European Journal of Internal Medicine 24 (2013) 729–739

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European Journal of Internal Medicine

journal homepage: www.elsevier.com/locate/ejim

Systemic amyloidoses: What an internist should know☆,☆☆

Giovanni Palladini, Giampaolo Merlini ⁎
Amyloidosis Research and Treatment Center, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo, Pavia, Italy
Department of Molecular Medicine, University of Pavia, Pavia, Italy

a r t i c l e i n f o a b s t r a c t

Available online 18 November 2013 Systemic amyloidoses are rare, complex diseases caused by misfolding of autologous proteins. Although these
diseases are fatal, effective treatments exist that can alter their natural history, provided that they are started
Keywords: before irreversible organ damage has occurred. The cornerstones of the management of systemic amyloidoses
Amyloidosis are early diagnosis, accurate typing, appropriate risk-adapted therapy, tight follow-up, and effective supportive
Diagnosis treatment. Internists play a key role in suspecting the disease, thus allowing early diagnosis, starting the
Treatment
diagnostic workup and selecting patients that should be referred to specialized centers, judiciously titrating
supportive measures, and following patients throughout the course of the disease. Here we review the
pathogenesis, diagnosis and treatment of the most common forms of systemic amyloidoses.
© 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.

1. Introduction 2. Pathogenesis

Systemic amyloidoses are caused by conformational changes and
aggregation of autologous proteins that deposit in tissues in the form
of fibrils [1]. This process causes functional damage of the organs
involved, and eventually leads to death, if left untreated. With an
estimated incidence of 9 cases per million person-year [2], systemic
amyloidoses are listed among rare diseases. Nevertheless, their
annual rate is comparable to that of chronic myelogenous leukemia
and Hodgkin's disease [3], which are well known to internists
despite their relative rarity. In recent years, our understanding of
the pathogenesis of systemic amyloidoses and our ability to treat
these diseases have much improved. The most common forms
of systemic amyloidoses are now treatable, patients' survival can
considerably improve, and quality of life can be restored, provided
the disease is diagnosed at early stages and appropriately managed
[4–7]. Thus, it is vital that physicians in general, and particularly
internists, to whom patients with multiorgan dysfunction are most
often referred for diagnosis, are aware of these diseases and are
able to recognize their early clinical manifestations timely, when
organ damage is still amenable to improve.
☆ This work was supported by grants from the Ministry of Health (Ricerca Finalizzata
Malattie Rare), “Istituto Superiore di Sanità” (526D/63); Ministry of Research and
University (2007AESFX2_003);and “Associazione Italiana per la Ricerca sul Cancro”
Special Program Molecular Clinical Oncology 5 per mille n. 9965.
☆☆ The authors have no conflicts of interest to disclose.
⁎ Corresponding author at: Amyloidosis Research and Treatment Center, Fondazione
IRCCS Policlinico San Matteo, Viale Golgi, 19, 27100 Pavia, Italy. Tel.: +39 0382 502994;
fax: +39 0382 502990.
E-mail address: gmerlini@unipv.it (G. Merlini).
Almost 15 forms of systemic amyloidoses are known and classified
according to the different amyloidogenic precursor proteins [8].
However, 5 types of amyloidosis account for more than 99% of the
patients referred to our center (Table 1). The molecular mechanisms
through which different soluble proteins become prone to undergo an
irreversible transition from their native conformation into highly
ordered aggregates sharing the unique structural features of amyloid
fibrils are diverse [1]. They involve increased synthesis, as in the
amyloidosis reactive to chronic inflammation, mutations increasing
the propensity to form amyloid in the hereditary amyloidoses, and
aging in senile systemic amyloidosis.
Immunoglobulin light chain (AL) amyloidosis is the most common
form of systemic amyloidosis in Western countries and accounts for
almost three fourths of patients with systemic amyloidosis referred to
our center. In AL amyloidosis the pathogenic protein is a monoclonal
light chain produced by a usually small-sized bone marrow plasma
cell clone [9]. Both the concentration of the light chain and mutations
increasing their amyloidogenic propensity are involved in the
pathogenesis of AL amyloidosis. The mechanisms of organ damage
are still debated. The observations that the infusion of light chains
from patients with cardiac AL amyloidosis increases end-diastolic
pressure in isolated rat hearts, well before amyloid deposits can
form [10], and that in patients in whom chemotherapy succeeds in
reducing the concentration of the circulating light chain, cardiac
dysfunction improves despite amyloid deposits remain unaltered
[11,12] indicate that cardiac damage is caused primarily by a direct
toxic effect of circulating light chains. More recent experimental
evidence, showing that amyloidogenic light chains cause cardiotoxicity
and early mortality in zebrafish, further supports this hypothesis [13].

0953-6205/$ – see front matter © 2013 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.ejim.2013.10.007
730 G. Palladini, G. Merlini / European Journal of Internal Medicine 24 (2013) 729–739

Table 1 Table 2
Most common forms of systemic amyloidosis. Conditions associated with AA amyloidosis.

Amyloid type Precursor protein Organ involvement Conditions Diseases

(main synthesizing
Heart Kidney Liver PNS ANS ST Inflammatory arthritides •Rheumatoid arthritis
organ)
•Ankylosing spondylitis
AL amyloidosis Immunoglobulin light ++ ++ + + + + •Adult Still's disease
chain (bone marrow) •Juvenile idiopathic arthritis
Hereditary ATTR Mutated transthyretin ++ ± − ++ + − •Psoriatic arthritis
amyloidosis (liver) •Gout
Hereditary Mutated apolipoprotein ++ + ++ − − − Inflammatory bowel diseases •Crohn's disease
AApoAI AI (liver, Gastrointestinal •Ulcerative colitis
amyloidosis tract) Systemic vasculitides •Behcet's disease
AA (reactive) Serum amyloid A protein ± ++ + − + − •Polyarteritis nodosa
amyloidosis (liver) •Giant cell arteritis
Senile systemic Wild type transthyretin ++ − − − − − •Takayasu's arteritis
amyloidosis (liver) •Polymyalgia rheumatica
Hereditary autoinflammatory •Familial Mediterranean fever
ANS, autonomic nervous system; ST, soft tissues; and PNS, Peripheral nervous system.
diseases •Tumor necrosis factor receptor associated
periodic syndrome (TRAPS)
•Muckle–Wells syndrome
•Neonatal-onset multisystem inflammatory
Specific structural features of the pathogenic light chains play a role disease (NOMID)/chronic infantile neurological,
in organ tropism. Three Vλ genes, IGLV2-14, IGVL6-57 and IGLV3-1 cutaneous and articular (CINCA) syndrome
contribute to encoding almost 60% of amyloidogenic λ light chains •Hyper-IgD syndrome
Neoplasms •Castleman's disease
[14–16], light chains of the λVI family are almost invariably associated
•Hodgkin's lymphoma
with amyloidosis most often involving the kidney [17,18], and •Waldenström's macroglobulinemia
the Vλ gene IGLV1-44 is preferentially associated with cardiac •Hairy cell leukemia
involvement [19]. •Hepatocellular adenoma
•Renal cell carcinoma
The most common form of hereditary systemic amyloidosis is
•Adenocarcinoma of the lung
caused by mutated transthyretin (TTR), a 127-amino acid protein that •Adenocarcinoma of the gut
forms tetramers transporting thyroxin and holoretinol binding protein •Mesothelioma
in plasma. The amyloid process initiates with the dissociation of the •Schnitzler syndrome
tetramer into monomers which misfold and aggregate into amyloid Chronic infections •Osteomyelitis
•Tuberculosis
fibrils. More than 110 mutations in the TTR gene are known to promote
•Pyelonephritis
the amyloid process. The age of onset and pattern of organ involvement •Leprosy
of hereditary TTR amyloidosis (ATTR) is influenced by different •Whipple's disease
TTR mutations, ranging from isolated cardiac amyloidosis to forms Conditions predisposing to •Bronchiectasis
chronic infections •Chronic cutaneous ulcers
exclusively characterized by peripheral neuropathy, through mixed
•Cystic fibrosis
cardiac and neuropathic phenotypes [20]. Wild-type TTR has an •Epidermolysis bullosa
intrinsic amyloidogenic propensity and, given enough time, can cause •Injection drug users
cardiac amyloid deposits in senile systemic amyloidosis (SSA), affecting •Jejuno-ileal bypass
men as young as 60 years and reaching a 15% prevalence in men over •Paraplegia
Hereditary and acquired •Common variable immunodeficiency
80 years old [21].
immunodeficiencies •Hypogammaglobulinemia
Mutated apolipoprotein A–I (ApoAI) can cause amyloidosis (AApoAI) •X-linked agammaglobulinemia
most frequently manifesting with asymptomatic cholestatic hepatopathy, •Cyclic neutropenia
renal failure, and testicular involvement with hypogonadism [22]. Certain •HIV infection/acquired immunodeficiency
syndrome
mutations can cause progressive cardiomyopathy, leading to heart failure
Other •Obesity
[23]. Proteolytic remodeling plays an important role in determining the •Sarcoidosis
amyloidogenic propensity of ApoAI variants [24]. •Synovitis Acne Pustulosis Hyperostosis
In reactive amyloidosis (AA), the amyloid fibrils are formed by Osteitis (SAPHO) syndrome
proteolytic fragments of the acute-phase protein serum amyloid A
(SAA). Reactive amyloidosis is a long-term complication of chronic
inflammatory disorders listed in Table 2 [25]. Inflammation triggers 3.1. Cardiac involvement
the production of cytokines, particularly IL-1, IL-6, and TNF-α, which,
in turn, increase liver synthesis of SAA. A persistently elevated Amyloid heart involvement presents as a typical restrictive
concentration of SAA is necessary for AA amyloidosis to develop; cardiomyopathy. The echocardiographic features of advanced cardiac
however, not all the patients with chronic inflammation eventually amyloidosis are distinctive, with non-dilated ventricles showing
present this complication. This indicates that disease-modifying marked thickening of the left and right ventricular walls, as well as of
factors must also play a role in the pathogenesis of AA amyloidosis. the interventricular and interatrial septa. Amyloid infiltration gives a
The best characterized of these factors is SAA1 genotype: SAA1.1 characteristic aspect to the myocardial texture that has been described
in Caucasians and SAA1.3 in Japanese are associated with higher as “granular sparkling”. The electrocardiography limb lead voltages
incidence and earlier onset of AA amyloidosis in subjects with tend to decrease as the ventricle wall thickens, resulting in a decreased
chronic inflammation [25]. ratio of voltage to echo-derived left ventricular mass, a finding that
strongly suggests an infiltrative cardiomyopathy [26]. Importantly,
it should be kept in mind that low voltages are not observed in SSA,
3. Clinical presentation and prognosis rendering more difficult the differential diagnosis with cardiac
hypertrophy secondary to hypertension in the elderly. Beyond
The clinical presentation of systemic amyloidoses is protean and allowing further insights into cardiac diastolic dysfunction, pulsed
mainly contingent upon organ involvement (Table 1). tissue Doppler imaging can demonstrate the presence of longitudinal
 G. Palladini, G. Merlini / European Journal of Internal Medicine 24 (2013) 729–739
systolic impairment before the ejection fraction becomes abnormal
[27–29]. Long-axis dysfunction might be demonstrated by strain
and strain rate imaging that may also have potential for evaluating
the prognosis in AL amyloidosis [27,28,30–34]. At comparable left
ventricular wall thickness, myocardial velocity gradient during
systole and early diastole is in fact depressed in cardiac amyloidosis
when compared with hypertensive heart disease and hypertrophic
cardiomyopathy [35]. Cardiac magnetic resonance imaging (MRI)
in patients with advanced cardiac amyloidosis shows an unusual
pattern characterized by global subendocardial late gadolinium
enhancement and associated abnormal myocardial and blood-pool
gadolinium kinetics [36–39]. In patients with endomyocardial biopsy-
proven cardiac AL amyloidosis, late gadolinium enhancement shows
good sensitivity (80%) and excellent specificity (94%), being strongly
correlated with symptoms of heart failure, as well as with B-type
natriuretic peptide (BNP) and troponin concentrations [40–42]. However,
a recent study showed that the prognostic value of cardiac MRI is
not independent from clinical assessment of heart failure [39].
Although echocardiographic and MRI features are indistinguishable
between the different types of amyloidosis involving the heart,
the progression of cardiac dysfunction is faster in AL amyloidosis,
and prognosis is worse compared to hereditary ATTR amyloidosis
and SSA [43]. It has been shown that radiolabeled bone tracers,
99m
Tc-3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD)
and 99mTc-pyrophosphate (99mTc-PYP), avidly localize in the heart
of patients with TTR amyloidosis, either wild-type or mutated, and
scintigraphy with this tracer represents a useful complement to
diagnosis, helping differentiating these forms from AL amyloidosis
[44–47].
Heart involvement, its presence and degree, is the most important
predictor of survival in patients with AL amyloidosis. Among 1399
patients with this disease evaluated at the Pavia Amyloidosis Research
and Treatment Center, the heart was involved in 70% of cases, and
cardiac involvement was responsible for 85% of deaths. Severe heart
involvement at presentation precludes aggressive treatment of the
underlying clonal disease and often results in death before therapy
has a chance to alter the course of the disease. Indeed, although in the
past 20 years the proportion of patients surviving 5 years increased
from 30 to 60%, no improvement was made in subjects who present
with advanced cardiac involvement [48]. Thus, the early detection
of cardiac amyloidosis and the accurate assessment of its severity are
of paramount importance. The most practical and useful metrics of
cardiac organ damage in AL amyloidosis are the cardiac biomarkers.
They provide relevant measures of early cardiac involvement, prognosis
and response to therapy. We showed that the serum concentration
of N-terminal pro BNP (NT-proBNP) is a sensitive marker of cardiac
involvement in AL amyloidosis and is a powerful prognostic
determinant, independent of clinical assessment of heart failure,
wall thickness and ejection fraction [11]. All patients with cardiac
AL amyloidosis have an elevated concentration of NT-proBNP,
indicating 100% sensitivity [11,49]. However, caution should be
taken in interpreting NT-proBNP values, since NT-proBNP is not a
specific marker and can be elevated in non-amyloid cardiac disease,
particularly in the presence of atrial fibrillation, as well as in renal
failure, which is not uncommon in patients with amyloidosis. In
patients with renal failure, BNP is a more specific marker of cardiac
dysfunction than NT-proBNP, but its sensitivity in the overall
population is lower (89%) [49]. Also the concentration of cTn
portends a poor outcome in AL amyloidosis, independently from
classical echocardiographic features [50]. These two biomarkers
can be combined in a very simple yet accurate staging system that
allows discrimination of patients at low, intermediate and high
risk, guiding the choice of therapy in single subjects and allowing
patients' stratification in clinical trials [51]. While low-risk patients
can survive long time even if they fail to respond to first-line
treatment, the median survival of high-risk patients is only 3.5 months
731
[51]. A European study showed that extremely elevated NT-proBNP
concentrations (N8500 ng/L) and low systolic blood pressure
(b 100 mmHg) identify a subset of patients with very advanced
cardiac disease who survive only few weeks [52]. Recently, a revised
staging system including the concentration of circulating free light
chains discriminated between four groups with significantly different
survival [53]. Refinement of prognostic stratification in AL amyloidosis
has also been attempted with novel cardiac biomarkers. Cardiac TnT
measured with a high-sensitivity assay (hs-cTnT) proved to be the
single most powerful prognostic determinant [54,55]. More recently,
midregional pro-adrenomedullin (MR-proADM) was shown to be an
additional strong prognostic marker in AL amyloidosis [56]. While
standard echocardiographic features, such as wall thickness and
ejection fraction, are of little value in prognostic assessment compared
to biomarkers, other, more refined, echocardiographic parameters,
in particular longitudinal left ventricular function, have been shown
to add relevant prognostic information [34]. Arrhythmia is also a
prominent feature of cardiac amyloidosis. Approximately one fourth
of patients die suddenly. Holter electrocardiography can be of help in
the initial assessment of patients with AL amyloidosis: subjects in
whom complex ventricular arrhythmias are detected are at high risk
of sudden death independently from echocardiographic variables [57].
Recently, it has been shown that fragmented QRS at standard
electrocardiogram has an independent prognostic factor in AL
amyloidosis and can help refining patient staging [58]. Cardiac
involvement in AL amyloidosis is also associated with conduction
disturbances, such as prolonged PQ, QRS, QT and QTc intervals and
intraventricular blocks that are associated with a poorer prognosis [59].
3.2. Renal involvement
Involvement of the kidney can manifest with proteinuria evolving to
overt nephrotic syndrome, renal failure progressing to end-stage renal
disease, or both. The kidney is involved in almost all the patients
with AA amyloidosis and in 70% of those with AL amyloidosis, and
albuminuria is the initial finding in these forms. In ApoAI amyloidosis
with renal involvement, a slowly progressing reduction in glomerular
filtration rate (GFR) without significant proteinuria is observed [60].
A recent study showed that the estimation of GFR at baseline, serum
albumin concentration, and the quality of hematologic response to
treatment independently predicted progression of renal damage in
AL amyloidosis. The latter two variables were also independently
associated with improvement of renal involvement [61]. More recently,
it has been reported that profound decreases in proteinuria (N95%)
1 year after treatment initiation are associated with improved survival
in AL amyloidosis [62]. In AA amyloidosis, progression to end-stage
renal disease and survival are independently affected by SAA
concentration and by the presence of end-stage renal disease at
presentation [63]. Patients with periodic fever have a better outcome
than those with chronic sepsis or Crohn's disease [63].
3.3. Liver involvement
Hepatic amyloidosis manifests with hepatomegaly and cholestasis.
However, hepatomegaly can also occur in patients with cardiac
amyloidosis and congestive heart failure in the absence of amyloid
infiltration of the liver. Slowly progressing cholestasis is the hallmark
of a form of hereditary ApoAI amyloidosis which is endemic in northern
Italy [22]. In AL amyloidosis the liver is involved in approximately one
fifth of patients. In a series of 98 patients with hepatic AL amyloidosis
diagnosed by liver biopsy, hepatomegaly was found in 81% of cases,
alkaline phosphatase was elevated in 86% of patients, aspartate
aminotransferase in 80%, total bilirubin in 21%, and 35% of subjects
had a prolonged prothrombin time [64]. Liver biopsy was associated
with a small (4%) risk of bleeding [64]. Patients with elevated bilirubin
had a very poor outcome, with a median survival of only one month
732 G. Palladini, G. Merlini / European Journal of Internal Medicine 24 (2013) 729–739
[64]. Kappa clones are more frequently found in subjects with liver
involvement, being responsible for 30–40% of cases [64,65]. However,
lambda light chains causing liver involvement seem to be associated
with more aggressive disease, more advanced cardiac involvement
and worse outcome [65].
3.4. Peripheral and autonomic nervous system involvement
Peripheral neuropathy is a feature of both AL and hereditary
ATTR amyloidosis. However, several TTR mutations give rise to
amyloidosis involving almost exclusively the peripheral nervous
system, as in the prototypical and most common form of familial
amyloid polyneuropathy caused by the Val30Met TTR variant, whereas
in AL amyloidosis neuropathy is seldom isolated (2% of cases in our
series of 1399 patients). The involvement of the peripheral nervous
system is assessed clinically in the presence of symmetric length-
dependent ascending sensorimotor peripheral neuropathy, initially
affecting sensitivity to pain and temperature [66]. Electromyography
and nerve conduction velocity studies frequently give negative results,
because amyloid initially involves small fibers [67].
Autonomic neuropathy manifests with postural hypotension,
impotence and bladder and bowel dysfunction, ranging from severe
diarrhea to constipation. However, multiorgan damage makes it
difficult to clinically evaluate autonomic nervous system involvement.
For instance, reduced cardiac output and hypoalbuminemia resulting
in contraction of plasma volume can also play a role in the genesis of
hypotension. When confirmation of GI involvement is needed, direct
biopsy is required, keeping in mind that the finding of amyloid deposits
only in the vascular walls on an endoscopic biopsy is very common
and often asymptomatic and is not evidence of GI involvement [66].
Asymptomatic involvement of the autonomic nervous system is also
very common in patients with AL amyloidosis, with deregulation of
arterial baroreflex and autonomic modulation of the heart rate [68].
3.5. Soft tissue involvement
In AL amyloidosis, soft tissue involvement is found in 12% of
patients and can include macroglossia, submandibular swelling,
Fig. 1. Soft tissue involvement in AL amyloidosis.
lymphadenopathy, vascular deposits manifested as purpura or
claudication of the jaw, muscular pseudohypertrophy, articular
deposits, the shoulder pad sign and carpal tunnel syndrome. When
present, these signs strongly suggest AL amyloidosis, since they are
only exceptionally found in other forms of systemic amyloidosis
(Fig. 1). Differently, carpal tunnel syndrome can be found both in
AL and in ATTR amyloidosis and can precede by several years the
other manifestation of the disease.
3.6. General manifestations of systemic amyloidosis
Besides symptoms and signs of specific organ involvement, systemic
amyloidoses are often accompanied by manifestations that cannot be
directly linked to any organ dysfunction. These include profound fatigue
and anorexia. In AL amyloidosis, malnutrition is best assessed by
measuring the serum concentration of prealbumin and independently
affects survival and quality of life [69–72]. Also in ATTR amyloidosis
the nutritional status, best assessed as modified body mass index
(mBMI), and gastrointestinal dysfunction strongly affect patients'
survival [73].
4. Diagnosis
Systemic amyloidoses are progressive diseases leading to irreversible
organ dysfunction and death. However, therapies are available that can
halt, and many times reverse, the course of the disease [4]. Thus, timely
diagnosis is vital. The early clinical manifestations that should raise the
suspicion of systemic amyloidosis, the so-called “red flags”, are reported
in Table 3. Early identification of cardiac AL amyloidosis is of particular
importance, because this disease progresses rapidly, and, although
cardiac function can be restored, this is possible only at early stages.
Since amyloidoses are rare diseases population screening is unfeasible.
However, it is reasonable to screen patients who are at particularly
high risk of developing amyloidosis. For instance, subjects with
monoclonal gammapathies of undetermined significance, who have
an altered free light chain (FLC) κ/λ ratio should have cardiac
biomarkers and albuminuria included in their periodic workup, in
order to timely detect the onset of cardiac and/or renal AL amyloidosis
 G. Palladini, G. Merlini / European Journal of Internal Medicine 24 (2013) 729–739
Table 3
Early “red flags” of the most common types of systemic amyloidoses.
Organ or Amyloidosis Early red flags
syndrome types
Heart AL NT-proBNP N332 ng/L (sensitivity 100%) or BNP N73 ng/L
(sensitivity 89%) in patients with monoclonal
gammapathy and elevated FLC κ/λ ratio
Kidney AL, AA Proteinuria N0.5 g/day (predominantly albumin)
Liver AL, AApoAI Elevation of ALP or γGT in the absence of other causes
Soft tissues AL, ATTR Carpal tunnel syndrome
ANS/PNS AL, ATTR Neuropathic pain and loss of sensitivity to temperature
Erectile dysfunction
Onset of hypotension or resolution of hypertension
ALP, alkaline phosphatase; ANS, autonomic nervous system; γGT, γ-glutamyl transpeptidase;
NT-proBNP, N-terminal pro-natriuretic peptide type B; PNS, peripheral nervous
system; and FLC, free light chain.
[6,7]. Also, it is advisable to periodically look for albuminuria in patients
suffering from chronic inflammatory diseases, who can develop renal
AA amyloidosis.
The diagnosis of systemic amyloidosis requires a tissue biopsy
showing amyloid deposits that are effectively detected by their green
birefringence under polarized light when stained with Congo red [66].
Subcutaneous abdominal fat aspiration is the simplest and least invasive
diagnostic procedure. Its sensitivity is above 80% in AL and AA
amyloidosis (with the exception of amyloidosis secondary to familial
Mediterranean fever), but is lower in ATTR [74]. Labial salivary gland
biopsy is also simple and yields a high diagnostic sensitivity in AL, AA,
and ATTR amyloidoses [75,76]. Amyloid deposits are found in the labial
salivary glands of almost 60% of patients with systemic amyloidosis and
negative abdominal fat aspirate, and the sequential biopsy of these two
sites has a negative predictive value of 91%, thus limiting the need for an
organ biopsy to less than 10% of patients [77].
The biopsy of the involved organs can be performed if amyloidosis is
still suspected but biopsies of alternative sites are negative. The small,
but significant, risk of hemorrhage should be taken into account. Rectal
biopsy has a good sensitivity in AL, AA, and ATTR amyloidosis [78,79],
however, abdominal fat aspirate should be preferred. Gastro-duodenal
biopsy can be as informative as rectal biopsy, at least in AA amyloidosis
[80,81]. It should be kept in mind that amyloid deposits are more
frequently found in the submucosa than in the muscularis mucosae
and in the mucosa, therefore biopsies should be deep enough to provide
the highest sensitivity [82].
Different types of amyloidosis require different therapeutic
approaches. Incorrect amyloid typing results in catastrophic therapeutic
consequences, such as exposing to useless and toxic chemotherapy
subjects with hereditary or senile amyloidosis. It must be kept in
mind that identifying amyloid deposits in a patient with a monoclonal
component is not conclusive evidence of AL amyloidosis, due to the
high prevalence of monoclonal gammapathies particularly in the
elderly [83–87]. Given the substantial overlap in disease manifestations
of the most common types of systemic amyloidosis, clinical evaluation
is of little help in differential diagnosis. Also, the absence of a family
history does not exclude the hereditary amyloidoses, due to the variable
penetrance of these diseases. However, in some instances the clinical
picture including typical macroglossia, periorbital purpura and/or the
shoulder pad sign, as well as the coexistence of cardiac and renal
involvement in a patient with a monoclonal gammapathy, strongly
suggest AL amyloidosis. In these cases, if cardiac dysfunction
requires the prompt initiation of chemotherapy, treatment can be
started while waiting for amyloid typing [88].
Light microscopy immunohistochemistry can consistently identify
AA amyloidosis. However, conventional immunohistochemistry, as
well as immunofluorescence on renal biopsies, is unreliable in AL,
when performed with commercial antibodies [89]. Nevertheless,
at referral centers using custom-made antibodies, light micros-
copy immunohistochemistry can be a valuable tool for amyloid
733
characterization [90]. At our center we routinely rely on immuno
electron microscopy performed on abdominal fat aspirates and organ
biopsies [91]. This technique co-localizes the antibody and the amyloid
fibril, thus increasing specificity, and could correctly identify the
amyloid type in more than 99% of cases in a series of 537 patients
referred to our center for suspected systemic amyloidosis [74]. Modern
proteomics makes typing of amyloid a direct matter, and several
proteomic approaches based on two-dimensional electrophoresis
[92,93], laser capture microdissection [94], and Multidimensional
Protein Identification Technology [95] have been developed by our
group and by Mayo Clinic investigators.
The results of tissue typing are confirmed by DNA analysis in the
hereditary amyloidoses, and by the demonstration of a monoclonal
component of the same isotype as that of the light chain forming the
amyloid fibrils in AL amyloidosis. The latter is not trivial endeavor
because of the small size of the plasma cell clone, and requires the
combination of different high-sensitivity techniques. The sensitivity of
standard serum and urine immunofixation in AL amyloidosis ranges
from 79% to 96% [96–101]. Immunofluorescence on bone marrow
aspirates can detect the amyloidogenic plasma cell clone in 84% of
cases [102]. The possibility of measuring circulating FLC offered a most
useful complement for the diagnosis of AL amyloidosis. Clonality can
be inferred by an altered FLC κ/λ ratio with a sensitivity ranging from
75% to 98% [96–101]. However, only the combination of immunofixation
of both serum and urine with the quantification of circulating FLC grants
a 98–100% diagnostic sensitivity [101,103,104].
5. Treatment
The mainstay of treatment of systemic amyloidoses is the suppression
of the synthesis of the amyloid protein. Alternative strategies include
reducing the amyloidogenic propensity of the precursor and targeting
the amyloid deposits. Supportive therapy, including organ transplant
also plays a major role in improving the patients' symptoms and quality
of life and supporting organ function while specific treatment has time to
take effect [105].
5.1. Reducing the supply of the amyloidogenic precursor
In AL amyloidosis reducing the concentration of the circulating FLC
translates in the improvement of organ dysfunction and prolonged
survival [12,96,106–108]. This is obtained by targeting the amyloidogenic
plasma cell clone with chemotherapy [109]. The treatment regimens
used in AL amyloidosis are adapted from those employed in multiple
myeloma. However, AL amyloidosis is not only a hematologic malignancy,
but its clinical manifestations and prognosis are dictated by
multiorgan dysfunction [110]. Thus, treating these patients is a
challenging undertaking even for the hematologists experienced in
the care of patients with multiple myeloma, as indicated by the
high treatment related mortality and morbidity observed in multicenter
studies. This, combined with the need for sophisticated diagnostic
techniques, facilitated the creation of a few highly specialized referral
centers, where physicians can evaluate and treat the hundreds of
patients necessary to develop adequate skills. Yet, the need to travel
to referral centers to be administered chemotherapy causes a significant
discomfort to patients and is often unfeasible. To overcome these
difficulties, more than 25 years ago, we established a network of clinical
centers dedicated to the treatment of AL amyloidosis coordinated by
our institution and sharing a common, annually updated, therapeutic
and diagnostic protocol [111].
The cornerstones of chemotherapy for AL amyloidosis are risk
stratification and frequent assessment of hematologic and cardiac
response, allowing for a rapid switch to second-line treatment in case
of suboptimal efficacy of first-line therapy. Both risk stratification and
response assessment are based on measurements of cardiac biomarkers
and FLC [112]. Response should be evaluated every two cycles, or three
734 G. Palladini, G. Merlini / European Journal of Internal Medicine 24 (2013) 729–739
months after autologous stem cell transplantation, using the recently
updated criteria for hematologic and cardiac response (Table 4) [5,113].
Very few randomized clinical trials exist to guide the choice
of treatment in AL amyloidosis; however, thanks to international
cooperation and validated response criteria several large trials are
ongoing that will eventually define a standard of care [114]. Awaiting
the results of the ongoing studies, some indications can be derived
from smaller uncontrolled trials and case series. Autologous stem cell
transplantation (ASCT), when performed with full dose (200 mg/m2)
melphalan, induces a hematologic response in approximately three
fourths of patients with complete responses (CR) in about 40% [115].
In the past two decades the mortality related to ASCT has progressively
decreased, thanks to improved patient selection based on cardiac
biomarkers [116,117]. Currently, ASCT is offered only to highly selected
patients, younger than 65 years, with cTnT b0.06 ng/mL and NT-proBNP
b6000 ng/L, GFR N 50 mL/min, performance status 0 to 2, ejection
fraction N 45%, systolic blood pressure N 90 mmHg (standing), and CO
diffusion capacity N 50%, who represent approximately 15% of patients
[6,118]. Patients who are not eligible for ASCT are usually offered
the oral combination of melphalan and dexamethasone (MDex). This
regimen grants a hematologic response in two thirds of patients, with
CR in one third of cases [119]. The durability of response to MDex is
comparable to that reported with ASCT [120]. Moreover, a randomized
trial failed to demonstrate the superiority of ASCT over MDex in terms
of both response rate and survival [121]. An alternative to MDex,
which has the advantage of sparing stem cells, is a combination of
cyclophosphamide, thalidomide and dexamethasone [122]. Currently,
the dyad ASCT/MDex is being challenged by the availability of
bortezomib. Bortezomib, the first in class proteasome inhibitor, is
thought to be particularly effective against amyloidogenic plasma
cells relying on proteasome activity to cope with the proteotoxicity
posed by the misfolded light chain they synthesize [123,124].
Indeed, both a large retrospective series [125] and a prospective
trial [126–128] showed a high rate of rapid responses to this drug
in previously treated patients, and suggested moving bortezomib
to first-line therapy. Recently, two independent small retrospective
case series showed an unprecedented rate of hematologic response
(81–94%, with CR in 42–71%) to the combination of cyclophosphamide,
bortezomib and dexamethasone (CyBorD) [129,130]. Since CyBorD is a
stem cell sparing regimen it has been proposed to treat with this
combination patients eligible to ASCT, actually performing transplant
only in subjects who do not attain a CR [113]. Bortezomib can also be
used after ASCT in order to increase the rate of CR [131]. A large,
international, randomized trial (NCT01277016) is ongoing comparing
MDex vs. MDex with the addition of bortezomib (BMDex). The
treatment of high-risk patient is yet an unsolved problem, since it
must conjugate maximum tolerability with rapid action. High-dose
Table 4
Criteria for hematologic response and cardiac response and progression in AL amyloidosis.
Definition Criteria
Hematologic response CR: negative serum and urine immunofixation and
normal FLC κ/λ ratio
VGPR: dFLC b40 mg/L
PR: dFLC decrease N50% compared to baseline
NR: all other patients
Cardiac response NT-proBNP decrease N30% and 300 ng/L in patients
with baseline NT-proBNP ≥650 ng/L or
Decrease by at least 2 NYHA classes in patients with
baseline NYHA class III or IV
Cardiac progression NT-proBNP increase N30% and 300 ng/L or
cTn increase ≥33% compared to baseline or
Decrease of at least 10% of ejection fraction
CR, complete response; dFLC, difference between involved (amyloidogenic) and
uninvolved free light chain concentration; FLC, free light chain; NR, no response;
NT-proBNP, N-terminal pro-natriuretic peptide type B; NYHA, New York Heart
association; PR, partial response; and VGPR, very good partial response.
dexamethasone is poorly tolerated in these patients, since it can
precipitate heart failure and cause severe arrhythmias [132,133],
and MDex cannot overcome their poor prognosis also when combined
with thalidomide [134–137]. Patients who fail to respond to first-line
therapy can effectively be rescued with dexamethasone associated
with thalidomide [138], lenalidomide, either alone [139–141] or
combined with alkylators [142–147], or pomalidomide [148].
Reduction of the supply of the precursor has been also the mainstay
of treatment of hereditary ATTR amyloidosis. This was obtained by liver
transplantation, replacing the production of the mutated TTR with
the wild type protein, beginning in 1990 [149]. Surgical outcome is
generally excellent, since patients are not in liver failure at the time of
transplant, and three fourth of subjects survive at least 5 years [150].
Factors associated with poor prognosis are an mBMI b600, disease
duration N7 years, non Val30Met mutations, and severe peripheral
and autonomic neuropathy at the time of transplant [150–152]. The
greatest benefits of liver transplant are stabilization and in some
instances improvement of neurological symptoms [150,151,153,154]
and amelioration of nutritional status, possibly secondary to rapid
improvement of gastrointestinal motility [155,156]. The benefit for
patients with significant cardiac involvement is less clear. Indeed, it
has been shown that cardiac amyloidosis can progress after liver
transplant, due to the deposition of wild-type TTR triggered by pre-
existing amyloid fibrils primarily composed of the mutated protein
[153,156–160]. Combined heart and liver transplant can extend the
eligibility to patients with advanced cardiac amyloidosis [161].
Progressive amyloid deposits following liver transplantation have
been documented also in the eye [162] and in the leptomeninges,
leading to intracranial hemorrhage [163], caused by production of
mutant TTR by the choroid plexus. Of interest, because the synthetic
function of the liver is intact in patients with ATTR amyloidosis,
the explanted liver can be transplanted into another individual
in a domino transplant. However, the occurrence of symptomatic
amyloid deposits in recipients has been reported [164,165]. Lowering
TTR concentration by small interfering RNA is an alternative promising
strategy which has been proven feasible in a phase I trial [166].
Also in AA amyloidosis, it has been shown that reduction of the
amyloidogenic precursor, SAA, results in improvement of organ
dysfunction and extended survival [167]. This goal is reached with
aggressive treatment of the underlying inflammatory disease. The
type of treatment depends on the nature of the inflammatory
condition. Attention should be paid to even temporary relapses
with increasing SAA concentration, that can be associated with
rapid worsening of previously recovered renal damage [25].
Early intervention with anti-TNFα agents is recommended in AA
amyloidosis secondary to rheumatoid arthritis that seems able to
induce improvement of renal dysfunction in spite of suboptimal
control of SAA [168]. However, use of these agents is associated
with a higher frequency of infections, including fatal sepsis [169].
Familial Mediterranean Fever (FMF) is effectively treated by colchicine
in more than 95% of cases. Other autoinflammatory diseases, as well
as FMF cases resistant to colchicine, can be effectively controlled by
means of anti-interleukin agents [170].
5.2. Interfering with precursor protein aggregation and targeting the
amyloid deposits
In the early nineties we demonstrated for the first time that a small
molecule, the anthracycline 4′-iodo-4′-deoxy-doxorubicin (I-DOX),
inhibited amyloidogenesis in vitro and could improve the clinical status
and promote resorption of amyloid deposits in patients with AL
amyloidosis [171,172]. Subsequently, it was reported that I-DOX could
disrupt the fibrillar structure of ATTR amyloidosis [173] and induce
“disaggregation” of pre-fibrillar oligomers [174]. A compound whose
molecular structure closely resembles that of I-DOX, the antibiotic
doxycycline, was also shown to disrupt amyloid fibrils in vitro and in a
 G. Palladini, G. Merlini / European Journal of Internal Medicine 24 (2013) 729–739
transgenic mouse model [175,176]. More recently it has been reported
that tauroursodeoxycholic acid (TUDCA) acts synergistically with
doxycycline in lowering TTR deposition [177]. Doxycycline and TUDCA
have the advantage of being marketed drugs that can be “repurposed”
for the treatment of ATTR amyloidosis. A trial evaluating the
combination of doxycycline and TUDCA in ATTR amyloidosis, both
hereditary and senile, showed that this therapy can stabilize the
disease for at least 1 year in the majority of patients [178].
The use of polyphenols as anti-amyloid compounds is also being
considered with interest [179,180]. Following the observations that
(-)-epigallocatechin-3-gallate (EGCG), the main polyphenolic constituent
of green tea, reduces cerebral amyloidosis in Alzheimer's transgenic mice
[181], and inhibits amyloid fibril formation [182], its action is being
explored in systemic amyloidosis. Ferreira and coworkers showed that
EGCG inhibits TTR aggregation in vitro, in a cell culture system, and in a
ATTR mouse model [183]. Subsequently, Dr. Werner Hunstein, former
professor of hematology at the University of Heidelberg, who had been
suffering from AL amyloidosis, observed an improvement in his cardiac
symptoms while he was purposely drinking high amounts of green tea
[184]. The clinical activity of EGCG was then confirmed in retrospective
case series both in AL and in ATTR amyloidosis [185,186]. More recently,
Ferreira et al. showed that EGCG has a dual effect on TTR amyloidogenesis
in a mouse model, both as TTR aggregation inhibitor and amyloid
fibril disruptor [187]. A randomized clinical trial is ongoing at our center
to evaluate the ability of EGCG in promoting regression of residual
cardiac damage in patients with AL amyloidosis who have completed
chemotherapy (NCT01511263).
Pepys et al. investigated the possibility of promoting resorption
of amyloid deposits by depleting serum amyloid P component (SAP),
a common constituent of amyloid deposits thought to protect them
from resorption, with a palindromic compound, CPHPC, a competitive
inhibitor of SAP binding to amyloid fibrils [188]. A pilot clinical study
of CPHPC, showed promising results in subjects with hereditary
fibrinogen amyloidosis [189]. More recently, the same group showed
that administration of anti-human-SAP antibodies to mice with amyloid
deposits containing human SAP triggers resorption of visceral amyloid
deposits [190]. The University of Tennessee group is also exploring
immunotherapy of systemic amyloidosis. They showed that infusion
of an anti-light-chain monoclonal antibody having specificity for
an amyloid-related epitope caused the resolution of amyloidomas
generated in mice by injection of amyloid proteins extracted from
the spleens or livers of patients with AL amyloidosis [191]. Similar
activity was observed in a mouse model of AA amyloidosis [192].
Two small molecules, diflunisal, an anti-inflammatory drug marketed
in the USA, and tafamidis, a specifically designed novel compound,
are able to stabilize the TTR tetramer, preventing its dissociation in
monomers and hence the amyloidogenic process. Early data from
the diflunisal trial indicate that the drug can be safely administered
also in patients with cardiac dysfunction [193,194]. Early results
suggest that tafamidis slows disease progression in patients with
TTR familial amyloid polyneuropathy and improves mBMI [195].
Tafamidis has been approved by the European Medicines Agency
in 2011.
Eprodisate, a small sulfonated molecule resembling heparan sulfate
interferes with the interaction between amyloidogenic proteins and
glycosaminoglycans and inhibits the development of amyloid deposits
in a mouse model of AA amyloidosis [196]. A randomized, placebo-
controlled trial showed the eprodisate can slow progression of renal
failure in AA amyloidosis [197]. A larger international trial is underway
to ascertain its efficacy (NCT01215747).
5.3. Supportive therapy
Supportive treatment is a fundamental part of the management of
AL patients. It is aimed at maintaining the quality of life and prolonging
survival, while specific therapy has time to take effect.
735
The mainstay of the treatment of congestive heart failure and
nephrotic syndrome are salt restriction and judicious diuretic use.
Cardiac function in amyloidosis is often preload dependent, and
reduction of intravascular volume should be avoided, particularly
in patients with hypoproteinemia and postural hypotension [105].
Many patients have asymptomatic involvement of the autonomic
nervous system [68], and symptomatic hypotension can easily
ensue after treatment with angiotensin-converting enzyme inhibitors
that should be used with great caution and at the lowest effective dose.
Heart failure and hypoproteinemia can contribute in lowering blood
pressure. Patients with hypotension can benefit from fitted elastic
leotards and midodrine. Patients with recurrent syncope may benefit
from pacemaker implantation. The utility of implantable cardioverter-
defibrillators (ICD) is controversial [198]. Neuropathic pain can benefit
from gabapentin or pregabalin treatment. Diarrhea due to gastrointestinal
and/or autonomic nervous system involvement can be controlled with
octreotide [199–202]. Maintenance of a good nutritional status is a vital
part of supportive treatment for systemic amyloidosis, since in AL and
ATTR amyloidosis malnutrition independently affects prognosis and
quality of life, and limits eligibility to effective therapies [69,70,150,203].
In AA amyloidosis a tight control of blood pressure can improve renal
response to treatment aimed at reducing SAA concentration [204].
Transplantation of the organs involved by amyloidosis may prolong
survival, improve quality of life, and render patients with advanced
disease eligible for aggressive specific treatment. The main concerns
with organ transplantation are recurrence of amyloidosis in the graft
and progression in other organs. In AL amyloidosis, organ transplant
can be considered in patients who attain CR, but have irreversible
end-stage organ damage. The role of renal transplant in this setting
has been recently reviewed [205]. Available data indicate that kidney
transplant can be offered to patients with AL amyloidosis with sustained
CR. Heart transplant followed by ASCT or other effective chemotherapy
can be the only effective option for young patients with isolated, severe
cardiac involvement [206–211]. Ventricular assist devices have been
used in patients with terminally compromised cardiac function with
disappointing results mostly due to high morbidity [212]. In ATTR
amyloidosis combined liver and heart transplant allows extending the
benefits of liver transplant therapy to subjects with heart involvement,
who would otherwise be ineligible due to the likely progression of
cardiac dysfunction despite liver transplant [161]. Renal transplantation
can be offered to carefully selected patients with AA amyloidosis and
end-stage renal disease, in whom a steady control of SAA concentration
has been achieved [213]. In AApoAI amyloidosis with cardiac
involvement, given the slow pace of the disease, heart transplant
can prolong survival by several years [214].
6. Conclusion
The cornerstones of the management of systemic amyloidoses
are early diagnosis, accurate typing, appropriate risk-adapted therapy,
tight follow-up, and supportive treatment. Systemic amyloidoses are
complex diseases, and most patients need to be referred to specialized
centers for diagnosis and for designing the therapeutic approach.
Nevertheless, internists play a key role in the care of patients suffering
from these diseases, in that they are often the first seeing these subjects
once early organ dysfunction manifests, therefore having the priceless
opportunity of making an early diagnosis. It is their responsibility to
recognize the disease, start the diagnostic workup and select patients
to be referred to amyloid centers. Moreover, internists have the
multidisciplinary background which is needed to provide these
patients with continuous, careful support during treatment and
follow-up. Whatever the advances amyloid researcher will make
in the future to better understand and possibly cure systemic
amyloidoses, they will always rely on internists to transfer them in
everyday clinical practice.
736 G. Palladini, G. Merlini / European Journal of Internal Medicine 24 (2013) 729–739
Learning points
• Systemic amyloidoses are caused by conformational changes
aggregation and deposition of autologous proteins in tissues,
leading to organ dysfunction, which is fatal if left untreated.
• Early diagnosis is the prerequisite for effective therapy, allowing
reversal of organ damage and extending survival.
• The different types of amyloidosis are treated differently, and
accurate identification of amyloid type is mandatory, if necessary
referring patients to specialized centers for diagnosis.
• Therapy should be guided by risk-stratification and frequent
assessment of response based on biomarkers.
• Careful supportive treatment can improve patients' quality of live
and grant time for specific therapy to exert its action.
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