Kidney transplant may be appropriate for some with AL amyloidosis

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By David Douglas

NEW YORK (Reuters Health) - In selected patients with light chain (AL) amyloidosis who are reaching end-stage renal disease (ESRD), kidney transplantation is a worthwhile approach, according to Boston-based researchers.

"Renal transplantation in patients with AL amyloidosis has been controversial due to lack of long-term outcome data and appropriate and validated eligibility criteria," Dr. Andrea Havasi of Boston University School of Public Health explained by email to Reuters Health.

In a paper online December 21 in Kidney International, Dr. Havasi and colleagues note that most published studies on the subject "predate the introduction of new systemic therapies that successfully suppress monoclonal light chain production."

To investigate further, the researchers studied data on 49 patients who underwent transplantation between 1987 and 2017. The patients' median age at diagnosis was 53.7 years, and the median time from diagnosis to ESRD was 1.5 years.

Median survival from diagnosis was 15.4 years, and 10.5 years from kidney transplantation. Graft survival was 94% at one year and 81% at five years.

Overall survival from diagnosis was significantly better in patients with hematologic complete response or very good partial response prior to transplantation (17.9 vs. 9.7 years). Corresponding survival after transplantation was 11.7 years versus seven years.

In the last decade of the study period (2007 to 2017), overall survival was significantly better than in the previous two decades (hazard ratio, 0.24). Moreover, say the researchers, overall survival "was superior in patients with hematologic response regardless of treatment modality."

"Our study shows that carefully selected patients, particularly those who had achieved a hematologic complete and very good partial response to plasma cell directed therapy at the time of renal transplantation demonstrated prolonged long term survival as well as graft survival," Dr. Havasi concluded.

"Importantly," she noted, "patient and graft survival of the patients with AL amyloidosis were comparable to outcomes achieved in non-AL amyloidosis patients. Our findings have the potential to shift current treatment paradigms and improve the life of AL amyloidosis patients."

Dr. Morie A Gertz of the Mayo Clinic, in Rochester, Minnesota, told Reuters Health by email, "Kidney transplantation is a viable option for renal replacement therapy in patients with immunoglobulin light-chain amyloidosis."

"Patients require chemotherapy and a deep preferably complete response to chemotherapy to be eligible for a transplant," stressed Dr. Gertz, who is a professor of medicine and a consultant in the department of hematology. "The amyloid should not involve organs outside the kidney."

SOURCE: https://bit.ly/2TMq1Dt

Kidney Int 2018.

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