1
|
Karam S, Haidous M, Royal V, Leung N. Renal AA amyloidosis: presentation, diagnosis, and current therapeutic options: a review. Kidney Int 2023; 103:473-484. [PMID: 36502873 DOI: 10.1016/j.kint.2022.10.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/26/2022] [Accepted: 10/31/2022] [Indexed: 12/13/2022]
Abstract
Amyloid A amyloidosis is thought to be the second most common form of systemic amyloidosis behind amyloidosis secondary to monoclonal Ig. It is the result of deposition of insoluble fibrils in the extracellular space of tissues and organs derived from the precursor protein serum amyloid A, an acute phase reactant synthesized excessively in the setting of chronic inflammation. The kidney is the most frequent organ involved. Most patients present with proteinuria and kidney failure. The diagnosis is made through tissue biopsy with involvement of the glomeruli in most cases, but also often of the vessels and the tubulointerstitial compartment. The treatment usually targets the underlying etiology and consists increasingly of blocking the inflammatory cascade of cytokines with interleukin-1 inhibitors, interleukin-6 inhibitors, and tumor necrosis factor-α inhibitors to reduce serum amyloid A protein formation. This strategy has also shown efficacy in cases where an underlying etiology cannot be readily identified and has significantly improved the prognosis of this entity. In addition, there has been increased interest at developing effective therapies able to clear amyloid deposits from tissues, albeit with mitigated results so far.
Collapse
Affiliation(s)
- Sabine Karam
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota, USA.
| | - Mohamad Haidous
- Department of Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Quebec, Canada
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| |
Collapse
|
2
|
Yoshida S, Matsumoto H, Temmoku J, Shakespear N, Kiko Y, Kikuchi K, Sumichika Y, Saito K, Fujita Y, Matsuoka N, Asano T, Sato S, Suzuki E, Watanabe H, Ohira H, Migita K. Case report: Rapid development of amyloid A amyloidosis in temporal arteritis with SAA1.3 allele; An unusual case of intestinal amyloidosis secondary to temporal arteritis. Front Immunol 2023; 14:1144397. [PMID: 37026007 PMCID: PMC10071027 DOI: 10.3389/fimmu.2023.1144397] [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: 01/14/2023] [Accepted: 03/10/2023] [Indexed: 04/08/2023] Open
Abstract
Temporal arteritis (TA) is a large-vessel vasculitis mostly seen in older patients. Amyloid A (AA) amyloidosis secondary to a chronic inflammation induces multiple organ dysfunctions, including a dysfunction of the gastrointestinal tract. Herein, we present a case of TA complicated by AA amyloidosis that was resistant to oral and intravenous steroids. An 80-year-old man with a history of new-onset headache, jaw claudication, and distended temporal arteries was referred to our department. On admission, the patient presented with tenderness and a subcutaneous temporal nodule in both temple arteries. Ultrasonography of the nodule revealed an anechoic perivascular halo surrounding the right temporal artery. Following the diagnosis of TA, high-dose prednisolone therapy was initiated. However, the patient presented with recurrent abdominal pain and refractory diarrhea. Due to the unclear origin of refractory diarrhea, an extensive workup, including biopsy of the duodenal mucosa, was performed. Endoscopy revealed chronic inflammation in the duodenum. Immunohistochemical analysis of duodenal mucosal biopsy samples revealed AA amyloid deposition resulting in the diagnosis of AA amyloidosis. After tocilizumab (TCZ) administration, refractory diarrhea reduced; however, the patient died of intestinal perforation 1 month after the start of TCZ administration. Gastrointestinal involvement was the main clinical manifestation of AA amyloidosis in the present case. This case highlights the importance of bowel biopsy screening for amyloid deposition in patients with unexplained gastrointestinal tract symptoms, even in a recent onset of large-vessel vasculitis. In the present case, the carriage of the SAA1.3 allele likely contributed to the rare association of AA amyloidosis with TA.
Collapse
Affiliation(s)
- Shuhei Yoshida
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Haruki Matsumoto
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Jumpei Temmoku
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Norshalena Shakespear
- Department of Diagnostic Pathology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuichiro Kiko
- Department of Diagnostic Pathology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kentaro Kikuchi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuya Sumichika
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kenji Saito
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Yuya Fujita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Naoki Matsuoka
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Tomoyuki Asano
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Shuzo Sato
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Eiji Suzuki
- Department of Rheumatology, Ohta-Nishinouchi Hospital, Koriyama, Japan
| | - Hiroshi Watanabe
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hiromasa Ohira
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Kiyoshi Migita
- Department of Rheumatology, Fukushima Medical University School of Medicine, Fukushima, Japan
- *Correspondence: Kiyoshi Migita,
| |
Collapse
|
3
|
Frequency of Renal Function Parameter Abnormalities in Patients with Psoriatic Arthritis and Rheumatoid Arthritis: Real-World Evidence from Clinical Practice. J Clin Med 2022; 11:jcm11041029. [PMID: 35207306 PMCID: PMC8880606 DOI: 10.3390/jcm11041029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 02/11/2022] [Accepted: 02/14/2022] [Indexed: 02/01/2023] Open
Abstract
Objective: Patients with psoriatic arthritis (PsA) or rheumatoid arthritis (RA) commonly develop renal dysfunction due to either systemic inflammation or drug-related nephrotoxicity. This study compared renal function parameters in patients with PsA versus those with RA and examined the impact of clinical remission or disease relapse on renal function. Methods: This single-center retrospective study was conducted at the University Hospital of Messina, Italy. Adult patients (aged ≥18 years) with PsA or RA who attended the rheumatology clinic within the past 6 months were identified from electronic medical records. Results: In total, 45 patients with PsA (n = 23) or RA (n = 22) were included. The mean (standard deviation) age was 55.6 (15.9) years, and 78% of participants were female. Patient age, renal function, and medical history were generally similar between the two disease groups, although significantly more RA patients were smokers, and more PsA patients had comorbid hypertension. The prevalence of estimated glomerular filtration rate [eGFR] ≤90 mL/min/1.73 m2 at 1, 6, and 12 months of treatment ranged from 38.5% to 58.3% in the PsA group and from 45.5% to 54.5% in the RA group and did not significantly differ between disease groups. Clinical remission did not appear to affect renal function parameters in either disease group; however, relapse was associated with significantly higher serum creatinine levels in PsA patients at the same timepoint. Conclusion: In this study, patients with PsA and RA had a similar prevalence of renal function parameter abnormalities over 12 months of treatment. Disease relapse may impact renal function in patients with PsA.
Collapse
|
4
|
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.
Collapse
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
| |
Collapse
|
5
|
Kilic L, Erden A, Sener YZ, Armagan B, Sari A, Kalyoncu U, Karadag O, Akdogan A, Dogan I, Apras Bilgen S, Kiraz S, Ertenli I. Rituximab Therapy in Renal Amyloidosis Secondary to Rheumatoid Arthritis. Biomolecules 2018; 8:biom8040136. [PMID: 30400666 PMCID: PMC6316109 DOI: 10.3390/biom8040136] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/17/2018] [Accepted: 10/24/2018] [Indexed: 12/03/2022] Open
Abstract
Secondary amyloid A (AA) amyloidosis is a late and serious complication of poorly controlled, chronic inflammatory diseases. Rheumatoid arthritis (RA) patients with poorly controlled, longstanding disease and those with extra-articular manifestations are under risk for the development of AA amyloidosis. Although new drugs have proven to be significantly effective in the treatment of secondary AA amyloidosis, no treatment modality has proven to be ideal. To date, only in small case series preliminary clinical improvement have been shown with rituximab therapy for AA amyloidosis secondary to RA that is refractory to TNF-α inhibitors (TNF-i) therapy. In these case series, we assessed the efficacy and safety of rituximab therapy for patients with RA and secondary amyloidosis. Hacettepe University Biologic Registry was developed at 2005. The data of the RA patients who were prescribed a biological drug were recorded regularly. Patients with biopsy proven AA amyloidosis patients were screened. Of 1022 RA patients under biologic therapy, 0.7% patients had clinically apparent histologically confirmed amyloidosis. Four of seven patients who were prescribed rituximab at least one infusion enrolled to those case series. Two of four patients showed significant clinical improvement and one of them also had decrease in proteinuria and the other one had stable renal function and proteinuria. The main goal for the treatment of AA amyloidosis is to control the activity of the underlying disorder. In this study, we showed that rituximab may be an effective treatment in RA patients with amyloidosis who were unresponsive to conventional disease modifying anti-rheumatic drugs (DMARDs) and/or TNFi.
Collapse
Affiliation(s)
- Levent Kilic
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Abdulsamet Erden
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Yusuf Ziya Sener
- Department of Internal Medicine, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Berkan Armagan
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Alper Sari
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Umut Kalyoncu
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Omer Karadag
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Ali Akdogan
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Ismail Dogan
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Sule Apras Bilgen
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Sedat Kiraz
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| | - Ihsan Ertenli
- Department of Internal Medicine, Division of Rheumatology, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey.
| |
Collapse
|
6
|
Pamuk ÖN, Kalyoncu U, Aksu K, Omma A, Pehlivan Y, Çağatay Y, Küçükşahin O, Dönmez S, Çetin GY, Mercan R, Bayındır Ö, Çefle A, Yıldız F, Balkarlı A, Kılıç L, Çakır N, Kısacık B, Öksüz MF, Çobankara V, Onat AM, Sayarlıoğlu M, Öztürk MA, Pamuk GE, Akkoç N. A multicenter report of biologic agents for the treatment of secondary amyloidosis in Turkish rheumatoid arthritis and ankylosing spondylitis patients. Rheumatol Int 2016; 36:945-53. [DOI: 10.1007/s00296-016-3500-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 05/16/2016] [Indexed: 12/21/2022]
|
7
|
Serum amyloid A as a marker of persistent inflammation and an indicator of cardiovascular and renal involvement in patients with rheumatoid arthritis. Mediators Inflamm 2014; 2014:793628. [PMID: 25525305 PMCID: PMC4265690 DOI: 10.1155/2014/793628] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 09/24/2014] [Accepted: 11/13/2014] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVES Rheumatoid arthritis (RA) is a systemic, inflammatory disease. Serum amyloid A (SAA) is an acute-phase protein, involved in pathogenesis of atherosclerosis. The aim of the study was to assess serum concentration of SAA in RA patients, with reference to other inflammatory parameters and markers of extra-articular involvement. METHODS The study population consisted of 140 RA patients, low/moderate disease activity (L/MDA) in 98 (70%) patients and high disease activity (HDA) in 42 (30%). Comprehensive clinical and laboratory assessment was performed with evaluation of electrocardiogram and carotid intima-media thickness. RESULTS The mean SAA concentration [327.0 (263.4) mg/L] was increased highly above the normal value, even in patients with L/MDA. Simultaneously, SAA was significantly higher in patients with HDA versus L/MDA. The mean SAA concentration was significantly higher in patients treated with glucocorticoids, was inversely associated with QTc duration, and was markedly higher in patients with atherosclerotic plaques, emphasizing increased CV risk. SAA was significantly higher in patients with increased cystatin-C level. CONCLUSIONS In RA patients, high serum SAA concentration was strongly associated with activity of the disease and risk of CV and renal involvement. Recurrent assessment of SAA may facilitate searching patients with persistent inflammation and risk of extra-articular complications.
Collapse
|