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Duan L, Hengphasatporn K, Sakai T, Fujiki R, Yoshida N, Hirota S, Shigeta Y. Why is Dimeric 3D Domain Swapping in Antibody Light Chains Missing from the Solution? Atomistic Insights Mechanisms. J Phys Chem B 2024. [PMID: 39268801 DOI: 10.1021/acs.jpcb.4c03234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
Misfolding of antibody light chains can lead to systemic light chain amyloidosis, which is associated with misfolding and aggregation. The antibody light chain may engage in 3D domain swapping within the variable region (#4VL) through hydrogen bonding (HB) interactions, potentially forming the tetramer, as revealed in solution and crystal structures. However, the 3D-domain swapping (3D-DS) dimers could not be detected experimentally. This study investigates the absence of 3D-DS using computational approaches, focusing on structural dynamics, solvation effects, and stability relevant to the loss of 3D-DS. Microscale molecular dynamics simulations of #4VL and 3D-DS confirm that native HB interactions are essential to maintain β-sheet structures in both #4VL and 3D-DS. A flickering native HB interaction in the 3D-DS system, caused by repulsive interaction with water molecules in the hydrophobic region, leads to intramolecular breathing motions and oligomerization in another 3D-DS. Structural dynamics of the 3D-DS dimer in long-run simulations were analyzed using the newly developed integrated solvation-based principal component analysis (3D-RISM/PCA) and density-based spatial clustering of applications with noise, confirm that if the 3D-DS cannot form the tetramer within the breathing motion process, the 3D-DS will collapse. This finding provides insights into why the 3D-DS dimer is missing from the solution and can be used to design and develop 3D-DS in other antibodies.
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Affiliation(s)
- Lian Duan
- Graduate School of Pure and Applied Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan
- Center for Computational Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan
| | - Kowit Hengphasatporn
- Center for Computational Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan
| | - Takahiro Sakai
- Division of Materials Science, Graduate School of Science and Technology, Nara Institute of Science and Technology, 8916-5 Takayama, Ikoma, Nara 630-0192, Japan
| | - Ryo Fujiki
- Center for Computational Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan
| | - Norio Yoshida
- Department of Complex Systems Science, Graduate School of Informatics, Nagoya University, Chikusa-ku, Nagoya 464-8601, Japan
| | - Shun Hirota
- Division of Materials Science, Graduate School of Science and Technology, Nara Institute of Science and Technology, 8916-5 Takayama, Ikoma, Nara 630-0192, Japan
| | - Yasuteru Shigeta
- Center for Computational Sciences, University of Tsukuba, 1-1-1 Tennodai, Tsukuba, Ibaraki 305-8577, Japan
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2
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Palladini G, Liedtke M, Zago W, Dolan P, Kinney GG, Gertz MA. The mechanism of action, pharmacological characteristics, and clinical utility of the amyloid depleter birtamimab for the potential treatment of AL amyloidosis. Leuk Lymphoma 2024; 65:1068-1078. [PMID: 38600883 DOI: 10.1080/10428194.2024.2337803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 03/27/2024] [Indexed: 04/12/2024]
Abstract
Amyloid light chain (AL) amyloidosis is a progressive plasma cell disorder caused by amyloid deposition resulting in organ damage and failure. Current standard-of-care treatments target clonal plasma cells, the source of misfolded light chains (amyloid precursors), yet only half of patients with advanced disease survive ≥6 months. The amyloid depleter birtamimab is an investigational humanized monoclonal antibody that binds misfolded κ and λ light chains with high specificity and was designed to neutralize soluble toxic light chain aggregates and promote phagocytic clearance of deposited amyloid. Post hoc analyses from the Phase 3 VITAL trial suggested birtamimab plus standard of care confers a survival benefit in patients with advanced (Mayo Stage IV) AL amyloidosis. AFFIRM-AL (NCT04973137), a Phase 3 confirmatory trial of birtamimab plus standard of care in patients with Mayo Stage IV AL amyloidosis, is ongoing. This review summarizes birtamimab's mechanism of action, attributes, and potential clinical utility.
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Affiliation(s)
- Giovanni Palladini
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
- Amyloidosis Research and Treatment Center, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | | | | | - Phil Dolan
- Prothena Biosciences Inc, Brisbane, CA, USA
| | | | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
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3
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Morfino P, Aimo A, Franzini M, Vergaro G, Castiglione V, Panichella G, Limongelli G, Emdin M. Pathophysiology of Cardiac Amyloidosis. Heart Fail Clin 2024; 20:261-270. [PMID: 38844297 DOI: 10.1016/j.hfc.2024.02.002] [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] [Indexed: 06/09/2024]
Abstract
Amyloidosis refers to a heterogeneous group of disorders sharing common pathophysiological mechanisms characterized by the extracellular accumulation of fibrillar deposits consisting of the aggregation of misfolded proteins. Cardiac amyloidosis (CA), usually caused by deposition of misfolded transthyretin or immunoglobulin light chains, is an increasingly recognized cause of heart failure burdened by a poor prognosis. CA manifests with a restrictive cardiomyopathy which progressively leads to biventricular thickening, diastolic and then systolic dysfunction, arrhythmias, and valvular disease. The pathophysiology of CA is multifactorial and includes increased oxidative stress, mitochondrial damage, apoptosis, impaired metabolism, and modifications of intracellular calcium balance.
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Affiliation(s)
| | - Alberto Aimo
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Maria Franzini
- Department of Translational Research and of New Surgical and Medical Technologies, University of Pisa, Pisa, Italy
| | - Giuseppe Vergaro
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Vincenzo Castiglione
- Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy; Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Giorgia Panichella
- Department of Clinical and Experimental Medicine, Careggi University Hospital, Florence, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy; Fondazione Toscana Gabriele Monasterio, via G. Moruzzi 1, 56124, Pisa, Italy.
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4
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Sanchorawala V. Systemic Light Chain Amyloidosis. N Engl J Med 2024; 390:2295-2307. [PMID: 38924733 DOI: 10.1056/nejmra2304088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2024]
Affiliation(s)
- Vaishali Sanchorawala
- From the Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston Medical Center, Boston
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5
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Schreiner S, Berghaus N, Poos AM, Raab MS, Besemer B, Fenk R, Goldschmidt H, Mai EK, Müller-Tidow C, Weinhold N, Hegenbart U, Huhn S, Schönland SO. Sequence diversity of kappa light chains from patients with AL amyloidosis and multiple myeloma. Amyloid 2024; 31:86-94. [PMID: 38206120 DOI: 10.1080/13506129.2023.2295221] [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: 03/26/2023] [Accepted: 12/11/2023] [Indexed: 01/12/2024]
Abstract
BACKGROUND AL amyloidosis (AL) results from the misfolding of immunoglobulin light chains (IG LCs). Aim of this study was to comprehensively analyse kappa LC sequences from AL patients in comparison with multiple myeloma (MM). OBJECTIVE We analysed IGKV/IGKJ usage and associated organ tropism and IGKV1/D-33 in terms of mutational analysis and theoretical biochemical properties. MATERIAL AND METHODS cDNA and bulk RNA sequencing of the LCs of AL and MM patients. RESULTS We studied 41 AL and 83 MM patients showing that IGKV1 was most expressed among kappa AL and MM, with higher frequency in AL (80% vs. 53%, p = .002). IGKV3 was underrepresented in AL (10% vs. 30%, p = .014). IGKJ2 was more commonly used in AL than in MM (39% vs. 29%). Patients with IGKV1/D-33 were associated with heart involvement (75%, p = .024). IGKV1/D-33-segments of AL had a higher mutation count (AL = 12.0 vs. MM = 10.0). FR3 and CDR3 were most frequently mutated in both, with a median mutation count in FR3 being the highest (AL = 4.0; MM = 3.5) and one mutation hotspot (FR3 (83I)) for IGKV1/D-33/IGKJ2 was associated with cardiac involvement. CONCLUSION This study confirmed that germline usage has an influence on AL amyloidosis risk and organ involvement.
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Affiliation(s)
- Sarah Schreiner
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Natalie Berghaus
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Alexandra M Poos
- Medical Department V, Heidelberg Myeloma Center, Heidelberg University Hospital, Germany
| | - Marc S Raab
- Medical Department V, Heidelberg Myeloma Center, Heidelberg University Hospital, National Centre for Tumor Diseases (NCT), Heidelberg, Germany
| | - Britta Besemer
- Department of Internal Medicine II, Tübingen University Hospital, Tübingen, Germany
| | - Roland Fenk
- Department of Hematology, Oncology, and Clinical Immunology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Hartmut Goldschmidt
- Medical Department V, Heidelberg Myeloma Center, Heidelberg University Hospital, National Centre for Tumor Diseases (NCT), Heidelberg, Germany
| | - Elias K Mai
- Medical Department V, Heidelberg Myeloma Center, Heidelberg University Hospital, National Centre for Tumor Diseases (NCT), Heidelberg, Germany
| | | | - Niels Weinhold
- Medical Department V, Heidelberg Myeloma Center, Heidelberg University Hospital, Germany
| | - Ute Hegenbart
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefanie Huhn
- Medical Department V, Heidelberg Myeloma Center, Heidelberg University Hospital, Germany
| | - Stefan O Schönland
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
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Anand SK, Sanchorawala V, Verma A. Systemic Amyloidosis and Kidney Transplantation: An Update. Semin Nephrol 2024; 44:151496. [PMID: 38490903 DOI: 10.1016/j.semnephrol.2024.151496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
Amyloidosis is a heterogeneous disorder characterized by abnormal protein aggregate deposition that often leads to kidney involvement and end-stage kidney disease. With advancements in diagnostic techniques and treatment options, the prevalence of patients with amyloidosis requiring chronic dialysis has increased. Kidney transplantation is a promising avenue for extending survival and enhancing quality of life in these patients. However, the complex and heterogeneous nature of amyloidosis presents challenges in determining optimal referral timing for transplantation and managing post-transplantation course. This review focuses on recent developments and outcomes of kidney transplantation for amyloidosis-related end-stage kidney disease. This review also aims to guide clinical decision-making and improve management of patients with amyloidosis-associated kidney disease, offering insights into optimizing patient selection and post-transplant care for favorable outcomes.
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Affiliation(s)
- Shankara K Anand
- Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA; Section of Hematology and Oncology, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA
| | - Ashish Verma
- Renal Section, Department of Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA; Amyloidosis Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA; Boston University Chobanian & Avedisian School of Medicine and Boston Medical Center, Boston, MA.
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7
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Del Pozo-Yauner L, Herrera GA, Perez Carreon JI, Turbat-Herrera EA, Rodriguez-Alvarez FJ, Ruiz Zamora RA. Role of the mechanisms for antibody repertoire diversification in monoclonal light chain deposition disorders: when a friend becomes foe. Front Immunol 2023; 14:1203425. [PMID: 37520549 PMCID: PMC10374031 DOI: 10.3389/fimmu.2023.1203425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/20/2023] [Indexed: 08/01/2023] Open
Abstract
The adaptive immune system of jawed vertebrates generates a highly diverse repertoire of antibodies to meet the antigenic challenges of a constantly evolving biological ecosystem. Most of the diversity is generated by two mechanisms: V(D)J gene recombination and somatic hypermutation (SHM). SHM introduces changes in the variable domain of antibodies, mostly in the regions that form the paratope, yielding antibodies with higher antigen binding affinity. However, antigen recognition is only possible if the antibody folds into a stable functional conformation. Therefore, a key force determining the survival of B cell clones undergoing somatic hypermutation is the ability of the mutated heavy and light chains to efficiently fold and assemble into a functional antibody. The antibody is the structural context where the selection of the somatic mutations occurs, and where both the heavy and light chains benefit from protective mechanisms that counteract the potentially deleterious impact of the changes. However, in patients with monoclonal gammopathies, the proliferating plasma cell clone may overproduce the light chain, which is then secreted into the bloodstream. This places the light chain out of the protective context provided by the quaternary structure of the antibody, increasing the risk of misfolding and aggregation due to destabilizing somatic mutations. Light chain-derived (AL) amyloidosis, light chain deposition disease (LCDD), Fanconi syndrome, and myeloma (cast) nephropathy are a diverse group of diseases derived from the pathologic aggregation of light chains, in which somatic mutations are recognized to play a role. In this review, we address the mechanisms by which somatic mutations promote the misfolding and pathological aggregation of the light chains, with an emphasis on AL amyloidosis. We also analyze the contribution of the variable domain (VL) gene segments and somatic mutations on light chain cytotoxicity, organ tropism, and structure of the AL fibrils. Finally, we analyze the most recent advances in the development of computational algorithms to predict the role of somatic mutations in the cardiotoxicity of amyloidogenic light chains and discuss the challenges and perspectives that this approach faces.
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Affiliation(s)
- Luis Del Pozo-Yauner
- Department of Pathology, University of South Alabama-College of Medicine, Mobile, AL, United States
| | - Guillermo A. Herrera
- Department of Pathology, University of South Alabama-College of Medicine, Mobile, AL, United States
| | | | - Elba A. Turbat-Herrera
- Department of Pathology, University of South Alabama-College of Medicine, Mobile, AL, United States
- Mitchell Cancer Institute, University of South Alabama-College of Medicine, Mobile, AL, United States
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8
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Baur J, Berghaus N, Schreiner S, Hegenbart U, Schönland SO, Wiese S, Huhn S, Haupt C. Identification of AL proteins from 10 λ-AL amyloidosis patients by mass spectrometry extracted from abdominal fat and heart tissue. Amyloid 2023; 30:27-37. [PMID: 35792725 DOI: 10.1080/13506129.2022.2095618] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Systemic AL amyloidosis arises from the misfolding of patient-specific immunoglobulin light chains (LCs). Potential drivers of LC amyloid formation are mutational changes and post-translational modifications (PTMs). However, little information is available on the exact primary structure of the AL proteins and their precursor LCs. OBJECTIVE We analyse the exact primary structure of AL proteins extracted from 10 λ AL amyloidosis patients and their corresponding precursor LCs. MATERIALS AND METHODS By cDNA sequencing of the precursor LC genes in combination with mass spectrometry of the AL proteins, the exact primary structure and PTMs were determined. This information was used to analyse their biochemical properties. RESULTS All AL proteins comprise the VL and a small part of the CL with a common C-terminal truncation region. While all AL proteins retain the conserved native disulphide bond of the VL, we found no evidence for presence of other common PTMs. The analysis of the biochemical properties revealed that the isoelectric point of the VL is significantly increased due to introduced mutations. CONCLUSION Our data imply that mutational changes influence the surface charge properties of the VL and that common proteolytic processes are involved in the generation of the cleavage sites of AL proteins.
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Affiliation(s)
- Julian Baur
- Institute of Protein Biochemistry, Ulm University, Ulm, Germany
| | - Natalie Berghaus
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Sarah Schreiner
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Ute Hegenbart
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan O Schönland
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Wiese
- Core Unit Mass Spectrometry and Proteomics, Medical Faculty, Ulm University, Ulm, Germany
| | - Stefanie Huhn
- Medical Department V, Section of Multiple Myeloma, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Haupt
- Institute of Protein Biochemistry, Ulm University, Ulm, Germany
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9
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Absmeier RM, Rottenaicher GJ, Svilenov HL, Kazman P, Buchner J. Antibodies gone bad - the molecular mechanism of light chain amyloidosis. FEBS J 2023; 290:1398-1419. [PMID: 35122394 DOI: 10.1111/febs.16390] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/19/2022] [Accepted: 02/03/2022] [Indexed: 12/19/2022]
Abstract
Light chain amyloidosis (AL) is a systemic disease in which abnormally proliferating plasma cells secrete large amounts of mutated antibody light chains (LCs) that eventually form fibrils. The fibrils are deposited in various organs, most often in the heart and kidney, and impair their function. The prognosis for patients diagnosed with AL is generally poor. The disease is set apart from other amyloidoses by the huge number of patient-specific mutations in the disease-causing and fibril-forming protein. The molecular mechanisms that drive the aggregation of mutated LCs into fibrils have been enigmatic, which hindered the development of efficient diagnostics and therapies. In this review, we summarize our current knowledge on AL amyloidosis and discuss open issues.
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Affiliation(s)
- Ramona M Absmeier
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Georg J Rottenaicher
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Hristo L Svilenov
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Pamina Kazman
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
| | - Johannes Buchner
- Center for Functional Protein Assemblies and Department of Chemistry, Technische Universität München, Garching, Germany
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10
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Diagnostic Challenges and Solutions in Systemic Amyloidosis. Int J Mol Sci 2023; 24:ijms24054655. [PMID: 36902083 PMCID: PMC10003318 DOI: 10.3390/ijms24054655] [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: 01/19/2023] [Revised: 02/10/2023] [Accepted: 02/25/2023] [Indexed: 03/04/2023] Open
Abstract
Amyloidosis refers to a clinically heterogeneous group of disorders characterized by the extracellular deposition of amyloid proteins in various tissues of the body. To date, 42 different amyloid proteins that originate from normal precursor proteins and are associated with distinct clinical forms of amyloidosis have been described. Identification of the amyloid type is essential in clinical practice, since prognosis and treatment regimens both vary according to the particular amyloid disease. However, typing of amyloid protein is often challenging, especially in the two most common forms of amyloidosis, i.e., the immunoglobulin light chain amyloidosis and transthyretin amyloidosis. Diagnostic methodology is based on tissue examinations as well as on noninvasive techniques including serological and imaging studies. Tissue examinations vary depending on the tissue preparation mode, i.e., whether it is fresh-frozen or fixed, and they can be carried out by ample methodologies including immunohistochemistry, immunofluorescence, immunoelectron microscopy, Western blotting, and proteomic analysis. In this review, we summarize current methodological approaches used for the diagnosis of amyloidosis and discusses their utility, advantages, and limitations. Special attention is paid to the simplicity of the procedures and their availability in clinical diagnostic laboratories. Finally, we describe new methods recently developed by our team to overcome limitations existing in the standard assays used in common practice.
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11
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Diagnosis and Treatment of AL Amyloidosis. Drugs 2023; 83:203-216. [PMID: 36652193 DOI: 10.1007/s40265-022-01830-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2022] [Indexed: 01/19/2023]
Abstract
Systemic light chain (AL) amyloidosis is caused by an usually small B cell clone that produces a toxic light chain forming amyloid deposits in tissue. The heart and kidney are the major organs affected, but all others, with the exception of the CNS, can be involved. The disease is rapidly progressive, and it is still diagnosed late. Screening programs in patients followed by hematologists for plasma cell dyscrasias should be considered. The diagnosis requires demonstration in a tissue biopsy of amyloid deposits formed by immunoglobulin light chains. The workup of patients with AL amyloidosis requires adequate technology and expertise, and patients should be referred to specialized centers whenever possible. Stagings are based on cardiac and renal biomarkers and guides the choice of treatment. The combination of daratumumab, cyclophosphamide, bortezomib and dexamethasone (dara-CyBorD) is the current standard of care. Autologous stem cell transplant is performed in eligible patients, especially those who do not attain a satisfactory response to dara-CyBorD. Passive immunotherapy targeting the amyloid deposits combined with chemo-/immune-therapy targeting the amyloid clone is currently being tested in controlled clinical trials. Response to therapy is assessed based on validated criteria. Profound hematologic response is the early goal of treatment and should be accompanied over time by deepening organ response. Many relapsed/refractory patients are also treated with daratumumab combination, but novel regimens will be needed to rescue daratumumab-exposed subjects. Immunomodulatory drugs are the current cornerstone of rescue therapy, while immunotherapy targeting B-cell maturation antigen and inhibitors of Bcl-2 are promising alternatives.
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12
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Martinez-Rivas G, Bender S, Sirac C. Understanding AL amyloidosis with a little help from in vivo models. Front Immunol 2022; 13:1008449. [PMID: 36458006 PMCID: PMC9707859 DOI: 10.3389/fimmu.2022.1008449] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Accepted: 10/27/2022] [Indexed: 08/01/2023] Open
Abstract
Monoclonal immunoglobulin (Ig) light chain amyloidosis (AL) is a rare but severe disease that may occur when a B or plasma cell clone secretes an excess of free Ig light chains (LCs). Some of these LCs tend to aggregate into organized fibrils with a β-sheet structure, the so-called amyloid fibrils, and deposit into the extracellular compartment of organs, such as the heart or kidneys, causing their dysfunction. Recent findings have confirmed that the core of the amyloid fibrils is constituted by the variable (V) domain of the LCs, but the mechanisms underlying the unfolding and aggregation of this fragment and its deposition are still unclear. Moreover, in addition to the mechanical constraints exerted by the massive accumulation of amyloid fibrils in organs, the direct toxicity of these variable domain LCs, full-length light chains, or primary amyloid precursors (oligomers) seems to play a role in the pathogenesis of the disease. Many in vitro studies have focused on these topics, but the variability of this disease, in which each LC presents unique properties, and the extent and complexity of affected organs make its study in vivo very difficult. Accordingly, several groups have focused on the development of animal models for years, with some encouraging but mostly disappointing results. In this review, we discuss the experimental models that have been used to better understand the unknowns of this pathology with an emphasis on in vivo approaches. We also focus on why reliable AL amyloidosis animal models remain so difficult to obtain and what this tells us about the pathophysiology of the disease.
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13
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Bu L, Javaugue V, Chauvet S, Napier J, Dasari S, Theis JD, Vrana JA, McPhail ED, Nasr SH. Light Chain-Only Immunotactoid Glomerulopathy: A Case Report. Am J Kidney Dis 2022; 81:611-615. [PMID: 36328099 DOI: 10.1053/j.ajkd.2022.08.025] [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: 05/25/2022] [Accepted: 08/29/2022] [Indexed: 12/24/2022]
Abstract
The monotypic variant of immunotactoid glomerulopathy (ITG), strongly associated with low-grade lymphoproliferative disorders, is characterized histologically by glomerulonephritis and microtubular deposits of monoclonal immunoglobulin G (IgG). We report a patient with high-risk κ light chain multiple myeloma who presented with acute kidney injury, hematuria, proteinuria, and hypocomplementemia. Kidney biopsy revealed immunotactoid glomerulopathy concomitant with κ light chain myeloma cast nephropathy. The glomerular microtubular deposits stained for κ light chain and C3 only. Proteomic analysis of glomeruli and atypical casts detected κ light chain constant domain and a single VL variability subgroup (IGKV3) in both glomeruli and casts (without γ, α, or μ heavy chain or λ light chain). C3, C5, C6, C7, and C9 were detected in glomeruli. No autoantibodies against alternative pathway of complement proteins were detected. Despite clone-directed chemotherapy, the patient remained on dialysis treatment. For this light chain-only variant of immunotactoid glomerulopathy, pathogenesis potentially involves activation of the alternative pathway of complement by a nephrotoxic κ light chain.
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Affiliation(s)
- Lihong Bu
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
| | - Vincent Javaugue
- Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, Minnesota; Department of Nephrology, Centre Hospitalier Universitaire, Université de Poitiers, Poitiers, France
| | - Sophie Chauvet
- Assistance Publique-Hôpitaux de Paris, European Hospital Georges Pompidou, Department of Nephrology, Paris, France; INSERM UMRS1138, Research Center Cordeliers, Paris Descartes Sorbonne Paris-Cité University, Paris, France
| | - Jerold Napier
- Up Health System Medical Specialists, Marquette, Michigan
| | - Surendra Dasari
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota
| | - Jason D Theis
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Julie A Vrana
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota.
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14
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Trakada G, Fotiou D, Kallianos A, Theodorakakou F, Migkou M, Gavriatopoulou M, Kanellias N, Malandrakis P, Ntanasis-Stathopoulos I, Eleutherakis-Papaiakovou E, Dialoupi I, Terpos E, Dimopoulos MA, Kastritis E. Pulmonary function tests reveal unrecognised lung dysfunction and have independent prognostic significance in patients with systemic AL amyloidosis. Amyloid 2022:1-8. [PMID: 36281984 DOI: 10.1080/13506129.2022.2136519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Lung involvement in AL amyloidosis is not very common, but post-mortem data and retrospective studies suggest it is likely underrecognized. AIM To perform a comprehensive evaluation of lung function with pulmonary function tests (PFTs) in patients with newly diagnosed AL amyloidosis. METHODS A prospective, non-interventional study of 139 consecutive patients with newly diagnosed AL amyloidosis. RESULTS PFTs indicated normal breathing physiology in 68% of patients, obstructive in 9% and restrictive in 23%; the latter was associated with worse survival (28.6 vs 76 months for obstructive/normal physiology, p = 0.002) and remained significant after adjustment for Mayo stage and abnormal chest-CT. Forced vital capacity <80% of predicted value, forced expiratory volume <80% of predicted value, and carbon monoxide diffusion capacity <70% were independently associated with poorer survival. Respiratory muscle strength (as assessed by maximal expiratory (Pe) and inspiratory (Pi) pressure) was affected in most patients (64% had Pi < 55% and 57% had Pe < 70% of predicted values). Pe% was an independent prognostic factor for survival (HR: 0.984 per 1% unit increase, p = 0.007). CONCLUSIONS Pulmonary dysfunction, as assessed with PFTs, is common and underrecognized in patients with systemic AL amyloidosis, with significant prognostic and potentially therapeutic implications, independent of the degree of cardiac dysfunction or chest-CT findings.
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Affiliation(s)
- Georgia Trakada
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Despina Fotiou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Anastasios Kallianos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Magdalini Migkou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Nikolaos Kanellias
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Panagiotis Malandrakis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Ntanasis-Stathopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | | | - Ioanna Dialoupi
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Meletios A Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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15
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Ikura H, Endo J, Kitakata H, Moriyama H, Sano M, Fukuda K. Molecular Mechanism of Pathogenesis and Treatment Strategies for AL Amyloidosis. Int J Mol Sci 2022; 23:6336. [PMID: 35683015 PMCID: PMC9181426 DOI: 10.3390/ijms23116336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/02/2022] [Accepted: 06/04/2022] [Indexed: 11/17/2022] Open
Abstract
In amyloid light-chain (AL) amyloidosis, small B-cell clones (mostly plasma cell clones) present in the bone marrow proliferate and secrete unstable monoclonal free light chains (FLCs), which form amyloid fibrils that deposit in the interstitial tissue, resulting in organ injury and dysfunction. AL amyloidosis progresses much faster than other types of amyloidosis, with a slight delay in diagnosis leading to a marked exacerbation of cardiomyopathy. In some cases, the resulting heart failure is so severe that chemotherapy cannot be administered, and death sometimes occurs within a few months. To date, many clinical studies have focused on therapeutics, especially chemotherapy, to treat this disease. Because it is necessary to promptly lower FLC, the causative protein of amyloid, to achieve a hematological response, various anticancer agents targeting neoplastic plasma cells are used for the treatment of this disease. In addition, many basic studies using human specimens to elucidate the pathophysiology of AL have been conducted. Gene mutations associated with AL, the characteristics of amyloidogenic LC, and the structural specificity of amyloid fibrils have been clarified. Regarding the mechanism of cellular and tissue damage, the mass effect due to amyloid deposition, as well as the toxicity of pre-fibrillar LC, is gradually being elucidated. This review outlines the pathogenesis and treatment strategies for AL amyloidosis with respect to its molecular mechanisms.
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Affiliation(s)
| | - Jin Endo
- Department of Cardiology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-City, Tokyo 160-8582, Japan; (H.I.); (H.K.); (H.M.); (M.S.); (K.F.)
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16
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An N-glycosylation hotspot in immunoglobulin κ light chains is associated with AL amyloidosis. Leukemia 2022; 36:2076-2085. [PMID: 35610346 DOI: 10.1038/s41375-022-01599-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/05/2022] [Accepted: 05/11/2022] [Indexed: 12/24/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is caused by a small, minimally proliferating B-cell/plasma-cell clone secreting a patient-unique, aggregation-prone, toxic light chain (LC). The pathogenicity of LCs is encrypted in their sequence, yet molecular determinants of amyloidogenesis are poorly understood. Higher rates of N-glycosylation among clonal κ LCs from patients with AL amyloidosis compared to other monoclonal gammopathies indicate that this post-translational modification is associated with a higher risk of developing AL amyloidosis. Here, we exploited LC sequence information from previously published amyloidogenic and control clonal LCs and from a series of 220 patients with AL amyloidosis or multiple myeloma followed at our Institutions to define sequence and spatial features of N-glycosylation, combining bioinformatics, biochemical, proteomics, structural and genetic analyses. We found peculiar sequence and spatial pattern of N-glycosylation in amyloidogenic κ LCs, with most of the N-glycosylation sites laying in the framework region 3, particularly within the E strand, and consisting mainly of the NFT sequon, setting them apart with respect to non-amyloidogenic clonal LCs. Our data further support a potential role of N-glycosylation in determining the pathogenic behavior of a subset of amyloidogenic LCs and may help refine current N-glycosylation-based prognostic assessments for patients with monoclonal gammopathies.
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17
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Staron A, Verma K, Sanchorawala V. Prevalence of plasma cell and lymphoproliferative disorders among blood relatives of patients with light chain amyloidosis. Br J Haematol 2022; 198:861-865. [PMID: 35499208 DOI: 10.1111/bjh.18225] [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: 03/21/2022] [Revised: 04/18/2022] [Accepted: 04/20/2022] [Indexed: 12/01/2022]
Abstract
With limited existing data on hereditary factors in light chain (AL) amyloidosis, we conducted a study of patients with plasma cell dyscrasias or lymphoproliferative disorders in their family history. Among 1621 patients, we identified 44 probands (2·7%) with 52 relatives affected. The most common disorders in family members were multiple myeloma (48%) and AL amyloidosis (18%). Light chain isotype was 100% congruent in families with known clonal immunoglobulin for both members. Despite matching light chain isotype, organ involvement varied between members in families with multiple cases of AL amyloidosis. These findings help generate hypotheses about familial influences in AL amyloidosis.
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Affiliation(s)
- Andrew Staron
- Amyloidosis Center, Boston University School of Medicine, Boston, Massachusetts, USA.,Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Karina Verma
- Department of Medicine, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine, Boston, Massachusetts, USA.,Section of Hematology and Medical Oncology, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts, USA
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18
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Berghaus N, Schreiner S, Granzow M, Müller-Tidow C, Hegenbart U, Schönland SO, Huhn S. Analysis of the complete lambda light chain germline usage in patients with AL amyloidosis and dominant heart or kidney involvement. PLoS One 2022; 17:e0264407. [PMID: 35213605 PMCID: PMC8880859 DOI: 10.1371/journal.pone.0264407] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/10/2022] [Indexed: 12/20/2022] Open
Abstract
Light chain amyloidosis is one of the most common forms of systemic amyloidosis. The disease is caused by the misfolding and aggregation of immunoglobulin light chains to insoluble fibrils. These fibrils can deposit in different tissues and organs such as heart and kidney and cause organ impairments that define the clinical presentation. In this study, we present an overview of IGLV-IGLJ and IGLC germline utilization in 85 patients classified in three clinically important subgroups with dominant cardiac, renal as well as cardiac and renal involvement. We found that IGLV3 was the most frequently detected IGLV-family in patients with dominant cardiac involvement, whereas in renal patients IGLV1 were most frequently identified. For patients with dominant heart and kidney involvement IGLV6 was the most frequently detected IGLV-family. In more detailed analysis IGLV3-21 was observed as the most dominant IGLV-subfamily for patients with dominant heart involvement and IGLV1-44 as the most frequent IGLV-subfamily in the group of patients with dominant kidney involvement. For patients with dominant heart and kidney involvement IGLV6-57 was the most frequently detected IGLV-subfamily. Additionally, we were able to show an exclusive linkage between IGLJ1 and IGLC1 as well as between IGLJ2 and IGLC2 in the fully assembled IGL mRNA.
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Affiliation(s)
- Natalie Berghaus
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Sarah Schreiner
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Granzow
- Institute of Human Genetics, Heidelberg University Hospital, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Medical Department V, Heidelberg University Hospital, Heidelberg, Germany
- National Centre for Tumor Diseases (NCT), Heidelberg, Germany
| | - Ute Hegenbart
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan O. Schönland
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefanie Huhn
- Medical Department V, Section of Multiple Myeloma, Heidelberg University Hospital, Heidelberg, Germany
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19
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Godara A, Wang AY, Arkun K, Fogaren T, Qamar AS, McPhail ED, Kryzanski J, Riesenburger R, Comenzo R. Unraveling a rare cause of spinal stenosis: Coexistent AL and ATTR amyloidosis involving the ligamentum flavum. Surg Neurol Int 2022; 13:12. [PMID: 35127212 PMCID: PMC8813631 DOI: 10.25259/sni_1235_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/07/2022] Open
Abstract
Background: Amyloidosis is a protein misfolding disorder that leads to the deposition of beta-pleated sheets of a fibrillar derivative of various protein precursors. Identification of the type of precursor protein is integral in treatment decision-making. The presence of two different types of amyloid in the same patient is unusually rare, and there are no previous reports of two different types of amyloid deposition in the ligamentum flavum (LF) in the same patient. Case Description: Here, we describe two patients with spinal stenosis who underwent laminectomies and were found to have AL and ATTR amyloid deposits in the LF. Conclusion: As the spine is becoming recognized as a site for ATTRwt amyloid deposition, patients undergoing spinal decompression surgery may potentially benefit from evaluation for amyloidosis in the LF.
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Affiliation(s)
- Amandeep Godara
- Department of Hematology and Hematologic Malignancies, University of Utah, Salt Lake, Utah,
| | - Andy Y. Wang
- Department of Neurosurgery, Tufts Medical Center, Washington, Boston, United States
| | - Knarik Arkun
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Washington, Boston, United States
| | - Teresa Fogaren
- Department of John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Washington, Boston, United States
| | - Adnan S. Qamar
- Department of Pathology and Laboratory Medicine, Tufts Medical Center, Washington, Boston, United States
| | - Ellen D. McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, New York, United States
| | - James Kryzanski
- Department of Neurosurgery, Tufts Medical Center, Washington, Boston, United States
| | - Ron Riesenburger
- Department of Neurosurgery, Tufts Medical Center, Washington, Boston, United States
| | - Raymond Comenzo
- Department of John Conant Davis Myeloma and Amyloid Program, Tufts Medical Center, Washington, Boston, United States
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20
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Radamaker L, Karimi-Farsijani S, Andreotti G, Baur J, Neumann M, Schreiner S, Berghaus N, Motika R, Haupt C, Walther P, Schmidt V, Huhn S, Hegenbart U, Schönland SO, Wiese S, Read C, Schmidt M, Fändrich M. Role of mutations and post-translational modifications in systemic AL amyloidosis studied by cryo-EM. Nat Commun 2021; 12:6434. [PMID: 34741031 PMCID: PMC8571268 DOI: 10.1038/s41467-021-26553-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 10/01/2021] [Indexed: 12/29/2022] Open
Abstract
Systemic AL amyloidosis is a rare disease that is caused by the misfolding of immunoglobulin light chains (LCs). Potential drivers of amyloid formation in this disease are post-translational modifications (PTMs) and the mutational changes that are inserted into the LCs by somatic hypermutation. Here we present the cryo electron microscopy (cryo-EM) structure of an ex vivo λ1-AL amyloid fibril whose deposits disrupt the ordered cardiomyocyte structure in the heart. The fibril protein contains six mutational changes compared to the germ line and three PTMs (disulfide bond, N-glycosylation and pyroglutamylation). Our data imply that the disulfide bond, glycosylation and mutational changes contribute to determining the fibril protein fold and help to generate a fibril morphology that is able to withstand proteolytic degradation inside the body.
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Affiliation(s)
- Lynn Radamaker
- Institute of Protein Biochemistry, Ulm University, 89081, Ulm, Germany
| | | | - Giada Andreotti
- Institute of Protein Biochemistry, Ulm University, 89081, Ulm, Germany
| | - Julian Baur
- Institute of Protein Biochemistry, Ulm University, 89081, Ulm, Germany
| | | | - Sarah Schreiner
- Medical Department V, Section of Multiple Myeloma, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Natalie Berghaus
- Medical Department V, Section of Multiple Myeloma, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Raoul Motika
- Department of Asia-Africa-Studies, Middle Eastern History and Culture, University of Hamburg, 20148, Hamburg, Germany
| | - Christian Haupt
- Institute of Protein Biochemistry, Ulm University, 89081, Ulm, Germany
| | - Paul Walther
- Central Facility for Electron Microscopy, Ulm University, 89081, Ulm, Germany
| | - Volker Schmidt
- Institute of Stochastics, Ulm University, 89081, Ulm, Germany
| | - Stefanie Huhn
- Medical Department V, Section of Multiple Myeloma, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Ute Hegenbart
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Stefan O Schönland
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, 69120, Heidelberg, Germany
| | - Sebastian Wiese
- Core Unit Mass Spectrometry and Proteomics, Medical Faculty, Ulm University, 89081, Ulm, Germany
| | - Clarissa Read
- Central Facility for Electron Microscopy, Ulm University, 89081, Ulm, Germany
- Institute of Virology, Ulm University Medical Center, 89081, Ulm, Germany
| | - Matthias Schmidt
- Institute of Protein Biochemistry, Ulm University, 89081, Ulm, Germany
| | - Marcus Fändrich
- Institute of Protein Biochemistry, Ulm University, 89081, Ulm, Germany.
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21
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Bianchi G, Zhang Y, Comenzo RL. AL Amyloidosis: Current Chemotherapy and Immune Therapy Treatment Strategies: JACC: CardioOncology State-of-the-Art Review. JACC: CARDIOONCOLOGY 2021; 3:467-487. [PMID: 34729520 PMCID: PMC8543128 DOI: 10.1016/j.jaccao.2021.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 12/19/2022]
Abstract
Immunoglobulin light chain (AL) amyloidosis is an incurable plasma cell disorder characterized by deposition of fibrils of misfolded immunoglobulin free light chains (FLC) in target organs, leading to failure. Cardiac involvement is common in AL amyloidosis and represents the single most adverse prognostic feature. A high index of clinical suspicion with rapid tissue diagnosis and commencement of combinatorial, highly effective cytoreductive therapy is crucial to arrest the process of amyloid deposition and preserve organ function. The clinical use of molecularly targeted drugs, such as proteasome inhibitors and immunomodulatory agents, monoclonal antibodies such as daratumumab, and risk-adjusted autologous stem cell transplant in eligible patients, has radically changed the natural history of AL amyloidosis. Here, we review the state-of-the-art treatment landscape in AL amyloidosis with an eye toward future therapeutic venues to impact the outcome of this devastating illness.
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Affiliation(s)
- Giada Bianchi
- Amyloidosis Program, Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Yifei Zhang
- John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Division of Hematology-Oncology, Division of Cardiovascular Diseases, Boston, Massachusetts, USA
| | - Raymond L Comenzo
- John C Davis Myeloma and Amyloid Program, Tufts Medical Center, Division of Hematology-Oncology, Division of Cardiovascular Diseases, Boston, Massachusetts, USA
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22
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Rognoni P, Mazzini G, Caminito S, Palladini G, Lavatelli F. Dissecting the Molecular Features of Systemic Light Chain (AL) Amyloidosis: Contributions from Proteomics. ACTA ACUST UNITED AC 2021; 57:medicina57090916. [PMID: 34577839 PMCID: PMC8471912 DOI: 10.3390/medicina57090916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/23/2021] [Accepted: 08/29/2021] [Indexed: 02/08/2023]
Abstract
Amyloidoses are characterized by aggregation of proteins into highly ordered amyloid fibrils, which deposit in the extracellular space of tissues, leading to organ dysfunction. In AL (amyloid light chain) amyloidosis, the most common form in Western countries, the amyloidogenic precursor is a misfolding-prone immunoglobulin light chain (LC), which, in the systemic form, is produced in excess by a plasma cell clone and transported to target organs though blood. Due to the primary role that proteins play in the pathogenesis of amyloidoses, mass spectrometry (MS)-based proteomic studies have gained an established position in the clinical management and research of these diseases. In AL amyloidosis, in particular, proteomics has provided important contributions for characterizing the precursor light chain, the composition of the amyloid deposits and the mechanisms of proteotoxicity in target organ cells and experimental models of disease. This review will provide an overview of the major achievements of proteomic studies in AL amyloidosis, with a presentation of the most recent acquisitions and a critical discussion of open issues and ongoing trends.
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Affiliation(s)
- Paola Rognoni
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, V.le Golgi 19, 27100 Pavia, Italy; (G.M.); (S.C.); (G.P.)
- Correspondence: (P.R.); (F.L.); Tel.: +39-0382502984 (P.R.); +39-0382502994 (F.L.)
| | - Giulia Mazzini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, V.le Golgi 19, 27100 Pavia, Italy; (G.M.); (S.C.); (G.P.)
| | - Serena Caminito
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, V.le Golgi 19, 27100 Pavia, Italy; (G.M.); (S.C.); (G.P.)
- Department of Molecular Medicine, University of Pavia, Via Forlanini 6, 27100 Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, V.le Golgi 19, 27100 Pavia, Italy; (G.M.); (S.C.); (G.P.)
- Department of Molecular Medicine, University of Pavia, Via Forlanini 6, 27100 Pavia, Italy
| | - Francesca Lavatelli
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, V.le Golgi 19, 27100 Pavia, Italy; (G.M.); (S.C.); (G.P.)
- Department of Molecular Medicine, University of Pavia, Via Forlanini 6, 27100 Pavia, Italy
- Correspondence: (P.R.); (F.L.); Tel.: +39-0382502984 (P.R.); +39-0382502994 (F.L.)
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23
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Abstract
Amyloidosis constitutes a large spectrum of diseases characterized by an extracellular deposition of a fibrillar aggregate, generating insoluble and toxic amasses that may be deposited in tissues in bundles with an abnormal cross-β-sheet conformation, known as amyloid. Amyloid may lead to a cell damage and an impairment of organ function. Several different proteins are recognized as able to produce amyloid fibrils with a different tissue tropism related to the molecular structure. The deposition of amyloid may occur as a consequence of the presence of an abnormal protein, caused by high plasma levels of a normal protein, or as a result of the aging process along with some environmental factors. Although amyloidosis is rare, amyloid deposits play a role in several conditions as degenerative diseases. Thus, the development of antiamyloid curative treatments may be a rational approach to treat neurodegenerative conditions like Alzheimer's disease in the future. Nowadays, novel treatment options are currently refined through controlled trials, as new drug targets and different therapeutic approaches have been identified and validated through modern advances in basic research. Fibril formation stabilizers, proteasome inhibitors, and immunotherapy revealed promising results in improving the outcomes of patients with systemic amyloidosis, and these novel algorithms will be effectively combined with current treatments based on chemotherapeutic regimens. The aim of this review is to provide an update on diagnosis and treatment for systemic amyloidosis.
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24
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Xu L, Su Y. Genetic pathogenesis of immunoglobulin light chain amyloidosis: basic characteristics and clinical applications. Exp Hematol Oncol 2021; 10:43. [PMID: 34284823 PMCID: PMC8290569 DOI: 10.1186/s40164-021-00236-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/11/2021] [Indexed: 02/05/2023] Open
Abstract
Immunoglobulin light chain amyloidosis (AL) is an indolent plasma cell disorder characterized by free immunoglobulin light chain (FLC) misfolding and amyloid fibril deposition. The cytogenetic pattern of AL shows profound similarity with that of other plasma cell disorders but harbors distinct features. AL can be classified into two primary subtypes: non-hyperdiploidy and hyperdiploidy. Non-hyperdiploidy usually involves immunoglobulin heavy chain translocations, and t(11;14) is the hallmark of this disease. T(11;14) is associated with low plasma cell count but high FLC level and displays distinct response outcomes to different treatment modalities. Hyperdiploidy is associated with plasmacytosis and subclone formation, and it generally confers a neutral or inferior prognostic outcome. Other chromosome abnormalities and driver gene mutations are considered as secondary cytogenetic aberrations that occur during disease evolution. These genetic aberrations contribute to the proliferation of plasma cells, which secrete excess FLC for amyloid deposition. Other genetic factors, such as specific usage of immunoglobulin light chain germline genes and light chain somatic mutations, also play an essential role in amyloid fibril deposition in AL. This paper will propose a framework of AL classification based on genetic aberrations and discuss the amyloid formation of AL from a genetic aspect.
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Affiliation(s)
- Linchun Xu
- Shantou University Medical College, Shantou, 515031, Guangdong, China
- The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, Guangdong, China
| | - Yongzhong Su
- Department of Hematology, The First Affiliated Hospital of Shantou University Medical College, Shantou, 515041, Guangdong, China.
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25
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Jamal S, Kichloo A, Bailey B, Singh J, Virk H, Soni R, Wani F, Ajmal M, Ananthaneni S, Edigin E, Sudhakar R, Kanjwal K. Clinical Outcomes and Disease Burden in Amyloidosis Patients with and Without Atrial Fibrillation-Insight from the National Inpatient Sample Database. J Innov Card Rhythm Manag 2021; 12:4542-4549. [PMID: 34234988 PMCID: PMC8225306 DOI: 10.19102/icrm.2021.120605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/05/2021] [Indexed: 01/09/2023] Open
Abstract
Amyloidosis is a systemic illness that affects multiple organ systems, including the cardiovascular, renal, gastrointestinal, and pulmonary systems. Common manifestations include restrictive cardiomyopathy, arrhythmias, nephrotic syndrome, and gastrointestinal hemorrhage. It is unknown whether coexisting atrial fibrillation (AF) worsens the disease burden and outcomes in patients with systemic amyloidosis. In this study, those with a diagnosis of amyloidosis with and without coexisting AF were identified by querying the Healthcare Cost and Utilization Project—specifically, the National Inpatient Sample for the year 2016—based on International Classification of Diseases, 10th Revision, Clinical Modification codes. During 2016, a total of 2,997 patients were admitted with a diagnosis of amyloidosis, including 918 with concurrent AF. Greater rates of mortality (7.4% vs. 5.6%); heart block (6.8% vs. 2.8%); cardiogenic shock (5% vs. 1.6%); placement of an implantable cardioverter-defibrillator, cardiac resynchronization therapy device, or permanent pacemaker (14.5% vs. 4.5%); renal failure (29% vs. 21%); heart failure (66% vs. 30%); and bleeding complications (5.7% vs. 2.8%) were observed in patients with a diagnosis of amyloidosis and coexisting AF when compared with in patients without AF. Interestingly, patients with amyloidosis without comorbid AF had greater odds of associated stroke relative to those with concurrent AF (7.9% vs. 3.4%).
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Affiliation(s)
- Shakeel Jamal
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Beth Bailey
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Jagmeet Singh
- Division of Nephrology, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Hafeez Virk
- Division of Cardiovascular Medicine, Albert Einstein College of Medicine, Philadelphia, PA, USA
| | - Ronak Soni
- Division of Cardiovascular Medicine, University of Toledo, College of Medicine, Toledo, OH, USA
| | - Farah Wani
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Muhammad Ajmal
- Division of Cardiovascular Medicine, University of Arizona, College of Medicine, Tucson, AZ, USA
| | - Sindhura Ananthaneni
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Ehizogie Edigin
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL, USA
| | - Rajeev Sudhakar
- Division of Cardiovascular Medicine, Ascension Medical Group, Central Michigan University, Saginaw, MI, USA
| | - Khalil Kanjwal
- Division of Electrophysiology, McLaren Greater Lansing Hospital, Michigan State University, Lansing, MI, USA
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Machine learning analyses of antibody somatic mutations predict immunoglobulin light chain toxicity. Nat Commun 2021; 12:3532. [PMID: 34112780 PMCID: PMC8192768 DOI: 10.1038/s41467-021-23880-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/23/2021] [Indexed: 02/05/2023] Open
Abstract
In systemic light chain amyloidosis (AL), pathogenic monoclonal immunoglobulin light chains (LC) form toxic aggregates and amyloid fibrils in target organs. Prompt diagnosis is crucial to avoid permanent organ damage, but delayed diagnosis is common because symptoms usually appear only after strong organ involvement. Here we present LICTOR, a machine learning approach predicting LC toxicity in AL, based on the distribution of somatic mutations acquired during clonal selection. LICTOR achieves a specificity and a sensitivity of 0.82 and 0.76, respectively, with an area under the receiver operating characteristic curve (AUC) of 0.87. Tested on an independent set of 12 LCs sequences with known clinical phenotypes, LICTOR achieves a prediction accuracy of 83%. Furthermore, we are able to abolish the toxic phenotype of an LC by in silico reverting two germline-specific somatic mutations identified by LICTOR, and by experimentally assessing the loss of in vivo toxicity in a Caenorhabditis elegans model. Therefore, LICTOR represents a promising strategy for AL diagnosis and reducing high mortality rates in AL.
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Abstract
Opportunities and challenges in the field of systemic amyloidosis can be grouped into 4 categories. First, a deeper understanding of the pathogenesis of the disease is required. Second, a greater awareness of the disease, which will lead to an earlier diagnosis, is imperative. Third, end points for interventional trials are required to convey us to our fourth aspirations, which are novel therapies for patients with light chain amyloidosis.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology, Mayo Clinic, 200 First Street SW Rochester, MN 55905, USA.
| | - Giampaolo Merlini
- Amyloidosis Center, Foundation IRCCS Policlinico San Matteo, University of Pavia, Viale Golgi 19, Pavia 27100, Italy
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IGVL gene region usage correlates with distinct clinical presentation in IgM vs non-IgM light chain amyloidosis. Blood Adv 2021; 5:2101-2105. [PMID: 33877297 DOI: 10.1182/bloodadvances.2020003671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 03/03/2021] [Indexed: 12/11/2022] Open
Abstract
Patients with immunoglobulin M (IgM) light chain (AL) amyloidosis have a distinct clinical presentation compared with those with non-IgM amyloidosis. We hypothesized that differential immunoglobulin light-chain variable region (IGVL) gene usage may explain the differences in organ involvement, because IGVL usage correlates with organ tropism. IGVL usage was evaluated by mass spectrometry of amyloid deposits (IgM, n = 45; non-IgM, n = 391) and differed across the 2 groups. In the λ family, LV2-08 (13% vs 2%; P < .001) and LV2-14 (36% vs 10%; P < .001) usage was more common in IgM vs non-IgM amyloidosis, whereas LV1-44 (0% vs 10%; P = .02) and LV6-57 (2% vs 18%; P = .004) usage was less common. In the κ family, there was a trend toward higher KV4-01 (11% vs 4%; P = .06) usage in IgM amyloidosis. IGVL usage correlated with disease characteristics/organ tropism. LV2-14 (more common in IgM amyloidosis) has historically been associated with peripheral nerve involvement and lower light chain burden, which were more frequent in IgM amyloidosis. LV1-44 (less common in IgM), associated with cardiac involvement, was less frequent in IgM patients. LV6-57 (less common in IgM) is associated with t(11;14), which was less frequent in IgM patients. In conclusion, IGVL gene usage differs in patients with IgM vs non-IgM amyloidosis and may explain the distinct clinical presentation.
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Bridoux F, Leung N, Belmouaz M, Royal V, Ronco P, Nasr SH, Fermand JP. Management of acute kidney injury in symptomatic multiple myeloma. Kidney Int 2021; 99:570-580. [PMID: 33440212 DOI: 10.1016/j.kint.2020.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/23/2020] [Accepted: 11/03/2020] [Indexed: 01/15/2023]
Abstract
Symptomatic multiple myeloma is commonly complicated by acute kidney injury through various mechanisms. The most frequent is the precipitation of monoclonal free light chains with uromodulin in the distal tubules, defining light chain cast nephropathy. Early diagnosis and identification of the cause of acute kidney injury are required for optimizing management and avoiding chronic kidney injury that strongly affects quality of life and patient survival. In light chain cast nephropathy, often manifesting with severe acute kidney injury, renal recovery requires urgent intervention based on vigorous rehydration, correction of precipitating factors, and efficient anti-plasma cell chemotherapy to rapidly reduce the secretion of nephrotoxic free light chains. Currently, the association of the proteasome inhibitor bortezomib with high-dose dexamethasone is the standard regimen in newly diagnosed patients. The addition of another drug such as cyclophosphamide or an immunodulatory agent may improve free light chain response but raises tolerance concerns in frail patients. Further studies are warranted to confirm the role of anti-CD38 monoclonal antibodies, whose efficacy and tolerance have been documented in patients without renal impairment. Despite controversial results from randomized studies, recent data suggest that in patients with light chain cast nephropathy and acute kidney injury requiring dialysis, the combination of chemotherapy with free light chain removal through high-cutoff hemodialysis may increase renal response recovery rates. Kidney biopsy may be helpful in guiding management and assessing renal prognosis that appears to depend on the extent of cast formation and interstitial fibrosis/tubular atrophy. Because of continuous improvement in life expectancy of patients with multiple myeloma, renal transplantation is likely to be increasingly considered in selected candidates.
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Affiliation(s)
- Frank Bridoux
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France; Centre National de la Recherche Scientifique UMR CNRS 7276/INSERM U1262, Université de Limoges, Limoges, France.
| | - Nelson Leung
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, Minnesota, USA; Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Mohamed Belmouaz
- Department of Nephrology, Dialysis, and Renal Transplantation, CIC INSERM 1402, CHU Poitiers, Poitiers, France; Centre national de référence Amylose AL & autres maladies par dépôts d'immunoglobulines monoclonales, CHU Poitiers, Poitiers, France
| | - Virginie Royal
- Division of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Canada
| | - Pierre Ronco
- Nephrology Department, Assistance Publique - Hôpitaux de Paris, Hôpital Tenon, Paris, France; Sorbonne Université and Institut National de la Santé Et de la Recherche Médicale (INSERM), Unité Mixte de Recherche S 1135, Paris, France
| | - Samih H Nasr
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jean Paul Fermand
- Department of Hematology and Immunology, Hôpital Saint Louis, Assistance Publique-Hôpitaux de Paris, INSERM UMR 1126, Paris, France; Intergroupe Francophone du Myélome (IFM), Paris, France
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Pradhan T, Annamalai K, Sarkar R, Huhn S, Hegenbart U, Schönland S, Fändrich M, Reif B. Seeded fibrils of the germline variant of human λ-III immunoglobulin light chain FOR005 have a similar core as patient fibrils with reduced stability. J Biol Chem 2020; 295:18474-18484. [PMID: 33093170 PMCID: PMC7939468 DOI: 10.1074/jbc.ra120.016006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/21/2020] [Indexed: 11/26/2022] Open
Abstract
Systemic antibody light chains (AL) amyloidosis is characterized by deposition of amyloid fibrils derived from a particular antibody light chain. Cardiac involvement is a major risk factor for mortality. Using MAS solid-state NMR, we studied the fibril structure of a recombinant light chain fragment corresponding to the fibril protein from patient FOR005, together with fibrils formed by protein sequence variants that are derived from the closest germline (GL) sequence. Both analyzed fibril structures were seeded with ex-vivo amyloid fibrils purified from the explanted heart of this patient. We find that residues 11-42 and 69-102 adopt β-sheet conformation in patient protein fibrils. We identify arginine-49 as a key residue that forms a salt bridge to aspartate-25 in the patient protein fibril structure. In the germline sequence, this residue is replaced by a glycine. Fibrils from the GL protein and from the patient protein harboring the single point mutation R49G can be both heterologously seeded using patient ex-vivo fibrils. Seeded R49G fibrils show an increased heterogeneity in the C-terminal residues 80-102, which is reflected by the disappearance of all resonances of these residues. By contrast, residues 11-42 and 69-77, which are visible in the MAS solid-state NMR spectra, show 13Cα chemical shifts that are highly like patient fibrils. The mutation R49G thus induces a conformational heterogeneity at the C terminus in the fibril state, whereas the overall fibril topology is retained. These findings imply that patient mutations in FOR005 can stabilize the fibril structure.
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Affiliation(s)
- Tejaswini Pradhan
- Helmholtz-Zentrum München (HMGU), Deutsches Forschungszentrum für Gesundheit und UmweltInstitute of Structural Biology (STB), Neuherberg, Germany; Munich Center for Integrated Protein Science (CIPS-M) at the Dept. of Chemistry, Technische Universität München (TUM), Garching, Germany
| | | | - Riddhiman Sarkar
- Helmholtz-Zentrum München (HMGU), Deutsches Forschungszentrum für Gesundheit und UmweltInstitute of Structural Biology (STB), Neuherberg, Germany; Munich Center for Integrated Protein Science (CIPS-M) at the Dept. of Chemistry, Technische Universität München (TUM), Garching, Germany
| | - Stefanie Huhn
- Medical Department V, Multiple Myeloma Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Ute Hegenbart
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan Schönland
- Medical Department V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Marcus Fändrich
- Institute of Protein Biochemistry, Ulm University, Ulm, Germany
| | - Bernd Reif
- Helmholtz-Zentrum München (HMGU), Deutsches Forschungszentrum für Gesundheit und UmweltInstitute of Structural Biology (STB), Neuherberg, Germany; Munich Center for Integrated Protein Science (CIPS-M) at the Dept. of Chemistry, Technische Universität München (TUM), Garching, Germany.
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Immunoglobulin variable domain high-throughput sequencing reveals specific novel mutational patterns in POEMS syndrome. Blood 2020; 135:1750-1758. [PMID: 32243509 DOI: 10.1182/blood.2019004197] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 03/13/2020] [Indexed: 12/22/2022] Open
Abstract
Polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome is a rare multisystem disease resulting from an underlying plasma cell (PC) dyscrasia. The pathophysiology of the disease remains unclear, but the role of the monoclonal immunoglobulin (Ig) light chain (LC) is strongly suspected because of the highly restrictive usage of 2 λ variable (V) domains (IGLV1-40 and IGLV1-44) and the general improvement of clinical manifestations after PC clone-targeted treatment. However, the diagnostic value of Ig LC sequencing, especially in the case of incomplete forms of the disease, remains to be determined. Using a sensitive high-throughput Ig repertoire sequencing on RNA (rapid amplification of cDNA ends-based repertoire sequencing [RACE-RepSeq]), we detected a λ LC monoclonal expansion in the bone marrow (BM) of 83% of patients with POEMS syndrome, including some in whom BM tests routinely performed to diagnose plasma cell dyscrasia failed to detect λ+ monoclonal PCs. Twenty-four (83%) of the 29 LC clonal sequences found were derived from the IGLV1-40 and IGLV1-44 germline genes, as well as 2 from the closely related IGLV1-36 gene, and all were associated with an IGLJ3*02 junction (J) gene, confirming the high restriction of VJ region usage in POEMS syndrome. RACE-RepSeq VJ full-length sequencing additionally revealed original mutational patterns, the strong specificity of which might crucially help establish or eliminate the diagnosis of POEMS syndrome in uncertain cases. Thus, RACE-RepSeq appears as a sensitive, rapid, and specific tool to detect low-abundance PC clones in BM and assign them to POEMS syndrome, with all the consequences for therapeutic options.
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Staron A, Connors LH, Zheng L, Doros G, Sanchorawala V. Race/ethnicity in systemic AL amyloidosis: perspectives on disease and outcome disparities. Blood Cancer J 2020; 10:118. [PMID: 33173025 PMCID: PMC7655813 DOI: 10.1038/s41408-020-00385-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/01/2020] [Accepted: 10/23/2020] [Indexed: 02/07/2023] Open
Abstract
In marked contrast to multiple myeloma, racial/ethnic minorities are underrepresented in publications of systemic light-chain (AL) amyloidosis. The impact of race/ethnicity is therefore lacking in the narrative of this disease. To address this gap, we compared disease characteristics, treatments, and outcomes across racial/ethnic groups in a referred cohort of patients with AL amyloidosis from 1990 to 2020. Among 2416 patients, 14% were minorities. Non-Hispanic Blacks (NHBs) comprised 8% and had higher-risk sociodemographic factors. Hispanics comprised 4% and presented with disproportionately more BU stage IIIb cardiac involvement (27% vs. 4-17%). At onset, minority groups were younger in age by 4-6 years. There was indication of more aggressive disease phenotype among NHBs with higher prevalence of difference between involved and uninvolved free light chains >180 mg/L (39% vs. 22-33%, P = 0.044). Receipt of stem cell transplantation was 30% lower in Hispanics compared to non-Hispanic White (NHWs) on account of sociodemographic and physiologic factors. Although the age/sex-adjusted hazard for death among NHBs was 24% higher relative to NHWs (P = 0.020), race/ethnicity itself did not impact survival after controlling for disease severity and treatment variables. These findings highlight the complexities of racial/ethnic disparities in AL amyloidosis. Directed efforts by providers and advocacy groups are needed to expand access to testing and effective treatments within underprivileged communities.
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Affiliation(s)
- Andrew Staron
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
- Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
| | - Lawreen H Connors
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
- Department of Pathology and Laboratory Medicine, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
| | - Luke Zheng
- Department of Biostatistics, Boston University School of Public Health, 715 Albany Street, Boston, MA, USA
| | - Gheorghe Doros
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA
- Department of Biostatistics, Boston University School of Public Health, 715 Albany Street, Boston, MA, USA
| | - Vaishali Sanchorawala
- Amyloidosis Center, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA.
- Section of Hematology and Oncology, Boston University School of Medicine and Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, USA.
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Herrera GA. Renal amyloidosis with emphasis on the diagnostic role of electron microscopy. Ultrastruct Pathol 2020; 44:325-341. [PMID: 33167761 DOI: 10.1080/01913123.2020.1844355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Our understanding of renal diseases with structured deposits has improved in the last two decades with the development of new diagnostic techniques that also changed the role of ultrastructural pathology in diagnostic decision-making. This review article addresses the current role of electron microscopy in the evaluation of structured deposits and discusses the impact of new developments. The diagnosis in a subset of structured deposits, amyloidosis, relies on morphologic and tinctorial characteristics at the light microscopic level. Congo red staining of tissue with demonstrable birefringence upon polarization has been regarded as the mainstay during tissue evaluation; however, there are pitfalls that must be considered, and electron microscopy remains a crucial adjunct investigative tool. Ultrastructurally the amyloid fibrils are unique with their characteristic appearance. They are randomly arranged, rigid, criss-crossing, non-branching, 7-15 nm (0.07-0.15 um) in diameter and of variable length. The morphology of fibrils is very similar in the different types of amyloidosis. By scanning electron microscopy amyloid fibrils appear artfully displayed. Immunofluorescence and immunohistochemical stains can be used to characterize the type of amyloidosis while mass spectroscopy is extremely useful in cases where typing of the amyloid using the above-mentioned techniques is difficult or equivocal.
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Cicco S, Solimando AG, Buono R, Susca N, Inglese G, Melaccio A, Prete M, Ria R, Racanelli V, Vacca A. Right Heart Changes Impact on Clinical Phenotype of Amyloid Cardiac Involvement: A Single Centre Study. Life (Basel) 2020; 10:life10100247. [PMID: 33081052 PMCID: PMC7603245 DOI: 10.3390/life10100247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/18/2022] Open
Abstract
Amyloidosis is due to deposition of an excessive amount of protein in many parenchymal tissues, including myocardium. The onset of cardiac Amyloidosis (CA) is an inauspicious prognostic factor, which can lead to sudden death. We retrospectively analyzed 135 patients with systemic amyloidosis, admitted to our ward between 1981 and 2019. Among them, 54 patients (46.30% F/53.70% M, aged 63.95 ± 12.82) presented CA at baseline. In 53 patients, it was associated with a multiorgan involvement, while in one there was a primary myocardial deposition. As a control group, we enrolled 81 patients (49.30% F/50.70% M, aged 58.33 ± 15.65) who did not meet the criteria for CA. In 44/54 of patients CA was associated with AL, 5/54 with AA and 3/54 of patients with ATTR, and in 1/54 AL was related to hemodialysis and in 1/54 to Gel-Amyloidosis. The most common AL type was IgG (28/44); less frequent forms were either IgA (7/44) or IgD (2/44), while seven patients had a λ free light chain form. The 32 AL with complete Ig were 31 λ-chain and just one k-chain. CA patients presented normal BP (SBP 118.0 ± 8.4 mmHg; DBP 73.8 ± 4.9 mmHg), while those with nCA had an increased proteinuria (p = 0.02). TnI and NT-proBNP were significantly increased compared to nCA (p = 0.031 and p = 0.047, respectively). In CA patients we found an increased LDH compared to nCA (p = 0.0011). CA patients were also found to have an increased interventricular septum thickness compared to nCA (p = 0.002), a decreased Ejection Fraction % (p = 0.0018) and Doppler velocity E/e’ ratio (p = 0.0095). Moreover, CA patients had an enhanced right atrium area (p = 0.0179), right ventricle basal diameter (p = 0.0112) and wall thickness (p = 0.0471) compared to nCA, and an increased inferior cava vein diameter (p = 0.0495) as well. TAPSE was the method chosen to evaluate systolic function of the right heart. In CA subjects very poor TAPSE levels were found compared to nCA patients (p = 0.0495). Additionally, we found a significant positive correlation between TAPSE and lymphocyte count (r = 0.47; p = 0.031) as well as Gamma globulins (r = 0.43, p = 0.033), Monoclonal components (r = 0.72; p = 0.047) and IgG values (r = 0.62, p = 0.018). Conversely, a significant negative correlation with LDH (r = −0.57, p = 0.005), IVS (r = −0.51, p = 0.008) and diastolic function evaluated as E/e’ (r = −0.60, p = 0.003) were verified. CA patients had very poor survival rates compared to controls (30 vs. 66 months in CA vs. nCA, respectively, p = 0.15). Mean survival of CA individuals was worse also when stratified according to NT-proBNP levels, using 2500 pg/mL as class boundary (174 vs. 5.5 months, for patients with lower vs. higher values than the median, respectively p = 0.013). In much the same way, a decreased right heart systolic function was correlated with a worse prognosis (18.0 months median survival, not reached in subjects with lower values than 18 mm, p = 0.0186). Finally, our data highlight the potential prognostic and predictive value of right heart alterations characterizing amyloidosis, as a novel clinical parameter correlated to increased LDH and immunoglobulins levels. Overall, we confirm the clinical relevance of cardiac involvement suggests that right heart evaluation may be considered as a new marker for clinical risk stratification in patients with amyloidosis.
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Affiliation(s)
- Sebastiano Cicco
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
- Internal Medicine Department, AUO Policlinico Ospedali Riuniti, Viale L. Pinto, I-71122 Foggia, Italy
| | - Antonio Giovanni Solimando
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
- IRCCS Istituto Tumori “Giovanni Paolo II” of Bari, Viale Orazio Flacco 65, I-70124 Bari, Italy
| | - Roberta Buono
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Nicola Susca
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Gianfranco Inglese
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Assunta Melaccio
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Marcella Prete
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Roberto Ria
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Vito Racanelli
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Angelo Vacca
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
- Correspondence:
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Wang Y, Xu L, Liu Y, Hu Y, Shi Q, Jin L, Yang L, Wang P, Zhang K, Huang X, Ge Q, Lu J. Transcriptional heterogeneity of clonal plasma cells and immune evasion in immunoglobulin light chain amyloidosis. Int J Hematol 2020; 113:231-242. [PMID: 33040275 DOI: 10.1007/s12185-020-03016-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/16/2020] [Accepted: 09/28/2020] [Indexed: 01/01/2023]
Abstract
Immunoglobulin light chain amyloidosis (AL amyloidosis) is characterized by the presence of B cells producing amyloidogenic immunoglobulin light chains (LCs). The low frequency of aberrant B cells in AL is often masked by a polyclonal B cell background, making it difficult for treatment. We analyzed the single-cell RNA sequencing data from GEO database to compare the plasma cell (PCs) in four individuals with AL amyloidosis, one AL subject after treatment, and six healthy controls. High interindividual variability in AL-derived PCs in their expression pattern of known overexpressed genes in multiple myeloma and their usage of V regions in LCs was demonstrated. We also found overexpression of MHC class I molecules as one of the common features of clonal PCs in individuals with AL amyloidosis. Significantly reduced frequencies of circulating natural killer (NK) cells were also observed in a small cohort of AL patients when compared to healthy controls. These data demonstrate that aberrant PCs in AL has a highly diverse transcriptome, an upregulation of MHC, and a dampened capability of immunosurveillance by reduction of circulating NK frequencies. The analysis of clonal PCs at single cell level may provide a better approach for precise molecular profiling and diagnosis of AL amyloidosis.
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Affiliation(s)
- Yujia Wang
- Department of Immunology, School of Basic Medical Sciences, NHC Key Laboratory of Medical Immunology, Peking University, Beijing, China
| | - Lushuang Xu
- Department of Immunology, School of Basic Medical Sciences, NHC Key Laboratory of Medical Immunology, Peking University, Beijing, China
| | - Yang Liu
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital and Institute of Hematology, Beijing, 100044, China
| | - Yuzhe Hu
- Department of Immunology, School of Basic Medical Sciences, NHC Key Laboratory of Medical Immunology, Peking University, Beijing, China
| | - Qiang Shi
- School of Life Sciences, Center for Bioinformatics, Peking University, Beijing, 100871, China
| | - Lixue Jin
- Department of Immunology, School of Basic Medical Sciences, NHC Key Laboratory of Medical Immunology, Peking University, Beijing, China
| | - Lijun Yang
- Department of Immunology, School of Basic Medical Sciences, NHC Key Laboratory of Medical Immunology, Peking University, Beijing, China
| | - Pingzhang Wang
- Department of Immunology, School of Basic Medical Sciences, NHC Key Laboratory of Medical Immunology, Peking University, Beijing, China
| | - Kunshan Zhang
- Translational Stem Cell Research Center, Tongji Hospital, Tongji University School of Medicine, Shanghai, 200065, China
| | - Xiaojun Huang
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital and Institute of Hematology, Beijing, 100044, China
| | - Qing Ge
- Department of Immunology, School of Basic Medical Sciences, NHC Key Laboratory of Medical Immunology, Peking University, Beijing, China. .,Department of Integration of Chinese and Western Medicine, School of Basic Medical Sciences, Peking University, Beijing, 100191, China. .,Peking University Health Sciences Center, 38 Xue Yuan Road, Beijing, 100191, China.
| | - Jin Lu
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Peking University People's Hospital and Institute of Hematology, Beijing, 100044, China. .,Collaborative Innovation Center of Haematology, Soochow University, Suzhou, Jiangsu, China.
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Basset M, Hummedah K, Kimmich C, Veelken K, Dittrich T, Brandelik S, Kreuter M, Hassel J, Bosch N, Stuhlmann-Laeisz C, Blank N, Müller-Tidow C, Röcken C, Hegenbart U, Schönland S. Localized immunoglobulin light chain amyloidosis: Novel insights including prognostic factors for local progression. Am J Hematol 2020; 95:1158-1169. [PMID: 32602121 DOI: 10.1002/ajh.25915] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 06/22/2020] [Accepted: 06/23/2020] [Indexed: 12/11/2022]
Abstract
In localized light chain amyloidosis (locAL), amyloidogenic light chains (aLC) are produced and deposited locally by a B-cell clone. We present 293 patients with immunohistochemically confirmed locAL. Lung (nodular pulmonary) with 63 patients was the most involved organ. The aLC was λ in 217 cases (κ:λ ratio 1:3). A local B-cell clone was identified in 30% of cases. Sixty-one (21%) had a concomitant autoimmune disorder (cAD). A monoclonal component (MC) were present in 101 (34%) patients and were more frequent in subjects with cAD (51% vs 34%; P = .03). Cigarette smoking was more prevalent in lung locAL (54% vs 37%; P = .018). After a median follow-up of 44 months, 16 patients died and 5- and 10-years locAL progression-free survival (PFS) were 62% and 44%. Interestingly, locAL-PFS was shorter among patients with an identified clonal infiltrate at amyloid deposition site (40 vs 109 months; P = .02) and multinuclear giant cells and/or an inflammatory infiltrate resulted in longer locAL-PFS in lung involvement (65 vs 42 months; P = .01). However, no differences in locAL PFS were observed in patients with cAD, a MC and involved organ site. Treatment was administered in 163 (54%) patients and was surgical in 135 (46%). Median locAL-PFS after first treatment was 56 months. Responders had longer locAL-PFS (78 vs 17 months; P < .001). Three patients with lung locAL and a MC were diagnosed as systemic AL amyloidosis at follow-up. In summary, locAL pathogenesis seems to be heterogeneous and the clonal infiltrate leads local progression.
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Affiliation(s)
- Marco Basset
- Medical Department V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Kamal Hummedah
- Medical Department V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Kimmich
- Medical Department V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Kaya Veelken
- Medical Department V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Dittrich
- Medical Department V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Simone Brandelik
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael Kreuter
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
- Center for interstitial and rare lung diseases, Thoraxklinik, University Hospital Heidelberg and German Center for Lung Research, Heidelberg, Germany
| | - Jessica Hassel
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
- Skin Cancer Center, Department of Dermatology and National Center for Tumor Diseases (NCT), University Hospital Heidelberg, Heidelberg, Germany
| | - Nikolaus Bosch
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
- Heidelberger StimmZentrum, Universitäts HNO Klinik Heidelberg, Heidelberg, Germany
| | | | - Norbert Blank
- Medical Department V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Medical Department V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Christoph Röcken
- Department of Pathology, Christian-Albrechts-University Kiel, Kiel, Germany
| | - Ute Hegenbart
- Medical Department V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Schönland
- Medical Department V, Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- Amyloidosis Center Heidelberg, University Hospital Heidelberg, Heidelberg, Germany
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38
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Bianchi G, Kumar S. Systemic Amyloidosis Due to Clonal Plasma Cell Diseases. Hematol Oncol Clin North Am 2020; 34:1009-1026. [PMID: 33099420 DOI: 10.1016/j.hoc.2020.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Immunoglobulin light chain amyloidosis is the most common systemic amyloidosis. The pathogenetic mechanism is deposition of fibrils of misfolded immunoglobulin free light chains, more often lambda, typically produced by clonal plasma cells. Distinct Ig light chain variable region genotypes underlie most light chain amyloidosis and dictate tissue tropism. Light chain amyloidosis fibrils cause distortion of the histologic architecture and direct cytotoxicity, leading to rapidly progressive organ dysfunction and eventually patient demise. A high index of clinical suspicion with rapid tissue diagnosis and commencement of combinatorial, highly effective cytoreductive therapy is crucial to avoid irreversible organ damage and early mortality.
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Affiliation(s)
- Giada Bianchi
- Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Shaji Kumar
- Myeloma, Amyloidosis, Dysproteinemia Group, Mayo Clinic, First Street Southwest, Rochester, MN 55904, USA.
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Basset M, Nuvolone M, Palladini G, Merlini G. Novel challenges in the management of immunoglobulin light chain amyloidosis: from the bench to the bedside. Expert Rev Hematol 2020; 13:1003-1015. [PMID: 32721177 DOI: 10.1080/17474086.2020.1803060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Immunoglobulin light chain (AL) amyloidosis is one of the most frequent systemic amyloidosis in Western countries. It is caused by a B-cell clone producing a misfolded light chain (LC) that deposits in organs. AREAS COVERED The review examines recent findings on pathophysiology and clinical management of AL amyloidosis. It contains an update on the recent hot topics as novel therapeutic approaches, definition of relapse, and hematologic response assessment. To review literature on AL amyloidosis, a bibliographic search was performed using PubMed. EXPERT OPINION Due to the proteotoxicity of amyloidogenic LCs, the therapeutic goal is a rapid and profound decrease in their concentration. The standard treatment is a risk-adapted chemotherapy targeting the B-cell clone. Novel, promising drugs, as daratumumab, are currently under evaluation in newly-diagnosed and relapsed/refractory patients. New sensitive techniques, as mass spectrometry approach and bone marrow minimal residual disease assessment, are available to evaluate depth of response. After first-line therapy, increase in LC concentration may precede worsening of organ dysfunction and should be considered carefully. Further clarification of molecular mechanisms of the disease are shedding light on new possible therapeutic targets. Innovative treatment strategies and novel technologies will improve our ability to treat AL amyloidosis, preventing organ deterioration.
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Affiliation(s)
- Marco Basset
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
| | - Mario Nuvolone
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
| | - Giovanni Palladini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation IRCCS Policlinico San Matteo, and Department of Molecular Medicine, University of Pavia , Pavia, Italy
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40
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Understanding Mesangial Pathobiology in AL-Amyloidosis and Monoclonal Ig Light Chain Deposition Disease. Kidney Int Rep 2020; 5:1870-1893. [PMID: 33163710 PMCID: PMC7609979 DOI: 10.1016/j.ekir.2020.07.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 02/07/2023] Open
Abstract
Patients with plasma cell dyscrasias produce free abnormal monoclonal Ig light chains that circulate in the blood stream. Some of them, termed glomerulopathic light chains, interact with the mesangial cells and trigger, in a manner dependent of their structural and physicochemical properties, a sequence of pathological events that results in either light chain–derived (AL) amyloidosis (AL-Am) or light chain deposition disease (LCDD). The mesangial cells play a key role in the pathogenesis of both diseases. The interaction with the pathogenic light chain elicits specific cellular processes, which include apoptosis, phenotype transformation, and secretion of extracellular matrix components and metalloproteinases. Monoclonal light chains associated with AL-Am but not those producing LCDD are avidly endocytosed by mesangial cells and delivered to the mature lysosomal compartment where amyloid fibrils are formed. Light chains from patients with LCDD exert their pathogenic signaling effect at the cell surface of mesangial cells. These events are generic mesangial responses to a variety of adverse stimuli, and they are similar to those characterizing other more frequent glomerulopathies responsible for many cases of end-stage renal disease. The pathophysiologic events that have been elucidated allow to propose future therapeutic approaches aimed at preventing, stopping, ameliorating, or reversing the adverse effects resulting from the interactions between glomerulopathic light chains and mesangium.
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Abstract
PURPOSE Amyloidosis represents an increasingly recognized but still frequently missed cause of heart failure. In the light of many effective therapies for light chain (AL) amyloidosis and promising new treatment options for transthyretin (ATTR) amyloidosis, awareness among caregivers needs to be raised to screen for amyloidosis as an important and potentially treatable differential diagnosis. This review outlines the diversity of cardiac amyloidosis, its relation to heart failure, the diagnostic algorithm, and therapeutic considerations that should be applied depending on the underlying type of amyloidosis. RECENT FINDINGS Non-biopsy diagnosis is feasible in ATTR amyloidosis in the absence of a monoclonal component resulting in higher detection rates of cardiac ATTR amyloidosis. Biomarker-guided staging systems have been updated to facilitate risk stratification according to currently available biomarkers independent of regional differences, but have not yet prospectively been tested. Novel therapies for hereditary and wild-type ATTR amyloidosis are increasingly available. The complex treatment options for AL amyloidosis are improving continuously, resulting in better survival and quality of life. Mortality in advanced cardiac amyloidosis remains high, underlining the importance of early diagnosis and treatment initiation. Cardiac amyloidosis is characterized by etiologic and clinical heterogeneity resulting in a frequently delayed diagnosis and an inappropriately high mortality risk. New treatment options for this hitherto partially untreatable condition have become and will become available, but raise challenges regarding their implementation. Referral to specialized centers providing access to extensive and targeted diagnostic investigations and treatment initiation may help to face these challenges.
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Theodorakakou F, Fotiou D, Dimopoulos MA, Kastritis E. Solid Organ Transplantation in Amyloidosis. Acta Haematol 2020; 143:352-364. [PMID: 32535598 DOI: 10.1159/000508262] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 04/28/2020] [Indexed: 12/25/2022]
Abstract
Amyloidosis comprises a diverse group of diseases characterized by misfolding of precursor proteins which eventually form amyloid aggregates and preceding intermediaries, which are deposited in target tissues causing progressive organ damage. In all forms of amyloidosis, vital organs may fail; depending on the specific amyloidosis type, this may occur rapidly or progress slowly. Beyond therapies to reduce the precursor protein (chemotherapy for light chain [AL] amyloidosis, anti-inflammatory therapy in serum A amyloid-osis [AA], and antisense RNA therapy in transthyretin amyloidosis [ATTR]), organ transplantation may also be a means to reduce amyloidogenic protein, e.g., in types of amyloid-osis in which the variant precursor is produced by the liver. Heart transplantation is a life-saving approach to the treatment of patients with advanced cardiac amyloidosis; however, amyloidosis may still be considered a contraindication to the procedure despite data supporting improved outcomes, similar to patients with other indications. Kidney transplantation is associated with particularly favorable outcomes in patients with amyloidosis, especially if the precursor protein has been eliminated. Overall, outcomes of solid organ transplantation are improving, but more data are needed to refine the selection criteria and the timing for organ transplantation, which should be performed in highly experienced centers involving multidisciplinary teams with close patient follow-up to detect amyloid recurrence.
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Affiliation(s)
- Foteini Theodorakakou
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Despina Fotiou
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Meletios A Dimopoulos
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Kastritis
- Plasma Cell Dyscrasia Unit, Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece,
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43
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Pelaez-Aguilar A, Valdés-García G, French-Pacheco L, Pastor N, Amero C, Rivillas-Acevedo L. Site-Specific Interactions with Copper Promote Amyloid Fibril Formation for λ6aJL2-R24G. ACS OMEGA 2020; 5:7085-7095. [PMID: 32280849 PMCID: PMC7143407 DOI: 10.1021/acsomega.9b03220] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/03/2020] [Indexed: 06/11/2023]
Abstract
Light-chain amyloidosis (AL) is one of the most common systemic amyloidoses, and it is characterized by the deposition of immunoglobulin light chain (LC) variable domains as insoluble amyloid fibers in vital organs and tissues. The recombinant protein 6aJL2-R24G contains λ6a and JL2 germline genes and also contains the Arg24 by Gly substitution. This mutation is present in 25% of all amyloid-associated λ6 LC cases, reduces protein stability, and increases the propensity to form amyloid fibers. In this study, it was found that the interaction of 6aJL2-R24G with Cu(II) decreases the thermal stability of the protein and accelerates the amyloid fibril formation, as observed by fluorescence spectroscopy. Isothermal calorimetry titration showed that Cu(II) binds to the protein with micromolar affinity. His99 may be one of the main Cu(II) interaction sites, as observed by nuclear magnetic resonance spectroscopy. The binding of Cu(II) to His99 induces larger fluctuations of the CDR1 and loop C″, as shown by molecular dynamics simulations. Thus, Cu(II) binding may be inducing the loss of interactions between CDR3 and CDR1, making the protein less stable and more prone to form amyloid fibers. This study provides insights into the mechanism of metal-induced aggregation of the 6aJL2-R24G protein and sheds light on the bio-inorganic understanding of AL disease.
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Affiliation(s)
- Angel
E. Pelaez-Aguilar
- Centro
de Investigación en Dinámica Celular-IICBA, Universidad Autónoma del Estado de Morelos, Cuernavaca, Morelos 62209, Mexico
| | - Gilberto Valdés-García
- Department
of Molecular Medicine and Bioprocesses, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Cuernavaca, Morelos 62210, Mexico
| | - Leidys French-Pacheco
- Centro
de Investigaciones Químicas-IICBA, Universidad Autónoma del Estado de Morelos, Cuernavaca, Morelos 62209, Mexico
| | - Nina Pastor
- Centro
de Investigación en Dinámica Celular-IICBA, Universidad Autónoma del Estado de Morelos, Cuernavaca, Morelos 62209, Mexico
- Department
of Molecular Medicine and Bioprocesses, Instituto de Biotecnología, Universidad Nacional Autónoma de México, Cuernavaca, Morelos 62210, Mexico
| | - Carlos Amero
- Centro
de Investigaciones Químicas-IICBA, Universidad Autónoma del Estado de Morelos, Cuernavaca, Morelos 62209, Mexico
| | - Lina Rivillas-Acevedo
- Centro
de Investigación en Dinámica Celular-IICBA, Universidad Autónoma del Estado de Morelos, Cuernavaca, Morelos 62209, Mexico
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44
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Cuddy SA, Falk RH. Amyloidosis as a Systemic Disease in Context. Can J Cardiol 2020; 36:396-407. [DOI: 10.1016/j.cjca.2019.12.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 12/09/2019] [Accepted: 12/10/2019] [Indexed: 12/19/2022] Open
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46
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Zhu Z, Yue C, Sun Y, Li X, Li M. Light-chain amyloidosis with renal involvement: renal outcomes and validation of two renal staging systems in the Chinese population. Amyloid 2019; 26:186-191. [PMID: 31339366 DOI: 10.1080/13506129.2019.1639149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background: Renal involvement is one of the most common complications of light-chain (AL) amyloidosis. For evaluating renal prognosis, two staging systems for renal involvement have been proposed, one in 2014 and one in 2017. However, the two staging systems have not yet been compared and widely used in clinic. Methods: A total of 76 patients with newly diagnosed AL amyloidosis and renal involvement proven by renal biopsy were included and followed up with an endpoint developing to dialysis. The renal outcome and two criteria were explored. Results: We confirmed the prognostic value of the 2014 renal staging system based on estimated glomerular filtration rate (eGFR) (<50 ml/min/1.73 m2) and proteinuria (>5 g/day) at diagnosis (p = 0.003). For the 2017 system, none of the patients progressed to dialysis in both stage 1 (24 h proteinuria to eGFR <30 mg/ml/min/1.73 m2) and stage 2 (24 h proteinuria to eGFR 30-99 mg/ml/min/1.73 m2). A significant difference in terms of requiring dialysis was seen only between stage 3 (24 h proteinuria to eGFR ≥100 mg/ml/min/1.73 m2) and the two other stages (p = 0.008). Conclusions: The prognostic value of the criteria based on eGFR and 24-hour proteinuria for predicting dialysis has been confirmed. These results might benefit guiding clinical treatment.
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Affiliation(s)
- Zixuan Zhu
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Cai Yue
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Ying Sun
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Xuemei Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
| | - Mingxi Li
- Department of Nephrology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences , Beijing , China
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47
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Maya-Martinez R, French-Pacheco L, Valdés-García G, Pastor N, Amero C. Different Dynamics in 6aJL2 Proteins Associated with AL Amyloidosis, a Conformational Disease. Int J Mol Sci 2019; 20:E4078. [PMID: 31438515 PMCID: PMC6747610 DOI: 10.3390/ijms20174078] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/16/2019] [Accepted: 05/22/2019] [Indexed: 12/12/2022] Open
Abstract
Light-chain amyloidosis (AL) is the most common systemic amyloidosis and is caused by the deposition of mainly insoluble immunoglobulin light chain amyloid fibrils in multiple organs, causing organ failure and eventually death. The germ-line λ6a has been implicated in AL, where a single point mutant at amino acid 24 (6aJL2-R24G) has been observed in around 25% of patient samples. Structural analysis has shown only subtle differences between both proteins; nevertheless, 6aJL2-R24G is more prone to form amyloid fibrils. To improve our understanding of the role of protein flexibility in amyloid fibril formation, we have used a combination of solution nuclear magnetic resonance spectroscopy and molecular dynamics simulations to complement the structural insight with dynamic knowledge. Fast timescale dynamics (ps-ns) were equivalent for both proteins, but suggested exchange events for some residues. Even though most of the intermediate dynamics (μs-ms) occurred at a similar region for both proteins, the specific characteristics are very different. A minor population detected in the dispersion experiments could be associated with the formation of an off-pathway intermediate that protects from fiber formation more efficiently in the germ-line protein. Moreover, we found that the hydrogen bond patterns for both proteins are similar, but the lifetime for the mutant is significantly reduced; as a consequence, there is a decrease in the stability of the tertiary structure that extends throughout the protein and leads to an increase in the propensity to form amyloid fibers.
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Affiliation(s)
- Roberto Maya-Martinez
- Laboratorio de Bioquímica y Resonancia Magnética Nuclear, Centro de Investigaciones Químicas, Instituto de Investigación en Ciencias Básicas y Aplicadas, Universidad Autónoma del Estado de Morelos, Cuernavaca 62209, Mexico
| | - Leidys French-Pacheco
- Laboratorio de Bioquímica y Resonancia Magnética Nuclear, Centro de Investigaciones Químicas, Instituto de Investigación en Ciencias Básicas y Aplicadas, Universidad Autónoma del Estado de Morelos, Cuernavaca 62209, Mexico
| | - Gilberto Valdés-García
- Centro de Investigación en Dinámica Celular, Instituto de Investigación en Ciencias Básicas y Aplicadas, Universidad Autónoma del Estado de Morelos, Cuernavaca 62209, Mexico
| | - Nina Pastor
- Centro de Investigación en Dinámica Celular, Instituto de Investigación en Ciencias Básicas y Aplicadas, Universidad Autónoma del Estado de Morelos, Cuernavaca 62209, Mexico
| | - Carlos Amero
- Laboratorio de Bioquímica y Resonancia Magnética Nuclear, Centro de Investigaciones Químicas, Instituto de Investigación en Ciencias Básicas y Aplicadas, Universidad Autónoma del Estado de Morelos, Cuernavaca 62209, Mexico.
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48
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Rennella E, Morgan GJ, Yan N, Kelly JW, Kay LE. The Role of Protein Thermodynamics and Primary Structure in Fibrillogenesis of Variable Domains from Immunoglobulin Light Chains. J Am Chem Soc 2019; 141:13562-13571. [PMID: 31364359 DOI: 10.1021/jacs.9b05499] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Immunoglobulin light-chain amyloidosis is a protein aggregation disease that leads to proteinaceous deposits in a variety of organs in the body and, if untreated, ultimately results in death. The mechanisms by which light-chain aggregation occurs are not well understood. Here we have used solution NMR spectroscopy and biophysical studies to probe immunoglobulin variable domain λV6-57 VL aggregation, a process that appears to drive the degenerative phenotypes in amyloidosis patients. Our results establish that aggregation proceeds via the unfolded state. We identify, through NMR relaxation experiments recorded on the unfolded domain ensemble, a series of hotspots that could be involved in the initial phases of aggregate formation. Mutational analysis of these hotspots reveals that the region that includes K16-R24 is particularly aggregation prone. Notably, this region includes the site of the R24G substitution, a mutation that is found in variable domains of λ light-chain deposits in 25% of patients. The R24G λV6-57 VL domain aggregates more rapidly than would be expected on the basis of thermodynamic stability alone, while substitutions in many of the aggregation-prone regions significantly slow down fibril formation.
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Affiliation(s)
- Enrico Rennella
- Departments of Molecular Genetics, Biochemistry and Chemistry , The University of Toronto , Toronto , Ontario , Canada M5S1A8
| | - Gareth J Morgan
- Departments of Molecular Medicine and Chemistry , The Scripps Research Institute , La Jolla , California 92037 , United States.,Department of Medicine , Boston University School of Medicine , Boston , Massachusetts 02118 , United States
| | - Nicholas Yan
- Departments of Molecular Medicine and Chemistry , The Scripps Research Institute , La Jolla , California 92037 , United States
| | - Jeffery W Kelly
- Departments of Molecular Medicine and Chemistry , The Scripps Research Institute , La Jolla , California 92037 , United States
| | - Lewis E Kay
- Departments of Molecular Genetics, Biochemistry and Chemistry , The University of Toronto , Toronto , Ontario , Canada M5S1A8.,The Hospital for Sick Children , Program in Molecular Medicine , 555 University Avenue , Toronto , Ontario , Canada M5G1X8
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49
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Liu Y, Wen L, Ma L, Kang Y, Liu KY, Huang XJ, Ruan GR, Lu J. MAGE genes: Prognostic indicators in AL amyloidosis patients. J Cell Mol Med 2019; 23:5672-5678. [PMID: 31222935 PMCID: PMC6653474 DOI: 10.1111/jcmm.14475] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 05/15/2019] [Accepted: 05/20/2019] [Indexed: 01/30/2023] Open
Abstract
A high frequency of MAGE-CT (cancer testis) antigens are expressed in Multiple Myeloma (MM) patients; however, in other plasma cell dyscrasias, their potential function remains unclear. We measured the expression of MAGE-CT genes (MAGE-C1/CT7, MAGE-A3, MAGE-C2/CT10) in 105 newly diagnosed amyloid light-chain (AL) amyloidosis patients between June 2013 and January 2018 at Peking University People's Hospital using real-time quantitative polymerase chain reaction. In the newly diagnosed AL patients, the positive expression rates of patients with MAGE-C1/CT7, MAGE-C2/CT10 and MAGE-A3 were 83.8% (88/105), 56.71% (38/67) and 22.0% (13/59) respectively. There was no significant correlation between organ propensity and MAGE-CT gene expression. Changes in the MAGE-C1/CT7 levels were consistent with a therapeutic effect. The expression levels of MAGE-C1/CT7, MAGE-C2/CT10 and MAGE-A3 provide potentially effective clinical indicators for auxiliary diagnoses and monitoring treatment efficacy in AL amyloidosis patients.
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Affiliation(s)
- Yang Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Lei Wen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ling Ma
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Ying Kang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Peking-Tsinghua Center for Life Sciences, Academy for Advanced Interdisciplinary Studies, Peking University, Beijing, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
| | - Guo-Rui Ruan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China
| | - Jin Lu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.,Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.,Collaborative Innovation Center of Hematology, Peking University, Beijing, China.,Collaborative Innovation Center of Hematology, Soochow University, Suzhou, China
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Proteomic evidence of specific IGKV1-8 association with cystic lung light chain deposition disease. Blood 2019; 133:2741-2744. [PMID: 30967366 DOI: 10.1182/blood.2019898577] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 03/19/2019] [Indexed: 01/13/2023] Open
Abstract
We previously reported a new form of light chain deposition disease (LCDD) presenting as diffuse cystic lung disorder that differs from the usual systemic form with respect to patient age, the male/female ratio, the involved organs, and the hematologic characteristics. We also demonstrated that the light chains were produced by an intrapulmonary B-cell clone and that this clone shared a stereotyped antigen receptor IGHV4-34/IGKV1. However, we only analyzed 3 patients. We conducted a retrospective study including lung tissue samples from 24 patients with pulmonary LCDD (pLCDD) matched with samples from 13 patients with pulmonary κ light chain amyloidosis (pAL amyloidosis) used as controls. Mass spectrometry-based proteomics identified immunoglobulin κ peptides as the main protein component of the tissue deposits in all patients. Interestingly, in pLCDD, IGKV1 was the most common κ family detected (86.4%), and IGKV1-8 was overrepresented compared with pAL amyloidosis (75% vs 11.1%, P = .0033). Furthermore, IGKV1-8 was predominantly associated with a diffuse cystic pattern (94%) in pLCDD. In conclusion, the high frequency of IGKV1-8 usage in cystic pLCDD constitutes an additional feature arguing for a specific entity distinct from the systemic form that preferentially uses IGKV4-1.
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