Transcript Serum free light chain assays

AL Amyloidosis and
renal complications
Alex Legg PhD
Scientific Affairs Manager
The Binding Site
[email protected]
Distributor in Poland BIOKOM
[email protected]
Why are FLCs associated with
kidney disease?
In plasma cell dyscrasias toxic monoclonal
FLCs are produced:
Light chain
physico-chemical
properties
organisation of
light chain
aggregates
Location of
deposits
Characteristic
organ/tissue
injury
Acute tubular necrosis
Fanconi’s syndrome
AL amyloid
LCDD
AL
Cast
nephropathy
CN
868 AL Amyloidosis patients
Kidney involvement
Nephrotic syndrome
Renal failure (creat >2mg/dL)
72%
52%
18%
Merlini, G. et al. 2008. 2(1): p. 287 - 293.
AL Amyloidosis Diagnosis
Monoclonal Protein Investigations
Serum electrophoresis: SPE + sIFE
+
Urine electrophoresis: UPE + uIFE
and/or?
Serum FLC assay
AL Amyloidosis
100000
Serum Lambda FLC (mg/L)
10000
Normal Sera
1000
- SPE
sensitivity
Kappa LCMM
AL Amyloid
100
Lambda LCMM
10
1
IFE sensitivity 0,1
0,1
1
10
100
1000
10000
100000
Serum Kappa FLC (mg/L)
Lachmann H. et al. BJH 2003; 122 :78-84
Diagnostic Performance in AL Amyloidosis (n = 110)
Assay
% Positive
FLC κ/λ ratio
91
Serum IFE
69
Urine IFE
83
Serum IFE + urine IFE
95
FLC κ/λ ratio + serum IFE
99
FLC κ/λ ratio + serum IFE + urine IFE
99
‘Urine IFE did not add any additional information.’
Katzmann et al. Clin Chem 2005; 51: 878-881
Diagnostic Performance in AL Amyloidosis (n = 115)
Assay
% Positive
FLC κ/λ ratio
76
Serum IFE
80
Urine IFE
67
Serum IFE + urine IFE
96
FLC κ/λ ratio + serum IFE
96
FLC κ/λ ratio + serum IFE + urine IFE
100
All three assays are complementary
Palladini et al. Clin Chem 2009; 55: 499-503
AL Amyloidosis Guidelines Summary
Screening
Publication
Screening
IMWG for sFLC analysis
sIFE + sFLC
+ uIFE
Dispenzieri, A., et al. Leukemia, 2009. 23(2): p. 215-24.
BCSH AL Amyloidosis guidelines
Bird, J.M., et al. Br J Haematol, 2004. 125(6): p. 681-700.
sIFE + sFLC
+ uIFE
Polyclonal sFLC increase
as GFR decreases
Kappa FLC
Lambda FLC
Hutchison Clin J Am Soc Nephrol 3: 1684–1690, 2008
/ ratio increases as GFR decreases
New renal reference range for ratio: 0.37 – 3.1
Hutchison Clin J Am Soc Nephrol 3: 1684–1690, 2008
Can sFLC assays be used to
diagnose multiple myeloma in
patients with renal failure?
• Audit of 142 patients with new dialysis
dependent acute renal failure
• 41 / 142 patients with multiple myeloma
Hutchison et al. BMC Nephrology 2008, 9:11
New reference range for / ratio
for renal impairment
ARF - Myeloma ()
ARF - Myeloma ()
10000
Serum lambda FLC (mg/L)
Serum lambda FLC (mg/L)
100000
ARF - No MG
1,000
1000
Normal sera
Normal
100
/ ratio
0.26 – 1.65
10
10
1
0.1
0.1
0.1
0.1
Proposed
renal range
/ = 0.37 – 3.1
1
10
10
100
1000
1,000
10000
100000
Serum kappa FLC concentration (mg/L)
Serum kappa FLC (mg/L)
Hutchison et al. BMC Nephrology 2008, 9:11
New reference range for / ratio
for renal impairment
1. Interpret sFLC results in the context of clinical
findings and other laboratory tests… including
renal function
2. If patient has renal impairment, then renal
reference range (/ = 0.37 – 3.1) may be
applicable
3. Renal reference range improves diagnostic
specificity without changing diagnostic
sensitivity
AL Amyloidosis Treatment
Serum amyloid P scans: Reduction of AL deposits in the
liver and spleen after one year of chemotherapy
AL amyloidosis: BD response
“..at least a 50% reduction occurred in all [responding]
patients within two courses of treatment.”
Progressive
disease
Kastritis Haematologica 2007; 92: 1351 - 1358
Definition of treatment Response
Haematological Response Criteria
Complete
response
Serum and urine negative immunofixation
Free light chain ratio normal
Marrow <5% plasma cells
Partial
response
If serum M component > 5g/L, a 50% reduction
If light chain in urine with visible peak and >100
mg/day and 50% reduction
If serum iFLC >100 mg/L and 50% reduction
Gertz et al., Am J Hematol, 2005: 79, 319-328
AL amyloidosis: Outcome
Gertz et al., Curr Opin Oncol 2007. 19; 136-141
AL Amyloidosis Guidelines Summary
Monitoring
Publication
Monitoring
IMWG for sFLC analysis
sFLC essential
Dispenzieri, A., et al. Leukemia, 2009. 23(2): p. 215-24.
BCSH AL Amyloidosis guidelines
Bird, J.M., et al. Br J Haematol, 2004. 125(6): p. 681-700.
International Consensus Opinion
Gertz, M.A., et al., Am J Hematol, 2005. 79(4): p. 319-28.
(Recommended for LCDD)
sFLC recommended
sFLC recommended
Light chain deposition disease
2 large published studies:
1)
2)
Mayo Clinic
NAC
n = 19
n = 17
abnormal sFLC ratio 89%
abnormal sFLC ratio 88%
Katzmann J. et al. Clin Chem 2002; 48: 1437 - 1444
Wechalekar A. et al. Haematologica 2005; 90: 1414
Utility in
monitoring:
Brockhurst I. et al. Nephrol Dial Transplant 2005; 20: 1251 - 1253
Number of AL amyloidosis/ LCDD diagnoses
Serum FLC
10
8
6
AL
LCDD
4
2
0
Gregorini, et al. 2008. Haematologica. 2(2): E41
Myeloma and renal insufficiency
• 10 – 20% myeloma patients present with
acute renal failure
Cast
Nephropathy:
• 10% remain dialysis dependent long term
– There is a high mortality rate
– Chemotherapy and transplantation are hazardous
Light chain removal strategies
for cast nephropathy
1.Plasma exchange
• Used since 1980s
2.Haemodialysis
• New treatment strategy
Plasma exchange to remove sFLCs
Challenges:
1. >80% of FLCs are extravascular.
2. PE procedures are of limited frequency &
duration (typically 6 x 1.5 hour sessions over 2
weeks)
Typical recovery rates: 10 - 20%.
Randomised control trial of
plasma exchange
100 %
Cumulative survival
80 %
60 %
40 %
20 %
Control
Plasma exchange
0%
0
1
2
3
4
5
6
Time to death (months)
Clark et al. Ann Intern Med 2005 143:777 – 84
Haemodialysis to remove sFLCs
• 7 dialysers evaluated in
vitro for filtration
efficiency
• The Gambro HCO 1100*
was the most efficient at
removing FLC
* Available in Poland
Hutchison, CA. et al. JASN 2007; 18: 886-895
Distribution of filter pore sizes
High
Flux
HighFlux
High
Cut-Off
Plasma
Plasmafilter
Filter
1,0
1,0
n/n
n/noo [-]
0,8
0,8
0,6
0,4
0,4
0,2
0,2
0,0
0,0
0,1
1
0,1
pore size [µm]
1
0,001
0,01
0,001
0,01
Pore size [m]
pore size [µm]
Size of albumin
Patient 3:
3000
Serum lambda FLC (mg/L)
2500
Dexamethasone
2000
Velcade
1500
Pre-dialysis FLC
Post-dialysis FLC
1000
500
0
0
5
10
15
20
25
30
Days
Hutchison, CA. et al. JASN 2007; 18: 886-895
Resolution of Cast Nephropathy
Renal biopsies: Haematoxylin and eosin stain
A: Presentation
B: After chemotherapy/ HCO1100 treatment
Basnayake et al. 2008. J Med Case Reports; 2, ePub
Pilot study: Renal recovery rates
28 days
Hutchison, CA. et al. 2009. Clin JASN 4, 745-54
European Trial of Free Light Chain Removal
by Extended Haemodialysis in Cast Nephropathy
Contact: Dr Colin Hutchison
[email protected]
AL amyloidosis? Publication in press
Guidelines Summary
IMWG 1
BCSH 2
Screening
N/A
+ sIFE & uIFE
Prognosis
International
Consensus
Opinion 3
-
N/A
Monitoring
1. Dispenzieri, A., et al. Leukemia, 2009. 23(2): p. 215-24
2. Bird, J.M., et al. Br J Haematol, 2004. 125(6): p. 681-700
3. Gertz, M.A., et al., Am J Hematol, 2005. 79(4): p. 319-28
Conclusions
FLCs in AL amyloidosis:
“The introduction of FLC assay has greatly improved
the management of patients with AL amyloidosis
and is now an essential tool in the care of this disease.”
Prof. G. Merlini
5th International Symposium, Bath Assembly Rooms
Biennial Meeting, 2008
• [email protected]
New reference range for / ratio
for renal impairment
ARF - Myeloma ()
ARF - Myeloma ()
10000
Serum lambda FLC (mg/L)
Serum lambda FLC (mg/L)
100000
ARF - No MG
1,000
1000
100
Normal sera
Normal
/ ratio
10
10
1
0.1
0.1
0.1
0.1
1
10
10
100
1000
1,000
10000
100000
Serum kappa FLC concentration (mg/L)
Serum kappa FLC (mg/L)
Hutchison et al. BMC Nephrology 2008, 9:11
Patient inclusion criteria
• Dialysis dependent renal failure, renal biopsy
proven cast nephropathy
• Fulfils diagnostic criteria for the diagnosis of
symptomatic de novo MM
• Abnormal sFLC ratio and sFLC > 500 mg/L
• Informed consent
• Commencement of study within 10 days of
presentation
16
14
Frequency
12
10
Serum negative
Urine
Ряд1 positive
n = 16
8
6
4
2
0
Monoclonal urine FLC (g/day)
14
12
Frequency
10
8
Serum Positive
Urine
Ряд1 negative
n = 52
6
4
2
0
sFLC concentrations (mg/L
Total: 219 patients
Mead, G.P., et al., Clin Lymphoma Myeloma, 2009. February: p. 153a.
AL amyloidosis:
Serum FLC negative and urine positive?
Patient X: Serum FLCs before developing AL amyloidosis:
Kappa:
Lambda:
k/l ratio:
10 mg/ L
10 mg/ L
1
Normal
Patient X then develops a very subtle AL amyloidosis tumour
Kappa:
Lambda:
k/l ratio:
12 mg/ L
8 mg/ L
1.5
Normal
This patient would normally be urine negative due to
normal kidney function......
Renal Metabolism of FLC
Glomerulus
damaged by
amyloids
sIF + sFLC:
98%
sIF + sFLC + uIF: 100%
Albumin
saturates
proximal tubule
Weakly positive
urine
Randomised and controlled
90 Patients recruited
Randomisation
Control Arm HD
45 Patients
Standard high-flux HD
Research Arm HD
45 Patients
Extended HD on HCO 1100
‘Modified PAD regimen’ Chemotherapy
(P) VELCADE™ (bortezomib)
iv
(A) Adriamycin (Doxorubicin)
iv
(D) Dexamethasone
oral
Assess outcome
1.0 mg/m2
9.0 mg/m2
40 mg
Trial time course
Day
0
1
Research √
arm HD
(6)
(Hours)
Chemo
sFLC
measured √
2
3
4
√ √
(8) (8)
5
6
7
√ √ √
(8) (8) (8)
V
V
A A A A
D D D D
√
√
√
8
√
9 10 11 12 13 14 15 16 17 18 19 20 21 22 onwards
√ √
(8) (8)
V
√
(8)
√
(8)
√
√
√
√
(8)
√
(8)
V
√
√
√
sFLC measured
•
at assessment
•
pre dialysis
•
post dialysis
•
non-dialysis
Accord. to
clin need (6)
As per PAD
protocol
D* D* D* D*
√
√
(8)
D* D* D* D*
√
√
√
√
√
√
√
√
√
√ √
Run within 24 hours
Run once /week
Four variables that had
maximum impact on
the outcome:
FLCdifference
troponin-T
BNP
B2M
Kumar, S., et al., Haematologica, 2008. 2(2): p. C19
Model of sFLC Removal - PE
12000
1.
2.
3.
Serum kappa (mg/L)
10000
100% tumour kill on day 1, RES clearance only
10% tumour kill/day, RES clearance only
10% tumour kill/day with PE
2
8000
6000
3
4000
2000
1
0
0
0
1
2
4
5
5
6
7
8
10 11
9
12
13
1515
14
17
18
2020
19
21
22
24 25
25
26
27
3030
28
Time (days)
Hutchison et al (2007) JASN 18, 886-895
Model of sFLC Removal – HCO1100
12000
1.
2.
3.
4.
5.
Serum kappa (mg/L)
10000
2
8000
100% tumour kill on day 1, RES clearance only
10% tumour kill /day, RES clearance only
10% tumour kill /day with PE
10% tumour kill /day with HD (3 x 4h /week)
10% tumour kill /day with HD (12h /day)
6000
3
4000
4
2000
1
5
0
0
0
1
2
4
55
6
7
8
9
10
11
12
13
14
15
15
17
Time (days)
18
19
20
20
25
21 22 24
25
26
30 3 0
27 28
Urine IFE + Serum IFE + Serum IFE only
and
and
Urine IFE + Urine IFE -
Abnormal
sFLC ratio
40/ 40
34/ 37
14/18
Abraham, R.S., et al., Am J Clin Pathol, 2003. 119(2): p. 274-8
All urine IFE+ AL amyloidosis patients
identified by sIFE + sFLC
Katzmann, J.A., et al., Mayo Clin Proc, 2006. 81(12): p. 1575-8.
Absolute FLC levels are prognostic in AL amyloidosis
patients undergoing peripheral blood stem cell
transplantation
Higher FLC concentration
correlated with:
Bone marrow plasmacytosis
Number of organs involved
Beta-2-microglobulin
Serum cardiac troponin T
Dispenzieri et al. Blood, 2006; 3378-3383
Higher FLC concentration
correlated with:
Bone marrow plasmacytosis
Number of organs involved
Beta-2-microglobulin
Serum cardiac troponin T
AL amyloidosis: MP response
A.R. Bradwell: Serum Free Light Chain Analysis 5th Edition
Monoclonal Protein Investigations
AL Amyloidosis Diagnosis
Serum electrophoresis: SPE + sIFE
Number of patients
100%
98%
53%
26%
Total
SPE+
21%
SPE
quantifiable
FLC 3%
SPE-/ IFE+ SPE-/ IFE-
FLC
Lachmann H. et al. BJH 2003; 122 :78-84
Absolute FLC levels are prognostic in AL
amyloidosis patients undergoing peripheral blood
stem cell transplantation
Dispenzieri et al. Blood, 2006; 3378-3383
Comparison SAP scans and serum FLCs in 127 AL amyloidosis
patients before and 12 months after chemotherapy.
Lachmann, H.J., et al., Br J Haematol, 2003. 122(1): p. 78-84
Monitoring plasma exchange with sFLC
Creatinine (mg/dL)
Serum FLC (mg/L)
Plasma exchanges
Chemotherapy:
B Bortezomib
Dexamethasone
c Cyclophosphamide
Thalidomide
Cserti Transfusion 2007 47: 511 - 514
A model of light chain
production and metabolism
Normal plasma cell
FLC production
Removal
by kidneys
Intravascular
FLC pool
Extravascular
FLC pool
Removal by
Reticuloendothelial system
A model of light chain
production and metabolism
Tumour
Removal
by kidneys
Intravascular
FLC pool
Extravascular
FLC pool
Removal
by PE or HD
Removal by
Reticuloendothelial system