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Hopson MB, Bhutani D, Sarkaria S, Maurer MS, Griffin JM, Mapara M, Lentzsch S, Chakraborty R. Impact of light chain isotype on clinical features and outcomes in systemic AL amyloidosis. Leuk Lymphoma 2022; 63:2109-2113. [DOI: 10.1080/10428194.2022.2060502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
| | - Divaya Bhutani
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Shawn Sarkaria
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | | | - Jan M. Griffin
- Irving Medical Center, Columbia University, New York, NY, USA
| | - Markus Mapara
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
| | - Suzanne Lentzsch
- Herbert Irving Comprehensive Cancer Center, Columbia University, New York, NY, USA
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2
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Basset M, Kimmich CR, Schreck N, Krzykalla J, Dittrich T, Veelken K, Goldschmidt H, Seckinger A, Hose D, Jauch A, Müller-Tidow C, Benner A, Hegenbart U, Schönland SO. Lenalidomide and dexamethasone in relapsed/refractory immunoglobulin light chain (AL) amyloidosis: results from a large cohort of patients with long follow-up. Br J Haematol 2021; 195:230-243. [PMID: 34341985 DOI: 10.1111/bjh.17685] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 12/14/2022]
Abstract
Lenalidomide and dexamethasone (RD) is a standard treatment in relapsed/refractory immunoglobulin light chain (AL) amyloidosis (RRAL). We retrospectively investigated toxicity, efficacy and prognostic markers in 260 patients with RRAL. Patients received a median of two prior treatment lines (68% had been bortezomib-refractory; 33% had received high-dose melphalan). The median treatment duration was four cycles. The 3-month haematological response rate was 31% [very good haematological response (VGHR) in 18%]. The median follow-up was 56·5 months and the median overall survival (OS) and haematological event-free survival (haemEFS) were 32 and 9 months. The 2-year dialysis rate was 15%. VGHR resulted in better OS (62 vs. 26 months, P < 0·001). Cardiac progression predicted worse survival (22 vs. 40 months, P = 0·027), although N-terminal prohormone of brain natriuretic peptide (NT-proBNP) increase was frequently observed. Multivariable analysis identified these prognostic factors: NT-proBNP for OS [hazard ratio (HR) 1·71; P < 0·001]; gain 1q21 for haemEFS (HR 1·68, P = 0·014), with a trend for OS (HR 1·47, P = 0·084); difference between involved and uninvolved free light chains (dFLC) and light chain isotype for OS (HR 2·22, P < 0·001; HR 1·62, P = 0·016) and haemEFS (HR 1·88, P < 0·001; HR 1·59, P = 0·008). Estimated glomerular filtration rate (HR 0·71, P = 0·004) and 24-h proteinuria (HR 1·10, P = 0·004) were prognostic for renal survival. In conclusion, clonal and organ biomarkers at baseline identify patients with favourable outcome, while VGHR and cardiac progression define prognosis during RD treatment.
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Affiliation(s)
- Marco Basset
- Division of Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany.,Department of Molecular Medicine, Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Christoph R Kimmich
- Division of Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Nicholas Schreck
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Julia Krzykalla
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Tobias Dittrich
- Division of Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Kaya Veelken
- Division of Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Anja Seckinger
- Division of Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Laboratory of Hematology and Immunology & Labor für Myelomforschung, Vrije Universiteit Brussel (VUB), Jette, Belgium
| | - Dirk Hose
- Division of Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Laboratory of Hematology and Immunology & Labor für Myelomforschung, Vrije Universiteit Brussel (VUB), Jette, Belgium
| | - Anna Jauch
- Institute of Human Genetics, University Heidelberg, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Division of Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Axel Benner
- Division of Biostatistics, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ute Hegenbart
- Division of Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | - Stefan O Schönland
- Division of Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.,Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
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3
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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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Abstract
The organs affected most commonly by AL amyloidosis are the kidneys and heart, however, liver and gastrointestinal (GI) tract are also commonly affected. Symptoms of GI amyloidosis often mimic those of other GI disorders; having a keen awareness of the need to evaluate for amyloidosis is critical in avoiding delay in diagnosis and intervention. GI and liver involvement is associated with significant complications, and challenges in symptomatic management. As with all AL-related organ disease, early systemic treatment can prevent progression of tissue damage and improve outcomes.
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Affiliation(s)
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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5
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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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Asiri MMH, Engelsman S, Eijkelkamp N, Höppener JWM. Amyloid Proteins and Peripheral Neuropathy. Cells 2020; 9:E1553. [PMID: 32604774 PMCID: PMC7349787 DOI: 10.3390/cells9061553] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/20/2020] [Accepted: 06/22/2020] [Indexed: 12/14/2022] Open
Abstract
Painful peripheral neuropathy affects millions of people worldwide. Peripheral neuropathy develops in patients with various diseases, including rare familial or acquired amyloid polyneuropathies, as well as some common diseases, including type 2 diabetes mellitus and several chronic inflammatory diseases. Intriguingly, these diseases share a histopathological feature-deposits of amyloid-forming proteins in tissues. Amyloid-forming proteins may cause tissue dysregulation and damage, including damage to nerves, and may be a common cause of neuropathy in these, and potentially other, diseases. Here, we will discuss how amyloid proteins contribute to peripheral neuropathy by reviewing the current understanding of pathogenic mechanisms in known inherited and acquired (usually rare) amyloid neuropathies. In addition, we will discuss the potential role of amyloid proteins in peripheral neuropathy in some common diseases, which are not (yet) considered as amyloid neuropathies. We conclude that there are many similarities in the molecular and cell biological defects caused by aggregation of the various amyloid proteins in these different diseases and propose a common pathogenic pathway for "peripheral amyloid neuropathies".
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Affiliation(s)
- Mohammed M. H. Asiri
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, 3584 EA Utrecht, The Netherlands; (M.M.H.A.); (S.E.); (J.W.M.H.)
- The National Centre for Genomic Technology, Life Science and Environment Research Institute, King Abdulaziz City for Science and Technology, P.O. Box 6086, 11461 Riyadh, Saudi Arabia
| | - Sjoukje Engelsman
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, 3584 EA Utrecht, The Netherlands; (M.M.H.A.); (S.E.); (J.W.M.H.)
| | - Niels Eijkelkamp
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, 3584 EA Utrecht, The Netherlands; (M.M.H.A.); (S.E.); (J.W.M.H.)
| | - Jo W. M. Höppener
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, 3584 EA Utrecht, The Netherlands; (M.M.H.A.); (S.E.); (J.W.M.H.)
- Center for Molecular Medicine, University Medical Center Utrecht, Utrecht University, 3584 EA Utrecht, The Netherlands
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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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8
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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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Sharpley FA, Fontana M, Martinez-Naharro A, Manwani R, Mahmood S, Sachchithanantham S, Lachmann HJ, Gillmore JD, Whelan CJ, Hawkins PN, Wechalekar AD. Cardiac biomarkers are prognostic in systemic light chain amyloidosis with no cardiac involvement by standard criteria. Haematologica 2019; 105:1405-1413. [PMID: 31399529 PMCID: PMC7193493 DOI: 10.3324/haematol.2019.217695] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 08/07/2019] [Indexed: 12/11/2022] Open
Abstract
Patients with systemic immunoglobulin light chain amyloidosis (AL) with no evidence of cardiac involvement by consensus criteria have excellent survival, but 20% will die within 5 years of diagnosis and prognostic factors remain poorly characterised. We report the outcomes of 378 prospectively followed Mayo stage I patients (N-terminal pro b-type natriuretic peptide <332 ng/L, high sensitivity cardiac troponin <55 ng/L). The median presenting N-terminal pro b-type natriuretic peptide was 161 ng/L, high sensitivity cardiac troponin 10 ng/L, creatinine 76 μmol/L and mean left ventricular septal wall thickness, 10 mm. Median follow up was 42 (1-117 months), with 71 deaths; median overall survival was not reached (78% survival at 5 years). Although no patients had cardiac involvement by echocardiogram, a proportion (n=25/90, 28%) had cardiac involvement by cardiac magnetic resonance imaging. Age, autonomic nervous system involvement, N-terminal pro b-type natriuretic peptide >152 ng/L, high sensitivity cardiac troponin >10 ng/L and cardiac involvement by magnetic resonance imaging were predictive for survival; on multivariate analysis only N-terminal pro b-type natriuretic peptide >152 ng/L (P<0.008, hazard ratio [HR] 3.180, confidence interval [CI]: 1.349-7.495) and cardiac involvement on magnetic resonance imaging (P=0.026, HR=5.360, CI: 1.219-23.574) were prognostic. At 5 years, 70% of patients with N-terminal pro b-type natriuretic peptide >152 ng/L were alive. In conclusion, N-terminal pro b-type natriuretic peptide is prognostic for survival in patients with no cardiac involvement by consensus criteria and cardiac involvement is detected by magnetic resonance imaging in such cases. This suggests that N-terminal pro b-type natriuretic peptide thresholds for cardiac involvement in AL may need to be redefined.
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Affiliation(s)
- Faye A Sharpley
- National Amyloidosis Centre, University College London, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, London, UK
| | | | - Richa Manwani
- National Amyloidosis Centre, University College London, London, UK
| | - Shameem Mahmood
- National Amyloidosis Centre, University College London, London, UK
| | | | - Helen J Lachmann
- National Amyloidosis Centre, University College London, London, UK
| | | | - Carol J Whelan
- National Amyloidosis Centre, University College London, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, London, UK
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10
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Kimmich C, Schönland S, Kräker S, Andrulis M, Ho AD, Mayer G, Dittrich T, Hundemer M, Hegenbart U. Amyloid in bone marrow smears in systemic light-chain amyloidosis. Amyloid 2017; 24:52-59. [PMID: 28434267 DOI: 10.1080/13506129.2017.1314959] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We performed a prospective sensitivity analysis to detect amyloid in bone marrow (BM) smears stained with Congo red (CR) and according to Pappenheim of patients with systemic light-chain (AL) amyloidosis. Results were directly compared to routine BM histology and fat aspiration. We analysed 198 BM smears from patients with the diagnosis or suspicion of systemic AL amyloidosis. Ultimately, the diagnosis could be established for 168 patients. Amyloid was detected on BM smears with CR in 33% (56/168). All patients suspicious for amyloid on Pappenheim staining (n = 39) showed substantial amyloid infiltration on CR. No patient without systemic AL amyloidosis stained positive. Sensitivity for routine BM histology was 57% (74/129) and for fat aspiration 96% (134/140). Patients with amyloid on BM smears had significantly more hepatic (42 vs. 9%, p < .001), renal (78 vs. 43%, p < .001) and gastrointestinal involvement (40 vs. 22%, p < .01) and less commonly cardiac involvement (58 vs. 76%, p < .03) and consecutively no adverse prognosis. CR staining of BM smears cannot be recommended as a primary screening tool for systemic AL as its overall sensitivity is far inferior to BM histology and fat aspiration. However, we recommend using the technique when suspecting amyloid on Pappenheim staining to establish the diagnosis of systemic AL amyloidosis.
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Affiliation(s)
- Christoph Kimmich
- a Amyloidosis Center, Department of Medicine V , University Hospital Heidelberg , Heidelberg , Germany
| | - Stefan Schönland
- a Amyloidosis Center, Department of Medicine V , University Hospital Heidelberg , Heidelberg , Germany
| | - Sandra Kräker
- a Amyloidosis Center, Department of Medicine V , University Hospital Heidelberg , Heidelberg , Germany
| | - Mindaugas Andrulis
- b Department of General Pathology , University Hospital Ulm , Ulm , Germany
| | - Anthony D Ho
- a Amyloidosis Center, Department of Medicine V , University Hospital Heidelberg , Heidelberg , Germany
| | - Gudrun Mayer
- a Amyloidosis Center, Department of Medicine V , University Hospital Heidelberg , Heidelberg , Germany
| | - Tobias Dittrich
- a Amyloidosis Center, Department of Medicine V , University Hospital Heidelberg , Heidelberg , Germany
| | - Michael Hundemer
- a Amyloidosis Center, Department of Medicine V , University Hospital Heidelberg , Heidelberg , Germany
| | - Ute Hegenbart
- a Amyloidosis Center, Department of Medicine V , University Hospital Heidelberg , Heidelberg , Germany
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11
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Clarifying immunoglobulin gene usage in systemic and localized immunoglobulin light-chain amyloidosis by mass spectrometry. Blood 2016; 129:299-306. [PMID: 27856462 DOI: 10.1182/blood-2016-10-743997] [Citation(s) in RCA: 81] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 11/09/2016] [Indexed: 01/30/2023] Open
Abstract
The goal of this study was to investigate the frequency of use of light-chain variable region (IGVL) genes among patients with systemic (ALS) and localized (ALL) amyloidosis and to assess for associations between IGVL gene usage and organ tropism. We evaluated clinic charts from 821 AL patients seen at the Mayo Clinic who had bone marrow, fat pad, and solid organ tissue samples typed by liquid chromatography tandem mass spectrometry (LC-MS). We identified 701 patients with ALS and 120 with ALL Overall, we were able to identify an IGVL gene in 87 (72%) patients with ALL and 573 (82%) patients with ALS When compared with ALL, LV6-57 was more common, whereas KV3-20 and heavy-chain codeposition were less common in ALS In this large series of ALS, characteristics particular to specific genotypes became apparent. LV6-57 patients were more likely to have renal involvement and to harbor a translocation 11;14. LV3-01 patients were less likely to have advanced cardiac disease and renal involvement. LV2-14 patients were more likely to have peripheral nerve involvement, an intact circulating immunoglobulin, and lower circulating dFLC. LV1-44 patients were more likely to have cardiac involvement. KV1-33 patients had more liver involvement and higher circulating dFLC. Finally, KV1-05 was associated with inferior overall survival but not independently of cardiac stage. IGVL gene usage appears to provide clues about disease pathophysiology and tissue tropism. LC-MS is a high-throughput and low-resource technique that can be used to identify IGVL gene from clinical tissue specimens.
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Abstract
Immunoglobulin light chain amyloidosis (AL) is a rare, complex disease caused by misfolded free light chains produced by a usually small, indolent plasma cell clone. Effective treatments exist that can alter the natural history, provided that they are started before irreversible organ damage has occurred. The cornerstones of the management of AL amyloidosis are early diagnosis, accurate typing, appropriate risk-adapted therapy, tight follow-up, and effective supportive treatment. The suppression of the amyloidogenic light chains using the cardiac biomarkers as guide to choose chemotherapy is still the mainstay of therapy. There are exciting possibilities ahead, including the study of oral proteasome inhibitors, antibodies directed at plasma cell clone, and finally antibodies attacking the amyloid deposits are entering the clinic, offering unprecedented opportunities for radically improving the care of this disease.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
- Division of Laboratory Medicine, Mayo Clinic, Rochester, MN, USA
| | - 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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Huang X, Wang Q, Jiang S, Chen W, Zeng C, Liu Z. The clinical features and outcomes of systemic AL amyloidosis: a cohort of 231 Chinese patients. Clin Kidney J 2014; 8:120-6. [PMID: 25713722 PMCID: PMC4310422 DOI: 10.1093/ckj/sfu117] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 10/13/2014] [Indexed: 11/12/2022] Open
Abstract
Background Few data are available on the clinical features and outcomes of Chinese patients with systemic immunoglobulin light-chain (AL) amyloidosis. The aim of this study is to reveal the clinical picture and risk factors of disease progression in a large cohort of Chinese patients with AL amyloidosis. Methods Patients in the Jinling Hospital amyloidosis registry from 2003 to 2011 were studied. The clinical and laboratory information were collected from first presentation to death or until the last available clinical follow-up. The patients' survival and renal outcomes were analyzed, and the relationships between the clinical parameters and survival were also assessed. Results A total of 231 patients were enrolled in this study, all the patients studied had renal involvement. One hundred and fifty-three (66.2%) were male, and the median age at diagnosis was 56 years. A total of 198 (85.7%) cases had light-chain λ-type. One hundred and forty-seven (63.6%) cases presented as nephrotic syndrome (NS), and 25% of patients had renal insufficiency at diagnosis. Liver involvement and NS appeared to be more common in patients of κ-type amyloidosis, and renal impairment is more severe in κ-type amyloidosis. The median survival time of all patients was 36.3 months, and the 1-, 2-, 3- and 5-year cumulative survival rates were 67, 53, 48 and 35%, respectively. Multivariate COX analysis showed that age, hepatic involvement and heart involvement can significantly influence survival in these patients. The median time that patients remained dialysis free was 50 months. The percentage of patients that remained dialysis free at 1, 2, 3 and 5 years were 78, 69, 62 and 37%, respectively. Multivariate COX analysis showed that serum creatinine and hypotension were the important risk factors of renal failure. Conclusion λ-Type is the most dominant type of AL amyloidosis in Chinese patients. The survival of patients with AL amyloidosis is poor. The risk factors included heart and hepatic involvement, hypotension and impairment of renal function. The high serum creatinine level and hypotension at diagnosis are associated with poor renal outcome.
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Affiliation(s)
- Xianghua Huang
- National Clinical Research Center of Kidney Diseases , Jinling Hospital, Nanjing University School of Medicine , Nanjing 21002 , China
| | - Qingwen Wang
- National Clinical Research Center of Kidney Diseases , Jinling Hospital, Nanjing University School of Medicine , Nanjing 21002 , China
| | - Song Jiang
- National Clinical Research Center of Kidney Diseases , Jinling Hospital, Nanjing University School of Medicine , Nanjing 21002 , China
| | - Wencui Chen
- National Clinical Research Center of Kidney Diseases , Jinling Hospital, Nanjing University School of Medicine , Nanjing 21002 , China
| | - Caihong Zeng
- National Clinical Research Center of Kidney Diseases , Jinling Hospital, Nanjing University School of Medicine , Nanjing 21002 , China
| | - Zhihong Liu
- National Clinical Research Center of Kidney Diseases , Jinling Hospital, Nanjing University School of Medicine , Nanjing 21002 , China
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Abstract
Systemic amyloidoses are rare, complex diseases caused by misfolding of autologous proteins. Although these diseases are fatal, effective treatments exist that can alter their natural history, provided that they are started before irreversible organ damage has occurred. The cornerstones of the management of systemic amyloidoses are early diagnosis, accurate typing, appropriate risk-adapted therapy, tight follow-up, and effective supportive treatment. Internists play a key role in suspecting the disease, thus allowing early diagnosis, starting the diagnostic workup and selecting patients that should be referred to specialized centers, judiciously titrating supportive measures, and following patients throughout the course of the disease. Here we review the pathogenesis, diagnosis and treatment of the most common forms of systemic amyloidoses.
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Affiliation(s)
- Giovanni Palladini
- Amyloidosis Research and Treatment Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
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