Dr. John Quinn Beaumont Hospital/RCSI

 48 year old female  May 2013  18 month history  Fatigue, weight loss, tongue swelling, ankle swelling  GP – urine – 4+ proteinuria  Referred to Nephrology Clinic  Cr 197

 TUP in 24 hours – 5.6g  Albumin 19  Raised Cholesterol Diagnosis: Nephrotic Syndrome

 FBC – NAD  SPEP and UPEP – small lambda paraprotein  Skeletal survey – no lytic disease  BMA – 5% plasma cells  Trephine – 5-10% plasma cells  Serum free light chain ratio: Lambda 342:Kappa 44.8  Ratio: 0.13  Echo – NAD  NTproBNP and TnI - Normal

 Renal Biopsy – Amyloidosis – Likely AA?  Biopsy sent to NAC at Royal Free Hospital  Diagnosis confirmed as AL Amyloidosis  Initial Treatment: Cyclophosphamide and Dexamethasone  Plan to add 3 rd drug depending on tolerability

 Good symptomatic response to dexamethasone  Discharged – but readmitted 4 days later  Collapsed every time she stood up  Severe autonomic neuropathy  Therefore, avoid bortezomib  Added increasing doses of fludrocortisone - mineralocorticoid  Subsequently midodrine 2.5mg tds – alpha-1-receptor agonist

 Allowed cautious diuresis  Thalidomide 50 mg added – 1 month after diagnosis  Warfarin thromboprophylaxis  6 weeks following diagnosis – albumin 17g/dl, TUP 6.8g/24 hours, creatinine 190  BP lying 103/64  BP standing 63/34  Wheelchair-dependent

 8 weeks after diagnosis: Normal SFLCr 1.6  Starting to manage day leave  BP-stabilising  Discharged  F/up in day ward  Completed a total of 4 cycles of CTD as complete clonal response  Only now fit to travel to NAC in UK  SAP scan – liver + spleen amyloid only

 Gradual improvement in symptoms over 6 months  Meds gradually withdrawn  Now 2.5 years post diagnosis  Albumin 37  Cr 109  Normal SFLCr  Off all meds  Asymptomatic, working full time

 A protein problem!  Increasing number of diagnoses  Cardiac MRI  Serum Free Light Chain Test  Survival improving for patients with AL Amyloidosis

Kappa Lambda Normal ratio is approximately 0.26 – 1.65 Increased ratio may be seen in in plasma cell dyscrasias Light chain only myeloma and amyloidosis Normal plasma cells secrete FLCs Assay relies on detecting an imbalance in the ratio between kappa and lambda light chains Useful assay for detection and monitoring of AL amyloidosis and non-secretory myeloma Abnormal SFLC ratios described in SLE and HIV infection

 N=1017  4yr OS  : 28%  : 30%  2003 – 2006: 42% Mayo Clinic Proceedings, Kumar et al 2011

 Amyloidosis is a rare systemic disorder  Mis-folding of aberrant precursor proteins  Unstable aggregates in a Beta-pleated structure  Fibrils are deposited in organs affecting structure and function  The unstable protein may be hereditary or acquired

 AL amyloidosis is most common  Amyloidogenic protein is a monoclonal light chain secreted by an underlying plasma cell dyscrasia  Amyloidosis caused by deposition of misfolded transthyretin is next most common  Others include misfolding of lysozyme and gelsolin  Localised AL amyldosis – amyloid deposits at a single site – bladder, skin, larynx, lung

>3000 patients seen at NAC since 1990

Mahmood et al, Haematologica 2014

Amyloid Acquired Underlying disease producing an amyloidogenic protein Abnormal protein which is amyloidogenic - AL Increased amounts of a normal protein which can form amyloid - AA Production of a normal protein which is inherently amyloidogenic – e.g. wtTTR or “senile amyloidosis ” Hereditary: genetic mutation leading to the formation of amyloid forming proteins e.g. Hereditary mutation in the transthyretin gene

Amyloid fibrils + Heparan/dermatan sulphate + Serum amyloid P component (SAP)

Symptoms are often non-specific!  Lethargy, fatigue  Weight loss  Peripheral oedema  Unexplained heart failure  Alternating diarrhoea/constipation  Peripheral/autonomic neuropathy  Postural Hypotension  Purpura  Macroglossia

Amyloid Type HeartKidneyLiverPNSANSSoft Tissue AL wtTTR Hereditary TTR AA Up to 10% of patients with hereditary amyloid have MGUS 21% of wtTTR (senile) patients may have MGUS

 Confirm presence of Amyloid – this requires a biopsy  Confirm AL Amyloid and not another subtype – this requires considerable expertise  If AL Amyloid confirmed – need plasma cell disorder work-up and to exclude Myeloma and Systemic W/Up

 Biopsy – What?  Biopsy of affected organ  Screening biopsy Abdominal fat FNA  highly variable sensitivity Rectal  more invasive, also not highly sensitive Van Gameren, Arth&Rheum 2006;54:2015 Ansari-Lari, Diagn Cytopathol 2004;30:178

 Essential  NB – Refer Case to NAC in London  Mass Spectrometry  Immuno-electromicroscopy  Immunohistochemistry  DNA Analysis NEJM 2002

AL AA

 FBC + Biochem + CPM  Albumin  SPEP  UPEP  SFLCr  24 Hour TUP  BMA + Biopsy  Skeletal Survey  CT if IgM paraprotein  Staging Investigations: NT-ProBNP and Troponin T  Echo +/- Cardiac MRI  US abdomen if ?liver involvement  Nerve conduction studies  SAP scan at NAC

o Cardiac Involvement predicts poor prognosis o Cardiac muscle injury leads to the release of troponins o NTproBNP is released in response to cardiac muscle stress o NTproBNP and Troponin T – based staging system – Mayo Staging o 98 patients undergoing stem cell transplantation for AL Amyloidosis Dispenzieri et al, Blood 2004

 810 patients  Newly diagnosed AL Amyloidosis  TnT, NTproBNP and FLCdiff predicted overall survival  FLCdiff>18mg/dl, TnT>0.025, NTproBNP>1800  1 point for each positive biomarker  Stages 1 – 4 with 0 to 3 points respectively  I – 25%  II – 27%  III – 25%  IV – 23% Kumar et al, JCO 2012

 Median OS  I – 94 months  II – 40.3 months  III – 14 months  IV – 5.8 months Kumar et al, JCO 2012

N=583N=303 N=103

Reduce the number of clonal plasma cells Reduce the production of abnormal light chains Slow or stop production of new amyloid Gradual regression of existing amyloid deposits

NEJM, 2007

Jaccard et al, NEJM 2007

 29/37 patients who received HDT survived to >3 months post-auto  Haematologic response rates were 68% for MD and 66% for HDT  Median time to progression was similar in both groups

Median OS 56.9 months in MD group and 22.2 months in HDT TRM 24% NB – 4 patients died during gCSF mobilisation Landmark analysis failed to show a benefit with HDT Similar outcome in patients with High Risk disease

 75 patients  ORR 74%  CR 21%  Attenuated doses of CTD  44 patients had relapsed disease  Median OS 41 months Wechelaker et al, Blood 2007

 European Collaborative Study - CyBorD  UK and Italy  N=230  55% alive at 5 yrs  62% RR  43% VGPR  NTproBNP >8500had RR of 42% and median OS of 7 months  If response achieved – 67% OS at 2yrs Palladini et al, Blood 2015

Mahmood S et al. Haematologica 2014;99:

Palladini G et al, JCO Patients from 7 centres

 Effective treatment reduces production of precursor protein  However regression of preformed amyloid deposits is very slow or does not occur at all  65% of Amyloid Cases are AL  20% of patients die within 6 months of diagnosis before delayed effects are realised

 Aim of studies was to stimulate normal phagocytic clearance mechanisms  Pre-treat with CPHPC  Mops up circulating SAP  Then administer humanised monoclonal IgG1 anti-SAP antibody  Activate macrophage destruction of Sap- containing amyloid deposits

 All amyloid deposits contain SAP  Normal plasma glycoprotein  Binding of SAP to amyloid fibrils is reversible

K Bodin et al. Nature, 2010 Elimination of visceral amyloid in AA amyloidotic mice after treatment with anti-SAP antibody.

 16 patients  Patients with clinical evidence of cardiac involvement or clinically significant renal or liver involvement were excluded  3 day infusion of CPHPC  Single dose of anti-SAP MaB  2 AA, 8 AL, 6 other Amyloid

 No SAEs  Most patients had mild IRRs which were manageable  Patients who received higher dose of the antibody showed evidence of an acute response  After 42 days  6/8 patients with liver involvement had reduced liver stiffness measured using a fibroscan

 4 patients had substantial reductions in liver amyloid by SAP-imaging  1 patient had reduction in renal amyloid on SAP-imaging  Next trial – include patients with significant cardiac and renal dysfunction

Richards et al, NEJM, 2015

 74 yr old man  Previously well  Increasing SOB x 9 months  Extensive investigations  Cardiac MRI – LGE consistent with Amyloid  Referred for evaluation

 Mild renal impairment  Small lambda paraprotein in serum  SFLCr – Lambda 670/Kappa 30  BM – 20% plasma cells  No lytic disease in bones  Not anaemic  Next Test??

 Fat pad aspirate – negative for amyloid  Trephine – no amyloid  NTproBNP – 6415  TnI – 0.25  Next test??

 More amyloid cases diagnosed  Better outcomes with newer agents and supportive care  Cardiac disease predicts survival  Follow disease with LC assay  Individualised treatment approach