New Insights into the Pathogenesis of Hemodialysis-Associated Amyloidosis

Serum Alpha-1-Antitrypsin in Hemodialysis Patients with Dialysis Arthropathy

Dialysis arthropathy is the most prominent dialysis-related amyloidosis feature. Alpha-1-antitrypsin (alpha-1-proteinase inhibitor) is the major circulating antiprotease. Twenty-three otherwise uncomplicated hemodialysis patients with well-documented dialysis arthropathy had a significantly (p < 0.05) lower serum mean concentration, 1,960 ± 410.4 mg/I of alpha-1-antitrypsin than 47 patients with no joint symptoms who had a mean concentration of 2,256.6 ± 424.5 mg/I. Decreased levels of the substance were detected in 13 (56.5%) of the 23 patients with dialysis arthropathy and in 13 (27.6%) of those 47 with no joint symptoms, the incidence in the former group being significantly (p < 0.05) higher than in the latter. In the dialysis arthropathy group, serum alpha-1-antitrypsin levels correlated inversely (r = −0.54, p < 0.01) with the dialysis duration and directly (r = 0.413, p < 0.05) with the corresponding beta-2-microglobulin determinations. We speculate that reduced antiprotease activity may play a role in amyloidogenesis in the setting of long-term hemodialysis.

Impaired lysosomal processing of beta2-microglobulin by infiltrating macrophages in dialysis amyloidosis

BACKGROUND

Macrophages may participate in amyloid fibril formation by processing the protein precursor. Although this theory seems to apply for amyloidosis, in which proteolytic cleavage is a prerequisite for amyloid fibril formation, it has not been demonstrated for beta2-microglobulin (beta2m) amyloidosis. We aimed to establish the role played by macrophages in beta2m amyloidosis.

METHODS

We used a double immunogold electron microscopy technique, including mouse antihuman CD68, rabbit antihuman beta2m, amyloid P component, and lysosome-associated membrane protein (LAMP-1) antibodies. Differential density labeling studies of beta2m and amyloid P component were performed extra- and intracellularly to assess protein processing by macrophages.

RESULTS

The cells surrounding amyloid fibrils were found to be mostly CD68 positive, suggesting that they were of monocyte-macrophage lineage. Intracellular accumulation of amyloid fibrils was also observed; these fibrils were constantly surrounded by LAMP-1-linked gold particles, demonstrating that intracellular beta2m was almost exclusively lysosomal. The rough-surface endoplasmic reticulum was not labeled by beta2m antibody, suggesting that there was no active synthesis of beta2m by the cells. As a marker of endocytosis, protruded cytoplasmic processes in close relation with the intracellular accumulations of beta2m amyloid fibrils were observed. No difference in density labeling (extracellular vs. intracellular) was observed for beta2m, whereas intracellular P component labeling was significantly decreased.

CONCLUSIONS

All of these data are strongly suggestive of phagocytosis and not synthesis of amyloid fibrils by macrophages. Further, they demonstrate an impaired lysosomal processing specific for beta2m, as other compounds of the amyloid fibrils (P component) are significantly cleared.

Alpha 2-macroglobulin protects some of the protein constituents of dialysis-associated amyloidosis from protease degradation

A crucial point to know in the prevention and treatment of beta 2-microglobulin (beta 2-m) amyloidosis is the putative resorption of amyloid fibrils in vivo. Although still controversial, long term clinical studies suggest that there is no resorption of amyloid fibrils in vivo, even after the suppression of the primary cause of amyloidosis. Two in vitro studies on murine and human AA amyloidosis as well as Alzheimer's disease suggest that protein constituents of amyloid fibrils may be resorbed. Protein resorption can be inhibited by the antiprotease amyloid P component. We extended these in vitro studies on beta 2-m amyloidosis, and assessed the effect of alpha 2-macroglobulin (alpha 2-M), a serum antiprotease previously found in this type of amyloidosis, on the putative protease induced protein resorption. Here, we show that amyloid proteins, beta 2-m and light chains of immunoglobulins, were degraded by trypsin. Preincubation of the amyloid proteins with alpha 2-M significantly inhibited the trypsin induced protein degradation of lambda chains. These data add further support to the hypothesis proposing a role for alpha 2-M and other antiproteases in the formation and/or persistence of beta 2-m amyloidosis.

Beta 2 microglobulin isoforms in healthy individuals and in amyloid deposits

beta 2 microglobulin (beta 2m) is classically known to have isoforms with isoelectric points (pI) 5.7 and 5.3. New isoforms of beta 2m with lower pI, probably due to modifications with advanced glycation end products, were found in the amyloid deposits of dialysis related amyloidosis (DRA), and they were proposed as the amyloidogenic forms of beta 2m. The other modifications in beta 2m from amyloid deposits are partial proteolysis and single amino acid replacement (Asn by ASp at position 17). However, there are no data on the sequence of the different isoforms of beta 2 m from amyloid deposits. Amyloid deposits surgically obtained from the carpal tunnel from 13 dialysis treated patients and urine from 10 healthy volunteers and 5 living-related kidney donors were analyzed for beta 2m content. Two-dimensional gel electrophoresis (2D-PAGE) of beta 2m from amyloid deposits showed the presence of four or more isoforms with pIs < 5.7. All the spots migrating at 12 kDa Mr region and between 4 and 6 pH reacted with rabbit anti-human beta 2m antibody by Western blotting, confirming that they were beta 2m isoforms. beta 2m isoforms from the amyloid deposits were then separately purified with an IEF column (PB94, Pharmacia) for analysis. Enough quantities of three pure beta 2m isoforms could be obtained in two cases. The sequence analysis showed an intact N-terminus in all the isoforms. There was Asn in the 17th residue in all the isoforms sequenced. 2D-PAGE of urine from 8 out of the 10 healthy volunteers showed the presence of beta 2m. In two of them beta 2m also displayed four different isoforms. At least four isoforms were observed in urine of all the kidney donors. The present study shows that the elution peaks of three different beta 2m isoforms in gel isoelectrofocusing contain beta 2m with intact N-terminus. None of them have deamidated their 17th residue. More importantly, the beta 2m isoforms with lower pI are not specific for amyloidosis as they were found in urine from kidney donors and in normal volunteers. These results bring into question the hypothesis that dialysis related amyloidosis is due to the known modifications on beta 2m. They suggest that the precipitation of beta 2m into amyloid fibrils should result from the interaction of beta 2m with other factors with amyloid enhancing activity.

[Carpal tunnel syndrome and amyloid tenosynovitis in patients undergoing chronic hemodialysis. Evaluation and treatment apropos of 130 cases]

Over a 12-year period (1979-1991), 130 carpal tunnel syndromes were diagnosed in 89 haemodialysed renal failure patients, representing 17% of all haemodialysed patients followed over the same period. 6% of patients had been haemodialysed for less than 5 years (mean duration of dialysis: 10.4 years). 25% of cases had a trigger finger and 21 out of 89 patients had amyloid arthropathy. No precise relationship was detected between the side of the carpal tunnel syndrome and the side of the arteriovenous fistula. In 130 cases, release of the median nerve and wide tenosynovectomy of the flexor tendons were performed under pneumatic tourniquet except in the case of a prosthetic shunt. Tenosynovial amyloid deposits were found in 84% of cases. The mean postoperative follow-up was 40 months (range: 6 to 120 months). Postoperatively, the acroparaesthesiae disappeared in 93% of cases. 79% of cases with a sensory defect obtained sensory recovery, versus 27% of cases with a motor deficit for motor recovery. In 20% of the 130 cases, decreased digital mobility was observed postoperatively due to extension of the tenosynovitis to the fingers. Four cases of recurrence were observed.

beta 2-Microglobulin and the kidney: an overview

beta 2 microglobulin is a potentially amyloidogenic low molecular weight protein. Increased serum levels are seen in renal diseases that decrease glomerular filtration and/or tubular reabsorption, dialysis patients, chronic inflammatory diseases, and certain malignancies. Various aspects of beta 2 microglobulin metabolism and its accumulation in the kidney are addressed.

Biocompatibility issues in hemodialysis

Hemodialysis, as a life-saving treatment modality for uremic patients, implies a repeated and compulsory contact of blood with foreign materials. As a consequence, biocompatibility problems are unavoidable. The same applies for the material used for the creation of vascular access, and for the alternative dialysis method, CAPD (continuous ambulatory peritoneal dialysis), although each system might cause its own and specific problems. Although in early dialysis the focus has been on maintenance of life and elimination of toxins, later on the important morbid implications of this lack of biocompatibility have been recognized. Eight major problems will be discussed, especially in the perspective of recent new findings in this field: (1) coagulation and clotting; (2) complement and leukocyte activation; (3) susceptibility to infection; (4) leaching or spallation; (5) surface alterations of solid materials; (6) allergic reactions; (7) shear; (8) transfer of compounds from contaminated dialysate. After description of the major biochemical and clinical implications of these problems, ways to prevent morbid events and future perspectives will be described.