1
|
Chiu A, Dasari S, Nasr SH, Dispenzieri A, Dao LN, Dalland JC, Howard MT, Larson DP, Rech KL, Theis JD, Vrana JA, McPhail ED. Salivary gland amyloidosis: Proteomic identification and clinicopathologic characterization of 57 cases. Hum Pathol 2024; 151:105628. [PMID: 39029535 DOI: 10.1016/j.humpath.2024.105628] [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: 05/22/2024] [Accepted: 07/16/2024] [Indexed: 07/21/2024]
Abstract
Salivary gland amyloidosis is an uncommon diagnosis. Most studies have focused on minor salivary gland biopsies as a surrogate site for diagnosing systemic amyloidosis, while only few studies have investigated major salivary gland amyloidosis. We retrospectively identified 57 major and minor salivary gland amyloidosis cases typed using a proteomics-based method between 2010 and 2022. Frequency of amyloid types, clinicopathologic features, and distribution patterns of amyloid deposits were assessed. The indication for salivary gland biopsy/resection (known in 34 cases) included suspected amyloidosis (N = 14; 41.2%), lesion/mass (N = 12; 35.3%), swelling/enlargement (N = 5; 14.7%), and rule out Sjogren syndrome (N = 3; 8.8%). Concurrent pathology was reported in 16 cases, and included chronic sialadenitis (N = 11), extranodal marginal zone lymphoma (N = 3), plasma cell neoplasm (N = 1), and pleomorphic adenoma (N = 1). We identified 3 types of amyloidosis: immunoglobulin light chain/AL (N = 47; 82.5%); immunoglobulin heavy chain/AH (N = 1; 1.8%), and transthyretin/ATTR (N = 9; 15.8%). The patterns of amyloid deposits (assessed in 35 cases) included: 1) Perivascular and/or periductal distribution (N = 18; 51.4%); 2) Mass formation (N = 9; 25.7%); 3) Stromal micronodule formation (N = 7; 20.0%); and 4) Diffuse interstitial involvement (N = 1; 2.9%). We also identified one case of AL amyloidosis localized to the major salivary gland, where only 6 other cases with adequate staging workup to exclude systemic amyloidosis were previously reported. In conclusion, salivary gland amyloidosis is an uncommon diagnosis but may be underrecognized due to low index of suspicion. Most cases of salivary gland amyloidosis are AL type, but a minority are ATTR. Therefore, proteomics-based typing remains essential for treatment and prognosis.
Collapse
Affiliation(s)
- April Chiu
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA.
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN, 55905, USA
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Angela Dispenzieri
- Department of Medicine, Division of Hematology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Linda N Dao
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Joanna C Dalland
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Matthew T Howard
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Daniel P Larson
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Karen L Rech
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Division of Hematopathology, Mayo Clinic, Rochester, MN, 55905, USA
| |
Collapse
|
2
|
Delrue C, Dendooven A, Vandendriessche A, Speeckaert R, De Bruyne S, Speeckaert MM. Advancing Renal Amyloidosis Care: The Role of Modern Diagnostic Techniques with the Potential of Enhancing Patient Outcomes. Int J Mol Sci 2024; 25:5875. [PMID: 38892061 PMCID: PMC11172584 DOI: 10.3390/ijms25115875] [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: 04/30/2024] [Revised: 05/24/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Renal amyloidosis is a set of complex disorders characterized by the deposition of amyloid proteins in the kidneys, which causes gradual organ damage and potential kidney failure. Recent developments in diagnostic methods, particularly mass spectrometry and proteome profiling, have greatly improved the accuracy of amyloid typing, which is critical for disease management. These technologies provide extensive insights into the specific proteins involved, allowing for more targeted treatment approaches and better patient results. Despite these advances, problems remain, owing to the heterogeneous composition of amyloid proteins and the varying efficacy of treatments based on amyloid type. Access to sophisticated diagnostics and therapy varies greatly, highlighting the global difference in renal amyloidosis management. Future research is needed to investigate next-generation sequencing and gene-editing technologies, like clustered regularly interspaced short palindromic repeats (CRISPR), which promise more profound insights into the genetic basis of amyloidosis.
Collapse
Affiliation(s)
- Charlotte Delrue
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Amélie Dendooven
- Department of Pathology, Ghent University Hospital, 9000 Ghent, Belgium; (A.D.); (A.V.)
- Faculty of Medicine, University of Antwerp, 2610 Wilrijk, Belgium
| | | | | | - Sander De Bruyne
- Department of Laboratory Medicine, Ghent University Hospital, 9000 Ghent, Belgium;
| | - Marijn M. Speeckaert
- Department of Nephrology, Ghent University Hospital, 9000 Ghent, Belgium;
- Research Foundation-Flanders (FWO), 1000 Brussels, Belgium
| |
Collapse
|
3
|
Bindi G, Smith A, Oliveira G, Eccher A, Vatrano S, Alberici F, Cazzaniga G, Galimberti S, Capitoli G, Magni F, Pagni F, L'Imperio V. Spatial resolution of renal amyloid deposits through MALDI-MSI: a combined digital and molecular approach to monoclonal gammopathies. J Clin Pathol 2024; 77:402-410. [PMID: 36813560 DOI: 10.1136/jcp-2023-208790] [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: 01/17/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
AIMS Identification and characterisation of monoclonal gammopathies of renal significance (MGRS) is critical for therapeutic purposes. Amyloidosis represents one of the most common forms of MGRS, and renal biopsy remains the gold standard for their classification, although mass spectrometry has shown greater sensitivity in this area. METHODS In the present study, a new in situ proteomic technique, matrix-assisted laser desorption/ionisation mass spectrometry imaging (MALDI-MSI), is investigated as an alternative to conventional laser capture microdissection MS for the characterisation of amyloids. MALDI-MSI was performed on 16 cases (3 lambda light chain amyloidosis (AL), 3 AL kappa, 3 serum amyloid A amyloidosis (SAA), 2 lambda light chain deposition disease (LCDD), 2 challenging amyloid cases and 3 controls). Analysis began with regions of interest labelled by the pathologist, and then automatic segmentation was performed. RESULTS MALDI-MSI correctly identified and typed cases with known amyloid type (AL kappa, AL lambda and SAA). A 'restricted fingerprint' for amyloid detection composed of apolipoprotein E, serum amyloid protein and apolipoprotein A1 showed the best automatic segmentation performance (area under the curve >0.7). CONCLUSIONS MALDI-MSI correctly assigned minimal/challenging cases of amyloidosis to the correct type (AL lambda) and identified lambda light chains in LCDD cases, highlighting the promising role of MALDI-MSI for amyloid typing.
Collapse
Affiliation(s)
- Greta Bindi
- Department of Medicine and Surgery, Proteomics and Metabolomics Units, University of Milano-Bicocca, Monza, Italy
| | - Andrew Smith
- Department of Medicine and Surgery, Proteomics and Metabolomics Units, University of Milano-Bicocca, Monza, Italy
| | - Glenda Oliveira
- Department of Medicine and Surgery, Proteomics and Metabolomics Units, University of Milano-Bicocca, Monza, Italy
| | - Albino Eccher
- Department of Pathology and Diagnostics, University and Hospital Trust of Verona, Verona, Italy
| | - Simona Vatrano
- Pathology Unit, ASP Catania, "Gravina" Hospital, Caltagirone, Italy
| | - Federico Alberici
- Nephrology Unit, Spedali Civili Hospital, ASST Spedali Civili di Brescia, Brescia, Italy
| | - Giorgio Cazzaniga
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Stefania Galimberti
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giulia Capitoli
- Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Fulvio Magni
- Department of Medicine and Surgery, Proteomics and Metabolomics Units, University of Milano-Bicocca, Monza, Italy
| | - Fabio Pagni
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Vincenzo L'Imperio
- Department of Medicine and Surgery, Pathology, University of Milano-Bicocca, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| |
Collapse
|
4
|
Unchagi A, Rao S, Nagappa M, Nandeesh BN, Yasha TC, Taly AB, Mahadevan A. Clinicopathological Features of Amyloid Neuropathy: A Four Decade Experience. Neurol India 2024; 72:597-602. [PMID: 39041979 DOI: 10.4103/neuroindia.ni_303_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 10/31/2021] [Indexed: 07/24/2024]
Abstract
BACKGROUND Peripheral neuropathy is one of the manifestations of primary or familial amyloidosis. Published studies from India are limited. MATERIALS AND METHODS We reviewed the clinical and pathological features of amyloid neuropathy diagnosed at our Institute over the last 39 years. RESULTS Fifty-five cases of amyloid neuropathies were diagnosed between 1981 and 2019, constituting 0.28% of peripheral nerve biopsies (55/19,081). Age at presentation ranged from 24 to 81 years (mean-48 years) with male preponderance [M:F = 3.58:1]. Duration of symptoms at presentation varied from 3 months to 10 years (mean-2.31 years). Majority presented with small fiber neuropathy (85%). Pure sensory symptoms predominated in 23%, while 72% had sensorimotor neuropathy and 35.8% had autonomic involvement, with isolated autonomic failure in one patient. Amyloid neuropathy was clinically suspected in 22.6% of nonfamilial cases. Familial amyloid neuropathy was suspected in eight patients. Genetic testing detected ATTR and gelsolin mutation in one each of tested patients. Nerve biopsies revealed characteristic birefringent amyloid deposits stained mahogany brown by Congo red predominantly surrounding endoneurial microvessels (34.5%), also in perineurium and epineurium in 25.45% cases. Preferential loss of small diameter myelinated fibers was noted. Axonal degeneration or regeneration was conspicuously absent. CONCLUSION Amyloid neuropathy is uncommon (0.28% of nerve biopsies in our series). Nerve biopsy is essential for the diagnosis. We report our experience of amyloid neuropathy and underscore the importance of making an assiduous search for amyloid deposits in the appropriate setting. Awareness of this entity is important for early diagnosis in the light of emerging therapeutic advances.
Collapse
Affiliation(s)
- Asha Unchagi
- Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Shilpa Rao
- Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Madhu Nagappa
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Bevinahalli N Nandeesh
- Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | | | - Arun B Taly
- Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| | - Anita Mahadevan
- Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bangalore, Karnataka, India
| |
Collapse
|
5
|
Leung N, Nasr SH. 2024 Update on Classification, Etiology, and Typing of Renal Amyloidosis: A Review. Am J Kidney Dis 2024:S0272-6386(24)00679-6. [PMID: 38514011 DOI: 10.1053/j.ajkd.2024.01.530] [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: 07/25/2023] [Revised: 12/20/2023] [Accepted: 01/29/2024] [Indexed: 03/23/2024]
Abstract
Amyloidosis is a protein folding disease that causes organ injuries and even death. In humans, 42 proteins are now known to cause amyloidosis. Some proteins become amyloidogenic as a result of a pathogenic variant as seen in hereditary amyloidoses. In acquired forms of amyloidosis, the proteins form amyloid in their wild-type state. Four types (serum amyloid A, transthyretin, apolipoprotein A-IV, and β2-macroglobulin) of amyloid can occur either as acquired or as a mutant. Iatrogenic amyloid from injected protein medications have also been reported and AIL1RAP (anakinra) has been recently found to involve the kidney. Finally, the mechanism of how leukocyte cell-derived chemotaxin 2 (ALECT2) forms amyloid remains unknown. This article reviews the amyloids that involve the kidney and how they are typed.
Collapse
Affiliation(s)
- Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota; Division of Hematology, Mayo Clinic, Rochester, Minnesota.
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
6
|
Goldis R, Kaplan B, Arad M, Dispenzieri A, Dasari S, Kukuy OL, Simon AJ, Dori A, Shavit-Stein E, Ziv T, Murray D, Kourelis T, Gertz MA, Dominissini D, Magen H, Muchtar E. Amino acid sequence homology of monoclonal serum free light chain dimers and tissue deposited light chains in AL amyloidosis: a pilot study. Clin Chem Lab Med 2024; 62:464-471. [PMID: 37747270 DOI: 10.1515/cclm-2023-0591] [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: 06/06/2023] [Accepted: 09/12/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVES Diagnosis of light chain amyloidosis (AL) requires demonstration of amyloid deposits in a tissue biopsy followed by appropriate typing. Previous studies demonstrated increased dimerization of monoclonal serum free light chains (FLCs) as a pathological feature of AL. To further examine the pathogenicity of FLC, we aimed at testing amino acid sequence homology between circulating and deposited light chains (LCs). METHODS Matched tissue biopsy and serum of 10 AL patients were subjected to tissue proteomic amyloid typing and nephelometric FLC assay, respectively. Serum FLC monomers (M) and dimers (D) were analyzed by Western blotting (WB) and mass spectrometry (MS). RESULTS WB of serum FLCs showed predominance of either κ or λ type, in agreement with the nephelometric assay data. Abnormal FLC M-D patterns typical of AL amyloidosis were demonstrated in 8 AL-λ patients and in one of two AL-κ patients: increased levels of monoclonal FLC dimers, high D/M ratio values of involved FLCs, and high ratios of involved to uninvolved dimeric FLCs. MS of serum FLC dimers showed predominant constant domain sequences, in concordance with the tissue proteomic amyloid typing. Most importantly, variable domain sequence homology between circulating and deposited LC species was demonstrated, mainly in AL-λ cases. CONCLUSIONS This is the first study to demonstrate homology between circulating FLCs and tissue-deposited LCs in AL-λ amyloidosis. The applied methodology can facilitate studying the pathogenicity of circulating FLC dimers in AL amyloidosis. The study also highlights the potential of FLC monomer and dimer analysis as a non-invasive screening tool for this disease.
Collapse
Affiliation(s)
- Rivka Goldis
- Department of Neurology, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Batia Kaplan
- Institute of Hematology and Sheba Cancer Research Center, Sheba Medical Center, Ramat Gan, Israel
| | - Michael Arad
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Heart Failure Institute, Leviev Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | | | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Olga Lesya Kukuy
- Institute of Nephrology and Hypertension, Sheba Medical Center, Ramat Gan, Israel
| | - Amos J Simon
- Institute of Hematology and Sheba Cancer Research Center, Sheba Medical Center, Ramat Gan, Israel
| | - Amir Dori
- Department of Neurology, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Efrat Shavit-Stein
- Department of Neurology, Sheba Medical Center, Ramat Gan, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tamar Ziv
- Smoler Protein Center, Faculty of Biology, Technion - Israel Institute of Technology, Haifa, Israel
| | - David Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | | | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Dan Dominissini
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Genomics Unit, Sheba Cancer Research Center, Sheba Medical Center, Ramat Gan, Israel
- Wohl Institute of Translational Medicine, Sheba Medical Center, Ramat Gan, Israel
| | - Hila Magen
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Multiple Myeloma Unit, Hematology Department, Sheba Medical Center, Ramat Gan, Israel
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| |
Collapse
|
7
|
Chen J, Chen H, Zhou L, Liu D, Du F, Xiang H. Strong positive light chain immunostaining in a patient with transthyretin amyloidosis. Hematology 2023; 28:2244315. [PMID: 37551718 DOI: 10.1080/16078454.2023.2244315] [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: 05/07/2023] [Accepted: 07/25/2023] [Indexed: 08/09/2023] Open
Abstract
The two most common systemic amyloidosis types are immunoglobulin light chain (AL) and amyloid transthyretin (ATTR) amyloidosis, in which the precursor proteins responsible for amyloidosis are light chain and transthyretin, respectively. Identification of precursor proteins is paramount to determine the type of amyloidosis, given that both amyloidosis types lack specificity in clinical presentation. Congo red staining followed by immunohistochemistry or immunofluorescence using fibril protein-specific antibodies is crucial for the diagnosis of amyloidosis. Here we describe a patient who was initially diagnosed with AL amyloidosis due to strong positive kappa light chain staining results. However, the diagnosis was corrected to hereditary ATTR amyloidosis using mass spectrometry and gene sequencing, confirming the important role of mass spectrometry in identifying the amyloid precursor protein and ruling out false-positive result from immunohistochemistry.
Collapse
Affiliation(s)
- Jiao Chen
- Department of Hematology, Shenzhen Luohu Hospital Group Luohu People's Hospital, Shenzhen, People's Republic of China
| | - Haifei Chen
- Department of Hematology, Shenzhen Luohu Hospital Group Luohu People's Hospital, Shenzhen, People's Republic of China
| | - Lingyun Zhou
- Department of Hematology, Shenzhen Luohu Hospital Group Luohu People's Hospital, Shenzhen, People's Republic of China
| | - Danbo Liu
- Department of Hematology, Shenzhen Luohu Hospital Group Luohu People's Hospital, Shenzhen, People's Republic of China
| | - Fang Du
- Department of Hematology, Shenzhen Luohu Hospital Group Luohu People's Hospital, Shenzhen, People's Republic of China
| | - Hongxian Xiang
- Department of Hematology, Shenzhen Luohu Hospital Group Luohu People's Hospital, Shenzhen, People's Republic of China
| |
Collapse
|
8
|
Frățilă G, Sorohan BM, Achim C, Andronesi A, Obrișcă B, Lupușoru G, Zilișteanu D, Jurubiță R, Bobeică R, Bălănică S, Micu G, Mocanu V, Ismail G. Oral Furosemide and Hydrochlorothiazide/Amiloride versus Intravenous Furosemide for the Treatment of Resistant Nephrotic Syndrome. J Clin Med 2023; 12:6895. [PMID: 37959360 PMCID: PMC10648037 DOI: 10.3390/jcm12216895] [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: 10/11/2023] [Revised: 10/30/2023] [Accepted: 11/01/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Data on diuretic treatment in nephrotic syndrome (NS) are scarce. Our goal was to assess the non-inferiority of the combined oral diuretics (furosemide/hydrochlorothiazide/amiloride) compared to intravenous (i.v.) furosemide in patients with NS and resistant edema. METHODS We conducted a prospective randomized trial on 22 patients with resistant nephrotic edema (RNE), defined as hypervolemia and a FENa < 0.2%. Based on a computer-generated 1:1 randomization, we assigned patients to receive either intravenous furosemide (40 mg bolus and then continuous administration of 5 mg/h) or oral furosemide (40 mg/day) and hydrochlorothiazide/amiloride (50/5 mg/day) for a period of 5 days. Clinical and laboratory measurements were performed daily. Hydration status was assessed by bioimpedance on day 1 and at the end of day 5 after treatment initiation. The primary endpoint was weight change from baseline to day 5. Secondary endpoints were hydration status change measured by bioimpedance and safety outcomes (low blood pressure, severe electrolyte disturbances, acute kidney injury and worsening hypervolemia). RESULTS Primary endpoint analysis showed that after 5 days of treatment, there was a significant difference in weight change from baseline between groups [adjusted mean difference: -3.33 kg (95% CI: -6.34 to -0.31), p = 0.03], with a higher mean weight change in the oral diuretic treatment group [-7.10 kg (95% CI: -18.30 to -4.30) vs. -4.55 kg (95%CI: -6.73 to -2.36)]. Secondary endpoint analysis showed that there was no significant difference between groups regarding hydration status change [adjusted mean difference: -0.05 L (95% CI: -2.6 to 2.6), p = 0.96], with a mean hydration status change in the oral diuretic treatment group of -4.71 L (95% CI: -6.87 to -2.54) and -3.91 L (95% CI: -5.69 to -2.13) in the i.v. diuretic treatment group. We observed a significant decrease in adjusted mean serum sodium of -2.15 mmol/L [(95% CI: -4.25 to -0.05), p = 0.04]), favored by the combined oral diuretic treatment [-2.70 mmol/L (95% CI: -4.89 to -0.50) vs. -0.10 mmol/L (95%CI: -1.30 to 1.10)]. No statistically significant difference was observed between the two groups in terms of adverse events. CONCLUSIONS A combination of oral diuretics based on furosemide, amiloride and hydrochlorothiazide is non-inferior to i.v. furosemide in weight control of patients with RNE and a similar safety profile.
Collapse
Affiliation(s)
- Georgiana Frățilă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
| | - Bogdan Marian Sorohan
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Department of Kidney Transplantation, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Camelia Achim
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Andreea Andronesi
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Bogdan Obrișcă
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Gabriela Lupușoru
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Diana Zilișteanu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| | - Roxana Jurubiță
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
| | - Raluca Bobeică
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
| | - Sonia Bălănică
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
| | - Georgia Micu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
| | - Valentin Mocanu
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
| | - Gener Ismail
- Department of Nephrology, Fundeni Clinical Institute, 022328 Bucharest, Romania; (G.F.); (C.A.); (A.A.); (B.O.); (G.L.); (D.Z.); (R.J.); (R.B.); (S.B.); (G.M.); (V.M.); (G.I.)
- Department of Nephrology, “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
| |
Collapse
|
9
|
Cardiac transthyretin/leukocyte chemotactic factor (LECT) 2 double amyloidosis in a patient suffering from heart failure. Clin Res Cardiol 2023; 112:444-449. [PMID: 35925392 DOI: 10.1007/s00392-022-02045-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 05/20/2022] [Indexed: 11/03/2022]
|
10
|
Diagnostic Challenges and Solutions in Systemic Amyloidosis. Int J Mol Sci 2023; 24:ijms24054655. [PMID: 36902083 PMCID: PMC10003318 DOI: 10.3390/ijms24054655] [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: 01/19/2023] [Revised: 02/10/2023] [Accepted: 02/25/2023] [Indexed: 03/04/2023] Open
Abstract
Amyloidosis refers to a clinically heterogeneous group of disorders characterized by the extracellular deposition of amyloid proteins in various tissues of the body. To date, 42 different amyloid proteins that originate from normal precursor proteins and are associated with distinct clinical forms of amyloidosis have been described. Identification of the amyloid type is essential in clinical practice, since prognosis and treatment regimens both vary according to the particular amyloid disease. However, typing of amyloid protein is often challenging, especially in the two most common forms of amyloidosis, i.e., the immunoglobulin light chain amyloidosis and transthyretin amyloidosis. Diagnostic methodology is based on tissue examinations as well as on noninvasive techniques including serological and imaging studies. Tissue examinations vary depending on the tissue preparation mode, i.e., whether it is fresh-frozen or fixed, and they can be carried out by ample methodologies including immunohistochemistry, immunofluorescence, immunoelectron microscopy, Western blotting, and proteomic analysis. In this review, we summarize current methodological approaches used for the diagnosis of amyloidosis and discusses their utility, advantages, and limitations. Special attention is paid to the simplicity of the procedures and their availability in clinical diagnostic laboratories. Finally, we describe new methods recently developed by our team to overcome limitations existing in the standard assays used in common practice.
Collapse
|
11
|
Szor RS, Fernandes F, Lino AMM, Mendonça LO, Seguro FS, Feitosa VA, Castelli JB, Jorge LB, de Oliveira Alves LB, de Menezes Neves PDM, de Oliveira Souza E, Cavalcante LB, Malheiros D, Kalil J, Martinez GA, Rocha V. Systemic amyloidosis journey from diagnosis to outcomes: a twelve-year real-world experience of a single center in a middle-income country. Orphanet J Rare Dis 2022; 17:425. [PMID: 36471404 PMCID: PMC9724300 DOI: 10.1186/s13023-022-02584-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 11/22/2022] [Indexed: 12/07/2022] Open
Abstract
BACKGROUND Systemic amyloidosis is caused by the deposition of misfolded protein aggregates in tissues, leading to progressive organ dysfunction and death. Epidemiological studies originate predominantly from high-income countries, with few data from Latin America. Due to the non-specific clinical manifestations, diagnosing amyloidosis is often challenging and patients experience a long journey and delay in diagnosis. This study aimed to assess clinical and laboratory characteristics, the diagnostic journey, and outcomes of patients with biopsy-proven systemic amyloidosis diagnosed between 2009 and 2020 at a university referral center in a middle-income Latin American country. Patients´ medical records were retrospectively reviewed. RESULTS One hundred and forty-three patients were included. The median age at diagnosis was 60 years and 54% were male. Until the diagnosis, most of the patients (52%) were seen by at least 3 specialists, the main ones being: general practitioners (57%), nephrologists (45%), and cardiologists (38%). The most common manifestations were renal (54%) and cardiac (41%) disorders, and cachexia was seen in 36% of patients. In 72% of the cases, ≥ 2 biopsies were required until the final diagnosis. The median time from symptoms onset to diagnosis was 10.9 months, and most patients (75%) had ≥ 2 organs involved. The following subtypes were identified: AL (68%), ATTR (13%), AA (8%), AFib (4%), and inconclusive (7%). Median OS was 74.3 months in the non-AL subgroup and 18.5 months in AL. Among AL patients, those with advanced cardiac stage had the worst outcome [median OS 8.6 months versus 52.3 for stage III versus I-II, respectively (p < 0.001)]. AL subtype, cardiac involvement, and ECOG ≥ 2 were identified as independent risk factors for reduced survival. CONCLUSIONS Systemic amyloidosis is still an underdiagnosed condition and the delay in its recognition leads to poor outcomes. Medical education, better diagnostic tools, improvement in access to therapies, and establishment of referral centers may improve patient outcomes in middle-income countries.
Collapse
Affiliation(s)
- Roberta Shcolnik Szor
- grid.11899.380000 0004 1937 0722Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas and Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP CEP 01246-000 Brazil
| | - Fabio Fernandes
- grid.11899.380000 0004 1937 0722Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil
| | - Angelina Maria Martins Lino
- grid.11899.380000 0004 1937 0722Divisão de Neurologia, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Leonardo Oliveira Mendonça
- grid.11899.380000 0004 1937 0722Departamento de Imunologia Clínica e Alergia, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Fernanda Salles Seguro
- grid.11899.380000 0004 1937 0722Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas and Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP CEP 01246-000 Brazil
| | - Valkercyo Araujo Feitosa
- grid.11899.380000 0004 1937 0722Divisão de Nefrologia, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Jussara Bianchi Castelli
- grid.11899.380000 0004 1937 0722Laboratório de Patologia, Instituto do Coração (InCor), Universidade de São Paulo, São Paulo, Brazil ,grid.466673.6Grupo Fleury, São Paulo, Brazil
| | - Lecticia Barbosa Jorge
- grid.11899.380000 0004 1937 0722Divisão de Nefrologia, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Lucas Bassolli de Oliveira Alves
- grid.11899.380000 0004 1937 0722Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas and Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP CEP 01246-000 Brazil
| | | | - Evandro de Oliveira Souza
- grid.11899.380000 0004 1937 0722Divisão de Gastroenterologia e Hepatologia Clínica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Livia Barreira Cavalcante
- grid.11899.380000 0004 1937 0722Divisão de Anatomia Patológica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Denise Malheiros
- grid.11899.380000 0004 1937 0722Divisão de Anatomia Patológica, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Jorge Kalil
- grid.11899.380000 0004 1937 0722Departamento de Imunologia Clínica e Alergia, Hospital das Clínicas, Universidade de São Paulo, São Paulo, Brazil
| | - Gracia Aparecida Martinez
- grid.11899.380000 0004 1937 0722Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas and Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP CEP 01246-000 Brazil
| | - Vanderson Rocha
- grid.11899.380000 0004 1937 0722Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas and Instituto do Câncer do Estado de São Paulo, Universidade de São Paulo, Av. Dr. Arnaldo, 251, Cerqueira César, São Paulo, SP CEP 01246-000 Brazil ,grid.4991.50000 0004 1936 8948Department of Hematology, Churchill Hospital, Oxford University, Oxford, UK
| |
Collapse
|
12
|
Bumma N, Kahwash R, Parikh SV, Isfort M, Freimer M, Vallakati A, Redder E, Campbell CM, Sharma N, Efebera Y, Stino A. Multidisciplinary amyloidosis care in the era of personalized medicine. Front Neurol 2022; 13:935936. [PMID: 36341129 PMCID: PMC9630033 DOI: 10.3389/fneur.2022.935936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/22/2022] [Indexed: 11/28/2022] Open
Abstract
Amyloidosis refers to a group of conditions where abnormal protein-or amyloid-deposits in tissues or organs, often leading to organ malfunction. Amyloidosis affects nearly any organ system, but especially the heart, kidneys, liver, peripheral nervous system, and gastrointestinal tract. Neuromuscular deficits comprise some of its ubiquitous manifestations. Amyloidosis can be quite challenging to diagnose given its clinical heterogeneity and multi-system nature. Early diagnosis with accurate genetic and serologic subtyping is key for effective management and prevention of organ decline. In this review, we highlight the value of a multidisciplinary comprehensive amyloidosis clinic. While such a model exists at numerous clinical and research centers across the globe, the lack of more widespread adoption of such a model remains a major hindrance to the timely diagnosis of amyloidosis. Such a multidisciplinary care model allows for the timely and effective diagnosis of amyloidosis, be it acquired amyloid light amyloidosis (AL), hereditary transthyretin amyloidosis (hATTR), or wild type amyloidosis (TTR-wt), especially in the current era of personalized genomic medicine. A multidisciplinary clinic optimizes the delivery of singular or combinatorial drug therapies, depending on amyloid type, fibril deposition location, and disease progression. Such an arrangement also helps advance research in the field. We present our experience at The Ohio State University, as one example out of many, to highlight the centrality of a multi-disciplinary clinic in amyloidosis care.
Collapse
Affiliation(s)
- Naresh Bumma
- Division of Hematology-Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Rami Kahwash
- Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Samir V. Parikh
- Division of Nephrology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Michael Isfort
- Division of Neuromuscular Medicine, Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Miriam Freimer
- Division of Neuromuscular Medicine, Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Ajay Vallakati
- Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Elyse Redder
- Oncology Rehabilitation, The Ohio State University James Cancer Center, Columbus, OH, United States
| | - Courtney M. Campbell
- Division of Cardiology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
- Cardiovascular Division, Cardio-Oncology Center of Excellence, Washington University in St. Louis, St. Louis, MO, United States
| | - Nidhi Sharma
- Division of Hematology-Oncology, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, United States
| | - Yvonne Efebera
- Ohio Health, Department of Hematology/Oncology and Blood and Marrow Transplant, Columbus, OH, United States
| | - Amro Stino
- Division of Neuromuscular Medicine, Department of Neurology, The University of Michigan Medical School, Ann Arbor, MI, United States
| |
Collapse
|
13
|
Marinkovic A, Zypchen LN, Chan J, Chen LY, Parkin S. Monoclonal gammopathy of clinical significance: what the rheumatologist needs to know. THE LANCET. RHEUMATOLOGY 2022; 4:e362-e373. [PMID: 38294033 DOI: 10.1016/s2665-9913(21)00348-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/29/2021] [Accepted: 10/18/2021] [Indexed: 02/01/2024]
Abstract
Monoclonal proteins can provide important information on the diagnosis of several non-malignant systemic inflammatory disorders. At low concentration, they most commonly represent monoclonal gammopathy of undetermined significance (MGUS), whereas high concentrations often signify plasma cell myeloma or B-cell lymphoma. However, several rare inflammatory conditions associated with variable concentrations of monoclonal proteins, systemic symptoms, and organ dysfunction also exist. These conditions are termed monoclonal gammopathies of clinical significance (MGCS). Patients with MGCS might present to rheumatologists with undiagnosed systemic inflammatory disorders and the monoclonal protein provides an important, underappreciated clue for diagnosis. In this Review, we provide an approach to distinguishing MGCS from MGUS and lymphoid neoplasms, focusing on four rare MGCS that rheumatologists must recognise: scleromyxedema, Schnitzler's syndrome, idiopathic systemic capillary leak syndrome (also known as Clarkson's disease), and telangiectasias, elevated erythropoietin and erythrocytosis, monoclonal gammopathy, perinephric fluid collections, and intrapulmonary shunting (known as TEMPI) syndrome.
Collapse
Affiliation(s)
- Angelina Marinkovic
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Leslie N Zypchen
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada
| | - Jonathan Chan
- Division of Rheumatology, University of British Columbia, Vancouver, BC, Canada
| | - Luke Yc Chen
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada; Centre for Health Education Scholarship, University of British Columbia, Vancouver, BC, Canada
| | - Stephen Parkin
- Division of Hematology, University of British Columbia, Vancouver, BC, Canada; Vancouver General Hospital, Vancouver, BC, Canada.
| |
Collapse
|
14
|
Abstract
Experimental studies of amyloids encounter many challenges. There are many methods available for studying proteins, which can be applied to amyloids: from basic staining techniques, allowing visualization of fibers, to complex methods, e.g., AFM-IR used to their detailed biochemical and structural characterization in nanoscale. Which method is appropriate depends on the goal of an experiment: verification of aggregational properties of a peptide, distinguishing oligomers from mature fibers, or kinetic studies. Insolubility, rapid aggregation, and the need of using a high-purity peptide may be a limiting factor in studies involving amyloids. Moreover, the results obtained by various experimental methods often differ significantly, which may lead to misclassification of amyloid peptides. Due to ambiguity of experimental results, laborious and time-consuming analysis, bioinformatical methods become more widely used for amyloids.
Collapse
Affiliation(s)
| | - Natalia Szulc
- Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Monika Szefczyk
- Department of Bioorganic Chemistry, Wroclaw University of Science and Technology, Wrocław, Poland
| |
Collapse
|
15
|
Clinical and Radiological Features of Intramuscular Orbital Amyloidosis: A Case Series and Literature Review. Ophthalmic Plast Reconstr Surg 2021; 38:234-241. [PMID: 34516528 DOI: 10.1097/iop.0000000000002061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Orbital amyloidosis of the extraocular muscles (EOMs) is a rare condition, and its clinicoradiological features are not well elucidated. This study describes the characteristic clinical signs, MRI features, and potential treatment options. METHODS Retrospective multicenter case series and literature review of EOM amyloidosis. RESULTS Five cases were identified for inclusion. Common clinical findings were diplopia, ophthalmoplegia, and proptosis. Systemic amyloidosis was more likely to present with multiple muscle involvement, but no particular pattern was observed with localized disease. On MRI, amyloid deposition was characterized as a heterogeneous intramuscular mass with T2 hypointensity and post contrast enhancement. Management is dependent on the extent of disease and functional impairment; options include surgical debulking and radiation therapy. CONCLUSION EOM amyloidosis is uncommon. The combination of clinical and radiologic findings described in this study should lead to its clinical suspicion.
Collapse
|
16
|
Minnella AM, Rissotto R, Antoniazzi E, Di Girolamo M, Luigetti M, Maceroni M, Bacherini D, Falsini B, Rizzo S, Obici L. Ocular Involvement in Hereditary Amyloidosis. Genes (Basel) 2021; 12:955. [PMID: 34206500 PMCID: PMC8304974 DOI: 10.3390/genes12070955] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/06/2021] [Accepted: 06/18/2021] [Indexed: 12/27/2022] Open
Abstract
The term amyloidosis describes a group of rare diseases caused by protein conformation abnormalities resulting in extracellular deposition and accumulation of insoluble fibrillar aggregates. So far, 36 amyloid precursor proteins have been identified, and each one is responsible for a specific disease entity. Transthyretin amyloidosis (ATTRv) is one of the most common forms of systemic and ocular amyloidosis, due to the deposition of transthyretin (TTR), which is a transport protein mainly synthesized in the liver but also in the retinal pigment epithelial cells. ATTRv amyloidosis may be misdiagnosed with several other conditions, resulting in a significant diagnostic delay. Gelsolin and keratoepithelin are other proteins that, when mutated, are responsible for a systemic amyloid disease with significant ocular manifestations that not infrequently appear before systemic involvement. The main signs of ocular amyloid deposition are in the cornea, irido-corneal angle and vitreous, causing complications related to vasculopathy and neuropathy at the local level. This review aims at describing the main biochemical, histopathological and clinical features of systemic amyloidosis associated with eye involvement, with particular emphasis on the inherited forms. We discuss currently available treatments, focusing on ocular involvement and specific ophthalmologic management and highlighting the importance of a prompt treatment for the potential sight-threatening complications derived from amyloid deposition in ocular tissues.
Collapse
Affiliation(s)
- Angelo Maria Minnella
- Dipartimento Universitario Testa-Collo Rgani di Senso, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.M.M.); (M.M.); (B.F.); (S.R.)
- UOC Oculistica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Roberta Rissotto
- Eye Clinic, San Paolo Hospital, University of Milan, 20142 Milan, Italy
| | - Elena Antoniazzi
- Institute of Ophthalmolgy, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| | - Marco Di Girolamo
- Former Director “Presidio Ambulatoriale per le Amiloidosi Sistemiche” Fatebenefratelli “San Giovanni Calibita” Hospital, 00135 Rome, Italy;
| | - Marco Luigetti
- Fondazione Policlinico A. Gemelli IRCCS. UOC Neurologia, 00168 Rome, Italy;
- Dipartimento di Neuroscienze, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Martina Maceroni
- Dipartimento Universitario Testa-Collo Rgani di Senso, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.M.M.); (M.M.); (B.F.); (S.R.)
| | - Daniela Bacherini
- Department of Neuroscience, Psychology, Drug Research and Child Health, Eye Clinic, University of Florence, 50139 Florence, Italy;
| | - Benedetto Falsini
- Dipartimento Universitario Testa-Collo Rgani di Senso, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.M.M.); (M.M.); (B.F.); (S.R.)
- UOC Oculistica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Stanislao Rizzo
- Dipartimento Universitario Testa-Collo Rgani di Senso, Università Cattolica del Sacro Cuore, 00168 Rome, Italy; (A.M.M.); (M.M.); (B.F.); (S.R.)
- UOC Oculistica, Fondazione Policlinico Universitario A. Gemelli-IRCCS, 00168 Rome, Italy
| | - Laura Obici
- Amyloidosis Research and Treatment Centre, IRCCS Fondazione Policlinico San Matteo, 27100 Pavia, Italy;
| |
Collapse
|
17
|
Karitzky PC, Trautmann-Grill C, Laske J, Beissert S, Meier F. Kutane Manifestation einer AL-Amyloidose mit Plasmazellmyelom vom Lambda-Leichtkettentyp. AKTUELLE DERMATOLOGIE 2021. [DOI: 10.1055/a-1406-8002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
ZusammenfassungDie mit einem multiplen Myelom assoziierte Immunoglobulin-Leichtketten (AL)-Amyloidose ist unter den systemischen Amyloidosen die häufigste Form, als Entität selbst jedoch relativ selten. Die durch den monoklonalen Plasmazellklon sezernierten instabilen Leichtketten führen als Amyloidablagerungen im Gewebe zu manifesten Organschäden, v. a. die renalen und kardialen Organmanifestationen führen häufig zu einer sehr schlechten Prognose. Besonders kutane Manifestationen wie beidseitige periorbitale Ödeme, Ekchymosen und eine Makroglossie können als pathognomonisch für die systemische AL-Amyloidose betrachtet werden und sollten zu einer raschen Abklärung führen. Wir berichten über einen Patienten mit einer kutanen Manifestation einer AL-Amyloidose mit assoziiertem „smouldering Myelom“.
Collapse
Affiliation(s)
- P. C. Karitzky
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden
| | - C. Trautmann-Grill
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden
| | - J. Laske
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden
| | - S. Beissert
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden
| | - F. Meier
- Klinik und Poliklinik für Dermatologie, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden
| |
Collapse
|
18
|
Masson Trichrome and Sulfated Alcian Blue Stains Distinguish Light Chain Deposition Disease From Amyloidosis in the Lung. Am J Surg Pathol 2021; 45:405-413. [PMID: 33002919 DOI: 10.1097/pas.0000000000001593] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Light chain deposition disease, characterized by nonamyloidogenic deposits of immunoglobulin light chains, is rare in the lung and possibly underdiagnosed due to low clinical suspicion and lack of readily accessible tests. We encountered a case of pulmonary light chain deposition disease (PLCDD) in which light chain deposits appeared crimson red with a Masson trichrome (MT) stain and salmon pink with a sulfated Alcian blue (SAB) stain. This prompted us to characterize a series of PLCDD cases and assess the utility of MT and SAB stains to distinguish them from amyloidosis. From the pathology archives of 2 institutions spanning 10 years, we identified 11 cases of PLCDD, including 7 diagnosed as such and 4 determined retrospectively. The deposits in all cases of PLCDD stained crimson red with MT and salmon pink with SAB, while the cases of pulmonary amyloid (n=10) stained blue-gray and blue-green, respectively. The immunoglobulin light chain nature of the deposits was confirmed in 10 of 11 cases by either immunofluorescence microscopy (n=5) or mass spectrometry (n=5). Transmission electron microscopy revealed osmiophilic, electron-dense deposits in all cases analyzed (n=3). An extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue type was diagnosed in 10 cases and 1 represented a plasma cell neoplasm. Our study highlights the importance of considering PLCDD in the differential diagnosis of amyloid-like deposits in the lung and the value of performing MT and SAB stains to distinguish between PLCDD and amyloidosis.
Collapse
|
19
|
Lin XY, Pan D, Sang LX, Chang B. Primary localized gastric amyloidosis: A scoping review of the literature from clinical presentations to prognosis. World J Gastroenterol 2021; 27:1132-1148. [PMID: 33828390 PMCID: PMC8006099 DOI: 10.3748/wjg.v27.i12.1132] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 01/10/2021] [Accepted: 02/25/2021] [Indexed: 02/06/2023] Open
Abstract
Localized gastric amyloidosis (LGA) is a rare disease characterized by abnormal extracellular deposition of amyloid protein restricted to the stomach and it is confirmed by positive results of Congo red staining. Over decades, only a few cases have been reported and studies or research focusing on it are few. Although LGA has a low incidence, patients may suffer a lot from it and require proper diagnosis and management. However, the pathology of LGA remains unknown and no overall review of LGA from its presentations to its prognosis has been published. Patients with LGA are often asymptomatic or manifest atypical symptoms, making it difficult to differentiate from other gastrointestinal diseases. Here, we report the case of a 70-year-old woman with LGA and provide an overview of case reports of LGA available to us. Based on that, we conclude current concepts of clinical manifestations, diagnosis, treatment, and prognosis of LGA, aiming at providing a detailed diagnostic procedure for clinicians and promoting the guidelines of LGA. In addition, a few advanced technologies applied in amyloidosis are also discussed in this review, aiming at providing clinicians with a reference of diagnostic process. With this review, we hope to raise awareness of LGA among the public and clinicians.
Collapse
Affiliation(s)
- Xin-Yu Lin
- Department of Neurology, The First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Dan Pan
- Department of Geriatrics, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Li-Xuan Sang
- Department of Geriatrics, The First Affiliated Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| | - Bing Chang
- Department of Gastroenterology, The First Hospital of China Medical University, Shenyang 110001, Liaoning Province, China
| |
Collapse
|
20
|
Abstract
PURPOSE OF REVIEW Cardiac amyloidosis is an underrecognized cause of heart failure. We review clinical clues to the diagnoses, a rational approach to testing, and current and emerging therapies. RECENT FINDINGS Advances in the diagnosis of amyloid cardiomyopathy include (1) use of 99mtechnetium (99mTc) bone-avid compounds which allow accurate noninvasive diagnosis of transthyretin cardiac amyloidosis (ATTR-CM) in the context of a negative monoclonal light chain screen; and (2) the use of serum and urine immunofixation electrophoresis with serum free light chains as an accurate first diagnostic step for light chain cardiac amyloidosis (AL-CM). Advances in treatment include tafamidis for ATTR-CM and immunologic therapies for AL-CM. With the advent of accurate noninvasive diagnostic modalities and effective therapies, early recognition of cardiac amyloidosis is paramount to implement a diagnostic algorithm and expeditiously institute effective therapies to minimize morbidity and mortality.
Collapse
|
21
|
Flood TA, Bradshaw SH, Veinot JP, Nair V. Cardiac Amyloid - A Hidden Contributor to Cardiac Dysfunction Following Cardiac Surgery: Case Report and Literature Review. Curr Cardiol Rev 2021; 16:350-353. [PMID: 31858904 PMCID: PMC7903502 DOI: 10.2174/1573403x16666191220143547] [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: 09/10/2019] [Revised: 11/09/2019] [Accepted: 12/05/2019] [Indexed: 11/22/2022] Open
Abstract
We present two patients who underwent cardiac surgery followed by post-operative low cardiac output, diastolic dysfunction and resistance to inotropic support. Despite aggressive medical management, both patients died. At autopsy, the hearts were enlarged and showed previously undiagnosed myocardial and vascular amyloidosis. Occult cardiac amyloidosis is an uncommon, often occult, contributor to post-operative complications post cardiac surgery. Pre-operative or intra-operative myocardial biopsy may be useful in patients with unexplained diastolic dysfunction.
Collapse
Affiliation(s)
- Trevor A Flood
- Division of Anatomical Pathology, Department of Pathology and Laboratory Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, ON K1H 8L6, Canada
| | - Scott H Bradshaw
- Division of Anatomical Pathology, Department of Pathology and Laboratory Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, ON K1H 8L6, Canada
| | - John P Veinot
- Division of Anatomical Pathology, Department of Pathology and Laboratory Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, ON K1H 8L6, Canada
| | - Vidhya Nair
- Division of Anatomical Pathology, Department of Pathology and Laboratory Medicine, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, ON K1H 8L6, Canada
| |
Collapse
|
22
|
Chean CS, Sovani V, Boden A, Knapp C. Lacrimal gland extranodal marginal zone B-cell lymphoma in the presence of amyloidosis. Orbit 2020; 41:350-353. [PMID: 33213206 DOI: 10.1080/01676830.2020.1852578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Amyloidosis is a protein metabolism disorder characterised by extracellular deposition of insoluble amorphous hyaline material. Orbital and ocular amyloid lesions account for only 4% of localised disease affecting the head and neck. Ocular adnexal lymphoma accounts for 1-2% of lymphoma, with lacrimal gland lymphomas being relatively uncommon. The most common form affecting the orbit is extranodal marginal zone lymphoma (EMZL) of mucosa-associated lymphoid tissue (MALT lymphoma). We report an extremely rare case of co-existent EMZL and amyloidosis of the lacrimal gland. Initial biopsy of the right lacrimal gland confirmed an EMZL with amyloid deposit, and a course of radiotherapy treatment was given. Recurrent lacrimal gland swelling developed within a year. Subsequent biopsy identified amyloidosis with scanty lymphoid tissue. To our knowledge, this is the first reported case of localised lacrimal gland amyloidosis of uncertain type with previous EMZL; the association described in this case report is not yet fully understood.
Collapse
Affiliation(s)
- Chung Shen Chean
- United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Lincoln, UK
| | - Vishakha Sovani
- Department of Histopatholog, Nottingham University Hospitals NHS Trust (City Campus), Nottingham, UK
| | - Ali Boden
- United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Lincoln, UK
| | - Christopher Knapp
- United Lincolnshire Hospitals NHS Trust, Lincoln County Hospital, Lincoln, UK
| |
Collapse
|
23
|
Spoladore R, Falasconi G, Marcatti M, Di Maio S, Fiore G, Slavich M, Margonato A, Turco A, Fragasso G. Advances in pharmacotherapy for cardiac amyloidosis. Expert Opin Pharmacother 2020; 22:469-481. [PMID: 33043721 DOI: 10.1080/14656566.2020.1836159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Amyloidosis is a group of progressive and devastating disorders resulting from extracellular deposition of misfolded proteins into tissues. When deposition of fibrils occurs in cardiac tissues, this systemic disease can lead to a very poor prognosis. Systemic amyloidosis can be acquired [light chain (AL) amyloidosis; AA amyloidosis], or hereditary [transthyretin (ATTR) amyloidosis]. Cardiac disease in amyloidosis is usually secondary to a systemic disease. The diagnosis of cardiac involvement is often delayed and yields an adverse prognosis. AREAS COVERED in this review, the authors report current literature on advances in pharmacotherapy for cardiac amyloidosis, mainly focused on AL and ATTR amyloidosis treatment. EXPERT OPINION Most pharmacological trials in amyloidosis patients, both AL and TTR, are directed to study the effects of drugs on polyneuropathy. However, since cardiac involvement carries a prominent negative survival impact in amyloidosis patients, future research should be more focused on amyloidosis cardiomyopathy as primary endpoint. Additionally, in AL amyloidosis therapies are mainly derived from experience on multiple myeloma treatment. In this specific setting, possible future research could particularly focus on immunotherapeutic agents able to optimize the standard chemotherapy results and, thus, allowing a larger population of patients to be treated by bone marrow stem cell transplantation.
Collapse
Affiliation(s)
- R Spoladore
- Hypertrophic Cardiomyopathy Unit, IRCCS San Raffaele University Hospital, Milan, Italy.,Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - G Falasconi
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - M Marcatti
- Haematology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - S Di Maio
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - G Fiore
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - M Slavich
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - A Margonato
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - A Turco
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - G Fragasso
- Clinical Cardiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy.,Heart Failure Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| |
Collapse
|
24
|
Abe R, Katoh N, Takahashi Y, Takasone K, Yoshinaga T, Yazaki M, Kametani F, Sekijima Y. Distribution of amyloidosis subtypes based on tissue biopsy site - Consecutive analysis of 729 patients at a single amyloidosis center in Japan. Pathol Int 2020; 71:70-79. [PMID: 33112446 DOI: 10.1111/pin.13041] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/06/2020] [Indexed: 01/30/2023]
Abstract
This study was performed to elucidate the distribution of amyloidosis subtypes based on tissue biopsy site. Samples obtained from 729 consecutive patients with amyloidosis were analyzed by immunohistochemical staining (IHC) and supplemental mass spectrometry (MS). The correlations between the type of organs from which samples were obtained and amyloidosis subtypes were investigated retrospectively. Among the patients, 95.1% were diagnosed by IHC and 4.9% were diagnosed by MS. The distribution of amyloidosis subtypes was as follows: AL, 59.1%; ATTR, 32.9%; AA, 4.0%; AH, 1.4%; Aβ2M, 0.8%; and others, 0.9%. AL was the most common subtype in most organs, including the liver, lung, kidney, lower urinary tract, bone marrow, gastrointestinal tract, and skin/subcutaneous tissue. ATTR was the most common subtype in the heart, carpal tunnel, and peripheral nerves. AH was the second most common subtype in renal biopsy. Three or more amyloidosis subtypes were detected in each organ. In conclusion, AL was the most common subtype in most biopsy sites except the heart, carpal tunnel, and peripheral nerve, in which ATTR was more common. Because several types of amyloidogenic protein were detected in each organ, amyloid typing must be pursued, no matter the site from where biopsy was obtained.
Collapse
Affiliation(s)
- Ryuta Abe
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Nagano, Japan
| | - Nagaaki Katoh
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Nagano, Japan
| | - Yusuke Takahashi
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Nagano, Japan
| | - Ken Takasone
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Nagano, Japan
| | - Tsuneaki Yoshinaga
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Nagano, Japan
| | - Masahide Yazaki
- Clinical Laboratory Science Division, Shinshu University Graduate School of Medicine, Nagano, Japan.,Institute for Biomedical Sciences, Shinshu University, Nagano, Japan
| | - Fuyuki Kametani
- Department of Dementia and Higher Brain Function, Tokyo Metropolitan Institute of Medical Science, Tokyo, Japan
| | - Yoshiki Sekijima
- Department of Medicine (Neurology and Rheumatology), Shinshu University School of Medicine, Nagano, Japan.,Institute for Biomedical Sciences, Shinshu University, Nagano, Japan
| |
Collapse
|
25
|
hATTR Pathology: Nerve Biopsy Results from Italian Referral Centers. Brain Sci 2020; 10:brainsci10110780. [PMID: 33114611 PMCID: PMC7692609 DOI: 10.3390/brainsci10110780] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 10/11/2020] [Accepted: 10/23/2020] [Indexed: 12/19/2022] Open
Abstract
Pathological evidence of amyloid on nerve biopsy has been the gold standard for diagnosis in hereditary transthyretin amyloidosis polyneuropathy (hATTR-PN) for a long time. In this article, we reviewed the pathological findings of a large series of sural nerve biopsies from a cohort of hATTR-PN patients, collected by different Italian referral centers. Patients and Methods: We reviewed clinical and pathological data from hATTR-PN patients, diagnosed and followed in five Italian referral centers for peripheral neuropathies. Diagnosis was formulated after a positive genetic test for transthyretin (TTR) mutations. Sural nerve biopsy was performed according to standard protocols. Results: Sixty-nine sural nerve biopsies from hATTR-PN patients were examined. Congo red positive deposits were found in 73% of cases. Only the Phe64Leu mutation failed to show amyloid deposits in a high percentage of biopsies (54%), as already described. Unusual pathological findings, such as myelin abnormalities or inflammatory infiltrates, were detected in occasional cases. Conclusions: Even if no longer indicated to confirm hATTR-PN clinical suspicion, nerve biopsy remains, in expert hands, a rapid and inexpensive tool to detect amyloid deposition. In Italy, clinicians should be aware that a negative biopsy does not exclude hATTR-PN, particularly for Phe64Leu, one of the most frequent mutations in this country.
Collapse
|
26
|
Karam S, Leung N. Renal Involvement in Systemic Amyloidosis Caused by Monoclonal Immunoglobulins. Hematol Oncol Clin North Am 2020; 34:1069-1079. [PMID: 33099424 DOI: 10.1016/j.hoc.2020.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Kidney involvement in immunoglobulin-related amyloidosis (AIg) is common. Although patients with renal-limited AIg tend not to have the high mortality that patients with cardiac amyloidosis have, they do experience significant morbidity and impact on quality of life. The complexity of the pathogenesis remains incompletely understood. Models have been established to prognosticate and assess for the response to therapy. Patients with advanced renal impairment from immunoglobulin light chain amyloidosis still have poor renal prognosis, and better therapy is needed in order to preserve kidney function. Patients who develop end-stage renal disease can undergo renal replacement therapy with kidney transplantation.
Collapse
Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, Saint George Hospital University Medical Center, PO Box 166 378 Achrafieh, Beirut 11 00 2807, Lebanon. https://twitter.com/sabinekaram6
| | - Nelson Leung
- Division of Nephrology and Hypertension, Division of Hematology, Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA.
| |
Collapse
|
27
|
Yamada S, Yoshihisa A, Hijioka N, Kamioka M, Kaneshiro T, Yokokawa T, Misaka T, Ishida T, Takeishi Y. Autonomic dysfunction in cardiac amyloidosis assessed by heart rate variability and heart rate turbulence. Ann Noninvasive Electrocardiol 2020; 25:e12749. [PMID: 32083399 PMCID: PMC7358876 DOI: 10.1111/anec.12749] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 12/03/2019] [Accepted: 01/08/2020] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Cardiac amyloidosis (CA) is characterized by left ventricular hypertrophy (LVH) and autonomic nervous imbalance due to amyloid infiltration. However, autonomic dysfunction is often seen in heart failure (HF) with LVH from other etiologies. We aimed to characterize autonomic dysfunction in CA from other etiologies of LVH. METHODS Fifty-five HF patients with LVH (35 males, mean age 65 ± 16 years) were enrolled. LVH was defined as left ventricular mass index measured by echocardiography >95 g/m2 in women and 115 g/m2 in men. The etiology was as follows: amyloid light chain (AL)-CA, n = 14; hypertrophic cardiomyopathy, n = 21; and aortic stenosis (AS), n = 20. With the patient in a clinically stable condition, heart rate variability (HRV) and heart rate turbulence (HRT), which reflect autonomic dysfunction, were measured using Holter monitoring and compared among the three groups. RESULTS Brain natriuretic peptide levels, LVH severity, left ventricular ejection fraction, and tissue Doppler index E/e' did not differ among the three groups. However, severe abnormalities of HRV and HRT were obtained in AL-CA. In the ROC analysis to identify AL-CA in HF with LVH, the best cutoff value for standard deviation of all R-R intervals, standard deviation of the 5-min mean R-R intervals, turbulence onset, and turbulence slope were 68.5 ms (AUC: 0.865), 58.5 ms (AUC: 0.834), 0.25% (AUC: 0.813), and 1.00 ms/RR (AUC 0.736), respectively. CONCLUSION Autonomic dysfunction is a hallmark of AL-CA, and its noninvasive assessment by Holter monitoring may be a useful tool for differential diagnosis of HF with LVH.
Collapse
Affiliation(s)
- Shinya Yamada
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Akiomi Yoshihisa
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
- Department of Advanced Cardiac TherapeuticsFukushima Medical UniversityFukushimaJapan
| | - Naoko Hijioka
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Masashi Kamioka
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Takashi Kaneshiro
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
- Department of Arrhythmia and Cardiac PacingFukushima Medical UniversityFukushimaJapan
| | - Tetsuro Yokokawa
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Tomofumi Misaka
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
- Department of Advanced Cardiac TherapeuticsFukushima Medical UniversityFukushimaJapan
| | - Takafumi Ishida
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| | - Yasuchika Takeishi
- Department of Cardiovascular MedicineFukushima Medical UniversityFukushimaJapan
| |
Collapse
|
28
|
Varga C, Dorbala S, Lousada I, Polydefkis MJ, Wechalekar A, Maurer MS, Comenzo RL. The diagnostic challenges of cardiac amyloidosis: A practical approach to the two main types. Blood Rev 2020; 45:100720. [PMID: 32616304 DOI: 10.1016/j.blre.2020.100720] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 06/11/2020] [Accepted: 06/17/2020] [Indexed: 12/28/2022]
Abstract
Systemic amyloidosis of the immunoglobulin light-chain (AL) or transthyretin type (ATTR) is a multisystem protein deposition disease that often involves the heart. Delays in diagnosis are very common and can have detrimental consequences on patient outcomes. Because both major types can now be distinguished quickly and treated effectively, clear approaches are required. There have been advances in radioisotope scintigraphy, monoclonal protein testing and mass spectrometry for typing that need coordinated application. We have entered an era in which rapid diagnosis and ready therapy will save lives, therefore we must develop coherent approaches to this multisystem disease. The prognosis for AL has improved significantly with the incorporation of novel agents such as proteasome inhibitors, immunomodulators and monoclonal antibodies against plasma cells. Multiple independent studies have demonstrated the efficacy of these agents in AL, though tolerability can become an issue with dose reductions required in many cases. Median overall survival for patients achieving complete responses after stem cell transplant and consolidation exceeds a decade. The prognosis for ATTR, both age-related wild-type (ATTRwt) and hereditary due to variants of transthyretin (ATTRv), has improved as well due to the availability of the stabilizer tafamidis and the RNA-interference agents patisiran and inotersen. In both AL and ATTR, with elimination or suppression of the pathologic amyloid-forming protein, symptomatic involvement of the heart, kidneys and peripheral nervous system can improve as well. In this review, we present the current state of diagnosing and treating the two major types of systemic amyloidosis, emphasizing the coherent clinical application of the new tools and treatments. Implementation of the approaches we provide will enable rapid identification of amyloid type and rational selection of therapy.
Collapse
Affiliation(s)
- Cindy Varga
- Department of Medicine, The John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA.
| | - Sharmila Dorbala
- Department of Radiology, Nuclear Medicine Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Michael J Polydefkis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London (Royal Free Campus), London, UK
| | - Mathew S Maurer
- Columbia University Irving Medical Center, New York, NY, USA
| | - Raymond L Comenzo
- Department of Medicine, The John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Boston, MA, USA
| |
Collapse
|
29
|
Nakov R, Sarafov S, Gospodinova M, Kirov A, Chamova T, Todorov T, Todorova A, Tournev I. Transthyretin amyloidosis: Testing strategies and model for center of excellence support. Clin Chim Acta 2020; 509:228-234. [PMID: 32564944 DOI: 10.1016/j.cca.2020.06.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 10/24/2022]
Abstract
Appropriate testing strategies and strict model for Center Of Excellence (CoE) support are essential for the correct diagnosis, follow-up strategy and treatment plan for transthyretin (ATTR) amyloidosis. CoE is defined as a programme within a healthcare institution established to provide an exceptionally high concentration of expertise and related resources centred on a particular area of medicine, delivering associated care in a comprehensive, interdisciplinary fashion to afford the best patient outcome. Ideally, CoEs provide regular education and training for healthcare professionals and share knowledge and learning with other CoEs and specialists to ensure the highest standards of care. CoEs and testing strategies are of significant value to those with rare diseases and their families, as there is naturally low awareness among healthcare professionals, a phenomenon that potentially delays diagnosis and treatment. In this review, we focus on the importance of performing the most appropriate testing strategies for ATTR amyloidosis and establishing a CoE for this rare disease. We highlight our experience in establishing a CoE in Sofia, Bulgaria and define the fundamental steps needed to successfully launch a programme.
Collapse
Affiliation(s)
- Radislav Nakov
- Clinic of Gastroenterology, Tsaritsa Joanna University Hospital, Medical University - Sofia, Bulgaria.
| | - Stayko Sarafov
- Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University - Sofia, Bulgaria
| | - Mariana Gospodinova
- Clinic of Cardiology, Medical Institute of Ministry of Interior, Sofia, Bulgaria
| | - Andrey Kirov
- Genetic and Medico-diagnostic Laboratory "Genica", Sofia, Bulgaria; Department of Medical Chemistry and Biochemistry, Medical University - Sofia, Bulgaria
| | - Teodora Chamova
- Clinic of Gastroenterology, Tsaritsa Joanna University Hospital, Medical University - Sofia, Bulgaria
| | - Tihomir Todorov
- Genetic and Medico-diagnostic Laboratory "Genica", Sofia, Bulgaria
| | - Albena Todorova
- Genetic and Medico-diagnostic Laboratory "Genica", Sofia, Bulgaria; Department of Medical Chemistry and Biochemistry, Medical University - Sofia, Bulgaria
| | - Ivailo Tournev
- Clinic of Nervous Diseases, Alexandrovska University Hospital, Medical University - Sofia, Bulgaria; Department of Cognitive Science and Psychology, New Bulgarian University, Sofia, Bulgaria
| |
Collapse
|
30
|
Kadota A, Iwaide S, Miyazaki S, Mitsui I, Machida N, Murakami T. Pathology and Proteomics-Based Diagnosis of Localized Light-Chain Amyloidosis in Dogs and Cats. Vet Pathol 2020; 57:658-665. [PMID: 32880234 DOI: 10.1177/0300985820934113] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Amyloidosis is classified according to the amyloid precursor protein, and accurate diagnosis of the amyloidosis type may guide appropriate treatment. Immunohistochemistry and Congo red staining are the most frequently used methods used to distinguish types of amyloidosis, but problems with specificity and sensitivity indicate the need for an alternative diagnostic method. In this study, we evaluated laser microdissection-liquid chromatography-tandem mass spectrometry (LMD-LC-MS/MS) for the diagnosis of amyloid light-chain (AL) amyloidosis in animals. Plasmacytomas with amyloid deposits from 15 dogs and 2 cats were subjected to Congo red staining with or without potassium permanganate pretreatment, immunohistochemistry for kappa and lambda light chains, and LMD-LC-MS/MS. Congo red staining was diagnostic in 12 of 17 cases based on resistance to potassium permanganate pretreatment, but in 5 of 17 cases the pretreatment unexpectedly reduced Congo red staining or abrogated the birefringence and a definitive diagnosis could not be reached. Immunohistochemistry detected kappa or lambda light chains in 6 of 17 cases. With LMD-LC-MS/MS, immunoglobulin lambda light chain was detected in all 17 cases. The amyloid signature proteins ApoA-I, ApoA-IV, and ApoE were detected in 9, 1, and 3 of the 15 canine cases by LMD-LC-MS/MS, but not in the feline cases. In conclusion, LMD-LC-MS/MS consistently determined the amyloid type in all examined specimens, while Congo red staining after potassium permanganate treatment and immunohistochemistry were less sensitive tests.
Collapse
Affiliation(s)
- Ayumi Kadota
- Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Susumu Iwaide
- Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Shinya Miyazaki
- Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Ikki Mitsui
- 13019Okayama University of Science, Ehime, Japan
| | - Noboru Machida
- Tokyo University of Agriculture and Technology, Tokyo, Japan
| | | |
Collapse
|
31
|
Juneja R, Pati HP. Approach to the Diagnosis of Amyloidosis. Indian J Hematol Blood Transfus 2020; 36:246-253. [PMID: 32425373 DOI: 10.1007/s12288-019-01208-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 10/01/2019] [Indexed: 11/26/2022] Open
Abstract
Amyloidosis is heterogeneous group of disorder characterized by extracellular deposition of misfolded insoluble proteinaceous material with cross beta pleated sheet structure leading to organ dysfunction. This disease is rare and indeed heterogeneous, as it may be hereditary (familial amyloidosis), secondary to spectrum of inflammatory conditions (AA amyloidosis) or member of plasma cell neoplasm family (AL amyloidosis). AL amyloidosis is the most common type of amyloid, however, is rarely accompanied by multiple myeloma or other lymphoproliferative disorder. This disparity in its origin and presentation needs to be addressed by exhaustive battery of investigation tools, to arrive at right diagnosis with correct typing. This is of utmost importance in guiding the treating physicians to choose appropriate therapeutic options. This review deals with diagnostic approach to amyloidosis and its various subtypes.
Collapse
Affiliation(s)
- Richa Juneja
- Department of Hematology, AIIMS, New Delhi, India
| | - H P Pati
- Department of Hematology, AIIMS, New Delhi, India
| |
Collapse
|
32
|
El Ters M, Bobart SA, Cornell LD, Leung N, Bentall A, Sethi S, Fidler M, Grande J, Hernandez LH, Cosio FG, Zand L, Amer H, Fervenza FC, Nasr SH, Alexander MP. Recurrence of DNAJB9-Positive Fibrillary Glomerulonephritis After Kidney Transplantation: A Case Series. Am J Kidney Dis 2020; 76:500-510. [PMID: 32414663 DOI: 10.1053/j.ajkd.2020.01.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 01/26/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE & OBJECTIVE Fibrillary glomerulonephritis (FGN) is a rare glomerular disease that often progresses to kidney failure requiring kidney replacement therapy. We have recently identified a novel biomarker of FGN, DnaJ homolog subfamily B member 9 (DNAJB9). In this study, we used sequential protocol allograft biopsies and DNAJB9 staining to help characterize a series of patients with native kidney FGN who underwent kidney transplantation. STUDY DESIGN Case series. SETTING & PARTICIPANTS Between 1996 and 2016, kidney transplantation was performed on 19 patients with a reported diagnosis of FGN in their native/transplant kidneys. Using standard diagnostic criteria and DNAJB9 staining, we excluded 5 patients (4 atypical cases diagnosed as possible FGN and 1 donor-derived FGN). Protocol allograft biopsies had been performed at 4, 12, 24, 60, and 120 months posttransplantation. DNAJB9 immunohistochemistry was performed using an anti-DNAJB9 rabbit polyclonal antibody. Pre- and posttransplantation demographic and clinical characteristics were collected. Summary statistical analysis was performed, including nonparametric statistical tests. OBSERVATIONS The 14 patients with FGN had a median posttransplantation follow-up of 5.7 (IQR, 2.9-13.8) years. 3 (21%) patients had recurrence of FGN, detected on the 5- (n=1) and 10-year (n=2) allograft biopsies. Median time to recurrence was 10.2 (IQR, 5-10.5) years. Median levels of proteinuria and iothalamate clearance at the time of recurrence were 243mg/d and 56mL/min. The remaining 11 patients had no evidence of histologic recurrence on the last posttransplantation biopsy, although the median time of follow-up was significantly less at 4.4 (IQR, 2.9-14.4) years. 3 (21%) patients had a monoclonal protein detectable in serum obtained pretransplantation; none of these patients had recurrent FGN. LIMITATIONS Small study sample and shorter follow-up time in the nonrecurrent versus recurrent group. CONCLUSIONS In this series, FGN had an indolent course in the kidney allograft in that detectable histologic recurrence did not appear for at least 5 years posttransplantation.
Collapse
Affiliation(s)
- Mireille El Ters
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Shane A Bobart
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Lynn D Cornell
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Andrew Bentall
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Sanjeev Sethi
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mary Fidler
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Joseph Grande
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Fernando G Cosio
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | - Ladan Zand
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Hatem Amer
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN; William von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN
| | | | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Mariam P Alexander
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN.
| |
Collapse
|
33
|
Curiel Cid RE, Crocco EA, Duara R, Garcia JM, Rosselli M, DeKosky ST, Smith G, Bauer R, Chirinos CL, Adjouadi M, Barker W, Loewenstein DA. A novel method of evaluating semantic intrusion errors to distinguish between amyloid positive and negative groups on the Alzheimer's disease continuum. J Psychiatr Res 2020; 124:131-136. [PMID: 32146222 PMCID: PMC10026350 DOI: 10.1016/j.jpsychires.2020.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 02/07/2020] [Accepted: 02/08/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The development and validation of clinical outcome measures to detect early cognitive decline associated with Alzheimer's disease (AD) biomarkers is imperative. Semantic intrusions on the Loewenstein Acevedo Scales of Semantic Interference and Learning (LASSI-L) has outperformed widely used cognitive measures as an early correlate of elevated brain amyloid in prodromal AD and has distinguished those with amnestic mild cognitive impairment (aMCI) and high amyloid load from aMCI attributable to other non-AD conditions. METHODS Since intrusion errors on memory tasks vary widely, we employed a novel method that accounts for the percentage of intrusion errors (PIE) in relation to total responses. Individuals with either high or low amyloid load across the spectrum of aMCI and dementia and amyloid negative cognitively normal older adults (CN) were studied. RESULTS Mean PIE on indices sensitive to proactive semantic interference (PSI) and failure to recover from proactive semantic interference (frPSI) could distinguish amyloid positive from amyloid negative aMCI and dementia groups. Number of correct responses alone, while able to differentiate the different diagnostic groups, did not differentiate amyloid positive aMCI from their counterparts without amyloid pathology. CONCLUSIONS PIE, a novel and sensitive index of early memory dysfunction, demonstrated high levels of sensitivity and specificity in differentiating CN from amyloid positive persons with preclinical AD. Mean levels of PIE are higher for amyloid positive aMCI and dementia participants relative to their amyloid negative counterparts.
Collapse
Affiliation(s)
- Rosie E Curiel Cid
- Center for Cognitive Neuroscience and Aging, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1695 NW 9th Avenue, Miami, FL, 33136, USA.
| | - Elizabeth A Crocco
- Center for Cognitive Neuroscience and Aging, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1695 NW 9th Avenue, Miami, FL, 33136, USA
| | - Ranjan Duara
- Wien Center for Alzheimer's Disease and Memory Disorders, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33140, USA
| | - Jessica M Garcia
- Center for Cognitive Neuroscience and Aging, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1695 NW 9th Avenue, Miami, FL, 33136, USA
| | - Monica Rosselli
- Department of Psychology, Florida Atlantic University, 777 Glades Road, Boca Raton, FL, 33431, USA
| | - Steven T DeKosky
- Department of Neurology and McKnight Brain Institute, University of Florida, 1149 Newell Drive Bldg. 59, Rm L5-101, Gainesville, FL, 32611, USA
| | - Glenn Smith
- Department of Clinical and Health Psychology, University of Florida, 1225 Center Dr., RM 3154, Gainesville, FL, 32606, USA
| | - Russell Bauer
- Department of Neurology and McKnight Brain Institute, University of Florida, 1149 Newell Drive Bldg. 59, Rm L5-101, Gainesville, FL, 32611, USA
| | - Cesar L Chirinos
- Wien Center for Alzheimer's Disease and Memory Disorders, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33140, USA
| | - Malek Adjouadi
- Center for Advanced Technology and Education, Florida International University, 10555 West Flagler Street, EC 2220, Miami, FL, 33174, USA
| | - Warren Barker
- Wien Center for Alzheimer's Disease and Memory Disorders, Mount Sinai Medical Center, 4300 Alton Road, Miami Beach, FL, 33140, USA
| | - David A Loewenstein
- Center for Cognitive Neuroscience and Aging, Department of Psychiatry and Behavioral Sciences, University of Miami Miller School of Medicine, 1695 NW 9th Avenue, Miami, FL, 33136, USA
| |
Collapse
|
34
|
Lee J, Kim K, Choi JO, Kim SJ, Jeon ES, Choi JY. 99mTc-DPD scintigraphy and SPECT/CT in patients with AL and ATTR type amyloidosis: Potential clinical implications. Medicine (Baltimore) 2020; 99:e18905. [PMID: 31977903 PMCID: PMC7004596 DOI: 10.1097/md.0000000000018905] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Although pathological confirmation is the gold standard for diagnosis of amyloidosis, there is a need for a relevant imaging modality to identify involved organs and evaluate disease extent. Thus, we prospectively investigated imaging findings of Tc-DPD scintigraphy in AL and ATTR amyloidosis.A total of 21 subjects with pathologically confirmed AL or ATTR amyloidosis were included. Pretreatment whole body Tc-DPD planar scanning and regional SPECT/CT were performed in all subjects. For allegedly involved organs, Tc-DPD uptake was visually and semi-quantitatively evaluated on a 4-point scale (grade 0: no uptake, 1: uptake less than spine, 2: uptake similar to spine, and 3: uptake greater than spine).There were 29 organs involved in AL and 12 in ATTR. Significant Tc-DPD uptake was found in 24 organs (sensitivity = 82.8%) in AL and 9 organs (sensitivity = 75.0%) in ATTR. Additional SPECT/CT was helpful to ensure abnormal DPD uptake in the involved organs, which was uncertain by attenuation in planar imaging. Degree of Tc-DPD uptake was significantly higher in ATTR compared with AL amyloidosis (P = .017). Diffuse soft tissue uptake with photon defects in the liver area was found only in ATTR amyloidosis.This study showed that Tc-DPD scintigraphy might have capacity to differentiate between AL and ATTR subtypes with good sensitivity in various organs involving primary systemic AL and ATTR amyloidosis. Additional SPECT/CT significantly improved the diagnostic efficacy of Tc-DPD scintigraphy.
Collapse
Affiliation(s)
| | - Kihyun Kim
- Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jin-Oh Choi
- Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seok Jin Kim
- Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Eun-Seok Jeon
- Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | |
Collapse
|
35
|
Zhu Z, Yue C, Sun Y, Li X, Li M. Light-chain amyloidosis with renal involvement: renal outcomes and validation of two renal staging systems in the Chinese population. Amyloid 2019; 26:186-191. [PMID: 31339366 DOI: 10.1080/13506129.2019.1639149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Renal involvement is one of the most common complications of light-chain (AL) amyloidosis. For evaluating renal prognosis, two staging systems for renal involvement have been proposed, one in 2014 and one in 2017. However, the two staging systems have not yet been compared and widely used in clinic. Methods: A total of 76 patients with newly diagnosed AL amyloidosis and renal involvement proven by renal biopsy were included and followed up with an endpoint developing to dialysis. The renal outcome and two criteria were explored. Results: We confirmed the prognostic value of the 2014 renal staging system based on estimated glomerular filtration rate (eGFR) (<50 ml/min/1.73 m2) and proteinuria (>5 g/day) at diagnosis (p = 0.003). For the 2017 system, none of the patients progressed to dialysis in both stage 1 (24 h proteinuria to eGFR <30 mg/ml/min/1.73 m2) and stage 2 (24 h proteinuria to eGFR 30-99 mg/ml/min/1.73 m2). A significant difference in terms of requiring dialysis was seen only between stage 3 (24 h proteinuria to eGFR ≥100 mg/ml/min/1.73 m2) and the two other stages (p = 0.008). Conclusions: The prognostic value of the criteria based on eGFR and 24-hour proteinuria for predicting dialysis has been confirmed. These results might benefit guiding clinical treatment.
Collapse
Affiliation(s)
- Zixuan Zhu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Cai Yue
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Ying Sun
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Mingxi Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| |
Collapse
|
36
|
Rech J, Arnulf B, Margerie‐Mellon C, Talbot A, Malphettes M, Vignon M, Royer B, Lavergne D, Kambouchner M, Meignin V, Bergeron A, Prevot G, Brillet P, Martinod E, Bridoux F, Nunes H, Jaccard A, Valeyre D, Uzunhan Y. Lower respiratory tract amyloidosis: Presentation, survival and prognostic factors. A multicenter consecutive case series. Am J Hematol 2019; 94:1214-1226. [PMID: 31396978 DOI: 10.1002/ajh.25608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 07/18/2019] [Accepted: 08/05/2019] [Indexed: 12/15/2022]
Abstract
Lower-respiratory-tract (LRT) amyloidosis has rarely been investigated. Our study presents characteristics, outcomes and survival of LRT amyloidosis. This multicenter retrospective study, from 1995 to 2017, included 73 patients with amyloidosis and LRT involvement. Respiratory patterns were: tracheobronchial (n = 17), nodular (n = 10), interstitial (n = 14) or composite (several respiratory involvements, n = 32). Interstitial and composite patterns were associated with multi-organ amyloidosis (n = 37, 80%) while tracheobronchial and nodular patterns were associated with organ-limited amyloidosis (n = 21, 78%). Amyloid light chain (AL) amyloidosis was diagnosed in 43 patients (59%), mainly of lambda type (n = 33, 77%). Smokers' proportion was higher in tracheobronchial (71%) and nodular (90%) patterns than in interstitial (14%) and composite (34%) patterns. The B-cell neoplasms involved 15 patients (21%), solid neoplasms 8 (11%), connective tissue diseases 8 (11%) and multiple myeloma 6 (8%). The B-cell and solid neoplasms were most prevalent in nodular pattern. Median follow-up was 4.4 years (2.2-8.9). Twenty-four patients died, mostly from respiratory infection. Survival at 1, 5, 10 years was respectively 88%, 70% and 54% for multi-organ amyloidosis, 96%, 89% and 69% for organ-limited amyloidosis (P = .125). Tracheobronchial and nodular patterns survival was better than in other respiratory patterns (P = .039). Death risk factors (multivariate analysis) were: cardiac localization (hazard-ratio [HR] 4.3 [95% confidence interval 1.6-11.5]; P = .004), age (HR 2.1 [1.2-3.7]; P = .008) and dyspnea at diagnosis (HR 4.0 [1.3-12.3]; P = .014). Various LRT amyloidosis patterns depend on smoking habits, organ-limited or multi-organ extension and comorbidities. They are associated with a different survival, which is also predicted by age, cardiac localization and dyspnea at presentation.
Collapse
Affiliation(s)
- Jean‐Simon Rech
- INSERM UMR‐1272, Paris 13 University and AP‐HP, Pneumology DepartmentAvicenne Hospital Bobigny France
| | - Bertrand Arnulf
- Paris 7 University and APHP, Immuno‐Hematology DepartmentSaint‐Louis Hospital Paris France
| | | | - Alexis Talbot
- Paris 7 University and APHP, Immuno‐Hematology DepartmentSaint‐Louis Hospital Paris France
| | - Marion Malphettes
- Paris 7 University and APHP, Immuno‐Hematology DepartmentSaint‐Louis Hospital Paris France
| | | | - Bruno Royer
- Paris 7 University and APHP, Immuno‐Hematology DepartmentSaint‐Louis Hospital Paris France
| | - David Lavergne
- Hematology DepartmentFrench Reference Center for AL Amyloidosis (Limoges‐Poitiers) CHU Limoges, Limoges France
| | | | | | - Anne Bergeron
- Paris 7 University and APHP, Pneumology DepartmentSaint‐Louis Hospital Paris France
| | | | - Pierre‐Yves Brillet
- INSERM UMR‐1272, Paris 13 University and AP‐HP, Radiology DepartmentAvicenne Hospital Bobigny France
| | - Emmanuel Martinod
- INSERM UMR‐1272, Paris 13 University and AP‐HP, Thoracic Surgery DepartmentAvicenne Hospital Bobigny France
| | - Franck Bridoux
- Nephrology Department, French Reference Center for AL Amyloidosis (Limoges‐Poitiers)CHU Poitiers Poitiers France
| | - Hilario Nunes
- INSERM UMR‐1272, Paris 13 University and AP‐HP, Pneumology DepartmentAvicenne Hospital Bobigny France
| | - Arnaud Jaccard
- Hematology DepartmentFrench Reference Center for AL Amyloidosis (Limoges‐Poitiers) CHU Limoges, Limoges France
| | - Dominique Valeyre
- INSERM UMR‐1272, Paris 13 University and AP‐HP, Pneumology DepartmentAvicenne Hospital Bobigny France
| | - Yurdagül Uzunhan
- INSERM UMR‐1272, Paris 13 University and AP‐HP, Pneumology DepartmentAvicenne Hospital Bobigny France
| |
Collapse
|
37
|
Gonzalez Suarez ML, Zhang P, Nasr SH, Sathick IJ, Kittanamongkolchai W, Kurtin PJ, Alexander MP, Cornell LD, Fidler ME, Grande JP, Herrera Hernandez LP, Said SM, Sethi S, Dispenzieri A, Gertz MA, Leung N. The sensitivity and specificity of the routine kidney biopsy immunofluorescence panel are inferior to diagnosing renal immunoglobulin-derived amyloidosis by mass spectrometry. Kidney Int 2019; 96:1005-1009. [DOI: 10.1016/j.kint.2019.05.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Revised: 03/27/2019] [Accepted: 05/02/2019] [Indexed: 10/26/2022]
|
38
|
Kimishima Y, Yoshihisa A, Kiko T, Yokokawa T, Miyata-Tatsumi M, Misaka T, Oikawa M, Kobayashi A, Takeishi Y. Utility of B-Type Natriuretic Peptide for Detecting Cardiac Involvement in Immunoglobulin Amyloidosis. Int Heart J 2019; 60:1106-1112. [DOI: 10.1536/ihj.19-043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Yusuke Kimishima
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, Fukushima Medical University
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University
| | - Takatoyo Kiko
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Tetsuro Yokokawa
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | - Tomofumi Misaka
- Department of Cardiovascular Medicine, Fukushima Medical University
- Department of Advanced Cardiac Therapeutics, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University
| | | | | |
Collapse
|
39
|
Witteles RM, Liedtke M. AL Amyloidosis for the Cardiologist and Oncologist: Epidemiology, Diagnosis, and Management. JACC CardioOncol 2019; 1:117-130. [PMID: 34396169 PMCID: PMC8352106 DOI: 10.1016/j.jaccao.2019.08.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/09/2019] [Accepted: 08/11/2019] [Indexed: 02/07/2023] Open
Abstract
AL amyloidosis results from clonal production of immunoglobulin light chains, most commonly arising from a clonal plasma cell disorder. Once considered a nearly uniformly fatal disease, prognosis has improved markedly over the past 15 years, predominantly because of advances in light chain suppressive therapies. Cardiac deposition of amyloid fibrils is common, and the severity of cardiac involvement remains the primary driver of prognosis. Improvements in chemotherapy/immunotherapy have prompted a reassessment of the role of advanced cardiac therapies previously considered contraindicated in most patients, including the role of implantable cardioverter-defibrillators and cardiac transplantation. This state-of-the-art review highlights the current state of the field, including diagnosis, prognosis, and hematologic- and cardiac-specific therapies.
Collapse
Key Words
- AL amyloidosis
- ASCT, autologous stem cell transplantation
- BNP, B-type natriuretic peptide
- CyBorD, cyclophosphamide, bortezomib, and dexamethasone
- FLC, free light chain
- ICD, implantable cardioverter-defibrillator
- MGUS, monoclonal gammopathy of undetermined significance
- NT-proBNP, N-terminal pro–B-type natriuretic peptide
- SAP, serum amyloid P
- SPIE, serum protein electrophoresis with immunofixation
- UPIE, urine protein electrophoresis with immunofixation
- amyloidosis
- diagnosis
- drug therapy
- heart failure
- imaging
- treatment
Collapse
Affiliation(s)
- Ronald M. Witteles
- Division of Cardiovascular Medicine, Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
| | - Michaela Liedtke
- Division of Hematology, Stanford Amyloid Center, Stanford University School of Medicine, Stanford, California, USA
| |
Collapse
|
40
|
Caruana D, McCusker S, Harper C, Bilsland D. Curious facial plaque diagnosed as nodular primary localised cutaneous amyloidosis. BMJ Case Rep 2019; 12:12/5/e228163. [PMID: 31061192 DOI: 10.1136/bcr-2018-228163] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Nodular primary localised cutaneous amyloidosis (NPLCA) is the rarest form of cutaneous amyloidosis, with a predilection for facial and acral skin. We present a 63-year-old Caucasian with a 10-year history of an asymptomatic plaque on his left cheek, starting 2 years after being scratched by a cat in the same area. A biopsy showed nodules of eosinophilic material in the deep dermis and subcutaneous fat, with plasma cells in the dermis. Congo red staining displayed apple-green birefringence within the eosinophilic material. Immunohistochemistry for serum amyloid P was positive within the eosinophilic material and immunohistochemistry showed lambda light chain restriction within the plasma cells, consistent with NPLCA. The causal relationship of the cat scratch to NPLCA in our patient remains unclear. While trauma-induced amyloidosis has been recognised in papular and macular amyloid, few case reports indicate an association with nodular amyloidosis.
Collapse
Affiliation(s)
- Dawn Caruana
- Department of Dermatology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Sarah McCusker
- Department of Dermatology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Christina Harper
- Department of Pathology, Queen Elizabeth University Hospital, Glasgow, UK
| | - David Bilsland
- Department of Dermatology, Queen Elizabeth University Hospital, Glasgow, UK
| |
Collapse
|
41
|
Dias T, Ferreira D, Moreira H, Nascimento T, Santos A, Carvalho A. A Case of Severe Cholestasis due to Hepatic AL Amyloidosis. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 26:425-429. [PMID: 31832498 DOI: 10.1159/000496185] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Accepted: 12/11/2018] [Indexed: 12/23/2022]
Abstract
Introduction Immunoglobulin light chain-associated amyloidosis results from extracellular tissue deposition of fibril-forming monoclonal immunoglobulin light chains, secreted by a clone of plasma cells. Although the liver is often involved histologically, most cases are clinically asymptomatic, and severe intrahepatic cholestasis as the primary manifestation of the disease is rare. Clinical Case We report an unusual case of primary amyloidosis in a 71-year-old man, presenting with rapidly progressive cholestasis, associated with hepatomegaly. There are a few reported cases in the literature of cholestasis and acute liver failure as the first manifestations of AL amyloidosis. Conclusion Infiltrative diseases, such as amyloidosis, must be considered when a patient presents with cholestatic hepatitis. A liver biopsy is essential for the diagnosis of amyloidosis when liver test abnormalities dominate the initial clinical presentation. Liver involvement in patients with amyloidosis is often an indicator of poor prognosis.
Collapse
Affiliation(s)
- Teresa Dias
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Diana Ferreira
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Hélder Moreira
- Department of Pathology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Telma Nascimento
- Department of Hematology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Arsénio Santos
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Armando Carvalho
- Department of Internal Medicine, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| |
Collapse
|
42
|
Mass Spectrometry Amyloid Typing Is Reproducible across Multiple Organ Sites. BIOMED RESEARCH INTERNATIONAL 2019; 2019:3689091. [PMID: 30834260 PMCID: PMC6374819 DOI: 10.1155/2019/3689091] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 01/10/2019] [Accepted: 01/21/2019] [Indexed: 11/17/2022]
Abstract
We have determined patient's amyloid subtype through immunohistochemical and proteomic analyses of formalin-fixed, paraffin-embedded (FFPE) tissue samples from two affected organs per patient. Amyloid typing, via immunohistochemistry (IHC) and laser microdissection followed by the combination of liquid chromatography with mass spectrometry (LMD-LC-MS), was performed using tissue samples of the human heart, liver, kidney, tongue, and small intestine from 11 patients, and the results were compared with clinical data. LMD-LC-MS correctly typed AL amyloidosis in all 22 FFPE tissue samples despite tissue origin. In contrast, IHC was successful only in the analysis of eight FFPE tissue samples with differences between the examined organs. In the majority of LMD-LC-MS typed samples, the level of IHC staining intensity for transthyretin and serum amyloid A was the same as that for Ig κ and Ig λ antibodies, suggesting low Ig κ or Ig λ antibodies reactivity and the additional antibody clones were essential for correct typing. Both methods used in the study were found to be suitable for amyloid typing, although LMD-LC-MS yielded more promising results than IHC.
Collapse
|
43
|
Congo Red and amyloids: history and relationship. Biosci Rep 2019; 39:BSR20181415. [PMID: 30567726 PMCID: PMC6331669 DOI: 10.1042/bsr20181415] [Citation(s) in RCA: 179] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 12/16/2018] [Accepted: 12/17/2018] [Indexed: 12/17/2022] Open
Abstract
Staining with Congo Red (CR) is a qualitative method used for the identification of amyloids in vitro and in tissue sections. However, the drawbacks and artefacts obtained when using this dye can be found both in vitro and in vivo. Analysis of scientific data from previous studies shows that CR staining alone is not sufficient for confirmation of the amyloid nature of protein aggregates in vitro or for diagnosis of amyloidosis in tissue sections. In the present paper, we describe the characteristics and limitations of other methods used for amyloid studies. Our historical review on the use of CR staining for amyloid studies may provide insight into the pitfalls and caveats related to this technique for researchers considering using this dye.
Collapse
|
44
|
Abstract
Systemic amyloidosis can be hereditary or acquired with autosomal dominant mutations in the transthyretin gene (TTR) being the most common cause of hereditary amyloidosis. ATTRm amyloidosis is a multi-system disorder with cardiovascular, peripheral and autonomic nerve involvement that can be difficult to diagnose due to phenotypic heterogeneity. This review will focus on the neuropathic manifestations of ATTRm, the genotype-phenotype variability, the diagnostic approach and the recent therapeutic advances in this disabling condition.
Collapse
Affiliation(s)
- Mahima Kapoor
- Department of Neuromuscular Diseases, MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology, Queen Square, London, UK
| | - Alexander M. Rossor
- Department of Neuromuscular Diseases, MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology, Queen Square, London, UK
| | - Matilde Laura
- Department of Neuromuscular Diseases, MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology, Queen Square, London, UK
| | - Mary M. Reilly
- Department of Neuromuscular Diseases, MRC Centre for Neuromuscular Diseases, UCL Institute of Neurology, Queen Square, London, UK
| |
Collapse
|
45
|
Kapoor M, Rossor AM, Jaunmuktane Z, Lunn MPT, Reilly MM. Diagnosis of amyloid neuropathy. Pract Neurol 2018; 19:250-258. [DOI: 10.1136/practneurol-2018-002098] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/10/2018] [Indexed: 12/31/2022]
Abstract
Systemic amyloidosis can be hereditary or acquired. The autosomal dominant hereditary transthyretin amyloidosis and the acquired light-chain amyloidosis, the result of a plasma cell dyscrasia, are multisystem disorders with cardiovascular, autonomic and peripheral nerve involvement. There are numerous investigational modalities available to diagnose systemic amyloidosis and to assess the extent of organ involvement, but it is frequently misdiagnosed due to its heterogeneous clinical presentations and misleading investigation findings. An accurate and timely diagnosis of amyloid neuropathy can greatly impact on the outcomes for patients, especially as there will soon be new gene-silencing treatments for hereditary transthyretin amyloidosis.
Collapse
|
46
|
Chen W, Ren G, Zuo K, Huang X. Complete remission of both immunoglobulin light chain amyloidosis and psoriasis after autologous hematopoietic stem cell transplantation: A case report. Medicine (Baltimore) 2018; 97:e13589. [PMID: 30558027 PMCID: PMC6320088 DOI: 10.1097/md.0000000000013589] [Citation(s) in RCA: 4] [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: 11/26/2022] Open
Abstract
RATIONALE Immunoglobulin light chain amyloidosis (AL amyloidosis) is characterized by the deposition of abnormal amyloid protein produced by a pathological plasma cell clone in various organs and soft tissues. Hematopoietic stem cell transplantation (HSCT) is an effective way to treat AL amyloidosis. Psoriasis is a common autoimmune disease (AID) and HSCT is a potential treatment for severe AIDs. We report a rare case of AL amyloidosis coincidence with psoriasis obtained continuous complete remission of the 2 diseases by autologous hematopoietic stem cell transplantation (ASCT). PATIENT CONCERNS A 58-year-old man with a 30-year history of psoriasis complaining of edema and hypotension for 2 weeks was referred to our institution. His urine protein was quantified 2.83 g/day, without hematuria and decrease of glomerular filtration rate. DIAGNOSIS Renal biopsy confirmed AL amyloidosis and multiple myeloma was excluded by bone marrow cytomorphologic examination. INTERVENTIONS Chemotherapy regimen based on bortezomib and thalidomide had achieved hematologic partial remission, but the kidney had no response and psoriasis was still active. Furthermore, he received a standard myeloablative conditioning with high dose melphalan followed by ASCT. OUTCOMES The erythema with slivery scales of psoriasis vulgaris gradually improved and almost disappeared after granulocyte implantation. He obtained persistent hematological complete remission, organ response and recovery of psoriasis. LESSONS We report a rare case of AL amyloidosis coincidence with psoriasis treated by ASCT. The outcome of this patient indicated that ASCT has therapeutic values both in AL amyloidosis and AIDs.
Collapse
Affiliation(s)
- Wencui Chen
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Jinling Clinical Medical College of Nanjing Medical University
| | - Guisheng Ren
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Ke Zuo
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| | - Xianghua Huang
- National Clinical Research Center of Kidney Diseases, Jinling Hospital, Nanjing University School of Medicine, Nanjing, Jiangsu, China
| |
Collapse
|
47
|
Abstract
Paraffin immunofluorescence is a well established "salvage" technique in renal pathology when representative glomeruli are not found in the fresh frozen tissue sent for routine direct immunofluorescence studies. A step of enzymatic digestion of the formalin-fixed paraffin-embedded biopsy exposes the antigenic immune complexes and allows staining with fluorochrome-tagged antibodies. We explored the utility of the technique of paraffin immunofluorescence outside the kidney in certain specific scenarios including extra renal amyloid and duodenal macroglobulinemia.
Collapse
|
48
|
Mestre-Torres J, Lorenzo-Bosquet C, Cuberas-Borrós G, Gironella M, Solans-Laque R, Fernández-Codina A, Bujan-Rivas S, Castell-Conesa J, Martínez-Valle F. Utility of the 18F-Florbetapir positron emission tomography in systemic amyloidosis. Amyloid 2018; 25:109-114. [PMID: 29706127 DOI: 10.1080/13506129.2018.1467313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Amyloidosis comprises a group of heterogeneous conditions. To ascertain the burden of disease is important because it can determine the treatment as well as the evolution of the disease. Recent reports have shown good results in diagnosing cardiac amyloidosis using 18F-florbetapir. We hypothesize that combining whole body PET/CT with 18F-Florbetapir can be useful to characterize the burden of the disease. We included 25 patients, 13 of them with different types of amyloidosis, and 12 with Alzheimer's disease as controls. Target-to-background ratio was computed for multiple organ using maximum standardized uptake values. Organ involvement was described (standardized techniques versus PET) according to different kinds of amyloidosis showing promising results in AA and AL types. Heart involvement showed poorer results when compared to tongue, lung or thyroid gland. Multiple organ involvement in patients previously labelled as having negative organ affectation could be identified. This is the first study to evaluate the utility of 18F-florbetapir in the assessment of the global extension of disease. Our results show that this technique is useful for its diagnosis.
Collapse
Affiliation(s)
- Jaume Mestre-Torres
- a Internal Medicine Department , Hospital Universitari Vall d'Hebron , Barcelona , Spain
| | | | - Gemma Cuberas-Borrós
- b Nuclear Medicine Department , Hospital Universitari Vall d'Hebron , Barcelona , Spain.,c Institut de Diagnòstic per la Imatge (IDI), Parc Sanitari Pere Virgili , Barcelona , Spain
| | - Mercedes Gironella
- d Hematology Department , Hospital Universitari Vall d'Hebron , Barcelona , Spain
| | - Roser Solans-Laque
- a Internal Medicine Department , Hospital Universitari Vall d'Hebron , Barcelona , Spain
| | | | - Segundo Bujan-Rivas
- a Internal Medicine Department , Hospital Universitari Vall d'Hebron , Barcelona , Spain
| | - Joan Castell-Conesa
- b Nuclear Medicine Department , Hospital Universitari Vall d'Hebron , Barcelona , Spain
| | | |
Collapse
|
49
|
Sethi S, Rajkumar SV, D'Agati VD. The Complexity and Heterogeneity of Monoclonal Immunoglobulin-Associated Renal Diseases. J Am Soc Nephrol 2018; 29:1810-1823. [PMID: 29703839 DOI: 10.1681/asn.2017121319] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Monoclonal gammopathies are characterized by the overproduction of monoclonal Ig (MIg) detectable in the serum or urine resulting from a clonal proliferation of plasma cells or B lymphocytes. The underlying hematologic conditions range from malignant neoplasms of plasma cells or B lymphocytes, including multiple myeloma and B-cell lymphoproliferative disorders, to nonmalignant small clonal proliferations. The term MGUS implies presence of an MIg in the setting of a "benign" hematologic condition without renal or other end organ damage. The term MGRS was recently introduced to indicate monoclonal gammopathy with MIg-associated renal disease in the absence of hematologic malignancy. Most MIg-associated renal diseases result from the direct deposition of nephrotoxic MIg or its light- or heavy-chain fragments in various renal tissue compartments. Immunofluorescence microscopy is essential to identify the offending MIg and define its tissue distribution. Mass spectrometry is helpful in difficult cases. Conditions caused by direct tissue deposition of MIg include common disorders, such as cast nephropathy, amyloidosis, and MIg deposition diseases, as well as uncommon disorders, such as immunotactoid glomerulopathy, proliferative GN with MIg deposits, light-chain proximal tubulopathy, and the rare entities of crystal-storing histiocytosis and crystalglobulinemia. Indirect mechanisms of MIg-induced renal disease can cause C3 glomerulopathy or thrombotic microangiopathy without tissue MIg deposits. Treatment of MIg-associated renal disease is aimed at eliminating the clonal plasma cell or B-cell population as appropriate. Both the renal and the underlying hematologic disorders influence the management and prognosis of MIg-associated renal diseases.
Collapse
Affiliation(s)
| | - S Vincent Rajkumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; and
| | - Vivette D D'Agati
- Department of Pathology, College of Physicians and Surgeons, Columbia University, New York, New York
| |
Collapse
|
50
|
Flodrova P, Flodr P, Pika T, Vymetal J, Holub D, Dzubak P, Hajduch M, Scudla V. Cardiac amyloidosis: from clinical suspicion to morphological diagnosis. Pathology 2018; 50:261-268. [DOI: 10.1016/j.pathol.2017.10.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 08/08/2017] [Accepted: 10/16/2017] [Indexed: 12/21/2022]
|