Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3099_Библиотеки_им_академика_М_И_Перельмана.pdf
Protein Studies in Light-Chain Amyloidosis
97
the FLC determination [18]. Troponin levels correlate with the value of left
ventricular ejection fraction, ventricular septal thickness and the effect of
therapy is associated with a decrease in their levels. It is known that persistent
or increasing levels of troponin indicate continuing loss of cardiomyocytes. A
limitation of troponins determination is a certain overvaluation of levels in
cases of renal insufficiency.
Natriuretic Peptides (N-Terminal Pro-Brain Natriuretic Peptide,
NT-ProBNP)
Determination of serum levels of NT-proBNP is currently already used
routinely in the care of patients with heart diseases [25]. In AL amyloidosis,
N-proBNP is also among the key indicators used not only to assess a heart
amyloid affection, but also for stratification and monitoring of treatment
response. It is a very sensitive parameter and it is possible to state that in the
case of normal levels is a myocardial amyloidosis almost excluded. Palladini
et al. used the serum cut-off value of NT-proBNP 152 pmol/L as a
stratification factor to evaluate the survival of patients, where patients with
NT-proBNP levels below the limit survived significantly longer [26]. At
present, determining of levels NT-proBNP is used as a part of the stratification
system in Mayo Clinic [23]. Change in serum levels of NT-proBNP correlates
with the FLC - circulating amyloidogenic precursors, as well as with the
improvement of echocardiographic finding after successful therapy, and
appears as a possible auxiliary parameter for optimization of therapy.
Determining of NT-proBNP levels will be probably used as an early indicator
of organ response, as was done in the work by Palladini et al. when the
criterion was change in the levels of NT-proBNP of 30% and 300 ng/L at least
[22]. The limitation of NT-proBNP levels determination is an overestimation
in the presence of renal insufficiency and the persistence of high levels during
therapy with lenalidomide, where the mechanism of this phenomenon is still
not fully understood [27, 28].
Proteinuria
Amyloid nephropathy is present in approximately half of the patients in
the time of diagnosis of AL amyloidosis. Often just renal impairment as the
Pavel Lochman
98
first symptom of AL amyloidosis brings the patient to the physician. The
clinical picture includes mostly fully expressed nephrotic syndrome and in
some patients renal insufficiency, wherein the morphological impairment
includes not only the glomeruli and tubules, but amyloid deposits are also in
the interstitium and in the vessel walls [2]. Urinalysis then proves a massive
non-selective proteinuria in most cases, mainly albuminuria. The degree of
proteinuria belongs among the criteria for renal disease in AL amyloidosis and
proteinuria above 0.5 g/day is considered to be a diagnostic value. The
criterion for organ treatment response or progression is 50% reduction or
increase of proteinuria and changes in the levels of creatinine and creatinine
clearance [13]. It is known that in early achievement of complete hematologic
response, renal organ response is often observed several months later.
Alkaline Phosphatase (ALP)
Amyloid hepatopathy is present in approximately 20% of patients with AL
amyloidosis. Clinical syndromes include hepatomegaly, portal hypertension
and coagulopathy, wherein the liver failure is rare [2]. Laboratory examination
shows increased activity of alkaline phosphatase, where the criterion of liver
disease is liver width of 15 cm or ALP elevations bigger than 1.5 times the
upper limit of normal (at the absence of heart failure). The criterion of
therapeutic organ response includes a 50% decrease of abnormal level of ALP
and liver width decrease of 2 cm. Conversely organ progression is defined as a
50% increase of ALP activity [13].
RESULTS AND DISCUSSION
FLC and MIg Determination
Examined cohort for FLC evaluation included 27 patients with biopsy-
verified systemic AL amyloidosis, where amyloidosis was not associated with
other hematological diseases (e.g., multiple myeloma or Waldenström’s
macroglobulinemia) and who were followed and treated at the Faculty
Hospital Olomouc, Czech Republic in years 2004-2014.
The median of age was 62 years (48-92 years), male to female ratio was
18:9, secretion kappa:lambda was 4:23. Serum free light chains were
Protein Studies in Light-Chain Amyloidosis
99
determined by FreeLite
TM
kit (The Binding Site, UK) using the nephelometer
Radim Delta (Radim Diagnostics, IT), and since the year 2010 by turbidimeter
SPA Plus (The Binding Site, UK). Normal range of serum levels is 3.3 to 19.4
mg/L for the light chain kappa (κ), and 5.7 to 26.3 mg/L for lambda (λ). The
normal ratio of the light chains kappa/lambda (κ/λ index) was determined from
0.26 to 1.65 and 0.37 to 3.1 in case of renal insufficiency. Determination of the
levels of monoclonal immunoglobulin (MIg) was performed by
electrophoresis (Hydrasys Sebia, FR) using kits Sebia Hydragel Protein(e) 30
followed by densitometric quantitation of MIg.
For MIg identification by immunofixation analysis was used Sebia
Hydragel 4 IF set for the same electrophoretic equipment. The detection and
quantitation of waste monoclonal immunoglobulin, i.e., Bence-Jones protein in
urine was performed using the same examination procedure and kits, when the
urine of the patient was examined by electrophoresis followed by
immunofixation in parallel with the serum. The values of total protein in
serum and urine used for calculating of the quantity of electrophoretic
fractions were determined on Cobas 8000 (Roche, CH) by kits TP2 and
TPUC3.
Electrophoresis showed serum MIg present in 17/27 (63%) patients, with
median level 3.8 g/L (0.3-14.2 g/L). Immunofixation identified 5 cases of
complete molecules of the IgG (1 IgGκ, 4 IgGλ), 4 cases of IgAλ and one
patient of IgDλ. In 7 patients were detected λ light chains in the serum only.
An analysis of urine proteins showed an excretion of Bence-Jones protein in
15 (56%) patients, in all cases quantity exceeded 200 mg/24 hours, in 3
patients also the presence of complete molecules of MIg in urine (1 IgA λ, 2
IgG λ) was found.
Analysis of serum free light chains showed abnormal values in all
patients, with median of 310 mg/L (53.6-1562 mg/L), and abnormal κ/λ index
was found in 25 patients (92.5%) (Figure 1). Two patients with a normal κ/λ
index and suffering from advanced renal insufficiency exhibited
simultaneously elevated both light chains. In 25 patients with abnormal levels
of FLC and κ/λ index, 23 patients showed differences in levels of the dominant
and uninvolved free light chains ˃50 mg/L, which is a generally accepted limit
defining measurable disease. In 85% patients determining FLC allows regular
monitoring of the disease (Figure 2).
Pavel Lochman
100
Figure 1. Serum FLC for patients with AL amyloidosis.
Figure 2. Changes in serum FLC levels, reflecting the achieved hematological response
rates (CR - complete remission, PR - partial remission, NR - no therapeutic response
achieved).
Protein Studies in Light-Chain Amyloidosis
101
Heavy/Light Chains Pairs (HLC)
Analyses of the HLC levels were performed in 13 patients. In the case of
IgA isotype we detected pathology of IgA-λ HLC levels along with the change
in HLC ratio in 3/4 patients. In IgG isotype, pathology of IgG-λ levels and
HLC ratio was detected in 2/2 patients. In the case of λ and immunofixation
negative sera there were no elevations of HLC levels of any isotype. In 5
patients suppression of IgG-κ isotype HLC combined with the change of HLC
ratio was observed. IgA and IgM isotype pair suppression was not observed. In
all cases is HLC more sensitively measurable parameter than
electrophoretically determined MIg.
Troponins and NT-ProBNP
The group for cardiac markers examination included 22 patients with
histologically verified AL amyloidosis, the criteria for heart involvement met
18 patients. In all patients were determined levels of cardiac biomarkers -
Troponin T (TnT) and N‑Terminal Pro‑Brain Natriuretic Peptide (NT‑
ProBNP). For risk stratification of patients was used Mayo staging system
based on the determination of both parameters, for evaluation of survival Log
Rank test was used.
Median survival of patients with a heart involvement was 10 months
versus 60 months for patients without signs of heart involvement (p = 0.133).
Among 4 patients without evidence of heart involvement positive levels TnT
in 1 patient and NT-proBNP in 2 patients were found. In patients with a heart
disease, abnormal level of NT-proBNP was recorded in all of them (median
4752 ng/L; range 415.7-35000), as well as positivity TnT (median 0.0815
mg/L; range 0.02 to 0.986). Mayo stratification system classified 2 patients in
stage 1, 5 patients in stage II and 15 patients in stage III. Median survival time
for each group was 60 (I) vs. 52 (II) vs. 6 (III) months (p = 0.050), showing an
evidence that the survival of patients in stage III is extremely limited. It is
evident that the decrease of both parameters reflects depth of treatment
response or achieving a complete hematologic remission. The results confirm
a benefit of the application of cardiac biomarkers assays in the diagnostics and
therapy in AL amyloidosis patients.
Pavel Lochman
102
CONCLUSION
AL amyloidosis is a less common disease from the group of monoclonal
gammopathies with a wide range of symptoms. It is an underdiagnosed
disease, where an early detection and treatment has a significant impact on the
quality and length of life of patients. Determination of selected biochemical
indicators plays an irreplaceable role not only in diagnosis but also in
monitoring of the disease progress and requires a close cooperation of
hematologists and biochemical stuff. Advanced laboratory facilities with
modern methods are a necessity for quality care for patients suffering from AL
amyloidosis and other monoclonal gammopathies.
AL amyloidosis is still an incurable disease, prognosis depends on the
timeliness of diagnosis, extent of organ involvement and achievement of
treatment response.
Determination of serum free light chains is a key laboratory parameter not
only in diagnosing and monitoring of the development of disease, but
especially in evaluating of the efficacy of therapy. Combination of standard
techniques for detection of MIG together with determination of blood FLC
enables monitoring of the vast majority of patients with AL amyloidosis.
Heart involvement represents an important prognostic factor.
Determination of cardiac biomarkers is an integral part of diagnostic algorithm
in patients with AL amyloidosis and together with echocardiography allows
not only detecting but also assessing the degree of cardiac dysfunction in these
patients. In successful chemotherapy decreased levels of cardiac biomarkers
reflect the restitution of cardiac dysfunction. Mayo stratification system
utilizing heart indicators is a robust tool for risk stratification of patients with
AL amyloidosis.
Potential benefit of HLC determination in patients with AL amyloidosis is
still not fully clarified and for the evaluation of HLC analysis is necessary to
obtain further results from more comprehensive group of patients.
REFERENCES
[1] Sipe JD, Benson MD, Buxbaum JN et al. Amyloid fibril protein
nomenclature: 2010 recommendations from the nomenclature committee
of International Society of Amyloidosis. Amyloid 2010; 17: 101-104.
Protein Studies in Light-Chain Amyloidosis
103
[2] Bird J, Cavenagh J, Hawkins P et al. Guidelines on the diagnosis and
management of AL amyloidosis. Brit J Hematol 2004; 125: 681-700.
[3] Gertz MA. Immunoglobulin light chain amyloidosis: 2011 update on
diagnosis, risk-stratification, and management. Am J Hematol 2011; 86:
181-186.
[4] Sanchorawala V, Blanchard E, Seldin DC, O´Hara C, Skinner M, Wright
DG. AL amyloidosis associated with B-cell lymphoproliferative
disorders: frequency and treatment outcomes. Am J Hematol 2006; 81:
692-695.
[5] Merlini G, Bellotti V. Molecular mechanisms of amyloidosis. N Engl J
Med 2003; 349: 583-596.
[6] Merlini G, Seldin DC, Gertz MA. Amyloidosis: pathogenesis and new
therapeutic options. J Clin Oncol 2011; 29: 1924-1933.
[7] Bradwell AR. Serum free light chain measurements move to center
stage. Clin Chem 2005; 51: 805-807.
[8] Katzmann JA, Kyle RA, Benson J et al. Screening panels for detection
of monoclonal gammopathies. Clin Chem 2009; 55: 1517-22.
[9] Abraham RS, Katzmann JA, Clark RJ, Bradwell AR, Kyle RA, Gertz
MA Quantitative analysis of serum free light chains. A new marker for
the diagnostic evaluation of primary systemic amyloidosis. Am J Clin
Pathol 2003; 119: 274-8.
[10] Palladini G, Russo P, Bosoni T et al. Identification of amyloidogenic
light chains requires the combination of serum-free light chain assay
with immunofixation of serum and urine. Clin Chem 2009; 55: 499-504.
[11] Akar H, Seldin DC, Magnani B et al. Quantitative serum free light chain
assay in the diagnostic evaluation of AL amyloidosis. Amyloid 2005; 12:
210-215.
[12] Dispenzieri A, Kyle RA, Merlini G et al. International Myeloma
Working Group guidelines for serum-free light chain analysis in
multiple myeloma and related disorders. Leukemia 2009; 23: 215-224.
[13] Gertz MA, Comenzo R, Falk RH et al. Definition of organ involvement
and treatment response in immunoglobulin light chain amyloidosis (AL):
a consensus opinion from the 10th International Symposium on Amyloid
and Amyloidosis. Am J Hematol 2005; 79: 319-328.
[14] Gertz MA, Merlini G. Definition of organ involvement and response to
treatment in AL amyloidosis: an updated consensus opinion. Amyloid
2010; 17: 48-49.
Pavel Lochman
104
[15] Comenzo RL, Reece D, Palladini G et al. Consensus guidelines for the
conduct and reporting of clinical trials in systemic light-chain
amyloidosis. Leukemia 2012; 26: 2317-2325.
[16] Kumar S, Dispenzieri A, Lacy MQ et al. Changes in serum-free light
chain rather than intact monoclonal immunoglobulin levels predicts
outcome following therapy in primary amyloidosis. Am J Hematol 2011;
86: 251-255.
[17] Kumar S, Dispenzieri A, Katzmann JA et al. Serum immunoglobulin
free light-chain measurement in primary amyloidosis: prognostic value
and correlations with clinical features. Blood 2010; 116: 5126-5129.
[18] Kumar S, Dispenzieri A, Lacy MQ et al. Revised prognostic staging
system for light chain amyloidosis incorporating cardiac biomarkers and
serum free light chain measurements. J Clin Oncol 2012; 30: 989-995.
[19] Bradwell, A. R., Harding, S., Fourrier, N. J. et al. Assesment of
monoclonal gammopathies by nephelometric measurement of individual
immunoglobulin kappa/lambda ratios. Clin. Chem., 2009, 55, pp. 1646-
55.
[20] Dispenzieri, A., Kyle, R. A., Gertz, M. A. et al. Survival in patients with
primary systemic amyloidosis and raised serum cardiac troponins.
Lancet, 2003, 361, pp. 1787-1789.
[21] Kristen, A. V., Giannitsis, E., Lehrke, S. et al. Assessment of disease
severity and outcome in patients with systemic light-chain amyloidosis
by the high-sensitivity troponin T assay. Blood, 2010, 116, pp. 2455-
2461.
[22] Palladini, G., Barassi, A., Klersy, C. et al. The combination of high-
sensitivity cardiac trponin T (hs-cTnT) at presentation and changes in N-
terminal natriuretic peptide type B (NT-proBNP) after chemotherapy
best predicts survival in AL amyloidosis. Blood, 2010, 116, pp. 3426-
3430.
[23] Dispenzieri, A., Gertz, M. A., Kyle, R. A. et al. Serum cardiac troponins
and N-terminal pro-brain natriuretic peptide: a staging system for
primary systemic amyloidosis. J. Clin. Oncol., 2004, 22, pp. 3751-3757.
[24] Dispenzieri, A., Gertz, M. A., Kyle, R. A. et al. Prognostication of
survival using cardiac troponins and N-terminal pro-brain natriuretic
peptide in patients with primary systemic amyloidosis undergoing
peripherial blood stem cell transplantation. Blood, 2004, 104, pp. 1881-
1887.
[25] Weber, M., Hamm, C. Role of B-type natriuretic peptide (BNP) and NT-
proBNP in clinical routine. Heart, 2006, 92, pp. 843-849.
Protein Studies in Light-Chain Amyloidosis
105
[26] Palladini, G., Campana, C., Klersy, C. et al. Serum N-terminal Pro-brain
natriuretic peptide is a sensitive marker of myocardial dysfunction in AL
amyloidosis. Circulation, 2003, 107, pp. 2440-2445.
[27] Dispenzieri, A., Dingli, D., Kumar, S. K. et al. Discordance between
serum cardiac biomarker and immunoglobulin free light chain response
in patients with immunoglobulin light-chain amyloidosis treated with
immune modulatory drugs. Am. J. Hematol., 2010, 85, pp. 757-759.
[28] Tapan, U., Seldin, D. C., Finn, K. T. et al. Increases in B-type natriuretic
peptide (BNP) during treatment with lenalidomide in AL amyloidosis.
Blood, 2010, 116, pp. 5071-5072.
