Hemodialysis-associated amyloidosis and beta-2 microglobulin. Clinical and immunohistochemical study

The beta-2 microglobulin type of amyloidosis was identified in articular and para-articular tissues of 14 patients with non-amyloid nephropathies undergoing long-term hemodialysis. Ten patients had carpal tunnel syndrome, 13 had juxta-articular radiolucent cysts (complicated by spontaneous fractures of the femoral neck in three), and six had destructive arthropathies of the large joints of the limbs. Massive amyloid deposits were found in the synovium, capsule, ligaments, articular cartilage, and/or bone. They were characterized by Congo red-induced green birefringence that was sensitive to potassium permanganate treatment. They reacted with anti-beta-2 microglobulin antiserum, whereas they did not react with antibodies directed against AA protein, prealbumin, or immunoglobulins. These data suggest that the potentially disabling arthropathy of hemodialysis is due to amyloid lesions. The persistently elevated plasma beta-2 microglobulin levels may play a role in the pathogenesis of this recently recognized complication, and if so, this complication should be preventable.     

Management of musculoskeletal complications in endstage renal disease: an update

People treated with prolonged hemodialysis now survive longer and increasingly develop musculoskeletal complications. Significant advances have been made in the management of musculoskeletal manifestations in patients undergoing hemodialysis for endstage renal disease. Noncalcium-based phosphate binders are preferred for the management of hyperphosphatemia. Vitamin D therapy is based on intact parathyroid hormone levels. Newer Vitamin D sterols and calcimimetic agents seem to control secondary hyperparathyroidism without increasing the calcium–phosphorous product. Use of biocompatible dialyzers for hemodialysis may delay articular manifestations of beta-2 microglobulin amyloidosis. Beta-2 microglobulin adsorption columns when used along with hemodialysis may lead to lower beta-2 microglobulin levels and improvement in articular manifestations of beta-2 microglobulin amyloidosis. In this review, we focus on the latest advancements in the management of secondary hyperparathyroidism and beta-2 microglobulin amyloidosis.     

The analysis of gastrointestinal amyloidosis in 78 patients with chronic renal failure.

Systemic amyloidosis is not a single disease, but the product of a variety of diseases. Amyloid proteins are insoluble fibrils that are deposited extracellularly in many organ tissues. They stain with Congo red and appear apple green under polarized light. Definitive diagnosis and classification ofamyloidosis requires histologic examination of tissue samples. Gastrointestinal tract involvement is common, and all parts of the system can be affected Immunohistochemical studies have shown that amyloid deposited in the gastrointestinal system is most often of the AA, A kappa, or A lambda types. Another type of amyloidprotein, beta-2 microglobulin (beta2M), predominantly affects the musculoskeletal system, and is usually seen in patients who have been on long-term hemodialysis. Mixed systemic amyloidosis (beta2M and AA) is seen only rarely in these patients. In this study, we attempted to answer why this is so, and examined whether or not mixed amyloidosis is related to amyloidogenesis. We studied gastrointestinal tissues from 78 chronic renal failure patients who had systemic amyloidosis with gastrointestinal involvement. A total of 115 endoscopic samples and 1 jejunal resection specimen were analysed immunohistochemically. Immunohistochemical testing using a panel of antisera directed against two major amyloid fibril proteins (AA-Monoclonal, Dako-, and beta2M-Polyclonal, Dako-) showed that all samples contained AA amyloid, but not beta2M type protein. These findings can be explained by the patients' relatively short average duration of hemodialysis and the predominance of endoscopic biopsy samples in our study.     

Lack of amyloid in abdominal fat aspirates from patients undergoing long-term hemodialysis

Recent reports describe the carpal tunnel syndrome (CTS) due to amyloid infiltration of the beta 2 microglobulin protein as a frequent complication of long-term hemodialysis. Carpal synovial and cystic bone lesion amyloid deposits have been reported; however, the extent of systemic amyloid deposition has not been determined. We examined 30 patients undergoing long-term hemodialysis for CTS and performed abdominal fat tissue aspiration for amyloid staining to evaluate the presence of systemic amyloid disease. In this group, CTS was frequent (37%) and its prevalence correlated with the duration of hemodialysis. In all patients, the abdominal fat tissue, stained with Congo red, was negative for amyloid deposits. These results confirm that CTS is a frequent complication of long-term hemodialysis; however, in this study, no detectable amyloid deposits were found in abdominal subcutaneous fat tissue. Thus, abdominal fat aspiration may not be a reliable screening test for hemodialysis-associated amyloidosis.     

Survey of the Effects of a Column for Adsorption of β2‐Microglobulin in Patients With Dialysis‐Related Amyloidosis in Japan

Dialysis‐related amyloidosis is a serious complication of long‐term hemodialysis. Its pathogenic mechanism involves accumulation of β2‐microglobulin in the blood, which then forms amyloid fibrils and is deposited in tissues, leading to inflammation and activation of osteoclasts. Lixelle, a direct hemoperfusion column for adsorption of β2‐microglobulin, has been available since 1996 to treat dialysis‐related amyloidosis in Japan. However, previous studies showing the therapeutic efficacy of Lixelle were conducted in small numbers of patients with specific dialysis methods. Here, we report the results of a nationwide questionnaire survey on the therapeutic effects of Lixelle. Questionnaires to patients and their attending physicians on changes in symptoms of dialysis‐related amyloidosis by Lixelle treatment were sent to 928 institutions that had used Lixelle, and fully completed questionnaires were returned from 345 patients at 138 institutions. The patients included 161 males and 184 females 62.9 ± 7.7 years age, who had undergone dialysis for 25.9 ± 6.2 years and Lixelle treatment for 3.5 ± 2.7 years. Based on self‐evaluation by patients, worsening of symptoms was inhibited in 84.9–96.5% of patients. Of the patients, 91.3% felt that worsening of their overall symptoms had been inhibited, while attending physicians evaluated the treatment as effective or partially effective for 72.8% of patients. Our survey showed that Lixelle treatment improved symptoms or prevented the progression of dialysis‐related amyloidosis in most patients.     

Prevalence of secondary amyloidosis in Asian North Indian patients with rheumatoid arthritis

OBJECTIVE: To study the prevalence of secondary amyloidosis in Asian North Indian patients with rheumatoid arthritis (RA) and to determine its clinical significance. METHODS: RA patients with disease duration > 5 years were included in this prospective study over a 2 year period. Abdominal subcutaneous fat pad aspiration (ASFA) was performed, and smears were stained with Congo red and observed for apple-green birefringence under polarized light microscopy. The amyloid deposits were graded from 1+ to 3+. Clinical, radiological, and laboratory variables of the patients were correlated with the presence or absence of amyloidosis. RESULTS: Thirty out of 113 patients were positive for amyloid by ASFA (26.5%). Out of these, 8 patients had features suggestive of clinical amyloidosis in the form of proteinuria, organomegaly, or symptomatic gastrointestinal involvement. In another 22 patients amyloidosis was subclinical. The majority of patients with clinical amyloidosis had either 2+ or 3+ deposits. CONCLUSION: Abdominal fat amyloid deposits are not uncommon in adult Asian North Indian patients with RA. However, only one-fourth of patients had evidence of clinical amyloidosis. A longer followup and a larger multicentric collaborative study is needed to determine the significance of subclinical amyloid deposits.     

Beta-2-microglobulin-associated amyloidosis in chronic hemodialysis patients with carpal tunnel syndrome

The clinical manifestations of beta-2-microglobulin (beta 2M)-associated amyloidosis in chronic hemodialysis patients with carpal tunnel syndrome from a medical center hospital are presented. The predominant morbidity of beta 2M-amyloid was musculoskeletal, with deposits identified in surgical or biopsy specimens from trigger fingers, carpal tunnels, fractures, and radiolucent bone lesions. Lucent bone lesions were the characteristic radiologic finding of beta 2M-amyloidosis and were most commonly found in carpal bones, humeral heads, and femoral heads. Carpal tunnel syndrome occurred in greater than 20% of our chronic hemodialysis patients. The longer the period of time on chronic hemodialysis the greater the morbidity from beta 2M-amyloid. Although significant amounts of beta 2M-amyloid were detected in the perivascular regions of viscera, clinical compromise of internal organs from this type of amyloid was not documented. In acute studies, beta 2M clearance during hemodialysis was markedly increased using the Fresenius polysulfone dialyzers compared to cuprophane dialyzers. In summary, beta 2M-amyloid is common and causes significant morbidity in chronic hemodialysis patients. Long-term dialysis with highly permeable membranes effects greater beta 2M clearance which may result in less tissue deposition of beta 2M-amyloid, and therefore, fewer clinical complications.     

Identification of pentosidine as a native structure for advanced glycation end products in beta-2-microglobulin-containing amyloid fibrils in patients with dialysis-related amyloidosis.

beta-2-Microglobulin (beta-2m) is a major constituent of amyloid fibrils in patients with dialysis-related amyloidosis (DRA). Recently, we found that the pigmented and fluorescent adducts formed nonenzymatically between sugar and protein, known as advanced glycation end products (AGEs), were present in beta-2m-containing amyloid fibrils, suggesting the possible involvement of AGE-modified beta-2m in bone and joint destruction in DRA. As an extension of our search for the native structure of AGEs in beta-2m of patients with DRA, the present study focused on pentosidine, a fluorescent cross-linked glycoxidation product. Determination by both HPLC assay and competitive ELISA demonstrated a significant amount of pentosidine in amyloid-fibril beta-2m from long-term hemodialysis patients with DRA, and the acidic isoform of beta-2m in the serum and urine of hemodialysis patients. A further immunohistochemical study revealed the positive immunostaining for pentosidine and immunoreactive AGEs and beta-2m in macrophage-infiltrated amyloid deposits of long-term hemodialysis patients with DRA. These findings implicate a potential link of glycoxidation products in long-lived beta-2m-containing amyloid fibrils to the pathogenesis of DRA.     

The analysis of gastrointestinal amyloidosis in 78 patients with chronic renal failure

Systemic amyloidosis is not a single disease, but the product of a variety of diseases. Amyloid proteins are insoluble fibrils that are deposited extracellularly in many organ tissues. They stain with Congo red and appear apple green under polarized light. Definitive diagnosis and classification of amyloidosis requires histologic examination of tissue samples. Gastrointestinal tract involvement is common, and all parts of the system can be affected. Immuno–histochemical studies have shown that amyloid deposited in the gastrointestinal system is most often of the AA, A kappa, or A lambda types. Another type of amyloid protein, beta–2 microglobulin (β2M), predominantly affects the musculoskeletal system, and is usually seen in patients who have been on long–term hemodialysis. Mixed systemic amyloidosis (β2M and AA) is seen only rarely in these patients. In this study, we attempted to answer why this is so, and examined whether or not mixed amyloidosis is related to amyloidogenesis.

We studied gastrointestinal tissues from 78 chronic renal failure patients who had systemic amyloidosis with gastrointestinal involvement. A total of 115 endoscopic samples and 1 jejunal resection specimen were analysed immunohistochemically. Immunohistochemical testing using a panel of antisera directed against two major amyloid fibril proteins (AA–Monoclonal, Dako–, and β2 MPolyclonal, Dako–) showed that all samples contained AA amyloid, but not β2M type protein. These findings can be explained by the patients' relatively short average duration of hemodialysis and the predominance of endoscopic biopsy samples in our study.     

The liver in systemic amyloidosis: insights from 123I serum amyloid P component scintigraphy in 484 patients

Background and aims—The liver is frequentlyinvolved in amyloidosis but the significance of hepatic amyloid has notbeen systematically studied. We have previously developed scintigraphywith ¹²³I serum amyloid P component (¹²³I-SAP)to identify and monitor amyloid deposits quantitatively in vivo and wereport here our findings in hepatic amyloidosis.
Methods—Between 1988 and 1995, 805 patients withclinically suspected or biopsy proven systemic amyloidosis wereevaluated. One hundred and thirty eight patients had AA amyloidosis,180had AL amyloidosis, 99 had hereditary amyloid syndromes, and 67haddialysis related (β₂ microglobulin) amyloid. One hundredand ninety two patients with amyloidosis were followed for six months to eight years.
Results—Hepatic amyloid was found in 98/180(54%) AL and 25/138 (18%) AA patients but in only 1/53 patients withfamilial transthyretin amyloid polyneuropathy and in none with dialysis related amyloidosis. There was complete concordance between hepatic SAPscintigraphy and the presence or absence of parenchymal amyloid deposits on liver histology. Amyloidosis was never confined to theliver. Mortality was rarely due to hepatic failure, although hepaticinvolvement with AA amyloid carried a poor prognosis. Successfultherapy to reduce the supply of amyloid fibril protein precursors wasfollowed by substantial regression of all types of amyloid.
Conclusions—SAP scintigraphy is a specific andsensitive method for detecting and monitoring hepatic amyloid. Liverinvolvement is always associated with major amyloid in other organsystems and carries a poor prognosis in AA type. Appropriate therapymay substantially improve prognosis in many patients.

Keywords:systemic amyloidosis; serum amyloid P component

     

beta 2 M-amyloidosis and gastrointestinal bleeding after renal transplantation

Dialysis-related amyloidosis is a disorder that commonly develops in long-term dialysis with an incidence that is linked to the duration of hemodialysis. The amyloid deposits are composed of the amyloid precursor beta 2 microglobulin, mainly affecting the osteoarticular system, but also involving extra-osteoarticular tissues. We present a patient with repeated rectal bleeding caused by a circumferential atone ulcer in the immediate posttransplantation period due to the use of a rectal canula after 27 years of treatment with hemodialysis. Histopathological examination of the rectal ulcer biopsy specimens revealed positive Congo red stain and additional immunohistochemical investigation showed the presence of beta 2-microglobulin in a blood vessel wall of the rectum. Although dialysis related amyloidosis may be partially prevented, it is important to remain alert for dialysis related amyloidosis complications after renal transplantation in patients with a longstanding history of dialysis.     

Synovial amyloidosis in patients undergoing long-term hemodialysis

Synovial amyloid deposits were found in 18 patients with end-stage renal failure due to various nonamyloid nephropathies, who had been treated with long-term, periodic hemodialysis (mean 116 months). All patients had carpal tunnel syndrome, which was bilateral in 14 of them; 4 patients also had finger flexor tenosynovitis. In 2 patients, destructive arthropathies required surgical replacement of the hip. Amyloid deposits were demonstrated by light microscopy in the synovium of the finger flexor tendon and/or transverse carpal ligament of all patients who had surgery for carpal tunnel syndrome, and in the synovium and capsula of the 2 surgically removed hips. Transmission electron microscopy of synovial samples from 6 patients demonstrated the characteristic fibrillar ultrastructure of amyloid deposits, the biochemical nature of which is still unknown. In addition, 9 patients had cystic radiolucencies of bone, which were interpreted as having resulted from local amyloid deposits, involving carpal bones, humeral heads, femoral heads, acetabula, or tibial plateaus. Our results show that amyloidosis is a frequent histologic finding in dialysis patients receiving surgical management of carpal tunnel syndrome, and that it can also be associated with cystic radiolucencies of bones and with destructive arthropathies.     

Elevated serum levels of soluble interleukin-2 receptor, neopterin and beta-2-microglobulin in idiopathic dilated cardiomyopathy: relation to disease severity and autoimmune pathogenesis

BACKGROUND: It has not been assessed whether high levels of soluble interleukin 2 receptor (sIL-2R), neopterin and beta-2 microglobulin in idiopathic dilated cardiomyopathy reflect heart failure severity and/or an active autoimmune process. The aim of this study was to relate serum levels of these markers to clinical and autoimmune features. METHODS: We studied 60 patients with idiopathic dilated cardiomyopathy, 67 controls with ischemic heart failure and 34 normals. RESULTS: Abnormal levels of sIL-2R, but not of neopterin and beta-2 microglobulin, were more frequent in idiopathic dilated cardiomyopathy than in ischemic patients (35% vs. 16%; P=0.02) or in normals (35% vs. 12%, P=0.01); mean sIL-2R levels were, however, similar in idiopathic dilated cardiomyopathy and ischemic heart failure (842+/-75 vs. 762+/-93 U/ml, P=NS). In idiopathic dilated cardiomyopathy abnormal levels of sIL-2R were associated with lower peak oxygen consumption (P=0.008), higher neopterin and HLA class II expression in the myocardium (P=0.02), but were unrelated to cardiac autoantibody status or titer. In addition, abnormal levels of neopterin were associated with adverse prognosis and higher beta-2 microglobulin; abnormal levels of beta-2 microglobulin with lower echocardiographic percent fractional shortening, higher sIL-2R and higher neopterin. CONCLUSIONS: There is no convincing evidence that abnormal sIL-2R, neopterin and/or beta-2 microglobulin are disease-specific markers of idiopathic dilated cardiomyopathy. The lack of association with cardiac autoantibodies suggests that these abnormalities are mainly related to heart failure severity rather than autoimmune pathogenesis. In keeping with this view, high levels of sIL-2R, neopterin and/or beta-2 microglobulin identified a subset of idiopathic dilated cardiomyopathy patients with advanced disease and poor prognosis.     

Pore formation by beta-2-microglobulin: a mechanism for the pathogenesis of dialysis associated amyloidosis.

Beta-2 microglobulin (beta 2M, molecular weight 10,000) is a 99 residue immune system protein which is part of the MHC Class I complex whose role is to present antigens to T cells. beta 2M serum levels rise dramatically in renal failure, and a syndrome called "dialysis associated amyloidosis" occurs with time in a majority of hemodialysis patients who exhibit beta 2M amyloid deposits in joints, bone and other organs. beta 2M can also induce Ca++ efflux from calvariae, collagenase production, and bone resorption. We report here that beta 2M formed relatively nonselective, long-lived, voltage independent ion channels in planar phospholipid bilayer membranes at physiologically relevant concentrations. The channels were inhibited by Congo red and blocked by zinc suggesting that they exist in an aggregated beta sheet state as is common with other amyloid fibril forming peptides. Multiple single channel conductances were seen suggesting that various oligomers of beta 2M may be capable of forming channel structures. We suggest that beta 2M channel formation may account for some of the pathophysiologic effects seen in dialysis associated amyloidosis. These findings lend further weight to the "channel hypothesis" of amyloid pathogenesis.     

Arthropathies associated with renal disease including dialysis-related amyloid.

In recent years most of the interest in musculoskeletal problems secondary to renal disease has focused on problems occurring in patients with chronic renal failure and specifically in patients on long-term hemodialysis. The musculoskeletal involvement in long-term hemodialysis may involve the joints, soft tissues, or both, and there is presently no good classification to which authors may refer when they report musculoskeletal problems in these patients. There has been intense interest in the past few years in the amyloidosis associated with long-term hemodialysis, and now, apparently, also with peritoneal dialysis. This type of amyloidosis is due to a specific type of amyloid, namely beta 2-microglobulin amyloid. Debate is ongoing about the role of both aluminum toxicity and iron deposition as cofactors affecting the location and extent of amyloid deposits. Debate is also unresolved about the role of specific dialysis membranes in lessening the incidence of dialysis-related amyloid. I review some of these areas as well as interesting new developments in localization of amyloid deposits in patients with chronic renal failure who are on hemodialysis.     

Patterns of pulmonary involvement in systemic amyloidosis.

The clinical and histopathologic features of pulmonary amyloidosis were reviewed in 22 patients with systemic amyloidosis who came to autopsy. Eleven of 12 patients (92 percent) with primary amyloidosis had prominent interalveolar amyloid deposits. Symptoms attributable to these deposits were found in four cases (33 percent), while severe lung involvement was the apparent cause of death in one. Extensive deposition was noted in all three cases of amyloidosis associated with multiple myeloma or Waldenstrom's macroglobulinemia. Five of seven patients (71 percent) with secondary amyloidosis showed histologic lung involvement, which was perivascular or tracheobronchial in location, but not associated with symptoms. Histologic lung involvement is frequent in all forms of amyloidosis and lung tissue obtained from any patient with unexplained interstitial or reticular-alveolar pulmonary disease should be stained with Congo-red and viewed for green birefringence under polarizing microscopy for the presence of amyloid.     

A Case Report of Severe Visceral β2‐Microglobulin‐derived Amyloidosis Without Obvious Joint Symptoms or Radiological Findings in a Chronic Hemodialyzed Patient With Systemic Lupus Erythematosus

Beta‐2‐microglobulin‐derived amyloidosis (Aβ2M amyloidosis) is a critical complication for patients undergoing long‐term renal replacement therapy. Osteoarticular lesions, rather than visceral organs, are susceptible to this type of amyloidosis, and the visceral form seems to occur at a relatively late stage. Herein, we report a case of severe visceral Aβ2M amyloidosis without obvious joint symptoms or radiological findings in a chronic hemodialyzed patient who had received long‐term treatment with glucocorticoid steroids for systemic lupus erythematosus. It should be noted that prominent visceral Aβ2M amyloidosis can develop without any osteoarticular symptoms or radiological abnormalities in dialyzed patients undergoing prolonged glucocorticoid therapy.     

Bullous amyloidosis in a hemodialysis patient is myeloma-associated rather than hemodialysis-associated amyloidosis.

We report a 78-year-old woman on hemodialysis who presented with refractory multiple pruritic vesicles and bullae on her trunk and extremities for 2 months. Histopathologic examination of skin biopsy specimen showed subepidermal bullae with many amyloid deposits in the papillary dermis. No evidence of systemic amyloidosis could be found on physical examination. While the initial clinical diagnosis was bullous pemphigoid, the histopathology and direct immunofluorescence result favored hemodialysis-associated amyloidosis. However, immunochemical study for beta(2)-microglobulin was negative. Further hematologic and immunologic work-up revealed the presence of multiple myeloma and that the deposit was AL amyloid. This is the first case of bullous amyloidosis in a hemodialysis patient and should remind dermatologists that bullous amyloidosis should be considered in addition to the usual presentation of porphyria cutanea tarda and pseudoporphyria for bullous dermatosis in the hemodialysis patient. We also suggest that hemodialysis-associated amyloidosis should not be taken for granted in the hemodialysis patient with cutaneous amyloidosis without systemic signs and symptoms. Further testing for other types of amyloid should be performed.     

Syncope in cardiac amyloidosis and chronic ischemic heart disease: A case report

Primary systemic amyloidosis is a relatively uncommon disease characterized by the production and deposition of pathological insoluble fibrillar proteins in organs and tissues. It has been estimated that between one-third and one-half of all patients with primary amyloidosis experience clinically significant cardiac involvement. The present study reports a case involving a 77-year-old woman with ischemic heart disease who presented to the cardiology department because of syncope due to slow atrial fibrillation. Laboratory tests revealed a monoclonal spike in the gamma fraction and impairment of renal function, normocytic anemia, mild hypercalcemia, hypoalbuminemia and increased levels of beta-2 microglobulin. Suspicion of cardiac involvement was supported by the echocardiographic pattern and increased levels of troponin I and brain natriuretic peptide, along with clinical signs of heart failure and systemic amyloidosis diagnosis, confirmed by abdominal fat aspiration.     

Cardiac findings at necropsy in patients with chronic kidney disease maintained on chronic hemodialysis

Studies of multiple hearts at necropsy are lacking in patients who have been on chronic hemodialysis for chronic kidney disease (CKD). We studied at necropsy 120 patients who had been treated with hemodialysis for more than 1 year (mean, 5.25 ± 4.33 yr). Their ages ranged from 24 to 81 years (mean, 53 yr); 91 (76%) were men. Calcific deposits were present in the heart at necropsy in 74 (62%) patients: in the epicardial coronary arteries in all 74 (62%); in the mitral annular region in 52 (42%) patients, and in the aortic valve cusps in 42 (35%) patients. The frequency and quantity of the cardiac calcific deposits were significantly greater in the older compared with the younger patients, and in those with longer durations of hemodialysis compared with those with shorter durations. Despite the calcific deposits, which were sometimes huge, only 47 (39%) patients had 1 or more coronary arteries narrowed more than 75% in cross-sectional area by atherosclerotic plaques, apparently no patient had clinical evidence of mitral stenosis, and 9 patients had clinical evidence of aortic valve stenosis. Thus, we found that CKD treated with hemodialysis is a major producer of cardiac calcific deposits, some of which can be massive. Only a minority of the calcific deposits, however, appeared to lead to cardiac dysfunction or myocardial ischemia during life.