Carpal tunnel syndrome caused by amyloid containing beta 2 microglobulin: a new amyloid and a complication of long term haemodialysis

Carpal tunnel release in the dialysis-dependent population: Incidence and outcomes

Level of evidence

Level III, retrospective case-control study.

Background

The association between dialysis and carpal tunnel syndrome is well-established. As the number of patients living with dialysis-dependent end-stage renal disease (ESRD) increases, it is important that we understand outcomes after carpal tunnel release in this population.

Purpose

To investigate (1) the prevalence of carpal tunnel syndrome (CTS) in dialysis-dependent patients, (2) the incidence of carpal tunnel release (CTR), and (3) the differences in complications after CTR between hemodialysis patients, peritoneal dialysis patients, and matched controls.

Patients and methods

Querying the PearlDiver database, we determined prevalence of CTS and incidence of CTR in dialysis-dependent and control patients. We compared peritoneal dialysis (PD) patients to matched populations of hemodialysis (HD) patients and non-dialysis-dependent controls. Complications were identified, including hospital admission, emergency department visits, infection, revision surgery, and postoperative chronic regional pain syndrome (CRPS).

Results

The rates of CTS and CTR in dialysis patients were significantly increased relative to controls. Dialysis-dependent patients had increased rates of hospital admission within 30 days postoperatively (OR 4.13, P ​< ​.0001 for PD; OR 4.42, P ​< ​.0001 for HD), infection within 6 months postoperatively (OR 2.32, P ​= ​.013 for PD; OR 3.20, P ​< ​.0001 for HD), and need for revision CTR (OR 2.04, P ​= ​.009 for PD; OR 1.62, P ​= ​.037 for HD). Emergency department presentation within 30 days postoperatively was less common in PD vs HD (OR 0.63, P ​= ​.038).

Conclusions

When compared to the control population, patients undergoing dialysis are more likely to be diagnosed with carpal tunnel syndrome, undergo carpal tunnel release, and are at significantly increased risk for perioperative complications.

Transthyretin amyloid deposits in lumbar spinal stenosis and assessment of signs of systemic amyloidosis

BACKGROUND

Wild-type transthyretin (ATTRwt) amyloidosis is the most common systemic amyloidosis in Western countries and manifests mainly as progressive restrictive cardiomyopathy.

OBJECTIVE

To study the prevalence of ATTR deposits in ligament tissue in patients undergoing surgery for lumbar spinal stenosis and to assess whether these deposits are associated with cardiac amyloidosis.

MATERIALS AND METHODS

A total of 250 patients, aged 50-89 (57% women), none with known cardiovascular disease, were included. Ligaments were investigated microscopically for amyloid. ATTR type was determined by immunohistochemistry and fibril type by Western blot. The amount of amyloid was graded 0-4. All patients with grade 3-4 ATTR deposits were offered cardiac investigation including ECG, cardiac ultrasound, plasma NT-proBNP and cardiac magnetic resonance (CMR), including modern tissue characterization.

RESULTS

Amyloid was identified in 221 of the samples (88.4%). ATTR appeared in 93 samples (37%) of whom 42 (17 women and 25 men) were graded 3-4; all had fibril type A (mixture of full-length TTR and fragmented TTR). Twenty-nine of 42 patients with grade 3-4 ATTR deposits accepted cardiovascular investigations; none of them had definite signs of cardiac amyloidosis, but five men had a history of carpal tunnel syndrome.

CONCLUSIONS

The prevalence of ATTR deposits in ligamentum flavum in patients with lumbar spinal stenosis was high but not associated with manifest ATTR cardiac amyloidosis. However, the findings of fibril type A, the prevalence of previous carpal tunnel syndrome and ATTR amyloid in surrounding adipose and vascular tissue indicate that amyloid deposits in ligamentum flavum may be an early manifestation of systemic ATTR disease.

Beta-2 Microglobulin in Peritoneal Dialysis Patients: Serum Levels and Peritoneal Clearances

Beta-2 microglobulin (B2M) is amyloidogenic in long-term hemodialysis patients, with amyloid deposition manifesting as lytic bone lesions, carpal tunnel syndrome, destructive arthropathies, tenosynovitis, and pathologic fractures. To study the behavior of this protein in the peritoneal dialysis population, serum levels of B2M from 14 chronic peritoneal dialysis (CPD) patients (4IPD, 10 CAPD) were compared to those of 15 chronic hemodialysis patients, and peritoneal clearances were measured in 9 CAPD patients. Standard cuprophan dialyzers were used for hemodialysis.

Serum B2M levels were significantly lower in the peritoneal dialysis group (mean ± SD 73.2 ± 20.9 mg/L) than in the hemodialysis group (100.3 ± 24.7 mg/L, p < .004). When CAPD patients alone were compared to the hemodialysis patients, lower serum B2M levels were again apparent, with mean 68.7 ± 16.4 mg/L (p ≤ .002). Mean serum B2M in IPD patients (84.6 ± 28.9 mg/L) did not differ statistically from either the CAPD or the hemodialysis group.

Peritoneal clearance of B2M, urea nitrogen, and creatinine over a 6 h exchange were obtained in 9 CAPD patients without peritonitis. Mean clearance (±SD) of B2M was 0.9 ± 0.4 ml/min/1.73 m2, urea nitrogen 5.3 ± 0.3 ml/min/1.73 m2, and creatinine 4.2 ± 0.8 ml/min/1.73 m2. Mean loss of B2M via the peritoneal cavity was 19.9 ± 6.6 mg/2 L-exchange/1.73 m2 (range 7.7 to 26.2 mg/2 L-exchange/1.73 m2).

Decreased serum B2M in peritoneal dialysis patients is consistent with increased clearance by the peritoneal membrane versus standard cellulosic hemodialysis membranes. Whether use of CPD rather than hemodialysis can prevent or even treat dialysis-associated amyloidosis (AB2M) remains speculative.

Beta-2 Microglobulin Amyloidosis in a Patient on LongTerm Continuous Ambulatory Peritoneal Dialysis (CAPD)

A 61-year-old female patient with ESRD due to analge sic nephropathy and treated solely with CAPD for 81 months is described. During this period she developed peritonitis 4 times. She eventually died of acute pulmonary edema due to coronary heart disease. The autopsy showed an analgesic nephropathy with contracted kidneys, diffuse peritoneal fibrosis, and articular and periarticular amyloidosis of AB2m-type. This form of amyloidosis is well known after hemodialysis; it was, however, not observed heretofore after sole long-term CAPD.

Neurological Complications of Vascular Access

Neurological problems are common in patients undergoing haemodialysis. Over 60% of patients will suffer from symptoms of underlying polyneuropathy due to uraemia or diabetes. Others will have subclinical disease demonstrable by nerve conduction studies.

Nerve injury following haemodialysis access surgery is underreported. However, sensory nerve lesions are probably common after most vascular access procedures but are rarely debilitating.

Nerve compression syndromes such as carpal tunnel and ulnar compression syndromes are common, especially in patients who have been on dialysis for some years and at least some of these are related to or exacerbated by the access. Recognition is essential as they are eminently treatable by decompression surgery. Tourniquet use appears to be safe for carpal tunnel or ulnar nerve decompression surgery.

Ischaemic monomelic neuropathy (IMN) is rare but follows a period of ischaemia during or as a result of access surgery, most commonly to construct a brachial arteriovenous fistula or graft. It is characterised by intense pain, out of proportion to any ischaemia, involves all of the upper limb nerves and may progress to involve the motor nerves eventually resulting in a useless clawed hand. It requires prompt treatment of any residual ischaemia after access creation, if necessary by access ligation, as in the established syndrome, like the even rarer complication of reflex sympathetic dystrophy, it is very difficult to offer any useful treatment other than symptomatic relief and physiotherapy.

Carpal tunnel release surgery and venous hypertension in early hemodialysis patients without amyloid deposits

AIM

Carpal tunnel syndrome (CTS) is one of the frequent problems of the patients who underwent hemodialysis (HD). The role of venous hypertension due to arteriovenous fistula (AVF) has not been clarified completely; therefore, we aimed to investigate the role of venous hypertension due to AVF in hemodialysis patients who had CTS.

PATIENTS AND METHODS

We included 12 patients who had been receiving HD treatment for less than 8 years and the newly diagnosed CTS patients with the same arm of AVF. All patients were diagnosed clinically and the results were confirmed by both nerve conduction studies and electromyography. Open carpal tunnel release surgery was performed on all of them. Venous pressure was measured in all patients before and after two weeks of surgery.

RESULTS

There were significant differences before and after the surgery with regard to pressures (P > 0.05). After the surgery, all carpal ligament specimens of the patients were not stained with Congo red for the presence of amyloid deposition.

CONCLUSION

Increased venous pressure on the same arm with AVF could be responsible for CTS in hemodialysis patients. Carpal tunnel release surgery is the main treatment of this disease by reducing the compression on the nerve.

Carpal tunnel syndrome: a major complication in hemodialysis patients

In order to assess the prevalence of the carpal tunnel syndrome (CTS) suggestive of beta 2 microglobulin amyloid deposit in patients undergoing hemodialysis with cuprophan and acetate membrane, we studied 30 patients who had been receiving hemodialysis for varying lengths of time. Besides a standard physical and rheumatological examination, nerve conduction velocity studies were done in median and ulnar motorsensory nerves. 12 patients had normal findings, 12 had CTS (9 pure CTS, 3 with neuropathy), and 9 had peripheral neuropathy. Nerve dysfunction was independent of the disease underlying renal failure, the side of the dialysis access shunt and factors such as age and sex. We suggest that hemodialysis patients need frequent EMG analysis to identify CTS early and to avoid irreversible nerve damage.

Systemic amyloidosis of beta 2 microglobulin type

A patient receiving haemodialysis for 15 years developed systemic amyloidosis of beta 2 microglobulin type. Noticeable deposits of amyloid were present in the myocardium, intervertebral discs, joint cartilages and tendons. Less conspicuous amounts were present in blood vessel walls in the lungs, liver, adrenal glands and brain, and within the stroma of the prostate, testis and kidney, often with foci of calcification.

Progress of brown tumors in patients with chronic renal insufficiency undergoing dialysis

In a group of 73 patients, affected by chronic renal insufficiency, whose skeleton was periodically checked, three cases of brown tumors were found. These cases demonstrated a variety of locations that were involved, especially the pelvis, ribs and mandible. During therapeutic treatment the brown tumors presented a different behavior; while some lesions tended toward complete sclerosis, others increased in size and in both instances new lesions appeared. Parathyroidectomy, carried out in two patients, determined a definitive sclerosis of these lesions. Brown tumors also correlate with high PTH levels and with lesions from osteitis fibrosa.

Some commonly unrecognized manifestations of metabolic arthropathies

The metabolic arthropathies are characterized by the deposition of abnormal substances in or around joints. Certain features of some of these arthropathies and their significance have only recently been recognized and others have been insufficiently emphasized. An important group of conditions are the arthropathies related to renal failure and its treatment, namely, aluminum toxicity, periarticular calcification and crystal deposition, hyperparathyroidism, and dialysis-related amyloidosis. Crystal deposition diseases, specifically, gouty arthritis, calcium pyrophosphate deposition, and calcium hydroxyapatite deposition, are also reviewed.

Immunohistological characterisation of amyloid deposits in renal biopsy specimens

The amyloid deposits in 21 renal biopsy specimens were subjected to a detailed immunohistochemical analysis using a panel of antibodies against recognised constituents of tissue amyloid. This was a retrospective study of material originally submitted during the investigation of various renal abnormalities and studied by a routine protocol including histochemistry, electron microscopy, and immunofluorescence. The presence of an amyloid was confirmed in all 21 cases. Seventeen cases contained P component and either amyloid A (AA) (11 cases) or an immunoglobulin light chain associated amyloid (six cases). Four cases contained amyloid material with unusual immunohistochemical findings; one case had AA and P-component (PC) in the interstitium, one case had lambda light chain and beta-2 microglobulin, one case had kappa light chain and Clq, and one case had lambda light chains only. It was possible, therefore, to identify precisely the amyloid constituents and thereby "type" the amyloid by immunohistochemical means. The availability of the antibodies used and their application using these techniques could simplify the confirmation of clinically suspected amyloidosis.

beta 2-Microglobulin amyloidosis. A systemic amyloid disease affecting primarily synovium and bone in long-term dialysis patients

A number of rheumatic disorders occur in patients on long-term hemodialysis treatment. In recent years a clinical syndrome comprising carpal tunnel syndrome, destructive arthropathy, and cystic bone lesions has been recognized in these patients. Congo-red staining and microscopy in polarized light reveal a high frequency of amyloid in the affected tissues. Amino acid sequence data of the isolated major amyloid fibril protein show its identity with beta 2-microglobulin. beta 2-microglobulin amyloid has a predilection for synovial tissues and bone, but visceral deposits may also occur indicating the systemic nature of the disease. The clinicopathological features, pathogenesis, and diagnosis of beta 2-microglobulin amyloidosis are reviewed, and the therapeutic and prophylactic measures discussed. The identification of beta 2-microglobulin as an amyloidogenic protein has in an important way contributed to the understanding of the mechanisms of amyloidogenesis in general and emphasized the complexity of amyloid disease and the diversity of proteins capable of forming congophilic fibrillar deposits in human tissues.

Beta 2-microglobulin kinetics in maintenance hemodialysis: a comparison of conventional and high-flux dialyzers and the effects of dialyzer reuse

beta 2-Microglobulin (beta 2M) forms synovial and bony amyloid deposits in long-term hemodialysis patients. To define the kinetics of beta 2M during hemodialysis and the effects of dialyzer reprocessing, we measured serum beta 2M, plasma C3a, and neutrophil counts immediately predialysis; 15, 90, and 180 minutes after beginning dialysis; and 15 minutes postdialysis in ten chronic hemodialysis patients. The studies were performed during first and third uses of cuprammonium rayon and polysulfone dialyzers processed by rinsing with water, then bleach, in an automated system (Seratronics DRS 4) and then packed in 1.5% formaldehyde. Mean serum beta 2M (corrected for ultrafiltration) decreased by 16.6% +/- 18.1% with new cuprammonium dialyzers and 57.1% +/- 12.8% with new polysulfone dialyzers. Dialyzer reprocessing had no significant effect on this decline. Predialysis serum beta 2M decreased by 30.4% +/- 15.5% 1 month after switching from cuprammonium to polysulfone dialyzers; these levels remained stable after 3 months of dialysis with polysulfone. Complement activation and neutropenia during dialysis were significantly more marked with cuprammonium, but were not affected by reprocessing of either dialyzer. In vitro adsorption of 124I-beta 2M to polysulfone fibers was greater than to cuprammonium; adsorption was not influenced by dialyzer reprocessing.

'Dialysis related arthropathy': a survey of 95 patients receiving chronic haemodialysis with special reference to beta 2 microglobulin related amyloidosis

Ninety five patients receiving chronic haemodialysis (CHD) were surveyed to determine the prevalence of rheumatic disease and, where possible, its aetiology. At least three distinct rheumatic syndromes were identified--a group of patients with a syndrome consisting of large and medium joint synovial swelling, restricted hips and shoulders, tenosynovitis, carpal tunnel syndrome, and bone cysts due to deposition of beta 2 microglobulin related amyloid (AM beta 2m); a second group with erosive azotaemic osteoarthropathy; and a third group with age related degenerative disease of small, large, and axial joints. The data presented suggest that in patients receiving CHD (a) the prevalence of AM beta 2m deposition and the associated syndrome increases with duration of dialysis, but in patients who have been dialysed for more than 10 years the risk of developing AM beta 2m is related to age; (b) AM beta 2m deposition in subchondral cysts, but not synovium, causes joint destruction; also, AM beta 2m may be more prone to deposition in synovium of joints already damaged by other processes; (c) in the absence of synovial iron deposition synovial AM beta 2m is not associated with an inflammatory infiltrate; (d) hyperparathyroidism and perhaps other factors such as synovial iron deposition are probably more important than AM beta 2m as causes of peripheral joint degeneration and destructive spondyloarthropathy in patients receiving CHD.

Bone cysts and haemodialysis-related amyloidosis

Carpal tunnel syndrome and arthropathy are frequent complications of long-term haemodialysis. Both are associated with cystic lesions of bone and are related to synovioarticular deposition of a new type of amyloid derived from circulating beta 2-microglobulin. Retrospective analysis of the radiographic skeletal surveys of all 58 patients on haemodialysis for 6 or more years revealed one or more cystic bone lesions in 36% of patients. Radiographic analysis indicated that a number of these cysts were due to hyperparathyroid bone disease or joint degeneration, but a majority showed features suggesting an arthropathy of another aetiology. We present evidence that the development of these latter cysts in an individual on long-term dialysis is an indicator of the presence of synovioarticular amyloidosis of the beta 2-microglobulin type. The radiographic characteristics and development of these cysts, which we believe are due to bony infiltration from synovioarticular amyloid are described.

Comparison of serum protein removal in haemodialysis therapy by partly protein-permeable haemodialysers

Partly protein-permeable haemodialysers were evaluated during haemodialysis therapy for removal of serum low-molecular-mass proteins (10,000-76,000) in patients with chronic renal failure. The six haemodialyser membranes used were cuproammonium rayon (CL-S12W), cellulose acetate (Duo-Flux HP and FF-22), ethylene-vinyl alcohol copolymer (KF-101-15), polyacrylonitrile (H12-2400S) and polymethyl methacrylate (BK2.0H). The analysis was carried out by gel permeation chromatography, sodium dodecyl sulphate polyacrylamide gel electrophoresis (SDS-PAGE) and two-dimensional gel electrophoresis (2-DE). The removal of ten serum proteins per haemodialysis therapy was also carried out by the immunodiffusion method. The protein removal in each haemodialyser is qualitatively comparable to that obtained by SDS-PAGE and 2-DE. beta 2-Microglobulin in the haemodialysate obtained with BK2.0H was removed to a lesser extent than that from the other haemodialysers, which seems to be the reason for its adsorption in the BK2.0H haemodialyser, which contains a polymethyl methacrylate membrane. The amount of serum protein excretion during haemodiafiltration treatment using the partly protein-permeable haemodialysers decreased in the order KF-101-15C greater than BK2.0H greater than CL-S12W greater than Duo-Flux HP greater than FF-22 greater than H12-2400S.

Clinical picture of the amyloid arthropathy in patients with chronic renal failure maintained on haemodialysis using cellulose membranes

The clinical picture of 15 patients (10 male, five female) with amyloid arthropathy secondary to chronic renal failure treated with haemodialysis has been studied. The average period of haemodialysis was 10.8 years. Joint symptoms appeared between three and 13 years after starting haemodialysis. No patient had renal amyloidosis. Early symptoms were varied and often overlapped: knee swelling (seven patients), painful and stiff shoulders (seven), and carpal tunnel syndrome (six) were the most prominent. Follow up showed extension to other joints. Joint effusions were generally of the non-inflammatory type. Radiologically, geodes and erosions of variable sizes were seen in the affected joints, which can develop into a destructive arthropathy. Amyloid was found in abdominal fat in three of the 12 patients on whom a needle aspiration was performed. Four of 12 patients showed changes compatible with amyloid infiltration in the echocardiogram. One patient had amyloid in the gastric muscular layer, another in the colon mucus, and two of four in rectal biopsy specimens. Amyloid deposits showed the presence of beta 2 microglobulin in 10 patients. The clinical and radiological picture was similar to the amyloid arthropathy associated with multiple myeloma. These patients can develop systemic amyloidosis.