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Chompoopong P, Mauermann ML, Siddiqi H, Peltier A. Amyloid Neuropathy: From Pathophysiology to Treatment in Light-Chain Amyloidosis and Hereditary Transthyretin Amyloidosis. Ann Neurol 2024. [PMID: 38923548 DOI: 10.1002/ana.26965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Revised: 03/20/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024]
Abstract
Amyloid neuropathy is caused by deposition of insoluble β-pleated amyloid sheets in the peripheral nervous system. It is most common in: (1) light-chain amyloidosis, a clonal non-proliferative plasma cell disorder in which fragments of immunoglobulin, light or heavy chain, deposit in tissues, and (2) hereditary transthyretin (ATTRv) amyloidosis, a disorder caused by autosomal dominant mutations in the TTR gene resulting in mutated protein that has a higher tendency to misfold. Amyloid fibrils deposit in the endoneurium of peripheral nerves, often extensive in the dorsal root ganglia and sympathetic ganglia, leading to atrophy of Schwann cells in proximity to amyloid fibrils and blood-nerve barrier disruption. Clinically, amyloid neuropathy is manifested as a length-dependent sensory predominant neuropathy associated with generalized autonomic failure. Small unmyelinated nerves are involved early and prominently in early-onset Val30Met ATTRv, whereas other ATTRv and light-chain amyloidosis often present with large- and small-fiber involvement. Nerve conduction studies, quantitative sudomotor axon testing, and intraepidermal nerve fiber density are useful tools to evaluate denervation. Amyloid deposition can be demonstrated by tissue biopsy of the affected organ or surrogate site, as well as bone-avid radiotracer cardiac imaging. Treatment of light-chain amyloidosis has been revolutionized by monoclonal antibodies and stem cell transplantation with improved 5-year survival up to 77%. Novel gene therapy and transthyretin stabilizers have revolutionized treatment of ATTRv, improving the course of neuropathy (less change in the modified Neuropathy Impairment Score + 7 from baseline) and quality of life. With great progress in amyloidosis therapies, early diagnosis and presymptomatic testing for ATTRv family members has become paramount. ANN NEUROL 2024.
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Affiliation(s)
| | | | - Hasan Siddiqi
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amanda Peltier
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
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2
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Moreno-Moraleda E, González-Moreno J, Cisneros-Barroso E, Ribot-Sansó MA, Ripoll-Vera T, Descals C, Uson M, Montalà JC, Figuerola A, Rodríguez A, Losada I. Validating the usefulness of Sudoscan in ATTRv: a single centre experience. Neurol Sci 2024; 45:2859-2867. [PMID: 38261153 DOI: 10.1007/s10072-024-07311-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/06/2024] [Indexed: 01/24/2024]
Abstract
BACKGROUND Variant transthyretin amyloidosis (ATTRv) can cause sensorimotor and autonomic neuropathy. Objective quantification of sudomotor function may be essential for early diagnosis and early initiation of treatment. The aim of this study is to evaluate the diagnostic value of the Sudoscan® in ATTRv. METHODS Electrochemical skin conductance (ESC) was measured in V30M ATTRv patients, asymtomatic V30M carriers and healthy controls. Comparisons between the three groups were made using the Kruskal-Wallis test, and ROC curves were used to estimate the discriminatory power of ESC values between groups. RESULTS ESC was measured in 52 ATTRv patients, 107 asymptomatic carriers and 40 healthy controls. ESC was significantly lower in ATTRv patients compared to asymptomatic carriers and healthy controls in both feet and hands; median values are as follows: 40 µS, 78 µS and 81 µS, respectively (p < 0.001), and 53 µS, 69 µS and 74 µS, respectively (p < 0.001). ESC in feet < 70.5 µS had a sensitivity of 89.7% and specificity of 84.6% to discriminate asymptomatic carriers from patients with ATTRv. CONCLUSION The determination of ESC by Sudoscan® is a rapid, noninvasive and easily reproducible technique capable of discriminating patients with ATTRv from asymptomatic carriers and healthy controls with adequate sensitivity and specificity.
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Affiliation(s)
| | - Juan González-Moreno
- Internal Medicine, Hospital Universitario Son Llàtzer, Palma, Spain
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain
- Medicine Department, University of the Balearic Islands, Palma, Spain
| | - Eugenia Cisneros-Barroso
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain.
| | - María Antonia Ribot-Sansó
- Internal Medicine, Hospital Universitario Son Llàtzer, Palma, Spain
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain
| | - Tomás Ripoll-Vera
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain
- Medicine Department, University of the Balearic Islands, Palma, Spain
- Cardiology Department, Hospital Universitario Son Llàtzer, Palma, Spain
| | - Cristina Descals
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain
- Neurology Department, Hospital Universitario Son Llàtzer, Palma, Spain
| | - Mercedes Uson
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain
- Neurology Department, Hospital Universitario Son Llàtzer, Palma, Spain
| | - Joan Carles Montalà
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain
- Neurology Department, Hospital Universitario Son Llàtzer, Palma, Spain
| | - Antoni Figuerola
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain
- Medicine Department, University of the Balearic Islands, Palma, Spain
- Neurology Department, Hospital Universitario Son Llàtzer, Palma, Spain
- Nursing and Physiotherapy Department, University of the Balearic Islands, Palma, Spain
| | - Adrián Rodríguez
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain
| | - Inés Losada
- Internal Medicine, Hospital Universitario Son Llàtzer, Palma, Spain
- Balearic Research Group in Genetic Cardiopathies, Sudden Death and TTR Amyloidosis, Instituto de Investigación Sanitaria de Las Islas Baleares (IdISBa), Palma, Spain
- Medicine Department, University of the Balearic Islands, Palma, Spain
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Chiaro G, Stancanelli C, Koay S, Vichayanrat E, Sander L, Ingle GT, McNamara P, Carr AS, Wechalekar AD, Whelan CJ, Gillmore JD, Hawkins PN, Reilly MM, Mathias CJ, Iodice V. Cardiovascular autonomic failure in hereditary transthyretin amyloidosis and TTR carriers is an early and progressive disease marker. Clin Auton Res 2024:10.1007/s10286-024-01038-z. [PMID: 38769233 DOI: 10.1007/s10286-024-01038-z] [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: 02/29/2024] [Accepted: 05/08/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND The cardiomyopathic and neuropathic phenotype of hereditary transthyretin amyloidosis are well recognized. Cardiovascular autonomic dysfunction is less systematically and objectively assessed. METHODS Autonomic and clinical features, quantitative cardiovascular autonomic function, and potential autonomic prognostic markers of disease progression were recorded in a cohort of individuals with hereditary transthyretin amyloidosis and in asymptomatic carriers of TTR variants at disease onset (T0) and at the time of the first quantitative autonomic assessment (T1). The severity of peripheral neuropathy and its progression was stratified with the polyneuropathy disability score. RESULTS A total of 124 individuals were included (111 with a confirmed diagnosis of hereditary transthyretin amyloidosis, and 13 asymptomatic carriers of TTR variants). Symptoms of autonomic dysfunction were reported by 27% individuals at T0. Disease duration was 4.5 ± 4.0 years [mean ± standard deviation (SD)] at autonomic testing (T1). Symptoms of autonomic dysfunction were reported by 78% individuals at T1. Cardiovascular autonomic failure was detected by functional testing in 75% individuals and in 64% of TTR carriers. Progression rate from polyneuropathy disability stages I/II to III/IV seemed to be shorter for individuals with autonomic symptoms at onset [2.33 ± 0.56 versus 4.00 ± 0.69 years (mean ± SD)]. CONCLUSIONS Cardiovascular autonomic dysfunction occurs early and frequently in individuals with hereditary transthyretin amyloidosis within 4.5 years from disease onset. Cardiovascular autonomic failure can be subclinical in individuals and asymptomatic carriers, and only detected with autonomic function testing, which should be considered a potential biomarker for early diagnosis and disease progression.
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Affiliation(s)
- Giacomo Chiaro
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, UCLH NHS Trust, London, UK
| | | | - Shiwen Koay
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, UCLH NHS Trust, London, UK
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Ekawat Vichayanrat
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, UCLH NHS Trust, London, UK
| | - Laura Sander
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, UCLH NHS Trust, London, UK
- Neurologic Clinic and Policlinic, Departments of Medicine and Clinical Research, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Gordon T Ingle
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, UCLH NHS Trust, London, UK
| | - Patricia McNamara
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, UCLH NHS Trust, London, UK
| | - Aisling S Carr
- Centre for Neuromuscular Diseases, Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Carol J Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Mary M Reilly
- Centre for Neuromuscular Diseases, Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology and the National Hospital for Neurology and Neurosurgery, London, UK
| | - Christopher J Mathias
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Valeria Iodice
- Autonomic Unit, National Hospital for Neurology and Neurosurgery, UCLH NHS Trust, London, UK.
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, University College London, London, UK.
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Reilly MM. Treating TTR amyloidosis - early diagnosis is essential. J Neurol Neurosurg Psychiatry 2024; 95:488. [PMID: 38071531 DOI: 10.1136/jnnp-2023-332841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/22/2023]
Affiliation(s)
- Mary M Reilly
- Institute of Neurology and National Hospital for Neurology and Neurosurgery, UCL, London, WC1H 9BT, UK
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Pareyson D, Fenu S. The tip of the iceberg in ATTRv: when to start carrier monitoring and when to initiate treatment? J Neurol Neurosurg Psychiatry 2024; 95:487. [PMID: 38071548 DOI: 10.1136/jnnp-2023-332842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/22/2023] [Indexed: 05/16/2024]
Affiliation(s)
- Davide Pareyson
- Unit of Rare Neurological Diseases, Department of Clinical Neurosciences, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
| | - Silvia Fenu
- Unit of Rare Neurological Diseases, Department of Clinical Neurosciences, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milano, Italy
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Pedroto M, Coelho T, Fernandes J, Oliveira A, Jorge A, Mendes-Moreira J. Heterogeneity in families with ATTRV30M amyloidosis: a historical and longitudinal Portuguese case study impact for genetic counselling. Amyloid 2024:1-11. [PMID: 38588550 DOI: 10.1080/13506129.2024.2332679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND Hereditary transthyretin amyloidosis (ATTRv amyloidosis) is an inherited disease, where the study of family history holds importance. This study evaluates the changes of age-of-onset (AOO) and other age-related clinical factors within and among families affected by ATTRv amyloidosis. METHODS We analysed information from 934 trees, focusing on family, parents, probands and siblings relationships. We focused on 1494 female and 1712 male symptomatic ATTRV30M patients. Results are presented alongside a comparison of current with historical records. Clinical and genealogical indicators identify major changes. RESULTS Overall, analysis of familial data shows the existence of families with both early and late patients (1/6). It identifies long familial follow-up times since patient families tend to be diagnosed over several years. Finally, results show a large difference between parent-child and proband-patient relationships (20-30 years). CONCLUSIONS This study reveals that there has been a shift in patient profile, with a recent increase in male elderly cases, especially regarding probands. It shows that symptomatic patients exhibit less variability towards siblings, when compared to other family members, namely the transmitting ancestors' age of onset. This can influence genetic counselling guidelines.
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Affiliation(s)
- Maria Pedroto
- Laboratory of Artificial Intelligence and Decision Support (LIAAD, INESCTEC), Porto, Portugal
- Department of Informatics Engineering, Faculty of Engineering, University of Porto, Porto, Portugal
- Department of Computer Sciences, Faculty of Sciences, University of Porto, Porto, Portugal
| | - Teresa Coelho
- Unidade Corino de Andrade, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Joana Fernandes
- Unidade Corino de Andrade, Centro Hospitalar Universitário de Santo António, Porto, Portugal
| | - Alexandra Oliveira
- ESS - Polytechnic of Porto (ESS-P.PORTO), Porto, Portugal
- Artificial Intelligence and Computer Science Laboratory (LIACC), Porto, Portugal
| | - Alípio Jorge
- Laboratory of Artificial Intelligence and Decision Support (LIAAD, INESCTEC), Porto, Portugal
- Department of Computer Sciences, Faculty of Sciences, University of Porto, Porto, Portugal
| | - João Mendes-Moreira
- Laboratory of Artificial Intelligence and Decision Support (LIAAD, INESCTEC), Porto, Portugal
- Department of Informatics Engineering, Faculty of Engineering, University of Porto, Porto, Portugal
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Berends M, Nienhuis HLA, Adams D, Karam C, Luigetti M, Polydefkis M, Reilly MM, Sekijima Y, Hazenberg BPC. Neurofilament Light Chains in Systemic Amyloidosis: A Systematic Review. Int J Mol Sci 2024; 25:3770. [PMID: 38612579 PMCID: PMC11011627 DOI: 10.3390/ijms25073770] [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: 02/17/2024] [Revised: 03/08/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024] Open
Abstract
Peripheral and autonomic neuropathy are common disease manifestations in systemic amyloidosis. The neurofilament light chain (NfL), a neuron-specific biomarker, is released into the blood and cerebrospinal fluid after neuronal damage. There is a need for an early and sensitive blood biomarker for polyneuropathy, and this systematic review provides an overview on the value of NfL in the early detection of neuropathy, central nervous system involvement, the monitoring of neuropathy progression, and treatment effects in systemic amyloidosis. A literature search in PubMed, Embase, and Web of Science was performed on 14 February 2024 for studies investigating NfL levels in patients with systemic amyloidosis and transthyretin gene-variant (TTRv) carriers. Only studies containing original data were included. Included were thirteen full-text articles and five abstracts describing 1604 participants: 298 controls and 1306 TTRv carriers or patients with or without polyneuropathy. Patients with polyneuropathy demonstrated higher NfL levels compared to healthy controls and asymptomatic carriers. Disease onset was marked by rising NfL levels. Following the initiation of transthyretin gene-silencer treatment, NfL levels decreased and remained stable over an extended period. NfL is not an outcome biomarker, but an early and sensitive disease-process biomarker for neuropathy in systemic amyloidosis. Therefore, NfL has the potential to be used for the early detection of neuropathy, monitoring treatment effects, and monitoring disease progression in patients with systemic amyloidosis.
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Affiliation(s)
- Milou Berends
- Department of Internal Medicine, Amyloidosis Center of Expertise, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (M.B.); (H.L.A.N.)
| | - Hans L. A. Nienhuis
- Department of Internal Medicine, Amyloidosis Center of Expertise, University Medical Center Groningen, 9700 RB Groningen, The Netherlands; (M.B.); (H.L.A.N.)
| | - David Adams
- Service de Neurologie, CHU Bicêtre, Assistance Publique—Hôpitaux de Paris, University Paris-Saclay, CERAMIC, Le Kremlin-Bicêtre, 94270 Paris, France;
| | - Chafic Karam
- Department of Neurology, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Marco Luigetti
- UOC Neurologia, Fondazione Policlinico A. Gemelli IRCCS, 00168 Rome, Italy;
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA;
| | - Mary M. Reilly
- Centre for Neuromuscular Diseases, Department of Neuromuscular Diseases, UCL Queen Square Institute of Neurology, London WC1N 3BG, UK;
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Matsumoto 390-8621, Japan;
| | - Bouke P. C. Hazenberg
- Department of Rheumatology & Clinical Immunology, Amyloidosis Center of Expertise, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
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