AMYLOIDOSIS: lecture

materials for students

 Definitions (according to different
sources)
• Amyloidosis is a systemic disease, characterized
by deposition of specific fibrillar protein, localizing
perireticularly or around the collagen fibers, that
leads to affected organs impairment.
• Amyloidosis is a disorder of protein metabolism,
which may be either acquired or hereditary,
characterized by extracellular deposition of
abnormal protein fibrils.
• Amyloidosis is a clinical disorder caused by
extracellular deposition of insoluble abnormal
fibrils that injure tissue. The fibrils are formed
by the aggregation of misfolded, normally
soluble proteins (2006).
Common features of all definitions

• presence of systemic protein

metabolism disorder (acquired or
hereditary)
• extracellular deposition of abnormal
protein fibrils
• impairment of affected organs due
to amyloid deposition
 What is amyloid? (physical
properties)
• straight, rigid, non-branching, 10 to
15nm in diameter; indeterminate
length; regular fibrillar structure
• consisting of β-pleated sheets
• aggregates are insoluble in
physiological solutions
• relatively resistant to proteolysis
 What are β-pleated sheets
• Every fibril consist of stacks of anti-
parallel β-pleated sheets
• Sheets are arranged with the long axes
perpendicular to the long axis of the fibril
• This structure resembles the structure of
silk (which is also proteinase resistant)
• Amyloid structure is visible by x-ray
diffraction)
 Chemical properties (main
components)
• Proteins and their derivates
• Glucosaminoglycans
• amyloid P component
• Other proteins in amyloid deposits: α1-
antichymotrypsin, some complement
components, apolipoprotein E, various
extracellular matrix or basement
membrane proteins. Significance of these
findings is unclear
 Main protein precursors (total 22)
• serum amyloid A protein (SAA)
• AL proteins (monoclonal light and heavy chains Ig -
whole or part of the variable (VL, VH) domains)
• Transthyretin (TTR) with normal aminoacids sequence
or genetically abnormal TTR
• β2-microglobulin
• β-amyloid protein precursor; abnormal atrial natriuretic
factor; IAPP insular amyloid polypeptide (amylin)
• Cystatin C; Gelsolin; Lysozyme; Apolipoproteins AI
and AII; Prion protein; ADan and ABri precursor
proteins; Lactoferrin; Keratoepithelin; Calcitonin;
Prolactin; Keratin; Medin etc
 Glycosaminoglycans
• significance in amyloid is unclear
• participate in organization of some
normal structural proteins into fibrils;
may have fibrillogenic effects on
certain amyloid fibril precursor
proteins.
• may be ligands to which serum
amyloid P component binds.
 amyloid P component and serum
amyloid P component
• amyloid deposits in all different
forms of the disease contain the
non-fibrillar glycoprotein amyloid P
component (AP)
• ins role remains unclear
Morphology and staining: common
features for all types
• Amorphous eosinophilic
appearance on light microscopy
after hematoxylin and eosin
staining
• Bright green fluorescence
observed under polarized light
after Congo red staining
 Clinical syndromes related to
amyloidosis
• General symptoms and intoxication:
weakness, fatigue, sometimes fever and
weight loss (not common)
• Skin: itching; urticar rash, papules,
nodules, and plaques usually on the face
and upper trunk; involvement of dermal
blood vessels results in purpura
occurring either spontaneously or after
minimal trauma
 Periphreral nervous system:
• axonal peripheral neuropathy with subsequent
demyelination:
- paresthesiae, numbness, muscular weakness;
begin from lower extremities and ascending over
time
- feeling constraint in the whole body
- painful sensory polyneuropathy (usually
symmetrical, usually affecting lower extremities)
with early loss of pain and temperature sensation
followed later by motor deficits
• carpal tunnel syndrome
• autonomic neuropathy: orthostatic hypotension,
impotence, poor bladder emptying and
gastrointestinal disturbances may occur alone or
together with the peripheral neuropathy
 Central nervous system
• cerebral blood vessels affection
• recurrent cerebral hemorrhages
• intracerebral plaques
• progressive dementia
 Gastrointestinal disorders:
• Tongue: increased, dense, red or purple; so that it
can’t go in mouth; tooth imprints, ulcers and
fissures; speech is difficult – disarthria; difficulties
in swallowing (dysphagia); excessive salivation
• Stomach: early satiety, chronic nausea, vomiting
• Gut: diarrhea and/or constipation; malabsorption,
obstruction or pseudo-obstruction (both due to
mucosal deposition); perforation; haemorrhage,
infarction (the last one is due to vascular deposits
and is mostly localized in descending and sigmoid
colon)
• Motility disturbances (often secondary to
autonomic neuropathy) may affect stomach and
gut
 Heart: myocardium
• increase of relative cardiac dullness, soft
heart sounds, systolic murmur at the apex
and diastolic at aorta (relative valves
insufficiency in dilated heart);
• congestive heart failure (with up to 50% of
fatal cases); hypotonia
• restrictive cardiomyopathy with signs and
symptoms of right ventricular failure
• cardialgias
 ECG: heart muscle affection
• ECG – decrease of voltage, plain or
inverted T, scars, pseudoinfarction
QS complexes in precordial leads.
 Heart: coronary arteries
• secondary coronary syndrome and
myocardial infarction.
• more marked affection of
intramyocardial arteries;
angiographic changes may not be
revealed
Rhythm and conductivity disorders
• conductivity disorders in sinus node,
AV node and left bundle branch with
dizziness, syncopes, bradycardia,
SA block and lower automaticity
centers activation
• predisposition to cardiac arrest
(especially ATTR)
• sensitivity to digoxin also may cause
fatal arrhythmias
 Pericardium and endocardium
affection
• Pericardium deposits – constrictive
pericarditis
• Valves affection (amyloid deposits in
valves): mild stenosis due to valve
rings infiltration
• Endomyocardial thrombi with
embolisms
 Echo
• The most common: thickening of
the intraventricular septum
(usually 15 mm and more; normal
values being <12 mm)
• granular "sparkling"
 WHO staging system for cardiac
amyloid
• 1 – no symptomatic or occult cardiac amyloid by
biopsy or non-invasive testing
• 2 – asymptomatic cardiac involvement by
biopsy or non-invasive testing eg wall thickness
> 1.1 cm in the absence of prior hypertension or
valvular disease, unexplained low voltage of
ECG
• 3 – compensated symptomatic cardiac
involvement
• 4 – uncompensated cardiomyopathy
 Vessels
• capillaries in the subcutaneous fat
• dermal capillars
• coronary and brain arteries (coronary
syndrome, recurrent strokes)
• aorta
• rare – pulmonary artery
 Liver and spleen
• Hepatomegaly; usually elevation of
alkaline phosphatase is revealed with
near normal levels of transaminases and
bilirubin
• Jaundice due to cholestasis
• Splenomegaly
• Rarely - portal hypertension; liver failure
 Kidneys: symptoms

• Proteinuria (usually – with nephrotic

syndrome)
• Chronic renal failure
• Acute renal failure due to tubules affection
 Kidneys: staging system
Stage Phase Course
Initial Proteinuric Slowly
progressing
Clinical -Nephrotic Rapidly
manifestations -Oedematic- progressing
proteinuric
-Hypertensive (rare)
Terminal Chronic renal failure Relapsing
 Joints affection
• usually occurs in association with
myeloma
• mimic acute polyarticular rheumatoid
arthritis affecting large joints
• asymmetrical arthritis affecting the hip or
shoulder.
• infiltration of the glenohumeral articulation
occasionally with characteristic shoulder
pad sign.
 Blood
• Acquired bleeding diathesis:
- deficiency of factor X and sometimes
factor IX, or increased fibrinolysis: (AL)
- in all variants may be serious bleeding in
the absence of any identifiable factor
deficiency.
• lymphadenopathy
• bone marrow affection
• splenomegaly
 Respiratory system
vocal cord infiltration
• associated with focal clonal immunocyte
dyscrasia
• nodular or diffuse infiltrative form
• manifested by a hoarse voice
 tracheobronchial
• associated with focal clonal immunocyte
dyscrasia
• nodular or diffuse infiltrative
• manifested by dyspnea, cough
• Occasionally - haemopthysis; distal
athelectasis with recurrent pneumonias
 parenchymal nodular
• associated with focal clonal immunocyte
dyscrasia
• solitary (amyloidoma) or multiple nodules in
lung parenchyma; usually peripheral or
subpleural, more frequently in lower lobes; may
be bilateral; diameter ranges from 0.4 to 15sm;
• grow slowly
• frequently cavitate or calcify
• larger nodules can occasionally produce space
occupying effects
 diffuse alveolar septal
• usually is a manifestation of systemic AL
amyloidosis associated with low grade
monoclonal gammopathy, myeloma;
ATTR, AA-variants etc
• restrictive respiratory symptoms
• restrictive functional tests changes and
impared gas exchange
• radiological changes may be absent
 intrathoracic lymphadenopathy
• usually manifestation of systemic AL
amyloidosis (hilar or meduastinal
amyloidosis)
• is uni- or bilateral
• may be asymptomatic
• may calcify
• may cause tracheal compression or vena
caval obstruction.
 Eye
• visible or palpable periocular mass or
tissue infiltration
• ptosis
• periocular discomfort or pain
• proptosis or globe displacement
• limitations in ocular motility
• recurrent periocular subcutaneous
hemorrhages
• diplopia
Endocrine and exocrine glands
• adrenal gland infiltration
(hypoadrenalism)
• thyroid infiltration (hypothyroidism)
• IAAP – progressive loss of insular
production
• corpora amylacea of the prostate (β2-
microglobulin)
• seminal vesicles
• salivary glands
 Classifications: before 1993
• AA (inflammatory)
• AL (light chains related)
• AF (familial)
• AS (senile)
• AD (dermal)
• AH (haemodyalysis-related)
WHO (1993): biochemical structure-based
classification. Systemic variants
• AA (ApoSAA): chronic inflammatory diseases;
periodical fever; Muckle-Wales
• AL (Systemically produced monoclonal light
chains Ig: Aλ(λVI); Aχ(χIII): primary (idiopathic)
or associated with gammapathies
• ATTR
- normal TTR: senile systemic amyloidosis with
gradual heart involvement
- Met30: Family amyloid polyneuropathy
- Met111: Family amyloid cardiopathy
• Aβ2M (β2-microglobulin): haemodialysis-
associated systemic amyloidosis
 WHO (1993): local variants
• AL (Locally produced monoclonal Ig):
local urogenital; skin, eyes, respiratory
• Aβ (β-amyloid protein precursor):
cerebral; cerebrovascular; Alzgeimer-
associated
• AANF (abnormal atrial natriuretic
factor): local atrial
• AIAPP (IAPP insular amyloid
polypeptide): Langerhans insuli
amyloidosis in II type of diabetes mellitus
• From 1993 to nowadays new
precursors and new variants were
found (2006 – 22 precursors).
• So, new approaches to
biochemistry-based classification
became necessary.
 Systemic
• Ig light chains (plasma cell disorders)
• Transthyretin (Familial amyloidosis,
senile cardiac amyloidosis)
• A amyloidosis (Inflammation,
Mediterranean fever
• Beta2 –microglobulin (Dialysis-
associated)
• Ig heavy chains(Systemic amyloidosis)
 Hereditary
(Familial systemic amyloidosis, sometimes
called Familial Renal)
• Fibrinogen alpha chain

• Apolipoprotein AI

• Apolipoprotein AII

• Lysozyme
 CNS amyloidosis
• Beta protein precursor (Alzheimer syndrome,
Down syndrome, hereditary cerebral
hemorrhage with amyloidosis - Dutch type)
• Prion protein (Creutzfeldt-Jakob disease,
Gerstmann-Strussler-Scheinker disease, fatal
familial insomnia)
• Cystatin C (hereditary cerebral hemorrhage
with amyloidosis - Icelandic type)
• ABri precursor protein (Familial dementia
British type)
• ADan precursor protein (Familial dementia
Danish type)
 Ocular
• Gelsolin (Familial amyloidosis;
Finnish type)

• Lactoferrin (Familial corneal

amyloidosis)

• Keratoepithelin (Familial corneal

dystrophies)
 Localized
• Calcitonin (Medullary thyroid carcinoma)
• IAAP= Amylin (Insulinoma, type 2
diabetes)
• Atrial natriuretic factor (Isolated atrial
amyloidosis)
• Prolactin (Pituitary amyloid)
• Keratin (Cutaneous amyloidosis)
• Medin (Aortic amyloidosis in elderly)
 Inflammatory amyloidosis
• 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 protein is a single non-glycosylated
polypeptide of mass 8000 Da containing 76
residues corresponding to the N-terminal portion
of the 104 residue serum amyloid A protein
(SAA)
• SAA is an apolipoprotein of high density
lipoprotein particles and is the polymorphic
product of a set of genes located on the short
arm of chromosome 11. SAA is a major acute
phase protein
• Produced: mostly - by hepatocytes;
transcriptional regulation by cytokines,
especially interleukin 1(IL-1), interleukin 6 (IL-
6), and TNF, acting via nuclear factor χB-like
and possibly other transcription factors.
• The circulating concentration can rise
from normal levels (3mg/l) to over
1000mg/;l within 24 to 48h of an acute
stimulus; in presence of chronic
inflammation the level may remain very
high.
• SAA as an exquisitely sensitive acute
phase protein (more sensitive than CRP)
• AA protein is derived from circulating SAA
by proteolytic cleavage by macrophages
and by a variety of proteinases
 Pathogenesis
• Inflammation
• Macrophages activation: IL-1, 6
• IL-1,6:
- Increased hepatic transcription of the messenger
ribonucleic acid (mRNA) for SAA (up to1000-times)
- High SAA level in serum
- macrophages: SAA proteolytic cleavage
• AA-peptide in blood
• In presence of amyloid synthesis accelerating
factor:
- macrophages’ surface: amyloid fibrils synthesis
(membrane-binding enzymes)
• Amyloid synthesis
 Causes
• chronic inflammatory disorders
• chronic inflammation due to bacterial
infections
• malignant neoplasms; proliferative
diseases of blood system
• subcutaneous drug abuse
Chronic inflammatory disorders
• Very often:
• rheumatoid arthritis and juvenile rheumatoid
arthritis – in 10% of arthrites cases
• Becchet disease
• ankylosing spondylitis
• Psoriatic arthritis
• Crohn's disease
• More rare:
• - systemic lupus erythematosus
• - ulcerative colitis
 Chronic bacterial infections
• tuberculosis; leprosy
• chronic osteomyelitis
• bronchiectasis
• chronic abscess (different localizations)
• chronically infected burns
• chronic ulcers of lower extremities
• other chronic bacterial infections
 Malignant neoplasms; proliferative
diseases of blood system
• Most frequent:
• diseases, causing fever, other systemic
symptoms, and a major acute phase response
(SAA protein) or increased IL-6 production
• - Hodgkin's disease
• - renal carcinoma
• Occasionally: atrial myxomas, renal cell
carcinomas, Hodgkin disease, hairy cells
leukemia, carcinomas of the lung and stomach
 Subcutaneous drug abuse
• Development of AA amyloidosis was
reported in subcutaneous drug
abusers in some cities in the United
States.
• Pathogenesis of this is not clear (drug
related or chronic inflammation due to
some contaminating substance)
 Clinical symptoms
• Relating to the main disease
• General: weakness, weight loss
• Kidneys affection (up to renal failure)
• GI symptoms: dyspepsia (nausea, episodes
of vomiting, loss of appetite); diarrhea, which is
not related with any infection
• Liver and spleen affection
(hepatosplenomegalia)
• Thyroid enlargement
• Involvement of the heart: Echo-signs in
10% ; doesn’t cause severe impairment.
 Course:
• Initially, disease is manifesting only by
transient proteinuria, increasing in cases
of main disease exacerbations.
• Course is progressive and is terminated by
chronic renal failure development
• Course is determined by the efficacy of the
main disease treatment
Outcomes and complications:
• Main outcome is chronic renal failure (end-stage
- 5-10 years from 1st symptoms); the first
proteinuric period is the longest – 2-4 years;
marked clinical manifestations period lasts about
1 year, then chronic renal failure develops).
• Renal vessels thrombosis may develop as a
complication, which makes prognosis more
unfavorable
• Fibrinous-purulent peritonitis, accompanying by
pain and ascitis, is a rare complication.
 Prognosis
• Depends on the course of the main disease
• Survival: 50% of patients die within 5 years
of the amyloid being diagnosed.
• Availability of chronic hemodialysis and
transplantation prevents early death from
uraemia
• Renal vessels thrombosis makes prognosis
more unfavorable
 Familiar Mediterranean fever
(recurrent polyserositis)
and AA-amyloidosis
• Epidemiology:
• Incidence: in families with healthy parents:
18%; with one affected parent – 36%
• Nationality: most often in non-Ashkenazi Jews,
Armenians, Anatolian Turks, and Levantine
Arabs; prevalence doesn’t depend on place of
settlement of these nationalities
representatives.
• Inheritance: autosomal recessive
• Sex: M:F 1.7:1
 Morphology
• serosa: non-specific inflammation;
hyperaemia and cellular infiltrate
(neutrophils, lymphocytes, monocytes,
sometimes, plasma cells and eosinophils)
• synovia: pannus formation and extensive
intra-articular damage is possible
• vascular changes - thickening of the
basement membrane; reduplication of the
basement membrane is possibly due to
repeated episodes of cell death and
regeneration.
 Pathogenesis
• genetic nature
• immunological disturbances (higher
incidence of autoimmune diseases and allergy
in patients with Mediterrhanian fever; high
serum Ig and circulating immune complexes
levels)
• involvement of vascular system
• C5a-inhibitor deficiency in joint and peritoneal
fluids may have a role in the pathogenesis of
the attacks (result in severe inflammatory
attacks following the accidental release of C5a).
 Clinical manifestations and
syndromes
• 1. Onset: in childhood (1st decade of life –
50%; before 20 -80%; over 40 – 1% only)
 2. Fever:
• may be even asymptomatic (afebrile
mild attacks)
• abdominal pain attacks with fever up to
38-40C with tachycardia, and (in 25%) –
chills; temperature returns to normal
after 12hours - 3days.
• in arthritis high fever peak lasts for 1-3
days
 3. Joints affection:
• from arthralgia to arthritis (24-84%,
mean 55%)
• symptoms increase during the first 24-
48h; may last about a week.
• course: accompanied by fever with high
peaks lasting 1-3 days; in 5% acute
attack fails to resolve and the symptoms
may persist several weeks or even
months before they abate with no
residual damage.
 A. most common:
• asymmetric, non-destructive mono- or
oligoarthritis affecting the large joints;
knees and ankles (3 times more often than
hips, shoulders, feet, wrists; involvement of
small joints is very rare).
• joints are painful and swollen without
marked local redness and heat.
• 1-2 large joints are affected at a time;
• in frequent attacks involvement of one joint
may start before previous joint improves, so
impression of migratory arthritis is present
 B. Rarely (2%):
• chronic destructive mono- or oligoarthritis
affecting most frequently the hip or the knee.
• permanent organic damage results from one
protracted attack or from repeated short
attacks.
• C. Also had been described:
• - sacroiliitis, frequently asymptomatic
 Investigations
• Synovial fluid
- usually turbid; forms a good mucin clot
- white count ranges between 15000 and
30000 polymorphonuclears per mm3
- is always sterile.
• Radiographic changes:
- loss of cortical definition
- sclerosis with or without bone erosion
- fusion of the joints.
 4. Chest (pleurisy) pain – more
than 50%
• sharp and stabbing, localized in the lower
part, mostly on the right side; radiating to
abdomen and shoulders; patients splint their
respiratory excursions
• suppression of breath sounds over the
affected side is usual but pleural friction is
exceptional
• small effusion may be in the costophrenic
angle.
 5. Abdominal pain - almost in all
patients
• attacks originate in one area, spread over whole
abdomen within few hours; patients flex their
thighs and lie motionless to relieve the pain;
intensity of pain vary from mild discomfort to that in
severe generalized peritonitis
• constipation and vomiting are frequent
• symptoms of acute peritonitis - exquisite
abdominal tenderness, involuntary rigidity, rebound
tenderness, and diminished peristalsis.
• attack usually reaches its peak in 12h; resolves
spontaneously and is usually over within 24 to 48h;
then pain subsides gradually.
 6. Skin rash – 10-20%
• typical is erysipelas; skin becomes bright-red, hot,
swollen, and painful; rash is usually unilateral and its
border may or may not be sharply defined
• localization - over extensor surfaces of the legs below
he knees, over the ankle joints, or the dorsum of the
foot.
• symptoms intensify rapidly and then disappear within
2-3 days without any therapy.
• on biopsy: mild acanthosis and hyperkeratosis,
dermis contains an inflammatory exudate consisting of
polymorpho-nuclear cells, lymphocytes, and some
histiocytes concentrated mainly around the blood
vessels.
• nodular rashes, Schonlein-Henoch purpura, and
urticaria are also reported.
 7. Other organs affection
• attacks of pericarditis (occasionally)
• severe headache may occur during attacks
• transient ECG signs of myopericarditis and non-
specific EEG abnormalities during paroxysms.
• severe myalgia; muscle atrophy at affected joints
• numerous attacks in children may lead to growth
retardation.
• colloid bodies are often found in the eye grounds
• spleen is palpable in more than 33% of patients.
 8. Kidneys: AA-amyloidosis
• at the late stages
• the first sign is massive albuminuria;
• within several years - nephrotic
syndrome
• progresses to chronic renal failure
 Amyloid deposits in other organs
• intestine
• adrenals
• heart
• ovaries
• pancreas
• muscles
• deposits are mostly perivascular.
 Clinical variants
• with abdominal; thoracic, joint and
fever syndromes dominating
• may vary in different life periods
of the individual
 Course
• at childhood first symptoms are usually sudden onset
of asymptomatic fever, arthralgia, chest and
abdominal pain.
• symptoms last for days or weeks and then relieve by
themselves with no objective symptoms revealed.
• attacks recur, usually at irregular periods of several
days to several months; spontaneous remissions may
last years.
• further progression includes recurrent episodes with
increasing frequency and shortening of the
asymptomatic periods.
 Factors influencing exacerbations

• physical exertion
• stress
• walking and standing
• pregnancy.
 Outcomes
• end-stage chronic renal failure and
death.
• adequate treatment can delay (but
not stop) the disease development
• rapid progression is observed after
the first signs of asotemia
 Immunoglobulin-related
amyloidosis (AL)
• 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
• Mostly related to light chains (AL-amyloidosis)
• In few reported patients amyloid deposits
contained immunoglobulin heavy (H) chains
amyloid H-chain type (AH).
• Light chains consist of the whole or part of the
variable (VL) domain, more commonly derived
from λ chains than from χ chains
• associated with gammapathies
Conditions causing AL-amyloidosis
• Multiple myeloma
• Waldenstrom disease
• Monoclonal gammapathy of undetermined
significance (MGUS)
 Pathogenesis
• In L chains certain amino acid and glycosylation
characteristics predispose to amyloid formation (why -
remains unknown).
• probably these changes promote aggregation and
insolubilization
• amyloidogenicity of particular monoclonal light chains
was confirmed in an in vivo model (injection of isolated
Bence Jones proteins into mice, who developed
typical amyloid deposits)
• In some patients with monoclonal gammapathy
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).
 Epidemiology
• Incidence: annually, 1-5 cases per 100,000
people occur (may be higher basing on
myeloma incidence – underdiagnosis?)
• Race: probably not related (no comparative
investigations)
• Sex: M:F 2:1
• Age: It is revealed usually in aged (in UK – 66%
were between 50 and 70 years old at diagnosis;
4% - less than 40 years. Median age – 64 years
old (Mayo clinic)
 Symptoms
• Major systemic amyloidosis with affection
of most organs described (except CNS)
• Most common initial symptoms:
peripheral edema, hepatomegaly, purpura,
orthostatic hypotension, peripheral
neuropathy (10-20%), carpal tunnel
syndrome (20%), and macroglossia (10%)
• Hepatosplenomegaly is revealed in 25%
• Heart is affected in about 90%
• Kidneys in 33-40%
 Localized amyloid L-chain type
• most commonly in respiratory tract
• often remains localized
• may involve ureter or urinary bladder
(hematuria)
• Amyloidomas may be also in soft tissues,
including the mediastinum and the
retroperitoneum
• Skin involvement can manifest as plaques and
nodules
• Isolated heart affection (not common in AL)
 Complications
• congestive heart failure, arrhythmias,
or both (cause of death more than 50%)
• renal failure
• bleedings
 Course and prognosis
• In the absence of chemotherapy always
progressive course
• Rapid development of heart or renal failure
• Treatment of heart and renal failure is usually
ineffective.
• Survival: 18 months-10 years; mean – 18-20
months; 1-year survival rate is 51%, 5 – 16%;
10 – 4.7%
• Heart affection is the most unfavorable sign
(mean survival after symptoms appearance – 6
months).
 ATTR –amyloidosis
• TTR is a serum protein that transports thyroxine and
retinol-binding protein.
• It circulates as a tetramer of 4 identical subunits of 127
amino acids each.
• TTR formerly was called prealbumin because it
migrates anodally to albumin on serum protein
electrophoresis, but this name was misleading
because TTR is not a precursor of albumin.
• TTR monomer contains 8 antiparallel beta pleated
sheet domains.
• TTR is synthesized primarily in the liver, as well as in
the choroid plexus and retina. Its gene is located on
chromosome 18 and contains 4 exons.
 Normal-sequence TTR
• senile cardiac amyloidosis (SCA).
• microscopic deposits are also found in
many other organs - senile systemic
amyloidosis (SSA)
 Clinical manifestations; SSA
• in 25% of old patients clinically silent
microscopic, systemic deposits of
transthyretin (TTR) amyloid involving the
heart and blood vessel walls, smooth and
striated muscle, fat tissue, renal papillae, and
alveolar walls are revealed.
• spleen and renal glomeruli are rarely affected
• brain is not involved.
• occasionally more extensive deposits in the
heart, affecting ventricles and atria and
situated in the interstitium and vessel walls,
cause significant impairment of cardiac
function and may be fatal.
 Clinical manifestations; SCA
• may be silent or accompanied by
significant impairment of cardiac
function
 TTR mutations
• accelerate the process of TTR amyloid
formation
• mutations destabilize TTR monomers or
tetramers and allow molecule to more easily
attain amyloidogenic intermediate
conformation
• more than 85 amyloidogenic TTR variants
cause systemic familial amyloidosis.
• Mostly autosomal dominant inheritance
 Variants of TTR systemic familial
amyloidosis
• FAP (family amyloid polyneuropathy) –Val30Met
(Valin to Metionin in 30 position)
• Cardiac amyloidosis (Leu111Met, Dutch)
• Cardiac amyloidosis V122I (late-onset (after age 60)
cardiac amyloidosis, most common)
• late-onset systemic amyloidosis T60A with cardiac,
and sometimes neuropathic, involvement (northwest
Ireland)
• amyloidosis of carpal ligament and nerves of the
upper extremities L58H (Germany, MidAtlantic
region)
• In total, 100 variants of TTR, about 98 are
amyloidogenic
 Epidemiology
• Incidence:
- cardiac ATTR with normal sequence – 15% of all the
autopsies after 80 years old
- for mutant TTR - depends on the type (V122I in USA
- 2%-3.9%)
• Race and region: types of mutations are region-
related
• Sex: all TTR variants encoded on chromosome 18,
so M=F; for unknown reasons, penetrance is more
and age of onset earlier in males.
• Age: depending on the mutation and region (age of
onset in V30M in Portugal, Brazil, and Japan is 32,
in Sweden – 56); normal TTR – after 60; rapid
increase after 80.
 Clinical manifestations
• General - cachexia
• Skin: purpura (vascular fragility due
to subendothelial deposits)
• Heart: heart failure, arrhythmias
(blocks, PVC, VT, postural
hypotension (subendothelial deposits
in peripheral vessels)
• GI – gastric symptoms, diarrhea
and/or constipation
• Liver: hepatomegaly
 Neuropathy: axonal degeneration of
small nerve fibers due to deposits
• sensorimotor impairment (V30M - lower limb
neuropathy; I84S, L58H - primarily upper limb
neuropathy).
• hyperalgesia; altered temperature sensation
• carpal tunnel syndrome – most typical for
L58H, may be in normal TTR
• autonomic dysfunction (sexual or urinary –
common for V30M)
• cranial neuropathy
• eye: deposits in corpus vitreum
FAP (family amyloid polyneuropathy) V30M
• major foci - Portugal, Japan, Sweden; age 20-70
• Clinical manifestations include:
• progressive peripheral and autonomic neuropathy;
vitreous and cornea of the eye affection;
• Varying degrees of visceral involvement: kidneys,
thyroid, adrenals
• General symptoms: weight loss etc
• Heart affection is not typical, but predisposition to
sudden heart stoppage exists
• Course and prognosis: progression; disorder is fatal.
Death results from the effects and complications of
peripheral and/or autonomic neuropathy, or from
cardiac or renal failure.
 Beta2 –microglobulin
(Dialysis-associated)
• Beta-2-microglobulin amyloidosis is a
condition affecting patients on long-
term hemodialysis or continuous
ambulatory peritoneal dialysis
(CAPD). Patients with normal or
mildly reduced renal function or those
with functioning renal transplant are
not affected.
 Pathogenesis
• Beta-2-microglobulin is a component of
beta chain of HLA class I molecule and is
present on the surface of most of the cells
• In normally functioning kidney, beta-2-
microglobulin is filtrated by glomerulus
• In renal failure , impaired renal catabolism
causes an increase in beta-2-
microglobulin synthesis leads to 10- to 60-
times increase of its level
• Role of IL-6 stimulation by dialysis is
discussed
 Epidemiology
• 1st symptoms – 4-8 years after
haemodialysis onset (in 20%)
• 10 years after – in 70% of cases
• 15 years after – in 95% of cases
• 20 years after – in 100% of cases

• Race, age and sex: no differences

 Clinical manifestations
• 1. Neurological syndromes:
• carpal tunnel syndrome – most common
(deposits in hands ligaments compress the
nerves)
- bilateral and progressive
- numbness, paresthesias, pain, swelling in
the region of the distal median nerve
- worse during dialysis and at night
- progresses to contraction of the hand and
atrophy of the muscles
 Joints and bones affection
• Flexor tenosynovitis
• Scapulohumeral arthropathy - shoulder pain
worse in supine position
• Spondyloarthropathy (more – cervical)
• Bone cysts (thin-walled; in carpal bone,
femoral heads, humerus, acetabulum,
spine), cause stiffness and/or pain.
• Pathological fractures (femoral neck mostly
common)
 Systemic manifestations
• after 10-15 years, usually asymptomatic
• GI: macroglossia, dysphagia, small bowel
ischemia, malabsorption, and
pseudoobstruction
• Cardiovascular: Myocardium, pericardium,
valves; small pulmonary arteries and veins
• Kidneys: renal and bladder calculi
containing beta-2-microglobulin deposits
• Reproductive: prostate and the female
reproductive tract
• Spleen deposits
 Familial Systemic (Familial Renal -
FRA)
• Syndrome of familial systemic amyloidosis
with predominant nephropathy
• First described in 1932 by Ostertag,
former name - Non-neuropathic systemic
amyloidosis, Ostertag type
• Autosomal dominant
• Age – from first decade to old age but
most typically in mid adult life
 Amyloid precursors

• Lysozyme
• Apolypoprotein I
• Apolipoprotein AII
• Fibrinogen A alpha-chain
 Lysozyme Ile56Thr, Asp67His,
Try64Arg
• Renal: Proteinuria and renal failure
• GI tract - Bleeding and perforation
• Liver and spleen - Organomegaly
and hepatic hemorrhage
• Salivary glands – Sicca syndrome
• Petechial rashes may occur
 Apolypoprotein I
• Proteinuria and renal failure – almost in all
• Peptic ulcers (Gly26Arg )
• Progressive neuropathy (Gly26Arg)
• Liver and spleen – varying from organomegaly to
liver failure (Trp50Arg ; deletions 60-71)
• Heart failure (Leu90Pro; Arg173Pro etc); aggressive
early IHD (deletion Lys107)
• Retina - Central scotoma (deletion 70-72)
• Skin: Infiltrated yellowish plaques (Leu90Pro);
acanthosis nigricans-like plaques (Arg173Pro)
• Larynx – dysphonia (Arg173Pro )
• Males reproductive: infertility (Ala175Pro )
 Apolipoprotein AI with normal
sequence

• Causes amyloid deposits in human

aortic atherosclerotic plaques
• Found in 20-30% of elderly
individuals at autopsy
 Apolipoprotein AII
• Proteinuria and renal failure
 Fibrinogen A alpha-chain
• Proteinuria and renal failure

• In Glu526Val variant
hepatosplenomegaly and liver
failure may occur (late sign)
 CNS amyloidosis
• Beta protein precursor (Alzheimer syndrome,
Down syndrome, hereditary cerebral hemorrhage
with amyloidosis - Dutch type)
• Prion protein (Creutzfeldt-Jakob disease,
Gerstmann-Strussler-Scheinker disease, fatal
familial insomnia)
• Cystatin C (hereditary cerebral hemorrhage with
amyloidosis - Icelandic type)
• ABri precursor protein (Familial dementia British
type)
• ADan precursor protein (Familial dementia
Danish type)
 Hereditary cerebral haemorrhage with
amyloidosis; hereditary cerebral amyloid
angiopathy
• Icelandic type
• autosomal dominant; symptoms early adult
life.
• cerebrovascular deposits (cystatin C)
• recurrent major cerebral haemorrhages
• appreciable but clinically silent amyloid
deposits are present in the spleen, lymph
nodes, and skin.
• no extravascular amyloid in the brain.
• multi-infarct dementia is common
 Dutch type
• autosomal dominant; starts at middle age
• β-protein deposits
• recurrent normotensive cerebral
hemorrhages
• Multi-infarct dementia; some patients
become demented in the absence of
stroke.
• Amyloid outside the brain has not been
reported
 Diagnosis of amyloidosis
• 1. Presence of amyloid: congo red staining
• 2. Type of amyloid: immunohistochemistry
• 3. Mutation type: amino acid sequence
analysis
 Tissues for biopsy
• subcutaneous fat aspiration (provides
enough material for all investigations) – 60%
• rectal biopsy 80-85%
• cheek biopsy 60%
• organ biopsy: if subcutaneous fat investigation
didn’t not provide enough information for
diagnosis
• Anyway, kidney biopsy is usually performed to
determine the cause of nephrotic syndrome
(informativity is 100%)
 AA
• SAA precursor level in blood
• Serum immunoglobulins (to exclude AL;in
AA amyloidosis usually polyclonal
hypergammaglobulinemia is presentdue to
underlying inflammation)
• Kidney function (urine analysis, daily
proteinuria, GFR)
 Instrumental methods
• Avoid IV pyelography if amyloidosis is
suspected (more frequent renal failure)
• Ultrasonography: kidneys’ size (non-specific)
• CT scanning: with technetium which binds to
soft-tissue amyloid deposits (to monitor
progression)
• Radiolabeled P-component gamma
scanning: total body burden of amyloid and its
disappearance after successful treatment of the
primary disease. most useful in AA amyloidosis
because the major sites of deposition are
accessible to the imaging agent
 AL
• Monoclonal immunoglobulin L chain - in
the serum or the urine of 80-90%
• immunoglobulin free light chain (FLC);
kappa and lambda chains
• bone marrow: in 40% of patients more
than 10% plasma cells
• L-chain immunophenotyping of the
marrow, even in absence of increased
number of plasma cells
 Biochemistry
• concentration of normal Ig is often
decreased
• amyloid A type is mostly associated with
hypergammaglobulinemia due to
persistent inflammation and interleukin 6
production.
 Functional systems tests

• clotting system abnormalities

• kidney function tests
• liver function tests
•
 Instrumental
• Echocardiography
• Radiolabeled P component scanning
• Bone imaging: plasma cell infiltration
• Chest radiography: pulmonary
deposits
 ATTR
• subcutaneous fat aspiration
• sural nerve biopsy
• rectum, stomach, myocardium biopsy
• Congo red; antiserum against TTR
 Instrumental
• Echocardiography
• Nerve conduction studies to monitor
course of disease and assess response to
treatment
• Genetic studies (TTR variant)
 Familial systemic (renal)
• Biopsy: amyloid confirmation
• Affection of organs
• Radiolabeled P component scanning
• DNA analysis obligatory in all patients with
systemic amyloidosis who cannot be
confirmed absolutely to have the AA or AL
type.
 beta-2-microglobulin
• reference range of serum beta-2-
microglobulin concentration of is 1.5-3
mg/L; can be elevated to values of 50-100
mg/L.
• Beta-2-microglobulin levels correlate with
elevated serum creatinine levels and are
inversely related to the glomerular filtration
rate
 Radiologic:

• joint erosions (usually large joints)

• lytic and cystic bone lesions (typically
juxta-articular)
• pathological fractures
• spondyloarthropathies
• vertebral compression fractures
• May precede the pain appearance
 CT
• amyloid deposits: intermediate attenuation.
• identification pseudotumors and
pseudocystic areas in the juxta-articular
bone.
• best method for detecting small areas of
osteolysis in cortical bone or osseous
erosions
• may be used in the assessment of the
distribution and extent of destructive
changes.
 MRI
• differentiating destructive
spondyloarthropathies from inflammatory
processes and infections.
 Ultrasound
• tendon thickness.
• rotator cuff thickness greater than 8 mm,
thickening of joint capsules (especially of
the hip and knee) may be present
• retention of synovial fluid may be present
 Scintigraphy
• radiolabeled P-component scans
Biopsy with Congo red staining and
with immunostaining  
• centrifuged synovial fluid sediments
• cystic bone lesions biopsy
• synovia biopsy
• most common site for biopsies:
sternoclavicular joint.
• rectal biopsy and subcutaneous fat
aspiration are of little value.
• antisera to beta-2-microglobulin
 Treatment: AA
• primary inflammatory disease treatment
• tumor necrosis factor-a inhibitors and
interleukin-1 inhibitors (arthritis, FMF)
• Colchicine – FMF
New approaches
• Anti–IL-6R therapy (clinical studies)
• anionic sulphonates (clinical studies)
• NC-503: interfers fibril formation and deposition
of amyloid by inhibiting interaction of SAA with
glycosaminoglycans (at study)
• palindromic compound (CPHPC) triggers:
dimerization of human SAP molecules (vivo pre-
clinical studies)
AL:
• melphalan plus prednisone
• melphalan, prednisone, and colchicine
• Other chemotherapeutic regimens used
for multiple myeloma (vincristine,
carmustine, melphalan,
cyclophosphamide, prednisone scheme
etc)
Pharmacologic therapy to solubilize
amyloid fibrils
anthracycline analogue of
doxorubicin, 4-iododoxorubicin
(Idox): in vivo and clinical studies
(solubilize amyloid L-chain
type deposits) in combination with
cytotoxic chemotherapy
 Treatment of localized amyloid L-
chain type 
• has not been studied systematically
• chemotherapy is not indicated
• Localized radiation therapy aimed at destroying
the local collection of plasma cells producing
the amyloid L-chain type can be administered
when a plasma cell collection can be identified
• Local collections of amyloid L-chain type 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.
 TTR
• Digoxin and calcium channel blockers are
contraindicated
• Liver transplantation
• patients with cardiac, leptomeningeal,
gastrointestinal, or ocular involvement often
progress despite transplantation
• Combined heart and liver or liver and kidney
transplantation has been reported in a very
few patients, with variable success
• no pharmacologic therapy is available for ATTR.
A number of small molecules that may have the
potential to inhibit or reverse TTR amyloid
formation are under preclinical study
 beta-2-microglobulin
• no adequate treatment (symptomatic)
• Improvement of dialysis membranes
• Online hemodiafiltration
•
Familial systemic (familial renal)
• Transplantation: liver (in case of liver
failure), kidney, heart