case report clinical remission of renal amyloidosis after … · 2014. 1. 16. · primary...

S25THE EWHA MEDICAL JOURNAL

Clinical Remission of Renal Amyloidosis after Autologous Peripheral Blood Stem Cell Transplantation

Seong Yeong An, Yon Hee Kim1, Young Eun Kwon, Yung Ly Kim, Ki Heon Nam, Heun Choi, Young Ju Kim, Kyoung Sook Park, Hyeon Joo Jeong1, Hyung Jung Oh, Jung Tak Park, Seung Hyeok Han, Shin-Wook Kang, Tae-Hyun Yoo Departments of Internal Medicine and 1Pathology, Yonsei University College of Medicine, Seoul, Korea

Introduction

Light-chainamyloidosis(ALamyloidosis)resultsfromextra

cellulardepositionoffibril-formingmonoclonalimmunoglobu-

linlightchains.Amongthesefiberdeposition-relatedorgan

disorders,renallesions(amyloidnephropathy)areobservedin

50~80%ofpatients[1].PrognosisofALamyloidosisispoor

ifuntreatedandisaffectedbythenature,number,extentof

organinvolvement,andthepresenceofconcurrentmyeloma

[2].Todate,thereisnoestablishedtreatmentforsystemicAL

amyloidosis.Conventionalchemotherapywithmelphalanand

dexamethasoneinducesatleastpartialhematologicresponsein

approximately60%ofpatients.Recently,high-dosemelphalan

andhematopoieticcelltransplantation(HDM/HCT)therapy

hasemergedasafirstlinetreatmentforALamyloidosis[3-5].

However,clinicalevidenceforthistherapywasmostlybasedon

retrospectiveanalysesandrandomizedcontrolledtrialsonthis

issuearescarce.Herein,wereportacaseofALamyloidosis

presentedwithnephroticsyndromeandclinicallyremittedafter

HDM/HCT.

Case

A51-year-oldwomanvisitedourhospitalduetogeneral-

izededema.Thepatientgainedweight5kgduringthelastone

month.Hermedicalhistorywasnotremarkable.Bloodpressure

was109/82mmHg,andpittingedemainbothlowextremi-

tieswasobservedonphysicalexamination.Initiallaboratory

testsshowedthefollowingvalues:hemoglobin,15.8g/dL;total

protein,4.4g/dL;serumalbumin,2.2g/dL;totalcholesterol,

CaseReport

Ewha Med J 2013;36(S):S25-S29http://dx.doi.org/10.12771/emj.2013.36.S.S25pISSN 2234-3180 • eISSN 2234-2591

Primary amyloidosis has unfavorable prognosis, particularly with organ involvement. Here, we report a case of clinical remission of renal amyloidosis after autologous he-matopoietic cell transplantation. A 51-year-old female patient visited our hospital due to generalized edema. Initial evaluation showed hyperlipidemia, hypoalbuminemia, and heavy proteinuria, which were consistent with nephrotic syndrome. However, IgM lamda type monoclonal gammopathy was detected in serum and urine electrophore-sis studies. Renal biopsy showed Congo red-positive amyloid deposition in mesangial area, glomerular capillary walls, and arterioles and amyloid fibers were confirmed by electron microscopy. Immunohistochemial study of the biopsy tissue demonstrated systemic light-chain amyloidosis (AL amyloidosis). Multiple myeloma was not evident on bone marrow examination. She received autologous hematopoietic cell transplan-tation after high dose melphalan treatment. Complete remissions were achieved after the treatment, respectively. Our findings suggest the potential role of autologous pe-ripheral blood stem cell transplantation in treatment of AL amyloidosis. (Ewha Med J 2013;36(Suppl):S25-S29)

Received August 2, 2013 Accepted September 16, 2013

Corresponding authorTae-Hyun YooDepartment of Internal Medicine, Yonsei University College of Medicine, 50, Yonsei-ro, Seodaemun-gu, Seoul 120-752, KoreaTel: 82-2-2228-1989, Fax: 82-2-393-6884E-mail: yoosy0316@yuhs.ac

Key WordsAL amyloidosis; Hematopoietic cell transplantation; Melphalan

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An SY, et al

Fig. 1. Initial renal biopsy findings. (A) Renal biopsy specimen shows normal glomeruli on light microscopy (H&E, ×400). (B) These materi-als show an apple green birefringence by Congo red staining under polarized light. (C) Immunofluorescence examinations demonstrate kappa and lambda-chain deposits in glomeruli and arterioles. (D) Electron microscopic findings reveal diffuse fusion of the foot processes, and non-branched fibers in both subepithelial and subendothelial spaces of the glomerulus. (E) Electron microscopic findings reveal that randomly ar-ranged fibrils are presented.

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Clinical Remission of Renal Amyloidosis after Autologous Peripheral Blood Stem Cell Transplantation

295mg/dL;aspartate/alanineaminotransferase,18/14IU/L;

totalbilirubin,0.8mg/dL;alkalinephosphatase,53IU/L;

serumcreatinine,0.8mg/dL(correspondingtoestimatedglo-

merularfiltrationrateof85mL/min/1.73m2);CK,57IU/L;

CK-MB,2.31ng/mL;troponin-T,0.023ng/mL;andNT-

proBNP,663.50pg/mL.

Electophoresisandimmunofixationstudiesofserumandurine

proteinsrevealedanIgMlamdatypemonoclonalgammopathy.

Serumkappafreelightchainlevelwas19.5mg/Landlambda

freelightchainwas73.5mg/Landtheirratiowas0.27.

Spoturineproteincreatinineratio(UPCR)and24hour

urinaryproteinexcretionwere7.79g/g,and6.95g/day,re-

spectively.OtherserologictestsforhepatitisBandC,human

immunodeficiencyvirus,antinuclearantibodyandantineutrophil

cytoplasmicantibodywerenegative,andserumcomplementlev-

elswerewithinthereferencerange.Nocardiomegalyorhepa-

tomegalywasseenonimagingstudies.Onechocardiography,

therewasnoenhancementofechogenicityincardiacwallswith

preservedejectionfraction.Esophagogastroduodenoscopicand

colonoscopicfindingswerenotremarkable.Renalbiopsywas

performed7daysaftertheinitialevaluation(Fig.1).Onlight

microscopy,amorphousperiodicacidSchiffpositivedeposits

wereobservedintheglomerularcapillarywalls,mesangialarea

inglomeruliandarterioles.Thesematerialsshowedanapple

Fig. 2. A second renal biopsy 25 month after high-dose melphalan and hematopoietic cell transplantation. (A) Renal biopsy specimen shows normal glomeruli on light microscopy (H&E, ×200). (B) These materials show an apple green birefringence by Congo red staining under polarized light. (C) Immunofluorescence examinations demonstrate weakly kappa and lambda-chain deposits in glomeruli and arterioles than initial renal biopsy.

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An SY, et al

greenbirefringencebyCongoredstainingunderpolarizedlight.

Immunofluorescenceexaminationsdemonstratedkappaand

lambdachaindepositsinglomeruliandarterioleswithoutg-,

m-,a-heavychaindeposits.Electronmicroscopicfindingsre-vealeddiffusefusionoffootprocesses,andnon-branchedfibers

inbothsubepithelialandsubendothelialspacesoftheglomeru-

lus.Immunohistochemicalstudyofthebiopsytissueexcluded

amyloidA(AA)amyloidosis.Onbonemarrowexamination,

plasmacellsaccountedfor0.6%inmarrowaspirate,suggesting

noevidenceofcoexistingmultiplemyeloma.

Thepatientreceivedautologoushematopoieticcelltransplan-

tationfollowingtheadministrationofmelphalanatadoseof

200mg/m2over2consecutivedays.Nomaintenancetherapy

wasgiventothepatientaftermelphalantreatmentandhemato-

poieticcelltransplantation.Electrophoresisandimmunofixation

studiesofserumandurineproteins1monthafterthetreatment

showedcompletehematologicremission.Kappafreelightchain

levelwaslessthan3.65mg/L,lambdafreelightchainwas

7.6mg/Landtheirratiowasnotabletocalculate.Nodefinite

monoclonalbandwasobservedinbothserumandurine.During

thetreatmenttimeandfollowupperiod,therewerenoepisodes

ofacutekidneyinjuryshowingunremarkablechangesinserum

BUNandcreatininevalues.

Contrarytohematologicresponse,nephroticrangeproteinuria

wasdecreasedby50%fromthebaselinevalueat9monthand

amountofproteinuriawasnormalized17monthsafterHDM/

HCT.Asecondrenalbiopsywasperformed25monthsafter

thetreatment.Congoredpositivematerialsweresubstantially

decreasedcomparedtotheinitialbiopsyfindings.However,

amyloiddepositsremainedinthesubendothelialareaofthe

glomerulus(Fig.2).SpotUPCRatthelastvisitwas0.26g/g.

Shehasbeeninclinicalremissionfor28months.

Discussion

PrimaryALamyloidosisisararesystemicdisorderandits

clinicalfeaturesareattributedtodepositionofproteinsderived

fromimmunoglobulinlightchainfragmentsinvariousorgans

suchaskidney,heart,andliver.Inparticular,renalmanifesta-

tionsincludeasymptomaticproteinuria,nephroticsyndrome,

orprogressiverenalfailure.Endstagerenaldiseaserequiring

dialysisdevelopsinabout20%ofpatientswithALamyloidosis

[6].Recently,HDM/HCThasbeenhighlightedasapotentially

curativetreatmentforALamyloidosis.Manystudieshavere-

portedhematologicremissionaswellasclinicalimprovementin

organmanifestationscausedbyamyloiddeposition.Thisreport

describesacaseofclinicalremissionofrenalamyloidosisafter

thistherapy.

BeforeHDM/HCTwasintroducedfortreatmentofALamy-

loidosis,chemotherapyaimedatsuppressingtheunderlying

plasmacellclonesecretingamyloidformingimmunoglobulinlight

chainwasthemaintherapy.However,overallsurvivalratewas

poor,asdemonstratedintworandomizedstudiesshowingthata

combinationofmelphalanplusprednisonehadlimitedbeneficial

effect,withamedianoverallsurvivalof18months,compared

to12monthsinpatientswhoreceivednotreatmentorcolchi-

cinetherapyalone[7,8].Althoughexperiencesofbonemarrow

transplantationfortreatmentofALamyloidosiswereoccasionally

reportedinthemid1990’s,thefeasibilityandefficacyofHDM/

HCTwasfirstsuggestedin1998byRayComenzoandcol-

leagues[9].Sincethen,manystudiesusingthesametreatment

strategyhavebeenreported.Itwasreportedthathematological

responseratewasmorethan60%,completeresponserateanda

mediansurvivalwerearound40%and4.5years,respectively,

afterHDM/HCTtreatment[5].However,HDM/HCTinAL

amyloidosisstillremainsrestrictedtoselectionofpatients;gener-

allyyoungerthan65yearsandwithlocalizedinvolvementless

thantwoorganswithoutadvancedcardiacamyloidosis.

Despitecompletehematologicremissionanddisappearance

ofurineMproteinandproteinuria,renalhistologyshowed

thatamyloiddepositsremainedinthesubendothelialareaof

theglomerulusinthispatient.Previousreportsalsodemon-

stratedthatrenalamyloiddepositionswerenotregressedeven

inpatientsshowingcompleteremissionofALamyloidosisafter

successfulHDM/HCT.Itsuggestedthatlightchainratherthan

renalamyloiddepositionmayinduceglomerularinjuryandin-

creaseinproteinpermeabilityinglomerulus,consequently[10].

However,carefulfollowupisstillnecessarytoconfirmthesig-

nificanceofamyloiddepositioninglomerulus.

Inthisreport,wedescribedacaseofALamyloidosis,which

presentedwithnephroticsyndromeandimprovedafterHDM/

HCT.

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