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Muchtar E, Gertz MA, Mwangi R, Hassan H, Dispenzieri A, Leung N, Buadi FK, Dingli D, Staron A, Sanchorawala V. Long-term outcomes of renal AL amyloidosis patients undergoing autologous stem cell transplantation: Validating the performance of the renal staging system. Am J Hematol 2024. [PMID: 39207186 DOI: 10.1002/ajh.27460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/31/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024]
Abstract
Renal AL amyloidosis can be complicated by end-stage renal disease (ESRD) requiring renal replacement therapy (RRT). In this study, we describe the long-term outcomes of renal AL amyloidosis patients undergoing autologous stem cell transplantation (ASCT) and assess the utility of the renal staging system. Retrospective study of renal AL patients (n = 697; Mayo Clinic, Boston University) who underwent ASCT between 2003 and 2020. Renal stage was assigned based on 24-h proteinuria and estimated glomerular filtration rate measurements. Renal survival was defined as the time from ASCT until initiation of RRT, while patients who were not placed on RRT were censored at their last follow-up. With a median follow-up of 10.4 years, RRT was required in 149 patients (21%). The median time from ASCT to ESRD was 3.4 years, with late events of progression to ESRD seen >10 years from ASCT. Pre-ASCT renal stage was significantly associated with the cumulative incidence of RRT: 3-year RRT rate was 3%, 10%, and 37% for renal stages I, II, and III, respectively. However, in the 2012-2020 period subset, a significant decrease in ESRD risk was noted across all renal stages (3-year RRT 0%, 5%, and 24%, respectively). In multivariate analysis, renal survival was independently associated with the pre-ASCT renal stage, lambda isotype, bone marrow plasmacytosis ≥20%, post-ASCT hematologic response, and year of ASCT. Long-term outcomes of renal AL amyloidosis treated with ASCT are presented. Renal stage reliably predicts renal outcomes in patients with AL undergoing ASCT, despite a reduction in the proportion of patients progressing to RRT in recent years.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Raphael Mwangi
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Hamza Hassan
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA
| | - Francis K Buadi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew Staron
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
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2
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De Michieli L, Cipriani A, Iliceto S, Dispenzieri A, Jaffe AS. Cardiac Troponin in Patients With Light Chain and Transthyretin Cardiac Amyloidosis: JACC: CardioOncology State-of-the-Art Review. JACC CardioOncol 2024; 6:1-15. [PMID: 38510286 PMCID: PMC10950441 DOI: 10.1016/j.jaccao.2023.12.006] [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: 08/31/2023] [Revised: 12/27/2023] [Accepted: 12/29/2023] [Indexed: 03/22/2024] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative disease caused by amyloid fibril deposition in the myocardium; the 2 forms that most frequently involve the heart are amyloid light chain (AL) and amyloid transthyretin (ATTR) amyloidosis. Cardiac troponin (cTn) is the biomarker of choice for the detection of myocardial injury and is frequently found to be elevated in patients with CA, particularly with high-sensitivity assays. Multiple mechanisms of myocardial injury in CA have been proposed, including cytotoxic effect of amyloid precursors, interstitial amyloid fibril infiltration, coronary microvascular dysfunction, amyloid- and non-amyloid-related coronary artery disease, diastolic dysfunction, and heart failure. Regardless of the mechanisms, cTn values have relevant prognostic (and potentially diagnostic) implications in both AL and ATTR amyloidosis. In this review, the authors discuss the significant aspects of cTn biology and measurement methods, potential mechanisms of myocardial injury in CA, and the clinical application of cTn in the management of both AL and ATTR amyloidosis.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | | | - Allan S. Jaffe
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota, USA
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3
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De Michieli L, Jaffe AS. Cancer Therapy-Related Cardiac Dysfunction: Expanding the Horizon of Cardiac Troponin in Clinical Practice. JACC CardioOncol 2024; 6:96-98. [PMID: 38510291 PMCID: PMC10950439 DOI: 10.1016/j.jaccao.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
| | - Allan S. Jaffe
- Cardiovascular Department, Mayo Clinic and Medical School, Rochester, Minnesota, USA
- Department of Laboratory Medicine and Pathology, Mayo Clinic and Medical School, Rochester, Minnesota, USA
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4
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D'Souza A. Amyloid consults do not have to be vexing. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2023; 2023:407-412. [PMID: 38066929 PMCID: PMC10727086 DOI: 10.1182/hematology.2023000440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Diagnosing amyloidosis can be challenging due to its clinical heterogeneity, need for multiple specialists to make a diagnosis, and lack of a single diagnostic test for the disease. Patients are often diagnosed late, in advanced stage, and after exhibiting multiple symptoms and signs for a long period. It is important to develop a clinical suspicion of amyloidosis, particularly in those with multisystemic symptoms and high-risk patient populations such as those with precursor hematologic conditions. A systematic approach to the workup of suspected amyloidosis is key, including a comprehensive clinical assessment, laboratory tests to assess organ involvement, advanced imaging studies, screening for plasma cell disorder, and tissue biopsy when necessary. After making a diagnosis of amyloidosis, accurate typing of amyloid deposits, differentiating between localized and systemic amyloidosis, and appropriately staging the disease is important. Early diagnosis is crucial for improving patient outcomes and quality of life in light chain amyloidosis.
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Affiliation(s)
- Anita D'Souza
- Division of Hematology/Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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5
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De Michieli L, Sinigiani G, De Gaspari M, Branca A, Rizzo S, Basso C, Trentin L, Iliceto S, Perazzolo Marra M, Cipriani A, Berno T. Light-chain cardiac amyloidosis for the non-expert: pearls and pitfalls. Intern Emerg Med 2023; 18:1879-1886. [PMID: 37338717 PMCID: PMC10543940 DOI: 10.1007/s11739-023-03335-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023]
Abstract
Cardiac amyloidosis (CA) is an uncommon, progressive, and fatal disease; the two main forms that can affect the heart are transthyretin CA and light chain CA (AL-CA). AL-CA is a medical urgency for which a diagnostic delay can be catastrophic for patients' outcome. In this manuscript, we focus on the pearls and pitfalls that are relevant to achieve a correct diagnosis and to avoid diagnostic and therapeutical delays. Through the aid of three unfortunate clinical cases, some fundamental diagnostic aspects are addressed, including the following: first, a negative bone scintigraphy does not exclude CA, with patients with AL-CA frequently showing no or mild cardiac uptake, and its execution should not delay hematological tests; second, fat pad biopsy does not have a 100% sensitivity for AL amyloidosis and, if negative, further investigations should be performed, particularly if the pre-test probability is high. Third, Congo Red staining is not sufficient to reach a definitive diagnosis and amyloid fibrils typing with mass spectrometry, immunohistochemistry, or immunoelectron microscopy is crucial. To achieve a timely and correct diagnosis, all the necessary investigations must be performed, always considering the yield and diagnostic accuracy of each examination.
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Affiliation(s)
- Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy.
| | - Giulio Sinigiani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
| | - Monica De Gaspari
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Antonio Branca
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
| | - Stefania Rizzo
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiovascular Pathology Unit, University Hospital of Padua, Padua, Italy
| | - Livio Trentin
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
| | - Sabino Iliceto
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Martina Perazzolo Marra
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padova, Via Giustiniani, 2, 35128, Padua, Italy
- Cardiology Unit, University Hospital of Padua, Padua, Italy
| | - Tamara Berno
- Hematology and Clinical Immunology Branch, Department of Medicine, University of Padova, Padua, Italy
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Nicol M, Vergaro G, Damy T, Kharoubi M, Baudet M, Canuti ES, Aimo A, Castiglione V, Emdin M, Royer B, Harel S, Cohen-Solal A, Arnulf B, Logeart D. Prognostic value of soluble ST2 in AL and TTR cardiac amyloidosis: a multicenter study. Front Cardiovasc Med 2023; 10:1179968. [PMID: 37600055 PMCID: PMC10433216 DOI: 10.3389/fcvm.2023.1179968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 07/12/2023] [Indexed: 08/22/2023] Open
Abstract
Background Both light-chain (AL) amyloidosis and transthyretin (ATTR) amyloidosis are types of cardiac amyloidosis (CA) that require accurate prognostic stratification to plan therapeutic strategies and follow-ups. Cardiac biomarkers, e.g., N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (Hs-cTnT), remain the cornerstone of the prognostic assessment. An increased level of soluble suppression of tumorigenesis-2 (sST2) is predictive of adverse events [all-cause death and heart failure (HF) hospitalizations] in patients with HF. This study aimed to evaluate the prognostic value of circulating sST2 levels in AL-CA and ATTR-CA. Methods We carried out a multicenter study including 133 patients with AL-CA and 152 patients with ATTR-CA. During an elective outpatient visit for the diagnosis of CA, Mayo Clinic staging [NT-proBNP, Hs-cTnT, differential of free light chains (DFLCs)] and sST2 were assessed for all AL patients. Gillmore staging [including estimated glomerular filtration rate (eGFR), NT-proBNP] and Grogan staging (including NT-proBNP and Hs-cTnT) were assessed for TTR-CA patients. Results The median age was 73 years [interquartile range (IQR) 61-81], and 53% were men. The endpoint was the composite of all-cause death or first HF-related hospitalization. The median follow-up was 20 months (IQR 3-34) in AL amyloidosis and 33 months (6-45) in TTR amyloidosis. The primary outcome occurred in 70 (53%) and 99 (65%) of AL and TTR patients, respectively. sST2 levels were higher in patients with AL-CA than in patients with ATTR-CA: 39 ng/L (26-80) vs. 32 ng/L (21-46), p < 0.001. In AL-CA, sST2 levels predicted the outcome regardless of the Mayo Clinic score (HR: 2.16, 95% CI: 1.17-3.99, p < 0.001). In TTR-CA, sST2 was not predictive of the outcome in multivariate models, including Gillmore staging and Grogan staging (HR: 1.17, CI: 95% 0.77-1.89, p = 0.55). Conclusion sST2 level is a relevant predictor of death and HF hospitalization in AL cardiac amyloidosis and adds prognostic stratification on top of NT-proBNP, Hs cTnT, and DFLC.
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Affiliation(s)
- Martin Nicol
- Cardiology Department Lariboisière Saint Louis Hospital, University of Paris, Paris, France
| | - Giuseppe Vergaro
- Cardiology Department, Scuola Superiore Sant’Anna and Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Thibaud Damy
- Referral Cardiac Amyloidosis Center and Cardiology Department, Mondor Hospital, IMRB U955 and Université Paris Est Créteil all at 94000Créteil, France
| | - Mounira Kharoubi
- Referral Cardiac Amyloidosis Center and Cardiology Department, Mondor Hospital, IMRB U955 and Université Paris Est Créteil all at 94000Créteil, France
| | - Mathilde Baudet
- Cardiology Department Lariboisière Saint Louis Hospital, University of Paris, Paris, France
| | | | - Alberto Aimo
- Cardiology Department, Scuola Superiore Sant’Anna and Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Vincenzo Castiglione
- Cardiology Department, Scuola Superiore Sant’Anna and Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Cardiology Department, Scuola Superiore Sant’Anna and Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Bruno Royer
- Immuno-Hematology Department, Saint Louis Hospital, University of Paris, Paris, France
| | - Stephanie Harel
- Immuno-Hematology Department, Saint Louis Hospital, University of Paris, Paris, France
| | - Alain Cohen-Solal
- Cardiology Department Lariboisière Saint Louis Hospital, University of Paris, Paris, France
| | - Bertrand Arnulf
- Immuno-Hematology Department, Saint Louis Hospital, University of Paris, Paris, France
| | - Damien Logeart
- Cardiology Department Lariboisière Saint Louis Hospital, University of Paris, Paris, France
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7
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Muchtar E, Dispenzieri A, Wisniowski B, Palladini G, Milani P, Merlini G, Schönland S, Veelken K, Hegenbart U, Geyer SM, Kumar SK, Kastritis E, Dimopoulos MA, Liedtke M, Witteles R, Sanchorawala V, Szalat R, Landau H, Petrlik E, Lentzsch S, Coltoff A, Bladé J, Cibeira MT, Cohen O, Foard D, Wechalekar A, Gertz MA. Graded Cardiac Response Criteria for Patients With Systemic Light Chain Amyloidosis. J Clin Oncol 2023; 41:1393-1403. [PMID: 36215675 PMCID: PMC10489422 DOI: 10.1200/jco.22.00643] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/28/2022] [Accepted: 08/17/2022] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Binary cardiac response assessment using cardiac biomarkers is prognostic in light chain amyloidosis. Previous studies suggested four-level cardiac responses using N-terminal prohormone of brain natiuretic peptide improves prognostic prediction. This study was designed to validate graded cardiac response criteria using N-terminal prohormone of brain natiuretic peptide/brain natiuretic peptide. PATIENTS AND METHODS This retrospective, multicenter study included patients with light chain amyloidosis who achieved at least a hematologic partial response (PR) and were evaluable for cardiac response. Four response criteria were tested on the basis of natriuretic peptide response depth: cardiac complete response (CarCR), cardiac very good partial response (CarVGPR), cardiac PR (CarPR), and cardiac no response (CarNR). Response was classified as best response and at fixed time points (6, 12, and 24 months from therapy initiation). The study primary outcome was overall survival. RESULTS 651 patients were included. Best CarCR, CarVGPR, CarPR, and CarNR were achieved in 16%, 26.4%, 22.9%, and 34.7% of patients, respectively. Patients in cardiac stage II were more likely to achieve CarCR than patients in cardiac stage IIIA and IIIB (22% v 13.5% v 3.2%; P < .001). A deeper cardiac response was associated with a longer survival (5-year overall survival 93%, 79%, 65%, and 33% for CarCR, CarVGPR, CarPR, and CarNR, respectively; P < .001). Fixed time-point analyses and time-varying covariates Cox regression analysis, to minimize survivorship bias, affirmed the independent survival advantage of deeper cardiac responses. Four-level response performed better than two-level response as early as 12 months from therapy initiation. CONCLUSION Graded cardiac response criteria allow better assessment of cardiac improvement compared with the traditional binary response system. The study re-emphasizes the importance of early diagnosis, which increases the likelihood of deep cardiac responses.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Brendan Wisniowski
- National Amyloidosis Centre, University College London, Royal Free Hospital Campus, London, United Kingdom
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Paolo Milani
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Stefan Schönland
- Medical Department V, Amyloidosis Center, University of Heidelberg, Heidelberg, Germany
| | - Kaya Veelken
- Medical Department V, Amyloidosis Center, University of Heidelberg, Heidelberg, Germany
| | - Ute Hegenbart
- Medical Department V, Amyloidosis Center, University of Heidelberg, Heidelberg, Germany
| | - Susan M. Geyer
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | | | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A. Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Michaela Liedtke
- Stanford Amyloid Center, Stanford University School of Medicine, Stanford, CA
| | - Ronald Witteles
- Stanford Amyloid Center, Stanford University School of Medicine, Stanford, CA
| | - Vaishali Sanchorawala
- Section of Hematology and Oncology, Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Raphael Szalat
- Section of Hematology and Oncology, Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Heather Landau
- Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Erica Petrlik
- Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Suzanne Lentzsch
- Division of Hematology/Oncology, Columbia University Medical Center, New York, NY
| | - Alexander Coltoff
- Division of Hematology/Oncology, Columbia University Medical Center, New York, NY
| | - Joan Bladé
- Department of Hematology, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | | | - Oliver Cohen
- National Amyloidosis Centre, University College London, Royal Free Hospital Campus, London, United Kingdom
| | - Darren Foard
- National Amyloidosis Centre, University College London, Royal Free Hospital Campus, London, United Kingdom
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, University College London, Royal Free Hospital Campus, London, United Kingdom
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8
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Zanwar S, Gertz MA, Muchtar E. Immunoglobulin Light Chain Amyloidosis: Diagnosis and Risk Assessment. J Natl Compr Canc Netw 2023; 21:83-90. [PMID: 36630897 PMCID: PMC10164359 DOI: 10.6004/jnccn.2022.7077] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/22/2022] [Indexed: 01/13/2023]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a clonal plasma cell disorder with multiple clinical presentations. The diagnosis of AL amyloidosis requires a high index of suspicion, making a delay in diagnosis common, which contributes to the high early mortality seen in this disease. Establishing the diagnosis of AL amyloidosis requires the demonstration of tissue deposition of amyloid fibrils. A bone marrow biopsy and fat pad aspirate performed concurrently have a high sensitivity for the diagnosis of AL amyloidosis and negate the need for organ biopsies in most patients. An accurate diagnosis requires amyloid typing via additional testing, including tissue mass spectrometry. Prognostication for AL amyloidosis is largely driven by the organs impacted. Cardiac involvement represents the single most important prognostic marker, and the existing staging systems are driven by cardiac biomarkers. Apart from organ involvement, plasma cell percentage on the bone marrow biopsy, specific fluorescence in situ hybridization findings, age at diagnosis, and performance status are important prognostic markers. This review elaborates on the diagnostic testing and prognostication for patients with newly diagnosed AL amyloidosis.
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Affiliation(s)
- Saurabh Zanwar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota
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9
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Chatzileontiadou S, Zegkos T, Frouzaki C, Apsemidou A, Efthimiadis G, Parcharidou D, Papaioannou M. Real world data on light chain cardiac amyloidosis: Still a delayed diagnosis. Front Oncol 2022; 12:944503. [PMID: 36276128 PMCID: PMC9583432 DOI: 10.3389/fonc.2022.944503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 09/08/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiac amyloidosis (CA) represents a myocardial disorder developed by fibril deposition of a heterogeneous group of misfolding proteins. Despite being rare, a high clinical index of suspicion and novel advanced diagnostic methods seem to facilitate its early recognition. Currently nine types of cardiac amyloidosis have been described with AL and ATTR being the most common. Light chain amyloidosis (AL) is a life-threatening disease, resulting from clonal plasma cells that produce amyloidogenic light chain fragments causing organ damage including the heart. Morbidity and mortality of these patients is strongly associated with the severity of cardiac involvement. Thus, early and precise diagnosis is crucial for prompt treatment initiation. In this study, we retrospectively analyzed data of 36 consecutive patients who were diagnosed with AL amyloidosis and treated in our center over the past 15 years. Heart involvement was present in 33 (92%) of them while 76% had severe cardiac disease as of stage IIIa and IIIb, according to the Mayo2004/European staging system. Almost one third of these patients experienced an early death occurring the first five months of diagnosis. To capture everyday clinical practice, we provide details on clinical presentation, diagnostic challenges, and outcome of these patients.
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Affiliation(s)
- Sofia Chatzileontiadou
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
- *Correspondence: Sofia Chatzileontiadou,
| | - Thomas Zegkos
- 1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christina Frouzaki
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Athanasia Apsemidou
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Georgios Efthimiadis
- 1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Despoina Parcharidou
- 1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Maria Papaioannou
- Hematology Unit, 1st Department of Internal Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
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10
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Vaxman I, Kumar SK, Buadi F, Lacy MQ, Dingli D, Hwa Y, Fonder A, Hobbs M, Hayman S, Kourelis T, Warsame R, Muchtar E, Leung N, Kapoor P, Grogan M, Go R, Lin Y, Gonsalves W, Siddiqui M, Kyle RA, Rajkumar SV, Gertz MA, Dispenzieri A. Outcomes among newly diagnosed AL amyloidosis patients with a very high NT-proBNP: implications for trial design. Leukemia 2021; 35:3604-3607. [PMID: 34021252 PMCID: PMC8632659 DOI: 10.1038/s41375-021-01297-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 04/30/2021] [Accepted: 05/10/2021] [Indexed: 12/14/2022]
Affiliation(s)
- I Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - S K Kumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - F Buadi
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - D Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Y Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - A Fonder
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M Hobbs
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - S Hayman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - T Kourelis
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - R Warsame
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - E Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - N Leung
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - P Kapoor
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M Grogan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - R Go
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Y Lin
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - W Gonsalves
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M Siddiqui
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - R A Kyle
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - S V Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - A Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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11
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Oghina S, Josse C, Bézard M, Kharoubi M, Delbarre MA, Eyharts D, Zaroui A, Guendouz S, Galat A, Hittinger L, Fanen P, Teiger E, Mouri N, Montestruc F, Damy T. Prognostic Value of N-Terminal Pro-Brain Natriuretic Peptide and High-Sensitivity Troponin T Levels in the Natural History of Transthyretin Amyloid Cardiomyopathy and Their Evolution after Tafamidis Treatment. J Clin Med 2021; 10:jcm10214868. [PMID: 34768388 PMCID: PMC8584290 DOI: 10.3390/jcm10214868] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND We assesse the evolution and prognostic value of N-terminal pro-brain natriuretic peptide (NT-proBNP) and high-sensitivity troponin T (cTnT-HS) in transthyretin amyloid cardiomyopathy (ATTR-CA) before and after tafamidis treatment. METHODS AND RESULTS 454 ATTR-CA patients without tafamidis (Cohort A) and 248 ATTR-CA with tafamidis (Cohort B) were enrolled. Event-free survival (EFS) events were death, heart transplant, or acute heart failure. In Cohort A, 27% of patients maintained NT-proBNP < 3000 ng/L and 14% cTnT-HS < 50 ng/L at 12 months relative to baseline levels. In Cohort B, the proportions were 49% and 29%, respectively. In Cohort A, among the 333 patients without an increased NT-proBNP > 50% relative to baseline EFS was extended compared to the 121 patients with an increased NT-proBNP > 50% (HR: 0.75 [0.57; 0.98]; p = 0.032). In Cohort A, baseline NT-proBNP > 3000 ng/L and cTnT-HS > 50 ng/L and a relative increase of NT-proBNP > 50% during follow-up were independent prognostic factors of EFS. The slopes of logs NT-proBNP and cTnT-HS increased with time before and stabilized after tafamidis. CONCLUSION ATTR-CA patients with increasing NT-proBNP had an increased risk of EFS. Tafamidis stabilize NT-proBNP and cTnT-HS increasing, even if initial NT-proBNP levels were >3000 ng/L. Thus suggesting that all patients, irrespective of baseline NT-proBNP levels, may benefit from tafamidis.
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Affiliation(s)
- Silvia Oghina
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
- Correspondence: ; Tel.: +33-1498-122-53; Fax: +33-1498-142-24
| | | | - Mélanie Bézard
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), FHU SENEC, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Mounira Kharoubi
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), FHU SENEC, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Marc-Antoine Delbarre
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Damien Eyharts
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Amira Zaroui
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Soulef Guendouz
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Arnault Galat
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Luc Hittinger
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), FHU SENEC, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Pascale Fanen
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), FHU SENEC, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Genetics Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Emmanuel Teiger
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), FHU SENEC, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | - Nadir Mouri
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Biochemistery Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
| | | | - Thibaud Damy
- Assistance Publique-Hôpitaux de Paris (AP-HP), Cardiology Department, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (M.B.); (M.K.); (M.-A.D.); (D.E.); (A.Z.); (S.G.); (A.G.); (L.H.); (E.T.); (T.D.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), French Referral Centre for Cardiac Amyloidosis, Cardiogen Network, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France; (P.F.); (N.M.)
- Assistance Publique-Hôpitaux de Paris (AP-HP), GRC Amyloid Research Institute, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), FHU SENEC, Henri Mondor University Hospital, 1 Rue Gustave Eiffel, F-94010 Créteil, France
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12
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Muchtar E, Dispenzieri A, Gertz MA, Kumar SK, Buadi FK, Leung N, Lacy MQ, Dingli D, Ailawadhi S, Bergsagel PL, Fonseca R, Hayman SR, Kapoor P, Grogan M, Abou Ezzeddine OF, Rosenthal JL, Mauermann M, Siddiqui M, Gonsalves WI, Kourelis TV, Larsen JT, Reeder CB, Warsame R, Go RS, Murray DL, McPhail ED, Dasari S, Jevremovic D, Kyle RA, Lin Y, Lust JA, Russell SJ, Hwa YL, Fonder AL, Hobbs MA, Rajkumar SV, Roy V, Sher T. Treatment of AL Amyloidosis: Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) Consensus Statement 2020 Update. Mayo Clin Proc 2021; 96:1546-1577. [PMID: 34088417 DOI: 10.1016/j.mayocp.2021.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/31/2021] [Accepted: 03/03/2021] [Indexed: 12/17/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is a clonal plasma cell disorder leading to progressive and life-threatening organ failure. The heart and the kidneys are the most commonly involved organs, but almost any organ can be involved. Because of the nonspecific presentation, diagnosis delay is common, and many patients are diagnosed with advanced organ failure. In the era of effective therapies and improved outcomes for patients with AL amyloidosis, the importance of early recognition is further enhanced as the ability to reverse organ dysfunction is limited in those with a profound organ failure. As AL amyloidosis is an uncommon disorder and given patients' frailty and high early death rate, management of this complex condition is challenging. The treatment of AL amyloidosis is based on various anti-plasma cell therapies. These therapies are borrowed and customized from the treatment of multiple myeloma, a more common disorder. However, a growing number of phase 2/3 studies dedicated to the AL amyloidosis population are being performed, making treatment decisions more evidence-based. Supportive care is an integral part of management of AL amyloidosis because of the inherent organ dysfunction, limiting the delivery of effective therapy. This extensive review brings an updated summary on the management of AL amyloidosis, sectioned into the 3 pillars for survival improvement: early disease recognition, anti-plasma cell therapy, and supportive care.
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Affiliation(s)
- Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN.
| | | | | | | | | | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | | | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - Rafael Fonseca
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | | | - Martha Grogan
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | | | | | | | | | | | - Jeremy T Larsen
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | - Craig B Reeder
- Division of Hematology/Oncology, Mayo Clinic, Scottsdale, AZ
| | | | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - David L Murray
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Dragan Jevremovic
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | | | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, MN
| | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | - Yi Lisa Hwa
- Division of Hematology, Mayo Clinic, Rochester, MN
| | | | | | - S Vincent Rajkumar
- Division of Hematology, Mayo Clinic, Rochester, MN; Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Vivek Roy
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
| | - Taimur Sher
- Division of Hematology/Oncology, Mayo Clinic, Jacksonville, FL
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13
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Prognostic restaging after treatment initiation in patients with AL amyloidosis. Blood Adv 2021; 5:1029-1036. [PMID: 33595624 DOI: 10.1182/bloodadvances.2020003782] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 12/14/2020] [Indexed: 11/20/2022] Open
Abstract
The utility of systemic light chain (AL) amyloidosis staging systems has been validated for newly diagnosed patients, but their role in restaging after treatment has not been explored. We designed this study to evaluate whether the currently used systems are of prognostic value at 3 and 6 months of starting first-line treatment, and whether stage migration from diagnosis impacts survival. This is a retrospective study including Mayo Clinic patients with AL amyloidosis diagnosed between 1 January 2006 and 30 June 2019; 536 and 204 patients had restaging data for at least 1 system at 3 and 6 months, respectively. Using modified Mayo 2004 staging at 3 months, median overall survival (OSs) were 11.8, 10.8, 4.6, and 1.1 years for stage I, II, IIIa, and IIIb, respectively. Using Mayo 2012, median OSs were 11.8, 9.0, 5.2, and 0.8 years for stage I, II, III, and IV, respectively. Using modified Mayo 2004 staging at 6 months, median OSs were not reached (NR), NR, 5.4, and 0.9 years for stage I, II, IIIa, and IIIb, respectively. Using Mayo 2012, OSs were NR, NR, 4.6, and 0.9 years for stage I, II, III, and IV, respectively. Worsening stage at 3 or 6 months was associated with worse survival than retaining baseline stage. In conclusion, the current staging systems can be used for restaging at 3 and 6 months from treatment initiation. Migration to higher stage predicts poor prognosis.
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14
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Al Hamed R, Bazarbachi AH, Bazarbachi A, Malard F, Harousseau JL, Mohty M. Comprehensive Review of AL amyloidosis: some practical recommendations. Blood Cancer J 2021; 11:97. [PMID: 34006856 PMCID: PMC8130794 DOI: 10.1038/s41408-021-00486-4] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 04/11/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022] Open
Abstract
Amyloid light chain (AL) amyloidosis is among the more common and more severe of the amyloidoses usually involving the slow proliferation of a bone-marrow-residing plasma cell (PC) clone and the secretion of unstable immunoglobulin-free light chains (FLC) that infiltrate peripheral tissues and result in detrimental end-organ damage. Disease presentation is rather vague, and the hallmark of treatment is early diagnosis before irreversible end-organ damage. Once diagnosed, treatment decision is transplant-driven whereby ~20% of patients are eligible for autologous stem cell transplantation (ASCT) with or without bortezomib-based induction. In the setting of ASCT-ineligibility, bortezomib plays a central role in upfront treatment with the recent addition of daratumumab to the current emerging standard of care. In general, management of AL amyloidosis is aimed at achieving deep, durable responses with very close monitoring for early detection of relapse/refractory disease. This article provides a comprehensive review of the management of patients with AL amyloidosis including goals of therapy, current treatment guidelines in the setting of both ASCT-eligibility and ineligibility, treatment response monitoring recommendations, toxicity management, and treatment of relapse/refractory disease.
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Affiliation(s)
- Rama Al Hamed
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Abdul Hamid Bazarbachi
- Department of Internal Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, New York, NY, USA
| | - Ali Bazarbachi
- Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
| | - Florent Malard
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, and INSERM, Saint-Antoine Research Centre, Paris, France
| | - Jean-Luc Harousseau
- Institut de Cancerologie de l'Ouest, Centre René Gauducheau, Nantes-St Herblain, France
| | - Mohamad Mohty
- Department of Clinical Hematology and Cellular Therapy, Saint-Antoine Hospital, AP-HP, Sorbonne University, and INSERM, Saint-Antoine Research Centre, Paris, France.
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15
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Second Stem Cell Transplantation for Relapsed Refractory Light Chain (AL) Amyloidosis. Transplant Cell Ther 2021; 27:589.e1-589.e6. [PMID: 33839316 DOI: 10.1016/j.jtct.2021.03.031] [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] [Received: 01/30/2021] [Revised: 03/17/2021] [Accepted: 03/30/2021] [Indexed: 11/22/2022]
Abstract
Autologous stem cell transplantation (ASCT) is an effective treatment modality in light chain (AL) amyloidosis but can be offered only to a subset of patients. The feasibility, benefit, and risks of second ASCT (ASCT2) have been rarely reported. The objective of this study was to assess the utility of ASCT2 in AL amyloidosis and to identify the target population with the greatest benefit. This retrospective study examined all AL patients who underwent ASCT2 for relapsed refractory disease between 2003 and 2020. Twenty-six patients were included. The use of ASCT2 has increased over time, from 2.5% of all ASCTs from 2003 to 2011 to 5% from 2012 to 2020 (P = .056). The median time between the first ASCT (ASCT1) and ASCT2 was 7.2 years (range, 0.6 to 17.7). Fifty-four percent of patients received at least one line of therapy between ASCTs. Second stem cell mobilization prior to ASCT2 was required in 42% of patients. Full-dose melphalan (200 mg/m2) was given to 73% of patients. Two patients had failed to engraft by day 100 but eventually recovered to normal blood counts. Both had second stem cell mobilization prior to ASCT2 with prior melphalan exposure. Four patients (15%) died before day 100. Progression-free and overall survival were significantly longer from ASCT2 for those who had durable remission after ASCT1 (≥5 years) and for those who did not receive therapy between ASCTs. ASCT2 is feasible and can produce favorable outcomes, especially among those with durable response to ASCT1. ASCT2, if chosen, should preferably be performed after durable response to ASCT1 and at first progression.
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16
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Muchtar E, Dispenzieri A, Magen H, Grogan M, Mauermann M, McPhail ED, Kurtin PJ, Leung N, Buadi FK, Dingli D, Kumar SK, Gertz MA. Systemic amyloidosis from A (AA) to T (ATTR): a review. J Intern Med 2021; 289:268-292. [PMID: 32929754 DOI: 10.1111/joim.13169] [Citation(s) in RCA: 131] [Impact Index Per Article: 43.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/15/2020] [Indexed: 01/09/2023]
Abstract
Systemic amyloidosis is a rare protein misfolding and deposition disorder leading to progressive organ failure. There are over 15 types of systemic amyloidosis, each caused by a different precursor protein which promotes amyloid formation and tissue deposition. Amyloidosis can be acquired or hereditary and can affect various organs, including the heart, kidneys, liver, nerves, gastrointestinal tract, lungs, muscles, skin and soft tissues. Symptoms are usually insidious and nonspecific resulting in diagnostic delay. The field of amyloidosis has seen significant improvements over the past decade in diagnostic accuracy, prognosis prediction and management. The advent of mass spectrometry-based shotgun proteomics has revolutionized amyloid typing and has led to the discovery of new amyloid types. Accurate typing of the precursor protein is of paramount importance as the type dictates a specific management approach. In this article, we review each type of systemic amyloidosis to provide the practitioner with practical tools to improve diagnosis and management of these rare disorders.
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Affiliation(s)
- E Muchtar
- From the, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - A Dispenzieri
- From the, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - H Magen
- Hematology Institute, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - M Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - M Mauermann
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - E D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - P J Kurtin
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - N Leung
- From the, Division of Hematology, Mayo Clinic, Rochester, MN, USA.,Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA
| | - F K Buadi
- From the, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - D Dingli
- From the, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - S K Kumar
- From the, Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - M A Gertz
- From the, Division of Hematology, Mayo Clinic, Rochester, MN, USA
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17
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Abstract
PURPOSE OF REVIEW Light chain (AL) amyloidosis is an insidious progressive disease which results in significant morbidity and inevitable mortality if not diagnosed and treated promptly. This review will highlight recent developments and summarize critical clinical points and updated practice changes for the clinician in 2020. RECENT FINDINGS Comparative analyses of staging systems, updated prognostic tools, and treatment response criteria now allow for improved patient stratification and treatment decisions; the role of minimal residual disease in response assessment is still being assessed. Clinical and genetic predictors for long-term survivors have been highlighted. Standard-of-care front-line bortezomib and the integration of anti-CD38 monoclonal antibodies in the relapsed disease have transformed treatment approach in recent years. Various clinical trials in the pipeline include novel anti-plasma cell therapies and therapies directed against amyloid deposits which promise to further advance the treatment landscape. Diagnosis, response assessment, and treatment paradigms for AL amyloidosis have evolved significantly in the past 15 years, translating into superior outcomes and increased chances of long-term survival for AL amyloidosis.
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Systemic AL Amyloidosis: Current Approaches to Diagnosis and Management. Hemasphere 2020; 4:e454. [PMID: 32885146 PMCID: PMC7430233 DOI: 10.1097/hs9.0000000000000454] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 06/22/2020] [Indexed: 12/19/2022] Open
Abstract
AL amyloidosis is characterized by a low-level expansion of an indolent, small plasma cell clone that produces amyloidogenic light chains. Amyloid aggregates or preceding intermediaries cause direct cell damage through their proteotoxicity, and amyloid deposits distort tissue architecture, and, eventually, lead to organ impairment. It is a rare, underdiagnosed disease with a diverse clinical presentation depending on the organ tropism of the amyloid fibrils; cardiac and renal involvement is most common, but any organ can be affected, excluding the central nervous system. A high level of awareness and a systematic approach using newly emerging screening biomarkers is required to achieve early diagnosis. Management should be multidisciplinary as supportive management tailored to management of organ dysfunction is paramount to survival and minimization of treatment-associated toxicity. The initial therapeutic aim is to rapidly eliminate the clonal plasma cell that produces the circulating amyloid precursor and achieve a complete hematologic response, and if possible with undetectable minimal residual disease as assessed by next-generation methods (flow and sequencing), with minimal toxicity. Treatment is tailored to the initial risk assessment of the patients. Treatments are based on regimens adapted from the expanding options that are available for multiple myeloma patients and hematological response rates have improved. Organ response rates are strongly associated with deeper hematologic response but usually lag behind hematological response and are also dependent on the initial organ function reserve. Agents directed against the amyloid deposits have been explored to aid amyloid clearance and improve organ function, but data are still negative.
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Cappelli F, Martone R, Gabriele M, Taborchi G, Morini S, Vignini E, Allinovi M, Di Gioia M, Bartolini S, Di Mario C, Perfetto F. Biomarkers and Prediction of Prognosis in Transthyretin-Related Cardiac Amyloidosis: Direct Comparison of Two Staging Systems. Can J Cardiol 2020; 36:424-431. [DOI: 10.1016/j.cjca.2019.12.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2019] [Revised: 12/13/2019] [Accepted: 12/22/2019] [Indexed: 01/17/2023] Open
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Ingraham BS, Sawatsky AP. 70-Year-Old Man With Fatigue, Shortness of Breath, and Bilateral Lower Extremity Edema. Mayo Clin Proc 2019; 94:e137-e143. [PMID: 31685263 DOI: 10.1016/j.mayocp.2019.05.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 04/24/2019] [Accepted: 05/01/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Brenden S Ingraham
- Resident in Internal Medicine, Mayo Clinic School of Graduate Medical Education, Rochester, MN
| | - Adam P Sawatsky
- Advisor to resident and Consultant in General Internal Medicine, Mayo Clinic, Rochester, MN.
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Vaxman I, Dispenzieri A, Muchtar E, Gertz M. New developments in diagnosis, risk assessment and management in systemic amyloidosis. Blood Rev 2019; 40:100636. [PMID: 31706583 DOI: 10.1016/j.blre.2019.100636] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 09/19/2019] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
Amyloidosis is a group of disorders characterized by a misfolded protein that deposits in organs and compromise their function. Clinician should have a high index of suspicion because in most cases, the clinical picture is non-specific. Typing of amyloid is of utmost importance and should be an integral part of accurately diagnosing a patient. AL amyloidosis is the most common systemic amyloidosis in the western world in which the misfolded proteins are immunoglobulin light chains secreted by clonal plasma cells. New data about prognostication of AL amyloidosis patients are accumulating. The treatment goal is to eradicate the amyloidogenic plasma cell clone, by using high dose melphalan and/or novel agents (proteasome inhibitors, immunomodulatory drugs, monoclonal antibodies against CD38). Early diagnosis is important for effectively treating the patient as late diagnosis hampers chances for organ recovery. ATTR amyloidosis is less recognized but is increasingly seen due to better recognition and improved diagnostic tools. New data about treatment options (patisiran, inotersen and tafamidis) have recently been published and are discussed.
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Affiliation(s)
- Iuliana Vaxman
- Division of Hematology, Mayo Clinic, Rochester, MN, USA; Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah-Tikva, Israel; Israel Sackler Faculty of Medicine Tel-Aviv University, Tel-Aviv, Israel
| | | | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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Abstract
Light chain (AL) amyloidosis is a rare plasma cell dyscrasia. An estimated 12,000 people live with the disease in the United States. AL amyloidosis occurs from the misfolding of proteins that deposit in organs (heart, kidneys, digestive tract, tongue, lungs, and nervous system), leading to progressive organ damage and impairment of quality of life. The treatment of AL amyloidosis has improved greatly over the past several years, with new treatments currently in development. This article will focus on the pathophysiology, diagnosis, and treatment of AL amyloidosis.
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Affiliation(s)
- Rebecca Lu
- The University of Texas MD Anderson Cancer Center, Houston, Texas
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Al Saleh AS, Sidiqi MH, Muchtar E, Dispenzieri A, Buadi FK, Dingli D, Lacy MQ, Warsame RM, Gonsalves WI, Kourelis TV, Hogan WJ, Hayman SR, Kapoor P, Kumar SK, Gertz MA. Outcomes of Patients with Light Chain Amyloidosis Who Had Autologous Stem Cell Transplantation with 3 or More Organs Involved. Biol Blood Marrow Transplant 2019; 25:1520-1525. [PMID: 31054986 DOI: 10.1016/j.bbmt.2019.04.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/23/2019] [Accepted: 04/28/2019] [Indexed: 10/26/2022]
Abstract
Prior reports have suggested that 3 or more organs involved is a contraindication for autologous stem cell transplant (ASCT) in amyloid light chain (AL) amyloidosis. Therefore, most centers limit transplantation to patients who have no more than 2 organs significantly involved. We retrospectively reviewed all patients with AL amyloidosis with ≥3 involved organs and who had ASCT between 1996 and 2015 at Mayo Clinic, Rochester, Minnesota to assess transplant safety and outcomes. Seventy-five patients with ≥3 organs involved underwent ASCT. Median age at diagnosis was 54 years, and 67% were men. The heart was involved in 95%, followed by the kidneys (84%). Thirty-eight patients (51%) had no induction treatment before ASCT. Full-dose melphalan (200 mg/m2) was given in 45%, and the remainder received 140 mg/m2. Overall hematologic response rate was 75%. The median progression-free survival (PFS) and overall survival (OS) were 16 and 68 months, respectively. The 100-day mortality was 16%, and 44 patients (59%) died during follow-up. The most common causes of death were cardiovascular events (32%) and progressive amyloidosis (25%). On multivariable analysis, predictors for PFS were Mayo 2012 stage III/IV (relative risk [RR], 3.3; P = .0012) and hematologic response (at least very good partial response; RR, .4; P = .012). An N-terminal pro-brain natriuretic peptide (NT-proBNP) level of ≥2000 pg/mL was an independent predictor for shorter PFS (RR, 2.6; P = .013). Predictors for OS included any hematologic response (RR, .12; P = .0015), melphalan 200 mg/m2 (RR, .2; P = .014), and Mayo 2012 stage III/IV (RR, 7.7; P = .0002). An NT-proBNP level ≥ 2000 pg/mL was a powerful predictor of OS (RR, 4; P = .013). The number of organs involved (3 versus >3) did not significantly impact PFS or OS. We conclude that the high prevalence and severity of cardiac involvement are the main drivers for the poor outcome in patients who have ≥3 organs involved. Using selection criteria defined for safe transplantation in cardiac amyloidosis should result in low therapy-related mortality independent of the number of organs involved. The severity of cardiac involvement should be the major criterion for transplanting patients with AL amyloidosis that have ≥3 organs involved and not merely the number of organs involved.
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Affiliation(s)
- Abdullah S Al Saleh
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota; King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - M Hasib Sidiqi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Eli Muchtar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Angela Dispenzieri
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Francis K Buadi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Martha Q Lacy
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Rahma M Warsame
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Wilson I Gonsalves
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Taxiarchis V Kourelis
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - William J Hogan
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Suzanne R Hayman
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Prashant Kapoor
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Shaji K Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic Rochester, Rochester, Minnesota.
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