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Dialysis-related amyloidosis: challenges and solutions

Authors Scarpioni R, Ricardi M, Albertazzi V, De Amicis S, Rastelli F, Zerbini L

Received 8 February 2016

Accepted for publication 21 June 2016

Published 7 December 2016 Volume 2016:9 Pages 319—328

DOI https://doi.org/10.2147/IJNRD.S84784

Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Lucy Goodman

Peer reviewer comments 2

Editor who approved publication: Professor Pravin Singhal

R Scarpioni, M Ricardi, V Albertazzi, S De Amicis, F Rastelli, L Zerbini

Department of Nephrology and Dialysis, Azienda Unità Sanitaria Local (AUSL) Hospital “Guglielmo da Saliceto”, Piacenza, Italy

Abstract: Amyloidosis refers to the extracellular tissue deposition of fibrils composed of low-molecular-weight subunits of a variety of proteins. These deposits may result in a wide range of clinical manifestations depending upon their type, location, and the amount of deposition. Dialysis-related amyloidosis is a serious complication of long-term dialysis therapy and is characterized by the deposition of amyloid fibrils, principally composed of β2 microglobulins (β2M), in the osteoarticular structures and viscera. Most of the β2M is eliminated through glomerular filtration and subsequent reabsorption and catabolism by the proximal tubules. As a consequence, the serum levels of β2M are inversely related to the glomerular filtration rate; therefore, in end-stage renal disease patients, β2M levels increase up to 60-fold. Serum levels of β2M are also elevated in several pathological conditions such as chronic inflammation, liver disease, and above all, in renal dysfunction. Retention of amyloidogenic protein has been attributed to several factors including type of dialysis membrane, prolonged uremic state and/or decreased diuresis, advanced glycation end products, elevated levels of cytokines and dialysate. Dialysis treatment per se has been considered to be an inflammatory stimulus, inducing cytokine production (such as interleukin-1, tumor necrosis factor-α, interleukin-6) and complement activation. The released cytokines are thought to stimulate the synthesis and release of β2M by the macrophages and/or augment the expression of human leukocyte antigens (class I), increasing β2M expression. Residual renal function is probably the best determinant of β2M levels. Therefore, it has to be maintained as long as possible. In this article, we will focus our attention on the etiology of dialysis-related amyloidosis, its prevention, therapy, and future solutions.

Keywords: chronic inflammation, long-term dialysis, β2 microglobulin, high-flux dialysis membrane, mineral bone disease

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