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Aguilan JT, Lim J, Racine-Brzostek S, Fischer J, Silvescu C, Cornett S, Nieves E, Mendu DR, Aliste CM, Semple S, Angeletti R, Weiss LM, Cole A, Prystowsky M, Pullman J, Sidoli S. Effect of dynamic exclusion and the use of FAIMS, DIA and MALDI-mass spectrometry imaging with ion mobility on amyloid protein identification. Clin Proteomics 2024; 21:47. [PMID: 38961380 PMCID: PMC11223398 DOI: 10.1186/s12014-024-09500-w] [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: 03/18/2024] [Accepted: 06/26/2024] [Indexed: 07/05/2024] Open
Abstract
Amyloidosis is a disease characterized by local and systemic extracellular deposition of amyloid protein fibrils where its excessive accumulation in tissues and resistance to degradation can lead to organ failure. Diagnosis is challenging because of approximately 36 different amyloid protein subtypes. Imaging methods like immunohistochemistry and the use of Congo red staining of amyloid proteins for laser capture microdissection combined with liquid chromatography tandem mass spectrometry (LMD/LC-MS/MS) are two diagnostic methods currently used depending on the expertise of the pathology laboratory. Here, we demonstrate a streamlined in situ amyloid peptide spatial mapping by Matrix Assisted Laser Desorption Ionization-Mass Spectrometry Imaging (MALDI-MSI) combined with Trapped Ion Mobility Spectrometry for potential transthyretin (ATTR) amyloidosis subtyping. While we utilized the standard LMD/LC-MS/MS workflow for amyloid subtyping of 31 specimens from different organs, we also evaluated the potential introduction in the MS workflow variations in data acquisition parameters like dynamic exclusion, or testing Data Dependent Acquisition combined with High-Field Asymmetric Waveform Ion Mobility Spectrometry (DDA FAIMS) versus Data Independent Acquisition (DIA) for enhanced amyloid protein identification at shorter acquisition times. We also demonstrate the use of Mascot's Error Tolerant Search and PEAKS de novo sequencing for the sequence variant analysis of amyloidosis specimens.
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Affiliation(s)
- Jennifer T Aguilan
- Laboratory for Macromolecular Analysis and Proteomics Facility, Albert Einstein College of Medicine, New York, 10461, USA
- Department of Pathology, Albert Einstein College of Medicine, New York, 10461, USA
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - Jihyeon Lim
- Janssen Research and Development, Malvern, PA, USA
| | | | | | | | | | - Edward Nieves
- Laboratory for Macromolecular Analysis and Proteomics Facility, Albert Einstein College of Medicine, New York, 10461, USA
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, 10461, USA
| | - Damodara Rao Mendu
- Clinical Chemistry Laboratory, Mount Sinai School of Medicine, New York, USA
| | - Carlos-Madrid Aliste
- Laboratory for Macromolecular Analysis and Proteomics Facility, Albert Einstein College of Medicine, New York, 10461, USA
- Department of Systems and Computational Biology, Albert Einstein College of Medicine, New York, 10461, USA
| | | | - Ruth Angeletti
- Laboratory for Macromolecular Analysis and Proteomics Facility, Albert Einstein College of Medicine, New York, 10461, USA
| | - Louis M Weiss
- Department of Pathology, Albert Einstein College of Medicine, New York, 10461, USA
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - Adam Cole
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - Michael Prystowsky
- Department of Pathology, Albert Einstein College of Medicine, New York, 10461, USA
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - James Pullman
- Montefiore Medical Center, Moses and Weiler Campus, New York, 10461, USA
| | - Simone Sidoli
- Department of Biochemistry, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
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Karam S, Kaushal A, Abu Amer N, Royal V, KItchlu A. Non-Immunoglobulin Amyloidosis-Mediated Kidney Disease: Emerging Understanding of Underdiagnosed Entities. ADVANCES IN KIDNEY DISEASE AND HEALTH 2024; 31:334-345. [PMID: 39084759 DOI: 10.1053/j.akdh.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Revised: 01/24/2024] [Accepted: 02/06/2024] [Indexed: 08/02/2024]
Abstract
Amyloidosis is a complex group of rare disorders characterized by the deposition of misfolded proteins in the extracellular space of various tissues and organs, leading to progressive organ dysfunction. The kidneys constitute a very common site affected, most notably by immunoglobulin-mediated (light chain, heavy chain, and light and heavy chain amyloidosis), but other types that include serum amyloid A (AA) amyloidosis and leukocyte chemotactic factor 2 amyloidosis, along with mutant proteins in several hereditary forms of amyloidosis such as transthyretin, fibrinogen α-chain, gelsolin, lysozyme, and apolipoproteins AI/AII/AIV/CII/CIII amyloidosis have been incriminated as well. The clinical presentation is variable and can range from minimal proteinuria for leukocyte chemotactic factor 2 amyloidosis to a full-blown nephrotic syndrome for AA amyloidosis. Clinical correlation, genetic analysis, and adequate tissue typing through a kidney biopsy are essential to make the correct diagnosis, especially when a family history of amyloidosis is absent. Except for AA and transthyretin amyloidosis, the treatment is usually purely supportive. Kidney transplantation is an acceptable form of treatment for end-stage kidney disease in all types of non-Ig-mediated renal amyloidosis.
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Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis.
| | - Amit Kaushal
- Division of Nephrology, West Virginia University, Morgantown, WV
| | - Nabil Abu Amer
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
| | - Abhijat KItchlu
- Division of Nephrology, University Health Network, University of Toronto, Toronto, ON, Canada
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Bellofatto IA, Schindler TH, Portincasa P, Carbone F, Canepa M, Liberale L, Montecucco F. Early diagnosis and management of cardiac amyloidosis: A clinical perspective. Eur J Clin Invest 2024; 54:e14160. [PMID: 38217112 DOI: 10.1111/eci.14160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 12/13/2023] [Accepted: 12/19/2023] [Indexed: 01/15/2024]
Abstract
Cardiac amyloidosis multidisciplinary team (MDT). We propose the creation of a multidisciplinary team (MDT) for cardiac amyloidosis in which internal medicine physicians could take a lead role in coordinating other specialists involved in patient care. Created with BioRender.com.
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Affiliation(s)
- Ilaria Anna Bellofatto
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Thomas H Schindler
- Mallinckrodt Institute of Radiology, Division of Nuclear Medicine, Cardiovascular Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Piero Portincasa
- Clinica Medica "A. Murri", Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, Bari, Italy
| | - Federico Carbone
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino-Italian Cardiovascular Network, Genoa, Italy
| | - Marco Canepa
- Cardiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Luca Liberale
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino-Italian Cardiovascular Network, Genoa, Italy
| | - Fabrizio Montecucco
- First Clinic of Internal Medicine, Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino-Italian Cardiovascular Network, Genoa, Italy
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4
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Gertz MA. Immunoglobulin light chain amyloidosis: 2024 update on diagnosis, prognosis, and treatment. Am J Hematol 2024; 99:309-324. [PMID: 38095141 DOI: 10.1002/ajh.27177] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 01/21/2024]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include heart failure with preserved ejection fraction, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical smoldering multiple myeloma or MGUS." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for the diagnosis of AL amyloidosis. Organ biopsy is not required in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP or BNP), serum troponin T(or I), and difference between involved and uninvolved immunoglobulin free light chain values are used to classify patients into four stages; 5-year survivals are 82%, 62%, 34%, and 20%, respectively. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Current first-line therapy with the best outcome is daratumumab, bortezomib, cyclophosphamide, and dexamethasone. The goal of therapy is a ≥VGPR. In patients failing to achieve this depth of response options for consolidation include pomalidomide, stem cell transplantation, venetoclax, and bendamustine. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy prior to the development of end-stage organ failure. Trials of antibodies to deplete deposited fibrils are underway.
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Affiliation(s)
- Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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Rosado F, Taveras P, Gayam V, Narendra N, Vigoda I. Intestinal Reactive Amyloid A (AA) Amyloidosis in a Patient With Multiple Myeloma: A Case Report and Literature Review. Cureus 2023; 15:e42906. [PMID: 37664311 PMCID: PMC10474897 DOI: 10.7759/cureus.42906] [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: 06/13/2023] [Accepted: 08/03/2023] [Indexed: 09/05/2023] Open
Abstract
Amyloidosis is a rare group of disorders characterized by the extracellular deposition of misfolded protein aggregates that interfere with the function of the tissue affected. In some patients, the presenting symptom of monoclonal gammopathies, such as multiple myeloma, can be a gastrointestinal bleed with a further report of amyloidosis in gastrointestinal samples. In all the cases the pathology report is read as AL (light chain) amyloidosis. We present a case of a 57-year-old male patient with no medical history who debuted with gastrointestinal bleeding. A colonoscopy revealed a colonic ulcer with a pathologic diagnosis of amyloid A (AA) amyloidosis. Further investigation led to the finding of multiple myeloma (MM) with no evidence of systemic amyloidosis. Although there is little evidence in the literature of the association or even causative relationship between multiple myeloma and AA amyloidosis, our case highlights the importance of searching for an underlying monoclonal gammopathy like MM in a patient with a confirmed diagnosis of AA amyloidosis.
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Affiliation(s)
- Flor Rosado
- Internal Medicine, St. Barnabas Hospital Health System, Bronx, USA
| | - Patxis Taveras
- Internal Medicine, St. Barnabas Hospital Health System, Bronx, USA
| | - Vijay Gayam
- Gastroenterology and Hepatology, The Brooklyn Hospital Center, Brooklyn, USA
| | - Nithan Narendra
- Gastroenterology, St. Barnabas Hospital Health System, Bronx, USA
| | - Ivette Vigoda
- Hematology and Oncology, St. Barnabas Hospital Health System, Bronx, USA
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Li X, Pan XH, Fang Q, Liang Y. Pomolidomide for relapsed/refractory light chain amyloidosis after resistance to both bortezomib and daratumumab: A case report. World J Clin Cases 2022; 10:12703-12710. [PMID: 36579116 PMCID: PMC9791522 DOI: 10.12998/wjcc.v10.i34.12703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 10/13/2022] [Accepted: 11/04/2022] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Immunoglobulin light chain (AL) amyloidosis is a rare disease characterized by deposition of ALs essentially in any organ or tissue, with cardiac involvement being very frequent (61%). Early diagnosis is of high importance because early initiation of treatment in AL amyloidosis may improve outcomes. Despite the administration of immunotherapeutic agents, in particular bortezomib and daratumumab, which have improved the outcomes of AL amyloidosis, anti-plasma cell therapy remains suboptimal for some patients.
CASE SUMMARY We report the case of a 55-year-old man presenting with heart failure who was diagnosed with cardiac AL amyloidosis by an endomyocardial biopsy. He experienced a short-term hematological remission with no organ response after being administered a bortezomib-daratumumab containing regimen. The treatment was switched to pomolidomide due to pulmonary involvement and progressive pleural effusion, in which flow cytometry analysis showed abnormal plasma cells. After two cycles of this regimen, the pleural effusion was controlled effectively with no recurrence.
CONCLUSION This case emphasizes the crucial role of endomyocardial biopsy in early diagnosis of cardiac amyloidosis and suggests that pomolidomide may be an effective treatment for patients with AL amyloidosis that is relapsed/refractory to both bortezomib and daratumumab.
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Affiliation(s)
- Xian Li
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Xiao-Hong Pan
- Department of Cardiology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
| | - Qiu Fang
- Department of Hematology, Huzhou Central Hospital, Affiliated Huzhou Hospital, Zhejiang University School of Medicine, Huzhou 313099, Zhejiang Province, China
| | - Yun Liang
- Department of Hematology, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou 310009, Zhejiang Province, China
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Riefolo M, Conti M, Longhi S, Fabbrizio B, Leone O. Amyloidosis: What does pathology offer? The evolving field of tissue biopsy. Front Cardiovasc Med 2022; 9:1081098. [PMID: 36545023 PMCID: PMC9760761 DOI: 10.3389/fcvm.2022.1081098] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022] Open
Abstract
Since the mid-nineteenth century pathology has followed the convoluted story of amyloidosis, recognized its morphology in tissues and made identification possible using specific staining. Since then, pathology studies have made a significant contribution and advanced knowledge of the disease, so providing valuable information on the pathophysiology of amyloid aggregation and opening the way to clinical studies and non-invasive diagnostic techniques. As amyloidosis is a heterogeneous disease with various organ and tissue deposition patterns, histology evaluation, far from offering a simple yes/no indication of amyloid presence, can provide a wide spectrum of qualitative and quantitative information related to and changing with the etiology of the disease, the comorbidities and the clinical characteristics of patients. With the exception of cardiac transthyretin related amyloidosis cases, which today can be diagnosed using non-biopsy algorithms when stringent clinical criteria are met, tissue biopsy is still an essential tool for a definitive diagnosis in doubtful cases and also to define etiology by typing amyloid fibrils. This review describes the histologic approach to amyloidosis today and the current role of tissue screening biopsy or targeted organ biopsy protocols in the light of present diagnostic algorithms and various clinical situations, with particular focus on endomyocardial and renal biopsies. Special attention is given to techniques for typing amyloid fibril proteins, necessary for the new therapies available today for cardiac transthyretin related amyloidosis and to avoid patients receiving inappropriate chemotherapy in presence of plasma cell dyscrasia unrelated to amyloidosis. As the disease is still burdened with high mortality, the role of tissue biopsy in early diagnosis to assure prompt treatment is also mentioned.
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Affiliation(s)
- Mattia Riefolo
- Cardiovascular and Cardiac Transplant Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Matteo Conti
- Pharmacology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Public Health Department, AUSL Imola, Bologna, Italy
| | - Simone Longhi
- Department of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Benedetta Fabbrizio
- Department of Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ornella Leone
- Cardiovascular and Cardiac Transplant Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Musetti V, Greco F, Castiglione V, Aimo A, Palmieri C, Genovesi D, Giorgetti A, Emdin M, Vergaro G, McDonnell LA, Pucci A. Tissue Characterization in Cardiac Amyloidosis. Biomedicines 2022; 10:3054. [PMID: 36551810 PMCID: PMC9775200 DOI: 10.3390/biomedicines10123054] [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: 08/25/2022] [Revised: 11/14/2022] [Accepted: 11/18/2022] [Indexed: 11/29/2022] Open
Abstract
Cardiac amyloidosis (CA) has long been considered a rare disease, but recent advancements in diagnostic tools have led to a reconsideration of the epidemiology of CA. Amyloid light-chain (AL) and transthyretin (ATTR) amyloidoses are the most common forms of cardiac amyloidosis. Due to the distinct treatments and the different prognoses, amyloid typing is crucial. Although a non-biopsy diagnosis can be obtained in ATTR amyloidosis when certain diagnostic criteria are fulfilled, tissue characterization still represents the gold standard for the diagnosis and typing of CA, particularly in AL amyloidosis. The present review focuses on the status of tissue characterization in cardiac amyloidosis, from histochemistry to immunohistochemistry and mass spectrometry, as well as on its future directions.
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Affiliation(s)
- Veronica Musetti
- Health Science Interdisciplinary Center, Scuola Superiore di Studi Universitari, S.Anna, 56127 Pisa, Italy
| | | | - Vincenzo Castiglione
- Health Science Interdisciplinary Center, Scuola Superiore di Studi Universitari, S.Anna, 56127 Pisa, Italy
| | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore di Studi Universitari, S.Anna, 56127 Pisa, Italy
- Fondazione Toscana G. Monasterio, 56124 Pisa, Italy
| | | | | | | | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore di Studi Universitari, S.Anna, 56127 Pisa, Italy
- Fondazione Toscana G. Monasterio, 56124 Pisa, Italy
| | - Giuseppe Vergaro
- Health Science Interdisciplinary Center, Scuola Superiore di Studi Universitari, S.Anna, 56127 Pisa, Italy
- Fondazione Toscana G. Monasterio, 56124 Pisa, Italy
| | | | - Angela Pucci
- Histopathology Department, Pisa University Hospital, 56124 Pisa, Italy
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Fedotov SA, Khrabrova MS, Anpilova AO, Dobronravov VA, Rubel AA. Noninvasive Diagnostics of Renal Amyloidosis: Current State and Perspectives. Int J Mol Sci 2022; 23:ijms232012662. [PMID: 36293523 PMCID: PMC9604123 DOI: 10.3390/ijms232012662] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 10/17/2022] [Accepted: 10/18/2022] [Indexed: 11/05/2022] Open
Abstract
Amyloidoses is a group of diseases characterized by the accumulation of abnormal proteins (called amyloids) in different organs and tissues. For systemic amyloidoses, the disease is related to increased levels and/or abnormal synthesis of certain proteins in the organism due to pathological processes, e.g., monoclonal gammopathy and chronic inflammation in rheumatic arthritis. Treatment of amyloidoses is focused on reducing amyloidogenic protein production and inhibition of its aggregation. Therapeutic approaches critically depend on the type of amyloidosis, which underlines the importance of early differential diagnostics. In fact, the most accurate diagnostics of amyloidosis and its type requires analysis of a biopsy specimen from the disease-affected organ. However, absence of specific symptoms of amyloidosis and the invasive nature of biomaterial sampling causes the late diagnostics of these diseases, which leads to a delayed treatment, and significantly reduces its efficacy and patient survival. The establishment of noninvasive diagnostic methods and discovery of specific amyloidosis markers are essential for disease detection and identification of its type at earlier stages, which enables timely and targeted treatment. This review focuses on current approaches to the diagnostics of amyloidoses, primarily with renal involvement, and research perspectives in order to design new specific tests for early diagnosis.
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Affiliation(s)
- Sergei A. Fedotov
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Pavlov Institute of Physiology, Russian Academy of Sciences, St. Petersburg 199034, Russia
| | - Maria S. Khrabrova
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Research Institute of Nephrology, Pavlov University, St. Petersburg 197101, Russia
| | - Anastasia O. Anpilova
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Research Institute of Nephrology, Pavlov University, St. Petersburg 197101, Russia
| | | | - Aleksandr A. Rubel
- Laboratory of Amyloid Biology, St. Petersburg State University, St. Petersburg 199034, Russia
- Department of Genetics and Biotechnology, St. Petersburg State University, St. Petersburg 199034, Russia
- Correspondence: ; Tel.: +7-812-428-40-09
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10
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Gertz MA. Immunoglobulin light chain amyloidosis: 2022 update on diagnosis, prognosis, and treatment. Am J Hematol 2022; 97:818-829. [PMID: 35429180 DOI: 10.1002/ajh.26569] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/08/2022] [Accepted: 04/10/2022] [Indexed: 12/15/2022]
Abstract
DISEASE OVERVIEW Immunoglobulin light chain amyloidosis is a clonal, nonproliferative plasma cell disorder in which fragments of immunoglobulin light or heavy chain are deposited in tissues. Clinical features depend on organs involved but can include heart failure with preserved ejection fraction, nephrotic syndrome, hepatic dysfunction, peripheral/autonomic neuropathy, and "atypical smoldering multiple myeloma or monoclonal gammopathy of undetermined significance (MGUS)." DIAGNOSIS Tissue biopsy stained with Congo red demonstrating amyloid deposits with apple-green birefringence is required for the diagnosis of AL amyloidosis. Invasive organ biopsy is not required in 85% of patients. Verification that amyloid is composed of immunoglobulin light chains is mandatory. The gold standard is laser capture mass spectroscopy. PROGNOSIS N-terminal pro-brain natriuretic peptide (NT-proBNP or BNP), serum troponin T (or I), and difference between involved and uninvolved immunoglobulin free light chain values are used to classify patients into four groups of similar size; median survivals are 73, 35, 15, and 5 months. THERAPY All patients with a systemic amyloid syndrome require therapy to prevent deposition of amyloid in other organs and prevent progressive organ failure. Current first-line therapy with the best outcome is daratumumab, bortezomib, cyclophosphamide, and dexamethasone. The goal of therapy is a complete response (CR). In patients failing to achieve this depth of response options for consolidation include pomalidomide, stem cell transplantation, venetoclax, and bendamustine. FUTURE CHALLENGES Delayed diagnosis remains a major obstacle to initiating effective therapy prior to the development of end-stage organ failure. Trials of antibodies to catabolize deposited fibrils are underway.
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Affiliation(s)
- Morie A. Gertz
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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11
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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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