Advances in amyloidosis

Inhibition of TTR aggregation-induced cell death--a new role for serum amyloid P component

Background

Serum amyloid P component (SAP) is a glycoprotein that is universally found associated with different types of amyloid deposits. It has been suggested that it stabilizes amyloid fibrils and therefore protects them from proteolytic degradation.

Methodology/Principal Findings

In this paper, we show that SAP binds not only to mature amyloid fibrils but also to early aggregates of amyloidogenic mutants of the plasma protein transthyretin (TTR). It does not inhibit fibril formation of TTR mutants, which spontaneously form amyloid in vitro at physiological pH. We found that SAP prevents cell death induced by mutant TTR, while several other molecules that are also known to decorate amyloid fibrils do not have such effect. Using a Drosophila model for TTR-associated amyloidosis, we found a new role for SAP as a protective factor in inhibition of TTR-induced toxicity. Overexpression of mutated TTR leads to a neurological phenotype with changes in wing posture. SAP-transgenic flies were crossed with mutated TTR-expressing flies and the results clearly confirmed a protective effect of SAP on TTR-induced phenotype, with an almost complete reduction in abnormal wing posture. Furthermore, we found in vivo that binding of SAP to mutated TTR counteracts the otherwise detrimental effects of aggregation of amyloidogenic TTR on retinal structure.

Conclusions/Significance

Together, these two approaches firmly establish the protective effect of SAP on TTR-induced cell death and degenerative phenotypes, and suggest a novel role for SAP through which the toxicity of early amyloidogenic aggregates is attenuated.

Tissue Doppler imaging in the evaluation of patients with cardiac amyloidosis

PURPOSE OF REVIEW

Although two-dimensional, M-mode, and Doppler echocardiography have played a major role in the assessment of amyloid deposition in the heart, diagnosis of cardiac amyloidosis (CA) based on these conventional techniques is often only possible once the disease is in a relatively advanced stage. To optimize survival, early diagnosis and institution of therapy are essential. Recently, tissue Doppler imaging (TDI) and myocardial strain rate (SR) have emerged as important clinical tools in the assessment of CA.

RECENT FINDINGS

Tissue Doppler imaging-derived modalities including TDI velocities, strain, and SR are currently being used in the early diagnosis and evaluation of patients with CA. Although these new indices have been examined in relatively few patients, findings suggest an important and expanding role of TDI in amyloid infiltration of the heart.

SUMMARY

This review summarizes the recent literature addressing the role of TDI velocities, strain, and SR in the diagnosis and assessment of CA.

Congo red-positive cardiac kappa-AL amyloidosis in plasmacytoma -- case report and review of the literature

We report on a 51-year-old female patient who was diagnosed in 2001 as suffering from plasmacytoma. The patient had had complaints of bilateral carpal tunnel syndrome in 1999, treated by a simple dissection without performing histological examination. Congestive heart failure had gradually developed since that time. In 2001 echocardiography revealed a pronounced thickening of the left ventricular wall with systolic and diastolic dysfunction. A kappa-light chain M component and kappa-light chain-restricted bone marrow plasmacytosis were detected. Amyloid deposits staining positive in the kappa-light chain-restriction analysis were observed in a gastric biopsy. Taking into consideration all these findings, a plasmacytoma-associated systemic AL amyloidosis was diagnosed. Cyclophosphamide/prednisolone chemotherapy regimen led to complete haematological remission. Cardiac transplantation, combined with autologous peripheral blood stem cell graft, was considered as the next therapeutic step, but the patient died while on the waiting list for transplantation. Autopsy detected a highly hypertrophic myocardium with narrowed heart cavities. Microscopic examination revealed dense, pink, acellular, Congo red-staining and kappa-immunoperoxidase-positive AL amyloid masses splitting the cardiomyocytes. The present case is remarkable as it demonstrates that carpal tunnel syndrome and congestive heart failure could be symptoms of plasma cell dyscrasia-associated amyloidoses.

Only amyloidogenic intermediates of transthyretin induce apoptosis

In diseases like Alzheimer's disease and familial amyloidotic polyneuropathy (FAP) amyloid deposits co-localize with areas of neurodegeneration. FAP is associated with mutations of the plasma protein transthyretin (TTR). We can here show an apoptotic effect of amyloidogenic mutants of TTR on a human neuroblastoma cell line. Toxicity could be blocked by catalase indicating a free oxygen radical dependent mechanism. The toxic effect was dependent on the state of aggregation and unexpectedly mature fibrils from FAP-patients who failed to exert an apoptotic response. Morphological studies revealed a correlation between toxicity and the presence of immature amyloid. Thus, we can show that toxicity is associated with early stages of fibril formation and propose that mature full-length fibrils represent an inert end stage, which might serve as a rescue mechanism.

Successful sequential liver and stem cell transplantation for hepatic failure due to primary AL amyloidosis

We report on a patient with primary AL amyloidosis who presented with progressive liver failure secondary to hepatic infiltration in the absence of significant extrahepatic involvement. Orthotopic liver transplantation was performed successfully. After an uneventful postoperative course, the patient developed evidence of significant recurrent amyloidosis requiring treatment. He then underwent stem cell transplantation 10 and 14 months after liver transplantation. After 28 months of follow-up posttransplantation, the patient continues to do well, with no clinical evidence of recurrent disease. This is the first reported patient with primary amyloidosis to undergo sequential liver and stem cell transplantation leading to resolution of the disease and only the second to undergo successful liver transplantation for this disorder.

The role of the synovium and cartilage in the pathogenesis of beta(2)-microglobulin amyloidosis

The predilection for beta(2)-microglobulin (beta(2)M) amyloid deposition in articular structures is unique compared to other forms of amyloid; this article focuses on possible pathogenic mechanisms. The synovium and/or cartilage appear to be important in the pathogenesis of beta(2)M amyloidosis (A beta(2)M), as amyloid is not found in the shafts of long bones. The concentration of beta(2)M in the joint fluid parallels that in serum. Once in the joint space, evidence suggests that the beta(2)M binds to collagen in cartilage as the initial site of deposition. This binding may serve as the first step in subsequent amyloid formation, although this remains to be proven. beta(2)M has been shown to have many direct effects on synovial fibroblasts, including induction of the release of cytokines, metalloproteinases, cyclooxygenase-2, and vascular cell adhesion molecule-1 (VCAM-1). The release of these inflammatory mediators that lead to tissue degradation is also observed in other forms of arthritis. Thus beta(2)M itself may elicit the release of inflammatory mediators from synovial fibroblasts even in the absence of cellular infiltrates.

Wild type ApoA-II gene does not rescue senescence-accelerated mouse (SAMP1) from short life span and accelerated mortality

Biochemical and genetic data suggest that the Apoa2c allele of the apolipoprotein A-II gene causes severe senile amyloidosis (AApoAII) in SAMP1, a mouse model for accelerated senescence. We analyzed the effects of replacement of Apoa2c in SAMP1 mice with non-amyloidogenic Apoa2b on amyloidosis, lipoprotein metabolism, and progression of senescence using a congenic strain, P1.R1-Apoa2b, which has the Apoa2b chromosome region of SAMR1 in the genome of SAMP1. Age-associated amyloid deposition was not observed, but plasma concentrations of apoA-II protein and HDL-cholesterol decreased with age in P1.R1-Apoa2b. P1.R1-Apoa2b showed lower scores of senescence than did SAMP1. However, the life span and mortality rate doubling time were similar in P1.R1-Apoa2b and SAMP1. These results suggest that replacement of Apoa2c with non-amyloidogenic Apoa2b does not rescue SAMP1 mice from a short life span and accelerated mortality.

Echocardiographic features of primary, secondary and familial amyloidosis

BACKGROUND

Currently recognized types of amyloidosis include primary, familial and secondary, each of which may affect the heart. There may be differences in the heart response to the deposition of amyloid fibrils in these three forms of the disease.

MATERIALS AND METHODS

Over a period of 10 years (1985-95), 28 consecutive patients with primary, 11 with secondary and 17 with familial amyloidosis were studied at the Departments of Cardiology of Laiko and Hammersmith Hospitals. The diagnosis of amyloidosis was confirmed by biopsies of subcutaneous fat, rectum, kidney, bone marrow, gum or sural nerve. Diagnosis of cardiac involvement was based on typical electrocardiographic and echocardiographic findings.

RESULTS

The left ventricular fractional shortening (%) was reduced in primary compared with familial or secondary amyloidosis (29.8 +/- 10.2 vs. 36.2 +/- 6.5 vs. 36 +/- 5.9, P < 0.05). The transmitral flow velocity pattern was compatible with abnormal relaxation in most patients in the three groups [primary 16 (57%), familial 11 (64. 7%), secondary 6 (54.5%), P = NS]. Right ventricular systolic dysfunction (right ventricular dP/dt < 220 mmHg s-1 or tricuspid annulus systolic excursion < 10 mm) was present in 8 (28.6%), 2 (11. 8%) and 0 patients. Patients with primary amyloidosis were followed up for 15 +/- 6 months. There were 12 deaths, and repeat echocardiography in the survivors revealed a significant deterioration of left ventricular systolic function (fractional shortening = 23.6% +/- 8.8%, P < 0.05 vs. baseline).

CONCLUSION

Primary amyloidosis is characterized by more severe cardiac involvement than the familial or secondary amyloidosis and has an ominous course.

Exposure of cryptic epitopes on transthyretin only in amyloid and in amyloidogenic mutants

The structural requirements for generation of amyloid from the plasma protein transthyretin (TTR) are not known, although it is assumed that TTR is partly misfolded in amyloid. In a search for structural determinants important for amyloid formation, we generated a TTR mutant with high potential to form amyloid. We demonstrated that the mutant represents an intermediate in a series of conformational changes leading to amyloid. Two monoclonal antibodies were generated against this mutant; each displayed affinity to ex vivo TTR and TTR mutants with amyloidogenic folding but not to wild-type TTR or mutants exhibiting the wild-type fold. Two cryptic epitopes were mapped to a domain of TTR, where most mutations associated with amyloidosis occur and which we propose is displaced at the initial phase of amyloid formation, opening up new surfaces necessary for autoaggregation of TTR monomers. The results provide direct biochemical evidence for structural changes in an amyloidogenic intermediate of TTR.

Systemic amyloidosis and the gastrointestinal tract

Systemic amyloidosis is caused by a variety of different diseases and frequently involves the gastrointestinal tract. Each type of amyloid affects the gastrointestinal tract differently. This article reviews the unique pathogenesis, pattern of gastrointestinal disposition, diagnosis, and treatment of the five systemic amyloidoses, and discusses the gastrointestinal diseases that cause systemic amyloidosis: inflammatory bowel disease and familial Mediterranean fever.

The recognition of haemoglobin by antibodies raised for the immunoassay of beta-amyloid

Canine and porcine cerebrospinal fluid (CSF) were fractionated by size exclusion chromatography and analysed by a luminescence enzyme linked immunosorbent assay (ELISA) configured to detect beta-amyloid. A peak of activity was observed in the CSF consistent with the molecular weight of beta-amyloid. When CSF contaminated with blood was analysed an additional peak of immunoreactivity at a higher molecular weight was observed. The peak of activity was found to be derived from cross-reactivity of the immunoglobulins employed in the ELISA with haemoglobin. These findings are discussed with reference to primary and structural sequence homology between beta-amyloid and haemoglobin from a number of species, the known properties of beta-amyloid and recent clinical reports.

Molecular diagnosis of transthyretin Met30 mutation in an Italian family with familial amyloidotic polyneuropathy

We report the molecular analysis of the transthyretin gene in a large Italian pedigree with familial amyloidotic polyneuropathy and demonstrate the presence of a Met30 mutation. The usefulness of the genetic analysis in the identification of presymptomatic persons and the diagnosis of individuals with partial symptoms is discussed.

Hepatic amyloidosis associated with systemic lupus erythematosus

The association between amyloidosis and systemic lupus erythematosus has rarely been described. We report a case of a 37-year-old man with a long-standing SLE who developed clinical and laboratory signs of hepatic dysfunction. A liver biopsy revealed secondary amyloidosis.

Induction of the mouse serum amyloid A3 gene by cytokines requires both C/EBP family proteins and a novel constitutive nuclear factor

Serum amyloid A (SAA) is a major acute-phase protein synthesized and secreted mainly by the liver. In response to acute inflammation, its expression may be induced up to 1,000-fold, primarily as a result of a 200-fold increase in the rate of SAA gene transcription. We have previously demonstrated that a 350-bp promoter fragment from the mouse SAA3 gene was necessary and sufficient to confer liver-specific and cytokine-induced expression. Deletion studies identified a distal response element that is responsible for the cytokine response and has properties of an inducible transcriptional enhancer. In this study, we further analyzed the distal response element and showed that it consists of three functionally distinct elements: the A element constitutes a weak binding site for C/EBP family proteins, the B element also interacts with C/EBP family proteins but with a much higher binding affinity, and the C element interacts with a novel constitutive nuclear factor, SEF-1. Site-specific mutation studies revealed that all three elements were required for maximum promoter activity. C/EBP alpha, C/EBP beta, and C/EBP delta were capable of interacting with elements A and B. Under noninduced conditions, C/EBP alpha was the major binding factor; however, upon cytokine stimulation C/EBP beta- and C/EBP delta-binding activities were dramatically increased and became the predominant binding factors. Consistent with these binding studies were the cotransfection experiments in which C/EBP beta and C/EBP delta were shown to be potent transactivators for the SAA3 promoter. Moreover, the transactivation required an intact B element despite the presence of other functional C/EBP-binding sites. Interestingly, although element C did not interact with C/EBP directly, it was nevertheless required for maximum transactivation by C/EBP delta. Our studies thus demonstrate that both C/EBP family proteins and SEF-1 are required to transactivate the SAA3 gene.

Induction of the mouse serum amyloid A3 gene by cytokines requires both C/EBP family proteins and a novel constitutive nuclear factor

Serum amyloid A (SAA) is a major acute-phase protein synthesized and secreted mainly by the liver. In response to acute inflammation, its expression may be induced up to 1,000-fold, primarily as a result of a 200-fold increase in the rate of SAA gene transcription. We have previously demonstrated that a 350-bp promoter fragment from the mouse SAA3 gene was necessary and sufficient to confer liver-specific and cytokine-induced expression. Deletion studies identified a distal response element that is responsible for the cytokine response and has properties of an inducible transcriptional enhancer. In this study, we further analyzed the distal response element and showed that it consists of three functionally distinct elements: the A element constitutes a weak binding site for C/EBP family proteins, the B element also interacts with C/EBP family proteins but with a much higher binding affinity, and the C element interacts with a novel constitutive nuclear factor, SEF-1. Site-specific mutation studies revealed that all three elements were required for maximum promoter activity. C/EBP alpha, C/EBP beta, and C/EBP delta were capable of interacting with elements A and B. Under noninduced conditions, C/EBP alpha was the major binding factor; however, upon cytokine stimulation C/EBP beta- and C/EBP delta-binding activities were dramatically increased and became the predominant binding factors. Consistent with these binding studies were the cotransfection experiments in which C/EBP beta and C/EBP delta were shown to be potent transactivators for the SAA3 promoter. Moreover, the transactivation required an intact B element despite the presence of other functional C/EBP-binding sites. Interestingly, although element C did not interact with C/EBP directly, it was nevertheless required for maximum transactivation by C/EBP delta. Our studies thus demonstrate that both C/EBP family proteins and SEF-1 are required to transactivate the SAA3 gene.