Definition of Amyloidosis

Definition of amyloid and amyloidosis

Amyloid is defined as in vivo deposited material distinguished by fibrillar electron micrographic appearance, amorphous eosinophilic appearance on hematoxylin and eosin staining (see the first image below), beta pleated sheet structure as observed by x-ray diffraction pattern, apple-green birefringence on Congo Red histological staining (see the second image below), and solubility in water and buffers of low ionic strength. All types of amyloid consist of a major fibrillar protein that defines the type of amyloid.[1, 2]

Amorphous eosinophilic interstitial amyloid observed on a

renal biopsy. Congo Red staining of a cardiac biopsy specimen containing amyloid, viewed under polarized light. Amyloidosis is a clinical disorder caused by extracellular and or intracellular deposition of insoluble abnormal amyloid fibrils that alter the normal function of tissues. Approximately 10% of amyloidosis depots consist of components such as glycosaminoglycans (GAGs), apolipoprotein E (apoE), and serum amyloid P (SAP) component, while 90% of the depots consist of the amyloid fibrils that are formed by the aggregation of misfolded proteins. These proteins either arise from proteins expressed by cells at the deposition site (localized) or precipitate systemically after production at a local site (systemic).[3] In humans, about 23 different unrelated proteins are known to form amyloid fibrils in vivo.[4] Many mechanisms of protein function contribute to amyloidogenesis, including "nonphysiologic proteolysis, defective physiologic proteolysis, mutations involving changes in thermodynamic or kinetic properties, and pathways that are yet to be defined."[4]

Classification Systems: Historical (Clinical Based) and Modern (Biochemical Based)

Historical classification systems (clinical based)

Until the early 1970s, the idea of a single amyloid substance predominated. Various descriptive classification systems were proposed based on the organ distribution of amyloid deposits and clinical findings. Most classification systems included primary (ie, in the sense of idiopathic) amyloidosis, in which no associated clinical condition was identified, and secondary amyloidosis, ie, associated with chronic inflammatory conditions. Some classification systems included myeloma-associated, familial, and localized amyloidosis. The modern era of amyloidosis classification began in the late 1960s with the development of methods to solubilize amyloid fibrils. These methods permitted chemical amyloid studies. Descriptive terms such as primary amyloidosis, secondary amyloidosis, and others (eg, senile amyloidosis), which are not based on etiology, provide little useful information and are no longer recommended.

Modern amyloidosis classification (biochemical based)

Amyloid is now classified chemically. The amyloidoses are referred to with a capital letter A (for amyloid) followed by an abbreviation for the fibril protein. For example, in most cases formerly called primary amyloidosis and in myeloma-associated amyloidosis, the fibril protein is an immunoglobulin light chain or light chain fragment (abbreviated L); thus, patients with these amyloidoses are now said to have light chain amyloidosis (AL). Names such as AL describe the protein (light chain), but not necessarily the clinical phenotype.[3] Similarly, in most cases previously termed senile cardiac amyloidosis and in many cases previously termed familial amyloid polyneuropathy (FAP), the fibrils consist of the transport protein transthyretin (TTR); these diseases are now collectively termed ATTR. Proteins that form amyloid fibrils differ in size function, amino acid sequence, and native structure but become insoluble aggregates that are similar in structure and in properties. Protein misfolding results in formation of fibrils that show a common beta sheet pattern on x-ray diffraction. In theory, misfolded amyloid proteins can be attributed to infectious sources (prions), de novo gene mutations, errors in transcription, errors in translation, errors in posttranslational modification, or protein transport. For example, in ATTR, 100 different points of single or double mutations, or deletions in the TTR gene and several different phenotypes of FAP have been documented.[5] Twenty-three different fibril proteins are described in human amyloidosis, with variable clinical features. The major types of human amyloid are outlined and discussed individually in the table below. Table. Human Amyloidoses (Open Table in a new window) Type Systemic Fibril Protein Immunoglobulin light chains Main Clinical Settings Plasma cell disorders

Familial amyloidosis, senile cardiac amyloidosis Inflammation-associated amyloidosis, familial Mediterranean fever Beta2 -microglobulin Dialysis-associated amyloidosis Immunoglobulin heavy Systemic amyloidosis chains Hereditary Fibrinogen alpha chain Familial systemic amyloidosis Apolipoprotein AI Familial systemic amyloidosis Apolipoprotein AII Familial systemic amyloidosis Lysozyme Familial systemic amyloidosis Central nervous Beta protein precursor Alzheimer syndrome, Down syndrome, system hereditary cerebral hemorrhage with amyloidosis (Dutch) Prion protein Creutzfeldt-Jakob disease, GerstmannStrussler-Scheinker disease, fatal familial insomnia, Kuru Cystatin C hereditary cerebral hemorrhage with amyloidosis (Icelandic) ABri precursor protein Familial dementia (British) ADan precursor protein Familial dementia (Danish) Ocular Gelsolin Familial amyloidosis (Finnish) Lactoferrin Familial corneal amyloidosis Keratoepithelin Familial corneal dystrophies Localized Calcitonin Medullary thyroid carcinoma Amylin* Insulinoma, type 2 diabetes Atrial natriuretic factor Isolated atrial amyloidosis amyloidosis Prolactin Pituitary amyloid Keratin Cutaneous amyloidosis Medin Aortic amyloidosis in elderly people *Islet amyloid polypeptide amyloidosis

Transthyretin A amyloidosis

Systemic Amyloidoses
A amyloidosis
The precursor protein in A amyloidosis (AA) is a normal-sequence apo-SAA (serum amyloid A protein) now called "A," which is an acute-phase reactant produced mainly in the liver in response to multiple cytokines.[3] "A" protein circulates in the serum bound to high-density lipoprotein. AA occurs in various chronic inflammatory disorders, chronic local or systemic microbial infections, and occasionally with neoplasms. The frequency of amyloidosis has been

shown to vary significantly in different ethnic groups.[6] Some of the conditions associated with AA include the following:

Rheumatoid arthritis (RA) Juvenile chronic arthritis Ankylosing spondylitis Psoriasis and psoriatic arthritis Still disease Behet syndrome Familial Mediterranean fever Crohn disease Leprosy Osteomyelitis Tuberculosis Chronic bronchiectasis Castleman disease Hodgkin disease Renal cell carcinoma Carcinoma of the gastrointestinal, lung, or urogenital tract Cryopyrin-associated periodic syndromes (CAPS)

Organs that are typically involved include the kidney, liver, and spleen. Worldwide, AA is the most common systemic amyloidosis; it was formerly termed secondary amyloidosis. Therapy has traditionally been aimed at the underlying inflammatory condition to reduce the production of the precursor amyloid protein SAA. Disease modifying antirheumatic drugs (DMARDS) such as colchicine, a microtubule inhibitor and weak immunosuppressant, can prevent secondary renal failure due to amyloid deposition specifically in familial Mediterranean fever. Newer therapies have become more targeted to avoid the cytotoxicity of older agents (chlorambucil, cyclophosphamide). Recently, the SAA amyloid seen in CAPS was reduced with a new biologic interleukin (IL)1 beta trap called rilonacept. Tumor necrosis factor (TNF)alpha is also thought to be involved in amyloid deposition.[7] Aggressive use of newer biologic therapies for RA, such as etanercept (a TNF-alpha blocker), have been used to decrease the concentration of SAA, serum creatinine, creatinine clearance, and proteinuria in renal AA associated with RA.[8] Additionally, SAA isoforms have been studied using high-resolution 2-dimensional gel electrophoresis and peptide mapping by reverse-phase chromatography, electrospray ionization tandem mass spectrometry, and genetic analysis down to the posttranslational modification level.[9] SAA is coded by 4 genes SAA1, SAA2, SAA3, and SAA4. The SAA1 gene contributes to most of the deposits and contains a single nucleotide polymorphism that defines at least 3 haplotypes. The saa1.3 allele was found to be a risk factor and a poor prognostic indicator in Japanese patients with RA. Genetic analysis has proven useful not only in selecting patients for biologic therapy but also in predicting outcome (see below).[10]

Light chain amyloidosis

The precursor protein is a clonal immunoglobulin light chain or light chain fragment. AL is a monoclonal plasma cell disorder closely related to multiple myeloma, as some patients fulfill diagnostic criteria for multiple myeloma. Typical organs involved include the heart, kidney, peripheral nerve, gastrointestinal tract, respiratory tract, and nearly any other organ. AL includes former designations of primary amyloidosis and myelomaassociated amyloidosis. Treatment usually mirrors the management of multiple myeloma (ie, chemotherapy). Selected patients have received benefit from high-dose melphalan and autologous stemcell transplantation, with reports of prolonged survival in recent studies. Alternative therapeutic approaches include thalidomide, lenalidomide, iododoxorubicin, etanercept, and rituximab.[11] Iododoxorubicin, a molecule that binds to and solubilizes amyloid fibrils, is undergoing clinical study. For more information, see Amyloidosis, Immunoglobulin-Related.

Heavy chain amyloidosis

In a few cases, immunoglobulin chain amyloidosis fibrils contain only heavy chain sequences rather than light chain sequences, and the disease is termed heavy chain amyloidosis (AH) rather than AL. Electron microscopy may be helpful in the detection of small deposits and in the differentiation of amyloid from other types of renal fibrillar deposits.[12] For more information, see Amyloidosis, Immunoglobulin-Related.

Transthyretin amyloidosis
The precursor protein is the normal- or mutant-sequence TTR, a transport protein synthesized in the liver and choroid plexus. TTR is a tetramer of 4 identical subunits of 127 amino acids each. Normal-sequence TTR forms amyloid deposits in the cardiac ventricles of elderly people (ie, >70 y); this disease was also termed senile cardiac amyloidosis. The prevalence of TTR cardiac amyloidosis increases progressively with age, affecting 25% or more of persons older than 90 years. Normal-sequence ATTR can be an incidental autopsy finding or can cause clinical symptoms (eg, heart failure, arrhythmias). Point mutations in TTR increase the tendency of TTR to form amyloid. Amyloidogenic TTR mutations are inherited as an autosomal-dominant disease with variable penetrance. More than 100 amyloidogenic TTR mutations are known.[13] The most prevalent TTR mutations include TTR Val30Met (common in Portugal, Japan, and Sweden), and TTR Val122Ile (carried by 3.9% of African Americans). Amyloidogenic TTR mutations cause deposits primarily in the peripheral nerves, heart, gastrointestinal tract, and vitreous. Mutant-sequence amyloidogenic TTR is treated with liver transplantation or supportive care. Liver transplantation should be performed in Val30Met-positive patients as early as

possible.[13] For normal-sequence amyloidogenic TTR, the treatment is supportive care. For details, see Amyloidosis, Transthyretin-Related.

Beta2 -microglobulin amyloidosis

The precursor protein is a normal beta2 -microglobulin (2 M), which is the light chain component of the major histocompatibility complex. In the clinical setting, 2 M is associated with dialysis and, rarely, renal failure in the absence of dialysis. 2 M is normally catabolized in the kidney. In patients with renal failure, the protein accumulates in the serum. Conventional dialysis membranes do not remove 2 M; therefore, serum levels in patients on hemodialysis can vault to 30-60 times the reference range. Traut et al (2007) reported that patients using polyamide high-flux membranes had lower 2 M concentrations than patients on low-flux dialyzers.[14] They postulated that the difference was mediated by an increase in 2 M mRNA, lower concentrations of 2 M released from the blood cells, and/or better 2 M clearance in patients treated with high-flux dialyzers.[14] Musculoskeletal involvement is common and is characterized by deposits in the carpal ligaments, synovium, and bone, resulting in carpal tunnel syndrome, destructive arthropathy, bone cysts, and fractures. Other organs involved include the heart, gastrointestinal tract, liver, lungs, prostate, adrenals, and tongue. Treatment includes renal transplantation, which may arrest amyloid progression. For details, see Amyloidosis, Beta2M (Dialysis-Related).

Cryopyrin-associated periodic syndromeassociated amyloidosis

Familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS), and neonatal-onset multisystem inflammatory disease (NOMID) are all types of CAPS. These disorders are typically associated with heterozygous mutations in the NLRP3 (CIAS1) gene, which encodes the cryopyrin (NALP3) protein, and are inherited in an autosomal-dominant manner.[15] The inflammation in CAPS is driven by excessive release of IL-1.[16] IL-1 release is normally regulated by an intracellular protein complex known as the inflammasome, which maps to a gene sequence called NLRP3. Mutations in NLRP3 may cause an aberrant cryopyrin protein inside the inflammasome, leading to the release of too much IL-1 and subsequent multisystem inflammation. Patients with CAPS have chronically elevated levels of acute-phase reactants, especially serum amyloid A (SAA) and high-sensitivity C-reactive protein (hsCRP), due to increased IL-1 levels.[17, 18, 19] With elevated SAA combined with multisystem cytokine dysregulation, multisystemic amyloid deposition can be severe, with the most feared complication including renal failure. By blocking the action of IL-1 or down-regulating its production, inflammation and therefore amyloid deposition can be reduced.[20]

In a recent randomized double-blind CAPS therapy trial, a novel soluble decoy receptor called rilonacept was shown to provide rapid and profound symptom improvement in addition to measures of inflammation such as hsCRP and SAA levels.[20] In the second part of the study, continued treatment with rilonacept maintained improvements, and discontinuation worsened disease activity.[20]

Muckle-Wells syndrome
MWS is another autoinflammatory syndrome secondary to a mutation in CIAS gene encoding cryopyrin, a component of the inflammasome that regulates the processing of IL-1. The IL-1 receptor antagonist anakinra has been shown to improve the signs and symptoms in MWS by decreasing serum CRP and SAA levels and cytokines such as IL6, IL-8, IL-12, and IL-1. In some cases, it improved sensory deafness, as well as the laboratory values for markers of inflammation MWS.[21]

Hereditary Renal Amyloidoses

Hereditary amyloidoses encompass a group of conditions that each are related to mutations in a specific protein. The most common form is TTR amyloidosis (usually neuropathic), but nonneuropathic amyloidoses likely result from abnormalities in lysozyme, fibrinogen, alpha-chain, or apolipoprotein A-I and A-II.[22] Consider these diseases when a renal biopsy demonstrates amyloid deposition and when they are likely diagnoses (rather than AL or AA) because the family history suggests an autosomaldominant disease. Again, the definitive diagnosis is made using immunohistologic staining of the biopsy material with antibodies specific for the candidate amyloid precursor proteins. A clinical correlation is required to diagnose amyloid types, even if a hereditary form is detected by amyloid protein typing.[23] For details, see Amyloidosis, Familial Renal. Apolipoprotein AI amyloidosis (apoAI) is an autosomal-dominant amyloidosis caused by point mutations in the apoAI gene. Usually, this amyloidosis is a prominent renal amyloid but can also form in many locations. ApoAI (likely of normal sequence) is the fibril precursor in localized amyloid plaques in the aortae of elderly people. ApoAI can manifest either as a nonhereditary form with wild-type protein deposits in atherosclerotic plaques or as a hereditary form due to germline mutations in the apoA1 gene.[24] Currently, more than 50 apoAI variants are known, and 13 are associated with amyloidosis.[24] As more gene locations are found, the clinical phenotypes are slowly being elucidated. Fibrinogen amyloidosis (AFib) is an autosomal-dominant amyloidosis caused by point mutations in the fibrinogen alpha chain gene. If DNA sequences indicate a mutant amyloid precursor protein, protein analysis of the deposits must provide the definitive evidence in laboratories with sophisticated methods.[23] Lysozyme amyloidosis (ALys) is an autosomal-dominant amyloidosis caused by point mutations in the lysozyme gene.

Apolipoprotein AII amyloidosis (AapoAII) is an autosomal-dominant amyloidosis caused by point mutations in the apoAII gene. The 2 kindreds described with this disorder have each carried a point mutation in the stop codon, leading to production of an abnormally long protein.

Central Nervous System Amyloidoses and Other Localized Amyloidoses

Central Nervous System Amyloidoses
Beta protein amyloid The amyloid beta precursor protein (AbPP), which is a transmembrane glycoprotein, is the precursor protein in beta protein amyloid (Ab). Three distinct clinical settings are as follows: 1. Alzheimer disease has a normal-sequence protein, except in some cases of familial Alzheimer disease, in which mutant beta protein is inherited in an autosomal-dominant manner. 2. Down syndrome has a normal-sequence protein that forms amyloids in most patients by the fifth decade of life. 3. Hereditary cerebral hemorrhage with amyloidosis (HCHWA), Dutch type, is inherited in an autosomal-dominant manner. The beta protein contains a point mutation. These patients typically present with cerebral hemorrhage followed by dementia. The accumulation of amyloid- peptide (A) in the brain, both in the form of plaques in the cerebral cortex and in blood vessels as cerebral amyloid angiopathy (CAA), causes progressive cognitive decline. Recently, experimental models and human clinical trials have shown that accumulation of A plaques can be reversed by immunotherapy. A immunization results in solubilization of plaque A42, which, at least in part, exits the brain via the perivascular pathway, causing a transient increase in the severity of CAA. The extent to which these vascular alterations following A immunization in Alzheimer disease are reflected in changes in cognitive function remains to be determined.[25] Prion protein amyloidosis The precursor protein in prion protein amyloidosis (APrP) is a prion protein, which is a plasma membrane glycoprotein. The etiology is either infectious (ie, kuru, transmissible spongiform encephalitis [TSE]) or genetic (ie, Creutzfeldt-Jakob disease [CJD], Gerstmann-Strussler-Scheinker [GSS] syndrome, fatal familial insomnia [FFI]). The infectious prion protein is a homologous protein encoded by a host chromosomal gene that induces a conformational change in a native protease-sensitive protein, increasing the content of beta-pleated sheets. The accumulation of these beta-pleated sheets renders the protein protease-resistant and therefore amyloidogenic.[26] Patients with TSE, CJD, GSS,

and FFI carry autosomal-dominant amyloidogenic mutations in the prion protein gene; therefore, the amyloidosis forms even in the absence of an infectious trigger. Similar infectious animal disorders include scrapie in sheep and goats and bovine spongiform encephalitis (ie, mad cow disease). Cystatin C amyloidosis The precursor protein in cystatin C amyloidosis (ACys) is cystatin C, which is a cysteine protease inhibitor that contains a point mutation. This condition is clinically termed HCHWA, Icelandic type. ACys is autosomal dominant. The clinical presentation includes multiple strokes and mental status changes beginning in the second or third decade of life. Many patients die by age 40 years. This disease is documented in a 7-generation pedigree in northwest Iceland. The pathogenesis is one of mutant cystatin that is widely distributed in tissues, but fibrils form only in the cerebral vessels; therefore, local conditions must play a role in fibril formation. Nonamyloid beta cerebral amyloidosis (chromosome 13 dementias) Two syndromes (British and Danish familial dementia) that share many aspects of clinical Alzheimer disease have been identified. Findings include the presence of neurofibrillary tangles, parenchymal preamyloid and amyloid deposits, cerebral amyloid angiopathy, and amyloid-associated proteins. Both conditions have been linked to specific mutations on chromosome 13; they cause abnormally long protein products (ABri and ADan) that ultimately result in different amyloid fibrils.

Other Localized Amyloidoses

Gelsolin amyloidosis The precursor protein in gelsolin amyloidosis (AGel) is the actin-modulating protein gelsolin. Amyloid fibrils include a gelsolin fragment that contains a point mutation. Two amyloidogenic gelsolin mutations are described. One example is Asp187Asn, which is endemic in southeast Finland. Clinical characteristics include slowly progressive cranial neuropathies, distal peripheral neuropathy, and lattice corneal dystrophy. Atrial natriuretic factor amyloidosis The precursor protein is atrial natriuretic factor (ANF), a hormone that controls salt and water homeostasis; it is synthesized by the cardiac atria. Amyloid deposits are localized to the cardiac atria. This condition is highly prevalent in elderly people and is of generally little clinical significance. Atrial natriuretic factor amyloidosis (AANF) is most

common in patients with long-standing congestive heart failure, presumably because of persistent ANF production. No relation exists to the amyloidoses that involve the cardiac ventricles (ie, AL, ATTR). Keratoepithelin amyloidosis and lactoferrin amyloidosis Point mutations occur in a gene termed BIGH3, which encodes keratoepithelin and leads to autosomal-dominant corneal dystrophies characterized by the accumulation of corneal amyloid. Some BIGH3 mutations cause amyloid deposits, and others cause nonfibrillar corneal deposits. Another protein, lactoferrin, is also reported as the major fibril protein in familial subepithelial corneal amyloidosis. The relationship between keratoepithelin and lactoferrin in familial corneal amyloidosis is not yet clear. Calcitonin amyloid In calcitonin amyloid (ACal), the precursor protein is calcitonin, a calcium regulatory hormone synthesized by the thyroid. Patients with medullary carcinoma of the thyroid may develop localized amyloid deposition in the tumors, consisting of normal-sequence procalcitonin (ACal). The presumed pathogenesis is increased local calcitonin production, leading to a sufficiently high local concentration of the peptide and causing polymerization and fibril formation. Islet amyloid polypeptide amyloidosis In islet amyloid polypeptide amyloidosis (AIAPP), the precursor protein is an islet amyloid polypeptide (IAPP), also known as amylin. IAPP is a protein secreted by the islet beta cells that are stored with insulin in the secretory granules and released in concert with insulin. Normally, IAPP modulates insulin activity in skeletal muscle. IAPP amyloid is found in insulinomas and in the pancreas of many patients with diabetes mellitus type 2. Prolactin amyloid In prolactin amyloid (Apro), prolactin or prolactin fragments are found in the pituitary amyloid. This condition is often observed in elderly people and has also been reported in an amyloidoma in a patient with a prolactin-producing pituitary tumor. Keratin amyloid Some forms of cutaneous amyloid react with antikeratin antibodies. The identity of the fibrils is not chemically confirmed in keratin amyloid (Aker). Medin amyloid

Aortic medial amyloid occurs in most people older than 60 years. Medin amyloid (AMed) is derived from a proteolytic fragment of lactadherin, a glycoprotein expressed by mammary epithelium.

Nonfibrillar Components of Amyloid

All types of amyloid deposits contain not only the major fibrillar component (solubility in water, buffers of low ionic strength) but also nonfibrillar components that are soluble in conventional ionic strength buffers. The role of the minor components in amyloid deposition is not clear. These components do not appear to be absolutely required for fibril formation, but they may enhance fibril formation or stabilize formed fibrils. The nonfibrillar components, contained in all types of amyloid, include the following:

Pentagonal component o Pentagonal (P) component comprises approximately 5% of the total protein in amyloid deposits. This component is derived from the circulating SAP component, which behaves as an acute-phase reactant. The P component is one of the pentraxin group of proteins, with homology to C-reactive protein. In experimental animals, amyloid deposition is slowed without the P component. o Radiolabeled material homes to amyloid deposits; therefore, this component can be used in amyloid scans to localize and quantify amyloidosis and to monitor therapy response. Radiolabeled P component scanning has proven clinically useful in England, where the technology was developed, but it is available in only a few centers worldwide. Apolipoprotein E o ApoE is found in all types of amyloid deposits. o One allele, ApoE4, increases the risk for beta protein deposition, which is associated with Alzheimer disease. ApoE4 as a risk factor for other forms of amyloidosis is controversial. o The role of apoE in amyloid formation is not known. Glycosaminoglycans o GAGs are heteropolysaccharides composed of long unbranched polysaccharides that contain a repeating disaccharide unit. These proteoglycans are basement membrane components intimately associated with all types of tissue amyloid deposits. Amyloidotic organs contain increased amounts of GAGs, which may be tightly bound to amyloid fibrils. Heparan sulfate and dermatan sulfate are the GAGs most often associated with amyloidosis. o Heparan sulfate and dermatan sulfate have an unknown role in amyloidogenesis. Studies of AA and AL amyloid have shown marked restriction of the heterogeneity of the GAG chains, suggesting that particular subclasses of heparan and dermatan sulfates are involved.

Compounds that bind to heparan sulfate proteoglycans (eg, anionic sulfonates) decrease fibril deposition in murine models of AA and have been suggested as potential therapeutic agents. Other components found in some types of amyloid include complement components, proteases, and membrane constituents.
o

Mechanisms of Amyloid Formation

Amyloid protein structures
In all forms of amyloidosis, the cell secretes the precursor protein in a soluble form that becomes insoluble at some tissue site, compromising organ function. All the amyloid precursor proteins are relatively small (ie, molecular weights 4000-25,000) and do not share any amino acid sequence homology. The secondary protein structures of most soluble precursor proteins (except for SAA and chromosomal prion protein [Prpc]) have substantial beta pleated sheet structure, while extensive beta sheet structure occurs in all of the deposited fibrils. In some cases, hereditary abnormalities (primarily point mutations) in the precursor proteins are always present (eg, lysozyme, fibrinogen, cystatin C, gelsolin). In other cases, fibrils form from normal-sequence molecules (eg, AL, 2 M). In other cases, normal-sequence proteins can form amyloid, but mutations underlying inflammatory milieu accelerate the process (eg, TTR, beta protein precursor, CAPS).

Deposition location
In localized amyloidoses, the deposits form close to the precursor synthesis site; however, in systemic amyloidoses, the deposits may form either locally or at a distance from the precursor-producing cells. Amyloid deposits primarily are extracellular, but reports exist of fibrillar structures within macrophages and plasma cells.

Proteolysis and protein fragments

In some types of amyloidosis (eg, always in AA, often in AL, ATTR), the amyloid precursors undergo proteolysis, which may enhance folding into an amyloidogenic structural intermediate. Also, some of the amyloidoses may have a normal proteolytic process that is disturbed, yielding a high concentration of an amyloidogenic intermediate. For example, it was shown that the mast cells of allergic responses may also participate in the development of secondary or amyloid AA in chronic inflammatory conditions. Mast cells hasten the partial degradation of the SAA protein that can produce highly amyloidogenic N-terminal fragments of SAA.[27] However, factors that lead to different organ tropisms for the different amyloidoses are still largely unknown. Whether the proteolysis occurs before or after tissue deposition is unclear in patients in whom protein fragments are observed in tissue deposits. In some types of amyloid (eg,

AL, A, ATTR), nonfibrillar forms of the same molecules can accumulate before fibril formation; thus, nonfibrillar deposits, in some cases, may represent intermediate deposition.

Approach To Diagnosing Amyloidosis

Pathologic diagnosis (Congo red staining and immunohistochemistry)
Immunocytochemical studies for amyloid should include stains for Congo Red apple green birefringence, hematoxylin and eosin staining (H&E) stains for amorphous material, kappa and lambda light chains, beta-amyloid A4 protein, TTR, beta 2microglobulin, cystatin C, gelsolin, and immunoreactivity with antiamyloid AA antibody.
[28]

Amyloidosis is diagnosed when Congo redbinding material is demonstrated in a biopsy specimen. Because different types of amyloidosis require different approaches to treatment, determining only that a patient has a diagnosis of amyloidosis is no longer adequate. A clinical situation may suggest the type of amyloidosis, but the diagnosis generally must be confirmed by immunostaining a biopsy specimen. Antibodies against the major amyloid fibril precursors are commercially available. For example, AL, ATTR, and A2 M can present as carpal tunnel syndrome or gastrointestinal amyloidosis, but each has a different etiology and requires a different treatment approach. Similarly, determining whether the amyloid is of the AL or ATTR type is often difficult in patients with cardiac amyloidosis because the clinical picture is usually similar. Without immunostaining to identify the type of deposited protein, an incorrect diagnosis can lead to ineffective and, perhaps, harmful treatment. Be wary of drawing diagnostic conclusions from indirect tests (eg, monoclonal serum proteins) because the results of these presumptive diagnostic tests can be misleading; for example, monoclonal serum immunoglobulins are common in patients older than 70 years, but the most common form of cardiac amyloidosis is derived from TTR.

Diagnosis by subcutaneous fat aspiration

For many years, rectal biopsy was the first procedure of choice. An important clinical advance was the recognition that the capillaries in the subcutaneous fat are often involved in patients with systemic amyloidosis and can often provide sufficient tissue for the diagnosis of amyloid, immunostaining, and, in some cases, amino acid sequence analysis; thus, biopsy of the organ with the most severe clinical involvement is often unnecessary. For example, in cardiac amyloidosis, the definitive diagnosis of the type of amyloid can be made using an endomyocardial biopsy specimen, with Congo red and immunologic staining of the tissue sample. Alternatively, when noninvasive testing suggests cardiac amyloidosis, a specific diagnosis is often made by studying a subcutaneous fat aspiration instead of endomyocardial biopsy, thereby avoiding an invasive procedure.

Organ biopsies
When the subcutaneous fat aspiration biopsy does not provide information to reach a firm diagnosis, biopsy samples can be collected from other organs. In addition, an advantage to performing a biopsy of an involved organ (eg, kidney, heart) is that it definitively establishes a cause-and-effect relationship between the organ dysfunction and amyloid deposition. It is important to recognize that not all biopsy sites offer the same sensitivity. The best sites to biopsy are the abdominal fat pad and rectal mucosa (approaching 90% sensitivity for fat pad and 73%-84% for rectal mucosa).[29] Other sites that are often sampled but have poor sensitivity for the diagnosis of amyloid include the salivary glands, skin, tongue, gingiva, stomach, and bone marrow.

Amyloid Arthropathy
RA and other autoimmune diseases (juvenile RA, spondyloarthropathies, autoinflammatory syndromes) can predispose to the deposition of amyloid fibrils.[30] Amyloidosis is actually a common cause of death in patients with ankylosing spondylitis. Amyloid deposition in inflammatory syndromes is amplified by the underlying inflammatory state, significantly increasing morbidity and mortality, especially in the case of renal amyloidosis.[31] However, autopsy study shows that amyloid arthropathy in RA is often undiagnosed in patients with long-standing severe RA.[32] Amyloid arthropathy is typically seen in the shoulders, knees, wrists, and elbows, especially because these joints are more easily aspirated to make tissue available for Congo Red and immunostaining. Amyloid arthropathy can actually mimic classic RA but usually lacks the intense distal synovitis and affects the hips and shoulder more than peripheral joints.[29] Synovial fluid found to contain amyloid fibrils, although not particularly inflammatory, with white blood cell counts on average less than 2000/L, contains marked synovial villi hypertrophy. The classic "shoulder-pad" sign denotes endstage amyloid deposits in the shoulder synovium and periarticular structures. Another articular structure commonly affected by amyloid deposition is the carpal tunnel. Carpal tunnel syndrome can be the presenting of sign of primary or secondary forms of amyloid, as only minimal deposits are required to impair nerve conduction. The diagnosis can be made with biopsy at the time of carpal tunnel release surgery or other joint procedures. In a pathology review of 124 patients undergoing carpal tunnel release without the previous diagnosis or clinical signs of amyloidosis, 82% had amyloid deposition. At 10-year follow up, only two patients had systemic amyloidosis diagnosed after amyloid was discovered in their tenosynovium.[33] Radiography can show irregularly shaped hyperlucencies, subchondral cysts, and erosions that correspond with low intensity signals on both T1 and T2 MRIs.[34] Ultrasonographic investigations may also show lucencies, soft-tissue changes, increased thickness of tendons, and joint effusions with echogenic zones.[35]

Up to 5% of patients with long-standing RA can develop systemic amyloidosis that usually presents as nephrotic syndrome.[29] Genetic studies can predict certain haplotypes that can increase the risk of developing amyloidosis 7-fold.[31] This increasing understanding of haplotypes and proteomics will hopefully lead to more specific therapies.[36] Interestingly, with the advent of newer, more effective therapies for inflammatory arthritis, the incidence of amyloidosis secondary to RA and other rheumatic conditions has recently decreased from 5% to less than 1%.[29]

Background
Amyloidosis comprises of a heterogeneous group of diseases in which normally soluble plasma proteins are deposited in the extracellular space in an abnormal, insoluble, fibrillar form. Amyloid A (AA) amyloidosis is the most common form of systemic amyloidosis worldwide. It is characterized by extracellular tissue deposition of fibrils that are composed of fragments of serum amyloid A (SAA) protein, a major acute-phase reactant protein, produced predominantly by hepatocytes. AA amyloidosis occurs in the course of a chronic inflammatory disease of either infectious or noninfectious etiology, hereditary periodic fevers, and with certain neoplasms such as Hodgkin disease and renal cell carcinoma. In developing countries, the most common instigator of AA amyloidosis is chronic infection; in industrialized societies, rheumatic diseases, such as rheumatoid arthritis (RA), are the usual stimuli. The United States is a major exception to this in that immunoglobulin-related amyloid light chain type (AL) of amyloidosis is more frequent than AA as the cause of systemic amyloid deposition. In AA amyloidosis, the kidney, liver, and spleen are the major sites of involvement. It becomes clinically overt mainly when renal damage occurs, manifesting either as proteinuria, nephrotic syndrome, or derangement in renal function. The tissue fibril consists of a 7500-dalton cleavage product of the SAA protein, which is an acute phase reactant, and like C-reactive protein, is synthesized by hepatocytes under the transcriptional regulation of cytokines including interleukin (IL)-1, IL-6 and tumor necrosis factor (TNF).[1] Under the influence of the inflammatory cytokine IL-6, hepatic transcription of the messenger ribonucleic acid (mRNA) for SAA may increase 1000-fold when exposed to an inflammatory stimulus. Intact circulating SAA (molecular weight 12,500 dalton) is complexed with high-density lipoproteins (HDL). During the course of inflammation, the apolipoprotein SAA (apoSAA) apparently displaces apolipoprotein A1 (apoA1) from the HDL particles and facilitates HDL-cholesterol uptake by macrophages.

Several lines of evidence have indicated that the conversion of SAA into amyloid fibrils occurs through its specific interaction with heparan sulphate, a ubiquitously expressed glycosaminoglycan component of the extracellular matrix. SAA specifically binds to heparan sulfate (HS) glycosaminoglycan, a common constituent of all types of amyloid deposits that has been shown to facilitate conformational transition of a precursor to betapleated sheet structure.[2] The protein has also been shown to be chemotactic for neutrophils, and it stimulates degranulation, phagocytosis, and cytokine release in these cells. Until relatively recently, the erythrocyte sedimentation rate (ESR) and the serum Creactive protein (CRP) level were used to monitor inflammation clinically. Current data suggest that, under some circumstances, changes in SAA may be a better measure. Increases in both CRP and SAA have been associated with active atherosclerotic coronary artery disease and cited as evidence for the inflammatory nature of that disease process. SAA also has been used to monitor the dissemination of malignancy. For information on other types of amyloidosis, see the article Amyloidosis, Overview in eMedicines Rheumatology volume.

Pathophysiology
Chronic or acute, recurrent, substantial elevations of SAA are necessary but not sufficient for the development of amyloidosis. The median plasma concentration of SAA in healthy persons is 3 mg/L, but the concentration can increase to more than 2000 mg/L during the acute-phase response. Many individuals with long-standing inflammatory disease, although severely compromised by their primary condition, clearly do not develop tissue amyloid deposition. What determines any patient's risk for the development of this complication of inflammation is not known. Therapy, genetic factors, and environmental factors have all been proposed as possible contributors to the response of the primary disease.

Genes and proteins involved:

Three protein isoforms of SAA are noted (ie, SAA 1, 2, 4). Each isoform is encoded by its own gene in a cluster on band 11p15.1 that also includes a pseudogene (SAA3P). SAA1 has 3 alleles (SAA1.1, SAA1.3, SAA1.5), defined by amino acid substitutions at positions 52 and 57 of the molecule.[3] The frequency of these alleles varies between populations and may be associated with the occurrence of AA amyloidosis in diseases such as rheumatoid arthritis. Also, it may have a role in determining the level of SAA in blood, clearance, susceptibility to proteolytic cleavage, severity of disease, and response to treatment. Seventy-six percent of Caucasians have SAA1.1, whereas only 5% have SAA1.3. In the Japanese population, the 3 alleles occur at approximately the same rate. Patients with a 1.1/1.1 genotype have a

3-fold to 7-fold increased risk of amyloidosis. But overall, the actual significance of the SAA genotype remains undefined.[2] Cellular and extracellular tissue factors : Mononuclear phagocytes might play a role in degradation of SAA and initiation of development of AA amyloidosis. Polymorphisms of the mannose-binding lectin 2(MBL-2) gene leading to decreased levels of functional MBL have been related to defective macrophage function. This suggests that genetic background may affect the ability of mononuclear phagocytes to effectively process and degrade SAA proteins. Additional tissue factors, such as enzymes found in the extracellular matrix, are likely to be involved in the proteolytic processing of SAA. Matrix metalloproteinases (MMPs) are involved in generation of SAA N-terminal fragments. In vitro studies confirmed that human SAAs and AA amyloid fibrils are susceptible to proteolytic cleavage by MMPs, generating fragments of different sizes. Studies have demonstrated that susceptibility to MMP-1 degradation is highly dependent on SAA1 genotype. The factors responsible for determining the site of deposition in any form of amyloidosis have not been identified. AA fibrils have been generated in tissue cultures by incubating SAA with macrophages. Deposits are frequently found in tissues with large numbers of phagocytic cells, notably the liver and spleen, but other affected organs, such as the kidneys, do not have the same cellular composition. Some data, derived from analysis of renal biopsy specimens, have suggested that glycoxidative modification of proteins, probably the AA protein itself, may also play a role in AA deposition in kidneys.

Epidemiology
Frequency

United States
The absolute prevalence of AA amyloidosis is difficult to ascertain because it depends on both the occurrence of predisposing inflammatory disorders and the proportion of individuals with those conditions who develop tissue amyloid deposition. The diseases in which AA amyloidosis has been reported are noted below, as are the frequencies (when such data are available). AA amyloidosis is far less common in the United States than in other countries, even in the setting of the same inflammatory disease. The variation in the occurrence of amyloid in a particular disease in different geographic locales may reflect genetic background, differences in treatment of the primary disease, or factors that are not currently understood.

International
As in the United States, the frequency of AA amyloidosis is determined by the prevalence of the associated diseases, as well as the incidence of amyloid deposition in those conditions. For instance, in some Middle Eastern countries, the prevalence of familial Mediterranean fever (FMF) is higher than anywhere else in the world. The frequency of renal amyloidosis in some populations with untreated FMF is almost 100%. In those countries, amyloidosis represents a significant proportion of all renal disease. Most available data to approximate the epidemiology of AA amyloidosis are derived from autopsies. The overall autopsy incidence of AA amyloidosis in western nations ranges from 0.50-0.86%.[4] Currently, rheumatic diseases such as rheumatoid arthritis (RA), ankylosing spondylitis (AS), psoriatic arthritis, and juvenile idiopathic arthritis are the most frequent causes (70%) of AA amyloidosis. The reported prevalence of amyloidosis in RA varies with the diagnostic procedure used (that is, autopsy, kidney biopsy or subcutaneous fat aspiration), the clinical status (preclinical or symptomatic disease), and the type of study (case series or population-based study). A study from Finland of the autopsy records of 1,666 patients with RA revealed a prevalence of amyloidosis of 5.8%, while a 10-year study of 1,000 patients with RA showed that 3.1% died of amyloidosis. The most common cause of renal involvement in ankylosing spondylitis is AA amyloidosis (62%), followed by IgA nephropathy (30%). Although its prevalence might be in decline, renal AA amyloidosis is a serious complication of AS, with a median survival time after onset of dialysis of 2.37 years, and with a 5-year survival rate of only 30%. The prevalence of the asymptomatic phase of AA amyloidosis in RA can range between 0.5% and 14%. Autopsy studies from the Netherlands have suggested a minimal prevalence of amyloidosis of approximately 1 per 75,000 population. Because 30-40% of amyloidosis cases in Western Europe is of the AL type, the estimated prevalence of AA amyloidosis is 1 per 100,000 population. Both the duration and severity of the inflammatory disease correlate with the frequency of amyloidosis as a complication. The occurrence of multiple alleles encoding the predominant fibril precursor raised the issue of whether each allele had the same propensity to form amyloid. If an amyloidogenic allele were more common in a particular population, then the frequency of amyloidosis in inflammatory disease would be expected to be higher. Three studies have indicated that a particular inherited form of SAA1 is associated with an increased frequency of amyloidosis in the course of a single inflammatory disease. In

Japanese people, in whom the SAA 1.5 allele is far more common than in whites (37.4% vs 5.3%), the 1.5 allele is enriched among patients with RA and amyloidosis. Individuals with RA and a single 1.5 gene have twice the risk for developing amyloid as those with no 1.5 alleles. People who are homozygous for the 1.5 allele have a relative risk of 4.48 compared with those with RA who lack any 1.5 alleles. The mechanism of the association may reside in the fact that the SAA 1.5 allele is associated with higher SAA levels in Japanese patients. The duration of the inflammatory disease prior to the development of amyloidosis appeared to be inversely related to the dose of the allele. In the United Kingdom, heterozygosity or homozygosity for the SAA 1.1 allele is associated with a greater risk for amyloidosis in whites with juvenile chronic arthritis; however, in patients with adult RA, the increase was not statistically significant.

Mortality/Morbidity
In some cases, usually of infectious origin, the clinical consequences of amyloid deposition may dissipate with reduction or disappearance of the tissue deposits if the inflammatory disease can be suppressed totally or eliminated. If treatment of the primary disease is unsuccessful, death of organ failure secondary to the amyloid deposition is the rule. In patients treated at centers in the United States, the United Kingdom, and Europe from 1956-1992, renal failure or sepsis was the mode of exitus in one half to three quarters of AA amyloidosis cases, with a median survival of 24-36 months. Series that are more current show a longer survival, which is based largely on the increased availability of renal replacement therapy. The progression of amyloidosis is related to the production and concentration of the circulating amyloidogenic precursor protein. The concentration of the acute phase protein SAA during follow-up correlates with deterioration of renal function, amyloid burden, and mortality in AA amyloidosis. In a study of 374 patients with AA amyloidosis who were followed for 15 years, the median survival after diagnosis of amyloidosis in those with a sustained acute phase response was 133 months. As per this study, the risk of death was 17.7 times as high among patients with SAA concentrations in the highest eighth, or octile, (155 mg/L) as among those with concentrations in the lowest octile (< 4 mg/L). In general, amyloidosis shortened the median life span 7.7 years, and survival strongly depended on controlling the underlying inflammatory process. Amyloid deposits regressed in 60% of patients who had a median SAA concentration of less than 10 mg/L, and survival among these patients was superior to survival among those in whom amyloid deposits did not regress. Sustained increased concentration of SAA is the most significant risk factor in AA amyloidosis, whereas reduction of SAA concentration improves survival and is associated with arrest or even regression of amyloid deposits.[5, 6,
7]

As per the Finnish Registry for Kidney Diseases, 502 patients with amyloidosis were identified entering RRT from 1987-2002. Eighty percent of these patients had amyloidosis associated with an underlying rheumatic disease. The 5-year survival rates among patients with the RA, AS, and juvenile idiopathic arthritis were 18%, 30%, and 27%, respectively.[8] Cardiac amyloidosis appears to be a predictor of worse outcome with a 5-year survival of 31% versus 63% for patients without cardiac involvement in a retrospective series of 42 patients from Japan.[9] The degree of renal involvement is important, with patients who have elevated creatinine levels doing worse compared with patients with a normal creatinine. The pattern of renal involvement is also important. Specifically, glomerular involvement with amyloid and fibrosis appear to have clinical course characterized by deteriorating renal function compared to patients with other types of renal involvement. Generally, however the median survival is over 5 years.[10] In a multicentric retrospective survey to assess the graft and patient survival in 59 renal recipients with AA amyloidosis, the recurrence rate of AA amyloidosis nephropathy was estimated at 14%. There was significant decrease in the 5-year and 10-year survival of patients in the AA amyloidosis group compared with the control group. Also, AA amyloidosis transplanted patients exhibited a high proportion of infectious complications after transplantation.[11]

Race
Very few appropriately controlled data address the question of racial prevalence of AA amyloidosis, other than observations suggesting that an increased frequency of AA amyloidosis occurs in the course of RA, which is related to variation in the distribution of particularly amyloidogenic SAA1 alleles among different ethnic groups. Within a single medical center in California, autopsies of patients of similar economic status with different ethnic origins displayed differences in the frequency of AA amyloidosis. In that series, AA amyloidosis was more common in Hispanic patients of Mexican origin than in either whites or African Americans.

Sex
In the United States, AA amyloidosis is more common in females, reflecting the fact that the major predisposing disease, RA, is predominantly a disorder of younger women and middle-aged men; hence, women are apt to have the disease for a longer period than men.

Despite the statistical female predominance in terms of overall numbers of AA amyloidosis cases, males seem to have an earlier average age of onset. FMF is more common in males than in females (male-to-female ratio, 60:40), but the frequency of renal amyloidosis in people who are affected appears to be similar.

Age
The age of onset of amyloidosis is related to the age of onset of the inflammatory disease, its severity, and the duration of the disease within the constraints imposed by the alleles of SAA carried by the patient. Thus, in the course of juvenile rheumatoid arthritis (JRA), amyloidosis occurs in teenagers. When it is a consequence of adult RA, it develops in late middle age. In the course of inadequately treated FMF, the renal amyloidosis is also of relatively early onset.

History
The most common presentation of amyloid A (AA) amyloidosis is renal. Renal involvement is found in as many as 90% of patients. Thus, symptoms reflect the appearance of proteinuria, progressive development of renal insufficiency, or nephrotic syndrome.

Weakness, weight loss, and peripheral edema are the most common symptoms. In patients with active RA, some of these symptoms may be incorrectly attributed to progression of the inflammatory disease or to adverse effects of drugs. But the development of proteinuria in patients with RA should always raise the suspicion of AA amyloidosis. The amyloid deposits occur in the spleen and liver. However, even a significant splenic and hepatic load may remain asymptomatic for long periods. Splenic involvement might be suspected if HowellJolly bodies are found in a peripheral blood smear of a nonsplenectomized patient, or by frequent episodes of infections. Rarely, evidence of bowel involvement dominates the presentation. GI involvement may lead to motility disorders and pseudo-obstruction. Amyloid accumulations in the small intestine can cause generalized malabsorption. The weakened bowel wall can rupture, leading to peritonitis. Blood vessel wall and tissue amyloid predispose to bleeding. Again, in patients with inflammatory joint disease, the GI symptoms can also be secondary to treatment, particularly with nonsteroidal anti-inflammatory drugs. Goiter has also been reported as a possible feature of symptomatic AA amyloidosis. Cardiac AA deposits may be revealed with echocardiography in about 10% of patients. Clinical evidence of cardiac involvement occurs in as many as 50% of patients with AL amyloidosis compared with less than 5% with AA amyloidosis. Amyloid accumulation in the heart may be suggested by by decreased voltage in the electrocardiogram limb leads, pseudoinfarction pattern in form of Q-waves in the anterior chest leads, and by thickening of the left ventricular wall disproportionate to the degree of current or prior hypertension. The hypomotile and pathological heart wall and failing heart predispose to mural thrombosis and embolic complications. Such right-sided heart involvement is a major prognostic determinant in AL amyloidosis, but uncommon in AA amyloidosis. Amyloid in the conduction pathways can lead to high-grade blocks.[12]

In contrast to AL amyloidosis and other amyloidoses, congestive heart failure, peripheral neuropathy, or carpal tunnel syndrome occasionally occurs during the course of AA amyloidosis, but they are rarely, if ever, a presenting manifestation. In patients with FMF, the history of periodic fever, arthritis, serositis, and the presence of the same disorder in other family members are characteristic. Some instances have been reported in which febrile episodes are not apparent, and renal amyloid is the first manifestation of disease. In patients with atrial myxoma or renal carcinoma, the appearance of symptoms consistent with nephrotic syndrome or renal failure due to amyloidosis may be the first evidence of the primary neoplastic disease. In general, the appearance of symptoms suggesting renal disease in a patient with chronic infectious or noninfectious inflammation should raise a warning flag with respect to the presence of AA amyloidosis as a complication. Rarely, a more specific symptom, such as abdominal fullness or right upper quadrant discomfort (reflecting hepatomegaly), might bring the patient to the physician.

Differentials

Amyloidosis, Familial Renal Amyloidosis, Immunoglobulin-Related Glomerulonephritis, Membranous Renal Vein Thrombosis

Laboratory Studies

The overwhelming factor in diagnosing amyloid A (AA) amyloidosis is considering the possibility that it is present. The development of proteinuria in any individual with chronic inflammatory disease or any of the associated conditions listed in Causes should prompt a search for tissue AA deposition, most commonly in the kidney. No specific tests for AA amyloidosis exist. o While the SAA precursor is usually elevated, prolonged elevation does not necessarily indicate tissue deposition because many patients with inflammatory disease have very high levels of SAA without developing amyloidosis. o Serum immunoglobulins should be evaluated because the presence of a monoclonal serum or urine protein suggests AL amyloidosis as a more likely diagnosis. o Patients with AA amyloidosis tend to show polyclonal hypergammaglobulinemia, reflecting their underlying inflammatory condition. Evaluate the parameters of renal function to monitor the course of the nephrotic syndrome or renal failure.

o o

Occasionally, patients show renal tubular acidosis as an early manifestation of renal involvement. Deterioration of a patient with the nephrotic syndrome may indicate progression of the amyloid renal disease, but consider the possibility of renal vein thrombosis because this complication can be observed in nephrotic syndrome due to any cause. A serum creatinine level greater than 2 mg/dL and/or a serum albumin level less than 2.5 g/dL have been associated with diminished survival rates, including renal survival.

Imaging Studies

Avoid intravenous pyelography in patients with suspected amyloidosis because dye exposure has been associated with more frequent renal failure in individuals with substantial proteinuria. Ultrasonography is useful in establishing renal size; however, kidneys may be large, small, or normal size in patients with renal amyloidosis. CT scanning may be useful because technetium occasionally binds to soft-tissue amyloid deposits. This was originally reported as an incidental finding. However, CT scanning does not yield great sensitivity, and reports concerning the specificity of CT scanning have varied considerably. If results are positive, CT scanning can be used to monitor gross progression of the deposition in a given organ. MRI may have a role in amyloidosis diagnosis in the future, but, currently, no formal studies have reported its use in a large series of patients. Radiolabeled P-component gamma scanning has been used in centers in London and France to demonstrate the total body burden of amyloid and its disappearance after successful treatment of the primary disease. This test has been most useful in AA amyloidosis because the major sites of deposition, ie, liver, kidneys, spleen, and adrenal glands, are readily accessible to the imaging agent.

Other Tests

In the 10% of cases of AA amyloidosis in showing cardiac involvement, conventional parameters of cardiac dysfunction, measured using electrocardiography, echocardiography, and cardiac catheterization with endomyocardial biopsy, provide the appropriate diagnostic information and tissue for the demonstration of AA (or other amyloid) deposition in the myocardium or coronary vessels.

Procedures
The choice of tissue specimen

For the detection of amyloid, biopsy of a clinically affected organ is the most sensitive method and may also detect concomitant pathologies. However, such a biopsy is invasive and carries the risk of complications, in particular bleeding. Thus, if amyloidosis is clinically suspected, a less invasive procedure may be desirable. In the early 1970s, Westermark and Stenkvist demonstrated that amyloid can be detected in subcutaneous fat. During the decades, subcutaneous fat pad biopsy, obtained via fine-needle aspiration, being safe, cheap, and rapid, has been introduced as a screening test for the detection of amyloidosis.[16] The tissue with the highest yield, particularly in the presence of proteinuria or renal failure, is the kidney. Technically adequate samples have a diagnostic yield close to 100%. Rectal biopsy is more useful than subcutaneous fat aspiration in AA amyloidosis. It has been found to produce positive results (assuming that submucosa is included in the biopsy specimen) in 80-85% of patients ultimately found to have tissue amyloid at a clinically relevant site. Samples from either the subcutaneous fat aspirate or the rectal biopsy can be stained as conventional tissue biopsies to determine the presence and nature of the amyloid precursor. Occasionally, patients have positive results on subcutaneous fat aspirates in the presence of a negative result on rectal biopsy, while others may have deposits in the rectal tissue and not in the aspirate. Use of both procedures may increase the yield to 90%. Abdominal subcutaneous fat biopsy results are not very sensitive in AA amyloidosis caused by FMF and in dialysis-related amyloidosis. The results are usually negative, probably because beta2-microglobulin does not accumulate in this tissue. Series from individual centers have shown that the labial gland or gastric mucosal biopsies can also be high-yield procedures, but these have not been used widely for amyloidosis, and their general utility remains to be definitively established. In the past, liver biopsy was a common procedure in the investigation of AA amyloidosis. Several reports of fatal liver rupture or bleeding, as well as the availability of sampling procedures with little or no morbidity and mortality, have resulted in its decreased use.

Detection of amyloid
Congo red stain continues to be the criterion standard for detection of amyloid deposits. In AL and AA amyloidosis, Congo red staining of aspirated subcutaneous abdominal fat has a sensitivity of 70-90% for the diagnosis. Kidney, heart, or liver samples have also been used for Congo red staining, but biopsy of rectal mucosa, skin, or subcutaneous fat is often sufficient, except in the cases of FMF, when it is rarely, if ever, positive. The tissue is stained with an alkaline solution of Congo red, and examined it under polarized light, where positive (green) birefringence is detectable in the presence of amyloidosis of any type. The nature of the fibril precursor can be established by immunohistochemical staining with antibodies specific for the major amyloid precursors

(AA, immunoglobulin L chains of or type, antitransthyretin). In AA amyloidosis, only the AA is positive. The amyloid nature of the deposit can by confirmed by staining with an antiserum specific for serum amyloid P-component (SAP). Once histological diagnosis of amyloidosis has been established, the amyloid type should be defined based on immunohistochemical analysis and genetic testing. Immunoelectron microscopy characterizes the amyloid deposits by co-localizing the specific proteins with the fibrils and can be performed on abdominal fat samples.

Histologic Findings
Infiltrated tissues show homogeneous eosinophilic staining with hematoxylin and eosin. The earliest deposits are usually vascular. In the kidney, early deposits may be mesangial, but, late in the course, entire glomeruli may be obliterated. Distinguishing these from glomerulosclerosis and from other causes is difficult prior to Congo red staining. Congo red binding by itself may be observed in other states, particularly in collagen-rich tissues, but the green birefringence is characteristic on examination with polarized light and the amyloid nature of the deposit can be demonstrated by observing the characteristic beta pleated sheet on electron microscopy. The nature of the precursor can be established with certainty using antisera specific for various amyloid precursors. In this case, staining with anti-AA serum is positive, as described above.

Staging
No formal staging system has been proposed for any of the amyloidoses.

Medical Care
At present, the major therapeutic strategy in amyloid A (AA) amyloidosis is treatment of the primary inflammatory disease in order to reduce the circulating levels of the amyloid precursor protein SAA. Intensive treatment that lowers SAA levels to less than 10 mg/L may halt disease progression and induce a slow progressive recovery of renal function. Accounts exist of the disappearance of the amyloid deposits associated with tuberculosis or chronically infected burns with appropriate treatment of the infection. Similarly, case reports exist of the disappearance of amyloid deposition associated with chronic inflammatory bowel disease after resection of the affected section of bowel. Data from a randomized prospective series of patients with juvenile chronic arthritis who were treated with chlorambucil or cyclophosphamide show that the occurrence of amyloidosis is markedly reduced.[17] The tradeoff for the aggressive use of alkylating agents is an increased incidence of leukemia. Treatment with TNF- inhibitors and IL-1 inhibitors has proved effective in controlling the progression of renal amyloid in patients with inflammatory arthritides and hereditary periodic fevers. The application of these agents possibly achieve similar therapeutic

effects without the additional risk, thus lowering the incidence of amyloidosis without increasing mortality. The rationale for using TNF inhibitors in secondary amyloidosis comes from the fact that these medications lower serum IL-6, which is an important mediator of the acute phase inflammatory response. By reducing IL-6, synthesis of acute-phase proteins is reduced, systemic inflammation suppressed, and SAA levels are lowered leading to reduction of amyloid deposits.[18] Biologic agents such a Tocilizumab (anti-IL6 receptor antibody) used in juvenile idiopathic arthritis, and Infliximab, an anti TNF antibody, have been used to successfully reduce inflammation and thereby induce SAA reduction in AA amyloidosis.[19] A case report described combination therapy with steroids, methotrexate and intravenous hyperalimentation benefiting GI symptoms in a patient with RA and intestinal AA amyloidosis.[20] Castelman disease, a rare IL-6 secreting tumor, can sometimes be completely excised. In those cases where surgery is not feasible or curative, evidence suggests benefit with antiIL-6 therapies.[15] The use of colchicine (0.6 mg tid) by patients with FMF has been shown to reduce or eliminate the febrile episodes and to prevent the appearance of renal amyloidosis. The mechanism of action is not clear, although the elimination of AA deposition is likely mediated through the suppression of the inflammatory response and SAA production, rather than having a primary effect on amyloidogenesis. Based on observations of people with FMF and mice with experimental AA amyloidosis, individual patients with the nephrotic syndrome secondary to renal AA amyloidosis in the course of inflammatory bowel disease, ankylosing spondylitis, and psoriatic arthritis were treated with colchicine and had clinical pictures consistent with the resolution of the nephrotic syndrome. Although none of these reports contained follow-up renal biopsies, the clinical information supports the conclusion; however, many unreported instances in which colchicine has been used unsuccessfully in similar circumstances also are likely to exist. The only attempt at a randomized prospective trial of colchicine has been carried out in AL disease, and it showed no effect on that process. Anakinra, a recombinant form of IL-1 receptor antagonist, has shown favorable effects on dermatologic and rheumatic manifestations in patients with MuckleWells syndrome and familial cold autoinflammatory syndrome. This treatment also resulted in the resolution of AA amyloidosis in these patients.[21] The following are new approaches to the treatment of AA amyloidosis that are currently undergoing clinical trials:

A lowmolecular-weight sulfonated molecule has been developed that interferes with fibril formation and deposition of amyloid by inhibiting interaction of SAA with glycosaminoglycans. In experimentally induced murine AA amyloidosis, this drug (NC-503) has been shown to reduce the amount of amyloid deposits. Dimerization of human SAP molecules in vivo with a palindromic compound (CPHPC) triggers very rapid clearance of the complexed protein by the liver, depleting SAP from the circulation within a few hours of drug administration. A case report describes severe protein-losing enteropathy with intractable diarrhea due to systemic AA amyloidosis successfully treated with corticosteroids and octreotide.[22] A single patient with AA amyloidosis secondary to Hodgkin disease was administered 4'-iodo-4'deoxydoxorubicin as antitumor therapy (see the treatment section in Amyloidosis, Immunoglobulin-Related); this patient has been reported to show a reduction in proteinuria and the liver amyloid burden on biopsy. The response was not complete and the resolution on liver biopsy may have been the result of sampling differentially infiltrated portions of tissue; nonetheless, the result is potentially exciting.[23] A more experimentally and theoretically based approach uses the observation that anionic sulphonates interfere with the deposition of AA fibrils in a murine model of inflammatory amyloidosis. Little or no toxicity was shown in the preclinical testing. The plasma glycoprotein serum amyloid P component (SAP) is a universal constituent of all types of amyloid plaques, and potentiates the amyloidogenic process. A study by Bodin and colleagues tested a two-step therapeutic strategy for amyloidosis that targeted SAP by first pharmacologically depleting circulating levels of SAP with the bivalent crosslinker CPHPC, and then subsequently administering anti-human-SAP antibodies. In mice transgenic for human SAP, an experimental model of systemic AA amyloidosis, this treatment regimen produced almost complete regression of hepatic and splenic amyloid deposits 4 weeks after anti-SAP treatment. These strikingly successful results strongly support the concept that amyloid deposition is reversible, and the initiation of clinical trials in humans will be of great interest.[24] Interactions between heparan-sulfate and dermatan-sulfate glycosaminoglycan (GAG)-containing proteoglycans and the misfolded amyloid precursor protein are also considered important for amyloidogenesis and the stabilization of amyloid. This insight has been used in a clinical trial to destabilize amyloid deposits with eprodisate, a negatively charged, sulfonated GAG analog, which binds to GAGbinding sites of the amyloid fibrils.[25] Experiments have shown that a number of agents appear to retard AA amyloidosis in animal models. These include fenofibrate, FK506, and lovastatin, inhibition of interactions between SAA and the receptor for advanced glycation end-products (RAGE).[26, 27] A study demonstrated the efficacy of pegylated INF-alpha once a week in FMF in the induction of a durable disease remission and the almost complete reversal of secondary renal AA amyloidosis.[28]

Six percent of the patients in whom the underlying inflammatory disease cannot be identified are a serious management challenge, and the therapy in these cases has to be empirical-guided by frequent assays of SAA. In patients with AA amyloidosis who were treated before 1990, the major cause of death was renal failure, generally accounting for 35-70% of mortality, with infection responsible for an additional 10-20%. The mean survival was 2-4 years, with the degree of renal insufficiency present at the time of diagnosis correlating with longevity. In a series of patients with AA amyloidosis presenting from 19851999, the median survival was 53 months, and the median renal survival (time alive and independent of renal replacement) was 18 months.[29] Because of the increased availability of renal replacement, renal failure was the cause of death in only 12.5% of people, and infection became dominant (42%). Nonetheless, the results of dialysis in patients with renal amyloid and an underlying inflammatory disease are worse than the results in those undergoing dialysis for other chronic renal diseases.

Surgical Care
Renal transplantation is an option in these patients, with some successes reported; however, data suggest that patients who have amyloidosis do not have as favorable a prognosis as patients transplanted for other forms of renal failure. Nonetheless, results have been improving, and transplantation is a reasonable option, particularly if the primary inflammatory disease has been treated successfully.

Consultations

Because AA amyloidosis is usually a complication of a primary chronic infectious or inflammatory disease, consultations with specialists in infectious diseases concerning antibiotics, surgical resection, and other diagnostic and therapeutic modalities are appropriate. o Consult a rheumatologist with regard to newer modes of antiinflammatory treatment before assuming that the patient will inevitably follow a downhill course. o Nephrologic and surgical management of the chronic renal failure also requires a coordinated team approach for an optimal outcome. o Cardiac complications at the time of transplantation seem to be more common in patients with amyloidosis than in those with other forms of renal failure.

Diet
No specific dietary recommendations for patients with amyloid disease exist.

Patients with chronic renal failure should be managed by a nutritionist who has experience with such patients, maintaining appropriate levels of sodium and protein intake. Occasionally, patients have significant gastrointestinal symptomatology, and attention should be paid to maintaining caloric intake with minimal gastrointestinal distress.

Activity
Encourage as much activity as the patient can tolerate in order to maintain muscle mass and a positive outlook.

Medication Summary
No specific therapeutic agents are recommended for the treatment of amyloid A (AA) amyloidosis. Therapy for the underlying inflammatory disorders should be as aggressive as possible.

Anti-inflammatory agents
Class Summary
Colchicine is a disaggregator of microtubules, not a member of any of the traditional categories of anti-inflammatory agents. View full drug information

Colchicine

Decreases leukocyte motility and phagocytosis in inflammatory responses. Effective in the treatment of acute gout, pseudogout, and the prophylaxis of acute febrile episodes of FMF. The latter effect probably is responsible for the reduced frequency of renal amyloidosis when treatment is adequate.

Further Inpatient Care

Inpatient care may be necessary for intercurrent infections or deterioration in renal function, requiring acute dialysis or the initiation of chronic dialysis.

Further Outpatient Care

Monitor renal function to assess progress and the ultimate need for dialysis or transplantation.

Inpatient & Outpatient Medications

Use medications effective in the treatment of the primary inflammatory diseases to completely suppress the inflammatory process, if possible. Colchicine may be administered concurrently with these agents, although no controlled studies indicate that it is effective in amyloid A (AA) amyloidosis, other than in cases associated with FMF.

Transfer

Diminishing renal function demands management by an experienced nephrologist, with particular emphasis placed on the need for dialysis and the availability of transplantation.

Deterrence/Prevention

The use of colchicine prophylaxis in FMF has been previously mentioned, as has the need for aggressive anti-inflammatory treatment for the predisposing inflammatory disorders (see Treatment). The recent introduction of anti-inflammatory biological agents for the treatment of rheumatologic disorders may decrease the current rate of appearance of tissue AA deposition.

Complications

The major consequence of renal amyloidosis is complete renal failure. Because it occurs in the natural course of AA amyloidosis, it may not be considered a complication but certainly requires aggressive management, with transplantation or maintenance with dialysis.

Prognosis

The prognosis of the AA amyloidosis, regardless of the prognosis of the primary disease, has generally been associated with the degree of renal compromise present at the time of diagnosis, ie, poor prognosis is associated with a serum creatinine level greater than 2 mg/dL or a serum albumin level of less than 2.5 g/dL. Mean survival is 2-3 years. More recent studies in which patients had access to renal replacement therapy suggest improved survival to more than 4 years. In the latter cases, infection was the major cause of death. With improved aggressive anti-infectious treatment,

further enhanced survival likely is possible, even without specific treatment that allows resorption of the deposited fibrils or inhibits further deposition. The idea has been suggested that, even with fibril resorption and no further deposition, residual tissue damage will persist or fibrillar material will redistribute, primarily to the kidney. At present, these speculations remain to be tested.

Patient Education

Inform patients about the natural course of AA amyloidosis and the fact that aggressive anti-inflammatory management could prevent ultimate organ failure. Preparing the patient for either renal transplant or dialysis is the major educational goal. Clearly, the manner in which this is presented depends on the relationship between the physician and the patient

Immunoglobulin-Related Amyloidosis

Background
Immunoglobulin-related amyloidosis is a monoclonal plasma cell disorder in which the secreted monoclonal immunoglobulin protein forms insoluble fibrillar deposits in 1 or more organs. In nearly all cases, the deposits contain immunoglobulin light (L) chains or L-chain fragments, termed L chaintype amyloidosis (AL). In a few reported patients, the amyloid deposits have contained immunoglobulin heavy (H) chains; these are termed H chaintype amyloidosis AH). Before the discovery that the major fibril component in these patients was an immunoglobulin fragment, patients with light chaintype amyloidosis were described as having primary (in the sense of idiopathic) amyloidosis or, when the burden of monoclonal plasma cells was large, myeloma-associated amyloidosis. Immunoglobulin L and H chains are 2 of 20 different fibril proteins that have been described in human amyloidosis. For a general discussion of the human amyloidoses, the types of human amyloidosis, and an approach to the diagnosis of amyloidosis, see Amyloidosis, Overview. L chaintype amyloidosis (AL) is related to both multiple myeloma and monoclonal gammopathy of undetermined significance (MGUS). These monoclonal plasma cell disorders can be categorized according to the total body burden of monoclonal plasma cells. When this burden is large, the diagnostic criteria for multiple myeloma are fulfilled; when this burden is lower, MGUS is diagnosed. Multiple myeloma and MGUS fall on a continuum, with 20% of patients with MGUS progressing to multiple myeloma within 10 years. In most patients with a monoclonal plasma cell disorder, whether multiple myeloma or MGUS, the monoclonal L chain secreted by the clone remains soluble in the bloodstream. However, in some patients, the physicochemical characteristics of the

immunoglobulin L chain or L-chain fragment lead to its deposition as amyloid. Thus, some patients with light chaintype amyloidosis meet the diagnostic criteria of multiple myeloma, whereas other patients can be considered as having MGUS in which the clonal immunoglobulin product is amyloidogenic. In addition to cases of monoclonal gammopathy in which the secreted clonal immunoglobulin remains in solution and those in which secreted clonal immunoglobulin forms amyloid deposits, a third group consists of cases in which the monoclonal proteins accumulate in various organs, but the deposits do not form fibrils. Patients with this form are described as having nonamyloid monoclonal immunoglobulin deposition disease (MIDD). The relationship among the plasma cell dyscrasias and the amyloidoses is depicted in the image below.

The relationship among light chaintype amyloidosis (AL), the other monoclonal plasma cell disorders, and the other amyloidoses. Ig = immunoglobulin; MGUS = monoclonal gammopathy of undetermined significance.

Pathophysiology
The most common light chaintype amyloidosis precursor proteins are L chains of the lambda (l) class. The lambda light chaintype amyloidosis is approximately twice as prevalent as the kappa (k) light chaintype amyloidosis, and L chains of the Vl 6 class are the most amyloidogenic. Clonal plasma cell proliferative diseases in which the Vl 6 gene is expressed are always associated with amyloid deposition. Among Vk genes, the Vk 1 subgroup is overrepresented among amyloid-forming L chains. Within the V region families, certain amino acid residues occurring at particular positions in the L-chain sequence render those chains are more amyloidogenic, with a combination of such residues increasing the chances of a particular L-chain protein being associated with tissue amyloid deposition. Another structural feature that appears to predispose to L chain type amyloid deposition is enzymatic glycosylation of the L chain. Although 15% of human L chains bear sugar residues, almost one third of amyloidogenic L chains are glycosylated. Why certain amino acid and glycosylation characteristics in L chains predispose to amyloid formation remains unknown. L chain type amyloid deposits contain intact L chains, L-chain fragments, or both (most patients). The fragments always include the amino terminus of the chain and range in mass from 5000 to 16,000 d. In 90% of patients, the deposited peptides include at least

some constant region sequence; therefore, the peptides react with commercially available antiL chain sera, which are specific for constant region determinants. These observations explain why 10% of deposits do not bind either commercial anti-k or anti-l antisera. L chain type amyloid deposits can develop in any organ system. The most common organs involved are the kidneys, the heart, the gastrointestinal (GI) tract, the peripheral nerves, and the liver. In most cases, the deposits affect multiple organ systems. Factors leading to the specific pattern of organ involvement in a particular patient are not understood. In a minority of cases, localized amyloid deposits, including amyloid masses (amyloidomas), may be found in various sites, even in the absence of systemic disease. The pathogenesis of localized light chaintype amyloidosis is not well understood, but a small, localized clone of plasma cells apparently produces immunoglobulin, which forms deposits near the site of synthesis. In some patients, plasma cells have been demonstrated histologically, accompanying the localized amyloid deposits. In one patient, DNA sequencing revealed that local plasma cells were producing the locally deposited L chains. Researchers from the University of Arkansas for Medical Sciences (UAMS) studied the gene profile of more than 500 patients treated for multiple myeloma at UAMS.[1] Of the about 25,000 genes in the body, the UAMS team found the expression of just 17 genes revealed which form of the disease the patients had.[1] A gene is expressed when its DNA is transcribed into RNA, which is later transcribed into protein. The expression level of those 17 genes becomes an overpowering and overriding predictor of outcome in therapy. It is questionable whether a drug that targets those genes will be developed.

Epidemiology
Frequency

United States
Annually, 1-5 cases of immunoglobulin-related amyloidosis per 100,000 people occur. The best available direct data on L chaintype amyloidosis prevalence in the United States come from Olmstead County, Minn, where the annual prevalence of L chaintype amyloidosis was calculated to be approximately 1 case per 100,000 people. The population in this location is primarily of northern European ancestry. Whether this prevalence applies to different populations is not known. Based on indirect calculations, the prevalence may be higher. The annual incidence of multiple myeloma is approximately 5 cases per 100,000 people, and the prevalence of L chaintype amyloidosis in patients with myeloma is approximately 20-35%, producing an overall incidence of combined L chaintype amyloidosis and myeloma of 1-1.5 cases per

100,000 people. Only 1 in 5 patients with L chaintype amyloidosis has frank myeloma; therefore, the total number of patients with L chaintype amyloidosis type is 5 times the number of patients with L chaintype amyloidosis and myeloma, or at least 5 cases per 100,000 people.

International
The prevalence of L chaintype amyloidosis appears to be the same in all populations. The only population-based direct measurement comes from the United States.

Mortality/Morbidity
Symptoms of immunoglobulin-related amyloidosis reflect the organs containing amyloid deposits. Factors that cause deposits in different organs in different patients are unknown. Cardiac deposition is the most severe consequence of systemic L chaintype amyloidosis, eventually occurring in most patients. Cardiac L chaintype amyloidosis is the cause of death in most patients with systemic L chaintype amyloidosis.

Race
L chaintype amyloidosis affects people of all racial and ethnic groups. No data are available comparing the incidence of disease in different groups.

Sex
The male-to-female incidence ratio of L chaintype amyloidosis is 2:1.

Age
The median age at diagnosis of immunoglobulin-related amyloidosis in the largest published series (from the Mayo Clinic) was 64 years.[2]

History
The most common presenting symptoms of immunoglobulin-related amyloidosis, including weakness and weight loss followed by purpura, particularly in loose facial tissue, are nonspecific. Other symptoms and physical findings vary widely, depending on which organs contain deposits. Amyloid deposition in a particular organ leads to similar clinical consequences and, therefore, similar complaints, regardless of the type of amyloid deposited. For example, cardiac L chaintype amyloidosis and cardiac transthyretin (TTR) amyloidosis cause similar symptoms. Clinical features and management outcome were evaluated in a case series of 24 patients with periocular and orbital amyloidosis.[3] Signs and symptoms included a visible or palpable periocular mass or tissue infiltration (95.8%), ptosis (54.2%), periocular

discomfort or pain (25%), proptosis or globe displacement (21%), limitations in ocular motility (16.7%), recurrent periocular subcutaneous hemorrhages (12.5%), and diplopia (8.3%).[3] Seven patients had B cells or plasma cells producing monoclonal immunoglobulin chains that were deposited as amyloid light chains.[3]

Renal involvement o The kidneys are the most frequent sites of deposition, with nephrotic syndrome being common; therefore, complaints of peripheral edema are common. o Patients can present with renal failure. Cardiovascular involvement o Involvement of the heart and the peripheral vasculature often leads to postural hypotension, with patients complaining of lightheadedness. o Patients also develop weakness, palpitations, dyspnea, and peripheral edema due to congestive heart failure and arrhythmias. o Occasionally, deposits in the coronary arteries (usually the smaller intracardiac arterioles) may cause anginal symptoms similar to those typical of atherosclerotic coronary artery disease. Peripheral neuropathy o Patients whose disease involves the peripheral nerves often report dysesthesia, decreased sensation, and decreased strength. o Symptoms usually affect the lower extremities more severely than the upper extremities. Gastrointestinal (GI) involvement: o Most patients with L chaintype amyloidosis have histologic evidence of infiltration of the gut, particularly in the blood vessels. However, deposition is symptomatic in only a minority of patients. o The most common GI symptoms are constipation or alternating constipation and diarrhea. Gastric L chaintype amyloidosis can cause hematemesis, nausea, and vomiting. Intestinal L chaintype amyloidosis can impair motility and cause hemorrhage, obstruction, constipation, and diarrhea or alternating constipation and diarrhea. o Myeloma-associated amyloidosis may rarely be first evident as subacute liver failure.[4] Carpal tunnel syndrome: Approximately 20% of patients with L chaintype amyloidosis initially report weakness and paresthesia of one or both hands, suggesting carpal ligament involvement.

Physical

General features o The most common initial physical findings in individuals with immunoglobulin-related amyloidosis include peripheral edema, hepatomegaly, purpura, orthostatic hypotension, peripheral neuropathy, carpal tunnel syndrome, and macroglossia.

Peripheral edema and hypotension result from congestive heart failure and nephrotic syndrome. o Purpura results from vascular fragility produced by amyloid deposition in the subendothelium of the small blood vessels. Cardiac involvement o Cardiac amyloidosis typically causes diastolic dysfunction; congestive heart failure; and arrhythmias, including heart block, premature ventricular contractions, and various tachyarrhythmias. o The physical findings observed are not specific for cardiac amyloidosis. Ecchymosis o Bleeding may be a severe manifestation of L chaintype amyloidosis or of any of the systemic amyloidoses. o Subendothelial deposition leads to capillary fragility and mucocutaneous bleeding. o A deficiency in coagulation factor X, resulting from its binding to L chaintype amyloid fibrils, can exacerbate bleeding. Neuropathy o In approximately 20% of people with L chaintype amyloidosis, deposition occurs in the peripheral nerves, causing sensorimotor peripheral neuropathy. Nerve deposition leads to symmetric sensory impairment and weakness, accompanied at times by painless ulcers similar to those of diabetic neuropathy. Cranial neuropathy is occasionally observed. Autonomic neuropathy may cause severe orthostatic hypotension, diarrhea, or impotence. o Patients with familial TTR amyloidosis commonly present with a combination of severe peripheral and autonomic neuropathy. Consider the alternative diagnosis of TTR amyloidosis in a young patient with severe amyloid neuropathy but no other severe organ involvement (see Amyloidosis, Transthyretin-Related and Amyloidosis, Overview). Orthostatic hypotension o L chaintype amyloidosis and other systemic amyloidoses can lead to severe orthostatic hypotension, to the point of producing syncope and preventing normal activity. o Poor cardiac contractility resulting from myocardial deposition, autonomic neuropathy resulting from amyloid deposits in the peripheral nerves, and impaired arteriolar responsiveness resulting from endothelial deposition may contribute to orthostatic hypotension. o Treating heart failure or the nephrotic syndrome with diuretics may exacerbate hypotension. Hepatosplenomegaly o Hepatic and splenic depositions causing hepatomegaly and/or splenomegaly are common and usually asymptomatic. o Rarely, spontaneous rupture of the liver or the spleen may present as a surgical emergency. Macroglossia
o

Macroglossia is present less frequently at diagnosis than was reported in earlier case series, probably because of earlier diagnosis. o When present, macroglossia can become severe enough to interfere with swallowing and breathing. o When it occurs, macroglossia highly suggests amyloidosis of the amyloid L-chain type, because this physical finding has apparently been described only in L chaintype amyloidosis and occasionally in 2 -microglobulin (B2M) amyloidosis. Musculoskeletal system o L chaintype amyloidosis deposits in the joints resembling seronegative rheumatoid arthritis may lead to a clinical examination. o Deposits in the glenohumeral articulation may cause localized pain and swelling ("shoulder pad" sign), whereas deposits in skeletal muscle may produce pseudohypertrophy. Localized L chaintype amyloidosis o For unknown reasons, localized L chaintype amyloidosis most commonly occurs in the respiratory tract. o Localized pulmonary L chaintype amyloidosis often remains localized (ie, does not progress to systemic disease). o Localized L chaintype amyloidosis may involve the ureter or the urinary bladder, causing hematuria. o Amyloidomas are often found in the soft tissues, including the mediastinum and the retroperitoneum. o Skin involvement can manifest as plaques and nodules.
o

Causes
No cause is known for any of the monoclonal plasma cell dyscrasias. Some evidence supports an etiologic role for human herpesvirus 8 (HHV-8), but this proposed etiology remains controversial.

Differentials

Amyloidosis, AA (Inflammatory) Amyloidosis, Beta2M (Dialysis-Related) Amyloidosis, Familial Renal Amyloidosis, Transthyretin-Related Monoclonal Gammopathies of Uncertain Origin Multiple Myeloma

Laboratory Studies
Blood and urine tests

Once the diagnosis of L chaintype amyloidosis established (see Procedures), perform laboratory studies to observe for abnormalities, such as abnormal renal function or coagulation, commonly found in L chaintype amyloidosis and to evaluate for possible multiple myeloma.

Monoclonal immunoglobulin (serum protein electrophoresis, urine protein electrophoresis, serum and urine protein immunoelectrophoresis) o Monoclonal immunoglobulin L chain, the cardinal laboratory finding in L chaintype amyloidosis, is detected on routine clinical laboratory testing in the serum or the urine of 80-90% of patients. This percentage reflects the limit to the sensitivity of routine laboratory testing rather than the biology of L chaintype amyloidosis. Because plasma cells in bone marrow (or occasionally in other sites) synthesize immunoglobulin L chains, which are deposited in various organs, the L chains must travel through the bloodstream. Thus, in theory, if a sufficiently sensitive assay were used, monoclonal serum L chains or L-chain fragments would be detected in all patients. o Overall survival is related to the free monoclonal light-chain concentration in the serum, independent of other risk factors, with higher concentrations associated with shorter survival.[5] o The concentration of normal immunoglobulin is often decreased, such as in multiple myeloma. The combination of hypogammaglobulinemia and proteinuria should suggest a diagnosis of L chaintype amyloidosis or MIDD. In contrast, renal amyloid of the amyloid A type is usually associated with hypergammaglobulinemia related to persistent inflammation and interleukin (IL) 6 production. o A study by Dispenzieri et al showed that the absolute value of immunoglobulin free light chain (FLC) as a precursor protein of amyloid is prognostic in patients with primary systemic amyloidosis undergoing peripheral blood stem cell transplantation (PBSCT).[6] There was a significantly higher risk of death in patients with higher baseline free light chains, and normalization of the free light chain level after PBSCT predicted for both organ response and complete hematologic response. Blood counts: The complete blood cell count (CBC) is usually unremarkable. Functional asplenism may occur, leading to mild thrombocytosis and Howell-Jolly bodies in the peripheral blood. Absolute lymphocyte count recovery at day 15 (ALC-15) after autologous stem cell transplantation seems to be a powerful prognostic indicator for overall survival and progression-free survival.[7] An ALC-15 of 500 or greater is associated with significantly improved clinical outcomes. Prothrombin time (PT) and activated partial thromboplastin time (aPTT) o Many clotting system abnormalities have been described in L chaintype amyloidosis. Occasionally, coagulopathy and prolongation of the PT or aPTT arise because of the binding of a clotting factor (most often factor X) to the amyloid deposits.

Acquired factor X deficiency is difficult to correct because infused factor X is cleared quickly from the circulation. Elevation in tissue and urine plasminogen activators and a decrease in tissue plasminogen activator inhibitor, leading to hyperfibrinolytic states, have also been reported. Urinary protein: When L chaintype amyloidosis involves the kidneys, proteinuria is invariably present. One third to one half of patients excrete at least 1 gram of protein per day in the urine, predominantly albumin. The 24-hour urinary protein level can be monitored serially to evaluate the response to chemotherapy. Improvement in response to treatment may be associated with a decrease in protein excretion. Liver function studies: Liver function abnormalities are rare, even in cases with massive deposition. Rarely, extensive liver involvement can lead to decreased levels of vitamin K-dependent clotting factors. Renal function studies: Severe azotemia is a late manifestation of renal L chain type amyloidosis and is less common than proteinuria, although mild elevation of the serum creatinine level (at least 2 mg/dL) is often present.
o

Bone marrow examination

Approximately 40% of patients have more than 10% plasma cells in the bone marrow. Lchain immunophenotyping of the marrow, even in the absence of increased numbers of plasma cells, usually exhibits the distortion in the k:l ratio, reflecting the L-chain type of the amyloid precursor. Studies using multiparameter flow cytometry immunophenotyping suggest that the quantitative distribution of monoclonal and normal plasma cell populations may be useful in establishing the prognosis of individual patients with respect to overall survival.[8] However, the report did not specifically evaluate responses to therapy in general or any specific treatment. This kind of prognostic information requires a much larger patient cohort.

Imaging Studies
Cardiac imaging
Cardiac deposition is the most serious complication of L chaintype amyloidosis. Cardiac involvement should be assessed and monitored by means of imaging studies. No noninvasive test is sufficiently sensitive or specific to definitively diagnose cardiac amyloidosis, although 2-dimensional echocardiography (2-D echo) and electrocardiography (ECG), particularly when combined, can strongly suggest cardiac amyloidosis.

Echocardiography o The most useful noninvasive diagnostic test for cardiac amyloidosis is echocardiography, which enables the visualization of increased ventricular wall thickness, increased septal thickness, and an appearance of granular

"sparkling." This finding is neither sensitive nor specific enough to be diagnostic, but it is highly suggestive when present. o L chaintype amyloid deposits in the heart occur in the ventricular interstitium, leading to thickening of the ventricular walls and intraventricular septum without an increase in intracardiac volume. Evaluation of diastolic function by using Doppler echocardiography reveals impaired ventricular relaxation early in the course of disease, which progresses to short deceleration. The ejection fraction is preserved until late in the disease course. Other echocardiographic findings include valvular thickening and insufficiency and atrial enlargement. Atrial thrombosis has also been described. Combining ECG and echocardiography appears to provide the most diagnostic value. Radiolabeled pentagonal (P) component scanning: This test, available only in Great Britain and France as of 2000, is a useful means of evaluating the total body burden of amyloid and is a sensitive, noninvasive means of diagnosing amyloid deposits in most organs. Serial studies are useful for monitoring response to therapy. P component scanning is not useful for diagnosing or monitoring cardiac amyloid, because the concentration of the label in the intracardiac blood pool obscures the weaker signal from the labeled molecule bound to myocardial amyloid. Other cardiac imaging studies: Computed tomography (CT) scanning and nuclear scintigraphy are of less value than ECG and echocardiography.

Bone imaging
As in any patient with a plasma cell dyscrasia, patients with L chaintype amyloidosis should have a skeletal survey that includes the skull, the entire spine, and the pelvis. Any bony pain that develops can result from plasma cell infiltration; therefore, obtain radiographs of any area where pain develops.

Chest radiography
Systemic L chaintype amyloidosis may deposit in any part of the respiratory tree, from the nasopharynx to the pulmonary alveoli. Involvement is often asymptomatic, although alveolar or diffuse interstitial involvement can cause dyspnea. Chest radiographs reveal a reticular nodular pattern or interstitial infiltration.

Radioimmunodetection of amyloid deposits

Care of patients with AL amyloidosis is currently limited by the lack of objective means to document the extent of the disease and lack of therapeutic options that expedite removal of pathologic deposits. A phase I study with fibril-reactive, amyloidolytic murine IgG1 mAb 11-IF4 labeled with I-124 followed by PET/CT scan was performed. In 9 of 18 subjects, there was striking uptake of reagent in liver, lymph nodes, bone marrow, intestine, and spleen (but not kidney or heart). According to the results of this

study, this method can be used to identify AL candidates for passive immunotherapy using the chimeric form of the antibody.[9]

Other Tests
ECG
The classic ECG finding is a low-voltage QRS complex in the limb leads, resulting from replacement of normal cardiac tissue by nonconducting amyloid material. In some cases, loss of anterior forces suggests anteroseptal infarction that is not confirmed at autopsy. A variety of arrhythmias are observed and can be life threatening.

Procedures
Biopsy with Congo red staining and immunostaining
Amyloidosis of all types is definitively diagnosed by exhibiting Congo red binding material in a biopsy specimen. For many years, a biopsy of the rectum was the procedure of choice. However, it is known that capillaries in subcutaneous fat are frequently involved. These capillaries can provide sufficient tissue for the diagnosis of amyloidosis, immunostaining, and, in some cases, amino acid sequence analysis. Currently, aspiration of subcutaneous abdominal fat is a simple and fast method for detecting systemic amyloidosis with a sensitivity of 80% that is associated with the use of a routine approach. If the results of fat tissue aspiration are negative, the additional value of a subsequent biopsy of the rectum is negligible. Thus, obtaining a biopsy from the organ with the most severe clinical involvement is not always necessary. However, a biopsy from an organ with impaired function, such as a kidney or the heart, definitively establishes a cause-and-effect relationship between the organ dysfunction and the amyloid deposition. L chain type amyloid deposition in the peripheral nerves leads to axonal degeneration of the small nerve fibers, which leads to polyneuropathy. The diagnosis can often be made through findings from a biopsy of the sural nerve, although the deposits may be proximal to the sural nerve and, therefore, not found in the biopsy sample. Obtaining a renal biopsy sample is rarely necessary, but findings exhibit deposits in the glomerular mesangium and, later, along the basement membrane. Other potential biopsy sites include the salivary glands, the stomach, and the bone marrow. Avoid obtaining a percutaneous liver biopsy. Such biopsies are contraindicated in the presence of coagulopathy. Severe and even fatal bleeding has occurred in this setting.

After Congo red staining is used to establish a diagnosis of amyloidosis, determine the specific type of amyloidosis by immunostaining a biopsy specimen using commercially available, specific antisera against k and l chains. Do not assume that the amyloid is of the L-chain type based on indirect tests, such as serum or urine protein electrophoresis or immunofixation, because monoclonal proteins are common in the elderly population and may be present as incidental findings in patients with other types of amyloidosis. Distinguishing between L chaintype amyloidosis and TTR cardiac amyloidosis on clinical grounds alone is particularly difficult. Without immunologic identification of the deposited protein, an incorrect presumptive diagnosis of L chaintype amyloidosis could lead to ineffective and perhaps harmful treatment.

Histologic Findings
Obtaining a biopsy sample of an affected organ followed by routine hematoxylin and eosin staining reveals Pacemakers homogeneous, interstitial, eosinophilic material. Amyloid material stained with Congo red and viewed under polarized light appears bright green. Specific staining with antibodies against kappa and lambda L chains proves the diagnosis of L chaintype amyloidosis (as opposed to other types of amyloidosis, which have a similar appearance after hematoxylin and eosin or Congo red staining) (see Amyloidosis, Overview). In MIDD, the immunoglobulin deposits do not bind Congo red stain, they do not contain P component or other components of amyloid fibrils, and (unlike in amyloidosis) they are not fibrillar. MIDD occurs most frequently in the kidneys and the heart. Nodular glomerulosclerosis observed on routine histologic examination in the absence of diabetes mellitus suggests MIDD. The pathologic diagnosis of nonamyloid MIDD depends on the identification of immunoglobulin deposits in tissues via immunostaining. MIDD may be underdiagnosed because immunostaining is not routinely performed. The clinical pathologic feature and diagnostic criteria of tongue amyloidosis is important. Twenty-five patients were pathologically diagnosed as tongue amyloidosis, although none had an enlarged tongue.[10] Hematoxylin and eosin and immunohistochemical staining were employed to detect the amyloid deposition on the tongue, with amyloid depositions in the basement membrane, muscle cell, vessel wall, and nerve fiber. Immunohistochemical study demonstrated kappa light-chain deposition in 64% of cases, and lambda light-chain deposition in 36% of them.[10] Thus, biopsy is an important means for the diagnosis of early tongue L chaintype amyloidosis, and the wide variety of amyloid light chains is helpful in the differential diagnosis (see Differential Diagnoses).

Medical Care
Standard treatment of L chaintype amyloidosis aims to reduce production of the monoclonal immunoglobulin precursor via chemotherapy or, occasionally, via radiation therapy or surgery of a localized amyloidogenic plasmacytoma. Experimental drugs that bind to amyloid fibrils, leading to their resorption, are also being studied. Supportive therapy to maintain organ function is equally important.

Chemotherapy: Chemotherapy is based on the principle that, as in myeloma, proliferation of a plasma cell clone causes L chaintype amyloidosis. Regimens most likely to benefit patients with this disease are the same as those that are useful for myeloma (ie, melphalan, prednisone). o Many more studies have been published on the treatment of myeloma than that of L chaintype amyloidosis, because myeloma is more common, and the response to therapy can be more easily monitored. In myeloma, the level of serum or urine monoclonal protein usually serves as a quantitative marker of tumor burden. In L chaintype amyloidosis, determining the response to therapy is difficult and requires indirect measurements of endorgan damage, serial biopsies, or serial P component scans when available. o After melphalan and prednisone were demonstrated to be useful for myeloma, the regimen was tried for L chaintype amyloidosis. The first 2 randomized studies of melphalan and prednisone versus placebo or colchicine suggested a value to chemotherapy but did not reach statistical significance for improved survival. o In the mid 1990s, 2 randomized placebo-controlled trials demonstrated a statistically significant survival benefit of melphalan and prednisone compared with colchicine. The colchicine arm in these trials essentially served as a placebo group, because colchicine is now known to be ineffective for L chaintype amyloidosis and is no longer used. Patients in 1 trial were randomized to 1 of 3 arms (melphalan and prednisone; melphalan, prednisone, and colchicine; or colchicine alone).[11] The median survival rate was greater in patients in the melphalan, prednisone, and colchicine arm (18 mo) and those in the melphalan and prednisone (17 mo) arm than patients in the colchicine-alone arm (8.5 mo).[11] In another trial, 100 patients were randomized to receive either oral melphalan, prednisone, and colchicine or colchicine alone.[12] The overall survival rate for the melphalan, prednisone, and colchicine group was 12.2 months compared with 6.7 months for the colchicine-alone group. This difference did not quite reach statistical significance (P = 0.087), reflecting the small sample size and several early deaths of patients with severe disease in both treatment groups. In addition, several patients did not receive the intended chemotherapy or were crossed over to chemotherapy by

their physicians (analysis was performed on an intent-to-treat basis).[12] Taken together, these studies demonstrate a survival benefit of melphalan and prednisone compared with placebo in L chaintype amyloidosis. Patients whose conditions are most likely to respond to chemotherapy with objective improvement in end-organ damage are those with renal involvement and nephrotic syndrome. Approximately 25% of this group has at least a 50% decrease in proteinuria, with most of these patients experiencing complete resolution of proteinuria. Improvement can occur in nearly any organ, but improvement in L chaintype amyloidosis neuropathy is rare. Other chemotherapeutic regimens used for multiple myeloma are also expected to benefit patients with L chaintype amyloidosis and are reasonable therapeutic options for this disease. In one randomized study, melphalan and prednisone use was compared with a 5-drug myeloma regimen (vincristine, carmustine, melphalan, cyclophosphamide, prednisone).[13] Response rates and survival did not differ between the 2 groups. In a phase II trial, high-dose dexamethasone also produced occasional objective organ responses, including responses in some patients who had received previous chemotherapy. Many experts consider melphalan plus prednisone to be standard therapy for L chaintype amyloidosis for patients not enrolled in a clinical trial, and it is the only regimen that has been shown to prolong survival compared with no chemotherapy. No regimen has been shown in a randomized trial to be superior to melphalan plus prednisone. Duration of initial chemotherapy and potential adverse effects are as follows: No data indicate the optimal treatment duration in patients whose conditions respond to chemotherapy. In patients in whom a response occurs with objective improvement in organ function and in whom toxicity does not develop, chemotherapy is usually continued for 1-2 years. When the disease initially responds and then progresses off treatment, chemotherapy, whether the same or a different regimen, can be resumed. Little information exists regarding whether any maintenance therapy, such as alpha interferon, is useful, again mirroring the situation in myeloma. When contemplating the duration of therapy, keep in mind the leukemogenic potential of melphalan. The actuarial risk of acute myelogenous leukemia (AML) in 1 study of patients with myeloma treated with melphalan was 17% at 50 months. In 2 studies of patients with L chaintype amyloidosis treated with melphalan-containing regimens, 5% of patients developed

myelodysplasia within 3 years of treatment. Some patients' conditions progressed to AML. o During the past decade, understanding of the molecular and cellular pathophysiology of myeloma has improved significantly, allowing identification of novel molecular pathways and targeting development of several new therapeutic possibilities. Among these, thalidomide has been the first antiangiogenetic drug effectively adopted initially in refractoryrelapsed patients and then as first-line treatment with better results respect to vincristine/doxorubicin/dexamethasone (VAD) or VAD-like regimens. Inhibitors of proteasome, such as bortezomib, and other immunomodulatory agents, such as lenalidomide, have been also studied more recently in myeloma patients. In 2003, bortezomib became the first proteasome inhibitor approved for the treatment of relapsed myeloma. Inhibition of proteasome activity appears to have greater cytotoxicity in malignant cells than in normal cells. Two phases II studies confirmed the efficacy of bortezomib in patients with relapsed/refractory myeloma.[14, 15] In the first study, 10% of patients exhibited a complete/almost complete response; 18%, a partial response; and 7%, a minimal response. The median time to disease progression was 13 months for complete and partial responses. 72 patients who did not attain at least a minimal response were given dexamethasone in combination with bortezomib; 18 demonstrated some response. Phase III studies have confirmed the superiority of bortezomib compared with dexamethasone. Bortezomib has been investigated in a number of combination regimens (eg VMPT [bortezomib/melphalan/prednisone/thalidomide]; bortezomib and pegylated liposomal doxorubicin; bortezomib with corticosteroids, etc). In a phase II study, bortezomib with dexamethasone was compared with a standard-dose VAD regimen in patients with newly diagnosed myeloma.[16] Complete response (20%) and objective response rate (82%) were higher in the bortezomib group than in the group that received standard-dose VAD (complete response, 9%; objective response rate, 67%). Several bortezomib-containing combinations are now being evaluated as induction therapy before high-dose therapy with autologous stem cell transplantation. The outcomes are summarized in Table I, below.

Table I. Phase II trials of bortezomib-based therapies in newly diagnosed patients with myeloma.[17] (Open Table in a new window) Trial Bortezomib Monotherapy ORR CR/Near CR Very good PR % % % 49 49 10 2 N

Jagannath et al[18]

63 40

10

NR

Anderson et al[14]

42 52

Dispenzieri et al[15]

Bortezomib/Dexamethasone

49 88

18

20

Jagannath et al[18]

48 67

21

10

Harousseau et al[16]

Bortezomib/ Doxorubicin/ Dexamethasone

21 95

29

33

19 89 Oakervee et al (standard dose)

[19]

16

26

Popat et al (reduced dose)[20]

Bortezomib/PLD/Dexamethasone

28 89

32

21

Jakubowiak et al[21]

N = number of patients; ORR = objective response rate; CR = complete response; PR = partial response; PLD = pegylated liposomal doxorubicin.

Drug resistance to bortezomib, probably related to heat-shock high protein expression led to the development of second-generation proteasome inhibitors (eg, salinosporamide A). The immunomodulatory drugs thalidomide, lenalidomide and carfilzomib affect myeloma through pleiotropic effects. Twenty-five to thirty percent of patients exhibit at least a partial response when these agents are given as monotherapy. In combination with other drugs (dexamethasone, cyclophosphamide, melphalan), the response rate is considerably higher. In a phase III study, thalidomide plus dexamethasone produced a significant improvement in the overall response rate (63%) compared with dexamethasone alone (41%; P = 0.0017). Combination melphalan/prednisone/thalidomide (MPT) therapy has been demonstrated to have superiority over melphalan/prednisone (MP) alone. The MPT regimen has become one of the standard therapeutic combinations for elderly patients with myeloma. Phase I and II studies in relapsed/refractory myeloma have confirmed a 29% partial response rate with lenalidomide. Similarly, a phase III trial confirmed the superiority of combination lenalidomide/dexamethasone therapy (complete response, 12,9%; objective response rate, 59%) versus dexamethasone alone (complete response, 0,6%; objective response rate 21%) (P < 0.001). These results led to the approval of lenalidomide as a second-line therapy for multiple myeloma. Lenalidomide has also been investigated as first-line combination therapy for myeloma. In a phase II trial, 91% of patients exhibited at least a partial response, with 32% exhibiting a complete or almost complete response. Thalidomide and lenalidomide are also being evaluated as maintenance therapy after autologous transplantation. Carfilzomib is a structurally and mechanistically novel proteasome inhibitor that exhibits a high level of selectivity for the unique N-terminal threonine active sites within the proteasome. Carfilzomib is similar to bortezomib in that it is a potent inhibitor of the proteasome chymotrypsinlike activity; but, unlike bortezomib, carfilzomib has shown minimal cross-reactivity with the other catalytic sites within the proteasome or across other protease classes. Phase 1 clinical studies confirmed that patients whose condition has relapsed or progressed following multiple therapies can still achieve durable antitumor responses with carfilzomib. In addition to the two phase 2 single-agent trials in myeloma and ongoing studies in lymphoma, a clinical trial in solid tumors and a trial exploring carfilzomib in combination with a Federal Drug Administration (FDA)-approved agent is pending. In the past few years, a number of agents have been developed to target specific aspects of myeloma cell biology. Major strategies are disruption of molecular pathways of myeloma cell growth and impairment of the drug-resistance mechanism. These agents target myeloma cells and the microenvironment. Among these agents, many of which are in early phases of clinical trials in relapsed myeloma, the most important include the following: o Inhibitors of the PI3KI/Akt/mTOR pathway: Perifosine

Inhibitors of the heat-shock protein 90: Tanespimycin Mitogen-activated protein kinase (MAPK) and farnesyl transferase inhibitors: Tipifarnib, lonafarnib o Histone deacetylase inhibitors: Vorinostat, depsipeptide, valproic acid o Inhibitors of vascular-endothelial growth factor (VEGF): Bevacizumab and others o Inhibitors of p38 mitogen-activated protein kinase o Targeting cell surface molecules High-dose chemotherapy followed by stem cell or autologous bone marrow rescue is as follows: o In both L chaintype amyloidosis and myeloma, standard dose regimens rarely, if ever, completely eradicate the plasma cell clone. Therefore, highdose chemotherapy followed by autologous bone marrow or peripheral blood stem cell rescue has been studied in selected patients. Similar to standard dose regimens, studies of high-dose therapy for myeloma predate similar studies for L chaintype amyloidosis, and more data are available on myeloma. o In myeloma, several phase II trials of high-dose chemotherapy in selected patients have demonstrated favorable responses and survival rates compared with historical controls. o One phase III trial randomized patients younger than 65 years to either a standard dose, 6-drug regimen or high-dose therapy (4-6 cycles of the same 6-drug regimen, followed by 140 mg/m2 of melphalan and total body irradiation) with autologous bone marrow transplantation. This trial found a 5-year survival benefit for high-dose therapy. However, even in myeloma, indications for high-dose therapy remain controversial; no consensus exists about which patients should be offered high-dose therapy with rescue. o In L chaintype amyloidosis, the indication for high-dose chemotherapy is even less established. Several centers have reported phase II trials of highdose chemotherapy, followed by rescue with autologous bone marrow or peripheral blood stem cells. o In one highly selected group of patients (median age 48 y; patients with severely impaired cardiac, pulmonary, or renal function were excluded), 11 (65%) of 17 patients exhibited a response, as assessed by objective improvement in end-organ function. Based on these data, high-dose chemotherapy regimens have become the recommended therapy in some centers for patients who are deemed able to tolerate the conditioning regimen. o In early studies of high-dose therapy with peripheral blood stem cell rescue, patients with severe cardiac involvement experienced very high early mortality. This complication is attributed to intolerance of fluid shifts that occur with peripheral blood stem cell harvesting. Therefore, patients with severe cardiac involvement are now generally deemed ineligible for high-dose chemotherapy. Another concern with high-dose therapy followed by stem cell rescue is that the autologous stem cells
o o

collected for reinfusion generally contain the clonal cells that produce the amyloidogenic L chain. o Diseases in which high-dose chemotherapy has the most significant impact are those in which the malignant cell population is dividing rapidly. However, this criterion does not apply to L chaintype amyloidosis. Until standard-dose chemotherapy is compared with highdose chemotherapy with rescue in a phase III randomized trial, deciding which therapy to use in individual patients will remain difficult and controversial. o The place of allogeneic stem cell transplantation in the management of myeloma remains controversial. Although it may induce long-term clinical and molecular remissions, high transplant-related toxicity after myeloablative preparative regimens has limited the role of allogeneic stem cell transplantation as first-line treatment. o Moreover, the toxicity related to infections and to graft versus host disease (GVHD) is very high. As a consequence of this toxicity, allogeneic stem cell transplantation could not be proposed for those older than 50-55 years, whereas the median age at diagnosis was over 65 years. Some reducedintensity conditioning regimens (including the addition of immunosuppressive agents as cyclosporine A, mycophenolate mofetil, tacrolimus) were developed. Allogeneic stem cell transplantation should be considered for patients with chemosensitive disease and a low tumor burden, which can be obtained after high-dose chemotherapy plus autologous stem cell transplantation. Results of ongoing trials will determine the place of these remedies related to the introduction of the novel therapeutic agents listed above. Pharmacologic therapy to solubilize amyloid fibrils o An anthracycline analogue of doxorubicin, 4'-iodo-4'-deoxydoxorubicin (Idox), is the first small molecule found with in vivo activity to solubilize L chaintype amyloid deposits. The antiamyloid activity of Idox was discovered fortuitously when the analogue was being studied as a chemotherapeutic agent in multiple myeloma. A patient with myeloma and L chaintype amyloidosis excreted L chains into the urine and improved symptomatically within days. Idox was then demonstrated to bind to amyloid fibrils, although the parent compound, doxorubicin, does not. o The ideal use of small molecule amyloid inhibitors, such as Idox, likely lies in combination with cytotoxic chemotherapy, both to decrease clonal L-chain production and to mobilize deposited L chains. Other small molecules that bind to amyloid fibrils of the L chaintype amyloidosis and other types of amyloidosis are under investigation. Treatment of localized amyloid L-chain type o Treatment of localized L chaintype amyloidosis (most often found in the pulmonary tract or the genitourinary tract) has not been studied systematically. Because progression to systemic disease does not occur often, treatment with chemotherapy is not indicated.

Localized radiation therapy aimed at destroying the local collection of plasma cells producing the L chaintype amyloid can be administered when a plasma cell collection can be identified. o Local collections of L chaintype amyloid in the genitourinary tract, even in the absence of an identified clonal plasma cell collection, can cause hematuria. In these patients, surgical resection of amyloidomas may be required to control the bleeding. Supportive care o Treatment of cardiac involvement is as follows: Diuretics are the mainstay of therapy for L chaintype amyloid related congestive heart failure. The optimal degree of diuresis is often difficult to judge. When edema is troubling and symptomatic postural hypotension is not present, fluid can be removed with careful diuresis. Conversely, hypotension resulting from a low ejection fraction, autonomic neuropathy, or both may limit diuretic use. Digoxin and calcium channel blockers are contraindicated in cardiac amyloidosis because these agents bind to amyloid fibrils, which may worsen heart failure and produce arrhythmias. Pacemakers are of use in some patients with symptomatic bradycardia. o Treatment of renal involvement is as follows: Hemodialysis and peritoneal dialysis can stabilize the course of patients with extensive kidney involvement. Hemodialysis should be offered to patients developing renal failure.
o

Surgical Care

Carpal tunnel release o Involvement of the carpal ligament is observed not only in L chaintype amyloidosis but also in B2M amyloidosis in patients undergoing dialysis and in patients with TTR amyloidosis (see Amyloidosis, Overview and Amyloidosis, Transthyretin-Related). o Treatment is surgical. At the time of carpal tunnel release, perform a biopsy if a definitive diagnosis has not been established, so that both Congo red staining and immunostaining can be performed. Why the carpal ligament is a favored location for amyloid deposition remains unknown. Organ transplantation: No randomized trials about organ transplantation in L chaintype amyloidosis are available to guide the decision-making process, but patients have received heart or kidney transplants. o Cardiac transplantation A few patients with L chaintype amyloidosis have received heart transplants. This therapy may be life saving for patients with severe disease, but, in the absence of effective systemic therapy to

eliminate production of the amyloidogenic L chain, amyloidosis can recur in the transplanted organ. For young patients with severe cardiac involvement, cardiac transplantation followed by high-dose chemotherapy and autologous stem cell or autologous bone marrow reinfusion has occasionally been considered. Renal transplantation Renal transplantation has been reported often in patients with amyloidosis, but most such cases have not been of the L chain type amyloidosis. Because L chaintype amyloidosis is generally a systemic disease and hemodialysis is generally effective and available, renal transplantation is rarely indicated in L chaintype amyloidosis, except perhaps in the occasional patient whose condition has had particularly good responses to chemotherapy and in whom longterm survival may be expected. Percutaneous cementoplasty A study by Tran Thang et al confirmed the beneficial effect of percutaneous cementoplasty on bone pain and functional improvement.[22]

Consultations
A hematology and/or oncology, cardiology, nephrology, or other subspecialty consultation may be indicated, depending on the disease's organ involvement.

Diet
No known diet changes affect L chaintype amyloidosis directly. Patients with nephrotic syndrome, renal failure, or congestive heart failure arising from L chaintype amyloidosis should receive appropriate dietary treatment for those conditions.

Medication Summary
Melphalan plus prednisone is considered standard therapy for L chaintype amyloidosis, with any myeloma regimen offering a reasonable therapeutic choice. An anthracycline analogue of 4'-iodo-4'-deoxydoxorubicin is the first small molecule found with in vivo activity to solubilize L chaintype amyloid deposits. The antiamyloid activity of 4'-iodo-4'-deoxydoxorubicin was discovered fortuitously when it was being evaluated as a chemotherapy agent in multiple myeloma. A patient with myeloma and L chaintype amyloidosis excreted L chains into the urine and improved symptomatically within days. 4'-Iodo-4'-deoxydoxorubicin was then demonstrated to bind to amyloid fibrils, although the parent compound, doxorubicin, does not.

Five of 8 patients in the first pilot trial of 4'-iodo-4'-deoxydoxorubicin responded with clinical improvement unrelated to any cytotoxic effect on the plasma cell clone.[23] From 1995 to 1997, 4'-iodo-4'-deoxydoxorubicin was administered to another 42 patients in Europe. Of the 42 patients, 13 had disease responses and 15 demonstrated stabilized disease. However, the clinical responses were transient, and the disease typically progressed after a period of months. From 1999 to 2000, 4'-iodo-4'-deoxydoxorubicin was studied for treatment of L chaintype amyloidosis in a phase II trial at 2 US centers. Results from this trial are not yet available. The ideal use of small molecule amyloid inhibitors, such as 4'-iodo-4'-deoxydoxorubicin, likely lies in combination with cytotoxic chemotherapy, both to decrease clonal L-chain production and to mobilize deposited L chains. Various small molecules that bind to amyloid fibrils of the L chain type amyloid and other types are under investigation. Diuretics are the mainstay of therapy for L chain type amyloidosis related congestive heart failure. The optimal degree of diuresis is often difficult to judge. When edema is troubling and symptomatic postural hypotension is not present, fluid can be removed with careful diuresis. Conversely, hypotension resulting from a low ejection fraction and/or autonomic neuropathy may limit diuretic use. Digoxin and calcium channel blockers are contraindicated in cardiac amyloidosis, because these agents bind to amyloid fibrils, which may worsen heart failure and produce arrhythmias.

Immunosuppressive Agents
Class Summary
Two slightly different regimens of melphalan and prednisone have been used in 2 large studies. Either regimen can be used to treat this condition. View full drug information

Melphalan (Alkeran) and prednisone (Deltasone, Orasone, Meticorten)

Melphalan reduces clonal plasma cell population. Inhibits mitosis by cross-linking DNA strands. Individual tolerance to melphalan varies. Adjust dosage after the first cycle, based on the degree of cytopenia in the previous cycles. Nadir counts appear 2-3 wk following administration. Should be taken on an empty stomach. Prednisone reduces clonal plasma cell population.

Antineoplastic Agent, Proteasome Inhibitor

Class Summary
Proteasome inhibitors are antineoplastic agents that inhibit cell growth and proliferation. View full drug information

Bortezomib (Velcade)

First drug approved of anticancer agents known as proteasome inhibitors. The proteasome pathway is an enzyme complex existing in all cells. This complex degrades ubiquitinated proteins that control the cell cycle and cellular processes and maintains cellular homeostasis. Reversible proteasome inhibition disrupts pathways supporting cell growth, thus decreases cancer cell survival.

Immunosuppressant Agents
Class Summary
Immunosuppressant agents may suppress the production of factors that mediate immune reactions. View full drug information

Thalidomide (Thalomid)

Immunomodulatory agent that may suppress excessive production of tumor necrosis factor-alpha (ie, TNF-alpha) and may downregulate selected cell-surface adhesion molecules involved in leukocyte migration. Because of concerns regarding teratogenicity, thalidomide can only be prescribed by registered physicians and dispensed by registered pharmacists. Patients must participate in ongoing surveys to receive therapy, and only a 28-day supply can be prescribed at a time. Indicated in conjunction with dexamethasone to treat newly diagnosed multiple myeloma. View full drug information

Lenalidomide (Revlimid)

Indicated for transfusion-dependent MDS subtype of deletion 5q cytogenetic abnormality. Structurally similar to thalidomide. Elicits immunomodulatory and

antiangiogenic properties. Inhibits proinflammatory cytokine secretion and increases antiinflammatory cytokines from peripheral blood mononuclear cells.

Further Outpatient Care

A hematologist with experience in administering chemotherapy should care for patients with L chaintype amyloidosis on an ongoing basis.

Complications

Complications of L chaintype amyloidosis reflect the organ systems involved. The most severe complication of systemic L chaintype amyloidosis is extensive cardiac deposition, with consequent congestive heart failure, arrhythmias, or both. Cardiac involvement eventually occurs in most patients and appears to be the cause of death in more than 50% of patients with L chaintype amyloidosis.

Prognosis

The prognosis for patients with L chaintype amyloidosis depends largely on the specificity of the tissue deposition. Any organ can be involved, with symptoms and physical findings reflecting the pattern of anatomic compromise. Patients with clinical cardiac involvement have the worst prognosis, with a median survival rate of 6 months. Patients with involvement limited to the peripheral nerves have the longest survival. Other favorable prognostic features include a small number of clonal plasma cells in the bone marrow and normal renal function. In the absence of chemotherapy, systemic L chaintype amyloidosis is always progressive. A subgroup of cases respond to chemotherapy with temporary resorption of amyloid fibrils and improvement of end-organ function.