Amyloidosis Nelson Leung, MD Mayo Clinic Rochester FOURTH - - PowerPoint PPT Presentation

Amyloidosis

Nelson Leung, MD Mayo Clinic Rochester

FOURTH INTERNATIONAL CONGRESS ON IMMUNOINTERVENTION IN NEPHROLOGY

Cagliari, 30 April- 3 May 2011

Outline

History AL AA Hereditary amyloidosis

History of Amyloidosis

First described in the 17

Century by Bonet

liver abscess and

enormous spleen with white stones (sago spleen)

1842- Rokitansky

waxy liver with

lardaceous degeneration in patients with TB, syphilis and rickets

• Kyle. Medicine 1975

Amyloid

Schleiden - 1838

First used the term to describe normal

amylaceous constituent of plants

Virchow - 1854

first to use the term in human pathology thought it may be starch or cellulose

Budd

later proposed amyloid is albuminous rather than

fatty

Friedreich and Kukulé

showed amyloid is albuminoid (protein) suggested to keep the term amyloid

• Kyle. Medicine 1975

Primary (Immunoglobulin light chain) AL amyloidosis

Wilks- 1856

described lardaceous viscera in a 51 yo male with

no tuberculosis, osteomyelitis or syphilis

Adams-1872

described a case of myeloma and amyloidosis

Wild-1886

Most credit with the first description of AL

amyloidosis

Westermark et al. Amyloid 2007

Amyloidogenesis

Merlini & Bellotti. NEJM 2003

Systemic Amyloidosis

Merlini & Bellotti. NEJM 2003

Amyloidosis Mayo Clinic 1960-2006

n=4,666

Primary (AL) 73% (3,389) Localized 15% (707) Senile 4% (206) Familial 4% (193) Secondary (AA) 3% (148) β2 M (11) 0.5%

CP1102576-5

Amyloidoma (12) 0.5%

AL/AH (Primary) Amyloidosis

Plasma cell dyscrasia

Lymphoproliferative disorders

Most common form of amyloidosis in

industrialized countries

Most rapidly progressive Organs involved

Heart / kidney Nerves Gastrointestinal/ liver Lung Soft tissue Coagulopathy endocrinopathies

Age Distribution of AL Patients

5 10 15 20 25 30 35 40 % <40 40-49 50-59 60-69 70-79 >80

Kyle & Gertz. Sem in Hematol 1995

Syndromes at Presentation

5 10 15 20 25 30 %

Nephrotic Syndrome Renal Insufficiency CHF Peripheral Neuropathy Orthostasis GI Carpel Tunnel

Kyle & Gertz. Sem in Hematol 1995

Melphalan & Prednisone Era

MPC C

Median survival for melphalan containing groups was 12 18 months Hematologic complete response (CR) rare Organ response - rare

Kyle et al. NEJM 1997 Skinner et al. Am J Med 1996

Ann Intern Med. 2004;140:85-93

Hematologic Complete Response 40% Organ response in 66% of patients with Hem CR, 30% in those without Hem CR

Melphalan & Dexamethasone

Treatment

Melphalan 0.22 mg/kg/day Dexamethasone 40mg/day Day 1-4 every 28 days

Results

56 patients Severe heart involvement

70%

Hematologic response

67% CR 33%

Palladini et al. Blood. 2004

Overall Survival was Superior in the MDex Treated Group

Jaccard et al. NEJM 2007

Criticism

10 patients died in the SCT group

prior to receiving SCT

3 others withdrew Those who received SCT had a

treatment related mortality of 24%

Jaccard et al. NEJM 2007

Differences in Survival were due to TRM in the High Risk Group

Jaccard et al. NEJM 2007

Renal Response after SCT

• 100%
• 80%
• 60%
• 40%
• 20%

0% 20% 40% 60% 3 6 9 12 18 24 36 48 60 72

Months Since Stem Cell Transplantation % Change in Proteinuria

Responders Non-responders

Leung et al. AJKD 2005

• Renal Responders
• Non-renal responders

Impact of Renal Response on Survival

P = 0.01

Leung et al. AJKD 2005

Leung et al. AJKD 2005

Renal Response and Survival

p = 0.04 Leung et al. AJKD 2005

AA (Secondary) Amyloidosis

More common in Europe and

developing countries

Associated chronic infections and

inflammatory diseases

Serum Amyloid A (SAA) protein

Apolipoprotein constituent of HDL Acute phase reactant

Synthesized in hepatocytes Controlled by cytokines 100 1000 folds increase

One of the wild type amyloidogenic

proteins

B2M IAPP-islet amyloid polypeptide- amylin Calcitonin Atrial natriuretic peptide Abeta Tau Prolactin Parmelee et al. Biochem 1982;3298-303 Westermark et al. Amyloid 2007;14:179-83 Simon & van der Meer. Am J Physiol 2007; 292:R86-98

Characteristics of Patients with AA

Organs involved

Kidney 97% Liver

Hepatomegaly 9% SAP scintigraphy 23%

Cardiac

1 CHF 2 Echocardiography

Neuropathy

Symptomatic none Adrenal deposit by SAP 41%

Median time from Sx to Dx - 17 years

Lachmann et al. NEJM 2007;356:2361-71

Incidence of AA

In the US:

AL:AA = 17-22: 1 1 in 2,125,000 to

2,750,000/yr

In Europe:

AL:AA = 2:1 1 in 125,000 -

250,000/yr

Verine et al. Hum Path 2007 Kyle et al. Sem Hem 1995 Kyle et al. Best Prac & Res Clin Hem 2007

Most Common Causes

Chronic inflammatory arthritis

Rheumatoid arthritis Ankylosing spondylitis

Chronic infections

Bronchiectasis Osteomyelitis Tuberculosis

Chronic inflamatory conditions

Castlemans disease Crohns disease Neoplasia

Periodic fever syndromes

Lachmann et al. NEJM 2007;356:2361-71 Verine et al. Hum Path 2007;38-1798-1809

Case

35 yo female referred for amyloidosis.

Long history of fever, abdominal pain, and

myalgia since puberty

No history of chronic infection/arthritis/back pain Was found to have 4.5 g/d of proteinuria after her

first pregnancy

She was taking large amount of ibuprofen for muscle pain This was stopped and proteinuria decreased to 200 mg/d. Proteinuria increased to 5 g/d after second child

Renal biopsy showed amyloidosis with no

predominate light chain

Family History

Mother

had always been sick with undulant fevers developed ESRD secondary to unknown

etiology

underwent a cadaveric kidney transplantation Died during surgery for bowel perforation Incidentally, pathology showed amyloidosis.

Sister and nephew have recurrent fevers,

abdominal pain.

Father side is Irish, Mother is English,

French, and German

Additional History

At one point, patient was felt to have

Familial Mediterranean Fever (FMF). Was placed on colchicine for several years with no benefit.

ESR > 100 CRP 17.8 mg/L Denies rash Denies hearing deficits No carpel tunnel No M-proteins on multiple occasions

Renal Biopsies

First biopsy- IF

IgG 2+ C3 4+ IgM 1+ IgA 1+ κ - 1+ λ - 1+ Fibrinogen, alb and C1q negative

Repeat Biopsy IF

albumin 1+ Rest were negative

Amyloid Battery

SAA (+) SAP (+) λ/κ - negative prealbumin - negative

Hereditary Periodic Fever Syndromes

Simon & van der Meer. Am J Physiol 2007; 292:R86-98

Familial Mediterranean Fever (FMF)

Most common of the hereditary autoinflammatory

syndromes

People of the Mediterranean basin Armenians, Sephardic Jews, Arabs, Turks

Symptoms

Fever, severe abdominal pain, serositis, arthritis Erysipeloid erythema confined to the legs

Mode of inheritance

Autosomal recessive

Mutation

MEFV (Mediterranean Fever gene) on chromosome 16p Pyrin

• Role in fever genesis is unknown
• (? survival advantage in heterozygotes)
• Co-localizes with microtubules

Church et al. Springer Semin Immun 2006 Simon & van der Meer. Am J Physiol 2007;292:R86-98

Hyper IgD Syndrome

High prevalence in Netherlands Symptoms

Lymphadenopathy and splenomegaly Triggered by vaccinations High levels of IgD and sometimes IgA Headaches Symptoms may improve with age

Mode of inheritance

Autosomal recessive

Mutation

Mevalonate kinase (MVK)

• Isoprenoid pathway cholesterol biosynthesis
• Mevalonic aciduria (mental retardation, ataxia, myopathy, failure to thrive,

early death)

• The build up of mevalonate increases urinary excretion of mevalonate

Simon et al. Clin Pharmacol Ther 2004

Muckle-Wells Syndrome

Cryopyrinopathies (MWS, FCAS,

NOMID/CINCA)

Symptoms

Cold provocation Urticaria Sensorineural deafness Anterior uveitis

Mode of inheritance

Most are autosomal dominant

Mutation

CIAS1 (cold induced autoinflammatory syndrome) Cryopyrin

Inflammasome Caspase-1 mediated IL-1β activation

Aksentijevich et al. Arthritis & Rheum 2007

TNF receptor type 1 (TRAPS)

Most common autosomal dominant HFS

2% N American & Irish, 9% African

Symptoms

Migratory myalgia, conjunctivitis, periorbital edema, rash,

testicular pain and inguinal hernia

Mode of inheritance

Autosomal dominant

Mutation

TNFRSF1A type 1 TNF receptor > 40 mutations identified, mostly involving CRDs (cysteine

rich domains)

Decreased shedding Mutant TNFR1 aggregates resulting in ligand independent

activation or enhanced unfolded protein response activation of IL-1β

CRD mutations are associated with more AA

TNF Pathway

Simon & van der Meer. Am J Physiol 2007; 292:R86-98

Treatment of Periodic Fever Syndromes

Syndrome Mutation Treatment

FMF MEFV(pyrin) colchicine/IFN α /thalidomide TRAPS TNFRSF1A(TNFR1) steroids/etanercept (infliximab/adalimumab)* HIDS MVK(mevalonate kinase) anakinra/statins MWS CIAS1 anakinra

*paradoxical reaction

Church et al. Springer Semin Immun 2006 Simon & van der Meer. Am J Physiol 2007; 292: R86-98 Jacobelli et al. Rheum 2007; 46: 1212-3

Response to Treatment

ESR Proteinuria

Steroids Dex 2mg QOD

Treatment of TRAP Syndrome

Index patient

Dexamethasone

Sister

Dexamethasone

Depression

Etanercept

Nephew

Etanercept

Rates of Amyloidosis in Periodic Fever Syndromes

FMF high prior to the colchicine TRAPS 25-40% MWS 25% HIDS- rare

Aganna et al. Genes and Immunity 2004 Lachmann et al. Arthritis & Rheumatism 2006 Masson et al. Joint Bone Spine 2004

Hereditary amyloidosis

350 amyloid patients with monoclonal

gammopathy

34 (9.7%) had amyloidogenic mutations

Fibrinogen A α chain Transthyretin Lyzozyme Apolipoprotein A-1

Misdiagnosis results in unnecessary cytotoxic

therapy

All amyloid must be subtyped

Westermark et al. Amyloid 2007

Methods for Subtyping Amyloid

Immunohistochemistry

Advantage actual typing the

precursor protein

Disadvantage- limited supply of the

reagent

Genetic testing

Advantage - easy for those the genes

that had been identified

Disadvantage - genes ≠ phenotypic

expression

Case

60 yo male with type 2 DM and

hypertension received an ABO incompatible (A B) kidney allograft.

No rejection was seen on 1 year protocol biopsy. At the 4 year follow-up, GFR decreased from 53

to 33 ml/min/1.73m2.

Repeat biopsy showed little change from previous

IF studies were negative EM showed randomly arranged fibrils consistent with

amyloid

Congo Red was negative

Serum and urine IFN were negative. Serum

FLCs were normal

Mass Spectrometry

Fibrinogen A-chain was identified Genetic testing showed a Val 526

mutation in the fibrinogen A-α chain

Immunofluorescence for fibrinogen

and Congo Red were negative.

Mass Spectrometry

Direct protein

typing

Large databases of

protein sequences that is constantly updated

High sensitivity

and specificity

Fluoro

Step 1: Histological examination

• f tissue section identifying

amyloid deposits. Step 2: Trace around amyloid deposits Step 3: Laser cuts out amyloid deposits Step 4: Tissue drops into microfuge cap Step 5: The microdissected and captured amyloid fragments are heated and digested (trypsin) into peptide fragments

Mass Spectrometry Results

TTHY_HUMAN (100% ), 15886.9 Da Transthyretin precursor (Prealbumin) (TBPA) (TTR) (ATTR) - Homo sapiens (Human) (P02766) 13 unique peptides, 16 unique spectra, 27 total spectra, 95/147 amino acids (65% coverage) M A S H R L L L L C L A G L V F V S E A G P T G T G E S K C P L M V K V L D A V R G S P A I N V A V H V F R K A A D D T W E P F A S G K T S E S G E L H G L T T E E E F V E G I Y K V E I D T K S Y W K A L G I S P F H E H A E V V F T A N D S G P R R Y T I A A L L S P Y S Y S T T A V V T N P K E SAMP_HUMAN (100%), 25387.8 Da Serum amyloid P-component precursor (SAP) (9.5S alpha-1-glycoprotein) [Contains: Serum amyloid P-component(1-20 7 unique peptides, 7 unique spectra, 13 total spectra, 82/223 amino acids (37% coverage) M N K P L L W I S V L T S L L E A F A H T D L S G K V F V F P R E S V T D H V N L I T P L E K P L Q N F T L C F R A Y S D L S R A Y S L F S Y N T Q G R D N E L L V Y K E R V G E Y S L Y I G R H K V T S K V I E K F P A P V H I C V S W E S S S G I A E F W I N G T P L V K K G L R Q G Y F V E A Q P K I V L G Q E Q D S Y G G K F D R S Q S F V G E I G D L Y M W D S V L P P E N I L S A Y Q G T P L P A N I L D W Q A L N Y E I R G Y V I I K P L V W V

Amyloid proteins: Observed: TTR, SAP NOT observed: Lambda, Kappa, SAA

Latest Amyloidosis

Case

65 yo male from Mexico

15 -20 years h/o of hypertension 4 years h/o of proteinuria Scr = 1.6 mg/dl (140 µmol/L)

Over the past year, more rapid

decline

Scr = 3.6 mg/dl (316 µmol/L) Proteinuria 1 g/d ESR 25 mm/1h

Outside laboratory data

SPEP monoclonal kappa UPEP polyclonal Bone marrow biopsy

5% plasma cells Polyclonal

Renal biopsy

Congo red positive IF lambda staining in areas of amyloid deposits

LECT2

stimulates the

growth of chondrocytes and

• steoblasts

May be related to

cell growth or repair

Benson et al. Kidney Int. 2008

LECT2

Known polymorphism

Valine or isoleucine at

position 58

No mutation found No inflammatory

markers

Questions

Inducible? Mutation in promoter

region?

60-70% of cases are

from Mexico

Benson et al. Kidney Int. 2008

Scottsdale, Arizona Scottsdale, Arizona Rochester, Minnesota Rochester, Minnesota Jacksonville, Florida Jacksonville, Florida

Questions