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Kvacskay P, Hegenbart U, Lorenz HM, Schönland SO, Blank N. bDMARD can prevent the progression of AA amyloidosis to end-stage renal disease. Ann Rheum Dis 2024:ard-2023-225114. [PMID: 38653531 DOI: 10.1136/ard-2023-225114] [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: 10/09/2023] [Accepted: 04/06/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION AA amyloidosis (AA) can be the consequence of any chronic inflammatory disease. AA is associated with chronic inflammatory diseases (cid+AA), autoinflammatory syndromes (auto+AA) or AA of unknown origin or idiopathic AA (idio+AA). The major organ manifestation is renal AA that can progress to end-stage renal disease (ESRD) and multiple organ failure. MATERIALS AND METHODS This study is a monocentric retrospective analysis of the renal outcome and survival of patients with cid+AA (n=34), auto+AA (n=24) and idio+AA (n=25) who were treated with cytokine-inhibiting biological disease-modifying antirheumatic drugs (bDMARDs). RESULTS 83 patients with renal AA were identified and followed for a mean observational period of 4.82 years. C reactive protein (CRP), serum amyloid alpha and proteinuria were significantly reduced with bDMARD therapy. Progression to ESRD was prevented in 60% (cid+AA), 88% (auto+AA) and 81% (idio+AA) of patients. Tocilizumab was given to 34 patients with cid+AA and idio+AA and was more effective in reducing CRP and progression to ESRD and death compared with other bDMARDs. CONCLUSIONS bDMARDs reduce systemic inflammation in various diseases, leading to a reduction of proteinuria and prevention of ESRD. Importantly, tocilizumab was more effective than other bDMARDs in controlling systemic inflammation in patients with chronic inflammatory diseases and idiopathic AA, leading to better renal and overall survival.
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Affiliation(s)
- Peter Kvacskay
- Department of Hematology, Oncology, and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Ute Hegenbart
- Department of Hematology, Oncology, and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hanns-Martin Lorenz
- Department of Hematology, Oncology, and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan O Schönland
- Department of Hematology, Oncology, and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | - Norbert Blank
- Department of Hematology, Oncology, and Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
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Ha JH, Xu Y, Sekhon H, Zhao W, Wilkens S, Ren D, Loh SN. Mimicking kidney flow shear efficiently induces aggregation of LECT2, a protein involved in renal amyloidosis. J Biol Chem 2024; 300:107231. [PMID: 38537700 PMCID: PMC11040205 DOI: 10.1016/j.jbc.2024.107231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/20/2024] [Accepted: 03/15/2024] [Indexed: 04/09/2024] Open
Abstract
Aggregation of leukocyte cell-derived chemotaxin 2 (LECT2) causes ALECT2, a systemic amyloidosis that affects the kidney and liver. Previous studies established that LECT2 fibrillogenesis is accelerated by the loss of its bound zinc ion and stirring/shaking. These forms of agitation create heterogeneous shear conditions, including air-liquid interfaces that denature proteins, that are not present in the body. Here, we determined the extent to which a more physiological form of mechanical stress-shear generated by fluid flow through a network of narrow channels-drives LECT2 fibrillogenesis. To mimic blood flow through the kidney, where LECT2 and other proteins form amyloid deposits, we developed a microfluidic device consisting of progressively branched channels narrowing from 5 mm to 20 μm in width. Shear was particularly pronounced at the branch points and in the smallest capillaries. Aggregation was induced within 24 h by shear levels that were in the physiological range and well below those required to unfold globular proteins such as LECT2. EM images suggested the resulting fibril ultrastructures were different when generated by laminar flow shear versus shaking/stirring. Importantly, results from the microfluidic device showed the first evidence that the I40V mutation accelerated fibril formation and increased both the size and the density of the aggregates. These findings suggest that kidney-like flow shear, in combination with zinc loss, acts in combination with the I40V mutation to trigger LECT2 amyloidogenesis. These microfluidic devices may be of general use for uncovering mechanisms by which blood flow induces misfolding and amyloidosis of circulating proteins.
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Affiliation(s)
- Jeung-Hoi Ha
- Department of Biochemistry and Molecular Biology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Yikang Xu
- Department of Biomedical and Chemical Engineering, Syracuse University, Syracuse, New York, USA
| | - Harsimranjit Sekhon
- Department of Biochemistry and Molecular Biology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Wenhan Zhao
- Department of Biomedical and Chemical Engineering, Syracuse University, Syracuse, New York, USA
| | - Stephan Wilkens
- Department of Biochemistry and Molecular Biology, State University of New York Upstate Medical University, Syracuse, New York, USA
| | - Dacheng Ren
- Department of Biomedical and Chemical Engineering, Syracuse University, Syracuse, New York, USA; Department of Civil and Environmental Engineering, Syracuse University, Syracuse, New York, USA; Department of Biology, Syracuse University, Syracuse, New York, USA.
| | - Stewart N Loh
- Department of Biochemistry and Molecular Biology, State University of New York Upstate Medical University, Syracuse, New York, USA.
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Ha JH, Xu Y, Sekhon H, Wilkens S, Ren D, Loh SN. Mimicking Kidney Flow Shear Efficiently Induces Aggregation of LECT2, a Protein Involved in Renal Amyloidosis. BIORXIV : THE PREPRINT SERVER FOR BIOLOGY 2023:2023.07.13.548788. [PMID: 37503176 PMCID: PMC10369975 DOI: 10.1101/2023.07.13.548788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Aggregation of leukocyte cell-derived chemotaxin 2 (LECT2) causes ALECT2, a systemic amyloidosis that affects the kidney and liver. Homozygosity of the I40V LECT2 mutation is believed to be necessary but not sufficient for the disease. Previous studies established that LECT2 fibrillogenesis is greatly accelerated by loss of its single bound zinc ion and stirring or shaking. These forms of agitation are often used to facilitate protein aggregation, but they create heterogeneous shear conditions, including air-liquid interfaces that denature proteins, that are not present in the body. Here, we determined the extent to which a more physiological form of mechanical stress-shear generated by fluid flow through a network of artery and capillary-sized channels-drives LECT2 fibrillogenesis. To mimic blood flow through the human kidney, where LECT2 and other proteins form amyloid deposits, we developed a microfluidic device consisting of progressively branched channels narrowing from 5 mm to 20 μm in width. Flow shear was particularly pronounced at the branch points and in the smallest capillaries, and this induced LECT2 aggregation much more efficiently than conventional shaking methods. EM images suggested the resulting fibril structures were different in the two conditions. Importantly, results from the microfluidic device showed the first evidence that the I40V mutation accelerated fibril formation and increased both size and density of the aggregates. These findings suggest that kidney-like flow shear, in combination with zinc loss, acts in combination with the I40V mutation to trigger LECT2 amyloidogenesis. These microfluidic devices may be of general use for uncovering the mechanisms by which blood flow induces misfolding and amyloidosis of circulating proteins.
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Affiliation(s)
- Jeung-Hoi Ha
- Department of Biochemistry and Molecular Biology, State University of New York Upstate Medical University, Syracuse, NY 13210
| | - Yikang Xu
- Department of Biomedical and Chemical Engineering, Syracuse University, Syracuse, NY 13244
| | - Harsimranjit Sekhon
- Department of Biochemistry and Molecular Biology, State University of New York Upstate Medical University, Syracuse, NY 13210
| | - Stephan Wilkens
- Department of Biochemistry and Molecular Biology, State University of New York Upstate Medical University, Syracuse, NY 13210
| | - Dacheng Ren
- Department of Biomedical and Chemical Engineering, Syracuse University, Syracuse, NY 13244
- Department of Civil and Environmental Engineering, Syracuse University, Syracuse, NY 13244
- Department of Biology, Syracuse University, Syracuse, NY 13244
| | - Stewart N. Loh
- Department of Biochemistry and Molecular Biology, State University of New York Upstate Medical University, Syracuse, NY 13210
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Ozdemir A, Yılmaz M, Ozagari AA, Kocak SY. Prognostic value of histopathological scoring and grading in patients with renal AA amyloidosis. Int Urol Nephrol 2022; 54:2591-2597. [PMID: 35275358 DOI: 10.1007/s11255-022-03163-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 02/23/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The amount and distribution pattern of amyloid deposits may contribute to renal function and outcome, given the great diversity of renal involvement in amyloidosis. The aim of this study was to analyze the impact of histological characteristics of patients with biopsy-proven renal AA amyloidosis (AAA) on renal outcome. METHODS Renal biopsies of 37 patients with AAA were re-evaluated. The distribution pattern of glomerular amyloid (GA) deposits was classified, the extent of amyloid deposits in glomeruli, vessel, and interstitium and other histopathologic lesions were scored, and renal amyloid prognostic score (RAPS) was determined by summing all scores. Their potential prognostic relevance on renal outcome was investigated. RESULTS GA and vascular amyloid (VA) deposits were noted in all cases, interstitial amyloid (IA) was detected in 70.2%. GA deposits were predominantly seen in diffuse mesengiocapillary fashions (class IV) (51.4%). GA class, the extent of GA, VA, IA deposit, and RAPS, as well as interstitial fibrosis (IF) and interstitial inflammation were correlated to renal function at diagnosis. During the median follow-up of 52 months, 13 patients developed doubling of serum creatinine or end stage renal disease and they had a higher degree of GA and VA load (p = 0.03 and p = 0.042, respectively) as compared to the remaining patients. VA load, but not GA and RAPS grade, was associated with poor renal outcome (HR 3.016, 95% CI 1.45-6.25, p = 0.003). CONCLUSIONS Baseline renal function is closely linked to the extent of AA amyloid deposit in renal parenchyma but only VA load was a predictor of renal outcome in AAA patients.
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Affiliation(s)
- Arzu Ozdemir
- Department of Nephrology, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Zuhuratbaba, Tevfik Saglam Cad. No:11, 34147, Bakirkoy, Istanbul, Turkey.
| | - Mürvet Yılmaz
- Department of Nephrology, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Zuhuratbaba, Tevfik Saglam Cad. No:11, 34147, Bakirkoy, Istanbul, Turkey
| | - Ayse Aysim Ozagari
- Department of Pathology, Sisli Hamdiye Etfal Education and Research Hospital, Halaskargazi Cd., 34371, Sisli, Istanbul, Turkey
| | - Sibel Yucel Kocak
- Department of Nephrology, University of Health Sciences, Bakirkoy Dr. Sadi Konuk Education and Research Hospital, Zuhuratbaba, Tevfik Saglam Cad. No:11, 34147, Bakirkoy, Istanbul, Turkey
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Ahmed S, Nasir H, Moatasim A, Khalil F. Renal Amyloidosis: A Clinicopathological Study From a Tertiary Care Hospital in Pakistan. Cureus 2022; 14:e21122. [PMID: 35165578 PMCID: PMC8830345 DOI: 10.7759/cureus.21122] [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] [Accepted: 01/11/2022] [Indexed: 12/05/2022] Open
Abstract
Introduction Systemic amyloidosis can affect any organ in the body, but the kidney is the most commonly involved site. It is characterized by the extracellular deposition of insoluble fibrillar proteins. Amyloid deposits can be identified histologically by Congo red stain, which gives apple-green birefringence under polarized light. Typing of renal amyloidosis is done by direct immunofluorescence on frozen tissue. The most common types of amyloidosis seen in renal tissue are amyloid light chain (AL) primary amyloidosis and amyloid A (AA) secondary amyloidosis. Although primary amyloidosis is considered the most common type in western countries, however, in the subcontinent region, secondary amyloidosis is more common. The spectrum of signs and symptoms in renal amyloidosis is variable including isolated proteinuria, nephrotic syndrome, hypertension, hypotension, and renal insufficiency. The present study aims to evaluate the incidence and aetiology of various types of renal amyloidosis, determine their distribution within the kidney, and study various clinicopathological features. Objective The present study aims to evaluate the aetiology and clinicopathological profile of renal amyloidosis, determine its various types, and their distribution within the kidney. Materials and methods This retrospective cross-sectional study was conducted from 1st January 2013 to 31st December 2020 at the Department of Histopathology, Shifa International Hospital (SIH), Islamabad. All renal biopsies diagnosed as renal amyloidosis were included in the study. Data were analysed using SPSS version 23 (IBM Corp., Armonk, NY). Frequency and percentages were calculated for qualitative variables, and mean and standard deviation were calculated for quantitative variables. Results A total of 131 cases were diagnosed with renal amyloidosis during the study period of eight years (from 1st January 2013 to 31st December 2020) at SIH. The age range varied from 17 to 82 years. The mean age of the patients was 45 ± 16.33 years. Out of 131 patients, 82 (62.6%) were males and 49 (37.4%) were females. Amongst them, 72 (54%) cases were diagnosed with secondary AA amyloidosis and 16 (12%) cases were diagnosed with primary AL amyloidosis. The rest of the cases 43 (34%) were of indeterminate type. The associated conditions in secondary amyloidosis were tuberculosis in 41 (57%), rheumatoid arthritis in 16 (22%), ankylosing spondylitis in five (7%), lymphoma in three (4%), diabetes in two (3%), and chronic osteomyelitis, chronic heart disease, hepatitis, and vasculitis in one case each (1.7%). Out of 16 cases reported with AL amyloidosis, 10 cases (62.5%) had a history of multiple myeloma. The most common clinical presentation was nephrotic syndrome followed by subnephrotic proteinuria, renal failure, and hypertension. Conclusion The findings of the present study show underlying etiological factors and clinicopathological characteristics of renal amyloidosis. AA amyloidosis is the most common type of renal amyloidosis in our study and tuberculosis is the most common aetiological factor. AL amyloidosis is less frequent in our population.
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Velayati S, Belkin A, Sidhu Kumar G, Tharayil ZJ, Kumar N, Patel S. Kidney-limited AL amyloidosis: a case report and review of the literature. J Community Hosp Intern Med Perspect 2021; 11:698-702. [PMID: 34567468 PMCID: PMC8462866 DOI: 10.1080/20009666.2021.1942624] [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: 05/07/2021] [Accepted: 06/09/2021] [Indexed: 11/01/2022] Open
Abstract
Amyloidosis involves the deposition of abnormal proteins in various tissues and results in progressive organ dysfunction, commonly affecting multiple organs. Two types of systemic amyloidosis are AA and AL; the former is associated with acute phase reactions and the latter is composed of light chain immunoglobulins. This disease commonly affects the kidneys and is evidenced by massive proteinuria. A biopsy is the gold standard of diagnosis, with Congo Red staining revealing an apple-green birefringence under polarized light. Although the kidneys are frequently affected in this disease, it is rare that amyloidosis is limited to the kidneys without involvement of other organs. We present an 83-year-old female with bilateral lower extremity swelling for several months who was found to have 12.374 grams of protein in a 24-hour urine sample and a large amount of free lambda chains. A renal biopsy demonstrated renal amyloidosis of the AL type. Serum immunofixation and flow cytometry were unremarkable for any plasma dyscrasia; a bone marrow biopsy did not reveal systemic amyloidosis and imaging with PET/CT scan did not show evidence of other organ involvement. She was diagnosed with renal-limited amyloidosis and started on bortezomib, melphalan, and steroids. Clinicians should be aware of the signs and symptoms of amyloidosis, specifically its ability to present with unusual involvement of individual organs.
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Affiliation(s)
- Sara Velayati
- Department of Internal Medicine, Long Island Community Hospital, Patchogue, NY, USA
| | - Alexander Belkin
- Department of Internal Medicine, Long Island Community Hospital, Patchogue, NY, USA
| | | | - Zubin J Tharayil
- Department of Internal Medicine, Long Island Community Hospital, Patchogue, NY, USA
| | - Neeru Kumar
- Department of nephrology, Brookhaven Nephrology Associates, P.C, Patchogue, NY, USA
| | - Samir Patel
- Department of hematology-oncology, Cancer and Blood Specialists, Patchogue, New York, USA
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Al-Obaidy KI, Grignon DJ. Primary Amyloidosis of the Genitourinary Tract. Arch Pathol Lab Med 2021; 145:699-703. [PMID: 32383975 DOI: 10.5858/arpa.2020-0102-ra] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Amyloidosis is caused by the deposition of misfolded proteins as insoluble eosinophilic material in the extracellular tissues of the body, leading to impairment of organ function. It can be systemic or localized. Localized genitourinary tract amyloidosis is rare and can be incidentally seen; however, in some cases, it can be the only presenting disease. OBJECTIVE.— To review the clinical presentation and pathologic findings related to primary amyloidosis of the urogenital system and highlight some of the associated pathologic findings based on our personal experience. DATA SOURCES.— Published peer-reviewed literature and personal experience of the senior author. CONCLUSIONS.— Primary localized amyloidosis within the urogenital tract can present as a neoplastic process and may be clinically and radiologically considered as a mass. Awareness of primary amyloidosis by pathologists and clinicians is required for accurate diagnosis and proper patient management.
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Affiliation(s)
- Khaleel I Al-Obaidy
- From the Department of Pathology & Laboratory Medicine, Indiana University School of Medicine, Indianapolis
| | - David J Grignon
- From the Department of Pathology & Laboratory Medicine, Indiana University School of Medicine, Indianapolis
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Owji SM, Raeisi Shahraki H, Owji SH. A 16-year Survey of Clinicopathological Findings, Electron Microscopy, and Classification of Renal Amyloidosis. IRANIAN JOURNAL OF MEDICAL SCIENCES 2021; 46:32-42. [PMID: 33487790 PMCID: PMC7812497 DOI: 10.30476/ijms.2019.82110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background Electron microscopy (EM) is a valuable tool in the diagnosis of renal amyloidosis, particularly in the early stages of the disease. In Iran, studies on EM and the clinical features of renal amyloidosis are scarce. The objective of the present study was to survey EM investigations, pathological classifications, and clinical features of renal amyloidosis. Methods This cross-sectional study was performed in Shiraz, Iran, during 2001-2016. Out of 2,770 kidney biopsies, 27 cases with a diagnosis of renal amyloidosis were investigated. EM investigation and six staining procedures for light microscopy (LM) were performed. Two pathological classifications based on glomerular, peritubular, perivascular, and interstitial involvement were made. Finally, the association between these classifications and the clinical features was assessed. Chi-square, Fisher's exact, Independent t test, and Multiple logistic regression analysis were used. P values<0.05 were considered statistically significant. Results In 51.9% of the cases, the clinical diagnosis was nephrotic syndrome. Proteinuria and edema were the most prevalent clinical manifestations. The role of EM investigation for diagnosis was graded "necessary" or "supportive" in 48.2% of the patients. In the classification based on glomerular classes, variables such as the mean blood pressure (P=0.003), history of hypertension (P=0.02), creatinine >1.5 (P=0.03), and severe tubular atrophy (P=0.03) were significantly higher in class B (advanced amyloid depositions). Conclusion EM plays an important role in the diagnosis of renal amyloidosis. EM in conjunction with LM investigation with Congo red staining is recommended, to prevent misdiagnosis of patients with a clinical suspicion of renal amyloidosis. Among different pathological features of renal amyloidosis, the severity of glomerular amyloid depositions had a clear relationship with clinical presentations.
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Affiliation(s)
- Seyed Mohammad Owji
- Department of Pathology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Hadi Raeisi Shahraki
- Department of Epidemiology and Biostatistics, School of Health, Shahrekord University of Medical Sciences, Shahrekord, Iran
| | - Seyed Hossein Owji
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
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Celtik A, Sen S, Keklik F, Saydam G, Asci G, Sarsik B, Ozkahya M, Toz H. A histopathological scoring and grading system to predict outcome for patients with AA amyloidosis. Int Urol Nephrol 2020; 52:1297-1304. [PMID: 32529382 DOI: 10.1007/s11255-020-02505-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 05/11/2020] [Indexed: 01/17/2023]
Abstract
PURPOSE Renal involvement is associated with significant morbidity and mortality in AA amyloidosis. Extend of amyloid deposition in kidney biopsies may be predictive for clinical manifestations and outcomes. The aim of our study is to assess clinical features of patients with biopsy-proven renal AA amyloidosis and to evaluate the relationship between histopathological scoring and grading of renal amyloid deposition with clinical findings and outcomes. METHODS The study included 86 patients who were diagnosed with renal AA amyloidosis. The demographic and clinical features at the time of biopsy and follow-up data were retrospectively collected. Amyloid deposition in glomeruli, interstitium, vessels and tubulointerstitial findings were scored and renal amyloid prognostic score (RAPS) was assigned by adding all scores. RAPS was further divided into three grades (RAPS grade I, II, III). RESULTS Median age was 50 (36-59) years. Familial Mediterranean fever was the leading cause. RAPS grade and interstitial inflammatory infiltration were associated with baseline eGFR and glomerular amyloid deposition was associated with proteinuria. During the follow-up period (median 50 months), 39 patients developed ESRD. Extensive (involving > 50%) glomerular amyloid deposition, baseline eGFR and proteinuria were independent risk factors for progression to end stage renal disease. Death censored renal survival was significantly lower among patients with RAPS grade III compared to those with RAPS grade I and II. Patient survival rate was not different according to RAPS grade. CONCLUSIONS Degree of renal amyloid accumulation is associated with renal function and outcome. The scoring and grading system may be predictive in clinical outcome and contribute to understanding of disease mechanism.
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Affiliation(s)
- Aygul Celtik
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Ege University, Bornova, 35100, Izmir, Turkey.
| | - Sait Sen
- Department of Pathology, School of Medicine, Ege University, Izmir, Turkey
| | - Fatma Keklik
- Department of Internal Medicine, School of Medicine, Ege University, Izmir, Turkey
| | - Guray Saydam
- Division of Hematology, Department of Internal Medicine, School of Medicine, Ege University, Izmir, Turkey
| | - Gulay Asci
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Ege University, Bornova, 35100, Izmir, Turkey
| | - Banu Sarsik
- Department of Pathology, School of Medicine, Ege University, Izmir, Turkey
| | - Mehmet Ozkahya
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Ege University, Bornova, 35100, Izmir, Turkey
| | - Huseyin Toz
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Ege University, Bornova, 35100, Izmir, Turkey
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Fonseca EO, Caldas MLR, Soares Filho PJ, Almeida JR. Correlation between amyloid deposits affecting renal compartments and glomerular filtration rate during renal biopsy in a renal amyloidosis case series. ACTA ACUST UNITED AC 2020; 53:e8625. [PMID: 32428129 PMCID: PMC7266501 DOI: 10.1590/1414-431x20208625] [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: 04/14/2019] [Accepted: 03/04/2020] [Indexed: 11/25/2022]
Abstract
Amyloidosis comprises a group of disorders that accumulate modified autologous proteins in organs, mainly the kidneys. Few studies have addressed the amyloid compartmental distribution and associated clinical outcomes. The aim of this study was to present a case series of renal amyloidosis correlating histopathological data with glomerular filtration rate (GFR) during kidney biopsy. We studied 53 cases reviewed by nephropathologists from 2000 to 2018 in a single kidney biopsy center in Brazil. GFR was estimated using the CKD-EPI formula. Cases were divided into Group A ≥60 and Group B <60 mL·min−1·(1.73 m2)−1 using the estimated GFR during kidney biopsy. Semiquantitative histopathological study was performed, including extension and distribution of amyloid deposits by compartments (glomeruli, tubulointerstitial tissue, and vessels). Statistical analyses were made to understand associations with lower GFR. No difference was seen for age, gender, proteinuria, hematuria, subtype of amyloid protein, arteriosclerosis, interstitial fibrosis/infiltrate, or glomerular and interstitial amyloid deposits. After a previous P value <0.1 in the descriptive analysis, the following variables were selected: globally sclerotic glomeruli, high blood pressure, and the extension of vascular amyloid deposition. A binary logistic regression model with GFR as the dependent variable showed history of hypertension and vascular amyloid to be robust and independent predictors of Group B <60 mL·min−1·(1.73 m2)−1. Beyond the histopathologic diagnosis of amyloidosis, a semiquantitative approach on renal biopsy could provide new insights. Vascular amyloid is an independent predictor of renal dysfunction in cases of renal amyloidosis.
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Affiliation(s)
- E O Fonseca
- Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brasil
| | - M L R Caldas
- Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brasil
| | - P J Soares Filho
- Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brasil
| | - J R Almeida
- Hospital Universitário Antônio Pedro, Universidade Federal Fluminense, Niterói, RJ, Brasil
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Hoelbeek JJ, Kers J, Steenbergen EJ, Roelofs JJTH, Florquin S. Renal amyloidosis: validation of a proposed histological scoring system in an independent cohort. Clin Kidney J 2020; 14:855-862. [PMID: 33777368 PMCID: PMC7986350 DOI: 10.1093/ckj/sfaa019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 01/17/2020] [Indexed: 01/28/2023] Open
Abstract
Background In systemic amyloidosis, the kidney is frequently affected and renal involvement has a major impact on survival. Renal involvement is clinically characterized by decreased estimated glomerular filtration rate (eGFR) and proteinuria. The two most common renal amyloidosis types are light chain-related amyloidosis (AL) and serum amyloid A (AA) amyloidosis. Standardized histopathological scoring of amyloid deposits is crucial to assess disease progression. Therefore, we aimed to validate the proposed scoring system from Rubinstein et al. (Novel pathologic scoring tools predict end-stage kidney disease in light chain (AL) amyloidosis. Amyloid 2017; 24: 205–211) in an independent patient cohort. Methods We attempt to reproduce the scoring system, consisting of an amyloid score (AS) and a composite scarring injury score (CSIS), in a multicentre AL and AA case series. Additionally, we analysed all renal amyloidosis kidney biopsies performed in the Netherlands between 1993 and 2012. Results Similar to the original study, AS and CSIS correlated to eGFR (r = −0.45, P = 0.0061 and r = −0.60, P < 0.0001, respectively) but not to proteinuria at diagnosis. Furthermore, AS, but not CSIS, was associated with renal outcome. The scoring system was not reproducible in AA patients. The median incidence rate for renal amyloidosis in the Netherlands was 2.3 per million population per year, and increased during the study period. Conclusions In our AL case series and the original study, AS and CSIS were correlated to eGFR but not to proteinuria, and AS correlated with renal outcome. Overall, we regard this scoring system as competent for standardized histopathological assessment of amyloid deposits burden and thereby disease advancement in renal biopsies.
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Affiliation(s)
- Joris J Hoelbeek
- Department of Pathology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jesper Kers
- Department of Pathology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric J Steenbergen
- Department of Pathology, Radboud University Nijmegen Medical Center, Radboud University Nijmegen, Nijmegen, The Netherlands
| | - Joris J T H Roelofs
- Department of Pathology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Sandrine Florquin
- Department of Pathology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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Giannini G, Nast CC. An Organ System-Based Approach to Differential Diagnosis of Amyloid Type in Surgical Pathology. Arch Pathol Lab Med 2019; 144:379-387. [PMID: 31697170 DOI: 10.5858/arpa.2018-0509-ra] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT.— Amyloidosis is an uncommon but important entity. A protein-based classification of amyloidosis defines the underlying disease process, directing clinical management and providing prognostic information. However, in routine surgical pathology there often is no attempt to classify amyloid other than staining to determine light chain-associated amyloidosis. Systemic and localized amyloidosis vary with respect to frequency of organ involvement by different amyloid types, and most amyloid proteins have commercial antibodies available for identification. OBJECTIVE.— To provide a guide for the likelihood of amyloid type by organ system. DATA SOURCES.— Literature review based on PubMed searches containing the word amyloid, specifically addressing the prevalence and significance of amyloid proteins in each organ system other than the brain, and the authors' practice experience. CONCLUSIONS.— In patients with amyloidosis, determination of the responsible protein is critical for appropriate patient care. In large subspecialty practices and reference laboratories with experience in using and analyzing relevant immunohistochemistry, most amyloid proteins can be identified with an organ-specific algorithm. Referring to an organ-based algorithm may be helpful in providing clinicians with a more specific differential diagnosis regarding amyloid type to help guide clinical evaluation and treatment. When the protein cannot be characterized, mass spectrometry can be performed to definitively classify the amyloid type.
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Affiliation(s)
- Gabriel Giannini
- From the Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Cynthia C Nast
- From the Department of Pathology, Cedars-Sinai Medical Center, Los Angeles, California
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Tariq H, Sharkey FE. Leukocyte Cell-Derived Chemotaxin-2 Amyloidosis (ALECT2) in a Patient With Lung Adenocarcinoma: An Autopsy Report and Literature Review. Int J Surg Pathol 2017; 26:271-275. [PMID: 29017384 DOI: 10.1177/1066896917735893] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Amyloidosis caused by deposition of leukocyte cell-derived chemotaxin-2 amyloidosis (ALECT2) is the most recently described form of systemic amyloidosis and has quickly emerged as a common and possibly underdiagnosed cause of slowly declining renal function, particularly in patients of Hispanic ancestry. We describe the autopsy findings in a 70-year-old Hispanic woman who died of metastatic lung adenocarcinoma and was incidentally found to have extensive amyloid deposition in the kidneys, liver, spleen, adrenal glands, small intestine, gallbladder, lungs, bilateral ovaries, and uterus. The type of amyloid was confirmed to be ALECT2 by mass spectrometry. The pattern of amyloid deposition in the kidneys and the liver was typical for what has been described for ALECT2. In addition, a unique pattern of amyloid deposition was observed in spleen, adrenal glands, small intestine, gallbladder, lungs, ovaries, and uterus. The pattern of amyloid deposition in ALECT2 is distinct from amyloid A and amyloid light-chain and needs to be recognized to avoid misdiagnosis as amyloid light-chain or amyloid A amyloidosis. After recognition, an accurate diagnosis by mass spectrometry and/or immunohistochemical staining is essential to guide treatment and avoid toxic therapies.
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Affiliation(s)
- Hamza Tariq
- 1 University of Texas Health Science Center at San Antonio, TX, USA
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Rubinstein S, Cornell RF, Du L, Concepcion B, Goodman S, Harrell S, Horst S, Lenihan D, Slosky D, Fogo A, Langone A. Novel pathologic scoring tools predict end-stage kidney disease in light chain (AL) amyloidosis. Amyloid 2017; 24:205-211. [PMID: 28758811 DOI: 10.1080/13506129.2017.1360272] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Light chain (AL) amyloidosis frequently involves the kidney, causing significant morbidity and mortality. A pathologic scoring system with prognostic utility has not been developed. We hypothesized that the extent of amyloid deposition and degree of scarring injury on kidney biopsy, could provide prognostic value, and aimed to develop pathologic scoring tools based on these features. METHODS This is a case-control study of 39 patients treated for AL amyloidosis with biopsy-proven kidney involvement at a large academic medical center. Our novel scoring tools, composite scarring injury score (CSIS) and amyloid score (AS) were applied to each kidney biopsy. The primary outcome was progression to dialysis-dependent end-stage kidney disease (ESKD) using a 12-month landmark analysis. RESULTS At 12 months, nine patients had progressed to ESKD. Patients with an AS ≥7.5 had a significantly higher cumulative incidence of ESKD than those with AS <7.5 (p = .04, 95% CI 0.13-0.64). CONCLUSIONS Using a 12-month landmark analysis, AS correlated with progression to ESKD. These data suggest that a kidney biopsy, in addition to providing diagnostic information, can be the basis for a pathologic scoring system with prognostic significance.
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Affiliation(s)
- Samuel Rubinstein
- a Department of Internal Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Robert F Cornell
- b Division of Hematology and Oncology, Department of Internal Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Liping Du
- c Department of Biostatistics , Vanderbilt University , Nashville , TN , USA
| | - Beatrice Concepcion
- d Division of Nephrology, Department of Internal Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Stacey Goodman
- b Division of Hematology and Oncology, Department of Internal Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Shelton Harrell
- b Division of Hematology and Oncology, Department of Internal Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Sara Horst
- e Division of Gastroenterology, Department of Internal Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Daniel Lenihan
- f Division of Cardiovascular Medicine, Department of Internal Medicine , Vanderbilt Heart and Vascular Institute , Nashville , TN , USA
| | - David Slosky
- g Vanderbilt University Medical Center , Nashville , TN , USA
| | - Agnes Fogo
- h Department of Pathology , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Anthony Langone
- d Division of Nephrology, Department of Internal Medicine , Vanderbilt University Medical Center , Nashville , TN , USA
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Kendi Celebi Z, Kiremitci S, Ozturk B, Akturk S, Erdogmus S, Duman N, Ates K, Erturk S, Nergizoglu G, Kutlay S, Sengul S, Ensari A, Keven K. Kidney biopsy in AA amyloidosis: impact of histopathology on prognosis. Amyloid 2017; 24:176-182. [PMID: 28686525 DOI: 10.1080/13506129.2017.1350158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
In AA amyloidosis, while kidney biopsy is widely considered for diagnosis by clinicians, there is no evidence that the detailed investigation of renal histopathology can be utilized for the prognosis and clinical outcomes. In this study, we aimed to obtain whether histopathologic findings in kidney biopsy of AA amyloidosis might have prognostic and clinical value. This is a retrospective cohort study that included 38 patients who were diagnosed with AA amyloidosis by kidney biopsy between 2005 and 2013.The kidney biopsy specimens of patients were evaluated and graded for several characteristics of histopathological lesions and their relationship with renal outcomes. Segmental amyloid deposition in the kidney biopsy was seen in 29%, global amyloid deposition in 71, diffuse involvement of glomeruli in 84.2%, focal involvement in 7%, glomerular enlargement in 53%, tubular atrophy in 75% and interstitial fibrosis in 78% of patients. Histopathologically, glomerular enlargement, interstitial fibrosis, tubular atrophy, interstitial inflammation and global amyloid deposition were significantly associated with lower estimated glomerular filtration rate (eGFR) (p = .02, p < .001, p = .001, p = .009, p = .002, respectively) in univariate analysis. In multivariate analysis, tubular atrophy was the only predictor of eGFR (p = .019 B = -20.573). In the follow-up at an average of 27 months, 18 patients developed end-stage renal disease (ESRD). Among them, global amyloid deposition was the only risk factor for the development of ESRD (p = .01, OR = 18.750, %95 CI= 2.021-173.942). This is the first study showing that the histopathological findings in kidney biopsy of AA amyloidosis might have a prognostic and clinical value for renal outcomes.
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Affiliation(s)
- Zeynep Kendi Celebi
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
| | - Saba Kiremitci
- b Department of Pathology , Ankara University School of Medicine , Ankara , Turkey
| | - Bengi Ozturk
- c Department of Internal Medicine , Ankara University School of Medicine , Ankara , Turkey
| | - Serkan Akturk
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
| | - Siyar Erdogmus
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
| | - Neval Duman
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
| | - Kenan Ates
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
| | - Sehsuvar Erturk
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
| | - Gokhan Nergizoglu
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
| | - Sim Kutlay
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
| | - Sule Sengul
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
| | - Arzu Ensari
- b Department of Pathology , Ankara University School of Medicine , Ankara , Turkey
| | - Kenan Keven
- a Department of Nephrology , Ankara University School of Medicine , Ankara , Turkey
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Matsuura M, Abe H, Tominaga T, Sakurai A, Murakami T, Kishi S, Bando Y, Minakuchi J, Nagai K, Doi T. A Novel Method of DAPI Staining for Differential Diagnosis of Renal Amyloidosis. THE JOURNAL OF MEDICAL INVESTIGATION 2017; 64:217-221. [DOI: 10.2152/jmi.64.217] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Motokazu Matsuura
- Division of Clinical Laboratory, Tokushima University Hospital
- Department of Nephrology, Institute of Biomedical Sciences, Tokushima University Graduate School
| | - Hideharu Abe
- Division of Clinical Laboratory, Tokushima University Hospital
| | | | - Akiko Sakurai
- Division of Clinical Laboratory, Tokushima University Hospital
| | - Taichi Murakami
- Division of Clinical Laboratory, Tokushima University Hospital
| | - Seiji Kishi
- Division of Clinical Laboratory, Tokushima University Hospital
| | - Yoshimi Bando
- Division of Pathology, Tokushima University Hospital
| | | | - Kojiro Nagai
- Division of Clinical Laboratory, Tokushima University Hospital
| | - Toshio Doi
- Division of Clinical Laboratory, Tokushima University Hospital
- Department of Nephrology, Institute of Biomedical Sciences, Tokushima University Graduate School
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Inoue R, Fujigaki Y, Kobayashi K, Tamura Y, Ota T, Shibata S, Ishida T, Kondo F, Yamaguchi Y, Uchida S. Clinical Presentation of Tubulointerstitial Nephritis Caused by Amyloid Light-chain Amyloidosis in a Patient with Sjögren's Syndrome. Intern Med 2017; 56:419-423. [PMID: 28202864 PMCID: PMC5364195 DOI: 10.2169/internalmedicine.56.7548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
We report a 70-year-old woman with Sjögren's syndrome who had severe renal dysfunction with mild proteinuria and elevated urinary low-molecular-weight proteins. Based on these clinical presentations, interstitial nephritis due to Sjögren's syndrome was strongly suspected. Unexpectedly, renal pathology revealed amyloid light-chain (AL) lambda-type depositions predominantly in the vasculatures with severe tubulointerstitial damage. Concentrated urine immunofixation was positive for Bence Jones lambda-type monoclonal proteins. Given the involvement in other organs, systemic AL amyloidosis was diagnosed. The patient underwent chemotherapy, but hemodialysis was ultimately instituted. It should be remembered that renal amyloidosis occurs as a clinical presentation of interstitial nephritis.
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Affiliation(s)
- Reiko Inoue
- Department of Internal Medicine, Teikyo University School of Medicine, Japan
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Sozeri B, Gulez N, Ergin M, Serdaroglu E. The experience of canakinumab in renal amyloidosis secondary to Familial Mediterranean fever. Mol Cell Pediatr 2016; 3:33. [PMID: 27590627 PMCID: PMC5010548 DOI: 10.1186/s40348-016-0058-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Accepted: 07/19/2016] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Familial Mediterranean fever (FMF) is an autosomal recessive disease characterized by self-limited recurrent attacks of fever and serositis. Patients may develop renal amyloidosis. Colchicine prevents attacks and renal amyloidosis. Five to 10 % of the patients with FMF are resistant or intolerant to colchicine. CASE DESCRIPTION Herein, we reported our experience with clinical-laboratory features and treatment responses of a pediatric FMF patient with amyloidosis treated with canakinumab. We observed a significant decrease in proteinuria and increase growth in the patient. DISCUSSION AND EVALUATION The most serious complication of FMF is the development of AA type amyloidosis which is characterized by proteinuria. Colchicine is the prototype drug that decreases production of amyloidogenic precursor protein. Occasionally, colchicine inadequate patient is observed, as in our case. Canakinumab is a human anti-IL-1β monoclonal antibody. Previously, canakinumab efficacy were shown in a limited number of studies. CONCLUSIONS Our data, though limited to only one patient, emphasize that therapeutic intervention with canakinumab seems to be improve kidney function in colchicine-resistant FMF with renal amyloidosis.
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Affiliation(s)
- Betul Sozeri
- Department of Pediatric Rheumatology, Ege University Faculty of Medicine, Izmir, Turkey.
| | - Nesrin Gulez
- Dr. Behcet Uz Children Diseases Teaching and Research Hospital Pediatric Immunology and Rheumatology, Izmir, Turkey
| | - Malik Ergin
- Dr. Behcet Uz Children Diseases Teaching and Research Hospital Pathology, Izmir, Turkey
| | - Erkin Serdaroglu
- Dr. Behcet Uz Children Diseases Teaching and Research Hospital Pediatric Nephrology, Izmir, Turkey
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Topaloglu R, Batu ED, Orhan D, Ozen S, Besbas N. Anti-interleukin 1 treatment in secondary amyloidosis associated with autoinflammatory diseases. Pediatr Nephrol 2016; 31:633-40. [PMID: 26563115 DOI: 10.1007/s00467-015-3249-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 10/07/2015] [Accepted: 10/08/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND Amyloidosis may complicate autoinflammatory diseases (AID). We aimed to evaluate the renal biopsy findings, and clinical and laboratory parameters in patients with AID-associated amyloidosis who have responded to anti-interleukin 1(IL1) treatment. METHODS Two children with systemic juvenile idiopathic arthritis and one with cryopyrin-associated periodic syndrome diagnosed as having reactive amyloidosis were treated with anti-IL1 drugs. The renal histopathological findings at the time of diagnosis of amyloidosis and after the onset of anti-IL1 were evaluated according to the amyloid scoring/grading system. RESULTS The median age of disease onset and diagnosis of amyloidosis were 3 and 12 years, respectively. Anakinra was started in all; however, anakinra caused a local cutaneous reaction in one, thus canakinumab was commenced. Proteinuria improved in all. Control renal biopsies were performed a median of 3 years after the first biopsies. The renal amyloid prognostic score did not improve in patient 1, and progressed in patients 2 and 3. The renal amyloid grade progressed in patient 2. CONCLUSIONS This is the first series demonstrating progression of renal tissue damage after the improvement of proteinuria with anti-IL 1 in AID-associated amyloidosis. Anti-IL1 drugs are important to prevent further amyloid accumulation; however, new treatment strategies are needed to target the amyloid deposits.
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Affiliation(s)
- Rezan Topaloglu
- Department of Pediatrics, Division of Nephrology, Hacettepe University Faculty of Medicine, Ankara, 06100, Turkey.
| | - Ezgi Deniz Batu
- Department of Pediatrics, Division of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Diclehan Orhan
- Department of Pediatrics, Division of Pathology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Seza Ozen
- Department of Pediatrics, Division of Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Nesrin Besbas
- Department of Pediatrics, Division of Nephrology, Hacettepe University Faculty of Medicine, Ankara, 06100, Turkey
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