sun Y, Xu T, Shi Y, Liang L, Liu P, Ge J. MGUS Predicts Worse Prognosis in Patients with Coronary Artery Disease. J Cardiovasc Transl Res 2020; 13:806-812. [PMID: 31900894 PMCID: PMC7541390 DOI: 10.1007/s12265-019-09950-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Accepted: 12/11/2019] [Indexed: 11/29/2022]
Abstract
We performed a retrospective cohort study to analyze all 87 CAD patients with MGUS and 178 CAD patients without MGUS admitted in Zhongshan Hospital Fudan University from 2015 to 2017. Patients were followed up via regular patient visits or telephone, and the median follow-up period was 2.9 years. The end point of follow-up was the occurrence of major adverse cardiac events (MACE). CAD patients with MGUS had a higher risk of MACE than those without MGUS (log-rank P = 0.0015). After adjustment for other markers in the stepwise Cox regression model, MGUS was still related to the increasing risk of MACE incident (P = 0.002, HR = 2.308). Then, we constructed the nomogram based on the Cox regression model, and the concordance index (C-index) was 0.667. Hence, MGUS might be added into the risk model of CAD.
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Affiliation(s)
- Zhao Xu
- Department of Hematology, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yifeng Sun
- Department of Hematology, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Tianhong Xu
- Department of Hematology, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Yidan Shi
- Department of Statistics and Actuarial Science, University of Waterloo, Waterloo, Canada
| | - Lifan Liang
- Department of Hematology, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, 200032, China
| | - Peng Liu
- Department of Hematology, Zhongshan Hospital Fudan University, 180 Fenglin Road, Shanghai, 200032, China.
| | - Junbo Ge
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital Fudan University, Shanghai, China
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14
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Sencar ME, Yıldız A, Haznedar R. Is urine immunofixation electrophoresis necessary for monitoring myeloma patients who have undergone hematopoietic stem cell transplantation? Transfus Apher Sci 2019; 58:102660. [PMID: 31734164 DOI: 10.1016/j.transci.2019.10.002] [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: 03/23/2019] [Revised: 10/01/2019] [Accepted: 10/03/2019] [Indexed: 10/25/2022]
Abstract
INTRODUCTION To investigate the role of urine immunofixation electrophoresis in detecting relapse in patients with myeloma who have undergone autologous and allogeneic hematopoietic stem cell transplantation (HSCT). METHODS The study included a total of 78 patients, comprising 49 males and 29 females, with progressive disease or relapse after HSCT. Serum protein electrophoresis (sPE), serum immunofixation electrophoresis (sIFE) and serum free light chain κ/λ ratio in addition to urine immunofixation (uIFE) were studied. RESULTS sPE, sIFE and κ/λ ratio demonstrated relapse in 65.3%, 88.3% and 58.9% of the cases by theirselves respectively. The combination panel of sPE and sIFE demonstrated relapse in 88.3% of patients whereas sPE, sIFE and κ/λ ratio all together demonstrated relapse in 95.8% of the patients. In relapsed patients, urine immunofixation was found to be positive in 16.2% of the patients. No patients with relapsed disease were missed by omitting uIFE from serum studies (sPE, sIFE and sFLC). CONCLUSION For evaluation of relapse in MM patients after HSCT, uIFE had no additional diagnostic capability compared to serum studies (sPE, sIFE, and sFLC). Therefore, urine studies should be performed more selectively.
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Affiliation(s)
- M Erkam Sencar
- Gazi University Faculty of Medicine, Department of Internal Medicine, Ankara, Turkey.
| | - Abdulkerim Yıldız
- Gazi University Faculty of Medicine, Department of Internal Medicine, Ankara, Turkey
| | - Rauf Haznedar
- Gazi University Faculty of Medicine, Department of Hematology, Ankara, Turkey
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15
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Abstract
Light chain (AL) amyloidosis is a rare plasma cell dyscrasia. An estimated 12,000 people live with the disease in the United States. AL amyloidosis occurs from the misfolding of proteins that deposit in organs (heart, kidneys, digestive tract, tongue, lungs, and nervous system), leading to progressive organ damage and impairment of quality of life. The treatment of AL amyloidosis has improved greatly over the past several years, with new treatments currently in development. This article will focus on the pathophysiology, diagnosis, and treatment of AL amyloidosis.
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Affiliation(s)
- Rebecca Lu
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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16
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Caponi L, Romiti N, Koni E, Fiore AD, Paolicchi A, Franzini M. Inter-assay variability in automated serum free light chain assays and their use in the clinical laboratory. Crit Rev Clin Lab Sci 2019; 57:73-85. [PMID: 31612753 DOI: 10.1080/10408363.2019.1670133] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Serum κ and λ free light chain levels are markers of plasma cell proliferation, and their measurements have been included in recent guidelines by the International Myeloma Working Group for the management of patients with plasma cellular dyscrasias. Five in vitro diagnostic methods for the immunochemical quantification of serum free light chains (FLC) are available, three based on polyclonal antibodies (Freelite®, The Binding Site; FLC ELISA κ and λ, Sebia; human κ and λ FLC, Diazyme Laboratories) and two on monoclonal antibodies (N Latex FLC, Siemens Healthineers; Seralite®, Sebia). Several studies have shown that these methods cannot be used interchangeably for the follow-up of patients because measured κ and λ FLC concentrations may differ significantly, especially at high levels. Because no international reference material for the measurement of FLC is available, it is not possible to establish which method is the most accurate. For this reason, knowledge about the analytical and diagnostic performances of the assays used is important. The aim of this review is to describe the main analytical features of the κ and λ FLC assays and how they may influence the clinical use of these parameters.
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Affiliation(s)
- Laura Caponi
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Nadia Romiti
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Elona Koni
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Annarita Di Fiore
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Aldo Paolicchi
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
| | - Maria Franzini
- Department of Translational Research and New Technologies in Medicine, University of Pisa, Pisa, Italy
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17
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Hayashi Y, Higashi T, Motoyama K, Jono H, Ando Y, Onodera R, Arima H. Hepatocyte-Targeted Delivery of siRNA Polyplex with PEG-Modified Lactosylated Dendrimer/Cyclodextrin Conjugates for Transthyretin-Related Amyloidosis Therapy. Biol Pharm Bull 2019; 42:1679-1688. [DOI: 10.1248/bpb.b19-00278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Yuya Hayashi
- Department of Physical Pharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University
- Japan Society for the Promotion of Science
| | - Taishi Higashi
- Department of Physical Pharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University
| | - Keiichi Motoyama
- Department of Physical Pharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University
| | - Hirofumi Jono
- Department of Pharmacy, Kumamoto University Hospital
- Department of Clinical Pharmaceutical Sciences, Graduate School of Pharmaceutical Sciences, Kumamoto University
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University
| | | | - Hidetoshi Arima
- Department of Physical Pharmaceutics, Graduate School of Pharmaceutical Sciences, Kumamoto University
- Program for Leading Graduate Schools ‘Health life science: Interdisciplinary and Glocal Oriented (HIGO) Program,’ Kumamoto University
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18
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Hwa YL, Fogaren T, Sams A, Faller DV, Stull DM, Thuenemann S, Mendelson L. Immunoglobulin Light-Chain Amyloidosis: Clinical Presentations and Diagnostic Approach. J Adv Pract Oncol 2019; 10:470-481. [PMID: 33457060 PMCID: PMC7779572 DOI: 10.6004/jadpro.2019.10.5.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Systemic immunoglobulin light-chain (AL) amyloidosis is a rare disorder arising from a plasma cell clone that produces misfolded immunoglobulin light chains, which are deposited in various tissues and organs as amyloid fibrils. Signs and symptoms are typically vague and overlap with those arising from other common diseases; consequently, diagnosis of AL amyloidosis is challenging for clinicians. Substantial delays between onset of symptoms and diagnosis are common, and result in poorer outcomes, particularly in patients with cardiac AL amyloidosis and others who develop advanced organ dysfunction. With the need to identify AL amyloidosis as early as possible, it is important for health-care practitioners, including advanced practice clinicians and nurses, to be aware of the hallmark presenting signs and symptoms, as well as the latest practice for evaluation and diagnosis. Increased awareness of signs and symptoms associated with AL amyloidosis, particularly relating to the most frequently involved organs, the heart and kidneys, represents an opportunity for achieving earlier diagnosis. Here we review these issues in AL amyloidosis, summarize the key presenting symptoms that clinicians need to be alert to, and discuss the latest diagnostic tests, with the aim of expediting patient identification and diagnosis with the goal of improving patient outcomes.
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Affiliation(s)
- Yi L Hwa
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Teresa Fogaren
- Division of Hematology-Oncology, Tufts Medical Center, Boston, Massachusetts
| | - Allison Sams
- Division of Hematology-Oncology, Outpatient Multiple Myeloma Service, Memorial Sloan-Kettering Cancer Center, New York City, New York
| | - Douglas V Faller
- Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Dawn M Stull
- Global Medical Affairs Oncology, Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Sara Thuenemann
- Global Medical Affairs Oncology, Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, a wholly owned subsidiary of Takeda Pharmaceutical Company Limited
| | - Lisa Mendelson
- Amyloidosis Center, Boston University School of Medicine, Boston, Massachusetts
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19
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Hereditary transthyretin amyloidosis: a model of medical progress for a fatal disease. Nat Rev Neurol 2019; 15:387-404. [PMID: 31209302 DOI: 10.1038/s41582-019-0210-4] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2019] [Indexed: 02/06/2023]
Abstract
Hereditary amyloidogenic transthyretin (ATTRv) amyloidosis with polyneuropathy (also known as familial amyloid polyneuropathy) is a condition with adult onset caused by mutation of transthyretin (TTR) and characterized by extracellular deposition of amyloid and destruction of the somatic and autonomic PNS, leading to loss of autonomy and death. This disease represents a model of the scientific and medical progress of the past 30 years. ATTRv amyloidosis is a worldwide disease with broad genetic and phenotypic heterogeneity that presents a diagnostic challenge for neurologists. The pathophysiology of the neuropathy is increasingly understood and includes instability and proteolysis of mutant TTR leading to deposition of amyloid with variable lengths of fibrils, microangiopathy and involvement of Schwann cells. Wild-type TTR is amyloidogenic in older individuals. The main symptoms are neuropathic, but the disease is systemic; neurologists should be aware of cardiac, eye and kidney involvement that justify a multidisciplinary approach to management. Infiltrative cardiomyopathy is usually latent but present in half of patients. Disease-modifying therapeutics that have been developed include liver transplantation and TTR stabilizers, both of which can slow progression of the disease and increase survival in the early stages. Most recently, gene-silencing drugs have been used to control disease in the more advanced stages and produce some degree of improvement.
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20
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Varga C, Titus SE, Toskic D, Comenzo RL. Use of novel therapies in the treatment of light chain amyloidosis. Blood Rev 2019; 37:100581. [PMID: 31167719 DOI: 10.1016/j.blre.2019.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 03/26/2019] [Accepted: 05/20/2019] [Indexed: 12/22/2022]
Abstract
Immunoglobulin light-chain (AL) amyloidosis is a rare life-threatening disease caused by light chains that are toxic to vital organs such as the heart, kidneys, liver and peripheral nervous system, and that misfold and assemble as amyloid fibrils and deposit both in affected organs and systemically in the vasculature and other tissues. Patients afflicted by this disease have B-cell disorders, almost always related to clonal plasma cells in the bone marrow, the burden of which can range from small clones involving 5% or less of marrow cells to frank multiple myeloma. The goal of therapy is to eliminate the clonal plasma cells producing these toxic light chains to halt and possibly reverse symptomatic organ damage. While autologous stem cell transplantation can be a very effective treatment modality in AL, it has a limited role due to the frailty of this particular population. Conservative treatment in the form of chemotherapy has become the backbone of therapy. Bortezomib combined with alkylators has proven quite successful in inducing hematologic responses. However, despite these advances, tolerability and resistance continue to be an ongoing issue. Novel anti-plasma cell therapies such as ixazomib, carfilzomib, lenalidomide and pomalidomide are actively being combined and evaluated in clinical trials for efficacy and toxicity in this challenging patient population. Other approaches, such as monoclonal antibodies targeting surface proteins and amyloid deposits, are being tested and combined with novel agents. In this review, we will provide an overview of the clinical trials that have led to current treatment algorithms and will also discuss monoclonal antibodies currently under investigation and in various stages of clinical development.
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Affiliation(s)
- Cindy Varga
- The John Conant Davis Myeloma and Amyloid Program, Division of Hematology-Oncology, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA; Department of Medicine, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA.
| | - Stephanie E Titus
- Department of Medicine, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA.
| | - Denis Toskic
- The John Conant Davis Myeloma and Amyloid Program, Division of Hematology-Oncology, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA
| | - Raymond L Comenzo
- The John Conant Davis Myeloma and Amyloid Program, Division of Hematology-Oncology, Tufts Medical Center, 800 Washington St., Boston, MA 02111, USA; Department of Medicine, Tufts Medical Center, 800 Washington St, Boston, MA 02111, USA.
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21
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Chang IC, Dispenzieri A, Scott CG, Lin G, Jaffe AS, Klarich KW, Grogan M. Utility of the Serum Free Light Chain Assay in the Diagnosis of Light Chain Amyloidosis in Patients With Heart Failure. Mayo Clin Proc 2019; 94:447-454. [PMID: 30718069 DOI: 10.1016/j.mayocp.2018.07.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 06/26/2018] [Accepted: 07/31/2018] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To determine the utility of the serum free light chain (FLC) assay for routine screening of light chain amyloidosis (AL) in patients with heart failure. PATIENTS AND METHODS We studied consecutive new patients referred to the Heart Failure Clinic who had the FLC assay performed for routine screening at Mayo Clinic's campus in Rochester, Minnesota, from January 1, 2011, through December 31, 2015. An FLC ratio between 0.26 and 1.65 was considered normal. RESULTS Of the 1173 patients in the study (mean age, 64±15 years), 207 had an abnormal FLC ratio. Light chain amyloidosis was diagnosed in 0.5% of all patients (6 of 1173) and in 2.9% of those with an abnormal FLC ratio (6 of 207). To increase the pretest probability of an abnormal FLC ratio in predicting AL, we considered patients with an N-terminal pro B-type natriuretic peptide level of 5000 pg/mL or greater (to convert to pmol/L, multiply by 0.1182) and a left ventricular posterior wall thickness of 13 mm or greater; this increased the diagnostic yield to 66.7% (6 of 9). CONCLUSION The prevalence of AL in patients with heart failure could be 0.5% or higher. Compared with the use of the serum FLC assay for routine screening, a targeted approach of the serum FLC assay in those with higher N-terminal pro B-type natriuretic peptide level (≥5000 pg/mL) and increased posterior wall thickness (≥13 mm) has a markedly higher yield for the diagnosis of AL.
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Affiliation(s)
- Ian C Chang
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Christopher G Scott
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | - Grace Lin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Allan S Jaffe
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Kyle W Klarich
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
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22
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Kidney disease and plasma cell dyscrasias: ambiguous cases solved by serum free light chain dimerization analysis. Clin Exp Nephrol 2019; 23:763-772. [PMID: 30734185 DOI: 10.1007/s10157-019-01699-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/18/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Plasma cell dyscrasias (PCD) comprise a wide spectrum of disorders, which may adversely affect the kidney. However, in some PCD cases associated with kidney disease, the routine laboratory tests may be incapable to determine precisely the form of PCD, i.e., benign or malignant. Moreover, the kidney biopsy needed for precise diagnosis may be risky or declined. To overcome these limitations, we have developed and reported a new non-invasive technique based on serum free light chains (FLC) monomer (M) and dimer (D) pattern analysis (FLC MDPA), which allowed differentiation between malignant and benign PCD forms. The objective of our retrospective study was to demonstrate the utility of FLC MDPA in solving ten puzzling PCD cases complicated with kidney disease (patients 1-10). METHODS Ten patients with uncertain form of PCD or with a questionable response to treatment were studied. In addition to routine laboratory tests and clinical evaluation of the PCD patients, our previously developed FLC MDPA in sera and biochemical amyloid typing in biopsy tissues were applied. RESULTS The FLC MDPA aided the diagnosis of the PCD underlying or accompanying the kidney disease in patients 1-5, and helped to interpret properly the response to treatment in patients 1, 6-10. The FLC MDPA findings were confirmed by a biochemical analysis of tissue amyloid deposits and subsequently by the outcome of these patients. CONCLUSIONS FLC MDPA is a non-invasive diagnostic test useful in the management of ambiguous cases of PCD associated with kidney disease.
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23
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Kristen AV, Ajroud-Driss S, Conceição I, Gorevic P, Kyriakides T, Obici L. Patisiran, an RNAi therapeutic for the treatment of hereditary transthyretin-mediated amyloidosis. Neurodegener Dis Manag 2019; 9:5-23. [DOI: 10.2217/nmt-2018-0033] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Hereditary transthyretin-mediated amyloidosis is a rapidly progressive, heterogeneous disease caused by the accumulation of misfolded transthyretin protein as amyloid fibrils at multiple sites, and is characterized by peripheral sensorimotor neuropathy, autonomic neuropathy and/or cardiomyopathy. Current treatment options have limited efficacy and often do not prevent disease progression. Patisiran is a novel RNA interference therapeutic that specifically reduces production of both wild-type and mutant transthyretin protein. In Phase II, III and long-term extension studies in patients with hereditary transthyretin-mediated amyloidosis, patisiran has consistently slowed or improved progression of neuropathy. In addition, the Phase III trial demonstrated significant improvements in quality of life measures and indicators of cardiomyopathy. Here, we highlight efficacy and safety data from the patisiran clinical trial programme.
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Affiliation(s)
- Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, D-69120, Germany
- Cardiovascular Center Darmstadt, Darmstadt, 64287, Germany
| | - Senda Ajroud-Driss
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL 60611, USA
| | - Isabel Conceição
- Centro Hospitalar Lisboa Norte, Hospital de Santa Maria, Universidade de Lisboa, Faculdade de Medicina, 1649-028, Portugal
| | - Peter Gorevic
- Department of Medicine, Mount Sinai Medical Center, New York, NY 10029, USA
| | | | - Laura Obici
- Amyloidosis Research & Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Pavia, 27100, Italy
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Optimizing deep response assessment for AL amyloidosis using involved free light chain level at end of therapy: failure of the serum free light chain ratio. Leukemia 2018; 33:527-531. [DOI: 10.1038/s41375-018-0258-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Revised: 08/09/2018] [Accepted: 08/14/2018] [Indexed: 11/08/2022]
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25
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Patient and Kidney Allograft Survival in Recipients With End-Stage Renal Disease From Amyloidosis. Transplantation 2018; 102:300-309. [DOI: 10.1097/tp.0000000000001930] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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26
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Rezk T, Lachmann HJ, Fontana M, Sachchithanantham S, Mahmood S, Petrie A, Whelan CJ, Pinney JH, Foard D, Lane T, Youngstein T, Wechalekar AD, Bass P, Hawkins PN, Gillmore JD. Prolonged renal survival in light chain amyloidosis: speed and magnitude of light chain reduction is the crucial factor. Kidney Int 2017; 92:1476-1483. [DOI: 10.1016/j.kint.2017.05.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 04/19/2017] [Accepted: 05/04/2017] [Indexed: 11/27/2022]
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27
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Palladini G, Jaccard A, Milani P, Lavergne D, Foli A, Bender S, Lavatelli F, Bosoni T, Valentini V, Pirolini L, Ferraro G, Basset M, Russo F, Nuvolone M, Albertini R, Cogne M, Merlini G. Circulating free light chain measurement in the diagnosis, prognostic assessment and evaluation of response of AL amyloidosis: comparison of Freelite and N latex FLC assays. Clin Chem Lab Med 2017; 55:1734-1743. [PMID: 28343171 DOI: 10.1515/cclm-2016-1024] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 02/23/2017] [Indexed: 01/12/2023]
Abstract
BACKGROUND The measurement of circulating free light chain (FLC) is essential in the diagnosis, prognostic stratification and evaluation of response to therapy in light chain (AL) amyloidosis. For more than 10 years, this has been done with an immunonephelometric assay based on polyclonal antibodies (Freelite), and cutoffs for staging and response assessment have been validated with this method. Recently, a new assay based on monoclonal antibodies (N latex FLC) has been marketed in Europe. METHODS We evaluated and compared the clinical performance of the two assays in 426 patients with newly diagnosed AL amyloidosis. RESULTS We found suboptimal agreement between the two methods, with differences between values obtained with the Freelite and N latex FLC assays increasing with the concentration of clonal FLC. The diagnostic sensitivity of the Freelite (82%) and N latex FLC (84%) assays was similar, and both improved to 98% in combination with serum and urine immunofixation. The concentration of FLC measured with both methods had prognostic significance. Less pronounced decreases in FLC best predicted improved survival with the N latex FLC assay (33% vs. 50%), and there was poor concordance (84%) in discrimination of responders. CONCLUSIONS The two assays have similar diagnostic and prognostic performance. However, they are not interchangeable, and follow-up should be done with either one. New response criteria are needed for the N latex FLC assay.
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Tuzovic M, Kobayashi Y, Wheeler M, Barrett C, Liedtke M, Lafayette R, Schrier S, Haddad F, Witteles R. Functional Cardiac Recovery and Hematologic Response to Chemotherapy in Patients With Light-Chain Amyloidosis (from the Stanford University Amyloidosis Registry). Am J Cardiol 2017; 120:1381-1386. [PMID: 28844519 DOI: 10.1016/j.amjcard.2017.07.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 06/27/2017] [Accepted: 07/07/2017] [Indexed: 11/19/2022]
Abstract
Cardiac involvement is common in patients with light-chain (AL) amyloidosis and portends a poor prognosis, although little is known about the changes in cardiac mechanics after chemotherapy. We sought to explore the relation between amyloidosis staging and baseline cardiac mechanics and to investigate short-term changes in cardiac mechanics after chemotherapy. We identified 41 consecutive patients from the Stanford Amyloid Center who had echocardiograms and free light-chain values before and after chemotherapy, along with 40 age- and gender-matched controls. Echocardiographic assessment included left ventricular global longitudinal strain, E/e' ratio, and left atrial (LA) stiffness. Hematologic response to chemotherapy was defined as ≥50% reduction in the difference between the involved and the uninvolved free light chain (dFLC). The mean age was 66.9 ± 8.4 years and 66% were men. Before chemotherapy, global longitudinal strain, E/e' ratio, and LA stiffness were impaired in patients with amyloidosis compared with controls, and the severity of impairment worsened with advanced staging. After chemotherapy, hematologic response was observed in 30 (73%) patients. There was a significant association between the change in dFLC and cardiac function (E/e' ratio: r = -0.43, p = 0.01; LA stiffness: r = -0.35, p = 0.05). There was no significant improvement in cardiac mechanics in patients without a hematologic response to chemotherapy. In conclusion, amyloidosis stage correlated with noninvasive measurements of cardiac mechanics, and improvement in dFLC correlated with cardiac improvement on short-term follow-up echocardiography.
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Affiliation(s)
- Mirela Tuzovic
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California.
| | - Yukari Kobayashi
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Matthew Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Christopher Barrett
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Michaela Liedtke
- Division of Hematology, Stanford University School of Medicine, Stanford, California
| | - Richard Lafayette
- Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Stanley Schrier
- Division of Hematology, Stanford University School of Medicine, Stanford, California
| | - Francois Haddad
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Ronald Witteles
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
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Sachchithanantham S, Berlanga O, Alvi A, Mahmood SA, Lachmann HJ, Gillmore JD, Hawkins PN, Harding S, Wechalekar AD. Immunoparesis defined by heavy+light chain suppression is a novel marker of long-term outcomes in cardiac AL amyloidosis. Br J Haematol 2017; 179:575-585. [PMID: 28990174 DOI: 10.1111/bjh.14908] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 07/23/2017] [Indexed: 01/14/2023]
Abstract
Cardiac involvement and presenting dFLC (difference between involved and uninvolved free light chains) are independent predictors of outcome in systemic AL amyloidosis. These markers have limited prognostic utility in patients surviving the initial months following diagnosis. Here we assessed immunoparesis, as determined by novel heavy+light chain (HLC) immunoassays, as a prognostic marker for survival in AL amyloidosis. HLC measurements identified immunoparesis of at least one immunoglobulin (Ig) isotype in 145 (85%) patients; and severe immunoparesis (≥2 Ig isotypes suppressed by >50% below normal levels) in 29 (17%) patients. Median overall survival (OS) on intention to treat (ITT) analysis was 26·2 months. In the ITT cohort, dFLC >180 mg/l was associated with shorter OS (P = 0·05); whereas HLC immunoparesis was not prognostic. On a landmark analysis of 127 patients alive at 6 months, presenting dFLC was not prognostic for OS (P = 0·33) and severe HLC immunoparesis trended towards poorer survival (20·2 vs. 42·8 months; P = 0·09). In the subset of patients with cardiac involvement, severe HLC immunoparesis conferred very poor outcome (median OS 8·8 vs. 29·9 months, P = 0·007). In conclusion, severe HLC immunoparesis is an independent marker of long-term poor prognosis in AL patients with cardiac involvement. The pathophysiological significance of this observation needs further study.
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Affiliation(s)
- Sajitha Sachchithanantham
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | | | - Azra Alvi
- The Binding Site Group Ltd., Birmingham, UK
| | - Shameem A Mahmood
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | - Helen J Lachmann
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | - Julian D Gillmore
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | - Philip N Hawkins
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
| | | | - Ashutosh D Wechalekar
- Centre for Amyloidosis and Acute Phase Proteins, University College London (Royal Free Campus), London, UK
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Clinical presentation and outcomes in light chain amyloidosis patients with non-evaluable serum free light chains. Leukemia 2017; 32:729-735. [PMID: 28919633 DOI: 10.1038/leu.2017.286] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 08/21/2017] [Accepted: 08/30/2017] [Indexed: 12/11/2022]
Abstract
Hematologic response criteria in light chain (AL) amyloidosis require the difference in involved and uninvolved free light chains (dFLC) to be at least 5 mg/dl. We describe the clinical presentation and outcomes of newly diagnosed amyloidosis patients with dFLC <5 mg/dl (non-evaluable dFLC; 14%, n=165) compared with patients with dFLC ⩾5 mg/dl (evaluable dFLC; 86%, n=975). Patients with non-evaluable dFLC had less cardiac involvement (40% vs 80%, P<0.001), less liver involvement (11% vs 17%, P=0.04) and a trend toward less gastrointestinal involvement (18% vs 25%, P=0.08). However, significantly higher renal involvement (72% vs 56%, P=0.0002) was observed in the non-evaluable dFLC cohort. Differences in treatment patterns were observed, with 51% of treated patients undergoing upfront stem cell transplantation in the non-evaluable cohort compared with 28% in the evaluable dFLC group (P<0.001). Progression-free survival (61 vs 13 months, P<0.001) and overall survival (OS; 101 vs 29 months, P<0.001) were significantly longer in the non-evaluable dFLC cohort. Normalization of involved light chain levels and decrease in dFLC <1 mg/dl (baseline at least 2 mg/dl) were predictive of OS and associated with better dialysis-free survival and may be used for response assessment in patients with non-evaluable FLC levels.
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Adams D, Suhr OB, Dyck PJ, Litchy WJ, Leahy RG, Chen J, Gollob J, Coelho T. Trial design and rationale for APOLLO, a Phase 3, placebo-controlled study of patisiran in patients with hereditary ATTR amyloidosis with polyneuropathy. BMC Neurol 2017; 17:181. [PMID: 28893208 PMCID: PMC5594468 DOI: 10.1186/s12883-017-0948-5] [Citation(s) in RCA: 125] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 08/22/2017] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Patisiran is an investigational RNA interference (RNAi) therapeutic in development for the treatment of hereditary ATTR (hATTR) amyloidosis, a progressive disease associated with significant disability, morbidity, and mortality. METHODS Here we describe the rationale and design of the Phase 3 APOLLO study, a randomized, double-blind, placebo-controlled, global study to evaluate the efficacy and safety of patisiran in patients with hATTR amyloidosis with polyneuropathy. Eligible patients are 18-85 years old with hATTR amyloidosis, investigator-estimated survival of ≥2 years, Neuropathy Impairment Score (NIS) of 5-130, and polyneuropathy disability score ≤IIIb. Patients are randomized 2:1 to receive either intravenous patisiran 0.3 mg/kg or placebo once every 3 weeks. The primary objective is to determine the efficacy of patisiran at 18 months based on the difference in the change in modified NIS+7 (a composite measure of motor strength, sensation, reflexes, nerve conduction, and autonomic function) between the patisiran and placebo groups. Secondary objectives are to evaluate the effect of patisiran on Norfolk-Diabetic Neuropathy quality of life questionnaire score, nutritional status (as evaluated by modified body mass index), motor function (as measured by NIS-weakness and timed 10-m walk test), and autonomic symptoms (as measured by the Composite Autonomic Symptom Score-31 questionnaire). Exploratory objectives include assessment of cardiac function and pathologic evaluation to assess nerve fiber innervation and amyloid burden. Safety of patisiran will be assessed throughout the study. DISCUSSION APOLLO represents the largest randomized, Phase 3 study to date in patients with hATTR amyloidosis, with endpoints that capture the multisystemic nature of this disease. TRIAL REGISTRATION This trial is registered at clinicaltrials.gov ( NCT01960348 ); October 9, 2013.
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Affiliation(s)
- David Adams
- CHU Hôpital Bicêtre, Le Kremlin-Bicêtre CEDEX, Paris, France
| | - Ole B. Suhr
- Department of Public Health and Clinical Medicine, Umeå University Hospital, Umeå, Sweden
| | - Peter J. Dyck
- Department of Neurology, Mayo Clinic, Rochester, MN USA
| | | | | | | | | | - Teresa Coelho
- Hospital Santo António, Centro Hospitalar do Porto, Porto, Portugal
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AL amyloidosis patients with low amyloidogenic free light chain levels at first diagnosis have an excellent prognosis. Blood 2017; 130:632-642. [DOI: 10.1182/blood-2017-02-767475] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 05/23/2017] [Indexed: 01/21/2023] Open
Abstract
Key PointsAL patients with an initial dFLC <50 mg/L represent a distinct clinical subgroup with mostly renal disease and a favorable prognosis. These patients are evaluable for hematologic response including a novel low-dFLC partial response, which predict renal and overall survival.
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Mankad AK, Sesay I, Shah KB. Light-chain cardiac amyloidosis. Curr Probl Cancer 2017; 41:144-156. [DOI: 10.1016/j.currproblcancer.2016.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Accepted: 11/14/2016] [Indexed: 12/17/2022]
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Clinical Proof of Concept for a Novel Hepatocyte-Targeting GalNAc-siRNA Conjugate. Mol Ther 2017; 25:71-78. [PMID: 28129130 DOI: 10.1016/j.ymthe.2016.10.019] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 10/19/2016] [Accepted: 10/21/2016] [Indexed: 01/05/2023] Open
Abstract
Advancement of RNAi-based therapeutics depends on effective delivery to the site of protein synthesis. Although intravenously administered, multi-component delivery vehicles have enabled small interfering RNA (siRNA) delivery and progression into clinical development, advances of single-component, systemic siRNA delivery have been challenging. In pre-clinical models, attachment of a triantennary N-acetylgalactosamine (GalNAc) ligand to an siRNA mediates hepatocyte uptake via the asialoglycoprotein receptor enabling RNAi-mediated gene silencing. In this phase 1 study, we assessed translation of this delivery approach by evaluating the safety, tolerability, pharmacokinetics, and pharmacodynamics of a GalNAc-siRNA conjugate, revusiran, targeting transthyretin (TTR). Subjects received a placebo or ascending doses of revusiran subcutaneously ranging from 1.25-10 mg/kg in the single and 2.5-10 mg/kg in the multiple ascending dose phases. Revusiran was generally well tolerated, with transient, mild to moderate injection site reactions the most common treatment-emergent adverse events. Doses of 2.5-10 mg/kg revusiran elicited a significant reduction of serum TTR versus the placebo (p < 0.01), with mean TTR reductions of approximately 90% observed with multiple dosing. These results demonstrate translation of this novel delivery platform, enabling clinical development of subcutaneously administered GalNAc-siRNAs for liver-based diseases.
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Ono K, Ishimaru G, Hayashi M, Bae Y, Ito T, Izumo T, Murata K. The Imaging Diagnosis of Less Advanced Cases of Cardiac Amyloidosis: The Relative Apical Sparing Pattern. Intern Med 2017; 56:315-319. [PMID: 28154276 PMCID: PMC5348456 DOI: 10.2169/internalmedicine.56.7610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
An early diagnosis is important for improving the prognosis of cardiac amyloidosis (CA). We herein describe the utility of two-dimensional speckle tracking echocardiography (2-D STE) in diagnosing CA at a less advanced stage. A 63-year-old woman with exertional dyspnea was suspected of having CA based on her echocardiographic and electrocardiographic findings. A myocardial biopsy was negative for amyloid deposits, while the relative apical sparing pattern was detected on 2-D STE, which was highly suggestive of CA. Chemotherapy was initiated as a treatment for CA, and the patient's symptoms were immediately relieved. Thereafter, amyloid deposits were detected in a skin biopsy specimen.
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Affiliation(s)
- Koya Ono
- Department of Hematology, Soka Municipal Hospital, Japan
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36
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Campbell JP, Heaney JL, Shemar M, Baldwin D, Griffin AE, Oldridge E, Goodall M, Afzal Z, Plant T, Cobbold M, Jefferis R, Jacobs JF, Hand C, Drayson MT. Development of a rapid and quantitative lateral flow assay for the simultaneous measurement of serum κ and λ immunoglobulin free light chains (FLC): inception of a new near-patient FLC screening tool. ACTA ACUST UNITED AC 2017; 55:424-434. [DOI: 10.1515/cclm-2016-0194] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 07/07/2016] [Indexed: 12/23/2022]
Abstract
AbstractBackground:Serum free light chains (FLC) are sensitive biomarkers used for the diagnosis and management of plasma cell dyscrasias, such as multiple myeloma (MM), and are central to clinical screening algorithms and therapy response criteria. We have developed a portable, near-patient, lateral-flow test (SeraliteMethods:Assay interference, imprecision, lot-to-lot variability, linearity, and the utility of a competitive-inhibition design for the elimination of antigen-excess (‘hook effect’) were assessed. Reference ranges were calculated from 91 healthy donor sera. Preliminary clinical validation was conducted by retrospective analysis of sera from 329 patients. Quantitative and diagnostic results were compared to FreeliteResults:SeraliteConclusions:Seralite
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Prokaeva T, Spencer B, Sun F, O'Hara RM, Seldin DC, Connors LH, Sanchorawala V. Immunoglobulin heavy light chain test quantifies clonal disease in patients with AL amyloidosis and normal serum free light chain ratio. Amyloid 2016; 23:214-220. [PMID: 27677679 DOI: 10.1080/13506129.2016.1219715] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND Serum and urine immunofixation electrophoreses (SIFE/UIFE) are used for clonal detection in plasma cell dyscrasias, while serum free light chain (sFLC) testing provides quantitation of clonal disease. Up to 20% of patients with light chain (AL) amyloidosis may present with normal FLC ratio (FLCr). METHODS We assessed the diagnostic, quantitative and prognostic potential of serum heavy light chain ratio (HLCr) in 199 untreated patients at initial evaluation. RESULTS An abnormal HLCr was found in 37.2%, abnormal FLCr in 81.9% and positivity by SIFE/UIFE in 94% of patients. HLCr together with SIFE/UIFE identified clonality in 94% patients; the combination with FLCr yielded 100% sensitivity. An HLCr abnormality was significantly over-represented in normal compared to abnormal FLCr group (63.9% versus 31.3%). HLCr did not predict overall survival (OS) (log rank, p = 0.09), while an abnormal FLCr was associated with decreased OS (log rank, p = 0.03). The combined use of both ratios trended toward increased OS in the abnormal HLCr/normal FLCr group (log rank, p = 0.11; Wilcoxon, p = 0.04). On multivariate analysis, HLCr was not predictive of OS, whereas an abnormal FLCr was associated with shorter OS (HR = 1.7, p = 0.04). CONCLUSIONS The HLC assay has potential as a supplemental test to quantify monoclonal protein in patients with normal FLCr results.
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Affiliation(s)
- Tatiana Prokaeva
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA
| | - Brian Spencer
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA
| | - Fangui Sun
- b Boston University School of Public Health , Boston , MA , USA
| | | | - David C Seldin
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,d Department of Medicine , Section of Hematology and Oncology, Boston Medical Center , Boston , MA , USA
| | - Lawreen H Connors
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA
| | - Vaishali Sanchorawala
- a Amyloidosis Center , Boston University School of Medicine , Boston , MA , USA.,d Department of Medicine , Section of Hematology and Oncology, Boston Medical Center , Boston , MA , USA
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A Case of Abdominal Aortic Retroperitoneal and Mesenteric Amyloid Light Chain Amyloidoma. Case Rep Rheumatol 2016; 2016:4146030. [PMID: 27752386 PMCID: PMC5056293 DOI: 10.1155/2016/4146030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/31/2016] [Indexed: 11/21/2022] Open
Abstract
We report the case of a Japanese woman with amyloid light chain (AL) amyloidoma in the abdominal aortic retroperitoneum and mesentery. Irregular soft tissue mass lesions with calcification in the abdominal aortic retroperitoneum and mesentery were initially detected by computed tomography at another hospital. The lesions gradually compressed the duodenum, causing symptoms of bowel obstruction. The patient was clinically diagnosed with retroperitoneal fibrosis, and prednisolone was administered at a dose of 40 mg/day. However, the lesions did not change in size and her symptoms continued. She was transferred to our hospital and underwent mesenteric biopsy for histopathology using abdominal laparotomy. The histopathological and immunohistological findings of the mesenteric specimen demonstrated lambda light chain deposition. Accordingly, the patient was finally diagnosed with AL amyloidoma with no evidence of systemic amyloidosis. After laparotomy, her general condition worsened because of complications of pneumonia and deep vein thrombosis. She died suddenly from acute myocardial infarction. We have concluded that abdominal aortic retroperitoneal and mesenteric AL amyloidoma may have very poor prognoses in accordance with previous reports. In addition, the size and location of AL amyloidoma directly influence the prognosis. We suggest that early histopathology is important for improving prognosis.
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Ackermann EJ, Guo S, Benson MD, Booten S, Freier S, Hughes SG, Kim TW, Jesse Kwoh T, Matson J, Norris D, Yu R, Watt A, Monia BP. Suppressing transthyretin production in mice, monkeys and humans using 2nd-Generation antisense oligonucleotides. Amyloid 2016; 23:148-157. [PMID: 27355239 DOI: 10.1080/13506129.2016.1191458] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Transthyretin amyloidosis (ATTR amyloidosis) is a rare disease that results from the deposition of misfolded transthyretin (TTR) protein from the plasma into tissues as amyloid fibrils, leading to polyneuropathy and cardiomyopathy. IONIS-TTRRx (ISIS 420915) is a 2nd-Generation 2'-O-(2-methoxyethyl) modified "2'-MOE" antisense oligonucleotide (ASO) that targets the TTR RNA transcript and reduces the levels of the TTR transcript through an RNaseH1 mechanism of action, leading to reductions in both mutant and wild-type TTR protein. The activity of IONIS-TTRRx to decrease TTR protein levels was studied in transgenic mice bearing the Ile84Ser human TTR mutant, in cynomolgus monkeys and in healthy human volunteers. Robust (>80%) reductions of plasma TTR protein were obtained in all three species treated with IONIS-TTRRx, which in mice and monkeys was associated with substantial reductions in hepatic TTR RNA levels. These effects were dose-dependent and lasted for weeks post-dosing. In a Phase 1 healthy volunteer study, treatment with IONIS-TTRRx for four weeks was well tolerated without any remarkable safety issues. TTR protein reductions up to 96% in plasma were observed. These nonclinical and clinical results support the ongoing Phase 3 development of IONIS-TTRRx in patients with ATTR amyloidosis.
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Affiliation(s)
| | - Shuling Guo
- a Ionis Pharmaceuticals , Carlsbad , CA , USA and
| | - Merrill D Benson
- b Department of Pathology and Laboratory Medicine , Indiana University School of Medicine , Indianapolis , IN , USA
| | - Sheri Booten
- a Ionis Pharmaceuticals , Carlsbad , CA , USA and
| | - Sue Freier
- a Ionis Pharmaceuticals , Carlsbad , CA , USA and
| | | | - Tae-Won Kim
- a Ionis Pharmaceuticals , Carlsbad , CA , USA and
| | - T Jesse Kwoh
- a Ionis Pharmaceuticals , Carlsbad , CA , USA and
| | - John Matson
- a Ionis Pharmaceuticals , Carlsbad , CA , USA and
| | - Dan Norris
- a Ionis Pharmaceuticals , Carlsbad , CA , USA and
| | - Rosie Yu
- a Ionis Pharmaceuticals , Carlsbad , CA , USA and
| | - Andy Watt
- a Ionis Pharmaceuticals , Carlsbad , CA , USA and
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Mahmood S, Wassef NL, Salter SJ, Sachchithanantham S, Lane T, Foard D, Whelan CJ, Lachmann HJ, Gillmore JD, Hawkins PN, Wechalekar AD. Comparison of Free Light Chain Assays: Freelite and N Latex in Diagnosis, Monitoring, and Predicting Survival in Light Chain Amyloidosis. Am J Clin Pathol 2016; 146:78-85. [PMID: 27353767 DOI: 10.1093/ajcp/aqw079] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Measurement of serum free light chains (FLCs) is critical in diagnosis, prognosis, and monitoring treatment responses in light chain (AL) amyloidosis. We compare the Freelite assay (polyclonal antibodies to hidden light chain epitopes), which is the current gold standard, with a new assay: a mixture of monoclonal antibodies to light chain epitopes (N Latex). METHODS We collected 240 serum samples from 94 consecutive patients with newly diagnosed AL amyloidosis (at least three serial serum samples during the first 6 months) analyzed at the National Amyloidosis Centre, London, from January 2011 to April 2012. Concordance in detecting abnormal light chain components and hematologic response was assessed at 2, 4, and 6 months. RESULTS The κ and λ clonal light chain involvement was 21% and 79%, respectively, with an abnormal κ/λ ratio or detectable protein in 78.7%. Median κ, λ, and difference in involved and uninvolved FLCs by Freelite and N Latex assays were 17.3 vs 16 mg/L (R(2 ) = 0.91), 48.8 vs 52.6 mg/L (R(2) = 0.52), and 43.2 vs 39.1 mg/L, respectively. Discordant κ/λ ratios at presentation were as follows: 10 of 90 abnormal by Freelite/normal by N Latex and 11 of 90 abnormal by N Latex/normal by Freelite. CONCLUSIONS Both FLC assays show good correlation in detecting the abnormal light chain subtype with discordance in absolute values and thus are not interchangeable.
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Affiliation(s)
- Shameem Mahmood
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Nancy L Wassef
- Clinical Biochemistry Department, Royal Free London Foundation Trust, London, United Kingdom
| | - Simon J Salter
- Clinical Biochemistry Department, Royal Free London Foundation Trust, London, United Kingdom
| | - Sajitha Sachchithanantham
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - T Lane
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - D Foard
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Carol J Whelan
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Helen J Lachmann
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Julian D Gillmore
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Philip N Hawkins
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
| | - Ashutosh D Wechalekar
- From the National Amyloidosis Centre, University College London Medical School, Royal Free Hospital Campus, London, United Kingdom
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Abstract
Amyloidosis is a disorder of protein folding in which normally soluble plasma proteins aggregate in an abnormal fibrillar form causing progressive disruption to tissue structure and organ function. This review covers systemic AA and AL amyloidosis which may arise as a consequence of chronic respiratory conditions; the manifestations of both systemic and of localised amyloid deposition within the respiratory tract and provides a summary of current approaches to diagnosis and management.
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Affiliation(s)
- H J Lachmann
- National Amyloidosis Centre and Centre for Amyloidosis and Acute Phase Proteins, Department of Medicine, Royal Free and University College Medical School, Royal Free Campus, London, UK.
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Bartels H, Dikkers FG, van der Wal JE, Lokhorst HM, Hazenberg BPC. Laryngeal Amyloidosis: Localized versus Systemic Disease and Update on Diagnosis and Therapy. Ann Otol Rhinol Laryngol 2016; 113:741-8. [PMID: 15453534 DOI: 10.1177/000348940411300913] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The clinical and pathological characteristics, possibility of systemic disease, and effect of local therapy were studied in laryngeal amyloidosis. Records of all patients with localized laryngeal amyloidosis in a single tertiary referral center were examined retrospectively at diagnosis and after local therapy. Of 188 new patients with amyloidosis between 1990 and 2003, 5 patients had localized laryngeal amyloidosis. A sixth patient with localized laryngeal amyloidosis turned out to have systemic AL (immunocyte-derived) amyloidosis 8 years later. Free light chains were found in this patient, as well as in 1 of the other 5 patients. Amyloid interfering with laryngeal or airway function was removed during microlaryngoscopy with a carbon dioxide laser or cold endoscopic excision. The best results were seen when glottic deposits were removed by cold endoscopic excision, and supraglottic deposits by a carbon dioxide laser. Four patients had recurrent disease. A systematic workup, including measurement of free light chains, helps to rule out systemic disease.
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Affiliation(s)
- Hilke Bartels
- Department of Otorhinolaryngology, University Hospital Groningen, Groningen, the Netherlands
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Abstract
Tissue deposition of protein fibrils causes a group of rare diseases called systemic amyloidoses. This Seminar focuses on changes in their epidemiology, the current approach to diagnosis, and advances in treatment. Systemic light chain (AL) amyloidosis is the most common of these conditions, but wild-type transthyretin cardiac amyloidosis (ATTRwt) is increasingly being diagnosed. Typing of amyloid fibrils, a critical determinant of therapy, has improved with the wide availability of laser capture and mass spectrometry from fixed histological tissue sections. Specific and accurate evaluation of cardiac amyloidosis is now possible using cardiac magnetic resonance imaging and cardiac repurposing of bone scintigraphy tracers. Survival in AL amyloidosis has improved markedly as novel chemotherapy agents have become available, but challenges remain in advanced disease. Early diagnosis, a key to better outcomes, still remains elusive. Broadening the amyloid-specific therapeutic landscape to include RNA inhibitors, fibril formation stabilisers and inhibitors, and immunotherapeutic targeting of amyloid deposits holds promise to transform outcomes in systemic amyloidoses.
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Affiliation(s)
- Ashutosh D Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK.
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
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Butler JS, Chan A, Costelha S, Fishman S, Willoughby JLS, Borland TD, Milstein S, Foster DJ, Gonçalves P, Chen Q, Qin J, Bettencourt BR, Sah DW, Alvarez R, Rajeev KG, Manoharan M, Fitzgerald K, Meyers RE, Nochur SV, Saraiva MJ, Zimmermann TS. Preclinical evaluation of RNAi as a treatment for transthyretin-mediated amyloidosis. Amyloid 2016; 23:109-18. [PMID: 27033334 PMCID: PMC4898164 DOI: 10.3109/13506129.2016.1160882] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
ATTR amyloidosis is a systemic, debilitating and fatal disease caused by transthyretin (TTR) amyloid accumulation. RNA interference (RNAi) is a clinically validated technology that may be a promising approach to the treatment of ATTR amyloidosis. The vast majority of TTR, the soluble precursor of TTR amyloid, is expressed and synthesized in the liver. RNAi technology enables robust hepatic gene silencing, the goal of which would be to reduce systemic levels of TTR and mitigate many of the clinical manifestations of ATTR that arise from hepatic TTR expression. To test this hypothesis, TTR-targeting siRNAs were evaluated in a murine model of hereditary ATTR amyloidosis. RNAi-mediated silencing of hepatic TTR expression inhibited TTR deposition and facilitated regression of existing TTR deposits in pathologically relevant tissues. Further, the extent of deposit regression correlated with the level of RNAi-mediated knockdown. In comparison to the TTR stabilizer, tafamidis, RNAi-mediated TTR knockdown led to greater regression of TTR deposits across a broader range of affected tissues. Together, the data presented herein support the therapeutic hypothesis behind TTR lowering and highlight the potential of RNAi in the treatment of patients afflicted with ATTR amyloidosis.
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Affiliation(s)
| | - Amy Chan
- a Alnylam Pharmaceuticals , Cambridge , MA , USA
| | - Susete Costelha
- b Instituto de Investigação e Inovação em Saúde, Universidade do Porto , Porto , Portugal .,c Molecular Neurobiology, IBMC - Institute for Molecular and Cell Biology Porto , Porto , Portugal
| | | | | | | | | | | | - Paula Gonçalves
- b Instituto de Investigação e Inovação em Saúde, Universidade do Porto , Porto , Portugal .,c Molecular Neurobiology, IBMC - Institute for Molecular and Cell Biology Porto , Porto , Portugal
| | - Qingmin Chen
- a Alnylam Pharmaceuticals , Cambridge , MA , USA
| | - June Qin
- a Alnylam Pharmaceuticals , Cambridge , MA , USA
| | | | - Dinah W Sah
- a Alnylam Pharmaceuticals , Cambridge , MA , USA
| | - Rene Alvarez
- a Alnylam Pharmaceuticals , Cambridge , MA , USA
| | | | | | | | | | | | - Maria J Saraiva
- b Instituto de Investigação e Inovação em Saúde, Universidade do Porto , Porto , Portugal .,c Molecular Neurobiology, IBMC - Institute for Molecular and Cell Biology Porto , Porto , Portugal
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Bravo García-Morato M, Padilla-Merlano B, Nozal P, Espiño M, Juárez C, Villar L, López-Trascasa M. Laboratory guidelines for the diagnosis and follow-up of patients with monoclonal gammopathies. Rev Clin Esp 2016. [DOI: 10.1016/j.rceng.2015.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dejoie T, Attal M, Moreau P, Harousseau JL, Avet-Loiseau H. Comparison of serum free light chain and urine electrophoresis for the detection of the light chain component of monoclonal immunoglobulins in light chain and intact immunoglobulin multiple myeloma. Haematologica 2016; 101:356-62. [PMID: 26635032 PMCID: PMC4815727 DOI: 10.3324/haematol.2015.126797] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 11/26/2015] [Indexed: 11/09/2022] Open
Abstract
Response criteria for multiple myeloma are based upon changes in monoclonal protein levels quantified using serum and/or urine protein electrophoresis. The latter lacks sensitivity at low monoclonal protein levels and since 2001, the serum free light chain test has been available and its clinical utility proven, yet guidelines have not recommended it as a replacement for urine assessment. Herein we evaluated responses using serum free light chain measurements and serum and urine electrophoresis after 2 and 4 cycles of therapy and after stem cell transplantation in 25 light chain and 157 intact immunoglobulin myeloma patients enrolled in the IFM 2007-02 MM trial. All 25 light chain patients had measurable disease by serum free light chain and urine methods at presentation. By contrast 98 out of 157 intact immunoglobulin patients had measurable disease by serum free light chain compared to 55 out of 157 by urine electrophoresis. In all patients there was substantial agreement between predicate (serum/urine protein electrophoresis) and test (serum protein electrophoresis and serum free light chain) methods for response assessment (Weighted Kappa=0.83). Urine immunofixation became negative in 47% light chain and 43% intact immunoglobulin patients after 2 cycles of therapy. At this time the serum free light chain ratio normalised in only 11% and 27% patients, respectively. In summary we found good agreement between methods for response assessment, but the serum free light chain test provided greater sensitivity than urine electrophoresis for monitoring. To our knowledge this is the first report comparing both methods for response assignment based on the International Myeloma Working Group guidelines. (Clinical Trials Register.eu identifier: 2007-005204-40).
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Affiliation(s)
| | - Michel Attal
- Institut Universitaire du Cancer, Toulouse, France
| | | | | | - Herve Avet-Loiseau
- Institut Universitaire du Cancer, University Hospital, CRCT, INSERM U1037, Toulouse, France
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Bridoux F, Javaugue V, Fermand JP, Jaccard A. Is there still a place for autologous stem cell transplantation in systemic AL amyloidosis with severe renal disease? Nephrol Dial Transplant 2016; 31:1199-202. [PMID: 26908764 DOI: 10.1093/ndt/gfv460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 12/22/2015] [Indexed: 11/13/2022] Open
Affiliation(s)
- Frank Bridoux
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Vincent Javaugue
- Department of Nephrology, Dialysis and Renal Transplantation, University Hospital of Poitiers, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Poitiers, France
| | - Jean Paul Fermand
- Department of Hematology and Clinical Immunology, Saint Louis University Hospital, Paris, France
| | - Arnaud Jaccard
- Department of Hematology, University Hospital of Limoges, Centre de référence de l'amylose AL et des autres maladies par dépôts d'immunoglobuline monoclonale, Limoges, France
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Weber N, Mollee P, Augustson B, Brown R, Catley L, Gibson J, Harrison S, Ho PJ, Horvath N, Jaksic W, Joshua D, Quach H, Roberts AW, Spencer A, Szer J, Talaulikar D, To B, Zannettino A, Prince HM. Management of systemic AL amyloidosis: recommendations of the Myeloma Foundation of Australia Medical and Scientific Advisory Group. Intern Med J 2016; 45:371-82. [PMID: 25169210 DOI: 10.1111/imj.12566] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Accepted: 08/19/2014] [Indexed: 11/30/2022]
Abstract
Systemic AL amyloidosis is a plasma cell dyscrasia with a characteristic clinical phenotype caused by multi-organ deposition of an amyloidogenic monoclonal protein. This condition poses a unique management challenge due to the complexity of the clinical presentation and the narrow therapeutic window of available therapies. Improved appreciation of the need for risk stratification, standardised use of sensitive laboratory testing for monitoring disease response, vigilant supportive care and the availability of newer agents with more favourable toxicity profiles have contributed to the improvement in treatment-related mortality and overall survival seen over the past decade. Nonetheless, with respect to the optimal management approach, there is a paucity of high-level clinical evidence due to the rarity of the disease, and enrollment in clinical trials is still the preferred approach where available. This review will summarise the Clinical Practice Guidelines on the Management of Systemic Light Chain (AL) Amyloidosis recently prepared by the Medical Scientific Advisory Group of the Myeloma Foundation of Australia. It is hoped that these guidelines will assist clinicians in better understanding and optimising the management of this difficult disease.
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Affiliation(s)
- N Weber
- Clinical Haematology and Bone Marrow Transplant Unit, Royal Brisbane and Women's Hospital, Brisbane, Australia
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50
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Free light chain testing for the diagnosis, monitoring and prognostication of AL amyloidosis. ACTA ACUST UNITED AC 2016; 54:921-7. [DOI: 10.1515/cclm-2015-0938] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 12/14/2015] [Indexed: 01/05/2023]
Abstract
AbstractThe disease causing agent in systemic AL amyloidosis is a monoclonal immunoglobulin free light chain, or fragments thereof, circulating in the blood. It is not surprising, therefore, that measurement of serum free light chains plays a central role in the management of this disorder. In this paper, we review the utility of the serum free light chain assay in the investigation, prognostication and monitoring of AL amyloidosis. Data on the two currently available commercial assays is compared and some practical applications of the assay’s use are presented. While there are limitations, it is clear that the availability of the free light chain assay in the laboratory is a major advance and plays an essential role in the management of patients with AL amyloidosis.
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