1
|
Smith MA, Feinglass NG. Perioperative implications of amyloidosis and amyloid cardiomyopathy: A review for anesthesiologists. J Clin Anesth 2024; 92:111271. [PMID: 37820520 DOI: 10.1016/j.jclinane.2023.111271] [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: 08/02/2023] [Revised: 09/17/2023] [Accepted: 09/22/2023] [Indexed: 10/13/2023]
Abstract
It is well recognized that amyloid protein can infiltrate many regions of the body. This can include the peripheral nerves, the liver, kidney, spleen, the gastrointestinal tract, and most importantly the myocardium. The amyloid proteins that cause cardiomyopathy may come from genetically altered liver genes (transthyretin amyloid, ATTR) or from the bone marrow with malignant plasma cells (light chain amyloid, AL) generating the aberrant protein. These two types of amyloidosis cause significant damaging effects on both the myocardial cells as well as the conduction system of the heart. The resultant changes can produce dyspnea and exercise intolerance which is thought to be secondary to diastolic dysfunction and reduced stroke volume. This subclinical decompensation poses a significant problem for members of a care team as it often goes unrecognized. In the operating room patients are exposed to dramatic hemodynamic changes and may have difficult airways, autonomic dysfunction, and conduction abnormalities. Although the topic of amyloidosis is well described in cardiology literature, it is underdiagnosed. The purpose of this review is to describe some of the pathophysiology behind the principle proteins that cause cardiac amyloidosis and to comprehensively describe perioperative considerations for anesthesia providers.
Collapse
Affiliation(s)
- Michael A Smith
- Mayo Clinic Dept. Anesthesiology and Perioperative Medicine, Critical Care Medicine, Mayo Graduate School of Medicine, USA.
| | - Neil G Feinglass
- Mayo Clinic Dept. Anesthesiology and Perioperative Medicine, Mayo Graduate School of Medicine, USA
| |
Collapse
|
2
|
Abstract
The extrinsic and autonomic nervous system intricately controls the major functions of the gastrointestinal tract through the enteric nervous system; these include motor, secretory, sensory, storage, and excretory functions. Disorders of the nervous system affecting gastrointestinal tract function manifest primarily as abnormalities in motor (rather than secretory) functions. Common gastrointestinal symptoms in neurologic disorders include sialorrhea, dysphagia, gastroparesis, intestinal pseudo-obstruction, constipation, diarrhea, and fecal incontinence. Diseases of the entire neural axis ranging from the cerebral hemispheres to the peripheral autonomic nerves can result in gastrointestinal motility disorders. The most common neurologic diseases affecting gastrointestinal function are stroke, parkinsonism, multiple sclerosis, and diabetic neuropathy. Diagnosis involves identification of the neurologic disease and its distribution, and documentation of segmental gut dysfunction, typically using noninvasive imaging, transit measurements, or intraluminal measurements of pressure activity and coordination of motility. Apart from treatment of the underlying neurologic disease, management focuses on restoration of normal hydration and nutrition and pharmacologic treatment of the gut neuromuscular disorder.
Collapse
|
3
|
González-Duarte A, Conceição I, Amass L, Botteman MF, Carter JA, Stewart M. Impact of Non-Cardiac Clinicopathologic Characteristics on Survival in Transthyretin Amyloid Polyneuropathy. Neurol Ther 2020; 9:135-149. [PMID: 32232748 PMCID: PMC7229108 DOI: 10.1007/s40120-020-00183-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Hereditary (variant) transthyretin amyloidosis (ATTRv) with polyneuropathy (ATTR-PN) is a rare genetic disorder that causes progressive autonomic and sensorimotor neuropathy, severe disability, and death within 10 years of onset. Previous studies have primarily focused on how baseline cardiac characteristics affect mortality, but the impact of non-cardiac baseline characteristics is less defined. METHODS We systematically searched PubMed/Medline (1990-2019) to identify studies that assessed the impact of baseline ATTR-PN characteristics on survival. Outcomes were first summarized descriptively. Extracted survival data were then disaggregated, and parametric mixture models were used to assess survival differences among patient groups defined by factors known to affect survival. RESULTS The search yielded 1193 records, of which 35 were retained for analysis. Median survival ranged from 0.5 to > 25 years. The largest survival differences were between cohorts who underwent liver transplantation (LTx) versus those who did not. Among LTx cohorts, pre-LTx ATTR-PN disease duration ≥ 7 years, poor nutritional status, and late disease onset reduced median survival by 13, 12, and 10 years, respectively. Other prognostic survival factors included non-Val30Met genotype and baseline presence of urinary incontinence, erectile dysfunction, or muscle weakness. CONCLUSION Survival in patients with ATTR-PN is highly variable and affected by non-cardiac baseline characteristics, such as autonomic dysfunction, large fiber involvement, late-onset disease, and non-Val30Met mutation. Careful interpretation of these findings is warranted given that this synthesis did not control for differences between studies. Survival in patients with ATTR-PN remains poor among those who are untreated or with delayed diagnosis.
Collapse
Affiliation(s)
| | - Isabel Conceição
- Department of Neurosciences and Mental Health, Hospital de Santa Maria-Centro Hospitalar Lisboa Norte (CHULN), Lisbon, Portugal
- Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | | | | | | | | |
Collapse
|
4
|
Obici L, Suhr OB. Diagnosis and treatment of gastrointestinal dysfunction in hereditary TTR amyloidosis. Clin Auton Res 2019; 29:55-63. [PMID: 31452022 PMCID: PMC6763516 DOI: 10.1007/s10286-019-00628-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 08/02/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE To review the management of gastrointestinal symptoms in patients with hereditary transthyretin amyloidosis, discussing diagnostic evaluations, assessment of disease progression and therapeutic strategies that could be implemented in routine practice. METHODS Literature review. Key search terms included "gastrointestinal symptoms", "autonomic neuropathy", "hereditary transthyretin amyloidosis" and "familial amyloid polyneuropathy". RESULTS Gastrointestinal disturbances are a common and serious manifestation of hereditary transthyretin amyloidosis, with significant effects on patients' quality of life and demonstrating a strong association with mortality. Gastrointestinal involvement is more often subclinical in the early stages of the disease, although in some patients gastric and/or bowel abnormalities may be the inaugural symptoms. In both cases, under-recognition, delayed investigation and suboptimal treatment frequently occur. A clear understanding of the mechanisms underlying gastrointestinal dysfunction in hereditary transthyretin amyloidosis is still lacking, but similar to diabetic enteropathy, multiple pathophysiological alterations seem to play a role. CONCLUSIONS Early detection and treatment of gastrointestinal disturbances is key to the successful treatment of this devastating disease. Gastroenterologists play a valuable role in both the diagnosis and the timely management of gastrointestinal symptoms in hereditary transthyretin amyloidosis and should, therefore, be part of a multidisciplinary and comprehensive approach to this disorder.
Collapse
Affiliation(s)
- Laura Obici
- Amyloidosis Research and Treatment Centre, Fondazione IRCCS Policlinico San Matteo, Viale Golgi, 19, 27100, Pavia, Italy.
| | - Ole B Suhr
- Department of Medicine, Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| |
Collapse
|
5
|
Marberg T, Karling P, Söderberg K, Anan I, Wixner J. Self-reported gastrointestinal symptoms are more common in liver transplanted transthyretin amyloidosis patients than in healthy controls and in patients transplanted for end-stage liver disease. Amyloid 2019; 26:47-48. [PMID: 31343318 DOI: 10.1080/13506129.2019.1582514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Therese Marberg
- a Department of Public Health and Clinical Medicine, Umeå University , Umeå , Sweden
| | - Pontus Karling
- a Department of Public Health and Clinical Medicine, Umeå University , Umeå , Sweden
| | - Karin Söderberg
- a Department of Public Health and Clinical Medicine, Umeå University , Umeå , Sweden
| | - Intissar Anan
- a Department of Public Health and Clinical Medicine, Umeå University , Umeå , Sweden
| | - Jonas Wixner
- a Department of Public Health and Clinical Medicine, Umeå University , Umeå , Sweden
| |
Collapse
|
6
|
Zhou HB. A case of multiple myeloma initially presenting as hematemesis. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 29:108-111. [PMID: 29391314 DOI: 10.5152/tjg.2018.17710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
A few cases of multiple myeloma with gastrointestinal bleeding have been reported, but hematemesis is rarely encountered as an initial symptom of multiple myeloma. Here we report a case of multiple myeloma with an initial symptom of hematemesis. Gastroscopy revealed ulceration in the angulus of the stomach. Colonoscopy revealed many ulcers in the ascending colon. A definite diagnosis of gastrointestinal amyloidosis was made using tissue biopsy. A definite diagnosis of multiple myeloma was made using bone marrow puncture. Hematemesis may be an initial symptom of multiple myeloma. A diagnosis of amyloidosis-induced hematemesis should be considered in patients with multiple myeloma.
Collapse
Affiliation(s)
- Hai Bo Zhou
- Department of Gastroenterology, Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| |
Collapse
|
7
|
Collins M, Pellat A, Antoni G, Agostini H, Labeyrie C, Adams D, Carbonnel F. Somatostatin analogues for refractory diarrhoea in familial amyloid polyneuropathy. PLoS One 2018; 13:e0201869. [PMID: 30161158 PMCID: PMC6116977 DOI: 10.1371/journal.pone.0201869] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Accepted: 07/24/2018] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Familial amyloid polyneuropathy (FAP) is a genetic disease leading to the production of a variant transthyretin (TTR) or a beta variant β2-microglobulin. FAP may be associated with refractory diarrhoea. In this study, we assessed the efficacy and tolerance of somatostatin analogues in refractory diarrhoea associated with FAP. METHODS FAP patients from the French national referral center who received somatostatin analogues for a refractory diarrhoea were retrospectively studied. We assessed remission of diarrhoea, as defined by a stool consistence of five or less on the Bristol stool scale, assessed after three to six months of follow-up. Stool frequency and continence before and after three to six months of treatment were also compared by the means of Wilcoxon and McNemar's exact tests, respectively. RESULTS Fourteen patients treated with somatostatin analogues were evaluable. After three to six months of follow-up, 9/14 patients (64% 95%CI = [35%; 87%]) had remission of diarrhoea. This was significantly higher than a theoretical remission rate of 20% (p = 0.0004). There was a significant decrease of daily bowel movement from 6 to 2.5 per day (p = 0.002). Twelve/14 (85%) patients had incontinence at baseline vs 8/14 (57%) after three to six months of follow-up (p = 0.134). Three out of 14 patients (21%) had a severe adverse event; two patients had hypoglycaemia, and one had endocarditis due to an injection-site bacterial infection. CONCLUSION This study suggests that somatostatin analogues may benefit to patients with FAP and refractory diarrhoea. Approximately 20% of patients had severe adverse events, including hypoglycaemia.
Collapse
Affiliation(s)
- Michael Collins
- AP-HP, Hôpital Bicêtre, Department of Gastroenterology, Le Kremlin Bicêtre, France
- * E-mail:
| | - Anna Pellat
- AP-HP, Hôpital Bicêtre, Department of Gastroenterology, Le Kremlin Bicêtre, France
| | | | - Hélène Agostini
- AP-HP, Hôpital Bicêtre, Unité de recherche clinique Paris-Sud, Le Kremlin-Bicêtre, France
| | - Céline Labeyrie
- French National Reference Centre for FAP (NNERF), Le Kremlin Bicêtre, France
- AP-HP, Hôpital Bicêtre, Department of Neurology, Le Kremlin Bicêtre, France
| | - David Adams
- French National Reference Centre for FAP (NNERF), Le Kremlin Bicêtre, France
- AP-HP, Hôpital Bicêtre, Department of Neurology, Le Kremlin Bicêtre, France
- INSERM UMR 1195; Paris Sud University, Le Kremlin Bicêtre, France
| | - Franck Carbonnel
- AP-HP, Hôpital Bicêtre, Department of Gastroenterology, Le Kremlin Bicêtre, France
- French National Reference Centre for FAP (NNERF), Le Kremlin Bicêtre, France
| |
Collapse
|
8
|
Wixner J, Suhr OB, Anan I. Management of gastrointestinal complications in hereditary transthyretin amyloidosis: a single-center experience over 40 years. Expert Rev Gastroenterol Hepatol 2018; 12:73-81. [PMID: 29073801 DOI: 10.1080/17474124.2018.1397511] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Hereditary transthyretin amyloidosis (ATTRm amyloidosis) is a rare disease caused by the deposition and accumulation of insoluble non-native transthyretin fibrils in the body. The disease inevitably results in widespread organ disruption, and poor life expectancy. The GI tract is one organ system vulnerable to disruption and, although the clinical presentation of the disease varies, GI involvement affects most patients with ATTRm amyloidosis. Areas covered: This article presents our experience with diagnosing and treating the GI symptoms of ATTRm amyloidosis patients at our center over the last 40 years, in the Swedish clustering area of the disease. Our aim is to help other physicians to better manage GI complications in patients with this rare but widespread condition. Expert commentary: GI symptoms are debilitating complications for ATTRm amyloidosis patients to experience, yet with the appropriate questioning and diagnosis methods, symptomatic treatments of these symptoms can be implemented to provide relief. Further, patients with fewer GI complications and a good nutritional status are also better candidates for liver transplantation which, in selected cases, is the best disease-modifying treatment of ATTRm amyloidosis to date.
Collapse
Affiliation(s)
- Jonas Wixner
- a Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Ole B Suhr
- a Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| | - Intissar Anan
- a Department of Public Health and Clinical Medicine , Umeå University , Umeå , Sweden
| |
Collapse
|